- Email: [email protected]
Meeting complex health needs in prisons
Public Health 123 (2009) 415–418
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Minisymposium
Meeting complex health needs in prisons M. Rutherford*, S. Duggan Prisons and Criminal Justice Programme, Sainsbury Centre for Mental Health, London, UK
a r t i c l e i n f o
s u m m a r y
Article history: Accepted 22 April 2009 Available online 30 May 2009
The vast majority of prisoners have several health needs which combine at different levels of severity. This complexity of needs often amalgamates to include mental and physical illnesses, homelessness, unemployment, and drug and alcohol addictions. ‘Complexity’ can serve as an umbrella term for a number of health and social justice agendas, including public health, primary and secondary care, and social care, and must be fully understood to meet the ‘complex needs imperative’ that exists in all prisons. Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Keywords: Complexity Offenders Prison Mental health Blood-borne viruses
Introduction Very few prisoners only have one health- or social-care need, and few only have two. In fact, the vast majority of prisoners have a plethora of needs which combine at different levels of severity. This complexity of needs often amalgamates to include mental and physical illnesses, homelessness, unemployment, and drug and alcohol addictions. Research by the Sainsbury Centre for Mental Health has shown that: ‘the ‘‘default’’ for prisoners is to have a complex range of problems that interplay with each other. The type of service which will best be able to help a prisoner is one that takes a holistic view and one that is geared to address complexity.’1 When looked at individually, prisoners’ needs are often considered to be ‘sub-threshold’ by individual service providers, which means that prisoners are excluded from access. However, when packaged together, prisoners’ needs frequently engender very ill and socially excluded individuals. Therefore, complexity needs to be fully accepted and understood by criminal justice, health- and social-care agencies to ensure that prisoners’ needs are addressed and that the right services are delivered within prisons. Engaging prisoners in health- and socialcare services is essential in order to ensure that positive health outcomes are achieved, to reduce re-offending, and to save public money.2 ‘Complexity’ can serve as an umbrella term for a number of health and social justice agendas, including public health, primary * Corresponding author. E-mail address: [email protected] (M. Rutherford).
and secondary care, and social care. Delivering services to address complexity will require dynamic and creative working between these agendas, and an understanding of the mechanisms for joint and strategic commissioning will be essential. This paper sets out some of the issues relating to complexity in prisons and, to demonstrate this further, a case study is set out at the end of this paper demonstrating the challenges presented in delivering health care to prisoners by highlighting the correlation between mental illness and blood-borne viruses.
Complexity: the facts In 2002, the UK Government’s Social Exclusion Unit reported that, compared with the general population, prisoners are: 13 times as likely to have been in care as a child; 13 times as likely to be unemployed; 10 times as likely to have been a regular truant; two and a half times as likely to have had a family member convicted of a criminal offence; six times as likely to have been a young father; 15 times as likely to be human immunodeficiency virus (HIV) positive; and 20 times more likely to have been excluded from school.3
In addition, the UK Government’s Social Exclusion Unit reported that: two-thirds of prisoners were using drugs before imprisonment, yet 80% have never had any contact with drug treatment services;
0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.04.006
416
M. Rutherford, S. Duggan / Public Health 123 (2009) 415–418
half of prisoners had no general practitioner before they came into custody; one-third of female sentenced prisoners have attempted suicide in the past; four-fifths of prisoners have the writing skills, two-thirds have the numeracy skills and half have the reading skills at or below the level of an 11-year-old; and prisoners have vastly higher rates of mental health and substance use problems compared with the general population.3 Further, the impact of prison upon prisoners is largely destructive. There are real dangers that prison will cause mental and physical health to deteriorate further, that life and thinking skills will be eroded, and that prisoners will be introduced, or have greater access, to drugs:
one-third of prisoners lose their home while in prison; two-thirds lose their job; over one-fifth face increased financial problems; and over two-fifths lose contact with their family.1
These figures remain as shocking 7 years on as they were in 2002, and illustrate the dramatic level of complex needs faced by prisoners and those managing or treating them. In addition, rising prison populations in most countries and overcrowding in nearly all prisons means that this myriad of problems has to be faced by an increasingly stretched criminal justice workforce, operating with more and more limited resources. Mental health problems and mental illnesses in prisons The 2008 World Health Organization (WHO) Europe ‘Trencin statement on prisons and mental health’, which followed the WHO HIPP International Conference on mental health and prisons in 2007, noted that ‘international research consistently shows that prisons in Europe hold a very high proportion of prisoners with mental disorders’.4 WHO estimates that 65–70% of prisoners suffer from a mental health problem and/or drug addiction.5 Severe and enduring mental illnesses, such as schizophrenia, are estimated to affect approximately 8% of prisoners. In the UK, the still-definitive studies by the Office for National Statistics showed that prisoners are also far more likely to suffer from mental health problems, including severe and enduring illnesses, than the general population (Table 1).6,7 A 2002 study of 23,000 prisoners across Europe found that approximately 4% of male and female prisoners have psychotic illnesses, 10% (men) and 12% (women) have major depression, and 42% (women) and 65% (men) have a personality disorder, including 21% (women) and 47% (men) with an antisocial personality disorder.8 The WHO Trencin statement suggested a number of reasons for this prevalence: a number of prisoners already have mental health problems before entering prison; Table 1 Mental illness among prisoners and the general population.
Schizophrenia and delusional disorder Personality disorder Neurotic disorder (e.g. depression) Source: Singleton et al. (1998, 2001).6,7
Prisoners
General population
8% 66% 45%
0.5% 5.3% 13.8%
prison environments are, by their nature, normally detrimental to protecting or maintaining the mental health of those admitted and held there; many vulnerable prisoners have a drug problem prior to entering prison, but a large proportion have their first drug experience in prison; diversion schemes prior to and at the point of sentencing are often poorly developed, under-resourced and badly managed; and prisons have too often become the place used to hold individuals who have a wide range of mental and emotional disorders.4
Mental health and drug dependency (‘dual diagnosis’, ‘co-morbidity’) The WHO Trencin statement noted that: ‘the global facts are clear and startling: of the nine million prisoners world-wide, at least one million suffer from a significant mental disorder, and even more suffer from common mental health problems such as depression and anxiety. There is often comorbidity (dual diagnosis) with conditions such as personality disorder, alcoholism and drug dependence.’4 A recent report by the Sainsbury Centre for Mental Health on prisoners’ experiences of mental health services noted that: ‘given the extent to which these two sets of issues (mental health and substance misuse) co-exist within the prison population, it is not unreasonable to describe this co-morbidity or dual diagnosis as a ‘default’ for prison mental health care.’1 In addition, WHO reported in 2005 that ‘a disproportionate number of prisoners in Europe have personal histories of drug use and many of the people entering prison have a severe drug problem’. The report found that: ‘illicit drug use varies widely in the European Union: between 22% and 86%.Regular drug use or dependence prior to imprisonment is reported by 8–73% of inmates and lifetime injecting drug use by about 15–50%, although some studies have reported values as low as 1% or as high as 69%.’9
Blood-borne viruses and prisons In addition to the complexities presented to prisoners and prison services by mental health problems and drug addiction, the risk and infection rate of blood-borne viruses is extremely high in prisoners compared with that in the community: ‘in most countries in Europe and central Asia, rates of HIV infection are much higher among prisoners than among the population outside prisons. Studies in countries in Europe have found great variation in the rates of HIV infection among prisoners.’9 WHO has reported that: ‘the rates are generally higher in Eastern Europe, for example: Estonia (12% in 2002), the Russian Federation (4% in 2002) and Ukraine (7% in 2000). High rates in prisoners have been reported in some western European countries, such as Portugal (11% in 2000), but other countries (such as England) that have successfully targeted injecting drug users with prevention interventions early in the epidemic have HIV prevalence rates among prisoners that are typically less than 1%.’9
M. Rutherford, S. Duggan / Public Health 123 (2009) 415–418
In the UK, a major report in 2005 by the Prison Reform Trust and the National Aids Trust10 reported that: ‘There are significantly higher rates of HIV and hepatitis C in UK prisons than in the general population. Many prisoners are at particular risk, not only because of injecting drug misuse prior to prison, but also because of the risks of transmission inherent in prison, such as sharing needles and unprotected sex.’ The report also indicated that one of the main reasons for this high rate of blood-borne viruses in prison is ‘the high proportion of injecting drug users in prison’.10 In 2002, the UK Government’s Social Exclusion Unit reported that rates of HIV were 15 times higher in prison than in the community. Hepatitis C infection was 20 times higher in prison than in the community – nearly one prisoner in 10 was infected with hepatitis C, compared with more than one in 200 in the community (Table 2).3 Additionally, of prisoners who are injecting drug users in England and Wales, 30% have hepatitis C and 20% have hepatitis B.11 This further illustrates the complexity of prisoners’ needs.
Case study to illustrate the kaleidoscopic nature of complex needs of prisoners: mental health and blood-borne viruses As noted above, the ‘default’ in prisons is for prisoners to have a complex range of problems that interplay with one other. The following case study demonstrates a clear link between mental illness and blood-borne viruses; a connection that is well documented in research conducted in the community. This unusual ‘dual diagnosis’ will undoubtedly be having a high impact in prisons, and demonstrates the challenges presented in trying to understand the complex needs of prisoners. Research has demonstrated that people with a mental illness are more likely to be infected by blood-borne viruses. Rosenburg et al., in a study of the US population, showed higher rates of HIV in people with severe mental illness compared with the general population (5.2% and 0.4%, respectively).12 Similarly, Gray et al. reported that 5% of people with schizophrenia were infected with HIV.13 Both Rosenburg and Gray cite ‘risky behaviours’ as the main cause of this prevalence (supported by research by Cournos et al.14). These ‘risky behaviours’ include homelessness, increase in highrisk behaviour, rapidly changing mood, injecting drugs, multiple partners, infrequent use of condoms, same-sex sexual activity, and trading sex for money and drugs. Additionally, Brunette et al.15 noted that the treatment for hepatitis B and C (‘interferon’) can have side effects, including depression. There have also been concerns that patients with mental illness may not be able to cope with other side effects, such as flu-like symptoms and fatigue. The study also noted the need to be aware of interactions between medication for HIV and medication for psychiatric illness. The factors that make people more likely to contract a bloodborne virus are also factors that fit with studies on the causes of offending by prisoners, and it is hardly surprising that high levels of
Table 2 Human immunodeficiency virus (HIV) and hepatitis C (and B) among prisoners and the general population.
HIV Hepatitis C
Male (female) prisoners
General
0.3% (1.2%) 9% (11%)
0.02% 0.4%
Source: Social Exclusion Unit (2002).3
417
social exclusion will make mental illness, blood-borne viruses, drug addiction and offending behaviour more likely. Conclusion This paper enables a number of conclusions to be drawn in relation to the ‘complex needs imperative’. It is clear that in comparison with people in the community, prisoners are far more likely to suffer multiple complex needs, which will often include mental health problems, drug dependency, blood-borne viruses, and a range of additional problems related to poor health and social exclusion. The case study used in this paper identified research conducted in the community showing a clear connection between mental illness and blood-borne viruses. Very little specific research has been conducted on blood-borne viruses and mental illness as a ‘dual diagnosis’ in prisoners, and in the prison estate, it is a largely, if not entirely, unexplored area. Specific research on mental illness and blood-borne viruses in prisons would be valuable, and would enable the complex needs of prisoners to be better understood. What the case study certainly shows is that in order to ensure that the ‘complex needs imperative’ is delivered in prisons, complexity must be fully understood. The kaleidoscopic nature of complexity seen in this paper highlights the fact that complexity can be the core component and driving force of many health and social justice agendas.
Ethical approval None sought. Funding None declared. Competing interests None declared. References 1. Durcan G. From the inside: experiences of prison mental health care. London: Sainsbury Centre for Mental Health; 2008. 2. Sainsbury Centre for Mental Health. Diversion: a better way for criminal justice and mental health. London: Sainsbury Centre for Mental Health; 2009. 3. Social Exclusion Unit. Reducing re-offending by ex-prisoners. London: Social Exclusion Unit; 2002. 4. WHO Europe. Trencin statement on prisons and mental health. Copenhagen: WHO Europe; 2008. 5. WHO Europe. Background paper for Trencin statement on prisons and mental Health towards best practices in developing prison mental health systems. Paper drafted as background paper for the WHO International Conference on Prison and Health, Trencin, Slovakia. Copenhagen: WHO; 18 October 2007. 6. Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners in England and Wales. London: Office for National Statistics; 1998. 7. Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households, 2000. London: Office of National Statistics; 2001. 8. Fazel S, Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 2002;359:545–50. 9. WHO Europe. Status paper on prisons, drugs and harm reduction. Copenhagen: WHO Europe; 2005. 10. Prison Reform Trust/National AIDS Trust. HIV and hepatitis in prisons: addressing prisoners’ healthcare needs. London: Prison Reform Trust/National AIDS Trust; 2005. 11. King’s College London, International Centre for Prison Studies, Prison Health and Public Health. The integration of prison health services. Conference report. International Centre for Prison Studies, London; 2004. 12. Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001;91:31–7.
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13. Gray R, Brewin E, Noak J, Wyke-Joseph J, Sonik B. A review of the literature on HIV infection and schizophrenia: implications for research, policy and clinical practice. J Psychiatr Ment Health Nurs 2002;9:405–9. 14. Cournos F, Horwath E, Guido JR. HIV-1 infection in severely ill psychiatric patients in New York City. AIDS Care 1994;6:443–52. 15. Brunette MF, Drake RE, Marsh BJ, Torrey WC, Rosenberg SD. Five-Site Health and Risk Study Research Committee. Blood-borne infections and persons with mental illness: responding to blood-borne infections among persons with severe mental illness. Psychiatr Serv 2003;54:860–5.
Appendix: recent and forthcoming projects by the Sainsbury Centre for Mental Health’s Prisons and Criminal Justice Programme Diversion Diversion: a better way for criminal justice and mental health’ was published in March 2009. The report found that court diversion and liaison schemes in England only work with one in five of the people with mental health problems who go through the criminal justice system. Many opportunities for diversion are being missed, and too little is being done to ensure that offenders with mental health problems make continuing use of community mental health services. The report concluded that good-quality diversion offers excellent value for money to the taxpayer. It can reduce the costs of expensive court proceedings and unnecessary imprisonment of people on remand or sentence. It can reduce the risk of re-offending among people who get mental health treatment in the community instead of being imprisoned. In addition, it can improve people’s mental health, which benefits them, their families and society as a whole. The report found that there is an especially strong case for diverting people who commit comparatively minor offences from short prison sentences to community sentences. For each person who is diverted from a prison service and who gets good-quality mental health care in their community, an average of £20,000 can be saved in crime-related costs alone. Every year, some 70,000 people go to prison on short sentences. The majority of these people have mental health problems. Many could safely be diverted from prison and offered mental health treatment, if necessary alongside other requirements to make amends for their offences. A report published in March 2009 showed that few people are given a Mental Health Treatment Requirement (MHTR) as part of a community sentence because it is poorly understood and is prone to long delays. ‘A missed opportunity?’ found that the MHTR is poorly understood by the very people who are needed to make it work. A lack of communication between health, probation and court staff is leaving people who could be diverted from prison languishing in custody. The report called on the UK Government to issue clear guidance on the use of the MHTR. It says that court diversion teams should take an active role in identifying people who could benefit from the MHTR, and that primary care trusts should make services available to support people on the MHTR. Convergence A project is underway to examine convergence of mental health and criminal law and legislation. The project will combine legislative analysis, written evidence from 50 leading experts and civil servants, and a scenario modelling event. The final report is
expected at the end of 2009, which will seek to demystify current law and policy, and propose recommendations for managing the implications of convergence for services in the future. Personality disorder In December 2008, the Sainsbury Centre for Mental Health held a very successful summit for leaders in policy, practice and research on young offenders and personality disorder to discuss the current evidence about personality disorder among young prisoners, successful practice examples, and where the Sainsbury Centre could have the most impact. On the same day, the Centre published a personality disorder briefing paper for people working in criminal justice, written in cooperation with the Police Federation and the Prison Officers Association. The Sainsbury Centre for Mental Health is now working with the Scottish Prison Service and the Personality Disorder Institute at the University of Nottingham, and aims, over the next quarter, to work with HMP Corton Vale (the only female young offenders’ institution and prison in Scotland) and the Personality Disorder Institute to train staff in working with young people with emerging personality disorders. Forensic mental health services Lord Bradley’s review reported in April 2009, and the Government response will follow, including the offender health strategy. While forensic services will be a significant component of the review and the strategy, it is anticipated that many gaps will remain. One major area for further work will be on ‘pathways to unlocking the forensic estate’, in particular medium secure psychiatric services for offenders sent from court and transferred prisoners. Nearly 4000 people are currently in forensic services, at huge cost to the National Health Service. However, discharge from forensic services is infrequent and services in the community are ill equipped to receive former forensic patients. In partnership with the National Mental Health Development Unit, this Sainsbury Centre-led project will provide new evidence on forensic mental health services. It will demonstrate the care pathway between prisons and the forensic estate, uncover and illustrate current problems and blocks, and identify solutions to improve systems. It will consider alternative models and make recommendations in light of the economic downturn. Youth justice Six youth liaison and diversion projects were launched officially in February 2009. Evidence indicates that many vulnerable young people’s mental health needs get identified too late in the youth justice system, and these pilots aim to identify young people at the point of entry into the police custody suite. Partners involved in these pilots include the police, the youth offending team, the Crown Prosecution Service, local child and adolescent mental health services and other local children’s trust services. The Sainsbury Centre for Mental Health is project managing these pilots on behalf of the Department of Health, ensuring that they roll out in a manner which is faithful to the theoretical model, and troubleshooting operational problems during site visits with pilot site areas.
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Minisymposium
Meeting complex health needs in prisons M. Rutherford*, S. Duggan Prisons and Criminal Justice Programme, Sainsbury Centre for Mental Health, London, UK
a r t i c l e i n f o
s u m m a r y
Article history: Accepted 22 April 2009 Available online 30 May 2009
The vast majority of prisoners have several health needs which combine at different levels of severity. This complexity of needs often amalgamates to include mental and physical illnesses, homelessness, unemployment, and drug and alcohol addictions. ‘Complexity’ can serve as an umbrella term for a number of health and social justice agendas, including public health, primary and secondary care, and social care, and must be fully understood to meet the ‘complex needs imperative’ that exists in all prisons. Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Keywords: Complexity Offenders Prison Mental health Blood-borne viruses
Introduction Very few prisoners only have one health- or social-care need, and few only have two. In fact, the vast majority of prisoners have a plethora of needs which combine at different levels of severity. This complexity of needs often amalgamates to include mental and physical illnesses, homelessness, unemployment, and drug and alcohol addictions. Research by the Sainsbury Centre for Mental Health has shown that: ‘the ‘‘default’’ for prisoners is to have a complex range of problems that interplay with each other. The type of service which will best be able to help a prisoner is one that takes a holistic view and one that is geared to address complexity.’1 When looked at individually, prisoners’ needs are often considered to be ‘sub-threshold’ by individual service providers, which means that prisoners are excluded from access. However, when packaged together, prisoners’ needs frequently engender very ill and socially excluded individuals. Therefore, complexity needs to be fully accepted and understood by criminal justice, health- and social-care agencies to ensure that prisoners’ needs are addressed and that the right services are delivered within prisons. Engaging prisoners in health- and socialcare services is essential in order to ensure that positive health outcomes are achieved, to reduce re-offending, and to save public money.2 ‘Complexity’ can serve as an umbrella term for a number of health and social justice agendas, including public health, primary * Corresponding author. E-mail address: [email protected] (M. Rutherford).
and secondary care, and social care. Delivering services to address complexity will require dynamic and creative working between these agendas, and an understanding of the mechanisms for joint and strategic commissioning will be essential. This paper sets out some of the issues relating to complexity in prisons and, to demonstrate this further, a case study is set out at the end of this paper demonstrating the challenges presented in delivering health care to prisoners by highlighting the correlation between mental illness and blood-borne viruses.
Complexity: the facts In 2002, the UK Government’s Social Exclusion Unit reported that, compared with the general population, prisoners are: 13 times as likely to have been in care as a child; 13 times as likely to be unemployed; 10 times as likely to have been a regular truant; two and a half times as likely to have had a family member convicted of a criminal offence; six times as likely to have been a young father; 15 times as likely to be human immunodeficiency virus (HIV) positive; and 20 times more likely to have been excluded from school.3
In addition, the UK Government’s Social Exclusion Unit reported that: two-thirds of prisoners were using drugs before imprisonment, yet 80% have never had any contact with drug treatment services;
0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.04.006
416
M. Rutherford, S. Duggan / Public Health 123 (2009) 415–418
half of prisoners had no general practitioner before they came into custody; one-third of female sentenced prisoners have attempted suicide in the past; four-fifths of prisoners have the writing skills, two-thirds have the numeracy skills and half have the reading skills at or below the level of an 11-year-old; and prisoners have vastly higher rates of mental health and substance use problems compared with the general population.3 Further, the impact of prison upon prisoners is largely destructive. There are real dangers that prison will cause mental and physical health to deteriorate further, that life and thinking skills will be eroded, and that prisoners will be introduced, or have greater access, to drugs:
one-third of prisoners lose their home while in prison; two-thirds lose their job; over one-fifth face increased financial problems; and over two-fifths lose contact with their family.1
These figures remain as shocking 7 years on as they were in 2002, and illustrate the dramatic level of complex needs faced by prisoners and those managing or treating them. In addition, rising prison populations in most countries and overcrowding in nearly all prisons means that this myriad of problems has to be faced by an increasingly stretched criminal justice workforce, operating with more and more limited resources. Mental health problems and mental illnesses in prisons The 2008 World Health Organization (WHO) Europe ‘Trencin statement on prisons and mental health’, which followed the WHO HIPP International Conference on mental health and prisons in 2007, noted that ‘international research consistently shows that prisons in Europe hold a very high proportion of prisoners with mental disorders’.4 WHO estimates that 65–70% of prisoners suffer from a mental health problem and/or drug addiction.5 Severe and enduring mental illnesses, such as schizophrenia, are estimated to affect approximately 8% of prisoners. In the UK, the still-definitive studies by the Office for National Statistics showed that prisoners are also far more likely to suffer from mental health problems, including severe and enduring illnesses, than the general population (Table 1).6,7 A 2002 study of 23,000 prisoners across Europe found that approximately 4% of male and female prisoners have psychotic illnesses, 10% (men) and 12% (women) have major depression, and 42% (women) and 65% (men) have a personality disorder, including 21% (women) and 47% (men) with an antisocial personality disorder.8 The WHO Trencin statement suggested a number of reasons for this prevalence: a number of prisoners already have mental health problems before entering prison; Table 1 Mental illness among prisoners and the general population.
Schizophrenia and delusional disorder Personality disorder Neurotic disorder (e.g. depression) Source: Singleton et al. (1998, 2001).6,7
Prisoners
General population
8% 66% 45%
0.5% 5.3% 13.8%
prison environments are, by their nature, normally detrimental to protecting or maintaining the mental health of those admitted and held there; many vulnerable prisoners have a drug problem prior to entering prison, but a large proportion have their first drug experience in prison; diversion schemes prior to and at the point of sentencing are often poorly developed, under-resourced and badly managed; and prisons have too often become the place used to hold individuals who have a wide range of mental and emotional disorders.4
Mental health and drug dependency (‘dual diagnosis’, ‘co-morbidity’) The WHO Trencin statement noted that: ‘the global facts are clear and startling: of the nine million prisoners world-wide, at least one million suffer from a significant mental disorder, and even more suffer from common mental health problems such as depression and anxiety. There is often comorbidity (dual diagnosis) with conditions such as personality disorder, alcoholism and drug dependence.’4 A recent report by the Sainsbury Centre for Mental Health on prisoners’ experiences of mental health services noted that: ‘given the extent to which these two sets of issues (mental health and substance misuse) co-exist within the prison population, it is not unreasonable to describe this co-morbidity or dual diagnosis as a ‘default’ for prison mental health care.’1 In addition, WHO reported in 2005 that ‘a disproportionate number of prisoners in Europe have personal histories of drug use and many of the people entering prison have a severe drug problem’. The report found that: ‘illicit drug use varies widely in the European Union: between 22% and 86%.Regular drug use or dependence prior to imprisonment is reported by 8–73% of inmates and lifetime injecting drug use by about 15–50%, although some studies have reported values as low as 1% or as high as 69%.’9
Blood-borne viruses and prisons In addition to the complexities presented to prisoners and prison services by mental health problems and drug addiction, the risk and infection rate of blood-borne viruses is extremely high in prisoners compared with that in the community: ‘in most countries in Europe and central Asia, rates of HIV infection are much higher among prisoners than among the population outside prisons. Studies in countries in Europe have found great variation in the rates of HIV infection among prisoners.’9 WHO has reported that: ‘the rates are generally higher in Eastern Europe, for example: Estonia (12% in 2002), the Russian Federation (4% in 2002) and Ukraine (7% in 2000). High rates in prisoners have been reported in some western European countries, such as Portugal (11% in 2000), but other countries (such as England) that have successfully targeted injecting drug users with prevention interventions early in the epidemic have HIV prevalence rates among prisoners that are typically less than 1%.’9
M. Rutherford, S. Duggan / Public Health 123 (2009) 415–418
In the UK, a major report in 2005 by the Prison Reform Trust and the National Aids Trust10 reported that: ‘There are significantly higher rates of HIV and hepatitis C in UK prisons than in the general population. Many prisoners are at particular risk, not only because of injecting drug misuse prior to prison, but also because of the risks of transmission inherent in prison, such as sharing needles and unprotected sex.’ The report also indicated that one of the main reasons for this high rate of blood-borne viruses in prison is ‘the high proportion of injecting drug users in prison’.10 In 2002, the UK Government’s Social Exclusion Unit reported that rates of HIV were 15 times higher in prison than in the community. Hepatitis C infection was 20 times higher in prison than in the community – nearly one prisoner in 10 was infected with hepatitis C, compared with more than one in 200 in the community (Table 2).3 Additionally, of prisoners who are injecting drug users in England and Wales, 30% have hepatitis C and 20% have hepatitis B.11 This further illustrates the complexity of prisoners’ needs.
Case study to illustrate the kaleidoscopic nature of complex needs of prisoners: mental health and blood-borne viruses As noted above, the ‘default’ in prisons is for prisoners to have a complex range of problems that interplay with one other. The following case study demonstrates a clear link between mental illness and blood-borne viruses; a connection that is well documented in research conducted in the community. This unusual ‘dual diagnosis’ will undoubtedly be having a high impact in prisons, and demonstrates the challenges presented in trying to understand the complex needs of prisoners. Research has demonstrated that people with a mental illness are more likely to be infected by blood-borne viruses. Rosenburg et al., in a study of the US population, showed higher rates of HIV in people with severe mental illness compared with the general population (5.2% and 0.4%, respectively).12 Similarly, Gray et al. reported that 5% of people with schizophrenia were infected with HIV.13 Both Rosenburg and Gray cite ‘risky behaviours’ as the main cause of this prevalence (supported by research by Cournos et al.14). These ‘risky behaviours’ include homelessness, increase in highrisk behaviour, rapidly changing mood, injecting drugs, multiple partners, infrequent use of condoms, same-sex sexual activity, and trading sex for money and drugs. Additionally, Brunette et al.15 noted that the treatment for hepatitis B and C (‘interferon’) can have side effects, including depression. There have also been concerns that patients with mental illness may not be able to cope with other side effects, such as flu-like symptoms and fatigue. The study also noted the need to be aware of interactions between medication for HIV and medication for psychiatric illness. The factors that make people more likely to contract a bloodborne virus are also factors that fit with studies on the causes of offending by prisoners, and it is hardly surprising that high levels of
Table 2 Human immunodeficiency virus (HIV) and hepatitis C (and B) among prisoners and the general population.
HIV Hepatitis C
Male (female) prisoners
General
0.3% (1.2%) 9% (11%)
0.02% 0.4%
Source: Social Exclusion Unit (2002).3
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social exclusion will make mental illness, blood-borne viruses, drug addiction and offending behaviour more likely. Conclusion This paper enables a number of conclusions to be drawn in relation to the ‘complex needs imperative’. It is clear that in comparison with people in the community, prisoners are far more likely to suffer multiple complex needs, which will often include mental health problems, drug dependency, blood-borne viruses, and a range of additional problems related to poor health and social exclusion. The case study used in this paper identified research conducted in the community showing a clear connection between mental illness and blood-borne viruses. Very little specific research has been conducted on blood-borne viruses and mental illness as a ‘dual diagnosis’ in prisoners, and in the prison estate, it is a largely, if not entirely, unexplored area. Specific research on mental illness and blood-borne viruses in prisons would be valuable, and would enable the complex needs of prisoners to be better understood. What the case study certainly shows is that in order to ensure that the ‘complex needs imperative’ is delivered in prisons, complexity must be fully understood. The kaleidoscopic nature of complexity seen in this paper highlights the fact that complexity can be the core component and driving force of many health and social justice agendas.
Ethical approval None sought. Funding None declared. Competing interests None declared. References 1. Durcan G. From the inside: experiences of prison mental health care. London: Sainsbury Centre for Mental Health; 2008. 2. Sainsbury Centre for Mental Health. Diversion: a better way for criminal justice and mental health. London: Sainsbury Centre for Mental Health; 2009. 3. Social Exclusion Unit. Reducing re-offending by ex-prisoners. London: Social Exclusion Unit; 2002. 4. WHO Europe. Trencin statement on prisons and mental health. Copenhagen: WHO Europe; 2008. 5. WHO Europe. Background paper for Trencin statement on prisons and mental Health towards best practices in developing prison mental health systems. Paper drafted as background paper for the WHO International Conference on Prison and Health, Trencin, Slovakia. Copenhagen: WHO; 18 October 2007. 6. Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners in England and Wales. London: Office for National Statistics; 1998. 7. Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households, 2000. London: Office of National Statistics; 2001. 8. Fazel S, Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 2002;359:545–50. 9. WHO Europe. Status paper on prisons, drugs and harm reduction. Copenhagen: WHO Europe; 2005. 10. Prison Reform Trust/National AIDS Trust. HIV and hepatitis in prisons: addressing prisoners’ healthcare needs. London: Prison Reform Trust/National AIDS Trust; 2005. 11. King’s College London, International Centre for Prison Studies, Prison Health and Public Health. The integration of prison health services. Conference report. International Centre for Prison Studies, London; 2004. 12. Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001;91:31–7.
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Appendix: recent and forthcoming projects by the Sainsbury Centre for Mental Health’s Prisons and Criminal Justice Programme Diversion Diversion: a better way for criminal justice and mental health’ was published in March 2009. The report found that court diversion and liaison schemes in England only work with one in five of the people with mental health problems who go through the criminal justice system. Many opportunities for diversion are being missed, and too little is being done to ensure that offenders with mental health problems make continuing use of community mental health services. The report concluded that good-quality diversion offers excellent value for money to the taxpayer. It can reduce the costs of expensive court proceedings and unnecessary imprisonment of people on remand or sentence. It can reduce the risk of re-offending among people who get mental health treatment in the community instead of being imprisoned. In addition, it can improve people’s mental health, which benefits them, their families and society as a whole. The report found that there is an especially strong case for diverting people who commit comparatively minor offences from short prison sentences to community sentences. For each person who is diverted from a prison service and who gets good-quality mental health care in their community, an average of £20,000 can be saved in crime-related costs alone. Every year, some 70,000 people go to prison on short sentences. The majority of these people have mental health problems. Many could safely be diverted from prison and offered mental health treatment, if necessary alongside other requirements to make amends for their offences. A report published in March 2009 showed that few people are given a Mental Health Treatment Requirement (MHTR) as part of a community sentence because it is poorly understood and is prone to long delays. ‘A missed opportunity?’ found that the MHTR is poorly understood by the very people who are needed to make it work. A lack of communication between health, probation and court staff is leaving people who could be diverted from prison languishing in custody. The report called on the UK Government to issue clear guidance on the use of the MHTR. It says that court diversion teams should take an active role in identifying people who could benefit from the MHTR, and that primary care trusts should make services available to support people on the MHTR. Convergence A project is underway to examine convergence of mental health and criminal law and legislation. The project will combine legislative analysis, written evidence from 50 leading experts and civil servants, and a scenario modelling event. The final report is
expected at the end of 2009, which will seek to demystify current law and policy, and propose recommendations for managing the implications of convergence for services in the future. Personality disorder In December 2008, the Sainsbury Centre for Mental Health held a very successful summit for leaders in policy, practice and research on young offenders and personality disorder to discuss the current evidence about personality disorder among young prisoners, successful practice examples, and where the Sainsbury Centre could have the most impact. On the same day, the Centre published a personality disorder briefing paper for people working in criminal justice, written in cooperation with the Police Federation and the Prison Officers Association. The Sainsbury Centre for Mental Health is now working with the Scottish Prison Service and the Personality Disorder Institute at the University of Nottingham, and aims, over the next quarter, to work with HMP Corton Vale (the only female young offenders’ institution and prison in Scotland) and the Personality Disorder Institute to train staff in working with young people with emerging personality disorders. Forensic mental health services Lord Bradley’s review reported in April 2009, and the Government response will follow, including the offender health strategy. While forensic services will be a significant component of the review and the strategy, it is anticipated that many gaps will remain. One major area for further work will be on ‘pathways to unlocking the forensic estate’, in particular medium secure psychiatric services for offenders sent from court and transferred prisoners. Nearly 4000 people are currently in forensic services, at huge cost to the National Health Service. However, discharge from forensic services is infrequent and services in the community are ill equipped to receive former forensic patients. In partnership with the National Mental Health Development Unit, this Sainsbury Centre-led project will provide new evidence on forensic mental health services. It will demonstrate the care pathway between prisons and the forensic estate, uncover and illustrate current problems and blocks, and identify solutions to improve systems. It will consider alternative models and make recommendations in light of the economic downturn. Youth justice Six youth liaison and diversion projects were launched officially in February 2009. Evidence indicates that many vulnerable young people’s mental health needs get identified too late in the youth justice system, and these pilots aim to identify young people at the point of entry into the police custody suite. Partners involved in these pilots include the police, the youth offending team, the Crown Prosecution Service, local child and adolescent mental health services and other local children’s trust services. The Sainsbury Centre for Mental Health is project managing these pilots on behalf of the Department of Health, ensuring that they roll out in a manner which is faithful to the theoretical model, and troubleshooting operational problems during site visits with pilot site areas.