Roskes, who is the chief psychiatrist for the Maryland Department of Public Safety and Correctional Services, oversees all psychiatric services in state prison systems.

Upstairs on the transition unit, however, the atmosphere is different. There is a dayroom with benches and a television set mounted on the wall, and inmates are allowed to have personal effects in their cells including pictures, television sets, and radios. One inmate, sitting on his cot, tunes in to find the "Jerry Springer Show." Through good behavior, he has earned the privilege of working at a job within the prison, and a family member has brought the small TV set to him to pass the time spent in his cell.

The transition unit is just a year old and houses stabilized offenders with mental illness who are scheduled to return to the community due to mandatory release or parole. All prisoners on this unit have agreed to participate in their treatment planning prior to leaving the prison and to follow treatment recommendations after release.

"The unit, said Roskes, "is the culmination of a formal collaboration between the Department of Public Safety and Correctional Services and the Maryland State Mental Hygiene Administration to improve prisoners’ transition from prison to the community."

In the six to eight months before their release, inmates participate in group and individual therapy sessions and meet with case managers to prepare for a return to the community.

Topics of group therapy sessions include budget management, addiction management, relapse management, and assertiveness training. "Spending time in prison takes these skills away from inmates," Roskes told Psychiatric News.

On average 77 percent of the inmates on this unit are African American, and the average inmate is 40 years old. The average length of incarceration for a prisoner who comes to the transition unit is eight years. A prisoner is usually referred from other parts of the Correctional Mental Health Center and has served time on another unit.

Crimes that landed the inmate participants in prison range from motor vehicle violations to homicide, but the two most frequent crimes are burglary and assault.

Most of the inmates are diagnosed with some type of psychotic disorder—33 percent with schizoaffective disorder, 16 percent with schizophrenia, and 16 percent with other psychoses. "There is also a high percentage of co-occurring substance abuse among these prisoners, which is frequently responsible for their failure to reintegrate successfully into society," said Roskes.

The Correctional Mental Health Center also includes a step-down unit, which is designed for a subgroup of mentally ill patients who are not seriously ill enough to be placed in the acute unit, yet cannot function effectively within the general prison population. Common problems in this population are social withdrawal, depression, substance abuse, and aggression.

The 250-bed facility is part of the Patuxent Institution, one of Maryland’s maximum-security prisons. Established in the early 1990s, the goal of the center is to get criminal offenders with mental illness the treatment they need and prepare them to return to society using the support of in-house psychiatrists, nursing and psychology staff, parole officers, and case managers in the community.

"The correctional providers aren’t necessarily the experts—we depend on the knowledge and experience of the community providers to develop the aftercare plan for the inmate." Roskes added, "The most important aspect of the collaboration between corrections and community mental health is an information flow in both directions."

Most of the community case workers drive from Baltimore to the prison regularly to meet with the inmates in the months before release, since a large number of the inmates are from the nearby city and will return there upon their release. "On the release date, the case workers will often drive to prison to pick up their assigned inmates and take them back to Baltimore, so they don’t have to take the bus." The stress of the bus ride, noted Roskes, can be a trigger for relapse for the newly released prisoners.

Roskes has been the director of the Correctional Mental Health Center since July 1999, and he has worked extensively in forensic, community, and emergency psychiatry. "It was emergency psychiatry in particular that opened my eyes to the importance of working as a team with the parole officers in the community," said Roskes. It was not uncommon for Roskes to see patients being discharged from prison or jail with only two days worth of medicine, and the patient would soon return to the emergency department looking for continuing treatment. Commented Roskes, "It seemed as if there was no climate where the issue of transition was important, and that is why I took the position here."

In the literature about prisons, there is a term known as "gate fever" or "short-time syndrome," Roskes said. "An inmate will often start to get anxious about his or her impending release—where the next meal is coming from, shelter, protection—all of the daily provisions taken for granted in prison." He noted that this anxiety is prevalent in the transition unit and is dealt with in individual or group therapy sessions.

"Ultimately, the offender will benefit from continuity of care from prison to the community, as well as understanding that corrections and community mental health are one big support system from which to get help," Roskes said.