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Mental Health Reform & Forensic Psychiatric Services “The Past, The Present and The Future” Dr. Myo Kyaw Oo Senior Medical Officer/Consultant Psychiatrist.

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Presentation on theme: "Mental Health Reform & Forensic Psychiatric Services “The Past, The Present and The Future” Dr. Myo Kyaw Oo Senior Medical Officer/Consultant Psychiatrist."— Presentation transcript:

1 Mental Health Reform & Forensic Psychiatric Services “The Past, The Present and The Future” Dr. Myo Kyaw Oo Senior Medical Officer/Consultant Psychiatrist Bellevue Hospital December 2, 2011

2 Mission To improve the mental health of the people of Jamaica so that individuals will attain a state of well being, where the individual will rely on his/her own abilities, be able to cope with life, work productively, make a contribution to his/her community and live harmoniously with others Mental Health Reform: The reallocation of services and phasing out Bellevue Hospital June 2003

3 Principles of Mental Health Reform DecentralizationDeinstitutionalizationDe-stigmatization

4 Decentralization Four Health Regions 1997 Regional & Parish Psychiatrists Regional Community Mental Health Services Community Mental Health Staffs Mental Health Act 1997, Amendment Bill 1999 Strategic Mental Health Plan 1999 Strategic Mental Health Plan 2009-2014

5 Common Principles Mental Health Policy Equity Human rights Role of scientific evidence integration

6 Psychiatric Specialty Services General Adult Psychiatry Child & Adolescent Psychiatry Addiction Psychiatry Forensic Psychiatry Disaster Psychiatry Geriatric Psychiatry Consultation-liaison Psychiatry

7 Forensic Psychiatric Services Jamaica History of Forensic Psychiatry King George III, Queen Victoria, M’Naghten Role of psychiatry and the Law Role of Psychiatry and defense Role of psychiatry and sentencing Role of psychiatry and disposal

8 Jamaica Landmarks in psychiatry Mental Hospital Act 1873 Community mental health services 1960s Closure of Forensic ward BVH 1975 Mental Health Act 1997 Mental Health Strategic Plan 1999 Bill to amend Mental Health Act 1999 Amendment to Criminal Justice (Administration) Act 2005

9 Forensic Psychiatric Services Regional Psychiatrists Bellevue Hospital UHWIDCS Community Mental Health Centers Psychiatrists in private practice

10 Treatment services, assessment & expert’s opinion Fitness to plea Fitness to stand trial Fitness for sentencing Diminished responsibility Fitness to be executed

11 Mental Health Reform Cabinet approved reform on March 20, 2006 The Development of Community Mental Health Services and De-Institutionalization. Mandated Ministry of Health to pursue further consultations and community involvement.

12 Facilities for Forensic patients Forensic ward closed in 1975 Criminal Justice (Administration) Act (Amendment) 2005 Cabinet Approval Decentralization & Development of Community Mental Health Services 2006 Bellevue Hospital Police jails Department of Correctional Services –Tower Street ACC –St. Catherine ACC –South Camp ACC –Fort Augusta ACC –Juveniles facilities

13 Bellevue Hospital 3000 inpatients in 1965 1500 inpatients in 1990 800 inpatients in 2011 policy decision made closure of forensic psychiatric ward in 1975 Transfer of patients to TSACC Bellevue is under reform









22 What do we have between Bellevue and Prisons ???

23 Balanced? Bellevue Community Mental Health Services Acute psychiatric wards in general hospitals Facilities for chronic mentally ill to offer rehabilitation and occupational therapy Child & Adolescent psychiatric services

24 What we do not want to see… Criminalization of mentally ill Trans-institutionalization Strategic Mental Health Plan Amendment to Criminal Justice (Administrative) Act 2005

25 UK, US, Singapore What are the challenges? What model of care for forensic psychiatric patients?










35 Woodbridge Hospital SG 1851 built facility, fully restructured 2000 psychiatric beds on 25 hectare campus Range of psychiatric facilities, adult, child & adolescent, geriatric, addiction, forensic, community, special clinics National Mental Health Blue Print 2007- 2012 88 millions in 2007, 35 millions in 2009


37 Caribbean/Regional Barbados Trinidad & Tobago

38 What do we have?? What commitment ? What have we invested?

39 Mentally ill Offenders Jails & Remand Centre Prisons Other institutions & community

40 What do we have? What do we need?

41 Mental Health Services Ministry of Health for police jails Bellevue & General Hospitals University Hospital Health Centers Prison Psychiatric Services Sessional Psychiatrists Psychologists Nursing staff Probation officers Chaplain Child Development Agency

42 Mental Health Reform Justice Reform Inter-agencies or multi-agencies involvement “Investment begins with a vision”

43 Justice Reform: Principle of Therapeutic Jurisprudence in Criminal Justice Criminal Responsibility Actus Reus & Mens Rea Jail Diversion Drug Court Mental Health Court

44 Objective is.. There should be NO mentally ill in prison. To provide a comprehensive rehabilitation To reduce recidivism

45 Mental illness in prisons Disorders present before admission and exacerbated by incarceration Disorders develops during incarceration

46 Factors related Widespread misconception that all with mental illness are a danger to society General intolerance of people to difficult and disturbing behaviour Sensational stories in the media of some charged with offences Failure to promote treatment rehabilitation Lack of mental health services/ poor and inefficient access to services

47 Poor physical conditions Situational crises Violence, harassment Discrimination, stigmatization Victimization Abuse and human right violations

48 Mentally ill in prisons PsychoticNon-psychotic

49 Psychotic Group GG pleasure with or without court date RM pleasure, unfit to plea with court date Convicted & Sentenced Diminished responsibility psychotic during incarceration Majority Schizophrenia & Drug Psychosis

50 Non-psychotic group Adjustment disorder Depression & suicide Personality disorder Gender identity disorder Substance abuse disorder Conduct disorder “DUAL DIAGNOSIS”

51 Prevention No drugs …No abusers No precursors…No manufacturing process How are you going to make prisons safe? How do inmates receive their supply? Zero Tolerance Policy?

52 Demand Reduction Educational Approach, school education, public education, sport & culture Health & medical Measure, treatment and rehabilitation programs Community involvement Economic empowerment Regional & International Cooperations Caribbean & OAS

53 Causes of Drug Addiction Moral/SpiritualBiologicalPsychodynamicBehaviouralSocio-culturalIndividual-drug-environmentINTEGRATIVE

54 Integrative No single cause Interaction of range of causes Bio-Psycho-SocialBio-Psycho-Socio-Cultural

55 General outline of demand reduction Treatment & Rehabilitation Prevention & follow-up

56 Models of Treatment facilities Residential based Hospital or centres Short, medium, long term Outpatient based Drug Court Treatment Prison based

57 Treatment Approaches Individual therapy Group therapy Family therapy Special program ( juvenile, Drug court, prison based, combined HIV,STI, TB, therapeutic communities, cultural)

58 Changing Model of Care Recovery is not an event but the process Incarceration by itself does little to break the cycle of illegal drug use and crime Offenders sentenced to Incarceration exhibit high rate of RECIDIVISM once they are released

59 Drug Abuse Prevalence in prisons Drug Abuse in prison is very common Estimated 22% - 86% Most frequently used illicit drug “ Cannabis” 8% - 60% British Study 60% heroin user reported use in prison, more than 25% initiated use in prison

60 Factors associated with substance abuse in prison Age, Ethnicity, Conduct disorder, abuses, school difficulties Psychiatric disorders Antisocial personality Support system Length of sentence

61 Jamaica Proposal to establish Drug Abuse Facility 1998 OAS/CICAD Belize City Drug Abuse workshop 2001 OAS/CICAD St. Lucia Drug Abuse workshop 2004 DCS Drug Abuse Survey 2005 DCS Drug Abuse Training Seminar 2006

62 Drug Abuse Survey in Jamaican Prisons 2005

63 Methodology 4 maximum security prisons Sampling Frame of 3434 inmates Stratified sampling method used Estimated prevalence rate 45% ± 5% A total of 440 inmates 42 items, 4 sections Questionnaire used

64 Results - Age A Total of 440 inmates Male 82% (360), Female 18% (80) Age range – 18 to 73 years Majority 53% (Age range 23-34)

65 Results – Age group by Gender Age group MaleFemaleTotal 17-22258 33 (8%) 23-289921 120 (27%) 29-349815 113 (26%) 35-407112 83 (19%) 83 (19%) 41-463512 47 (11%) 47 (11%) 47-52209 29 (6%) 53 & over 123 15 (3%)

66 Results – Education by gender LevelMaleFemaleTotal Primary22425 249 (57%) Secondary12837 165 (38%) Tertiary818 26 (5%) 26 (5%)

67 Results – Literacy level LevelMaleFemaleTotal Excellent5740 97 (22%) Good8924 113 (25%) Can help self 1209 129 (29%) Just a little 666 72 (16%) Can not read/write 281 29 (8%)

68 Knowledge Ganja is a drug72% Ganja smoking is harmful61% Alcohol, tobacco & beady are drugs78% Ganja improves sexual performance33% Alcohol improves sexual performance38% Addiction is drug dependency85% A link between drug abuse & STI 73%

69 Prevalence PrevalenceNoYes Drug abuse before incarceration 163 273 ( 62% ) Drug abuse during incarceration 233 201 ( 46% )

70 Prevalence Drug abuse before incarcerated62% Drug abuse during incarceration 46%

71 Type of Substances abused (N=305) TypeNumber Ganja 172 (39%) Tobacco 98 (22%) Alcohol 21 (5%) Crack 6 (1%) Valium 5 (1%) Inhalant 3 (0.7%) 3 (0.7%)

72 Pattern of Abuse TypeDailyWeeklyOccasionally Ganja 98 (22%) 13 62 (14%) Tobacco 75 (17%) 7 42 (10%) Alcohol 9 (2%) 1 32 (7%) Valium 6 (1%) 0 6 (1%) 6 (1%) Crack 4 (0.9%) 4 (0.9%)0 3 (0.7%) 3 (0.7%) Inhalants 1 (0.2%) 1 (0.2%)0 2 (0.5%) 2 (0.5%)

73 Factors affecting frequency FactorsStatistics Money 122 (28%) Availability 63 (14%) 63 (14%) Afraid of Disciplinary action 11 (3%) Afraid of being seen 6 (1%) 6 (1%)

74 Reason for Drug use To feel more relaxed11927% To meditate9923% To cope with prison8419% To sleep6515% Curiosity4611% Lonely368% Peer pressure266% Addiction225% Religion82%

75 Source of supply in prison Fellow inmates189 43% Correctional officers 13 3% Over prison wall/fence 8 2% Family/friends 5 1%

76 Motivation for change Want to stop drug abuse150 34% Request assistance to stop113 26% Interest to participate in program 348 79%

77 Best group to sensitize drug abuse program GroupStatistics Recovering addicts 233 (53%) Church 108 (25%) Family 34 (8%) Fellow inmate 29 (7%) Others 22 (5%) Correctional officers 14 (2%)

78 Survey Summary Prevalence of drug abuse46% Ganja is most commonly abused39% 34% of inmates are motivated to quit and 26% requested assistance. 34% of inmates are motivated to quit and 26% requested assistance. 79% showed interest to participate in the drug abuse program in prison.

79 Principle of Therapeutic Jurisprudence Prof. Bruce Winnick Prof. David Wexler

80 Application of TJ Offenders with underlying drug abuse problems Incarceration alone does not help or reduce recidivism Therapeutic principle is applied in Judicial process Diversion Programme Drug Court & Mental Health Court Prison Based Programme Parallel Model

81 Diversion Programme Drug Court Treatment & Rehabilitation May 2001 Kingston, July 2001 Montego Bay Drug Court Act 1999 Offenders with Minor Offences who meet eligible criteria Bail offered Six months outpatient programme under court supervision and weekly urine testing

82 What about those ineligible Offenders?

83 Prison Based Programme Prison based Program ? Legislation Political will Budget commitment Outpatient Drug Court Legislation Court supervision Probation period after graduation Criminal offence not recorded

84 to address ALL Mental Health Issues including substance abuse to address ALL Mental Health Issues including substance abuse Punitive Model without Rehabilitation does not solve underlying issues Try innovative methods and programs

85 What we need? Forensic Psychiatric Hospitals Community Forensic Psychiatric Services Faculty of Forensic Psychiatry & Law, UWI Ongoing combined or cross training of Law & Psychiatry Professionals with special interest Partnership building & networking Legal & Mental Health Reform Proper enumeration & classification Research & evaluation Legislation

86 There is no good health without a good mental health nobody is immune to mental illness

87 “Making mental health a Jamaican Priority, investing in development of forensic psychiatric services through advocacy and actions”

88 Policy direction Secured Forensic psychiatric hospital Community Forensic Services HR & legislatives Quality assurance guidelines Training & Research Inter-agencies co-ordination (Ministries of Health/Justice/National Security Advocacy & support groups Budgetary commitment

89 Plan includes..(not limited to) Promotion & prevention Detection & screening Proper treatment Referral upon released Non-discriminatory Respect with human right principles Consultation, inclusion of inmates/staff/community for strategic planning HR issues, training Research & Evaluation Net working, inter-agencies, Regional and Global partnership

90 To ensure development of forensic psychiatric services and to stop mentally ill entering to prisons

91 We need “a change” Political will & commitment Philosophical concept with a vision budgetary

92 There is no good health without a good mental health Lets make Mental health a priority through your action and advocacy A great push, a great investment Nobody is immune to mental illness

93 “The Great Push” “Investing in Mental Health” Timely investment in Forensic Services Healthy minds, Healthy people, Healthy Nation One Nation, One People, One Love

94 Thank You Dr. Myo Kyaw Oo MBBS, DPM, DM Psych. December 2, 2011 Norman Manley Law School UWI

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