Dealing with mental disorder in prisonersBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7280 (Published 22 November 2012) Cite this as: BMJ 2012;345:e7280
Figures quoted for psychiatric morbidity in prison are often very high. Around 90% of prisoners in England and Wales are reported to have at least one type of mental disorder or substance misuse problem.1 This is not just a British phenomenon: a systematic review of surveys from Western countries2 found 3.7% of male prisoners had psychotic illness, 10% major depression, and 65% personality disorder, figures that are much higher than in the general population (table⇓).
Although crime has been consistently associated with severe mental illness,3 there is no agreed explanation for the high prevalence of mental disorder in prison. Many studies assume that prisoners’ mental health difficulties predate imprisonment.4 An opposing view is that the prison experience worsens mental health, and anxiety and depression are understandable reactions to prison regimes.4 Another perspective is that prisons are behaving as intended. If the purpose of prison is to contain “difficult” sections of the population, then a substantial number of mentally disordered people in prison is to be expected.5
In this article I focus on prisons in England and Wales and examine three broad concerns: how to keep mentally disordered people out of prison, how to recognise and treat them when in prison, and what happens on their release back into the community.
Keeping mentally disordered people out of prison: diversion
“Diversion” is a process by which someone who is in contact with the criminal justice system is identified and directed towards appropriate mental healthcare, particularly as an alternative to imprisonment.6 Diversion can take place at any stage in the criminal justice process. For instance, at the time of arrest a forensic medical examiner can judge a suspect unfit for interview and refer him or her to mental health services7 or a court may pass an order under the Mental Health Act instead of a prison sentence.7
Schemes for diversion in England and Wales focus on magistrates courts, with some based in police stations.6 These services were first introduced in the 1990s but, with no national strategy, evolved in an uncoordinated way, leading to wide variations in size, effectiveness, and availability.8 A 2009 report from the Centre for Mental Health, a non-governmental organisation, described diversion arrangements as “seriously underperforming.”6 The report estimated that diversion services see only one fifth of people with mental ill health passing through the criminal justice system and that the opportunity to divert some people with severe mental illness is missed.6 Also published in 2009, the Bradley report examined the experiences of the criminal justice system among people with mental health problems.9 It proposed the creation of a network of criminal justice mental health teams to divert people towards support services.9
Bradley wrote that community, rather than prison, punishment leads to an improvement in clinical outcomes.9 Two suggested reasons for this are better access to mainstream mental health services for people when they are outside prison and the improved well being that results from an individual being kept within their own community environment.9
The coalition government accepted the Bradley report’s recommendations and stated its commitment to the implementation of liaison and diversion services at all police custody suites and criminal courts in England and Wales by 2014 subject to “business case approval.”10 Additional funding of £50m (€63m; $81m) was provided,11 and existing diversion services are involved in development and evaluation of this service. The initiative has attracted support from prison reform and mental health advocacy groups,12 but information on progress is not yet publically available. There are no estimates to indicate the expected effect on the number of prisoners with mental health problems or its cost effectiveness.
Treatment of mental disorders in prison
Management of people with mental disorders within a prison is challenging. Prisoners make complex patients. They have multiple social disadvantages before they enter prison, such as low educational attainment, unemployment, and homelessness,13 and psychiatric comorbidity is much higher than in the general population. One study found that over 70% of male sentenced prisoners showed evidence of two or more mental disorders.1 14
The prison environment is testing for healthcare staff and prisoners. Prisons are crowded, noisy, boring, and porous to illegal drugs15; prescribed medication is also traded.16 Prisoners are confined to their cells for as long as 23 hours a day.17 In 2009-10 in England and Wales an average of 1587 prisoners are transferred between prisons each week,13 and it is difficult to build therapeutic relationships with prisoners who are relocated frequently.18 Some prisoners do not view themselves as psychiatrically disordered and do not wish for psychiatric treatment. Other prisoners will lack the motivation to comply with treatment, particularly for substance misuse and personality disorder.19
All prisoners are screened for mental disorder during a short basic health examination on arrival in prison as part of the reception process. This has been criticised for being undertaken by poorly trained staff, and for health records failing to accompany prisoners on transfer.18 The recent introduction in England and Wales of SystmOne,20 a prison-wide electronic health records system, should improve the exchange of information.18 However, there are concerns that reception fails to identify some prisoners with severe mental disorder.21 Screening is largely a one-off event,21 but the time available for assessment may be too short or the physical setting not conducive.21 Prisoners may also be reluctant to reveal details of mental health problems for fear of appearing weak.21 Although prisons often contact general practitioners for health information on new prisoners, they are not required to do so. However, since 40% of prisoners say they have not had any contact with a GP,22 health records may not be available.
In general, prison psychiatry teams have a similar structure to community teams. Common mental disorders such as depression and anxiety are seen by prison general practitioners, and “in-reach” teams assess and treat severe and enduring mental illness.18 Prisoners are usually referred to in-reach teams by non-psychiatric prison healthcare staff, although prison officers or the prisoners themselves sometimes make the referral.23 There is no standard for in-reach teams; some are very well resourced, but others considerably less so.18 In reach teams have varying degrees of consultant psychiatrist support.18 In many prisons the introduction of in-reach teams has exposed inadequacy in primary care for mental health problems,8 with teams receiving referrals for problems that could be treated without specialist input.8 High demand for mental health expertise in prisons means that many in-reach teams can provide care only to those most severely in need, 24 and some prisoners may not be seen by either primary or secondary care staff.21 25
In-reach teams often work in isolation,24 and there is a tendency for the various teams that support prisoners with mental health problems to work separately rather than together.18 Poor links were found with other teams, such as those involved with resettlement or supervising suicidal or self harming prisoners, and joint work between substance misuse and mental health teams is often weak.24 This “siloed” working means that many mentally ill prisoners do not receive the range of services they require.18
Intellectual impairment in prisoners is largely neglected.24 There is no agreed prevalence,26 but one estimate is that it affects 20-30% of prisoners in England and Wales.26 Even if impairment is identified, prisons have little to offer.24 Also poorly served are prisoners whose mental health problems make it difficult for them to engage with their sentence plan—an action plan that focuses on those issues a prisoner must address to reduce the possibility of reoffending. “If you’re a lifer or on an indeterminate sentence for public protection this is a disaster,” says Luke Birmingham, consultant forensic psychiatrist at Isle of Wight Prison. “Since they can’t do interventions to reduce risk, prisoners don’t progress and parole boards won’t consider their release. Prisoners get stuck and end up way over their sentence tariff with no prospect of release.”
Out of prison care and resettlement
Neither prisons nor their healthcare facilities in England and Wales are recognised as hospitals under the Mental Health Act, and prisoners require transfer if they need compulsory treatment. This could be to a community inpatient ward or a medium secure unit. The time taken for transfers was a concern raised by many people contacted during research for this article. The process can drag on for months,18 and resulting delays are distressing to prisoners, families, and staff. Reasons for delay include reluctance on the part of general services to work with prisoners,27 separate assessments for each possible placement,27 and high secure service bed occupancy.27
Ensuring continuity of psychiatric care and maintaining any improvement on release to the community is another major challenge and frustration. Prisoners can be released unexpectedly and return to distant communities. “Release is a breakpoint for care,” one prison psychiatrist told me. “Prisoners we’re seeing as patients can be released without warning. They go to court in the morning and don’t return later in the day. Our team then has to do its best to sort things out,” he said. Even when a release is planned, “linking prisoners into community services is difficult when community mental health teams have different referral thresholds and decline to automatically see patients previously under prison secondary care,” he said.
Even a better planned release can be problematic. There is little assistance for any prisoner on leaving prison.18 Half of released prisoners can be without a general practitioner.22 Former prisoners have poor employment prospects,13 and many return to the same environment they encountered before their sentence. Prisoners with mental health problems are less likely than other prisoners to benefit from prison based rehabilitation.28
What way forward for prison mental health?
When considering the current state of prison mental healthcare, we must acknowledge that provision of community mental healthcare also has significant shortfalls. Nevertheless, there is plenty of scope for improving prison care. Evidence on the needs of prisoners with mental health problems and how best to respond to them needs strengthening, and continued development of diversion services must be a priority since prison is not a suitable place for anyone with acute severe mental illness. Integrated team working, better identification of psychiatric morbidity, and improved discharge procedures are also needed. Ever increasing prisoner numbers in England and Wales put prison staff and facilities under strain, creating an environment that is unpleasant for prisoners and creates obstacles to good care. If problems are not to be exacerbated, government and agencies must work together to improve the prison experience.
Cite this as: BMJ 2012;345:e7280
This is the third in a series of articles examining the challenges of looking after prisoners’ health
I thank the following people for help with this series: Louis Appleby, national director for health and criminal justice; Annie Bartlett, clinical academic and clinical director; Michelle Baybutt, programme lead, Health, Inclusion & Citizenship, Lancashire University; Marcus Bicknell, chair, Royal College of General Practitioners secure environments group; Luke Birmingham, consultant forensic psychiatrist, Southern Health NHS Foundation Trust; Rex Bloomstein, documentary filmmaker; Richard Byng, senior clinical academic in primary care, Institute of Health Service Research, Peninsula College of Medicine and Dentistry; Clive Chatterton, former prison governor, HMP Styal; Angela Clay, chairman, Association of Members of Independent Monitoring Boards; Sally Cottrell, head of evaluation, Avon Primary Care Research; Andrew Coyle, former director, International Centre for Prison Studies; Graham Durcan, associate director, Criminal Justice Programme; Dawn Edge, research fellow, University of Manchester; Tim Exworthy, consultant forensic psychiatrist, St Andrew’s Hospital; Helen Fair, research associate, International Centre for Prison Studies; Michael Farrell, director, National Drug and Alcohol Research Centre; Seena Fazel, clinical senior lecturer, Department of Psychiatry, University of Oxford; Andrew Forrester, honorary senior lecturer in forensic psychiatry, South London and the Maudsley NHS Trust; Andrew Fraser, director of health and care, Scottish Prison Service; Claire Gauge, head of learning lessons, Prisons and Probation Ombudsman England and Wales; Paul Hayton, deputy director, WHO (Europe), Collaborating Centre for Health and Prisons; Alex Hewson, policy and programmes manager, Prison Reform Trust; Adarsh Kaul, clinical director, Offender Health, Nottinghamshire Healthcare NHS Trust; Annabel Kennedy, director, Birth Companions; Richard Knowles, head of prison healthcare, NHS Isle of Wight; Nick Le Mesurier, independent researcher and honorary lecturer, Staffordshire University; Jonathan Lloyd, GP, HMP Nottingham; Juliet Lyon, director, Prison Reform Trust; Eoin McLennan-Murray, president, Prison Governors; Natalie Mann, lecturer in criminology, Anglia Ruskin University; Ryan Mullally foundation year 2 trainee, Nottingham University Hospitals; Nigel Newcomen, prisons and probation ombudsman, England and Wales; Éamonn O’Moore, consultant in public health, Offender Health; Frankie Owens, former prisoner; Mary Piper, senior public health consultant, Offender Health; Emma Plugge, department of public health, Oxford University; John Podmore, former prison governor, HMP Brixton; Lord David Ramsbotham, former HM inspector of prisons; David Scott, senior lecturer in criminology and criminal justice, University of Central Lancashire; Toby Seddon, professor, School of Law, Manchester University; Joe Sim, professor, School of Humanities and Social Science, Liverpool John Moore University; Nicola Singleton, Director of Policy & Research UK Drug Policy Commission; Richard Smith, former editor, BMJ; Alastair Storey, clinical lead and manager Find&Treat; Elizabeth Tysoe, head of healthcare inspection, HM Inspectorate of Prisons; Azrini Wahidin, reader in criminology and criminal justice Queen’s University Belfast; Stuart Ware, founder of Restore Support Network; Susan Yates, research nurse, Royal Free Hospital; the staff and governor of HMP Nottingham; the staff and governor of HMP Isle of Wight.
Contributors and sources: SG is an ST5 trainee in general adult psychiatry and was the 2011-12 Roger Robinson BMJ editorial registrar. Information for this series was obtained from an unsystematic literature review, prison visits, and discussions with prison doctors, prison nurses, prison and forensic psychiatrists, prison governors, prison reformers, prison health managers, prisoners, criminologists, sociologists, and prison inspectors.
Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.