Mental illness at reception into prison

Mental illness at reception intoprison

LUKE BIRMINGHAM1, JANINE GRAY2, DEBBIE MASON3 AND DONGRUBIN4 1University of Southampton; 2University of Teesside;3Parkhead Hospital, Glasgow; 4University of Newcastle upon Tyne

ABSTRACT Background Many remand prisoners suffer from mental disorder, but this usuallyremains undetected by prison reception health screening. We set out to comprehen-sively evaluate the prison screening process with the intention of finding ways inwhich the process might be improved.Method The prison screen for mental disorder of 546 consecutive male remands toDurham prison in England was compared with an independent research screen. Theprison reception and induction processes during which health screening took placewere observed, the findings of the screens compared, prison healthcare staff inter-viewed, and prisoners’ views on health screening recorded. Information collected bythe research assessment was used to construct a model to identify those at high risk ofsuffering from mental illness.Results Health assessments took place under unsatisfactory conditions, many prisonhealthcare staff lacked appropriate training, relationships with prisoners did notencourage inmates to volunteer information, and screening records were missing orseriously incomplete in one in ten cases. We identified four variables that togetherwere the best predictors of mental illness in this population. The screening instru-ment used by prison healthcare workers included questions relating to all four vari-ables, and this assessment was the most informative of the two prison receptionhealth screens. The subsequent mental health assessment carried out by prison doc-tors was often cursory and added little further information.Discussion We concluded that the health screen for new prisoners needs revisionand improvement. We recommend a preliminary screen administered by a trainedprison healthcare worker which focuses on a limited amount of information, aimed atidentifying prisoners at high risk of suffering from mental illness. The routine assess-ment of mental health carried out by prison doctors on every new prisoner should bedispensed with, and the prison doctor should instead focus on a more in-depth assess-ment of those who screen positive according to the healthcare worker’s assessment.

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Introduction

Point prevalence studies of mental disorder (including substance misuse) inEnglish prisoners, undertaken by researchers from the Institute of Psychiatryin London, found that over a third of sentenced male prisoners (Gunn et al.,1991) and nearly two-thirds of unconvicted male remand prisoners (Brooke etal., 1996) have psychiatric disorders of which 2% and 5% respectively are psy-chotic in nature. The authors of these studies argued that among the prisonpopulation in England and Wales there are likely to be approximately 1800men who require transfer to hospital for psychiatric treatment, including 1100with serious mental illness; of these , nearly 400 are held on remand.

The results of the 1997 English prison survey of psychiatric morbidity,published recently by the Office for National Statistics, indicate even higherrates of mental disorder (Singleton et al., 1998). More than 3000 prisonersacross England and Wales (a cross-section of male and female, remand andsentenced prisoners) were interviewed, and 7% of sentenced men and 10%of men on remand were found to have functional psychotic disorders (with-in the preceding year). Most had a diagnosis of schizophrenia. This study isthe most comprehensive and reliable indicator of psychiatric morbidityamong prisoners to date. The findings indicate that the prison population inEngland and Wales now contains approximately 4500 men with seriousmental illness.

Point prevalence studies provide little information about the extent towhich individuals with mental health problems are identified by the prisonhealth service. In a longitudinal study at a large remand prison in the NorthEast of England, however, we found that of the 26% of unconvicted, newlyremanded male prisoners who suffered from some form of mental disorder(excluding substance misuse) on their entry to prison, only a minoritybecame known to the prison health service during their time spent onremand. In particular, the routine prison healthcare screen administeredto all new prisoners detected abnormalities in less than one-quarter of thesemen, with those suffering from acute psychoses just as likely to be missedas those with other forms of mental disorder (Birmingham et al., 1996,1998).

If our findings are generalized throughout the prison system, then in 1995,when 43% of the 124 300 new prison receptions in England and Wales wereuntried male remands (Home Office, 1996), 13 800 male remand prisonerscould have been expected to have some form of mental disorder at the time ofreception. Of these, 10 630 will have passed through prison reception screen-ing without any significant mental abnormality being detected.

In this paper we present in more detail our findings in relation to te prisonhealth-screening process, focusing on screening for signs of mental illness,with the aim of identifying ways in which this process may be improved.

78 Birmingham et al.


Methods

The study was based at Durham prison, a typical large local male remandprison. As per national practice, every new inmate received there undergoes aroutine two-stage reception health screen as set out in prison circular HealthCare Standards for Prisons in England and Wales (Prison Service, 1995). Theinitial health screen on the day of reception is administered by a healthcareworker who uses a standard questionnaire known as form F2169. The purposeof this initial screen is to gather factual information relating to the individ-ual’s physical and mental health. This information is used by the prison med-ical officer who sees the inmate the following working day to carry out aa fur-ther assessment of mental and physical health: the findings are recorded on amedical assessment pro forma.

Subjects and sources of information

Between 1 October 1995 and 30 April 1996 each new unconvicted maleremand prisoner was approached within the first few days of his receptioninto prison and asked to participate in the study. Those who gave their con-sent were screened for mental disorder by a research psychiatrist (LB or DM).A semi-structured psychiatric interview was used to generate DSM-IV diag-noses (American Psychiatric Association, 1994). The interview incorporatedwell-validated instruments used in other prison studies (Gunn et al., 1991;Brooke et al., 1996), including the Schedule for Affective Disorders andSchizophrenia – Lifetime version (Endicott & Spitzer, 1978) to diagnosemental disorder, the CAGE Questionnaire (Mayfield et al., 1974) to assessproblem drinking and the Severity of Dependence Questionnaire (Phillips etal., 1987) to quantify levels of drug dependence. The research screeninginterview took between 20 minutes and one hour to complete, depending onthe nature and complexity of any problems encountered. After this, eachsubject’s inmate medical record was inspected and the findings of his prisonreception health screen recorded. In addition, the prison-reception andhealth-screening processes themselves were observed, the prison medical offi-cers and healthcare workers who carried out the screening assessments wereinterviewed to determine their experience and attitudes towards screening,and prisoners were asked about their experiences and views of the screeningprocess.

Analysis of data

Diagnoses of mental illness (non-organic, non-substance-related DSM axis Idiagnoses) rather than mental disorder (any DSM-IV axis I and II disorder,excluding substance abuse and dependency diagnoses) were used in order to

Mental illness at reception into prison 79


focus on the population with the most significant healthcare needs. Detailsrelevant to mental health recorded in both the healthcare worker and medicalofficer screens were compared with that obtained by the research assessment.

It was apparent when analysing the data collected by the research assess-ments that certain demographic and historical features were associated withthe presence of mental illness in the population interviewed. Recognizing theimplications this could have for improving the prison reception health screenadministered by healthcare workers, variables linked to simple factual infor-mation rather than those requiring subjective interpretation that mightrequire specialist training were selected from the research assessment to testtheir discriminatory power in detecting the presence of mental illness.Univariate logistic regression models were used for each of the variables inturn to identify those associated with a current diagnosis of mental illness.Any variable that did not display a significant association (p > 0.2) was dis-carded. The remaining variables were entered into a logistic regression modeland a subset that was independently predictive of mental illness was identifiedusing backwards stepwise techniques. Results for the logistic regression modelsare presented in terms of odds ratios together with 95% confidence intervals.Sensitivity, specificity, and negative and positive predictive values were calcu-lated for the final model.

Study sample

During the study period 606 men were newly remanded, of whom 37 appearedin court the following day and did not subsequently return to the prison, 19refused to participate in the study, and one was unfit to be interviewed. All ofthe remaining 549 inmates agreed to be interviewed; 546 of these assessmentscontained sufficient data for analysis and were included in this study. Mentaldisorder (excluding substance misuse) was present in 143 (26%), and a prima-ry diagnosis of mental illness was made in 104 (19%) men. This was of a seri-ous nature (psychosis or major mood disorder) in 34 (6%) subjects.

Inter-rater reliability

Prior to commencing the main study a pilot study was undertaken. During thisand regularly throughout the study itself inter-rater reliability was monitored.Limited time and a lack of available interview rooms precluded a totally inde-pendent assessment of inter-rater subjects by each researcher. It was also feltthat many of these subjects would have refused to undergo a second interview.Therefore, inter-rater reliability was measured with one researcher interview-ing the subject and the other observing. Both researchers recorded lifetimediagnoses without conferring, and agreement between raters was measured bycalculating a kappa coefficient (Maxwell, 1977). A total of 116 interviewswere jointly rated. During these, 51 lifetime diagnoses of mental disorder



(excluding substance misuse) were recorded by either one or both raters.Diagnostic agreement occurred in 41 of these (kappa = 0.86). Most disagree-ments were over diagnoses of personality disorder (kappa = 0.76) and adjust-ment disorder (kappa = 0.65). In respect of the 15 lifetime diagnoses of psy-chosis there was complete diagnostic agreement between raters (kappa = 1.0).

Results

Staffing and facilities for prison health screening

According to Prison Health Care Standards 1.1(d) and 1.1(e) (Prison Service,1995) the healthcare worker performing the initial health screen should be‘fully trained in healthcare reception procedures, assessment methods andcounselling skills’ and the assessment given ‘sufficient time, in privacy to facil-itate one-to-one contact between the prisoner and healthcare worker. Anaverage of 10 minutes per screening to be allowed.’

Four permanent vacancies meant that during the study period the screen-ing work, along with other healthcare duties, was distributed between 16(instead of 20) healthcare workers. Two of these were ‘E’ grade nurses, sevenwere prison officers with NHS nursing qualifications, and seven were prisonofficers who held a certificate from a Home Office six-month nursing coursethat became obsolete six years ago. The number of healthcare staff availablefor screening on any particular day varied, but staffing levels were reported asbeing critically low most of the time. One major reason for this was the highlevel of sick leave amongst healthcare workers.

On arrival at the prison all new prisoners passed through reception.Included in this process was the initial prison health screen, administered by ahealthcare worker. There was considerable movement of prisoners in and outof the prison on each working day, and because prisoners conveyed to theprison from the courts arrived in batches, the reception area was at timescrowded and busy. Privacy was lacking and the emphasis was on processingprisoners.

The medical officer assessments formed part of the induction processwhich each new prisoner attended on the second working day followingreception. The doctors held the view that experience gained from working ina prison was more important than formal training or qualifications. They stat-ed that pressure of time and prisoners deliberately withholding informationhampered their work, but believed that screening was still worthwhile, waseffective, and that substantial changes were not required.

The research interviews also took place during the induction process. Thisallowed researchers to observe some of the medical assessments taking placeand obtain information about the medical assessment from prisoners who hadjust seen the doctor. The doctors’ findings, which were recorded in theinmate’s medical records, were also examined.



The assessments carried out by the medical officers were usually brief andcould be cursory, in some cases lasting under one minute. Privacy was lacking:the medical room opened directly on to an open waiting area, the door wasnot infrequently left open, sometimes the prisoner was left to stand in front ofthe doctor and a healthcare officer was invariably present during the assess-ment. The medical entries in the inmate medical records were brief and themedical assessment tended to duplicate what had already been covered in thehealthcare worker’s screen.

Prisoners themselves tended to be critical of the prison healthcare screen,and many felt that healthcare staff did not have their best interests at heart. Aconsiderable number said that because of such perceptions they did not volun-teer, and often deliberately withheld, information during prison screeningassessments. Even when recognizing that they suffered from significant mentalhealth problems some stated that they would rather take their chances in nor-mal prison accommodation than disclose their problems and risk being placedin unfurnished (stripped) cells, where more disturbed prisoners are managed.

Information detected during health screening

Twelve of the 546 sets of inmate medical records were missing. In the remain-ing 534, eight healthcare-worker screens and 31 medical-assessment sheetswere either missing or largely incomplete.

Instances where either prison screen recorded a mental health-related find-ing not identified by the research assessment were rare. The prison screens,however, failed to detect a considerable amount of factual information relat-ing to psychiatric morbidity (Table 1). The healthcare workers’ screen tendedto be the more complete of the two prison screens. Furthermore, although thisinitial screen was made available to the medical officers to guide them in theirhealth assessments, prison doctors appeared to overlook this important sourceof information and often recorded negative findings when a positive responsehad already been elicited by the healthcare worker.

Variables associated with the presence of mental illness

Fourteen variables were chosen for investigation of a possible association witha current diagnosis of mental illness. These variables are listed in Table 2,together with the odds ratios, 95% confidence intervals and p-values obtainedfrom the individual logistic regression models. Table 3 shows the variablesthat were found to discriminate best in terms of predicting the presence ofcurrent mental illness when considered alongside the other variables: a historyof self-harm, a past history of psychiatric care, a charge of homicide and theprescription of antidepressants prior to remand. The variables listed in Table2, which demonstrated a statistically significant association with the presenceof mental illness, but which were ultimately discarded from the final model




Table 1: A comparison of research and prison reception screen findings in 546 remandprisoners

Result of prison Research screen findingscreening

History of self- Past psychiatricharm * (%) (n =133) history * (%) (n = 242)

Identified by both prison screens 43 (32%) 55 (23%)Identified by healthcare worker alone 60 (45%) 51 (21%)Identified by prison medical officer alone 6 (5%) 19 (8%)Not identified by either prison screen 24 (18%) 117 (48%)

Note: *Prison screening noted 10 histories of self-harm and 18 past psychiatric historieswhich researchers did not identify.

Table 2: Factors considered as possible predictors of current mental illness together with theodds ratio, 95% confidence interval and p value from individual logistic regression models

Factor Odds ratio 95% confidence interval p-value

History of self-harm No 1Yes 3.79 2.42–5.97 < 0.001

History of homelessness No 1Yes 1.87 1.22–2.88 0.004

Past history of psychiatric care No 1(outpatient or inpatient Yes 5.80 3.67–9.18 < 0.001care as an adult)Family history of mental No 1health problems Yes 1.38 0.89–2.13 0.151Significant life event(s) No 1in the past six months Yes 1.73 1.12–2.69 0.014Nature of most serious No 1charge is dishonesty Yes 0.84 0.55–1.29 0.43Nature of most serious No 1charge is violence Yes 0.76 0.49–1.18 0.225Nature of most serious No 1charge is sexual Yes 1.38 0.57–3.32 0.48Nature of most serious Nocharge is homicide Yes 11.65 3.58–37.94 < 0.001Nature of most serious No 1charge is arson Yes 1.22 0.25–5.95 0.244Prescribed antidepressants No 1prior to remand Yes 8.35 4.02–17.33 < 0.001Prescribed antipsychotics No 1prior to remand Yes 10.37 3.13–34.39 < 0.001Prescribed benzodiazepines No 1prior to remand Yes 2.15 1.21–3.84 0.009Prescribed opiates No 1(methadone) prior to Yes 1.29 0.64–2.63 0.476remand


(Table 3), added no extra predictive power to those retained. Each of the fourvariables retained is covered by form F2169, the screening instrument used byprison healthcare workers.

Utility of the model

The logistic regression model was created in order to select a group of prison-ers who were at high risk of suffering from a current mental illness. The speci-ficity and sensitivity of the model will depend on the criteria by which prison-ers are considered to screen positive. These criteria can be chosen, subjective-ly, in a number of ways and two examples are declaring screen positive if theyhave any of the four variables, or declaring screen positive if they have all ofthem; the former will be more sensitive but less specific, containing more falsepositives (that is, identifying prisoners as suffering from mental illness whenthey do not), while the latter will be more specific but less sensitive, having ahigher false-negative rate (that is, missing prisoners who are suffering frommental illness). Given the purpose of the screen, false negatives were consid-ered more of a concern than false positives, and therefore prisoners were clas-sified as screening positive if they scored positively on any of the four variablesin the model.

Table 4 compares the numbers who screen positive using this model withthe actual presence of mental illness at reception as determined by theresearch screen. Table 5 illustrates the number of prisoners who screen posi-tive when applying the findings of the healthcare officer screen to thismodel.

From these tables it can be seen that, using the researchers’ data, 205(38%) men in the sample screened positive for mental illness, of whom 79(39%) were in fact mentally ill; these 79 represented 76% of the 104 inmateswith mental illness, and included 28 (82%) of the 34 inmates with severe


Table 3: The final logistic regression model

Factor Odds ratio 95% confidence interval

History of self-harm No 1Yes 2.3 1.4–4.0

Past history of psychiatric care No 1(outpatient or inpatient care as an adult) Yes 3.5 2.0–5.9

Nature of most serious charge is homicide No 1Yes 10.5 2.8–39.3

Prescribed antidepressants prior to remand No 1Yes 4.0 1.8–9.2


mental illness (psychoses and major mood disorders). Of the 341 men whoscreened negative using the model, just 25 (7%) had mental illness. Usingthe information recorded in the healthcare workers’ reception health screens,165 men screened positive. Among these men were, 64 (62%) of the mentallyill and 23 (68%) of the severely mentally ill identified by the researchassessment.

Discussion

Health screening of new prisoners has been carried out routinely since thePrisons Act (1865) made specific reference to the need for prison surgeons toinspect every new arrival in prison (Smith, 1981). Its purpose is not to makedefinitive diagnoses, but to identify those inmates who need further review.Although large amounts of time and resources are dedicated to this activity,its efficacy has never been evaluated to any significant extent. What researchhas been carried out has highlighted conditions that hinder the detection ofclinically significant information, the lack of established procedure in the


Table 4: Performance of the logistic regression model according to research screen findings

ClassificationNegative screen Positive screen Total

Mentally ill at reception No 316 126 442(judged by researchers)

Yes 25 79 104

Total 341 205 546

Notes: A prisoner is deemed to have screened positive if any of the variables in Table 3 is pre-sent. Sensitivity = 76%; specificity = 71%; negative predictive value = 93%; positive predic-tive value = 39%.

Table 5: Performance of the logistic regression model according to healthcare workers’ findings

ClassificationNegative screen Positive screen Total

Mentally ill at reception No 341 101 442(judged by researchers)

Yes 40 64 104

Total 381 165 546

Notes: A prisoner is deemed to have screened positive if any of the variables in Table 3 is pre-sent. Sensitivity = 62%; specificity = 77%; negative predictive value = 90%; positive predic-tive value = 39%.


event of such information being detected, and the unproven reliability andvalidity of the health-screening questionnaires (Mitchison et al., 1994).

Our observations lend support to these concerns. We found that while onein four men entering prison on remand suffered from some form of mental dis-order, the prison reception screen failed to identify over three-quarters ofthem. Mental disorder was no more readily recognized in those with psychoticillnesses. Because the prison screen failed to identify the bulk of the psychi-atric morbidity amongst new remands, many individuals were placed in ordi-nary prison accommodation and did not receive psychiatric assessment ortreatment. Furthermore, many of these men had little or no recent contactwith healthcare services in the community. Missed by the health screen, anopportunity to engage these men with community psychiatric services waslost. Why should this have been the case?

Strict guidelines for how screening should be undertaken are contained inHealth Care Standards for Prisons in England and Wales (Prison Service, 1995)and Standing Order 13. Health Care Standard 1.2, for example, requires doctorsto take a full medical and psychiatric history followed by physical and psychi-atric assessments of every new prisoner, including a review of all the major sys-tems as well as a complete mental state examination. Such a thorough exami-nation is likely to take nearly an hour to carry out properly, an amount of timethat is simply not available to doctors in a busy remand prison.

Lack of time was not the only difficulty in this respect; other factors thathampered the detection of psychiatric morbidity included, the conditions inwhich screening was carried out, training of prison staff and the relationshipsbetween prisoners and prison healthcare staff.

At present, the health screen is in two stages:, the first is carried out by ahealthcare worker, the second by the prison doctor. We found that these tend-ed to duplicate each other, and it was rare for the latter to uncover mentalhealth problems missed by the former.

We found that a model combining four straightforward screening questionsoffers a method of identifying prisoners at high risk of having current mentalillness. These four variables are included in the existing healthcare workerscreen. Furthermore, although prison reception health screening failed todetect most of those suffering from mental disorder, our findings suggest thatthe healthcare worker screen did detect the factual information needed toanswer the four questions in the screening model sufficiently well for aninstrument that included these variables to operate with an acceptable level ofsensitivity and specificity. This would, of course, need to be evaluated undernormal prison screening conditions.

While a two-stage screening process is basically sound, our findings callinto question whether it is worthwhile for the prison medical officer to con-tinue to screen all new prisoners for mental disorder. Instead, provided that ahigher risk group can be identified by an initial screen (and our findings suggest that healthcare workers can probably achieve this task), the prison



medical officer could then spend more time conducting a more thorough men-tal health assessment on these individuals.

Because the prison medical officer would still carry out a physical healthassessment on each new prisoner, the statutory requirement for every prisonerto see a doctor on entry into custody would still be fulfilled. However, givenour findings in respect of mental health, it might also be useful to review theefficacy of the current screening procedure for physical health problems.

References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders,4th edn (DSM IV). Washington, DC: APA.

Birmingham L, Mason D, Grubin D (1996) Prevalence of mental disorder in remand prisoners:consecutive case study. British Medical Journal 313: 1521–1524.

Birmingham L, Mason D, Grubin D (1998) A follow-up study of mentally disordered menremanded to prison. Criminal Behaviour and Mental Health 8: 202–213.

Brooke D, Taylor C, Gunn J, Maden A (1996) Point prevalence of mental disorder in uncon-victed male prisoners in England and Wales. British Medical Journal 313: 1524–1527.

Endicott J, Spitzer R (1978) A diagnostic interview: schedule for affective disorders and schizo-phrenia. Archives of General Psychiatry 35: 837–844.

Gunn J, Maden A, Swinton M (1991) Mentally Disordered Prisoners. London: Home Office.Home Office (1996) The prison population in 1995. Home Office Statistical Bulletin. London:

Home Office.Maxwell A (1977) Coefficients of agreement between observers and their interpretation. British

Journal of Psychiatry 130: 79–83.Mayfield D, McLeod G, Hall M (1974) The CAGE Questionnaire: validation of a new alco-

holism screening instrument. American Journal of Psychiatry 131(10): 1121–1123.Mitchison S, Rix K, Renvoize EB, Schweiger M (1994) Recorded psychiatric morbidity in a

large prison for male remanded and sentenced prisoners. Medicine Science and the Law 34(4):324–330.

Phillips G, Gossop M, Edwards G, Sutherland G, Taylor C, Strang J (1987) The application ofthe SODQ to the severity of opiate dependence in a British sample. British Journal ofAddictions 82(6): 691–699.

Prison Service (1995) Health Care Standards for Prisons in England and Wales. London: PrisonService.

Singleton N, Meltzer H, Gatward R, Coid J, Deasy D (1998) Psychiatric Morbidity amongPrisoners in England and Wales. London: Stationery Office.

Smith R (1981) Trial by Medicine. Edinburgh: Edinburgh University Press, p 21.

Address correspondence to: Dr Luke Birmingham, Ravenswood House,Southampton Community Services NHS Trust, Knowle, Fareham PO17 5NA.



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Mental illness at reception into prison