Critical time Intervention for Severely mentally ill Prisoners (CrISP): a randomised controlled trial

Background The transition from prison to community is difficult for prisoners with mental illness. Critical time intervention (CTI) is designed to provide intensive support to meet health, social care and resettlement needs through close working between client and key worker pre, and up to 6 weeks post, release. Objectives To establish whether or not CTI is effective in (1) improving engagement of discharged male prisoners who have mental illness with community mental health teams (CMHTs) and (2) providing practical support with housing, finance and re-establishing social networks. Trial design A multicentre, parallel-group randomised controlled trial, with follow-up at 6 weeks and at 6 and 12 months. A subset of prisoners and case managers participated in a complementary qualitative study. Setting Eight English prisons. Participants One hundred and fifty adult male prisoners, convicted or remanded, cared for by mental health in-reach teams and diagnosed with severe mental illness, with a discharge date within 6 months of the point of recruitment. Intervention Participants were randomised to either the intervention or the control (treatment as usual). The intervention group was assigned a case manager who assessed mental and physical health before and following release, made appropriate links to health, housing and financial services and supported the re-establishment of family/peer contact. Outcome The primary outcome measure was engagement with a CMHT 6 weeks post discharge. Secondary outcomes included contact with mental health services at 6 and 12 months. A health economic evaluation was undertaken using service contact at the follow-up time points. We were unable to assess the intervention’s effect on reoffending and longer-term health-care use because of study delays. Results One hundred and fifty prisoners were recruited: 72 were randomised to the intervention and 78 were randomised to the control. Engagement with teams at 6 weeks was 53% for the intervention group compared with 27% for the control group [95% confidence interval (CI) 0.13% to 0.78%; p = 0.012]. At 6 months’ follow-up, intervention participants showed continued increase in engagement with teams compared with control participants (95% CI 0.12% to 0.89%; p = 0.029); there were no significant differences at 12 months. Increased engagement resulted in higher levels of service use and costs for the intervention than for the control. Qualitative data showed the intervention group reporting better continuity of care and improved access to services. Conclusion The intervention significantly improved contact with services at 6 weeks, although at a higher cost than the control. This is important as, in the days and weeks following release, recently released individuals are at a particularly high risk of suicide and drug overdose. Further research is required to establish how teams can better maintain contact with clients when the intervention ends. Future work Further studies are indicated for groups with different needs, for example women, young prisoners and those in police custody, and at other transition points, for example following arrest and short-term custody, and at points of transition between different mental health services. Trial registration Current Controlled Trials ISRCTN98067793. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information

Preliminary evaluation of the use of pharmacological treatment with convicted sexual offenders experiencing high levels of sexual preoccupation, hypersexuality and/or sexual compulsivity

The current study presents the preliminary evaluation of the impact of pharmacological treatment (Selective Serotonin Reuptake Inhibitors and anti-androgens) on hypersexuality, sexual preoccupation and sexual compulsivity. The participant pool comprised 64 convicted UK sexual offenders who had been voluntarily referred for pharmacological treatment to reduce their hypersexual arousal, 51 of whom agreed to take the medication (with a further five individuals on hold or under assessment at the time of data extraction). The preliminary findings were very encouraging; analysis on measures assessing sexual preoccupation, hypersexuality and sexual compulsivity indicated a significant reduction between pre- and post-medication, across both types of medication. Limitations of the current research are discussed

Care versus custody: Challenges in the provision of prison mental healthcare

Prison mental health in-reach teams (MHIRTs) were introduced to provide the same range and quality of services to prisoners with severe and enduring mental health problems as is available to the general population (‘equivalence of care’). Drawing on a qualitative study of a MHIRT at an English prison, this chapter highlights the difficulties of striving to provide equivalent care in an anti-therapeutic environment which prioritises security and control. It argues that the team were heavily co-opted into penal governance and risk management activities and faced considerable hostility from those who saw prisoners as undeserving of care. It questions the notion of ‘healthy prisons’ and recommends that resources currently invested in the prison system be redirected into efforts to create socially just communities

Barriers and facilitators to a criminal justice tobacco control coordinator: an innovative approach to supporting smoking cessation among offenders

Aims To examine the barriers and facilitators to effective operation of a regional tobacco control coordinator working within and across criminal justice and public health, whose goal was to raise tobacco control awareness and support the development of smoking cessation treatment for offenders. Design A reflexive, mixed-methods case study approach using in-depth interviews, project reports and observation of advisory board meetings. Setting The coordinator worked with prisons, probation and police custody, where there are high levels of social disadvantage and smoking. Participants Interviews (n = 34) at different stages of project with the coordinator, project advisers and local stakeholders from criminal justice and public health. Measurements Analysis of facilitators and barriers and the coordinator role from different perspectives. Findings Readiness to develop cessation services was a critical predictor of different criminal justice settings' engagement with the coordinator role. The coordinator enhanced cessation service delivery in individual prisons where there was a requirement and infrastructure in place to provide such services. In police custody, where there was no central guidance or pre-existing requirements, efforts to establish smoking cessation on the local agenda proved ineffective. In probation settings, the coordinator documented examples of good practice and supported brief intervention training. Variability in willingness to engage limited the project's ability to create joined-up working across criminal justice settings. Conclusions In the English criminal justice system, the prison service appears to provide a favourable context for development of smoking cessation support and a means of accessing hard-to-reach groups. Other criminal justice settings, most specifically police custody, appear less responsive to such activity. A coordinator role can improve smoking cessation support in the prison setting, and develop local improvements in tobacco control interventions in other settings such as probation, but as configured here, does not have the capacity to effect change across the criminal justice system

Subjective experience of early imprisonment

Background: Some say 'prison works', others say that it only harms. Overall, longitudinal studies of prisoners suggest some positive impact on mental state, but post-release recidivism is high. How do men at high risk for repeated imprisonment experience it? Aim: To explore prison (gaol) experience among men awaiting trial in custody. Methods: In a prospective longitudinal study, 170 men were interviewed just after reception about their social context and mental state and again three weeks later, when each was asked to describe his current prison experience; 75% had been in prison before. Data were analysed qualitatively and quantitatively. Results: Each man had views on his imprisonment. Data were saturated after 20 interviews. The core concern was its overall emotional impact, in full negative to positive range, with recognition that this could and did change in either direction, both passively and through active processes. Underpinning themes were along the dimensions of missing people to asylum from the outside world; in-prison bullying to positive staff and/or inmate relationships; boredom to relief in routine; and 'doing my head in' to salvation from drug-induced decline. Testing the model in the whole sample confirmed no association between prison impact and pre-prison factors. Negative experience was associated with severe depression within but not before this imprisonment. More positive experience related to good in-prison relationships. Conclusions: During pre-trial custodial detention, there is a greater range of experience than generally previously reported. The simple expedients of prison staff developing good relationships with prisoners, and facilitating these between prisoners, could be life-saving. Highly positive experiences may be more an indictment on community services than an endorsement of imprisonment