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

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

3. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk Environment project Collaborative project Funded by the National Programme for Forensic Mental Health R&D

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

6. www.ohrn.nhs.uk Aims 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?

7. www.ohrn.nhs.uk Prisons 5 local prisons – 1 female – 1 high secure

8. www.ohrn.nhs.uk Measures General Health Questionnaire-12 (Goldberg 1976) GHQ Brief Psychiatric Rating Scale–E (Overall & Gorham, 1962; Ventura et al., 1993) BPRS Measuring the Quality of Prison Life (Liebling, 2002) MQPL

9. www.ohrn.nhs.uk Method

10. www.ohrn.nhs.uk Method

11. www.ohrn.nhs.uk Method

12. www.ohrn.nhs.uk Method

13. www.ohrn.nhs.uk Sample Variable T1T2T3 n%n%n% PriSnQuest outcome PriSnQuest positive887915139016088 PriSnQuest negative931059102212 Gender Male769794387716289 Female21122134232011 Legal status Remand506522995210558 Convicted47448273487742 Psychiatric diagnosis Any psychosis10110539169 MDD31832181325631 Any other MI1221273133017 None43945265468044 All 980100572100182100 Table 1: Key sample characteristics at T1, T2 and T3

14. www.ohrn.nhs.uk 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

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

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

17. www.ohrn.nhs.uk Findings p=.82 p=<.01 p=.24

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

19. www.ohrn.nhs.uk Findings 8 groups: Male convicted– SMIFemale convicted– SMI Male remand – SMIFemale remand – SMI Male convicted– noneFemale convicted - none Male remand - noneFemale remand - none

20. www.ohrn.nhs.uk Findings 8 groups: Male convicted– SMIFemale convicted– SMI Male remand – SMIFemale remand – SMI Male convicted– noneFemale convicted - none Male remand - noneFemale remand - none

21. www.ohrn.nhs.uk Factors predictive of meeting GHQ cut-off at any time: Findings GroupRisk ratio Male convicted– none (ref. group)1.0 * p<.05

22. www.ohrn.nhs.uk Factors predictive of meeting GHQ cut-off at any time: Findings GroupRisk ratio Female remand – SMI6.1* Male remand – SMI5.5* Female convicted– SMI4.9* Male convicted– SMI4.1* Male remand - none2.2* Female remand - none1.8 Female convicted - none1.2 Male convicted– none (ref. group)1.0 * p<.05

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

24. www.ohrn.nhs.uk Findings p=.02 p=<.001 p=.71

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

26. www.ohrn.nhs.uk Factors predictive of clinically significant suicidality (BPRS) at any time: Findings GroupRisk ratio Male convicted– none (ref. group)1.0 * p<.05

27. www.ohrn.nhs.uk Factors predictive of clinically significant suicidality (BPRS) at any time: Findings GroupRisk ratio Male remand – SMI31.7* Female remand – SMI29.1* Female convicted– SMI23.5* Male convicted– SMI14.2* Female convicted - none4.1* Female remand - none3.6* Male remand - none3.0* Male convicted– none (ref. group)1.0 * p<.05

28. www.ohrn.nhs.uk 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

29. www.ohrn.nhs.uk 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 Disagree Strongly Disagree

30. www.ohrn.nhs.uk Quality of life dimension Prison AllABCDE Race relationships 131211 Physical safety 233211 Clarity 317811 Family contact 474154 Dignity 582514 Order & security 62410513 Care & safety 7571059 Fairness 88132116 Relationships 9124889 Assistance for vulnerable 1087 89 Respect 111275146 Overall distress 1216 586 Personal development 13127141113 Frustration 14171510169 Drug control 1557181116 Entry support 16813171415 Individual care 1712161519 Addressing offending behaviour 1817161517 Entry into custody 19171918 17 Measuring the Quality of Prison Life: dimension scores by rank Best 3 Worst 3

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

32. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk What can we do? Reception screening emergencies only Keep everyone safe until: – Mental health assessment -case finding, medication assessment – Robust pathways to care

42. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk Question 2 Transitions Reception problematic What about discharge?

44. www.ohrn.nhs.uk 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

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

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

47. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk 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. www.ohrn.nhs.uk Prison adaptation Informed by: – qualitative interview with prisoners pre- discharge – Interviews with prison health care staff and CMHT staff

50. www.ohrn.nhs.uk 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

51. www.ohrn.nhs.uk 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

52. www.ohrn.nhs.uk 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)

53. www.ohrn.nhs.uk Excluded (n=33) Trial consort Referral to in-reach Referral to in-reach Baseline assessments (n=49) Randomised (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) Engaged (n=3) Not engaged (n=3) Engaged (n=13) CTI intervention (n=21) CTI intervention (n=21) Excluded (n=5) Excluded (n=15) p<.01 Met eligibility criteria (n=82)

54. www.ohrn.nhs.uk Results Highly successful Feasible to introduce an intervention into prison setting Possible to follow-up post discharge

55. www.ohrn.nhs.uk Positives Feasible Staff liked it Encouraging pilot Large scale RCT

56. www.ohrn.nhs.uk BUT... Expensive Time intensive Staff selection, training & supervision

57. www.ohrn.nhs.uk Next steps Obtain funding for RCT Economic evaluation Hard sell!

58. www.ohrn.nhs.uk Why bother with all of this anyway?

59. www.ohrn.nhs.uk Prison health is public health Chaotic lifestyles Social exclusion Crisis-led contact with healthcare services Poor clinical outcomes Uneconomic Revolving door Death Re-offending?

60. www.ohrn.nhs.uk In prison today next door to you tomorrow… So maximise opportunity for treatment

61. www.ohrn.nhs.uk Thank you Contact details: Jennifer.j.shaw@manchester.ac.uk Jenny.shaw@lancashirecare.nhs.uk