Attention deficit hyperactivity disorder (ADHD), characterized by such symptoms as hyperactivity, impulsivity, and inattention, was previously thought of as a childhood condition that children eventually would outgrow. In recent years, we have realized that ADHD symptoms do not necessarily disappear or lessen by adulthood for many.

In the highly structured prison setting, untreated ADHD does not typically impair daily functioning to the degree that it might for those in the community. Nonetheless, some inmates with untreated ADHD may get into altercations with others and receive conduct reports for violating prison rules because of their impulsivity. Likewise, others may not do as well in prison educational and rehabilitation programs because of difficulty concentrating and staying organized.

While ADHD is a recognized psychiatric condition, it is not typically thought of as a major mental illness such as bipolar disorder, major depressive disorder, or schizophrenia. In the community, when ADHD is treated with medications, stimulants (Ritalin, Adderall, dextroamphetamine, and others) are the most commonly prescribed medications. These are potentially habit-forming medications that are very abusable by those with substance abuse histories. Some nonstimulant alternatives such as Wellbutrin and Strattera may be used in some cases.

To a person naive to providing health care in a  prison setting, it may seem perfectly reasonable to provide inmates with the same pharmacologic and nonpharmacologic treatments that others with ADHD receive in the community. However, the practice of psychiatry in a correctional setting is different for various reasons.

In many institutions, approximately 70% of the inmates have substance abuse diagnoses. Although stimulants may be used appropriately by some, even those who truly have ADHD may be tempted to abuse (crush and snort), trade, or sell their medication to other inmates. Such issues directly affect the security of an institution. Not only do the medications cost money, but there is also cost associated with nursing taking off orders, pharmacy packaging the medications, and staff dispensing them. Lots of psychiatrist time is spent evaluating inmates who complain of histories of ADHD and want stimulants.

Fortunately many correctional systems have stimulant protocols. I think having a protocol is a very good idea in many ways. I believe it does improve the quality of psychiatric practice, and it also helps to reduce issues related to malingering.

Despite the benefits of a protocol, though, in some ways I still wonder if it makes sense. Would it be better simply to ban stimulants altogether from the correctional setting? These particular patients take up valuable psychiatry time from patients with more serious mental health problems. Stimulants, even if restricted by a protocol, still present incentives for malingering and diversion. Given our current national budget crisis, can we taxpayers, who are struggling with our own health care coverage and cost issues, be footing the bill for incarcerated people to receive stimulants? I’m torn on this issue.

What do you think? Please leave your thoughts on this issue. I’m especially interested in hearing opinions and experiences from other correctional psychiatrists.

To read more about this topic, below are links to 2 articles from the Journal of the American Academy of Psychiatry and the Law (AAPL). The first article is about a stimulant protocol that was developed in Massachusetts. The second article is a commentary on the protocol.

Attention Deficit Hyperactivity Disorder in Prison: A Treatment Protocol

Commentary: The Top Ten Reasons to Limit Prescripton of Controlled Substances in Prisons