Challenges in Correctional Psychiatry: Off-Label Prescribing

Worldwide, the number of persons in jails and prisons has risen to alarming rates, with a total of more than 10 million people held in places of detention. In the United States, 2.2 million are incarcerated. In Canada, the total number in 2014 was 37,864 for an incarceration rate of 106/100,000 of the population, as compared with 698/100,000 in the United States. The world incarceration rate, based on the United Nations estimates of national population levels, is 144 per 100,000. ¹

Since about the year 2000, the world prison population has grown by almost 20%, which is slightly above the estimated 18% increase in the world’s general population over the same period. The total prison population in the Americas rose by more than 40%; in Europe, by contrast, the total prison population has decreased by 21%. The prison population has increased by 14% in the United States, by more than 80% in Central American countries, and by 145% in South America. The female prison population total has increased by 50% since about 2000, whereas for males, the increase is 18%. The female total has increased proportionately more than for males on every continent. The proportion of women and girls in the total world prison population has risen from 5.4% in about 2000 to 6.8% today. ¹

In a survey of 62 studies from 12 countries of the prevalence of mental illness among offenders, Fazel and Danesh ² reported that 3.7% of men had psychotic illnesses, 10% had major depression, and 65% had a personality disorder, including 47% with antisocial personality disorder. Of women, 4.0% had psychotic illnesses, 12% had major depression, and 42% had a personality disorder, including 21% with antisocial personality disorder. ² Similar higher rates than in the general population have been reported by others, with prisoners several times more likely to have a major psychotic or mood disorder. Offenders are 10 times more likely to have antisocial personality disorder than the general population. ^{2 –5} Similarly, rates of anxiety and substance use disorders are higher in correctional institutions. ⁶

In Canada, the prevalence of mental illness among incarcerated populations is 2 to 3 times higher in federal corrections than in the general population and has increased in recent years. ⁷ In a study of Canadian federal offenders at intake, 30.0% of newly admitted male inmates in federal penitentiaries in the province of British Columbia met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for a mental disorder, with 12.0% having a serious mood or psychotic disorder. ⁸ More than a decade later, the Office of the Correctional Investigator reported that “the proportion of federal offenders with significant, identified mental health needs had more than doubled between 1997 and 2008.” ^9(p6) In a recent study of major mental disorders at intake of federal male inmates in Canada, 73% met criteria for any mental disorder, with more than 50% reporting a lifetime prevalence of major disorders. This is an alarming rate even after excluding substance- or alcohol-related or antisocial personality disorder. ¹⁰ Mood disorders had a lifetime prevalence of 30%, anxiety disorders 34.1%, and 44% had a lifetime prevalence of antisocial personality. ¹⁰

During the early 2000s, there was a 71.0% increase in the proportion of Canadian federal offenders diagnosed with mental disorders and an 80.0% increase in the number of offenders on prescribed medications. ⁹ More recent data revealed that from 2014 to 2015, 27.6% of Canadian federal offenders experienced mental health concerns, having required 1 or more treatments or inpatient stays related to mental health. ¹¹ These, then, are persons with significant and concurrent psychiatric treatment needs, often compounded by serious personality disturbance and substance use—in short, a challenging group of patients difficult to treat.

Correctional psychiatrists are faced with the daunting task not only of making a correct diagnosis but also of engaging the patient in a therapeutic relationship often fraught with attempts at malingering symptoms so as to obtain medications desirable in correctional settings for diversion or abuse (e.g., benzodiazepines, amphetamines, opioid agonist medications, sleep medications, quetiapine, bupropion, trazodone, tricyclics to be hoarded for suicide). Correctional psychiatrists provide care in settings that may be suboptimal in terms of person-centred care. In his 2014-2015 Annual Report, ¹² the Correctional Investigator stated that security-driven responses (e.g., force, restraints, and segregation) increasingly have been used to manage offenders who are self-injurious, suicidal, and/or mentally ill, providing further context to the challenging therapeutic setting within which correctional clinicians provide care.

In examining these issues, concerns have been raised regarding the high rates of psychotropic prescription in Canadian federal prisons, especially for female offenders ¹¹ ; the alleged use of such medications for purposes of control and institutional order ¹³ ; and the off-label use of psychotropic medications. ¹⁴

In this edition of the CJP, Brown and colleagues ¹⁵ address the above issues with specific reference to the Canadian federal prison context. The authors discuss earlier research that found rates of psychotropic prescriptions in Canadian federal prisons to be about 8 times higher than in the general population. These rates, disturbing as they may be, are in rough keeping with findings in other countries; for example, in U.S. jails, the rate is 1 to 3 times higher than in the general population; in England, it is 5 to 6 times higher; in Spain, the rate is almost 3 times higher; and in Western Australia, it is twice as high as in the general population. Given the report by Fazel and Danesh ² that worldwide rates of mental illness in prison are 2 to 4 times that of the community, the frequencies of these prescriptions are perhaps less alarming when regarded as a reflection of associated treatment needs.

The issue of “off-label” prescribing in places of detention has also been highlighted as a concern. ¹⁴ While attempting to avoid off-label prescriptions, the correctional psychiatrist, having excluded malingered symptoms in an offender with a severe substance use history, faces the challenge of how treat reported insomnia or how to treat severe, ongoing aggression in a person with personality disorder for whom only off-label options are available. In these instances, prescribing trazodone or quetiapine for sleep difficulties may (despite the risk of abuse and diversion) avoid risking relapse into benzodiazepine dependence; similarly, off-label use of mood stabilisers may represent a reasonable intervention in alleviation of aggression and violence.

These issues were the focus of the research by Brown et al. reported in this edition of the journal. ¹⁵ Using a mixed-methods approach, the researchers reviewed the files of 468 inmates (295 men, 173 women) randomly selected from 13 of 43 federal institutions, with at least 1 psychotropic medication prescribed. Authoritative international and Canadian formularies and texts guided the classification of prescriptions as either approved or off-label.

The findings from this study are encouraging indeed; rates of off-label prescriptions were of the same order as previous Canadian research on off-label prescribing rates in the general population and lower than international rates of such prescribing in general populations. The higher rates found when treating insomnia reflect the challenges when caring for persons with histories of substance abuse and dependence in diversion-prone settings. A further finding and source of confidence in correctional physicians is that the results did not support allegations that medications are prescribed off-label for the control of disruptive behaviours. Prescription of off-label medications was unrelated to gender or race, and there was no correlation with length of sentence, indicating that physicians are persistently professional and adhere to formularies consistently whether during earlier periods of adjustment or later in the sentence.

These findings are encouraging and indicative of professional and ethical prescribing practices among correctional colleagues. They are to be congratulated and encouraged.