The disease profile of Texas prison inmates

PURPOSE: Whereas prison inmates are reported to exhibit poorer overall health status and higher rates of health care utilization than the general population, no current information exists on the overall disease profile of the U.S. prison population. The present study examined the prevalence of major acute and chronic conditions in one of the nation's largest prison populations. METHODS: The study population consisted of 170,215 Texas Department of Criminal Justice (TDCJ) inmates who were incarcerated between August 1997 and July 1998. Information on medical conditions and sociodemographic factors was obtained from an institution-wide medical information system. RESULTS: Infectious diseases (29.6%) constituted the most prevalent major disease category among inmates. This was followed by diseases of the musculoskeletal system and connective tissue (15.3%), diseases of the circulatory system (14.0%), mental disorders (10.8%), and diseases of the respiratory system (6.3%). Among the specific conditions examined, evidence of tuberculosis infection without active pulmonary disease (20.1%) was found to be the most prevalent condition, followed by hypertension (9.8%), asthma (5.2%), low back pain (5.1%), and viral hepatitis (5.0%). CONCLUSIONS: The present study shows that for a number of conditions, the prison population exhibited prevalence rates that were substantially higher than those reported for the general population. Moreover, estimates for a number of diseases varied substantially according to age, race, and gender. Understanding the disease profile in U.S. incarcerated populations will permit correctional administrators to develop more efficient health care delivery systems for prison inmates.     

Antiretroviral prescribing patterns in the texas prison system

PURPOSE: Although prison inmates are reported to exhibit substantially elevated rates of HIV infection, little is known about HIV treatment patterns, particularly pharmacotherapy, in correctional institutions. The purpose of the present study, therefore, was to describe antiretroviral prescribing patterns in one of the nation's largest prison populations.METHODS: The study population consisted of all known (n = 2,360) HIV-infected inmates incarcerated in the Texas prison system in 1998. Information on medical conditions, sociodemographic factors, and pharmacotherapy was obtained from an institution-wide medical information system. Inmates who received more than one type of pharmacotherapy in 1998 were included in the appropriate number of categories.RESULTS: In 1998, 66.8 percent (95% CI = 64.0-69.4) of all HIV-infected inmates with CD4 counts below 500 were treated with highly active antiretroviral therapy (HAART); and 31.1 percent (95% CI = 29.3-33.0) were given no antiretroviral therapy. Logistic regression results showed that HAART treatment decreased monotonically as a function of patient CD4 count category.CONCLUSIONS: A substantial proportion of HIV-infected TDCJ inmates were placed on therapies that were not consistent with the generally recommended DHHS guidelines for their disease stage. It will be important to for future investigations to assess whether such patterns continue to exist among prison populations, and to assess the determinants of these patterns.     

HIV Seroprevalence among newly incarcerated inmates in the Texas correctional system

PURPOSE: The seroprevalence of HIV infection was examined among a sample of incoming inmates in the Texas Department of Criminal Justice prison system. Rates were compared across sociodemographic factors and three types of prison facilities: substance abuse felony punishment units (SAFPs), state jails, and prisons. METHODS: The study sample consisted of 4386 incoming inmates incarcerated for any duration, dating from November 1, 1998, to May 31, 1999. RESULTS: Among males, inmates entering state jails had a higher HIV infection rate (3.7%) than either inmates entering prisons (1.9%) or those entering SAFPs (0.5%). Among females, inmates entering prisons had a higher rate of infection (9.3%) than those entering state jails (2.5%) or SAFPs (4.5%). CONCLUSIONS: Although a number of blinded HIV seroprevalence studies have been conducted in U.S. prison systems, scarce information is currently available on HIV infection rates in alternative correctional facilities. The present study shows that HIV seropositivity varied substantially according to race, gender, and prison facility type. Given the shorter incarceration periods for inmates held in alternative facilities, understanding how infection rates vary according to type of incarceration facility holds particular public health relevance.     

Profile of HIV seropositive inmates diagnosed in Maryland's state correctional system.

Correctional systems increasingly serve as the health care nexus for the initial diagnosis and treatment of human immunodeficiency virus (HIV) infection, particularly among traditionally underserved populations. A survey was conducted to describe the clinical profile of inmates in a State correctional system diagnosed with HIV infection by various testing strategies. Approximately 50 percent of the inmates diagnosed were potential candidates for anti-retroviral therapy, and 17 percent were severely immunocompromised. Implementation of voluntary HIV testing at prison entry increased the number of persons identified with HIV infection; however, since volunteers at entry had higher CD4 cell counts compared with infected inmates diagnosed by other methods, there was not a parallel increase in the percentage requiring immediate medical treatment. These data are important for planning medical resources in the correctional setting and underscore the opportunity to provide prevention and therapy for a vulnerable population with HIV infection. Public health interventions within the correctional setting have a broader societal impact, since most infected inmates serve short sentences (median, 3 years). Clinical case management is critical for inmates with HIV infection released to the community so that linkages with primary care providers and support services can be established.     

The treatment gap in mental health care

Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.     

HIV prevalence and risk factors in a Brazilian penitentiary

HIV infection among prison inmates shows one of the highest prevalence rates for specific population subgroups, reaching as high as 17% in Brazil and elsewhere in the world. The present study aimed to estimate HIV antibody prevalence and risk factors for infection in male inmates at the Ribeir?o Preto Penitentiary, S?o Paulo State, Brazil, from May to August 2003. Using simple random sampling, 333 participants were selected, answered a standardized questionnaire, and had blood samples collected. Enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence were used for HIV serological diagnosis. Overall HIV prevalence among inmates was 5.7% (95%CI: 3.2-8.2). All variables associated with HIV antibodies in the univariate analysis were submitted to unconditional multivariate logistic regression. Independent predictors of HIV infection were: total prison sentence less than five years and sharing needles and syringes.     

End-stage liver disease in a state prison population

OBJECTIVES: Information on the epidemiology of end-stage liver disease (ESLD) in US correctional populations is limited. We examined the prevalence, mortality and clinical characteristics of ESLD in the nation's second largest state prison system. METHODS: We collected and analyzed medical and demographic data from 370,511 offenders incarcerated in Texas' prison system during a 3.5-year period. RESULTS: ESLD was diagnosed in 484 inmates (131/100,000); 213 (57/100,000) died of ESLD. Offenders who were Hispanic, 30-49 years of age, > or =50 years of age, HIV monoinfected, hepatitis C virus (HCV) monoinfected, or HIV/HCV coinfected had elevated ESLD prevalence and mortality rates. CONCLUSIONS: ESLD mortality in Texas' prison population is approximately 3 times higher than that of the general population, reflecting elevated rates of HCV and HIV/HCV coinfection among prisoners. Ultimately, the only viable treatment option for many prisoners with ESLD will be liver transplantation. The enormous costs of organ transplantation and immunosuppressive therapy are staggering and have the potential to decimate the healthcare budgets of most prison systems. Consequently, it is imperative that correctional healthcare programs expand HCV treatment and prevention strategies.     

Implementing a Routine, Voluntary HIV Testing Program in a Massachusetts County Prison

Although U.S. prison inmates have higher rates of HIV infection than the general population, most inmates are not routinely tested for HIV infection at prison entry. The study objective was to implement a routine, voluntary HIV testing program in a Massachusetts county prison. During admission, inmates were given group HIV pre-test counseling and were subsequently offered private HIV testing. This intervention was compared to a control period during which HIV testing was provided only upon inmate or physician request. Between November 2004 and April 2005, 1,004 inmates met inclusion criteria and were offered routine, voluntary HIV testing. Of these, 734 (73.1%) accepted, 2 (0.3%) were HIV-infected, and 457 (45.5%) had been tested for HIV in the previous year. The testing rate of 73.1% was significantly increased from the rate of 18.0% (318 of 1,723) during the control period (p<0.001). Among the inmates tested for HIV in the prior year, 78.2% had received their last HIV test in the prison setting. Careful attention should be paid to prevent redundancy of testing efforts in the prison population. Implementing a routine HIV testing program among prison inmates greatly increased testing rates compared to on-request testing. Liddicoat is with the Department of Medicine, Greater Los Angeles Veterans Administration, Mail 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Zheng, Freedberg, and Walensky are with the Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Freedberg and Walensky are with the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Zheng, Freedberg, and Walensky are with the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Internicola and Golan are with the Suffolk County House of Corrections, Boston, MA, USA; Golan is with the Department of Infectious Disease, Tufts University Medical School, Boston, MA, USA; Rubinstein is with the HIV/AIDS Bureau, Massachusetts Department of Public Health, Boston, MA, USA; Werner and Kazianis are with the Massachusetts State Laboratory Institute, Boston, MA, USA.     

HIV transmission among male inmates in a state prison system--Georgia, 1992-2005

The estimated prevalence of human immunodeficiency virus (HIV) infection is nearly five times higher for incarcerated populations (2.0%) than for the general U.S. population (0.43%). In 1988, the Georgia Department of Corrections (GDC) initiated mandatory HIV testing of inmates upon entry into prison and voluntary HIV testing of inmates on request or if clinically indicated. GDC offered voluntary HIV testing to inmates annually during July 2003-June 2005 and currently offers testing to inmates on request. During July 1988-February 2005, a total of 88 male inmates were known to have had both a negative HIV test result upon entry into prison and a subsequent confirmed positive HIV test result (i.e., seroconversion) during incarceration. Of these 88 inmates, 37 (42%) had had more than one negative HIV test result before their HIV diagnosis. In October 2004, GDC and the Georgia Division of Public Health invited CDC to assist with an epidemiologic investigation of HIV risk behaviors and transmission patterns among male inmates within GDC facilities and to make HIV prevention recommendations for the prison population. This report describes the results of that investigation, which identified the following characteristics as associated with HIV seroconversion in prison: male-male sex in prison, tattooing in prison, older age (i.e., age of >26 years at date of interview), having served > or =5 years of the current sentence, black race, and having a body mass index (BMI) of < or =25.4 kg/m2 on entry into prison. Findings from the investigation demonstrated that risk behaviors such as male-male sex and tattooing were associated with HIV transmission among inmates, highlighting the need for HIV prevention programs for this population.     

Methylenetetrahydrofolate reductase (MTHFR) genetic polymorphisms and psychiatric disorders: a HuGE review

The authors performed a meta-analysis of studies examining the association between polymorphisms in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, including MTHFR C677T and A1298C, and common psychiatric disorders, including unipolar depression, anxiety disorders, bipolar disorder, and schizophrenia. The primary comparison was between homozygote variants and the wild type for MTHFR C677T and A1298C. For unipolar depression and the MTHFR C677T polymorphism, the fixed-effects odds ratio for homozygote variants (TT) versus the wild type (CC) was 1.36 (95% confidence interval (CI): 1.11, 1.67), with no residual between-study heterogeneity (I(2) = 0%)--based on 1,280 cases and 10,429 controls. For schizophrenia and MTHFR C677T, the fixed-effects odds ratio for TT versus CC was 1.44 (95% CI: 1.21, 1.70), with low heterogeneity (I(2) = 42%)--based on 2,762 cases and 3,363 controls. For bipolar disorder and MTHFR C677T, the fixed-effects odds ratio for TT versus CC was 1.82 (95% CI: 1.22, 2.70), with low heterogeneity (I(2) = 42%)-based on 550 cases and 1,098 controls. These results were robust to various sensitively analyses. This meta-analysis demonstrates an association between the MTHFR C677T variant and depression, schizophrenia, and bipolar disorder, raising the possibility of the use of folate in treatment and prevention.     

Imprisonment, alcohol dependence and risk of delusional disorder: a cross-sectional study

BackgroundCompared to the general population, an excess of psychotic illnesses, major depression and dependence disorders among prisoners has been reported. However, the impact of prison on detainees’ psychopathology has rarely been studied.ObjectiveTo determine the mental disorders liable to develop or regress on entry into prison and over time.MethodTwo samples of French prisoners detained in local prisons were interviewed using the same methodology. The first sample consisted of 267 new arrivals. The second was a random sample of 450 prisoners. Diagnoses were assessed using a thorough methodology: each prisoner was interviewed for approximately 2 hours by two clinicians. One of the clinicians used a structured clinical interview, which generates DSM IV diagnoses (MINI plus v 5.0); the second completed the procedure with an open clinical interview. The final DSM IV diagnoses were obtained as a consensus between the two approaches. Multilevel logistic regressions were used to take into account potential confounders.ResultsPrevalence rates of mental disorders were substantially higher in prison even for the sample of newcomers (major depression disorder: 24.7%, substance dependence: 17.6% and schizophrenia: 4.1%). Alcohol dependence disorder was significantly more frequent in the sample of newcomers (OR 1.84 [1.01–3.51]). No significant difference was evidenced between samples for substance dependence disorder. Psychotic disorders were significantly less frequent at entry into prison, particularly delusional disorder (OR 0.29 [0.08–0.98]).ConclusionThis study shows the contrasted potential effects of prison on psychopathology: alcohol dependence disorders were significantly more frequent for the newcomers, while the frequency of delusional disorders was lower. This evidence is arguing in favour of the validity of the old concept: prison psychosis. Moreover, prisoners should receive relevant help from clinicians to cope with these disorders.     

HIV epidemiology and risk behavior promoting HIV transmission in Austrian prisons

In 1989, 1990 and 1992, 19%, 15% and 10%, respectively, of all prisoners newly admitted to prisons and penitentiary institutions in Austria underwent HIV antibody tests. Based on the HIV test outcome in prisons in which more than 80% of the newly admitted inmates were tested, annual HIV prevalences among prison inmates in Austria were determined. These were 0.5% (11/2,223), 1.3% (19/1,466) and 0.9% (14/1,509) in 1989, 1990 and 1992, respectively. The prevalence rates among prison inmates in Austria are thus 5 times higher than those in the general Austrian population. About 5% of all inmates belong to the high-risk group of intravenous drug users. Inquiries into HIV risk behavior among prison inmates showed that, in Austrian prisons just like in those of many other countries, intravenous drug use and sexual contacts are common practices. As disposable needles and condoms are not available to prison inmates, these practices carry a particularly high risk of HIV transmission. The data collected can be taken as a basis for developing strategies which are designed to reduce the risk of HIV transmission in prisons and which have a major bearing on the development of the HIV pandemic.     

Pox in the docks: varicella outbreak in an Australian prison system

OBJECTIVES: 1. Describe an outbreak of varicella in a prison system. 2. Highlight the risks of disease transmission within the prison environment. 3. Promote infection control guidelines for high-risk sub-groups within the prison system, including the application of quarantine. SETTING: Four prisons, one prison hospital, the prison transport system, one courthouse. MAIN OUTCOME MEASURES: Number of cases of varicella infection; reported varicella immunity status of cases and contacts; immunity status of known HIV antibody positive inmates. RESULTS: Five cases of chickenpox were identified. There were 23 contacts of the Index Case occurring during transport between prison and court and whilst being held in the court holding cells. Two of these contacts developed chickenpox despite having given a prior history of infection. There were over 300 inmates exposed to varicella zoster virus (VZV) during the outbreak, including one HIV antibody positive inmate who had serologically confirmed immunity. This inmate developed shingles following exposure to VZV from one of the cases. CONCLUSIONS: There is an elevated risk of respiratory transmission of infections such as chickenpox in prisons. Clear guidelines should be in place to protect HIV antibody positive people, pregnant women, and others who are at increased risk of complications from such infections. In the case of varicella, all inmates and staff without documented immunity should be screened to determine immunity, and if non-immune, should be offered VZV vaccination. Every effort should be made to prevent HIV antibody positive inmates being exposed to varicella, regardless of their varicella immunity status. If an HIV antibody positive inmate, who is known to be non-immune is exposed to varicella, Varicella Zoster immunoglobulin should be given within 96 h.     

Bipolar illness in primary care: an overview

Primary care providers are in the front line of detecting and diagnosing psychiatric illness. Managed care barriers to direct psychiatric treatment have made it necessary for primary care providers to increase their sophistication in the recognition of psychiatric disorders. Primary care providers often formulate provisional diagnoses and initiate treatment or specialty referral in spite of the time constraints of the primary care setting. The patient presenting in primary care with an affective disturbance must be evaluated for a major mood disorder, which includes unipolar and bipolar illness. Research has shown that more patients than previously estimated have milder forms of bipolar illness disorder, such as bipolar type II and cyclothymia. Patients with these milder forms of bipolar are less likely to present for treatment in a psychiatric setting and more likely to share symptoms of the illness in a primary care setting. This article provides an overview for the primary care provider in the detection, assessment, and treatment of bipolar patients with an emphasis on the differentiation of unipolar and bipolar depression.     

Schizophrenia, substance use disorders and medical co-morbidity

OBJECTIVES: This study compared medical treatment costs of adults with schizophrenia to adults with both substance use disorders and schizophrenia. METHODS: This cross-sectional observational study used a paid claims data base to identify 6884 adults treated for schizophrenia. Twenty percent of these also had substance use disorder. We report the costs and likelihood of hospitalization for eight common medical diseases, and the categories of injuries and poisoning, and ill defined conditions. Multivariate analyses were used to adjust rates of treatment for age and sex differences in the comparison groups. RESULTS: There were higher rates of treatment for five of the eight medical disorders, higher treatment costs for two of the medical disorders and much higher costs for psychiatric treatment among those with comorbid substance use disorders. Both groups had high rates of treatment in the categories of injury and poisoning and ill defined conditions. CONCLUSIONS: Closer working relationships among mental health and medical professionals are needed to care for those with schizophrenia and substance use disorders: first, greater attention to the treatment of substance use disorders may improve the health status of those with schizophrenia, reduce their costly medical and psychiatric care and stabilize their psychiatric condition, and second, continuity of care among professionals may promote willingness to seek medical attention or alleviate misunderstandings when adults with schizophrenia present with medical problems.     

Effects of patients with bipolar, schizophrenic, and major depressive disorders on the mental and other healthcare expenses of family members

Family members who live with patients with serious mental disorders incur increased healthcare expenses. A retrospective study measured these increased expenses using administrative data from a large Blue Cross Blue Shield health plan in the USA. Mental and other healthcare expenses of family members of patients with bipolar disorder, schizophrenia, or major depression were compared to those of control family members. Ordinary least squares and logistic regression were used to estimate differences. In comparison with control (families of two or more members without these psychiatric disorders), mental and other healthcare expenses per family member per month were increased for subject family members as follows: bipolar disorder, $8.85 (213%; P<0.0001) and $10.65 (7.4%; P<0.0001); schizophrenia, $4.03 (81%; P<0.0001) and $5.96 (4.2%; P<0.005); and major depression $8.24 (219%; P<0.0001) and $9.46 (6.5%; P<0.0001). Among other factors, older family members had a greater likelihood of using mental healthcare and higher levels of other healthcare; males were less likely than females to use mental healthcare but had higher levels of other healthcare, and managed forms of coverage were associated with higher levels of both mental and other healthcare. We conclude that living with a person with serious mental illness significantly increases healthcare expenses of family members, especially mental healthcare. Family members of patients with bipolar disorder and major depression experienced larger increases in expenses than family members of patents with schizophrenia, despite the fact that patients with schizophrenia were more seriously ill as reflected in the much higher mental healthcare expenses of these patients.     

Somatotyping of schizophrenic and affective disorder patients

INTRODUCTION: Constitutional traits have been found to show a distinct relevance to major psychiatric disorders. Syndromal modified expressivity is also closely related to somatotypic constitution. In this view somatotyping appears valuable in diagnosis and prognosis of mental disorders. AIM: The present study was conducted in an attempt to outline somatotypic characteristics of schizophrenia and affective disorders with the aim of providing a logical basis for diagnosis of these major psychiatric disorders. MATERIAL AND METHODS: The somatotype of 54 schizophrenic and 68 affective disorder inpatients who fulfil the DSM-IV criteria for schizophrenia (subjects with schizophreniform, schizoaffective, schizoid and schizotypal personality disorders were excluded from the sample) and affective disorder (bipolar and unipolar) was assessed using the Health-Carter anthropometric method. RESULTS: The overall assessment of the somatotypes determined both groups as endomorphs mesomorphs with somatotype components 4.50-4.44-1.90 for schizophrenic patients and 5.87-5.40-0.36 for affective disorder patients. The difference between the two groups was statistically significant for any of the somatotype components. CONCLUSION: It is suggested that the constitutional and somatotypic characterization appears reasonable element in the multifactorial analysis of diagnostic decisions in these major psychiatric disorders.     

HIV testing in prisoners: is mandatory testing mandatory?

We studied 977 newly incarcerated Oregon inmates to compare voluntary versus mandatory human immunodeficiency virus antibody (HIVAb) testing in the prison setting. All inmates were offered HIVAb counseling and testing. Blood drawn for routine syphilis serology from those who declined this offer was also tested for HIVAb after personal identifiers had been removed. Only 1.2 percent (12) prisoners were HIV positive. However, 62.5 percent (611) inmates were at risk for HIV infection by being an intravenous drug user, a male homosexual, or hepatitis B core antibody (HBcAb) positive. The ratio of at-risk, as yet uninfected inmates to those already HIV infected was 53 to 1. Two-thirds of all inmates including those at-risk chose to receive counseling and testing. In areas where most at-risk inmates are not yet infected, it may be more appropriate for HIV prevention activities in prison to focus on voluntary programs that emphasize education and counseling rather than mandatory programs that emphasize testing.