Brie A. Williams

Psychiatric Disorders and Repeat Incarcerations: The Revolving Prison Door

OBJECTIVE A number of legal, social, and political factors over the past 40 years have led to the current epidemic of psychiatric disorders in the U.S. prison system. Although numerous investigations have reported substantially elevated rates of psychiatric disorders among prison inmates compared with the general population, it is unclear whether mental illness is a risk factor for multiple episodes of incarceration. The authors examined this association in a retrospective cohort study of the nations largest state prison system. METHOD The study population included 79,211 inmates who began serving a sentence between September 1, 2006, and August 31, 2007. Data on psychiatric disorders, demographic characteristics, and history of incarceration for the preceding 6-year period were obtained from statewide medical information systems and analyzed. RESULTS Inmates with major psychiatric disorders (major depressive disorder, bipolar disorders, schizophrenia, and nonschizophrenic psychotic disorders) had substantially increased risks of multiple incarcerations over the 6-year study period. The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had four or more previous incarcerations compared with inmates who had no major psychiatric disorder. CONCLUSIONS Prison inmates with major psychiatric disorders are more likely than those without to have had previous incarcerations. The authors recommend expanding interventions to reduce recidivism among mentally ill inmates. They discuss the potential benefits of continuity of care reentry programs to help mentally ill inmates connect with community-based mental health programs at the time of their release, as well as a greater role for mental health courts and other diversion strategies.

Use of a Modified Informed Consent Process among Vulnerable Patients: A Descriptive Study

BACKGROUND: Little is known about patient characteristics associated with comprehension of consent information, and whether modifications to the consent process can promote understanding.OBJECTIVE: To describe a modified research consent process, and determine whether literacy and demographic characteristics are associated with understanding consent information.DESIGN: Descriptive study of a modified consent process: consent form (written at a sixth-grade level) read to participants, combined with 7 comprehension questions and targeted education, repeated until comprehension achieved (teach-to-goal).PARTICIPANTS: Two hundred and four ethnically diverse subjects, aged ≥50, consenting for a trial to improve the forms used for advance directives.MEASUREMENTS: Number of passes through the consent process required to achieve complete comprehension. Literacy assessed in English and Spanish with the Short Form Test of Functional Health Literacy in Adults (scores 0 to 36).RESULTS: Participants had a mean age of 61 years and 40% had limited literacy (s-TOHFLA<23). Only 28% of subjects answered all comprehension questions correctly on the first pass. After adjustment, lower literacy (P=.04) and being black (P=.03) were associated with requiring more passes through the consent process. Not speaking English as a primary language was associated with requiring more passes through the consent process in bivariate analyses (P<.01), but not in multivariable analyses (P>.05). After the second pass, most subjects (80%) answered all questions correctly. With a teach-to-goal strategy, 98% of participants who engaged in the consent process achieved complete comprehension.CONCLUSIONS: Lower literacy and minority status are important determinants of understanding consent information. Using a modified consent process, little additional education was required to achieve complete comprehension, regardless of literacy or language barriers.

A Clinical Framework for Improving the Advance Care Planning Process: Start with Patients’ Self-identified Barriers

OBJECTIVES: To explore barriers to multiple advance care planning (ACP) steps and identify common barrier themes that impede older adults from engaging in the process as a whole.

Unraveling the relationship between literacy, language proficiency, and patient–physician communication ☆ ☆☆

OBJECTIVE To examine whether the effect of health literacy (HL) on patient-physician communication varies with patient-physician language concordance and communication type. METHODS 771 outpatients rated three types of patient-physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant). RESULTS Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL. CONCLUSION Limited health literacy impedes patient-physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication. PRACTICE IMPLICATIONS Patient-physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.

Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults.

OBJECTIVES: To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

Aging in Correctional Custody: Setting a Policy Agenda for Older Prisoner Health Care

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.

Lost in Translation: The Unintended Consequences of Advance Directive Law on Clinical Care

BACKGROUND Advance directive law may compromise the clinical effectiveness of advance directives. PURPOSE To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. DATA SOURCES Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010. STUDY SELECTION Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings. DATA EXTRACTION Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus. DATA SYNTHESIS Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates. LIMITATION Only appellate-level legal cases were available, which may have excluded relevant cases. CONCLUSION Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs and the Pfizer Foundation.

Addressing the aging crisis in U.S. criminal justice health care

The U.S. criminal justice population is aging at a significantly more rapid rate than the overall U.S. population, with the population of older adults in prison having more than tripled since 1990. This increase is at the root of a prison healthcare crisis that is spilling into communities and public healthcare systems because nearly 95% of prisoners are eventually released. The graying prison population is also straining state and local budgets. In prison, older prisoners cost approximately three times as much as younger prisoners to incarcerate, largely because of healthcare costs. In the community, older former prisoners present the least risk of recidivism yet are vulnerable to serious and costly social and medical challenges such as housing instability, poor employability, multiple chronic health conditions, and health‐related mortality; however older current and former prisoners are largely ignored in the current geriatrics evidence base. Knowledge about the health, functional, and cognitive status of older prisoners is limited, with even less known about risk factors for long‐term poor health outcomes during and after incarceration. This article provides an overview of aging in the criminal justice system. It then describes how geriatric models of care could be adapted to address the mounting older prisoner healthcare crisis and identifies areas where additional research is needed to explore prison‐specific models of care for older adults.

Being Old and Doing Time: Functional Impairment and Adverse Experiences of Geriatric Female Prisoners

The number of older prisoners is increasing exponentially. For example, the number of geriatric female prisoners in California has increased 350% in the past decade. Despite an increasing population of geriatric female prisoners, the degree of functional impairment in this population is unknown. Therefore, the goals of this study were to describe the prevalence and nature of functional impairment in geriatric female prisoners in California and to identify aspects of the prison environment that may exacerbate functional impairments.

Functional Limitations, Socioeconomic Status, and All‐Cause Mortality in Moderate Alcohol Drinkers

OBJECTIVES: To determine whether the survival benefit associated with moderate alcohol use remains after accounting for nontraditional risk factors such as socioeconomic status (SES) and functional limitations.