Algorithm-driven pharmacological management of bipolar disorder in Connecticut prisons

Adaptation of the Clinical Global Impression for Use in Correctional Settings: The CGI-C

Background: Provision of mental health care in correctional settings presents unique challenges. There is a need for a simple-to-use tool to measure severity of mental illness in correctional settings that can be used by mental health staff from different disciplines. We adapted the severity scale of the Clinical Global Impression for use in correctional settings, which we have called CGI-C, and carried out a reliability study. Method: Clinical descriptions of typical inmate presentations were developed to benchmark each of the seven possible ratings of the CGI. Twenty-one case vignettes were then developed for study of inter-rater reliability, which were then rated using the CGI-C by five forensic psychiatrists (on three occasions) and 11 multidisciplinary health care clinicians (twice). The tool was introduced into clinical practice, and the first 57 joint assessments carried out by both a psychiatrist and a clinician in which a CGI-C was rated were compared to measure inter-rater reliability. Results: We found very good inter-rater and test-retest reliability in all analyses. Gwet's AC, calculated on initial ratings of the vignettes by the psychiatrists, was 0.85 (95% CI 0.81-0.90, p < 0.001) and 0.87 (95% CI 0.83-0.91, p < 0.001) for clinician ratings. Inter-rater reliability based on 57 joint face-to-face assessments of inmates showed Gwet's AC coefficient of 0.93 (95% CI 0.88-0.97). Conclusion: The CGI-C is simple to use, can be used by members of the multidisciplinary team, and shows high reliability. The advantage in correctional settings is that it can be used even with the most severely ill and behaviorally disturbed, based on observation and collateral information.

Violent criminal behavior in the context of bipolar disorder: Systematic review and meta-analysis

BACKGROUND

Despite the potential importance of understanding violent criminal behavior (VCB) in individuals suffering from bipolar disorder (BD), previous findings are conflicting. The aims of the present study are to clarify the association of VCB and BD in comparison to general population and other psychiatric conditions.

METHODS

A systematic review of literature from January 1st, 1980 through January 16th, 2017 from 3 electronic databases (MEDLINE/PubMed, EMBASE and PsycInfo), following the PRISMA and the MOOSE statements. Original peer-reviewed studies reporting data on VCB in BD were included. A random-effects meta-analysis was performed. Potential sources of heterogeneity were examined through subgroup and meta-regression analyses. The protocol was registered in PROSPERO, CRD42017054070.

RESULTS

Twelve studies providing data from 58,475 BD participants. The prevalence of VCB in BD was 7.1% (95%CI = 3.0‒16.5%; k = 4). The association of BD and VCB compared to general population was not significant (OR = 2.784; 95% CI, 0.687‒11.287, P = .152). The association was significant only in cross-sectional studies, in studies in which VCB was assessed through self-reported measures, and in studies conducted in the USA. BD was more likely to be associated with VCB when BD patients were compared to controls with depressive disorders, whilst it was found to be less associated with VCB when BD was compared to psychotic disorders.

LIMITATIONS

1. the methodological heterogeneity across the included studies. 2. causal inferences were precluded by the inclusion of cross-sectional studies.

CONCLUSIONS

These findings might provide a more balance portrait of the association between BD and VCB to clinicians, law enforcement and general public.

Adaptation of the Texas Implementation Medication Algorithm for Bipolar Disorder in Adult Female Offenders

Use of medication algorithms in the correctional setting may facilitate clinical decision making, improve consistency of care, and reduce polypharmacy. The objective of the present study was to evaluate effectiveness of algorithm (Texas Implementation of Medication Algorithm [TIMA])-driven treatment of bipolar disorder (BD) compared with Treatment as Usual (TAU) in the correctional environment. A total of 61 women inmates with BD were randomized to TIMA (n = 30) or TAU (n = 31) and treated over a 12-week period. The outcome measures included measures of BD symptoms, comorbid symptomatology, quality of life, and psychotropic medication utilization. In comparison with TAU, TIMA-driven treatment reduced polypharmacy, decreased overall psychotropic medication utilization, and significantly decreased use of specific classes of psychotropic medication (antipsychotics and antidepressants). This pilot study confirmed the feasibility and benefits of algorithm-driven treatment of BD in the correctional setting, primarily by enhancing appropriate use of evidence-based treatment.

Behind bars: the compelling case for academic health centers partnering with correctional facilities

Academic health centers (AHCs), particularly those that are publicly funded institutions, have as their mission the treatment of disadvantaged populations, the training of the next generation of clinicians, and the development and dissemination of new knowledge to reduce the burden of disease and improve the health of individuals and populations. Incarcerated populations have the most prevalent and acute disease burden and health disparities in the United States, even in comparison with inner-city populations. Yet, only a small proportion of AHCs have reached out to incarcerated populations to fulfill their mission. Those AHCs that have partnered with correctional facilities have overcome concerns about the value and popularity of "training behind bars"; the cost, liability, and pragmatics of caring for a medically complicated population; and the viability of correctional health research and extramural research funding. They have done so to great benefit to patients, students, and faculty. Partnering with correctional facilities to provide health care offers opportunities for AHCs to fulfill their core missions of clinical service, education, and research, while also enhancing their financial stability, to the benefit of all. In this Commentary, the authors discuss, based on their experiences, these concerns, how existing partnerships have overcome them, and the benefits of such relationships to both AHCs and correctional facilities.

A comparison of psychiatric diagnoses among HIV-infected prisoners receiving combination antiretroviral therapy and transitioning to the community

BACKGROUND

The criminal justice system (CJS), specifically prisons and jails, is ideally suited for uniform screening of psychiatric (PD) and substance use disorders (SUDs) among people living with HIV/AIDS (PLWHA), who are concentrated in these settings. By accurately diagnosing PDs and SUDs in these controlled settings, treatment can be initiated and contribute to improved continuity of care upon release. In the context of PLWHA, it may also improve combination antiretroviral treatment (cART) adherence, and reduce HIV transmission risk behaviors.

METHODS

A retrospective data analysis was conducted by creating a cohort of PLWHA transitioning to the community from prison or jail enrolled who were enrolled in a controlled trial of directly administered antiretroviral (DAART). Participants were systematically assessed for PDs and SUDs using the Mini International Neuropsychiatric Interview (MINI), a standardized psychiatric assessment tool, and compared to diagnoses documented within the correctional medical record.

RESULTS

Findings confirm a high prevalence of Axis I PDs (47.4%) and SUDs (67.1%) in PLWHA even after prolonged abstinence from alcohol and drugs. Although prevalence of PDs and SUDs were high in the medical record, there was fair to poor agreement among PDs using the MINI, making evident the potential benefit of more objective and concurrent PD assessments to guide treatment.

CONCLUSIONS

Additional PD diagnoses may be detected in PLWHA in CJS using supplementary and objective screening tools. By identifying and treating PDs and SUDs in the CJS, care may be improved and may ultimately contribute to healthier outcomes after community release if patients are effectively transitioned.