Mental health professionals are increasingly concerned about the number of persons with mental illness in jails.1 This is a growing public health problem. According to Bureau of Justice Statistics, 283,000 mentally ill offenders were in U.S. prisons or jails in mid-1998, and 547,800 were on probation in the community.2 More than 75% had at least one prior conviction, and were more likely than other prisoners to have a prior sentence for a violent offense.
On any one day, more mentally ill persons are in Cook County Department of Corrections (CCDOC) in Chicago than in any state hospital in Illinois. Those with severe mental illness comprise approximately 10% of the average daily census of 10,000 to 11,000 inmates at CCDOC, which is one of the nation's largest correctional institutions. Each day approximately 20 to 30 patients are admitted to its psychiatric units, including a number of highly recidivistic individuals who have been unable to access or have been noncompliant with community-based psychiatric services. Many more probably are in need of psychiatric services.
Teplin detected high rates of mental illness among men34 and women5 on intake processing at CCDOC. A stratified random sample of pretrial detainees was interviewed with the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule. Altogether, 62% of the men and 70% of the women met DSM-IIUDSM-IIl-R criteria for at least one disorder currently or in the prior 6 months. Six percent of the men and 15% of the women had a "severe mental disorder" (schizophrenia, mania, or major depressive episode). Most men with a severe mental disorder also had substance abuse or antisocial personality disorder.6 Substance use disorder was more prevalent among women than men (60% vs 29%), and antisocial personality disorder was much more prevalent among men than women (48% vs 14%). Among women, 22% had posttraumatic stress disorder; comorbidity data for women have not been published.5 Rates for inmates were significantly higher than those estimated by the Epidemiologic Catchment Area study of the general population.
As in managed care, detainees are not detained for long. They generally are held 48 hours to 1 year after arraignment. Department of Justice7 census data indicate that only one-third stay longer than 4 days. Thus, stabilization on medications with a planned transition to the community8 often is not practical. In a relatively short time they are released, and are likely to be at risk for recidivistic behavior due to untreated or undertreated mental illness. Therefore, shortterm management of antipsychotic medication and provision of necessities such as housing, money, nutrition, and health care9 prior to release are of paramount importance.
In 1989, the American Psychiatric Association (APA) Task Force on Psychiatric Services in Jails and Prisons issued recommended guidelines for essential services.10 Eight years later, Steadman and Veysey11 published the results of a survey of mental health services in jails with capacities of 50 or more. Although most jails offered at least one mental health service, few provided a comprehensive range. In areas recommended in the APA report, 83% provided intake screening, 60% provided mental health evaluations, 42% provided psychotropic medications, 43% provided crisis intervention services, and 21% provided discharge planning.11
Cohen and Dvoskin12 delineated three treatment goals in correctional settings: (1) reduce disabling effects of serious mental illness to maximize the ability to participate in programs; (2) decrease human suffering; and (3) keep the facility safe. Metzner et al.13 add that treatment should be "multidisciplinary and eclectic." However, as Teplin's studies indicate, access to treatment is problematic. Only one-third of men with severe mental illness were treated within 1 week of incarceration.14 Whereas 24% of women with symptomatic schizophrenia or major affective disorder, severe cognitive impairment, or moderate to severe substance use disorder with disorientation received needed services while in jail, only 10% of the women with less severe mental illness received these services.15
THE MANDATE FOR TREATMENT
"Mandated correctional mental health care" evolved from class action suits in the 1970s. These paved the way for improving mental health systems for inmates.13 Constitutional protections for the mental health treatment of inmates are based on the 8th and 14th amendments. In Estelle ? Gamble,10 the U.S. Supreme Court extended the 8th amendment's prohibition of cruel and unusual punishment to include health-related claims for persons incarcerated subsequent to criminal conviction. The Court reasoned that persons unable to have basic survival needs met due to captivity would suffer needlessly unless their medical needs were met.
What constitutional protections are there for jail detainees awaiting trial? Guarantees afforded by the 8th amendment apply only to those convicted, not to pretrial detainees. In Bell ? Wolfish,17 the U.S. Supreme Court extended the 14th amendment's Due Process Clause, which provides that persons awaiting trial cannot be punished because the government's right to punish requires first a valid conviction. As in Estelle ? Gamble, because needless suffering or death may be an untoward consequence of denying medical care, the Due Process Clause mandates such needed care to protect pretrial detainees from this potential harmful outcome.
Unfortunately, by not defining what constitutes "serious mental illness," the Court failed to address the major precondition for receiving care,13 nor is there a clear definition of what constitutes "adequate care."18 Constitutional liability applies only if the mental disorder or need is deemed "serious."13 There does seem to be general agreement that major Axis I diagnoses such as acute depression and paranoid schizophrenia would qualify, but that behavioral and emotional problems alone would not.19
Patients do not necessarily view the right to treatment as a benefit of incarceration. Driven by the inadequate treatment at some facilities, the right to receive treatment led to litigation upholding the right to refuse medication,20 and ultimately to the right to refuse all treatments.21 Summarizing Washington ? Harper,22 Metzner et al.13 delineated procedures for administering medication to inmates involuntarily: (1) document the mental disorder; (2) demonstrate that treatment is in the inmate's medical interests; (3) administer medication as directed by a licensed psychiatrist; and (4) meet due process by an administrative hearing or a judicial proceeding.
UNIQUE ASPECTS OF PSYCHOTROPIC DRUG USE IN THE IAIL
Maier and Fulton21 note that "neuroleptics are equally effective with patients with schizophrenia in hospitals and prison psychiatric units." Nevertheless, there are differences in the jail environment that can affect prescribing decisions and add a level of complexity to pharmacologic management. Lost days due to disability among staff and injury to other patients attributable to inmate violence can have considerable economic impact.23
The Food and Drug Administration (FDA) has not approved any medication specifically for violent or aggressive behavior.24 Current treatment of aggression often involves the use of polypharmacy administered on a trial-and-error basis, with varying degrees of response.25 The need for this disparate group of drugs reflects our limited understanding of the neurobiology of violence, which likely involves multiple neurotransmitters, including GABA, serotonin, norepinephrine, dopamine, and glutamate systems.23"26
Following arrest, transfer from police lockup to the receiving and classification area of the jail usually takes 24 to 72 hours. Detainees are screened to ascertain the presence of psychiatric illness, comorbid medical conditions, and substance use or intoxication, and to identify problems relating to patient safety. Detainees assessed as dangerous to self or others, or who may be vulnerable to victimization in the jail's general population due to psychiatric illness, are admitted to a jail-based or affiliated acute care unit for observation and treatment.
Stable patients are transferred to what is known as the "residential treatment unit" (RTU). Because there is more freedom of movement in the RTU, substance abuse and hoarding and selling medication are potential problems. Other medications tend to be substituted for the potentially more abusable benzodiazepines. Sedating antidepressants such as trazodone or doxepin commonly are prescribed for insomnia instead. Clonazepam, which is useful for treating anxiety and mood lability, commonly is discontinued before patients are transferred to the jail's general population. Anxiety often is treated with buspirone.
Administration of medications in the general population is a real challenge in any large jail. Some staff claim that once-a-day dosing, preferably at night, is the most reliable method. Others claim that if a medication is prescribed three times a day, it is possible that the inmate will get it only once or twice due to security emergencies or unexpected detainee movement in the system. Depot medications may be prescribed (or overprescribed) in an effort to cope with pharmacy and nursing shortages, thereby exposing patients to the risk of neuroleptic malignant syndrome or toxicity associated with dehydration due to overheating on units, where environmental temperature control may be problematic.
Another problem unique to this institutional setting is gastrointestinal upset due to difficulty timing doses with the jail's unusual mealtimes. Breakfast may be served at 4 am and dinner at 3 pm, but medications dispensed two times a day (9 am and 9 pm) or three times a day (9 am, 1 pm, and 5 pm). Add to this the concern regarding neuroleptic response times. Maier and Fulton21 suggest that the stressful, paranoia-inducing environment encountered by incarcerated mentally ill offenders may contribute to longer lag times to symptom reduction. Onset of action may be quicker for antiaggression effects due to the sedation, whereas reliable remission of psychosis may require at least 2 to 3 weeks.
The mentally ill detainee may be released unexpectedly. Even with advance notice, community linkage is a challenge due to combined stigma of mental illness, substance abuse, and criminal recidivism. Even well-subsidized assertive community treatment or linkage case management programs will try to "skim off" the patients with severe mental illness who have comorbid personality disorders or serious medical illness to improve their outcomes. Funding for housing, food, medication, and medical care is difficult to obtain when a detainee leaves the jail. Psychiatrists often prescribe for symptom management in the jail, not in the community. For example, refractory patients may be receiving "crushed," liquid, or intramuscular preparations until release and may not be educated about or prepared for the therapeutic benefit or side effects of medication. Without adequate education and substance abuse treatment, noncompliance and recidivism may be guaranteed.
Once a detainee is in the community, treatment should focus on stabilization of illness, enhancement of independent functioning, and maintenance of internal and external controls that prevent violence and recidivism.27 Continuous care should include depot antipsychotic medication to ensure compliance.
There are additional precautions and problems that are unique to correctional settings. For example, lithium, beta-blockers, anticonvulsants, and clozapine have demonstrated efficacy for managing aggression and violence. Medroxyprogesterone acetate may be prescribed for sex offenders to prevent acting out in the jail. These medications require assessments of blood levels, blood counts, and liver function tests and renal function tests to detect potential adverse effects. Their use may be limited by delays in the return of laboratory results.
NEUROPHARMACOLOGY OF AGGRESSIVE BEHAVIOR
There is substantial evidence that many forms of aggression in animals are mediated by serotonin. Serotonin mediates both anxiety and aggression,28-29 and may mediate the pro-aggressive properties of testosterone.30 Glucocorticoid, catecholamine, and benzodiazepine systems may mediate aggression as well.31,32 Impulsive aggression in intoxicated individuals with early-onset alcoholism is associated with low levels of serotonin in the brain.33 Alcohol intoxication frequently is associated with aggression,34 which may be mediated at least in part by serotonin.
SPECIFIC CLASSES OF PSYCHOPHARMACOTHERAPEUTIC AGENTS
Neuroleptics often have been prescribed at inordinately high doses in this population.23'35 The antiaggressive effect probably is due to sedation in agitated patients.24,36 High doses may aggravate aggression by causing akathisia and drug-induced behavioral toxicity.37 Generally, typical neuroleptics should be replaced with atypical agents (clozapine, risperidone, olanzapine, and quetiapine).23,38
Volavka and Citrome38 reviewed the controlled clinical trials using atypical agents for treating aggression. Only 3 of 14 studies were randomized, and none of the 3 was conducted in a longterm-care or correctional facility. In none of the trials were patients selected for aggressive behavior.39"41 Methodologie difficulties include selection bias in recruitment, inadequate and inappropriate control groups, and problems operationalizing and measuring outcome. Confounding factors include inattention to comorbidity and concomitant medication use, which should be accounted for in the data analysis. Large samples with long follow-up are necessary to track these unpredictable and relatively rare events. Ethical concerns regarding informed consent cannot be ignored, because they influence the types of study designs that can be used (eg, no placebo control) and subject recruitment and contribute to selection bias and nonrepresentative samples.23-38 Methodologie heterogeneity and unevenness in study quality together limit the feasibility of conducting valid meta-analyses.24
Atypical neuroleptics are efficacious for treating negative and positive symptoms, and have much less propensity to induce intolerable side effects, including tardive dyskinesia.23 Outcomes in forensic populations suggest that atypicals should be prescribed for almost all psychotic offenders.42-44 Particularly, risperidone and clozapine have been shown to quell aggression, hostility, and impulsive behavior, perhaps mediated by effects on serotonin and dopamine systems.23'25'40'41-43'45'46 Furthermore, at least in the case of clozapine, the antiaggressive effects appear not to be due to sedation; whether the therapeutic effect is mediated by general antipsychotic effects or is a specific antiaggressive effect requires investigation.38 Clozapine is an effective blocker of the serotonin 5-HT2 receptor and this is the likely candidate mechanism for the difference between clozapine and typical neuroleptics. Effects mediated by the dopamine D4-type receptor are probably not relevant.47
Reports have not been uniformly favorable in this regard, particularly concerning risperidone. m a retrospective analysis comparing risperidone and conventional neuroleptics for decreasing threats and assaults committed by patients with long-term schizophrenia on forensic wards of a state mental hospital, Beck et al.48 found no unique advantage for risperidone. Buckley et al.49 compared risperidone and conventional antipsychotics for patients with severe mental illness on seclusion and restraint use in a nonforensic hospital and found no significant difference.
In contrast, Menditto et al.50 showed that clozapine decreased aggressive behavior 10-fold, although this may be due at least in part to a regression-to-the-mean effect. Baseline aggression was much higher for patients treated with clozapine than for the control group. Volavka51 indicates that clozapine also may benefit patients with schizophrenia who have comorbid alcoholism or other substance use disorders. With comorbidity rates approaching 50%,52 particularly for mentally ill offenders within correctional settings,4"6 clozapine could be an important therapeutic adjunct. Controlled trials using appropriately selected samples and standardized outcome measures are needed to assess the comparative efficacy of atypical and typical neuroleptics, and to determine whether clozapine has a specific antiaggressive effect.43'53
Persons with personality disorders make up a large proportion of the violent mentally ill; antagonist and hostile traits are found in eight of the personality disorders.54 One percent to 2% of the general population have borderline personality disorder (BPD) and approximately 70% of patients with BPD abuse alcohol or drugs.55 Individuals with BPD show recurrent anger, aggression, and violent behaviors. Symptoms of BPD include impulsiveness, characterized by aggression and self-mutilation, eating disorders, and sensation-seeking behavior such as substance abuse; affective, including mood liability and depressive, symptoms; and psychosis.56 Treatment of BPD is complex because different subtypes require different classes of drugs.
Several controlled clinical trials have shown that antipsychotics are efficacious for BPD. Goldberg et al.57 conducted a double-blind, placebo-controlled study of 50 patients with BPD or schizotypal personality disorder and found thiothixene to be superior to placebo, with most improvement demonstrated in illusions, ideas of reference, and psychoticism. There were 7 patients with BPD only, 6 with schizotypal personality disorder only, and 11 with both; only the latter two patient groups showed meaningful improvement. In a sample of patients with borderline-schizotypal personalities, Serban and Siegal58 found thiothixene to be more effective than haloperidol. However, their sample was less psychotic than those in earlier studies.
Neuroleptics have been compared with antidepressants for BPD. Soloff et al.59 compared haloperidol, amitriptyline, and placebo in 90 patients and found the neuroleptic to be clearly superior to amitriptyline or placebo, especially for psychotic and hostile depression symptoms. Both haloperidol and amitriptyline improved depression, but haloperidol also benefited psychotic symptoms, general severity, hostility, and impulsive behavior. These data suggest that tricyclic use could be associated with poor outcomes in BPD, particularly for those with schizotypal features. Cornelius et al.60 compared haloperidol, phenelzine, and placebo in a 4month continuation study. The conditions of those patients who were receiving haloperidol deteriorated quicker, with two-thirds dropping out in the first 8 weeks in contrast to only onefourth of those receiving placebo. In addition, patients receiving haloperidol showed more depression, particularly when compared with those receiving phenelzine. In Cowdry and Gardner's61 multiple crossover study, trifluoperazine was compared with tranylcypromine, alprazolam, and placebo in 16 female patients with BPD. Although the conditions of many in the neuroleptic group clinically deteriorated, those who completed the trial displayed modest benefit compared with those who did not tolerate the medication.
There is a growing literature that atypical antipsychotics may be effective for controlling agitated aggressive behavior in mentally retarded adults. Sandman et al.62 studied the effects of risperidone on disruptive, agitated, aggressive, or self-injurious behaviors and on prosocial behavior in 63 adult men with developmental disabilities in comparison with previous behavior while taking typical neuroleptics, usually haloperidol. Although this was not a blinded study, staff collected monthly behavior data without knowledge of medication. Targeted behaviors were measured for 6 months before risperidone and then for each month after. The mean dose of risperidone was 5.6 mg/d and the mean duration of treatment was 643 days. Remarkably, risperidone reduced self-injurious behavior from 55 to 18 and aggressive behavior from 23 to 9, with a modest increase in prosocial behaviors. The most striking findings were the before and after aspect of the study and that reductions of abnormal aggression were not due to simple sedation, because prosocial behaviors increased. The use of atypical antipsychotics for mentally retarded or near mentally retarded detainees clearly is warranted.
Anticonvulsants have been considered the treatment of choice for patients with outbursts of rage and abnormal electroencephalogram (EEG) findings, whereas h'thium appears to be effective for treating aggression among nonepileptic inmates.24 The role of mood stabilizers in managing aggression is most evident when it is due to an underlying affective disorder.23 lithium, carbamazepine, and valproate have been demonstrated to be equally effective for treating the manic phase of classic bipolar disorders, both acutely and in maintenance.23'24 Persons With mixed bipolar disorder or rapid cycling respond much better to anticonvulsants (particularly divalproex) than to lithium.63 Mood stabilizers may be especially beneficial for managing aggression that persists due to uncontrollable affective symptoms.23 They also may be effective for reducing aggressive impulses in schizophrenia and other psychotic states.24 Trials have been initiated to study their efficacy in personality disorders, especially those characterized by impulsive behavior, aggression, or both.
McElroy64'65 recommends identifying whether an affective component is present during a rage attack, and, if so, classifying it as unipolar or bipolar. Patients with a unipolar component should be treated with antidepressants and those with a bipolar component should be treated with mood stabilizers, particularly divalproex, lithium, or carbamazepine.
Sheard66 studied 66 aggressive prisoners, 16 to 24 years old, who had long-term impulsive aggression and demonstrated, in a placebo-controlled study, that lithium had an antiaggressive effect. One limitation was that 80% of those in the lithium group correctly guessed their treatment.
Links et al.67 performed a small, blind, crossover study of patients with BPD treated with lithium, desipramine, and placebo. Eight of 13 responded to desipramine, but 6 of 12 also responded to placebo. Of those patients with high scores for anger and suicide symptoms, 4 of 11 responded to desipramine, whereas 5 of 6 responded to placebo. In one small placebo-controlled study of patients with impulsive BPD, lithium decreased symptoms of anger and suicide55; in another trial, carbamazepine was beneficial.68
Depression is commonly experienced by inmates. A variety of stressors associated with arrest, incarceration, and the legal process may contribute to the expression of this relatively common human emotion. Our experience suggests that most detainees on the jail's psychiatric units report that the onset of their current depressive episode antedated incarceration. Before treating the depressive symptom cluster as a nonpathological process akin to grief due to traumatic loss,21 we recommend clarifying symptoms and chronology and then providing antidepressant medication. Using this model, we rarely observe the most serious sequela of untreated or undertreated depression - suicide attempts or completed suicide. The article by Freeman and Alaimo in this issue discusses this topic further.
The term "anger attacks" was coined by Keith Anderson and is characterized by episodes of anger with tachycardia, sweating, hot flashes, and ti^titness of the chest.69'70 Although these symptoms are reminiscent of panic attacks, anger attacks appear to occur in one-third to half of depressed patients and may be more associated with depression than with panic disorder.70-71 In a double-blind, placebo-controlled trial of depressed outpatients, anger attacks stopped in 53% who were taking sertraline, 57% who were taking Imipramine, and 37% who were taking placebo, a nonsignificant difference owing to the small sample.72
Although anger attacks are not an approved indication for any treatment, Fava24 recommends antidepressants as the treatment of choice for aggressiveness and hostility among patients with unipolar depression and anger attacks. If the diagnosis of depression is made, aggressive treatment with tricyclics, selective serotonin reuptake inhibitors (SSRIs), or other newer generation antidepressants should be administered. Fava24 suggests that SSRIs may be particularly effective for depressed patients with pathological aggression and anger attacks; they lessen irritability and aggressive behavior. The role of antidepressants in treating pathological aggression in nondepressed patients needs further investigation.24
Salzman73 reported on a small, placebo-controlled, randomized, double-blind study of fluoxetine for patients with mild to moderately severe BPD, impulsive subtype. In this 13-week trial, 13 patients received fluoxetine and 9 received placebo. Patients receiving fluoxetine were 7 times as likely to show a decrease in anger, independent of changes in depression. These results were consistent with Norden's74 findings for 12 patients with BPD without major depression. Fluoxetine produced substantial improvement that was maintained through a 6-month follow-up period. Seventy-five percent of patients were assessed as much or very much improved for a wide variety of symptoms, including rejection sensitivity, anger, mood lability, irritability, impulsivity, substance abuse, and overeating. Also, 6 patients who interrupted medication experienced an increase in symptoms, which remitted after fluoxetine was restarted.
An SSRI may be the antidepressant of choice in this population due to comparative safety in overdose and because the serotonergic effect may reduce aggressive behavior. Markovitz et al.75 have shown that fluoxetine is effective for treating offenders who have borderline and schizotypal personality disorders. Vartiainen et al.76 have shown that Citalopram reduces aggression in patients with schizophrenia. In this condition, SSRIs are hypothesized to improve impulse dyscontrol that develops as a function of serotonergic dysregulation. Fava24 suggested that SSRIs may be an effective intervention for patients who are pathologically aggressive. Contrary to an earlier report,77 these agents do not appear to increase the risk of suicidal behavior in depressed or anxious patients78"80 or of anger attacks in depressed patients.72
Benzodiazepines are used relatively sparingly within correctional facilities because of their known abuse potential and the high rates of substance users in these settings. Short-acting benzodiazepines such as lorazepam, which have a rapid-onset calming effect that lasts several hours, have been recommended as an option for managing short-term aggression.23 However, benzodiazepine use also has been associated with increased levels of aggressive behavior, behavioral inhibition, and paradoxical induction of rage.36 Other short-term disadvantages include excessive sedation, memory impairment, and respiratory depression.23 These drugs are not helpful for treating persistent aggression, which requires long-term use and for which neuroleptics are the treatment of choice.23 Because there are effective alternatives for anxiety and insomnia, there may be little need to prescribe benzodiazepines for forensic populations. When used adjunctively to potentiate neuroleptics, benzodiazepines have demonstrated some efficacy in the short-term management of psychotic agitation.81
There have been many double-blind, controlled studies comparing buspirone with benzodiazepines and placebo. Buspirone is as effective as benzodiazepines even at week 1, and both are superior to placebo.82"85 Buspirone does not block benzodiazepine withdrawal symptoms,86 nor does it have a acute effect in the first few hours or days. In our clinical opinion, approximately 4 to 6 days are required for buspirone to begin to be effective, although time of onset has not been quantitatively studied. Buspirone does not produce liability for abuse nor does abruptly stopping it produce a withdrawal syndrome.86 It does not block symptoms of benzodiazepine withdrawal87 and does not have sedative properties. Because buspirone does not produce a feeling of sedation or euphoria just after the first tablet, it is not popular with substance abusers, who see it as a placebo. Clinically, these properties are considered an advantage in this population. There is consistent strong evidence from many studies of the antianxiety properties of buspirone.
Beta-blockers have been effective for reducing violent and assaultive behavior in a variety of conditions. However, systematic research on efficacy is lacking,81 and the use of beta-blockers may be limited by hypotension and bradycardia at higher doses.24 Their benefit at high doses may be related to sedation.
Serenics are a new class of investigational "antiaggression" drugs. These phenylpiperazine compounds are serotonin 5-HT1A/1B receptor agonists.88 Unfortunately, the efficacy observed in pilot studies was not confirmed in larger studies.89
As the population of the seriously mentally ill has been shifted by deinstitutionalization and inadequate community care to the nation's jails and prisons, the standard of care provided by psychiatrists and other mental health professionals in correctional settings has increased dramatically due to recruitment of quality staff and university affiliations. Further improvement will result from addressing issues such as better availability of state-of-the-art drugs and upgrading of information, medical records, and laboratory services. Also needed is improved collaboration among state, county, and community mental health leaders to facilitate provision of medications and "wraparound" services to mentally ill offenders on release from jail or prison. It is hoped that this cycle of clinical and criminal recidivism can be stopped with advances in pharmacotherapy and recognition by all the caregivers and stakeholders of the need to work together for better outcomes.
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