To the Editor: The recent editorial by White and Whiteford raises the important issue of the need to provide more extensive and more effective mental health services for the prison population.1

However, their discussion of the reasons for the increased level of need does not consider one important problem that often results in the inappropriate imprisonment of people with mental illness. This is the frequent refusal of acute psychiatric units to accept mentally ill people referred by the courts.

I recently reviewed a series of 102 referrals for medicolegal assessment from Legal Aid New South Wales between February 1999 and March 2006. The results were presented at the 2006 meeting of the Forensic Section of the Australian and New Zealand College of Psychiatrists.2

Of the 55 patients meeting the criteria for mental illness under section 32 or 33 of the Mental Health (Criminal Procedure) Act 1990 (NSW), 27 (49%) were seen in custody. For 14 of these patients, their incarceration had resulted from the failure of the local area heath service to accept patients for admission if they had drug-related exacerbations of mental illness. Hospital registrars would return patients to court with a certificate saying that they had no mental illness, even though some of them were currently under a community treatment order recommended by other professionals from the same mental health service.

To some extent, this may be because of the strict application of the guidelines for compulsory hospitalisation. These are more stringent than the criteria for defining mental illness under the Mental Health (Criminal Procedure) Act, but one is left with anomalous situations such as the one described above.

Important issues leading to this situation appear to be the presence of dual diagnoses (10 of the patients reviewed had a combination of psychosis and substance misuse) and violent behaviour. The rejection of violent patients reflects both occupational health and safety considerations in the context of inadequate resources and an industrial stance (usually informal) taken by the nursing staff.

It is therefore important that some of the additional resources recently committed by Australian governments to the reform of forensic mental health services be directed towards the provision of acute hospital inpatient services for disturbed patients, so that the incidence of imprisonment in the acutely disturbed psychiatric population is reduced. This is more humane and may be more cost-effective than simply applying all the resources within the prison system.