The pivotal role of primary care in meeting the health needs of people recently released from prison.

OBJECTIVE: Australia's prison population is growing at a rate well in excess of population growth. Indigenous Australians are over-represented by a factor of 13. Prisoners are a profoundly marginalised group characterised by complex health and social needs. Despite improvements in health during incarceration, poor health outcomes after release are common, and the net effect of incarceration is usually health depleting. Given the need for effective care coordination, primary care plays a pivotal role in meeting the health needs of this population. In this paper we review what is known about patterns of primary care utilisation in ex-prisoners, identify evidence-based strategies for increasing access to primary care in ex-prisoners, and consider how such contact may shape subsequent health service outcomes. CONCLUSIONS: Primary care is a necessary but not sufficient condition for effective post-release support. Positive outcomes may depend more on the quality than the quantity of care received. Given massive over-representation of Indigenous people in Australia's prisons, and compelling evidence of preventable morbidity and mortality after release from prison, effective models of care for this population are an important component of closing the gap in Indigenous life expectancy.

[Specific aspects and management of psychiatric conditions in correctional settings]. / Aspects particuliers de la pathologie psychiatrique en prison et de sa prise en charge.

Correctional psychiatry is a patient-centered medicine, similar to that practiced anywhere else, independent, governed by the same objectives (deliver the highest standard of care) and the same obligations (respect patients' dignity, their informed consent and the confidentiality they are entitled to). However, it has been a victim of its own success. As correctional psychiatry was expanding, so was the psychiatric morbidity among inmates. Consequently, the initial clinical hypothesis, which was based on the integrative function of correctional psychiatry, created in the early eighties, comes up against the segregating impact of an intramural specialty practice.

[Correctional health care]. / Moyens et limites de la prise en charge médicale: l'offre de soins en prison.

Court decisions taking away someone's freedom by requiring them to serve a jail sentence should not deny them access to the same health care available to free citizens in full compliance with patient confidentiality. Health institutions, responsible for administering somatic care, offer a comprehensive response to the medical needs of those under justice control, both in jails and conventional care units. For a physician, working in the correctional setting implies accepting its constraints, and violence, and protecting and enforcing fundamental rights, as well as rights to dignity, confidential care and freedom to accept or refuse a treatment.

Balancing punishment and compassion for seriously ill prisoners.

Compassionate release is a program that allows some eligible, seriously ill prisoners to die outside of prison before sentence completion. It became a matter of federal statute in 1984 and has been adopted by most U.S. prison jurisdictions. Incarceration is justified on 4 principles: retribution, rehabilitation, deterrence, and incapacitation. Compassionate release derives from the theory that changes in health status may affect these principles and thus alter justification for incarceration and sentence completion. The medical profession is intricately involved in this process because eligibility for consideration for compassionate release is generally based on medical evidence. Many policy experts are calling for broader use of compassionate release because of many factors, such as an aging prison population, overcrowding, the increasing deaths in custody, and the soaring medical costs of the criminal justice system. Even so, the medical eligibility criteria of many compassionate-release guidelines--which often assume a definitive prognosis--are clinically flawed, and procedural barriers may further limit their rational application. We propose changes to address these flaws.

Naltrexone implants compared to methadone: outcomes six months after prison release.

BACKGROUND: After prison release, offenders with heroin use problems are at high risk of relapse and overdose death. There is a particular need for treatments that can be initiated in prison and continued after release into the community. Methadone maintenance treatment has been shown to reduce heroin use, criminality and mortality. Naltrexone implant treatment has not previously been evaluated in prison settings. METHODS: This study compares the effects of naltrexone implants and methadone treatment on heroin and other illicit drug use, and criminality among heroin-dependent inmates after release from prison. RESULTS: Forty-six volunteers were randomly allocated to naltrexone implants or methadone before release. Intention-to-treat analyses showed reductions in both groups in frequency of use of heroin and benzodiazepines, as well as criminality, 6 months after prison release. CONCLUSIONS: Naltrexone implants may be a valuable treatment option in prison settings.

Persistent dispositionalism in interactionist clothing: fundamental attribution error in explaining prison abuse.

The Stanford Prison Experiment demonstrated some important lessons about the power of social situations, settings, and structures to shape and transform behavior. At the time the study was done, the authors scrupulously addressed the issue of whether and how the dispositions or personality traits of the participants might have affected the results. Here the authors renew and reaffirm their original interpretation of the results and apply this perspective to some recent socially and politically significant events.

From Punishment to Treatment: The "Clinical Alternative to Punitive Segregation" (CAPS) Program in New York City Jails.

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

COPD characteristics and socioeconomic burden in Hellenic correctional institutions.

BACKGROUND: The high prevalence of smoking (80%) in Greek correctional institutions is anticipated to result in high prevalence of COPD in such settings. AIM: The aim of the Greek obstructive luNg disease epidemiOlogy and health economics Study In corrective institutionS (GNOSIS) is to determine the prevalence of smoking and COPD among inmates and to assess the health-related quality of life. METHODS: GNOSIS, a cross-sectional epidemiological study, was conducted between March 2011 and December 2011 in seven correctional institutions in Greece. RESULTS: A total of 552 participants, 91.3% male, median age of 43.0 years (interquartile range: 35-53), were enrolled. COPD prevalence was 6.0% and was found to increase with age (18.6% among those ≥60 years), length of prison stay, and length of sentence. Of the participants diagnosed with COPD, 36.4% were diagnosed with Global initiative for chronic Obstructive Lung Disease (GOLD) stage I and 51.5% were diagnosed with stage II. Dyspnea severity was assessed as grades 0-1 on the medical research council dyspnea scale for 88.3%, while 31% reported ≥2 COPD exacerbations in the past year. Seventy-nine percent of the total number of the participants were smokers, with a median smoking of 20.0 cigarettes per day, while 42.9% were assessed as having a strong addiction to nicotine. The median EuroQol visual analog scale score was 70.0 (interquartile range: 60.0-90.0). Problems in the dimension of anxiety/depression were reported by 82.8%. CONCLUSION: The results of the study support the notion that the prevalence of COPD among inmates of Greek correctional institutions may increase in the following years. The findings underscore the importance of taking actions to limit COPD prevalence and its risk factors in the Greek correctional system.

Gender differences in life-course theory of recidivism: a survival analysis.

This study of 300 women and 300 men graduates of a boot camp finds that there are noteworthy gender differences in predictors of tenure in the community without criminal recidivism in a 5-year follow-up. The Cox proportional hazards models show that urban residence, childhood and recent abuses, living with a criminal partner, selling drugs, stress, depression, fearfulness, and suicidal thoughts are stronger positive predictors of recidivism for women than for men. Men are more likely to return to prison because of criminal peer associations, carrying weapons, alcohol abuse, and aggressive feelings. Job satisfaction and education lengthen time in the community more for men than women, whereas the number of children and relationships are more important to tenure in the community for women. The implications for the findings for theory are discussed.

Learning from peer support schemes--can prison listeners support offenders who self-injure in custody?

PURPOSE: The purpose of this paper is to critically evaluate the current evidence for peer support in prisons, in particular its contribution to working with prisoners who self-injure and the extent to which the success of peer support schemes such as the prison listeners, hinges upon staff's willingness to engage with the initiative. DESIGN/METHODOLOGY/APPROACH: The review was constructed by using primary and secondary terms to search the literature. The studies focused on peer support in custody with reference to mental health and self-injury. Searches identified papers on the prison listener scheme and staff perspectives on prison peer support, as these formed a central focus of the review. Studies were excluded from the review if the participants' behaviours was explicitly linked to suicidal intent, as the review focused on self-injury as a coping strategy. FINDINGS: A total of 24 studies were selected according to specific inclusion criteria (six were grey literature, 18 academic literature). Of the 24 studies ten studies focused on peer support and self-injury. Of the 24 studies the listener scheme was the focus of 16 studies, of these 16 studies self-injury and the listener scheme was a focus of eight studies. ORIGINALITY/VALUE: Evidence from the review suggests that prison peer support could be considered on a continuum depending on the different degrees of peer involvement.

Challenges to implementing opioid substitution therapy in Ukrainian prisons: Personnel attitudes toward addiction, treatment, and people with HIV/AIDS.

BACKGROUND: Ukraine is experiencing one of the most volatile HIV epidemics globally, fueled primarily by people who inject drugs (PWIDs), and a parallel incarceration epidemic. Opioid substitution therapy (OST) is internationally recognized as one of the most effective forms of treatment for opioid dependence and is among the most effective HIV prevention strategies available, yet efforts to adopt it in Ukraine's Criminal Justice System (CJS) have been thwarted. METHODS: To understand the reluctance of the Ukrainian CJS to adopt OST despite the overwhelming evidence pointing to its health benefits and improved criminal justice outcomes, we conducted the first survey of Ukrainian prison administrative, medical and custodial staff (N=243) attitudes towards addiction in general, OST, and people living with HIV/AIDS (PLWHA) in representative regions of Ukraine. RESULTS: Results revealed that Ukrainian CJS workers' attitudes toward OST, PLWHA, and drug addiction were universally negative, but differed substantially along geographic and occupational lines. Whereas geographic and cultural proximity to the European Union drove positive attitudes in the west, in the southern region we observed an identifiability effect, as workers who worked directly with prisoners held the most positive attitudes. We also found that knowledge mediated the effect of drug intolerance on OST attitudes. CONCLUSION: In Ukraine, adoption of OST is more influenced by myths, biases and ideological prejudices than by existing scientific evidence. By elucidating existing attitudes among CJS personnel, this study will help to direct subsequent interventions to address the barriers to implementing evidence-based HIV prevention treatments.

An algorithm for the treatment of schizophrenia in the correctional setting: the Forensic Algorithm Project.

The Forensic Algorithm Project (FAP) was born of the need for a holistic approach in the treatment of the inmate with schizophrenia. Schizophrenia was chosen as the first entity to be addressed by the algorithm because of its refractory nature and high rate of recidivism in the correctional setting. Schizophrenia is regarded as a spectrum disorder, with symptom clusters and behaviors ranging from positive to negative symptoms to neurocognitive dysfunction and affective instability. Furthermore, the clinical picture is clouded by Axis II symptomatology (particularly prominent in the inmate population), comorbid Axis I disorders, and organicity. Four subgroups of schizophrenia were created to coincide with common clinical presentations in the forensic inpatient facility and also to parallel 4 tracks of intervention, consisting of pharmacologic management and programming recommendations. The algorithm begins with any antipsychotic medication and proceeds to atypical neuroleptic usage, augmentation with other psychotropic agents, and, finally, the use of clozapine as the common pathway for refractory schizophrenia. Outcome measurement of pharmacologic intervention is assessed every 6 weeks through the use of a 4-item subscale, specific for each forensic subgroup. A "floating threshold" of 40% symptom severity reduction on Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale items over a 6-week period is considered an indication for neuroleptic continuation. The forensic algorithm differs from other clinical practice guidelines in that specific programming in certain prison environments is stipulated. Finally, a social commentary on the importance of state-of-the-art psychiatric treatment for all members of society is woven into the clinical tapestry of this article.

The past and future of U.S. prison policy. Twenty-five years after the Stanford prison experiment.

In this article, the authors reflect on the lessons of their Stanford Prison Experiment, some 25 years after conducting it. They review the quarter century of change in criminal justice and correctional policies that has transpired since the Stanford Prison Experiment and then develop a series of reform-oriented proposals drawn from this and related studies on the power of social situations and institutional settings that can be applied to the current crisis in American corrections.

Implementing a performance evaluation system in a correctional managed care pharmacy.

The development and implementation of a departmental performance evaluation system for a correctional managed care pharmacy are described. Health care services for approximately 150,000 offenders within the Texas Department of Criminal Justice are provided through an arrangement with two university systems, the University of Texas Medical Branch (UTMB) and Texas Tech University Health Sciences Center. UTMB provides all distributive pharmacy services through a central pharmacy located in Huntsville, Texas. The pharmacy department distributes 9,000-15,000 medication orders daily to over 140 facilities. Each department within UTMB Correctional Managed Care is evaluated against predetermined quality indicators. This evaluation system is collectively called the operational performance evaluation system (OPES) and is used, in part, to determine pay-for-performance eligibility. Before fiscal year 2001, pharmacy distributive services were provided under a third university system. Joining the UTMB system required the pharmacy department to not only participate in OPES but to develop quality indicators and measurement systems to evaluate departmental performance. Indicators were chosen to reflect a commitment to quality while assuring appropriate productivity in the provision of pharmaceutical care. Seven pharmaceutical care quality indicators were chosen and weighted by perceived importance. A system for data collection, measurement, and reporting was also developed. Implementation of a departmental performance evaluation system provides a means to measure service quality, identify areas of weakness, track performance over time, and lower costs. By setting concrete goals, this system raises awareness and promotes interdependence among department personnel.