Prison population: mental health needs

Understanding the scale of mental health needs in Scotland's prison population

• There are no current, robust figures for the prevalence of mental health needs of people in prison in Scotland.
• In the absence of such figures, the likely prevalence of several mental health problems of Scotland's prison population were estimated using modelling from the non-prison population. Findings suggest at least 15% of individuals in prison have a long-term mental health condition, 17% a history of self-harm, 30% an alcohol use disorder, 16% symptoms of anxiety over the past week, and 18% symptoms of depression over the past week.
• Data on the transfer of individuals from prison to inpatient psychiatric units indicated that, relative to Scotland's prison population as a whole, these individuals were disproportionately female and on remand. The vast majority were transferred for the treatment of a psychotic disorder.

As has been set out in this report, evidence from prospective research studies undertaken in UK prisons indicates that a majority of people in prison likely experience difficulty relating to their mental health whilst in prison. Estimates for each condition range between studies due to factors including differences in the population of study (gender, legal status) and method of screening and assessment.

Estimating the prevalence of mental health needs of Scotland's prison population can assist in planning service provision effectively in order to reduce the gap between health needs and interventions. However, data on the mental health needs of Scotland's prison population, and whether these are being met, are not currently collected centrally. This prevents the direct assessment of mental health needs from existing data. There is no national, systematic process in place to comprehensively assess and monitor the level of mental health needs of those in Scotland's prisons. In the absence of such data, quantitative analysis of existing secondary datasets, and known information on the prison population, can assist in estimating the proportion of people in Scotland's prisons who likely have a mental health problem. Utilising this methodology means the needs of population subgroups (for example based on gender, ethnicity, and age group) can also be considered.

Every approach to establishing the prevalence of mental health needs in the prison population has its disadvantages and each dataset its limitations. Data on the number of individuals accessing different types of mental health services will miss those who may be unwell but have chosen not to seek help (for example, due to fear of stigma) or are otherwise unable to access these services (e.g. service waiting lists, limited availability in the relevant geographical area, disengagement from mental health services). Self-reported history of or current experience of mental health problems collected through survey methodology can be affected by bias resulting from differential response rates for certain groups of people, through imprecise screening tools, and because of difficulty verifying the information provided.

The selected approach was informed by epidemiological research methodology and shaped by the availability of existing data. These findings are likely to be helpful to inform prison mental health policy and augmentation of services available to individuals in prison.

Data sources

A variety of datasets were accessed and analysed to estimate the likely range of mental health needs of Scotland's prison population.

Scottish Health Survey

The Scottish Health Survey (SHeS) is an annual survey conducted on the Scottish population in private households and is used and monitored as an indicator of health of the people in Scotland. The self-reported prevalence of certain common mental health problems is derived from this dataset, including anxiety, depression, alcohol use disorders and history of self-harm or suicide attempt. Data from SHeS were used to estimate an individual-level probability model for the non-prison population of Scotland having mental health needs. Though the survey is conducted annually, the 2019 dataset, accessed from the UK Data Service, was used in the present study as it was the most recent year for which its methods were not substantively affected by the COVID-19 pandemic.

Extract from the SPS PR2 system

SPS provided a dataset describing demographics of Scotland's prison population as of January 2022. These data were extracted from PR2, which is the operational information system used by SPS to manage the prison population. A wide range of information is included in the PR2 system and there are several fields relating to mental health. However, following discussions with SPS regarding how this information is collected, verified, and updated it was determined that it would not be a reliable or valid indicator of mental health needs for this study. Therefore, the PR2 variables used in this study were limited to age, gender, ethnicity, and legal status.

Use of Rule 41 extensions for reasons relating to mental health

Rule 41 in the Prisons and Young Offenders Institutions (Scotland) Rules 2011 allows a prison Governor to order that an individual in prison be accommodated in specified conditions due to a health condition where they are a risk to themselves or others, following advice from a healthcare professional. This enables certain measures to be taken to protect the health and welfare of a person or people in prison. Individuals subject to Rule 41 may be accommodated in a specified part of the prison or separately from other prison residents, for example confined to their own cell or placed in segregation. A Rule 41 initiated by an establishment cannot last for more than 14 days unless an extension is authorised by Scottish Ministers. Extensions may be granted for an additional one-month period and multiple extensions may be requested for one individual. While SPS Headquarters do not collate data on the initial use of Rule 41, data on the number of extensions to the use of Rule 41 during the years 2018 to 2021 was available and provided by SPS.

Forensic inpatient care

People with a mental illness, learning disability or related condition who are accused of or convicted of a criminal offence may be placed under the Criminal Procedure (Scotland) Act 1995, which allows the individual to be treated in hospital. Hospitals that accept these transfers include high, medium, low security forensic hospitals and intensive psychiatric care units. The MWC and the Forensic Network monitor the transfer of individuals from prison to psychiatric units under the Act. Data on prison-hospital transfers were retrieved from MWC annual reports and from a report provided by the Forensic Network office.

Analytic approach

Because current and robust figures on the mental health needs of Scotland's prison population are not available, the proportion of individuals in prison in Scotland who have mental health needs was modelled from available data on the non-prison population of Scotland. Individual likelihood of having one of five mental health problems was derived from the SHeS 2019 data using logistic regression and applied to the current prison population using the PR2 extracts. The five mental health problems modelled were:

• having a long-term mental health condition,
• having a history of deliberate self-harm or suicide attempt,
• drinking behaviour consistent with a likely alcohol use disorder,
• anxiety symptoms in the previous week,
• and depression symptoms in the previous week.

Demographic characteristics measured in both datasets were used as predictor variables: gender, age, ethnicity, and Scottish Index of Multiple Deprivation (SIMD) quintile.

Full details of the statistical approach is set out in Appendix C. Descriptive statistics are reported relating to Rule 41 extensions and to individuals in prison who require inpatient psychiatric treatment.

Results

Prevalence estimates

Quantitative modelling found that, relative to the mental health needs in the non-prison population, the estimated prevalence of all five mental health needs is higher for individuals in prison in Scotland. The estimated prevalence of mental health problems is set out in Table 2. The relative difference between the two populations was greatest for alcohol use disorders. Prevalence estimates were also derived for subgroups of the prison population, set out in Appendix D.

Comparison to previous Scottish research

Comparison to previous assessments of mental health in Scotland's prison population is limited due to differences in how mental health problems were operationalised and measured. However, Cooke (1994) found that 7.3% of men in prison have experienced major psychiatric disturbance in their lifetime, and Graham (2007) reported 14% of the prison population had a history of psychiatric disorder, according to SPS recorded data. Following direct screening, Davidson et al (1995) reported that 24.8% had a neurotic disorder (which would include anxiety and depression), 2.3% had psychosis, 22% alcohol use disorder and 73% drug use disorder. In the Scottish Prisoner Survey 2019, 39% of respondents self-reported being diagnosed with depression prior to coming into prison, 29% an anxiety or phobic disorder and 4% schizophrenia.

Use of Rule 41 extensions for reasons relating to mental health

While data are not available on initial use of Rule 41 in prisons across Scotland, between 2018 and 2021 there were 340 authorisations (for 235 individuals) to extend the use of Rule 41 beyond the initial 14-day period. Over the same period there were 94 second extensions (meaning beyond the initial 14 days plus initial one-month extension) for 85 individuals, and 43 third extensions for 42 individuals. Figures on subsequent extensions (up to seventh extension) were also provided, though pertain to a very small number of episodes. Comparison across years showed no global trend in Rule 41 extensions, except for a slight increase in the number of subsequent extensions from 2020 to 2021, although 2020 was the only year where sixth and seventh extensions were authorised, pertaining to fewer than five cases.

Use of forensic inpatient services

The Mental Welfare Commission for Scotland (2021) reports figures on the compulsory treatment of individuals subject to criminal proceedings. Assessment and treatment orders can be used to remand individuals to hospital for care. In 2018-2019, there were 222 assessment and treatment orders, 239 in 2019-20 and 204 in 2020-2021 (Mental Welfare Commission, 2021). Orders of transfer for treatment direction (TTD) are used for the transfer of individuals who have been sentenced. According to the MWC there were 41 TTD orders issued in 2018-19, 36 in 2019-20 and 36 in 2020-21. Applying figures released by the Scottish Government (2021a) on the total number of sentenced individuals in custody each year, approximately 1% require inpatient psychiatric care in a given year (1.1% 2018-19; 1.2% 2019-20; data not yet available for 2020-21).

The Forensic Network provided additional information on prison hospital transfers. Between 2018 and 2021, 20% of transfers were for women, although women make up only 3.6% of the current prison population. The majority of those transferred (62.3%) are on remand, even though people remanded to prison comprise 29.6% of the current prison population. The average number of days between date of referral and date of transfer ranged from 14.6 to 25.6 calendar days, an average of 21.1 days in 2021. The Department of Health & Social Care for England (2018) recommends transfer take no more than 28 days from referral. There is no standard set out for Scotland.

According to the Forensic Network's comprehensive inpatient census undertaken on 26 November 2013 (the most recent data available), there were 111 patients in hospital who were admitted from prisons, comprising 21.3% of the forensic inpatient population at that time. The most represented diagnostic category among the people in prison who require forensic inpatient care is psychotic disorders (81.1%), the next largest group being affective disorders (5.4%) and personality disorder (4.5%).

Summary

In the absence of robust indicators at the national level on the mental health needs of Scotland's prison population, the estimated prevalence of several mental health needs was modelled using data in the SHeS on a representative sample of the non-prison population. Analysis found 15% of the prison population likely has a long-term mental health condition, 17% a history of self-harm, 30% an alcohol use disorder, 16% symptoms of anxiety and 18% symptoms of depression in the past week. Estimated prevalence was generally higher in the remand population, in younger age groups, and in women relative to men except for AUD and depression. Data on the transfer of people from prison for inpatient psychiatric treatment between 2018 and 2021 indicated that, relative to Scotland's prison population as a whole, these individuals were disproportionately female and on remand. The vast majority were transferred for the treatment of a psychotic disorder.