Interventions at the Transition from Prison to the Community for Prisoners with Mental Illness: A Systematic Review

Mental health of prerelease incarcerated women

BACKGROUND

The mental health of incarcerated women is particularly poor, yet little is known about their condition during the prerelease period. This critical transition is shaped by stressors related to incarceration and the challenges of reintegration, raising important concerns. Notably, the release phase that follows is characterized by risks of rehospitalization, reincarceration and suicide among individuals with psychiatric disorders and/or substance use disorders (SUDs). The aim of this study was to estimate the prevalence of psychiatric disorders, SUDs and dual diagnoses (DDs, i.e., the combination of severe psychiatric disorder and SUD) among incarcerated women scheduled to be released soon.

METHODS

We conducted a cross-sectional survey from April 2021 to September 2022 across 4 women's correctional facilities in Northern France. This study included all adult women identified by the prison administration as having a scheduled release date within 30 days. Each participant was interviewed via a structured interviewer-administered questionnaire, which included the Mini International Neuropsychiatric Interview.

FINDINGS

Among the 248 women identified by the prison administration, 127 were ultimately enrolled in this study (mean age 36.3 years). We found high prevalences of psychiatric disorders (of the participants, 48.0% had current depressive episodes, 28.3% had current generalized anxiety disorder, and 26.8% had current posttraumatic stress disorder), SUDs (59.1%) and DDs (38.6%).

INTERPRETATION

The alarming prevalences of psychiatric disorders, SUDs, and DDs among our sample highlight the urgent need for integrated care that bridges incarceration and postrelease psychiatric settings for incarcerated women. Combining psychiatric, addiction, and social support services is essential for addressing the complex mental health needs and improving reintegration outcomes in this population.

FUNDING

This study was funded by the French Direction Générale la Santé - Directorate-General of Health (DGS) and Santé Publique France - Public Health France (SPF).

Cognitive dysfunction-an under looked avenue to promote health in incarcerated elderly population through yoga

The correctional "ageing crisis" underlined by accelerated ageing, attributed to a prior history of poor health and lifestyle choices amongst prisoners, and other imprisonment-related factors has been associated with a global burgeoning burden of cognitive impairment in prison settings. Cognitive impairment imposes a crucial, urgent economic and medical challenge for carceral healthcare systems. Further, lack of awareness and absence of regular diagnostic screenings and lack of implementation of appropriate interventions in the prison settings worsen the scenario. Amongst the limited efficacy and reported side effects of pharmacological treatments for cognitive dysfunction, Yoga, a cost-effective and scalable intervention could provide better avenues for halting cognitive deterioration in elderly prisoners. This article presents a perspective on how the adaptation of Yoga-based regimes in carceral settings could improve the needs of people with cognitive deficits across Indian prison settings. However, we also emphasize the need to understand the essence of readiness to achieve clinical effectiveness for combating cognitive deterioration, via the implementation of well-structured Yoga based rehabilitative programs.

They Judge You By Your Incarceration: A Qualitative Study of Mistrust Among Formerly Incarcerated People Navigating Mental Health Care

The goal of this paper is to explore the experiences of formerly incarcerated people navigating mental health care post-release and understand how mistrust of mental health services and providers is manifested among this population. Interviews were conducted between 2021 and 2022 with 25 people released from incarceration within the past five years. We partnered with community organizations to recruit a diverse sample of participants, using voluntary response and purposive sampling. The interview transcripts were coded using a modified grounded theory approach and the analysis further guided by critical phenomenology in order to center silenced or marginalized perspectives. Mistrust of mental health care was a prominent theme across interviews. Overall, participants felt that they did not have autonomy over their treatment planning and management. Participants described experiencing stigmatizing treatment from providers, suspicion of mandated mental health treatment, and believing that profit over patients was prioritized in the industry-all of which contributed to growing mistrust of the larger mental health system. The participants' experiences of losing control over their lives and treatment, compounded by a perceived complicity between mental health and carceral systems, shaped their mistrust toward mental health care. Nevertheless, many demonstrated remarkable persistence in seeking care and engaging with multiple providers, while also actively seeking to reclaim their autonomy.

Development of serious mental illness in young adult violent offenders: Early-life risk factors and long-term adverse outcomes

This study explored serious mental illness (SMI) in young adult offenders imprisoned for violent or sexual crimes, estimating the effects of neurodevelopmental disorders and early-life risk factors on the development of SMI, and its prospective long-term adverse outcomes. An all-male cohort of 266 violent offenders, assessed during imprisonment when aged 18-25 years (M = 21.8, SD = 1.9), was followed prospectively (Myears = 6.2, SD = 1.3) in Swedish national registers together with a general population group (n = 10,000). The baseline prevalence of SMI in late adolescence or young adulthood was 10 % (n = 26) in the violent offender cohort. Childhood-onset conduct disorder (OR 2.7 [1.0-7.1]) was associated with SMI in multivariable logistic regression analyses. Prospectively, violent offenders with, versus without, SMI exhibited heightened total crime rate (IRR 1.4 [1.0-2.2]), prison reconvictions (IRR 1.5 [1.0-2.1]), and psychiatric inpatient care (IRR 3.7 [1.6-8.4]), in zero-inflated Poisson regression models. The usage of outpatient psychiatric and somatic care was low in violent offenders with SMI, even relative to the general population group. The results emphasize the need for early identification of at-risk children, such as those with childhood-onset conduct disorder, and challenges with engaging violent offenders with SMI in healthcare.

Chronic Disease Burden and Healthcare Utilization by Gender Among US Adults with Lifetime Criminal Legal Involvement

BACKGROUND

Criminal legal involvement (CLI) has been associated with increased burden of disease, worse health outcomes, and high healthcare utilization. The health needs of women with CLI are often overlooked despite the rising proportion of women in the US legal system.

OBJECTIVE

Examine differences by binary gender in the prevalence of disease and healthcare utilization among individuals with lifetime CLI.

DESIGN/SETTING

Cross-sectional nationally representative multivariate logistic regression and negative binomial regression.

PARTICIPANTS

Adult respondents with lifetime CLI (N = 37,279) with response rate of 66-69%.

MEASURES

The primary independent variable was binary gender (woman/man). Outcomes included medical conditions, substance use disorders, mental illness, and healthcare utilization. Covariates included sociodemographic confounders.

RESULTS

Women comprised 29.1% of respondents with lifetime CLI and reported 0.83 times the odds of chronic heart disease compared to men (95%CI 0.74, 0.92; p = 0.001), but 1.86 times the odds of COPD (95%CI 1.63, 2.13; p < 0.001), 1.78 times the odds of asthma (95%CI 1.63, 1.93; p < 0.001), and 1.30 times the odds of cancer (95%CI 1.08, 1.53; p = 0.005). While women were less likely to have a substance use disorder (OR 0.84; 95%CI 0.78, 0.90), they were more likely to currently smoke (OR 1.29, 95%CI 1.20, 1.28; p < 0.001) and to have any mental illness (OR 2.45; 95%CI 2.26, 2.63; p < 0.001). Women reported increased rates of all forms of healthcare utilization compared to men after adjustments.

CONCLUSIONS

Women with lifetime CLI experience a different profile of diseases compared to men with increased prevalence of any mental illness and chronic disease, especially respiratory diseases. They also had higher rates of healthcare utilization. Additional research should focus on interventions tailored to the unique needs of this population.

The Effectiveness of Schema Therapy in Individuals Who Committed Crimes: A Systematic Review

Research suggests that individuals who commit crimes often exhibit various early maladaptive schemas (EMSs). EMSs are a broad and pervasive theme or pattern consisting of memories, emotions, cognitions, and bodily sensations concerning oneself and one's relationships with others. Furthermore, EMSs play a crucial role in the onset and maintenance of different types of offending behaviors, highlighting the need to implement schema therapy (ST) for perpetrators. Therefore, the present systematic review assesses the effectiveness of ST for individuals who committed crimes. Four databases (PubMed, Scopus, Web of Science, and Scielo) were searched for studies examining the effectiveness of ST for individuals who committed crimes. Seventeen studies were identified, but only 15 met the criteria for inclusion. Results showed that ST can lead to beneficial effects in EMSs, schema modes, personality symptoms, and risk factors to commit crimes (e.g., cognitive distortions). However, the studies, besides being scarce, revealed some methodological limitations. ST is a promising therapy for individuals who committed crimes, despite the studies' methodological shortcomings, which prevent us from drawing more firm conclusions. Although promising, more research is needed to enhance our understanding of the impact of ST therapies in forensic settings.

A multifaceted approach to identifying and managing juvenile delinquency by integrating psycho-physiological indicators

To understand and treat juvenile delinquency, the study explores the relevance of psycho-physiological indicators. It also emphasizes the necessity for thorough research to minimize the gap existing between psycho-physiological measurements and conventional psychosocial components. The study focuses on the relevance of personality features, habituation, and autonomic arousal required to monitor the proper management of delinquent conduct. Through the integration of biological, psychological, and social elements into a multidimensional approach, researchers can uncover novel insights and create cutting-edge therapies for youths who are at risk of delinquent behavior. The study proposes to develop a comprehensive framework that considers biological antecedents in addition to conventional metrics to reach the root cause of delinquency; thereby drawing special attention to current literature and research that emphasizes the psycho-physiological correlates of delinquency. By examining the complex interactions between stress, physiology, emotions, behavior, and social structures, the study highlights the intricacy of delinquent conduct and the necessity for adopting a multifaceted strategy to fully address the problematic areas. Future research paths are emphasized, with a focus on the significance of longitudinal studies, moderating and mediating variables, and creative treatment techniques. By utilizing psycho-physiological markers and psychosocial traits, researchers can tailor intervention strategies to meet individual needs effectively. Early identification of psycho-physiological deficits in children is crucial for implementing successful behavior modification techniques and promoting the well-being of future generations. This is expected to help the government agencies to save time and public money.

Transfer to community and prison mental health care from Ireland's main remand prison over three years: 2015-2017

Background

The post-release period is associated with an increased risk of morbidity and mortality. Previous studies have identified deficits in pre-release planning for mentally ill people in prison, particularly in remand settings.

Objectives

We aimed to determine the proportion of mentally ill people in Ireland's main remand prison who were referred for mental health follow up in community and prison settings, who achieved face to face contact with the receiving service.

Method

This retrospective observational cohort study was based in Ireland's main male remand prison, Cloverhill. Participants included all those individuals on the caseload of the prison inreach mental health team who were referred for mental health follow up in community and prison settings at the time of discharge, prison transfer or release from custody over a three-year period, 2015 - 2017. Successful transfer of care (TOC) was defined as face-to-face contact with the receiving service, confirmed by written correspondence or by follow up telephone call. Clinical, demographic and offence related variables were recorded for all participants.

Results

There were 911 discharges from the prison inreach mental health team within the three-year study period. Of these, 121 were admitted to hospital, 166 were transferred to other prison inreach mental health services and 237 were discharged to community based mental health follow up in psychiatric outpatient or primary care settings. One third (304/911) had an ICD-10 diagnosis of schizophreniform or bipolar disorder (F20-31) and 37.5% (161/911) were homeless. Over 90% (152/166) of those referred to mental health teams in other prisons achieved successful TOC, with a median of six days to first face-to face assessment. Overall, 59% (140/237) of those referred to community psychiatric outpatient or primary care services achieved TOC following referral on release from custody, with a median of nine days from release to assessment. Clinical and demographic variables did not differ between those achieving and not achieving successful TOC, other than having had input from the PICLS Housing Support Service.

Conclusion

Successful transfer of care can be achieved in remand settings using a systematic approach with an emphasis on early and sustained interagency liaison and clear mapping of patient pathways. For incarcerated individuals experiencing homelessness and mental health disorders, provision of a housing support service was associated with increased likelihood of successful transfer of care to community mental health supports.

Reaching the Unreachable: Intensive Mobile Treatment, an Innovative Model of Community Mental Health Engagement and Treatment

In this paper we introduce the Intensive Mobile Treatment (IMT) model, which arose from a 2016 New York City initiative to engage individuals who were "falling through the cracks" of the mental health, housing, and criminal justice systems. People who are referred to IMT often have extensive histories of trauma. They experience structural racism and discrimination within systems and thus can present as distrustful of treatment teams. We detail the structure of the program as we practice it at our non-profit agency and outline the psychodynamic concepts that inform our work with challenging populations. We acknowledge IMT's role in engaging in advocacy and addressing social justice in our work. We also discuss how through this model we are able to both mitigate and tolerate risk in participants with difficult-to-manage behaviors. This is typically a long-term, non-linear process. We address how this impacts the team dynamic as a whole and explain how with long-term, trusting therapeutic relationships, participants can change and grow over time. We also explain the ways in which our non-billing model plays an integral role in the treatment we are able to provide and identify several challenges and areas for program growth. In outlining our model and its methodology, we hope to empower other practitioners to adapt IMT to other settings beyond the New York City area.

Assertive community treatment as an alternative to incarceration for American pretrial detainees

In the United States and elsewhere around the world, people with serious mental illness (SMI) are overrepresented in the criminal justice system. Clinical interventions to divert such individuals out of correctional settings, including Assertive Community Treatment (ACT), have been shown to reduce rates of criminal justice recidivism when modified to allow for the use of court sanctions to encourage treatment adherence. However, these interventions are noted to be underutilized as alternative to incarceration (ATI) programs. This paper summarizes the results of a retrospective cohort study conducted in a New York State forensic psychiatric hospital of 87 pretrial detainees admitted after being found incompetent to stand trial between January 2019 and January 2022. Of these, 49 patients were referred to an ACT team that served as an ATI program. The study outcomes noted that patients referred to this ACT team were 20% less likely to remain in pretrial detention than those that were not. Moreover, patients referred to the ACT program were also 34% more likely to be granted an ATI plea bargain in the community that did not involve serving a prison term. These results suggest that pretrial detainees with SMI are more likely to be granted an ATI program that offers more intensive treatment services such as ACT, due to the capability of such programs to also provide more intensive outreach and community supervision than traditional outpatient mental health service providers.

Inequities in Mental Health Services: A 16-Year Longitudinal Study of Youth in the Justice System

OBJECTIVE

To examine: (1) if youth who have mental health disorders receive needed services after they leave detention-and as they age; and (2) inequities in service use, focusing on demographic characteristics and type of disorder.

METHOD

We used data from the Northwestern Juvenile Project, a longitudinal study of 1,829 youth randomly sampled from detention in Chicago, Illinois in 1995. Participants were re-interviewed up to 13 times through 2015. Interviewers assessed disorders using structured diagnostic interviews and assessed service use using the Child and Adolescent Service Assessment and the Services Assessment for Children and Adolescents.

RESULTS

Less than 20% of youth who needed services received them, up to median age 32 years. Female participants with any disorder had nearly twice the odds of receiving services compared with male participants (OR: 1.82; 95% CI: 1.41, 2.35). Compared with Black participants with any disorder, non-Hispanic White and Hispanic participants had 2.14 (95% CI: 1.57, 2.90) and 1.50 (95% CI: 1.04, 2.15) times the odds of receiving services. People with a disorder were more likely to receive services during childhood (< age 18) than during adulthood (OR: 2.29; 95% CI: 1.32, 3.95). Disorder mattered: participants with an internalizing disorder had 2.26 times and 2.43 times the odds of receiving services compared with those with a substance use disorder (respectively, 95% CI: 1.26, 4.04; 95% CI: 1.49, 3.97).

CONCLUSION

Few youth who need services receive them as they age; inequities persist over time. We must implement evidence-based strategies to reduce barriers to services.

Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

Psychiatric admissions in young people after expiration of criminal justice supervision in Australia: a retrospective data linkage study

BACKGROUND

Mental health services are available for young people involved with the criminal justice system. However, they have unmet mental health needs after the expiration of criminal justice supervision.

OBJECTIVE

To determine the incidence rate and identify predictors of psychiatric hospitalisations within 24 months after the expiration of criminal justice supervision among young people involved with the New South Wales (NSW) criminal justice system.

METHODS

Retrospective data from 1556 individuals aged 14-22 years who participated in four surveys of justice-involved young people in NSW were harmonised and linked to four NSW data collections. We calculated the incidence rates of psychiatric hospitalisations within 24 months postsupervision and identified predictors of these hospitalisations using a competing risks regression analysis.

RESULTS

Within 24 months postsupervision, 11.4% had a psychiatric hospitalisation compared with 3.5% during supervision. 20.7% of those admitted had a known history of mental illness and engaged with community-based and outpatient mental health services postsupervision. Predictors of psychiatric hospitalisations were: female sex (adjusted subdistribution HR (asHR) 1.84, 95% CI 1.24 to 2.73); previous incarceration (highest asHR for ≥4 episodes 1.67, 95% CI 1.01 to 2.78); head injury (asHR 1.63, 95% CI 1.20 to 2.21); personality disorder (asHR 3.66, 95% CI 2.06 to 6.48) and alcohol and substance use disorder (asHR 1.89, 95% CI 1.29 to 2.77).

CONCLUSION

Justice-involved youth have higher rates of psychiatric admissions after criminal justice supervision. Engagement with mental health services postsupervision is important in addressing emerging or persisting mental health needs.

Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review

BACKGROUND

Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions.

METHODS

A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention.

RESULTS

A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes.

CONCLUSION

Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Protocol of a monocentric, double-blind, randomized, superiority, controlled trial evaluating the effect of in-prison OROS-methylphenidate vs. placebo treatment in detained people with attention-deficit hyperactivity disorder (BATIR)

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is characterized by difficulty paying attention, poor impulse control, and hyperactive behavior. It is associated with several adverse health and social outcomes and leads to an increased risk of criminality and recidivism. Worldwide, ADHD is thus highly prevalent in prisons. However, ADHD treatment has been neglected in such environments. Stimulant medications such as osmotic-release oral system methylphenidate (OROS-MPH) are first-line treatments in the general population, but they are under-prescribed in prisons due to concerns about abuse, even though such claims are not empirically supported. This project aims to compare the efficacy of a 3-month in-prison OROS-MPH vs. placebo treatment on the severity of core ADHD symptoms and relevant in- and post-prison outcomes.

METHODS

This study is a phase III, double-blinded, randomized, superiority, controlled trial of OROS-MPH vs. placebo. After randomization, the participants will receive 3 months of treatment with OROS-MPH or placebo (1:1 ratio) while incarcerated. Upon release, all participants will be offered the treatment (OROS-MPH) for 1 year but will remain blinded to their initial study group. The study will be conducted at the Division of Prison Health, Geneva, Switzerland, among incarcerated men (n = 150). Measures will include (1) investigator-rated ADHD symptoms, (2) acute events collected by the medical and prison teams, (3) assessment of the risk of recidivism, (4) medication side effects, (5) medication adherence, (6) study retention, (7) health care/prison costs, and (8) 1-year recidivism. Analyses will include bivariable and multivariable modeling (e.g., regression models, mixed-effects models, survival analyses) and an economic evaluation (cost-benefit analysis).

DISCUSSION

We expect that early identification and treatment of ADHD in prison will be an important public health opportunity and a cost-effective approach that is likely to reduce the vulnerability of incarcerated individuals and promote pathways out of criminal involvement. The study will also promote standards of care for people with ADHD in prison and provide recommendations for continuity of care after release.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05842330 . Registered on June 5, 2023. Kofam.ch SNCTP000005388. Registered on July 17, 2023.

"Shared experience makes this all possible": documenting the guiding principles of peer-led services for people released from prison

BACKGROUND

There is a growing body of evidence demonstrating the effectiveness of peer-led services in supporting community reintegration for people released from prison. This study aims to document the guiding principle of a peer-led service for people released from prison, from the perspective of peer mentors.

METHODS

Data were collected using focus groups (N = 10; 2 groups with 5 participants each) and one-on-one interviews (N = 5) including a total of 13 people, representing all UTGSS staff at the time of the study. An inductive thematic analysis was used to identify patterns in the data. Initial coding was done by using "in-vivo" codes (i.e. applying codes to terms used by participants). This informed the direction of the next stage of analysis, which focused on identifying categories that synthesized the codes and data across transcripts. In this stage, broad themes and sub-themes were developed.

FINDINGS

Six themes were constructed to reflect the guiding principles of UTGSS staff. This includes four central themes: 1) Offering hope; 2) Building respectful relationships; 3) Providing consistent support; 4) Meeting people where they are at. Two connected themes are also reported: 1) Relying on shared experience, which participants reported serves as the foundation for practicing these guiding principles and 2) Bridging connections to services, which reflects the outcome of practicing these guiding principles.

CONCLUSION

The principles identified in this study can be used by UTGSS staff as a guide for checking-in on progress with clients and may be considered as a model for reflection on practice by staff providing similar peer-led services. These principles should not be applied in a prescriptive way, as relationship building is at the centre of peer support, and different applications will be required depending on clients' goals and the range of supports available within their community.

Mental health intervention research in Latin American correctional settings: A scoping review

BACKGROUND

The Latin American prison population has grown faster than anywhere else globally over the past two decades, reaching a total of 1.7 million people at any given time. However, research on mental health prevention and treatment interventions in Latin American prisons remains scarce.

AIMS

This study aimed to systematically review and synthesize research on prison mental health interventions conducted in the region.

METHODS

We used a two-stage scoping review design guided by the JBI Manual for Evidence Synthesis. Searches took place in December 2021 in nine databases using descriptors and synonyms. First, all prison mental health research in Latin America was retained. Secondly, using title and abstract screening, all research possibly related to interventions was retained for full text evaluation. Studies reporting interventions were assessed by country, language, institution, population, intervention type, intervention focus and outcomes.

RESULTS

N = 34 studies were included in this review. These were 13 case reports, seven expert consensus papers and 14 quantitative studies (four randomized controlled trials, nine cohort studies, one quasi-experimental study). Fourteen interventions were targeted at promoting prosocial behavior, seven studies each aimed to improve mental health and to treat substance use disorders. Six studies involved the treatment of sexual offending behavior, and 3 focused on reducing criminal recidivism. Psychoeducation (n = 12) and motivational interviewing (n = 5) were the most frequent intervention types studied. Promising data from trials showed that anger management, depression, substance use and reoffending could be successfully addressed through interventions.

CONCLUSIONS

Implementation and effectiveness research of mental health interventions in Latin American prisons is scarce. Addressing mental health, substance use and prosocial behavior outcomes should be considered in future research. There is a particular dearth of controlled trials describing quantifiable outcomes.

Record linkage studies of primary care utilisation after release from prison: A scoping review protocol

INTRODUCTION

There is a need to improve the implementation and provision of continuity of care between prison and community in order that people who have been in prison and have a history of low engagement with services or who are vulnerable receive appropriate and timely health care and treatment. Observational studies using record linkage have investigated continuity of care after release from prison but this type of research evidence has not been synthesised.

OBJECTIVE

This paper presents a protocol designed to review record linkage studies about primary care utilisation after prison release in order to inform future research and guide service organisation and delivery towards people who are at-risk following release from prison.

METHODS

This scoping review will follow the framework by Arksey and O'Malley (5 stages) and guidance developed by the Joanna Briggs Institute (JBI). MEDLINE, EMBASE and Web of Science Core Collection will be searched (January 2012-March 2023) using terms relating to (i) 'former prisoners' and (ii) 'primary care'. The review will focus on observational studies that have investigated this topic using linked data from two or more sources. Two authors will independently screen titles and abstracts (step 1) and full publications (step 2) using predefined eligibility criteria. Data will be extracted from included publications using a piloted data charting form. This review will map the findings in this research area by methodology, key findings and gaps in research, and current evidence will be synthesised narratively given the expected considerable heterogeneity across studies.

DISCUSSION

This review is part of a work programme on health in prison (Administrative Data Research Centre, Northern Ireland). This work may be used to inform future research, policy and practice. Findings will be shared with stakeholders, published in a peer-reviewed journal and presented at relevant conferences. Ethical approval is not required.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

The prevalence of self-reported mental illness among those imprisoned in New South Wales across three health surveys, from 2001 to 2015

OBJECTIVE

The prevalence of mental illness among those in prison is much higher than in the community; however, very few studies have examined whether rates have changed over time, in line with increasing self-reported rates in the community.

METHODS

This study compares the prevalence of self-reported mental illness, self-harm and suicidal thoughts/behaviours, and drug and alcohol use across three waves (2001, 2009 and 2015) of health surveys involving men and women in New South Wales prisons and compared these rates with published community-level findings.

RESULTS

The prevalence of those reporting any mental health diagnosis increased significantly across the three surveys, even after adjustment for socio-demographic and criminal justice variables that also changed over time. Individuals surveyed in 2015 were more likely to report a mental health diagnosis than those surveyed in 2001 (adjusted odds ratio = 2.66, 95% confidence interval = [2.16, 3.27]). The prevalence of self-harm and suicidal thoughts and behaviours remained stable across the three surveys, while self-reported regular drug use decreased over the period. Women experienced a far greater burden of mental illness than men across all three surveys and experienced more growth in the prevalence of most psychiatric disorders.

CONCLUSION

These findings have important implications for public and prison health systems given the poor social, health and criminal justice outcomes of those imprisoned with mental illness, both in custody and post-release.

Serious mental illness in probation: A review

Research into serious mental illness and probation is reviewed. In addition, there is a specific review of the role of specialist mental health probation staff in the United States (US). In the discussion, we compare progress with the care of the seriously mentally ill within probation in Europe and the US. We conclude that the specialist role for probation staff developed in the US has significant advantages which have been well evaluated which should be implemented, in a large multi-centre trial, across Europe.

Sex differences in suicide, suicidal ideation, and self-harm after release from incarceration: a systematic review and meta-analysis

PURPOSE

People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex.

RESULTS

Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I2 = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I2 = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I2 = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I2 = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I2 = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I2 = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I2 = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences.

CONCLUSION

People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.

A prison mental health network in the RANZCP

OBJECTIVE

Consider the unique features and challenges of prison psychiatry.

CONCLUSIONS

A Prison Mental Health Network within the Royal Australian and New Zealand College of Psychiatrists would serve many useful functions including improving the quality of mental health services by promoting high clinical standards and ethical practice by psychiatrists working in prisons.

Do Prisoners With Reintegration Needs Receive Relevant Professional Assistance?

Ex-prisoners often experience barriers to successful transition regarding employment, finances, housing, healthcare, and valid identification. Based on the Offender Management framework, assistance during imprisonment by prison- and community-based professionals is considered key in preparing prisoners for release regarding these reintegration needs. Therefore, the current study examines the degree to which prisoners with reintegration needs are assisted by relevant professionals. We used self-reported data from 4,309 prisoners of the Dutch Prison Visitation Study, part of the Life in Custody Study. The results showed that prisoners have more contact with prison-based than with community-based professionals, but that the latter relatively often have contact with prisoners with related reintegration needs. Yet, a specific group of prisoners with reintegration needs remains invisible. Prisoners with complex, health, or valid identification needs, and prisoners in the start or pre-release phase require further attention. It is discussed what can be learned from these findings on Dutch Offender Management practices.

Supporting Vulnerable People During Challenging Transitions: A Systematic Review of Critical Time Intervention

Critical Time Intervention (CTI) is designed to reduce the risk of homelessness and other adverse outcomes by providing support to individuals during challenging life course transitions. While several narrative reviews suggest the benefit of CTI, the evidence on the model's effectiveness has not been systematically reviewed. This article systematically reviews studies of CTI applied to a variety of populations and transition types. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis for protocols (PRISMA-P) guidelines, we reviewed 13 eligible experimental and quasi-experimental studies. Findings were summarized by individual outcome domains, including housing, service engagement use, hospitalization or emergency services, mental health, substance use, family and social support, and quality of life. CTI had a consistent positive impact on two primary outcomes-reduced homelessness and increased service engagement use-among different populations and contexts. Despite the effectiveness of CTI, the specific mechanisms of the model's positive impacts remain unclear. Implications for practice, policy and research are addressed.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

INTRODUCTION

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

METHODS

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants' release. Data were thematically analyzed.

RESULTS

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of 'take-home' OAT medications were common barriers.

CONCLUSIONS

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Association of Mental Health Services Access and Reincarceration Among Adults Released From Prison in British Columbia, Canada

IMPORTANCE

Diagnosis of mental disorder is prevalent among people who have been incarcerated. Nevertheless, community mental health services are often limited following release from prison, and reincarceration rates are high. The prevalence of mental disorders is growing among people who are incarcerated in British Columbia (BC), Canada, increasing the urgency of timely and accessible mental health services after release.

OBJECTIVE

To examine the association of mental health services access and timeliness of services access with reincarceration risk among people released from prison.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, mental disorder diagnoses were derived from International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in administrative health records. Data on prison release and reincarceration were retrieved from corrections records. Population-based health and corrections data were retrieved from the BC Provincial Overdose Cohort, which contains a 20% general population random sample of 1 089 677 BC residents. This study examined releases from provincial prisons between January 1, 2015, and December 31, 2018, among people in the 20% random sample who had a mental disorder diagnosis in the year before their release. Analyses were performed from January to June 2022.

EXPOSURES

Mental health services access (primary care, emergency department visits, or hospitalization) and sociodemographic, health, and incarceration characteristics.

MAIN OUTCOMES AND MEASURES

A multistate modeling approach was taken. Cox proportional hazards models were stratified by transition, from release to reincarceration, with and without mental health services access. A state arrival extended model examined the influence of timeliness of mental health services access on subsequent hazard of reincarceration.

RESULTS

A total of 4171 releases among 1664 people (3565 releases among male individuals [84.6%]; 2948 releases [70.7%] among people <40 years old; 2939 releases [70.5%] among people with concurrent substance use disorder diagnosis) were identified. The total study follow-up time was 2834.53 person-years, with a mean (SD) of 0.68 (0.93) years and median (IQR) of 0.25 (0.07-0.84) years per release. Mental health services access was associated with a reduction in the hazard of reincarceration (hazard ratio, 0.61; 95% CI, 0.39-0.94). For each additional month between release and mental health services access, the hazard of reincarceration was increased by 4% (hazard ratio, 1.04; 95% CI, 1.01-1.07).

CONCLUSIONS AND RELEVANCE

In this cohort study of people with mental disorder diagnoses released from prison in BC, mental health services access was associated with reduced reincarceration risk. These findings suggest that these services may have the greatest impact on reducing reincarceration risk when they are available in a timely manner in the days and weeks immediately following release.

Enhancing community integration after incarceration: findings from a prospective study of an intensive peer support intervention for veterans with an historical comparison group

BACKGROUND

The transition to the community after incarceration presents challenges for returning citizens, including the immediate need to secure housing, employment, and income. Additionally, health care is essential for this population due to high rates of chronic physical health and mental health problems and substance use disorders. There is growing recognition of the need for interventions that support returning citizens as they navigate community reintegration while simultaneously tending to physical and behavioral health needs. We developed and pilot tested a peer support intervention designed to provide social, emotional, and logistic support and promote linkage and engagement in healthcare for returning citizens. We tested the intervention with US military veterans in Massachusetts who were being released from prison and jail. Outcomes related to linkage to and engagement in healthcare were evaluated using an historical comparison group. Engagement in peer support, housing status, and reincarceration rates were monitored for the intervention group.

RESULTS

There were 43 veterans in the intervention group, and 36 in the historical comparison group. For linkage to primary care within 90 days of release, there were no statistically significant differences between the intervention and comparison groups (58% versus 67%). Intervention participants were significantly more likely to receive substance use treatment than the comparison group (86% versus 19%, p < .0001) and the mean monthly substance use visits was greater in the intervention group (0.96 versus 0.34, p < .007). Engagement in mental health services was greater for the intervention group than the comparison group (93% versus 64%, p < .003). There were no significant differences between groups for emergency department use and hospitalization. At the end of the study period, the majority of intervention participants who had been released for over a year were living in permanent housing (84%). Recidivism among the was low, with 7% re-arrested during the study period.

CONCLUSIONS

Augmenting reentry support through intensive peer support appears to have substantial benefits for veterans in terms of engaging them in health care and contributing to their longer-term stability, including housing and recidivism. Flexible reentry support such as this intervention may be well suited to meet the widely varying needs of returning citizens.

Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Conducting Randomized Controlled Trials of Complex Interventions in Prisons: A Sisyphean Task?

Randomized Controlled Trials (RCT) are the "gold standard" for measuring the effectiveness of an intervention. However, they have their limitations and are especially complex in prison settings. Several systematic reviews have highlighted some of the issues, including, institutional constraints e.g., "lock-downs," follow-ups, contamination of allocation conditions and a reliance on self-report measures. In this article, we reflect on our experiences and will describe two RCTs. People in prison are a significantly disadvantaged and vulnerable group, ensuring equitable and effective interventions is key to reducing inequality and promoting positive outcomes. We ask are RCTs of complex interventions in prisons a sisyphean task? We certainly don't think so, but we propose that current accepted practice and research designs may be limiting our understanding and ability to test complex interventions in the real-world context of prisons. RCTs will always have their place, but designs need to be flexible and adaptive, with the development of other rigorous methods for evaluating impact of interventions e.g., non-randomized studies, including pre-post implementation studies. With robust research we can deliver quality evidence-based healthcare in prisons - after all the degree of civilization in a society is revealed by entering its prisons.

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study

Background

Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison.

Methods

We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method.

Results

The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state.

Conclusions

Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07985-5.

Record linkage studies of drug-related deaths among former adult prisoners who have been released to the community: a scoping review protocol

INTRODUCTION

Prisoners often have a complex mix of health and care needs including needs relating to mental and physical ill-health conditions. In addition, substance use disorders are common in prisoners. The transition between prison and community poses risks in terms of a disruption to treatment and care and a deterioration in health. Studies have demonstrated an increased risk of drug-related deaths among former prisoners during the first weeks following release from custody. The aim of this scoping review is to provide an up-to-date account of evidence from record linkage studies about drug-related deaths among former adult prisoners.

METHODS AND ANALYSIS

This is a protocol for a scoping review. The framework for conducting scoping reviews by Arksey and O'Malley, in addition to the methodology and guidance developed by the Joanna Briggs Institute (JBI) and the JBI Collaboration will be followed. MEDLINE, EMBASE, PsychINFO and Web of Science will be searched for studies from 2011 to 2021 using search terms relating to 'mortality', 'drugs' and 'ex-prisoner'. A preliminary search in MEDLINE identified at least 473 potentially eligible papers. Two authors will independently screen all titles and abstracts for eligibility using the inclusion and exclusion criteria. There will be no geographical restrictions but non-English language papers will be excluded. Data will be extracted using a piloted customised charting form and the findings will be mapped (guided by the population, concept and context inclusion criteria) and grouped by main conceptual categories (including methodology, key findings and gaps in the research).

DISCUSSION, ETHICS AND DISSEMINATION

This scoping review will identify, map and summarise publicly available sources of research and therefore does not require ethical approval. The results will inform our empirical investigation of ex-prisoner mortality as well as being shared with key stakeholders, disseminated in a peer-reviewed journal and presented at relevant conferences.

Quality indicators and performance measures for prison healthcare: a scoping review

BACKGROUND

Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare.

METHODS

An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking.

RESULTS

Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population.

CONCLUSIONS

Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison.

Transition Planning from Jail; Treatment Engagement, Continuity of Care, and Rearrest

Mental illness is experienced at a higher rate among incarcerated individuals than the general population. This study is one of the first assessing the association of a jail-based mental health (MH) transition planning program with continuity of care (CoC) (defined as no gap in treatment upon reentry), behavioral health treatment engagement, and rearrest. A one group pre-posttest design merged three data sources: program, community-based MH treatment, and jail data. Participants included 161 people from a Midwest metropolitan county jail. The utilization of MH treatment significantly increased after the program, particularly stabilizing services (i.e. case management). Individuals who engaged most in the program had greater odds of treatment engagement and increased odds of CoC. Time to first rearrest was delayed for those who received CoC. By providing transition planning services, jails and community-based services may increase treatment engagement and CoC, and reduce the risk and frequency of rearrest.

A Systematic Review of Reviews of Correctional Mental Health Services Using the STAIR Framework

BACKGROUND

Rising demand for correctional mental health services (CMHS) in recent decades has been a global phenomenon. Despite increasing research, there are major gaps in understanding the best models for CMHS and how to measure their effectiveness, particularly studies that consider the overall care pathways and effectiveness of service responses. The STAIR (Screening, Triage, Assessment, Intervention, and Re-integration) model is an evidence-based framework that defines and measures CMHS as a clinical pathway with a series of measurable, and linked functions.

METHOD

We conducted a systematic review of the reviews of CMHS elements employing PRISMA guidelines, organized according to STAIR pillars. We assessed the quality of included studies using the AMSTAR-2 criteria. Narrative reviews were read and results synthesized.

RESULTS

We included 26 review articles of which 12 were systematic, metaanalyses, and 14 narrative reviews. Two systematic reviews and seven narrative reviews addressed screening and triage with strong evidence to support specific screening and triage systems. There was no evidence for standardised assessment approaches. Eight systematic reviews and seven narrative reviews addressed interventions providing some evidence to support specific psychosocial interventions. Three systematic reviews and six narrative reviews addressed reintegration themes finding relatively weak evidence to support reintegration methods, with interventions often being jurisdictionally specific and lacking generalizability.

CONCLUSIONS

The STAIR framework is a useful way to organize the extant literature. More research is needed on interventions, assessment systems, care pathway evaluations, and reintegration models.

Continuity of mental health care during the transition from prison to the community following brief periods of imprisonment

PURPOSE

The prison-to-community transition period is one of high risk and need, particularly for those with mental illness. Some individuals cycle in and out of prison for short periods with little opportunity for mental health stabilization or service planning either in prison or the community. This study describes the socio-demographic, clinical and criminal justice characteristics of individuals with mental illness and frequent, brief periods of imprisonment, examines continuity of mental health care between prison and the community for this group, and reports on their post-release mental health and criminal justice outcomes.

DESIGN/METHODOLOGY/APPROACH

This study examined a sample of 275 men who had recently entered prison in New South Wales (NSW), Australia, who had been charged with relatively minor offenses and had been identified on reception screening as having significant mental health needs. Baseline demographic and mental health information was collected via interview and file review and contacts with the prison mental health service were recorded for the period of incarceration. Follow-up interviews were conducted 3 months post-release to determine level of health service contact and mental health symptoms. Information on criminal justice contact during the 3 month period was also collected.

FINDINGS

The majority (85.5%) of the sample had contact with a mental health professional during their period of incarceration. Mental health discharge planning was, however, lacking, with only one in 20 receiving a referral to a community mental health team (CMHT) and one in eight being referred for any kind of mental health follow-up on release. Of those followed up 3 months post-release (n = 113), 14.2% had had contact with a CMHT. Of those released for at least 3 months (n = 255), one in three had received new charges in this period and one in five had been reincarcerated.

CONCLUSION

Continuity of mental health care for those exiting prison is poor, particularly for those with mental health needs experiencing brief periods of imprisonment, and rates of CMHT contact are low in the immediate post-release period. These findings suggest a need for early identification of individuals in this group for timely commencement of intervention and release planning, and opportunities for diversion from prison should be utilized where possible.

Supporting prisoners with mental health needs in the transition to RESETtle in the community: the RESET study

BACKGROUND

Homelessness is linked to poor mental health and an increased likelihood of offending. People often lose accommodation when they enter prison and struggle to find accommodation upon release leading to an increased likelihood of relapse and reoffending. The RESET intervention was developed to support prisoners with mental health needs for 12 weeks after release to coordinate their transition into the community and obtaining secure housing.

METHODS

The primary objective of the study was to assess the participants housing situation. A prospective cohort design followed up 62 prisoners with mental health needs for 9 months post-release. Data were collected at three time points regarding accommodation, reoffending and contact and engagement with services. Inferential statistics using Chi-squared tests and t tests were used to examine differences in scores between the two groups at each time point.

RESULTS

The RESET group was significantly more likely to have secure housing at all three time points being housed for approximately twice as many days than the comparison group (244 vs 129 days at 9 months: p ≤ 0.01). The RESET group also had a significantly greater level of contact with GPs and significantly more received benefits at all three time points.

CONCLUSION

This is the first study to focus on reducing homeless for recently released prisoners with mental health needs. The RESET intervention was successful in achieving its main objective; accommodating participants in permanent housing and reducing homelessness. There was also an association between receiving the intervention and greater engagement with other services. This supports the view that secure housing is important in ensuring a positive transition from prison to the community for prisoners with mental health needs.

The mental health of ex-prisoners: analysis of the 2014 English National Survey of Psychiatric Morbidity

PURPOSE

Prisoners experience extremely high rates of psychiatric disturbance. However, ex-prisoners have never previously been identified in representative population surveys to establish how far this excess persists after release. Our purpose was to provide the first community-based estimate of ex-prisoners' mental health in England using the data from the 2014 Adult Psychiatric Morbidity Survey (APMS).

METHODS

APMS 2014 provides cross-sectional data from a random sample (N = 7546) of England's household population aged 16 or above. Standardised instruments categorised psychiatric disorders and social circumstances. Participants who had been in prison were compared with the rest of the sample.

RESULTS

One participant in seventy had been in prison (1.4%; 95% CI 1.1-1.7; n = 103). Ex-prisoners suffered an excess of current psychiatric problems, including common mental disorders (CMDs), psychosis, post-traumatic disorder, substance dependence, and suicide attempts. They were more likely to screen positive for attention-deficit/hyperactivity disorder and autistic traits, to have low verbal IQ, and to lack qualifications. They disclosed higher rates of childhood adversity, including physical and sexual abuse and local authority care. The odds (1.88; 95% CI 1.02-3.47) of CMDs were nearly doubled in ex-prisoners, even after adjusting for trauma and current socioeconomic adversity.

CONCLUSIONS

Prison experience is a marker of enduring psychiatric vulnerability, identifying an important target population for intervention and support. Moreover, the psychiatric attributes of ex-prisoners provide the context for recidivism. Without effective liaison between the criminal justice system and mental health services, the vulnerability of ex-prisoners to relapse and to reoffending will continue, with consequent personal and societal costs.

The Prison and Transition Health (PATH) cohort study: Prevalence of health, social, and crime characteristics after release from prison for men reporting a history of injecting drug use in Victoria, Australia

BACKGROUND

People who inject drugs are overrepresented in prison and have diverse and complex health needs. However, outcomes after release from prison are poorly understood, limiting effective interventions supporting community reintegration. We describe the prevalence of socio-demographics, physical and mental health, alcohol and other drug use, and crime characteristics of men with histories of injecting drug use after their release from prison in Victoria, Australia.

METHODS

Data come from the Prison and Transition Health (PATH) prospective cohort study. Interviews were undertaken approximately three, 12, and 24 months after release from their index prison episode and were completed in the community, or in prison for those reimprisoned during the study. We present cross-sectional descriptive statistics for each follow-up wave of the PATH study.

RESULTS

Among 400 men recruited into PATH, 85 % (n = 336) completed at least one follow-up interview; 162 (42 %) completed all three interviews. Participants reported social disadvantage and health inequity, including high rates of unemployment, homelessness, and physical and mental health morbidities at each follow-up time point. Rapid return to illicit substance use was common, as was overdose (ranging 9 %-13 %), receptive syringe sharing (ranging 20 %-29 %), involvement in crime-related activities (ranging 49 %-58 %), and reimprisonment (ranging 22 %-50 %) over the duration of follow-up.

CONCLUSION

Men in this study experienced substantial health and social challenges across a 24-month prospective follow-up period. Improved understanding of characteristics and experiences of this group after release from prison can inform more coordinated and continued care between prison and the community.

Effectiveness of psychological interventions in prison to reduce recidivism: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Repeat offending, also known as criminal recidivism, in people released from prison has remained high over many decades. To address this, psychological treatments have been increasingly used in criminal justice settings; however, there is little evidence about their effectiveness. We aimed to evaluate the effectiveness of interventions in prison to reduce recidivism after release.

METHODS

For this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, Embase, Global Health, MEDLINE, PsycINFO, and Google Scholar for articles published from database inception to Feb 17, 2021, without any language restrictions. We searched for randomised controlled trials (RCTs) that evaluated the effect of psychological interventions, delivered to adolescents and adults during incarceration, on recidivism outcomes after release. We excluded studies of solely pharmacological interventions and of participants in secure psychiatric hospitals or special residential units, or attending therapies mainly delivered outside of the prison setting. We extracted summary estimates from eligible RCTs. Data were extracted and appraised according to a prespecified protocol, with effect sizes converted to odds ratios. We used a standardised form to extract the effects of interventions on recidivism and estimated risk of bias for each RCT. Planned sensitivity analyses were done by removing studies with fewer than 50 participants. Our primary outcome was recidivism. Data from individual RCTs were combined in a random-effects meta-analysis as pooled odds ratios (ORs) and we explored sources of heterogeneity by comparing effect sizes by study size, control group, and intervention type. The protocol was pre-registered with PROSPERO, CRD42020167228.

FINDINGS

Of 6345 articles retrieved, 29 RCTs (9443 participants, 1104 [11·7%] females, 8111 [85·9%] males, and 228 [2·4%] unknown) met the inclusion criteria for the primary outcome. Mean ages were 31·4 years (SD 4·9, range 24·5-41·5) for adult participants and 17·5 years (SD 1·9; range 14·6-20·2) for adolescent participants. Race or ethnicity data were not sufficiently reported to be aggregated. If including all 29 RCTs, psychological interventions were associated with reduced reoffending outcomes (OR 0·72, 95% CI 0·56-0·92). However, after excluding smaller studies (<50 participants in the intervention group), there was no significant reduction in recidivism (OR 0.87, 95% CI 0·68-1·11). Based on two studies, therapeutic communities were associated with decreased rates of recidivism (OR 0·64, 95% CI 0·46-0·91). These risk estimates did not significantly differ by type of control group and other study characteristics.

INTERPRETATION

Widely implemented psychological interventions for people in prison to reduce offending after release need improvement. Publication bias and small-study effects appear to have overestimated the reported modest effects of such interventions, which were no longer present when only larger studies were included in analyses. Findings suggest that therapeutic communities and interventions that ensure continuity of care in community settings should be prioritised for future research. Developing new treatments should focus on addressing modifiable risk factors for reoffending.

FUNDING

Wellcome Trust, Fonds de recherche du Québec - Santé.

Patterns and Predictors of Reincarceration among Prisoners with Serious Mental Illness: A Cohort Study: Modèles et prédicteurs de réincarcération chez les prisonniers souffrant de maladie mentale grave : Une étude de cohorte

BACKGROUND

A small proportion of people who have serious mental illness and rapid and frequent incarcerations account for a disproportionate amount of overall service use and cost. It is important to describe such individuals, so that services can respond more effectively.

METHODS

We investigated a cohort of 4,704 incarcerated men and women who were discharged from a correctional mental health service and followed for a median of 535 days. We investigated social, clinical, demographic, and offense characteristics as predictors of return to the service using Cox survival analyses. Secondly, we characterized individuals as high-frequency service users as those who had 3 or more incarcerations during a 1-year period and investigated their characteristics.

RESULTS

We found that a higher rate of return to custody was associated with schizophrenia spectrum/bipolar affective disorder (BPAD), personality disorder traits, crack cocaine and methamphetamine use, and unstable housing. Charges of theft/robbery and breach of probation were also positively associated, and sex assault was negatively associated with return to custody. Within a 1-year time period, we found 7.2% of individuals were high-frequency service users, which accounted for 19.5% of all reincarcerations.

CONCLUSION

Identification of the characteristics of those with mental illness in custody, especially those who have high-frequency returns to custody, may provide opportunity to target resources more effectively. The primary targets of intervention would be to treat those with schizophrenia/BPAD and substance use problems, particularly those using stimulants, and addressing homelessness. This could reduce the problem of repeated criminalization of the mentally ill and reduce the overall incarceration rate.

Societal Reentry of Prison Inmates With Mental Illness: Obstacles, Programs, and Best Practices

Societal reentry from prison presents a wide array of extreme challenges to inmates attempting to reintegrate with society. This process is significantly more daunting for inmates suffering from mental illness for several reasons. This paper examines the reentry process for inmates with mental illness. Three sample reentry programs (Forensic Assertive Community Treatment, Critical Time Intervention, and Thresholds' Prison Aftercare Program) that were developed for inmates with mental illness are discussed along with research testifying to the effectiveness of these programs. Finally, components that would comprise an ideal prison reentry program for mentally ill inmates are outlined, which include a three-phase structure and a focus on preparing both inmates and communities for the reentry process.

Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery

PURPOSE

Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA.

RECENT FINDINGS

Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.

Prison mental health in-reach teams in Aotearoa New Zealand: A national survey

The STAIR in-reach model of care for prisoners with serious mental illness focuses on screening, triage, assessment, interventions and reintegration by using the principles of assertive community treatment. An evidence base exists for the efficacy for its use in Aotearoa New Zealand. However, little is known about its adoption throughout the country. This national survey of managers of in-reach teams to all prisons (N = 19) aimed to determine the pattern of in-reach service delivery. It compared STAIR in-reach teams with other teams regarding service structure, staffing, interventions, reintegration strategies and training needs. This study signals gains made by adopting the STAIR model (multi-disciplinary team service delivery, 'through the wire' support and use of technologies to assist discharge planning) and potential areas of improvement (further use of psychosocial interventions and training needs). To assist national adoption of STAIR, a review is required to consider the cultural responsivity, gender-responsivity and recovery-orientated characteristics of the model.

Veterans Universal Passport: a pilot of a health and social care record for UK ex-service personnel

BACKGROUND

The transfer of care between different health and social care systems are often associated with poor outcomes and disengagement. Indeed, following the transition from military to civilian life, ex-service personnel report difficulties in navigating civilian health and social care services. Personal healthcare records are associated with a number of benefits, including improved continuity of care and patient empowerment. As such, this pilot project aimed to assess the benefits of the Veterans Universal Passport (VUP) in supporting UK ex-service personnel accessing NHS services.

METHODS

In-depth semi-structured interviews were carried out with eight participants (three ex-service personnel, two carers, three health and social care professionals) who had used the VUP. Interviews explored the benefits, challenges and unmet needs associated with the VUP. A thematic analysis was used to identify themes within this framework.

RESULTS

Participants felt that the VUP improved continuity of care and promoted a feeling of control over care. The military-specific nature of the VUP promoted a sense of identity and provided a 'support scaffold' for navigating the complexities of the civilian healthcare system. Challenges included awareness among health and social care professionals, and engagement of users. All participants suggested development into a digital application.

CONCLUSIONS

Findings suggest that the VUP had a positive impact on veterans' access to civilian health and social care services, highlighting that it provided a much-needed structure to their journey through treatment. Considering the parallels with other health and social care transitions, translation for other populations may be beneficial.

Mental health in the criminal justice system: A pathways approach to service and research design

BACKGROUND

Care pathway approaches were introduced into health care in the 1980s and have become standard international practice. They are now being introduced more specifically for health care in the criminal justice system. Care pathway delivery has the theoretical advantage of encouraging a whole-systems approach for health and social care within the criminal justice system, but how well is it supported by empirical evidence?

AIMS

The aim of this study is to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000.

METHOD

We used an exploratory narrative method to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000. The available literature was reviewed using a keyword search approach with three databases: PubMed, Medline, and Google Scholar.

FINDINGS

Research in this field has covered police custody, courts, prisons, and the wider community, but there is little that follows the entire career through all these elements of offender placement. Main themes in the research to date, regardless of where the research was conducted, have been counting the disorder or the need, development and evaluation of screening tools, and evaluation of clinical intervention styles. Most evidence to date is simply observational, although the possibility of conducting randomised controlled trials of interventions within parts of the criminal justice system, especially prisons, is now well established.

CONCLUSIONS

Access to health care while passing through the criminal justice system is essential because of the disproportionately high rates of mental disorder among offenders, and the concept of structured pathways to ensure this theoretically satisfying, but as yet empirically unsupported. Further, substantial cuts in services, generally following government economies, are largely unresearched. Considerable investment in new possibilities, driven by both pressure groups and government, tend to be informed by good will and theory rather than hard evidence and are often not evaluated even after introduction. This must change.

Mental health of people detained within the justice system in Africa: systematic review and meta-analysis

Worldwide, people with mental disorders are detained within the justice system at higher rates than the general population and often suffer human rights abuses. This review sought to understand the state of knowledge on the mental health of people detained in the justice system in Africa, including epidemiology, conditions of detention, and interventions. We included all primary research studies examining mental disorders or mental health policy related to detention within the justice system in Africa. 80 met inclusion criteria. 67% were prevalence studies and meta-analysis of these studies revealed pooled prevalence as follows: substance use 38% (95% CI 26-50%), mood disorders 22% (95% CI 16-28%), and psychotic disorders 33% (95% CI 28-37%). There were only three studies of interventions. Studies examined prisons (46%), forensic hospital settings (37%), youth institutions (13%), or the health system (4%). In 36% of studies, the majority of participants had not been convicted of a crime. Given the high heterogeneity in subpopulations identified in this review, future research should examine context and population-specific interventions for people with mental disorders.