County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care

Mental Healthcare Practices from Entry to Release across Southeastern Jails

Background

Individuals with mental illnesses are disproportionately incarcerated in jails, which have become de facto mental health institutions across the US. Yet there is limited research describing mental healthcare practices from entry to release among multiple jails and states.

Methods

We conducted 34 semi-structured interviews with jail healthcare personnel across five Southeastern states.

Results

We report results on challenges and practices related to mental health staffing, screening, additional evaluations and services, and discharge planning in jails. Initial mental health screenings were often restricted to the detection of suicidality and history of treatment and medications as opposed to current mental health symptoms. Use of validated mental health screening forms was uncommon. We found delays in care between the initial health screening and being evaluated by a mental health professional. Most jails reported primary responsibilities for mental health care as preventing suicides and managing psychiatric medications. Jails reported mental health care as challenging to manage, with high volumes of individuals with mental health needs, yet limited resources, especially regarding staffing. Discharge planning was limited despite reports of poor continuity of mental healthcare.

Conclusions

Jails have a constitutional duty and opportunity to provide adequate healthcare to individuals with mental illnesses, yet practices are insufficient and resources are limited across jails. Based on our findings, we recommend 1) greater adoption and revisions of jail health standards 2) system improvement that expands identification of mental illnesses and quicker, less variable follow-up mental health evaluations, 3) improved linkages and supports for community resources that prevent incarceration of this population.

Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

The role of detention officers in the provision of jail healthcare in the Southeastern United States

Jailed individuals have considerable healthcare needs, yet jail healthcare resources are often limited. We interviewed staff from 34 Southeastern jails about strategies that jails use to deliver healthcare. One of the most prominent strategies was the use of detention officers to provide or facilitate the provision of healthcare. Officers' roles included assessing the need for medical clearance, conducting medical intake screenings, monitoring for suicide/withdrawal, transporting patients to medical appointments, medication administration, monitoring blood glucose and blood pressure, responding to medical emergencies, and communication with healthcare personnel. Several participants reported that due to officer shortages, conflicting priorities, and lack of adequate training, officers' healthcare roles can compromise privacy, delay access to care, and result in inadequate monitoring and safety. Findings suggest the need for training and standardized guidelines for officers' involvement in jail healthcare delivery and reassessment of the scope of officers' healthcare responsibilities.

Prevalence of Psychiatric Disorders by Demographics in Jail Populations

Many individuals incarcerated in jails suffer from psychiatric disorders and require mental health treatment. However, there has yet to be a study which comprehensively described the prevalence of mental illness diagnoses by demographic variables or compared results to the general population. Data for this study were the Survey of Inmates in Local Jails, 2002. Binary logistic regression was run to compare the prevalence of diagnoses to demographic variables of the jail population. Results were compared to studies in the general population. Males were less likely than females to report five of the seven disorder categories, and employed individuals were less likely to report all seven disorders. The results were consistent with research on the general population. It is important to understand the population of individuals with mental illness in jail so we can better serve them and catch psychiatric disorders early while they are more easily treatable.

Police, courts, and corrections: Experiences of procedural injustice among Black adults

Racial disparities and a corresponding lack of trust have been documented within the criminal legal system. In response, criminal legal system actors have sought to strengthen the legitimacy of their agencies. However, legitimizing these agencies can be problematic. Some argue that the current criminal legal system continues the legacy of slavery and Jim Crow as Blacks are disproportionately policed and incarcerated. As a framework, procedural injustice can offer a unique backdrop and interrogate ways in which the criminal legal system engages in delegitimizing actions that provoke noncompliance and enable social control. Using a procedural injustice lens, this study examines how justice-involved Black adults experience mistreatment by justice system actors. Semistructured interviews were conducted with 84 Black adults in Newark and Cleveland. Study findings offer a comprehensive account of how participants experience procedural injustice as arrestees, defendants, and incarcerated persons. More specifically, participant narratives describe deliberately antagonistic, abusive, and dehumanizing treatment by justice-system agents-often depicted as racially motivated. Participant accounts also describe this mistreatment as occurring in a context of coercion and powerlessness and as being institutionally sanctioned. Implications for the preservation of racial hierarchies, research, practice, and community psychology are discussed.

Nutrition availability for those incarcerated in jail: Implications for mental health

PURPOSE

Using a seven-day cycle menu and commissary items at a rural county jail, this study aims to describe provisions of micronutrients known to be associated with mental health disorders and if they meet dietary guidelines.

DESIGN/METHODOLOGY/APPROACH

The nutritional content of a seven-day cycle menu and four available commissary food packs were evaluated using NutritionCalc® Plus software (McGraw-Hill Education version 5.0.19) and compared to Dietary Reference Intakes (DRI).

FINDINGS

Menu mean values of Vitamin B6, Vitamin B12, Vitamin C and zinc met DRI recommendations. However, Vitamin D (for men and women), magnesium (for men only) and omega-3s (for men only) did not meet the DRI recommendations.

ORIGINALITY/VALUE

As deficits of Vitamin D, magnesium and omega-3s are known to exacerbate bipolar disorder, anxiety and depression, small changes to food would increase the offerings and potential intake of nutrients that may improve mental health.

A Comparison Between Rural and Urban Jail Proximities to Inpatient Mental Health Care in New York State

The authors created a model to examine the distance between jails and inpatient mental health care facilities in rural counties versus urban counties in New York State. Using U.S. census data, the top seven most rural counties and top seven most urban counties were selected for analysis. Results indicate that, overall, urban jails have closer access than rural jails to inpatient mental health care, with the furthest facilities for urban jails being 15.1 kilometers and the furthest for rural jails being 43.6 kilometers. The closest inpatient mental health care facility for urban jails was 174 meters, whereas the closest mental health care facility for rural jails was 0.02 kilometers. Average distance from inpatient mental health care was 4.3 kilometers for urban jails and 26 kilometers for rural jails. Policy implications are discussed.

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Glaucoma Care of Incarcerated Patients at an Academic Institution: A Case-Control Study

Purpose:

To evaluate medication and follow-up adherence in incarcerated patients examined at an academic glaucoma clinic, in comparison to nonincarcerated controls.

Methods:

Retrospective, case-control study. Consecutive prisoners presenting for initial visits in the Glaucoma Clinic at the Illinois Eye and Ear Infirmary between December 2015 and December 2017 were included in the study. Nonincarcerated patients seen in the same Glaucoma Clinic with similar initial visit dates, age, race, sex, and disease severity were selected as controls. Glaucoma Clinic visits from each patient were reviewed until December 2018. Examination information, surgical intervention, follow-up and treatment recommendations, and patient-reported medication usage were recorded for each visit. Number of visits, loss to follow-up, follow-up delays, and medication nonadherence were studied as primary outcome measures.

Results:

Twenty-four prisoners and 24 nonincarcerated controls were included. Prisoners had an average of 2.46 ± 2.38 visits during the study period, compared to 5.04 ± 3.25 for controls (P = 0.001). Follow-up visits occurred more than 30 days after the recommended follow-up time in 57.4% (95% confidence interval [CI]: 44.2%–70.6%) of prisoners, compared to 17.9% (95% CI: 10.2%–25.6%) of controls (P < 0.00001). 70.8% of prisoners (95% CI: 66.3–74.5%) were lost to follow-up, compared to 29.2% of controls (95% CI: 25.5%–32.9%; P < 0.01). Medication nonadherence rates were similar between prisoners (13.6%; 95% CI: 12.1%–15.2%) and controls (12.0%; 95% CI: 11.4%–12.6%; P = 0.78).

Conclusions:

Glaucoma follow-up adherence was significantly worse in prisoners compared to a nonincarcerated control population. Further study into causative factors is needed.

Glaucoma Care of Prison Inmates at an Academic Hospital

Importance

Glaucoma care for prison inmates is underrepresented in the literature even though managing the treatment of such patients may provide unique challenges.

Objectives

To evaluate the glaucoma profile of prison inmates treated at an academic ophthalmology center and to report on the medical and surgical management and follow-up metrics.

Design, Setting, and Participants

This retrospective cohort study assessed data from 82 incarcerated patients treated at the glaucoma clinic, an academic referral center at the University of Illinois at Chicago, between January 2013 and December 2017.

Main Outcomes and Measures

Diagnosis, glaucoma severity, medical and surgical interventions, and patient-reported medication adherence were recorded for each visit. Recommended and actual follow-up times were recorded and compared. Data analyses were conducted from January 2013 to December 2018.

Results

In total, 82 patients (161 eyes) had 375 visits during the study period. All patients were male and ranged from 20 to 75 years of age (mean [SD] age, 50.8 [11.9] years). Most participants were black patients (65 [79.3%]). The most common diagnoses were primary open-angle glaucoma (POAG; 53 eyes [32.9%]) and POAG suspect (52 eyes [32.3%]). Glaucoma severity ranged from mild (25 of 77 eyes [32.5%]) to advanced (41 of 77 eyes [53.2%]). Overall, 59 patients (73.2%) were treated medically with up to 4 topical agents (40.0%). Of those treated, 70.0% of patients (95% CI, 57.7%-81.2%) reported medication nonadherence during at least 1 visit. Medication nonadherence was more common among those taking 4 different topical medications (21 of 24 [87.5%]) compared with others taking fewer medications (20 of 35 [57.1%]), for a difference of 30.4% (95% CI, 7.0%-53.6%; P = .02), and among those with advanced disease (22 of 26 [84.6%]) compared with glaucoma suspect (6 of 13 [46.2%]), for a difference of 38.4% (95% CI, 9.3%-67.5%; P = .02). Nineteen office procedures, including laser peripheral iridotomy and laser trabeculoplasty, were performed on 14 eyes. Seventeen incisional glaucoma procedures were performed on 15 eyes, including glaucoma drainage device implant (11 procedures [64.7%]) and trabeculectomy (3 procedures [17.6%]). Only 26.6% of return office visits (95% CI, 21.3%-32.3%) occurred within the recommended follow-up time frame. Furthermore, 93 patients (34.8%; 95% CI, 28.2%-40.0%) were seen more than 1 month after the recommended follow-up.

Conclusions and Relevance

Despite incarceration in prison, where medication administration and appointment attendance are theoretically controlled, the results of this study suggested that substantial medication and follow-up nonadherence exists among inmates.

Initiation of a multidisciplinary telemental health clinic for rural justice-involved populations: Rationale, recommendations, and lessons learned

Videoconferencing technology (VCT) is rapidly increasing in the mental healthcare industry and is becoming an attractive option to reach justice-involved populations. This paper first highlights the need for alternative service delivery solutions and reviews current literature on the use of VCT for correctional clients. We then outline the specific timeline, procedures, and barriers associated with the initiation of a virtual, multidisciplinary telemental health clinic for jailed and community-released offenders in a rural Mississippi county aimed at reducing criminogenic and psychiatric risks. Finally, we summarize generalizable recommendations for establishing community partnerships, developing structural and logistical processes, and delivering VCT while accounting for unique client factors and integrating evidence-based intervention strategies. We hope other community leaders will feel empowered to initiate similar programs that address needs within in their own jurisdictions.

The Structuration of Community-Based Mental Health Care: A Duality Analysis of a Volunteer Group's Local Agency

Using a lens of structuration theory, this study highlights the ways that specific structures within the current community-based model of mental health care might enable and constrain individuals and families living with mental illness. Through a case study of a volunteer mental illness advocacy group, the authors employed a duality analysis on a variety of data collected from the case (i.e., interviews, organizational documents, and community health care data). Findings indicate that while group members encountered structural barriers to their organizational mission, they also used communicative agency creatively and collectively to (re)create structures within the current community-based model of mental health care. Member agency is examined in relation to perceived structural influence. Theoretical and practical applications of the findings are discussed.

Pharmacy Practice in the South Dakota Correctional System: Discovery of an Unconventional Experiential Practice Site

Pharmacists must be prepared to care for populations where health disparities are greatest and their services can best impact public health needs. Such preparation requires that students have access to practice experiences in underserved environments where pharmacy practice, cultural competence and knowledge of population health are experienced simultaneously. The correctional facility is such a place. The American Society of Health-System Pharmacists recommends that students receive preceptorship opportunities within the correctional system. The occasional collaboration or experiential opportunity, like Kingston's early model, has occurred between health professional schools and correctional facilities. However, to date, the correctional facility-experiential site remains an untapped opportunity, at least in a complete, coordinated, pharmaceutical care, patient management framework. Consequently, a short research study asked: To what extent is there potential for correctional facilities to serve as experiential practice sites for pharmacy students? The research objective was to identify pharmaceutical practices within South Dakota correctional system and compare those practices to the guidelines established by the Association of American College of Pharmacy's as optimal for student training. To understand medical and pharmaceutical practices in SDPS, three South Dakota Adult prison facilities were included in the exploratory study. Data was collected through a mixed methods approach designed to obtain perspectives about the SDPS health care system from individuals representing the numerous job levels and roles that exist within the health care continuum. Interviews and a web-based surveys were used to collect data. A review of a 36-page transcript along with 498 freeform survey comments revealed that while exact themes from the Exemplary Practice Framework may not have been evident, related words or synonyms for patient-centered care, informatics, public health, medication therapy management, and quality improvement appeared with great frequency.