Continuity of supply of psychiatric medicines for newly received prisoners

Factors That Promote and Hinder Medication Adherence From the Perspective of Inmates in a Provincial Remand Center: A Mixed Methods Study

Effective medication delivery to inmates within correctional facilities is essential for managing symptoms, preventing relapse, slowing disease progression, and enabling recovery. Despite its importance, medication adherence in correctional facilities is poor. This mixed methods study explores the factors that affect medication adherence from the perspective of 20 inmates at a provincial remand center in Alberta, Canada. Themes describing factors that promote or hinder medication adherence emerged: patient-related factors (addiction, social support, insight into disease, and purpose of medications), health care provider-related factors (health care provider attributes and trust in physicians), and correctional setting factors. The findings of this study inform recommendations to improve medication adherence and disease management in correctional facilities.

Accounting for psychotropic medication changes in prisons: patient and doctor perspectives

Psychotropic medicines are widely used to treat mental illness; however, people entering prison commonly report that prescribed psychotropic medicines are changed or withdrawn, adding to their distress in difficult times. Drawing on three extracts from a larger qualitative dataset in which patients and doctors were interviewed about psychotropic medication use in English prisons, we combined discursive psychological and Foucauldian discourse analysis techniques to examine how individuals accounted for medication changes. Patients used four discursive strategies to organize descriptions of medication changes: they established entitlement to psychotropic medication, questioned the clinical judgment of prison doctors; highlighted communication problems; and attributed negative health outcomes to medication regime changes. In contrast, we examined an effective defense by a general practitioner, which showed how clinical needs were prioritized over previously held prescriptions when making prescribing decisions. Wider implications for continuity and equivalence of care between prisons and the wider community are discussed.

‘You can't have them in here’: experiences of accessing medication among older men on entry to prison

Older prisoners are the fastest growing sub-group in the English and Welsh prison estate. They have complex health needs, in spite of which there is a dearth of literature concerning their access to prescribed medication. Literature relating to younger prisoners highlights common issues around maintaining continuity of medication upon reception into prison custody. The objective of the study was to explore the lived experience of older male prisoners regarding continuity of medication upon entry into prison. This paper presents findings from part of a large-scale research project regarding health and social care services for older male adult prisoners. Semi-structured interviews were conducted with male participants (N = 27) aged 60 years and over who had been newly received into prison. Interviews were conducted within the first ten weeks of custody. Participants were asked about their experience of accessing medication on entry into prison. Data were analysed using the constant comparison method. Eighty-five per cent of participants were in receipt of prescribed medication when committed to prison. Older prisoners’ experiences of receiving medication in prison were reflected in four key themes: delays in confirming medicines; changes to medication; communication difficulties; and enforced helplessness. Whilst these experiences mirrored those of prisoners of all ages reported in previous studies, these issues are especially relevant to older prisoners who are likely to have greater and more complex medication needs than their younger peers. In addition, older prisoners experienced unmet needs related to restricted mobility and functional skills that could have impaired their ability to maintain concordance with medication regimes. This study shows that there is need for increased awareness of prescribing issues specific to older prisoners to allay related feelings of anxiety and distress and to ensure they receive appropriate medication.

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.

A comparison of psychotropic medication prescribing patterns in East of England prisons and the general population

While the prevalence of mental illness is higher in prisons than in the community, less is known about comparative rates of psychotropic medicine prescribing. This is the first study in a decade to determine the prevalence and patterns of psychotropic medication prescribing in prisons. It is also the first study to comprehensively adjust for age when making comparisons with the general population. Four East of England prisons, housing a total of 2222 men and 341 women were recruited to the study. On census days, clinical records were used to identify and collect data on all prisoners with current, valid prescriptions for hypnotic, anxiolytic, antipsychotic, antimanic, antidepressant and/or stimulant medication, as listed in chapters 4.1 to 4.4 of the British National Formulary. Data on 280,168 patients were obtained for comparison purposes from the Clinical Practice Research Datalink. After adjusting for age, rates of psychotropic prescribing in prison were 5.5 and 5.9 times higher than in community-based men and women, respectively. We also found marked differences in the individual psychotropic drugs prescribed in prison and community settings. Further work is necessary to determine whether psychotropic prescribing patterns in prison reflect an appropriate balance between managing mental illness, physical health risks and medication misuse.

Suicide in prisoners with bipolar disorder and other psychiatric disorders: a systematic review

OBJECTIVES

To examine the risk of suicide and suicide attempts in prisoners with bipolar disorder and other psychiatric disorders compared with prisoners without psychiatric disorders.

METHODS

We conducted a systematic review and meta-analysis of observational studies comparing suicide outcomes in prisoners with bipolar disorder and other psychiatric disorders to other prisoners.

RESULTS

Five studies reported the risk of suicidal outcomes in prisoners with bipolar disorder compared with other prisoners, with a random effects pooled odds ratio of 2.4 (95% confidence interval: 1.6-3.7; I(2) = 0%). This appeared to be lower than the risk of suicidal outcomes for all psychiatric disorders and for depression, specifically, and, in meta-regression, significantly lower (p = 0.03) than for schizophrenia-spectrum disorders.

CONCLUSIONS

Although bipolar disorder is associated with suicide and non-fatal suicidal behavior in prisoners, further research is necessary to confirm any associations and mediating mechanisms.

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.