Level of Mental Health Intervention and Clinical Need Among Inmates With Mental Illness in Five English Jails

Individuals entering custody in five English jails between April 2006 and February 2007 were recruited. All jails accepted individuals directly from court, and roughly half had not been convicted. In England, all new inmates undergo mandatory, brief standardized health screening on their first day in custody to detect immediate general medical and mental health needs, followed by a detailed health assessment the next day. Screening includes questions addressing previous psychiatric treatment, use of prescribed psychotropic medications, substance misuse, and risk of self-harm or suicide. On the basis of health screening, referrals are made to relevant primary care, mental health, or substance misuse services for further assessment and treatment.

Inmates who did not speak English, had been transferred from another jail, lacked capacity to give consent, or whom jail staff considered unsafe to interview were excluded. After participants received a full description of the study, written informed consent was obtained. Ethical approval was given by the Thames Valley Multisite Research Ethics Committee. Participants were screened for mental illness (N=3,079) with the Prison Screening Questionnaire (PriSnQuest) (10). Participants screening positive (N=1,097) were invited for full clinical interviews with the Schedule for Affective Disorders and Schizophrenia (SADS) (11) to diagnose psychiatric illness. Of these, 81% (N=887) were subsequently available and willing to be interviewed.

All participants who screened positive using PriSnQuest and who were diagnosed with the SADS as having a current mental illness were identified (N=524). We successfully located and accessed clinical records for 78% of these individuals, giving a final sample size of 409. [A flowchart depicting the sampling strategy is available as an online data supplement to this article.] Tests for attrition bias found no significant differences between participants with accessible records and those with nonaccessible records in terms of race-ethnicity, age, index offense, and primary psychiatric diagnosis. We were, however, more successful in accessing women’s records than men’s (N=127, 98%, versus N=282, 71%; χ²=41.6, df=1, p<.001).

Interviews to diagnose mental illness and substance misuse and to assess symptom severity were conducted by trained researchers within one week of participants’ entry into custody. Demographic and criminological information was also collected. SADS was used to diagnose psychiatric illness, and diagnoses were grouped into three hierarchical categories: schizophrenia or any other psychosis, major depressive disorder, and other mental illness (including minor depressive disorder, general anxiety disorder, obsessive-compulsive disorder, and phobias). The Michigan Alcoholism Screening Test (MAST) (12) and the Drug Abuse Screening Test (DAST) (13) were used to diagnose alcohol and drug misuse, respectively. Both the number and severity of symptoms were assessed, as recommended by current U.K. guidance for using stepped-care models within mental health care (14). Severity of psychiatric symptoms was assessed with the expanded, 24-item version of the Brief Psychiatric Rating Scale (BPRS-E) (15) and the 12-item General Health Questionnaire (GHQ-12) (16). Severity of symptoms associated with substance misuse was assessed with MAST and DAST total scores, which address lifetime and current alcohol and drug use. Training in conducting the assessment was facilitated by an experienced consultant psychiatrist, with regular training updates throughout the study to ensure consistency and competence.

Clinical records (paper and electronic), including all health care and substance misuse treatment records available in the jail, were retrieved for each participant and reviewed to determine interventions received during the first month of custody. Following a standard review protocol, we identified, recorded, and coded all consultations, assessments, treatment interventions, and care planning events documented in clinical records. Participants’ clinical records were accessed at weekly intervals for up to one month or until they left the jail, whichever was sooner.

Individuals were allocated to one of three hierarchical groups according to the highest level of mental health intervention received during their first month in jail: secondary care intervention (including contact with a psychiatrist, psychologist, or member of the specialist mental health team), primary care intervention (including contact with the medical officer, general practitioner, or general nursing staff), and no intervention. Among individuals with co-occurring disorders (mental illness and a substance misuse problem as diagnosed with the MAST or DAST), interventions received from substance misuse services during the first month in custody were also noted, including contact for detoxification with medical or nursing staff or substance misuse team workers.

Analyses were conducted with Stata, version 10, for Windows (17). Descriptive statistics (means and percentages) were used to describe the characteristics of participants allocated to each intervention level. Associations between dichotomous variables were examined by chi square tests and odds ratios. For continuous and normally distributed variables, differences between group means were tested with t tests (two-tailed). A p value of <.05 was considered significant. To complement p values from t tests, effect sizes were estimated with Cohen’s d (the standardized difference between two means) with the metan command in Stata. Logistic regression modeling techniques were used to identify multivariate predictors of level of intervention in jail, with demographic, clinical, and criminological characteristics as independent variables.

Demographic, clinical, and criminological characteristics of the groups that received primary mental health care, secondary mental health care, and no intervention are summarized in Table 2. During their first month in custody, 133 individuals (33%) received secondary mental health care, 181 (44%) received primary mental health care, and 95 (23%) received no intervention.

We first compared individuals who received no intervention with those who received a primary care intervention, excluding those who received secondary mental health care (Table 2). Individuals treated in primary care were more likely to be female (odds ratio [OR]=7.07, 95% confidence interval [CI]=3.19–15.68), to have a diagnosis of depression (OR=2.01, CI=1.20–3.36), and to have received one of the following medications immediately before custody: antidepressant (OR=2.4, CI=1.30–4.60), hypnotic or anxiolytic (OR=3.16, CI=1.54–6.50), or detoxification medication (OR=4.28, CI=1.81–10.14). Compared with individuals treated in primary care, those who received no intervention were more likely to have a diagnosis of psychosis (OR=2.43, CI=1.23–4.77), to not be convicted (OR=1.77, CI=1.06–2.96), or to be charged with or convicted of a violent index offense (OR=1.85, CI=1.02–3.34). No significant associations were found between level of intervention and symptom severity.

Next, we compared individuals who received primary mental health care with those who received secondary mental health care, excluding those who received no intervention (Table 2). Individuals who received secondary care were more likely to be male (OR=1.66; CI=1.03–2.67), to have a diagnosis of psychosis (OR=3.34, CI=1.81–6.17), to report any previous contact with mental health care services (OR=2.32, CI=1.4–3.87), to report being in contact with mental health care services immediately before custody (OR=2.05, CI=1.15–3.64), and to report being prescribed antipsychotics immediately before custody (OR=4.10, CI=1.97–8.55). Compared with those treated in secondary care, those treated in primary care were more likely to have been discharged from custody within a week (OR=9.53, CI=2.13–42.62), to have a diagnosis of mental illness other than depression or psychosis (OR=2.14, CI=1.14–4.04), and to report being prescribed a hypnotic or anxiolytic (OR=1.70, CI=1.00–2.92) or detoxification medication immediately before custody (OR=2.90, CI=1.50–5.60). Individuals treated in secondary care had higher BPRS-E scores (t=–2.96, df=296, p=.003), indicating more severe symptoms; however, the effect size was small (d=.35).

All variables that had a statistically significant association (p<.05) with level of intervention (as indicated in Table 2) were entered into an ordered logistic regression model, with level of mental health care intervention as the ordinal dependent variable (hierarchically defined as none, primary, or secondary). The following variables remained significant (p<.05): gender, major depressive disorder, duration in custody, prescribed antipsychotic use before custody, and BPRS-E total score. The overall model was significant (χ²=52.26, df=13, p<.001).

A total of 344 (84%) participants had a coexisting drug or alcohol misuse problem. Overall, 180 (52%) individuals with co-occurring disorders received an intervention from substance misuse services within one month of jail arrival (Table 3).

Participants with a drug misuse problem were more likely to receive an intervention than those with an alcohol misuse problem alone (OR=3.67, CI=1.91–7.05). Symptoms of drug misuse (total DAST score) were significantly higher in the group that received an intervention (moderate effect size, d=.59). No significant differences were found in symptoms related to alcohol misuse (MAST scores) between those who did or did not receive an intervention. Intensity of psychiatric symptoms was not associated with receipt of an intervention from substance misuse services.

Receipt of an intervention from substance misuse services was more likely among men (OR=1.91, CI=1.18–3.11) and among white individuals (OR=2.26, CI=1.15–4.44). Receipt was less likely among those with a violent index offense (OR=.58, CI=.34–.96); however, this difference was not significant when adjustments were made for alcohol misuse. No significant group differences were found with respect to legal status and duration in custody. Individuals who had been in contact with community drug treatment services immediately before custody were more likely to receive an intervention in jail from substance misuse services (OR=2.86, CI=1.84–4.44). Participants who had received inpatient drug detoxification in the past were less likely to receive an intervention while in custody (OR=.47, CI=.31–.71). With regard to prescribed medication, individuals prescribed detoxification medication prior to custody were more likely than those not prescribed detoxification medication to receive an intervention from substance misuse services (OR=3.56, CI=1.90–6.67).

All variables that had a statistically significant association (p<.05) with receipt of a substance misuse service intervention (as indicated in Table 3) were entered into a binary logistic regression model, with receipt of an intervention from substance misuse services (yes or no) as the binary dependent variable. Only ethnicity, inpatient drug detoxification (lifetime), and prescribed detoxification medication immediately before custody remained significant (p<.05). The overall model was significant (χ²=54.12, df=9, p<.001).