France's Prisons Are Overcrowded — With Psychiatric Patients

Medscape

18 hours ago

Eric Kania, MD
Eric Kania, MD, who has been a psychiatrist at Baumettes Prison in Marseille, France, for 25 years, has witnessed an increasing proportion of inmates being treated for psychiatric disorders.
In an interview with Medscape's French edition, he explains how care teams are organizing treatment in often overcrowded prisons and describes the special monitoring implemented for inmates at highest risk for suicide.
How did you become a prison physician?
I studied medicine in Marseille and specialized in psychiatry. During my residency, I completed a 6-month internship at Baumettes Prison, which greatly interested me. After completing my thesis and working in hospitals, I returned to the prison because I wanted to continue this work. I now work half-time at Baumettes and half-time in private practice.
Why this attraction to prison work?
Prison is a place that requires dedication. It sits at the confluence of multiple issues: social, sociologic, medical, and judicial. I'm particularly interested in the criminal responsibility of offenders with psychiatric disorders. Like many of my colleagues, I've read the work of Michel Foucault — particularly his 1975 book Surveiller et punir: Naissance de la prison (Discipline and Punish: The Birth of the Prison) — which helped shape my thinking around justice, mental illness, and social structures. These reflections played a significant role in my decision to work in the prison system.
How are psychiatric services organized at Baumettes?
We are a team of seven psychiatrists — some of us, like myself, working part-time. We collaborate with a nursing team of eight for level 1 psychiatric care, and a second team handles level 2 care.
Baumettes is a very old facility, originally opened in 1930, and it has housed a regional medico-psychological service since 1980. Today, we provide psychiatric care for more than 1000 inmates. The renovated section of Baumettes, which opened in 2017, was designed to accommodate 580 men and 200 women. However, overcrowding became an issue almost immediately. Although the cells were intended for single occupancy, additional fold-out beds had to be added owing to limited space. The older part of the facility previously held up to 2000 inmates in a space built for 1300.
Currently, two detention buildings are in use, and three more are under construction, expected to open within 1-2 years. In the long term, the total capacity at Baumettes will once again double. Although we hope this will help relieve overcrowding, experience has shown that any new space tends to fill up very quickly.
What are the main psychiatric disorders among inmates?
There is an overrepresentation of psychiatric disorders in prisons. Epidemiologic studies show five to eight times more severe psychiatric disorders (bipolar disorder or schizophrenia) among inmates than in the general population. We also manage more common pathologies, such as depression and anxiety. Sometimes, people with no prior psychiatric history develop anxiety reactions owing to the prison environment.
Do you have enough resources to care for everyone?
Resource availability is a complex issue. It's reasonable to assume that there aren't enough mental health professionals working in prisons. This shortage was one of the reasons behind the creation of specially adapted hospital units, located within public health facilities, to provide care for incarcerated individuals. These units represented real progress, but they also had an unintended consequence: The more mental health staff we place in prisons, the more it appears that mental illness is prevalent in these settings.
Is this a reality?
The reality is that society, the justice system, and law enforcement are now more likely to send individuals with mental illness to prison, partly because they know that mental health professionals are available there to manage them. I've been practicing in prison since 2000. In the past, it was rare to see a person with schizophrenia incarcerated after committing an offense during an escape from a psychiatric hospital. Today, that scenario has become unfortunately common. Psychiatric patients are being sent to prison because understaffed hospitals are increasingly unwilling, or unable, to take them back.
Should we conclude that France's psychiatric crisis is increasing the prison population?
Penrose's law, named after an English psychiatrist, suggests that in several countries, reductions in psychiatric hospital beds have been associated with increases in the prison population. In France, the decrease in psychiatric inpatient capacity has coincided with a rise in both overall incarceration rates and the number of inmates with psychiatric disorders. Although correlation does not imply causation, the pattern is worth considering. Of course, other factors may also contribute to the growing number of individuals with mental illness in prison.
What are those factors?
Many believe that the 1994 reform of the French Penal Code, which introduced the concept of partial criminal responsibility, contributed to an increase in the number of mentally ill individuals in prison. Previously, under the 1810 Penal Code, a person deemed to be in a state of insanity was exempt from criminal responsibility and was transferred to a psychiatric hospital. The 1994 reform amended this principle, specifying that individuals whose judgment is impaired, but not completely abolished, by mental illness can still be held criminally liable. This change led to convictions that might not have occurred under the previous legal framework. Sociologist Caroline Protais has shown that the number of rulings of criminal irresponsibility has decreased since the reform.
Another policy that has significantly contributed to the increase in mentally ill inmates is comparution immédiate (immediate appearance), a legal procedure introduced in 1983 and strengthened in the mid-2000s under then-Interior Minister Nicolas Sarkozy. This fast-track process has been a major driver of prison overcrowding, particularly among individuals with serious psychiatric disorders that often go unrecognized at the time of sentencing. By the time their condition is identified in prison, the sentence has already been handed down, making transfer to a psychiatric facility no longer possible.
How are inmates cared for? Can a patient request to see you? Are there mandatory check-ups?
Every inmate undergoes a medical consultation upon arrival, typically with a general practitioner. If needed — whether due to existing psychiatric care or observed concerns — they are referred the same day for a psychiatric evaluation. If we identify signs of 'carceral shock' (a psychological reaction to incarceration) during this initial assessment, we schedule follow-up and initiate appropriate care. Additionally, if an inmate requests to see a psychiatrist or psychologist at any point during their incarceration, or if someone in their environment alerts us to an urgent situation, we make arrangements to see the patient promptly.
What are your main concerns? Are inmates treated differently than other patients?
The context for providing care in prison is very specific, and we have to account for that. Inmates often reach out to us because the prison environment intensifies their psychological distress. At times, we need to coordinate with the prison administration to adjust detention conditions, even though that falls outside our formal responsibilities. If an inmate expresses suicidal thoughts, we inform the administration so that special monitoring can be implemented. At night, correctional officers check through the cell's observation window to ensure the inmate is safe. Every 2 weeks, a multidisciplinary committee reviews the cases of these at-risk individuals.
How far does this special monitoring go?
If inmates are at high risk for suicide or attempt to hang themselves during the night, the prison administration may transfer them to the emergency department. They can also place the individual in an 'emergency protection cell' designed to ensure safety until appropriate care can be arranged. These cells are smooth and free of any anchor points. In many cases, an emergency protection system is also activated, which consists of making the prisoner wear a tear-away gown to avoid any risk for hanging. The following morning, the inmate is seen by the regional medico-psychological service, which determines — based on clinical assessment — whether hospitalization is required.
A recent study by the penitentiary administration shows rising suicide rates among inmates. Are you concerned?
We have always been concerned about this issue. There have been several suicides at Baumettes in recent years; some involved patients we were actively treating, while others were unknown to us. Each case is a tragedy. Importantly, suicides are not limited to individuals who previously expressed distress; many had no diagnosed psychiatric illness. In some cases, the act may have been a way to protest or attempt to change detention conditions. Fortunately, not all suicide attempts result in death.
Psychiatric care for the approximately 80,000 incarcerated individuals in France is organized into a three-tiered system. Level 1 care is available in all 187 prisons across the country and provides outpatient psychiatric services. Inmates leave their cells to attend appointments in the prison's health unit, where they may be seen by a psychiatrist, psychologist, psychiatric nurse, and, when appropriate, a social worker or educator.
When level 1 care is insufficient owing to the severity of the condition, inmates can access level 2 care through day hospitals. Twenty-six prisons are equipped with both level 1 and level 2 services, including a day hospital as part of the regional medico-psychological service.
If level 2 care is still inadequate — typically when a patient is highly unstable — they may be transferred to level 3 care, which involves full-time inpatient psychiatric hospitalization. This may occur in a nearby psychiatric hospital when the patient is experiencing an acute emergency, such as a psychotic episode or suicidal crisis.
The inmate may remain hospitalized for several days and can be admitted to one of the nine specially adapted hospital units located in Lyon, Nancy, Toulouse, Villejuif, Lille, Rennes, Orléans, Bordeaux, and Marseille. These units accept inmates under voluntary or compulsory care, based on a decision by a state representative when the patient is deemed incapable of providing informed consent. These secure facilities — equipped with video surveillance, barbed wire, and security checkpoints — are dedicated healthcare environments. Prison staff only intervene in cases of agitation or violence; otherwise, all care is provided exclusively by medical professionals.