An Algorithm for the Treatment of Schizophrenia in the Correctional Setting: The Forensic Algorithm Project
J Clin Psychiatry 2000;61:767-783
© Copyright 2014 Physicians Postgraduate Press, Inc.
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The Forensic Algorithm Project (FAP) was born of the need for
a holistic approach in the treatment of the inmate with
schizophrenia. Schizophrenia was chosen as the first entity to be
addressed by the algorithm because of its refractory nature and
high rate of recidivism in the correctional setting.
Schizophrenia is regarded as a spectrum disorder, with symptom
clusters and behaviors ranging from positive to negative symptoms
to neurocognitive dysfunction and affective instability.
Furthermore, the clinical picture is clouded by Axis II
symptomatology (particularly prominent in the inmate population),
comorbid Axis I disorders, and organicity.
Four subgroups of schizophrenia were created to coincide with
common clinical presentations in the forensic inpatient facility
and also to parallel 4 tracks of intervention, consisting of
pharmacologic management and programming recommendations. The
algorithm begins with any antipsychotic medication and proceeds
to atypical neuroleptic usage, augmentation with other
psychotropic agents, and, finally, the use of clozapine as the
common pathway for refractory schizophrenia. Outcome measurement
of pharmacologic intervention is assessed every 6 weeks through
the use of a 4-item subscale, specific for each forensic
subgroup. A "floating threshold" of 40% symptom
severity reduction on Positive and Negative Syndrome Scale and
Brief Psychiatric Rating Scale items over a 6-week period is
considered an indication for neuroleptic continuation. The
forensic algorithm differs from other clinical practice
guidelines in that specific programming in certain prison
environments is stipulated. Finally, a social commentary on the
importance of state-of-the-art psychiatric treatment for all
members of society is woven into the clinical tapestry of this