Self-harm following release from prison: A prospective data linkage study

Associations Between Supported Accommodation and Health and Re-offending Outcomes: a Retrospective Data Linkage Study

Following release from prison, housing and health issues form a complex and mutually reinforcing dynamic, increasing reincarceration risk. Supported accommodation aims to mitigate these post-release challenges. We describe the impact of attending Rainbow Lodge (RL), a post-release supported accommodation service for men in Sydney, Australia, on criminal justice and emergency health outcomes. Our retrospective cohort study using linked administrative data includes 415 individuals referred to RL between January 2015 and October 2020. Outcomes of interest were rates of criminal charges, emergency department (ED) presentations and ambulance attendance; and time to first reincarceration, criminal charge, ED presentation and ambulance attendance. The exposure of interest was attending RL; covariates included demographic characteristics, release year and prior criminal justice and emergency health contact. Those who attended RL (n = 170, 41%) more commonly identified as Aboriginal or Torres Strait Islander (52% vs 41%; p = 0.025). There was strong evidence that attending RL reduced the incidence criminal charges (adjusted rate ratio [ARR] = 0.56; 95% confidence interval [CI] 0.340.86; p = 0.009). Absolute rates indicate a weak protective effect of RL attendance on ED presentation and ambulance attendance; however, adjusted analyses indicated no evidence of an association between attending RL and rates of ED presentations (ARR = 0.88; 95% CI = 0.65-1.21), or ambulance attendance (ARR = 0.82; 95% CI = 0.57-1.18). There was no evidence of an association between attending RL and time to first reincarceration, charge, ED presentation or ambulance attendance. Greater detail about reasons for emergency health service contact and other self-report outcome measures may better inform how supported accommodation is meeting its intended aims.

No health without access: using a retrospective cohort to model a care continuum for people released from prison at an urban, safety net health system

BACKGROUND

Release from prison is characterized by discontinuity of healthcare services and results in poor health outcomes, including an increase in mortality. Institutions capable of addressing this gap in care seldom collaborate in comprehensive, data-driven transition of care planning. This study harnesses information from a data exchange between correctional facilities and community-based healthcare agencies in Colorado to model a care continuum after release from prison.

METHODS

We merged records from Denver Health (DH), an urban safety-net healthcare system, and the Colorado Department of Corrections (CDOC), for people released from January 1 to June 30, 2021. The study population was either (a) released to the Denver metro area (Denver and its five neighboring counties), or (b) assigned to the DH Regional Accountable Entity, or (c) assigned to the DH medical home based on Colorado Department of Healthcare Policy and Financing attribution methods. Outcomes explored were outpatient, acute care, and inpatient utilization in the first 180 days after release. We used Pearson's chi-squared tests or Fisher exact for univariate comparisons and logistic regression for multivariable analysis.

RESULTS

The care continuum describes the healthcare utilization at DH by people released from CDOC. From January 1, 2021, to June 30, 2021, 3242 people were released from CDOC and 2848 were included in the data exchange. 905 individuals of the 2848 were released to the Denver metro area or attributed to DH. In the study population of 905, 78.1% had a chronic medical or psychological condition. Within 180 days of release, 31.1% utilized any health service, 24.5% utilized at least one outpatient service, and 17.1% utilized outpatient services two or more times. 10.1% utilized outpatient services within the first 30 days of release.

CONCLUSIONS

This care continuum highlights drop offs in accessing healthcare. It can be used by governmental, correctional, community-based, and healthcare agencies to design and evaluate interventions aimed at improving the health of a population at considerable risk for poor health outcomes and death.

Sex differences in acute health service contact after release from prison in Australia: a data linkage study

OBJECTIVES

Women released from prison typically experience worse health outcomes than their male counterparts. We examined sex differences in the patterns, characteristics, and predictors of acute health service contact (AHSC) (i.e. ambulance and/or emergency department use) after release from prison.

STUDY DESIGN

Data linkage study.

METHODS

Baseline survey data from 1307 adults (21% women) within six weeks of expected release from prisons in Queensland, Australia (2008-2010) were linked prospectively with state-wide ambulance and emergency department, correctional, mental health, and death records. Crude and adjusted incidence rates and incidence rate ratios of AHSC were calculated overall and by sex. An Andersen-Gill model was fit to examine whether sex predicted AHSC. The interaction effect between sex and each model covariate was tested.

RESULTS

The crude incidence rates of AHSC after release from prison were 1.4 (95% confidence interval [CI]: 1.3-1.5) and 1·1 (95%CI: 1.1-1.2) per person-year for women and men, respectively. The relationship between perceived physical health-related functioning at the baseline and AHSC was modified by sex (P = 0·039). The relationship between perceived health-related functioning and AHSC also differed among women. Compared to women who perceived their physical health as fair or good at the baseline, women who perceived their physical health as poor were at greater risk of AHSC (hazard ratio = 2.4, 95%CI: 1.4-3·9, P = 0.001) after release from prison.

CONCLUSIONS

Among people released from prison, women's and men's AHSC differs depending on how they perceive their own physical health. The specific needs of women and men must be considered in transitional support policy and planning to improve their health outcomes.

The incidence and profile of self-harm among prisoners: findings from the Self-Harm Assessment and Data Analysis Project 2017-2019

PURPOSE

Internationally, rates of suicide and lifetime self-harm are higher in prisoners compared to the general population. This study aims to identify specific characteristics of self-harming behaviour and to establish a profile of prisoners who engage in self-harm.

DESIGN/METHODOLOGY/APPROACH

Data from the Self-Harm Assessment and Data Analysis Project (SADA) on self-harm episodes in prisons in the Republic of Ireland during 2017-2019 was used. Annual rates per 1,000 were calculated by age and gender.

FINDINGS

The rate of self-harm between 2017 and 2019 was 31 per 1,000 prisoners for men and six times higher at 184 per 1,000 prisoners for women. The rate of self-harm was twice as high among prisoners on remand than sentenced prisoners (60.5 versus 31.3 per 1,000). The highest rates of self-harm among sentenced prisoners were observed among 18-29-year-old men (45 per 1,000) and women (125 per 1,000). The rate of self-harm was higher among women prisoners in all age groups. Contributory factors associated with self-harm were mainly related to mental health but also linked to a prisoner's environment and relationships.

PRACTICAL IMPLICATIONS

There is a need to ensure access to timely and suitable mental health services, including both appropriate referral and provision of evidence-based mental health interventions to address the needs of these cohorts.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first national study to systematically examine incidence and patterns of self-harm among the prison population in Ireland. The recording of severity/intent of each episode is novel when assessing self-harm among the prison population.

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.

Self-harm and suicide attempts among incarcerated lesbian, gay and bisexual people in Australia

OBJECTIVES

Guided by minority stress theory, we explored the association between sexual identity, justice system involvement, self-harm and suicide attempts, among a cohort of incarcerated adults in Australia.

METHODS

A sample of 2698 adults incarcerated in Queensland and Western Australia were surveyed between 1 August 2008 and 12 August 2016 about their current psychological distress, mental health diagnoses, contact with mental health services, and lifetime and recent self-harm and suicide attempts. We used multivariable logistic regression to explore the relationship between sexual orientation, prior criminal justice system involvement, mental health and demographic factors.

RESULTS

Five percent of the sample identified as gay, lesbian or bisexual, with 37% of lesbian, gay, bisexual and other same-sex attracted individuals reporting that they had self-harmed (vs 14% of heterosexual peers; χ² = 52.4; p < 0.001) and 49% reporting a history of at least one suicide attempt (vs 23%; χ² = 49.2; p < 0.001). Lesbian, gay, bisexual and other same-sex attracted people were 2.1 times (95% confidence interval: [1.4, 3.3]) and 1.8 times (95% confidence interval: [1.2, 2.8]) more likely to report a history of self-harm and suicide attempt, respectively, than non-lesbian, gay, bisexual and other same-sex attracted respondents.

CONCLUSION

Intersectionality theory suggests that people who are navigating two or more marginalised identities often experience a compounding of internal and external stressors. Consistent with that theory, lesbian, gay, bisexual and other same-sex attracted people who experience incarceration may be at particularly high risk of self-harm and suicidal behaviour. Custodial settings should both improve cultural competency for frontline staff working with lesbian, gay, bisexual and other same-sex attracted individuals and improve access to mental health services during incarceration.

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.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Association between contact with mental health and substance use services and reincarceration after release from prison

Objective

People released from prison who experience mental health and substance use problems are at high risk of reincarceration. This study aimed to examine the association between contact with mental health and substance use treatment services, and reincarceration, among adults released from prison.

Methods

Pre-release survey data from 1,115 adults released from prisons in Queensland, Australia were linked with administrative health and correctional records covering a median of 787 days post-release. We constructed marginal structural Cox proportional hazards models, adjusting for pre-release variables and time-varying indicators of emergent mental health and substance use problems, to examine the association between contact with mental health and substance use treatment services, and reincarceration.

Results

The adjusted hazard ratio (AHR) for reincarceration associated with mental health service contact was 1.76 (95%CI 1.23,2.51). Among those not on parole following release, the AHR for reincarceration associated with substance use treatment service contact was 3.16 (95%CI 2.09,4.77); we found no evidence for an association among those who were released on parole (AHR = 1.07; 95%CI 0.80,1.43).

Conclusions

Although we cannot eliminate the possibility of residual confounding, our findings suggest that infrequent or unsustained contact with community-based mental health and substance use treatment services is not protective against reincarceration, and may even be iatrogenic. Increased investment in high-quality and timely behavioural health services for people released from prison may simultaneously improve health outcomes, and reduce reincarceration.

Psychiatric well-being among men leaving prison reporting a history of injecting drug use: A longitudinal analysis

BACKGROUND

Community reintegration from prison is typically stressful, with several health and social outcomes impacting psychiatric well-being during this time, often exacerbated among individuals with histories of drug use. Longitudinal data was used to assess change in psychiatric well-being over 2 years following release from prison among men who reported a recent history of injecting drug use.

METHODS

Data for this study come from the Prison and Transition Health cohort study of 400 men recruited in prison prior to release and followed up over three time points. Psychiatric well-being was assessed using the 12-item General Health Questionnaire. We calculated change in individual General Health Questionnaire scores between interviews and identified covariates associated with General Health Questionnaire score using linear mixed-effects regression.

RESULTS

Data from 690 follow-up interviews among 326 participants were included in analyses. There was considerable variation in individuals' General Health Questionnaire scores. Moving accommodation frequently and frequent illicit drug injections were associated with an increase in General Health Questionnaire score (i.e. decline in psychiatric well-being). Two or more prior adult imprisonment episodes, social supports and past month primary healthcare attendance were associated with a decrease in General Health Questionnaire score.

CONCLUSION

Our findings identify health, social and structural influences on psychiatric well-being after release from prison that can inform re-entry programmes to support community reintegration.

Criminal Justice Involvement after Release from Prison following Exposure to Community Mental Health Services among People Who Use Illicit Drugs and Have Mental Illness: a Systematic Review

Illicit drug use and mental illness are common among people in prison and are associated with higher rates of reoffending and reimprisonment. We conducted a systematic review, searching MEDLINE, Embase, and PsycINFO to January 10, 2022, for studies reporting criminal justice involvement following exposure to community mental health services among people released from jail or prison who use illicit drugs and have mental illness. Our search identified 6954 studies; 13 were eligible for inclusion in this review. Studies were separated into three broad categories based on community mental health service type. Eleven of 13 studies reported a reduction in criminal justice involvement among participants exposed to community mental health services compared to a comparison group. Findings indicate a need to expand and improve integration and referral mechanisms linking people to community mental health services after jail or prison release, alongside a need for tailored programs for individuals with complex illicit drug use and mental health morbidities.

Multimorbidity and quality of primary care after release from prison: a prospective data-linkage cohort study

Background

The period after release from prison can be challenging, especially due to a higher risk of morbidity and mortality despite commonly increased use of healthcare services. However, little is known about the quality of the healthcare offered to this population, which limits the possibility of addressing this important health inequity. This study characterised multimorbidity and investigated the relationship between multimorbidity and quality of primary healthcare in adults within 2 years after release from prison.

Methods

This was a prospective cohort study of 1046 participants of a service brokerage intervention after release from prison between August 2008 and July 2010 in Queensland, Australia. Participants had their baseline survey and clinical data linked prospectively with their medical, correctional and death records. Multimorbidity was ascertained using the Cumulative Illness Rating Scale and classified into three categories: none, moderate (morbidity in 2–3 domains) and complex (morbidity in 4 or more domains). Outcomes were Usual Provider Continuity Index (UPCI), Continuity of Care (COC) Index, and having at least one extended primary care consultation (> 20 minutes). Descriptive statistics and logistic regression were used in the analyses.

Results

Multimorbidity was present for 761 (73%) participants, being more prevalent among females (85%) than males (69%), p < 0.001. Moderate multimorbidity was not associated with UPCI or COC, but was associated with having at least one long consultation (AOR = 1.64; 95% CI:1.14–2.39), after adjusting for covariates. Complex multimorbidity was positively associated with all outcomes in the adjusted models. Indigenous status was negatively associated with UPCI (AOR = 0.54; 95% CI: 0.37–0.80) and COC (AOR = 0.53; 95% CI: 0.36–0.77), and people younger than 25 years were at 36% lower odds (AOR = 0.64; 95% CI: 0.44–0.93) of having a long consultation than the middle-aged group (25–44 years) in the adjusted models.

Conclusion

Moderate multimorbidity was associated with having at least one extended primary care consultation, but not with adequate continuity of care, for adults within 2 years of being released from prison. Nearly half of those with complex multimorbidity did not receive adequate continuity of care. The quality of primary care is inadequate for a large proportion of adults released from prison, constituting an important and actionable health inequity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08209-6.

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.

Leveraging data science to enhance suicide prevention research: a literature review

OBJECTIVE

The purpose of this research is to identify how data science is applied in suicide prevention literature, describe the current landscape of this literature and highlight areas where data science may be useful for future injury prevention research.

DESIGN

We conducted a literature review of injury prevention and data science in April 2020 and January 2021 in three databases.

METHODS

For the included 99 articles, we extracted the following: (1) author(s) and year; (2) title; (3) study approach (4) reason for applying data science method; (5) data science method type; (6) study description; (7) data source and (8) focus on a disproportionately affected population.

RESULTS

Results showed the literature on data science and suicide more than doubled from 2019 to 2020, with articles with individual-level approaches more prevalent than population-level approaches. Most population-level articles applied data science methods to describe (n=10) outcomes, while most individual-level articles identified risk factors (n=27). Machine learning was the most common data science method applied in the studies (n=48). A wide array of data sources was used for suicide research, with most articles (n=45) using social media and web-based behaviour data. Eleven studies demonstrated the value of applying data science to suicide prevention literature for disproportionately affected groups.

CONCLUSION

Data science techniques proved to be effective tools in describing suicidal thoughts or behaviour, identifying individual risk factors and predicting outcomes. Future research should focus on identifying how data science can be applied in other injury-related topics.

Interventions to reduce suicidal thoughts and behaviours among people in contact with the criminal justice system: A global systematic review

BACKGROUND

People who experience incarceration die by suicide at a higher rate than those who have no prior criminal justice system contact, but little is known about the effectiveness of interventions in other criminal justice settings. We aimed to synthesise evidence regarding the effectiveness of interventions to reduce suicide and suicide-related behaviours among people in contact with the criminal justice system.

METHODS

We searched Embase, PsycINFO, MEDLINE, and grey literature databases for articles published between 1 January 2000 and 1 June 2021. The protocol was registered with PROSPERO (CRD42020185989).

FINDINGS

Thirty-eight studies (36 primary research articles, two grey literature reports) met our inclusion criteria, 23 of which were conducted in adult custodial settings in high-income, Western countries. Four studies were randomised controlled trials. Two-thirds of studies (n=26, 68%) were assessed as medium quality, 11 (29%) were assessed as high quality, and one (3%) was assessed as low quality. Most had considerable methodological limitations and very few interventions had been rigorously evaluated; as such, drawing robust conclusions about the efficacy of interventions was difficult.

INTERPRETATION

More high-quality evidence from criminal justice settings other than adult prisons, particularly from low- and middle-income countries, should be considered a priority for future research.

FUNDING

This work was funded by the Australian government's National Suicide Prevention Taskforce. RB is supported by a National Health and Medical Research Council (NHMRC) Emerging Leader Investigator Grant (EL2; GNT2008073). MW is supported by a NHMRC Postgraduate Scholarship (GNT1151103). SF was funded by the NIHR HTA Programme (HTA Project:16/159/09).

Amphetamine-type stimulant use and self-harm: protocol for a systematic review of observational studies

INTRODUCTION

Amphetamine type stimulant (ATS) use and self-harm are both major public health concerns globally. Use of ATS is associated with a range of health and social problems, and has been increasing internationally in the last decade. Self-harm and ATS use share a number of underlying risk factors and occur at elevated rates in marginalised groups with high rates of exposure to trauma. The relationship between self-harm and ATS use is likely complex, and the causal pathway may run in either direction. A comprehensive review, synthesis and analysis of the evidence are warranted to investigate this relationship and inform policy and practice.

METHODS AND ANALYSIS

We will search the Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Scopus databases for relevant observational studies published in peer-reviewed journals. The initial search was conducted on 5 February 2021, with a final search expected on 1 February 2022. All studies will be independently screened by two reviewers, first on title and abstract, and then on full-text to determine inclusion in the review. We place no restriction on the population that studies investigate, our exposure of interest is both prescription and illicit ATS use, comparators will be those not currently using ATS, and our primary outcome of interest is the prevalence of self-harm. Data will be extracted using a predesigned template, and pooled prevalence and pooled measures of effect for the association between ATS use and self-harm. If sufficient data are available, we will perform multiple meta-analyses to produce pooled measures of effect for each measure of ATS exposure, as well as different population sub-groups. The Methodological Standard for Epidemiological Research scale will be used to assess study quality, and Egger's test and I² values will be used to assess publication bias and heterogeneity, respectively.

ETHICS AND DISSEMINATION

No ethical approval is required for this review. We will only synthesise information from published studies that were conducted with ethical approval, so no individual participant data will be used. We will disseminate our findings via publication in a peer-reviewed journal, national and international conference presentations, and presentations to stakeholders in the community.

TRIAL REGISTRATION NUMBER

This study has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021226562).

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.

Contact with Mental Health Services After Acute Care for Self-Harm Among Adults Released from Prison: A Prospective Data Linkage Study

OBJECTIVE

To determine the care pathway and rate and predictors of mental health care contact within seven days of discharge from acute care following self-harm.

METHOD

In a representative cohort of adults released from prisons in Queensland, Australia, we probabilistically linked person-level, statewide ambulance, emergency department, and hospital records, both prospectively and retrospectively, and community mental health service and Medicare records prospectively, to baseline survey data. We fit multivariate modified log-linked Poisson regression models to examine the association between sociodemographic, health, and criminal justice factors and mental health care contact after self-harm.

RESULTS

Of 217 discharges from acute care following self-harm, 55% (n = 119) received mental health care within seven days of discharge. Mental health care contact was associated with substance use disorder (adjusted relative risk (ARR) = 0.48; 95% CI: 0.27-0.85), dual diagnosis (ARR = 0.58; 95% CI: 0.41-0.82), physical health-related functioning (ARR = 0.98; 95% CI: 0.97-0.99), being female (ARR = 1.39; 95% CI: 1.02-1.90), being identified as at risk of self-harm by correctional authorities (ARR = 1.50; 95% CI: 1.07-2.09), and prior engagement with state-funded mental health care (ARR = 1.55; 95% CI: 1.08-2.22).

CONCLUSION

Our findings highlight the need to improve the integration of community mental health care for people who present to acute care following self-harm with a recent history of incarceration, particularly for men and those with substance use disorder or dual diagnosis.

Adverse childhood experiences: a retrospective study to understand their associations with lifetime mental health diagnosis, self-harm or suicide attempt, and current low mental wellbeing in a male Welsh prison population

BACKGROUND

Prisoners are at increased risk of poor mental health and self-harming behaviours, with suicide being the leading cause of death in custody. Adverse childhood experiences (ACEs) such as child maltreatment are strong predictors of poor mental health and wellbeing yet despite high levels of ACEs in offender populations, relatively few studies have explored the relationships between ACEs and prisoners' mental health and wellbeing. We conducted an ACE survey with 468 male adult prisoners in a Welsh prison who were not currently considered to be at risk of self-harm and suicide and explored relationships between ACEs, lifetime mental illness diagnosis, self-harm (lifetime and lifetime in prison) or suicide attempt (lifetime and lifetime in prison), and current low mental wellbeing.

RESULTS

Most participants (84.2%) had suffered at least one ACE and 45.5% had suffered ≥4 ACEs. Prevalence of lifetime mental illness diagnosis, self-harm (lifetime and lifetime in prison) or suicide attempt (lifetime and lifetime in prison), and current low mental wellbeing increased with exposure to ACEs. For example, 2.7% of those with no ACEs reported lifetime self-harm or suicide attempt in prison compared with 31.0% (self-harm in prison) and 18.3% (suicide attempt in prison) of those with ≥4 ACEs. Compared with participants with no ACEs, those with ≥4 ACEs were four times more likely to report lifetime mental illness diagnosis and suicide attempt, and over 10 times more likely to report lifetime self-harm than those with no ACEs. Independent of lifetime mental illness diagnosis, self-harm or suicide attempt, participants with ≥4 ACEs were almost three times more likely to have current low mental wellbeing than those with no ACEs.

CONCLUSIONS

Male prisoners that have suffered multiple ACEs are substantially more likely to have lifetime mental illness diagnosis, self-harm or suicide attempt, and to have current low mental wellbeing whilst in prison. Findings suggest that trauma-informed approaches are needed in prisons to support prisoner mental health and wellbeing.

Self-reported sleep disturbance in ambulance attendances for suicidal ideation and attempted suicide between 2012 and 2017

BACKGROUND

Sleep disturbances are among the top-ten warning signs for suicide, however there has been limited investigation of the relationship between these variables in acute presentations, particularly community settings. We examined ambulance attendances for suicide ideation and attempt to explore the role of sleep and co-morbid factors (mental health symptoms, attendance time, and alcohol and benzodiazepine use).

METHODS

Coded clinical records from Ambulance Victoria for the period 1 January 2012 to 30 June 2017 were analysed.

RESULTS

Paramedics attended 97,198 cases of suicidal ideation or suicide attempt during the study period. Just over half (56.4%) of these were for suicidal ideation, and 43.6% were for attempted suicide. Depression symptomology-related attendances were more common than those for anxiety and despite a lower proportion of both sleep and current anxiety-related symptoms, benzodiazepine use was significantly more common in attendances for suicide attempts (25.9%) than for ideation (2.2%). Co-morbid benzodiazepine use was associated with attempted suicide (OR: 10.37 (10.04-10.72), in a hierarchical regression model.

LIMITATIONS

Data represent self-report/paramedic observation only, and do include validated measures of sleep or drug use. Sleep disturbance is likely under recorded in ambulance attendances given the primary role of paramedics is to stabilise patients, and minimise risk of harm during transport.

CONCLUSION

This study reports internationally unique data, and provides the first examination of ambulance coded clinical records for suicide ideation and attempt. Sleep disturbances had a unique role in these attendances, over and above common co-occurring factors including drug use and mental health diagnoses.

Frequent Attendance to the Emergency Department after Release from Prison: a Prospective Data Linkage Study

The aim of this paper was to identify characteristics and predictors of frequent emergency department (ED) use among people released from prisons in Queensland, Australia. Baseline interview data from a sample of sentenced adults were linked to ED and hospital records. The association between baseline characteristics and frequent ED attendance was modelled by fitting multivariate logistic regression models. Participants who had ≥ 4 visits to the ED in any 365-day period of community follow-up were defined as frequent attenders (FA). The analyses included 1307 people and mean follow-up time in the community was 1063 days. After adjusting for covariates, those with a dual diagnoses of mental illness and substance use (RR = 2.42, 95% CI 1.47–3.99) and those with mental illness alone (RR = 2.47, 95% CI 1.29–4.73) were at higher risk of frequent ED attendance, compared with those with no disorder. Future research should assess whether individually tailored transition supports from prison to community reduce the frequency of ED use among this population.

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

Emergency health service contact and reincarceration after release from prison: A prospective cohort study

BACKGROUND

Adults released from prison often have complex health needs. They are at high risk of poor health outcomes and reincarceration, with health service use unlikely to be planned.

AIMS/HYPOTHESES

To determine the incidence of emergency health service (EHS) use, ambulance attendance and/or emergency department presentation, among 1,181 adults released from Australian prisons. We hypothesised that EHS contact would be associated with increased reincarceration risk.

METHODS

Baseline surveys were conducted within 6 weeks before release. Postrelease EHS contacts and reincarceration were identified through prospective data linkage. For each participant, EHS contacts within a 24-hour period were combined to make an episode. We used Cox proportional hazards regression to examine the relationship between EHS episodes and reincarceration, controlling for covariates.

RESULTS

More than half (53.3%) of participants had at least one EHS contact over a median of 25.6-month follow-up. In adjusted analyses, compared to those with no EHS contacts, the hazard of reincarceration was greater for participants who had one to three EHS episodes (hazard ratio [HR] = 1.84; 95% confidence interval [CI] [1.48, 2.29]) or four or more (HR = 2.35; 95% CI [1.67, 3.29]).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Emergency department attendance by people with a history of imprisonment may be indicative of wider decompensation. Improved management of such patients may improve health outcomes and have collateral benefits for reducing reincarceration.

Lifetime prevalence and correlates of self-harm and suicide attempts among male prisoners with histories of injecting drug use

BACKGROUND

Histories of self-harm and suicide attempts are common among people in prison in Australia, and substance dependence is an established risk factor for these lifetime experiences. We describe the prevalence of self-reported history of non-suicidal self-injury (NSSI) and suicide attempts in a cohort of men with recent histories of injecting drug use (IDU) imprisoned in Victoria, Australia. Baseline interviews from the Prison and Transition Health (PATH) prospective cohort study were conducted in the weeks prior to release from prison among 400 incarcerated men who reported regular IDU in the six months prior to incarceration.

RESULTS

Participants completed a researcher-administered structured questionnaire that collected information on sociodemographics, substance use patterns, and physical and mental health indicators. More than one third (37%) reported a history of NSSI and almost half of participants (47%) reported a history of suicide attempts. In multivariable Poisson regression models, a history of NSSI was associated with: being aged 30-39 years; moving accommodation three or more times in the year prior to current sentence; self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting three or more previous drug overdoses. History of suicide attempts was significantly associated with: self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting a history of 1-2 and > 3 drug overdoses.

CONCLUSION

We observed a disconcertingly high lifetime prevalence of non-suicidal self-injury and suicide attempts among incarcerated males with a history of recent regular injecting drug use. Significant associations with indicators of mental illness and drug related harms support the need to prioritise in-prison screening and early intervention to reduce the risk of future harms for this population.

Self-harm and suicidal behaviour among incarcerated adults in the Australian Capital Territory

BACKGROUND

Suicide is the leading cause of death in prisons worldwide. Improved understanding of the factors associated with suicide is necessary to inform targeted suicide prevention and interventions. Here we aim to (a) document the prevalence of suicide attempts, suicidal ideation, self-harm, and mental disorder; and (b) identify demographic, mental health, and criminal justice correlates of suicidal ideation, in a sample of incarcerated adults in Australia.

METHODS

Data were obtained from the 2016 Detainee Health and Wellbeing Survey conducted in the Alexander Maconochie Centre, the Australian Capital Territory's only adult prison. Interviews with 98 incarcerated adults were conducted in October 2016. Descriptive statistics were calculated for all measures. Crude differences between participants who reported experiencing suicidal ideation in their lifetime and those who did not were compared using Fisher's exact test.

RESULTS

Nearly half of the participants (48%, n = 47) reported lifetime suicidal ideation and 31% (n = 30) reported attempting suicide at some point in their lives. Eighteen participants (18%) reported a lifetime history of having engaged in self-harm. Factors significantly associated with suicidal ideation included lifetime history of mental disorder, self-harm, experiencing a drug overdose, and being hospitalized in the past 12 months.

CONCLUSION

The burden of suicidal ideation and prior suicide attempts among people in prison is substantial. Incarceration is a pivotal opportunity to identify people with a history of mental health problems and target interventions aimed at reducing adverse outcomes including suicide mortality.

Evaluation of a complex intervention (Engager) for prisoners with common mental health problems, near to and after release: study protocol for a randomised controlled trial

INTRODUCTION

The 'Engager' programme is a 'through-the-gate' intervention designed to support prisoners with common mental health problems as they transition from prison back into the community. The trial will evaluate the clinical and cost-effectiveness of the Engager intervention.

METHODS AND ANALYSIS

The study is a parallel two-group randomised controlled trial with 1:1 individual allocation to either: (a) the Engager intervention plus standard care (intervention group) or (b) standard care alone (control group) across two investigation centres (South West and North West of England). Two hundred and eighty prisoners meeting eligibility criteria will take part. Engager is a person-centred complex intervention delivered by practitioners and aimed at addressing offenders' mental health and social care needs. It comprises one-to-one support for participants prior to release from prison and for up to 20 weeks postrelease. The primary outcome is change in psychological distress measured by the Clinical Outcomes in Routine Evaluation-Outcome Measure at 6 months postrelease. Secondary outcomes include: assessment of subjective met/unmet need, drug and alcohol use, health-related quality of life and well-being-related quality of life measured at 3, 6 and 12 months postrelease; change in objective social domains, drug and alcohol dependence, service utilisation and perceived helpfulness of services and change in psychological constructs related to desistence at 6 and 12 months postrelease; and recidivism at 12 months postrelease. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action and look for unintended consequences. An economic evaluation will estimate the cost-effectiveness.

ETHICS AND DISSEMINATION

This study has been approved by the Wales Research Ethics Committee 3 (ref: 15/WA/0314) and the National Offender Management Service (ref: 2015-283). Findings will be disseminated to commissioners, clinicians and service users via papers and presentations.

TRIAL REGISTRATION NUMBER

ISRCTN11707331; Pre-results.

Correlates of self-harm and suicide attempts in justice-involved young people

The purpose of this study was to ascertain the prevalence and correlates of self-harm among young people in detention in Australia. The sample included 215 (177 male; 38 female) young people who were in youth detention in the state of Victoria, Australia. Participants were administered a series of questionnaires related to self-harm, mental health, socio-environmental experiences and behaviours. Overall, one-third (33%) of the sample reported previous self-harm and 12% reported at least one suicide attempt. In a multivariate logistic regression analysis, a history of childhood trauma, contact with mental health services, and low educational interest significantly increased the likelihood of self-harm. Young people who reported a suicide attempt scored significantly higher on the measure of childhood trauma than did youth who had engaged in non-suicidal self-harm. Findings demonstrate a strong connection between childhood traumatic experiences and suicidal behaviours for youth in detention. Trauma histories and mental health concerns must be considered when identifying youth at increased risk of self-harm.

Extending smoking abstinence after release from smoke-free prisons: protocol for a randomised controlled trial

BACKGROUND

A smoking ban was implemented across all prisons in Queensland, Australia, in May 2014, with the aim of improving the health of prisoners and prison staff. However, relapse to smoking after release from prison is common. Only one previous study, conducted in the United States, has used a randomised design to evaluate an intervention to assist individuals in remaining abstinent from smoking following release from a smoke-free prison.

METHODS

This paper describes the rationale for and design of a randomised controlled trial of an intervention to extend smoking abstinence in men after release from smoke-free prisons in the state of Queensland, Australia. Participants in the intervention group will receive a brief intervention involving four group sessions of motivational interviewing and cognitive behavioural therapy, initiated 4 weeks prior to release from prison. The comparison group will receive a pamphlet and brief verbal intervention at the time of baseline assessment. Assessment of self-reported, post-release smoking status will be conducted by parole officers at regular parole meetings with the primary outcome measured at 1 month post release.

DISCUSSION

The prevalence of smoking and related health harms among people who experience incarceration is extremely high. Effective interventions that result in long-term smoking cessation are needed to reduce existing health disparities in this vulnerable population.

TRIAL REGISTRATION

Current Controlled Trials ACTRN12616000314426.

Suicidal ideation while incarcerated: Prevalence and correlates in a large sample of male prisoners in Flanders, Belgium

Prisoners constitute a high-risk group for suicide. As an early stage in the pathway leading to suicide, suicidal ideation represents an important target for prevention, yet research on this topic is scarce in general prison populations. Using a cross-sectional survey design, correlates of suicidal ideation while incarcerated were examined in a sample of 1203 male prisoners, randomly selected from 15 Flemish prisons. Overall, a lifetime history of suicidal ideation and attempts was endorsed by 43.1% and 20.3% of respondents, respectively. Approximately a quarter of all prisoners (23.7%) reported past-year suicidal ideation during their current incarceration, which was significantly associated with both imported vulnerabilities (psychiatric diagnoses and a history of attempted suicide) and variables unique to the prison experience (lack of working activity, exposure to suicidal behaviour by peers, and low levels of perceived autonomy, safety and social support) in the multivariate regression analysis. A first-ever period of imprisonment and a shorter length of incarceration (≤12months) were also associated with increased odds of recent suicidal ideation. Collectively, the current findings underscore the importance of both vulnerability factors and prison-specific stressors for suicidal ideation in prisoners, and hence the need for a multi-faceted approach to suicide prevention in custodial settings. In addition to the provision of appropriate mental health care, environmental interventions that target modifiable aspects of the prison regime could provide a substantial buffer for the onset and persistence of suicidal ideation in this at-risk population.

Ambulance attendances resulting from self-harm after release from prison: a prospective data linkage study

OBJECTIVE

Incarcerated adults are at high risk of self-harm and suicide and remain so after release into the community. The aims of this study were to estimate the number of ambulance attendances due to self-harm in adults following release from prison, and to identify factors predictive of such attendances.

METHODS

Baseline surveys with 1309 adults within 6 weeks of expected release from prison between 2008 and 2010 were linked prospectively with state-wide correctional, ambulance, emergency department, hospital and death records in Queensland, Australia. Associations between baseline demographic, criminal justice and mental health-related factors, and subsequent ambulance attendances resulting from self-harm, were investigated using negative binomial regression.

RESULTS

During 4691 person-years of follow-up (median 3.86 years per participant), there were 2892 ambulance attendances in the community, of which 120 (3.9%) were due to self-harm. In multivariable analyses, being Indigenous [incidence rate ratio (IRR): 2.10 (95% CI 1.14-3.86)], having previously been hospitalised for psychiatric treatment [IRR: 2.65 (95% CI 1.44-4.87)], being identified by prison staff as being at risk of self-harm whilst incarcerated [IRR: 2.12 (95% CI 1.11-4.06)] and having a prior ambulance attendance due to self-harm [IRR: 3.16 (95% CI 1.31-7.61)] were associated with self-harm attendances.

CONCLUSIONS

Ambulance attendances resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. The high prevalence of such attendances, in conjunction with the strong association with prior psychiatric problems, reinforces the importance of providing appropriate ambulance staff training in the assessment and management of self-harm, and mental health problems more broadly, in this vulnerable population.

Accuracy and predictive value of incarcerated adults' accounts of their self-harm histories: findings froman Australian prospective data linkage study

BACKGROUND

Self-harm is prevalent in prison populations and is a well-established risk factor for suicide. Researchers typically rely on self-report to measure self-harm, yet the accuracy and predictive value of self-report in prison populations is unclear. Using a large, representative sample of incarcerated men and women, we aimed to examine the level of agreement between self-reported self-harm history and historical medical records, and investigate the association between self-harm history and medically verified self-harm after release from prison.

METHODS

During confidential interviews with 1315 adults conducted within 6 weeks of expected release from 1 of 7 prisons in Queensland, Australia, participants were asked about the occurrence of lifetime self-harm. Responses were compared with prison medical records and linked both retrospectively and prospectively with ambulance, emergency department and hospital records to identify instances of medically verified self-harm. Follow-up interviews roughly 1, 3 and 6 months after release covered the same domains assessed in the baseline interview as well as self-reported criminal activity and contact with health care, social and criminal justice services since release.

RESULTS

Agreement between self-reported and medically verified history of self-harm was poor, with 64 (37.6%) of 170 participants with a history of medically verified self-harm disclosing a history of self-harm at baseline. Participants with a medically verified history of self-harm were more likely than other participants to self-harm during the follow-up period. Compared to the unconfirmed-negative group, the true-positive (adjusted hazard ratio [HR] 6.2 [95% confidence interval (CI) 3.3-10.4]), false-negative (adjusted HR 4.0 [95% CI 2.2-6.7]) and unconfirmed-positive (adjusted HR 2.2 [95% CI 1.2-3.9]) groups were at increased risk for self-harm after release from prison.

INTERPRETATION

Self-reported history of self-harm should not be considered a sensitive indicator of prior self-harm or of future self-harm risk in incarcerated adults. To identify those who should be targeted for preventive strategies, triangulation of data from multiple verifiable sources should be performed whenever possible.

Use of prescribed smoking cessation pharmacotherapy following release from prison: a prospective data linkage study

BACKGROUND

A significant proportion of people who cycle through prisons express a desire to quit smoking, yet smoking rates in this population are two to four times higher than in the general community. Smoking cessation pharmacotherapy (SCP) is an important component of evidence-based cessation support, yet no studies have examined use of this pharmacotherapy after release from prison.

METHODS

We linked data from a survey of 971 smokers who were within 8 weeks of release from prison in Queensland, Australia, with federal Pharmaceutical Benefits Scheme (PBS) records for the 2 years after release, to identify subsidised use of SCP (varenicline, bupropion and nicotine patches). We used Cox proportional hazards regression to identify independent predictors of SCP use.

FINDINGS

According to PBS data, 86 participants (8.9%) accessed SCP in the 2 years following release from prison. Participants who were aged 25 years or older (HR 2.51, 95% CI 1.19 to 5.31), employed before prison (HR 1.93, 95% CI 1.14 to 3.28), highly nicotine dependent at baseline (HR 2.21, 95% CI 1.23 to 3.97) and using non-psychotropic medications in prison (HR 2.29, 95% CI 1.24 to 4.22) were more likely to use subsidised SCP during follow-up.

CONCLUSION

Despite a very high rate of tobacco use among people cycling through prisons and the very low cost of (subsidised) SCP in Australia, few ex-prisoners obtain pharmaceutical assistance with quitting smoking. Policy attention needs to focus on supporting former prisoners to access SCP, to reduce the high rate of tobacco-related morbidity and mortality in this profoundly marginalised population.

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.