Jennifer Nelson is a Clinical Pharmacy Specialist in Psychiatry at the Dallas County Jail. Dr. Nelson discusses the prevalence of mental illness in the jail system and describes how multidisciplinary healthcare including a psychiatric clinical pharmacy specialist can contribute to the care of patients.

The Dallas County Jail (DCJ) is the 7th largest Jail in the United States and houses approximately 7,000 inmates, with over 250 inmates taken in and released each day. In comparison, the largest correctional healthcare system in the U.S. is Rikers Island in New York, which houses as many as 130,000 inmates each year (around 15,000 at any one time). California houses the most populous prison system in the nation, with about 175,000 inmates, while North Dakota only has around 1,300 inmates, making its prison population the smallest in the U.S.1 

At the DCJ approximately 50% of the inmates at Central Intake have an acute or chronic medical or mental health condition. Multiple services are offered within our system ranging from a HIV clinic to Dialysis Care. In the last five years, both an orthopedic and an anticoagulation clinic have been established within the system. Chronic illnesses are common in the inmates with up to 21% of inmates diagnosed with hypertension, 15% with asthma/COPD, and 2% with HIV. There are over 3,200 patients receiving medications daily within the system. The DCJ staff pharmacists process nearly 20,000 new prescriptions a month and dispense around 400,000 doses each month.

Approximately 22% of the inmates incarcerated in the DCJ system report a mental illness. This rate is comparable to the national average of 20%.2 Inmates with mental illness have been reported to have longer sentences than those without such a diagnosis. Furthermore, most of the rule violations and fight-related injuries occurred more often among inmates with mental illness. Women within correctional institutions have been reported to have a higher rate of mental illness than their male counterparts. The DCJ has a female population that consists of about 26% of the intakes. Female inmates within the correctional system are three times more likely to report being physically or sexually abused prior to incarceration, and to have never received care for this abuse.2 

I started at the DCJ 5 years ago as the Clinical Pharmacy Specialist in Psychiatry, and over the years, have had the privilege of working with both men and women in the system who suffer from severe and chronic mental illnesses. Currently, I'm on a treatment team consisting of a psychiatrist, nurse practitioner, psychologist, and a mental health liaison. Together we are responsible for the care of 124 women, who are considered the “sickest” within our system. These women are either CBOs (closed behavioral observation – locked down for 23 hours/day) or OBOs (open behavioral observation – only locked down between midnight and 4AM). Texas Administrative Code 295.13 allows me to work under a collaborative practice agreement with the psychiatrist on the team. Within this collaborative practice agreement, the psychiatrist's responsibilities include conducting the patient's initial visit, establishing a diagnosis, initiating medication(s) and ordering appropriate laboratory work. I am then responsible for the patient's follow-up visits including implementing or modifying drug therapy, refilling medications, and ordering subsequent laboratory work, EKGs and radiologic testing (if done in consultation with a physician). As a primary provider, I have gained a deeper understanding and expanded knowledge base regarding the patients' illnesses and stressors. This has also had an impact on their medication response and adherence.

Since starting at the DCJ, I have seen many changes in the mental health care provided to the inmates, such as the addition of therapy groups for the CBO patients. Some of groups added included anger management, substance abuse, art therapy groups, choirs directed by the Mental Health Officers, and the newest addition being a nutrition group. The nutrition group stemmed from a patient (DF) I had been following in one of the CBO housing units, who had been in the system for around six months. At the time of arrest, this patient weighed around 180 lbs (she is 5'5). She was initiated on olanzapine, which was increased to a dose of 20 mg per day, while awaiting transport to the State Hospital, after being found incompetent to stand trial. The patients have access to a “commissary”, which is a roving store where they can purchase various food items. The most popular item on the commissary is a honey bun, containing 750 calories and 45 grams of fat. DF would consistently consume her daily commissary allowance (around $60/day), with high calorie foods such as cupcakes, Snickers®, Jolly Ranchers®, etc. Her eating preferences combined with minimal daily activity resulted in DF gaining 20 lbs in two months. DF began to complain of increased thirst and urination. She was seen by our medical staff and diagnosed with insulin-dependent diabetes mellitus (IDDM) and uncontrolled hypertension (HTN). DF's medications were then adjusted to risperidone and valproic acid, along with her new insulin regimen. During discussions with DF regarding her poor diet, it was discovered that she had a minimal understanding of how the sugar content in foods affected her mental health medications as well as her new insulin regimen. Thus, the nutrition group was initiated. I, along with my current resident or student, visit multiple housing units each week, discussing topics such as the connection between psychiatric illness and weight gain, lack of motivation, the side effect of weight gain from medications, etc. Discussions on healthy food options, both while in the DCJ and once the patient has been released, are also included. This includes specific information for patients with HTN, diabetes, and dyslipidemia. The patients are also asked to identify food groups, such as proteins, carbohydrates, and vegetables. It has been an eye-opening experience to see how few of the patients can even identify a protein versus a carbohydrate. Patients are then provided a list of the available options on the commissary, including their caloric content, fat grams and sodium content. They are also supplied with information on how to make healthier food choices at the commissary. The team has felt this group has made an impact on our patients' health, both while the patient resides in the DCJ, as well as when they are released.

Working within the correctional system has provided several unique opportunities as well as challenges. It is a growing population of mental health patients who need improved access to care. As a clinical pharmacist within this system, I have had the privilege of gaining a deeper understanding of the management of these complex patients, as well as educating them. It is hoped that through both medication management and education of the DCJ patients, they will ultimately see improvement in their quality of life as well as decreased recidivism.

1.
Bureau of Justice Statistics
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Available at: http://bjs.ojp.usdoj.gov/. Accessed December 12, 2011
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2.
Metzner
JL.
Evolving Issues in Correctional Psychiatry
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Psychiatric Times
2007
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24
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3.
Criminal Justice/Mental Health Consensus Project
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Council of State Governments, June 2002. Available at: http://consensusproject.org/. Accessed December 12, 2011
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