Title: Mental Health and Linkage to Care: Insights and Considerations for Successful Intervention
1Mental Health and Linkage to Care Insights and
Considerations for Successful Intervention
- Lawrence Michael Mc Glynn MD
- Clinical Associate Professor
- Stanford University
- San Jose AETC
- March 20, 2013
2Introduction
- Some sobering statistics
- Some studies
- Some things that worked
- Some that didnt
- Our experience
- Putting it all together
3Some Sobering Statistics
4HIV in Corrections
- Each year, one in thirty individuals in the
United States spends time within a locked
criminal justice system facility - Each year, one in six individuals with HIV in the
United States spends time within a locked
criminal justice system facility - In 2006, around 1 in 4 of all HIV-positive Black
men in the US spent time in a jail or prison - By the end of 2008, 1.5 of male inmates and 1.9
of female inmates were HIV-positive or had
AIDS.
5Mental Illness and Corrections
- In 2007, an estimated 2,161,705 people with
severe mental illness were incarcerated in the
United States - A U.S. Bureau of Justice Statistics special
report found that 64 of jail inmates had mental
illness symptoms - A 2007 study found that 15 of male and 31 of
female inmates in five jails (N822) had severe
mental illness - A retrospective study of a random sample of
inmates (N104) found that 76 had severe mental
illness
6Mental Illness and Corrections
- Risk factors for incarceration included
- prior incarcerations
- co-occurring substance-related diagnoses
- homelessness
- schizophrenia, bipolar, or other psychotic
disorder diagnoses - male gender
- no Medicaid insurance
- and being African American
Psychiatric Services 632632, 2012)
7Mental Illness and Corrections
- Risk factors for reincarceration included
- co-occurring substance-related diagnoses
- prior incarceration
- diagnosed schizophrenia or bipolar disorder
- homelessness
- and incarceration for three or fewer days
- Patients whose first service after release from
incarceration was outpatient or case management
were less likely to receive subsequent emergency
services or to be reincarcerated within 90 days
Psychiatric Services 632632, 2012)
8Psychiatric Disorders and HIV Infection inthe
Correctional Setting
- Inmates diagnosed with HIV infection exhibited
elevated rates of - major depression
- dysthymia
- bipolar disorder
- schizophrenia
- schizoaffective disorder
- non-schizophrenic psychotic disorder
Ann Epidemiol 200313606612
9Depression and Implicationsfor Release Back to
Communities
- A high proportion of HIV infected inmates (44.5)
screened positive for depression - Depressed inmates were significantly more likely
- to have low coping self-efficacy scores (180 vs.
214), - to report having had resource needs (OR 2.91)
prior to incarceration - and to anticipate needing income (OR 2.81),
housing (OR 4.07), transportation (OR 9.15),
and assistance with adherence (OR 8.67)
post-release.
AIDS Behav (2010) 14300307
10Why the worry?
- Movement in and out of jails has been
demonstrated to disrupt access to HIV care
11Some Studies
12Accessing Antiretroviral TherapyFollowing
Release From Prison Texas Study
- Hispanic and African-Americans less likely to
fill prescription within 10 and 30 days after
release - Predictors of better outcome
- Undetectable viral load
- Being released on parole
- Having assistance completing ADAP forms
JAMA. 2009301(8)848-857
13Accessing Antiretroviral TherapyFollowing
Release From Prison Texas Study
- In Texas, only 5 filled antiretroviral
prescriptions in time to avoid an interruption in
care, and only 30 filled prescriptions by 60
days post-release
Baillargeon J, Giordano TP, Rich JD, et al.
Accessing antiretroviral therapy following
release from prison. JAMA J Am Med Assoc.
2009301(8)84857.
14Five factors necessary to improve treatment
outcomes for HIV, released inmates
- Case management services to facilitate linkage to
care - Continuity of antiretroviral therapy (ART)
- Treatment of substance use disorders
- Continuity of mental illness treatment
- Reduction of HIV-associated risk-taking behaviors
Clin Infect Dis. 201153(5)46979.
15Enhancing Linkages to HIV PrimaryCare in Jail
Settings Initiative
- 1,021 HIV-infected releasees
- 79 received clinical services and 74 received
additional community services within 30 days
post-release. - Factors associated with linkage including
- receipt of HIV or medication education in jail
- having a completed discharge plan at release,
- staff awareness of clients release date
- stable housing on the 30th day post-release
- White male gt 40 y/o on probation/parole
16Self-reported needs ofProject Bridge clients
17Our Experience
18(No Transcript)
19Axis I Mental Illnesses to Consider
- Psychotic Disorders
- Mood Disorders
- Major Depressive Disorder
- Bipolar Disorder
- Substance Abuse
- PTSD
- HAND and other cognitive dysfunctions
20Psychotic Disorders
- Cognitive impairment common and may impair
adherence to medications and appointments - Stressors can lead to decompensation, even in the
presence of prior stability on neuroleptic
medications - Psychotic delusions may lead to violence (against
self and others) - Distress may lead to substance abuse
21Mood Disorders
- Depression is a risk factor for medical decline
- Depressed individuals are at an elevated risk of
poor adherence (and of course, suicide) - Manic individuals may display impulsivity,
psychosis, poor judgment, and reduced adherence
with medications and appointments
22Substance Abuse
- Oftentimes this illness is what led to the
incarceration - Getting into treatment, even if the individual
was clean during the incarceration, is
essential - Psychotropic medications can be helpful for some,
especially the self-medicators - Some patients may prioritize substances above
filling prescriptions - Substance intoxication may lead to depression,
anxiety, and psychosis - Substance withdrawal may lead to depression,
anxiety, and psychosis
23PTSD
- Frequently seen in our patient population
- May lead to dissociation, hypervigilence,
avoidance - Consider substance abuse in this population
- Assure domestic safety
24HAND and other neurocognitive impairments
- HIV presents a subcortical picture of impairment
- Cognitive dysfunction, even in its milder forms,
may affect adherence and judgment - Screening tools are available
- HIV Dementia Scale
- MOCA
- International HIV Dementia Scale
- Scales of functionality
- Mainstay of treatment includes antiretroviral
- Studies of other treatments are ongoing
25Axis II Personality Disorders
- Personality enduring pattern of perceiving,
relating, and thinking about the environment and
oneself - When disordered, it is maladaptive, deeply
ingrained, and often distressing for both the
patient and significant others
26Personality Disorders
- According to a recent report by 57 independent
monitoring boards of prisons in the United
Kingdom (UK), 90 percent of inmates have at least
one diagnosable mental disorder - Axis II disorders extend beyond prison
antisocial personality disorder
Psychiatry (Edgemont) 20096(10)1620
27Borderline and Incarcerated
- A substantial majority of studies note higher
rates of BPD in prison populations than in
community samples, with rates generally ranging
between 25 and 50 percent - Rates among women appear to be consistently
higher than in men - Linked to childhood sexual abuse, domestic
violence, violent offenses, and presence of
antisocial personality traits
Psychiatry (Edgemont) 20096(10)1620