Clozapine Reduces Self-Injurious Behavior in a State Prison Population

[摘要] Self-injurious behavior (SIB) is a common, disruptive, and costly occurrence in U.S. prisons. In this study, we describe the use of clozapine to treat 10 offenders with chronic, repetitive self-injury refractory to other medications and behavioral therapies. The primary diagnosis for all 10 offenders was a personality disorder. Eight of the 10 inmates allowed weekly blood draws and took medication regularly (approximately 95% adherence), whereas two inmates discontinued treatment within the first two weeks. For these eight patients, we compared the number of in-house urgent care visits and outside emergency room visits related to SIB for the six-month periods before and after treatment with clozapine. After initiation of clozapine treatment, there were 66 fewer urgent care visits (94 versus 28) and 26 fewer emergency room visits (37 versus 11), a 70 percent reduction in each. As a secondary outcome, we assessed disciplinary infractions. There were 132 fewer infractions (197 versus 65), a 67 percent reduction. The median dose of clozapine used was 125 mg/day, substantially lower than doses typically used to treat schizophrenia. Clozapine appears to be a feasible and effective treatment for some patients with chronic, repetitive SIB for whom other treatments have failed. Self-injurious behavior (SIB) is a prevalent, costly, and disruptive problem in prison populations. ^{1 , – , 6} SIB is defined as “the deliberate destruction or alteration of body tissue without conscious suicidal intent.” ⁷ In forensic settings, this can manifest as cutting, head banging, scratching, burning, hitting, biting, amputation, foreign body insertion/ingestion, overdose, enucleation, smearing feces into wounds/orifices, and opening old wounds. Prevalence estimates of SIB among inmates vary widely. In a recent review of SIB in England and Wales, 5 to 6 percent of male prisoners and 20 to 24 percent of female prisoners engaged in SIB each year over a five-year period. ⁶ A national survey of prison mental health directors in the United States found that less than two percent of inmates engaged in SIB each year, but that 85 percent of prison systems observed SIB on a weekly basis. ³ Repetition of SIB among inmates is common, and a substantial clustering effect of SIB in prisoners, both in time and location, has been noted. ⁶ The cost of care for individuals with repeated episodes of SIB is markedly higher than for other offenders, primarily due to frequent emergency room and urgent care visits. ⁸ Repetitive self-injury also takes a toll on prison staff in terms of one-to-one monitoring, transport to medical facilities, and burnout. SIB in prisons has been associated with risk factors including younger age, white race, female sex, prior mental health diagnoses, history of violence, prior trauma, prior substance use history, developmental or intellectual disabilities, and placement in restrictive housing. ^{2 , 5 , 6 , 9} Restrictive housing, also known as segregation or solitary confinement, involves confining inmates to a cell for up to 23 hours per day, with one hour out for solitary exercise or hygiene. SIB in offenders is a risk factor for both future suicide and violence toward others. ^{6 , 10} Conventional management of SIB in prisons involves use of medications, seclusion, restraint, and behavioral therapies. ^{3 , 11 , 12} To date, there is no FDA-approved medication indicated for the treatment of chronic, severe SIB, nor is there any medication approved for borderline personality disorder (BPD) or antisocial personality disorder (ASPD), illnesses that increase the risk of such behaviors, particularly in the forensic setting. Two recent reviews show limited effectiveness of pharmacological management of SIB in adults in non-correctional settings; however, these reviews relied exclusively on randomized trials and did not include clozapine. ^{13 , 14} Clozapine is a second-generation antipsychotic medication with demonstrated effectiveness for treatment-refractory schizophrenia and reduction in risk of recurrent suicidal behavior in individuals with schizophrenia or schizoaffective disorder. ^{15 , – , 17} Numerous reports document clozapine's benefits in decreasing SIB and aggression in both psychotic and non-psychotic populations. ^{18 , – , 22} Despite its superiority to other antipsychotics, clozapine remains underutilized in the United States for a variety of reasons, primarily its requirement for hematological monitoring. In 2016, a workgroup of the National Association of State Mental Health Program Directors issued a white paper addressing the underutilization of clozapine. ²³ The paper noted that “accumulating evidence supports clozapine's utility for a variety of other disorders and conditions such as treatment of hostility and aggression…and borderline personality disorder” (Ref. 23 , p 7). The authors also recommended expanding clozapine's use in forensic facilities, given the increasing number of incarcerated individuals with mental illness. There are few published reports of clozapine's use in prisons and jails, and most studies have focused on patients with schizophrenia. ^{24 , – , 27} Brown et al. have described clozapine's use in a cohort of non-schizophrenic violent men with ASPD, reporting reductions in impulsivity and aggression after a median of 14 weeks of treatment. ²⁶ However, much of the aggression in this group did not involve physical assaults against others. Mela and Depiang analyzed post-release patients with a psychotic disorder on clozapine and other antipsychotics and found a significantly longer time to first offense and more crime-free time in the community in the clozapine group. ²⁷ To our knowledge, there are no published articles examining the use of clozapine for chronic SIB in a prison population. This study had two primary objectives. We sought to examine the feasibility of prescribing clozapine to male offenders in a restrictive housing setting who exhibit chronic, severe SIB, for whom multiple prior pharmacological and psychosocial therapies had failed. If feasible, we then attempted to determine whether this intervention was effective in reducing the number of episodes of SIB. As a secondary measure, we sought to determine whether there was any reduction in disciplinary infractions. We hypothesized that there would be a reduction in both SIB and infractions after treatment with clozapine for at least some patients.

[学科分类] 儿科学