Prisoner mental health – addressing

complexity

Sophie Davison

Senior Research Fellow and Consultant Forensic Psychiatrist

NMAMHS and School of Psychiatry & Clinical Neurosciences, UWA

Correctional Service Healthcare Summit

August 2015

Melbourne

Mental health in prisons

Prisoner populations characterised by disadvantage, stigmatisation, social exclusion and poor health

Studies from Western countries have consistently shown that prisoners have higher rates of mental disorder than general community:

Psychosis

Depression

Antisocial personality disorder

Substance misuse

Suicide

Comorbidity

Physical health problems

Rates of mental disorder highest in remand/reception prisoners

Also high rates of morbidity and mortality after prison

Overview

Present findings from a survey of the mental

health and psychosocial needs of reception

prisoners in Western Australia

Discuss the implications for addressing complex

needs in prison and the community

Give an example of a pilot project to address

those needs on release

WA survey of mental health needs of reception

prisoners

Collaboration between North Metro Area Mental Health Service, and UWA

Funded by

WA Mental Health Commission,

WA Drug and Alcohol Office and

WA Department of Corrective Services

Ethical approval from:

UWA ethics,

WAAHIEC and

Corrective Services Research Evaluation Committee

Please note that this data cannot be considered as either endorsed

by or an expression of the policies or views of the WA Department of

Corrective Services. S Davison, J Fleming, T Butler et al (2015). Mental health and substance use problems in

Western Australian prisons. Report from the Health and Emotional Wellbeing Survey of Western

Australian Reception Prisoners, 2013. WA Department of Health, 2015.

Method

Interviewed 705 reception prisoners (145 women and

560 men) on average one week after arrival in prison

658 completed interviews

Used structured interview to look at

psychiatric diagnoses,

clinical and social needs

life stressors

social and emotional wellbeing

and sociodemographic data

Participants

Aboriginal Non

Aboriginal

n % n %

Women 63 43% 82 57%

Men 165 29% 409 71%

Total 228 32% 491 68%

Main finding 1

High incidence of mental health problems

WA study findings compared with national

figures (SHIP Morgan et al 2012; NSMHWB Slade et al 2009)

Women reception

prisoners in WA

Women in

general

population age

16-85

Male reception

prisoners in WA

Men in general

population age

16-85

Current disorder 12 month

prevalence

Current disorder 12 month

prevalence

Anxiety disorders 53% 17.9% 32% 10.8%

Mood disorders 36.2% 7.1% 22.7% 5.3%

Substance use

disorders

74% 3.3% 77% 7%

Suicidal ideation

in last month

26.6% 2.7% 16.3% 1.9%

Schizophrenia

and related

disorders

20%** 0.35*% 13%** 0.54%*

Main finding 2

Very high rates of alcohol and other drug use

problems

Substance use in last twelve months compared

with general population (National Drug Strategy Household Survey2014)

Used in last 12

months

Women in

general

population

WA Women

reception

prisoners

Men in general

population

WA Men

reception

prisoners

Tobacco 11.2% 85.6% 14.5% 87.1%

Cannabis 7.6% 63.6% 12.8% 44.1%

Amphetamine/

methampheta

mine

1.5% 62.1% 2.7% 60.8%

Alcohol and substance use disorders (DSM IV)

26.7

6.9

58.9

4.5

66.9

33.5

16.8

50.8

13.7

77

0

10

20

30

40

50

60

70

80

90

Alcoholdependence

AlcoholAbuse

DrugDependence

Drug abuse Anydependence

or abuse

% Women

Men

Main finding 3

High rates of co-occurring disorders

Co-occurring mental health problems and

alcohol and other drug use disorder

12.6 15.9

11.8

6.9

22.7

39.4

52.9

37.9

0

10

20

30

40

50

60

Women Men

%

No mental illness orsubstance use disorder

Mental illness only

Substance use disorderonly

Mental illness andsubstance use disorder

Main finding 4

High rates of physical health problems

Head and neck injuries injury

41

39

38

42

36

37

38

39

40

41

42

43

treated in hospital knocked unconscious

% Women

Men

Number of health conditions reported by men

and women

21.7

39.5

24.5 27.1

37.1

29.5

16.8

3.8

0

5

10

15

20

25

30

35

40

45

Women Men

%

0

1

2 to 4

5 or more

Main finding 5

High rates of life stressors

Life stressors in last 12 months Men Women

% %

Trouble with police* 78 76

Drug related problems 46 57

Death of a family member or close friend 35 56

Witnessing violence 29 48

Not able to get a job 31 44

Abuse or violent crime 25 44

Mental illness 19 40

Been abused, raped or beaten up 10 38

Sent to/in jail (other than current time) 39 34

Really bad illness 15 25

Alcohol related problems 31 25

Really bad accident 12 19

Suicide of a family member or close friend 15 18

Divorce or separation 18 18

Overcrowding at home 10 12

Lost job, made redundant, sacked or retired 20 11.0

Main finding 6

Multiple areas of need- met and unmet in the

last month

CANFOR (Thomas et al 2003)

25 domains

Social

Clinical

Functional

Health

Need- prisoner considers that area a problem in the last month

Met need- they have received effective help in that area in the last month

Unmet need- they have not received effective help in the last month

We asked about the previous month so refers to the weeks before

coming to prison.

Most commonly reported areas of need in

previous 4 weeks

0

10

20

30

40

50

60

%

women

men

Effect of co-occurring disorder on unmet needs

1.35

2.36 2.53

5.27

0.86

1.98 1.69

4.22

0

1

2

3

4

5

6

7

no mental illness or substanceuse disorder

mental illness only Substance use disorder only mental illness and substanceuse disorder

Mean #

Unm

et N

eeds

Female

Male

Main finding 7

Women have higher prevalence of mental

disorders, social disadvantage and needs

Women have unique needs

Women

Higher prevalence of mental disorders

Higher distress

67% had children cf 49% men

13% in paid employment prior to prison cf. 41%

men

More had children taken away by welfare

Women

More unmet needs in month prior to prison:

Lack of adequate accommodation

Psychological distress

Lack of treatment

Lack of adequate daytime activities

Poor physical health

Psychotic symptoms

Problems with childcare

Problems in intimate relationships

Main finding 7

Indigenous prisoners have particular patterns of

service use and particular profile of needs

Indigenous prisoners

More likely to have been imprisoned previously

Less likely to be in paid employment (4% of

women)

More likely to have experienced the death of a

close family member and/or the suicide of a

close friend or family member

Less likely to have previously sought help for

mental health problems

Same rate of mental health problems

Indigenous prisoners needs

No difference in number of met and unmet needs

Indigenous women more likely to report unmet needs in

relation to

Alcohol problems

Information about psychiatric treatment

Indigenous women less likely to report unmet need

Poor physical health

Lack of company and social life

Indigenous prisoner needs

Indigenous men more likely to report unmet

needs in relation to

Alcohol problems

Less likely to report needs in relation to

Accommodation

Resilience in Indigenous women

Indigenous women rated their positive wellbeing

self esteem and social support higher than non-

Indigenous women.

Service implications- addressing complex

needs in the community and in custody

To address high rates of depression, anxiety,

PTSD in context of life stressors need

Trauma informed care

Trauma specific care

Adequate psychological therapies

A program, organization, or system that is

trauma-informed: Realizes the widespread impact of trauma and understands

potential paths for recovery;

Recognizes the signs and symptoms of trauma in clients, families,

staff, and others involved with the system;

Responds by fully integrating knowledge about trauma into policies,

procedures, and practices; and

Seeks to actively resist re-traumatization.”

(from the Substance Abuse and Mental Health Administration

website 2015)

Trauma informed care (Stathopoulos 2012)

Principles Understand trauma and its impact –eg how it can lead to

maladaptive help seeking, drug taking

Promoting safety

Ensuring cultural competence

Supporting choice, control and autonomy- therapeutic framework

is to regain a sense of control over one’s life versus prison which

reduce autonomy and others have total control over your life.

Sharing power and governance

Integrating care

Promoting the knowledge healing happens in relationships

Recovery is possible

Address particular needs of women

High rates of mental disorder

Children and family supports

High rates of victimisation

High rates of social disadvantage

Areas of unmet needs

Implications for services in community and

prison

Address particular needs of Indigenous men and

women

High rates of problems but less likely to have

been diagnosed previously

Resilience- harness

Different profile of needs

Implications for services in the community and

in prison

Address complexity-

Can’t treat anything in isolation

Agencies need to work in partnership across

disciplines and sectors and across settings

Addressing complexity- example of inter-agency working

Statewide forensic mental health service, Partners in

Recovery, Outcare, Ruah and Department of Corrective

Services Co-morbidity Service

Working in collaboration to develop a recovery oriented

approach and inter-agency service collaborations to

support people with severe and persistent mental illness

and complex needs and their carers and families on

release from prison- along case brokerage lines.

Aiming to develop an evidence base about how best to

support people with severe and persistent mental illness

and complex needs on release from prison

Outcomes

In particular we hope to examine whether the

transition case brokerage approach improves

recovery outcomes

engagement with mental health services,

drug and alcohol services,

primary care,

housing,

social support

and meaningful activities on release