On 14th May 2010, when Kenneth Clarke returned to the Ministry of Justice, the prison population in England and Wales was 85,009. When he had previously been Home Secretary in 1992-93, the average prison population had been 44,628 (Prison Briefing 2010). This represents a 90% increase in a period when crime rates were generally falling. The prison system has been consistently overcrowded in this period despite a large expansion programme including the establishment of private prisons. Clarke, himself was shocked by this increase and made some initial attempts to reverse this trend. However, his was an isolated voice.
The prison population has continued to rise until relatively recently. It still stands at historically high levels. This is an important context for the discussion of this research paper. The paper is an analysis of the literature that examines the effectiveness of a range of screening tools used in prison settings.
The mental health needs of those who come into contact with the Criminal Justice System (CJS) have long been neglected. The recently signed Mental Health Crisis Concordat highlighted the increasing role that the police have been forced to take in the provision of mental health care to individuals experiencing extreme mental distress. The well-documented failings of community care have led to the CJS becoming a default provider of mental health care. As with this review, the focus of the research in this field has been on the prison. Other areas, particularly police custody are, in comparison, largely overlooked.
This paper is a very clearly written review of the effectiveness of a range of mental health screening tools that are used in prisons. The results include screening tools used in the UK, USA, Canada, New Zealand and Denmark. One of the most startling findings is that the authors found 22 different screening tools that had been used, although only 6 of these tools had published replication studies with independent samples. The main focus of the study is on the six screening tools where replications studies had been undertaken:
- Brief Jail Mental Health Screen (BJMHS)
- Correctional Mental Health Screen for Men (CMHS-M)
- Correctional Mental Health Screen for Women (CMHS-W)
- England Mental Health Screen (EMHS)
- Jail Screening Assessment Tool (JSAT)
- Referral Decision Screen (RDS)
The Trenčín Statement on the treatment of prisoners emphasised that in accordance with the UN’s basic principles for the treatment of inmates:
Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.
This involves mental health care, and there is no excuse for not providing it. However, this paper highlights some of the difficulties in providing mental health care in a prison.
The first is that the prison will never be a therapeutic environment. In overcrowded prisons, where substance misuse is common, violence and bullying seemingly endemic, it is clear that staff will struggle to address the mental health needs of inmates.
In addition, risk factors for self-harm and suicide such as a history of drug misuse, poor social skills, unemployment and being a victim of childhood sexual abuse are much more common amongst men and women in prison. This makes screening more difficult but also vital if the most vulnerable are to have access to appropriate treatment. There is a fundamental issue here of how the limited resources that are available can be targeted at the most needy.
As noted above, the study examined six screening tools. There are no decisive conclusions to state, in terms of which is the most effective instrument:
- The BJMHS was developed to replace the RDS so the RDS is not an optimal tool to use.
- The screening tools are, on the whole, questionnaires, that can be administered quickly – usually in five minutes or so – by prison officers rather than mental health professionals. The JSAT is a longer examination – 20 minutes that has to be undertaken by a nurse or psychologist.
- The EMHS is very reliant on past psychiatric history. The authors feel that this may explain the reason why it is not as effective in studies undertaken in Canada and New Zealand. The argument here is, if there are minority communities that are less likely to access mental health care but are overrepresented in prison populations, then a screening tool that focuses on previous contacts with mental health systems is weaker.
The paper concludes whichever tool is used, the identity of the staff carrying out the screening is vitally important. Female and non prison staff were the most effective in gaining a full picture of the mental health needs of prisoners. This was particularly the case when female prisoners were being assessed.
The screening tools examined in this paper are generally effective – particularly if they are administered by civilian staff. Prisoners are, it seems, much more likely to be open in these circumstances. The need for such screening tools is not in doubt. However, what we really need is fully resourced community based mental health services and an end to the era of mass imprisonment.
Martin MS, Colman I, Simpson AI, McKenzie K. Mental health screening tools in correctional institutions: a systematic review. BMC Psychiatry. 2013 Oct 29;13:275. doi: 10.1186/1471-244X-13-275.
Trenčín statement on prisons and mental health (PDF). WHO, 18 Oct 2007.
Screening for mental health problems in the adult prison population: On 14th May 2010, when Kenneth Clarke ret… http://t.co/nUZS0dlK22
“@Mental_Elf: Screening for mental health problems in the adult prison population http://t.co/DTscjMfcBG” interesting but not unpredictable
@Mental_Elf excellent! Widen the focus to housing and you’ll see the same thing. Ppl need support to sustain tenancies @Shelter
Mental Elf: Screening for mental health problems in the adult prison population http://t.co/XOMnI23j2d
From the @mental_elf I think there must be so much undiagnosed health issues in prisons. Mental & physical…
Thank you for a well-written, informative and balanced summary of this study about an important topic.
There was one respect in which I think you could have made the blog more valuable. Although it isn’t so much highlighted, it appears that the study is written especially with the situation in England & Wales in mind. Clarifying that context would have been valuable.
Overall, IMO, the study restricted itself too much to the question of efficacy of the instruments, as opposed to effectiveness of their usage in actual practice.
The study doesn’t refer to the frequency of use of the instruments. If they’re used to screen 1%, as opposed to 10%, or 90% of inmates, that makes an enormous difference as to the relevance of the study. Is nothing really known about that?
And finally, whilst training of the staff administering the instruments is mentioned, no indication is given as to standards in this respect. Outside jails, in the NHS, I doubt if instruments would be administered by staff untrained in their use. In prisons, I’m not so sure.
It’s this whole nexus of context, relevance, effectiveness in practice and real-life applicability that I missed in the study. I think your blog would have been an excellent opportunity to point that out.
Thank you for locating and highlighting this study!
With the prison population nearly doubling in the last 20 years, it’s hardly surprising that mental illness is rife http://t.co/LQzJ1JrwkP
Start your day the #headclutcher way http://t.co/6mEzz4OU3D for #mentalhealth problems in the adult prison population By @Mental_Elf
In the news: Screening for mental health problems in the adult prison population, via @Mental_Elf http://t.co/xuNUon0CDE #mentalhealth
@IanCummins9 reports on a systematic review of mental health screening tools for the adult prison population http://t.co/LQzJ1JrwkP
The #prison population has doubled in the last 20 years. At the expense of misplaced persons #mentalhealth #stigma http://t.co/6Awyp6jaE3
This includes mental health care, and there is no excuse for not providing it http://t.co/LQzJ1JrwkP 2/2 @IanCummins9
It’s great to have Senior Lecturer @IanCummins9 in our team. Former probation officer & social worker #experienced http://t.co/LQzJ1JrwkP
In case you missed it: Screening for mental health problems in the adult prison population http://t.co/LQzJ1JrwkP
@Mental_Elf @jpags http://t.co/HxHIllZndR nice to see increased focus on under Tx/recognition of mental illness in prisons. Time 4 change
“Prison will never be a therapeutic environment,” but state psych institutions are at least as bad! http://t.co/EnXdqeRtbt