Gender Differences in Chronic Medical, Psychiatric, and Substance-Dependence Disorders Among Jail Inmates

Objectives. We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found.Methods. We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders.Results. Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P ≤ .01 for each) and drug dependence (P < .001), but women had a lower prevalence of alcohol dependence (P < .001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence.Conclusions. Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.Approximately 13 million individuals spent time in a US jail facility during 2007.¹ At midyear, 780 581 individuals were held in a jail.¹ Jails are facilities, generally operated by local city or county governments, that hold individuals before trial or sentencing (adjudication) or individuals serving short sentences.² Despite the explosive growth of the criminal-justice population over the last 30 years,³ the exclusion of inmates from most national health surveys has made it difficult to systematically study the broad range of health conditions that inmates face. Estimates of disease prevalence among inmates in the United States have generally had to rely on data from individual cities or states,⁴ use extrapolations from the general, noninstitutionalized population,⁵ or focus on infectious diseases.^6–8 Even less epidemiological information is available about the health problems of female inmates and gender differences among jail inmates.In the noninstitutionalized, general population, women report worse physical health and a higher prevalence than men of some mental-health disorders, such as depression and anxiety.⁹ Among jail inmates in the United States, a higher proportion of women (53%) than men (35%) report a current medical problem.¹⁰ In correctional facilities in New South Wales, Australia, a survey of inmates found that 81% of women and 65% of men had at least 1 chronic health condition.¹¹ In a nonrandom sample of individuals being released from a New York City jail, women reported a higher prevalence of depression, anxiety, and asthma than men, and women were more likely to have visited an emergency room or have had a hospital admission than men.¹² However, gender differences reported in these previous studies did not account for age, race, and education as possible confounders.Many women in jail have a history of sexual and physical abuse,¹³ psychiatric disorders,^14,15 psychological distress,^16,17 and substance dependence,^18,19 conditions that can complicate the recognition of and provision of medical care for other chronic medical conditions. For instance, drug dependence can complicate the management of chronic medical conditions in the community (e.g., hypertension) because of competing needs for drug treatment, housing, employment, and income, and because of mistrust between drug users and medical providers. Drug and alcohol dependence, common in jail inmates,¹⁸ also causes health problems, either directly via the toxic effects of the substance (e.g., overdose, alcoholic hepatitis) or indirectly via use practices (e.g., sharing syringes, which can cause blood-borne infections). Therefore, in jail inmates, substance dependence should be considered when assessing gender differences in other chronic medical and psychiatric conditions.The complexity of conducting large surveys in correctional settings and the exclusion of inmates from other major health surveys in the United States (e.g., the National Health Interview Survey) have made national-level comparisons of male and female inmates difficult. To understand and meet the needs of women who interact with the criminal justice system, there is a need for greater knowledge about the relationship between gender and the chronic health characteristics of jail inmates. Management of the wide range of chronic conditions among inmates is particularly important in light of inmates'' increased risk of death after release from incarceration.^20–30 Although many deaths are related to drug use and suicide, there is also an excess risk of death related to cardiovascular disease, liver disease, and other diseases.We examined whether there were gender differences in chronic medical conditions, psychiatric disorders, and drug and alcohol dependence among jail inmates at a national level. Our first aim was to determine whether the prevalence of chronic medical conditions, psychiatric disorders, and drug and alcohol dependence differed between male and female jail inmates after differences in demographic and socioeconomic factors were accounted for. Our second aim was to determine whether gender differences in chronic medical conditions and psychiatric disorders persisted after adjusting for differences in drug and alcohol dependence. Our hypothesis was that female inmates would have a higher prevalence of chronic medical disorders, psychiatric disorders, and substance-dependence disorders than male inmates, even after other demographic and socioeconomic factors had been adjusted for. We further hypothesized that substance dependence would attenuate the differences in medical and psychiatric conditions between men and women in jail.     

Health Information Privacy and Health Information Technology in the US Correctional Setting

Electronic health records and electronic health information exchange are essential to improving quality of care, reducing medical errors and health disparities, and advancing the delivery of patient-centered medical care. In the US correctional setting, these goals are critical because of the high numbers of Americans affected, yet the use of health information technology is quite limited.In this article, I describe the legal environment surrounding health information sharing in corrections by focusing on 2 key federal privacy laws: the Health Insurance Portability and Accountability Act of 1996 and the federal Confidentiality of Alcohol and Drug Abuse Patient Records laws.In addition, I review stakeholder concerns and describe possible ways forward that enable electronic exchange while ensuring protection of inmate information and legal compliance.The widespread use of electronic health records (EHRs) and electronic health information exchange is essential to improving quality of care, reducing medical errors, decreasing health disparities, and advancing the delivery of patient-centered medical care.1 At the same time, it is recognized that appropriate privacy and security policies must be established and enforced if we are to truly achieve the benefits of electronic exchange.2In the US correctional setting, these goals are critical because of the number of Americans affected: in 2008, more than 2.3 million people were inmates on any given day, more than 1 in 100 American adults. Local jails admitted an estimated 11.6 million people during the 12 months ending June 30, 2012, with a midyear inmate population of 744 524.4,5 (Prisons are correctional institutions designated by federal or state law for the confinement of offenders who are judicially ordered into custody for punishment. Jails are locally operated correctional facilities that confine accused individuals awaiting trial and incarcerate convicted individuals, usually for up to 1 year and typically for misdemeanor offenses.⁵)The implications of and possibilities for health information sharing in this context through the use of health information technology with appropriate privacy protections in place should not be overlooked. Inmates at correctional facilities are a discrete population living in close contact, and maintaining accurate and easily accessible records is important to the overall health of the population. This population is also aging6,7 and disproportionately ill, with high rates of health problems (e.g., chronic8,9 and infectious disease,10 injuries11), psychiatric disorders,12,13 and substance use disorders.14,15Furthermore, the jail population is transient: only about 4% of jail admissions result in prison sentences; 96% of jail detainees and inmates return directly to the community, along with their often-untreated health conditions.16 Many detainees are released on bail pending trial after just several hours or a few days, with 60.2% of the jail population turning over every week.4 Half of the jail population is confined as a result of probation or parole violations or bond forfeiture.16Once returned to the community, inmates released from secure correctional facilities represent 17% of the total AIDS population, 13% to 19% of those with HIV, 12% to 16% of those with hepatitis B, 20% to 32% of those with hepatitis C, and 35% of those with tuberculosis.15,16 The ancillary impact of the health problems in this population on society as a whole can be enormous, from the potential spread of communicable diseases to the effects of substance abuse and untreated psychiatric disorders.The use of health information technology in correctional settings is quite limited, however. One recent study showed a range of technological sophistication among prison facilities, with rare use of EHRs.17 Furthermore, there is very little electronic exchange of health information within correctional systems or between systems and community providers. There are signs that EHR use is increasing, however, including reported adoption by the Federal Bureau of Prisons,18 the Texas Department of Criminal Justice,19,20 and the Georgia Department of Corrections,21 among others.22–24 There also appears to be growing interest among government leaders at all levels in the potential of health information technology to help bridge the divide between jails and their communities.25,26Here I explore the legal environment in which health information sharing occurs in correctional settings. Numerous state and federal laws shape this environment, but a comprehensive legal review is beyond the scope of this article. After a brief review of underlying principles, I focus on 2 key federal privacy laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the federal Confidentiality of Alcohol and Drug Abuse Patient Records laws (hereafter Part 2).The overarching purpose of these laws—encouraging and enhancing patient participation in the health care system—is sometimes modified in the correctional environment because of the drafters’ recognition of public safety needs. Their application also varies depending on factual circumstances; that is, an institution’s methods of health care delivery and its organizational/administrative structure might affect the determination of any particular legal question. In addition to reviewing stakeholder concerns regarding privacy law and the use of health information technology in the correctional environment, I describe possible ways forward that enable electronic exchange while ensuring protection of information and compliance with the law.     

Sexually Transmitted Infections Among Incarcerated Women: Findings From a Decade of Screening in a Los Angeles County Jail, 2002–2012

Objectives. We describe and report findings from a screening program to identify sexually transmitted infections (STIs) and HIV among female inmates in Los Angeles County Jail.Methods. Chlamydia and gonorrhea screening was offered to entering female inmates. Women were eligible if they were (1) aged 30 years or younger, or (2) pregnant or possibly pregnant, or (3) booked on prostitution or sex-related charges. Voluntary syphilis and HIV testing was offered to all women between 2006 and 2009. This analysis reports on data collected from 2002 through 2012.Results. A total of 76 207 women participated in the program. Chlamydia prevalence was 11.4% and gonorrhea was 3.1%. Early syphilis was identified in 1.4% (141 of 9733) and the overall prevalence of HIV was 1.1% (83 of 7448). Treatment levels for early syphilis and HIV were high (99% and 100%, respectively), but only 56% of chlamydia and 58% of gonorrhea cases were treated.Conclusions. Screening incarcerated women in Los Angeles County revealed a high prevalence of STIs and HIV. These inmates represent a unique opportunity for the identification of STIs and HIV, although strategies to improve chlamydia and gonorrhea treatment rates are needed.The ability of correctional facilities to provide access to medically underserved and otherwise marginalized populations makes them an ideal location for health screening and prevention measures, representing an important public health opportunity.1–3 Populations passing through correctional facilities represent a group that is at increased risk for sexually transmitted infections (STIs), including HIV, as the prevalence of risk factors such as substance use, transactional sex, previous history of an STI, and inconsistent condom use with multiple partners is high.3–6 Furthermore, in some instances correctional facilities have noted higher prevalence of STIs and HIV than other institutions (e.g., sexual health clinics) serving high-risk clients. Studies of STI prevalence conducted in jails have revealed relatively high prevalence of chlamydia among inmates ranging from 7% to 22%, with gonorrhea prevalence ranging from less than 1% to 9%.7–10 Likewise, the prevalence of HIV among jail inmates is relatively high with an estimated 1.2% to 1.8% infected, compared with 0.3% in the US general population.11,12 In fact, modeling data suggests that approximately 14% of persons living with HIV pass through a correctional facility in their lifetime, with the proportion being as high as 20% among African Americans and Hispanics.13Beyond reducing the disease burden in correctional facilities, the potential community-level benefits from programs aimed at STI and HIV prevention, screening, and treatment are substantial.8,11,12,14–16 An examination of community-level chlamydia prevalence following the establishment of a jail screening program in San Francisco, California, revealed a significant decline in chlamydia positivity among young women testing at community clinics serving a population with high incarceration rates.8 Specifically, the authors noted that chlamydia positivity among female attendees at a clinic located in a neighborhood in which the prevalence of jail testing was high declined from 16% in 1997 to 8% in 2004, while no changes occurred in a clinic located in a neighborhood with low jail testing (5% in 1997 and 5% in 2004).8 The potential community-level impact of STI screening services has been noted in other jail settings.14,15 In New York City, implementation of universal screening for men aged 35 years and younger entering jail resulted in a 59% increase in citywide reported male chlamydia case rate and the adult jails identified and reported 40% more cases than all 10 New York City public STI clinics.15 The population-level impact of jail screening is also supported by modeling data, which suggest that the community prevalence of chlamydia can be reduced by up to 54% by using jail-based chlamydia screen-and-treat programs.16Despite the fact that correctional facilities serve populations that are at increased risk for STIs, screening services in jails are limited.17,18 Potential reasons for this are manifold, and include the competing agendas of security and control versus health and welfare, as well as other logistical concerns including staffing, space, and rapid turnover of inmates in jail settings.1,17 However, jail-based STI and HIV interventions could potentially have a significant public health impact. Jails, which are most often run by sheriff departments or local governments, are designed to hold individuals awaiting trial or serving short sentences. As such, a much larger number of people cycle through jails than through prisons with more than 12 million admissions in the United States in 2012 compared with nearly 700 000 for prisons.19,20 Recognizing an important public health opportunity, the Los Angeles County Sheriff’s Department (LASD) in California developed a partnership with the Los Angeles County Department of Public Health (DPH) to offer STI screening for female inmates in the Los Angeles County Jail—the largest jail system in the United States.21 The objective of this report is to describe our experience and report findings from this screening program among women incarcerated in the Los Angeles County Jail from 2002 to 2012.     

Survey of US Correctional Institutions for Routine HCV Testing

To ascertain HCV testing practices among US prisons and jails, we conducted a survey study in 2012, consisting of medical directors of all US state prisons and 40 of the largest US jails, that demonstrated a minority of US prisons and jails conduct routine HCV testing. Routine voluntary HCV testing in correctional facilities is urgently needed to increase diagnosis, enable risk-reduction counseling and preventive health care, and facilitate evaluation for antiviral treatment.There are an estimated 4 to 7 million persons in the United States infected with HCV.1,2 Morbidity and mortality from HCV are increasing and in 2007, death from HCV exceeded that from HIV infection for the first time.3,4 Persons who inject drugs are at increased risk for HCV infection and for being incarcerated. Multiple studies have demonstrated high HCV prevalence rates among persons behind bars.5–7 In 2010, the Institute of Medicine (IOM) called for the development of comprehensive viral hepatitis services for incarcerated populations including offering testing, hepatitis B virus vaccination, education, and medical management in partnership with community providers.8Despite the Centers for Disease Control and Prevention (CDC) releasing HCV testing recommendations in 1998 and subsequent recommendations for prevention and control of viral hepatitis within correctional facilities in 2003,9-10 recent studies estimate that 50% of persons infected with HCV are unaware of their infection,11–14 thus reducing opportunities for risk-reduction counseling and treatment. In response to this, the CDC updated HCV testing recommendations for the US general population in 2012, which added at least 1-time testing among persons born between 1945 and 1965, now commonly referred to as the “birth cohort” screening recommendations.15 However, the 2012 recommendations did not provide a specific testing recommendation for incarcerated individuals. Given the increased prevalence of HCV among criminal justice populations, we conducted a survey among US prisons and jails to gain a better understanding of current HCV testing practices within correctional facilities.     

Older Jail Inmates and Community Acute Care Use

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release.Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use.Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89).Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.Jail has become a critical site for linking medically vulnerable older adults to community health care. Approximately 12 million Americans pass through jails each year and nearly all return to the community within 6 months where many struggle to access nonemergency medical care. Between 1996 and 2008 the number of “older” or “geriatric” inmates (aged 55 years or older) increased 278% compared with a 53% growth in the overall jail population.1,2 Now, approximately 550 000 older adults spend time in jail each year, comprising 10% of all inmates. Yet little is known about their health care and social service needs.Reducing acute care use (hospitalizations and emergency department [ED] use) and improving insurance access for former inmates is a priority in the Affordable Care Act (ACA).3 Although most inmates are without health insurance,4 those with insurance demonstrate reduced recidivism and better access to mental health and substance abuse treatment when released.5–7 The ACA expands Medicaid eligibility for low-income adults and allows eligible inmates to apply for coverage while in jail.3,8 As most persons passing through jails will be eligible for Medicaid in states participating in the expansion, an estimated 4 to 6 million jail inmates will gain new coverage by the end of 2014 through outreach and patient navigator assistance.9For community-dwelling older adults, health and social factors beyond insurance drive community acute care use, such as functional impairment, uncontrolled symptoms, and housing instability.10–12 This may also be true for older former inmates, many of whom experience “accelerated aging” because of high rates of disability and chronic disease at relatively young ages.13 Therefore, we conducted a study of older jail inmates to describe predetainment acute care use and anticipated plans for using acute care after release, and to assess the factors associated with use.     

What Women Want: A Qualitative Study of Contraception in Jail

Objectives. We undertook this study to understand women’s perceptions of receiving contraception at Rikers Island Jail.Methods. We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques.Results. Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by women’s negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception.Conclusions. Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.The number of women incarcerated in the United States has tripled over the past 10 years; there are currently more than 1 million women who are incarcerated, under parole, or on probation.1 However, medical services in correctional facilities have failed to meet the needs of this growing population.2,3 Among some of the more salient unmet medical needs is reproductive health care. This is of special concern because most women in correctional facilities are of reproductive age.4 More than 80% of incarcerated women have reported a history of unintended pregnancy.5 Incarcerated women interested in contraceptive care have reported barriers to care before incarceration, including difficulties with payment, finding a clinic, and transportation.6 Previous surveys have found that most incarcerated women are interested in starting birth control either while incarcerated or soon after release (60%–77.9%).5–7 Unfortunately, contraception is not routinely available. In one study, only 38% of correctional health providers indicated that their facilities provided birth control.8Evidence suggests that women will use contraceptive services if they are offered in a correctional facility. When contraceptive services were introduced at a facility in Rhode Island, initiation of a method increased from 4% to 47%.9 Women who did not want to become pregnant were more likely to want to start a form of birth control compared with women with ambivalent attitudes.10 However, the preferences for and perceived barriers to receiving contraceptive services while incarcerated or upon release remain otherwise unknown.Previous studies of contraceptive services for incarcerated women used surveys to examine women’s preferences and provider practices. We used qualitative interviews to explore this topic. Qualitative methods are useful for exploring topics about which little is known. We conducted this research to understand women’s contraceptive needs as they prepare to re-enter their communities and to learn about their perceptions of receiving contraception at Rikers Island.     

Deaths in New York City Jails, 2001–2009

Approximately 90 000 inmates are admitted annually to the New York City jail system, many of whom require a high level of medical or mental health services. According to our analysis of deaths in custody from 2001 to 2009, crude death rates have dropped significantly despite the increasing age of the population. Falling HIV-related mortality appears to contribute to this change. Other observations include low rates of suicide across all 9 years and increasing age of the population in recent years.Although relatively little has been published concerning deaths of inmates in jail, available information from the Department of Justice indicates declining numbers of deaths in jails starting in 2008, with comparable declines in deaths specifically related to HIV.1 These data also show that suicide and cardiovascular disease are leading causes of death. Medical care in the New York City jail system is provided by the Correctional Health Services (CHS) bureau of the New York City Department of Health and Mental Hygiene, whereas all custody and security is provided by the New York City Department of Correction (DOC). Extensive health care screening occurs during the jail admission process, and necessary care is afforded to all patients.2The prevalence of medical and mental health problems in jails is high.3 Although the CHS performs rigorous reviews of every death, we undertook an analysis of deaths in the aggregate as part of quality improvement efforts. We present data on the deaths of CHS patients who died while incarcerated from 2001 to 2009.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Solitary Confinement and Risk of Self-Harm Among Jail Inmates

Objectives. We sought to better understand acts of self-harm among inmates in correctional institutions.Methods. We analyzed data from medical records on 244 699 incarcerations in the New York City jail system from January 1, 2010, through January 31, 2013.Results. In 1303 (0.05%) of these incarcerations, 2182 acts of self-harm were committed, (103 potentially fatal and 7 fatal). Although only 7.3% of admissions included any solitary confinement, 53.3% of acts of self-harm and 45.0% of acts of potentially fatal self-harm occurred within this group. After we controlled for gender, age, race/ethnicity, serious mental illness, and length of stay, we found self-harm to be associated significantly with being in solitary confinement at least once, serious mental illness, being aged 18 years or younger, and being Latino or White, regardless of gender.Conclusions. These self-harm predictors are consistent with our clinical impressions as jail health service managers. Because of this concern, the New York City jail system has modified its practices to direct inmates with mental illness who violate jail rules to more clinical settings and eliminate solitary confinement for those with serious mental illness.Self-harm is a prevalent and dangerous occurrence within correctional settings.1 Inmates in jails and prisons attempt to harm themselves in many ways, resulting in outcomes ranging from trivial to fatal. Suicide is a leading cause of death among the incarcerated; however, suicide and suicide attempt represent a small share of all acts of self-harm.2 The motivations of inmates who harm themselves are complex and often difficult to discern.3 Inmates often arrive in correctional settings with significant pre-existing mental illness and histories of self-harm, but they may also be influenced by environmental stressors within correctional settings or aim to avoid certain situations or punishments.4Approximately one third of those admitted to the jail in New York City (NYC) receive care for mental health services during their incarceration, a proportion that has been increasing over time. Inmates who harm themselves become patients in the mental health service. Those who harm themselves while in solitary confinement may be diverted from that punitive setting to a therapeutic setting outside solitary confinement, which may provide an incentive for self-harm. The purpose of this analysis was to better understand the complex risk factors associated with self-harm and consider whether patients might be better served with innovative approaches to their behavioral issues.     

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Reducing Psychosocial and Behavioral Pregnancy Risk Factors: Results of a Randomized Clinical Trial Among High-Risk Pregnant African American Women

Objectives. We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence).Methods. Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up.Results. Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021).Conclusions. In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.Adverse pregnancy outcomes are particularly common among women who are members of racial/ethnic minority groups.^1–4 African American infants are 3.4 times more likely than are White infants to die in the neonatal period, a disadvantage that persists even when mothers have appropriately early and equal access to prenatal care.⁵ In Washington, DC, death rates among non-Hispanic African American infants remain unacceptably high (17.0 per 1000 live births in 2005) despite an overall decline in infant mortality from 18.6 per 1000 live births in 1992 to 14.0 per 1000 births in 2005.⁶ Psychosocial and behavioral risks are recognized as potential contributors to poor reproductive outcomes.^7–9 Poverty,¹⁰ limited social support,¹¹ smoking,¹² illicit drug use,¹³ depression,¹⁴ anxiety,^14,15 and intimate partner violence (IPV)^16,17 are all associated to varying degrees with pregnancy complications, premature and low-birthweight deliveries, stillbirths, and infant mortality.There is increasing recognition of the role of primary care in screening, diagnosis, and treatment of behavioral, mental health, and psychosocial concerns,^18–27 because of the significant association between medical morbidity and behavioral and mental health problems.²⁸ Although interventions involving primary care providers may have limited success, they can be cost-effective.^18,24 Because access to and use of behavioral and mental health care remain problematic, especially among members of underserved minority groups,^29–32 making such care available through primary care services may avert missed opportunities.Prenatal care may be a venue to address behavioral and mental health issues that can potentially affect the health of pregnant women and their unborn children.³³ The guidelines of the American College of Obstetrics and Gynecology and the American Academy of Pediatrics^34,35 suggest ways primary care providers can screen for behavioral and psychosocial risk factors. Despite these guidelines, many providers still fail to screen pregnant women,^35–38 with screening rates varying according to type of provider,^36,39 risk factors,³⁶ population group,⁴⁰ and provider risk perceptions.⁴¹ Furthermore, when implemented, psychosocial and behavioral interventions have been only moderately successful.^42,43Such inconsistent results may arise from multiple factors, including differences in study design, participant engagement, and intervention content or implementation, including approaches that address only 1 of multiple, co-occurring psychosocial or behavioral risk factors. Behavioral and psychosocial factors associated with poor pregnancy outcomes are related to and serve as risk factors for one another⁴⁴; therefore, an alternative approach would be to provide an intervention simultaneously addressing multiple psychosocial and behavioral risk factors among pregnant women, as has been done in relation to other health risks.^45–47A recent study focusing on 3569 Medicaid-eligible pregnant women examined the effects of the Prenatal Plus Program in Colorado with respect to smoking, inadequate prenatal weight gain, and “psychosocial problems” (defined as “significant or severe stress as a result of personal or family safety needs, lack of support systems, or an inability to meet basic needs”).^48(p1955) Women who had at least 10 Prenatal Plus visits were more likely than were women who did not to reduce these risks; in addition, only 7.0% of women who resolved all of their risks delivered low-birthweight infants, whereas 13.2% of those who resolved none of their risks did so. In spite of these promising results, the nonexperimental nature of the Colorado study may have created unquantifiable biases favoring the intervention.Moreover, only 4% of all births in Colorado, and 7% of Prenatal Plus deliveries, occurred among African American women, the group at greatest risk of adverse pregnancy outcomes. Thus, further experimental investigations in which rigorous randomized trial designs are used to assess vulnerable African American women are needed to better appreciate the potential merits of an integrated intervention focusing on psychosocial and behavioral risk factors during pregnancy.We conducted a randomized clinical trial testing the efficacy of an integrated intervention targeting multiple behavioral and psychosocial risk factors among pregnant African American women in the District of Columbia. The risk factors we chose to address were cigarette smoking, secondhand smoke exposure, depression, and IPV.     

The Case for Improving the Health of Ex-Prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill.There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings.There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.The world prison population is more than 10.75 million and is growing at a rate in excess of population growth.1 Although in the United States there is a distinction between prisoners (felony offenders incarcerated in state and federal prisons) and jail detainees (mostly misdemeanor offenders), this distinction is not made in most countries. Here we use the term prisoner to refer to both prisoners and jail detainees. Because of the rapid turnover of custodial populations, it has been estimated that globally, more than 30 million people move through prisons each year.2 Incarceration rates vary markedly within and between countries, and are heavily influenced by public policy decisions, such as the criminalization of drug users3 and the de-institutionalization of the mentally ill.4 The United States has the highest incarceration rate in the world (743 per 100 000 population) and accounts for more than one fifth of the world’s prisoners, with approximately 2.2 million people in custody on any one day.1 Of these, 1.5 million are held in state and federal prisons, and spend on average three years in custody before returning to the community; more than 700 000 are held in local jails, where the average stay is less than seven days. Given the large incarcerated population and rapid turnover of jail detainees, in excess of 11 million persons pass through US correctional facilities each year—more than in any other country.5–7Prisoners globally are characterized by complex and multifaceted health problems.8 Although imprisonment confers its own unique health risks,9,10 health usually improves in custody, where stable accommodation and regular meals are provided at little or no cost, illicit drugs are less readily available, and high-intensity health services are routinely provided.11,12 Unfortunately, these health gains are often rapidly lost after return to the community, where many ex-prisoners experience poor health-related outcomes, including poorly controlled disease,13 elevated rates of life-threatening drug overdose,14,15 preventable hospitalization,16,17 and mortality.18,19 Key to improving these outcomes is increased access to health care for ex-prisoners,20 but this has proven difficult to achieve. Despite recent encouraging research findings,21 the greater challenge has been translating promising pilot programs into policy, at scale and in a sustainable way. Here we make the case for improving the health of ex-prisoners, in the hope that this will provide a platform for evidence-based advocacy to improve the health of this profoundly marginalized, challenging, and underserved population.     

Medication Prescribing Practices for Older Prisoners in the Texas Prison System

Objectives. We sought to assess appropriateness of medication prescribing for older Texas prisoners.Methods. In this 12-month cross-sectional study of 13 117 prisoners (aged ≥ 55 years), we assessed medication use with Zhan criteria and compared our results to prior studies of community prescribing. We assessed use of indicated medications with 6 Assessing Care of Vulnerable Elders indicators.Results. Inappropriate medications were prescribed to a third of older prisoners; half of inappropriate use was attributable to over-the-counter antihistamines. When these antihistamines were excluded, inappropriate use dropped to 14% (≥ 55 years) and 17% (≥ 65 years), equivalent to rates in a Department of Veterans Affairs study (17%) and lower than rates in a health maintenance organization study (26%). Median rate of indicated medication use for the 6 indicators was 80% (range = 12%–95%); gastrointestinal prophylaxis for patients on nonsteroidal anti-inflammatories at high risk for gastrointestinal bleed constituted the lowest rate.Conclusions. Medication prescribing for older prisoners in Texas was similar to that for older community adults. However, overuse of antihistamines and underuse of gastrointestinal prophylaxis suggests a need for education of prison health care providers in appropriate prescribing practices for older adults.More than 1 in 100 Americans are incarcerated in a US prison or jail¹ and older prisoners are among the most rapidly growing correctional populations.^1–4 With high rates of chronic disease,^5–7 older prisoners cost on average 2 to 3 times more than younger prisoners to incarcerate.^1,8 Yet prisons are often ill-equipped to care for older prisoners with complex medical problems, such as functional or cognitive impairments.^9–12 This is largely because older adults have substantively different health care needs than younger adults who have traditionally been the focus of prison health care.¹² Despite the increasing numbers and cost of older prisoners, research about the quality of geriatric care in prisons is sparse.One important difference in the care of younger and older adults is medication prescribing.^13,14 Older adults often require medications for multiple chronic diseases, whereas younger adults typically require short-term medications for acute injuries or infection. Although older patients are at increased risk for medication-related adverse events leading to morbidity, mortality, and high costs,^15,16 underuse of indicated medications can deny older adults improved quality and length of life.¹⁵ Despite the safety concerns and high cost associated with inappropriate medication use in older adults, little is known about medication prescribing practices for older prisoners.We assessed medication prescribing practices among older prisoners in the Texas Department of Criminal Justice (TDCJ)—one of the nation''s largest state prison systems. Since 1994, when the TDCJ implemented an academic-based managed care system run by the University of Texas Medical Branch, it has reported substantial improvements in health care and has been proposed as a nationwide model.^17,18 It is unknown if this improved quality has extended to elements of care of the older prisoners, such as medication prescribing quality.     

All-cause and cause-specific mortality among men released from state prison, 1980-2005

Objectives. We compared mortality of ex-prisoners and other state residents to identify unmet health care needs among former prisoners.Methods. We linked North Carolina prison records with state death records for 1980 to 2005 to estimate the number of overall and cause-specific deaths among male ex-prisoners aged 20 to 69 years and used standardized mortality ratios (SMRs) to compare these observed deaths with the number of expected deaths had they experienced the same age-, race-, and cause-specific death rates as other state residents.Results. All-cause mortality among White (SMR = 2.08; 95% confidence interval [CI] = 2.04, 2.13) and Black (SMR = 1.03; 95% CI = 1.01, 1.05) ex-prisoners was greater than for other male NC residents. Ex-prisoners'' deaths from homicide, accidents, substance use, HIV, liver disease, and liver cancer were greater than the expected number of deaths estimated using death rates among other NC residents. Deaths from cardiovascular disease, lung cancer, respiratory diseases, and diabetes were at least 30% greater than expected for White ex-prisoners, but less than expected for Black ex-prisoners.Conclusions. Ex-prisoners experienced more deaths than would have been expected among other NC residents. Excess deaths from injuries and medical conditions common to prison populations highlight ex-prisoners'' medical vulnerability and the need to improve correctional and community preventive health services.The United States has the highest incarceration rate in the world,¹ but 95% of prisoners are eventually released,² with most reentering society after less than 2 years of imprisonment.³ The result is a large and ever-increasing population of former inmates.⁴This growing population shoulders a heavy burden of disease, particularly infectious diseases such as hepatitis C virus, HIV, and other sexually transmitted infections.⁵ This burden is a reflection of high disease rates in the impoverished communities from which prisoners come and prisoners'' engagement in behaviors that are both illegal and harmful to health.⁶ Mental health conditions, including substance use disorders, are also common among prisoners.^7,8 These conditions are not only directly harmful, they also may exacerbate other comorbidities (e.g., cardiovascular disease and diabetes)^9,10 and are associated with diminished access to routine medical care.^11,12The transition from prison back into the community is typically difficult. Ex-prisoners often need to seek out housing and employment, reestablish personal relationships, navigate access to supportive services, and abide by the restrictions of parole and other legal sanctions.¹³ These needs frequently supersede routine health care.¹⁴For some, the transition is also dangerous. For ex-prisoners, risk of death in the first year—and especially in the first few weeks—after release is high compared with the risk of death among the general population.^15–18 The vast majority of these deaths are the result of nonnatural causes, particularly homicide, suicide, and drug overdose.^15–18 In one of the few US studies of its kind, risk of death among former Washington state prisoners during the first 2 weeks after release was 12.7 times the risk of death among other state residents, and risk of death from drug overdose during the first 2 weeks after release was 129 times that of other state residents.¹⁸Even less well-studied in the United States are the long-term health outcomes of former prisoners. A large retrospective study conducted in Australia reported that mortality among prisoners exceeded that of the general population across all major causes of death.¹⁹ The public health implication of these findings for the United States is troubling given the large size of the US ex-prisoner population, the heavy burden of disease among prisoners, and the legal sanctions and social stigma that diminish access to resources after release from prison.The purpose of our study was to examine the mortality of prisoners after their release. Specifically, we used age-standardized mortality ratios stratified by race to examine overall and cause-specific mortality among male former inmates. In addition, we examined the relative risk of mortality among former prisoners after we controlled for a measure of socioeconomic status (SES) and assessed time between prison release and death from injuries common to former prisoners. Enumeration of mortality disparities among former inmates could help detect lapses in the continuity between correctional and community health care resources.     

Efficacy of a Process Improvement Intervention on Delivery of HIV Services to Offenders: A Multisite Trial

Objectives. We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision.Methods. As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service.Results. The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point.Conclusions. Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments.The National Institute on Drug Abuse launched the Criminal Justice Drug Abuse Treatment Studies, Phase 2 in 2008, under a cooperative agreement with multiple research organizations and a coordinating center. The purpose was to test implementation strategies for health-related interventions for offenders incarcerated in prisons and jails or supervised by probation and parole agencies. The research centers designed the protocols and conducted the trials. The HIV Services and Treatment Implementation in Corrections (HIV-STIC) study evaluated implementation strategies in HIV/AIDS prevention–education, testing, and treatment.Inmates and other offenders are at high risk for HIV infection, and the rate of confirmed AIDS cases among state and federal prisoners has been about 2.4 times the rate in the general US population.1–4 In 2009, the Centers for Disease Control and Prevention released practice guidelines for managing HIV risk among offenders in correctional systems; they called for HIV testing, prevention programming, and discharge planning for seropositive inmates.5 Although many correctional facilities offer HIV testing, prevention, and antiretroviral medication services, studies have demonstrated that many gaps remain in delivering effective HIV services.6 Furthermore, although inmates identified as HIV positive are provided with antiretroviral therapy (ART) by correctional facilities, gaps in access to medications when inmates are released to the community are common and can have catastrophic consequences for offenders and collateral contacts.7,8For the HIV-STIC study, we found helpful ideas in the model of implementation research developed by Proctor et al.9,10 They (and other theorists) propose that experimental testing has identified many effective public health interventions, so that now the pressing need is to test implementation strategies to achieve successful use of those interventions in organizations. Another important concept is service penetration to recipients (the number of eligible persons who use a service as a proportion of the total number of persons eligible for the service).10,11 Effective HIV prevention models for correctional populations have been identified,12,13 but transferring these programs from carefully controlled trials into real-world practice is difficult,14,15 and few studies have tested the implementation processes in field settings.14,16Quality improvement strategies have become common in health care systems. The Network for the Improvement of Addiction Treatment (NIATx)17 trains coaches to help local agency change teams learn how to try out and assess new organizational processes for targeted improvements such as improved patient retention in treatment.18,19HIV continues to be a major public health problem (even though research has established the efficacy of HIV testing, prevention practices, and ART) because these services have not been adequately implemented for high-risk populations. We sought to expand the new field of implementation science to evidence-based HIV services for a very high-risk population: offenders in correctional facilities or recently released from such facilities. We also tested a NIATx model modified for the implementation of HIV services in prisons and jails.Nine research centers cooperated in planning and conducting the research. Our long-term goal was improved health services for an at-risk population: offenders under correctional supervision. Specifically, we aimed to more effectively implement improvements in HIV services for preventing, detecting, and treating HIV. Our primary hypothesis was that, compared to the control condition facilities, proportionally more offenders in our experimental condition facilities (where staff were exposed to the modified NIATx model) would receive improved delivery of HIV services.     

Mental Health of Prisoners: Identifying Barriers to Mental Health Treatment and Medication Continuity

Objectives. We assessed mental health screening and medication continuity in a nationally representative sample of US prisoners.Methods. We obtained data from 18 185 prisoners interviewed in the 2004 Survey of Inmates in State and Federal Correctional Facilities. We conducted survey logistic regressions with Stata version 13.Results. About 26% of the inmates were diagnosed with a mental health condition at some point during their lifetime, and a very small proportion (18%) were taking medication for their condition(s) on admission to prison. In prison, more than 50% of those who were medicated for mental health conditions at admission did not receive pharmacotherapy in prison. Inmates with schizophrenia were most likely to receive pharmacotherapy compared with those presenting with less overt conditions (e.g., depression). This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison.Conclusions. A substantial portion of the prison population is not receiving treatment for mental health conditions. This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.Mental health disorders among prisoners have consistently exceeded rates of such disorders in the general population, and correctional facilities in the United States are often considered to be the largest provider of mental health services.1–3 Despite court mandates for access to adequate health care in prisons (these mandates are even further limited to “severe” and “serious” mental illness treatment requirements in prison settings), inmate access to health and mental health care has been sporadic.4,5 Treatment decisions often depend on the limited available resources, public support of correctional treatment, and correctional management decision-making.4,5 Some studies report that at least half of male inmates and up to three quarters of female inmates reported symptoms of mental health conditions in the prior year (compared with 9% or fewer in the general population).3,6–8 These rates underscore the importance of access to mental health treatment for inmates, because lack of access to treatment can have important policy implications, particularly when financial resources are limited for correctional intervention and treatment.Individuals with untreated mental health conditions may be at higher risk for correctional rehabilitation treatment failure and future recidivism on release from prison.2,9,10 In fact, Baillargeon et al.10 found that after release from prison, former inmates who received a professional diagnosis of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental health disorder were 70% more likely to return to prison at least once than were those who were not given a diagnosis. Furthermore, among those who have been previously incarcerated, the rates of recidivism are between 50% and 230% higher for persons with mental health conditions than for those without any mental health conditions, regardless of the diagnosis.The limited treatment options in many prison settings are directly reflected in the greater number of disciplinary problems, rule violations, and physical assaults among those who have mental health disorders,11 often compounded by the resulting solitary confinement as punishment for these behaviors.1 Although all prisons are required to provide some level of health care, we know very little about whether mental health treatment is actually available to inmates on a case-by-case basis.3,9 In fact, Wilper et al. found that most prisoners, even those who have chronic medical conditions (such as diabetes or hypertension), had limited access to health care in prison.3 Therefore, we used a nationally representative sample of US prisoners to assess whether all persons with a history of mental health conditions were screened and evaluated by a medical professional for these conditions and whether medication use was continuous from the community setting to the prison setting.Mental health conditions represent a different level of need when compared with physical health needs among prisoners. For instance, tuberculosis transmission is a physical health hazard to all inmates and staff. Therefore, correctional administrators ensure that individuals suspected of having tuberculosis obtain proper assessment and subsequent access to health care. Symptoms inherent to many mental health disorders, however, may be less obvious to prison staff, especially without assessment by trained mental health professionals. In addition, a report on mental health care in prison emphasized the need for screening and treatment of mental health conditions among inmates from both a legal and a humanitarian perspective.12 Specifically, several US Supreme Court decisions have supported the rights of prisoners to receive health care, including mental health care (see Bowring v Godiva, 551 F2d 44 [4th Cir 1977]; Laamon v. Helgemoe, 437 F Supp 269 [DNH 1977]; and Ruiz v Estelle, 503 F Supp 1265 [SD Tex 1980]). To date, however, a great deal of variation remains in screening for and treatment of mental health disorders in prison settings.13,14 The use of pharmacotherapy, in conjunction with counseling and self-help groups, to treat mental health conditions in correctional settings has been largely accepted in the correctional community; however, many medications are expensive and, therefore, not offered widely within institutions.4,12,13,15Several practical issues might explain why an individual in the correctional system would have difficulty receiving (or continuing to receive) pharmacotherapy for mental health conditions. First, psychologists and psychiatrists who may properly diagnose disorders are in short supply,12 and the screening tools that are typically used in prison settings are not diagnostic tests. Instead, the purpose of these tools is to gauge the security risk of a new inmate at the institution.4 Second, the continuously declining correctional budget may limit treatment access to those with only the most serious mental health conditions.5 In an ideal situation in which a licensed professional properly diagnoses inmates, specialized treatment programs (rarely located inside of prison facilities) are available. Unfortunately, the use of these outside treatment programs is limited, because correctional budgets do not have the extensive resources necessary to manage inmates enrolled in off-site treatment or to handle the logistics (such as secure transport) involved.15The incarceration experience itself poses a challenge to mental health treatment. Untreated mental health (and physical health) conditions are known to result in poor adjustment to life in prison.12 Furthermore, crowded living quarters, lack of privacy, increased risk of victimization, and solitary confinement within the institution have been identified as strong correlates for self-harm and adaptation challenges for those with mental health conditions in prison settings.16,17Given the strong relation between mental health and criminal behavior,18 the public health system has a great deal to gain from better mental health treatment among inmates, particularly in reducing the costs associated with high recidivism rates.5,10,19 Therefore, this study extends previous research on prisoner health conducted by Wilper et al.3 by assessing the continuity of pharmacotherapy (e.g., medication used to treat a mental health condition in prison), beyond the prevalence rates of pharmacotherapy in prison. Furthermore, we examined potential explanations for both continuity and discontinuity of treatment in the inmate population. Specifically, this study will contribute to the literature by evaluating 3 specific aims: (1) to assess medication continuity for a mental health condition since admission to prison; (2) to assess the correlates of medication continuity, medical screening, and receipt of examinations by medical personnel; and (3) to assess the degree to which medication continuity is predicted by screening prisoners for mental health conditions at intake to prison.