Mental disorder in the New South Wales prisoner population

Diagnostic accuracy of the Composite International Diagnostic Interview (CIDI 3.0) in an urban Indigenous Australian sample

OBJECTIVE

The Composite International Diagnostic Interview 3.0 is a standardised diagnostic interview commonly used in population-based mental health surveys, but has not been used in community-residing Indigenous Australians. This paper seeks to determine whether the Composite International Diagnostic Interview 3.0 can produce valid diagnostic information when compared with a diagnostic interview in an urban Indigenous Australian sample.

METHOD

This research was conducted over 10 weeks with adult Indigenous clients of two participating Aboriginal Medical Services in South-East Queensland. Using a cross-sectional, repeated-measures design, participants were administered the Composite International Diagnostic Interview 3.0 by an Indigenous interviewer and within 2 weeks attended a second appointment with an Indigenous clinical psychologist, who produced a diagnostic summary. The Composite International Diagnostic Interview 3.0 diagnoses were compared with the diagnostic summaries and clinical concordance between the two measures was calculated.

RESULTS

The diagnostic accuracy of the Composite International Diagnostic Interview 3.0 differed by module. The Post-traumatic Stress Disorder and Major Depression modules had good utility in diagnosing post-traumatic stress disorder and major depressive episodes, respectively; however, the Mania module that provides diagnoses of bipolar disorder was found to be unsuitable for this population. Although there were no identified contraindications for the use of the Generalised Anxiety and Alcohol Use Disorder modules, further research on the diagnostic accuracy of these modules is warranted.

CONCLUSIONS

The Composite International Diagnostic Interview 3.0 can accurately diagnose some common mental disorders in an Indigenous Australian population, but was found to be unsuitable for others. Given these findings, care should be taken when using the Composite International Diagnostic Interview 3.0 in epidemiological prevalence studies with Indigenous Australian populations.

Arguments for the abolition of the defence of mental impairment

This article summarises arguments for abolishing the mental impairment defence, using the example of the defence in Victoria, taking a historical and comparative approach. It considers the defence in practice, its origins and stagnation in medieval and Victorian England, a better approach based on modern developments in the UK and Europe, its resistance to meaningful reform, and its failure to achieve its laudable, humane and principled aim of sparing vulnerable people with severe mental health problems from punishment. We conclude that the only way to actually achieve this aim is to abolish the mental impairment defence and replace it with an approach that allows for flexible mental health disposals for mentally disordered offenders based on clinical needs and, where necessary, the need for containment, incorporated in and aligned with mental health legislation, regardless of culpability, and with modern systems and services that bring Victoria out of the nineteenth century.

Profiling mentally ill offenders in Hong Kong: A 10-year retrospective review study

INTRODUCTION

This study aimed to analyze the estimated prevalence of mental disorders among offenders and compare the estimated crime rate between mentally ill patients and the total population in Hong Kong.

METHODS

Service data of offenders referred to psychiatrists at the Siu Lam Psychiatric Centre from January 2011 to December 2020 were analyzed. Demographic data of gender, age on admission, educational level, principal psychiatric diagnosis, index offense, and assessment outcome were collected.

RESULTS

Data of 7535 offenders (74.8% males) aged 14 to 97 (mean: 41.3 ± 13.7) years were analyzed. More than 60% (66.2%) had a diagnosable mental disorder. The most prevalent principal psychiatric diagnosis was schizophrenia and related disorder (22.8%), followed by mental and behavioral disorders due to psychoactive substance use (18.6%), and mood disorders (8.8%). The commonest index offenses were theft and related offenses (20.5%), followed by acts intended to cause injury (19.7%), and illicit drug offenses (11.6%). The estimated prevalence of mental illness among prison population was 7.1% (male: 8.2%, female: 5.0%). The estimated crime rate for mentally ill patients was found to be 43.3 to 263.2 per 100 000 population.

DISCUSSION

The estimated prevalence of mental disorders among offenders and the estimated crime rate for mentally ill patients are relatively low in Hong Kong. The result was an important effort to document the changing characteristics of mentally ill offenders and provide an estimation of the prevalence and crime rate for mentally ill patients in Hong Kong.

Patient outcomes in an Australian low secure forensic psychiatric rehabilitation inpatient unit: a 10-year retrospective study

The aim of this study is to investigate the background and discharge outcomes of the forensic patient population rehabilitated through a low secure forensic psychiatric rehabilitation inpatient unit. Currently within Australia and internationally there is a scarcity of research completed within this setting. A quantitative methodology was selected coupled with descriptive statistics to investigate a total of 23 patients and analyse their demographics, historical information, length of stay and post-discharge outcomes including readmission and breach of forensic orders. This study provides insights into this unique patient group and further clarifies their psychiatric treatment and biopsychosocial needs. A significant variance was found within patient length of stay throughout each stage of the forensic system. Low rates of readmissions and breaches of forensic orders were found. Additional research is needed in this low secure psychiatric rehabilitation setting to clarify the forensic pathways of care and needs amongst this cohort.

Health-related quality of life measures in incarcerated populations: protocol for a scoping review

INTRODUCTION

Incarcerated populations represent a vulnerable and marginalised segment of society, with increased health needs and a higher burden of communicable and non-communicable diseases. Traditional population health outcomes do not capture physical, mental, emotional and social well-being. Health-related quality of life (HRQoL) outcomes attempt to measure these important parameters. To date, there has not been a scoping review to summarise the HRQoL literature in the incarcerated population. Thus, we aim to perform such a review to inform health policy decisions in incarcerated populations and support health economic evaluations of interventions in incarcerated populations.

METHODS AND ANALYSIS

We will conduct a scoping review of the literature on the HRQoL in the incarcerated population informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the corresponding PRISMA Extension for Scoping Reviews. The submissions records of six electronic databases with peer-reviewed literature and three health technology assessment agencies will be searched. The search strategy was informed by recommendations for HRQoL reviews. We will include studies that report HRQoL, health state utility values or reference to quality adjusted life years or quality-adjusted life expectancies of incarcerated populations. No assessments of items' quality will be made, as the purpose of this scoping review is to synthesise and describe the coverage of the evidence. We will also identify knowledge gaps on the HRQoL in the incarcerated population.

ETHICS AND DISSEMINATION

Research ethics approval is not required as primary data will not be collected. The findings of this scoping review will be used to inform health economic analyses for the incarcerated population and will be disseminated through peer-reviewed publications and conference presentations.

Defining Optimal Post-prison Care for Those With Psychosis: A Delphi Study

Background: Early treatment (considered as early contact with community mental health services) and treatment retention are associated with reduced reoffending among those with a previous diagnosis of psychosis, yet the attributes of care required to best achieve this is largely unexplored for people with psychosis leaving prison. This study sought consensus from a sample of experts and consumers regarding the attributes of an "optimal model of care" for those with a prior episode of psychosis leaving prison in New South Wales, Australia. Methods: A Delphi method was used, which involved establishing a consensus from a panel of 25 experts and consumers. Following three meetings, 34 model of care attributes and 168 attribute levels were generated for two rounds of online scoring. All attributes and levels were included in the final model if they scored "very important" or "extremely important;" or if the attribute was agreed on by 70% or more of participants. The participant retention rate across scoring rounds was 96% for Round 1 and 84% for Round 2, where consensus was reached. Two "member checking" procedures were undertaken to enhance the integrity of findings: a model "stress test" and an online consumer poll. Results: Thirty-two attributes and 72 attribute levels were included in the final model across four components: pre-release care planning and coordination; treatments in community; diversion from prison; and evaluation. Member checking endorsed a person-centered approach with carers and peer-support central to care. Conclusions: Participants agreed that an optimal model of care should involve a specialized team who works independent of community health service teams to directly deliver certain treatments and services while helping consumers to access external social an economic supports and services.

First diagnosis of psychosis in the prison: results from a data-linkage study

BACKGROUND

Psychosis is more prevalent among people in prison compared with the community. Early detection is important to optimise health and justice outcomes; for some, this may be the first time they have been clinically assessed.

AIMS

Determine factors associated with a first diagnosis of psychosis in prison and describe time to diagnosis from entry into prison.

METHOD

This retrospective cohort study describes individuals identified for the first time with psychosis in New South Wales (NSW) prisons (2006-2012). Logistic regression was used to identify factors associated with a first diagnosis of psychosis. Cox regression was used to describe time to diagnosis from entry into prison.

RESULTS

Of the 38 489 diagnosed with psychosis for the first time, 1.7% (n = 659) occurred in prison. Factors associated with an increased likelihood of being diagnosed in prison (versus community) were: male gender (odds ratio (OR) = 2.27, 95% CI 1.79-2.89), Aboriginality (OR = 1.81, 95% CI 1.49-2.19), older age (OR = 1.70, 95% CI 1.37-2.11 for 25-34 years and OR = 1.63, 95% CI 1.29-2.06 for 35-44 years) and disadvantaged socioeconomic area (OR = 4.41, 95% CI 3.42-5.69). Eight out of ten were diagnosed within 3 months of reception.

CONCLUSIONS

Among those diagnosed with psychosis for the first time, only a small number were identified during incarceration with most identified in the first 3 months following imprisonment. This suggests good screening processes are in place in NSW prisons for detecting those with serious mental illness. It is important these individuals receive appropriate care in prison, have the opportunity to have matters reheard and possibly diverted into treatment, and are subsequently connected to community mental health services on release.

DECLARATION OF INTEREST

None.

Investigating the Impact of Past Trauma and Defense Styles on Posttraumatic Stress Following Homicide and Psychiatric Co-morbidity

To examine the prevalence of PTSD following homicide and investigate the relationship between PTSD from past traumas, defense styles and PTSD following homicide and psychiatric co-morbidity. 167 male homicide perpetrators participated in the study and completed the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire-28 and the Defense Styles Questionnaire. 45% met the criteria for PTSD following homicide and 55% for no-PTSD. With the number of times for imprisonment adjusted, regression analyses showed that immature defense style was associated with PTSD following homicide with the severity of PTSD from past traumas as a moderator. Neurotic and immature defense styles and PTSD from past trauma were significantly and independently associated with psychiatric co-morbidity. Homicide perpetrators could develop PTSD following homicide. The severity of PTSD from past traumas could affect PTSD following homicide and other psychological problems, and influence the effect of using immature defense against PTSD from homicide. Past trauma, immature and neurotic defense styles had a unique and specific pattern of influence on psychological symptoms, other than trauma symptoms.

Australia's $40 per pack cigarette tax plans: the need to consider equity

In May 2016, the Australian Government announced that it would implement annual increases in tobacco excise of 12.5% up to and including 2020, raising the cost of a pack of cigarettes to $A40. This increase will lead to Australia having one of the highest prices of cigarettes in the world. Increasing the cost of tobacco is considered by public health experts to be one of the most effective strategies to reduce tobacco use, and is generally well supported by the public. However, tobacco tax increases differentially impact various subgroups of the population. Based on a review of existing literature, this paper examines some of the potential (unintended) consequences of the tax to individual and family income; illicit trade; social stigma and opportunities for lobbying by the tobacco industry. In light of these considerations, we offer strategies that might be used by policymakers to mitigate potential harms. While this paper focuses on the impacts primarily on populations in Australia, the consequences and strategies offered may be useful to other countries implementing tobacco excise increases.

Developmental delays and psychiatric diagnoses are elevated in offspring staying in prisons with their mothers

The aim of the study was to describe the sociodemographic and clinical features of the mothers and their offspring staying with them in prison. The study was planned as a cross-sectional, single-center study of mothers residing in Tarsus Closed Women's Prison of Turkish Ministry of Justice along with their 0 to 6 years old offspring. Mothers were evaluated via Structured Clinical Interview for DSM-IV Axis I Disorders. A psychologist blind to maternal evaluations applied the Denver Developmental Screening Test II (DII-DST). Children/mothers were also evaluated by a child and adolescent psychiatrist via K-SADS-PL. Twenty-four mothers with a mean age of 29.3 years were included. Most common diagnoses in mothers were nicotine abuse (n = 17, 70.8%), specific phobia (n = 8, 33.3%), alcohol abuse (n = 7, 29.2%) and substance abuse (n = 5, 20.8%). Twenty-six children (53.9% female) were living with their mothers in prison, and the mean age of those was 26.3 months. Results of the D-II-DST were abnormal in 33.3% of the children. Most common diagnoses in children were adjustment disorder (n = 7, 26.9%) separation anxiety disorder (n = 3, 11.5%) and conduct disorder (n = 2, 7.7%). A multi-center study is necessary to reach that neglected/under-served population and address the inter-generational transmission of abuse, neglect, and psychopathology.

Substance use disorders among Aboriginal and Torres Strait Islander people in custody: a public health opportunity

Background

To describe the prevalence, type, and mental health correlates of substance use disorders in a large sample of incarcerated Indigenous Australians.

Methods

An epidemiological survey of the mental health of Indigenous people in custody in the state of Queensland, Australia was conducted using culturally informed methods. The prevalence, type and mental health correlates of substance use disorders were determined using a diagnostic interview and questionnaire.

Results

In a sample of 396 Indigenous people (331 males, 65 females) the prevalence of any substance use disorder was 66%. Alcohol dependence (males 47%, females 55%) was the most common type of substance use disorder, followed by cannabis dependence (males 20%, females 26%). Mental illness (anxiety, depression and psychotic disorder), and lifetime suicide thoughts and attempts, were significantly more likely among those with a substance use disorder. The majority of the sample reported intoxication with alcohol (70%) and/or other drugs (51%) at the time of arrest. Most individuals (87%) had not accessed alcohol and other drug services in the 12 months prior to custody.

Conclusions

Substance dependence was common in this sample and was associated with other forms of mental health adversity, yet most individuals reported no access to health services prior to incarceration. Effectively responding to substance dependence for Indigenous Australians is a public health and criminal justice priority. Culturally capable alcohol and other drug treatment services in custody and in the community are critical, and should be co-located and coordinated with mental health services.

O impacto da prisão na saúde mental dos presos do estado do Rio de Janeiro, Brasil

Resumo O artigo tem como objetivo analisar as condições de saúde mental dos presos e custodiados do estado do Rio de Janeiro e sua relação com o aprisionamento, através da análise de escala de depressão e do Inventário de Sintomas de Estresse. Amostra: 1573 indivíduos, obtidos por amostragem estratificada proporcional ao tamanho. População estudada: mais da metade possui até 29 anos; 70,6% têm cor da pele preta/parda; 80% têm religião, 77,4% com bom vínculo familiar; 42,9% têm menos de um ano de prisão; 22,9% trabalham no presídio. Estresse: 35,8% dos homens e 57,9% das mulheres. Fatores associados ao estresse entre homens: tempo de prisão e vínculo familiar. Presos com 1 a 9 anos de prisão possuem uma chance igual a 0,55 a daqueles com menos de 1 ano de reclusão; aqueles com vínculo regular e ruim possuem chance maior em relação àqueles com bom vínculo. Entre as mulheres, o vínculo regular/ruim representa maior chance de desenvolvimento dos problemas de saúde mental; trabalho representou proteção contra o estresse. Depressão: 7,5% das mulheres e 6,3 % dos homens apresentam sintomas depressivos graves. Entre os homens, praticar alguma religião, ter bom vínculo familiar e trabalhar na prisão são fatores protetores. Entre mulheres, apenas vínculo familiar associou-se com sintomas depressivos.

Treating substance abuse is not enough: comorbidities in consecutively admitted female prisoners

INTRODUCTION

Several studies have pointed to high rates of substance use disorders among female prisoners. The present study aimed to assess comorbidities of substance use disorders with other mental disorders in female prisoners at admission to a penal justice system.

METHODS

A sample of 150 female prisoners, consecutively admitted to the penal justice system of Berlin, Germany, was interviewed using the Mini-International Neuropsychiatric Interview (MINI). The presence of borderline personality disorder was assessed using the Structured Clinical Interview II for DSM-IV. Prevalence rates and comorbidities were calculated as percentage values and 95% confidence intervals (CIs).

RESULTS

Ninety-three prisoners (62%; 95% CI: 54-70) had substance use disorders; n=49 (33%; 95% CI: 24-42) had alcohol abuse/dependence; n=76 (51%; 95% CI: 43-59) had illicit drug abuse/dependence; and n=53 (35%; 95% CI: 28-44) had opiate use disorders. In the group of inmates with substance use disorders, 84 (90%) had at least one other mental disorder; n=63 (68%) had comorbid affective disorders; n=45 (49%) had borderline or antisocial personality disorders; and n=41 (44%) had comorbid anxiety disorders.

CONCLUSIONS

Female prisoners with addiction have high rates of comorbid mental disorders at admission to the penal justice system, ranging from affective to personality and anxiety disorders. Generic and robust interventions that can address different comorbid mental health problems in a flexible manner may be required to tackle widespread addiction and improve mental health of female prisoners.

Did female prisoners with mental disorders receive psychiatric treatment before imprisonment?

BACKGROUND

Throughout the world, high prevalence rates of mental disorders have been found in prison populations, especially in females. It has been suggested that these populations do not access psychiatric treatment. The aim of this study was to establish rates of psychiatric in- and outpatient treatments prior to imprisonment in female prisoners and to explore reasons for discontinuation of such treatments.

METHODS

150 consecutively admitted female prisoners were interviewed in Berlin, Germany. Socio-demographic characteristics, mental disorders, and previous psychiatric in- and outpatient treatments were assessed by trained researchers. Open questions were used to explore reasons for ending previous psychiatric treatment.

RESULTS

A vast majority of 99 prisoners (66%; 95% CI: 58-73) of the total sample reported that they had previously been in psychiatric treatment, 80 (53%; 95 CI: 45-61) in inpatient treatment, 62 (41%; 95 CI: 34-49) in outpatient treatment and 42 (29%; 21-39) in both in- and outpatient treatments. All prisoners with psychosis and 72% of the ones with any lifetime mental health disorder had been in previous treatment. The number of inpatient treatments and imprisonments were positively correlated (rho = 0.27; p < 0.01). Inpatient treatment was described as successfully completed by 56% (N = 41) of those having given reasons for ending such treatment, whilst various reasons were reported for prematurely ending outpatient treatments.

CONCLUSION

The data do not support the notion of a general 'mental health treatment gap' in female prisoners. Although inpatient care is often successfully completed, repeated inpatient treatments are not linked with fewer imprisonments. Improved transition from inpatient to outpatient treatment and services that engage female prisoners to sustained outpatient treatments are needed.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.

Pre-sentence mental health service use by adult offenders in Western Australia: baseline results from a longitudinal whole-population cohort study

BACKGROUND

Little is known about community mental health service use prior to offending.

AIM

This study aimed to investigate the 1-year community mental health service use by adult offenders (18-44 years) prior to their first ever criminal sentence in Western Australia.

METHODS

Administrative mental health service data were compared between all offenders (n = 23,755) commencing their first ever criminal sentence in Western Australia during 1985-1994 and a matched community group of 21,977 non-offenders.

RESULTS

Just over 8% of offenders had used mental health services prior to sentence compared with 1% of non-offenders. After adjusting for age, offenders were more likely to have used these services than non-offenders in all gender-race groups, but the effect was strongest for non-Indigenous women, who were over 12 times more likely to have used such services, and weakest among Indigenous men, who were about twice as likely to have used them as their non-offending peers. Service use for substance use disorder, the most common diagnosis, was about one and a half times more prevalent among Indigenous than non-Indigenous offenders, regardless of gender. For non-Indigenous offenders, prevalence of any mental health service contact was higher for violent than non-violent offenders, irrespective of gender. Service use was no different between offenders receiving custodial or non-custodial sentences in all gender-race groups.

CONCLUSION

The higher likelihood of mental health service use by offenders in the year prior to their first ever sentence than by non-offenders suggests that, insofar as the disorder was relevant to offending, there were some opportunities for preventive measures during that time. Differential service use according to gender and Indigenous/non-Indigenous status is of concern. It would be important to understand more about this apparently unequal service access, not least because Indigenous populations tend to be over-represented in prison.

Lifetime trauma exposure and posttraumatic stress disorder in women sentenced to drug court

The aims of this study were to characterize trauma exposure and posttraumatic stress disorder (PTSD) in female drug court participants and test for differences in socioeconomic status and familial status between women with: (i) no trauma exposure, (ii) trauma exposure without PTSD, and (iii) trauma exposure resulting in PTSD. Three hundred and nineteen women were recruited from drug courts. Rates of exposure and likelihood of traumatic events leading to PTSD were examined, sociodemographic characteristics were compared across groups, and a logistic regression analysis was conducted to test for differences in PTSD risk for assaultive vs. non-assaultive events. Twenty percent of participants met PTSD criteria, 71% had trauma exposure without PTSD, and 9% did not endorse any traumatic events. Prostitution and homelessness were more prevalent in women with vs. without a history of trauma, but among trauma-exposed women prevalences did not vary by PTSD status. No differences in risk for PTSD were found between assaultive and non-assaultive events (OR=0.91; 95%CI: 0.48-1.75). Women sentenced to drug court represent a heavily trauma-exposed population, for whom risk for PTSD is not limited to assaultive events. Within this high-risk population, trauma is associated with elevated rates of homelessness and prostitution, even in the absence of PTSD.

The life conditions of Australian ex-prisoners: an analysis of intrapersonal, subsistence, and support conditions

Successful reintegration of ex-prisoners into the community is multifaceted. The life conditions of 36 adult Australian ex-prisoners (20 male and 16 female) were examined via a questionnaire administered at 1 to 4 weeks post release, and a subset of 19 of the original respondents were interviewed again at 3 to 4 months post release. Interviews focused on intrapersonal conditions (physical and psychological health and substance use), subsistence conditions (housing, employment, and finance), and support conditions (social support, support services/program participation, and criminal justice support). The majority of ex-prisoners self-reported chronic physical and mental health problems as well as a history of substance use and/or current substance use. Although the housing conditions of ex-prisoners were largely favourable and constant, the employment and financial conditions of this group were generally unfavourable. Level of social support was variable. Theoretical implications and practical applications of the present investigation for reintegration theory are discussed.

Psychopathy and internalizing psychopathology

There is general consensus in clinical and research literature that the core feature of psychopathy consists of an affective deficit. However, previous studies tend to find weak and inconsistent associations between psychopathy and measures of internalizing psychopathology. In this study we test whether the predominant practice of using questionnaires to assess internalizing psychopathology has influenced the results of previous research. We argue that questionnaires measure general distress rather than specific symptoms of internalizing psychopathology, and that the validity of questionnaires might be impaired by psychopathic traits, such as impression management and lack of affective experience. Combining a questionnaire (Depression Anxiety Stress Scales-21; DASS-21) and a semi-structured interview (Structured Clinical Interview for DSM-IV-R Axis 1 Disorders; SCID-I) for internalizing psychopathology, we test the differential association of both measures with the Psychopathy Checklist-Revised (PCL-R) in a sample of 89 male detainees. In accordance with our prediction, we found moderate negative associations between the Interpersonal and Affective facets of the PCL-R and SCID-I, but no significant associations with the DASS-21. We found no evidence that psychopathic traits decrease the validity of the responses on a questionnaire. We conclude that the interpersonal and affective features of psychopathy are negatively related to specific symptoms of internalizing psychopathology, but not with general distress.

Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory

Although interpersonal style is a defining feature of personality and personality disorder and is commonly identified as an important influence on aggressive behavior, treatment completion, and the development of an effective therapeutic alliance, it is rarely considered in practice guidelines for preventing, engaging, and managing patients at risk of aggression. In this article, the authors consider three potential applications of interpersonal theory to the care and management of patients at risk of aggression during hospitalization: (a) preventing aggression through theoretically grounded limit setting and de-escalation techniques, (b) developing and using interventions to alter problematic interpersonal styles, and (c) understanding therapeutic ruptures and difficulties establishing a therapeutic alliance. Interpersonal theory is proposed to offer a unifying framework that may assist development of intervention and management strategies that can help to reduce the occurrence of aggression in institutional settings.

Psychiatric symptoms and histories among people detained in police cells

OBJECTIVES

This study examined the psychiatric symptoms, mental health histories and psychiatric medication use in a sample of people detained in police cells. Offences that led to the detention episode were compared between those with and without psychiatric symptoms.

METHOD

Detainees were interviewed by nurses who completed a clinical interview and the Brief Psychiatric Rating Scale. Full histories of contact data for participants were then drawn from the public mental health services database and the police database, and from their general practitioners.

RESULTS

One-third of the 614 detainees exhibited psychiatric symptoms in police custody; and 42% received medical treatment after arrest. Over half (55%) of the detainees had previous contact with the public mental health system. Having a history of contact with mental health services was found to contribute significantly to psychiatric symptoms in police cells. Offences committed by detainees did not differ between those presenting with and without psychiatric symptoms.

CONCLUSIONS

Many detainees in police cells experience psychiatric symptoms. This creates a significant clinical need necessitating timely access to health care and a continuity of care with health service providers beyond the initial police cell contact. Such a service model will require the development of functional interagency partnerships between the police and health services.

Benchmarking forensic mental health organizations

OBJECTIVE

This paper describes the forensic mental health forums that were conducted as part of the National Mental Health Benchmarking Project (NMHBP). These forums encouraged participating organizations to compare their performance on a range of key performance indicators (KPIs) with that of their peers.

METHOD

Four forensic mental health organizations took part in the NMHBP. Representatives from these organizations attended eight benchmarking forums at which they documented their performance against previously agreed KPIs. They also undertook three special projects which explored some of the factors that might explain inter-organizational variation in performance.

RESULTS

The inter-organizational range for many of the indicators was substantial. Observing this led participants to conduct the special projects to explore three factors which might help explain the variability - seclusion practices, delivery of community mental health services, and provision of court liaison services. The process of conducting the special projects gave participants insights into the practices and structures employed by their counterparts, and provided them with some important lessons for quality improvement.

CONCLUSIONS

The forensic mental health benchmarking forums have demonstrated that benchmarking is feasible and likely to be useful in improving service performance and quality.

Diversion down under - Programs for offenders with mental illnesses in Australia

This article provides an overview of mental health courts and diversion programs operating for offenders with mental illnesses in Australia. Methods of diversion that have been established in Australia include Magistrates courts diversion programs, psychiatric court liaison services and legislative powers of diversion. Some of the problems associated with diversionary options are discussed and recommendations for reform made. It is argued that no matter what form diversionary programs take, detailed consideration must be given to how the court or program will be evaluated and that sufficient funding be allocated for ongoing evaluation.

Características, sintomas depressivos e fatores associados em mulheres encarceradas no Estado do Rio Grande do Sul, Brasil

O estudo objetivou traçar o perfil, descrever as características sociodemográficas e clínicas da mulher prisioneira, além de verificar a prevalência de sintomas depressivos e de desesperança, uso, abuso e dependência de drogas e álcool. Participaram 287 mulheres de uma Penitenciária Feminina do Estado do Rio Grande do Sul, Brasil. O delineamento foi de um estudo quantitativo e transversal. Os achados mostram que o perfil caracteriza-se por ser solteira, jovem, ter no mínimo dois filhos, ter exercido atividades informais e geralmente de baixo status social e/ou econômico, possuir até o Ensino Fundamental incompleto. Foi encontrada alta prevalência de sintomas depressivos e uso, abuso e dependência de drogas, porém baixa prevalência de sintomas de desesperança. Diversos fatores, principalmente ligados à vida pregressa das participantes, foram associados significativamente com os sintomas depressivos.

Effect of early intervention on 5-year outcome in non-affective psychosis

BACKGROUND

Early specialised care may improve short-term outcome in first-episode non-affective psychosis, but it is unclear if these benefits endure.

AIMS

To assess the long-term effect of early intervention in psychosis.

METHOD

Individuals with first-episode psychosis were randomised to specialised care or care as usual (trial number: ISRCTN73679874). Outcome after 5 years was assessed by case-note review.

RESULTS

There were no significant differences in the admission rate (coefficient 0.096, 95% CI -0.550 to 0.742, P = 0.770) or the mean number of bed days (coefficient 6.344, 95% CI -46 to 58.7, P = 0.810).

CONCLUSIONS

These findings that specialist intervention did not markedly improved outcome at 5 years accord with those from a larger OPUS study. The sample size of this study was small and these results should be generalised with caution. More research is needed.

Prevalence, characteristics and comorbidities of anxiety disorders in France: results from the "Mental Health in General Population" survey (MHGP)

PURPOSE

Only a few European countries have carried out large, community-based, national surveys about psychiatric morbidity. Here is presented the first national French survey, aiming to estimate the prevalence of anxiety disorders and associated comorbidities according to sociodemographic characteristics.

MATERIALS AND METHODS

The Mental Health in General Population (MHGP) database is derived from a representative national survey of the French adult population (n=36,105), conducted between 1999 and 2003. Data collection was done using an anonymous face-to-face interview. The presence of anxiety disorders (generalized anxiety disorder, panic disorder, agoraphobia, social phobia and post-traumatic stress disorder) was assessed using the Mini International Neuropsychiatric Interview.

RESULTS

The overall prevalence of anxiety disorders was estimated to be 21.6%, generalized anxiety disorder being the most prevalent one (12.8%). Women, young people, and people earning low income were identified as the more at risk. Major depressive episode, alcohol abuse and drug addiction frequently co-occur with anxiety disorders (28.3, 4.4 and 2.8% respectively).

CONCLUSION

The MHGP study showed that anxiety disorders are highly prevalent in France with a high frequency of comorbidities. Our results highlight the need for considering anxiety disorders as a public health priority in France as well as in other European countries.

The insidious problem inside: mental health problems of Aboriginal and Torres Strait Islander People in custody

OBJECTIVE

Despite recognition of the extremely high rates of mental illness among custodial populations and the fact that Indigenous people represent around one-quarter of Australia's custodial population, little is known about the mental health of Aboriginal and Torres Strait Islander people in custody. Mental health is an important component of social and emotional wellbeing for Indigenous people and this paper considers current evidence regarding the mental health status of Indigenous Australians in custody.

METHOD

A systematic review was undertaken of the quantitative literature relating to the mental health problems of Indigenous people in custody in Australia.

RESULTS

Despite high incarceration rates for Indigenous people and evidence that both mental health problems and rates of mental illness are extremely high in this group, studies in this area are few and limited in scope.

CONCLUSION

The first step toward addressing the marked social and mental health problems for Indigenous people in custody is to systematically identify the nature and extent of these problems.

Neuropsychiatric correlates of traumatic brain injury (TBI) among Australian prison entrants

PRIMARY OBJECTIVE

To investigate the association between reported past traumatic brain injury (TBI) and demographic, neuropsychiatric and criminographic parameters among individuals recently received into custody.

RESEARCH DESIGN

A random sample of men recently received into the New South Wales (Australia) criminal justice system were screened for a history of TBI and the details of up to five separate TBI episodes were obtained. We also screened for depression, psychosis, personality disorder, drug and alcohol use, and 'social connectedness'.

MAIN OUTCOME AND RESULTS

Among the 200 study participants, 82% reported past TBI. TBI was associated with a history of engagement in contact sports, school expulsion, daily illicit drug use, depression and psychosis.

CONCLUSIONS

Past TBI is common among prisoners entering the criminal justice system and, amongst other correlates, appears to be highly associated with increased rates of major mental illness.

A Prison Mental Health Screening Unit: a first for New South Wales

OBJECTIVE

The aims of this paper are to provide a description of a newly available service the Mental Health Screening Unit (MHSU), within the NSW prison system and to present the first 12 months in terms of the patients, its adaptations and its limitations.

METHODS

The first section of this paper provides a thorough description of the MHSU. The second looks at data collected for the period 1 July 2006 to 30 June 2007. A variety of databases were utilized as sources.

RESULTS

There were a total of 604 admissions. The most common primary diagnoses were schizophrenia-related disorders. There were relatively few adverse incidents, and 18% of the acute unit population were transferred to the Long Bay Prison Hospital.

CONCLUSION

The MHSU had a considerable throughput of patients and managed a range of severe mental illnesses. The initial objectives of the MHSU have broadly been achieved. There are several future areas of research discussed.

Court outcomes for clients referred to a community mental health court liaison service

Court liaison and diversion services come in a variety of forms, but the similarities and differences between these services are not well characterized. Findings from a six-year audit of the Newcastle (Australia) Mental Health Court Liaison (MHCL) service are reported, including client characteristics, offence and service contact profiles, court outcomes, and interrelationships among these variables. During the audit period, there were 2383 service episodes by 1858 clients (1478 males, 380 females). Drug and alcohol disorders (40.9%) and psychotic disorders (17.0%) were the most prevalent mental health problems, while assault (23.1%), theft (23.1%), offences against justice procedures (15.4%), driving offences (13.4%) and malicious damage to property (8.3%) were the most frequently recorded charges. Among service episodes with a finalized court outcome, 70.0% involved a punishment (bond: 49.5%; jail term: 29.7%). Females were less likely to be punished, but more likely to have their case dismissed under sections of the relevant Act that required further assessment and monitoring. Being married, or having an adjustment or drug and alcohol disorder, were also associated with an increased likelihood of punishment, while clients with a psychotic or bipolar disorder were less likely to be punished. Among clients who were punished, those referred from inpatient mental health services were more likely to receive a non-jail punishment, while unemployed clients were more likely to be jailed. A substantial proportion of clients had court outcomes that required an ongoing involvement with local mental health services. By being part of community mental health services, our MHCL service is able to work efficiently and effectively with the criminal justice system, while facilitating ready access to existing mental health services and continuation of care.

Mental illness and intellectual disability in Magistrates Courts in New South Wales, Australia

BACKGROUND

Little is known about the prevalence of intellectual disability (ID) and/or cognitive impairment (CI) among accused persons in the Magistrates (Local) Courts, the personal, health and mental health characteristics of this cohort, and their service provision needs in the community. The study aimed to determine the prevalence of dual diagnoses of ID and/or CI and psychiatric disorder in a sample of accused persons appearing before four Magistrates Courts. Accused persons with ID and/or CI may not be identified in the Magistrates Court as having a disability and therefore may be unable to access the legal safeguards which exist for their protection within the criminal justice system and/or may fail to receive appropriate community health and welfare services.

METHOD

The sample was drawn from accused persons aged over 18 years appearing before four Magistrates Courts in metropolitan and urban areas of a large city. Participants were assessed using the Kaufman Brief Intelligence Test, Second Edition (KBIT-2), Vineland Adaptive Behavior Scales, Second Edition (VABS2) and the Psychiatric Assessment Schedules for Adults with Developmental Disabilities Checklist.

RESULTS

On the KBIT-2, 10% of participants achieved a standard score (SS) below 70 (mild ID range) and a further 20% were in the 70-79 (borderline) range. The VABS2 results indicated that 12% of participants had SS below 70 and a further 9% were in the 70-79 (borderline) range. The prevalence of mental illness in the group with intellectual deficits was 46%, compared with a prevalence of 36% for those without intellectual deficits.

CONCLUSIONS

People with ID and/or CI were found to be over-represented in the Magistrates Court. Furthermore, results highlight the unmet mental health needs of this cohort in the criminal justice system. The results of the study have implications for the planning of services and diversionary options to facilitate better management of defendants with ID and/or CI with mental health needs.

Attention deficit/hyperactivity disorder in female offenders: prevalence, psychiatric comorbidity and psychosocial implications

Attention deficit-/hyperactivity disorder (ADHD) is associated with social maladaptation and delinquency in later life. This study was conducted to determine the prevalence of ADHD and comorbid conditions in female prison inmates. One hundred and ten adult female prison inmates of a German prison for women were investigated. SCID-I and -II interviews and standardized German instruments for the assessment of ADHD in adults (HASE) were used. The lifetime prevalence of ADHD was 24.5 and 10% for persisting ADHD according to DSM-IV criteria. A decline of the prevalence of persisting ADHD with age from 17.9% (age <25 years) to 10% (age 26-45 years) and 0% (age >45 years) was observed. Female prisoners with ADHD were younger at their first conviction as compared with females without ADHD and they showed longer incarceration periods in relation to age. The prevalence of other axis I disorders was high in both the ADHD and the non-ADHD female population, but significantly higher in ADHD females. Mean number of axis I diagnoses was 3.6 in females with ADHD and 2.3 in females without ADHD. No differences were found between females with and without ADHD regarding the prevalence of psychotic, affective, anxiety, somatization and posttraumatic disorders. Substance use disorders and in particular the use of stimulants were more frequent in females with ADHD as well as borderline personality disorder and eating disorders. The results suggest a high prevalence of ADHD in female prisoners that exceeds the prevalence estimates from epidemiological studies in general female populations. Moreover, it appears that ADHD is particularly frequent in adolescent and young adult female offenders and increases the risk for further psychiatric morbidity. The results indicate the need of adequate psychiatric support of female prison inmates including therapeutic programs for ADHD.

Temperament, substance use and psychopathology in a prisoner population: implications for treatment

OBJECTIVE

The association between temperament and drug use or temperament and psychopathology has previously been restricted to community clinical or non-clinical samples. The aim of the present study was therefore to examine these associations in a large cohort of Australian offenders using Cloninger's Temperament and Character Inventory (TCI).

METHODS

A total of 1322 prisoners from New South Wales (NSW) who completed all dimensions of the TCI and were screened for mental illness using the Australian National Survey of Mental Health and Wellbeing were included in the study.

RESULTS

A total of 15% of the sample fulfilled the criteria for a diagnosis for depression, 36% for anxiety disorders and 54% for a substance abuse disorder. Using logistic regression analysis, the TCI dimensions of harm-avoidance and low self-direction predicted depression. Being female, a poly-substance user and having high harm-avoidance, persistence, self-direction and self-transcendence predicted anxiety disorders. Significant stepped trends across age, gender, and type of drug use were found for all TCI dimensions.

CONCLUSIONS

The TCI is useful in identifying prisoners with a history of psychopathology and substance misuse. This tool also provides clinically relevant information about at-risk individuals and has the potential to guide the development of intervention programmes for inmates.

Aboriginal and non-Aboriginal health differentials in Australian prisoners

OBJECTIVE

Compare the self-reported physical and mental health of Aboriginal and non-Aboriginal prisoners in New South Wales (NSW).

DESIGN

Cross-sectional random sample.

SETTING

Twenty-nine correctional centres (27 male and two female) in NSW.

PARTICIPANTS

747 men (227 Aboriginal) and 167 women (29 Aboriginal) in full-time custody.

METHODS

Face to-face interviews were used to record self-reported health status.

RESULTS

Aboriginal prisoners differed significantly from non-Aboriginal inmates in several socio-demographic and criminographic factors. However, few differences were observed in health status between Aboriginal and non-Aboriginal men and women. After adjusting for age, Aboriginal men were more likely to report high blood pressure and diabetes. No differences were found in chronic health conditions in the female group. Aboriginal men had higher SF-36 scores than non-Aboriginal men on general health, vitality, and mental health. Aboriginal women had lower scores than non-Aboriginal women on social functioning and role-emotional but scored higher on the role-physical dimension. Aboriginal inmates were more likely to report seeing certain health professionals (doctors, dentists, drug and alcohol counsellors, and optometrists) in prison compared with the community.

CONCLUSIONS

The health of Aboriginal and non-Aboriginal prisoners is remarkably similar in this population group. Few differences were observed in self-reported chronic health conditions. Aboriginal prisoners report using prison health services more while in prison compared with the community. This highlights that for many, prison is a rare opportunity to contact health services.

Mental health status of Aboriginal and non-Aboriginal Australian prisoners

OBJECTIVE

To compare the mental health of Aboriginal and non-Aboriginal prisoners in New South Wales.

METHODS

The sample consisted of a cross-sectional random sample of sentenced prisoners, and a consecutive sample of reception prisoners. The sample was drawn from 29 correctional centres (27 male, two female) across New South Wales. Overall, 1208 men (226 Aboriginal), and 262 women (51 Aboriginal) participated in the study. Mental illness was detected using the Composite International Diagnostic Interview (CIDI-A) and a number of other screening measures incorporated into the programme.

RESULTS

No differences were detected in mental illness between Aboriginal and non-Aboriginal men, apart from depression, which was lower in the latter group. Aboriginal woman were more likely than non-Aboriginal women to screen positive for symptoms of psychosis in the prior 12 months and have a higher 1 month and 12 month prevalence of affective disorder; they also had higher psychological distress scores. Suicidal thoughts and attempts were the same in both groups.

CONCLUSIONS

These findings confirm that the demand for mental health services in prisons is considerable, and that Aboriginal women are one of the most vulnerable groups. Services and programmes providing an alternative to incarceration are needed, as are culturally sensitive approaches to treatment.

Smoking and its correlates in an Australian prisoner population

Despite evidence of high rates of smoking among prisoners, there has been limited research that describes smoking patterns and risk factors associated with smoking in this group. This study describes inmate smokers and identifies factors associated with smoking in prison, using a survey comprising a cross-sectional random sample of inmates stratified by sex, age and Aboriginality. A total of 914 adult inmates (747 men, 167 women) were recruited from 29 New South Wales (Australia) correctional centres. Information on the prevalence of smoking, smoking history, smoking behaviours and other risk factors were collected. Of the participants, 79% were current smokers (78% men, 83% women). Younger inmates were more likely than older inmates to smoke (86% vs. 64%). Most individuals smoked between 11 and 20 cigarettes a day and a median of 50 grams per week. In the previous year, over half (52%) of current smokers had attempted to quit or reduce the amount they smoked. At the time of the survey, 58% of smokers had plans to quit; 21% within 3 months. Independent predictors of current smoking in the multivariate analysis were past use of cannabis and a history of illicit drug use. The prevalence of smoking in prison is extraordinarily high and exceeds that of the general community. Despite this, the majority of prisoners report plans to quit. Readily available smoking cessation advice, support and treatment are needed to assist those wanting to quit in this stressful environment. As the prevalence of smoking within the general community declines, assisting cessation in groups containing a disproportionate number of smokers will become increasingly important. Despite high levels of tobacco dependence, many prisoners intend to quit and health planners and custodial authorities need to encourage and support inmates who do attempt to quit.

Mental disorders in Australian prisoners: a comparison with a community sample

BACKGROUND

The plight of those with mental health problems and the possible role of prisons in "warehousing" these individuals has received considerable media and political attention. Prisoners are generally excluded from community-based surveys and to date no studies have compared prisoners to the community.

OBJECTIVE

The objective was to examine whether excess psychiatric morbidity exists in prisoners compared to the general community after adjusting for demographics.

METHOD

Prison data were obtained from a consecutive sample of reception prisoners admitted into the state's correctional system in 2001 (n = 916). Community data were obtained from the 1997 Australian National Survey of Mental Health and Wellbeing (n = 8168). Mental health diagnoses were obtained using the Composite International Diagnostic Interview and a number of other screening measures. Weighting was used in calculating the 12-month prevalence estimates to control for demographic differences between the two samples. Logistic regression adjusting for age, sex and education was used to compare the prison and community samples.

RESULTS

The 12-month prevalence of any psychiatric illness in the last year was 80% in prisoners and 31% in the community. Substantially more psychiatric morbidity was detected among prisoners than in the community group after accounting for demographic differences, particularly symptoms of psychosis (OR = 11.8, 95% CI 7.5-18.7), substance use disorders (OR = 11.4, 95% CI 9.7-13.6) and personality disorders (OR = 8.6, 95% CI 7.2-10.3). Mental functioning and disability score were worse for prisoners than the community except for physical health.

CONCLUSIONS

This study found an overrepresentation of psychiatric morbidity in the prisoner population. Identifying the causes of this excess requires further investigation.

The effect of hepatitis C virus infection on health-related quality of life in prisoners

Hepatitis C virus (HCV) infection in prisoners represents an important public health problem. However, there is very little information about HCV-related health-related quality of life (HRQOL). We examined the effect of HCV antibody positivity, HCV viremia, and being a prisoner on prisoners'' HRQOL. Population-based health surveys incorporating HCV screening were conducted among prisoners at New South Wales (NSW), Australia, correctional centers in 1996 and 2001. HCV antibody and HCV RNA status were determined from venous blood sampling. HRQOL and mood status were assessed using the Short Form-36 (SF-36) Health Survey and Beck Depression Inventory (BDI). Comparison of HRQOL scores between HCV antibody negative, HCV antibody positive/non-viremic, and HCV antibody positive/viremic and assessment of temporal change in HRQOL between 1996 and 2001 within groups were made using ANCOVA adjusting for confounders. Factors associated with HRQOL were determined in linear regression models. Analyses between HCV antibody negative (n = 423), HCV positive/non-viremic (n = 89), and HCV positive/viremic (n = 178) prisoners found no measurable effect of HCV on HRQOL, including that attributable to HCV viremia. Compared to uninfected Australian population norms, prisoners had lower HRQOL irrespective of HCV status. The prevalence of 'moderate' to 'severe' depressive symptoms was greater in the HCV antibody positive/viremic group than the HCV antibody positive/non-viremic group or the HCV antibody negative group. Selected demographic factors (age), co-morbidity, severity of depressive symptoms and medical care utilization influenced HRQOL. There was evidence to support the effect of knowledge of HCV status on HRQOL. In conclusion, our findings contrast with previous studies in non-prisoner groups in which HCV infection appears to decrease overall HRQOL. Non-HCV factors may override HCV-specific HRQOL impairment in this population. Targeted management strategies are required to improve HRQOL of prisoners.