Mari Anne Harty

Prospective cohort study of mental health during imprisonment

BACKGROUND Mental illness is common among prisoners, but little evidence exists regarding changes in symptoms in custody over time. AIMS To investigate the prevalence and predictors of psychiatric symptoms among prisoners during early custody. METHOD In a prospective cohort study, 3079 prisoners were screened for mental illness within 3 days of reception. To establish baseline diagnoses and symptoms, 980 prisoners were interviewed; all remaining in custody were followed up 1 month and 2 months later. RESULTS Symptom prevalence was highest during the first week of custody. Prevalence showed a linear decline among men and convicted prisoners, but not women or remand prisoners. It decreased among prisoners with depression, but not among prisoners with other mental illnesses. CONCLUSIONS Overall, imprisonment did not exacerbate psychiatric symptoms, although differences in group responses were observed. Continued discussion regarding non-custodial alternatives for vulnerable groups and increased support for all during early custody are recommended.

The security, clinical and social needs of patients in high security psychiatric hospitals in England

Previous studies have indicated that between one and two thirds of patients in the high security psychiatric hospitals (HSPHs) could be transferred to lower security. The aim of this study was to measure the individual and placement needs of all patients in the three HSPHs in England. In total 1255 patients were assessed using staggered census dates. Five hundred (40%) patients were rated as suitable for transfer to lower security. Long-term medium and low security facilities constituted over half of the recommended alternative placements. Unmet needs for the total population were most frequently reported with daytime activities, substance misuse, sexual offending, safety to others, and psychotic symptoms. Most clinical and social needs were met. High secure Responsible Medical Officers (RMOs) reported that 500 patients could be transferred immediately to lesser levels of hospital security if such facilities existed. However 60% of patients were rated as continuing to require high secure care therefore special hospitals, or their equivalent, continue to be needed for the foreseeable future in England.

Inverse care for mentally ill prisoners: unmet needs in forensic mental health services

Previous studies have demonstrated increasing levels of psychiatric morbidity among the UK prison population. Few studies of this population have been conducted using systematic needs assessment instruments. We tested the hypotheses that mentally disordered offenders (MDOs) who go into prison from the community differ significantly from general adult patients in having (1) more needs and (2) more unmet needs. We compared 73 consecutive male patients who had psychotic illness and were transferred from prison with 84 male patients who had psychotic illness and were in the community. Patients were interviewed using the Camberwell Assessment of Need schedule (CAN). Inmate medical records were examined and prison healthcare staff were interviewed. The results showed that the prison group had significantly more total needs on average and significantly more unmet needs than their general adult patient counterparts. The greater unmet needs were in the following domains: psychotic symptoms, psychological distress, welfare benefits, money, daytime activities, company and food. The results suggest an inverse care law so that MDOs in the community have high rates of need and low levels of treatment and care.

Interventions with women offenders: a systematic review and meta-analysis of mental health gain

Currently, a conjunction of policy, legislative change in health and social care and the criminal justice system, combined with funding for innovative services make it opportune to assess the evidence base for interventions with women offenders. Women offenders have a distinctive criminological, health and social profile and a gender specific approach to their difficulties is advocated. This systematic review and meta-analysis focus on mental health gain in adult women offenders in forensic health settings, criminal justice institutions and in the community, following therapeutic interventions. Interventions were assessed in terms of specific outcome measures of depression, trauma symptomatology and global mental health status. Comprehensive search strategies yielded 3018 articles, from which we obtained 199 full text articles. Seventeen articles were included in the final review, of which six were excluded from the meta-analysis as there was no comparator group. There is a modest, but increasing, body of evidence for the utility of some interventions, notably those addressing the consequences of earlier trauma, including interventions which also address comorbid substance misuse. This does not amount, to date, to a robust evidence base. Limitations of these studies are discussed and include small sample sizes, their restriction mainly to prison populations and that they were substantially undertaken in the US. Variations in outcome measures follow-up and the difficulties inherent in measuring change in this complex population are also detailed. However, the review delineates definite avenues for further work. To achieve this, those responsible for policy, practice and purchase of services should both be mindful of existing evidence and promote additional, high quality research into interventions which are designed around a coherent, theoretical approach.

Pathways of care of women in secure hospitals: which women go where and why.

BACKGROUND Care pathways for women needing expensive, secure hospital care are poorly understood. AIMS To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type. METHOD Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fishers exact tests for categorical data. Thematic analysis was used for free text data. RESULTS The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone. CONCLUSIONS Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

Women's secure hospital services: national bed numbers and distribution

A mapping exercise as part of a pathway study of women in secure psychiatric services in the England and Wales was conducted. It aimed to (i) establish the extent and range of secure service provision for women nationally and (ii) establish the present and future care needs and pathways of care of women mentally disordered offenders (MDO) currently in low, medium and enhanced medium secure care. The study identified 589 medium secure beds, 46 enhanced medium secure beds (WEMSS) and 990 low secure beds for women nationally. Of the 589 medium secure beds, the majority (309, 52%) are in the NHS and under half (280, 48%) are in the independent sector (IS). The distribution of low secure beds is in the opposite direction, the majority (745, 75%) being in the IS and 254 (25%) in the NHS. Medium secure provision for women has grown over the past decade, but comparative data for low secure provision are not available. Most women are now in single sex facilities although a small number of mixed sex units remain. The findings have implications for the future commissioning of secure services for women.

Health and social care services for women offenders: current provision and a future model of care

Secure provision for women in both the Criminal Justice System and the Health Service has evolved in the last decade, in line with emerging gender-specific policy. Notable gains have been the approach to self-harm in prison and a reduction in the inappropriately high levels of secure hospital care. Although treatment pilots in UK settings are in progress, much practice remains poorly described and insufficiently evaluated. Recent strategic initiatives by both the Ministry of Justice and the Department of Health, as well as the commissioning changes that have followed the Health and Social Care Act 2012, provide a basis for reconsideration and a further paradigm shift. Suggestions for a reinvigorated model of gender-sensitive provision are made, relying on principles of resilience and autonomy.

Unmet needs of male prisoners under the care of prison Mental Health Inreach Services

Recent government policy has emphasised the importance of a patient centred approach, based on individual needs, in service design and planning. Mental Health Inreach Services (MHIS) have been developed in UK prisons, designed on the principle of providing equivalence of care to community mental health teams (CMHTs). To date no studies have systematically examined the needs of patients on MHIS caseloads, let alone obtained these prisoner–patient views of their needs. This study is the first to describe the self-reported ratings of needs of male prisoners (n = 151) under the care of prison MHIS in the UK, using the forensic version of the Camberwell Assessment of Need Forensic – Short Version (CANFOR-S). Inmate medical records were examined and prisoners were interviewed to obtain their ratings of their needs. The results showed that prisoners on MHIS caseload have six needs on average, of which almost half (2.6) are unmet. The most frequent unmet needs were for: daytime activities, psychotic symptoms, psychological distress and accommodation. The findings have implications for commissioning and resource allocation for this population.