Questions/Answers

Currently, Thailand has a total of 351,137 prisoners (Department of Corrections, 2020). A study on the development of the mental health and psychiatric service system for prisoners indicated that 45.67% of the prisoners are facing mental health problems, including alcohol and substance addiction, depression, suicide risk, and schizophrenia (Kamonchanok Montasewi, 2018). In 2016, there were 3,311 psychiatric prisoners, which was a small proportion compared to the prisoners nationwide. Due to the lack of psychiatrist under the Department of Corrections, the restricted process of going to receive services outside the prison, the limited number of multidisciplinary teams in mental health and psychiatry under the Ministry of Public Health to serve psychiatric patients in the prison, most of the psychiatric prisoners have not met the psychiatrist on a regular basis and the prison officers need to collect the medicine on behalf of them. This reflects the limitations of access to mental health services among the prisoners, who are the vulnerable group with limited freedom and ability to protect their own rights. Thus, using communication technology to enhance access to mental health and psychiatric services for psychiatric prisoners can be an innovative way to cope with this situation. The Galya Rajanagarindra Institute is the main organization, initiating the use of telepsychiatry program to solve the aforementioned limitations and encouraging the organizations affiliated with the Department of Mental Health to adopt this program. In foreign countries, telepsychiatry system has been used in prisons because those prisons are mostly located in remote areas and face a limited access to multidisciplinary teams in mental health and psychiatry. The objectives of the telepsychiatry program are to enable prisoners to directly receive treatment, follow-up care, and continuous medication from the psychiatrist and to save budget for sending the psychiatric prisoners to external health facilities under limited resources.

In Thailand, the telepsychiatry program has been developed for psychiatric prisoners and juvenile offenders, who are the vulnerable group that have the rights to receive standardized healthcare in the same way as other people do. Due to the limited access to treatment combined with the restrictions of the prisons and juvenile detention centers, the digital technology has been applied to develop the telepsychiatry program in order to increase access to mental health services and enable forensic psychiatric patients to receive treatment on a continuous basis.

Prisoners are at a higher risk of developing mental and psychiatric problems compared to the general people. They have limited freedom and power to protect their own rights and also lack access to mental health and psychiatric services. These limitations inevitably affect their health and well-being, which reflects inequalities in access to health services. To solve this problem, it is necessary to provide them with proactive services through the use of the telepsychiatry program, which can help the psychiatric patients in prisons and detention centers to gain equal access to health services, have good mental health and well-being, receive timely and continuous health care, and experience no recurrent symptoms.

The Galya Rajanagarindra Institute has developed the telepsychiatry system since 2016. In 2018, the MOU between the Ministry of Public Health and Department of Corrections was signed to provide psychiatric services to prisoners. In 2020, the collaboration has been extended under the Pansuk Correctional Program, aiming to provide prisoners with equal access to psychiatric treatment. As a results, the network of psychiatric care for prisoners has been established nationwide, causing all psychiatric prisoners to have access to treatment and able to develop good mental health and readiness for becoming a major force for social and economic development after being released.

Due to the limited access to mental health services of prisoners, the difficulty of having the multidisciplinary team provide services in prisons, the restriction of sending prisoners to receive treatment at hospitals, the risks in transportation and service receiving/providing, and the limitation of manpower, a cooperation between multidisciplinary teams and medical personnel of each prison has been made. Although they have a completely different work context, they have the same common goal in providing prisoners of all ages and genders with equal access to standardized mental health and psychiatric services. Thus, the telepsychiatry program has been developed to solve all limitations and make the psychiatric prisoners, who are the vulnerable group with restricted freedom and limited power for personal right protection, have access to treatment based on the concept “Providing equal services at acceptable standards without leaving anyone behind.”

In Thailand, prisoners are taken care of under the Bangkok Rules, which are the internationally recognized rules for the treatment of the female prisoners. As prisons have been principally designed for men and not conducive to the well-being of women, the female prisoners tend to receive unequal treatment opportunities. Development of the telepsychiatry program in Thailand complies with the Bangkok Rules in providing mental health services to prisoners of all ages and genders in a fair and thorough manner.

The target group includes the male and female prisoners in correctional facilities and prisons, including juveniles in detention centers nationwide. In the past, a small number of psychiatric prisoners were treated because they had to wait for the multidisciplinary teams and faced with limitations in going out to hospitals. After the adoption of the telepsychiatry program, the number of psychiatric prisoners receiving treatment has increased from 68 males in 2016 to 206 males in 2017, 347 males and 12 females in 2018, 875 males and 31 females in 2019, and 873 males, 150 females, and 30 juveniles in 2020. The telepsychiatry program has been provided to all genders and age groups without leaving anyone behind.

In 2016, there were many psychiatric prisoners, who did not receive continuous care. Some were reported more severe psychiatric symptoms due to a lack of treatment resulting from the restrictions of receiving treatment outside the prison and the limited number of personnel. Moreover, there was no follow-up service for treated patients. The Galaya Rajanagarindra Institute, therefore, has initiated the use of the telepsychiatry system to examine and monitor the treatment and condition of the psychiatric prisoners. The pilot test was carried out on 1 psychiatric prisoner, who had physical disease and was unable to receive the treatment outside the prison. Later, the telepsychiatry system was established in Nakhon Sawan Rajanagarindra Psychiatric Hospital to serve 67 service recipients. During 2017-2018, the telepsychiatry system were increasingly established in other psychiatric hospitals, including 3 agencies under the Department of Mental Health. The number of service recipients increased from 206 in 2017 to 359 in 2018. In 2019, there were 4 agencies serving 906 service recipients and the telepsychiatry program manual was created to be used as a guideline for providing mental health and psychiatric services to prisoners. In 2020, the Galya Rajanagarindra Institute initiated the telepsychiatry program in the juvenile detention centers. The Department of Mental Health also set an indicator that the psychiatric hospitals must implement the telepsychiatry program. Thus, in this year, there are 11 agencies out of 20 under the Department of Mental Health providing the telepsychiatry program to 1,083 service recipients.

The main implementation obstacle is the attitude of medical personnel and prison officers. This is because the use of video conference is different from normal medical service, where the doctor and patient are in the same place. The use of the internet is also against prison regulations. However, after understanding the nature of the system and the importance of psychiatric service provision to prisoners, the telepsychiatry program was established. Psychiatric knowledge was provided to relevant parties so that they could solve provide therapy and work in the same direction. The telepsychiatry program manual and consent letter were created as well.

The Galya Rajanagarindra Institute has initiated the telepsychiatry program to provide mental health and psychiatric services to prisoners for the first time in Thailand. This program allows the psychiatric prisoners to receive examination and treatment from the psychiatrist through a remote communication system. It not only makes the psychiatric prisoners have access to continuous care and medication, but also helps to prevent prison escape, save budget for sending the patients to external health facilities, and reduce operational problems for prison officers.

The telepsychiatry program was inspired by the telemedicine system that offers medical services to the patients in remote areas. However, the telepsychiatry system is specifically applied to the prisoners with mental health and psychiatric problems and lacks of access to multidisciplinary services.

The telepsychiatry program complies with Thailand’s Digital Government Development Plan on expanding health services to remote areas. This program uses the hi-speed internet and advanced transmission technology to provide examination and treatment to the psychiatric prisoners. Although it cannot replace real mental health services, it helps to increase access to psychiatric services. The first psychiatric prisoner of this program had physical disease and could not go to receive treatment at the hospital. The results from the first patient were satisfactory so this program has been continually expanded to cover partner hospitals under the Ministry of Public Health across the country.

The telepsychiatry program was initiated by the Galya Rajanagarindra Institute in collaboration with Thonburi Special Prison. The service was initially limited to specific areas. Later, after the Ministry of Public Health and the Department of Corrections mutually recognize the importance of the mental health of prisoners, the telepsychiatry program has been expanded to other areas in order to provide all prisoners with access to mental health and psychiatric services. In addition, the telepsychiatry program was introduced in the 2nd Asia and Pacific Conference on Prison Health (APCPH) 2018 held by the ICRC in Cambodia. The ICRC team also visited the Galya Rajanagarindra Institute to observe the implementation of the telepsychiatry program. Many countries in the Asia-Pacific region are inspired to develop a telepsychiatry system to increase access to mental health and psychiatric services in their own country.

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1) laptop equipped with audio/video recording, 2) fast and stable internet system used to transmit audio/video data between service providers and service recipients, 3) budget for maintaining the system, ensuring system security, preventing misuse of data, and protecting the rights of prisoners, 4) IT personnel capable of maintaining the system, 5) service place with no access from the public because this program is specifically provided for the psychiatric prisoners. Above all, the most important resource is human. Providing services to vulnerable prisoners with psychiatric problems requires the cooperation from all management and personnel in correctional and public health systems.

The key factor contributing to the sustainability of this program is the participatory collaboration between the Ministry of Public Health and the Department of Corrections in caring for the mental health of the prisoners. As both of them jointly determined the service policy of this program, all affiliated agencies, including partner hospitals and prisons, need to allocate the budget to establish the required system in order to deliver the telepsychiatry service throughout the country.

Yes

The psychiatric prisoners were interviewed by the personnel from the Department of Mental Health, they said that they are happy to be able to discuss their symptoms directly with the psychiatrist through the telepsychiatry program. The prison nurses were also satisfied with this program because it made the psychiatric prisoners able to receive continuous treatment and helped to reduce the risk. Moreover, the psychiatrists from the agencies under the Department of Mental Health were happy to have a direct talk with the patients instead of listening to their conditions from the prison officers that came to collect the medicine.

The indicators were determined based on the 5th indicator of the Measures to Improve Public Sector Efficiency 2020 regarding the achievement of the development of telemedicine systems. The Galya Rajanagarindra Institute has been appointed as the performance management unit (PM) to monitor and report the development of the telepsychiatry program among the agencies under the Department of Mental Health.

The Department of Mental Health has a total of 20 service agencies in 2020. Based on the indicators of achievement, there are 11 agencies successfully providing the telepsychiatry program, accounting for 55% of the total service agencies.

The Galya Rajanagarindra Institute is the main agency that has initiated the use of the telepsychiatry program and encouraged the agencies under the Department of Mental Health to adopt this program by cooperating with the agencies under the Department of Corrections and the Department of Juvenile Observation and Protection.

The development of the telepsychiatry program in Thailand has been carried out under collaboration between the Department of Mental Health, the Department of Corrections and the Department of Child and Youth Observation and Protection. The representatives from these three organizations have continuously participated in the joint meetings in order to 1) understand the needs for mental health and psychiatric services of the prisoners and the obstacles to providing mental health services in prisons, 2) work together in planning the telepsychiatry system in prisons, 3) cooperatively prepare a manual for the telepsychiatry program, 4) jointly evaluate the performance of the telepsychiatry program, and 5) use the evaluation results to improve the telepsychiatry program on a continuous basis.

The Galya Rajanagarindra Institute recognizes the benefits of providing mental health and psychiatric services to the prisoners through the telepsychiatry program. The number of agencies providing mental health services through the telepsychiatry program continues to increase. The number of psychiatric prisoners receiving treatment through this system has also increased. Therefore, there is a plan to help and support the hospitals that are not affiliated with the Department of Mental Health to establish the telepsychiatry system in order to provide mental health and psychiatric services to prisoners as well as children and youth in juvenile detention centers in the future.