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Malingering of depression in a prison population: Evaluating the utility of the Beck Depression Inventory - II

ProQuest Dissertations and Theses, 2009
Author: Nicole L Zenger
The purpose of this study was to evaluate the utility of the Beck Depression Inventory - II in a prison mental health facility, and to understand the frequency and impact of a feigned response style on the measure. Archival data from testing that was part of standard assessment procedure in a prison mental health unit was used. The PAI and MMPI-2 validity scales were used to classify inmates as honest responders or feigners, and classification rates across indices were compared. Psychometric characteristics, including nonparametric item analyses, of the BDI-II for both response style groups are presented. Results suggest that the BDI-II is impacted by a feigned response style, and may mask the measures ability to accurately determine depression severity in a context with a high probability of malingering. Results from the honest responding inmates indicate some response option weights are inappropriate for prison inmates seeking mental health services. Some BDI-II items do not discriminate depression severity at all among honest responding inmates, and thus do not appear to measure depression in prison. Given the impact of a feigned response style on the BDI-II, as well as the different manner inmates respond to the item options, the BDI-II is unlikely to provide clinical utility in a prison mental health facility.

Table of Contents Acknowledgments vi Table of Contents vii List of Tables ix List of Figures x Introduction 1 Depression in Prison Populations 1 Treatment Issues 4 Assessment 5 Malingering 7 Assessment: Methods and Procedures 14 Testing 15 Setting a Standard of Practice 20 Empirically Supported Instruments in Prisons 22 Boothby and Durham's Study 26 Justification for This Study 28 Methods 29 Participants 29 Instruments 30 Procedures 32 Statistical Analyses 32 Results 38 Objective Personality Inventory Results 38 vii

Beck Depression Inventory - II Results 42 Nonparametric Item Analyses 49 Discussion 56 Malingering in a Prison Mental Health Unit 57 The Utility of the Beck Depression Inventory - II in a Prison Mental Health Unit....59 Limitations of Study 65 Conclusions 67 References 69 Appendix 78 vni

List of Tables 1. MMPI-2 Malingering Indices' Scores 39 2. PAI Malingering Indices' Scores 40 3. Response Styles of Personality Protocols 41 4. Response Style Categories: Scales' Means and Standard Deviations 42 5. BDI-II Traditional Classification (Valid protocols) 43 6. Response Styles of Personality Protocols Associated with a BDI-II 44 7. BDI-II Traditional Classification within Response Style 45 8. BDI-II Item Factor Loadings for All Protocols and Honest Responders 48 9. BDI-II Item Descriptive Statistics for Honest and Feigned Protocols 50 IX

List of Figures 1. Item and Option Characteristic Curves for BDI-II Item 19 (concentration difficulty) for Honest Responders 52 x

Malingering of Depression in a Prison Population: Evaluating the Utility of the Beck Depression Inventory - II Mental illness in general, and depression in particular, is quite prevalent in prison populations. However, the correctional context is unique and complicated, leading to challenges when assessing and treating mental illness. Due to increased demands and scarce resources for mental health services, it is imperative that psychological instruments used for assessment be accurate. However, traditional measures may be impacted differently when used in prisons due to this population's higher base rates of mental illness, as well as motivations to malinger. Therefore, it is necessary to evaluate the utility of standard methods of assessment in this particular population. The goal of this paper was to evaluate the utility of the Beck Depression Inventory - II (BDI-II; Beck, Steer, & Brown, 1996)—a measure that has met the need for a quick, accurate measure of depression severity in other contexts—in a prison mental health unit. Depression in Prison Populations Prison inmates who have been incarcerated for various crimes are often construed and dismissed as characterologically defective. Regardless of whether or not they are antisocial or sociopathic, inmates are certainly not immune to psychiatric disorders (Rogers & Bender, 2003; Rogers & Vitacco, 2002; Vitacco and Rogers, 2005). Estimates of the prevalence of mental illness in prison populations have varied, but there is general agreement that rates are two to three times higher than in the general population (Boothby & Clements, 2000; Fazel & Danesh, 2002; Teplin, 1994), with evidence that rates continue to rise.

2 Although inmates have presented with all manner of psychological disorders, depression is particularly prevalent, more so than other Axis I disorders. A survey of clinical psychologists working in prisons found that 80% of clinicians endorsed depression as the most frequent problem encountered (Boothby & Clements, 2000), which was twice as high as the next most common problem of anger. A survey of state and federal prisoners found that 56.2% inmates had a mental disorder, with 23% having a depressive disorder specifically (James & Glaze, 2006). Fazel and Danesh (2002) estimated the prevalence of mental illness in prison populations by systematically reviewing studies conducted in Western countries from 1966 to 2001. They estimated that 10% of men and 12% of women inmates have a depressive disorder at any time, rather high when compared to the point prevalence of men (2-3%) and women (5-9%) in the general population (DSM-IV; American Psychiatric Association, 2000). Some studies show that up to 60% of inmates meet at least some of the criteria for depression at any given time (Chiles, von Cleve, Jemelka, & Trupin, 1990; Eyestone and Howell, 1994; James & Glaze, 2006). These estimates of prevalence raise some important points of inquiry: what accounts for these higher rates and why the discrepancies in findings? To begin with, this may be more apparent than real, with poor assessment procedures leading to elevations and discrepant findings between studies. First, the method or instrument used to measure depression may be inaccurate. For example, Fazel and Danesh (2000) used studies that based the depression diagnoses on objective psychological instruments (10 - 12%), whereas James and Glaze (2006) findings were based on inmates' informal self-report (23%). Accuracy of rates of depression can depend on which measure is more reliable

3 and valid. Second, given that symptoms of a depressive disorder can be associated with other psychological disorders common in prison populations (e.g., alcoholism, personality disorder), rates may seem higher if proper attention is not paid to differential diagnosis. Therefore, we must consider that the apparent higher rates of depression may be a misrepresentation of the actual prevalence due to poor or inaccurate assessment procedures. Despite these potential flaws in studies suggesting higher rates of depression, depression is likely a real problem among prisoners. Assuming prevalence of depression in prison populations is actually greater than in the general population, it begs the question of "why." No doubt, the losses associated with conviction and incarceration, as well as the stresses of prison life are factors. In contrast, it may also be that, for some persons, vulnerability to depression contributed to their criminal activity. Examples of possible mechanisms include: (a) poor judgment arising from the depressive state; (b) lifestyle consequences of period institutionalization; (c) relationship difficulties leading to violent reactions; (d) economic necessity arising from the lowered functioning associated with depression; or (e) substance abuse as a means to self-medicate the depression. Regardless of the reasons for higher rates of mental illness in prison inmates, it is a significant concern among policy-makers, administrators, and mental health providers. One reason for concern is that failure to find solutions to mental health issues while in prison may lead to greater recidivism in cases wherein the mental illness contributes to criminal activity. Another reason for concern is the increased risk of suicide among mentally ill inmates, which remains the third leading cause of death in prison inmates

4 (Mumola, 2005). Third, mental health professionals have an ethical responsibility to provide services to the mentally ill, and it is legally mandated (e.g., Bowring v Godwin, 1977; Estelle v Gamble, 1976). Treatment Issues Given ethical and legal requirements, incarceration should provide mentally ill inmates with an opportunity to receive treatment from a mental health professional. Unfortunately, both inmates and prison staff report that not all inmates with a mental illness receive treatment (Beck & Maruschak, 2001; James & Glaze, 2006). Mental health policies in correctional facilities are only partly driven by treatment needs, as the high rates of mental illness and the limited availability of resources preclude simply providing services to all those who complain of depressive or other symptoms. It is estimated that 13% of inmates receive treatment at any one time (Beck & Maruschak, 2001). When this estimate is applied to all prisoners in the United States, the number of inmates in treatment is equal to twice as many people in all psychiatric hospitals in the United States (Fazel & Danesh, 2002). This gives some perspective to the real burden placed on corrections. Given the stretched resources, quality of treatment has come into question (Teplin, 1994). From the 1394 correctional facilities in the United States that have a mental health policy, only a small portion of inmates are able to filter into the 155 facilities in the United States that specialize in mental health services (Beck & Maruschak, 2001). This leaves two-thirds of inmates receiving mental health services in a facility that does not specialize in providing mental health treatment. Although federal and state corrections have made attempts to address this problem by increasing

counseling programs and the number of correctional psychologists (Stephan & Karberg, 2003), they have not been able to match the increasing number of inmates with mental illness. Although limited resources have been blamed for this gap in care, funding to corrections has averaged an increase of 6.2% annually (Stephan, 2004), outpacing health care, education, and natural resources. Therefore, legislators and tax payers are unlikely to respond to cries for more resources to fund inmates' treatment needs, particularly if there is evidence of a misallocation or straining of resources unnecessarily. For example, clinical psychologists in corrections have reported that administrative duties take most of their time and are increasingly removing them from providing services to inmates (Boothby & Clements, 2000). Raising another concern, Teplin (1994) argued that the primary problem with mental health treatment in corrections is an inefficient application of treatment programs. Assessment One may argue that a reasonable approach to the mental health problem in prisons is to simply identify those who are in greater need of services. However, such an approach is naive, given the complexity of the correctional institution. To begin with, this would involve routinely evaluating inmates' mental health status. However, assessment has taken a backseat to other practices. For example, despite 89% of confinement facilities in state prisons having a mental health policy (Beck & Maruschak, 2001), services primarily consist of therapy/counseling, medication, and an intake screening at the time of incarceration. Psychological assessments are not as common, being conducted in only 65% of the facilities. This is unfortunate given that many of the

6 mental health issues in prisons arise much later than intake. For example, only 7 % of prison suicides occur within the first month of incarceration, with one third of suicides occurring after five years of incarceration (Mumola, 2005). Therefore, assessment cannot be a critical issue only at intake, but rather needs to be an ongoing process. However, clinical psychologists working in prisons report that only 18% of their time goes to assessment (Boothby & Clements, 2000). Considering the lack of sufficient resources and high demands for mental health treatment, it seems to be a serious concern that assessment is not a bigger part of the mental health policies. The lack of assessments may increase the likelihood that resources are misallocated by providing services to those in less need or failing to treat those who are in need. However, conducting assessments does not ensure diagnostic accuracy. For example, corrections staff tend to be poor at identifying genuinely depressed inmates (Steadman, Scott, Osher, Agnese, & Robbins, 2005), and Teplin (1990) found that only 7.1% of depressed jail detainees were detected with standard intake screening procedures. Such insensitive assessment typically occurs during intake screens and demonstrate the inefficiency of screening for mental illness in a prison setting, as these screens tend to be overly simplistic and unreliable (Vitacco & Rogers, 2005). Although there has been a proliferation of research on improving intake-screening measures, psychological assessment and the instruments used for such have been neglected. Given the pivotal nature of deciding how to allocate limited resources, an accurate and complete psychological assessment is critical. Unfortunately, improving the dissemination of services by developing more sensitive methods to detect mentally ill inmates is not a simple solution. As with other

7 areas of psychological assessment, increased sensitivity often results in poorer selectivity. When one has abundant resources at their disposal, treating all potential problems is a safer solution and may not be a major concern. However, the inadequate mental health resources of corrections make indiscriminate expenditure of those resources impossible. Allocation of services to those without a critical need—those with less impairment or no impairment at all—reduce service availability to the most needy. This typically occurs when assessment procedures fail to detect an inmate who is faking or exaggerating symptoms (i.e. malingering) to receive a perceived benefit. For example, most screening methods used in correctional facilities to identify those in need of treatment may not account for this phenomenon. Therefore, an inmate who over-reports symptoms (false positive) and appears worse than an actually depressed inmate (true positive), diverts already limited resources from those truly in need. This is a critical issue that must be taken seriously in the assessment process with incarcerated offenders. Malingering The DSM-IV (American Psychiatric Association, 2000) describes malingering as the deliberate fabrication or gross exaggeration of physical or psychological symptoms, as motivated by external incentives. Although the estimated rate of malingering varies between studies, it is consistently reported to be high and pervasive in forensic situations, particularly corrections. People in prisons are more likely to lie to get what they want and, as with other settings, the prevalence of malingering increases as natural motivations become stronger. For example, a survey of forensic psychologists estimated that 17.4% of evaluation referrals were malingering (Rogers, Salekin, Sewell, Goldstein, & Leonard, 1998), whereas psychologists in non-forensic mental health settings reported only 7.4%

8 of cases had malingered. Using an empirically validated instrument for detecting malingering (i.e. the Structured Interview of Reported Symptomotology, SIRS; Rogers, Bagby, & Dickens, 1992), several studies have consistently found higher rates in corrections. Rogers, Ustad, and Salekin (1998) identified 19.5% of jail detainee referrals as malingering, whereas correctional mental health facilities have estimated rates anywhere from 34 to 46% (Guy & Miller, 2004; Walters, White, & Greene, 1988; Wang et al., 1997). While methodological limitations may account for some of the variation in rates (see Rosenfeld, Sands, & Van Gorp, 2000) and make it difficult to get a stable base rate estimate of malingering, contextual issues appear to be a powerful predictor of malingering. Rogers and Cruise (1998) were concerned that research on malingering was predominantly simulated and likely lacked external validity. They found that when real incentives were present (rather than imagined) and had greater rewards or punishments, there was a powerful effect on a person's attempt to malinger on testing. Therefore, the higher rates of malingering in correctional mental health facilities are likely due to, at least in part, an incentive rich context where inmates are actually seeking to receive or maintain services. Conceptualizing and assessing malingering. Nevertheless, reported rates of malingering probably vary due to the challenge of measuring a historically ill-defined construct. There has been an ongoing debate among forensic experts as to how malingering should be conceptualized and how a clinician can arrive at an accurate diagnosis (Resnick, 1984; Rogers, Sewell, & Goldstein, 1994; Rogers & Vitacco, 2002; Ziskin, 1984). Rogers (1990) has highlighted the importance of being accurately

9 informed on malingering, as it appears that a clinician's explanation of why a person malingers influences his or her conceptualization (i.e. when to look for it and when not to), as well as how they will detect malingering (e.g. following the DSM, assessing antisocial personality disorder first) (Rogers, Salekin, et al., 1998). However, this can lead to rather inaccurate conclusions, as biases may lead to false positives of malingering or false negatives (Rogers & Vitacco, 2002). The DSM-IV model of malingering. Although the DSM-IV is the clinician's reference to assist with diagnosis, many have criticized its definition of malingering and find its criteria difficult to apply (Rogers & Vitacco, 2002; Walters, 2006), while also lacking any scientific foundation. Determining whether behavior is intentional and externally motivated must be contrasted with fabrication that is internally motivated (i.e. factitious disorder) or involuntary with no apparent motivation (i.e. somatization disorder). Making such distinctions is difficult to do with a reasonable degree of diagnostic certainty. Similarly, deciding on the threshold of what constitutes malingering is not as simple as whether or not symptoms are present. Malingerers feign to different degrees— faking symptoms altogether all the way down to mildly exaggerating real symptoms. This is an important distinction to make, as symptom embellishment typically occurs when a patient wants to ensure services and is crying out for help. It would be unethical to deny these truly affected individuals mental health services just because we caught them exaggerating, and prisons are not exempt from these ethics. However, assessment procedures to determine malingering are typically not sensitive enough to determine to what degree a person is malingering and why (Rogers & Vitacco, 2002; Rogers &

10 Bender, 2003). Thus, the naive evaluator may deny a malingerer services, despite a critical need (for some, any excuse will do when demand for services far outweighs resources). There has been particular caution in diagnosing malingering due to the consequences of such a label (Rogers & Vitacco, 2002; Rogers & Bender, 2003), including punishment and a loss of future services. An additional criticism of the DSM-IV definition of malingering is its association with a criminological model (Rogers et al., 1994; Rogers, Salekin, et al., 1998). It highlights antisocial personality disorder as a strong indicator of malingering and, along with malingering being designated as a V-code rather than a disorder, often makes mental health services unlikely. The criminal population, and antisocial personality disorder in particular, typically receive little empathy and is seen as unresponsive to treatment. If a clinician in corrections adopts the criminological model, he or she can develop "an unhealthy level of cynicism or the indiscriminant dismissal of legitimate mental health complaints" (Vitacco & Rogers, 2005, p. 137-138). Additionally, there has been less empirical support for the criminological model of malingering (Rogers et al., 1994; Rogers, Salekin, et al., 1998; Vitacco & Rogers, 2005). For example, when there is no motivation present, those with antisocial personality disorder are no more likely to malinger than others (Rogers & Bender, 2003). Prisons certainly have a higher rate of malingering, but this appears to be strongly related to the incentives in this setting, coupled with the high rates of antisocial personality disorder. Thus, the criminological model is not recommended as a detection method (Rogers & Vitacco, 2002), as there is a high false positive using this model, with 80% of a criminal forensic population qualifying for a malingering diagnosis (Rogers, 1990).

11 The adaptational model of malingering. In response to the problems with the explanatory model of malingering provided by the DSM-IV, Rogers (1990) outlined a model of malingering to aid clinicians in recognition and diagnosis. This adaptational model, with cost-benefit analysis and adversarial context components, has received the most empirical support for understanding motivation (Rogers et al., 1994; Rogers, Salekin, et al., 1998). In this model, individuals malinger after appraising the different means available to get what they want and determine that manipulation is the most prudent option available in that situation. When individuals have high personal investment in the consequences of an evaluation and feel they have little options to achieve their desire, malingering is likely. Prison is particularly conducive to malingering, as is evidenced by the higher prevalence. In this setting, there is a high degree of punishment and little reward, with few adaptive options available. Inmates may do whatever it takes to avoid negative consequences and/or gain benefits. Some inmates who are not depressed may fake their symptomatology in order to get such incentives as the more aesthetically inviting accommodations of mental health units, increased privileges, or access to medication as a means to medicate an addiction. There are also mentally ill inmates who are aware of the limited space available in the mental health unit and may feel they have no other alternative but to exaggerate real symptoms or fake additional symptoms to ensure services (Vitacco & Rogers, 2005; Walters, 2006). For example, the loudest, most abrasive inmate is more likely to be heard, whereas a depressed inmate who is less conspicuous can go untreated because he is not noticed (Teplin, 1990). Malingering and mental illness are not mutually exclusive, and determining whether or not there is a

12 mental illness, despite malingering, is an important part of the assessment (Rogers & Bender, 2003; Rogers & Vitacco, 2002). However, it is important to note that, despite the strong influence of situational factors on malingering, not all individuals in the same situation will seek a potential incentive at any cost. It is rather difficult to ascertain whether or not an individual is motivated by an external incentive, as "the simple possibility of an incentive.. .cannot be taken as actual evidence that the incentive actually played any role in the behavior" (Vitacco & Rogers 2005, p. 135). Therefore, assessment remains essential, as the clinician balances knowledge of high rates of malingering in incentive rich contexts with understanding that individual factors play a role as well. Vitacco and Rogers (2005) propose that adopting the adaptational explanatory model can help the prison clinician reduce cynicism and be more objective in this assessment. When in a forensic setting, Rogers and Bender (2003) recommend that a clinician have a low threshold for suspecting malingering, but high requirements for a final diagnosis of malingering. Assessment. Despite diagnostic challenges, malingering is pervasive enough in prisons that it requires serious clinical attention. Clinicians in the community may be less concerned with malingering, as they tend to see clients who have less motivation to distort their presentation. Therefore, community clinicians are more likely to err on the side of providing treatment rather than risking a false malingering diagnosis. The prison clinician cannot adopt such a practice, as there are greater costs to account for in the prison setting (Resnik, 1984; Ziskin, 1984). For example, decisions may affect people other than the patient—taxpayers and other inmates who lose services due to the drain on resources. Assessment is further complicated by the clinician's responsibility to his or

13 her employer (i.e. the correctional facility) and society at large. When there are attitudes that prisons are for punishment and inmates are dishonest, it can be difficult for the clinician to justify diagnosing a mental illness. Due to the serious consequences of the evaluation in prisons, as well as the many concerns to which they must answer, a prison clinician must have more precision than perhaps is expected elsewhere so as to ensure the integrity of the evaluation and the subsequent decisions made (Rogers & Vitacco, 2002). There are several strategies for detecting deception that have been rationally derived and empirically supported (Rogers & Bender, 2003; Rogers & Vitacco, 2002; Vitacco & Rogers, 2005). These strategies are the basis for most scale and test construction when measuring distortion and include: inconsistencies between reported symptoms and observed symptoms; improbable symptom endorsement; indiscriminate symptom endorsement (e.g. more is better); endorsement of more blatant symptoms relative to subtle symptoms; higher endorsement of rare symptoms relative to a clinical population; endorsement of unlikely symptom combinations (common alone, but rarely together); and rating more symptoms as severe, rather than the variation in severity seen even in clinical populations. However, it is important to note that these methods of detecting deception are not directly measuring malingering. Any scale or instrument used to detect distortion actually describes a response style (e.g., atypically or inconsistently responding) and says nothing about motivation or intention (Rogers & Cruise, 1998; Walters, 2006). Thus, tests simply determine if the presentation was fabricated or grossly exaggerated (initial diagnostic requirement), but do not identify motivation (second diagnostic requirement) (Vitacco & Rogers, 2005). Nor do these tests address the threshold of malingering—

14 what constitutes flat out lying versus exaggeration of real symptoms. Given the difficulty in determining the type and degree of motivation, Rogers and Vitacco (2002) recommend using a nondiagnostic term of "feigning" when discussing results of testing. This describes a response style and is more useful clinically, with no assumption of motivation. Thus, most tests merely indicate that malingering should be further investigated. This typically means reviewing background information and observations to find further inconsistencies to corroborate results of the test. Assessment: Methods and Procedures A full psychological assessment can determine the presence and severity of a mental illness, associated problems, and comorbid conditions. In the prison setting, making diagnostic determinations is quite difficult when most inmates are demonstrating at least some behavioral problems. For example, it can be difficult to differentiate a disorder from bad behavior (Teplin 1990), with institutional needs often being met first by treating disruptive inmates who cause more trouble (e.g., harmful behaviors) rather than those with less obvious symptoms who are nonetheless in serious need of treatment. Further, non-mental health prison staff tend to be unreliable at finding the more subtle— less behavioral—disorders, such as depression (Steadman et al., 2005). Differential diagnosis is particularly important when a clinician is faced with determining whether or not a patient is malingering or actually mentally ill. Clinician biases in the prison setting—either assuming that malingering will be found or naive enough to believe anything an inmate says—can impede sound clinical practice when the clinician allows his or her assumptions to overshadow any data, resulting in unjustifiable conclusions (Rogers & Vitacco, 2002; Vitacco & Rogers, 2005). Thus, even more so

15 than in non-prison settings, an assessment must be comprehensive for accuracy, with converging information from multiple sources due to limitations of each source by itself (usually including at least background, records, collateral contact, observations, interview, and testing). Testing While the importance of other methods used in assessment cannot be overstated, the focus of the present study is to evaluate one method used in the assessment process— psychological tests. Test data are commonly regarded as the most amenable to a normative foundation and minimization of clinician biases. However, the prison setting presents some unique challenges to using this kind of data. It is important to understand limitations of an instrument in a particular setting, as using the data inappropriately can lead to erroneous results and conclusions that have serious consequences (Rogers & Vitacco, 2002; Walters, 2006). Face validity. Content saturation, usually from obvious content, has received much support in terms of diagnostic utility of objective personality instruments. Unfortunately, face valid items are more obvious and easy to distort for one's purpose. Nevertheless, subtle content items do not perform better at predicting diagnostic criteria, as had been the intention by weeding out distorters (Burgess, Campbell, & Zylberberg, 1984; Holden & Jackson, 1981). Subtle content items on depression scales in particular have been poor predictors of diagnosis, often even correlating in the opposite direction expected when compared to a criterion (Burgess et al., 1984). Therefore, the solution to distinguishing a depressive diagnosis from malingering will not be to have a measure with non-face valid items. Malingerers do tend to endorse obvious symptoms to a greater

Full document contains 102 pages
Abstract: The purpose of this study was to evaluate the utility of the Beck Depression Inventory - II in a prison mental health facility, and to understand the frequency and impact of a feigned response style on the measure. Archival data from testing that was part of standard assessment procedure in a prison mental health unit was used. The PAI and MMPI-2 validity scales were used to classify inmates as honest responders or feigners, and classification rates across indices were compared. Psychometric characteristics, including nonparametric item analyses, of the BDI-II for both response style groups are presented. Results suggest that the BDI-II is impacted by a feigned response style, and may mask the measures ability to accurately determine depression severity in a context with a high probability of malingering. Results from the honest responding inmates indicate some response option weights are inappropriate for prison inmates seeking mental health services. Some BDI-II items do not discriminate depression severity at all among honest responding inmates, and thus do not appear to measure depression in prison. Given the impact of a feigned response style on the BDI-II, as well as the different manner inmates respond to the item options, the BDI-II is unlikely to provide clinical utility in a prison mental health facility.