I recently published a post asking for readers to submit questions to me that they might have (primarily about my profession). I’ve paraphrased when necessary:
1. “Why do people who truly do have mental issues despise taking their medicine-often times going off of it and landing themselves back into the hospital due their condition? They say they don’t need the medicine-but obviously they do. And those who fake an illness love their medicines and will fight, steal and lie to have these medications.”
A: Most people do not actually want to have a mental illness. For various reasons they resist it and can be in some degree of denial. One aspect of some mental illnesses is also a lack of insight (or varying insight depending on how sick they are). People who fake illnesses for secondary gain (entitlements, attention, etc.) have a large incentive to stay in the illness role to obtain what they seek. The better they play the part, the less likely their cover will be blown.
2. “Do you have any risk management tips? What are some practical things correctional medical and mental health providers can do to minimize lawsuits by inmates?”
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Doctors, nurses, and other health care professionals often find themselves in situations where they must speak up for their patients. Typically such patients either do not realize what they need, do not know how to ask for what they need, or they lack the authority to obtain what they need.
The circumstances and challenges of advocating for patients vary significantly depending on the practice setting. I’ve previously written about how practicing in correctional settings presents unique challenges. Essentially the main challenge in any jail or prison, regardless of how “treatment-friendly” it may be, is that a correctional facility exists for the primary mission of security, not treatment.
So, if you’re a health care professional in corrections and you have a patient who needs your voice, how can you go about being an effective advocate?
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In the U.S., correctional facilities are required by law to provide inmates with access to medical care. As health care costs have spiraled out of control everywhere, jails and prisons have attempted to develop innovative ways of reducing this hefty financial burden while simultaneously meeting their legal obligation to provide care.
One approach that has gained significant popularity in recent years is to require inmates to pay a small fee, usually less than $10, to gain access to medical care in certain situations. There are arguments both for and against these co-pays. I’ll list just the main points.
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Correctional psychiatrists inevitably treat patients who have been convicted of a broad array of crimes. There is a correlation between the security level of the institutions in which one works and the severity of the crimes of the inmates being housed there.
Since I’ve treated inmates of minimum, medium, and maximum custody levels, I’ve had the opportunity to work with people who have been convicted of everything from drug possession to multiple murders.
What’s it like treating patients who have killed other human beings?
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I’ve previously written about the many challenges of practicing medicine in correctional settings. But if there are so many cons (pun intended), why should anyone consider such a career?
Well, there are many benefits to it as well. If you are a psychiatrist or primary care physician and are either looking for a change or just starting your career, you may want to consider correctional medicine.
Although I’ve done correctional work for quite a few years, my experience has been limited to one geographical area of the country. I contacted correctional healthcare recruiter, Vikkie Schill, from MHM Services, Inc., to help me to convey accurate information about this topic. I want to take this opportunity to thank her for her input. I have no relationship either with Ms. Schill or with MHM Services, Inc.
Here are my top 5 reasons to consider a career in correctional medicine:
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When I first started working in corrections, I was discussing with a seasoned prison psychologist the unique challenges that all helping professions face in a prison environment.
He told me that prisons have always been staffed by “Nazis and Saints.” He was referring to two diverse groups: one wanting to punish people and the other wanting to help people. Of course he did not mean this literally, but it was a useful metaphor for me when I was new to practicing medicine behind bars.
In reality, the literal truth lies somewhere in the middle. Most security staffs are not “Nazis.” I’ve met many dedicated officers who take their jobs seriously and want to see inmates change their ways for the better. These officers accept me and the role I play and realize that when mentally ill inmates are stable, it benefits everyone. Likewise, there are probably health care professionals who are attracted to correctional work because they want to punish people.
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Reducing health care costs is a daily news topic lately. Correctional health care costs are also very high and continue to rise.
While I believe that we should continue to explore ways to reduce correctional health costs, the obvious but politically unpopular issue that needs to be addressed is the fact that these costs would be much lower in the U.S. if we didn’t have by far the world’s highest rate of incarceration.
This exorbitant and increasing incarceration rate combined with an aging inmate population is going to drive costs steeply higher. The percentage of older inmates (over 50) is expected to rise sharply over the next decade. In fact, according to this post from California Budget Bites:
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As correctional health care professionals, there may be times when we are tempted to conduct ourselves in a less than professional manner simply because we can.
We may be able to get away with speaking to our patients rudely, using profanity profusely, or wearing inappropriate clothing. After all, we work in jails and prisons. This culture is far from prim and proper. And, our patients are inmates. Many may tolerate misbehavior from us that patients on the outside would not and should not tolerate.
I’ve previously written about how I’ve found the book, Games Criminals Play, to be an invaluable resource. One key point that I learned is that many inmates, especially those trying to set up and manipulate staff, want to know whether each prison worker is a fellow inmate or “the police.” In other words, do we side with the inmates, or are we professional workers who take our jobs seriously?
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Bupropion (Wellbutrin, Zyban) is a unique but commonly prescribed antidepressant that inhibits the reuptake of dopamine and norepinephrine. It is FDA approved for the treatment of major depressive disorder, seasonal affective disorder, and smoking cessation. It is commonly used off-label for the treatment of attention deficit hyperactivity disorder (ADHD).
Anecdotally there have long been reports of abuse and diversion of bupropion in jails and prisons. In my own personal experience in these settings, I have not seen much evidence of such misuse. Inmates rarely present to me seeking this medication. By contrast, and about which I have previously written, quetiapine (Seroquel) is highly desired medication in corrections.
I conducted a literature search on this topic and
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As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.
One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.
Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.
Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate, prescribing habits.
My prescription style inevitably evolved further when
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