SAMH RESEARCH BRIEFING
MENTAL HEALTH AND CRIMINAL JUSTICE IN SCOTLAND

Summary
Scotland now imprisons more of its people than many other places in Europe.
The prison population has greatly increased over the past decade, and is
projected to reach 9,500 by 2019-201. People with mental ill-health are
disproportionately found in the prison system, and imprisonment can lead to an
acute worsening of mental health problems. Custody can also greatly increase
the risk of self-harm and suicide.
Within Scotland’s prisons, there are still too many gaps in provision and too much
unmet and sometimes unrecognised need when it comes to mental health. There
are serious failings in processes to identify and meet the needs of people with
mental health problems. Even where these problems are uncovered, there is a
lack of skilled staff and resources to deal with them. Prison healthcare is to be
managed by the NHS from October 2011, creating a valuable opportunity to
address some of these concerns.
There is an increased recognition in Scotland that high prison populations do not
reduce crime. In fact, they are more likely to create pressures that drive
reoffending. The financial costs of imprisonment are also high; the average cost
of a prisoner place being £32k per annum2. This figure is arguably higher still for
prisoners with severe mental health problems due to extra care and other costs,
such as holding people in seclusion.
There has recently been a shift in criminal justice policy away from short prison
sentences towards community sentences with a focus on rehabilitation. The
introduction of Community Payback Orders (with the option of a Mental Health
Treatment Requirement) provides an opportunity to focus efforts on improving
mental health and addressing some of the causes of crime.
Prisons can provide better and more focused care for those who need to be
there; but this is only possible if there is sufficient alternative provision for those
1
The Scottish Government: Statistical Release Crime and Justice Series: Scottish prison
population projections: 2010-11 to 2019-20, 2011
2 HM Chief Inspector of Prisons for Scotland, 2009-2010 Annual Report, 2010
who should not be there, and effective community support for prisoners on
release.

Mental health in Scotland’s prisons
The Scottish prison population has been increasing since 2000-01, reaching an
average daily population of 7,964 during 2009-103. The latest set of prison
population projections suggest that the daily prison population in Scotland will
increase from an annual average of 7,900 in 2010-11 to 9,500 by 2019-20.
These projections are in line with the steady longer term growth trend observed
since 20004.
It is very difficult to gain a full understanding of mental health in the context of
Scottish prisons as huge gaps exist in information pertaining to this area.
However, UK wide research has consistently shown that mental illness is much
more prevalent among prisoners than the general population, with variations
according to the type of prisoner: sentenced, remand, male or female.
The most exhaustive UK study of the prevalence of mental health problems was
conducted by the Office of National Statistics in 19975. This study is specific to
England and Wales, but perhaps remains the best indicator of the prevalence of
mental ill-health in Scottish prisons. It found that up to 90% of prisoners have
some form of mental health problem, and 70% have two or more such problems:
mental ill health is the norm, not the exception, among the prison population.
In 2008, a thematic inspection of severe and enduring mental health problems in
Scotland’s prisons was conducted6. It found that a very large proportion of
prisoners have some form of mental health problem. Of these, only a small
proportion have severe and enduring mental health problems. At least 315
prisoners were identified as having severe mental health problems; 4.5 per cent
of the prison population and four times the level among the general public. The
most common problems identified were schizophrenia and bi-polar affective
disorder.
Figures obtained from parliamentary questions showed there were 219 cases of
self-harm in Scottish jails in 2010, an increase of 140% from 91 cases in 2004.
Kilmarnock Prison, run by private operator Serco, has the highest recorded
incidence of self-harm in Scotland, with 280 incidents since 2004. Cornton Vale
women's prison also has high levels of self-harm, with 232 incidents since 2004.
3
The Scottish Government: Statistical Bulletin Crime and Justice Series: Prison Statistics
Scotland: 2009-10, 2010
4 The Scottish Government: Statistical Release Crime and Justice Series: Scottish prison
population projections: 2010-11 to 2019-20, 2011
5 Singleton, N., Meltzer, H. & Gatward, R. Psychiatric morbidity among prisoners in England and
Wales. London: Office for National Statistics, 1998
6 HM Chief Inspector of Prisons in Scotland, Out of Sight: Severe and Enduring Mental Health
Problems in Scotland’s Prisons, 2008
Minority groups
Whilst there are race relations officers in each prison, the aggregated
experiences of BME and LGBT prisoners are largely unknown because of a lack
of monitoring and evaluation.
Research has shown that Black groups have more than six times the rate of
psychotic illness than the general population, and are presenting direct to acute
care via the criminal justice system7.
Women
In numerical terms, women comprise a relatively small, but increasing, part of the
overall prison population: In 2009/10, approximately 5% of prisoners in Scotland
were female and 95% were male. However, the female prison population has
doubled in a decade – to around 424 in 2010, from 199 in 19998 – despite
various major initiatives which aimed to divert women from prison.
The Equal Opportunities Committee recently undertook an inquiry into female
offenders in the Scottish criminal justice system. It found that although women
prisoners are affected by issues that affect both male and female prisoners, in
almost every case those issues are more significant and more prominent for
women9. Reports on Cornton Vale (Scotland’s womens only prison) have
commented that 98% of the prisoners had drug addiction problems and 80% had
mental health problems10. An EU study11 has also found that Scottish women
face such huge problems that they regard a jail term as "a refuge"; some women
choosing jail to escape abusive partners, others to stabilise debt problems or
drug addiction.
The Scottish Government has announced12 plans to set up a commission
examining how female offenders are dealt with in the criminal justice system.
The announcement followed criticism from the Chief Inspector of Prisons
regarding the poor treatment and condition of prisoners at Cornton Vale,
especially women with poor mental health.
Young people
7
Fairness and Freedom: The Final Report of the Equalities Review, 2007
The Scottish Government: Statistical Release Crime and Justice Series: Scottish prison
population projections: 2010-11 to 2019-20, 2011
9 Equal Opportunities Committee Report, Female offenders in the criminal justice system, 2009
(Session 3)
10 HM Inspectorate of Prisons, HMP & YOI Cornton Vale 19-20, 2007
11 EU Report, Female drug users in prison and after release: A five-country follow-up study in
Europe on relapse prevention, 2007
12 Response to Cornton Vale report, 2010
8
About 13 per cent of prisoners in Scotland are young offenders,13 with the young
offender population consisting predominantly of medium term prisoners with
sentences between six months and two years. Polmont is Scotland's national
holding facility for Young Offenders (YOs), where most male YOs are held.
Almost all female young offenders are held in Cornton Vale (female YOs making
up around 19 per cent of all YOs).
The Scottish Prisons Commission explored the use of imprisonment in relation to
16 and 17 year olds, finding that Scotland imprisons a disproportionately high
number of under 18 year olds14. It also found that that about one in nine young
men from the most deprived communities in Scotland would spend time in prison
before they were 23; highlighting substance misuse and mental health problems
as contributory factors.
The Scottish Government has since pursued initiatives in an effort to address
offending behaviour among children and young people, recently producing a
Diversion from Prosecution Toolkit15 and guidance on developing a ‘whole
system approach’ to young people involved in offending16. This highlights
research which suggests that young offenders with complex difficulties, and in
particular mental health problems, stand to greatly benefit from a coordinated
system of community-based care and resources.

Unemployment, education and social exclusion
The majority of prisoners in Scotland are from poor socio-economic
backgrounds, with underlying causes of offending related to drug and alcohol
misuse, mental ill health and physical and sexual abuse. In most cases, there
has also been poor connection during childhood with the education system: 60%
of offenders have literacy and numeracy levels at SCQF level 4 or below,
compared to 15% of adults across Scotland.17 The HMIP 2008-09 Annual Report
states:
“Bad physical health, bad mental health, bad educational attainment, bad
employment record, bad addiction history, bad family support, bad self-esteem,
bad company, bad criminal record. That is the typical picture of a prisoner
arriving at the prison gate to start a sentence.”
13
The Scottish Government: Statistical Release Crime and Justice Series: Scottish prison
population projections: 2010-11 to 2019-20, 2011
14 Scottish Prisons Commission, Scotland's Choice, 2008
15 The Scottish Government, Diversion from Prosecution Toolkit - Diverting Young People from
Prosecution, 2011
16 The Scottish Government, Alternatives to Secure Care and Custody: Guidance for Local
Authorities, Community Planning Partnerships and Service Providers, 2011
17 HM Chief Inspector of Prisons for Scotland, 2009-2010 Annual Report, 2010
The final report of the Equalities Review18 found a strong association between
offending, and exclusion from school and failure at school. The same report also
found that a child who experiences a mental health problem is more likely to
truant or to have unauthorised absences from school, and to under-perform
educationally.
It has also been identified that the prospects of most prisoners on release are still
bleak. Very few prisoners gain employment on release, and unemployment is
often the cause of re-offending.19 Very large numbers of prisoners have no bank
account on release and may not know the GP with whom they are registered20.
SPS has recently made new links with Job Centre Plus - to develop greater
awareness of service gaps and continuity in relation to employability issues - and
piloted the use of job trials to assist prisoners into employment on release.21

Mental health care in prison
Prison healthcare is to be managed by the NHS from 29th October 2011.
There are national and local programmes being carried out to ensure that
the current level of service is maintained and there is minimal disruption.
Funding and staffing will transfer from the Scottish Prison Service to the
NHS. The nine health boards which have prisons located in their areas and
to which they provide direct throughcare in the prison, will be the
recipients of the funding.
Primary mental health care
Currently, provision of primary health care in prisons is the responsibility of the
SPS. This is achieved through directly employed or contracted health
professionals with separate arrangements from those of the NHS. Where
required, the local NHS does provide hospital care for prisoners.
A Health Centre Manager/Clinical Manager oversees primary health services in
each prison. Primary Care medical services and pharmaceutical services are
currently provided to each establishment under national contracts with outside
providers. Many other staff are involved including psychologists, psychiatrists
and social workers.
The level and nature of healthcare staff, and particularly mental health specialist
staff varies widely across prisons. Generally, nursing teams are available on a
weekly basis, although there is little or no mental health nursing cover on-site
overnight or at weekends. Most prisons have access to a psychiatrist, although
18
Fairness and Freedom: The Final Report of the Equalities Review, 2007
HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
20 HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
21 HM Chief Inspector of Prisons for Scotland, 2009-2010 Annual Report, 2010
19
for a relatively small number of hours. There is concern about the level of
specialist staffing resources available, the number of competing priorities, and
the extent to which existing arrangements have sufficient resilience to cope with,
for example, a member of staff leaving22.
Healthcare beds have been phased out in virtually all prisons, which has given
rise to concerns both within prisons, and among NHS staff. This means that more
prisoners who might have been located in these beds are now located in halls23.
Care and treatment for people with severe and enduring mental health
problems
Once prisoners have been identified as having severe and enduring mental
health problems which do not require transfer to hospital, the treatment which
they receive in prisons generally includes: medication; access to a psychiatrist;
and input from a mental health nurse.
Segregation units and separate cells are used at times, with difficulties faced in
making distinctions between mental health and behavioural or management
problems.
The thematic inspection of severe and enduring mental health problems
uncovered concerns with aspects of existing provision, including variations and
gaps in practice and treatment; issues with medication; issues with the use of
segregation; a lack of an holistic approach; a lack of day care facilities; a lack of
“talking treatments”; the removal of in-patient facilities; and issues relating to
overcrowding, staffing, information and other resources.
Transfer to hospital
Prisoners diagnosed with a mental illness who require transfer to hospital for
treatment may wait longer than similar people in the community24.
An audit was conducted which tracked prisoners managed under the Mental
Health (Care and Treatment) (Scotland) Act 2003 within the SPS. It found that
there was a variation in time from the first concern being raised about a prisoner
to seeing a psychiatrist of 1-47 days, and a variation in time from being seen by a
psychiatrist to a diagnosis requiring sectioning being made of between 0-199
days. A key finding was that there was convincing evidence to support the view
22
HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
24 HM Chief Inspector of Prisons in Scotland, Out of Sight: Severe and Enduring Mental Health
Problems in Scotland’s Prisons, 2008
23
that acutely mentally ill people were being sent to prison when they should have
been diverted to health care from either police custody or court25.
Identifying mental health problems
Reception and induction processes can provide the first opportunity to identify
mental health needs. However, reception in prison can be a chaotic and not well
suited to identifying health needs despite the high risk of self harm and suicide in
the first few days in prison. During a sentence, the main ways of identifying
mental health problems are through observation by prison staff, other workers,
prisoners, and through self-referral26.
There are a number of gaps in the identification of mental health problems and
needs. These include: problems with the transfer of information from courts and
the community; difficulties for prisoners in disclosing issues; problems with
processes and operational issues; and problems with staff being able to identify
issues. These difficulties can mean that some prisoners with severe and
enduring mental health problems may not access assessment and referral27.
Care after release
Prisoners face a range of issues prior to release, and accessing support is very
important. Some work is being carried out in prisons to assist prisoners in
preparing for their release and in accessing support, but the nature of this varies,
particularly in relation to the level of formalised planning undertaken. In many
cases, prisoners being released from prison have to pro-actively approach
organisations in the community, with limited external support available. Some
prisoners with severe and enduring mental health problems are released from
prison with few if any links to continuing support in the community, and without
any arrangements for the continuation of any work which had started in prison28.
There are a number of perceived difficulties in securing access to services upon
release, such as GP services, hospital services, and housing services. There are
also geographical variations in the capacity of services, as well as a lack of
communication between agencies29.

Alternatives to imprisonment
Since taking office in 2007, the SNP administration has signalled a shift in
criminal justice policy away from short prison sentences towards community
25
Dr Lesley Graham, Audit of the Implementation of the Mental Health (Care and Treatment)
(Scotland) Act 2003 in the Scottish Prison Service, 2007
26 HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
27 HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
28 HM Chief Inspector of Prisons for Scotland, 2008 -2009 Annual Report, 2009
29 HM Chief Inspector of Prisons in Scotland, Out of Sight: Severe and Enduring Mental Health
Problems in Scotland’s Prisons, 2008
sentences with a focus on rehabilitation. The Scottish Government has set out to
put in place the elements of a credible system of community sentences, changing
the law in a number of key areas; most notably in relation to the Scottish
Sentencing Council, a presumption against short custodial sentences, and the
introduction of community payback sentences.
The Reducing Reoffending Programme was set up in January 2009 to help
deliver the Scottish Governments policy. Recent and planned developments for
implementation include:
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Introduction of Community Payback Orders by February 2011.
Richer information on offenders in Social Enquiry Reports by March 2011.
New approaches to diverting young people from criminal proceedings by
the police by March 2011.
New national standards for risk management by November 2011.
Implementation of the first part of a new national IT programme to aid the
consistent risk assessment of individuals by December 2012.
Community Payback Orders
Community Payback Orders were introduced by the Criminal Justice and
Licensing (Scotland) Bill, and gives courts the flexibility to divert people from
custody provided they agree to comply with one or more of a range of
requirements, such as participation in alcohol, drug or mental health treatment
interventions.
Mental health treatment requirement
The purpose of the mental health treatment requirement is to ensure that an
individual who has been diagnosed with a mental health condition receives
support, care and treatment. For the purposes of the legislation, a mental health
condition includes any mental illness, personality disorder or learning disability as
defined by the Mental Health (Care and Treatment) (Scotland) Act 2003.
For a mental health treatment requirement to be imposed the court has to be
satisfied following evidence from an approved medical practitioner that:
 the person has a mental condition;
 the condition requires and may be susceptible to treatment; and
 the person does not require compulsory treatment.
The court must also be satisfied, following evidence from the registered medical
practitioner or registered psychologist who will treat the individual, that the
treatment is appropriate, and that arrangements have been made for the
treatment.
There are provisions for the treatment to be varied where the practitioner thinks it
is appropriate e.g. for the individual to receive a different kind of treatment or to
receive it at a different place. The offender’s consent is required when treatment
required under a mental health treatment requirement is to be changed.
The first available figures pertaining to the number of CPOs issued relate to
February and March 2011. These show that there were at total of 333 CPOs
imposed by Courts over the two month period, of these only 2 included the
mental health requirement. This suggests that Scotland may replace the
problems seen in England, where similar provision already exits, where many
opportunities for diversion are being missed and the Mental Health Treatment
Requirement (MHTR) is rarely used30.
30
Centre for Mental Health, A Missed Opportunity? 2009