Ireland's justice and mental health systems are failing people in the prison system who are mentally ill, according to a report published by the Mental Health Commission.
The report, entitled 'Access to Mental Health Services for People in the Criminal Justice System', said those with mental illness often do not receive the treatment required for them to recover.
It shows longstanding and persistent gaps in the mental health and criminal justice systems in Ireland.
A lack of diversion services means many with mental illnesses who come into contact with the criminal justice system are not being treated in a psychiatric setting, according to the report.
This is the latest report by the Inspector of Mental Health Services Dr Susan Finnerty, who under the Mental Health Act has to review a sector of mental health services in the State.
This year she chose to look at the criminal justice system.
Dr Finnerty visited three prisons and spoke to prisoners who had mental health difficulties, prison officers and the general nurses.
The report finds that there are opportunities to stop people with a mental illness who may have offended (in the context of that mental illness) getting into the prison service.
One of the main findings is that unlike other jurisdictions, there are no pre-arrest or diversion teams in the country.
Pre-arrest diversions would allow gardaí use their discretion to divert individuals suspected of non-violent, low-level offences away from the criminal justice system and towards mental health services.
That is a big gap in service, according to Dr Finnerty, who says a pre-arrest diversion would prevent people going into prison acutely mentally ill, often for minor offences.
When they do end up in prison, they are often subject to bullying and intimidation, victimised and mocked by other prisoners.
Dr Finnerty said their medication might be taken from them or they might be asked to try out illicit drugs.
"They find it quite difficult to obey prison rules. When you are psychotic it's very difficult to do that," she said.
The report said prison officers are ill-equipped to deal with the complex needs of prisoners with mental illnesses, while mental health treatment programmes and resources are severely lacking.
The report also outlines details of visits to Cloverhill Prison, Mountjoy Men's Prison and Mountjoy Women's Prison (Dóchas Centre) by the Inspector of Prisons and the Inspector of Mental Health Services.
They looked at access to appropriate mental health care for prisoners with mental illness.
In Cloverhill, they found that mentally ill prisoners were held in a wing that was overcrowded, with some cells occupied by three men.
One prisoner was lying on a mattress on the floor in a cell. He was severely mentally ill, refusing food and drink, and refusing medication. He was waiting for a bed in the Central Mental Hospital.
There were no therapeutic activities and few recreational activities for the men.
There were no mental health care professionals based in the area, which was supervised by prison officers.
The report notes that the inreach forensic mental health team had a very active presence in the wing and provided psychotropic medication where a prisoner consented.
They also provided therapeutic sessions.
In Mountjoy Men’s Prison, mentally unwell prisoners were accommodated in a nine-bed High Support Unit (HSU) and progressed to a low support unit when they were well enough.
According to the report, it was staffed by prison officers who had a special interest in mentally unwell prisoners.
It found that the inreach team provided a comprehensive mental health service and could decide who was admitted or discharged from the unit.
Prisoners told the inspectors that they preferred to be away from the main prison when they were unwell, and that it was more peaceful and quieter in the HSU.
It was here that the inspectors were informed that mentally ill prisoners were likely to be bullied and abused in the main part of the prison.
Mountjoy Women’s Prison (Dóchas Centre) had a medical unit with single cells where women with severe mental illness were located.
During the visit by inspectors, there were three severely mentally ill women locked in isolation cells, two of whom were waiting for a bed in the Central Mental Hospital.
Both had difficulty in articulating their needs due to the severity of their illness.
The report said there was regular input from the inreach team, but both needed urgent admission to the Central Mental Hospital and appropriate inpatient mental health care.
The report also looks in detail at the Central Mental Hospital.
After decades of reports stating that the facility in Dundrum was not fit for purpose, a new building in Portrane with an increase in beds from 102 to 170, including a unit for children and an Intensive Care Regional Unit, will open soon.
The new facility will bring forensic beds from 2 per 100,000 to 3.5 per 100,000, which according to the report, is still substantially lower than many other European countries.
"It is not a sufficient number now and won’t be into the future, especially bearing in mind the absence of investment in other areas of general and forensic mental health care", it said.
Professor Harry Kennedy is Executive Clinical Director for the National Forensic Mental Health Service at the Central Mental Hospital.
He said the report by the Mental Health Commission focused attention during difficult and unique times on the numbers of people with severe mental illness passing through the courts and the prisons who need treatment for severe mental illnesses.
"The great majority of them have a dual diagnosis. They have both a severe mental illness - delusions, hallucinations for example - and they also have serious problems with substance misuse," he said.
Prof Kennedy said more needed to be done rather than placing people in a prison or a forensic mental health service.
He pointed out that there are about 4,000 people in prison in Ireland and 10,000 people a year are passing through those 4,000 places.
Prof Kennedy said 3% of them will have a severe mental illness, mostly with a dual diagnosis at any time.
"That's a lot of people, we need a large model of care which includes the forensic hospital and the forensic clinics in the prisons and in the community, but much, much more so that we actually help to both treat those who have long-term treatment needs and we're very, very blind to long term treatment needs and then also think about what we can do to prevent people getting in trouble with the law," he said.
The Chief Executive of the Mental Health Commission, John Farrelly, has said prisons are unsuitable locations for those with mental disorders and the negative effects of incarceration on a person with mental illness are profound.
He also said that many of these prisoners are accommodated in an extremely restricted daily regime.
"These restrictions amount to inhuman and degrading treatment. The treatment of prisoners who are mentally ill must be addressed as a matter of extreme urgency," he said.