Psychotic Patients in the Criminal Justice System

Background:

The incarceration of mentally ill patients, who are often imprisoned due to issues related to mental health problems, is a major public health issue. According to the National Alliance for Mental Illness (NAMI), 2 million people with mental illness are imprisoned each year and up to 15% of these men and 30% of women have a serious mental health condition. Studies show that the prevalence of psychosis is 10 times higher in prison inmates than in the general population. Patients in the early stages of psychosis are more likely to be arrested and put in jail compared to those with chronic illness. In addition, minority patients from socially disadvantaged backgrounds are incarcerated at a higher rate.

Wicked Problem Description:

Psychotic disorders, such as schizophrenia and psychotic bipolar disorder, are severe and debilitating disorders that strike patients in late adolescence or early adulthood and lead to chronic functional impairment. It has long been recognized that reducing the duration of untreated psychosis is pivotal in the long-term prognosis of patients. The presence of significant psychotic symptoms also increases the risk of recidivism in inmates who are released, and the lack of appropriate treatment increases risk of violence and re-incarceration. The diagnosis and treatment of psychosis among incarcerated young adults is a major unmet need in our society, yet one that is fraught with complex socio-political barriers.

Project Strategies:

Our project is designed to address the crisis of undiagnosed and untreated psychosis in the incarcerated population. In addition to those with psychotic disorders who are jailed in the criminal justice system, we will target inmates that are being released from jail for intensive treatment and case management. We will aim for proper stabilization in terms of their medications and provide appropriate outpatient referrals in order to reduce the risk and recidivism and re-incarceration. We will use an approach grounded on evidence-based methods on the treatment of early psychosis but adapted to the unique circumstances of treating such patients in prisons.

1. Screening for psychosis: While studies have found that there is 10-fold higher number of patients with psychosis in the prisons, there is no concerted effort to screen incarcerated individuals. By using the Prodromal Questionnaire, Brief Version (PQ-B) we will identify undiagnosed and untreated inmates who have a psychotic disorder.
2. Treatment Optimization: Young adults in the early stages of psychosis, especially in the criminal justice system, are a difficult population to treat. Issues of treatment alliance, consideration of side effects, choice of optimal medication regimen are important aspects in maximizing treatment adherence. We will use our experience in this regard to develop an effective treatment plan for each patient.
3. Group therapy: We have found that group therapy with peers is very helpful for young adults with psychosis as they discuss their struggles, their symptoms and the positive and negative aspects of treatment. The positive experiences of some of the patients show those on the fence that group treatment can be helpful. We will use our experience running groups for young adults with psychosis to adapt a group therapy paradigm that will work in the criminal justice setting.
4. Case Management: Beyond helping with diagnosis and treatment during imprisonment, we will guide incarcerated patients to a one-way door out of jail. Studies have consistently shown that intensive specialized treatment in the early years of illness is crucial for good prognosis. We are part of a network of first-episode programs around the state and we will refer patients being released from jail to appropriate specialty psychosis clinics that are located near their home bases.

Outcomes:

The primary goals of the project are to identify inmates with undiagnosed or untreated psychotic disorders, provide guidance for appropriate treatment while they are confined in the criminal justice system and set them up for appropriate outpatient referrals upon release. Our anticipated outcomes are as follows:

1. Identification of inmates with undiagnosed or untreated psychotic disorders.
2. Symptom reduction and functional recovery in treated patients.
3. Reduced recidivism and re-incarceration in released patients.

Timeline:

Year 1

• Meetings with correctional staff
• Orientation for jail procedures
• Collaborative design of a logistical framework for work in the jail.
• Start screening procedures for psychosis.
• Identify inmates appropriate for the program.
• Start group activities — tentatively a group for transitioning to life out of jail and another group on mindfulness meditation.
• Provide psychiatric consultation to prison staff.

Year 2

• Gather feedback from corrections staff and program participants to make iterative changes to the program.
• Continue group therapy sessions.
• Continue to provide psychiatric consultation.
• Start intensive case management for inmates with psychosis who are scheduled to be released.

Year 3

• Initiate discussions with corrections staff and administration on evaluating the program and planning future work.
• Continue group therapy sessions.
• Continue to provide psychiatric consultation.
• Continue intensive case management for inmates with psychosis who are scheduled to be released.
• Gather information on program participants who are released to evaluate the impact of the program.
• Plan to apply for funding to expand the program in area jails and potentially into prisons.

Partnerships:

Middlesex County Sheriff’s Office in Billerica, MA

Evaluation Strategies:

From the onset of our project, we will maintain an active record of our efforts in order to measure the progress of our project and evaluate our efficacy in the following ways:

1. We will maintain data on inmates that complete the Prodromal Questionnaire, Brief Version (PB-Q) including demographic information and age, and examine the proportion of inmates who score in the PB-Q screening tool and those who get a clinical diagnosis of a psychotic disorder upon follow-up comprehensive evaluation.
2. Among identified inmates, we will collect data on the formal diagnosis that the inmates receive. We will record the proportion of inmates who agree to treatment and are medication compliant.
3. For inmates who are identified for treatment, we will quantify their symptoms at baseline at the time of their diagnosis and follow their progress every three months using a Brief Psychiatric Rating Survey (BPRS) and the Psychotic Symptom Rating Scales (PSYRATS). We will also keep track of the medications they are prescribed and how likely inmates are to stay on the different medications.
4. For inmates who are released from prison, we will follow up with them every three months during their first two years after release in order to monitor their treatment status and functional recovery. At the end of the project duration, we will analyze our data to determine the effectiveness of the three aspects of our program and identify any necessary changes in our approach. The results and experience from this project will help us identify the strengths and weaknesses of our approach and help us to improve the design in order to expand this approach to other correctional institutions as well.