Janet Parrott

Characteristics, needs and reoffending in a group of patients with schizophrenia formerly treated in medium security

Abstract A cohort of 63 patients with schizophrenia formerly treated in medium security and discharged were followed up with case-notes and interview, up to 10 years later. Outcome variables studied included reconviction, reoffending behaviour, contact with psychiatric services, mortality, health and social needs, and patient satisfaction. Previously, the group had high levels of inpatient psychiatric care (86%), violent offending (68%), substance abuse (71%), alcohol abuse (29%), history of conduct disorder (48%) and periods in care (22%). At follow-up, 2 were dead (by suicide); of the remainder, 92% had retained links with psychiatric services, 30% had been reconvicted of at least one violent offence, and more than this proportion, again, had reoffended violently. Episodes of violent reoffending outnumbered violent reconviction by nearly 4:1. Most violence was ‘non-serious’. In terms of violence, comorbidity with conduct disorder or problem alcohol use doubled reoffending rates compared with schizophren...

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.

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.

Unmet Needs of Remand Prisoners

A needs assessment protocol which examines 11 problem areas was devised. This was administered to 277 prisoners on remand at Brixton Prison. We found high levels of unmet need for housing, treatment of substance abuse and neurotic symptoms. Twenty-nine per cent were transferred to hospital under the provisions of the Mental Health Act and about a third of those at liberty to do so complied with a discharge plan. Diversion and discharge planning can potentially meet the unmet needs of remand prisoners.

Study to assess the effect of a structured communication approach on quality of life in secure mental health settings (Comquol): study protocol for a pilot cluster randomized trial.

BackgroundForensic mental health services have largely ignored examining patients’ views on the nature of the services offered to them. A structured communication approach (DIALOG) has been developed with the aim of placing the patient’s perspective on their care at the heart of the discussions between patients and clinicians. The effectiveness of the structured communication approach in community mental health services has been demonstrated, but no trial has taken place in a secure psychiatric setting. This pilot study is evaluating a 6-month intervention combining DIALOG with principles of solution-focused therapy on quality of life in medium-secure settings.Methods and designA cluster randomized controlled trial design is being employed to conduct a 36-month pilot study. Participants are recruited from six medium-secure inpatient services, with 48 patients in the intervention group and 48 in the control group. The intervention uses a structured communication approach. It comprises six meetings between patient and nurse held monthly over a 6-month period. During each meeting, patients rate their satisfaction with a range of life and treatment domains with responses displayed on a tablet. The rating is followed by a discussion of how to improve the current situation in those domains identified by the patient. Assessments take place prior to the intervention (baseline), at 6 months (postintervention) and at 12 months (follow-up). The primary outcome is the patient’s self-reported quality of life.DiscussionThis study aims to (1) establish the feasibility of the trial design as the basis for determining the viability of a large full-scale trial, (2) determine the variability of the outcomes of interest (quality of life, levels of satisfaction, disturbance, ward climate and engagement with services), (3) estimate the costs of the intervention and (4) refine the intervention following the outcome of the study based upon the experiences of the nurses and patients. The intervention allows patients to have a greater say in how they are treated and targets care in areas that patients identify as important to them. It is intended to establish systems that support meaningful patient and caregiver involvement and participation.Trial registrationCurrent Controlled Trials,ISRCTN34145189

Influencing the care pathway for prisoners with acute mental illness

BACKGROUND Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area. AIM To establish whether clinical pathway interventions can reduce such transfer delays. METHODS Two clinical pathway interventions - one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) - were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways. RESULTS Both interventions produced significant reductions in prison to hospital transfer times. CONCLUSIONS/IMPLICATIONS FOR PRACTISE The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale.

Mental illness and parenthood: being a parent in secure psychiatric care

Background Research into parenting and mental illness seldom includes forensic mental health service users, despite its relevance to therapeutic, family work and risk management. Aims This study aimed to understand the experiences of parents and the variety of parenting roles maintained during admission to a secure forensic hospital. Methods Narrative interviews with 18 parents (eight mothers and 10 fathers) at an English medium security hospital were analysed thematically, using the framework approach. The proportion of patients who are parents and their contact patterns with their children were estimated from records. Results About a quarter of men and 38% of women were parents. Parenthood was of central importance to their emotional life, spanning experiences of loss, shame and failed expectations, joy, responsibility and hope. Fewer fathers maintained contact with their children than mothers yet fatherhood remained a vital aspect of mens identities, with impact on their self-esteem. Parenting during lengthy admissions – while constrained and dependent on professional support and surveillance – ranged from sending gifts and money to visits and phone calls. Offending was seen as a particularly shameful aspect of admission, contributing to distancing from the children and difficulty explaining detention to them. Conclusions Such complex experiences call for multidisciplinary knowledge and skills. Provision of focused therapy, as well as appropriate visiting spaces, creative approaches to contact time and support for patients in explaining their mental illness and detention to their children are recommended.

Limited duration restriction orders: What are they for?

Abstract This study reviews the use of limited duration restriction orders in the 10 years following the introduction of the Mental Health Act 1983. In this period 73 such orders were imposed and they represent 5 per cent of all restriction orders. The typical duration of an order is 3 years. These orders are intended for use when there is medical evidence that a patient will recover in a set period of time. However, the majority of these orders did not result from a medical recommendation for a time limited order and our study found little evidence that their use was guided by medical evidence of good prognosis. Rather there is some evidence suggesting they are used to serve a tariff-based punitive function.

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

Cannabis use has been associated with the onset, course and relapse of psychosis. Population studies and data from samples of young people at high risk for psychosis have indicated that cannabis use may be related to the onset of psychosis. Cannabis use has also been found to have a deleterious impact on psychotic symptom severity and has emerged as the strong predictor of psychotic relapse. To date, there has been little collaboration between neuroscience and clinical research groups examining the link between cannabis use and psychosis, despite the potential for these fi elds to inform the other. This symposium seeks to begin to redress this gap.