The prevalence of serious mental illnesses in prisons is estimated to be significantly higher than in the community. The antipsychotic medication clozapine is very effective in managing treatment-resistant psychosis and may also reduce suicidal and self-injurious behaviors but is underused due to several logistic challenges. A partnership between the North Carolina prison system and University of North Carolina School of Medicine established a consultative system for clozapine initiations that has led to a 390% increase in the number of incarcerated people using clozapine over a 5-year period. This article reviews the benefits and challenges of clozapine use in corrections based on the North Carolina experience and practical strategies on how to expand use in a prison system.
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References
1.
AlvirJ. M. J., LiebermanJ. A., SaffermanA. Z., SchwimmerJ. L., & SchaafJ. A. (1993). Clozapine-induced agranulocytosis—Incidence and risk factors in the United States. New England Journal of Medicine, 329(3), 162–167. https://doi.org/10.1056/NEJM199307153290303
2.
AndersenH. S., SestoftD., LillebækT., GabrielsenG., HemmingsenR., & KrampP. (2000). A longitudinal study of prisoners on remand: Psychiatric prevalence, incidence and psychopathology in solitary vs. non-solitary confinement. Acta Psychiatrica Scandinavica, 102(1), 19–25. https://doi.org/10.1034/j.1600-0447.2000.102001019.x
3.
AppelbaumK. L., SavageauJ. A., TrestmanR. L., MetznerJ. L., & BaillargeonJ. (2011). A national survey of self-injurious behavior in American prisons. Psychiatric Services, 62(3), 285–290. https://doi.org/10.1176/ps.62.3.pss6203_0285
4.
AroraS., GeppertC. M. A., KalishmanS., DionD., PullaraF., BjeletichB., SimpsonG., AlversonD. C., MooreL. B., KuhlD., & ScalettiJ. V. (2007). Academic health center management of chronic diseases through knowledge networks: Project ECHO. Academic Medicine, 82(2), 154–160. https://doi.org/10.1097/ACM.0b013e31802d8f68
5.
BalbuenaL., MelaM., WongS., GuD., AdelugbaO., & TempierR. (2010). Does clozapine promote employability and reduce offending among mentally disordered offenders? Canadian Journal of Psychiatry, 55(1), 50–56. https://doi.org/10.1177/070674371005500108
6.
BlackD. W., GunterT., AllenJ., BlumN., ArndtS., WenmanG., & SieleniB. (2007). Borderline personality disorder in male and female offenders newly committed to prison. Comprehensive Psychiatry, 48(5), 400–405. https://doi.org/10.1016/j.comppsych.2007.04.006
7.
CohenT. R., MujicaC. A., GardnerM. E., HwangM., & KarmacharyaR. (2020). Mental health units in correctional facilities in the United States. Harvard Review of Psychiatry, 28(4), 255–270. https://doi.org/10.1097/HRP.0000000000000267
8.
FazelS., HayesA. J., BartellasK., ClericiM., & TrestmanR. (2016). Mental health of prisoners: Prevalence, adverse outcomes, and interventions. The Lancet Psychiatry, 3(9), 871–881. https://doi.org/10.1016/S2215-0366(16)30142-0
9.
FortneyJ. C., PyneJ. M., TurnerE. E., FarrisK. M., NormoyleT. M., AveryM. D., HiltyD. M., & UnützerJ. (2015). Telepsychiatry integration of mental health services into rural primary care settings. International Review of Psychiatry, 27(6), 525–539. https://doi.org/10.3109/09540261.2015.1085838
10.
KaneJ. M., AgidO., BaldwinM. L., HowesO., LindenmayerJ.-P., MarderS., OlfsonM., PotkinS. G., & CorrellC. U. (2019). Clinical guidance on the identification and management of treatment-resistant schizophrenia. Journal of Clinical Psychiatry, 80(2), 18com12123. https://doi.org/10.4088/JCP.18com12123
11.
KaneJ., HonigfeldG., SingerJ., & MeltzerH. (1988). Clozapine for the treatment-resistant schizophrenic: A double-blind comparison with chlorpromazine. Archives of General Psychiatry, 45(9), 789–796. https://doi.org/10.1001/archpsyc.1988.01800330013001
12.
KellyD. L., FreudenreichO., SayerM. A., & LoveR. C. (2018). Addressing barriers to clozapine underutilization: A national effort. Psychiatric Services, 69(2), 224–227. https://doi.org/10.1176/appi.ps.201700162
13.
KrausM. S., & KeefeR. S. E. (2007). Cognition as an outcome measure in schizophrenia. British Journal of Psychiatry, 191(Suppl. 50). https://doi.org/10.1192/bjp.191.50.s46
LuiS. S. Y., YangT. X., NgC. L. Y., WongP. T. Y., WongJ. O. Y., EttingerU., CheungE. F. C., & ChanR. C. K. (2018). Following instructions in patients with schizophrenia: The benefits of actions at encoding and recall. Schizophrenia Bulletin, 44(1), 137–146. https://doi.org/10.1093/schbul/sbx026
16.
LynchT. R., TrostW. T., SalsmanN., & LinehanM. M. (2007). Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3(1), 181–205. https://doi.org/10.1146/annurev.clinpsy.2.022305.095229
17.
ManuelJ. I., EssockS. M., WuY., PangilinanM., & StroupS. (2012). Factors associated with initiation on clozapine and on other antipsychotics among Medicaid enrollees. Psychiatric Services, 63(11), 1146–1149. https://doi.org/10.1176/appi.ps.201100435
18.
MathisD., & O'ReillyK. (2010). Point-of-care INR determination, Coumadin dosage changes, and use of a historical, self-updating database in a prison. Journal of Correctional Health Care, 16(2), 139–146. https://doi.org/10.1177/1078345809356536
19.
MelaM., & DepiangG. (2016). Clozapine's effect on recidivism among offenders with mental disorders. Journal of the American Academy of Psychiatry and the Law, 44(1), 82–90. http://www.ncbi.nlm.nih.gov/pubmed/26944747
20.
Novartis InternationalAG. (2010). Clozaril [package insert]. Novartis International AG.
21.
PrinsS. J. (2014). Prevalence of mental illnesses in U.S. state prisons: A systematic review. Psychiatric Services, 65(7), 862–872. https://doi.org/10.1176/appi.ps.201300166
22.
RohdeC., PolcwiartekC., CorrellC. U., & NielsenJ. (2018). Real-world effectiveness of clozapine for borderline personality disorder: Results from a 2-year mirror-image study. Journal of Personality Disorders, 32(6), 823–837. https://doi.org/10.1521/PEDI_2017_31_328
23.
SheitmanB. B., CatlettT. L., & ZarzarT. R. (2019). Limited availability and use of clozapine in state prisons. Psychiatric Services, 70(3), 256. https://doi.org/10.1176/appi.ps.201800470
24.
SiskindD., SiskindV., & KiselyS. (2017). Clozapine response rates among people with treatment-resistant schizophrenia: Data from a systematic review and meta-analysis. Canadian Journal of Psychiatry, 62(11), 772–777. https://doi.org/10.1177/0706743717718167
25.
StroupT. S., GerhardT., CrystalS., HuangC., & OlfsonM. (2014). Geographic and clinical variation in clozapine use in the United States. Psychiatric Services, 65(2), 186–192. https://doi.org/10.1176/appi.ps.201300180
26.
TiihonenJ., LönnqvistJ., WahlbeckK., KlaukkaT., NiskanenL., TanskanenA., & HaukkaJ. (2009). 11-year follow-up of mortality in patients with schizophrenia: A population-based cohort study (FIN11 study). The Lancet, 374(9690), 620–627. https://doi.org/10.1016/S0140-6736(09)60742-X
VelliganD. I., CarrollC., LageM. J., & FairmanK. (2015). Outcomes of Medicaid beneficiaries with schizophrenia receiving clozapine only or antipsychotic combinations. Psychiatric Services, 66(2), 127–133. https://doi.org/10.1176/appi.ps.201300085
29.
WimberleyT., MacCabeJ. H., LaursenT. M., SørensenH. J., AstrupA., HorsdalH. T., GasseC., & StøvringH. (2017). Mortality and self-harm in association with clozapine in treatment-resistant schizophrenia. American Journal of Psychiatry, 174(10), 990–998. https://doi.org/10.1176/appi.ajp.2017.16091097
30.
ZarzarT., & McEvoyJ. (2013). Clozapine for self-injurious behavior in individuals with borderline personality disorder. Therapeutic Advances in Psychopharmacology, 3(5), 272–274. https://doi.org/10.1177/2045125313484323
31.
ZarzarT. R., CatlettT. L., O'ConnellM. G., HarrelsonB. H., WilsonV. P., RashadG. N., MorrisD. B., WilliamsJ. B., PeeblesS. S., & SheitmanB. B. (2019). Clozapine reduces self-injurious behavior in a state prison population. Journal of the American Academy of Psychiatry and the Law, 47(1), 61–67. https://doi.org/10.29158/JAAPL.003818-19
32.
ZarzarT. R., MayoJ. P., RosenD. L., WilliamsJ. B., CatlettT. L., O'ConnellM. G., RashadG. N., ReedJ. G., BrownC. L., RobbinsB. V., NaftelH. A., & SheitmanB. B. (2021). Effect of clozapine on time assigned to restrictive housing in a state prison population. Journal of the American Academy of Psychiatry and the Law, 49(4), 581–589. https://doi.org/10.29158/JAAPL.210011-21
33.
ZarzarT. R., RosenD. L., MayoJ. P. III, O'ConnellM. G., CatlettT. L., ReedJ. G., WilliamsJ. B., & SheitmanB. B. (2022). Clozapine reduces recurrent suicidal and self-injurious behavior in treatment-refractory incarcerated individuals. Journal of Correctional Health Care, 28(5), 329–335. http://doi.org/10.1089/jchc.21.02.0014
