Andrew Forrester

Identifying men at ultra high risk of psychosis in a prison population

BACKGROUND The prevalence of psychotic disorders among prisoners is relatively high. We sought to investigate the prevalence of men who have a very high risk of developing psychosis in a prison population. METHODS The Prodromal Questionnaire - Brief Version (Loewy, Pearson, Vinogradov, Bearden and Cannon, 2011), was used to screen newly-arrived prisoners in a London prison for features associated with an increased risk of psychosis. Concurrent validity was evaluated using the Comprehensive Assessment for At Risk Mental State (Yung et al., 2005). RESULTS 750 prisoners were screened and 301 were underwent further clinical assessment. 5% the total number of those screened met diagnostic criteria for the ARMS and 3% had recently developed a first episode of psychosis. Using endorsement of items that also caused distress, the PQ-B predicted an ARMS or a psychotic disorder with 90% sensitivity and 44% specificity. CONCLUSIONS The PQ-B is effective in identifying people who are vulnerable to developing psychosis in a prison population.

Continuity of care for recently released prisoners with mental illness: a pilot randomised controlled trial testing the feasibility of a Critical Time Intervention

AIMS Prisoners with mental illness on release from prison often face complex challenges with little support, leading to poor clinical and social outcomes. This feasibility study aimed to see whether a Critical Time Intervention (CTI) in the first weeks post-release effectively connects mentally ill prisoners with social, clinical, housing, and welfare services on leaving prison. The study took place in 2007 and involved local prisons in London and Manchester. METHODS A pilot randomised controlled trial in which CTI was compared to Treatment as Usual (TAU). RESULTS Sixty prisoners were randomised in the trial, with outcome measures completed on 23. A higher proportion of prisoners in CTI group were in contact with services at follow-up than those receiving TAU. CTI prisoners were significantly more likely to be receiving medication, and be registered with a General Practitioner (GP) than those in the TAU group. CONCLUSIONS Continuity of care for prisoners with severe mental illness can be improved by working with them to identify their needs prior to release, and by assisting them to engage effectively to the necessary agencies in the community.

Clinical hopes and public fears in forensic mental health

Forensic mental health services are charged with two potentially conflicting tasks: public protection and ethical patient care. The challenge to fulfil these dual roles is most acute when considering the prolonged detention of patients who have been acquitted of serious violent offences on grounds of insanity, or found unfit to stand trial. The duration of their hospital stay often far exceeds that required to treat the most acute manifestations of their illness. Despite this, it is often argued that the seriousness of the offence should not be taken into account when determining duration of hospitalization. This paper argues that risk assessment is a complex process, involving consideration of many factors in addition to acute symptomatology. All such assessments carry an inherent level of uncertainty, which can be minimized by lengthy rehabilitation and assertive community care. It is argued that authorities are justified in considering the seriousness of the index offence when making judgements as to what level of uncertainty in risk assessment can be considered acceptable in the long term management of forensic patients. The implications of this for services, legislators and politicians are discussed.

Variations in prison mental health services in England and Wales.

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the worlds overall prison population of over 10 million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development.

The medium-secure project and criminal justice mental health

1460 www.thelancet.com Vol 378 October 22, 2011 1 Karamanoli E. Dept crisis strains Greece’s ailing health system. Lancet 2011; 378: 303–04. 2 Stuckler D, Basu S, McKee M. International Monetary Fund and aid displacement. Int J Health Serv 2011; 41: 67–76. 3 Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis outcomes in post-communist countries. PLoS Med 2008; 5: 1079–90. 4 Gupta S. Response of the International Monetary Fund to critics. Int J Health Serv 2010; 40: 323–26. 5 Paparrigopoulos T, Liappas I. Greek academic psychiatry and neurology before the fi ring squad? Lancet 2011; 378: 313. parts (probation, prisons, courts, and police stations) and to encourage the expansion of preventive services. Such expansion involves providing better support for those with a range of problems, not simply psychosis, and a return to a focus on problem behaviours (ie, provision of services to assess and treat those who threaten, stalk, exhibit poor anger control, or develop sexually deviant interests). The way forward is through the dismantling of the current artifi cial barriers between forensic psychiatry services and the criminal justice system, and a move towards a convergence of care eff orts, while maintaining agency integrity. This integration would be more likely to produce equitable mental health delivery for all in the system, not just the lucky few, through ensuring better interagency cooperation and coordination of care. In doing so, it would also aid in preventing people from entering or reentering the criminal justice system, and so further their own interests as well as those of public protection.

Prison health-care wings: psychiatry's forgotten frontier?

BACKGROUND There is worldwide evidence of high rates of mental disorder among prisoners, with significant co-morbidity. In England and Wales, mental health services have been introduced from the National Health Service to meet the need, but prison health-care wings have hardly been evaluated. AIMS/HYPOTHESES To conduct a service evaluation of the health-care wing of a busy London remand (pre-trial) prison and examine the prevalence and range of mental health problems, including previously unrecognised psychosis. METHODS Service-use data were collected from prison medical records over a 20-week period in 2006-2007, and basic descriptive statistics were generated. RESULTS Eighty-eight prisoners were admitted (4.4 per week). Most suffered from psychosis, a third of whom were not previously known to services. Eleven men were so ill that they required emergency compulsory treatment in the prison under Common Law before hospital transfer could take place. Over a quarter of the men required hospital transfer. Problem behaviours while on the prison health-care wing were common. CONCLUSIONS AND IMPLICATIONS Prison health-care wings operate front-line mental illness triaging and recognition functions and also provide care for complex individuals who display behavioural disturbance. Services are not equivalent to those in hospitals, nor the community, but instead reflect the needs of the prison in which they are situated. There is a recognised failure to divert at earlier points in the criminal justice pathway, which may be a consequence of national failure to fund services properly. Hospital treatment is often delayed.

Prisoners with neurodevelopmental disorders

Purpose – The purpose of this paper is to review the evidence on providing services to people with neurodevelopmental disorders in prisons, with a focus on those prisoners with autism spectrum disorder (ASD).Design/methodology/approach – Electronic databases were used to search for literature specifically on ASD in prisons. The literature was supplemented with the authors’ experiences of carrying out research on ASD in prison.Findings – The searches only identified four articles and therefore the broader literature on people with ASD and other developmental disorders was reviewed in relation to the prison context.Originality/value – The paper highlights the current limited evidence base on prisoners with autism spectrum disorders.

Characteristics of prisoners with neurodevelopmental disorders and difficulties

BACKGROUND Previous studies have found high rates of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and intellectual disability (ID) within the criminal justice system (CJS). However, little is understood about prisoners with neurodevelopmental disorders and difficulties (NDD) or their needs. This study aimed to identify prisoners with NDD and compare their characteristics with prisoners without NDD on a range of socio-demographic and social functioning measures. METHOD This was a descriptive, cross-sectional study carried out using face-to-face interviews with 240 participants in a London Category C prison. Standardised tools were used to assess prisoners for ADHD, ASD and ID. RESULTS The study identified 87 prisoners who screened positive for one or more type of NDD. Participants with NDD were significantly younger and more likely to be single [(odds ratio) OR = 2.1], homeless (OR = 3.4) or unemployed (OR = 2.6) before they came into prison. They also had poorer educational achievements that those without NDD. Over 80% of those with NDD had a previous conviction or imprisonment. CONCLUSIONS The findings confirm the presence of significant numbers of people with NDD in a male prison. Services across the CJS are required for this group; specifically, there is a need for raised awareness among those working in the CJS to improve the recognition of offenders with NDD. Services in the community need to work with individuals with NDD who are at risk of offending, targeting those who are homeless, unemployed and have poor employment opportunities.

Preventing self-harm and suicide in prisoners: job half done

Prison populations have grown worldwide, and now exceed 10 million people globally. Although some countries have clear and independent mechanisms of inspection, scant information is available about the conditions in which many prisoners are held. By necessity, published work in prisons represents a skewed sample of those countries from which evidence is made available. We must bear this discrepancy in mind because we know so little. What we do know is that prisoners have high levels of mental health morbidity. Suicide is the prevailing cause of death in prison worldwide, with mortality rates more than three times higher than the general population. The risk of death is highest in the early period after prison reception. In male prisoners, deaths occur most typically in local adult prisons that take people directly from the courts, whereas self-harm happens widely in female prisons. Mental disorder, substance misuse, white ethnic origin, violent off ending, awaiting trial, and having suicidal ideas are risk factors for death, many of which are common globally. Although most risk factors for suicide are also prevalent in the general population, their frequency in prison is alarming. Writing in The Lancet, Keith Hawton and colleagues provide important confi rmation of risk factors for self-harm and suicide in prison. They did a 6-year epidemiological study in the prison population of England and Wales and recorded 139 195 self-harm incidents among 26 510 prisoners over 5 years. High annual self-harm rates were noted, in 5–6% of male inmates and 20–24% of female prisoners. Self-harm incidents accumulated in younger people and those of white ethnic origin, and an association was noted with prison type, serving a life sentence, or being unsentenced. Violent off ending behaviour raised the risk of self-harm in female prisoners, and recurrence was common. The reported clustering of self-harm in time and location (adjusted intra-class correlation 0·15, 95% CI 0·11–0·18) highlights the importance of the priso n context in understanding self-harm. Hawton and colleagues showed a temporal link between self-harm and completed suicide; 109 suicides in prison were reported in individuals who self-harmed, and more than half the deaths occurred within a month of self-harm. These fi ndings indicate the importance of swift intervention after an incident of self-harm, and this work has already had an eff ect on the way the Prison Service in England and Wales manages people at risk. The risk factors identifi ed for self-harm are similar to those identifi ed elsewhere for suicide, thereby challenging the notion that self-harming behaviour and suicide might represent diff erent entities: instead, a direct link seems to exist for many prisoners. Hawton and colleagues make a vital contribution to answering the questions of who self-harms and how often does it happen, which complements previous work to address why people self-harm and what methods work to reduce self-harm and suicidal behaviour. However, additional work is now needed to address these questions, to reduce self-harm in prison further. Although this work by Hawton and colleagues will assist practice in prisons in England and Wales, a broad range of risk factors have been incorporated into assessment training and processes provided by the Prison Service for some years. To mitigate against diminishing returns through expansion, we need to understand why most prisoners do not self-harm and why some who harm themselves are propelled towards suicide whereas others are not. The answers to these questions do not necessarily sit with further examination of over-represented groups, but instead could be studied by focusing on process, including specifi c investigation of prisoners from groups with enhanced vulnerabilities—eg, inmates who are foreign nationals, or people with neurodevelopmental

Too little, too late? The treatment of mentally incapacitated prisoners

Prisoners in England and Wales who are mentally ill are treated against their wishes under common law only rarely and in situations of dire emergency. We believe that current practice is based on a mistaken interpretation of the common law,and is at odds with an evidence-based approach to the management of mental illness.