Research around the world consistently finds that people in prison are more likely to have mental health needs than the general population. Certain groups of people, including young people and older adults, as well as those with physical or learning disabilities, are at a high risk of experiencing poor mental health while in prison. This report uses the term 'mental health needs' to refer to the broad set of psychological and behavioural problems associated with mental disorder, personality disorder, substance use, neurodevelopmental disorder and other brain conditions for which mental health services can offer support.
The mental health needs of individuals in prison are often multiple and complex. They range from common problems such as anxiety, depression and substance dependency to serious mental disorder including schizophrenia. In the 17th SPS Prisoner Survey (SPS, 2019a) individuals in prison self-reported having been assessed and diagnosed with mental disorder at the following rates: depression 39%, anxiety/panic disorders 29%, post-traumatic stress disorder (PTSD) 11% and schizophrenia 4%, indicating high levels of need. These mental health needs are highly comorbid, meaning they frequently experience multiple co-occurring problems. Unfortunately, adverse outcomes from poor mental health, including self-harm and suicide, are also more common in prisons and these events have noticeably risen among Scotland's prison population in recent years (SPS, 2018; 2019b).
Increased mental health burden in the prison population is a problem multifactorial in origin. For many individuals, these issues precede imprisonment and are thought to be associated with predisposing factors such as higher rates of traumatic or adverse life experiences, head injury and substance use. Individuals who come into prison are also more likely to be from communities characterised by multiple deprivation, to have spent time in local authority care, and to have experienced interpersonal victimisation. Imprisonment itself, however, can also be damaging to someone's mental health. The remand period is recognised to be one of particular vulnerability. Removing people from society and their loved ones, disrupting their sense of purpose and restricting their personal control, can detrimentally affect their wellbeing and lead to hopelessness. According to SPS data, two-thirds of all deaths by apparent suicide in prison occur during the first three months of custody (His Majesty's Inspectorate of Prisons for Scotland, 2019). Isolation has detrimental and enduring effects on a person's ability to cope in prison, particularly for young people. The prison environment and custodial factors perpetuate this; overcrowding, bullying and discrimination can have further negative effects. Some people in prison use illicit drugs to try to cope with negative feelings, though drugs can both exacerbate existing difficulties and precipitate serious mental and physical illness and even death.
Not all people in prison who have mental health needs engage with services to address these needs. The research literature evidences, and prison healthcare providers generally acknowledge, that, too often, problems can go unrecognised by prison staff and health teams. Public stigma around mental illness and distrust of health professionals lead to a reluctance to disclose ongoing problems. However, the scale of need and degree of comorbidities often far outstrip the resources available to support individuals even when their needs are known. Furthermore, there is a small cohort of individuals with high levels of mental health need, usually because of underlying personality disorder, who exhibit problematic behaviours and may be moved between prisons, usually within separation and reintegration units (SRU). There is widespread concern that this arrangement leaves people with personality disorder in prison with unmet needs.
Scottish health legislation and policy embraces the internationally agreed principle of equivalence. This ensures an ethical and legal obligation for individuals in prison to be able to access the same level, range and quality of healthcare as that provided in the community. However, there is also a view that equivalence of care is insufficient and greater investment in prison health services is needed to compensate for the levels of deprivation, risk factors for poor mental health and health inequalities experienced by the prison population. This view draws upon evidence demonstrating that improved health and mental health is associated with positive social and economic outcomes, and reduced re-offending after imprisonment. Prison is just one setting where health services are likely to find 'hard-to-reach' people who can benefit from engagement with services. SPS' health improvement framework, Better Health Better Lives (Brutus et al., 2012), advocated a 'whole-prison' approach, recognising that many risk factors are inter-related and can best be tackled through comprehensive, integrated programmes. From this it follows that prisons can be a setting for positive mental health, as well as the treatment of illness and protection against worsening of mental health needs.
Given the extent of mental health needs among Scotland's prison population, it is essential to have effective, consistent, and cohesive management of mental health, substance use and neurodevelopmental service provision in prisons. While mental health is a whole-prison concern, involving multiple agencies working in partnership, the NHS has been responsible for the delivery of primary and community healthcare in prisons in Scotland since 2011. The National Prison Care Network (formerly National Prisoner Healthcare Network) leads a 'once for Scotland' approach to the planning, design and delivery of health and social care in prison. Prison-based multidisciplinary mental health teams provide primary and secondary care largely for common mental health needs. Services for mental illness and learning disabilities are in most cases organised and operated separately from substance use services. Individuals in prison or accused of a criminal offence who have severe mental illness, or those with particularly complex needs, can access specialised, tertiary care including assessment and treatment by transfer to one of 20 high, medium, low security psychiatric units, locked wards or intensive psychiatric care units which accept transfers from prison. Secure hospitals, part of Scotland's forensic mental healthcare system, represent a largely separate system of care but one which interfaces heavily with prison mental healthcare in its operation.
Working independently, but often in partnership, with NHS colleagues to support mental health and wellbeing of people in prison in Scotland is a range of third and voluntary sector organisations. These organisations operate within the prison and offer throughcare support for people leaving prison. Problems upon liberation in relation to housing, relationships, and challenges finding employment can negate any improvements in mental health and wellbeing. Since 2011, SPS has had a more limited operational role in support for mental health services in prisons though it continues to be involved in promoting wellbeing, in identifying and supporting individuals with mental health needs in prison and in implementation of its suicide risk management strategy, 'Talk to Me'.
The provision of mental health services across the Scottish prison estate is variable and in need of improvement to meet the scale and nature of need (National Prisoner Healthcare Network, 2014; 2016). There is also recognition of problems implementing a whole-prison approach with considerable silo working among health, social work, SPS and third sector agencies and this fails to meet the needs of those in custody and following liberation. The sustainability of the current mental healthcare model in prisons has been questioned, with likely demand outstripping available resources. This is in part due to concerns about the numbers of nursing staff and the ability to provide an effective mental health service with clinical time routinely taken up by treating substance use problems. As will be detailed in this report, this and other staffing problems have been exacerbated by the pressures of the ongoing COVID-19 pandemic.
Reports in recent years have evidenced that existing mental health services are not proactively designed to meet the needs of their patient groups. Reports from His Majesty's Inspectorate of Prisons for Scotland (HMIPS), the Mental Welfare Commission for Scotland (MWC) and the European Committee for the Prevention of Torture highlighted serious concerns regarding access to appropriate mental health treatment for young people and women at HMYOI Polmont and HMP YOI Cornton Vale, respectively. Most recently, a thematic report by HMIPS stressed age-specific mental health needs of older people living in prisons, which services must adapt to meet, particularly given the growth of this cohort in Scottish prisons. There appears significant appetite for change from relevant partners to address these pressing issues.
The Scottish Government has commissioned four national needs assessments in relation to Scotland's prison population. These include social care support, physical and general health, substance use, and the present mental health needs assessment. SPS is developing strategies for mental health and drugs and alcohol, which are expected to update the organisation's role in supporting the mental health and wellbeing of individuals in prison. Locally, several mental health needs assessments led by NHS Boards have been completed or are ongoing. These pieces of work indicate that significant and acutely needed changes in prison mental healthcare are afoot.
An in-depth national mental health needs assessment was overdue, with SPS and the National Prisoner Healthcare Network calling for it in substantive reports in 2007, 2014, and 2016. It is necessary to ensure that future changes to prison mental health services are evidence-based and person-centred. This report will aid the Scottish Government's objective to deliver integrated health and social care in prisons. It uses a triangulation of sources and the best available data to determine the scale and nature of mental health needs within Scotland's prison population, to understand current service provision in custody, and as part of throughcare, and engage with stakeholders to gather their views and insights on current challenges.
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