Challenges and Limitations to Treating ADHD in Incarcerated Populations

To the Editor

We read with interest the commentary by Hall and Myers.¹ We applaud them for their excellent work in reviewing the standard treatments for attention-deficit/hyperactivity disorder (ADHD). We agree with them that more research is needed to guide corrections staff on how best to approach these patients. We believe any effort in research and education for the purpose of improving treatment outcome of ADHD or other mental health disorders should be strongly encouraged. In general, mental health services in the United States have been dismal over the past decades, and this is particularly true in correctional institutions.²

In recent years, the facts indicate that obtaining psychiatric care in the United States has become increasingly difficult, even in the community population. Funding for community resources has been shrinking for decades. This problem has caused much difficulty and challenges in seeking mental health care throughout the country.³

The lack of mental health assistance in the community is worse in pediatric patients. There are about 5 million American children who have mental illnesses, including ADHD, schizophrenia, bipolar disorder, major depression, and other psychiatric disorders. Many of these conditions are severe enough to cause substantial life impairment, including an inability to live safely at home or attend school. Findings from a government report have demonstrated that 7,500 pediatric psychiatrists are currently available serving children and adolescents, which is far from the needed estimate of approximately 20,000. Children with mental problems have no adequate central place to go for help. This lack of services has been the reality for years throughout the United States.³

We agree with Hall and Myers that patients in a correctional facility are entitled both legally and ethically to a standard of care equivalent to that applied within the community. However, in reality, whether patients can receive that standard of care largely depends on what is dictated by health care policy, insurance companies, third party payers, and politicians' mandates, rather than by science and clinical research.

For example, methadone maintenance is a highly effective treatment option for opioid use disorder. A randomized controlled trial demonstrated the effectiveness of methadone maintenance therapy.⁴ The World Health Organization (WHO) recommends the provision of buprenorphine or methadone maintenance as the best practice for opioid agonist therapy in incarcerated individuals. Accordingly, many nations, including Iran, Canada, and most of the European Union, have made methadone maintenance therapy available in correctional facilities.⁴

In a recent article by Milloy and Wood,⁵ published in The Lancet, the authors commented, “Individuals with opioid dependence will often have their medically effective treatment such as methadone discontinued on incarceration in most U.S. correctional institutions.”

To this end, obviously, it is not the lack of science or research. Much more is needed to improve the access to mental health care in incarcerated patients with ADHD and other psychiatric disorders. A comprehensive common sense approach to mental health for those imprisoned, involving all stakeholders, should yield logical solutions and strategies, ultimately benefitting society.

• © 2016 American Academy of Psychiatry and the Law