PERSPECTIVE
Prison prescribing practice: practitioners’ perspectives on why prison is different of imprisonment. Prisoners have high rates of personality disorders, typically borderline, paranoid and antisocial types (4); all affect the quality of interpersonal relationships. Brief states of high arousal are common. Accompanying pseudopsychotic symptoms are hard to classify; they can be part of a mental illness or indicate a stress reaction in someone with a vulnerable personality, or both. These are areas of clinical practice where prescribing practice is debated (13) and inconsistent (14). There is specific prison guidance (15), but the frequency of this constellation of psychiatric dilemmas means that the task for prison, primary care clinicians is above and beyond that commonly expected in external primary care settings. A responsive, secondary mental health service is important to advise both on diagnosis and starting or continuing psycho-active medication. This is particularly important as few primary care clinicians have training or expertise in mental health (10).
The current prison population in England and Wales has multiple, complex healthcare needs, presenting unique challenges to those caring for prisoners. Prison numbers have increased dramatically in the last 10 years. There are now approximately 84,000 prisoners in England and Wales (1) and 120,000 new episodes of imprisonment each year (2). The authors all contribute to prison healthcare. Below, we discuss a key issue arising from first-hand experience of prisoners’ health and social care needs, the prescription of psycho-active drugs by primary and secondary care practitioners. This is a core medical task, but beset with difficulties. These difficulties are not necessarily encountered in other areas of prison healthcare. However, they do illustrate how providing healthcare to prisoners is complex, often lacking a research base and can have pitfalls that are not obvious to the outsider. Mental health problems are common in prisoners (3–5) and this has been a consistent finding over many years in both the UK and elsewhere (6). Both severe and enduring mental illness and common neurotic disorders may require medication. Many prisoners are prescribed psycho-active drugs. Suicide in prisoners is linked to both a history of psychiatric disorder and use of psycho-active medication (7) as is near lethal self-harm (8). Overdose is a common method of self-harm and a cause of suicide in prison, as elsewhere (9). The Prison Inspectorate has expressed concern about patterns of prescribing of psycho-active medication in UK prisons (10).
Major diagnostic challenges in mental health Prisoners often have more than one mental health problem (4,10). Achieving diagnostic clarity in our patient group is vital but difficult, for several reasons. Harmful use of drugs and alcohol, including dependence, is common (11,12). Seven in 10 prisoners report drug use in the 12 months prior to imprisonment and of these individuals, 4 in 10 will have injected drugs in the preceding month. Many remand prisoners require chemical detoxification. This is frequently accompanied by mood disturbance and fluctuating mental states during the first weeks
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417. doi: 10.1111/ijcp.12362
The challenge of routine clinical complexity in prisons
Medicalisation of social problems There is also a fine line between a depressive disorder and an understandable reaction to difficult social circumstances. Prisoners have experienced social disadvantage and exclusion prior to imprisonment (16). This may predispose them to the development of mental illness, but health professionals must also identify the very real, social stressors, which so many prisoners face. Prison can offer an opportunity to take stock of lives lived in crisis; it can, itself, also inflict harm. Prisoners, particularly those on remand, can find custody disorientating and difficult. Criminal courts are stressful. Many hours are spent confined to cells, without access to meaningful activities (17). Many prisons date from the Victorian era; their physical environment is harshly institutional and the acoustics poor; noise frequently reverberates around wings disrupting sleep. In summer, heat and poor ventilation can contribute to tension and irritability in housing blocks. As well as detention, the nature of the crime
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(e.g. sexual offending) can reduce support networks, inside and outside the prison. Women prisoners, in particular, often have childcare responsibilities. They can be intensely preoccupied with the practical and emotional welfare of children for whom alternative arrangements (extended family or social services) have to be made (18). Elderly prisoners are a poorly described but increasing proportion of the prison population. They may be particularly mentally and physically frail and struggle with the physical and social environment of the prison (19,20). Drug users who do achieve abstinence are faced with a sober awareness of how devastating their behaviour has been for themselves and their families. Not surprisingly, the risk of self-harm is greatest in the first few months of custody, as prisoners adjust to the realities of life in prison (21–23).
and aid sleep (24) and facilitate the development of a therapeutic relationship, which can ultimately lead to patients being more receptive to non-pharmacological treatments. Just as there are those prisoners who are medication seeking, prison also contains individuals who reject offers of useful medication and others who may warrant medication, but whose needs are not well recognised (25,26). Importantly, prisoners with acute psychosis may lack insight into the need for help. Engagement in these cases can be hard and the inapplicability of the Mental Health Act in prison limits the scope for enforced medication. Prompt transfer to hospital is paramount, although, in practice, often hard to achieve (27,28). This leaves prison health and discipline staff managing high levels of behavioural disturbance.
Better engagement and negotiating treatment
The perils of trading drugs
Clinicians need to consider the meaning of the medication, particularly in prisoners who seem much attached to their prescriptions. Sudden reductions can be perceived as insensitive, even punitive. This can be labour intensive. Cavalier approaches, particularly to prisoners with previous experience of being plugged into overly simplistic, psychological, ‘quick fixes’ can turn prisoners away from helpful, psychological avenues of care. Sympathetic management of a prisoner’s medicines may pave the way for engagement in more meaningful and effective, alternative treatments. This patient group has limited coping strategies and drug-seeking behaviour is common, particularly in those with long-standing, substance misuse problems. Many arrive in prison on long-term prescriptions of psycho-tropics including antidepressants, antipsychotics, sedatives and anxiolytics. There may be limited evidence that the medication is helpful or compliance robust. Clinicians may feel unable to reduce or rationalise prescriptions in the face of on-going crises and significant pressure from their patients. Clearly, this scenario is not unique to the prison population, but the combination of addiction problems and personality difficulties makes it common. To withdraw ineffective medicines is to risk an increase in self-harm, subjective distress and protest. Prisoners may seek to obtain medication from others in the prison by trading or exploitation. In addition, clinicians who rely solely on a framework of ‘mental illness’ to conceptualise distress and who invest heavily in pharmacological therapy may limit the patient’s access to alternative, perhaps more effective solutions. However, prescribing, when appropriate, can have additional merit. It can help prisoners cope
Almost all drugs have some trading value in prison. A strong desire to ‘use’ creates a market for both illicit drugs and prescribed medication. This seems fuelled in part by boredom. Remand prisons tend to have less structured activities and training opportunities and prisoners are often subject to greater stresses. High currency drugs tend to be either sedating or stimulating in action. Sedating drugs enable prisoners to try and ‘manage’ boredom by sleeping away their time and can reduce distressing emotions (29). Stimulants can lead either to euphoria, lifting mood or disinhibition, helping prisoners to socialise in what can be a very testing environment. Drugs of abuse include sedating antidepressants such as mirtazapine and trazadone, but there is also a market for the antipsychotics, especially quetiapine (30), anxiolytics, analgesics and anticonvulsants (pregabalin, gabapentin and clonazepam) (15). Prisoners can show remarkable perspicacity in learning which combinations of medication will have the desired effect. This valuable information if shared with other prisoners can lead to even greater opportunities for the abuse of medication that doctors have, in good faith, prescribed. Personal poly-pharmacy, generated by trading, can deprive the prescribed individual of medication that might help them and cloud the clinical picture. In addition, the risk of inadvertent overdose or adverse reaction is heightened, more so in individuals already receiving maintenance or substitute medication such as methadone and buprenorphine (recognised to interact with antipsychotics and antidepressants). The scale of trading in prescribed medication is unknown as is the scale of use of illegal drugs (31). However, recent prison fatalities have been linked with trading in both illegal and prescribed medicaª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
Perspective
tion, hoarding of prescribed medication and using both prescribed and illegal drugs (32).
Lack of alternative approaches to medication In this context, we welcome and campaign for the increased availability of alternatives to psycho-active medication. Psycho-social treatments in prison should be available to all, not reserved for serious offenders. This risk is real as the Offender Personality Disorder Strategy is rolled out to replace the previous Dangerous and Severe Personality Disorder programme of interventions (33). Psychological treatments ideally need to be embedded in rapid, holistic packages of care to address the many psycho-social factors (e.g. housing crisis, child care emergencies, debt) relevant to the genesis of depression and other acute mental disorders. Such treatments can be difficult to deliver comprehensively, particularly to remand prisoners who may not stay in prison for long. Effective partnership with prison staff and Third Sector agencies is key. In prison, a broad range of psychological therapies (i.e. short- and long-term counselling (such as bereavement counselling), psycho-dynamic work, art and music therapy) can be offered on an individual or group basis. Prisoners should have access to patient centred, individualised care, equivalent to that available in the community. This remains an aspiration in many prisons. Prison health commissioners in NHS England must look beyond the financial spend on psycho-active drugs and recognise the need for a full range of approaches.
Opportunities for prison healthcare research We are largely ignorant of the rationales behind prisoners’ drug preferences. At a clinical level, amnesia about the detail of illegal and prescribed, personal drug use (linked with repeated periods of intoxication), reticence in the clinical encounter, complexity of historical drug use, inconsistent responses over time and lack of knowledge about the nature of substances ingested all contribute to clinical uncertainty about an individual patient’s choices. For many prisoners, their behaviour is not unique to the prison environment. High-risk behaviour is a core component of their life in the wider community. It may be that getting hold of any pill is better than no pill, i.e. the possibility of short-term pharmacological relief of distress, even if risky, is better than living sober. Possibly, prisoners have a good experiential understanding of the likely effects of particular psycho-active ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
medication on their individual mental states. However, there is scope for research on patterns of illegal drug use in prison, trading of prescribed medication and how both relate to individual factors (pre and post imprisonment) and the organisation of the prison. It is also true that, to date, little convincing research has been undertaken on prison-based psycho-social alternatives to prescribed medication. This is needed because of the scale of the problem and the personal and financial cost of inaction.
Commissioning changes and cautious optimism Meanwhile, prison doctors are between a rock and a hard place. It may well be clinically appropriate to prescribe psychotropic medication to a specific prisoner, but there is no guarantee that the medicine will end up being ingested by that individual. In custodial environments such as ours, our script might help fuel a culture of trading, destabilising the prison and encouraging bullying and violence (34). In addition, unwarranted prescribing contributes to the medicalisation of social distress and disempowers the patient. Our ability to provide alternative interventions, such as psycho-social treatments, is compromised by a lack of resources. These interventions are often unavailable or in short supply. When they do exist, we may be too slow to deliver them. Lastly, there will ultimately always be a cohort of patients to whom a psychological treatment is unacceptable. In these cases, we risk leaving unsupported prisoners in crisis. New commissioning arrangements (35) offer cautious grounds for hope. To benchmark needs and interventions (pharmacological and psychological) across multiple prisons would be a significant improvement and is now feasible. Aberrant prescribing of psycho-active drugs in a given prison could more easily be identified. Effective service development and performance monitoring should help eradicate it. Gaps in psychological alternatives could be identified, laying foundations for improved, equitable service delivery. New liaison and diversion services, staffed by health and social care workers, are in vogue. In line with the recommendations of the Bradley Report (36), they divert people with mental health problems out of the criminal justice system, principally from courts and police stations. We welcome this, but we remain concerned that it may distract attention from the needs of prisoners. Whatever the size of the prison estate in England and Wales, it is likely that high levels of physical and mental morbidity will
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continue among prisoners for the foreseeable future. They require a better range of services than they currently receive (37). Well-targeted resourcing will not only be cost effective in the long term, but could reduce the high rate of suicide, currently seen in the first 7 days after imprisonment (21,22). Commissioners must not let slip today’s opportunity. They must commission to demonstrate health gain, not just service equivalence (38). We need both better prescribing of medication and more available psycho-social interventions to tackle the wealth of misery that our prisons contain.
References 1 Ministry of Justice. Offender management statistics (quarterly) October to December 2012, 2013. https://www.gov.uk/government/publications/offen der-management-statistics-quarterly–2 (accessed November 2013). 2 Receptions Q1, 2012. Gov.uk https://www.gov.uk/ …/omsq-q1-2012-prison-reception-tables.xls.xls (accessed May 2013). 3 Brooke D, Taylor C, Gunn J, Maden A. Point prevalence of mental disorder in unconvicted male prisoners in England and WalesBr Med J 1996; 313: 1524–7. 4 Singleton N, Meltzer H, Gatward R, Coid J, Deasy D. Psychiatric morbidity among prisoners in England and Wales: A survey carried out in 1997 by the Social Survey Division of ONS on behalf of the Dept of Health. London: The Stationery Office, 1998. 5 Brugha T, Singleton N, Meltzer H, Bebbington P, Farrell M, Jenkins R. 2005 psychosis in the community and in prisons: a report from the British National Survey of Psychiatric Morbidity. Am J Psychiatry 2005; 162: 774–80. 6 Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and metaregression analysis. Br J Psychiatry 2012; 200: 364–73. 7 Fazel S, Cartwright J, Norman-Nott A., Hawton K. Suicide in prisoners: a systematic review of risk factors. J Clin Psychiatry 69(11): 1721–31. 8 Marzano L, Fazel S, Rivlin A, Hawton K. Psychiatric disorders in women prisoners who have engaged in near-lethal self-harm: case control study. Br J Psychiatry 2010; 197: 219–226. 9 National Confidential Inquiry. National study of self inflicted deaths by prisoners in England and Wales 2008-2010, 2013. http://www.bbmh.manchester. ac.uk/cmhr/research/centreforsuicideprevention/nci/ reports/ (accessed September 2013). 10 HM Inspectorate of Prisons. The mental health of prisoners, 2007. www.justice.gov.uk/downloads/ publications/inspectorate-reports/hmipris/thematicreports-and-researchpublications (accessed September 2013). 11 Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction 2006; 101: 181–191. 12 DH Patel Report. Prison drug treatment strategy REVIEW GROUP, 2010. https://www.gov.uk/ government/uploads/system/…data/…/dh_119850.pdf (accessed September 2013).
A. Bartlett,* N. Dholakia,* R. England,* H. Hales,† E. van Horn,* T. McGeorge,* B. Moss,* S. Ovaisi,* E. Tukmachi,* S. Patel* *CNWL FT, London, UK † Wells Unit, West London Mental Health Trust, London, UK
13 NICE. Borderline personality disorder treatment and management, 2009. http://www.legislation.gov. uk/ukpga/2003/44/contents (accessed July 2013). 14 Black DW, Allen J, McCormick B, Blum N. Treatment received by persons with BPD participating in a randomized clinical trial of the Systems Training for Emotional Predictability and Problem Solving programme. Pers Ment Health 2011; 5: 159–168. 15 Royal College of General Practitioners/Royal Pharmaceutical Society. Safer prescribing in prisons: guidance for clinicians, 2011. www.rcgp.org.uk/pdf/Safer_Prescribing_in_Prison.pdf. (accessed July 2013). 16 Social Exclusion Unit. Reducing Re-offending by Ex-prisoners. London: Office of the Deputy Prime Minister, 2002. 17 HMIP. Remand prisoners: a thematic review, 2012. http://www.justice.gov.uk/publications/inspectoratereports/hmi-prisons/thematic-research (accessed September 2013). 18 Booker-Loper A., Tuerk E. Improving the emotional adjustment and communication patterns of incarcerated mothers: effectiveness of a prison parenting intervention. J Child Family Stud 2011; 20, 89–101. 19 Ginn S. Elderly prisoners. Br Med J 2012; 345: e626320. 20 Bartlett A, Evans S. Up to date service evaluations and needs assessments would be useful in caring for elderly prisonersBr Med J 2012; 345: e7578. 21 Humber N, Piper M, Appleby L, Shaw J. Characteristics of and trends in subgroups of prisoner suicides in England and Wales. Psychol Med 2011; 41 (11): 2275–85. 22 Shaw J, Baker D, Hunt IM, Moloney A, Appelby L. Suicide by prisoners. National Clinical Survey. Br J Psychiatry 2004; 184: 263–7. 23 Marzano L, Hawton K, Rivlin A, Fazel S. Psycho-social influences on prisoner suicide: a case control study of near lethal self-harm in women prisoners. Soc Sci Med 2011; 72(6): 874–83. 24 Hassan L, Edge D, Senior J, Shaw J. Staff and patient perspectives on the purpose of psychotropic prescribing in prisons: care or control. Gen Hosp Psychiatry 2013; 35: 433–438. 25 Fazel S, Hope T, O’Donnell I, Jacoby R. Hidden psychiatric morbidity in elderly prisoners. Br J Psychiatry 2001; 179: 535–9. 26 Birmingham L, Coulson D, Mullee M, Kamal M, Gregoire A. The mental health of women in prison mother and baby units. J Forensic Psychiatry Psychol 2006; 17(3): 393–404.
Correspondence to: Annie Bartlett, Mental Health, CNWL FT/SGUL, London SW17 0RE, UK Tel.: + 44 2087 253 452 Fax: + 44 2082 666 470 Email: [email protected]
27 Bartlett A, Somers N, Reeves C, White S. Women prisoners: an analysis of the process of hospital transfers. J Forensic Psychiatry Psychol 2012; 23(4): 538–553. 28 Forrester A, Exworthy T, Chao O, Slade K, Parrott J. Influencing the care pathway for prisoners with acute mental illness. Crim Behav Ment Health 2013; 23: 217–226. 29 Ritter C, Broers B, Elger B. Cannabis use in a Swiss male prison: qualitative study exploring detainees’ and staffs’ perspectives. Int J Drug Policy 2013, doi: 10.1016/j.drugpo.2013.05. 30 Tamburello AC, Lieberman JA, Baum RM, Reeves R. Successful removal of quetiapine from a correctional formulary. J Am Acad Psychiatry Law 2012; 40(4): 502–8. 31 McFeely M. NOMS review of unclassified deaths, 2012. iapdeathsincustody.independent.gov.uk/wp-co ntent/uploads/2012/06/1.-NOMS-review-of-unclassi fied-deaths-between-2010-and-2011.pdf (accessed September 2013). 32 Prisons and probation Ombudsman. Learning lessons bulletin fatal incidents investigations issue 1, 2012. www.ppo.gov.uk/…/LLB_FII_01_Learning_ from_approved_premises_f… (accessed September 2013). 33 Joseph N, Benefield N. A joint offender personality disorder pathway strategy: an outline summary. Crim Behav Ment Health 2012; 22(3): 210–7. 34 Chambers M. Coming clean. Combating drug misuse in prisons. Policy Exchange, 2010. http://www. policyexchange.org.uk/publications/category/item/ coming-clean-combating-drug-misuse-in-prisons (accessed July 2013). 35 NHS Commissioning Board. Securing equity and excellence in commissioning specialised services, 2012. http://www.england.nhs.uk/resources/spec-commresources (accessed July 2013). 36 The Bradley Report. Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system, 2009. http://webarchive.nationalarchives.gov.uk/2013010710 5354/http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_ 098694 (accessed October 2013). 37 Ginn S. Dealing with mental disorder in prisoners. BMJ 2012; 345: e7280. 38 Department of Health. The future organisation of prison health care, 1999. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006944. (accessed September 2013). ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
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Disclosure Annie Bartlett, Reader and Hon. Consultant in Forensic Psychiatry, SGUL and HMP Holloway, Offender Care CNWL FT. Neera Dholakia, Salaried GP, HMP Holloway, Offender Care CNWL FT. Lead GP for Safeguarding Children, Kensington and Chelsea. Darzi Fellow, Newham CCG and Office of London CCG. Rhiannon England, Salaried GP, HMP Holloway, Offender Care CNWL
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
FT. Mental Health Lead for City and Hackney Clinical Commissioning Group. Heidi Hales, Consultant Adolescent Forensic Psychiatrist, Wells Unit, WLMHT. Elizabeth van Horn, Consultant Psychiatrist HMP Wormwood Scrubs, Offender Care CNWL FT. Tristan McGeorge, Locum Consultant Forensic Psychiatrist, HMP Wormwood Scrubs Offender Care CNWL FT. Bronwen Moss, Salaried GP HMP Holloway Offender
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Care CNWL FT. Shazia Ovaisi, Salaried GP HMP Holloway Offender Care CNWL FT. Shamir Patel, Consultant Forensic Psychiatrist HMP Bronzefield, Offender Care CNWL FT. Emma Tukmachi Salaried GP HMP Holloway, Offender Care CNWL FT. Lead GP for Safeguarding Children in Tower Hamlets. Paper received July 2013, accepted October 2013
Prison prescribing practice: practitioners’ perspectives on why prison is different of imprisonment. Prisoners have high rates of personality disorders, typically borderline, paranoid and antisocial types (4); all affect the quality of interpersonal relationships. Brief states of high arousal are common. Accompanying pseudopsychotic symptoms are hard to classify; they can be part of a mental illness or indicate a stress reaction in someone with a vulnerable personality, or both. These are areas of clinical practice where prescribing practice is debated (13) and inconsistent (14). There is specific prison guidance (15), but the frequency of this constellation of psychiatric dilemmas means that the task for prison, primary care clinicians is above and beyond that commonly expected in external primary care settings. A responsive, secondary mental health service is important to advise both on diagnosis and starting or continuing psycho-active medication. This is particularly important as few primary care clinicians have training or expertise in mental health (10).
The current prison population in England and Wales has multiple, complex healthcare needs, presenting unique challenges to those caring for prisoners. Prison numbers have increased dramatically in the last 10 years. There are now approximately 84,000 prisoners in England and Wales (1) and 120,000 new episodes of imprisonment each year (2). The authors all contribute to prison healthcare. Below, we discuss a key issue arising from first-hand experience of prisoners’ health and social care needs, the prescription of psycho-active drugs by primary and secondary care practitioners. This is a core medical task, but beset with difficulties. These difficulties are not necessarily encountered in other areas of prison healthcare. However, they do illustrate how providing healthcare to prisoners is complex, often lacking a research base and can have pitfalls that are not obvious to the outsider. Mental health problems are common in prisoners (3–5) and this has been a consistent finding over many years in both the UK and elsewhere (6). Both severe and enduring mental illness and common neurotic disorders may require medication. Many prisoners are prescribed psycho-active drugs. Suicide in prisoners is linked to both a history of psychiatric disorder and use of psycho-active medication (7) as is near lethal self-harm (8). Overdose is a common method of self-harm and a cause of suicide in prison, as elsewhere (9). The Prison Inspectorate has expressed concern about patterns of prescribing of psycho-active medication in UK prisons (10).
Major diagnostic challenges in mental health Prisoners often have more than one mental health problem (4,10). Achieving diagnostic clarity in our patient group is vital but difficult, for several reasons. Harmful use of drugs and alcohol, including dependence, is common (11,12). Seven in 10 prisoners report drug use in the 12 months prior to imprisonment and of these individuals, 4 in 10 will have injected drugs in the preceding month. Many remand prisoners require chemical detoxification. This is frequently accompanied by mood disturbance and fluctuating mental states during the first weeks
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417. doi: 10.1111/ijcp.12362
The challenge of routine clinical complexity in prisons
Medicalisation of social problems There is also a fine line between a depressive disorder and an understandable reaction to difficult social circumstances. Prisoners have experienced social disadvantage and exclusion prior to imprisonment (16). This may predispose them to the development of mental illness, but health professionals must also identify the very real, social stressors, which so many prisoners face. Prison can offer an opportunity to take stock of lives lived in crisis; it can, itself, also inflict harm. Prisoners, particularly those on remand, can find custody disorientating and difficult. Criminal courts are stressful. Many hours are spent confined to cells, without access to meaningful activities (17). Many prisons date from the Victorian era; their physical environment is harshly institutional and the acoustics poor; noise frequently reverberates around wings disrupting sleep. In summer, heat and poor ventilation can contribute to tension and irritability in housing blocks. As well as detention, the nature of the crime
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(e.g. sexual offending) can reduce support networks, inside and outside the prison. Women prisoners, in particular, often have childcare responsibilities. They can be intensely preoccupied with the practical and emotional welfare of children for whom alternative arrangements (extended family or social services) have to be made (18). Elderly prisoners are a poorly described but increasing proportion of the prison population. They may be particularly mentally and physically frail and struggle with the physical and social environment of the prison (19,20). Drug users who do achieve abstinence are faced with a sober awareness of how devastating their behaviour has been for themselves and their families. Not surprisingly, the risk of self-harm is greatest in the first few months of custody, as prisoners adjust to the realities of life in prison (21–23).
and aid sleep (24) and facilitate the development of a therapeutic relationship, which can ultimately lead to patients being more receptive to non-pharmacological treatments. Just as there are those prisoners who are medication seeking, prison also contains individuals who reject offers of useful medication and others who may warrant medication, but whose needs are not well recognised (25,26). Importantly, prisoners with acute psychosis may lack insight into the need for help. Engagement in these cases can be hard and the inapplicability of the Mental Health Act in prison limits the scope for enforced medication. Prompt transfer to hospital is paramount, although, in practice, often hard to achieve (27,28). This leaves prison health and discipline staff managing high levels of behavioural disturbance.
Better engagement and negotiating treatment
The perils of trading drugs
Clinicians need to consider the meaning of the medication, particularly in prisoners who seem much attached to their prescriptions. Sudden reductions can be perceived as insensitive, even punitive. This can be labour intensive. Cavalier approaches, particularly to prisoners with previous experience of being plugged into overly simplistic, psychological, ‘quick fixes’ can turn prisoners away from helpful, psychological avenues of care. Sympathetic management of a prisoner’s medicines may pave the way for engagement in more meaningful and effective, alternative treatments. This patient group has limited coping strategies and drug-seeking behaviour is common, particularly in those with long-standing, substance misuse problems. Many arrive in prison on long-term prescriptions of psycho-tropics including antidepressants, antipsychotics, sedatives and anxiolytics. There may be limited evidence that the medication is helpful or compliance robust. Clinicians may feel unable to reduce or rationalise prescriptions in the face of on-going crises and significant pressure from their patients. Clearly, this scenario is not unique to the prison population, but the combination of addiction problems and personality difficulties makes it common. To withdraw ineffective medicines is to risk an increase in self-harm, subjective distress and protest. Prisoners may seek to obtain medication from others in the prison by trading or exploitation. In addition, clinicians who rely solely on a framework of ‘mental illness’ to conceptualise distress and who invest heavily in pharmacological therapy may limit the patient’s access to alternative, perhaps more effective solutions. However, prescribing, when appropriate, can have additional merit. It can help prisoners cope
Almost all drugs have some trading value in prison. A strong desire to ‘use’ creates a market for both illicit drugs and prescribed medication. This seems fuelled in part by boredom. Remand prisons tend to have less structured activities and training opportunities and prisoners are often subject to greater stresses. High currency drugs tend to be either sedating or stimulating in action. Sedating drugs enable prisoners to try and ‘manage’ boredom by sleeping away their time and can reduce distressing emotions (29). Stimulants can lead either to euphoria, lifting mood or disinhibition, helping prisoners to socialise in what can be a very testing environment. Drugs of abuse include sedating antidepressants such as mirtazapine and trazadone, but there is also a market for the antipsychotics, especially quetiapine (30), anxiolytics, analgesics and anticonvulsants (pregabalin, gabapentin and clonazepam) (15). Prisoners can show remarkable perspicacity in learning which combinations of medication will have the desired effect. This valuable information if shared with other prisoners can lead to even greater opportunities for the abuse of medication that doctors have, in good faith, prescribed. Personal poly-pharmacy, generated by trading, can deprive the prescribed individual of medication that might help them and cloud the clinical picture. In addition, the risk of inadvertent overdose or adverse reaction is heightened, more so in individuals already receiving maintenance or substitute medication such as methadone and buprenorphine (recognised to interact with antipsychotics and antidepressants). The scale of trading in prescribed medication is unknown as is the scale of use of illegal drugs (31). However, recent prison fatalities have been linked with trading in both illegal and prescribed medicaª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
Perspective
tion, hoarding of prescribed medication and using both prescribed and illegal drugs (32).
Lack of alternative approaches to medication In this context, we welcome and campaign for the increased availability of alternatives to psycho-active medication. Psycho-social treatments in prison should be available to all, not reserved for serious offenders. This risk is real as the Offender Personality Disorder Strategy is rolled out to replace the previous Dangerous and Severe Personality Disorder programme of interventions (33). Psychological treatments ideally need to be embedded in rapid, holistic packages of care to address the many psycho-social factors (e.g. housing crisis, child care emergencies, debt) relevant to the genesis of depression and other acute mental disorders. Such treatments can be difficult to deliver comprehensively, particularly to remand prisoners who may not stay in prison for long. Effective partnership with prison staff and Third Sector agencies is key. In prison, a broad range of psychological therapies (i.e. short- and long-term counselling (such as bereavement counselling), psycho-dynamic work, art and music therapy) can be offered on an individual or group basis. Prisoners should have access to patient centred, individualised care, equivalent to that available in the community. This remains an aspiration in many prisons. Prison health commissioners in NHS England must look beyond the financial spend on psycho-active drugs and recognise the need for a full range of approaches.
Opportunities for prison healthcare research We are largely ignorant of the rationales behind prisoners’ drug preferences. At a clinical level, amnesia about the detail of illegal and prescribed, personal drug use (linked with repeated periods of intoxication), reticence in the clinical encounter, complexity of historical drug use, inconsistent responses over time and lack of knowledge about the nature of substances ingested all contribute to clinical uncertainty about an individual patient’s choices. For many prisoners, their behaviour is not unique to the prison environment. High-risk behaviour is a core component of their life in the wider community. It may be that getting hold of any pill is better than no pill, i.e. the possibility of short-term pharmacological relief of distress, even if risky, is better than living sober. Possibly, prisoners have a good experiential understanding of the likely effects of particular psycho-active ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
medication on their individual mental states. However, there is scope for research on patterns of illegal drug use in prison, trading of prescribed medication and how both relate to individual factors (pre and post imprisonment) and the organisation of the prison. It is also true that, to date, little convincing research has been undertaken on prison-based psycho-social alternatives to prescribed medication. This is needed because of the scale of the problem and the personal and financial cost of inaction.
Commissioning changes and cautious optimism Meanwhile, prison doctors are between a rock and a hard place. It may well be clinically appropriate to prescribe psychotropic medication to a specific prisoner, but there is no guarantee that the medicine will end up being ingested by that individual. In custodial environments such as ours, our script might help fuel a culture of trading, destabilising the prison and encouraging bullying and violence (34). In addition, unwarranted prescribing contributes to the medicalisation of social distress and disempowers the patient. Our ability to provide alternative interventions, such as psycho-social treatments, is compromised by a lack of resources. These interventions are often unavailable or in short supply. When they do exist, we may be too slow to deliver them. Lastly, there will ultimately always be a cohort of patients to whom a psychological treatment is unacceptable. In these cases, we risk leaving unsupported prisoners in crisis. New commissioning arrangements (35) offer cautious grounds for hope. To benchmark needs and interventions (pharmacological and psychological) across multiple prisons would be a significant improvement and is now feasible. Aberrant prescribing of psycho-active drugs in a given prison could more easily be identified. Effective service development and performance monitoring should help eradicate it. Gaps in psychological alternatives could be identified, laying foundations for improved, equitable service delivery. New liaison and diversion services, staffed by health and social care workers, are in vogue. In line with the recommendations of the Bradley Report (36), they divert people with mental health problems out of the criminal justice system, principally from courts and police stations. We welcome this, but we remain concerned that it may distract attention from the needs of prisoners. Whatever the size of the prison estate in England and Wales, it is likely that high levels of physical and mental morbidity will
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continue among prisoners for the foreseeable future. They require a better range of services than they currently receive (37). Well-targeted resourcing will not only be cost effective in the long term, but could reduce the high rate of suicide, currently seen in the first 7 days after imprisonment (21,22). Commissioners must not let slip today’s opportunity. They must commission to demonstrate health gain, not just service equivalence (38). We need both better prescribing of medication and more available psycho-social interventions to tackle the wealth of misery that our prisons contain.
References 1 Ministry of Justice. Offender management statistics (quarterly) October to December 2012, 2013. https://www.gov.uk/government/publications/offen der-management-statistics-quarterly–2 (accessed November 2013). 2 Receptions Q1, 2012. Gov.uk https://www.gov.uk/ …/omsq-q1-2012-prison-reception-tables.xls.xls (accessed May 2013). 3 Brooke D, Taylor C, Gunn J, Maden A. Point prevalence of mental disorder in unconvicted male prisoners in England and WalesBr Med J 1996; 313: 1524–7. 4 Singleton N, Meltzer H, Gatward R, Coid J, Deasy D. Psychiatric morbidity among prisoners in England and Wales: A survey carried out in 1997 by the Social Survey Division of ONS on behalf of the Dept of Health. London: The Stationery Office, 1998. 5 Brugha T, Singleton N, Meltzer H, Bebbington P, Farrell M, Jenkins R. 2005 psychosis in the community and in prisons: a report from the British National Survey of Psychiatric Morbidity. Am J Psychiatry 2005; 162: 774–80. 6 Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and metaregression analysis. Br J Psychiatry 2012; 200: 364–73. 7 Fazel S, Cartwright J, Norman-Nott A., Hawton K. Suicide in prisoners: a systematic review of risk factors. J Clin Psychiatry 69(11): 1721–31. 8 Marzano L, Fazel S, Rivlin A, Hawton K. Psychiatric disorders in women prisoners who have engaged in near-lethal self-harm: case control study. Br J Psychiatry 2010; 197: 219–226. 9 National Confidential Inquiry. National study of self inflicted deaths by prisoners in England and Wales 2008-2010, 2013. http://www.bbmh.manchester. ac.uk/cmhr/research/centreforsuicideprevention/nci/ reports/ (accessed September 2013). 10 HM Inspectorate of Prisons. The mental health of prisoners, 2007. www.justice.gov.uk/downloads/ publications/inspectorate-reports/hmipris/thematicreports-and-researchpublications (accessed September 2013). 11 Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction 2006; 101: 181–191. 12 DH Patel Report. Prison drug treatment strategy REVIEW GROUP, 2010. https://www.gov.uk/ government/uploads/system/…data/…/dh_119850.pdf (accessed September 2013).
A. Bartlett,* N. Dholakia,* R. England,* H. Hales,† E. van Horn,* T. McGeorge,* B. Moss,* S. Ovaisi,* E. Tukmachi,* S. Patel* *CNWL FT, London, UK † Wells Unit, West London Mental Health Trust, London, UK
13 NICE. Borderline personality disorder treatment and management, 2009. http://www.legislation.gov. uk/ukpga/2003/44/contents (accessed July 2013). 14 Black DW, Allen J, McCormick B, Blum N. Treatment received by persons with BPD participating in a randomized clinical trial of the Systems Training for Emotional Predictability and Problem Solving programme. Pers Ment Health 2011; 5: 159–168. 15 Royal College of General Practitioners/Royal Pharmaceutical Society. Safer prescribing in prisons: guidance for clinicians, 2011. www.rcgp.org.uk/pdf/Safer_Prescribing_in_Prison.pdf. (accessed July 2013). 16 Social Exclusion Unit. Reducing Re-offending by Ex-prisoners. London: Office of the Deputy Prime Minister, 2002. 17 HMIP. Remand prisoners: a thematic review, 2012. http://www.justice.gov.uk/publications/inspectoratereports/hmi-prisons/thematic-research (accessed September 2013). 18 Booker-Loper A., Tuerk E. Improving the emotional adjustment and communication patterns of incarcerated mothers: effectiveness of a prison parenting intervention. J Child Family Stud 2011; 20, 89–101. 19 Ginn S. Elderly prisoners. Br Med J 2012; 345: e626320. 20 Bartlett A, Evans S. Up to date service evaluations and needs assessments would be useful in caring for elderly prisonersBr Med J 2012; 345: e7578. 21 Humber N, Piper M, Appleby L, Shaw J. Characteristics of and trends in subgroups of prisoner suicides in England and Wales. Psychol Med 2011; 41 (11): 2275–85. 22 Shaw J, Baker D, Hunt IM, Moloney A, Appelby L. Suicide by prisoners. National Clinical Survey. Br J Psychiatry 2004; 184: 263–7. 23 Marzano L, Hawton K, Rivlin A, Fazel S. Psycho-social influences on prisoner suicide: a case control study of near lethal self-harm in women prisoners. Soc Sci Med 2011; 72(6): 874–83. 24 Hassan L, Edge D, Senior J, Shaw J. Staff and patient perspectives on the purpose of psychotropic prescribing in prisons: care or control. Gen Hosp Psychiatry 2013; 35: 433–438. 25 Fazel S, Hope T, O’Donnell I, Jacoby R. Hidden psychiatric morbidity in elderly prisoners. Br J Psychiatry 2001; 179: 535–9. 26 Birmingham L, Coulson D, Mullee M, Kamal M, Gregoire A. The mental health of women in prison mother and baby units. J Forensic Psychiatry Psychol 2006; 17(3): 393–404.
Correspondence to: Annie Bartlett, Mental Health, CNWL FT/SGUL, London SW17 0RE, UK Tel.: + 44 2087 253 452 Fax: + 44 2082 666 470 Email: [email protected]
27 Bartlett A, Somers N, Reeves C, White S. Women prisoners: an analysis of the process of hospital transfers. J Forensic Psychiatry Psychol 2012; 23(4): 538–553. 28 Forrester A, Exworthy T, Chao O, Slade K, Parrott J. Influencing the care pathway for prisoners with acute mental illness. Crim Behav Ment Health 2013; 23: 217–226. 29 Ritter C, Broers B, Elger B. Cannabis use in a Swiss male prison: qualitative study exploring detainees’ and staffs’ perspectives. Int J Drug Policy 2013, doi: 10.1016/j.drugpo.2013.05. 30 Tamburello AC, Lieberman JA, Baum RM, Reeves R. Successful removal of quetiapine from a correctional formulary. J Am Acad Psychiatry Law 2012; 40(4): 502–8. 31 McFeely M. NOMS review of unclassified deaths, 2012. iapdeathsincustody.independent.gov.uk/wp-co ntent/uploads/2012/06/1.-NOMS-review-of-unclassi fied-deaths-between-2010-and-2011.pdf (accessed September 2013). 32 Prisons and probation Ombudsman. Learning lessons bulletin fatal incidents investigations issue 1, 2012. www.ppo.gov.uk/…/LLB_FII_01_Learning_ from_approved_premises_f… (accessed September 2013). 33 Joseph N, Benefield N. A joint offender personality disorder pathway strategy: an outline summary. Crim Behav Ment Health 2012; 22(3): 210–7. 34 Chambers M. Coming clean. Combating drug misuse in prisons. Policy Exchange, 2010. http://www. policyexchange.org.uk/publications/category/item/ coming-clean-combating-drug-misuse-in-prisons (accessed July 2013). 35 NHS Commissioning Board. Securing equity and excellence in commissioning specialised services, 2012. http://www.england.nhs.uk/resources/spec-commresources (accessed July 2013). 36 The Bradley Report. Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system, 2009. http://webarchive.nationalarchives.gov.uk/2013010710 5354/http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_ 098694 (accessed October 2013). 37 Ginn S. Dealing with mental disorder in prisoners. BMJ 2012; 345: e7280. 38 Department of Health. The future organisation of prison health care, 1999. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006944. (accessed September 2013). ª 2014 John Wiley & Sons Ltd Int J Clin Pract, April 2014, 68, 4, 413–417
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Disclosure Annie Bartlett, Reader and Hon. Consultant in Forensic Psychiatry, SGUL and HMP Holloway, Offender Care CNWL FT. Neera Dholakia, Salaried GP, HMP Holloway, Offender Care CNWL FT. Lead GP for Safeguarding Children, Kensington and Chelsea. Darzi Fellow, Newham CCG and Office of London CCG. Rhiannon England, Salaried GP, HMP Holloway, Offender Care CNWL
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FT. Mental Health Lead for City and Hackney Clinical Commissioning Group. Heidi Hales, Consultant Adolescent Forensic Psychiatrist, Wells Unit, WLMHT. Elizabeth van Horn, Consultant Psychiatrist HMP Wormwood Scrubs, Offender Care CNWL FT. Tristan McGeorge, Locum Consultant Forensic Psychiatrist, HMP Wormwood Scrubs Offender Care CNWL FT. Bronwen Moss, Salaried GP HMP Holloway Offender
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Care CNWL FT. Shazia Ovaisi, Salaried GP HMP Holloway Offender Care CNWL FT. Shamir Patel, Consultant Forensic Psychiatrist HMP Bronzefield, Offender Care CNWL FT. Emma Tukmachi Salaried GP HMP Holloway, Offender Care CNWL FT. Lead GP for Safeguarding Children in Tower Hamlets. Paper received July 2013, accepted October 2013
