The Belmarsh Scheme. A prospective study of the transfer of mentally disordered remand prisoners from prison to psychiatric units

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

BACKGROUND

As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales.

METHODS

Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses.

RESULTS

Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes.

CONCLUSIONS

Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform.

TRIAL REGISTRATION

CRD42017071663.

A suitable waiting room? Hospital transfer outcomes and delays from two London prisons

Aims and Method

To describe a group of prisoners who required transfer to mental health units from two London prisons. Data were collected from prison clinical records.

Results

Overall, 149 patient-prisoners were transferred over a 17-month period. Around a quarter were not previously known to services. the aggregate wait was 36.5 years (averaging between 93 and 102 days per prisoner) and the total saving to the National Health Service (NHS) has been estimated at £6.759 million.

Clinical Implications

Both prisons manage a large number of prisoners with untreated psychosis. While in prison, they save the NHS considerable sums of money, but transfer delays prevent timely treatment and could now be legally challenged.

Mental illness in Black and Asian ethnic minorities: pathways to care and outcomes

A substantial body of research indicates that, for people from Black and Asian ethnic minorities, access to, utilisation of and treatments prescribed by mental health services differ from those for White people (Lloyd & Moodley, 1992; for a review see Bhui, 1997). Pathways to mental health care are important, and the widely varying pathways taken in various societies may reflect many factors: the attractiveness and cultural appropriateness of services; attitudes towards services; previous experiences; and culturally defined lay referral systems (Goldberg, 1999). Contact with mental health care services may be imposed on the individual, but people who choose to engage with services usually do so only if they think that their changed state of functioning is health-related and potentially remediable through these services. In such cases, they will contact whoever they perceive to be the most appropriate carer, and these carers are often not part of a national health care network.

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK

Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants' cultural beliefs and practices.

Mental health in-reach in an urban UK remand prison

Purpose

– Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK.

Design/methodology/approach

– Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111).

Findings

– Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited.

Practical implications

– Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template.

Originality/value

– One of the first ground-level evaluations of MHITs in England and Wales.

Ethnicity as a predictor of detention under the Mental Health Act

BACKGROUND

There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for.

METHOD

Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments - either resulting in 'detention' or 'no detention'.

RESULTS

Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention.

CONCLUSIONS

There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

Psychotic disorders are more common in ethnic minority than in Dutch native defendants

PURPOSE

The prevalence of psychotic disorders among prisoners from racial or ethnic minority groups remains uncertain. We therefore compared the frequency of psychotic disorder in ethnic minority and Dutch native defendants using the nationwide database of elaborate pre-trial reports.

METHODS

Analysis of a nationwide database of pre-trial reported defendants in the Netherlands between 2000 and 2006 (n = 12,752).

RESULTS

A diagnosis of a psychotic disorder was more common in ethnic minority than in Dutch native defendants (21.1 vs. 10.2%). The odds ratio of this diagnosis, adjusted for age, gender, IQ below 85 and abuse of cannabis or hard drugs, was 2.6 (95% CI 2.2-3.0). This odds ratio was highest for African defendants (OR = 5.2; 95% CI 3.7-7.4).

CONCLUSIONS

Psychotic disorders were more common among pre-trial reported defendants from ethnic minorities than among their Dutch native counterparts.

Influencing the care pathway for prisoners with acute mental illness

BACKGROUND

Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area.

AIM

To establish whether clinical pathway interventions can reduce such transfer delays.

METHODS

Two clinical pathway interventions - one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) - were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways.

RESULTS

Both interventions produced significant reductions in prison to hospital transfer times.

CONCLUSIONS/IMPLICATIONS FOR PRACTISE

The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale.

Pathways to forensic mental health care in Toronto: a comparison of European, African-Caribbean, and other ethnoracial groups in Toronto

OBJECTIVE

To describe pathways taken to care by a sample of patients in a secure forensic unit who have been found not criminally responsible or unfit to stand trial, and to investigate the pathways taken by patients within 3 ethnoracial subgroups of origin: European, African or Caribbean, and Other.

METHOD

Fifty patients from secure forensic units were interviewed using the Encounter Form developed for pathways mapping undertaken in the World Health Organization field trials. Differences in the types of caregivers seen, the total number of caregivers seen, and the time taken to reach forensic psychiatric services were compared across the 3 ethnoracial groupings.

RESULTS

Most people committed their index offence after they had already had contact with general mental health services. Few significant differences were observed in the pathways to secure forensic units across the European, African-Caribbean, and Other ethnoracial groups.

CONCLUSIONS

These findings suggest that improvements in general mental health services may be a key to decreasing the use of forensic psychiatric services. Further research is required to explore factors that may predict and prevent offending. Larger studies are needed to examine ethnoracial differences in pathways to care.

Prevalence of mental disorder and related treatments in a local jail: a 20-month consecutive case study

Aims – To define the prevalence of mental disorder within an Italian local jail and to describe main psychiatric treatments provided. Methods – Cross-sectional study of consecutive male prisoners referred, over a twenty-month period, for a clinical psychiatric assessment, among population (N=990) of Casa circondariale “Torre del Gallo”, Pavia (I); clinical DSM-IV diagnostic assessment and retrospective analysis of provided psychiatric treatments (i.e. psychiatric visits and pharmacological prescriptions). Results – 191 men (19.3%) had one or more current mental disorders (excluding substance misuse), including 13 (1.3%) psychosis; 53 (5.4%) mood disorder; 24 (2.4%) anxiety disorder; 26 (2.6%) adjustment disorder; 40 (4.1%) personality disorder; 32 (3.2%) personality disorder plus mood disorder; 3 (0.3%) mental retardation. Substance- (N=89, 47%) and HIV-related (N=19, 10%) disorders comorbidity is recognised. Psychiatric visits are mainly provided to psychosis and personality disorder plus mood disorder subgroups. Off-label antipsychotics prescriptions are frequent. Conclusions – The prevalence of mental disorder in this population is higher than US and EU averages, and for particular diagnostic subgroups it could be underestimated. Psychiatric management in prison should be reorganized according to national and European health guidelines.

Ethnicity and the Mental Health Act 1983

BACKGROUND

Black and minority ethnic (BME) patients are disproportionately detained under the Mental Health Act 1983. There has been no systematic exploration of differences within and between ethnic groups, nor of the explanations put forward for this excess.

AIMS

To systematically review detention and ethnicity, with meta-analyses of detention rates for BME groups, and to explore the explanations offered for ethnic differences in detention rates.

METHOD

Literature search and meta-analysis. Explanations offered were categorised, supporting literature was accessed and the strength of the evidence evaluated.

RESULTS

In all, 49 studies met inclusion criteria; of these, 19 were included in the meta-analyses. Compared with White patients, Black patients were 3.83 times, BME patients 3.35 times and Asian patients 2.06 times more likely to be detained. The most common explanations related to misdiagnosis and discrimination against BME patients, higher incidence of psychosis and differences in illness expression. Many explanations, including that of racism within mental health services, were not supported by clear evidence.

CONCLUSIONS

Although BME status predicts psychiatric detention in the UK, most explanations offered for the excess detention of BME patients are largely unsupported.

Fear, black people and mental illness: a vicious circle?

The relationships between black communities and the mental health (MH) services are fraught. Paradoxically, black communities receive the MH services they don't want, but not the ones they do or might want. Black people mistrust and often fear services, and staff are often wary of the black community, fearing criticism, and not knowing how to respond, are fearful of black people, in particular, young black men. The situation is fueled by prejudice, misunderstanding, misconceptions and sometimes racism. The present paper describes the findings of a study to explore the issues in greater depth. The study was premised on a belief that there are 'circles of fear' which lead to poorer treatment of black communities. A purposive sampling approach was used to seek out groups and individuals in whom the 'circles of fear' were likely to be evident. The findings suggest that there are fears which impact negatively on the interaction between black communities and MH services. Two major themes emerged in this study, i.e. the sources of fear and the consequences of fear. Sources of fear included perceptions of MH services, attitudes to mental illness and diagnosis, and experiences of hospital care. The impact of fear included limited trust, limited engagement and delayed help-seeking behaviour. The study concludes that these fears mar the interactions between these communities and MH services, affect help-seeking behaviour adversely, and lead to restrictive and punitive interventions. Progress will only be made in breaking the 'circles of fear' if there is a systematic change in the experience of black services users at each point in the care pathway.

Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry

It has been consistently reported that the African-Caribbean population in the UK are more likely than their White counterparts to access psychiatric services via the police and under compulsion. The reasons for these differences are poorly understood. This paper comprises two main parts. The first provides a comprehensive review of research in this area, arguing the current lack of understanding stems from a number of methodological limitations that characterise the research to date. The issue of ethnic variations in pathways to psychiatric care has been studied almost exclusively within a medical epidemiological framework, and the potential insights offered by sociological and anthropological research in the fields of illness behaviour and health service use have been ignored. This has important implications as the failure of research to move beyond enumerating differences in sources of referral to psychiatric services and rates of compulsory admission means no recommendations for policy or service reform have been developed from the research. The second part of the paper sets out the foundations for future research, arguing that the pathway to care has to be studied as a social process subject to a wide range of influences, including the cultural context within which illness is experienced. It is further argued that Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry, University of California Press, Los Angeles, 1980) Health Care System model offers a particularly valuable preliminary framework for organising and interpreting future research. It is only through gaining a more qualitative understanding of the processes at work in shaping different responses to mental illness and interactions with mental health services that the patterns observed in quantitative studies can be fully understood. This further reflects the need for a bridge between the social sciences and psychiatry if services are to be developed to respond to the increasing diversity of modern societies.

Ethnic differences in prisoners. 1: criminality and psychiatric morbidity

BACKGROUND

In England and Wales, persons of African-Caribbean origin are more likely to be both imprisoned and admitted to secure hospitals.

AIMS

To estimate population-based rates of imprisonment in different ethnic groups, and compare criminal behaviour and psychiatric morbidity.

METHOD

We examined Home Office data on all persons in prison, and carried out a two-stage cross-sectional survey of 3142 remanded and sentenced, male and female, prisoners in all penal establishments in England and Wales in 1997.

RESULTS

We confirmed high rates of imprisonment for Black people and lower rates for South Asians. Different patterns of offending and lower prevalence of psychiatric morbidity were observed in Black prisoners.

CONCLUSIONS

Despite increased risks of imprisonment, African-Caribbeans show less psychiatric morbidity than White prisoners. This contrasts with the excess of African-Caribbeans in secure hospitals, an inconsistency possibly in part due to the effects of ethnic groups on admission procedures.

Admission trends to a special hospital: court diversion and prison transfers

This paper reviews the literature regarding the diversion of mentally disordered offenders from the criminal justice system to the mental health services, with a specific focus on the high security psychiatric special hospitals. The traditional sources of admission to these institutions have been predominantly courts and prisons, with the majority of patients being admitted via the former route. This study reports on the admissions to a special hospital over a 20-year period, and shows that over the previous decade there has been a reversal in this trend, with the number of patients transferred from prison being greater than that via any other route. The factors that may have contributed to this reversal are discussed and conclusions are drawn as to the external and internal forensic factors that may influence the court's decision in the referral process.

Managing terminally ill prisoners: reflection and action

In 1997 a young remand prisoner was 'shackled' to his bed until shortly before his death. An outcry ensued. This paper discusses issues concerning care of terminally ill prisoners. In Cardiff, the Prison Service, local National Health Service trusts and the hospice have produced joint guidance on the escorting of ill prisoners and managing a bedwatch; these are outlined.

Unmet needs of remand prisoners

A needs assessment protocol which examines 11 problem areas was devised. This was administered to 277 prisoners on remand at Brixton Prison. We found high levels of unmet need for housing, treatment of substance abuse and neurotic symptoms. Twenty-nine per cent were transferred to hospital under the provisions of the Mental Health Act and about a third of those at liberty to do so complied with a discharge plan. Diversion and discharge planning can potentially meet the unmet needs of remand prisoners.

African-Caribbean men remanded to Brixton Prison. Psychiatric and forensic characteristics and outcome of final court appearance

BACKGROUND

African-Caribbean men are over-represented in psychiatric and forensic services and in the prison population. A failure of community services to engage mentally ill African-Caribbean men and their presentation through the criminal justice system culminates in a repeated pattern of forensic service and criminal justice system contact.

METHOD

We carried out a cross-sectional survey during a one-year period of a sample of potentially mentally ill men remanded to HMP Brixton in south London. Men were interviewed to establish their place of birth, first language, socio-demographic profile, ethnicity, psychiatric diagnosis, levels of alcohol and substance misuse, criminality, violence involved in their index offence, past psychiatric and forensic contacts and outcome of court appearance.

RESULTS

Two hundred and seventy-seven men were interviewed. In comparison with White men, African-Caribbean men were more often diagnosed as having schizophrenia and were more often sent to hospital under a mental health act order. African-Caribbean men were remanded in custody despite more stable housing conditions and more favourable indices of lifetime criminality, substance misuse and violence.

CONCLUSIONS

Community services, including diversion schemes, should be especially sensitive to African-Caribbean men with schizophrenia who 'fall out of care', who are not diverted back into care and are therefore unnecessarily remanded.

The Bentham Unit: a pilot remand and assessment service for male mentally disordered remand prisoners. I: Clinical activity in the first year, and related ethical, practical and funding issues

BACKGROUND

Because of continuing concern regarding the inadequacy of existing NHS provision for mentally disordered remand prisoners, the Bentham Unit was commissioned as a pilot project to provide rapid assessment and, where appropriate, hospital admission for such prisoners from the former North West Thames catchment area.

METHOD

Information is presented on the 150 referrals and 62 admissions in the first year of the service's operation.

RESULTS

The service met the Reed Report targets for assessment time. Most of those referred were previously known to psychiatric services. The alleged offences were more serious than anticipated. Those admitted were transferred to appropriate services at the conclusion of their court cases, and remained in contact with services three months later. Waiting for the conclusion of court proceedings significantly prolonged the length of stay. Substantial cost transfers from the criminal justice system to the health system were evident.

CONCLUSIONS

Adequate services for mentally disordered remand prisoners are entirely achievable; provision of such services is a resource issue, not a clinical problem.

The essential elements of culturally sensitive psychiatric services

The recent re-structuring of the British National Health Service (NHS) involving a greater emphasis on community treatment has not specifically taken account of the unequal access to mental health services experienced by black people. The greater use amongst black people of compulsory orders, police involvement and reliance on psychotropic medication, although well established, has not influenced policy or led to a strategy to ensure that services appropriately meet the needs of the culturally diverse population in this country. We present the literature on service utilisation by black people and emphasise potential solutions in areas with which black people are dissatisfied. The service structures, ideology and mechanisms presented form the foundations of good practice.