Early detection of psychosis in Brixton Prison

1. Early detection of psychosis in Brixton Prison SPRiG 2011

2. Study context Mental Health of prisoners Background to early detection Method Results Limitations Conclusion Presentation

3. In Prison Custody • Total Population Sept 11: 86, 596 • Women and girls: 4,253 • Approximately 12,000 under aged 21 • Under aged 18: 2,155 Types of Prisons Categorised – gender, age and security Remand and Training

4. Study Context • NHS take over responsibility for prisoners’ healthcare from Prison Service in 2006 • ‘Principle of Equivalence’ (HM Inspectorate of Prisons, 1996)

5. OASIS:(Outreach And Support in South London) • Prevent transition to psychosis • Improve outcome if psychosis develops • Primary Care setting (improve access & avoid stigmatisation) • Help seeking population (OASIS - 40% accessed at least 2 services previously, 10% 3 services, 5% > 5services)

6. Prisoner Population • 29% in care as child • 50% excluded from school • 67% unemployed before reception • 32% homeless before reception • 50% no GP • 80% reading age of 11yrs or less

7. Mental Health of Prisoners • High rates psychosis 4-10% (Singleton et al., 1998; Shaw et al., 2011) • 40% overall attempted suicide rate • High levels co-morbidity personality disorder learning disability substance misuse

8. Aims and Objectives Is OASiS in prison feasible? • Non help seeking population • Prevalence of ARMS • Screening tool • Logistics of introducing service • Differences between groups

9. On reception to prison • ID Card • Healthcare screening • Physical and Mental Illness • Risk of self harm / suicide • First nighters wing • Move to normal location 1-5 days • Unlocked 2 hours per day

10. Mental Health Pathway in Prison • Reception – healthcare screening • Normal Location – In-reach • Inpatient Unit …BUT … • No Mental Health Act • Transfer times 60-100 days • Half awaiting transfer – no treatment

11. Early Detection: Retrospective Studies • Interviews with patients & families, records problems concentration low drive/motivation depressed mood anxiety social withdrawal suspiciousness decline in functioning (Review: Yung & McGorry, 1996) ‘prodrome’ retrospective concept..

12. Prospective Studies ‘At Risk Mental State’ – increased risk, not inevitability.. Basic Symptoms - subtle non specific symptoms Ultra High Risk Criteria: attenuated or transient psychotic symptoms

13. Basic Symptoms (Early Prodrome): Thought pressure, blocking and interference Problems receptive language Confusion memory and fantasy Ideas of reference Derealisation Visual-perceptual disturbances (e.g. hypersensitivity to light) Acoustic-perceptual disturbances (e.g.hypersensitivity to sounds) Transition rates: 58% over 8 years (Klosterkotter et al., 1997)

14. Late prodrome: Ultra High Risk Symptoms Depression Feeling anxious Irritable Disturbed patterns of sleeping or eating Confused or muddled thinking Noticing that things and people seem strange or unreal Being preoccupied with particular ideas or thoughts Unusual auditory or visual experiences Withdrawing from family and friends Struggling to cope at school, college or work Transition rates 20-40% over 1-2 years (Yung et al.)

15. Method: Setting • HMP Brixton • Operational Capacity: 796 • Category B local prison • - males, aged 21 or over • - awaiting trial or short sentences (<2yrs) • - mean stay 3 months • 25 Inpatient beds

16. Method: Sample • Inclusion Criteria: • New Receptions • Aged 35 or under • From SLaM geographical area • No history of psychosis

17. Screening for ARMS • Prodrome Questionnaire – Brief Version

18. Ultra High Risk Criteria Comprehensive Assessment of At Risk Mental State (CAARMS) Ultra High Risk Criteria • Attenuated psychotic symptoms • Transient psychotic symptoms (BLIP) • Trait vulnerability + decline in functioning Age 18 -35 (community) 21- 35 (prison)

19. Method: Other assessments • Demographic data • Childhood adversity • Self harm and attempted suicide • Substance Misuse • CJS data

20. Results: Feb 2009 – Sept 2011

21. Screen Sensitivity and Specificity PQ-B sensitive but not specific: • Anxious on arrival in prison • Recent substance misuse • Other mental health issues • Validation of PQ-B in prisoner population

22. “If I was in control, I wouldn’t be here”. • “Sometimes I do things that I know I shouldn’t do – like I hit someone, when I know I shouldn’t, I can’t stop myself”. • “I find it difficult to concentrate”.

23. “I think too much” • “I don’t think to do the right things” • “I do stupid things, I’m a bit impulsive” • “I’ve made some bad decisions in life”

24. Results (Feb 2009 – April 2011)

25. UHR vs non-UHR prisoners • characteristics • social exclusion (homelessness, unemployment) • higher levels of childhood trauma • self harm and attempted suicide • family psychiatric history • functioning

26. Characteristics Mean age 28 (sd 5.3) no differences between groups

27. Social Exclusion

28. Substance misuse • Alcohol • Cannabis • Glue, petrol, gas • Cocaine • Crack • Ecstasy • Stimulants • Heroin • LSD, Mushrooms, PCP • Other

29. Substance Misuse • Alcohol: No differences between groups • Drugs: No differences EXCEPT use of • Cocaine (P<0.003) • Other stimulants (p<.04) in last month associated with ARMS

30. Childhood Adverse Events: up to 17 yrs age • Bullying • Physical Abuse • Witnessing family violence • Being separated from parents • Being in care • Sexual Abuse • Serious illness or injury • Racial discrimination

31. Adverse Childhood Events

32. Self harm and attempted suicide

33. Family psychiatric history 20% no data one side of family

34. Functioning

35. Functioning • 22 hour bang up • After detox, functioning • Drop in functioning not due to mental state • Does being active criminally count as good functioning?

36. Correlates for ARMS • High anxiety • High depression • Previous self harm • Bullying • Sexual abuse • Lower functioning and drop in functioning

37. Limitations • 309 excluded due to language • 115 refused • Measuring functioning in prison • Difficult to engage once they leave prison • No follow up

38. Conclusion • Screening identifies prisoners wanting help – useful for triage • Prevalence: 5% ARMS & 3% psychosis • Comparison prison vs community groups • Introduction of service – in progress

39. Lucia Valmaggia (PI) Tom Craig Andrew Forrester Janet Parrott Toby Winton-Brown Majella Byrne David Ndegwa Philip McGuire HMP Brixton Prisoners and Staff OASIS Team Helen McGuire Philipe Wuyt manuela.jarrett@kcl.ac.uk Acknowledgements