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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
Clinical Assessment of Incarcerated Patient :
Correctional Mental Health

Diagnostic interview should include:
• Presenting condition
Diagnosing and Treating
Inmates with Mental Illness
• Past mental health and medical history / family history
• Mental Status Exam
• Assessment and initial treatment plan
Lawrence Reccoppa, MD
Correct Care Solutions
Psychiatric Consultant
Statistics on Mental Illness in Prisons/Jails
Interviewing Strategies with the Incarcerated Patient :

Approximately 300,000 mentally ill offenders

15% with “severe” mental illness

“I hear voices”

154% increase in system between 1980
and 1998

“I’m depressed”

“I’m suicidal”

“I’m homicidal”

“I have mood swings”

“I’m paranoid”

“I am bipolar, ADD with schizophrenic tendencies

Investigate “trite” chief complaints:
Up to 4 times higher rate of completed suicide
in county jails (not state prsions)
Weinstein HC, et al. Psychiatric Services in Jails and Prisons. A Task Force Report of the American Psychiatric Association
Second Edition. Washington DC, 2000 , APA Press
Deinstitutionalization - Reintegration = Incarceration

1955
Interviewing Strategies with the Incarcerated Patient :
560,000 in state hospitals
200,000 jail/prison cells

1960s-1970s
Widespread use of neuroleptics and
budget cuts result in deinstitutionalization

2002
60,000 in state hospitals

Utilize open ended, exploratory questions

Do not rely solely on inmate’s self report

Focus on objective findings

Employ DSM-5 criteria in your documentation
2,000,000 jail/prison cells

1980s-2000s
Persistent symptoms,noncompliance,
limited resources result in
homelessness/incarceration
NAMI , 2002
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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
“ Mood Swings ” =/= Bipolar Disorder
Suspect other etiologies including Axis II when :

Symptoms directly and immediately related to
psychosocial triggers

Rapid resolution contingent upon environment

Duration does not meet DSM IV criteria

Absence of constellation of symptoms (DSM IV)

Symptoms only coincide with substance use
Rogers R. Clinical Assessment of Malingering and Deception. Guilford Press 1997. Pp 58-62
Goodwin FK, Jamison KR. Manic-Depressive Illness. New York: Oxford University Press; 1990.
“ I Hear Voices ” =/= Thought Disorder
Suspect feigning of mental illness when :
Summary of DSM-5 Criteria for
Manic Episodes in Bipolar Disorder


Not associated with delusions / other symptom clusters

Continuous rather than intermittent

Inaudible or stilted language


No strategies to diminish voices


Reports obeying all commands

“Visions” that are abnormally sized / black+white


Consider other causes (e.g., alcohol,organic,MR)


“All or none” response to antipsychotics
Rogers R. Clinical Assessment of Malingering and Deception. Guilford Press 1997. Pp 58-62
“ I’m Paranoid ” =/= Thought Disorder
Suspect feigning when :



Abnormally and persistently elevated, expansive, or irritable mood
for at least 1 week*
Along with at least 3 (4 if mood is irritable) of the following:
Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in activities that have a high potential for
painful consequences
* This symptom must be present.
Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
Arlington, VA : American Psychiatric Association, 2013.
Manipulative Behavior =/= Sociopathy

Inmates may be both “mad and bad”

Absence of other symptom clusters
- negative, cognitive, and mood

Rates of comorbidity of schizophrenia and ASPD
vary from 10% to 63%

Abrupt onset or termination

The “institutionalized” patient with serious illness

Eagerness to call attention to delusions

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Conduct inconsistent with delusional content
The “depressed” sociopath may utilize deception
compulsively to :

Caution - ? reality based in corrections setting
Rogers R. Clinical Assessment of Malingering and Deception. Guilford Press 1997. Pp 58-62
- stave off disorganization / protect grandiose self
- “get over on others” to bolster self-esteem
Rogers R. Clinical Assessment of Malingering and Deception. Guilford Press, NY 1997, pp 68-70
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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
Challenges in assessing patients for mental illness
in the correctional setting

Rapid turnover rates / high acuity (jails)

Substance induced issues (jails >> prisons)
- intoxication
- withdrawal (acute and protracted)

Other Comorbidities in this population
- medical (HIV, HCV, others)
- head trauma / neurologic disorders
- developmentally delayed
Diagnostic Challenges in Corrections
Doubt severe mental illness (other than substance abuse) when:

Demands medications (especially certain agents)

Divulges symptoms too eagerly or dramatically

Dependent (conditional) threats of self harm,
assault, or litigation

Deliberate, calculated acting out with low
potential for serious injury
Reccoppa, L. “Clinical Pearls – 3D’s Suggest Malingering.” Vol. 8, No. 12 / December 2009. Current Psychiatry.
Challenges in assessing patients for mental illness
in the correctional setting

Reliability of historian
false positives – impact legal issues / housing; procure meds / disability
false negatives – unconscious denial, concealment of history


Lack of collateral information / records
Factors Aiding and Abetting the Correctional
Assessment

“Time is on my side” (state prisons >> jails)

“HMO-less”

Consultation with colleagues / team approach

Input from security staff / controlled setting
Diminished therapeutic alliance
- countertransference – dismissal of genuine illnesses as feigned
- “skepticism versus cynicism”
Hidden Agendas for Incarcerated Patients
to Feign Mental Illness :
Short-Term and Long-Term Goals of
Correctional Therapy

Impact legal status / diminish responsibility

Treat serious psychiatric conditions

Influence housing location

Prevent suicide

Alter camp assignment / procure transfer (prison)

Reduce relapse / recidivism

Perpetuate substance abuse

Contain costs but maintain quality

Obtain contraband

Enhance safety of facility / assist security

Collect disability after release
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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
“Hidden” Costs of Ineffective Treatment
in the Correctional Setting :
Correctional Psychiatry
• Relapse / Rehospitalization
security time / transfer costs
Appropriate Utilization of
Psychotropics in the
Correctional Setting
• Suicides / legal ramifications
• End Of Sentence – Reintegration = Recidivism
Appropriate Utilization of Psychotropics – Overview:

Establish an accurate diagnosis

Treat conditions which significantly impair functioning
within the correctional setting

Remain cognizant of the high prevalence
(70-85%) of substance abuse in this population

“20 minutes versus 20 seconds” rule in assessment

Employ input from other staff (nursing, therapists,
security) regarding adherence and response to
treatment given your time constraints
Impact of Inaccurate Diagnoses

Mental Health – time / services diverted

Pharmacy – unnecessary expenses / time

Security – overtime / strains relationship with MH

Nursing – time / services / safety (inpatient)

Inmates – limits care available for severely mentally ill
U.S. Bureau of Justice Statistics. www.ojp.usdoj.gov/bjs. Jan 5, 1999
“Hidden” Costs of Ineffective Treatment
in the Correctional Setting :



Assaults / disciplinary problems
- loss of “gain time” / longer stays (prison > jail)
Cost Effective and Rational Prescribing of
Psychotropics in Corrections

May require initial withholding (days to weeks) of certain psychotropics
to allow for detoxification/withdrawal from other substances

Considering trials off psychotropics for monitoring of
symptoms/behaviors in a controlled setting

Prescribing for syndromes not symptoms / accurate diagnoses

Focus on objective outcome measures (e.g., disciplinary issues,
self-injurious behaviors, inpatient admissions) less often
than inmate self report
Concomitant psychotropics / Unnecessary Polypharmacy
Noncompliance and Switching of agents
- pharmacy / nursing / psych time
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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
Cost Effective and Rational Utilization of
Psychotropics in Corrections

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Guidelines for Medication Treatment of ADHD in the
Correctional Setting

More judicious prescribing (e.g, monotherapy, generics) by clinicians
leading to less externally imposed formulary restrictions
In general, avoid usage of stimulants given the high rates of
comorbid substance use disorders in this population

Utilize single dose, directly observed medication dispensing
to enhance compliance and curtail diversion of agents (prison > jail)
Be cognizant of potential for abuse/diversion and the pressure which
other inmates may place on those with mental illness to obtain these
agents

Deemphasize use of certain agents (with abuse potential)
especially for questionable indications
Based on the severity of the symptoms and impact on objective
functioning (e.g., GED classes, disciplinary issues), stimulant
treatment is clinically justified in a minority of cases

Clinicians should consider non-controlled alternatives
(e.g., atomoxetine,TCAs) for inattention and possibly other agents
for associated impulsivity/hyperactivity
Appelbaum KL. “Assessment and Treatment of Correctional Inmates with ADHD”. Am J Psychiatry 165:12, Dec 2008
Psychotropics potentially misused by the
inmate population

Psychotropics potentially misused by the
inmate population

Benzodiazepines / stimulants
- typically not available in DOC

Anticholinergics
- e.g., Artane

Tricyclic antidepressants
- particularly Elavil / Sinequan
Benzodiazepines / stimulants
- typically not available in DOC
Delpaggio,D et al. “Abuse of Psychotropic Medication in the Correctional Setting”.
Poster Presentation – Alameda County Correctional Meeting. Oakland,CA March 2005.
Guidelines for Utilization of Benzodiazepines
in the Correctional Setting
Delpaggio,D et al. “Abuse of Psychotropic Medication in the Correctional Setting”.
Poster Presentation – Alameda County Correctional Meeting. Oakland,CA March 2005.
Psychotropics potentially misused by the
inmate population

Avoid long term usage given the high rates of comorbid substance
use disorders in this population

Be cognizant of potential for abuse/diversion and the pressure
which other inmates may place on those with mental illness to
obtain these agents


Appropriate to use short term (1-2 week in tapering schedule)
upon intake to minimize withdrawal syndromes (bzd’s, alcohol, etc.)


De novo initiation (limited duration) may be necessary in rare
instances but clinicians should consider non-controlled, FDA
approved alternatives (e.g., SSRIs,SNRIs,TCAs) for anxiety
disorders meeting DSM IV criteria
APA: Psychiatric Services in Jails and Prisons: A Task Force Report of the APA, 2nd Edition. Washington, DC. 2000

Wellbutrin SR (Bupropion SR)
- per California and Michigan DOC (1)
Neurontin (Gabapentin)
- per Florida DOC report (2)
Seroquel (Quetiapine)
- per California and FL DOC report (3)
1)
2)
3)
Personal communications and Delpaggio,D – Poster presentation. March 2005.
Gabapentin Abuse in Inmates with Prior History of Cocaine Dependence.
Reccoppa,L et al. The American Journal on Addictions, 13:321-323, 2004.
Intranasal Quetiapine Abuse. Pierre,JM et al. Am J Psychiatry 161:9, September 2004
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2016 Jail Health Care Conference
Plenary 1: Diagnosing and Treating Inmates with Mental Illness
Summary




Significant minority of inmate population suffer from
serious mental illness
Utilize appropriate and effective standard of care
to reduce suffering and enhance institutional safety
Focus on objective findings in both assessment and
monitoring of treatment response
Be cognizant of issues / side effects specific to
correctional population – think “Inside the Gates”
Questions and Discussion
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