A systematic review of psychotropic drug prescribing for prisoners

Sociodemographic and clinical factors associated with prescription of first- versus second-generation long-acting antipsychotics in incarcerated adult males

Information on patterns of prescription of long-acting injection (LAI) antipsychotics among people who are incarcerated is lacking. Therefore, we aimed to evaluate prescribing rates for first-generation antipsychotic (FGA)-LAI versus second-generation antipsychotic (SGA)-LAI and to identify the factors associated with the prescription of one of the two classes of LAI. A cross-sectional study was conducted among incarcerated adult males hosted in Monza detention center between January 2013 and April 2023. Socio-demographic and clinical data were retrospectively collected. Descriptive and univariate statistics as well as logistic regression analyses were performed. Data were available for 135 consecutive incarcerated adult males with different mental disorders who received a LAI as part of their treatment. 75.6% of our sample was treated with FGA-LAIs, with haloperidol as the most commonly prescribed drug, followed by zuclopentixol and aripiprazole. Diagnosis of bipolar disorder and concomitant administration of antidepressants were statistically significant predictors of SGA-LAI prescription. Some patients' characteristics may influence prescription patterns in prison. Further longitudinal studies with larger samples should confirm these findings.

Analysis of antipsychotic drugs prescribing in incarcerated persons in a Serbian correctional facility

PURPOSE

Prison settings have limited resources, and it is of particular interest to analyze which antipsychotics are commonly prescribed in these conditions and to determine the prevalence of the adverse effects.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional, epidemiological survey was used to measure the prevalence of antipsychotic prescribing among adult prisoners in Sremska Mitrovica Prison in 2020.

FINDINGS

The prevalence of antipsychotic use was 7.58%. The most commonly prescribed antipsychotic was clozapine (45.36%), but also olanzapine, haloperidol and risperidone were prescribed. The incidence of extrapyramidal adverse effects was nonexistent and the metabolic parameters did not differ between participants using metabolic syndrome-inducing antipsychotics and those who were prescribed metabolically inert medications. The prescribed doses were lower compared with the recommended.

RESEARCH LIMITATIONS/IMPLICATIONS

This research includes certain points that should be cautiously considered. First, the data were cross-sectional and the findings did not provide causal interpretations. Second, the data are from a single penitentiary institution, albeit the largest in the country; however, that may affect the generalizability of the findings. Third, because the included subjects were not hospitalized, some laboratory analyses were not available, according to the local regulations, and thus the prevalence of metabolic syndrome could not be precisely determined.

PRACTICAL IMPLICATIONS

The prevalence of the antipsychotic use in prison environment is significantly higher than in general population. The most frequently prescribed antipsychotics are clozapine and olanzapine. The prevalence of adverse effects is rare, however, that is possibly due to low doses of the prescribed antipsychotics. The list of therapeutic options available to the incarcerated persons in this facility is also limited. The list of available antipsychotics does not include some atypical antipsychotics with more favorable safety and tolerability profile, such as aripiprazole or cariprazine. Long-acting antipsychotic injectables were also not available to these patients. Laboratory analyses are not regularly conducted and do not include some essential parameters such as lipid status or differential blood count. Low-dose antipsychotics for behavioral symptoms appears to be well tolerated under prison conditions where adherence is assured. It is effective during the prison stay but long-term effects, especially after release from prison, had not been studied.

SOCIAL IMPLICATIONS

This paper advocates for better quality of health care in this correctional facility: more therapeutic options and better laboratory monitoring. The authors justify the use of clozapine in this settings due its benefits in reducing violence and aggression; however, further research would be necessary to clarify does the use of clozapine in incarcerated persons cause behavioral improvements that could result in shorter incarcerations, less recidivism and better quality of life.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first insight of the antipsychotic prescribing practice in Serbia. There is very limited data on prisoners' health care, especially mental health care, in Balkan countries. The antipsychotic prescribing pattern in this sample is characterized with higher than expected clozapine use, but without expected adverse effects.

Polypharmacy and drug-drug interactions among older and younger male prisoners in Switzerland

PURPOSE

The purpose of this paper is to determine the prevalence of polypharmacy and drug-drug interactions (DDIs) in older and younger prisoners, and compared if age group is associated with risks of polypharmacy and DDIs.

DESIGN/METHODOLOGY/APPROACH

For 380 prisoners from Switzerland (190 were 49 years and younger; 190 were 50 years and older), data concerning their medication use were gathered. MediQ identified if interactions of two or more substances could lead to potentially adverse DDI. Data were analysed using descriptive statistics and generalised linear mixed models.

FINDINGS

On average, older prisoners took 3.8 medications, while younger prisoners took 2.1 medications. Number of medications taken on one reference day was higher by a factor of 2.4 for older prisoners when compared to younger prisoners (p = 0.002). The odds of polypharmacy was significantly higher for older than for younger prisoners (>=5 medications: odds ratio = 5.52, p = 0.035). Age group analysis indicated that for potentially adverse DDI there was no significant difference (odds ratio = 0.94; p = 0.879). However, when controlling for the number of medication, the risk of adverse DDI was higher in younger than older prisoners, but the result was not significant.

ORIGINALITY/VALUE

Older prisoners are at a higher risk of polypharmacy but their risk for potentially adverse DDI is not significantly different from that of younger prisoners. Special clinical attention must be given to older prisoners who are at risk for polypharmacy. Careful medication management is also important for younger prisoners who are at risk of very complex drug therapies.

Approved and Off-Label Use of Prescribed Psychotropic Medications among Federal Canadian Inmates

OBJECTIVE

To examine psychotropic medication prescription practices in federal Canadian penitentiaries.

METHOD

468 files were drawn from a purposive sample of thirteen Canadian federal institutions representing the five regions, different security levels, and male and female designated facilities. Information on the names of all psychotropic medications prescribed, indications for use, dosage, frequency, and route of administration was retrieved. Designation of approved or off-label use of medications was determined by consulting: (1) the Health Canada (2016) Drug Product Database, (2) the Canadian Compendium of Pharmaceuticals and Specialties 2016, and (3) the American Hospital Formulary Service Drug Information 2016. Prescription rates were examined by gender, Indigenous ancestry, drug class, institutional infractions, and current offence.

RESULTS

36.2% of prescriptions for psychotropic medication were coded as 'off-label'. Anxiolytic/hypnotics drugs were the psychotropic drugs most commonly used for off-label purposes. There were no differences in the prevalence of approved versus off-label prescriptions based on Indigenous ancestry or gender, and no pattern of elevated off-label prescription practices for offenders involved in institutional misconducts or those sentenced for the most serious crimes.

CONCLUSIONS

The rates of prescribing 'off-label' psychotropic medication are not elevated relative to other correctional settings or to rates cited in Canadian surveys conducted in the community.

What works in inclusion health: overview of effective interventions for marginalised and excluded populations

Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.

Interventions for drug-using offenders with co-occurring mental health problems: a systematic review and economic appraisal

BACKGROUND

Drug-using offenders with co-occurring mental health problems are common in the criminal justice system. A combination of drug use and mental health problems makes people more likely to be arrested for criminal involvement after release compared to offenders without a mental health problem. Previous research has evaluated interventions aimed broadly at those with a drug problem but rarely with drug use and mental health problems. This systematic review considers the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

METHODS

We searched 14 electronic bibliographic databases up to May 2014 and five Internet resources. The review included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and/or criminal activity. Data were reported on drug and crime outcomes, the identification of mental health problems, diagnoses and resource information using the Drummond checklist. The systematic review used standard methodological procedures as prescribed by the Cochrane collaboration.

RESULTS

Eight trials with 2058 participants met the inclusion criteria. These evaluated: case management (RR, 1.05, 95 % CI 0.90 to 1.22, 235 participants), motivational interviewing and cognitive skills, (MD-7.42, 95 % CI-0.20.12 to 5.28, 162 participants) and interpersonal psychotherapy (RR 0.67, 95 % CI 0.3 to 1.5, 38 participants). None of these trials reported significant reductions in self-report drug misuse or crime. Four trials evaluating differing therapeutic community models showed reductions in re-incarceration (RR 0.28, 95 % CI 0.13 to 0.63, 139 participants) but not re-arrest (RR 1.65, 95 % CI 0.83 to 3.28, 370 participants) or self-report drug use (RR 0.73, 95 % CI 0.53 to 1.01, 370 participants). Mental health problems were identified across the eight trials and 17 different diagnoses were described. Two trials reported some resource information suggesting a cost-beneficial saving when comparing therapeutic communities to a prison alternative.

CONCLUSIONS

Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. Specifically, tailored interventions are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Prevalence and appropriateness of psychotropic medication prescribing in a nationally representative cross-sectional survey of male and female prisoners in England

BACKGROUND

Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons.

METHODS

We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9 % of male and 20.5 % of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95 % CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink.

RESULTS

Overall, 47.9 % (CI 44.4-51.4) of women and 16.9 % (CI 16.0-17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36-6.61) and four times higher among men (PR 4.02 CI 3.75-4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7 %, CI 32.5-37.0) of cases, most commonly low mood and personality disorder.

CONCLUSIONS

Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress.

A cross-sectional prevalence survey of psychotropic medication prescribing patterns in prisons in England

Background

The prevalence of mental illness is significantly higher among prisoners than among people in the wider community. Psychotropic prescribing in prisons is a complex and controversial area, where prescribers balance individual health needs against security and safety risks. However, there are no current data on prescribing patterns in prisons or how these compare with those in the wider community.

Aims

The study aimed to determine the prevalence, appropriateness and acceptability of psychotropic prescribing in prisons. The objectives were to determine rates of prescribing for psychotropic medications, compared with those in the wider community; the appropriateness of psychotropic prescribing in prisons; and the perceived satisfaction and acceptability of prescribing decisions to patients and general practitioners (GPs).

Method

Eleven prisons, housing 6052 men and 785 women, participated in a cross-sectional survey of psychotropic prescribing. On census days, data were extracted from clinical records for all patients in receipt of hypnotics, anxiolytics, antipsychotics, antimanics, antidepressants and central nervous system stimulants. The Clinical Practice Research Datalink supplied an equivalent data set for a random sample of 30,602 patients prescribed psychotropic medicines in the community. To determine the acceptability of prescribing decisions, patients attending GP consultations at three prisons were surveyed (n = 156). Pre- and post-consultation questionnaires were administered, covering expectations and satisfaction with outcomes, including prescribing decisions. Doctors (n = 6) completed post-consultation questionnaires to explore their perspectives on consultations.

Results

Overall, 17% of men and 48% of women in prison were prescribed at least one psychotropic medicine. After adjusting for age differences, psychotropic prescribing rates were four times higher among men [prevalence ratio (PR) 4.02, 95% confidence interval (CI) 3.75 to 4.30] and six times higher among women (PR 5.95, 95% CI 5.36 to 6.61) than among community patients. There were significant preferences for certain antidepressant and antipsychotic drugs in prison, compared with in the community. In 65.3% of cases, indications for psychotropic drugs were recorded and upheld in theBritish National Formulary. Antipsychotic prescriptions were less likely than other psychotropics to be supported by a valid indication in the patient notes (PR 0.75, 95% CI 0.67 to 0.83). In the acceptability study, patients who identified mental health as their primary problem were more likely than individuals who identified other types of health problems to want to start, stop and/or change their medication (PR 1.46, 95% CI 1.23 to 1.74), and to report dissatisfaction following the consultation (PR 1.76, 95% CI 1.01 to 3.08). Doctors were more likely to issue prescriptions when they thought that the patient wanted a prescription (PR 4.2, 95% CI 2.41 to 7.28), they perceived pressure to prescribe (PR 1.66, 95% CI 1.26 to 2.19), and/or the problem related to mental health (PR 1.67, 95% CI 1.27 to 2.20).

Conclusions

Psychotropic medicines were prescribed more frequently in prisons than in the community. Without current and robust data on comparative rates of mental illness, it is not possible to fully assess the appropriateness of psychotropic prescribing. Nonetheless, psychotropic medicines were prescribed for a wider range of clinical indications than currently recommended, with discernible differences in drug choice. Complex health and security concerns exist within prisons. Further research is necessary to determine the effect of psychotropic prescribing on physical health, and to determine the optimum balance between medicines and alternative treatments in prisons.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Staff and patient perspectives on the purpose of psychotropic prescribing in prisons: care or control?

OBJECTIVE

The objective was to explore perspectives on reasons for psychotropic medication use in prisons.

METHOD

We recruited a purposive sample of healthcare staff and patients prescribed psychotropic medicines from four East of England prisons. Participants took part in qualitative, semistructured interviews, which were recorded, transcribed and analyzed thematically.

RESULTS

While patients and healthcare staff viewed psychotropic medicines primarily as a treatment for reducing symptoms of mental illness, they were also used as a coping strategy and to reduce insomnia. Appropriate psychotropic prescribing was also thought to contribute towards the rehabilitation agenda and helped to maintain order in prisons. Staff voiced concerns regarding possible overreliance on psychotropic medicines. However, patients perceived insufficient access to alternative, nonpharmacological forms of treatment and support in prison.

CONCLUSION

Psychotropic medicines are used for multiple purposes in prisons and are generally considered a useful resource. Nonetheless, further work may be needed to find the right balance between psychotropic medicines and alternative, nonpharmacological therapies.

All-cause and external mortality in released prisoners: systematic review and meta-analysis

OBJECTIVES

We systematically reviewed studies of mortality following release from prison and examined possible demographic and methodological factors associated with variation in mortality rates.

METHODS

We searched 5 computer-based literature indexes to conduct a systematic review of studies that reported all-cause, drug-related, suicide, and homicide deaths of released prisoners. We extracted and meta-analyzed crude death rates and standardized mortality ratios by age, gender, and race/ethnicity, where reported.

RESULTS

Eighteen cohorts met review criteria reporting 26,163 deaths with substantial heterogeneity in rates. The all-cause crude death rates ranged from 720 to 2054 per 100,000 person-years. Male all-cause standardized mortality ratios ranged from 1.0 to 9.4 and female standardized mortality ratios from 2.6 to 41.3. There were higher standardized mortality ratios in White, female, and younger prisoners.

CONCLUSIONS

Released prisoners are at increased risk for death following release from prison, particularly in the early period. Aftercare planning for released prisoners could potentially have a large public health impact, and further work is needed to determine whether certain groups should be targeted as part of strategies to reduce mortality.