Draft Key Questions
Disposition of Comments Report
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To comprehensively review the evidence for treatments for offenders with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depression) in jail, prison, or forensic hospital, or transitioning from any of these settings to the community (e.g., home, halfway house).
We searched 12 internal and external databases including MEDLINE®, PreMEDLINE®, and Embase® for the time period January 1, 1990, through August 20, 2012.
We refined the topic, Key Questions, and protocol with experts in the field and determined the study inclusion criteria and risk-of-bias items a priori. Abstract and full-text review and the risk-of-bias assessment were done in duplicate. A second reviewer verified data extraction. Extracted study information included study design, patient enrollment and baseline characteristics, risk-of-bias items, and outcome data. Because of the nature of the available evidence, we chose to perform a qualitative synthesis rather than meta-analysis. We graded the strength of evidence for each treatment comparison and outcome based on the size, risk of bias, and results of the evidence base. We discussed applicability by focusing on the populations, interventions, and settings of the studies.
We included 19 publications describing 16 comparative trials. The studies were conducted in the United States, Canada, United Kingdom, New Zealand, and Australia. The risk of bias for all reported outcomes was medium for 15 trials and low for 1 trial.
For incarceration-based interventions, evidence of low strength favored antipsychotics other than clozapine over treatment with clozapine for improving psychiatric symptoms. For all other incarceration-based interventions assessed—other pharmacologic therapies, cognitive therapy, and modified therapeutic community—evidence was insufficient to draw any conclusions.
For individuals transitioning from the incarceration setting to the community, evidence of low strength supported discharge planning with benefit-application assistance and integrated dual disorder treatment compared with standard of care for increasing mental health service use and/or reducing psychiatric hospitalizations. Evidence was insufficient for comparing interventions administered by a forensic specialist with interventions administered by mental health professionals and for comparing interpersonal therapy with psychoeducation for offenders transitioning from incarceration to the community.
More comparative trials are needed to increase our confidence in the findings for which the strength of evidence is low and to address the questions for which the evidence was insufficient.
We identified some promising treatments for individuals with serious mental illness during incarceration or during transition from incarceration to community settings. Treatment with antipsychotics other than clozapine appears to improve psychiatric symptoms more than clozapine in an incarceration setting. Two interventions, discharge planning with Medicaid-application assistance and integrated dual disorder treatment programs, appear to be effective interventions for seriously mentally ill offenders transitioning back to the community. The applicability of our findings may be limited to the populations and settings in the included studies.