People in prison experience numerous and often complex mental health and behavioural difficulties at a higher rate than people in the community. Mental health services in prison should be equivalent to those in the community in terms of accessibility, quality, and the types and range of interventions available. Research undertaken in the United Kingdom documents elevated prevalence of a range of common mental health problems and serious mental disorder, and evidences particular vulnerabilities and service gaps for certain groups, including women, young people, older adults, and people on remand. As part of a wider health needs assessment programme, the Scottish Government commissioned a national assessment of mental health needs among Scotland's prison population to ensure that future changes to prison mental health services are evidence-based and person-centred.
A mapping of mental health services available to individuals in and leaving prison
A mapping exercise was undertaken to describe the services available to support the mental health of people in Scotland's prisons. While there have been major positive developments in multi-disciplinary prison mental health services in the past decade since responsibility for prison healthcare delivery transferred to the NHS, the findings evidenced inequities across certain prisons resulting in inconsistent and somewhat arbitrary service resource allocation not closely linked to the number of prison residents. The current allocation of NHS resources directs support by necessity to the acutely mentally ill while leaving a large population of people in prison without support from which they could benefit. Service pressures resulting from difficulties in staff recruitment and retention have been exacerbated by the COVID-19 pandemic and require action. While there is a role and willingness from non-health agencies to support the mental health and wellbeing of people in prison, these efforts are hindered by reduced opportunity for relevant staff training, and limited cross-agency partnership working and information sharing between justice, health and third sector organisations.
Understanding the scale of mental health needs in the prison population
Robust data on the mental health needs of Scotland's prison population are required to develop services designed to meet the particular needs of this group. However, data on mental health needs of people living in Scotland's prisons are not routinely collected at the national level. Quantitative modelling was used to estimate the proportion of Scotland's prison population that likely has mental health needs, using information known about the needs of people in the community. The findings show that 15% of the prison population likely has a long-term mental health condition, 17% a history of self-harm, 30% a current alcohol use disorder, 16% symptoms of anxiety and 18% symptoms of depression over the past week. Estimated prevalence of needs was higher in the remand population, in younger age groups, and in women relative to men, except for alcohol use disorder and depression. Data on the use of inpatient forensic services by people in prison were examined and indicate that, relative to Scotland's prison population as a whole, these individuals were disproportionately female and on remand. The vast majority were transferred for the treatment of a psychotic disorder.
Engagement with professional stakeholders and individuals with lived experience
Reflecting on current mental health service provision and challenges related to this, professional stakeholders working across justice, health, third sector organisations and other partner agencies called for a 'cultural shift' and cited that 'a big sea change' would need to happen for mental health to be more meaningfully supported within Scotland's prisons. They also highlighted the need for increased resources across the Scottish Prison Service (SPS) and NHS mental health teams, and improved access to relevant training for SPS staff to support the implementation of a trauma-informed approach within prisons.
People with lived experience of having mental health needs while in prison recalled a reluctance to share their mental health concerns with prison officers due to a general lack of dignitity and respect from officers, or perceived lack of training to provide sought after support.
Conclusions and recommendations
This needs assessment found that current service provision to support the mental health and wellbeing of people in prison places too much responsibility on the individual to engage and choose to share information with mental health services to gain necessary support. Mental health services in prison are not equivalent to care available to people in the community, and do not adequately address the high levels of need in this population. A fundamental change in the approach to prison care and prison mental health services is required.
Joint and coordinated action from justice, health and social care, and third sector providers is needed to overcome longstanding and structural challenges to supporting the mental health and wellbeing of people in prison. This could be achieved through the development of a formal partnership at the national level, empowered to deal with strategic and operational issues, and would offer opportunities for governance, quality improvement and assurance in multi-agency mental health services and support. The findings also underscore the need for additional prison mental health services resources, particularly in prisons where this is currently limited, in order to achieve consistency across the prison estate. Changes in practice at the operational level are needed to better facilitate cross-agency partnership working and information sharing. Relevant mental health training should be mandatory for all staff who work with people in prison, in keeping with the whole-prison approach to supporting individuals' mental health and wellbeing.
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