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Considerations for Death Row Psychiatry Programs

Yanofski, J. Setting up a death row psychiatry program. Innovations in Clinical Neuroscience 8(2):19-22, 2011.

By Lori Whitten, Staff Writer, RTI International, Rockville, MD

Almost half of inmates incarcerated for capital crimes suffered from mental illness prior to their infraction. Jason Yanofski, M.D., argues that correctional institutions with significant death row populations should form teams to establish uniform policies regarding mental healthYanofski 2011 iStock_000013753942Small_purchased treatment of such inmates. Since 1976, when the United States Supreme Court ruled that deliberate refusal of a prison system to provide necessary medical care to an inmate amounts to cruel and unusual punishment (Estelle v. Gamble), death row inmates have had the right to physical and mental health treatment up until the very moment that they are executed. Institutions would be prudent to establish death row psychiatry programs to recognize the unique clinical, ethical, and legal issues of treating death row inmates and ensure that policies are well considered on medical or forensic grounds.

The clinical issues among mentally ill inmates on death row are complex. Psychiatric assessment-always a critical first step-can be difficult to achieve with members of this population, who often have severe and co-morbid disorders. These individuals also demonstrate higher rates of anxiety, dissociation, and psychosis than other prisoners. Death row inmates also have unique psychiatric risks, including psychological awareness of impending execution. Such awareness can be traumatizing, increasing the likelihood that such inmates will experience symptoms associated with clinical depression.

Landmark cases established that "insane" inmates and those with mental retardation could not be executed (Ford v. Wainwright [1986] and Atkins v. Virginia [2002]). Along with the right to be competent for execution, prisoners also have established the right not to be forcibly medicated for the purpose of restoring competency for execution. This presents personal ethical decisions for clinicians, and some may feel that restoring incompetent death row inmates to legal competency is against their moral principles. They may choose to treat symptoms while avoiding restoration therapy, although restoration may still result.

Although the relevant legal standards vary by state, many of the main clinical and ethical issues addressed by death row psychiatry programs are consistent across jurisdictions (see box). Complex dilemmas and challenging situations will always present themselves when dealing with mentally ill inmates on death row. A multidisciplinary team whose members meet regularly to thoughtfully review issues and develop policies consistent with state law and institutional views will help protect the clinical, ethical, and legal interests of all those involved.

Some Issues Death Row Psychiatry Programs Address

The presence of mentally ill prisoners on death row presents complex clinical, legal, and ethical dilemmas. Correctional facilities with a large number of death row inmates should consider establishing a multidisciplinary team to set general policies reflecting the views of the institution and the particular laws of the state.

Among the clinical issues to be addressed are the awareness and treatment of the symptoms and disorders most common in death row inmates, possible changes in medication regimens, continuity of therapy up to the day of execution, and the role of religious figures versus that of psychiatrists. Ethical and legal issues arise in areas such as participating in restoration services for inmates considered incompetent to be executed, receiving an inmate's admission of guilt during the appeal process, and proper treatment of inmates who give up the right to appeal and volunteer for execution. 

For more information, contact Jason Yanofski, M.D., Minor Traumatic Brain Injury Clinic at the U.S. Army Garrison, Bamberg, Germany, email:

Posted Fri, Mar 2 2012 12:46 PM by Tracey Vessels


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