Prescribing psychotropic medication to prisoners

To the Editor

The paper by Griffiths et al. (2012) is described as a systematic review of psychotropic drug prescribing to prisoners. This is an important issue. The prevalence of serious mental illness among prisoners is high (Fazel and Seewald, 2012) and many do not receive treatment for their mental conditions (Morris et al., 2007; Simpson et al., 2003). The authors raise important issues about polypharmacy, dosage, supervision, monitoring and review of prescribing. They state that these issues are ‘associated with the prisoners’ environment’.

Unfortunately, the paper by Griffiths et al. (2012) is not a review of prescribing for prisoners. Of the 32 studies in the review, 14 studies are of prescribing in prison settings, but 18 studies are of hospital settings. Fewer than half of the papers address prescribing to, and the problems of, persons in prisons. The particular hospital settings cited are all health facilities, including maximum security and medium security forensic hospitals and tertiary health services for persons with intellectual disability. Forensic hospitals generally treat people with serious mental illness, and of these only a small subset are remand or sentenced prisoners. Forensic hospitals are generally (and most of the ones in this review) run by health authorities, not correctional authorities (for example, all the UK maximum and medium secure forensic services included).

Why should this matter? The types of disorders seen in a mental health outpatient clinic within a prison are very different to the ones seen in an inpatient forensic facility. The processes of assessment, prescribing (specialist or primary physician), dispensing and monitoring of medications are dramatically different between prison and hospital settings. For instance, prisoners almost always have the right to refuse mental health treatment. Forensic inpatients almost always are subject to compulsory orders of one sort or another.

The paper could have usefully separated the papers into those that were located in prisons, and compared these studies to psychotropic prescribing in other outpatient settings, from the forensic hospital papers which could have been compared with prescribing patterns in other mental health inpatient facilities. This would have told us more about the impact of settings on prescribing, as well as controlled to some extent for the very different clinical populations in the two settings.