CLINICAL HANDBOOK OF SCHIZOPHRENIA

Pharmacological Treatment35. Treatment in Jails and Prisons 361The use of medication to ameliorate an inmate’s symptoms of schizophrenia is an essentialcomponent of correctional mental health treatment. Medication management of schizophreniais perhaps the most widely researched among the evidence-based practices forschizophrenia, and the range of effective medication options grows each year. The principalclass of medications used in treating schizophrenia is the “antipsychotics,” which can besubdivided further into typical antipsychotics (older, with common side effects including sedationand movement disorders) and atypical antipsychotics (newer, sometimes better tolerated).Older medications used to treat schizophrenia can cost $150–250 a year, whereasnewer agents cost $2,000–6,000 a year. There is continued controversy over both the benefitsand risks of various antipsychotics in correctional settings.Proponents of atypical medication cite the fact that the medications are well tolerated,with relatively few unpleasant side effects. In addition, several studies in correctionalsettings have indicated an association between atypical medication use and decreasedhostility and aggression, which in turn decreases the need for seclusion andrestraint and may reduce officer and inmate injury. Clozapine has been shown to reducerates of suicide in prison, and studies indicate that use of atypicals is associated with increasedcompliance rates. Opponents of atypical medications cite the increased risk ofweight gain, glucose intolerance, and the enormous costs associated with these neweragents as reasons for not using them as first-line agents.The fact that inmates present with varied treatment histories, symptom profiles, andco-occurring conditions is the basis for the APA’s recommendation that psychiatrists havethe ability to prescribe any psychotropic medication in correctional settings. Medicationalgorithms for schizophrenia have allowed care providers to establish multiple treatmentoptions supported by empirical data related to effectiveness and side effects. Several correctionalfacilities have developed their own algorithms for the treatment of schizophrenia.The New York Forensic Algorithm Project (FAP) started with the identification offour subgroups of inmates with schizophrenia and developed four parallel interventionplans. With regard to medications, the FAP begins with the use of any antipsychotic medication,suggests the use of atypicals, then augmentation with other psychotropic agents,and finally recommends clozapine for inmates with refractory schizophrenia. Importantly,the FAP also recommends specific programming in certain prison environments asan adjunct to medication management.Whatever the protocol, the correctional medication management program must beconsistent with community standards that include the following:• Prescription use should only occur in the context of an adequate psychiatric evaluation.• Medications should only be dispensed by licensed health care professionals.• The goal of treatment must be determined individually rather than being designedto serve institutional goals of behavior control or population management.• Continuity in medication management between community providers and correctionalproviders should be maintained.Treatment of Co-Occurring DisordersAn estimated 5–13% of jail and prison inmates have co-occurring mental health and substanceuse disorders. This population has pronounced biopsychosocial problems (e.g.,homelessness, unemployment, HIV/AIDS) and is at elevated risk for violence and behav-