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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 1 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 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 2 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 3 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 4 2016 Jail Health Care Conference Plenary 1: Diagnosing and Treating Inmates with Mental Illness Cost Effective and Rational Utilization of Psychotropics in Corrections 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 5 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 6