Psychiatric Medication Refill Practices of Juvenile Detainees

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Child Psychiatry & HumanDevelopment ISSN 0009-398X Child Psychiatry Hum DevDOI 10.1007/s10578-013-0365-y

Psychiatric Medication Refill Practices ofJuvenile Detainees

Mallery R. Neff, Matthew C. Aalsma,Marc B. Rosenman & Sarah E. Wiehe

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ORIGINAL ARTICLE

Psychiatric Medication Refill Practices of Juvenile Detainees

Mallery R. Neff • Matthew C. Aalsma •

Marc B. Rosenman • Sarah E. Wiehe

� Springer Science+Business Media New York 2013

Abstract To examine the psychiatric medication fill rates

of adolescents after release from juvenile detention. The

team reviewed 177 charts. A fill was defined as a psychi-

atric medication charge to Medicaid 30- or 90-days after

release. Differences in demographic characteristics were

compared among individuals with fills at 30- or 90-days

and those with no medication fills. Forty-five percent of

patients were on at least one psychiatric medication.

Among detainees on a psychiatric medication, 62 % had a

fill by 30 days after release, and 78 % by 90 days. At least

50 % of the adolescents on a psychiatric medication were

on an atypical antipsychotic. There was no significant

relationship between medication fill and race, age, or sex.

Despite the known associations between mental health

diagnosis and treatment-seeking with age, sex, and race, it

appears that psychiatric medication fill patterns after release

from detention are not associated with these factors.

Keywords Adolescence � Delinquency � Psychiatric

medication � Medication refill

Introduction

More than two million adolescents are arrested yearly in the

United States [1]. On any day, [100,000 youth reside in

nearly 3,000 detention facilities after their arrest [2]. These

youth have substantially higher rates of psychiatric diag-

noses than the general population [3], with 40–70 % of

detainees meeting criteria for at least one mental health

disorder [4, 5], and approximately half meeting criteria for

two or more diagnoses [6]. Juveniles in the justice system are

at increased risk of conduct disorder, psychosis, attention

deficit hyperactivity disorder [7], and major depression [8].

Disparities in the juvenile justice system exist by age,

sex, and race/ethnicity. Black individuals comprise 13 % of

the general population, but 44 % of individuals incarcerated

[9]. Over-representation of minority youth among detainees

is present in every state and more pronounced in states with

smaller proportions of minorities [10]. The court system is

more likely to deem white juveniles as ‘‘mentally dis-

turbed’’ and black juveniles as ‘‘disorderly’’ [11]. There are

similar disparities by sex, as girls tend to be detained at an

earlier age, for fewer offenses, and for longer periods [12].

The disparities in the juvenile justice system are also

noted in mental health diagnosis and treatment. White and

female youth are diagnosed with mental illness more fre-

quently, and they are more likely to receive treatment when

diagnosed [13–15]. In one study of young offenders, race

was the only significant predictor of receiving treatment,

with white youth significantly more likely to receive

treatment than black youth [16]. Even in studies where the

level of disturbance is considered, white youth are dis-

proportionately more likely to receive treatment in deten-

tion [17, 18]. Finally, when minority youth are referred for

treatment, they are generally less likely to use formal

health care services than white youth [19].

M. R. Neff (&) � M. B. Rosenman � S. E. Wiehe

Department of Pediatrics, Indiana University School

of Medicine, 410 West 10th Street, HS1020, Indianapolis,

IN 46202, USA

e-mail: [email protected]

M. C. Aalsma

Department of Pediatrics, Indiana University School

of Medicine, 410 West 10th Street, HS1001, Indianapolis,

IN 46202, USA

M. B. Rosenman � S. E. Wiehe

Regenstrief Institute, Indianapolis, IN, USA

123

Child Psychiatry Hum Dev

DOI 10.1007/s10578-013-0365-y

Author's personal copy

Recidivism among youth offenders is a common occur-

rence. As many as two-thirds of youth are re-arrested within

4.5 years of their release from detention [20–22]. Mental

health treatment is an important consideration as appropri-

ate treatment can significantly reduce recidivism [23, 24]. In

a study of incarcerated youth diagnosed with bipolar dis-

order (n = 31), medication compliance in the year fol-

lowing release significantly decreased the likelihood of

reoffending [25]. Although detention can interrupt mental

health care or medication compliance [26, 27], there is

limited literature directly addressing refill practices among

juveniles after release. A notable exception explored state-

wide Medicaid and Justice Department data and found that

only 63 % of detainees who were filling psychiatric medi-

cations at least 30 days before detention were filling the

medications 30 days after release [26]. The characteristics

of those who did or did not fill were not described. Based on

the idea that sex and race disparities exist for diagnosis and

treatment, it is possible that these and other characteristics

may correlate with individuals’ refill practices.

In this study, we investigated differences between

detained youth who did and did not fill their psychiatric

medications after release. There is limited literature on how

various characteristics affect medication compliance after

detention release. Therefore, in an attempt to limit the

hypothesis to what might be indicated by previous litera-

ture [13–15], the authors hypothesized that female white

youth would be more likely to fill medications after release.

Methods

Population and Study Design

As a part of a broader research project assessing access

to health care by youth in a large, Midwestern deten-

tion center, electronic juvenile court records of subjects

12–18 years old between June 2004 and February 2008

were accessed and linked to data in the Regenstrief Medical

Record System, using unique identifiers and a probabilistic

matching algorithm [28]. All participants were eligible for

Medicaid, the federal medical insurance program for those

individuals with limited financial means. Electronic Med-

icaid eligibility records and claims for psychiatric medica-

tions were extracted. A review of medical records was

conducted based on a sample of Medicaid-enrolled youth

(n = 355) who were detained within the study timeframe

(Fig. 1). The medical record consisted of the individual’s

medical chart, including medical history, list of medications

dispensed or prescribed, and notes for all contacts with

medical personnel. Charts are created for all detainees, and

maintained in the on-site clinic by medical personnel until

the individual is 18 years of age. Approximately half of the

charts (n = 178) were unavailable because of systematic

storage procedures at the detention facility. A chart is

removed when a detainee turns 18 years old, or when

2 years has elapsed after the most recent detention stay.

Once placed in storage, the charts are inaccessible. Among

the remaining 177 charts, records for the most recent

detention were reviewed. Seventy-nine of those individuals

with available charts had been prescribed psychiatric

medications. Only detentions with a release date before

January 1, 2008 were analyzed, as Medicaid prescription

data were available for this project through March 31, 2008.

Finally, individuals whose detentions ended in a Depart-

ment of Corrections (DOC—prison) stay were excluded, as

their refill data inside the DOC were not available. Of the 79

charts with medications, 60 had Medicaid continuously for

at least 90 days after detention release, and a release date

before January 1, 2008.

The study was approved by the Indiana University

Purdue University Indianapolis Institutional Review Board.

Detained adolescents 12-18 years old between 6/04-2/08 and continuous enrollment in

Medicaid > 30 days after releaseTable 1N=355

1 detention stay per person reviewed (most recent stay)

Table 1N=177

Unavailable charts (aged out of detention facility)

N=178

On psychiatric medication(s)(based on chart review)

Table 1N=79

With > 30 days continuous Medicaid coverage

Tables 2, 3N=68

Not on psychiatric medication(based on chart review)

N=98

Placement in Department of Corrections

N=11

Without > 90 days continuous Medicaid enrollment OR

release date after 1/1/2008 N=8

With > 90 days continuous Medicaid coverage

Tables 2, 3N=60

Fig. 1 Study population definition


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Procedures and Measures

The chart review was performed by one individual (MRN),

using a chart abstraction form for specific data elements

including demographics, detention stay period, medication

data, and related diagnosis codes. Medications were

abstracted from the detention intake form. Additional

medication data and related diagnosis codes were abstrac-

ted from records of mental health assessments performed

by clinicians. A detainee was considered to have been on a

medication listed on the intake form or mental health

assessment, regardless of whether the medication was

dispensed during the detention stay.

Medications

Psychiatric medications were categorized based on com-

mon classification schemes [29], and modified based on

consensus of the research team. Categories included

selective serotonin reuptake inhibitors (SSRI), ADHD

medications (e.g., atomoxetine), non-SSRI mood medica-

tions (e.g., bupropion), atypical antipsychotics (e.g., ris-

peridone), clonidine, and non-benzodiazepine sedatives

(e.g., trazadone). All psychiatric medications found during

the chart review were categorized.

Medication fills were defined as a psychiatric medication

charge to Medicaid within 30 or 90 days after release from

detention. The detention facility has policies to terminate or

suspend Medicaid for youths held for longer than 30 days.

However, no individuals included in this study had their

coverage terminated based during their detention stay.

Mental Health Diagnosis

Diagnosis categories were developed using common DSM

diagnoses [30]: ADHD (any subtype); mood (e.g., major

depression, bipolar disorder); psychosis (e.g., schizophre-

nia); personality disorder; anxiety (e.g., generalized anxiety

disorder); substance abuse; conduct (e.g., conduct disorder,

oppositional defiant disorder); adjustment disorder; and

other. All psychiatric diagnoses found during the chart

review were placed into one of the above categories.

Diagnoses were recorded during the chart review if docu-

mented on intake form or diagnosed during their stay after

referral to the on-site psychiatrist.

Crime Severity

In descending order of severity, charge categories include

felonies (e.g., murder and rape), misdemeanors (e.g., theft

and battery), status offenses (i.e., offenses unique to juve-

niles including truancy), violations of probation require-

ments (e.g., violating house arrest), and warrant arrests

(e.g., failure to appear in court). Because a juvenile could

be detained for multiple counts of varying severities, each

charge was a separate variable, expressed in bivariate (yes/

no) fashion for each stay.

Detention Length

Length of stay was calculated by subtracting the release

date from the start date.

Criminal Case Disposition

Criminal cases sometimes lead to a youth being court-

ordered into a program (e.g., probation, community ser-

vice, or counseling) and/or into a placement facility (e.g.,

mental health care group homes, respite/foster care, or

residential treatment facility). DOC is also an option for

placement; however, this is a separate variable, and an

exclusion criterion for this study. A single detention stay

often has multiple associated charges. For each charge, the

court can generate a distinct program and/or placement. To

be as inclusive as possible, each program and placement

category was recorded in bivariate (yes/no) fashion for

each detention stay (‘‘yes’’ if any of the charges resulted in

the particular program or placement category). All outpa-

tient non-DOC placement options charge Medicaid for

refills, and thus those refills are included in the data set.

Demographic Information

Age, gender, and self-reported race/ethnicity are recorded

when a youth is admitted by detention center staff. For the

regression analyses, we categorized race/ethnicity as white,

black, and other race.

Analysis

Analyses were performed using Stata/SE [31]. The popu-

lation of all juvenile detainees meeting inclusion criteria,

with available charts, and on medications was described

using available detention and clinical data. Subjects who

were prescribed medications were further stratified by refill

patterns post-release. Logistic regression with robust stan-

dard errors was used to assess the odds of fill at either 30 or

90 days. First, a model including only the variables age,

sex, and race was created to look for significance in these

three primary demographic characteristics. Second, after

initially including all available variables in another

regression model, a parsimonious model was derived by

including only those variables that were significant and

meaningful (based on the existing literature and a priori

hypotheses), in order to conserve power given the limited

sample size of this study.


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Results

There were few differences between the eligible individu-

als (n = 355) and those whose charts were reviewed

(n = 177; Table 1). More of those without charts had an

age of 17 at most recent detention, which was anticipated

based on the record storage system for individuals who

‘‘age out’’ of the juvenile justice system.

The majority of the 177 subjects were male, black, or 15

or 16 years old (Table 1). This is consistent with the general

detention center census. Eighty-eight of 177 individuals

(50 %) had a first arrest before age 12. The mean length of

stay was 27 days (SD 20 days). Most detainees had a pro-

gram disposition at the time of release, and 45 % ended

their detention with a placement. Approximately 11 % were

placed into the DOC. Most individuals had continuous

Medicaid enrollment for 1–2 years prior to detention, while

after release the majority had 6–11 months. This difference

was related to right-censoring of the available data.

Of the 177 subjects, seventy-nine (45 %) were on at

least one psychiatric medication. Subjects on psychiatric

medication were similar to the chart review population,

excluding two areas. Among those on psychiatric medi-

cations, there was a slightly higher percentage of white

youth and youth with detention stays of C5 weeks.

Among subjects with at least one mental health diag-

nosis, the majority was on at least one medication (range:

67–100 % by diagnosis category). Atypical antipsychotics

were the most common medication prescribed, regardless

of diagnosis. Excluding youth with anxiety disorders and

no diagnosis, at least 50 % of those with any diagnosis

were on an atypical antipsychotic (Table 2).

Among the 60 detained youth on psychiatric medica-

tions who met criteria for the final analysis, 62 % had at

least one medication fill within 30 days after release, 78 %

within 90 days. Those with a medication fill within 30 days

were similar to those with a fill within 90 days except that

the former were more likely to have had a script filled in

the 365 days prior to detention (Table 3).

There was some difference in refill patterns by medication

category. SSRIs were filled more frequently at both 30 and

90 days than other medication categories; however it was not a

statistically significant difference (data available on request).

The increase in the number of individuals who filled at 90 days

from 30 days was consistent for all groups, approximately 20 %.

In the multivariable demographics-only analysis (Table 4),

age, sex, and race were not significantly associated with

increased or decreased odds of refill within 30 days. In the

30-day parsimonious model number of medications, a status

violation, diagnosis with a mood disorder, and having any

placement were significantly associated with increased odds

of filling at least one psychiatric medication. Detention for a

misdemeanor approached significance (p = 0.055). In the

Table 1 Characteristics of study population

Detainees

with charts

(n = 177)

(%)

Detainees

with

medications

(n = 79) (%)

All

records

(n = 355)

(%)

Gender

Male 77 71 79

Age at detention

12 3 3 3

13 10 13 7

14 20 20 15

15 25 22 21

16 33 30 31

17 8 13 23

18 0 0 1

Race/ethnicity

White 25 35 23

African American 68 57 70

Hispanic 2 0 1

Asian 1 1 1

Multi-racial 3 6 5

Charge severitya

Felony 39 35 43

Misdemeanor 44 43 41

Status 20 19 17

Probation violation 33 37 30

Warrant 40 38 41

Infraction 0 0 1

Stay length (weeks)

1 16 10 39

2 9 5 6

3 22 27 14

4 21 19 15

5 25 34 21

6 or more 7 5 5

Disposition

Any program 73 70 –

Placement

Any non-DOC placement 45 52 –

DOC placement 11 14 9

Arrest before age 12 50 56 43

Medicaid before detention (months)

Less than 6 1 0 1

6–11 1 0 1

12–23 9 11 12

24 or more 89 89 87

Medicaid after detention (months)

Less than 6 9 9 5

6–11 54 52 49

12–23 34 39 45

24 or more 3 0 1


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90-day parsimonious model, fewer variables were statistically

associated with odds of medication refill. The number of

medications and a misdemeanor or status violation were the

only variables that were significant. Age less than 12 or 13

approached significance (p = 0.06).

Discussion

Similar to other studies, we found that in a comparable

sample of juvenile detainees on Medicaid, approximately

two thirds of individuals filling a script prior to detention

filled 30 days after detention [26]. In our population, it seems

that incarceration may be a destabilizing factor for detainees

with regard to medication compliance. Our sample was small

as compared to Cuellar et al., but it is worthwhile to note the

consistent percentage of refills, especially if other samples

produce similar results. This also suggests that barriers to

medication refill, either personal or systematic, occur with a

similar frequency among the detained youth population.

The specific aim of this study was to look at how

demographic characteristics might correlate with refill

patterns. As discussed above, there were more predictors of

refill within 30 days after release than at 90 days. Trends

for gender and race were in the same direction as in other

studies (females and whites had higher medication fill

rates) but were not statistically significant [13–15, 32, 33].

The diagnosis of a mood disorder had a significant asso-

ciation with medication fills in the 30-day model but not in

the 90-day model.

In many of the bivariate analyses, those who filled

prescriptions within 30 or 90 days after detention release

were more likely to have filled prescriptions before

detention. However, prescription fills before detention was

not a significant factor in the multivariable analyses. This

suggests that one cannot assume that those who were

compliant before detention will remain compliant after

their release.

We found that number of medications was associated

with medication fills after release. In the both the 30- and

90-day regression model, there was a linear, significant

relationship between the number of medications prescribed

and the likelihood of a fill after release. It is possible that

this speaks to severity of illness. Individuals with severe

disease may require multiple medications to control their

symptoms, and their caregivers may be more likely to

continue their medications after detention. This may indi-

cate that detainees with fewer medications, or illness that is

perceived as less severe by caregivers, would be a worth-

while focus for interventions targeting medication com-

pliance. Further research is needed to determine what

characteristic associated with number of medications pre-

scribed affects refill patterns, and how interventions can be

targeted to improve compliance based on this information.

Beyond number of medications, type of medication was

also found to be important. SSRIs were the medications

most often refilled, whereas atypical were least often

refilled. Mood disorders were found to be a significant

variable for refill at 30 days. Given that girls are diagnosed

with more mood disorders than boys [32–34], it may be

that this association between SSRIs/mood disorders and fill

patterns is confounded by sex. However, sex was not sig-

nificantly related to medication fills in either the bivariate

or multivariable analysis and, therefore, likely did not

completely account for this finding. A second possible

explanation for the increased fill rate of SSRIs may be that

the symptoms targeted by these medications are effectively

treated, and patients’ poor coping skills necessitate a con-

tinuation of these medications for symptom management.

This does not explain the lack of significance in the 90 day

model. Whether the significance is due to sex, symptom

Table 1 continued

Detainees

with charts

(n = 177)

(%)

Detainees

with

medications

(n = 79) (%)

All

records

(n = 355)

(%)

Number of medications

0 55 0 –

1 13 29 –

2 17 38 –

3 10 22 –

4 or more 5 11 –

Medication refill (days prior to detention)a

30 16 35 16

90 32 61 25

365 47 81 41

Number of diagnoses

0 58 18 –

1 8 11 –

2 9 16 –

3 14 30 –

4 or more 11 24 –

Diagnosisa

ADHD 26 53 –

Mood 25 56 –

Conduct-type 23 48 –

Anxiety 6 13 –

Personality disorder 1 3 –

Psychotic disorder 1 1 –

Substance abuse 9 18 –

Adjustment disorder 5 8 –

Other 6 10 –

a Multiple categories possible


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treatment, or other factors not captured by our data, further

research is needed to investigate the pattern of SSRIs and

increased medication refills.

This study was limited by a small sample size; however

chart review study design allowed verification of individuals

prescribed medications, rather than relying on previous

filling patterns to define current medications. The chart

review design did limit the reliability of our diagnostic data,

as this was by self-report or referral diagnosis only. Youth

are not systematically evaluated by mental health providers

upon admission. Thus, our diagnostic data may exclude

individuals with mild or internalizing symptoms who were

not referred while detained. We were only able to assess

individuals with continuous Medicaid coverage who were

not placed in a residential facility not charging Medicaid.

Filling events were only followed to 30 and 90 days after

detention due to availability of Medicaid data, and a larger

window of filling patterns, both before and after detention,

would have provided a more complete picture of an indi-

vidual’s compliance. However, given that all included

individuals had Medicaid coverage, some uniformity in

health care access was assured. Medicaid coverage by itself

does not guarantee access, especially in the setting of mental

health care for adolescents. Access to mental health care is

limited. There are at least 13 million children in need of

mental health services in the US, with a generally decreasing

availability of services [35]. The generalizability of this

study may be limited by local or regional factors influencing

prescribing or follow-up patterns. Our analysis did not

account for medications dispensed in the detention center at

the time of release. Such dispensing would likely have been

for less than a 1-month supply; refills after release would

likely have been identified in the 30-day analysis and cer-

tainly in the 90-day analysis. The study cannot account for

unmeasured confounding, such as personal beliefs held by

the detainee or parent/guardian, degree of symptoms, and

number of contacts with the health system.

This study suggests several areas for further research.

First, replicating this study with a larger sample size could

more definitively describe demographic predictors of

medication refill after release. Second, many detainees are

on atypical antipsychotics, regardless of diagnoses. We did

not find this to be true with other medication classes.

Atypical antipsychotics have common, serious side effects

[36], including increased risk of sudden cardiac death [37].

Further research should investigate why detainees are

prescribed these medications and, more importantly, whe-

ther these medications are being used effectively. Finally, it

may be important to consider how personal perception or

attitudes towards psychiatric medications affect compli-

ance. These factors may better predict compliance than the

demographic variables studied here. Williams, Hollis, and

Benoit, in interviews of female detainees regarding their

concerns about taking psychiatric medications, found that

overall attitude, type of concern, and number of specific

concerns were not associated with age, race, school grade,

or offense [38]. This may be consistent with the finding

that age, race, nor sex, was significantly associated with

Table 2 Type of medication based on diagnosis

ADHD

(n = 46) (%)

Mood disorder

(n = 45) (%)

Conduct

disorder

(n = 40) (%)

Substance

abuse

(n = 16) (%)

Adjustment

disorder

(n = 9) (%)

Any medication 91.00 98.00 95.00 88.00 67.00

ADHD 61.00 35.56 40.00 31.25 33.33

SSRI 30.43 42.22 25.00 12.50 11.11

Mood 17.39 35.56 32.50 25.00 11.11

Atypical 67.39 71.11 75.00 50.00 44.44

Clonidine 2.17 4.44 0.00 6.25 0.00

Non-benzo 2.17 0.00 2.50 6.25 0.00

Anxiety

disorder

(n = 13) (%)

Psychotic

disorder

(n = 1) (%)

Personality

disorder

(n = 2) (%)

Other

(n = 10) (%)

No diagnosis

(n = 104) (%)

Any medication 100.00 100.00 100.00 80.00 14.42

ADHD 20.00 0.00 50.00 30.00 7.69

SSRI 30.00 0.00 100.00 20.00 4.81

Mood 50.00 100.00 50.00 30.00 3.85

Atypical 60.00 100.00 100.00 60.00 5.77

Clonidine 0.00 0.00 0.00 20.00 0.00

Non-benzo 0.00 0.00 0.00 0.00 0.00


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patterns of psychiatric medication refill in any model

developed during this study.

A large number of mentally-ill adolescents are detained

and released through the juvenile justice system in America.

Many reoffend and commit more serious crimes as they age

[20–22]. Given that appropriate mental health treatment

Table 3 Characteristics of detainees who fill prescriptions

No refill within

90 days after

release

(n = 13) (%)

Refill within

30 days after

release

(n = 35) (%)

Refill within

90 days after

release

(n = 47) (%)

Male 77 66 64

Age at detention (years)

12 0 3 4

13 8 17 17

14 15 20 17

15 38 20 19

16 31 26 32

17 8 14 11

18 0 0 0

Race/ethnicity

White 23 46 45

African

American

69 46 47

Hispanic 0 0 0

Asian 0 0 2

Multi-racial 8 9 6

Charge severitya

Felony 31 34 32

Misdemeanor 23 49 47

Status 8 26 26

Probation

violation

31 37 38

Warrant 46 37 38

Infraction 0 0 0

Stay length (weeks)

1 0 9 6

2 0 6 9

3 23 29 34

4 54 14 13

5 15 40 36

6 or more 8 3 2

Disposition

Any program 85 63 68

Placement

Any

placement

31 63 57

Arrest before

age 12

62 51 51

Medicaid before detention (months)

Less than 6 0 0 0

6–11 0 0 0

12–23 31 6 6

24 or more 69 94 94

Medicaid after detention (months)

Less than 6 0 3 2

6–11 69 46 47

12–23 31 51 51

Table 3 continued

No refill within

90 days after

release

(n = 13) (%)

Refill within

30 days after

release

(n = 35) (%)

Refill within

90 days after

release

(n = 47) (%)

24 or more 0 0 0

Number of medications

1 46 23 30

2 54 34 34

3 0 31 23

4 or more 0 11 13

Medication refill (days prior to detention)a

30 8 51 43

90 23 77 74

365 54 86 87

Number of diagnoses

0 8 23 19

1 15 14 13

2 23 17 19

3 46 20 23

4 or more 8 26 26

Diagnosisa

ADHD 54 54 49

Mood 69 60 60

Conduct-type 46 37 43

Anxiety 15 14 13

Personality

disorder

0 3 2

Psychotic

disorder

8 0 0

Substance

abuse

15 17 19

Adjustment

disorder

0 6 9

Other 8 6 13

Medication typea

ADHD 38 49 45

SSRI 15 43 38

Mood 15 29 32

Atypical 62 71 66

Clonidine 0 3 4

Non-benzo

sedative

8 0 0

a Multiple categories possible


123


reduces the probability of these adverse outcomes [23–25],

identifying factors which increase the likelihood that a

former detainee would comply with prescribed medications

is necessary to guide interventions and decrease recidivism.

Interventions in this population have the potential to make a

significant public health impact [39].

Table 4 Odds of medication

refill at 30- and 90-days

following release among

juvenile detainees on

psychiatric medications

(n = 60)

Gender/age/race model Adjusted model

OR 95 % CI OR 95 % CI

Odds of 30 day refill

Male 0.85 0.28, 2.58 2.21 0.32, 15.09

Age (years)

12 or 13 1.00 Referent 1.00 Referent

14–18 1.45 0.35, 5.88 1.92 0.32, 11.37

Race

African American 1.00 Referent 1.00 Referent

White 1.93 0.63, 5.95 1.10 0.20, 5.93

Hispanic/Asian/Multiracial 1.34 0.17, 10.33 2.86 0.16, 50.50

Any diagnosis – – 0.02 0.00, 0.66

Number of meds – – 3.25 1.15, 9.15

Charge severity

Felony – – 1.75 0.31, 9.95

Misdemeanor – – 5.44 0.96, 30.72

Status – – 17.80 2.24, 142.26

Probation violation – – 0.26 0.04, 1.64

Warrant – – 0.86 0.14, 5.23

Any placement – – 7.77 1.32, 45.77

Diagnosis

ADHD – – 3.75 0.74, 19.02

Mood – – 6.91 1.14, 41.76

Conduct-type – – 0.99 0.19, 5.15

Odds of 90 day refill

Male 0.45 0.10, 1.96 0.75 0.01, 47.03

Age (years)

12 or 13 1.00 Referent 1.00 Referent

14–18 4.21 0.58, 30.43 32.42 0.86, 1,219.82

Race

African American 1.00 Referent 1.00 Referent

White 3.20 0.72, 14.11 1.32 0.12, 14.20

Hispanic/Asian/Multiracial 1.41 0.10, 19.02 2.00 0.02, 215.97

Any diagnosis – – 0.07 0.00, 12.66

Number of meds – – 24.71 1.22, 499.67

Charge severity

Felony – – 4.87 0.53, 44.67

Misdemeanor – – 171.29 2.07, 14,183.48

Status – – 1,709.25 5.53, 528,546.60

Probation violation – – 0.79 0.07, 8.55

Warrant – – 14.75 0.37, 583.20

Any placement – – 2.80 0.22, 35.29

Diagnosis

ADHD – – 0.14 0.00, 4.45

Mood – – 0.51 0.03, 10.08

Conduct-type – – 5.95 0.12, 291.96


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Summary

Based on past literature showing a correlation between

demographic characteristics, such as age and race, to

mental health diagnosis and treatment seeking, this paper

attempted to determine if similar patterns existed in psy-

chotropic medication refill practices of juvenile detainees.

A total of 177 charts were reviewed. A medication fill was

defined as a psychiatric medication charge to Medicaid

within either a 30- or 90-day window after release from

detention. Differences in demographic characteristics were

compared among individuals with fills at 30- or 90-days

and no medication fills, using Stata/SE. Of the 177 patients

whose charts were reviewed, 45 % were on at least one

psychiatric medication during their most recent detention

during the study period. Among detainees who were on a

psychiatric medication and had at least 90 days of Med-

icaid coverage after release, 62 % had a refill by 30 days

after release, and 78 % by 90 days. At least 50 % of the

adolescents on a psychiatric medication were on an atypi-

cal antipsychotic. There was no significant relationship

between medication fill by 30 or 90 days and race, age, or

sex. Despite the known associations between mental health

diagnosis and treatment-seeking with age, sex, and race, it

appears that psychiatric medication fill patterns after

release from detention are not associated with these factors.

This chart review also found that a large percentage of

detained youth are prescribed antipsychotics, regardless of

diagnosis. As these medications have significant side

effects, more research is necessary to determine if these

medications are being used effectively in this population.

Acknowledgments This study was supported with funding from the

Maternal and Child Health Bureau R4008721 (MCA, MBR) and the

National Institutes of Health R21AI084060-01 (SEW, MCA, MBR).

The authors would like to thank members of the Wishard Teen Care

and Wellness program that staff the Marion County Juvenile Detention

Center for their help and support in accomplishing the chart review.

We also gratefully acknowledge Faye Smith, M.A., of the Regenstrief

Institute, for extracting and managing data and for her knowledge of

the information systems. Thank you Gael Deppert, JD, Jason Melchi,

Judge Moores, and Sara Rhea for help in accessing, managing and

interpreting the juvenile detention data, and Jane Wang, PhD for help

in managing the Regenstrief Medical Record System data.

References

1. Snyder HN (2005) Juvenile arrests, 2003. Office of Juvenile

Justice and Delinquency Prevention, Washington

2. Sickmund M (2005) Juveniles in corrections: Juvenile offenders

and victims national report series bulletin. US Department of

Justice, National Institute of Justice, Washington

3. Cocozza JJ, Skowyra KR (2000) Youth with mental health dis-

orders: Issues and emerging responses. Juv Justice 7(1):3–13

4. Wasserman GA et al (2002) The voice DISC-IV with incarcer-

ated male youths: Prevalence of disorder. J Am Acad Child

Adolesc Psychiatry 41(3):314–321

5. Vermeiren R, Jespers I, Moffitt T (2006) Mental health problems

in juvenile justice populations. Child Adolesc Psychiatr Clin N

Am 15(2):333–351

6. Abram KM et al (2004) Posttraumatic stress disorder and trauma

in youth in juvenile detention. Arch Gen Psychiatry 61(4):

403–410

7. Costello EJP, Egger HMD, Angold AMRC (2005) 10-year research

update review: the epidemiology of child and adolescent psychiatric

disorders: I. Methods and public health burden. [Miscellaneous

Article]. J Am Acad Child Adolesc Psychiatry 44(10):972–986

8. Costello EJ et al (2003) Prevalence and development of psychi-

atric disorders in childhood and adolescence. Arch Gen Psychi-

atry 60(8):837–844

9. Harrison PM, Beck AJ (2005) Prison and jail inmates at midyear

2004. Bureau Justice Stat 6(30/03):1–14

10. Leiber MJ (2002) Disproportionate minority confinement (DMC)

of youth: an analysis of state and federal efforts to address the

issue. Crime Delinquency 48(1):3–45

11. Cohen R et al (1990) Characteristics of children and adolescents

in a psychiatric hospital and a corrections facility. J Am Acad

Child Adolesc Psychiatry 29(6):909–913

12. Plotch A, Hahn J, Reis S (1996) Prevention and parity: girls in

juvenile justice. US Department of Justice, Washington

13. Abram KMP et al (2008) Perceived barriers to mental health

services among youths in detention. J Am Acad Child Adolesc

Psychiatry 47(3):301–308

14. Pope CE, Lovell R, Hsia HM (2002) Disproportionate minority

confinement: a review of the research literature from 1989

through 2001. US Department of Justice, Washington

15. Teplin LA et al (2005) Detecting mental disorder in juvenile detain-

ees: who receives services. Am J Public Health 95(10):1773–1780

16. Shelton D (2005) Patterns of treatment services and costs for

young offenders with mental disorders. J Child Adolesc Psychi-

atric Nurs 18(3):103–112

17. Dembo R et al (1994) Screening high-risk youths for potential

problems: field application in the use of the problem-oriented

screening instrument for teenagers (POSIT). J Child Adolesc

Subst Abuse 3:69–93

18. Thomas J, Stubbe D (1996) A comparison of correctional and mental

health referrals in the juvenile court. Psychiatry Law 24:379–400

19. Walker A (1996) Health and illness in African (black) American

communities. In: Spector R (ed) Cultural diversity in health and

illness. Appleton & Lange, Stamford, pp 191–214

20. Benda BB, Corwyn RF, Toombs NJ (2001) Recidivism among

adolescent serious offenders: prediction of entry into the cor-

rectional system for adults. Crim Justice Behav 28:588–613

21. Heilbrun K et al (2000) Risk factors for juvenile criminal

recidivism: the postrelease community adjustment of juvenile

offenders. Crim Justice Behav 27:275–291

22. Wilson JJ et al (2001) Substance abuse and criminal recidivism: a

prospective study of adolescents. Child Psychiatry Hum Dev

31:297–312

23. Boothroyd RA (2003) The Broward mental health court: process,

outcomes, and service utilization. Int J Law Psychiatry 26:55–71

24. Herinckx HA et al (2005) Rearrest and linkage to mental health

services among clients of the Clark County mental health court

program. Psychiatric Serv 56(7):853–857

25. Dailey LF et al (2005) Recidivism in medication-noncompliant

serious juvenile offenders with bipolar disorder. J Clin Psychiatry

66:477–484

26. Cuellar AE et al (2008) Incarceration and psychotropic drug use

by youth. Arch Pediatr Adolesc Med 162(3):219–224


123


27. Cuellar AE et al (2005) Medicaid insurance policy for youths

involved in the criminal justice system. Am J Public Health

95(10):1707–1711

28. Grannis SJ et al (2003) Analysis of a probabilistic record linkage

technique without human review. AMIA annual symposium

proceedings, pp 259–263

29. LaGow B (2007) PDR drug guide for mental health professionals,

vol 3. Thompson Healthcare Inc, Montvale

30. Association AP (2000) Diagnostic and statistical manual of

mental disorders, 4th edn. American Psychiatric Association,

Washington

31. StataCorp LP (2007) Stata statistical software: release 10. Stata

Corporation, College Station

32. Abram KM et al (2003) Comorbid psychiatric disorders in youth

in juvenile detention. Arch Gen Psychiatry 60(11):1097–1108

33. Cauffman E (2004) A statewide screening of mental health

symptoms among juvenile offenders in detention. J Am Acad

Child Adolesc Psychiatry 43(4):430–439

34. Fazel S, Doll H, Langstrom N (2008) Mental disorders among

adolescents in juvenile detention and correctional facilities: a

systematic review and metaregression analysis of 25 surveys.

J Am Acad Child Adolesc Psychiatry 47(9):1010–1019

35. Pediatrics AA (2000) Insurance coverage of mental health and

substance abuse services for children and adolescents: a con-

sensus statement. Pediatrics 106:860–862

36. Reynolds GP, Kirk SL (2010) Metabolic side effects of anti-

psychotic drug treatment—pharmacological mechanisms. Phar-

macol Ther 125(1):169–179

37. Ray WA et al (2009) Atypical antipsychotic drugs and the risk of

sudden cardiac death. N Engl J Med 360(3):225–235

38. Williams RA, Hollis HM, Benoit K (1998) Attitudes toward

psychiatric medications among incarcerated female adolescents.

J Am Acad Child Adolesc Psychiatry 37(12):1301–1307

39. Glaser JB, Greifinger RB (1993) Correctional health care: a

public health opportunity. Ann Intern Med 118(2):139


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Psychiatric Medication Refill Practices of Juvenile Detainees

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