433893

2012
ANP46510.1177/0004867411433893Griffiths et al.ANZJP Articles

Review

Australian & New Zealand Journal of Psychiatry

A systematic review of psychotropic 46(5) 407­–421

DOI: 10.1177/0004867411433893

drug prescribing for prisoners © The Royal Australian and

New Zealand College of Psychiatrists 2012
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Elise V Griffiths1, Jon Willis2 and M Joy Spark1

Abstract

Objective: To conduct a review of the literature on prescribing psychotropic drugs for prisoners.
Methods: Articles were retrieved from nine databases, reference lists, citations, governmental prison websites, and
contact with authors. The articles included were written in English, focused on adults’ time as prisoners, included at least
one drug of interest, and discussed prescribing. Thirty-two articles met these inclusion criteria.
Results: Five main themes were identified from the reviewed studies: polypharmacy, high-dose therapy, duration of
treatment, documentation and monitoring, and issues associated with the prisoners’ environment.
Conclusions: Consideration of these themes within the included studies identified areas for future research, particu-
larly models of good practice, as numerous descriptions of poor practice exist. Policy-makers and prescribers should
review current systems and practices, to ensure the care being offered to prisoners is optimal.

Keywords
Psychotropic drugs, forensic medicine, forensic psychiatry, physician’s practice patterns, inappropriate prescribing

Introduction
Mental illnesses are prevalent in today’s society, with
almost half of the Australian adult population experiencing
one or more mental disorder(s) at some stage in their life
(Slade et al., 2009). Deinstitutionalisation of the mentally
ill aimed to improve integration with the rest of the com-
munity, but has resulted in many patients being admitted
into correctional facilities instead (Baillargeon and
Contreras, 2001; Buscema et al., 2000). Around the world,
prisons may now be considered among the main centres for
treatment of the mentally ill, despite the environment being
the antithesis of everything required (Bressington et al.,
2008; Buscema et al., 2000; Erickson et al., 2007; Gray
et al., 2008; Lund et al., 2002). The correctional facility
environment may also result in the development of disor-
ders, especially insomnia and anxiety (Elger et al., 2002;
Feron et al., 2005; Lekka et al., 2003).
Psychotropic drugs may be used to manage the symp-
toms of mental illnesses (Koda-Kimble et al., 2009;
and nursing homes (Byrne, 2008; Gisev et al., 2006;
Goldney and Bain, 2006; Greve and O’Connor, 2005; Knott
and Ibister, 2008; Magliano et al., 2004; Meagher and
Moran, 2003). These studies found problems such as over-
and under-dosing, multiple ‘when required’ (pro re nata, or
PRN) orders, prescriptions for two drugs from the same
therapeutic class (polypharmacy) and significant drug
interactions. All of these issues stem from sub-optimal pre-
scribing and poor patient outcomes may result.
To date, the research on medication use by prisoners has
primarily focused on the use of antipsychotic medications,
rather than the more encompassing category of psycho-
tropes (Alia-Klein et al., 2007; Baillargeon and Contreras,
2001; Bains and Nielssen, 2003; Bressington et al., 2008;
1School of Pharmacy and Applied Science, La Trobe University, Bendigo,
Australia
2Department of Public Health & Environment, La Trobe University,

Psychotropic Expert Group, 2008; Rossi, 2009). Without Bendigo, Australia

such medications, the incidence of suicide, relapse and vio-
Corresponding author:
lent behaviour all markedly increase (Erickson et al., 2007;
M Joy Spark, School of Pharmacy and Applied Science, Faculty of
Herings and Erkens, 2003). A low rate of adherence to pre- Science, Technology and Engineering, La Trobe University, PO Box 199,
scribing guidelines for psychotropes has consistently been Bendigo, VIC 3552, Australia.
identified in hospitals, community mental health centres Email: j.spark@latrobe.edu.au

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408 ANZJP Articles
Lund et al., 2002; Martin et al., 2008; Veysey et al., 2007).
However, there is a small body of literature on anxiolytics,
hypnotics and antidepressants (Elger, 2004; Fos-Claver and
Soler-Garcia, 2008; Lekka et al., 2003).
There are several reasons why it was important to deter-
mine how psychotropic medications are being prescribed
for prisoners, and more specifically if any areas for
improvement exist. Firstly, the internationally recognised
human rights laws state that prisoners retain their right to
be treated with respect and dignity, and therefore should
not be subjected to cruel punishment (United Nations High
Commissioner for Human Rights, 2007). The right to qual-
ity health services is also inherent in this concept (Bruce
and Schleifer, 2008). Secondly, psychotropic medications
may have severe adverse effects, including blood disor-
ders, neuroleptic malignant syndrome, serotonin toxicity,
and hypertensive crisis (Rossi, 2009). Optimal prescribing
is required to minimise the risk of iatrogenic morbidity or
mortality. Thirdly, time in a correctional facility may be an
opportunity to improve the well-being of people who may
not have regular contact with health professionals whilst in
the community (Feron et al., 2005). Quality health care
may improve their quality of life, as well as potentially
reducing the risk of reoffending (Gray et al., 2008). For
these reasons, it is important that a comprehensive under-
standing of prescribing practices is obtained. The aim
of this review was to compile, evaluate and discuss the
literature on the prescribing of psychotropic drugs for
prisoners.
Methods
Search strategy and selection criteria
Qualitative and quantitative studies discussing the use of
psychotropic medications for prisoners were reviewed
using a protocol. The list of medications considered
(Appendix 1) consisted of the drugs common to the psy-
chotropic or psychiatric section of three nationally recog-
nised references (Koda-Kimble et al., 2009; Psychotropic
Expert Group, 2008; Rossi, 2009). Facilities where prison-
ers may be treated, such as prisons, jails, and forensic wards
or hospitals, were included. A prescribing issue was defined
as any practice by a doctor that was not in accordance with
guidelines or accepted best practice, or any factor that
potentially adversely affected the quality of prescribing. All
levels of evidence were accepted, provided the study was
methodologically sound.
In the first fortnight of October 2009, the following
databases were searched: AMED, AMI, APAIS Health,
CINAHL, CINCH-Health, Cochrane Library, DRUG,
eMedicine Clinical Knowledge Base, Embase, International
Pharmaceutical Abstracts, MEDLINE, Proquest 5000
International, PsycINFO, SCOPUS, and Web of Science.
The search terms used were: (psychotrop* OR neurolept*
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OR psychoacti* OR antipsychot* OR antidepress* OR
anxioly* OR hypnot* OR sedati* OR dependence OR
mood stabilis*) AND (prison* OR correction* OR jail
OR forensic OR gaol OR inmate OR felon OR incarcer-
ate* OR offender* OR penitentiary OR remand OR con-
vict*) AND (prescri*).
The inclusion criteria were: the study focused on adults’
time as prisoners and one or more drugs of interest, and
discussed prescribing. The study could be set anywhere in
the world, but the full text had to be available in English, as
translation services were not available, and published
between January 1999 and October 2009. The only imme-
diate exclusion criterion was an inability to access the full
text article.
Initial screening was based on title and abstract; full text
documents were obtained for the articles appearing to meet
the inclusion criteria. Where more than one article was
written using the same raw data, both were included if at
least one new prescribing issue was raised in the second
article. The reference list of every relevant article was
screened for potential additional useful articles, and the rel-
evant articles were also searched in Google Scholar,
SCOPUS and Web of Science for useful citations. Each of
the eight Australian state and territory government correc-
tional services websites and one specialised journal, the
Journal of Correctional Health Care, were searched for
related research. To minimise publication bias, 23 authors
of included articles were emailed requesting further pub-
lished or unpublished research articles and suggestions for
other avenues for investigation.
During the full text assessment, the relevance of each
study to the review was considered, as was the level of evi-
dence, potential for bias, and methodological strengths and
weaknesses. The latter were assessed using a checklist
(Liberati et al., 2009) for qualitative or quantitative studies
(CASP, 2006), and using a tool for assessing risk of bias
(The Cochrane Collaboration, 2009). Reports were classi-
fied as higher or lower quality evidence, based on the meth-
odology. The relatively small body of literature in existence
on this topic discouraged exclusion of studies. Consequently,
all relevant studies have been included, with notes on the
lower-quality studies whose results must be interpreted
cautiously.
Data extraction and study validity
assessment
The data extraction was conducted on all retrieved articles
by one author (EG), and then discussed with a second
author for confirmation (JW). Differences in opinion were
resolved by discussion. A spreadsheet was created for the
collection and collation of the extracted data based on a
template (Torgerson, 2003). This was completed twice:
data was extracted, and then several days later each article
was read again and the information on the spreadsheet
Griffiths et al. 409

Figure 1.  Data search flow diagram.

595 records identified

226 duplicate records
through database searching

342 records excluded as

369 records screened
irrelevant

27 records identified as
6 records identified through other relevant
sources:
Reference lists (2)
Citations (1)
Research proposal (1)
Unpublished research (1) 1 record excluded
Searching of specialised journal (1) 33 records to be
through inability to
included in review
access full text

32 records to be
included in review

was confirmed and augmented. Clarification was sought Identified themes

by email from the corresponding authors of several arti-
cles as to whether their study sample included prisoners.
There were multiple categories in the data extraction
spreadsheet, including referencing details, study setting
and design, objective, participants, results, a quality
appraisal for strengths and weaknesses, and prescribing
issues.
Points arising from the data were coded, and codes were
gradually refined and rechecked against original articles to
ensure accurate representation of the identified prescribing
issues. These were then grouped into themes, and have
been reported in accordance with the tenets of the PRISMA
Statement (Liberati et al., 2009).
Results
Database searching identified 595 reports (see Figure 1 for
flow diagram). Of these, 226 were excluded through dupli-
cation, and 342 due to an irrelevant title or abstract. An
additional six reports were found using other planned
search methods. The full text version of one article was not
obtainable. Data was extracted from the final sample of 32
articles (Tables 1 and 2).
An extraordinarily high prevalence of mental illness
amongst prisoners was noted, and the possible contribution
of the setting to this finding, especially for insomnia and
anxiety, was suggested in the literature. However, there was
often a lack of comparisons in the prevalence of the issues
identified between subgroups in the populations, such as
between genders, age groups and ethnicities.
Theme one: polypharmacy
The most common theme identified was polypharmacy
(Acosta-Armas et al., 2004; Bains and Nielssen, 2003;
Bressington et al., 2008; Dalvi et al., 2003; Gray et al., 2008;
Harrington et al., 2002; Haw and Stubbs, 2003a; Jukic et al.,
2008; Lelliott et al., 2002; Martin et al., 2008; Parker et al.,
2002; Paton et al., 2002; Renkel and Rasmussen, 2006;
Sazhin and Reznik, 2008; Tavernor et al., 2000; Walker and
MacAulay, 2005). Many national and international guide-
lines state that the use of more than one antipsychotic medi-
cation is strongly discouraged in almost all situations
(Psychotropic Expert Group, 2008). The incidence and sup-
posed advantages of combining different dosage forms,

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 Table 1.  Data extraction summary for high-quality studies, minimal risk of bias.
410

Population and sample Intervention and

Study Country (number) comparison Standards Drug class(es) Prescribing issues Outcome

Acosta- UK Cross-sectional snapshot Same study carried Royal College Antipsychotics Polypharmacy Polypharmacy and high-
Armas et al. of entire population out for 69 patients in of Psychiatrists High doses and dose therapy decreasing
(2004) of forensic psychiatric 2001 guidelines duration
hospital inpatients (66) Adherence to
guidelines

Appelbaum USA Range of prison staff in Implement protocol Protocol Stimulants for Protocol restrictions Decreased inappropriate
(2009) Massachusetts for prescribing developed ADHD and advantages medication-seeking,
stimulants; compare on literature but restrictive on
with prescribing pre- review, expert prescribing for some
intervention opinion and
stakeholders’

Australian & New Zealand Journal of Psychiatry,

opinions

Baillargeon USA Cross-sectional snapshot Compared to studies – Antidepressants – Prescribing Higher percentage

46(5)
et al. (2001) of all inmates with major set in the community TCAs and SSRIs differences between prescribed a TCA
depression, dysthymia subgroups than an SSRI; 21.8% no
or bipolar (5305) in antidepressant
Texas Department of
Criminal Justice inmates
in 1998–99

Bains and Australia All patients in three Compared to 40 – Antipsychotics Polypharmacy Depot medication
Nielssen forensic hospitals, NSW treatment-resistant High dose added due to
(2003) (105) patients living in three Insufficient trial treatment resistance,
supervised group non-compliance, and
homes in community facilitate transfer

Dalvi et al. UK All patients on high- – Royal College Antipsychotics Polypharmacy Length of high-dose

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(2003) dose antipsychotics in of Psychiatrists High doses and treatment from few
three tertiary services consensus duration months to 5 years
for people with learning statement Adherence to
disabilities (18) guidelines

Department UK Questionnaire sent to all – – All Guidelines Prescribing doesn’t

of Health prisons in England and Consistency appear largely
(2003) Wales (100 responded, Continuity of care evidenced-based; lack of
37 did not) feedback for prescribers
on how their data
compares to national
figures
ANZJP Articles
 Table 1. (Continued)

Population and sample Intervention and

Study Country (number) comparison Standards Drug class(es) Prescribing issues Outcome
Griffiths et al.

Elger (2004) Switzerland All non-substance- – Asia Pacific Anxiolytics Duration of Almost 55% prescribed
misusing prisoners with Family Medicine Hypnotics treatment more than 1 anxiolytic/
insomnia in Champ- Insomnia Polypharmacy hypnotic; 55.3% still
Dollon prison (112) guidelines Adherence to prescribed hypnotic
guidelines upon release; limited
documentation

Elger et al. Switzerland All prisoners who Compared to 151 – Anxiolytics Overuse of More prisoners
(2002) attended a consultation patients from medical Hypnotics tranquillisers and prescribed
in 3 week period at polyclinic reasons benzodiazepines than
Champ-Dollon prison Duration of community patients
(113) treatment at the clinic; a third
of hypnotics and
benzodiazepines at both
locations prescribed for
more than 3 weeks

Fazel et al. UK All elderly prisoners in – National Psychotropes Unmet psychiatric 18% of prisoners with
(2004) prisons with more than Service needs psychiatric condition
10 elderly prisoners Framework prescribed medication
and within 100 miles of for it
Oxford (15 prisons, 203
prisoners)

Feron et al. Belgium Systematic random Compared to – Psychotropes Brief appointments Lack of access to
(2005) sampling of discharged studies performed in High demand on informal health
prisoners from any community samples time services and mental

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Belgian prison in health difficulties
3-month period (513) associated with prison
life main reasons for
appointments

Fos-Claver Spain All prisoners prescribed Compared to study Defined Anxiolytics Influence of High level of
and Soler- an anxiolytic, performed in same daily dose as Antipsychotics pharmaceutical psychotrope
Garcia antipsychotic or population previous assigned by the Antidepressants companies on use, especially
(2008) antidepressant in prison year World Health prescribing benzodiazepines
of Valencia (2471) Organization Benzodiazepine use

(Continued)

Australian & New Zealand Journal of Psychiatry, 46(5)

411
 Table 1. (Continued)
412

Population and sample Intervention and

Study Country (number) comparison Standards Drug class(es) Prescribing issues Outcome

Gibbon UK Random sampling at Recommendations Local guidelines All medications Documentation of Population may be at
and Khalifa Arnold Lodge, East made after baseline by Leicester ADR was sub- increased risk of ADRs;
(2005) Midlands Centre for audit Partnership optimal despite recording of ADRs
Forensic Mental Health NHS Trust recommendations may decrease risk of
(30) (two ADRs to an recurrence – suboptimal
antipsychotic not recording at the
reported) moment

Hales and UK All male patients from – – Sedative PRN Poor PRN PRN medications
Gudjonsson 1995 to 2000 there for medications documentation prescribed upon
(2004) at least 6 months; Denis Prescribing admission more
Hill Regional Secure Unit differences between frequently to younger

Australian & New Zealand Journal of Psychiatry,

inpatients (42) subgroups patients; associated
documentation poor

46(5)
Harrington UK All adult mental health – Developed Antipsychotics Polypharmacy 20% of patients on
et al. (2002) services invited (47 from national High doses high-dose therapy;
participated) guidelines/ Consent poor documentation of
consensus Monitoring justification and consent
statements on Documentation
antipsychotics
in five countries

Hassan UK Newly received – Standards All Continuity of care Psychotropic

(2009) prisoners (not transfers) adapted Documentation medications usually
reporting taking from prison continued in prison;
prescription medication and wider when withheld usually
in four prisons (375) healthcare done deliberately with

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policy documented reason

Haw and UK All patients regularly – – Antipsychotics High doses Polypharmacy mainly
Stubbs prescribed two or more Polypharmacy commenced due to
(2003a) antipsychotics at St lack of efficacy of
Andrew’s Psychiatric monotherapy
Hospital (40)

Haw and UK All drug charts reviewed – – All Errors Prescribing errors:
Stubbs by a pharmacist in the 87.5% were writing
(2003b) course of their normal errors, rest were
work at St Andrew’s decision making; drug
Psychiatric Hospital (260 administered in 42% of
errors found) cases
ANZJP Articles
 Table 1. (Continued)

Population and sample Intervention and

Study Country (number) comparison Standards Drug class(es) Prescribing issues Outcome
Griffiths et al.

Jukic et al. Croatia All patients prescribed – – Antipsychotics Polypharmacy Number of patients
(2008) an antipsychotic on Prescribing subject to polypharmacy
1 October each year differences between increased; females
from 2001 to 2005 at subgroups more often on atypical
Psychiatric Hospital, antipsychotics than
Vrapče: 264 in 2001; 358 males
in 2002; 303 in 2003; 414
in 2004; 257 in 2005

Lekka et al. Greece Prisoners regularly Compared to 192 – Benzodiazepines Polypharmacy Characteristics of
(2003) prescribed a prisoners with no Length of treatment those prescribed a
benzodiazepine for at current or history of Potentially more benzodiazepine are
least 6 months at high- benzodiazepine use suitable medications significantly different
security prison Aghios to others; 58%
Stefanos, Patras (192 polypharmacy
prisoners; 10 refused to
participate)

Lelliott et al. UK All patients prescribed – – Antipsychotics Polypharmacy 50.5% polypharmacy;

(2002) an antipsychotic at 49 High doses more likely in younger,
mental health inpatient male, detained patients,
services (3576) on rehabilitation or
forensic ward, with
schizophrenia

Martin et al. Australia All patients on clozapine Compared to – Clozapine Monitoring Clozapine patients had
(2008) at Long Bay Prison 26 patients not Polypharmacy higher rate of substance

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Hospital, NSW (47) prescribed clozapine Education abuse and comorbidity;
high rate of side effects,
discontinuation common

Parker et al. UK Unclear sampling – Royal College Antipsychotics Polypharmacy 25% polypharmacy,
(2002) method at Langdon of Psychiatrists Antidepressants High dose and 16% high doses;
Hospital, England (69) guidelines Mood stabilisers Monitoring prescribers may not
Benzodiazepines Documentation have realised on high
Anticholinergics dose as each drug within
limits

(Continued)

Australian & New Zealand Journal of Psychiatry, 46(5)

413
 414

Table 1. (Continued)

Population and sample Intervention and

Study Country (number) comparison Standards Drug class(es) Prescribing issues Outcome

Paton et al. UK All consultants not – – Antipsychotics Polypharmacy Benefits of atypical

(2002) working as a locum or Monitoring antipsychotics over-
in learning disability in Drug knowledge estimated, and
forensic psychiatry in Education/ side effects under-
England (134) compliance estimated; majority
often prescribed
polypharmacy

Reeves et al. USA New Jersey Department Development of Consensus Atypical Monitoring Dramatic increase
(2009) of Corrections electronic metabolic statement antipsychotics Documentation in monitoring

Australian & New Zealand Journal of Psychiatry,

monitoring program of American of physiological
Diabetes measurements after

46(5)
Association software modified
et al.

Renkel and Norway All consecutively – Guidelines from Antipsychotics High dose Increase in number of
Rasmussen admitted patients with National Board Monitoring patients prescribed high
(2006) schizophrenia who were of Health in dosages over time, but
admitted and discharged Norway and length of stay unaltered
between 1987 and 2000 international
at regional maximum guidelines
security psychiatric unit
(82)

Tavernor UK All patients on high-dose Compared to 25 – Antipsychotics Monitoring High-dose patients

et al. (2000) antipsychotic therapy matched control Polypharmacy had more psychiatric

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in mental health units, patients from same High doses morbidity, side effects
Ashworth Hospital (25 population on doses of and aggression than
patients, 7 refused) antipsychotics within controls; psychosis best
recommended range predicted the dose

Walker and UK All patients on – Clinical Antipsychotics Monitoring 91% of respondents

MacAulay antipsychotic therapy at Standards for Polypharmacy reported low or
(2005) State Hospital, Carstairs Schizophrenia, medium level of side
(152 patients, 32 Scotland effects; 9.8% of patients
refused) on polypharmacy
ANZJP Articles
 Griffiths et al.

Table 2.  Data extraction summary for lower quality studies, risk of bias present.

Population and sampling Prescribing

Study Country (number) Comparison Drug class(es) issues Outcome Potential bias

Bressington UK Convenience sampling Studies set in Antipsychotics Information Prisoners motivated to Convenience sampling for
et al. (2008) of prisoners on an the community provided take medications are study on adherence
antipsychotic at three Length of more adherent
local prisons (44 out of 56 appointment
approached) Side effects

Gray et al. UK Convenience sampling – Antipsychotics Polypharmacy Adherence correlated Convenience sampling for
(2008) of prisoners on an High doses with insight, motivation study on adherence
antipsychotic at three Information and recognition of *Same data as
local prisons (44 out of 56 beneficial effects Bressington
approached)

Pinta and USA Case history from Ohio – Quetiapine Threats issued Inmate planned to illegally Personal experience and
Taylor correctional system (1) to manipulate purchase drug from other case history
(2007) prescribing inmates when supply
denied

Sazhin and Australia All male patients
Reznik involuntarily treated with
(2008) major mental illness at acute
psychiatric ward, Long Bay
Forensic Hospital, NSW
– Antipsychotics
Polypharmacy Cardiovascular risk
Monitoring factors need more
thorough review and
treatment in psychiatric
patients in custody
Letter to the editor,
insufficient detail due
to space restriction to
assess fully

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(44)

Swinton and UK Ashworth Hospital, – Clozapine Persuasion Description of steps to Viewpoint – personal
McNamee Liverpool Information establish and maintain report of one hospital’s
(2003) patients on clozapine approach, no indication
of successfulness

Australian & New Zealand Journal of Psychiatry, 46(5)

415
416 ANZJP Articles
typically an oral atypical antipsychotic and a depot injection
of a typical antipsychotic, were discussed (Bains and
Nielssen, 2003; Haw and Stubbs, 2003a; Paton et al., 2002;
Renkel and Rasmussen, 2006). Several studies sought prac-
titioners’ justifications for these prescribing decisions; the
most common rationalisations were an insufficient response
to monotherapy (Bains and Nielssen, 2003; Harrington
et al., 2002; Haw and Stubbs, 2003a), concerns about safety
(Bains and Nielssen, 2003; Haw and Stubbs, 2003a) and
adherence (Bains and Nielssen, 2003; Paton et al., 2002), a
desire to leave medications unchanged if patients were rea-
sonably well, and to not contribute to further deterioration if
they were not well (Haw and Stubbs, 2003a). Linked to this
theme were concerns about the influence of PRN medica-
tions, and the total dose of antipsychotic being received.
Polypharmacy of benzodiazepines and hypnotics was
identified in two studies. One reported on the use of multi-
ple benzodiazepines (Lekka et al., 2003), the other focused
on the practice of combining a benzodiazepine and a hyp-
notic (Elger, 2004), as some benzodiazepines are indicated
for insomnia (Rossi, 2009). This prescribing practice was
most commonly found in patients with minimal improve-
ment to their insomnia with one drug (Elger, 2004).
Theme two: high doses
The use of dosages above the maximum recommended daily
dose is generally discouraged by guidelines, although some
authors advocated their use in certain situations (Brotman
and McCormick, 1990). One study found that polyphar-
macy was the greatest predictor of high-dose therapy, with
patients prescribed more than one antipsychotic medication
41 times more likely to be on high doses than those on mon-
otherapy (Lelliott et al., 2002). Although polypharmacy was
not always considered, these problems were clearly linked
(Acosta-Armas et al., 2004; Harrington et al., 2002; Haw
and Stubbs, 2003a; Lelliott et al., 2002; Parker et al., 2002;
Renkel and Rasmussen, 2006; Tavernor et al., 2000).
PRN medications were also implicated in high dosages
(Harrington et al., 2002; Lelliott et al., 2002). Several
researchers wondered if prescribers were aware that the
patients were on high-dose therapy and whether it was an
intentional prescribing decision (Acosta-Armas et al., 2004;
Harrington et al., 2002; Haw and Stubbs, 2003a; Parker
et al., 2002). Concern was expressed about prescriber aware-
ness of polypharmacy and PRN medications, and also for
some patients on antipsychotic monotherapy (Acosta-
Armas et al., 2004; Bains and Nielssen, 2003; Gray et al.,
2008; Harrington et al., 2002; Haw and Stubbs, 2003a;
Lelliott et al., 2002; Renkel and Rasmussen, 2006).
Theme three: duration of treatment
The duration of treatment was a third area of interest.
Concern was expressed that there may have been an
Australian & New Zealand Journal of Psychiatry, 46(5)
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insufficient trial of monotherapy for patients on an antip-
sychotic before a second drug was prescribed to supple-
ment the effect (Bains and Nielssen, 2003; Harrington
et al., 2002). Patients had long periods of high-dose
antipsychotic therapy without official review (Acosta-
Armas et al., 2004; Dalvi et al., 2003; Parker et al., 2002).
Long duration of treatment with hypnotics (Elger, 2004;
Elger et al., 2002) and benzodiazepines (Lekka et al., 2003)
for insomnia was also an area of concern. Short-term therapy
is desirable as benzodiazepines have been associated with an
increase in hostility and aggression (Lekka et al., 2003).
Theme four: documentation and monitoring
Documentation and monitoring of patients was consistently
raised as an area needing improvement (Acosta-Armas
et al., 2004; Dalvi et al., 2003; Harrington et al., 2002;
Martin et al., 2008; Parker et al., 2002; Reeves et al., 2009;
Renkel and Rasmussen, 2006; Sazhin and Reznik, 2008;
Swinton and McNamee, 2003; Tavernor et al., 2000). A
lack of adherence to relevant guidelines recommending
more specialised monitoring for antipsychotics was appar-
ent, especially when high doses were employed (Acosta-
Armas et al., 2004; Dalvi et al., 2003; Elger, 2004;
Harrington et al., 2002; Parker et al., 2002; Renkel and
Rasmussen, 2006). A need for more formalised monitoring
of the efficacy of treatment for all psychotropes has been
recommended (Elger, 2004; Fos-Claver and Soler-Garcia,
2008; Haw and Stubbs, 2003a; Martin et al., 2008; Swinton
and McNamee, 2003). Documentation associated with
PRN medications was found to be poor, an area of particu-
lar concern as prescribers and nurses may have different
understandings of how and when PRN medication is to be
used (Hales and Gudjonsson, 2004). Assessment of need
for treatment was poorly documented (Elger, 2004; Fazel
et al., 2004; Hales and Gudjonsson, 2004). Monitoring for
side effects (Bressington et al., 2008; Martin et al., 2008;
Tavernor et al., 2000; Walker and MacAulay, 2005) and the
recording of adverse drug reactions (Gibbon and Khalifa,
2005) were both irregularly completed. A software program
designed to improve the compliance of physicians with
monitoring requirements recommended by guidelines was
tested with promising results (Reeves et al., 2009).
Documentation of consent to high-dose treatment was
almost completely absent (Harrington et al., 2002; Parker
et al., 2002), especially before an intervention (Acosta-
Armas et al., 2004). However, one study set in the UK
found that all 18 participants had given their consent, or
appropriate forms had been completed where the patient
was incapable of giving consent (Dalvi et al., 2003).
Theme five: environment
Prescribing issues associated with the environment in
which the treatment occurred comprised the fifth theme. A
Griffiths et al. 417
lack of consistency was often noted between prescribers
within a facility, and between different sites (Appelbaum,
2009; Department of Health, 2003; Lelliott et al., 2002;
Parker et al., 2002; Walker and MacAulay, 2005).
Prescribers working solely in correctional facilities may
also suffer from a scarcity of unbiased information that
community practitioners have in abundance, both on best
practice (Department of Health, 2003; Fos-Claver and
Soler-Garcia, 2008; Paton et al., 2002) and, in the UK, on
their prescribing patterns compared with national data
(Department of Health, 2003). Limited financial resources
in these settings meant that other non-pharmacological
treatment options may have been unavailable (Baillargeon
et al., 2001; Bressington et al., 2008; Elger, 2004; Lekka
et al., 2003), which can result in an increased workload for
the general practitioner (Feron et al., 2005). The resulting
high demand shortens appointment times (Bressington
et al., 2008), which may be one of the explanations for pris-
oners feeling they did not receive sufficient information
about their treatment (Bressington et al., 2008; Gray et al.,
2008). The two studies revealing this possibility were
classed as lower quality evidence in this review as they
were both written using the same data from a study on sat-
isfaction and adherence to therapy that employed conveni-
ence sampling.
The correctional facility environment and anxiety about
legal proceedings and the future was frequently the cause
of the insomnia, therefore patients may benefit from review
before release to reduce the risk of withdrawal or unneces-
sary continued use of hypnotics and benzodiazepines in the
community (Elger, 2004).
The continuity of care upon admission to, and on
release from, these facilities has not been explored exten-
sively, but current findings suggest significant room for
improvement (Department of Health, 2003) (L. Hassan,
2009, personal communication). Physicians experienced
difficulties in ascertaining what medications a patient was
previously taking, and risked being pressured into pre-
scribing against their better judgement through threats of
legal action or suicide (Appelbaum, 2009; Pinta and
Taylor, 2007). Drugs that were more likely to provoke this
type of behaviour were the controlled drugs, and those
that may be abused or were valuable for bartering; pre-
scribers also need to consider the risk of intimidation of
prisoners by others wishing to procure a supply of a cer-
tain drug (Appelbaum, 2009; Lekka et al., 2003; Pinta and
Taylor, 2007). One of these reports was classed as lower
quality evidence as it was a sole case study (Pinta and
Taylor, 2007).
Conversely, the prescriber may need to use their powers
of persuasion to convince a patient that the therapy would be
beneficial (Swinton and McNamee, 2003). Although this
issue was only directly raised by a lower quality report of
methods employed by one facility (Swinton and McNamee,
2003), there were indirect mentions made several times of
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the need for prescribers to encourage compliance (Bains and
Nielssen, 2003; Tavernor et al., 2000).
The independence of prescribers may be challenged by
the desires and concerns of other staff about the potential
for violent behaviour in certain prisoners. They may have
been encouraged to prescribe more sedating drugs for those
patients considered a risk (Acosta-Armas et al., 2004; Jukic
et al., 2008; Parker et al., 2002). Differences in prescribing
between subgroups based on gender, age and race have
been reported, though the reasons behind this are not clear
(Baillargeon et al., 2001; Fazel et al., 2004; Jukic et al.,
2008; Lekka et al., 2003). It has been questioned whether
the needs of prisoners are being met, as one study found
that only 18% of older people with a psychiatric condition
were prescribed medication (Fazel et al., 2004), and defi-
ciencies were noted for those with depression (Baillargeon
et al., 2001). Imposed protocols may also affect a physi-
cian’s prescribing autonomy. There were some complaints
about the restrictiveness of an attention deficit hyperactiv-
ity disorder (ADHD) protocol, but there were also many
positive remarks about the benefit of guidance and backing
that it provided after implementation in an American state
prison system (Appelbaum, 2009).
Prescribing errors have also been identified. Of the 311
prescribing errors found in one study, 87.5% were associ-
ated with prescription writing, and the remainder with deci-
sion making. The authors estimated that 85% of the errors
would have been preventable had the electronic prescribing
system available in community settings at the time been
used (Haw and Stubbs, 2003b).
Discussion
Identified themes
Polypharmacy was widespread. Increased mortality rates,
hospital admissions and severe adverse drug reactions have
been associated with polypharmacy, so it should be avoided
whenever possible (Baker et al., 2007; Bell et al., 2007).
Use of more than one benzodiazepine and extended dura-
tion of treatment may increase the risk of side effects,
dependence and tolerance (Rossi, 2009).
Very high doses of psychotropes, especially antipsy-
chotics, were common. These high doses confer little or no
increase in therapeutic effect, but significantly increase the
risk of adverse effects including poor cognitive functioning
and death (Gisev et al., 2006; Sim et al., 2008). Although
there may be cases where regimens of polypharmacy or
high doses are appropriate for an individual, the recom-
mended associated documentation and monitoring were
generally not being done. Antipsychotic medications can
have a variety of undesirable effects on weight, blood glu-
cose, blood pressure, and lipid levels (Rossi, 2009), so reg-
ular monitoring is required to enable early intervention if
detrimental changes occur. Additionally, the recording of,
Australian & New Zealand Journal of Psychiatry, 46(5)
418 ANZJP Articles
and monitoring for, side effects and adverse drug reactions
are important because of both the potential severity of
adverse drug events and their potential impact on patient
adherence and trust.
A wide variety of challenges faced when prescribing for
prisoners were raised, but many of these were only found in
one or two studies. An issue that was raised in several arti-
cles was poor continuity of care, both upon entering a cor-
rectional facility, and upon release. Continuity of care is
also relevant when prisoners are transferred from one facil-
ity to another; consistency between prescribers and facili-
ties has been noted as lacking by prisoners in this situation.
A final issue was the use of persuasive or coercive tech-
niques by some prisoners in an attempt to manipulate pre-
scribing. Physicians need to be aware of this possibility.
Limitations of existing research
A number of limitations of the existing research became
evident during the appraisal process. Several of the identi-
fied articles were written by the same authors. This may
indicate that some facilities or regions are over-represented
in the existing literature; almost all of the articles discuss-
ing polypharmacy were conducted in the UK. We do not
know whether these issues are identifiable in other areas of
the world. It was frequently challenging to determine
whether studies included prisoners because of poor popula-
tion and sample descriptions. Other common weaknesses
included no justification of sample size or description of
sampling method.
There was limited depth in the research. Many studies
reported the incidence of polypharmacy, high-dose therapy,
and the failure to adequately monitor physiological param-
eters; however, little research has been conducted to deter-
mine the reasons for, and possible solutions to, these issues.
There was also limited replication of studies addressing
issues more specific to prisoners.
Applications of this review
This review adds to current understanding of prisoner
health, and may have several applications. Firstly, it pro-
vides an overview of previously identified areas for con-
cern in prescribing for prisoners. This may be useful for
physicians working in this area to review and improve their
prescribing practices. Secondly, this review may prompt
facilities to review their relationships and communication
with other facilities and with practitioners in the commu-
nity. This may help to standardise care and improve conti-
nuity of care upon admission or transfer. Thirdly, this
review may prompt research into areas found to be mini-
mally or poorly addressed in current literature. It may also
provide some support for those aiming to improve health
care in correctional facilities. Finally, policy makers may
be able to more fully appreciate the possible avenues for
Australian & New Zealand Journal of Psychiatry, 46(5)
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resource allocation to provide the greatest improvement in
prisoner health.
Limitations of this review
The risk of bias in the higher quality studies has been
deemed to be low. As this review was based on qualitative
rather than quantitative design, lower quality documents
were included as they offered some new factors for consid-
eration on potential prescribing concerns. There were only
five studies that fell into this category, not significantly
increasing the risk of bias of this review.
It was not possible to contact all of the authors of articles
reviewed for information about other relevant research,
published or otherwise. In addition, many authors failed to
respond, presumably as they had no information to offer,
but this cannot be confirmed.
Limitations were placed on the searches to improve
manageability. The articles were restricted to those pub-
lished from the beginning of 1999 onwards, although some
of the studies included data from earlier than this, and those
published in English. This could potentially bias the under-
standing of current standards for prisoners in countries
where English is not the first language, as contradictory
findings may have been published in another language.
Forensic hospitals, high-security psychiatric wards, prisons
and jails were all included in this review; issues identified
in one setting may not necessarily apply to others.
Potential future research
Many of the included studies focused on assessing the
prevalence of issues identified in other settings. To mini-
mise the risk of the research becoming repetitive, it would
be useful to focus attention of researchers on the influ-
ence of the prisoner’s environment on prescribing, as
there has been comparatively little research conducted on
this topic.
An approach or policy for continuity of care was not
identified for prisoners. Research about the potential use-
fulness of effective community continuity of care models
for prisoners would be beneficial.
If further studies are to be conducted on polypharmacy
and high-dose therapy, more in-depth analysis would be
required to fill gaps in the literature. Rather than merely
reporting the prevalence of this issue, research should help
to identify reasons for its occurrence, and ways to minimise
this problem. Discovering the proportion of patients legiti-
mately requiring high-dose therapy due to induction of
metabolising enzymes or genetic differences would be use-
ful. This has been briefly discussed as possible justification
for the prescribing, but no studies investigating this poten-
tial explanation for prisoners were identified.
Descriptive studies are useful, especially initially to
fully comprehend the nature and extent of a problem, but
Griffiths et al. 419
the time has come for something to be done with the know­
ledge that has been acquired.
Barriers to optimal psychotropic use
There are many barriers to optimal psychotropic use and
care for mentally ill prisoners. The motivations and desires
of prisoners, security staff, healthcare professionals, admin-
istrative staff and policy makers may be quite dissimilar,
and any proposed change may be met with resistance
(Appelbaum, 2009). There are also considerations of liabil-
ity, as well as privacy of prisoners.
Identification of prisoners who may benefit from psy-
chotropics is a significant hindrance to optimising treat-
ment. Research has suggested the potential benefits of
having standardised screening tools used in police holding
cells to enable early identification and treatment of men-
tally ill detainees (Baksheev et al., 2010). Appropriate ther-
apy may also reduce the risk of recidivism, as one study
found that selective serotonin reuptake inhibitors decrease
impulsivity; this is a contributing factor to violent crimes
(Butler et al., 2010).
Conclusion
Very few examples of good practice were identified,
together with many ways in which prescribing of psy-
chotropic drugs to prisoners could have been improved.
Prescribers may decide a patient warrants polypharmacy
and/or high-dose therapy, and be able to justify their
decision; however, this should be accompanied by the
appropriate monitoring and documentation of decisions.
The consequences for poor prescribing of psychotropic
drugs could be iatrogenic morbidity or mortality.
Prisoners are known to have elevated rates of mental
illness, and prescribers are in a position to make a
difference to their quality of life, be it positive or
negative.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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Appendix 1. Psychotropic drugs

Antidepressants

Monoamine oxidase inhibitors Selective serotonin reuptake Tricyclic antidepressants Selective noradrenaline
(MAOI) inhibitors (SSRI) (TCA) reuptake inhibitors
Phenelzine Citalopram Amitriptyline Reboxetine
Tranylcypromine Escitalopram Clomipramine  
  Fluoxetine Dothiepin  
  Fluvoxamine Doxepin  
  Paroxetine Imipramine  
  Sertraline Nortriptyline  
  Trimipramine  
Monoamine oxidase inhibitor, Serotonin and noradrenaline Tetracyclic  
type A (MAO-A) reuptake inhibitors (SNRI) antidepressants
Moclobemide Duloxetine Mianserin  
  Venlafaxine Mirtazapine  

Antipsychotics Anxiolytics and hypnotics

Typical Atypical Benzodiazepines Other

Chlorpromazine Amisulpride Alprazolam Buspirone
Droperidol Aripiprazole Bromazepam Zolpidem
Flupenthixol Clozapine Clobazam Zopiclone
Fluphenazine Olanzapine Diazepam  

Haloperidol Paliperidone Flunitrazepam  

Pericyazine Quetiapine Lorazepam  

Pimozide Risperidone Nitrazepam  

Oxazepam  
Thiothixene Ziprasidone
Temazepam  
Trifluoperazine  
Triazolam  
Zuclopenthixol  

Drugs for bipolar disorder

Lithium

Drugs for attention deficit hyperactive disorder

Atomoxetine
Dexamphetamine
Methylphenidat

Australian & New Zealand Journal of Psychiatry, 46(5)

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