The stakes of this question are considerable. Large numbers of people with psychiatric illness receive their treatment, such as it is, inside jails and prisons rather than in hospitals or community clinics. Epidemiological work has consistently shown that the prevalence of serious mental illness in correctional settings far exceeds that of the general population, and umbrella reviews have documented heavy burdens of both mental and physical morbidity among imprisoned people. Formerly incarcerated individuals face dramatically elevated risks of death after release, including from suicide and overdose. Yet the physicians best positioned to care for these patients, psychiatrists in particular, remain in short supply within correctional systems, and relatively few medical schools expose their students to carceral medicine in any structured way. National surveys of medical school curricula have found that criminal justice and health is rarely taught, and a 2025 systematic review concluded that education on justice-involved health remains patchy and inconsistent across institutions.

The UNC research team, led by Rachel Hianik, Katelyn Einloth, and Theodore Zarzar of the UNC School of Medicine, together with Paul Mihas of the university’s Odum Institute for Research in Social Sciences, set out to understand what actually happens inside the minds of learners who take the plunge into a carceral clinical environment. Their specific aims were threefold: to identify students’ beliefs before the rotation, to determine whether those beliefs changed as a result of the clinical experience, and to assess whether the elective motivated students to pursue future work in carceral medicine or instead deterred them from it. The researchers gathered deidentified written reflections from 19 medical students who participated in the correctional psychiatry elective between July 2022 and October 2025.

Methodologically, the study followed a well-established inductive qualitative approach. Two independent coders read through the student reflections and constructed a codebook of themes that emerged organically from the text rather than being imposed in advance. The reflections were then systematically coded using ATLAS.ti, a widely used qualitative data analysis software package, version 23.2.1. As coding progressed and new themes surfaced, the codebook itself was revised, and any discrepancies between the two coders were resolved through consensus discussions. This iterative process is designed to minimize the risk that the researchers’ own expectations shaped the findings, and it allowed the team to trace patterns across multiple students’ narratives with a degree of rigor that anecdotal reports cannot match. The study was exempted from Institutional Review Board oversight by the UNC Office of Human Research Ethics, and the authors report no conflicts of interest and no external funding.

The analysis yielded five dominant categories of themes running through the student reflections. The first was preconceived notions, the baggage students carried in before they ever set foot in a prison. The second covered perceptions of the prison environment itself, the physical and institutional atmosphere students encountered. The third concerned perceptions of the people in prisons, that is, how students came to see incarcerated patients as human beings rather than as the caricatures they had imagined. The fourth addressed perceptions of the prison system, the structural and bureaucratic realities of delivering health care behind bars. The fifth captured insights gained, the personal and professional lessons students drew from the experience. Within this framework, one finding stood out with particular force: most students reported that their actual clinical experience simply did not align with what they had expected, especially regarding safety and the perceived aggressiveness of incarcerated people.

That misalignment appears to have been transformative rather than merely surprising. Many students described moments in which clinical interactions humanized incarcerated individuals, collapsing the psychological distance between “patient” and “prisoner” that many had brought with them. At the same time, the reflections were not uniformly rosy. Students frequently recognized the deep shortcomings of the carceral system, from its limitations as a site of care to the moral discomfort of practicing medicine within a coercive institution. The researchers note that students managed to hold both truths simultaneously: an acknowledgment that the system fails its patients in important ways, alongside an appreciation that their own work within it was meaningful and rewarding. This tension echoes earlier writing by study co-author Theodore Zarzar on moral distress, hope, and the carceral experience, and it suggests that the elective does not indoctrinate students into cheerleading for correctional medicine but instead equips them to see the system with clear eyes.

Perhaps the study’s most consequential conclusion concerns how those attitudinal shifts actually occurred. The researchers found that students’ preconceived notions were challenged most powerfully during direct student-patient interactions, not during didactic teaching or observational learning. This carries an important implication for medical education: clinical rotations involving direct patient care may hold unique value compared with lecture-based curricula about carceral health care. The finding aligns with a growing literature on experiential learning and with prior qualitative work, including an Australian study of clinical placements in correctional health in which learners reported having “no idea” what prison was actually like before their placements, and an earlier BMC Medical Education study linking prison health service experiences to social cognitive career choice. It also dovetails with research on the “hidden curriculum” of caring for incarcerated patients, which argues that unexamined attitudes toward this population are transmitted to trainees precisely because structured, reflective exposure is so often absent.

The career implications are equally significant. According to the study’s conclusions, the elective led many students to consider working with incarcerated people in the future. This matters because the pipeline into correctional psychiatry is thin. A 2012 study asked whether exposure during residency training could help address the shortage of psychiatrists in correctional settings, and subsequent surveys of general psychiatry residents have documented wide variability in forensic training. Workforce researchers have also documented persistent misconceptions about working in correctional psychiatry, including exaggerated fears about personal safety, that likely deter candidates who might otherwise find the field rewarding. If a brief medical student elective can measurably loosen those misconceptions before they harden into career decisions, the findings suggest a practical lever for building a workforce capable of serving one of the country’s largest and most neglected psychiatric populations.

The scale of that population lends urgency to the educational problem. The World Prison Population List estimates that more than eleven million people are held in prisons worldwide, with the United States accounting for a disproportionately large share; Bureau of Justice Statistics data indicate that correctional populations in the United States remain in the millions when jails, prisons, probation, and parole are combined. Within US state prisons, systematic reviews have estimated that a substantial fraction of inmates meet criteria for psychiatric illness. The people who cycle through these facilities return to communities, often with untreated or poorly managed conditions, and the transition from carceral to community care is a documented point of catastrophic risk. Physicians who understand this world, because they have seen it firsthand rather than through the distorted lens of popular culture, are therefore not a luxury but a public health necessity.

The UNC study grew out of a correctional psychiatry elective developed with an explicit focus on structural competency, a framework that trains clinicians to recognize how institutional and social forces shape individual health. That design choice may help explain the richness of the reflections the team analyzed: students were not merely shadowing clinicians but were being asked to think critically about the systems surrounding their patients, and then to write reflectively about what they saw and felt. The authors caution, as qualitative researchers do, that their findings derive from a single elective at a single institution with a modest sample of reflective essays, and that the generalizability of the themes to other programs and settings remains to be tested. Quantitative follow-up, tracking whether students who complete such electives actually enter correctional medicine at higher rates, would be a natural next step.

Still, the core message is difficult to ignore. Attitudes that might otherwise persist for an entire career, such as the assumption that incarcerated patients are inherently dangerous, can be revised within the span of an elective through the simple, ancient mechanism of a clinician sitting down with a patient and listening. The study suggests that medical schools seeking to prepare graduates for the realities of American health care should not confine carceral medicine to the lecture hall. It lives or dies, the UNC team’s evidence indicates, in the examination room, where twenty-three-year-old students discover that the person across from them is not a character in a crime drama but a patient, and that treating them can be among the most rewarding experiences of their training. In a field where the patients are numerous, the doctors are few, and the misconceptions run deep, that discovery may be the beginning of everything.

The prevalence of mental health issues among incarcerated individuals is alarming, with studies indicating that between 20% to 30% of those in jails experience serious mental illnesses. This statistic emphasizes the need to address mental health at every stage of the incarceration process. The journey begins when individuals first enter the jail system, where initial assessments can dictate the level and type of care they receive. The findings of DiRosa et al. underscore the necessity for comprehensive psychological evaluations immediately upon intake, which serves as a critical step in allocating resources effectively.

Upon entry, the role of mental health screenings cannot be underestimated. Early identification of mental health problems not only aids in tailoring appropriate treatment plans but also helps reduce the risk of dangerous behaviors within the jail environment. However, the study found significant variability in the quality and consistency of these screenings across different facilities, indicating an urgent need for standardized protocols. Such consistency would ensure that every inmate receives the recommended assessment regardless of which facility they enter, thereby creating a more equitable system.

As incarcerated individuals transition through the jail system, their mental health management requires careful consideration. The study reveals that ongoing psychiatric care is frequently inconsistent, with some facilities lacking sufficient mental health professionals. This shortage can lead to delayed treatments, missed follow-up appointments, and inadequate responses to individuals in crisis. DiRosa and her team call for investments in training and recruitment of qualified mental health staff, asserting that adequate human resources are essential to creating a responsive healthcare system within jails.

Moreover, the report sheds light on the various mental health interventions available to inmates. Cognitive behavioral therapy (CBT), medication management, and group therapy are commonly employed strategies; however, the efficacy of these methods hinges on how well they are implemented. The researchers found that while some facilities excelled in providing therapeutic programs, others often fell short due to lack of funding or insufficient staff training. Effective implementation of best practices should be prioritized to ensure all inmates can benefit from proven therapeutic strategies.

The complexities of mental health care within correctional settings are compounded by the overarching issue of stigma. Many inmates may feel reluctant to seek help due to fear of judgment from peers or even staff. DiRosa and colleagues advocate for educational initiatives aimed at reducing stigma, emphasizing that a culture of openness and support can significantly impact inmates’ willingness to engage with mental health services. Addressing stigma is not merely an ancillary concern; rather, it should be central to any reform efforts aimed at improving mental health care within jails.

Another critical aspect uncovered in the study is the transition from incarceration back into society. The process of re-entry is fraught with challenges, particularly for those managing mental health conditions. Many individuals leave jail with inadequate support systems, elevated stress levels, and unresolved mental health issues, which can lead to recidivism. DiRosa’s research suggests that implementing structured re-entry programs with comprehensive mental health support could dramatically improve outcomes for released individuals.

In addition to focusing on clinical aspects, the report also highlights the importance of multidisciplinary approaches that engage different sectors such as community services, healthcare providers, and social support systems. The involvement of various stakeholders can create a more holistic approach to mental health recovery, offering continuity of care that extends beyond the walls of the jail. Incorporating community resources into jail healthcare can enhance the quality of services delivered and help inmates reintegrate more smoothly into society.

The insights provided by DiRosa et al. not only clarify the shortcomings of current practices but also present actionable recommendations for stakeholders at all levels. Advocacy for policy changes that prioritize mental healthcare is paramount—these changes can range from funding allocations to legislative reform that facilitates better training for law enforcement on mental health issues. The significance of collaboration among governmental bodies, healthcare providers, and criminal justice systems cannot be overstated in efforts to create a more integrated approach to mental health.

The future of mental healthcare in jails hinges on the commitment of all involved parties to learn from the findings of this study. By prioritizing mental health as a critical component of the criminal justice continuum, we can change the narrative surrounding incarcerated individuals. This study serves as a vital call to action that should resonate not just in academic circles but among policymakers, healthcare advocates, and the general public, who all share the responsibility of fostering a healthier society.

As discussions around mental health continue to evolve, this research lays the groundwork for future inquiries. Further studies might expand the scope to include longitudinal analyses of mental health outcomes as well as qualitative assessments of inmates’ experiences navigating these systems. By broadening the scope of research to capture diverse perspectives, stakeholders can better understand and respond to the intersection of mental health and incarceration.

In conclusion, understanding the nuances of mental healthcare in jails is crucial for achieving meaningful reform. As highlighted by DiRosa and collaborators, the combination of comprehensive intake assessments, consistent care, stigma reduction, and robust re-entry strategies can lead to significant progress in addressing mental health challenges faced by incarcerated individuals. Future efforts must not only focus on treatment within jails but also promote an overarching philosophy of care that continues to support individuals long after their release. By taking a proactive stance, we can cultivate a system that encourages recovery, reduces recidivism, and ultimately promotes public health.

Embracing these findings and principles can empower stakeholders to advocate for systemic changes, harnessing the knowledge gained from this research to foster a more compassionate and effective approach to mental health care within jails. The pursuit of equitable mental health services is not merely a goal but a necessity for creating a just and humane society.

Subject of Research: Mental healthcare practices in Southeastern jails

Article Title: Mental healthcare practices from entry to release across Southeastern jails

Article References:

DiRosa, E., Van Deinse, T., Cuddeback, G. et al. Mental healthcare practices from entry to release across Southeastern jails.
BMC Health Serv Res 25, 1355 (2025). https://doi.org/10.1186/s12913-025-13507-w

Image Credits: AI Generated

DOI: 10.1186/s12913-025-13507-w

Keywords: mental health, incarceration, healthcare practices, mental illness, re-entry, prison reform