Are prisons good for our mental health?

www.ohrn.nhs.ukwww.ohrn.nhs.uk

Jenny ShawUniversity of Manchester

Guild Lodge, Preston

This talk

• What happens to our mental health in

prison?

• What happens at points of transition?

• What should we do?

In prison

• Increased prevalence of mental health problems in prison (Singleton 1998, Fazel 2000)

• Why?

Imported vulnerability (Liebling 2004)

Prison environments are ‘anti-therapeutic’ (Sim, 1994; Hughes, 2000)

Environment project

• Collaborative project

• Funded by the National Programme for Forensic Mental Health R&D

First question

• What happens to our mental health in prison?

• But why is the transition into prison problematic?

Research questions:

1. How does time spent in prison affect the mental health of prisoners in general?

2. How does time spent in prison affect the health of those prisoners with mental illness?

Prisons

• 5 local prisons

– 1 female

– 1 high secure

Measures

•General Health Questionnaire-12 (Goldberg 1976)

•Brief Psychiatric Rating Scale–E (Overall & Gorham, 1962; Ventura et al., 1993)

•Measuring the Quality of Prison Life (Liebling, 2002)

Method

Screening(PriSnQuest)

• 1097 (36%) +ve

• 1982 (64%) -ve

Method

• 1097 (36%) +ve

• 1982 (64%) -ve

Interview(SADS, GHQ, BPRS)

• 887 (81%) +ve

• 93 (5%) - ve

Method

• 1097 (36%) +ve

• 1982 (64%) -ve

• 887 (81%) +ve

• 93 (5%) - ve

Follow-up(GHQ, BPRS, MQPL)

• 572 (58%)

Method

• 1097 (36%) +ve

• 1982 (64%) -ve

• 887 (81%) +ve

• 93 (5%) - ve

Follow-up(GHQ, BPRS)

• 182 (32%)

Follow-up(GHQ, BPRS, MQPL)

• 572 (58%)

Sample

VariableT1 T2 T3

n % n % n %

PriSnQuest outcome PriSnQuest positive 887 91 513 90 160 88

PriSnQuest negative 93 10 59 10 22 12Gender Male 769 79 438 77 162 89

Female 211 22 134 23 20 11Legal status Remand 506 52 299 52 105 58

Convicted 474 48 273 48 77 42Psychiatric diagnosis Any psychosis 101 10 53 9 16 9

MDD 318 32 181 32 56 31

Any other MI 122 12 73 13 30 17

None 439 45 265 46 80 44All 980 100 572 100 182 100

Table 1: Key sample characteristics at T1, T2 and T3

Findings

Overview:

• Mental illness

– Psychiatric diagnosis

– Gender

– Legal status

• Prisoner quality of life Note: All results have been weighted by PriSnQuest outcome to account for the two-phase sampling design

Findings

p=<.01

Fig 1: Percentage meeting GHQ cut-off by diagnosis

Findings

Fig 2: Percentage meeting GHQ cut-off by diagnosis and gender

Findings

p=<.01

Findings

The course of mental health in prison is affected by:

• Diagnosis

• Gender

• Legal status

• Interactions between all of the above

Findings

8 groups:

Male convicted– SMI Female convicted– SMI

Male remand – SMI Female remand – SMI

Male convicted– none Female convicted - none

Male remand - none Female remand - none

Findings

8 groups:

Male convicted– SMI Female convicted– SMI

Male remand – SMI Female remand – SMI

Male convicted– none Female convicted - none

Male remand - none Female remand - none

Factors predictive of meeting GHQ cut-off at any time:

Findings

Group Risk ratio

Male convicted– none (ref. group) 1.0

* p<.05

Factors predictive of meeting GHQ cut-off at any time:

Findings

Group Risk ratio

Female remand – SMI 6.1*

Male remand – SMI 5.5*

Female convicted– SMI 4.9*

Male convicted– SMI 4.1*

Male remand - none 2.2*

Female remand - none 1.8

Female convicted - none 1.2

* p<.05

Findings

p=<.01p=.54

Fig 4: Percentage with clinically significant suicidality by diagnosis

Findings

p=<.001p=.71

Findings

p=.02p=<.001p=.99p=.63

Fig 6: Percentage with clinically significant suicidality by diagnosis and legal status

Factors predictive of clinically significant suicidality (BPRS) at any time:

Findings

Group Risk ratio

* p<.05

Factors predictive of clinically significant suicidality (BPRS) at any time:

Findings

Group Risk ratio

Male remand – SMI 31.7*

Female remand – SMI 29.1*

Female convicted– SMI 23.5*

Male convicted– SMI 14.2*

Female convicted - none 4.1*

Female remand - none 3.6*

Male remand - none 3.0*

* p<.05

Findings

Overview:

• Mental illness

– Psychiatric diagnosis

– Gender

– Legal status

• Prisoner quality of life Note: All results have been weighted by PriSnQuest outcome to account for the two-phase sampling design

Measuring the Quality of Prison Life (Liebling, 2002):

• 112 statements:

• “When I first came to this prison I felt looked after”• “I often feel depressed in this prison”• “The regime in this prison is fair”

Findings

Strongly Agree Agree

Neither agree nor disagree

DisagreeStrongly Disagree

Quality of life dimensionPrison

All A B C D ERace relationships 1 3 1 2 1 1

Physical safety 2 3 3 2 1 1

Clarity 3 1 7 8 1 1

Family contact 4 7 4 1 5 4

Dignity 5 8 2 5 1 4

Order & security 6 2 4 10 5 13

Care & safety 7 5 7 10 5 9

Fairness 8 8 13 2 11 6

Relationships 9 12 4 8 8 9

Assistance for vulnerable 10 8 7 10 8 9

Respect 11 12 7 5 14 6

Overall distress 12 16 16 5 8 6

Personal development 13 12 7 14 11 13

Frustration 14 17 15 10 16 9

Drug control 15 5 7 18 11 16

Entry support 16 8 13 17 14 15

Individual care 17 12 16 15 19 19

Addressing offending behaviour 18 17 16 15 17 17

Entry into custody 19 17 19 18 18 17

Measuring the Quality of Prison Life: dimension scores by rank

Best 3Worst 3

Summary

• Limitations• Mental health was poorest early on in

custody across all groups• Prisoners perceived early custody to be a

stressful time

Summary

• Mental health improved, or at least did not worsen, over time in custody across all groups

• Among those with SMI:– Remand prisoners had poorer mental health

than convicted prisoners– Women had poorer mental health than men– Prisoners with psychosis had poorer mental

health than those with depression

Implications

• How can we reduce prisoner distress, particularly early on in custody?

• What can we do to improve outcomes for women and those with SMI in prison?

• Early identification and support• Robust care pathways• Further work

Key Findings

• Mental health is worst during the initial period following entry into custody but improves from this point onwards across all groups

• Poorer outcomes for females with MI

• Psychotic symptoms failed to settle over time amongst females

• Prisoners rate entry into custody as a particularly difficult time

Transition

– Mental health problems

– Charged/convicted/loss of liberty

– Uncertainty about

process/threats/bullying

– Separation from family/friends

– Drug/alcohol misuse/withdrawal

– Medication prescription (Bowen, 2006)

Reception

• Male locals between 10 and 50 per night

• Up to 75% arrive between 6 and 8

• 14 different procedures to complete

• Health screen

• 20%health screen by non health care

professionals (Senior, 2009)

Health screen• Designed to detect ‘high risk ‘individuals. Mental health

problems to be detected by mental health assessment later

• Most prisons using reception screen as main case finding

process (Senior 2009)

• If not detected at reception-not detected at all (Birmingham

• Pathways into care

Pathways to care

• 5 prisons

• Collaboration with IOP

• 500 health care records at each site

• Screening results

• Referral/Contact/Intervention in first four

PathwaysCurrent ideas of self harm– 3% reception screens– 2/3 ACCT– 60% further assessment by mental

health Positive marker for mental disorder

– 1 in 5 past history psychiatric contact. – 20% no assessment

Medication• 1 in 5 medication• 25% never assessed• Only 1/3 prescribed medication (Shaw, 2008)

• Why? Ongoing study (Hassan & Judge)

-not on it-not needed-not checked/prescribed

What can we do?

• Reception screening emergencies only

• Keep everyone safe until:

– Mental health assessment

-case finding, medication assessment

– Robust pathways to care

Why detect mental health problems?

• Good opportunity for engagement• Prison suicides (Shaw 2009)Case control studyPsychiatric diagnosis 4 times riskContact with psychiatric services 5 times

riskHistory of self harm 7 times risk

Question 2• Transitions • Reception problematic• What about discharge?

Other end-discharge

• What proportion of people under in-reach engage with CMHTs on release?

241 in-reach clients

14 referred upon

release

3 made contact

upon release

Qualitative interviews

– Priorities on release:– Housing

– Financial

– Establish significant relationships

– Not contact with mental health services

– Release is unpredictable

What can we do?

Critical Time Intervention (CTI)(Susser, 1998)

CTI• Susser and Colleagues New York

• To prevent recurrent homelessness

• ‘Bridging the gap’

• Intensive case management– Five areas:

• Psychiatric treatment & medication management• Money management• Substance abuse treatment• Housing crisis management• Life skills training

CTI original trial– 96 men recruited

Usual services

– Outcome measure – reduction in homeless nights

– CTI clients had fewer homeless nights (30 days) than control group (91 days)

Prison adaptation

Informed by:– qualitative interview with prisoners pre-

discharge

– Interviews with prison health care staff and CMHT staff

Adaptation• Formulate treatment plan early in custody

• Arrange accommodation & financial support

• Arrange appointments

• Predict release

• Attend court with medication

• Accompany patient to discharge address

• Accompany patient to GP and CMHT appointments

Community

• Treatment plan formulated

• Linking to community resources established

• Testing and adjusting of systems of support

• Ensure smooth handover of care

• Decide long term goals

• Gradually reduce support

Feasibility trial platform

• Three adult male establishments holding remand prisoners

• Prisoners with SMI under in-reach

• Study design

– Treatment groups

• Modified CTI (experimental group)

• Treatment as usual (control group)

Excluded (n=33)

Trial consort

Referral to in-reach

Baseline assessments

(n=49)

Randomised(n=49)

Treatment as usual (n=28)

Followed –up (n=16)

Lost to follow –up (n=0)

Followed –up (n=13)

Lost to follow –up (n=0)

Not engaged (n=10)

Engaged (n=3)Not engaged

(n=3)Engaged (n=13)

CTI intervention (n=21)

Excluded (n=5)

Excluded (n=15)

Met eligibility criteria (n=82)

Results

• Highly successful

• Feasible to introduce an intervention into

prison setting

• Possible to follow-up post discharge

Positives

• Feasible

• Staff liked it

• Encouraging pilot

• Large scale RCT

BUT ...

• Expensive

• Time intensive

• Staff selection, training & supervision

Next steps

• Obtain funding for RCT

• Economic evaluation

• Hard sell!

Why bother with all of this anyway?

Prison health is public health

• Chaotic lifestyles

• Social exclusion

• Crisis-led contact with healthcare services

• Poor clinical outcomes

• Uneconomic

• Revolving door

• Death

• Re-offending?

In prison todaynext door to you tomorrow…

So maximise opportunity for treatment

Thank you

Contact details:

Jennifer.j.shaw@manchester.ac.ukJenny.shaw@lancashirecare.nhs.uk

Are prisons good for our mental health?

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