DBSA 2011 NATIONAL CONFERENCE May 20-22

Colorado Bill Seeks to Limit Use of Solitary Confinement

Colorado legislators are seeking to limit the number of inmates with mental illness who can be placed into solitary confinement. The legislation would require state prisons to have a physician evaluate inmates with such illnesses as bipolar mood disorders or paranoid schizophrenia before they're placed in solitary confinement. A state report found that the percentage of Colorado inmates with mental health problems who were placed in solitary confinement more than doubled between 1999 and 2008, and many were released from prison without having a chance to readjust to human interaction. (Pueblo Chieftain, 3/13/11)

FDA Orders New Cautions on Antipsychotic Drugs

By John Gever, Senior Editor, MedPage Today

Published: February 22, 2011

http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtg4N1-pYs_DXy5sGZyl_JqZRQ6S__GGivGRdDhhjQAGnT87c4ApeeqM-vZNl8MnT4Kirqg6R8hwMg5U5l4iRyJO-vyN-gJSz1DYsjxvzjDHy8MJ3cp6-5Ae0Vu--LIef1TRTx1HZDtN2FvUT8QEEmyzZtadl_Vib0I= 

WASHINGTON -- All antipsychotic drugs, including older agents as well as second-generation products, must contain new label information regarding their use in pregnancy, the FDA said.

In particular, the new labeling will address the risk of extrapyramidal symptoms (EPS) and withdrawal syndromes in newborns.

"FDA has updated the Pregnancy section of drug labels for the entire class of antipsychotic drugs to include consistent information about the potential risk for EPS and/or withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy," the agency said in a notification to healthcare professionals.

The FDA has identified 69 episodes of neonatal EPS or withdrawal in adverse event reports submitted to the agency through October 2008.

Among the symptoms listed in the reports: agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder.

However, blood levels of the drugs involved were not provided in the reports, the agency said, so it was "not possible to determine whether the events resulted from antipsychotic drug toxicity or withdrawal."

Onset of symptoms ranged from birth to one month later, and the severity varied as well. The FDA indicated that some infants recovered within hours while others needed intensive care and prolonged hospitalization.

Most of the cases also involved other potential causes of the symptoms, such as other psychotropic drugs and medical problems associated with the pregnancy or delivery.

"However, there were some cases which suggest that neonatal EPS and withdrawal may occur with antipsychotics alone," the FDA said.

The agency's announcement did not indicate which specific antipsychotic drugs were named in the adverse event reports.

In any event, the FDA is requiring the standardized cautions be carried on all antipsychotic drugs -- 20 different types sold under 23 brand names are included in the order. These range from the first antipsychotic drug used in modern practice, chlorpromazine (Thorazine), to such newer agents as aripiprazole (Abilify) and quetiapine (Seroquel).

All the products are approved to treat schizophrenia; some also have been cleared for bipolar disorder.

The official order can be read at http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtiUHzIcX1zPrMMeu7RbjgzLOGeS1R5vSEPycP_IGuIFgPwJ3u9br8C6AnbII2XdxeN_WyjYhK84BTUjtiLIYWmDr2X3r0OK45YMuKbnSEBZPwQp673XT2FfUpvaiukBE7ud1I-1iwEiVQ==. 

You and Me By Debbie Suela

If you're overly excited, you're happy

If I'm overly excited, I'm manic

If you imagine the phone ringing, you're stressed out

If I imagine the phone ringing, I'm psychotic

If you're crying and sleeping all day, you're sad and need time out

If I'm crying and sleeping all day, I'm depressed and need to get up

If you're afraid to leave your house at night, you're cautious

If I'm afraid to leave my house at night, I'm paranoid

If you speak your mind and express your opinions, you're assertive

If I speak my mind and express my opinions, I'm aggressive

If you don't like something and mention it, you're being honest

If I don't like something and mention it, I'm being difficult

If you get angry, you're considered upset

If I get angry, I'm considered dangerous

If you over-react to something, you're sensitive

If I over-react to something, I'm out of control

If you don't want to be around others, you're taking care of yourself and relaxing

If I don't want to be around others, I'm isolating myself and avoiding

If you talk to strangers, you're being friendly

If I talk to strangers, I'm being inappropriate.

For all of the above, you're not told to take a pill or are hospitalized, but I am!

Inmate’s Death Exposes Health Care Problems in Local Jails

The Texas Tribune By BRANDI GRISSOM Published: February 12, 2011

LONGVIEW — Amy Lynn Cowling was 33, she had three children, and her first grandchild was born a day after she died in an East Texas jail — slumped over her bed, clutching a bottle of Diet Dr Pepper, after a day of wailing and seizures.

Amy Lynn Cowling’s mother, Vicki Bankhead, talks with the family’s lawyer, Jarom Tefteller.

Sheriff Maxey Cerliano defends the medical treatment at the Gregg County Jail. Amy Lynn Cowling’s death was the ninth at the jail since 2005.

Ms. Cowling was pulled over on Christmas Eve for speeding and arrested for outstanding warrants on minor charges. She was bipolar and methadone-dependent and took a raft of medications each day. For the five days she was in Gregg County Jail, Ms. Cowling and her family pleaded with officials to give her the medicines that sat in her purse in the jail’s storage room. They never did.

Ms. Cowling’s death is the most recent at Sheriff Maxey Cerliano’s Gregg County Jail in Longview. Since 2005, nine inmates have died there — most were attributed to health conditions like cancer, diabetes and stomach ulcers — far more than at other facilities its size. Bowie County Jail, in East Texas on the Arkansas border, reported five deaths in the same period, as did Brazoria County Jail, south of Houston on the Gulf Coast. In Williamson County in Central Texas near Austin, the jail reported just two deaths.

Interviews with prison experts and people with firsthand experience with the Gregg County lockup and its medical staff, as well as a review of scores of public documents, reveal a troubled local jail where staff turnover is high and inmates routinely complain about conditions. Criminal justice advocates say the situation in Gregg County is not unique; it is representative of systemic problems that plague local jails statewide.

Sheriff Cerliano defends the medical treatment in his jail and said he does his best to weed out bad jailers. “It’s only about doing the right thing,” he said.

Vicki Bankhead never went a day without talking to Ms. Cowling, her daughter and best friend. “I miss hearing her voice,” Ms. Bankhead said, sobbing. Ms. Cowling became a mother at age 15. She had become addicted to prescription pills and was found guilty in 2001 of possessing a fraudulent prescription. She struggled to keep a job.

Although Ms. Cowling had been clean for several years and was getting treatment at a methadone clinic, Ms. Bankhead said, her daughter had other health problems, including bipolar disorder, heart troubles and a failing kidney. “Amy needed her medication to stay alive,” she said. “That’s why I was begging them to help her repeatedly.”

Public records show that Ms. Cowling told Gregg County Jail officials that she had high blood pressure, arthritis and only one kidney. She reported that she took Seroquel to treat bipolar disorder and that she had been receiving methadone treatment for a decade — but neither of those drugs is allowed in the jail.

State standards require only that jails provide treatment according to the facility’s health care plan. Dr. Lewis A. Browne, the county health administrator and jail doctor since 1992, decides which drugs are allowed. Drugs like Seroquel and methadone, he said, are often traded among inmates for illicit favors.

Gregg County officials said that Ms. Cowling had received appropriate substitute medications.

Reports on her case submitted to the Texas attorney general’s office show that Ms. Cowling began having “seizure activity” while she was in the facility. The morning before she died, a jail nurse called Dr. Browne to report that Ms. Cowling was “hollering and uncooperative.” Dr. Browne told the nurse to give Ms. Cowling a dose of the antipsychotic drug Haldol. When a nurse called Dr. Browne later to report that Ms. Cowling was yelling again, he ordered more Haldol and put her on suicide watch. Ms. Cowling was booked on a Friday morning, and a jailer discovered her dead just after midnight on Wednesday.

Precisely what caused Ms. Cowling’s death remains unknown. A preliminary autopsy was inconclusive. Her family has retained a lawyer.

County officials contend that Ms. Cowling’s death was not their fault. She was not honest with them about all of her health problems, said Robert Davis, a lawyer for the county. “I absolutely do not believe that the jail or jail staff contributed to this inmate’s death whatsoever,” Mr. Davis said.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

Sheriff Cerliano, however, concedes that not everything went according to the jail’s policies. After Ms. Cowling’s death, he conducted an investigation that he said showed that one jailer falsified observation logs that night. He fired five jailers and a sixth resigned. (Not all of the firings were related to Ms. Cowling’s death, he said, but were for conduct discovered during the investigation.) Two of the jailers were arrested for falsifying government documents.

Still, he said, the jail staff followed medical protocol in caring for Ms. Cowling. “We do everything we can to take care of inmates,” he said.

Since 2008, Gregg County inmates have filed more than 20 complaints with the Texas Commission on Jail Standards about conditions in the lockup. Most of the complaints were health-care-related; inmates said they could not get medicine and did not receive timely medical attention. An inmate who hanged himself in the jail in 2009 had complained that among many other grievances, he was not allowed medication he had been prescribed on the outside and had not been seen by a doctor.

In letters responding to nearly all the complaints, Adan Muñoz, the commission’s executive director, wrote, “The Texas Commission on Jail Standards does not question the professional opinion of medical personnel.”

Inmates have sued Sheriff Cerliano and Dr. Browne at least twice since 2005, alleging that their constitutional rights were violated by the jail’s deliberate indifference to their medical needs. In both cases, the courts found that Dr. Browne and the jail had attempted to provide adequate care.

Dr. Browne, who has his own family medical practice in Longview, is paid more than $100,000 per year to act as the jail doctor and director of the county health authority. He said that inmate health care was “the toughest medical situation to deal with.” Inmates are often uncooperative and dishonest about their health conditions, he said, and many are drug addicts. Adding to the challenge is that it is hard to retain medical staff, Dr. Browne said.

Medical staff members at the jail are not the only ones with a high turnover rate; records from the sheriff’s department show that in 2009 and 2010, more than 40 percent of the 167 jail employees either quit or were fired.

Sheriff Cerliano said the pay is low for jailers and that they have to go through months of training, pass drug screenings and work in challenging situations.

Lt. David Drosche, who works in the Brazos County Sheriff’s Office and is president of the Texas Jail Association, agreed that retaining jailers is difficult but said that a 40 percent turnover rate is “extremely high.” The higher turnover, he said, results in more inexperienced jailers.

County lockups in Texas are accountable to the Texas Commission on Jail Standards. Before Ms. Cowling’s death, the Gregg County Jail had passed every commission inspection for the last five years. Within weeks after she died, the commission, which reviews county jail deaths, decided the jail was in compliance with state standards.

But the commission does not require that jails meet specific health care criteria, only that they have medical plans on file. It also doesn’t keep track of jail staff turnover.

Diana Claitor, executive director of the Texas Jail Project, which advocates for improved jail conditions, said better health care standards and monitoring of data like staff turnover could help prevent more deaths like Ms. Cowling’s. From January 2005 to September 2009, more than 280 inmates died from illnesses in Texas county jails.

“One of the chief factors playing into mistreatment or neglect would be ill-trained, inexperienced staff,” she said. But with the state budget crunch, pressing the jail standards commission to provide additional oversight is a tough sell, Ms. Claitor said.

Sheriff Cerliano said his jailers already receive more training than is required by state standards and that the medical staff provides the best care possible. Ms. Cowling’s death was unfortunate, he said, but it does not mean that wholesale changes are needed in the way jails are regulated.

“We do have inmates that come in sick,” he said. “It’s incumbent upon us to try to do the best we can.”

APA: Bipolar Patients May Be at Risk for High Blood Pressure

By Kristina Fiore, Staff Writer, MedPage Today

Published: May 23, 2010

Reviewed by Robert Jasper, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

NEW ORLEANS -- Patients with bipolar disorder have a higher prevalence of hypertension than in the general population, putting them at risk for subsequent heart disease, researchers said here.

In a single-center study, the prevalence of hypertension among patients with bipolar disorder was 45%, compared with 30.5% in the general population, Dale D'Mello, MD, of Michigan State University, and colleagues reported at the American Psychiatric Association meeting here.

"Our study suggests the possibility of a link [between bipolar and hypertension]," D'Mello said during a scientific session here.

Previous research has shown that patients with biopolar disorder have a disproportionate burden of cardiometabolic disorders, including heart disease, metabolic syndrome, and stroke.

Yet the underlying mechanisms of this association aren't well understood.

So the researchers assessed 99 patients with bipolar disorder who were treated at St. Lawrence Hospital in Lansing, Mich., between 2002 and 2006.

About half of the patients were male, they had a mean blood pressure of 137/83 mm Hg, and their mean body mass index (BMI) was 30.

There was a high prevalence of smoking, D'Mello said, and 37% were obese.

The researchers found that 45% of the patients were hypertensive - a proportion much higher than recent data from a Healthy People 2010 analysis, which put the prevalence of hypertension in general population at 30.5%.

D'Mello said the hypertensive patients were older (mean age 44 versus 37) and more obese (mean BMI 33 versus 28).

They also had higher mean scores on a mania scale (40 versus 35, P=0.04), as well as earlier onset of bipolar disorder, with a mean age of 24, compared with 29 in nonhypertensive patients (P=0.05).

"They start having hypertension at an earlier age, and have a longer duration," D'Mello said.

But he also noted, "there were many confounding factors we didn't control for in this study."

For example, certain antipsychotic drugs - which some patients may have taken earlier in their lifetime - can lead to metabolic syndrome. The possible role of these medications should be examined in the future, he said.

If it's found that bipolar disease is indeed a cause of hypertension, then "treating bipolar disease may prevent morbidity and mortality," he added, comparing the link to studies that have pointed to depression as a risk factor for coronary artery disease.

"As psychiatrists," he concluded, "we have the opportunity to manage and perhaps prevent a physical disorder."

Primary source:

American Psychiatric Association

Source reference:

D'Mello D, et al "The prevalence and clinical consequences of concurrent hypertension in patients with bipolar disorder" APA 2010; Abstract NR4-17.
Notes:
This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

The study did not control for some factors that may have influenced the results, such as previous medications patients may have taken.

D'Mello reported relationships with Pfizer, AstraZeneca, and Shering.