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Mental Health and Linkage to Care: Insights and Considerations for Successful Intervention

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Title: Mental Health and Linkage to Care: Insights and Considerations for Successful Intervention


1
Mental 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

2
Introduction
  • Some sobering statistics
  • Some studies
  • Some things that worked
  • Some that didnt
  • Our experience
  • Putting it all together

3
Some Sobering Statistics
4
HIV 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.

5
Mental 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

6
Mental 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)
7
Mental 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)
8
Psychiatric 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
9
Depression 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
10
Why the worry?
  • Movement in and out of jails has been
    demonstrated to disrupt access to HIV care

11
Some Studies
12
Accessing 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
13
Accessing 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.
14
Five 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.
15
Enhancing 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

16
Self-reported needs ofProject Bridge clients
17
Our Experience
18
(No Transcript)
19
Axis I Mental Illnesses to Consider
  • Psychotic Disorders
  • Mood Disorders
  • Major Depressive Disorder
  • Bipolar Disorder
  • Substance Abuse
  • PTSD
  • HAND and other cognitive dysfunctions

20
Psychotic 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

21
Mood 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

22
Substance 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

23
PTSD
  • Frequently seen in our patient population
  • May lead to dissociation, hypervigilence,
    avoidance
  • Consider substance abuse in this population
  • Assure domestic safety

24
HAND 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

25
Axis 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

26
Personality 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
27
Borderline 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
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