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Background: The high prevalence of smoking (80%) in Greek correctional institutions is anticipated to result in high prevalence of COPD in such settings., Aim: The aim of the Greek obstructive luNg disease epidemiOlogy and health economics Study In corrective institutionS (GNOSIS) is to determine the prevalence of smoking and COPD among inmates and to assess the health-related quality of life., Methods: GNOSIS, a cross-sectional epidemiological study, was conducted between March 2011 and December 2011 in seven correctional institutions in Greece., Results: A total of 552 participants, 91.3% male, median age of 43.0 years (interquartile range: 35-53), were enrolled. COPD prevalence was 6.0% and was found to increase with age (18.6% among those ≥60 years), length of prison stay, and length of sentence. Of the participants diagnosed with COPD, 36.4% were diagnosed with Global initiative for chronic Obstructive Lung Disease (GOLD) stage I and 51.5% were diagnosed with stage II. Dyspnea severity was assessed as grades 0-1 on the medical research council dyspnea scale for 88.3%, while 31% reported ≥2 COPD exacerbations in the past year. Seventy-nine percent of the total number of the participants were smokers, with a median smoking of 20.0 cigarettes per day, while 42.9% were assessed as having a strong addiction to nicotine. The median EuroQol visual analog scale score was 70.0 (interquartile range: 60.0-90.0). Problems in the dimension of anxiety/depression were reported by 82.8%., Conclusion: The results of the study support the notion that the prevalence of COPD among inmates of Greek correctional institutions may increase in the following years. The findings underscore the importance of taking actions to limit COPD prevalence and its risk factors in the Greek correctional system.

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

Objective: Australia's prison population is growing at a rate well in excess of population growth. Indigenous Australians are over-represented by a factor of 13. Prisoners are a profoundly marginalised group characterised by complex health and social needs. Despite improvements in health during incarceration, poor health outcomes after release are common, and the net effect of incarceration is usually health depleting. Given the need for effective care coordination, primary care plays a pivotal role in meeting the health needs of this population. In this paper we review what is known about patterns of primary care utilisation in ex-prisoners, identify evidence-based strategies for increasing access to primary care in ex-prisoners, and consider how such contact may shape subsequent health service outcomes., Conclusions: Primary care is a necessary but not sufficient condition for effective post-release support. Positive outcomes may depend more on the quality than the quantity of care received. Given massive over-representation of Indigenous people in Australia's prisons, and compelling evidence of preventable morbidity and mortality after release from prison, effective models of care for this population are an important component of closing the gap in Indigenous life expectancy., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Background: Ukraine is experiencing one of the most volatile HIV epidemics globally, fueled primarily by people who inject drugs (PWIDs), and a parallel incarceration epidemic. Opioid substitution therapy (OST) is internationally recognized as one of the most effective forms of treatment for opioid dependence and is among the most effective HIV prevention strategies available, yet efforts to adopt it in Ukraine's Criminal Justice System (CJS) have been thwarted., Methods: To understand the reluctance of the Ukrainian CJS to adopt OST despite the overwhelming evidence pointing to its health benefits and improved criminal justice outcomes, we conducted the first survey of Ukrainian prison administrative, medical and custodial staff (N=243) attitudes towards addiction in general, OST, and people living with HIV/AIDS (PLWHA) in representative regions of Ukraine., Results: Results revealed that Ukrainian CJS workers' attitudes toward OST, PLWHA, and drug addiction were universally negative, but differed substantially along geographic and occupational lines. Whereas geographic and cultural proximity to the European Union drove positive attitudes in the west, in the southern region we observed an identifiability effect, as workers who worked directly with prisoners held the most positive attitudes. We also found that knowledge mediated the effect of drug intolerance on OST attitudes., Conclusion: In Ukraine, adoption of OST is more influenced by myths, biases and ideological prejudices than by existing scientific evidence. By elucidating existing attitudes among CJS personnel, this study will help to direct subsequent interventions to address the barriers to implementing evidence-based HIV prevention treatments., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The purpose of this paper is to critically evaluate the current evidence for peer support in prisons, in particular its contribution to working with prisoners who self-injure and the extent to which the success of peer support schemes such as the prison listeners, hinges upon staff's willingness to engage with the initiative., Design/methodology/approach: The review was constructed by using primary and secondary terms to search the literature. The studies focused on peer support in custody with reference to mental health and self-injury. Searches identified papers on the prison listener scheme and staff perspectives on prison peer support, as these formed a central focus of the review. Studies were excluded from the review if the participants' behaviours was explicitly linked to suicidal intent, as the review focused on self-injury as a coping strategy., Findings: A total of 24 studies were selected according to specific inclusion criteria (six were grey literature, 18 academic literature). Of the 24 studies ten studies focused on peer support and self-injury. Of the 24 studies the listener scheme was the focus of 16 studies, of these 16 studies self-injury and the listener scheme was a focus of eight studies., Originality/value: Evidence from the review suggests that prison peer support could be considered on a continuum depending on the different degrees of peer involvement.

Objective: The aim of this study was to devise and test a triage protocol to prioritise patients' dental needs in a prison environment. Secondary aims were to include in the triage process oral health promotion and information about accessing prison dental services. Also to work collaboratively with the prison staff to improve referrals to the dental services., Method: The triage system was devised to have three strands: (1) an oral health assessment conducted by the dental nurse during the induction process for each new prisoner; (2) a simple oral health examination conducted in monthly screening clinics; (3) the prioritisation of referrals from prison landing staff using the prisons computer system PRISM. The triage was evaluated by assessing the first 100 patients' records with regard to the prioritisation of the triage category at the time of the clinical dental examination., Results: Of the 100 patients triaged 95% were prioritised into the correct triage category. Seventy-two percent of patients were seen in the appropriate timeframe. Referral patterns from prison landing staff were improved along with interdisciplinary working in the prison. All new prisoners were seen within 72 hours of committal and received oral health advice and information on accessing dental services., Conclusion: This is the first triage system to be introduced into Hydebank Wood Prison, facilitating a targeted approach to dental care. It has improved access to the prison dental services; introduced oral health advice and information into the regular prison healthcare structure; and improved the efficiency of the clinical dental sessions. It is hoped to strategically address problems with waiting times and inequity in service utilisation.

Suicide and nonsuicidal self-injury represent significant causes of morbidity and mortality in jail settings. The New York City Department of Health and Mental Hygiene instituted a database of suicidal and nonsuicidal self-injuries in 2007. Between 2007 and 2011, there were eight deaths by suicide and 2,514 acts of self-injury, with the annual rate of self-injury increasing significantly throughout this time period. The most frequent methods of self-injury were lacerations (816), ligature tied around the neck (569), attempted overdose (501), and swallowed foreign objects (372). This review led to improvements in surveillance as well as improvement of the newly implemented electronic health record.

Objective: To assess the comprehensive care program for the mentally ill in prison (PAIEM), which has been implemented for 3 years in Spanish prisons with the aim of improving processes and results., Methods: Descriptive study of the data gathered from an anonymous questionnaire completed by members of the PAIEM team in prisons. Frequency distributions were obtained of all the variables relating to facts, attitudes, opinions, experiences, situations and processes of the PAIEM., Results: 91.2% of the PAIEM teams responded. Psychologists, educators, doctors and social workers were the professionals that collaborated most actively in the PAIEM (73%-84%) and were the ones to act most frequently as tutors. The mentally ill are usually located in ordinary modules (80%). The most commonly used activities for their psycho-social rehabilitation are self care (73%), education for health, preparation for daily life and social skills (more than 60%). Interventions with families are basically by telephone (79%). Bivariate analysis showed that the PAIEMs that operate most effectively are those that coordinate well with other technical teams, that prepare referral more than six months prior to release and ones where the NGOs process the referrals. Over 71% of the professionals observed improvements of disabilities and needs in over half the patients more than half of the professionals involved are satisfied (3.4/5) with their participation, although they acknowledge that there is a greater work load., Conclusions: The activities of the PAIEM are adequate, especially in the phases of early detection, stabilisation and rehabilitation and less so in the social incorporation phase, which improves when the third sector intervenes in referrals of patients to the social health care network outside prison.

Purpose: In spite of past and current efforts at implementing effective rehabilitative interventions in carceral settings, institutions of confinement are primarily concerned with the maintenance of order within their walls. The purpose of this paper is to better understand associations between inmates' developmental background and the experience of institutional discipline, to collect information on childhood maltreatment and disciplinary measures for a sample of Canadian prisoners., Design/methodology/approach: Information relative to socio-economic background, childhood maltreatment and experience of discipline while in custody was obtained using face-to-face interviews and institutional file review for a sample of 416 male and 106 female offenders in Canadian provincial institutions., Findings: Results from logistic regression analyses provided support for the association between childhood maltreatment and the experience of discipline, specifically in the form of increased monitoring from correctional staff. Furthermore, this association was found to be more pronounced for female offenders., Research Limitations/implications: The findings highlight the need to incorporate a developmental perspective to current understanding of the use of disciplinary interventions in a prison environment. Such an approach may allow for preventing the enactment of a cycle of coercion, with negative consequences for the inmates., Originality/value: This study is original in its use of latent variable analytic methods to uncover the structure underlying the construct of childhood maltreatment in adult offenders. In addition, it provides valuable data of interest to researchers, corrections personnel and policy makers on the possible links between earlier developmental experiences and adjustment to the prison environment.

Objective: The objective was to explore perspectives on reasons for psychotropic medication use in prisons., Method: We recruited a purposive sample of healthcare staff and patients prescribed psychotropic medicines from four East of England prisons. Participants took part in qualitative, semistructured interviews, which were recorded, transcribed and analyzed thematically., Results: While patients and healthcare staff viewed psychotropic medicines primarily as a treatment for reducing symptoms of mental illness, they were also used as a coping strategy and to reduce insomnia. Appropriate psychotropic prescribing was also thought to contribute towards the rehabilitation agenda and helped to maintain order in prisons. Staff voiced concerns regarding possible overreliance on psychotropic medicines. However, patients perceived insufficient access to alternative, nonpharmacological forms of treatment and support in prison., Conclusion: Psychotropic medicines are used for multiple purposes in prisons and are generally considered a useful resource. Nonetheless, further work may be needed to find the right balance between psychotropic medicines and alternative, nonpharmacological therapies., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Renewed interest in prisoner rehabilitation to improve postrelease outcomes occurred in the 1990s, as policy makers reacted to burgeoning prison populations with calls to facilitate community reintegration and reduce recidivism. In 2003, the Federal government funded grants to implement locally designed reentry programs. Adult programs in 12 states were studied to determine the effects of the reentry programs on multiple outcomes., Research Design: A two-stage matching procedure was used to examine the effectiveness of 12 reentry programs for adult males. In the first stage, "intact group matching" was used to identify comparison populations that were similar to program participants. In the second stage, propensity score matching was used to adjust for remaining differences between groups. Propensity score weighted logistic regression was used to examine the impact of reentry program participation on multiple outcomes measured 3 months after release., Subjects and Data: The study population was 1,697 adult males released from prisons in 2004-2005. Data consisted of interview data gathered 30 days prior to release and approximately 3 months following release, supplemented by administrative data from state departments of correction and the National Crime Information Center., Results and Conclusions: Results suggest programs increased in-prison service receipt and produced modest positive outcomes across multiple domains (employment, housing, and substance use) 3 months after release. Although program participants reported fewer crimes, differences in postrelease arrest and reincarceration were not statistically significant. Incomplete implementation and service receipt by comparison group members may have resulted in insufficient statistical power to identify stronger treatment effects.

Understanding the prevalence and type of personality disorder within prison systems allows for the effective targeting of resources to implement strategies to alleviate symptoms, manage behaviour and attempt to reduce re-offending. This study aimed to determine the prevalence of personality disorder (PD) traits within a local urban high-turnover adult male prison with a remand/recently sentenced population in London, UK. The International Personality Disorder Examination - Screening Questionnaire (IPDE-SQ) self-administered questionnaire (ICD-10 version) was completed by 283 prisoners (42% completion rate). 77% of respondents reached the threshold for one or more PDs. The most common PD types were Paranoid PD (44.5%), Anankastic PD (40.3%), Schizoid PD (35%) and Dissocial PD (25.8%). These results confirm and extend existing knowledge regarding the prevalence of PD in prison populations into a high-turnover, urban, remand population. The stark comparison with community samples indicates that a more equitable standard of service delivery within the criminal justice system, focussing on preventive and early intervention services, is now required., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Court decisions taking away someone's freedom by requiring them to serve a jail sentence should not deny them access to the same health care available to free citizens in full compliance with patient confidentiality. Health institutions, responsible for administering somatic care, offer a comprehensive response to the medical needs of those under justice control, both in jails and conventional care units. For a physician, working in the correctional setting implies accepting its constraints, and violence, and protecting and enforcing fundamental rights, as well as rights to dignity, confidential care and freedom to accept or refuse a treatment.

Correctional psychiatry is a patient-centered medicine, similar to that practiced anywhere else, independent, governed by the same objectives (deliver the highest standard of care) and the same obligations (respect patients' dignity, their informed consent and the confidentiality they are entitled to). However, it has been a victim of its own success. As correctional psychiatry was expanding, so was the psychiatric morbidity among inmates. Consequently, the initial clinical hypothesis, which was based on the integrative function of correctional psychiatry, created in the early eighties, comes up against the segregating impact of an intramural specialty practice.

Compassionate release is a program that allows some eligible, seriously ill prisoners to die outside of prison before sentence completion. It became a matter of federal statute in 1984 and has been adopted by most U.S. prison jurisdictions. Incarceration is justified on 4 principles: retribution, rehabilitation, deterrence, and incapacitation. Compassionate release derives from the theory that changes in health status may affect these principles and thus alter justification for incarceration and sentence completion. The medical profession is intricately involved in this process because eligibility for consideration for compassionate release is generally based on medical evidence. Many policy experts are calling for broader use of compassionate release because of many factors, such as an aging prison population, overcrowding, the increasing deaths in custody, and the soaring medical costs of the criminal justice system. Even so, the medical eligibility criteria of many compassionate-release guidelines--which often assume a definitive prognosis--are clinically flawed, and procedural barriers may further limit their rational application. We propose changes to address these flaws.

Background: After prison release, offenders with heroin use problems are at high risk of relapse and overdose death. There is a particular need for treatments that can be initiated in prison and continued after release into the community. Methadone maintenance treatment has been shown to reduce heroin use, criminality and mortality. Naltrexone implant treatment has not previously been evaluated in prison settings., Methods: This study compares the effects of naltrexone implants and methadone treatment on heroin and other illicit drug use, and criminality among heroin-dependent inmates after release from prison., Results: Forty-six volunteers were randomly allocated to naltrexone implants or methadone before release. Intention-to-treat analyses showed reductions in both groups in frequency of use of heroin and benzodiazepines, as well as criminality, 6 months after prison release., Conclusions: Naltrexone implants may be a valuable treatment option in prison settings., (2010 S. Karger AG, Basel.)

Setting: Rio de Janeiro (RJ) State prisons, where tuberculosis (TB) is highly endemic., Objective: To measure TB prevalence, identify risk factors and ascertain the most appropriate screening method among inmates of the RJ prisons., Design: Systematic chest X-rays (CXRs) were performed in 1696 male inmates of three RJ prisons. Inmates were selected for sputum examination and culture if their CXRs showed evidence of any pulmonary, pleural or mediastinal abnormality. TB diagnosis was based on bacteriological results or, if bacteriological results were negative, on response to TB treatment., Results: TB prevalence was 2.7% (46/1696), and 32/46 cases (69%) were bacteriologically confirmed, including 19 smear-positive cases. CXR lesions were extensive in 43% of cases. In the logistic regression model, TB-associated variables were being illiterate (adjusted OR 2.10, 95%CI 1.02-4.34), cough >or=3 weeks (aOR 2.85, 95%CI 1.54-5.27), history of TB treatment (aOR 3.61, 95%CI 1.76-7.39), and living in Rio City suburbs (aOR 4.54, 95%CI 1.02-20.07) and in Rio City (aOR 5.48, 95%CI 1.29-23.33). A screening based on cough >or=3 weeks followed by sputum smear examination would have identified only 9 of the 46 cases., Conclusion: These results call for screening on admission to prison based, if feasible, on CXR, and demonstrate the urgent need to improve detention conditions and medical assistance in police remand cells.

Nationwide, methicillin-resistant Staphylococcus aureus (MRSA) presents an increasing hazard to inmates. This article reviews our 1-year (2005) experience with skin and soft tissue infections (SSTIs) in a medium-sized county jail. As part of a quality assurance process, the authors cultured every SSTI presenting to our institution. The authors found that a full 68% of SSTIs (50 of 74) were MRSA species, and new MRSA cases presented regularly throughout the year. Inmates usually have poor understanding of infectious processes and need constant support and education. Correctional health care providers must approach their antibiotic treatment for today's SSTIs with the knowledge that MRSA is very common. This article reviews treatment options, preventive measures, and institutional hygiene.

HIV illness has emerged as one of the pressing public health concerns in correctional systems. This article is a qualitative exploration of the state of health care services with regard to HIV/AIDS in three correctional facilities in Maharashtra state in India. Case studies of 10 reported cases of HIV-positive inmates were prepared from their narratives obtained through face-to-face in-depth unstructured interviews. The data were analyzed thematically. High-risk behavior among prisoners, inadequate access to health care services for HIV-positive inmates, and lack of HIV/AIDS prevention programs emerged as some of the major areas of concern. Collaboration of the Prison Department with the National Aids Control Programme is a key recommendation.

Approximately 60% to 70% of all individuals on parole are reincarcerated within 3 years of release from prison. The purpose of this study was to examine the impact of parolees' correctional experiences on their reintegration efforts. Qualitative data were collected via individual interviews with 17 male parolees. Findings revealed 3 types of correctional system adaptations-acquiescence, inaction, and aggression-and 2 patterns of system dependency-reluctant acceptance and complete reliance. Effective health and reintegration policy for individuals on parole must integrate the problems and issues of long-term involvement in correctional and criminal life into programs and interventions for these individuals.

No evidence-based interventions (EBIs) have been designed for implementation during the critical period when HIV-infected prisoners are being transitioned from prison to the community. We therefore conducted formative research aimed at systematically selecting and adapting an EBI that integrates HIV risk reduction and adherence to antiretroviral therapy to implement among HIV-infected prisoners transitioning back to the community. Our formative research involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews with key stakeholders in community and correctional settings and members of the target population. Between September 2006 and February 2007, structured one-on-one interviews were conducted with key stakeholders in the target organizations (n = 19) and with members of the target population (n = 26) in Hartford and New Haven, Connecticut. Based on the formative research, we abbreviated and adapted the Holistic Health Recovery Program targeting people living with HIV (HHRP+), an EBI, to consist of four 45-minute sessions that cover a range of prespecified topics so that participants may individually apply intervention content as needed to their own HIV risk profile and antiretroviral adherence issues. The EBI was adapted so that it could be provided in an individual or group format and delivered in either consecutive or weekly sessions and so that it could be provided within the prison system and delivered just prior to release, or in a community-based setting where it could be delivered immediately after release. This study provides a comprehensive exemplar of the process of selecting and adapting an EBI taking into account both empirical evidence and input from target organization stakeholders and target population members in real-world settings where high-risk populations are concentrated.

Since 2001 hepatitis B vaccination has been offered to prisoners on reception into prisons in England and Wales. However, short campaigns of vaccinating the entire population of individual prisons have achieved high vaccination coverage for limited periods, suggesting that short campaigns may be a preferable way of vaccinating prisoners. A model is used that describes the flow of prisoners through prisons stratified by injecting status to compare a range of vaccination scenarios that describe vaccination on prison reception or via regular short campaigns. Model results suggest that vaccinating on prison reception can capture a greater proportion of the injecting drug user (IDU) population than the comparable campaign scenarios (63% vs. 55.6% respectively). Vaccination on prison reception is also more efficient at capturing IDUs for vaccination than vaccination via a campaign, although vaccination via campaigns may have a role with some infections for overall control.

Objective: To investigate which aspects of treatment satisfaction are the best predictors of improved health, improved mental health and achievement of abstinence in drug misuse treatment services., Design: Data were collected as part of the Drug Outcome Research in Scotland study, a prospective cohort study designed to evaluate drug misuse treatment provided in Scotland. Data were collected using a structured interview. Participants were recruited between 1 October 2001 and 30 June 2002. Follow-up interviews were carried out approximately 8 months later. Logistic regression analysis is used to explore client satisfaction with treatment on outcomes, using the Treatment Perceptions Questionnaire (discussed in Marsden et al., Assessing client satisfaction with treatment for substance use problems and the development of the Treatment Perceptions Questionnaire (TPQ). Addict Res 2000;8:455-70)., Setting: Prison, residential and community facilities., Participants: A total of 841 drug users starting a new episode of drug treatment in Scotland in 2000-01., Interventions: Methadone, substitute drugs other than methadone, residential rehabilitation, residential detoxification and non-clinical., Main Outcome Measures: Reported improvements in physical health, mental health and abstinence., Results: Client satisfaction predicted positive outcomes, independent of treatment setting. Predicting abstinence and improved physical and mental health were the items: 'I have received the help that I was looking for' and 'The staff have helped to motivate me to sort out my problems'., Conclusions: Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement.

This study of 300 women and 300 men graduates of a boot camp finds that there are noteworthy gender differences in predictors of tenure in the community without criminal recidivism in a 5-year follow-up. The Cox proportional hazards models show that urban residence, childhood and recent abuses, living with a criminal partner, selling drugs, stress, depression, fearfulness, and suicidal thoughts are stronger positive predictors of recidivism for women than for men. Men are more likely to return to prison because of criminal peer associations, carrying weapons, alcohol abuse, and aggressive feelings. Job satisfaction and education lengthen time in the community more for men than women, whereas the number of children and relationships are more important to tenure in the community for women. The implications for the findings for theory are discussed.

Preventive detention can be ordered, if a person falls back into crime repeatedly and shows a "disposition to commit substantial offences". In the trial and at subsequent points of time expert opinions supporting this personal disposition have to be obtained. However up to now it is not clear on which basis such statements should be made. On the basis of a retrospective investigation of the author's own expert opinions the paper discusses the relevance of Hare's psychopathy concept for opinions on criminal disposition.

The development and implementation of a departmental performance evaluation system for a correctional managed care pharmacy are described. Health care services for approximately 150,000 offenders within the Texas Department of Criminal Justice are provided through an arrangement with two university systems, the University of Texas Medical Branch (UTMB) and Texas Tech University Health Sciences Center. UTMB provides all distributive pharmacy services through a central pharmacy located in Huntsville, Texas. The pharmacy department distributes 9,000-15,000 medication orders daily to over 140 facilities. Each department within UTMB Correctional Managed Care is evaluated against predetermined quality indicators. This evaluation system is collectively called the operational performance evaluation system (OPES) and is used, in part, to determine pay-for-performance eligibility. Before fiscal year 2001, pharmacy distributive services were provided under a third university system. Joining the UTMB system required the pharmacy department to not only participate in OPES but to develop quality indicators and measurement systems to evaluate departmental performance. Indicators were chosen to reflect a commitment to quality while assuring appropriate productivity in the provision of pharmaceutical care. Seven pharmaceutical care quality indicators were chosen and weighted by perceived importance. A system for data collection, measurement, and reporting was also developed. Implementation of a departmental performance evaluation system provides a means to measure service quality, identify areas of weakness, track performance over time, and lower costs. By setting concrete goals, this system raises awareness and promotes interdependence among department personnel.

The Forensic Algorithm Project (FAP) was born of the need for a holistic approach in the treatment of the inmate with schizophrenia. Schizophrenia was chosen as the first entity to be addressed by the algorithm because of its refractory nature and high rate of recidivism in the correctional setting. Schizophrenia is regarded as a spectrum disorder, with symptom clusters and behaviors ranging from positive to negative symptoms to neurocognitive dysfunction and affective instability. Furthermore, the clinical picture is clouded by Axis II symptomatology (particularly prominent in the inmate population), comorbid Axis I disorders, and organicity. Four subgroups of schizophrenia were created to coincide with common clinical presentations in the forensic inpatient facility and also to parallel 4 tracks of intervention, consisting of pharmacologic management and programming recommendations. The algorithm begins with any antipsychotic medication and proceeds to atypical neuroleptic usage, augmentation with other psychotropic agents, and, finally, the use of clozapine as the common pathway for refractory schizophrenia. Outcome measurement of pharmacologic intervention is assessed every 6 weeks through the use of a 4-item subscale, specific for each forensic subgroup. A "floating threshold" of 40% symptom severity reduction on Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale items over a 6-week period is considered an indication for neuroleptic continuation. The forensic algorithm differs from other clinical practice guidelines in that specific programming in certain prison environments is stipulated. Finally, a social commentary on the importance of state-of-the-art psychiatric treatment for all members of society is woven into the clinical tapestry of this article.

The Addiction Treatment Unit is a dual diagnosis program which exists in the California Department of Corrections. It is housed in the California Medical Facility in Vacaville, California. Program residents must meet the diagnostic criteria of having a major mental disorder substantiated by a DSM-IV Axis I diagnosis and also meet the criteria for a substance abuse/dependence disorder. All patients are housed in one wing of the facility, which is based on the format of a modified therapeutic community and focuses on the concept of recovery. A multidisciplinary treatment team comprised of a psychiatrist, a psychologist, a social worker and a psychiatric technician delivers clinical interventions, including individual and group therapy as well as medication management. The focus of the drug treatment aspect is an Alcoholics Anonymous/Narcotics Anonymous approach based on 12-Step philosophy. Research involving other therapeutic communities running in prisons is discussed as is the aspect of dual diagnosis programs. Logistical and environmental constraints which pose challenges to running the Addiction Treatment Unit are considered. A summary section reflects on aspects which have been successful, what has not worked or has been changed and upcoming program revisions.

In this article, the authors reflect on the lessons of their Stanford Prison Experiment, some 25 years after conducting it. They review the quarter century of change in criminal justice and correctional policies that has transpired since the Stanford Prison Experiment and then develop a series of reform-oriented proposals drawn from this and related studies on the power of social situations and institutional settings that can be applied to the current crisis in American corrections.

The tremendous growth in state and federal correctional populations has focused greater attention on the needs of mentally ill and substance abusing inmates. Although an estimated 3-11% of prison inmates have co-occurring mental health (psychotic and major mood) disorders and substance abuse disorders, few treatment programs are described in the literature and there is little available information regarding effective treatment strategies for this population. The current study provides an integrative review of seven 'dual diagnosis' treatment programs that recently have been developed in state and federal prisons. Many of these have evolved from existing substance abuse treatment programs and approaches. Key program components include an extended assessment period, orientation/motivational activities, psychoeducational groups, cognitive-behavioral interventions such as restructuring of 'criminal thinking errors', self-help groups, medication monitoring, relapse prevention, and transition into institution or community-based aftercare facilities. Many programs use therapeutic community approaches that are modified to provide (a) greater individual counseling and support, (b) less confrontation, (c) smaller staff caseloads, and (d) cross-training of staff. Research is underway in three of the seven sites to examine the effectiveness of these new programs.

This article profiles the suicide prevention practices at a large metropolitan jail, a facility that experienced nine inmate suicides in a recent 24-month period. The suicide rate in this facility was found to far exceed the rate for jails of comparable size as well as the national rate of jail suicides. The nine suicides are summarized and common features (including the issue of protective custody) of the deaths and systemic jail deficiencies are discussed. The process by which the jail system developed a suicide prevention program based upon the principles of staff training, identification/screening, communication, levels of supervision, housing, and intervention is offered.

Intermediate Care Programs were jointly established by the New York State Office of Mental Health and Department of Correctional Services to reduce risk and better manage inmates with psychiatric disorders. In an earlier study, we collected data from the mental health and corrections records of 209 inmates who were admitted to Intermediate Care Programs. Our analysis of those data showed there were significant reductions in the mean number of serious problem behaviors, correctional restrictions, and mental health crisis services during the six months before and after admission. In the present study, we used Wilcoxon tests to assess changes in the distribution of scores on variables assessed by the earlier study. The Wilcoxon tests showed there were significant changes in the distribution of scores on most of the variables. We then focused on inmates who scored positive on the respective variables, either before admission or after admission, and determined the percentage who improved, stayed the same, or worsened on those variables. The highest reductions occurred in mental health observations (65%), suicide attempts (63%), and emergency medications (43%). Lower reductions occurred in correctional infractions and restrictions (26% to 31%). Overall, the data from this study and our earlier one suggest that Intermediate Care Programs are effective in reducing risk and managing inmates with psychiatric disorders.

As part of a class action suit, the author was asked to assess the quality of mental health services in eight prisons in Georgia. This paper describes the background to the suit, reviews selected literature on assessing quality of correctional mental health care, and describes methods used to survey prison mental health services. A standardized survey instrument was developed with probe questions to assess the quality of services. Individual cases were reviewed, inmates were interviewed, and the quality of mental health structures, processes, and outcomes were assessed. Key findings from the survey are summarized. The author concluded that the quality of mental health services in the prisons surveyed was so low overall as to constitute a pattern of deliberate indifference, and that the services were constitutionally inadequate.