Journal of Correctional Health Care - April 2023 - 109
Journal of Correctional Health Care
Volume 29, Number 2, 2023
ยช The Author(s) 2023
DOI: 10.1089/jchc.21.06.0059
Open camera or QR reader and
scan code to access this article
and other resources online.
BEST PRACTICES
Expanding Clozapine Use in State Prisons:
A Review of the North Carolina Experience
Megan E. Pruette, MD,1* Theodore R. Zarzar, MD,1 and Brian B. Sheitman, MD2
Abstract
The prevalence of serious mental illnesses in prisons is estimated to be significantly higher than in the community.
The antipsychotic medication clozapine is very effective in managing treatment-resistant psychosis
and may also reduce suicidal and self-injurious behaviors but is underused due to several logistic challenges.
A partnership between the North Carolina prison system and University of North Carolina School
of Medicine established a consultative system for clozapine initiations that has led to a 390% increase in
the number of incarcerated people using clozapine over a 5-year period. This article reviews the benefits
and challenges of clozapine use in corrections based on the North Carolina experience and practical strategies
on how to expand use in a prison system.
Keywords: clozapine, self-injurious behaviors, suicide, schizophrenia, antipsychotic agents
Serious Mental Illness in Prisons
Regardless of the expressed purpose of the nation's
prison system, it was never intended to house and treat
people with severe mental illness. As state psychiatric
hospital beds dwindle and community resources remain
scarce, correctional facilities have become ever-larger
providers of mental health care in our country (Torrey
et al., 2014). This increase comes with a host of challenges
for correctional systems. Despite attempts to make correctional
settings more rehabilitative, there continues to be
many difficult-to-manage illnesses and behaviors in prisons
(Appelbaum et al., 2011; Fazel et al., 2016).
A review of studies conducted between 1989 and 2013
found the prevalence of schizophrenia in state prisons
ranged from 2.0% to 6.5% (Prins, 2014). Approximately
30% of all people with schizophrenia are considered
treatment refractory (Kane et al., 2019), meaning that
their illness does not respond adequately to two separate
trials of antipsychotics. People with treatment-refractory
schizophrenia tend to experience frequent and intense
hallucinations, delusions, and disorganized or bizarre behaviors.
They often have difficulty following basic rules
and instructions due to attention and concentration problems
(Kraus & Keefe, 2007; Lui et al., 2018).
In addition to schizophrenia, people with severe personality
disorders have also been overrepresented in prisons
(Black et al., 2007). Patients with borderline personality
disorder struggle with severe and frequent mood swings,
anger outbursts, chaotic interpersonal relationships, and
impulsivity. Many engage in self-injurious behavior
(SIB) to alleviate or distract from negative emotions, to
have a sense of control, or as a means of punishment.
Often this behavior requires outside hospitalization for
medical attention or, at a minimum, placement on suicide
1Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
2North Carolina Department of Public Safety-Prisons, Raleigh, North Carolina, USA.
*Address correspondence to: Megan E. Pruette, MD, Department ofPsychiatry, University ofNorth Carolina School ofMedicine, 77 Vilcom Dr. #300, Chapel Hill, NC 27514, USA,
Email: mepruett@ad.unc.edu
109
Journal of Correctional Health Care - April 2023
Table of Contents for the Digital Edition of Journal of Correctional Health Care - April 2023
Journal of Correctional Health Care - April 2023 - Cover1
Journal of Correctional Health Care - April 2023 - Cover2
Journal of Correctional Health Care - April 2023 - 89
Journal of Correctional Health Care - April 2023 - 90
Journal of Correctional Health Care - April 2023 - 91
Journal of Correctional Health Care - April 2023 - 92
Journal of Correctional Health Care - April 2023 - 93
Journal of Correctional Health Care - April 2023 - 94
Journal of Correctional Health Care - April 2023 - 95
Journal of Correctional Health Care - April 2023 - 96
Journal of Correctional Health Care - April 2023 - 97
Journal of Correctional Health Care - April 2023 - 98
Journal of Correctional Health Care - April 2023 - 99
Journal of Correctional Health Care - April 2023 - 100
Journal of Correctional Health Care - April 2023 - 101
Journal of Correctional Health Care - April 2023 - 102
Journal of Correctional Health Care - April 2023 - 103
Journal of Correctional Health Care - April 2023 - 104
Journal of Correctional Health Care - April 2023 - 105
Journal of Correctional Health Care - April 2023 - 106
Journal of Correctional Health Care - April 2023 - 107
Journal of Correctional Health Care - April 2023 - 108
Journal of Correctional Health Care - April 2023 - 109
Journal of Correctional Health Care - April 2023 - 110
Journal of Correctional Health Care - April 2023 - 111
Journal of Correctional Health Care - April 2023 - 112
Journal of Correctional Health Care - April 2023 - 113
Journal of Correctional Health Care - April 2023 - 114
Journal of Correctional Health Care - April 2023 - 115
Journal of Correctional Health Care - April 2023 - 116
Journal of Correctional Health Care - April 2023 - 117
Journal of Correctional Health Care - April 2023 - 118
Journal of Correctional Health Care - April 2023 - 119
Journal of Correctional Health Care - April 2023 - 120
Journal of Correctional Health Care - April 2023 - 121
Journal of Correctional Health Care - April 2023 - 122
Journal of Correctional Health Care - April 2023 - 123
Journal of Correctional Health Care - April 2023 - 124
Journal of Correctional Health Care - April 2023 - 125
Journal of Correctional Health Care - April 2023 - 126
Journal of Correctional Health Care - April 2023 - 127
Journal of Correctional Health Care - April 2023 - 128
Journal of Correctional Health Care - April 2023 - 129
Journal of Correctional Health Care - April 2023 - 130
Journal of Correctional Health Care - April 2023 - 131
Journal of Correctional Health Care - April 2023 - 132
Journal of Correctional Health Care - April 2023 - 133
Journal of Correctional Health Care - April 2023 - 134
Journal of Correctional Health Care - April 2023 - 135
Journal of Correctional Health Care - April 2023 - 136
Journal of Correctional Health Care - April 2023 - 137
Journal of Correctional Health Care - April 2023 - 138
Journal of Correctional Health Care - April 2023 - 139
Journal of Correctional Health Care - April 2023 - 140
Journal of Correctional Health Care - April 2023 - 141
Journal of Correctional Health Care - April 2023 - 142
Journal of Correctional Health Care - April 2023 - 143
Journal of Correctional Health Care - April 2023 - 144
Journal of Correctional Health Care - April 2023 - 145
Journal of Correctional Health Care - April 2023 - 146
Journal of Correctional Health Care - April 2023 - 147
Journal of Correctional Health Care - April 2023 - 148
Journal of Correctional Health Care - April 2023 - 149
Journal of Correctional Health Care - April 2023 - 150
Journal of Correctional Health Care - April 2023 - 151
Journal of Correctional Health Care - April 2023 - 152
Journal of Correctional Health Care - April 2023 - 153
Journal of Correctional Health Care - April 2023 - 154
Journal of Correctional Health Care - April 2023 - 155
Journal of Correctional Health Care - April 2023 - 156
Journal of Correctional Health Care - April 2023 - 157
Journal of Correctional Health Care - April 2023 - 158
Journal of Correctional Health Care - April 2023 - 159
Journal of Correctional Health Care - April 2023 - 160
Journal of Correctional Health Care - April 2023 - 161
Journal of Correctional Health Care - April 2023 - 162
Journal of Correctional Health Care - April 2023 - 163
Journal of Correctional Health Care - April 2023 - 164
Journal of Correctional Health Care - April 2023 - 165
Journal of Correctional Health Care - April 2023 - 166
Journal of Correctional Health Care - April 2023 - 167
Journal of Correctional Health Care - April 2023 - 168
Journal of Correctional Health Care - April 2023 - Cover3
Journal of Correctional Health Care - April 2023 - Cover4
https://www.nxtbookmedia.com