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Mental Health Concerns for Educators in PrisonAn Overview Of Mental Health

Services In NC Prisons

Rich Bruner, Staff Psychologist II

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Overview:

Delivery and Structure of MH servicesMajor diagnosesTypical presentations and medicationsClassroom concernsQuestions, comments…

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Mental Health Service Delivery

Intake Initial screening:

- Mental Health Screening Inventory- IQ testing -Achievement testing: WRAT-3

-Reading, Spelling, Arithmetic standard scores and grade equivalent

Therapeutic Services:- Individual and Group Psychotherapy- Psychiatry- Hospitalization - Special Programs – Day Treatment, SOAR

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Identifying DD/MR

Beta scores < 70 (x2)

WAIS-III score < 70 - with significant social impairment

Adaptive Behavior Checklist of Substantial Life Functions

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Adaptive Behavior Checklist

Self Care Receptive and Expressive

Language Learning Mobility Self-Direction Capacity for Independent

Living Economic Self-Sufficiency

Three or more significant life function deficits to meet Developmentally Disabled criteria

150 identified MR inmates in the system

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Structure of MH Services

Outpatient Services - Psychological ……………..48/78 prisons

- Psychiatric………………...22 prisons

Residential Treatment……........3 prisons

Inpatient Treatment (Hospital)...2 prisons

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Numbers

Inpatient……………......…28♀+87♂=115 Residential…………..…………….210 Outpatient

- Psychologist (or social worker) …....1500

- Psychiatrist….......................1900

TOTAL: 3700+ *approx. 10% of 37,000 inmates

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Prison Population Projections

2006: 38,000 2010: 40,000+ 2015:~45,000 (Job security !?!)

Only 6% are misdemeanor offenders i.e. (short terms)

* Community Mental Health shortage of services

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Reference:

DSM-IV™Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition

© 1994 American Psychiatric Association, Washington, DC

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Classification of Mental Disorders

Axis I - Clinical Disorders -and other conditions of clinical attention

Psychosis and Delusional Disorders Mood Disorders Anxiety Disorders Substance Dependence Attention Deficit Disorder (ADHD)

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Classification of Mental Disorders

Axis II - Personality Disorders- Antisocial Personality Disorder- Others

- Mental Retardation

Axis III - General Medical Conditions

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Psychotic Disorders

1/6 of prison caseload ~ 600+ inmates

- many in Inpatient or Residential treatment

Typically 0.2 – 2% of non-prison population- with differences in rural vs urban, etc.

~ 1.6% prison pop.

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Psychotic Disorders:What will you see?Symptoms: Perception and thought……………

Language and Communication…..

Behavioral Monitoring……………..

Productivity of thought…………….

Affect………………………………..

Volition, drive and attention……….

Presentation: Low productivity of thought,

delusions and hallucinations Disorganized speech

Disorganized behavior, catatonic

Excessive or diminished thought

Reduced emotional expression

Avolition, reduced drive

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Medications for Psychotic Disorders--Limited formulary…

Oral (most choices):- Risperdal- Haldol- Geodon- Abilify- Others

Injectable:- Haldol Decanoate- Prolixin- Risperdal Consta - $$$

Good Effects:- Less hallucinations!- Sedation- Improved thought - More volition, motivation

Bad Effects:- Tremors- Rigid expression- Dystonic reactions (spastic)- Over sedation / restlessness- Weight gain

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Mood Disorders- Depressive and Bipolar

Disorder

Symptoms: Depression- Anhedonia- Disturbances in appetite, sleep, energy- Feelings of worthlessness, guilt- Difficulty thinking/concentrating- Thoughts of death and self-harm ___________

*Ask directly!

Mania: High energy, sleeplessnesselevated mood, pressure of speech

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Medications for Mood Disorders

DEPRESSION:Limited Formulary – No Tricyclic Antidepressants:

- sedating medications, cheaper, but more side effects and less effectiveness

- SSRI’s: Prozac, Celexa, Paxil, Zoloft- SNRI: Effexor- Atypical: Wellbutrin

MANIA: Mood stabilizers, anti-psychotic meds -Depakote, Tegretol, Risperdal, Geodon

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Anxiety Disorders Panic Disorder

- with and without agoraphobia

Phobias Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder

-------------------------------------------------Range of symptoms: Frequency, Duration, or Intensity

sufficient enough to result in significant social impairment

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Substance DependenceSeveral types with mood and scholastic effects…

- Crack cocaine- Methamphetamine- Hallucinogens – LSD, Ecstasy- Alcohol, Opioids, Inhalants

Temporary and permanent brain effects…- Diminished receptor sites with regrowth- Alzheimer’s like brain damage

Treatment: Substance specific groups -AA, NA; and Residential D.A.R.T. Psychotherapy for presenting secondary disorder

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Attention Deficit – Hyperactivity Disorder (ADHD)

Child onset, originally thought to disappear in adulthood, now 30 to 50% of ADHD children thought to carry diagnosis to adulthood.

- Low level of diagnosis in prisons: (40) Underdiagnosed?

DX: Hyperactive-impulsive and Inattentive Behaviors

Causing impairment prior to age 7

In at least two settings – home, school, work, social situations

With clear interference in developmentally appropriate social, academic or occupational functioning

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Adult ADHD in the Classroom (Adapted from Wender PH. Attention-deficit hyperactivity disorder in adults. New York: Oxford University Press, 1995:122-43.)

I. Childhood history consistent with ADHD II. Adult symptoms

Two of the following: Poor concentration (less hyperactivity) Inability to complete tasks and disorganization Affective lability Hot temper Stress intolerance Impulsivity

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Treatment for Adult ADHD

Info-therapy Skills training – organizational, environmental

Medication (rarely in prison)

Stimulants: Strattera – but not Ritalin, Dexedrine, etc

SSRI’s: Prozac, Paxil – less efficacy, symptomatic tx.

Other: Wellbutrin (atypical antidepressant)

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Axis II:Personality Disorders

Antisocial

Paranoid

Schizotypal

Histrionic

Dependent

Narcissistic

Personality Disorder NOS

and others!

- An enduring pattern of inner experience and behavior that deviates markedly from expectations of the individual’s culture, is pervasive and inflexible, has an early onset, is stable over time, and leads to distress or impairment.

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Antisocial Personality DisorderCommon in prisons for some reason…

#’s 677 diagnosed, Personality Disorder NOS # 680 (Out of 3700 patients)Pervasive pattern of disregard for and violation of rights of others since age 15

– with childhood Conduct Disorder

Failure to conform to social norms and lawful behaviors Deceitfulness, lying, conning for profit or pleasure Impulsivity, failure to plan ahead Irritability and aggressiveness Reckless disregard for safety of self or others Consistent irresponsibility – in work or financial obligations Lack of remorse – indifferent or rationalizing

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DangerousnessKnowing the risks

- Axis I (Clinical) versus Axis II (Personality) risks

Personal boundaries - and imposed limitations

Assistance is available

Consult, refer, and excuse!

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Questions and Comments?

Rich Bruner, Staff Psychologist IIAvery-Mitchell Correctional Institution