It will surprise few that mental health problems are common in people in prison, especially those on remand.1,2 But in the light of the longstanding policy consensus that people with severe mental illness should be cared for in health and social services, the results of a recent national survey of mental disorders in prisons are still a shocking indication of inappropriate and inadequate psychiatric care on a huge scale.
The survey, funded by the Department of Health,3 was based on semistructured clinical interviews and is the latest in the important series of studies of psychiatric epidemiology in Great Britain carried out by the Office for National Statistics.4 Its most dramatic finding is the high rate of functional psychosis: 7% of sentenced men, 10% of men on remand, and 14% of women in both categories were assessed as having a psychotic illness within the past year. Although methodological differences render comparisons with previous studies of prisoners difficult, the key comparative figure is 0.4% for adults in the general population.4 People with a dual diagnosis of mental illness and substance abuse pose a special problem, also a current concern in the United States.5
Some may discount neurotic symptoms as inevitable—even the rate of 75% of women on remand—for who would not be depressed or anxious? But the 20% of men and 40% of women who have attempted suicide at least once (over 25% of women in the previous year, 2% of men and women in the previous week) suggests that these symptoms are not wholly related to their current situation. The high prevalence of antisocial personality disorder also may not cause much surprise in this population: 63% of remanded men, 49% of sentenced men, and 31% of women in both groups. But it suggests that longer term strategies are needed beyond punishment for specific offences.
In 1996 Farrar from the NHS Executive could write that government policy had been consistent in 1983-95 in advocating that mentally ill offenders “should be cared for in health and social systems and not the criminal justice system.”6 Six years after the Reed report recommended diverting many people from prison into psychiatric care,7 and in spite of some initial growth of court diversion schemes and transfers of mentally disordered prisoners to hospitals,8 the numbers in our prisons are still substantial. Five years after the Health of the Nation strategy made mental illness a key area and drew specific attention to the needs of mentally ill offenders9 there is little evidence that government policy is effecting the fundamental changes required.
The policy implications are important and far reaching. Firstly, secure hospital accommodation is already inadequate and under pressure. Uncertainty surrounds the future of the high security special hospitals, and any reduction or reconfiguration of them would shift patients into the NHS. The Secretary of State for Health’s policy initiative emphasising safety for both patients and the public may also add to the demand for secure NHS provision.10 Addressing these pressures concurrently will require vision, dedication, and resources.
Secondly, there are many hundreds of men and women remanded in prison for long periods of time, many of whom suffer from longstanding mental disorder, current mental illness, or both. For them, effective treatment is an issue of basic human rights, as is the need to continue speeding up the criminal justice process itself.
Thirdly, many men and women now in prison are no threat to the public and their primary need is for good psychiatric treatment and long term care. They should not be in the criminal justice system, but we have not solved all the problems of providing alternative care. It is not a circumscribed medical problem or merely a matter of compliance with drug regimes; indeed, traditional medical models are seriously limited in this context. Long term care is needed, mostly in the community, and—though it has been said endlessly before—it must be by partnership and teamwork between medical, social, educational, and criminal justice agencies. Clear leadership is also needed, and a commitment to a rehabilitation culture that has never been widely adopted.
An effective service combining individual care and public protection must be a flexible, 24 hour service. If this means something more assertive than aftercare and more paternalistic than current practice, so be it, but community care programmes for these clients must recognise their peculiar lifestyles. Out of prison many are essentially homeless, with limited, not very supportive, social networks, often close to alcohol and drug cultures. Routine health care cannot easily serve them. We need to find some way of mobilising individual continuing care packages which will address both their mental health and social problems and reduce the risk of their reoffending.
If this is to happen the government must be realistic about the scale of the task. Far more secure NHS accommodation and community programmes may be needed than has ever been envisaged. The survey indicates that there may be about 4500 men and 400 women in prison with recent or current psychotic illness. A single professional team with a ring fenced health and social care budget for severe mental illness community care must replace existing fragmented arrangements. Offenders are especially vulnerable to social exclusion, and local psychiatric and social services need a shared ideology of commitment and engagement rather than deflection and avoidance. Nothing short of a government wide response is required. Department of Health action has effected substantial but still insufficient development of local medium secure forensic psychiatry services,11 but health care in the prisons remains a Home Office responsibility. The responsibility for rehabilitation and reintegration into stable communities is shared by many government departments. The secretary of state for health’s cabinet colleagues should be reminded of their common responsibility for a just and effective response to the needs of this most vulnerable and marginalised group in our society.