Mental Health Needs of Female Prisoners Dr Pradeep Pasupuleti NHS GG&C Consultant Forensic Psychiatrist Visiting Psychiatrist at HMP Cornton Vale

Today’s talk 20 slides Case examples Evidence on prevalence of mental disorder is prisons HMP Cornton Vale stats Challenges

Case example 1 42 year old, h/o “hearing voices” for 17 years, diagnosis of paranoid schizophrenia, had few very long admissions into psychiatric hospitals, no improvement in symptoms, diagnosis reviewed to BPD 3 years ago before discharging from psychiatric services. Banned from GP practice, frequent attendee at A&E asking to get admitted into hospital, evicted from 4 previous temporary accommodations. 6 prison sentences in the past 3 years. Longest in the community 4 weeks. Repeated public order offences. Presentation in prison characterised by responding to auditory hallucinations, occasional abusive towards staff and fellow inmates but no major management problems. Liberation in 4 weeks.

Case example 2 A 26 year old presenting with frequent history of self harm, excessive drinking and non-compliance with any of the community support packages. Repeat offender, most offences were against support workers including the index offence. Has been on various antidepressants from the age of 18, had few crisis admissions mostly in the context of self harm whilst under the influence of alcohol. h/o CSA, disruptive at school, alcoholism in the family. Disruptive in prison, poor frustration tolerance, unpredictable behavior involving self harm and violence. Due for liberation in 4 weeks.

Case example 3 19 year old, 4th time in custody, mostly for BoP (para suicide) and BoB. h/o CSA, abusive family. Previously contacts with CAMHS, seen by LD services, poor compliance, discharged as ‘nothing much to offer’. Evidently low IQ, frequent self harm behaviour in prison and “wants to end her life”. SW very anxious about her liberation as she goes back into same abusive household, ‘no help’ from health and unlikely to comply with any conditions.

Mental disorders in prisons Fazel and Danesh (2002) Systematic review of 62 surveys (12 countries), 23000 prisoners: 4% psychosis, 12% major depressive disorder, 47% (M) & 21% (F) ASPD Singleton et al, 1998 The largest study into prisoners in England and Wales Psychosis 7% in convicted male prisoners (n=1121) and 10% in male remanded prisoners (n=1250). 40% and 59% respectively had neurotic disorder, 63% and 58% alcohol abuse, and 43% and 51% drug abuse.

Scottish studies Cook et al (1994): 7.3% major psychological disorder, 32% neurotic, 38% alcohol abuse or dep and 21% drug abuse or dep Davidson et al (1995): in a study on remand prisoners (n=389) 2.3% psychosis, 24.8% neurotic, 22% alcohol abuse or dependence and 73% drug abuse or dep

Scottish studies Bartlett et al (2000): study of inceptions into HMP Barlinnie over a one week period, 5% psychotic and 30% depression and anxiety Fraser, Thomson and Graham: A six month audit of prison transfers, 16/22 within 3 days HMIP report 2007: 80% in Cvale had some MH problems; 60% under the influence of drugs at the time of offence Her Majesty’s Inspectorate of Prisonsreport

Female prison estate Prison Number Cornton Vale 186 Polmont 104 Edinburgh 106 Greenock 52 Aberdeen (Community Integration Centre) 3 Total 451 Data accurate on 20.03.2013

2012 statistics Average admissions per year to HMP Cornton Vale: 2000 Number of referrals to prison mental health team: 693 (93- 33 per month) Total new appointments: 81 Total number of follow-up appointments: 133 (41 patients)

D&A Statistics Addictions referrals Oct 12- Mar 13 (5 months) Type Number Average no. of admissions 834 Total number of referrals 428 (51%) Drug detox 345 (41%) Alcohol detox 83 (10%)

Prison transfers Year Number of transfers 2007 7 2008 6 2009 8 2010 13 2011 15 2012 29

2012 prison transfers Section Number S 136 6 S 52 21 Informal 2

Statistics Diagnosis Number (%) Schizophrenia, relapse 17 (65%) Acute Psychotic episode 6 (23%) Manic episode 3 (12%) Depressive episode 1 (4%) Others- Organic psychosis, Munchausen 2 (8%)

Distribution

Levels of security

Health Board distribution

Key challenges Variations in Court diversion framework Problems with centralization Poor correspondence Prison as a facility for “further psychiatric assessment” Provision of Psychiatric reports to the court- delays Centralization: female prisoners find themselves far from home. Problems with visits from family. Problems to access services during and aftercare.

Challenges in custodial setting Complex needs Diagnostic complexity: Mental illness V PD Undiagnosed LD ASD Co-morbid substance misuse ARBD Problem behaviour

Challenges Model of care for the visiting psychiatrist: Clinic list management V Case management Ideal Prison Mental Health Team Hospital transfers: access to beds Young offenders

Aftercare challenges Follow-up arrangements PD, a “diagnosis of exclusion” Homelessness D&A Variations in inter-agency working models

Current practice Developing multidisciplinary approach MDMHT as a forum for case discussions Case management model in complex cases (CPA, ASP Act) New challenging behaviour service Teaching and training Good relationships