Charlotte Lennox

Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health

BackgroundThis paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors.MethodsWe applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions.ResultsAn integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders’ health and social care needs.ConclusionsAs part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.

The management of released prisoners with severe and enduring mental illness

Prisoners have higher rates of mental disorder than the general population. Imprisonment provides an opportunity to engage with mental health services. Release from prison is associated with a range of negative outcomes including increased mortality and suicide. This prospective, longitudinal cohort design study established the proportion of prisoners with severe and enduring mental illness in contact with prison mental health in-reach services who make contact with Community Mental Health Teams (CMHT) on discharge from prison. A total of 137 participants were recruited from prison mental health in-reach team caseloads and assessed as having severe and enduring mental illness. At a six-month follow-up, 53 (39%) had been released, but only four were in contact with the CMHT. There is a need for robust discharge planning and proactive through care for prisoners with mental health problems.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation

BACKGROUND The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.

The development of the comprehensive health assessment tool for young offenders within the secure estate

Health inequalities are high among offending groups. The comprehensive health assessment tool (CHAT) is a semi-structured assessment developed to provide a standardised approach to health screening for all young offenders admitted to the secure estate. The four sections of the CHAT (physical health, mental health, substance misuse and neurodisability) were evaluated within a two-phased study of male adolescents (aged 15–18 years) within a young offenders institution in the north-west of England. Within Phase 1, a consecutive sample of 127 new receptions was assessed using the physical health, mental health and substance misuse sections of the CHAT against a range of reference standard assessments. Phase 2 of the study evaluated the neurodisability section on 93 male adolescents against reference standard tools. The four sections of the CHAT demonstrated fair to good convergent validity when compared against reference standard tools in male offenders. The diagnostic accuracy rate was 76% for mental health, 63% for physical health, 83% for substance misuse and 53% for neurodisability when compared against reference standard assessment tools. The introduction of the CHAT offers the opportunity to enhance existing reception screening practices and create an integrated approach to the assessment of health needs across the secure estate.

Traumatic brain injury in juvenile offenders: findings from the comprehensive health assessment tool study and the development of a specialist linkworker service

Background:Young people in contact with the youth juvenile justice system have well-documented vulnerabilities including high rates of mental health and neurodevelopmental disorders. Studies have suggested that they may also be at increased risk of traumatic brain injury (TBI). Objective:(1) To describe the profile of a cohort of juvenile offenders with TBI and associated comorbidity with other neurodevelopmental disorders, mental health needs, and offending behavior. (2) To describe the development of a specialist brain injury service for juvenile offenders with TBI within custody. Methods:Ninety-three male participants aged 15 to 18 years were consecutively admitted to a custodial secure facility. They were evaluated using a range of different neurocognitive and mental health measures including the Rivermead Post-Concussion Symptoms Questionnaire and the Comprehensive Health Assessment Tool. Results:Eight-two percent of those interviewed reported experiencing at least 1 TBI, and 44% reported ongoing neuropsychological symptoms. Eighteen percent of those sustaining a TBI reported moderate-severe postconcussion symptoms. Conclusions:There is a high prevalence of TBI in juvenile offenders in custody, with many experiencing multiple episodes. This study highlights the need for further research in this area. An example of a specialist brain injury linkworker service is described as one example of a model of service delivery for this group.

Temperament and character and psychopathy in male conduct disordered offenders

Adult male offenders with high psychopathy scores are characterized by high Novelty Seeking, low Harm Avoidance and low Cooperativeness; temperament and character traits that may moderate treatment outcomes. This is the first study to investigate if a similar profile is present in juveniles. One hundred and twenty two incarcerated juvenile male offenders who met the criteria for conduct disorder in the absence of current psychiatric disorder (e.g. psychosis, depression, anxiety) were rated on the Temperament and Character Inventory (TCI) and the Psychopathy Checklist: Youth Version (PCL: YV). PCL: YV total score was positively correlated with Novelty Seeking but negatively correlated with Cooperativeness and Harm Avoidance. Examination of the PCL: YV facets indicated a significant negative correlation between Harm Avoidance and PCL: YV Interpersonal and PCL: YV Antisocial; and Reward Dependence and Cooperativeness and PCL: YV Lifestyle/Behavioral. Relationships were primarily with lifestyle/behavioral and antisocial facets of psychopathy. The TCI profile resembles that seen in adult offenders and has implications for treatment as low cooperativeness and reward dependency are likely to be key responsivity factors that need to be addressed in treatment planning.

The effectiveness of an enhanced thinking skills programme in offenders with antisocial personality traits

Although evidence is emerging that enhanced thinking skills (ETS) interventions are effective in reducing recidivism in prisoners, there is limited evidence supporting the effectiveness of ETS improving behaviour and functioning in prisoners with antisocial personality disorder (ASPD) traits. This study investigated the effectiveness of a group ETS programme in improving antisocial attitudes, anger regulation and social problem-solving skills in offenders with traits diagnostic of ASPD. A controlled trial was conducted comparing ETS programme with treatment as usual (TAU). Outcome measures were the Antisocial Personality Questionnaire, the Novaco Anger Scale and the Social Problem-Solving Inventory-Short Form. Significant improvements in the ETS group on all of the outcome measures were evident, when compared to TAU group. This study provides evidence that cognitive skills programmes based on ETS improve functioning in offenders with traits diagnostic of ASPD. The ETS programmes may be a therapeutic option when working with this historically difficult to treat group. However, further research is required that includes a randomised design, more objective behavioural outcome measures and a longer follow-up period.

A prospective cohort study of the changing mental health needs of adolescents in custody

Objective To investigate changes in mental health and other needs, as well as clinical and diagnostic ‘caseness’, in a sample of adolescents over a 6-month period following entry into a Young Offenders Institution in the UK. Design Prospective cohort study. Setting One Young Offenders Institution between November 2006 and August 2009. Participants 219 male adolescents aged 15–18 years (M=16.56; SD=0.6) were assessed at baseline (median=4; range 0–26 days following reception into custody) on the Salford Needs Assessment Schedule for Adolescents (SNASA) and Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Participants were then reassessed at 3-month and 6-month postbaseline to document any change in mental health. Results Of the initial baseline sample, 132 were still in the study at 3-month postbaseline and 63 were still available for assessment at 6 months. There were no differences between those who were not available for assessment at the three key stages in terms of demographic and criminological data. Over time there was a general improvement in mental health. While the proportion of participants with a mental health need (SNASA) did not change over time, symptom severity as measured by the SNASA did reduce significantly. When we assessed diagnostic ‘caseness’ using the K-SADS, three young people showed significant mental health deterioration. Conclusions In line with previous studies, we found that symptoms in prison generally improved over time. Prison may provide an opportunity for young people previously leading chaotic lifestyles to settle into a stable routine and engage with services; however, it is unclear if these would be maintained either within the prison or on release into the community.

The health needs of young people in prison

INTRODUCTION There has been an unprecedented reduction in the number of young people in prison; however, questions remain about the appropriateness and effectiveness of custody, given the high prevalence of health needs, self-inflected deaths while in custody and high reoffending rates. SOURCES OF DATA Articles relating to the health needs of young people, aged 10-17 years in prison in England and Wales were sourced through PubMed and ISI Web of Knowledge, plus additional key reports were included if deemed relevant. AREAS OF AGREEMENT Young people in prison have much higher rates of multiple and complex health problems compared with young people in the general population. However, many of their health-care needs are unrecognized and unmet. AREAS OF UNCERTAINTY/RESEARCH NEED There is an urgent need for up-to-date and robust prevalence data of all health needs across the age ranges in England and Wales. Research has neglected physical health and neurodevelopmental disorders and the quality of research for females and Black and Minority Ethnic groups requires improvement. There is a dearth of high-quality evaluations of health interventions with robust and sensitive short- and long-term outcome measures.

Information sharing between the National Health Service and criminal justice system in the United Kingdom

&NA; Offenders with mental health problems often have complex and interrelated needs which separately challenge the criminal justice system (CJS) and National Health Service (NHS) in the United Kingdom (U.K.). Consequently, interagency collaboration and timely information sharing are essential. This study focused on the sharing of information about people with mental health problems in contact with the CJS. Questionnaires were distributed to a range of health and criminal justice personnel. The results showed that there was a mismatch between what service user information criminal justice agencies felt they needed and what was routinely received. Prison Service staff received more information (between 15% and 37%) from health agencies than the police (between 6% and 22%). Health professionals received most of the information they needed from criminal justice agencies (between 55% and 85%). Sharing service user information was impeded by incompatible computer systems and restrictions due to data protection/confidentiality requirements. In the U.K., recent governmental publications have highlighted the importance of information sharing; however there remains a clear mismatch between what health related information about service users criminal justice agencies need, and what is actually received. Better guidance is required to encourage and empower people to share.