The practice of prescribing in jails and prisons is often different from that in the community. Serious mental illness is common among incarcerated persons, as are co-morbidities such as substance use disorders, impulse-control disorders, attention-deficit/hyperactivity, and personality disorders. Operational requirements, staffing, and the physical plant of the institution may complicate the provision of treatment according to community standards. Problems related to medication nonadherence, as well as the pursuit of medications for nonmedical reasons, are frequently seen in these settings and may be managed differently than they are elsewhere. Existing practice resources rarely account for these challenges.
The original version of this practice resource was published in 2018.1,2 Since then, there have been important developments in the fields of psychiatry and correctional medicine. The Council of the American Academy of Psychiatry and the Law (AAPL) approved a task force to develop a revision on October 23, 2020. This version was approved by the AAPL Council on January 24, 2022.
This practice resource is a review of the literature and expert opinion to give guidance and assistance for providing psychiatric treatment to adults in correctional facilities, with a focus on psychopharmacology. The process of developing this document incorporated a thorough review that integrated feedback and revisions from AAPL members into the final draft. It reflects a consensus among members and experts about the principles and practice of prescribing psychiatric medications in correctional settings. Although recommendations are sometimes articulated when supported by research evidence, ethics standards, or expert opinion, this document should not be construed as a practice guideline, or as dictating the standard of care. Rather, it is intended to inform practice in this area.
The AAPL Practice Resource for Prescribing in Corrections is organized as follows. Section 1 states the intent and limitations of the document. Section 2 describes the legal framework for prescribing in jails and prisons. Section 3 focuses on operational matters, such as medication administration and systems-level oversight of prescribing practices. Section 4 covers general prescribing concerns, including continuity and coordination of care, assessment, the role of education and nonpharmacologic treatment, and informed consent. Section 5 describes evidence-based practices related to specific psychiatric diagnoses or problems. Section 6 examines topics that are not addressed elsewhere but may have an impact on prescribing decisions, such as special settings within correctional institutions, adverse effects of medications, medication nonadherence, treatment over objection, and misuse and diversion of psychotropic medications. All sections in this revision were updated to reflect the most current literature available. New sections are included on gender dysphoria (5.12), pregnancy and lactation (6.7), and continuity of care during a public health crisis or other emergency (6.8). The sections on psychiatric emergencies (5.1) and substance use disorders (5.11) have been substantially expanded.
This document is intended for the education of students, residents, and forensic fellows; for the orientation of professionals new to practicing in jails and prisons; as a resource for those currently providing psychiatric care for incarcerated persons; and to identify gaps in the existing knowledge base and current practices that present opportunities for research and policy development.
Acknowledgments
The authors acknowledge contributions to this version by Debra A. Pinals, MD, and Ashley Weiss, MD.
Footnotes
Original Task Force (2015–2018): Anthony Tamburello, MD, Jeffrey Metzner, MD, Elizabeth Fergusen, MD, Michael K. Champion, MD, CCHP, Elizabeth Ford, MD, Graham Glancy, MD, Kenneth Appelbaum, MD, Joseph Penn, MD, Kathryn Burns, MD, and Jason Ourada, MD.
Disclosures of financial or other potential conflicts of interest: None.
- © 2022 American Academy of Psychiatry and the Law
