Are prisons good for our mental health?

1. Are prisons good for our mental health? Jenny Shaw University of Manchester Guild Lodge, Preston

2. This talk What happens to our mental health in prison? What happens at points of transition? What should we do?

3. 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)

4. Environment project Collaborative project Funded by the National Programme for Forensic Mental Health R&D

5. First question What happens to our mental health in prison? But why is the transition into prison problematic?

6. Aims Research questions: How does time spent in prison affect the mental health of prisoners in general? How does time spent in prison affect the health of those prisoners with mental illness?

7. Prisons • 5 local prisons • 1 female • 1 high secure

8. Measures

9. Method Screening (PriSnQuest) • 1097 (36%) +ve • 1982 (64%) -ve

10. Method Screening (PriSnQuest) • 1097 (36%) +ve • 1982 (64%) -ve T1 Interview (SADS, GHQ, BPRS) • 887 (81%) +ve • 93 (5%) - ve

11. Method Screening (PriSnQuest) • 1097 (36%) +ve • 1982 (64%) -ve T1 T2 Interview (SADS, GHQ, BPRS) Follow-up (GHQ, BPRS, MQPL) • 887 (81%) +ve • 93 (5%) - ve • 572 (58%)

12. Method Screening (PriSnQuest) • 1097 (36%) +ve • 1982 (64%) -ve T1 T3 T2 Interview (SADS, GHQ, BPRS) Follow-up (GHQ, BPRS) Follow-up (GHQ, BPRS, MQPL) • 887 (81%) +ve • 93 (5%) - ve • 182 (32%) • 572 (58%)

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

14. Findings Note: All results have been weighted by PriSnQuest outcome to account for the two-phase sampling design Overview: • Mental illness • Psychiatric diagnosis • Gender • Legal status • Prisoner quality of life

15. Findings Fig 1: Percentage meeting GHQ cut-off by diagnosis p=.03 p=.01 p=<.01

16. Findings Fig 2: Percentage meeting GHQ cut-off by diagnosis and gender p=.05

17. Findings p=.82 p=<.01 p=.24

18. Findings The course of mental health in prison is affected by: Diagnosis Gender Legal status Interactions between all of the above

19. Findings

20. Findings

21. Findings Factors predictive of meeting GHQ cut-off at any time: * p<.05

22. Findings Factors predictive of meeting GHQ cut-off at any time: * p<.05

23. Findings Fig 4: Percentage with clinically significant suicidality by diagnosis p=.02 p=<.01 p=.54

24. Findings p=.02 p=<.001 p=.71

25. Findings Fig 6: Percentage with clinically significant suicidality by diagnosis and legal status p=.02 p=<.001 p=.99 p=.63

26. Findings Factors predictive of clinically significant suicidality (BPRS) at any time: * p<.05

27. Findings Factors predictive of clinically significant suicidality (BPRS) at any time: * p<.05

28. Findings Note: All results have been weighted by PriSnQuest outcome to account for the two-phase sampling design Overview: • Mental illness • Psychiatric diagnosis • Gender • Legal status • Prisoner quality of life

29. 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

30. Measuring the Quality of Prison Life: dimension scores by rank Best 3 Worst 3

31. Summary Limitations Mental health was poorest early on in custody across all groups Prisoners perceived early custody to be a stressful time

32. 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

33. 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

34. 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

35. 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)

36. 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)

37. Health screen Designed to detect ‘high risk ‘individuals. Mental health problems to be detected by mental health assessment later BUT Most prisons using reception screen as main case finding process (Senior 2009) SO If not detected at reception-not detected at all (Birmingham 2004) ALSO Pathways into care

38. Pathways to care 5 prisons Collaboration with IOP 500 health care records at each site Screening results Referral/Contact/Intervention in first four weeks

39. Pathways Current 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

40. 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

41. What can we do? Reception screening emergencies only Keep everyone safe until: Mental health assessment -case finding, medication assessment Robust pathways to care

42. Why detect mental health problems? Good opportunity for engagement Prison suicides (Shaw 2009) Case control study Psychiatric diagnosis 4 times risk Contact with psychiatric services 5 times risk History of self harm 7 times risk

43. Question 2 Transitions Reception problematic What about discharge?

44. Other end-discharge What proportion of people under in-reach engage with CMHTs on release?

45. Why? Qualitative interviews Priorities on release: Housing Financial Establish significant relationships Not contact with mental health services Release is unpredictable

46. What can we do? Critical Time Intervention (CTI) (Susser, 1998)

47. 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

48. CTI original trial 96 men recruited CTI Usual services Outcome measure – reduction in homeless nights CTI clients had fewer homeless nights (30 days) than control group (91 days)

49. Prison adaptation Informed by: qualitative interview with prisoners pre-discharge Interviews with prison health care staff and CMHT staff

50. 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