Trouble sleeping inside: a cross-sectional study of the prevalence and associated risk factors of insomnia in adult prison populations in England.

OBJECTIVE: To investigate the prevalence of insomnia and identify associated demographic, clinical and forensic risk factors in adult prisoners in England. METHODS: A cross-sectional study of 237 prisoners aged 18-72 years, across two male prisons and one female prison in North England. We used the Sleep Condition Indicator to measure probable DSM-V insomnia disorder (ID) and the Pittsburgh Sleep Quality Index to examine sleep quality. Multiple demographic, sleep, clinical and forensic self-reported measures were recorded to identify any associations with insomnia. RESULTS: Overall, the prevalence of possible DSM-V ID was 61.6% (95% CI, 55.5%-67.8%). Subjective poor sleep quality was reported by 88.2% (95% CI, 84.1%-92.3%). Seven in ten (70.6%) female prisoners had possible DSM-V ID (95% CI, 64.8%-76.4%). Multivariable logistic regression analysis, adjusting for gender and age, indicated odds of having possible ID in prison were increased for the following factors: history of physical ill-health (OR = 3.62, 95% CI, 1.31-9.98); suicidality (OR = 2.79, 95% CI, 1.01.7.66), previously asked for help for insomnia (OR = 2.58, 95% CI, 1.21-5.47), depression (OR = 2.06, 95% CI 1.31-3.24), greater endorsement of dysfunctional beliefs about sleep (OR = 1.50, 95% CI, 1.21-1.87), poor sleep hygiene (OR = 1.11, 95% CI, 1.04-1.19), and problematic prison environment (eg, noise, light or temperature) (OR = 1.07, 95% CI, 1.02-1.12). CONCLUSIONS: For the first time we have established the prevalence and associated factors of insomnia in a large sample of adult English prisoners. ID and poor sleep quality are common, especially in female prisoners. These findings emphasize/amplify the need for dedicated treatment pathways to improve screening, assessment and treatment of insomnia in prison.

Insomnia management in prisons in England and Wales: a mixed-methods study.

Insomnia in prison is common; however, research is limited regarding the management strategies that prison establishments employ. To address this knowledge gap, we conducted a survey to identify how insomnia is detected, diagnosed and treated in adult prisons in England and Wales. Telephone interviews with a purposive sample of health-care managers were then conducted. The survey was sent to all establishments holding adult prisoners, covering screening and assessment methods to detect insomnia; treatment options, both pharmacological and non-pharmacological; the importance of insomnia as a treatable condition; and staff training available. Eighty-four (73%) prisons completed the survey. Few had a stepped approach to insomnia management, as recommended by National Institute for Health and Care Excellence (NICE) guidelines. The most common treatments available were sleep hygiene education and medication, offered by 94 and 88% of respondents, respectively. Analysis of telephone interviews revealed four main themes: insomnia as a normal occurrence in prison; the problem of medication in prison; the negative impact of the prison environment; and effective management of insomnia in prison. The current findings suggest that logistical, ethical and security barriers and a lack of staff knowledge and training impact negatively on the management of insomnia in prison.

Prevalence and appropriateness of psychotropic medication prescribing in a nationally representative cross-sectional survey of male and female prisoners in England.

BACKGROUND: Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons. METHODS: We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9 % of male and 20.5 % of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95 % CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink. RESULTS: Overall, 47.9 % (CI 44.4-51.4) of women and 16.9 % (CI 16.0-17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36-6.61) and four times higher among men (PR 4.02 CI 3.75-4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7 %, CI 32.5-37.0) of cases, most commonly low mood and personality disorder. CONCLUSIONS: Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress.

The development of a mental health screening tool and referral pathway for police custody.

BACKGROUND: Time spent in police custody should present an opportunity for the early identification of mental ill health. However, this stage of the criminal justice system (CJS) is currently the least developed in terms of its links with health and social services. In England, police custody sergeants administer a standardized risk assessment tool to determine a detainee's need for health-care and/or risk reduction measures while detained. Specialized mental health services are often reliant on this process to generate referrals; however, previous research has shown this to be ineffective. The aim of this study was to develop an improved mental health screening tool and referral pathway to better identify individuals with mental ill health in police custody. METHODS: Mental health professionals, police officers and service users across six sites throughout England took part in qualitative interviews, controlled feedback consultations and an action learning group. RESULTS: By combining a previously validated CJS mental health screening tool with elements of the custody risk assessment, the Police Mental Health Screening Questionnaire (PolQuest) was created. It is accompanied by a referral pathway that outlines services' responsibilities, expected actions and response times. CONCLUSION: The study resulted in a screening tool, referral pathway and training package. PolQuest is expected to facilitate the mental health screening of all adult detainees; improve the early identification of mental ill health; aid timely access to services; provide clear indicators for referral; and reduce ambiguity in the roles and responsibilities of staff across a range of criminal justice and health-care services.

Social and custodial needs of older adults in prison.

BACKGROUND: older prisoners are a fast-growing group but there is limited evidence for how well their needs are being met. OBJECTIVES: to quantify the social and custodial needs of older prisoners and suggest improvements for service provision. DESIGN: cross-sectional study. SETTING: twelve prisons holding adult males in North West England. SUBJECTS: two hundred and sixty-two prisoners; 97 aged between 50 and 59, 165 aged 60 and over. METHODS: interview and case-note review for issues of social and custodial need and quality of life in prison, including Forensic Camberwell Assessment of Need and Lubben Scale for social networks. RESULTS: many had problems mixing with younger prisoners, accommodation and activities, and limited contact with friends and family. A small group had personal care needs which were not well managed in prison. CONCLUSION: older prisoners have distinct social and custodial needs which need to be addressed by a national strategy for their care and management.

Filicide: mental illness in those who kill their children.

BACKGROUND: Most child victims of homicide are killed by a parent or step-parent. This large population study provides a contemporary and detailed description of filicide perpetrators. We examined the relationship between filicide and mental illness at the time of the offence, and care received from mental health services in the past. METHOD: All filicide and filicide-suicide cases in England and Wales (1997-2006) were drawn from a national index of homicide perpetrators. Data on people in contact with mental health services were obtained via a questionnaire from mental health teams. Additional clinical information was collected from psychiatric reports. RESULTS: 6144 people were convicted of homicide, 297 were filicides, and 45 cases were filicide-suicides. 195 (66%) perpetrators were fathers. Mothers were more likely than fathers to have a history of mental disorder (66% v 27%) and symptoms at the time of the offence (53% v 23%), most often affective disorder. 17% of mothers had schizophrenia or other delusional disorders. Overall 8% had schizophrenia. 37% were mentally ill at the time of the offence. 20% had previously been in contact with mental health services, 12% within a year of the offence. CONCLUSION: In the majority of cases, mental illness was not a feature of filicide. However, young mothers and parents with severe mental illness, especially affective and personality disorder who are providing care for children, require careful monitoring by mental health and other support services. Identifying risk factors for filicide requires further research.

The health and social needs of older male prisoners.

OBJECTIVES: This study aimed to quantify the health and social needs of older male prisoners in the North West of England, to determine whether their needs were being met, and to explore an age cut-off for this group. METHODS: Data were collected by interview and case note review. Areas covered included physical health, mental health, personality disorder, cognitive impairment and social need. RESULTS: A total of 262 prisoners were included in the study. Over 90% had a physical health disorder, most commonly hypertension and osteoarthritis. A total of 61% had a mental disorder, most commonly major depressive disorder and alcohol misuse disorder. There were few differences within age bands for physical health problem or health/social need, but those aged 50-59 years had more mental disorder, including mental illness, substance misuse disorder and personality disorder. CONCLUSIONS: Older prisoners have a high level of health need and a different profile to the rest of the prison population. Fifty appears to be a useful age over which to define this group, and service provision should reflect this in a national management strategy.

Improvements to suicide prevention training for prison staff in England and Wales.

Suicide prevention training for the prison service in England and Wales has been criticized. STORM is a package emphasizing the practice and review of interactions with suicidal persons and was evaluated in a pilot study for use in prisons. Trainees completed questionnaires immediately before and after training and at 6 to 8 months follow-up. Training significantly improved attitudes, knowledge, and confidence, and improvements were maintained at follow-up. Satisfaction with training was very high. STORM was successfully adapted for prison settings, and showed good effects among staff trained. It should be provided to the wider prison estate, with regular refresher training.

Homicide of infants: a cross-sectional study.

OBJECTIVE: To describe the sociodemographic, clinical, and forensic characteristics of people convicted of killing infants, including their outcome in court and the gender differences in these characteristics. METHOD: A consecutive case series of people convicted of infant homicide in England and Wales (1996-2001). Information on social demographic and clinical characteristics of perpetrators was collected from psychiatric reports prepared for court. Detailed clinical information was gathered from questionnaires completed by mental health teams for those in contact with mental health services. RESULTS: Of the 2660 identified perpetrators that were convicted of homicide, 112 (4%) were convicted of infant homicide. Fathers killed 56 infants (50%); mothers killed 35 (31%). Forty-nine infants (44%) were killed within 3 months of birth, and 87 (78%) within 6 months. Seventeen perpetrators (24%) had symptoms of mental illness at the time of the offense. Thirty-eight (34%) had a lifetime history of mental illness. In total, 16 (14%) had been under the care of mental health services. Ten women (29%) were diagnosed with affective disorder, and 25 men (53%) had a history of alcohol or drug misuse. Men were more likely to have previous convictions for violence compared to women (p = .01). Most male perpetrators received a custodial sentence (N = 71, 96%), whereas 28 women (74%) received community sentences or hospital disposals. CONCLUSIONS: This study highlights the need for increased perinatal assessment and parenting support to encourage parents to seek help. Further research using a psychological autopsy methodology focusing on criminological and psychiatric antecedents may improve our understanding of why these deaths occur and prevent future tragedies.