Karen Slade

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

Shifting the paradigm of prison suicide prevention through enhanced multi-agency integration and cultural change

This study examines an unusually sustained reduction in suicide rates in a local London prison during the three year period 2008–2011. The likelihood of this reduction taking place by chance was <2:100,000, and its perceived success was such that the prison service recommended an evaluation of its characteristics. This study arose from that recommendation, and it used a retrospective case study multi-method approach (including factor identification, qualitative interviews and triangulation with official documentation) to identify factors which had been associated with the reduced suicide rates. The results endorsed a number of factors which have already been internationally identified as best practice, along with some local innovation factors. Two further pivotal factors emerged through analysis, and they are the key to service improvements. These factors – senior management support for cultural change and cross-professional collaborative working – indicate that positive leadership and multi-agency integration are vital ingredients.

Outcomes of psychological therapies for prisoners with mental health problems: a systematic review and meta-analysis

Objective: Prisoners worldwide have substantial mental health needs, but the efficacy of psychological therapy in prisons is unknown. We aimed to systematically review psychological therapies with mental health outcomes in prisoners and qualitatively summarize difficulties in conducting randomized clinical trials (RCTs). Method: We systematically identified RCTs of psychological therapies with mental health outcomes in prisoners (37 studies). Effect sizes were calculated and meta-analyzed. Eligible studies were assessed for quality. Subgroup and metaregression analyses were conducted to examine sources of between-study heterogeneity. Thematic analysis reviewed difficulties in conducting prison RCTs. Results: In 37 identified studies, psychological therapies showed a medium effect size (0.50, 95% CI [0.34, 0.66]) with high levels of heterogeneity with the most evidence for CBT and mindfulness-based trials. Studies that used no treatment (0.77, 95% CI [0.50, 1.03]) or waitlist controls (0.71, 95% CI [0.43, 1.00]) had larger effect sizes than those that had treatment-as-usual or other psychological therapies as controls (0.21, 95% CI [0.01, 0.41]). Effects were not sustained on follow-up at 3 and 6 months. No differences were found between group and individual therapy, or different treatment types. The use of a fidelity measure was associated with lower effect sizes. Qualitative analysis identified difficulties with follow-up and institutional constraints on scheduling and implementation of trials. Conclusions: CBT and mindfulness-based therapies are modestly effective in prisoners for depression and anxiety outcomes. In prisons with existing psychological therapies, more evidence is required before additional therapies can be recommended.

Mental health in-reach in an urban UK remand prison

PURPOSE Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK. DESIGN/METHODOLOGY/APPROACH Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111). FINDINGS Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited. PRACTICAL IMPLICATIONS Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template. Originality/value - One of the first ground-level evaluations of MHITs in England and Wales.

Improving access to psychological therapies in prisons

ANDREW FORRESTER, FRANCES MACLENNAN, KAREN SLADE, PENELOPE BROWN AND TIM EXWORTHY, Forensic Psychiatry, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry/King’s College London, London, UK; HM Prison and YOI Holloway, Parkhurst Road, London N7 0NU, UK; Forensic Psychology, College of Business Law and Social Sciences, School of Social Sciences, Nottingham Trent University, Nottingham, UK; Forensic Psychiatry, Institute of Psychiatry/King’s College London, London, UK; Forensic Psychiatry, St Andrew’s Healthcare and Institute of Psychiatry/King’s College London, London, UK

Can theory predict the process of suicide on entry to prison? Predicting dynamic risk factors for suicide ideation in a high-risk prison population.

BACKGROUND Each year approximately 110,000 people are imprisoned in England and Wales and new prisoners remain one of the highest risk groups for suicide across the world. The reduction of suicide in prisoners remains difficult as assessments and interventions tend to rely on static risk factors with few theoretical or integrated models yet evaluated. AIMS To identify the dynamic factors that contribute to suicide ideation in this population based on Williams and Pollocks (2001) Cry of Pain (CoP) model. METHOD New arrivals (N = 198) into prison were asked to complete measures derived from the CoP model plus clinical and prison-specific factors. It was hypothesized that the factors of the CoP model would be predictive of suicide ideation. RESULTS Support was provided for the defeat and entrapment aspects of the CoP model with previous self-harm, repeated times in prison, and suicide-permissive cognitions also key in predicting suicide ideation for prisoners on entry to prison. CONCLUSION An integrated and dynamic model was developed that has utility in predicting suicide in early-stage prisoners. Implications for both theory and practice are discussed along with recommendations for future research.

Measuring IPDE-SQ personality disorder prevalence in pre-sentence and early-stage prison populations, with sub-type estimates

Understanding the prevalence and type of personality disorder within prison systems allows for the effective targeting of resources to implement strategies to alleviate symptoms, manage behaviour and attempt to reduce re-offending. This study aimed to determine the prevalence of personality disorder (PD) traits within a local urban high-turnover adult male prison with a remand/recently sentenced population in London, UK. The International Personality Disorder Examination - Screening Questionnaire (IPDE-SQ) self-administered questionnaire (ICD-10 version) was completed by 283 prisoners (42% completion rate). 77% of respondents reached the threshold for one or more PDs. The most common PD types were Paranoid PD (44.5%), Anankastic PD (40.3%), Schizoid PD (35%) and Dissocial PD (25.8%). These results confirm and extend existing knowledge regarding the prevalence of PD in prison populations into a high-turnover, urban, remand population. The stark comparison with community samples indicates that a more equitable standard of service delivery within the criminal justice system, focussing on preventive and early intervention services, is now required.

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.

Suicide ideation amongst people referred for mental health assessment in police custody

Purpose The purpose of this paper is to examine the prevalence of suicide ideation amongst a group of people who had been arrested and taken into police custody, and were then referred to a mental health service operating in the police stations. Design/methodology/approach A referred sample of 888 cases were collected over an 18-month period during 2012/2013. Clinical assessments were conducted using a template in which background information was collected (including information about their previous clinical history, substance misuse, alleged offence, any pre-identified diagnoses, and the response of the service) as part of the standard operating procedure of the service. Data were analysed using a statistical software package. Findings In total, 16.2 per cent (n=144) reported suicide ideation, with women being more likely to report than men. In total, 82.6 per cent of the suicide ideation sample reported a history of self-harm or a suicide attempt. Suicide ideation was also associated with certain diagnostic categories (depression, post-traumatic stress disorder and personality disorder), a history of contact with mental health services, and recent (within 24 hours) consumption of alcohol or drugs. Originality/value This evaluation adds to the limited literature in this area by describing a large sample from a real clinical service. It provides information that can assist with future service designs and it offers support for calls for a standardised health screening process, better safety arrangements for those who have recently used alcohol or drugs (within 24 hours) and integrated service delivery across healthcare domains (i.e. physical healthcare, substance use, and mental health).

Demographic and clinical characteristics of 1092 consecutive police custody mental health referrals

Abstract The 43 police forces in England and Wales have made over 13 million arrests in the last decade. Yet, despite this high volume criminal justice system activity, and evidence of substantial health morbidity across the criminal justice pathway, mental health services in police custody have only been patchily developed, and the literature in this area is limited. Referrals (n = 1092) to a pilot mental health service operating across two police stations in a London borough were examined over an 18-month period in 2012/2013. The referred group had high levels of mental health and substance misuse problems (including acute mental illness, intoxication and withdrawal), self-harm, suicide risk and vulnerability (including intellectual disability), with some important gender differences. Although this work has limitations, the findings are broadly consistent with the small existing literature and they confirm the need for services that are sufficiently resourced to meet the presenting needs.