It has been difficult lately to turn on a TV or read a newspaper without being confronted by the shocking reality of prison life. Figures released by the Ministry of Justice at the end of January found that self harm and suicide in the country’s prisons.1
According to the prison reform trust, 49% of women and 23% of male prisoners were assessed as suffering from anxiety and depression, while 26% of women and 16% of men said they had received treatment for a mental health problem in the year before custody.2 With a prison population of around 80,000 in England and Wales, this presents a significant challenge to mental health services in the NHS.
‘Prison affects people in different ways,’ said Gordon Leonard, forensic lead at Cheshire and Wirral Partnership NHS Trust, and a mental health nurse. ‘Some people are have mental health issues have issues before they are in prison, other develop them in prison. That could be any level, minor depression or anxiety all the way through a full psychotic episode.’
However, the problems do not dissipate after release. In fact the transition from the structured environment of incarceration can exacerbate mental health problems. The adjustment from prison life to the outside world can be difficult for patients without mental health problems. According to a report from the Centre for Mental Health3 ‘leaving prison remains problematic for people with mental health problems, with little continuity of care. ‘‘Through the gate’ interventions are widely supported but access to these is limited’.
The disruption caused by discharge from prison may cause severe problems for prisoners with mental health needs. In some prison settings, patients may have access to targeted interventions, with many settings having merged primary and secondary care facilities. No such programme exists in public life.3 Freedom may mean an arbitrary end to an effective course of treatment. While these services may be available in prison, pressures on the mental health service have led to raised entry thresholds for community mental health treatment. had reportedly raised their entry thresholds in the past 12-18 months. ‘Most of the people we work with in here would not meet the criteria for secondary care,’ said a nurse cited in the Centre for Mental Health’s report. ‘In the community has always been difficult to pass some on to a community mental health team, but it is much more difficult now.’3
The pressures of the prison system can also exacerbate mental health problems, creating significantly more severe cases when they are released. ‘Most patients have coping strategies to help their condition, such as stroking a pet or going for a walk,’ added Ms Willetts. ‘None of these are available in prison. Some people also find the prison regime very difficult.’ The Centre for Mental Health report also identifies an issue in prescribing regimens in prisons. Prisoners who may have had access to medications before incarceration may not be provided with them until prison structures, which can cause exacerbations in their conditions.
Ms Willets also stated that the wide availability of novel psychoactive substances such as spice in the prison system were contributing to the deterioration of the mental health of prisoners. ‘The use of substances is difficult in any setting. The problem with spice and new psychoactive substances is that they have a really unpredictable response to them. People who use substances for many years and have accessed help for that can use one of these new substances and they just don’t know the impact it will have mentally. They are really difficult in a mental health context.’
According to the report,3 the first few days and weeks after release pose many challenges for those released and are a time of heightened risk, not least of self-harm and suicide. A systematic review of the research on suicides in former prisoners4 found that the risk of suicide in released prisoners was 6.76 times that of the general population. The increased risk is likely to be linked to high levels of mental illness documented in prisoners, combined with the stress of the transition from prison to the community,’ said the authors of the suicide risk study.3
Ensuring continuity of care was deemed ‘incredibly difficult and people leaving prison who by and large have multiple and complex needs often left prison with no or very limited support,’ by the authors of the Centre for Mental Health Report.3 The primary care services available to prisoners were also identified as the weakest part of the pathway.
‘It depends on the individual prisoners. Some are known to the mental health services in their area, so we can link up with the local services, who often maintain contact with the prisoner throughout their sentence,’ said Natalie Willets, head of healthcare at HMP Birmingham. ‘If someone presents during their sentence, we often have to speak with their general practice to ask them to refer the patient.
Leaving prison can present a shock to the system, after leaving a highly structed environment focused on routine. Additionally, the often unconventional lives of ex-prisoners pose barriers to accessing healthcare in general, especially mental health services. On leaving prison, it is the practice of all prison mental health services to send information to a prisoner’s general practice.
However, many prisoners is do not have a fixed address at release, so prison mental health services are only able to provide guidance on how to register to the prisoner upon their discharge, with a letter on any treatment received and ongoing health needs.
‘An awful lot of the people who leave here have nowhere to go to and we don’t know where they will be released to, but it will be a hostel somewhere,’ said another nurse cited in the report.3 ‘This makes it impossible for us to connect that person even with primary care... the best we can do is send them out with a letter detailing their needs and treatment. They can give this to their GP when they find one.’
Mr Leonard also stated that improvement to communication between services were necessary to ensure a prisoner will receive continuity of care before their release. ‘We were having referrals for people coming very late before release. Sometimes days or maybe a week,’ said Mr Leonard. ‘That isn’t enough time to realistically to ensure that people get the correct provision. We need to be very proactive and have discussions in the prison up to six months before.’
What can be done?
According to Ministry of Justice guidance, here a prisoner approaching release has a mental health problem and does not already have a community-based care co-ordinator ‘healthcare services in the establishment must consider whether there is a clinical need to make a referral to the local community mental health team.’ General practice staff will also need to be informed of the prisoner’s entry into primary care services.
One innovative scheme has been pioneered by charity Rethink working with Nottinghamshire Health Trust. Prisoners identified as having a mental health problem on reception to the prison are assigned with the ‘resettlement workers’. According to the charity, prisoners often ‘fall through the net’ of statutory service because they do not qualify for support from the probation service and are not tracked through prison by mental health services. Once released from prison this group is vulnerable to a further decline in their mental health and/or
a high likelihood of reoffending.
The resettlement team supports the prisoner throughout their sentence, and when the person is discharged a resettlement worker will meet them at the gates to facilitate their reintegration into the community. They assist them with structures such as general practice, drug and alcohol teams, employment support and community mental health teams. The resettlement worker is specially trained to support people with mental health problems such as personality disorder, depression, anxiety, bi-polar disorder or schizophrenia.
Mr Leonard also referenced the Custodial Partnership Groups scheme set up in the Cheshire and Wirral Area. The scheme is designed to can improve communication between prison and NHS staff. Mr Leonard stated that health services require a period of time to conduct proper assessments of a patient’s mental health, which often did not happen.
‘What that means is we have a meeting every six to eight weeks with the local prisons,’ he said. Some prisons are more proactive than other. At these meetings we discuss cases where prison staff feel that there is a requirement for mental healthcare. A lot of the time we know the individual. We arrange to see the individual to see the patient at a time before release.’
The pressures on the NHS and its mental health services are well known and well documented, but the mental health of prisoners presents a unique challenge for staff working in both primary care and the prison system.
No matter the crimes they have committed, former prisoners have a human right to good mental health, and society has an interest in providing it.
1. Ministry of Justice. Safety in custody quarterly update to September 2015.
2.Prison Reform Trust, Mental Healthcare in Prisons. www.prisonreformtrust.org.uk/projectsresearch/ment...
3. Centre for Mental Health. Preventing Prison Suicide. https://www.centreformentalhealth.org.uk/preventin...
4. Jones D and Maynard A. Suicide in recently released prisoners: a systematic review. 2013. Mental Health Practice. 17, 3, 20-27.