Letters

• correctional psychiatry
• drug formulary
• informed consent

Editor:

Morris et al.,¹ the authors of “Drug Formularies in Correctional Settings,” make a very persuasive argument for the standardization of drug formularies at U.S. correctional facilities. Morris et al.¹ identify a critical topic of promoting uniformity and greater ease of access to pharmacotherapies for the prison population experiencing psychiatric illnesses.¹ Although the U.S. Federal Bureau of Prisons Health Services National Formulary lists formulary/nonformulary medications commonly used in psychiatric care, each correctional facility has its own unique list.² As the article explains, variations are attributed to site-specific drug policies, availability, and ease of laboratory services (such as phlebotomy) for monitoring, availability of licensed and trained personnel, and many other factors that ultimately dictate which drugs are available to a patient.¹

As a correctional psychiatrist, one of us (AK) grapples with these challenges daily, particularly with transfer patients who cannot access the same medication they were prescribed at a previous correctional facility. When patients who were successfully treated with antidepressants such as bupropion at a previous facility can no longer access the same medication, a lot of unnecessary problems occur. It would therefore be more practical for patients and prescribers if the corrections department in each state followed the standardized formulary set by the Bureau of Prisons to match federal prisons. This would then encourage standardization in facilities operated by counties and municipalities, including juvenile detention centers. A standardized drug formulary is, however, far more effective if there are accompanying nonformulary protocols. The added transparency offers patients a better overall understanding of why certain medications are included, excluded, restricted, or unavailable, further encouraging informed consent.

While Morris et al.¹ offer valuable recommendations for how to develop standardized drug formularies, we would like to take this opportunity to elucidate some other areas for improvement, such as the inclusion of atypical long-acting formulations for antipsychotic medications. Although second-generation antipsychotic medications are more expensive, they tend to decrease patient diversion and increase adherence, which is more cost-effective in the long run. Patients also report fewer side effects than with oral counterparts and benefit from a constant plasma level of the drug. These attributes aid patients in maintaining effective treatment once they re-enter society.

Morris et al.¹ suggest a model formulary derived from a methodical process that incorporates input and collaboration from correctional prescribers, evidence-based rationale for the inclusion or exclusion of specific drugs, well-planned alternatives, and standardization among correctional facilities. We agree with all these recommendations and further suggest the Bureau of Prisons and all state correctional departments adopt a recurring schedule for updating standardized formularies and nonformulary protocols. Prescribers from correctional facilities should take part in making evidence-based recommendations founded on the effectiveness of commonly used psychiatric medications, cost-effective alternatives, new medications and generics, as well as the omission of drugs that have the potential for abuse and misdirection.

• © 2021 American Academy of Psychiatry and the Law