Early detection of
psychosis in Brixton
Prison
SPRiG 2011
Presentation
Study context
Mental Health of prisoners
Background to early detection
Method
Results
Limitations
Conclusion
In Prison Custody
 Total Population Sept 11: 86, 596
 Women and girls: 4,253
 Approximately 12,000 under aged 21
 Under aged 18: 2,155
Types of Prisons
Categorised – gender, age and security
Remand and Training
Study Context
 NHS take over responsibility for prisoners’
healthcare from Prison Service in 2006
 ‘Principle of Equivalence’ (HM Inspectorate of Prisons, 1996)
OASIS:(Outreach And Support in
South London)
Prevent transition to psychosis
Improve outcome if psychosis develops
Primary Care setting (improve access &
avoid stigmatisation)
Help seeking population (OASIS - 40%
accessed at least 2 services previously, 10%
3 services, 5% > 5services)
Prisoner Population
29% in care as child
50% excluded from school
67% unemployed before reception
32% homeless before reception
50% no GP
80% reading age of 11yrs or less
Mental Health of Prisoners
 High rates psychosis 4-10% (Singleton et al., 1998;
Shaw et al., 2011)
 40% overall attempted suicide rate
 High levels co-morbidity
personality disorder
learning disability
substance misuse
Aims and Objectives
Is OASiS in prison feasible?
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Non help seeking population
Prevalence of ARMS
Screening tool
Logistics of introducing service
Differences between groups
On reception to prison
 ID Card
 Healthcare screening
 Physical and Mental Illness
 Risk of self harm / suicide
 First nighters wing
 Move to normal location 1-5 days
 Unlocked 2 hours per day
Mental Health Pathway in Prison
 Reception – healthcare screening
 Normal Location – In-reach
 Inpatient Unit …BUT …
• No Mental Health Act
• Transfer times 60-100 days
• Half awaiting transfer – no
treatment
Early Detection: Retrospective
Studies
 Interviews with patients & families, records
problems concentration
low drive/motivation
depressed mood
anxiety
social withdrawal
suspiciousness
decline in functioning
(Review: Yung & McGorry, 1996)
‘prodrome’ retrospective concept..
Prospective Studies
‘At Risk Mental State’ – increased risk, not
inevitability..
Basic Symptoms - subtle non specific
symptoms
Ultra High Risk Criteria: attenuated or
transient psychotic symptoms
Basic Symptoms (Early Prodrome):
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Thought pressure, blocking and interference
Problems receptive language
Confusion memory and fantasy
Ideas of reference
Derealisation
Visual-perceptual disturbances (e.g. hypersensitivity
to light)
 Acoustic-perceptual disturbances
(e.g.hypersensitivity to sounds)
Transition rates: 58% over 8 years (Klosterkotter et al.,
1997)
Late prodrome: Ultra High Risk
Symptoms
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Depression
Feeling anxious
Irritable
Disturbed patterns of sleeping or eating
Confused or muddled thinking
Noticing that things and people seem strange or
unreal
Being preoccupied with particular ideas or thoughts
Unusual auditory or visual experiences
Withdrawing from family and friends
Struggling to cope at school, college or work
Transition rates 20-40% over 1-2 years (Yung et al.)
Method: Setting
HMP Brixton
Operational Capacity: 796
Category B local prison
 - males, aged 21 or over
 - awaiting trial or short sentences (<2yrs)
 - mean stay 3 months
 25 Inpatient beds
Method: Sample
 Inclusion Criteria:
 New Receptions
 Aged 35 or under
 From SLaM geographical area
 No history of psychosis
Screening for ARMS
 Prodrome Questionnaire – Brief Version
Ultra High Risk Criteria
Comprehensive Assessment of At Risk Mental
State (CAARMS)
Ultra High Risk Criteria
1. Attenuated psychotic symptoms
2. Transient psychotic symptoms (BLIP)
3. Trait vulnerability
+ decline in functioning
Age 18 -35 (community) 21- 35 (prison)
Method: Other assessments
Demographic data
 Childhood adversity
 Self harm and attempted suicide
Substance Misuse
 CJS data
Results: Feb 2009 – Sept 2011
806 screened with
PQ-B
443 negative
60 CAARMS
1 positive
356 positive
206 negative
39 positive
(2 transitions)
25 psychotic
Screen Sensitivity and Specificity
PQ-B sensitive but not specific:
 Anxious on arrival in prison
 Recent substance misuse
 Other mental health issues
 Validation of PQ-B in prisoner population
 “If I was in control, I wouldn’t be here”.
 “Sometimes I do things that I know I shouldn’t
do – like I hit someone, when I know I
shouldn’t, I can’t stop myself”.
 “I find it difficult to concentrate”.
5. Have you felt that you are not in control of your own ideas or thoughts?
 YES
 NO
If YES: When this happens, I feel frightened, concerned, or it causes problems for me:
 Strongly disagree
 disagree
 neutral
 agree
 strongly agree
5a. Do you sometimes feel that another person or force is interfering with your thoughts?
 “I think too much”
 “I don’t think to do the right things”
 “I do stupid things, I’m a bit impulsive”
 “I’ve made some bad decisions in life”
14. Do you worry at times that something may be wrong with your mind?
 YES
 NO
If YES: When this happens, I feel frightened, concerned, or it causes problems for me:
 Strongly disagree
 disagree
 neutral
14a. Do you worry at times that you may be losing your mind?
 agree
 strongly agree
Results (Feb 2009 – April 2011)
324 CAARMS
266 negative
for ARMS
39 At Risk
Mental State
25 first episode
psychotic
UHR vs non-UHR prisoners
 characteristics
 social exclusion (homelessness,
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unemployment)
higher levels of childhood trauma
self harm and attempted suicide
family psychiatric history
functioning
Characteristics
90
neg
80
pos
70
psy
60
%
50
40
30
20
10
0
1st time in prison
remand
white
Mean age 28 (sd 5.3) no
differences between groups
Social Exclusion
80
neg
70
pos
60
psy
50
% 40
30
20
10
0
unemployed
temp accomodation
no qualifications
Substance misuse
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Alcohol
Cannabis
Glue, petrol, gas
Cocaine
Crack
Ecstasy
Stimulants
Heroin
LSD, Mushrooms, PCP
Other
Substance Misuse
 Alcohol: No differences between groups
 Drugs: No differences EXCEPT use of
 Cocaine (P<0.003)
 Other stimulants (p<.04)
in last month associated with ARMS
Childhood Adverse Events: up to
17 yrs age
 Bullying
 Physical Abuse
 Witnessing family violence
 Being separated from parents
 Being in care
 Sexual Abuse
 Serious illness or injury
 Racial discrimination
w
ily
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in
at
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se
vi
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al
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fa
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ill
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ss
,i
itn
es
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bu
Adverse Childhood Events
80
neg
pos
60
psy
% 40
20
0
Self harm and attempted suicide
neg
70
pos
60
psy
50
40
%
30
20
10
0
self harm
suicide
Family psychiatric history
60
50
40
neg
% 30
pos
psy
20
10
0
family history
family psychosis
20% no data one side of family
Functioning
100
80
neg
60
score
pos
40
psy
20
0
lowest sofas
highest sofas
Functioning
 22 hour bang up
 After detox, functioning
 Drop in functioning not due to mental state
 Does being active criminally count as good
functioning?
Correlates for ARMS
 High anxiety
 High depression
 Previous self harm
 Bullying
 Sexual abuse
 Lower functioning and drop in
functioning
Limitations
 309 excluded due to language
 115 refused
 Measuring functioning in prison
 Difficult to engage once they leave prison
 No follow up
Conclusion
Screening identifies prisoners wanting help
– useful for triage
Prevalence: 5% ARMS & 3% psychosis
Comparison prison vs community groups
Introduction of service – in progress
Acknowledgements
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Lucia Valmaggia (PI)  HMP Brixton Prisoners
and Staff
Tom Craig
Andrew Forrester
 OASIS Team
Janet Parrott
Toby Winton-Brown  Helen McGuire
 Philipe Wuyt
Majella Byrne
David Ndegwa
manuela.jarrett@kcl.ac.uk
Philip McGuire