Acceptability and feasibility pilot randomised controlled trial of medical skin camouflage for recovery of women prisoners with self-harm scarring (COVER): the study protocol

Self-harm in prison is a major public health concern. Less than 5% of UK prisoners are women, but they carry out more than a fifth of prison self-harm. Scars resulting from self-harm can be traumatising and stigmatising, yet there has been little focus on recovery of women prisoners with self-harm scarring. Medical skin camouflage (MSC) clinics treat individuals with disfiguring skin conditions, with evidence of improved well-being, self-esteem and social interactions. Only one community study has piloted the use of MSC for self-harm scarring. We describe an acceptability and feasibility pilot randomised controlled trial; the first to examine MSC for women prisoners who self-harm. We aim to randomise 20-25 women prisoners to a 6-week MSC intervention and 20-25 to a waitlist control (to receive the MSC after the study period). We aim to train at least 6-10 long-term prisoners with personal experience of self-harm to deliver the intervention. Before and after intervention, we will pilot collection of women-centred outcomes, including quality of life, well-being and self-esteem. We will pilot collection of self-harm incidents during the intervention, resources used to manage/treat self-harm and follow-up of women at 12 weeks from baseline. Data on recruitment, retention and dropout will be recorded. We aim for the acceptability of the intervention to prison staff and women prisoners to be explored in qualitative interviews and focus groups. Ethical approval for COVER has been granted by the North East-York Research Ethics Committee (REC) for phases 1 and 2 (reference: 16/NE/0030) and West of Scotland REC 3 for phases 3 and 4 (reference: 16/WS/0155). Informed consent will be the primary consideration; it will be made clear that participation will have no effect on life in prison or eligibility for parole. Due to the nature of the study, disclosures of serious self-harm may need to be reported to prison officials. We aim for findings to be disseminated via events at the study prison, presentations at national/international conferences, journal publications, prison governor meetings and university/National Health Service trust communications. NCT02638974; Pre-results. [Abstract copyright: © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.

Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: a qualitative study

Abstract Background There are now effective drugs to prevent cardiovascular disease and guidelines recommend their use. Patients do not always choose to accept preventive medication at levels of risk reduction recommended in guidelines. The purpose of the study was to identify and explore the attitudes of patients and general practitioners towards preventative medication for cardiovascular disease (CVD) after they have received information about it; to identify implications for practice and prescribing. Methods Qualitative interviews with GPs and patients following presentation of in depth information about CVD risks and the absolute effects of medication. Setting: GP practices in Birmingham, United Kingdom. Results In both populations: wide variation on attitudes to preventative medication; concerns about unnecessary drug taking & side effects; preferring to consider lifestyle changes first. In patient population: whatever their attitudes to medication were, the vast majority explained that they would ultimately do what their GP recommended; there was some misunderstanding of the distinction between curative and preventative medication. A common theme was the degree of trust in their doctors' judgement and recommendations, which contrasted with scepticism of the role of pharmaceutical companies and academics. Scepticism in guidelines was also common among doctors although many nevertheless recommended treatment for their patients Conclusions A guideline approach to prescribing preventative medication could be against the interests and preferences of the patient. GPs must take extra care to explain what preventative medication is and why it is recommended, attempt to discern preferences and make recommendations balancing these potentially conflicting concerns.</p

Case Scenario 1: Ethics Commentary

10.1353/asb.2013.0054Asian Bioethics Review53184-19

Assisted self-harm in mental health care facilities : an ethically acceptable approach?

The aim of the thesis is to establish whether "assisted self-harm" is ethical or moral, when used in adult acute inpatient environments; in other words, whether it is consistent with how people should live their lives and treat others. "Assisted self-harm" refers to management strategies for self-harm which strive to reduce/limit, rather than stop, the behaviour. Strategies include offering advice on safer places to injure or allowing/providing sharp implements. In the project I used an "empirical ethics" approach, combining philosophical analysis with empirical studies to produce normative, not descriptive, conclusions. I conducted individual qualitative interviews with 5 patients and 20 inpatient or home intervention mental health professionals. Two focus groups were conducted: (I) with people from adult community services (n=4); and (2) with people from a specialist service for personality disorder (n=12). The interviews provided descriptive data about people's motivations, reasons and intentions when they self-injure, as well as predictive data about the possible consequences of allowing injury and participant-driven arguments for or against the approach. This data was used to complement theoretical analysis of the key concepts "autonomy", "responsibility" and "harm" and was integrated into my own arguments, to provide recommendations for action. Based on the combined analysis, I argue that "assisted self-harm" is justifiable in the shortterm as a means to reduce long-term harm, provided that five conditions are met. Thus, where the patient: is using self-injury primarily to manage distress; is injuring in a way which is associated with a low probability of physical damage (given the presence of appropriate support, such as advice on technique); possesses sufficient mental acuity after injury to engage with therapy; has an honest and open relationship with staff who are familiar with their history; and is capable of injuring in private, then "assisted self-harm" m.ay be an appropriate and effective approach.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Abstracts of the RCPsych International Congress 2023, 10-23 July

AIMS: As of 2018, there were over 11 million people imprisoned globally. Suicide and self-harm rates have been found to be markedly elevated among imprisoned individuals, however there is much less literature reporting on risk factors for suicide and self-harm following prison release. The immediate post-release period has been found to be a particularly high-risk period for suicide and self-harm. Since many more people are released into the community every year than people kept imprisoned, released prisoners' health is a matter of public health concern. With the societal impact of this topic in mind, this systematic review aims to collate the risk factors for suicide and self-harm upon release from prison.METHODS: PubMed, PsycINFO, MEDLINE, and Cochrane were systematically searched using keywords relating to prison release, self-harm and suicide for articles published since 1/1/12. Studies were included if they reported data on risk factors for self-harm or suicide and followed prespecified inclusion criteria. Articles were screened by the author and uncertainty was settled by two independent reviewers. Included studies were evaluated using standardised quality assessment tools. Quantitative data were narratively synthesised due to a high level of heterogeneity in between studies.RESULTS: 248 articles were identified in total. 10 articles were included, reporting data on self-harm and suicide risk factors from 5 countries. Studies ranged from moderate (n = 2) to high quality (n = 8). Risk factors were categorised into the following: demographic characteristics, psychiatric history, conviction type, and imprisonment history. Risk factors which did not fit into any of these categories were categorised into an ”other” group. It was found that there were many non-modifiable factors such as violent convictions, female sex, Indigenous (Torres Strait Islander or Aboriginal) ethnicity, and single relationship status which increase self-harm or suicide risk upon release.CONCLUSION: To our knowledge, this is the first systematic review to collate the risk factors for suicide and self-harm following prison release. The results show a complex variety of risk factors. The high mortality rate in this group necessitates the need for strategies to intervene before community re-entry. Study into risk factors post-release may guide identification of at-risk groups to target with proactive, coordinated care pre- and post-release. It is likely this will require a multifactorial approach including health, social and community programmes.</p

Scoping review of mental health in prisons through the COVID-19 pandemic

Objective To examine the extent, nature and quality of literature on the impact of the COVID-19 pandemic on the mental health of imprisoned people and prison staff.Design Scoping review.Data sources PubMed, Embase, CINAHL, Global Health, Cochrane, PsycINFO, PsychExtra, Web of Science and Scopus were searched for any paper from 2019 onwards that focused on the mental health impact of COVID-19 on imprisoned people and prison staff. A grey literature search focused on international and government sources and professional bodies representing healthcare, public health and prison staff was also performed. We also performed hand searching of the reference lists of included studies.Eligibility criteria for selection of studies All papers, regardless of study design, were included if they examined the mental health of imprisoned people or prison staff specifically during the COVID-19 pandemic. Imprisoned people could be of any age and from any countries. All languages were included. Two independent reviewers quality assessed appropriate papers.Results Of 647 articles found, 83 were eligible for inclusion, the majority (58%) of which were opinion pieces. The articles focused on the challenges to prisoner mental health. Fear of COVID-19, the impact of isolation, discontinuation of prison visits and reduced mental health services were all likely to have an adverse effect on the mental well-being of imprisoned people. The limited research and poor quality of articles included mean that the findings are not conclusive. However, they suggest a significant adverse impact on the mental health and well-being of those who live and work in prisons.Conclusions It is key to address the mental health impacts of the pandemic on people who live and work in prisons. These findings are discussed in terms of implications for getting the balance between infection control imperatives and the fundamental human rights of prison populations