The Prevalence of Cognitive Impairment and Dementia in Incarcerated Older Adults.

OBJECTIVES: In view of the growing number of older incarcerated persons in the United States, cognitive impairment represents one of the most challenging and costly health care issues facing the U.S. correctional system. This study examined the prevalence and correlates of this growing public health issue in the nation's largest prison system. METHODS: In this study of a random sample of 143 older (≥55 years) adults incarcerated in the Texas prison system, we assessed-using the Montreal Cognitive Assessment (MoCA)-the percentage of inmates who met the MoCA thresholds for mild cognitive impairment (MCI; <23) and dementia (<18). Due to sample size limitations, our multivariable analysis assessed the binary outcome, MoCA <23. RESULTS: Overall, 35.0% of our random sample of incarcerated older adults in Texas met the threshold for MCI and 9.1% met the threshold for dementia. After adjusting for covariates, study participants who were Black (odds ratio [OR] = 4.12, 95% confidence interval [CI] = 1.57-10.82), Hispanic (OR = 4.34, 95% CI = 1.46-12.93), and those with a diagnosis of major depressive disorder (8.56, 95% CI = 1.21-60.72) all had higher prevalence of a positive screen for MCI or dementia. Dementia was underdiagnosed in our study sample of incarcerated adults, with 15.4% of MoCA-diagnosed dementia patients having a dementia diagnosis documented in their medical records. DISCUSSION: Future studies of cognitive impairment in prisons and jails can inform health care planning and resource allocation, such as expansion of access to palliative care, advance care planning, and targeted cognitive screening in older age groups.

Addressing the challenge of community reentry among released inmates with serious mental illness.

The purpose of the paper is to discuss the formidable challenges to community reentry and reintegration faced by U.S. prison inmates with serious mental illness and to describe various strategies for improving transitional services for these individuals. We review epidemiologic data supporting the high prevalence of severe mental illness in U.S. prisons as well as the historical factors underlying the criminalization of the mentally ill. The importance and challenges of providing adequate psychiatric care for mentally ill prisoners during their incarceration are discussed. We also review the numerous psychosocial and economic challenges confronting these individuals upon their release from prison, such as unemployment and vulnerability to homelessness, as well as specific barriers they may encounter in attempting to access community-based mental health services. We follow with a discussion of some of the more promising strategies for improving the transition of the mentally ill from prison to the community. In the final sections, we review the evidence for a relationship between serious mental illness and recidivism and briefly discuss emerging alternatives to incarceration of the mentally ill.

Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders.

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.

Contracting for safety with patients: clinical practice and forensic implications.

The contract for safety is a procedure used in the management of suicidal patients and has significant patient care, risk management, and medicolegal implications. We conducted a literature review to assess empirical support for this procedure and reviewed legal cases in which this practice was employed, to examine its effect on outcome. Studies obtained from a PubMed search were reviewed and consisted mainly of opinion-based surveys of clinicians and patients and retrospective reviews. Overall, empirically based evidence to support the use of the contract for safety in any population is very limited, particularly in adolescent populations. A legal review revealed that contracting for safety is never enough to protect against legal liability and may lead to adverse consequences for the clinician and the patient. Contracts should be considered for use only in patients who are deemed capable of giving informed consent and, even in these circumstances, should be used with caution. A contract should never replace a thorough assessment of a patient's suicide risk factors. Further empirical research is needed to determine whether contracting for safety merits consideration as a future component of the suicide risk assessment.

Psychiatric disorders and suicide in the nation's largest state prison system.

This study examined the relationship between the overall rate of psychiatric disorders and suicides in the nation's largest state prison population. Data from 234,031 Texas Department of Criminal Justice inmates who were incarcerated for any duration between September 2006 and September 2007 were analyzed by Poisson regression, to assess the independent associations of major psychiatric disorders and demographic characteristics with suicide. Across the entire study cohort, 41 inmates (18 per 100,000) were reported to have committed suicide during the 12-month follow-up period; 21 of them had a diagnosis of a serious mental illness. An elevated risk of suicide was observed among inmates with major depressive disorder (relative risk [RR] = 5.1, 95% confidence interval [CI] = 1.9-13.8), bipolar disorder (RR = 4.6, CI = 1.3-15.9), and schizophrenia (RR = 7.3, CI = 1.7-15.9). The highest overall risk was present in those inmates with a nonschizophrenic psychotic disorder (RR = 13.8, CI = 5.8-32.9). These findings highlight the importance of maintaining suicide prevention programs in correctional settings, with particular emphasis on screening and monitoring of patients with severe psychiatric disorders.

A Test of Problem Behavior and Self-Medication Theories in Incarcerated Adolescent Males.

The purpose of this study is to examine the problem behavior and self-medication models of alcohol abuse in incarcerated male adolescents. Male adolescents (N = 56) incarcerated in a juvenile correction facility were administered a battery of psychological measures. Approximately 84% of adolescents with clinically significant alcohol-related problems prior to incarceration indicated use of alcohol for purposes of self-medication and 73% indicated that their alcohol use was associated with aggressive and rebellious behavior. Further, adolescents with clinically significant alcohol-related problems prior to incarceration reported higher levels of affective symptoms, mood-related cognitive distortion, and less use of social support during incarceration than adolescents without clinically significant alcohol-related problems. They also reported more symptoms associated with oppositional defiant but not conduct disorder. For the majority of incarcerated male adolescents in this sample, alcohol-related problems appeared to be associated with both self-medication and problem behavior. Incarcerated adolescents with a history of alcohol-related problems may require skills training in addition to substance abuse services to address affective symptoms and coping skill deficits.

An overview of juveniles and school violence.

Despite the relative rarity of school shootings, targeted violence, and school-associated violent deaths, any youth who presents with words, gestures, or actions of a threatening or violent nature in a school setting should be assessed and referred for further evaluation by a mental health professional and, if clinically indicated, a forensic evaluator.The request for a juvenile risk assessment for future dangerousness requires careful delineation of role and agency; confidentiality issues; a comprehensive diagnostic evaluation of the youth; and a detailed assessment of the youth's perceived threat or problematic behavior. Various protective and risk factors and consideration of other individual, family, school/peer, and situational factors should also be explored.There is still much information that is unknown when considering school violence or targeted school violence. There is clearly a need for additional research on the identification of at-risk youths, the contributions and significance of various protective and risk factors, the impact of peer relationships, and perceived rejection, socioeconomic status, subtypes of aggression, and developmental stages. Examples of future research direction might include difference by gender, presence of affective or psychotic disorders, substance abuse, emerging characterologic disturbances, and physiologic markers, such as cortisol or serotonin. Additional research regarding best practices and the development of clinical guidelines or practice parameters is also needed.

Practice parameter for the assessment and treatment of youth in juvenile detention and correctional facilities.

This practice parameter presents recommendations for the mental health assessment and treatment of youths in juvenile detention and correctional facilities. Mental and substance-related disorders are significant public health problems affecting youths in juvenile justice settings. Sufficient time is necessary to conduct a comprehensive diagnostic assessment, interview collateral historians, and review pertinent records to identify primary and comorbid conditions. Potential role conflicts (i.e., forensic evaluator versus clinical care provider) need to be clarified before beginning any evaluation or treatment program, and particular attention must be paid to the issue of patient confidentiality. Issues of special concern in correctional health care, such as self-mutilative behaviors, suicide attempts, malingering, mandated reporting, ethical issues, cultural competency, institutional policies affecting clinical care, and the role of the clinician, are reviewed.

Use of the adolescent SASSI in a juvenile correctional setting.

The Substance Abuse Subtle Screening Inventory-Adolescent (SASSI-A) is used in evaluation and treatment planning for incarcerated juveniles. Validity of the SASSI-A in a juvenile correctional facility was examined using archival data. Findings generally support the validity of SASSI-A substance use scales. However, there is concern regarding the potential for ethnic bias in this setting. Cut-scores suggest that the SASSI-A may best be used for detecting problematic alcohol consumption using the Face Valid Alcohol Scale > or = 3. Future studies should more closely investigate whether the three underlying dimensions of the SASSI-A are useful in treatment planning. Results are presented in light of the relatively new SASSI-A2.

Suicide attempts and self-mutilative behavior in a juvenile correctional facility.

OBJECTIVE: To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration. METHOD: A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation. RESULTS: Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non-self-mutilative adolescents. CONCLUSIONS: Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non-self-mutilative counterparts, suggesting a need for mental health treatment.

Juvenile justice mental health services.

As the second century of partnership begins, child psychiatry and juvenile justice face continuing challenges in meeting the mental health needs of delinquents. The modern juvenile justice system is marked by a significantly higher volume of cases, with increasingly complicated multiproblem youths and families with comorbid medical, psychiatric, substance abuse disorders, multiple family and psychosocial adversities, and shrinking community resources and alternatives to confinement. The family court is faced with shrinking financial resources to support court-ordered placement and treatment programs in efforts to treat and rehabilitate youths. The recognition of high rates of mental disorders for incarcerated youth has prompted several recommendations for improvement and calls for reform [56,57]. In their 2000 annual report, the Coalition for Juvenile Justice advocated increased access to mental health services that provide a continuum of care tailored to the specific problems of incarcerated youth [58]. The specific recommendations of the report for mental health providers include the need for wraparound services, improved planning and coordination between agencies, and further research. The Department of Justice, Office of Juvenile Justice and Delinquency Prevention has set three priorities in dealing with the mental health needs of delinquents: further research on the prevalence of mental illness among juvenile offenders, development of mental health screening assessment protocols, and improved mental health services [59]. Other programs have called for earlier detection and diversion of troubled youth from juvenile justice to mental health systems [31,56]. Most recently, many juvenile and family courts have developed innovative programs to address specific problems such as truancy or substance use and diversionary or alternative sentencing programs to deal with first-time or nonviolent delinquents. All youths who come in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing. Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system [58]. If delinquent youths do not receive the necessary evaluation, treatment, and rehabilitation, they face the real prospect of further incarceration in adult correctional facilities. Improved screening and treatment require better interagency collaboration, established standards of care, and continuing research on the mental health needs of youth in the juvenile justice system. Better mental health care for youth in the juvenile justice system supports the goal of rehabilitation. Mental health professionals should support these efforts as the appropriate response to meet the challenges of the new century.

Psychoactive Medication Misadventuring in Correctional Health Care.

Due to multiple factors, unprecedented numbers of individuals with mental health disorders and many with comorbid substance use disorders are now incarcerated in jails and prisons. This article details a variety of medication use and potential abuse/misuse/misadventuring topics that are unique to the correctional health care setting, with emphasis on how the large number of persons with psychiatric and/or substance use disorders affects these issues and methods that correctional systems commonly use to manage these inmate-patients. Also discussed are the potential for inmate feigning or malingering as a goal-directed behavior, potential for misadventuring/abuse of commonly used medications, urine drug screening/surveillance, and the effect of psychoactive medications on heat tolerance and environmental issues.

Bupropion diversion and misuse in the correctional facility.

The antidepressant bupropion plays an important role in the treatment of mental health disorders. It is well known that incarcerated individuals are at increased risk of experimenting with psychiatric medications and it is imperative for prescribers and clinicians to understand the misuse potential of these medications, including bupropion. The mechanism of reinforcement of misuse of bupropion is related to the effect on dopamine and norepinephrine neurotransmitter systems. When bupropion is crushed and ingested via nasal insufflation, a faster and higher affinity for neurotransmitters occurs, heightening the misuse potential. A literature search and illustrative case studies are presented demonstrating the misuse potential, along with a review of the clinical implications. This article concludes that in the incarcerated population, bupropion is a medication with significant misuse and diversion potential.

Prevalence of psychiatric disorders in the Texas juvenile correctional system.

Most studies assessing the burden of psychiatric disorders in juvenile correctional facilities have been based on small or male-only samples or have focused on a single disorder. Using electronic data routinely collected by the Texas juvenile correctional system and its contracted medical provider organization, we estimated the prevalence of selected psychiatric disorders among youths committed to Texas juvenile correctional facilities between January 1, 2004, and December 31, 2008 (N = 11,603). Ninety-eight percent were diagnosed with at least one of the disorders. Highest estimated prevalence was for conduct disorder (83.2%), followed by any substance use disorder (75.6%), any bipolar disorder (19.4%), attention-deficit/hyperactivity disorder (18.3%), and any depressive disorder (12.6%). The estimated prevalence of psychiatric disorders among these youths was exceptionally high and showed patterns by sex, race/ethnicity, and age that were both consistent and inconsistent with other juvenile justice samples.

Disparities in justice and care: persons with severe mental illnesses in the U.S. immigration detention system.

As the total number of persons held within the U.S. immigration detention system has grown, the number of detained persons with severe mental illnesses has grown correspondingly. Reports issued by the government, legal and human rights advocates, and the media have brought to light a problematic and growing detention system with pervasive legal and mental health care disparities. Described are the structure and funding of the U.S. immigration detention system, the legal state of affairs for immigration detainees with mental illnesses, and what is known about the present system of mental health care within the U.S. immigration detention system. Attention is given to the paucity of legal protections for immigration detainees with severe mental illnesses, such as no right to appointed legal counsel and no requirement for mental competence before undergoing deportation proceedings. A case example and discussion of potential alternatives to detention highlight the need for wide-ranging reform.

Psychiatric disorders and repeat incarcerations: the revolving prison door.

OBJECTIVE: A number of legal, social, and political factors over the past 40 years have led to the current epidemic of psychiatric disorders in the U.S. prison system. Although numerous investigations have reported substantially elevated rates of psychiatric disorders among prison inmates compared with the general population, it is unclear whether mental illness is a risk factor for multiple episodes of incarceration. The authors examined this association in a retrospective cohort study of the nation's largest state prison system. METHOD: The study population included 79,211 inmates who began serving a sentence between September 1, 2006, and August 31, 2007. Data on psychiatric disorders, demographic characteristics, and history of incarceration for the preceding 6-year period were obtained from statewide medical information systems and analyzed. RESULTS: Inmates with major psychiatric disorders (major depressive disorder, bipolar disorders, schizophrenia, and nonschizophrenic psychotic disorders) had substantially increased risks of multiple incarcerations over the 6-year study period. The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had four or more previous incarcerations compared with inmates who had no major psychiatric disorder. CONCLUSIONS: Prison inmates with major psychiatric disorders are more likely than those without to have had previous incarcerations. The authors recommend expanding interventions to reduce recidivism among mentally ill inmates. They discuss the potential benefits of continuity of care reentry programs to help mentally ill inmates connect with community-based mental health programs at the time of their release, as well as a greater role for mental health courts and other diversion strategies.

Pediatric psychotropic polypharmacy.

STUDY OBJECTIVE: This study was a literature review designed to assess the rates of psychotropic "polypharmacy" in the pediatric population. Psychotropic polypharmacy was defined as the practice of prescribing two or more medications (e.g. concomitant psychotropic medications) for one or more diagnosed psychiatric conditions and/or behavioral symptoms. METHODS: A literature review of relevant articles pertaining to polypharmacy was completed using the Pub Med database from 1994 through April 2004 for pediatric populations under 18 years old. RESULTS: Studies were reviewed from various pediatric settings. While the extent of polypharmacy varied from the different populations, all the studies comparing these rates across time showed an increase in this practice. The use of stimulants with another psychotropic medication was the most frequent combination. CONCLUSIONS: There is limited information about the actual rates of psychotropic polypharmacy in the pediatric population. However, the data that are available demonstrate that this practice is on the rise. This is of specific concern due to the increase of adverse events with polypharmacy. The implications of polypharmacy, including efficacy and side effects, are generally unknown and may vary by specific combination. Therefore, these prescribing practices should be conducted with caution, and systematic research is needed.

Juvenile Correctional Workers' Perceptions of Suicide Risk Factors and Mental Health Issues of Incarcerated Juveniles.

Correctional staff knowledge, attitudes, and perceptions of incarcerated juveniles' mental health needs, including suicide prevention, have not been studied empirically. This study measured juvenile correctional officers' knowledge and attitudes regarding suicide risk factors and mental health and substance abuse issues through administration of the Mental Health Knowledge and Attitude Test (MHKAT) before and after a staff training on suicide prevention. Seventy-six participants completed the pre- and post-training MHKAT. They demonstrated significant improvement in knowledge of and attitudes toward mental health treatment of incarcerated youth as reflected by higher post-training MHKAT scores. Findings suggest that correctional staff are receptive to increasing knowledge of critical mental health issues. Studies of the retention and implementation of this new knowledge by direct care staff over time and the optimal type and frequency of new staff training and continuing education are indicated.