An Algorithm for the Treatment of Schizophrenia in the Correctional Setting: The Forensic Algorithm Project

The Forensic Algorithm Project (FAP) was born of the need fora holistic approach in the treatment of the inmate withschizophrenia. Schizophrenia was chosen as the first entity to beaddressed by the algorithm because of its refractory nature andhigh rate of recidivism in the correctional setting.Schizophrenia is regarded as a spectrum disorder, with symptomclusters and behaviors ranging from positive to negative symptomsto neurocognitive dysfunction and affective instability.Furthermore, the clinical picture is clouded by Axis IIsymptomatology (particularly prominent in the inmate population),comorbid Axis I disorders, and organicity.

Four subgroups of schizophrenia were created to coincide withcommon clinical presentations in the forensic inpatient facilityand also to parallel 4 tracks of intervention, consisting ofpharmacologic management and programming recommendations. Thealgorithm begins with any antipsychotic medication and proceedsto atypical neuroleptic usage, augmentation with otherpsychotropic agents, and, finally, the use of clozapine as thecommon pathway for refractory schizophrenia. Outcome measurementof pharmacologic intervention is assessed every 6 weeks throughthe use of a 4-item subscale, specific for each forensicsubgroup. A “floating threshold” of 40% symptomseverity reduction on Positive and Negative Syndrome Scale andBrief Psychiatric Rating Scale items over a 6-week period isconsidered an indication for neuroleptic continuation. Theforensic algorithm differs from other clinical practiceguidelines in that specific programming in certain prisonenvironments is stipulated. Finally, a social commentary on theimportance of state-of-the-art psychiatric treatment for allmembers of society is woven into the clinical tapestry of thisarticle.