Suicide by people in a community justice pathway: population-based nested case-control study.

The elevated risk of suicide in prison and after release is a well-recognised and serious problem. Despite this, evidence concerning community-based offenders' suicide risk is sparse. We conducted a population-based nested case-control study of all people in a community justice pathway in England and Wales. Our data show 13% of general population suicides were in community justice pathways before death. Suicide risks were highest among individuals receiving police cautions, and those having recent, or impending prosecution for sexual offences. Findings have implications for the training and practice of clinicians identifying and assessing suicidality, and offering support to those at elevated risk.

Prospective cohort study of mental health during imprisonment.

BACKGROUND: Mental illness is common among prisoners, but little evidence exists regarding changes in symptoms in custody over time. AIMS: To investigate the prevalence and predictors of psychiatric symptoms among prisoners during early custody. METHOD: In a prospective cohort study, 3079 prisoners were screened for mental illness within 3 days of reception. To establish baseline diagnoses and symptoms, 980 prisoners were interviewed; all remaining in custody were followed up 1 month and 2 months later. RESULTS: Symptom prevalence was highest during the first week of custody. Prevalence showed a linear decline among men and convicted prisoners, but not women or remand prisoners. It decreased among prisoners with depression, but not among prisoners with other mental illnesses. CONCLUSIONS: Overall, imprisonment did not exacerbate psychiatric symptoms, although differences in group responses were observed. Continued discussion regarding non-custodial alternatives for vulnerable groups and increased support for all during early custody are recommended.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation.

BACKGROUND: The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES: To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION: Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS: Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES: Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS: Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS: Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS: Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS: High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS: The National Institute for Health Research Health Technology Assessment programme.

Level of mental health intervention and clinical need among inmates with mental illness in five English jails.

OBJECTIVE: This study examined associations between clinical, demographic, and criminological characteristics of inmates with mental illness and level of mental health intervention received during early custody. METHODS: In a prospective study, 3,079 participants entering five English jails were recruited and screened for mental illness with a standardized tool. Individuals who screened positive were assessed for mental illness and symptom severity within one week of arrival. Clinical records of those who received a diagnosis of mental illness (N=409) were reviewed for one month (or until discharge, if sooner) to determine mental health care interventions received. Main outcomes were the level of mental health intervention received (none, primary, or secondary) and whether an intervention was received from substance misuse services. RESULTS: Compared with individuals who did not receive services, those who received primary mental health care were more likely to have a diagnosis of major depressive disorder than another mental illness (OR=2.01, CI=1.20­3.36). Compared with those who received primary care services, those who received secondary mental health care were more likely to have a diagnosis of psychosis (OR=3.34, CI=1.81­6.17). However, 23% of the sample received no intervention. Offenders with mental illness who misused drugs were more likely than those who misused alcohol alone to receive an intervention from substance misuse services (OR=3.67, CI=1.91­7.05). CONCLUSIONS: Level of intervention was not consistently linked with diagnoses or symptom severity among inmates with mental illness. Triage processes should be improved to ensure that mental health care resources in jails are appropriately matched to clinical need.