Incarcerated Women’s Experiences and Beliefs About Psychotropic Medication: An Empirical Study

During a single day in September 2015, all 535 women at a medium-security correctional institution in a Mid-Atlantic state were invited to participate in the study. Security staff escorted the women to a large gymnasium in five separate groups over the course of about two hours. Informed consent forms and questionnaires were offered upon entry. Once the women were seated, we described the study in detail, reviewed the consent form, and responded to any questions. Prospective participants were informed that we were looking for volunteers who had taken or were currently taking psychotropic medication in the prison setting. The women chose whether to complete the consent form or the survey. After about 15 minutes, they were thanked and asked to place their blank or completed informed consent forms and questionnaires anonymously in separate cardboard boxes as they exited. The effort produced 274 usable questionnaires. The study was approved by the full board of Virginia Commonwealth University’s Institutional Review Board as well as the research review board of the Department of Corrections in the state where the research was conducted.

We developed an original questionnaire for the study, crafting items around relevant topics from several sources. First, literature on medication use with incarcerated populations was consulted (3,12), as well as literature on the effects of psychotropic medication among persons with serious mental illness (18,19). Some questionnaire items were drawn from existing measures of attitudes toward medication (20–23). The questionnaire for this study included 22 items assessing beliefs about and experiences with psychotropic medication (Cronbach’s α=.762).

In addition, during development of the questionnaire, we conducted a focus group with mental health clinicians and administrators from the Department of Corrections to solicit their feedback on the research questions and instrumentation. Participants in the focus group indicated that they believed locus of control might be a fruitful avenue of investigation. Specifically, their experiences as service providers suggested that incarcerated women, who often have histories of victimization, might see themselves as having less personal agency in life, which might affect their beliefs about and experiences with medication. On the basis of this observation and discussions of locus of control in the literature, we added six items from Rotter’s Internal-External Control Scale (24), which were assessed to be most relevant for incarcerated populations. Three items were intended to measure external locus of control, and three were intended to measure internal locus of control. These items used the same 10-point Likert scale as the other items, rather than the forced-choice format used in the original instrument.

The complete questionnaire consisted of 35 items: six on demographic information, six measuring locus of control, and 22 measuring experiences with psychotropic medication. A final open-ended item asked participants to respond to the question: “What is the most important thing you would want people to know about your experiences with mental health medication?”

Using SPSS Statistics 23, we began with various univariate analyses to assess frequencies of demographic and clinical variables, including current psychotropic medication use and self-reported psychiatric diagnosis. Next, to discern the underlying factor structure of the data, we conducted an exploratory principal-components factor analysis with varimax rotation of the 22 questionnaire items pertaining to experiences with and perceptions of psychotropic medication. Factors with an Eigenvalue greater than one were retained, as suggested by Costello and Osborne (25). Composite scores were calculated for the six factors that emerged. To incorporate locus of control into the statistical models, the average score for internal control items was subtracted from the average score for external control items, yielding a single score for which higher values indicated more external control. We conducted linear regression analyses to determine whether demographic variables, incarceration history, locus of control, current psychotropic medication use, and number of mental health diagnoses predicted experiences with and perceptions of psychotropic medication use. An analysis of covariance (ANCOVA) examined the role of polypharmacy. Responses to the open-ended item were subjected to a content analysis involving quantitative word counts, as well as an inductive process of organizing the narrative data into themes.

As shown in Table 1, most respondents were Caucasian (80%) and between ages 25 and 44 (70%). The average time incarcerated during adulthood was 6.24 years, with a range from six months to 30 years. The most frequently self-reported psychiatric diagnoses were anxiety disorder (76%) and depressive disorder (72%), but a large percentage of women also reported trauma-based disorders (58%), substance use disorders (49%), and bipolar disorder (47%). Sleep disorders (31%) and personality disorders (20%) were also reported. Over three-quarters (77%) reported that they were currently taking psychotropic medication (Table 2), which accounted for 40% of the institutional census on the day of data collection. Antidepressants were the most common medication (93%), followed by mood stabilizers (33%). More than half (51%) reported taking more than one type of psychotropic medication. No statistically significant differences in race-ethnicity, age, or incarceration history were found between participants currently taking medication and those who took it only in the past.

We calculated mean scores and standard deviations for responses to the questionnaire items pertaining to experiences with psychotropic medication use (Table 3). Perhaps most interesting was the overwhelming endorsement of items related to positive effects of psychotropic medication, such as “For me, the good things about medication outweigh the bad” (mean=7.48 on a scale of 1 to 10, with higher scores indicating stronger agreement) and of items related to personal agency in decision making regarding medication use, such as “I take medications of my own free choice” (mean=9.17)—the highest mean score among all items. On the other hand, items pertaining to seemingly negative aspects of medication use were not endorsed. For example, participants generally disagreed with the statements “My medication is a way the prison controls me” (mean=2.18) and “I feel ashamed that I take medication” (mean=2.28). Mean scores on the three items intended to measure internal locus of control were higher than those on the three items intended to measure external locus of control, indicating that respondents in general had greater internal locus of control.

The exploratory factor analysis of the 22 questionnaire items pertaining to experiences with psychotropic medication yielded a six-factor solution that explained 62% of the variance, suggesting that the questionnaire captured six dimensions of the women’s experiences with psychotropic medication use. One item (“I know the names and dosages of all my medications”) was not assigned to a factor because of its low communality (<.3) and factor loading score. Based on a factor loading threshold of .40, we assigned items to six factors, which were named thematically as six dimensions of psychotropic medication–related experience: perception of therapeutic effects, perception of the impact of medication on life, perception of medication as a means of control, perception of personal agency regarding medication use, experience of stigma related to medication use, and feelings of biological vulnerability.

Six linear regression analyses were performed to examine predictors of women’s scores on subscales representing of each of the six dimensions of experience with psychotropic medication (Table 4). For each analysis, the independent variables were age group, race-ethnicity, number of incarcerations, years incarcerated, external locus of control, current versus past medication use, and number of psychiatric diagnoses. External locus of control significantly predicted a greater likelihood of experiencing stigma related to medication use (B=.35, t=3, df=266, p=.003), an increased perception of medication as a means of control (B=.33, t=3.65, df=266, p<.001), a decreased perception of personal agency regarding medication use (B=–.16, t=−2.09, df=266, p=.038), and increased perception of biological vulnerability (B=.35, t=.08, df=266, p=.001). Not surprisingly, current medication use significantly predicted both a more positive view of therapeutic effects (B=10.33, t=5.28, df=266, p<.001) and a perception of a high impact of medication on life (B=8.2, t=5.88, df=266, p<.001). Current medication use also significantly predicted a stronger sense of personal agency related to medication use (B=1.37, t=2.44, df=266, p=.015). Number of self-reported psychiatric diagnoses significantly predicted both an increased perception of medication’s impact on life (B=1.03, t=3.26, df=266, p=.001) and an increased perception of biological vulnerability (B=1.22, t=6.82, df=266, p<.001). Number of years incarcerated was also a statistically significant predictor of the experience of stigma (B=.22, t=2.89, df=266, p=.004) as well as a perception of more positive therapeutic effects (B=.35, t=2.05, df=266, p=.042). In addition to current medication use, age group was a highly significant predictor of perception of high impact of medication on life (B=2.52, t=3.61, df=267, p<.001). Race-ethnicity and number of incarcerations were not statistically significant predictors in any model.

To explore the potential role of polypharmacy in women’s experiences with medication use, we conducted an ANCOVA to examine differences in mean scores on dependent variables for which current medication use was a statistically significant predictor between those taking one type of medication and those taking more than one type. The number of medications currently being taken had a significant effect on perceived impact of medication (F=13.35, df=3 and 258, p<.001); the more types of medication being taken, the more likely the woman was to perceive medication as having a high impact on her life.

A total of 197 participants (72%) responded in some way to the single open-ended questionnaire item, “What is the most important thing you would want people to know about your experience with mental health medication?” A content analysis of the responses yielded three dominant themes and three less prominent but still important ideas. The dominant themes can be encapsulated with the sentence “It helps me [do this and not do that] under certain “right” conditions, and only through a time-consuming trial-and-error process.” Of those who responded to the question, 42% (N=83) used some form of the word “help” in their response; the word “right” appeared 59 times in the responses. Participants specifically wanted others to know that psychotropic medication helped them achieve positive change, such as staying calm or “sane” and staying stable or focused, and helped them cope, get rest, “face what comes,” control their temper, and “be a good person.” Medication likewise helped these women avoid negative symptoms or outcomes, such as depression, mood swings, suicidal ideation, apathy, being scared, or just “being a worse person.”

A caveat to the strong endorsement of the positive effects of psychotropic medication was the strong cautionary note that medication is helpful only under the “right” circumstances—that is, if the person needs it, and it is the right medication, in the right combination, at the right dosage, taken in the right manner, and for the right reasons. Respondents repeatedly indicated that they wanted people to realize that ensuring this set of circumstances is a lengthy and imperfect process of trial and error. Many women also offered direct advice to others (don’t be ashamed of taking medication, and work with your doctor) and expressed concerns about the structural issues in prisons and in society that influence their mental health care (limited choices of medication types behind bars, prison schedule dictating when medications are distributed, and stigma).