Early detection of Early detection of psychosis in Brixton psychosis in Brixton
Prison Prison
SPRiG 2011
PresentationPresentation
Study contextStudy contextMental Health of prisonersMental Health of prisonersBackground to early detectionBackground to early detectionMethodMethodResultsResultsLimitationsLimitationsConclusionConclusion
In Prison CustodyIn Prison Custody
Total Population Sept 11: 86, 596Total Population Sept 11: 86, 596 Women and girls: 4,253Women and girls: 4,253 Approximately 12,000 under aged 21Approximately 12,000 under aged 21 Under aged 18: 2,155Under aged 18: 2,155
Types of PrisonsTypes of Prisons
Categorised – gender, age and securityCategorised – gender, age and security
Remand and TrainingRemand and Training
Study ContextStudy Context
NHS take over responsibility for prisoners’ NHS take over responsibility for prisoners’ healthcare from Prison Service in 2006healthcare from Prison Service in 2006
‘‘Principle of Equivalence’ Principle of Equivalence’ (HM Inspectorate of Prisons, 1996)(HM Inspectorate of Prisons, 1996)
OASIS:OASIS:(Outreach And Support in (Outreach And Support in South London)South London)
Prevent transition to psychosis Prevent transition to psychosis Improve outcome if psychosis developsImprove outcome if psychosis develops
Primary Care setting (improve access & avoid Primary Care setting (improve access & avoid stigmatisation)stigmatisation)
Help seeking population (OASIS - 40% Help seeking population (OASIS - 40% accessed at least 2 services previously, 10% accessed at least 2 services previously, 10% 3 services, 5% > 5services)3 services, 5% > 5services)
Prisoner PopulationPrisoner Population
29% in care as child29% in care as child50% excluded from school50% excluded from school67% unemployed before reception 67% unemployed before reception 32% homeless before reception32% homeless before reception50% no GP50% no GP80% reading age of 11yrs or less80% reading age of 11yrs or less
Mental Health of PrisonersMental Health of Prisoners
High rates psychosis 4-10% (Singleton et al., 1998; Shaw et High rates psychosis 4-10% (Singleton et al., 1998; Shaw et al., 2011)al., 2011)
40% overall attempted suicide rate40% overall attempted suicide rate
High levels co-morbidity High levels co-morbidity
personality disorderpersonality disorder
learning disabilitylearning disability
substance misusesubstance misuse
Aims and ObjectivesAims and Objectives
Is OASiS in prison feasible?Is OASiS in prison feasible?
Non help seeking population Non help seeking population Prevalence of ARMSPrevalence of ARMS Screening toolScreening tool Logistics of introducing serviceLogistics of introducing service Differences between groupsDifferences between groups
On reception to prisonOn reception to prison
ID CardID Card Healthcare screeningHealthcare screening
Physical and Mental IllnessPhysical and Mental Illness Risk of self harm / suicideRisk of self harm / suicide
First nighters wingFirst nighters wing Move to normal location 1-5 daysMove to normal location 1-5 days Unlocked 2 hours per dayUnlocked 2 hours per day
Mental Health Pathway in PrisonMental Health Pathway in Prison
Reception – healthcare screeningReception – healthcare screening Normal Location – In-reachNormal Location – In-reach
Inpatient Unit …BUT …Inpatient Unit …BUT …• No Mental Health ActNo Mental Health Act• Transfer times 60-100 daysTransfer times 60-100 days• Half awaiting transfer – no Half awaiting transfer – no
treatmenttreatment
Early Detection: Retrospective Early Detection: Retrospective StudiesStudies
Interviews with patients & families, recordsInterviews with patients & families, records
problems concentrationproblems concentration low drive/motivationlow drive/motivation depressed mooddepressed mood anxietyanxiety social withdrawalsocial withdrawal suspiciousnesssuspiciousness decline in functioningdecline in functioning (Review: Yung & McGorry, 1996)(Review: Yung & McGorry, 1996)
‘‘prodrome’ retrospective concept.. prodrome’ retrospective concept..
Prospective StudiesProspective Studies
‘‘At Risk Mental State’ – increased risk, not At Risk Mental State’ – increased risk, not inevitability..inevitability..
Basic Symptoms - subtle non specific Basic Symptoms - subtle non specific symptomssymptoms
Ultra High Risk Criteria: attenuated or Ultra High Risk Criteria: attenuated or transient psychotic symptomstransient psychotic symptoms
Basic Symptoms (Early Prodrome):Basic Symptoms (Early Prodrome): Thought pressure, blocking and interferenceThought pressure, blocking and interference Problems receptive languageProblems receptive language Confusion memory and fantasyConfusion memory and fantasy Ideas of referenceIdeas of reference DerealisationDerealisation Visual-perceptual disturbances (e.g. hypersensitivity Visual-perceptual disturbances (e.g. hypersensitivity
to light)to light) Acoustic-perceptual disturbances Acoustic-perceptual disturbances
(e.g.hypersensitivity to sounds)(e.g.hypersensitivity to sounds)
Transition rates: 58% over 8 years (Klosterkotter et al., Transition rates: 58% over 8 years (Klosterkotter et al., 1997)1997)
Late prodrome: Ultra High Risk Late prodrome: Ultra High Risk SymptomsSymptoms
DepressionDepression Feeling anxiousFeeling anxious IrritableIrritable Disturbed patterns of sleeping or eatingDisturbed patterns of sleeping or eating Confused or muddled thinkingConfused or muddled thinking Noticing that things and people seem strange or Noticing that things and people seem strange or
unrealunreal Being preoccupied with particular ideas or thoughtsBeing preoccupied with particular ideas or thoughts Unusual auditory or visual experiencesUnusual auditory or visual experiences Withdrawing from family and friendsWithdrawing from family and friends Struggling to cope at school, college or workStruggling to cope at school, college or work
Transition rates 20-40% over 1-2 years (Yung et al.)Transition rates 20-40% over 1-2 years (Yung et al.)
Method: SettingMethod: Setting
HMP BrixtonHMP BrixtonOperational Capacity: 796Operational Capacity: 796Category B local prison Category B local prison
- males, aged 21 or over- males, aged 21 or over - awaiting trial or short sentences (<2yrs)- awaiting trial or short sentences (<2yrs) - mean stay 3 months- mean stay 3 months
25 Inpatient beds25 Inpatient beds
Method: SampleMethod: Sample
Inclusion Criteria:Inclusion Criteria:
New ReceptionsNew Receptions Aged 35 or underAged 35 or under From SLaM geographical areaFrom SLaM geographical area No history of psychosisNo history of psychosis
Screening for ARMSScreening for ARMS
Prodrome Questionnaire – Brief VersionProdrome Questionnaire – Brief Version
Ultra High Risk CriteriaUltra High Risk CriteriaComprehensive Assessment of At Risk Mental State Comprehensive Assessment of At Risk Mental State
(CAARMS)(CAARMS)
Ultra High Risk CriteriaUltra High Risk Criteria1.1. Attenuated psychotic symptomsAttenuated psychotic symptoms2.2. Transient psychotic symptoms (BLIP)Transient psychotic symptoms (BLIP)3.3. Trait vulnerability Trait vulnerability
+ decline in functioning+ decline in functioning
Age 18 -35 (community) 21- 35 (prison)Age 18 -35 (community) 21- 35 (prison)
Method: Other assessmentsMethod: Other assessments
Demographic dataDemographic data Childhood adversityChildhood adversity Self harm and attempted suicideSelf harm and attempted suicideSubstance MisuseSubstance Misuse CJS dataCJS data
Results: Feb 2009 – Sept 2011Results: Feb 2009 – Sept 2011806 screened with
PQ-B
443 negative 356 positive
60 CAARMS1 positive
206 negative
39 positive(2 transitions)
25 psychotic
Screen Sensitivity and SpecificityScreen Sensitivity and Specificity
PQ-B sensitive but not specific:PQ-B sensitive but not specific:
Anxious on arrival in prisonAnxious on arrival in prison Recent substance misuseRecent substance misuse Other mental health issues Other mental health issues Validation of PQ-B in prisoner populationValidation of PQ-B in prisoner population
““If I was in control, I wouldn’t be here”.If I was in control, I wouldn’t be here”. ““Sometimes I do things that I know I shouldn’t Sometimes I do things that I know I shouldn’t
do – like I hit someone, when I know I do – like I hit someone, when I know I shouldn’t, I can’t stop myself”.shouldn’t, I can’t stop myself”.
““I find it difficult to concentrate”.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 think too much” ““I don’t think to do the right things”I don’t think to do the right things” ““I do stupid things, I’m a bit impulsive”I do stupid things, I’m a bit impulsive” ““I’ve made some bad decisions in life”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 agree strongly agree
14a. Do you worry at times that you may be losing your mind?
324 CAARMS
266 negative for ARMS
39 At RiskMental State
25 first episode psychotic
Results Results (Feb 2009 – April 2011)(Feb 2009 – April 2011)
UHR vs non-UHR prisonersUHR vs non-UHR prisoners
characteristicscharacteristics social exclusion (homelessness, social exclusion (homelessness,
unemployment)unemployment) higher levels of childhood traumahigher levels of childhood trauma self harm and attempted suicideself harm and attempted suicide family psychiatric historyfamily psychiatric history functioningfunctioning
CharacteristicsCharacteristics
Mean age 28 (sd 5.3) no differences between groups
0
10
20
30
40
50
60
70
80
90
1st time in prison remand white
%
neg
pos
psy
Social ExclusionSocial Exclusion
0
10
20
30
40
50
60
70
80
unemployed temp accomodation no qualifications
neg
pos
psy
Substance misuseSubstance misuse AlcoholAlcohol CannabisCannabis Glue, petrol, gasGlue, petrol, gas CocaineCocaine CrackCrack EcstasyEcstasy StimulantsStimulants HeroinHeroin LSD, Mushrooms, PCPLSD, Mushrooms, PCP OtherOther
Substance MisuseSubstance Misuse
Alcohol: No differences between groupsAlcohol: No differences between groups Drugs: No differences EXCEPT use ofDrugs: No differences EXCEPT use of
Cocaine (P<0.003)Cocaine (P<0.003) Other stimulants (p<.04)Other stimulants (p<.04)
in last month associated with ARMSin last month associated with ARMS
Childhood Adverse Events: up to Childhood Adverse Events: up to 17 yrs age17 yrs age
BullyingBullying Physical AbusePhysical Abuse Witnessing family violenceWitnessing family violence Being separated from parentsBeing separated from parents Being in careBeing in care Sexual AbuseSexual Abuse Serious illness or injurySerious illness or injury Racial discriminationRacial discrimination
Adverse Childhood EventsAdverse Childhood Events
0
20
40
60
80
%
neg
pos
psy
Self harm and attempted suicideSelf harm and attempted suicide
0
10
20
30
40
50
60
70
self harm suicide
neg
pos
psy
Family psychiatric historyFamily psychiatric history
0
10
20
30
40
50
60
family history family psychosis
%
neg
pos
psy
20% no data one side of family
FunctioningFunctioning
0
20
40
60
80
100
lowest sofas highest sofas
score
neg
pos
psy
FunctioningFunctioning
22 hour bang up22 hour bang up After detox, functioning After detox, functioning Drop in functioning not due to mental stateDrop in functioning not due to mental state Does being active criminally count as good Does being active criminally count as good
functioning? functioning?
Correlates for ARMSCorrelates for ARMS
High anxietyHigh anxiety High depressionHigh depression Previous self harmPrevious self harm BullyingBullying Sexual abuse Sexual abuse Lower functioning and drop in Lower functioning and drop in
functioningfunctioning
LimitationsLimitations
309 excluded due to language309 excluded due to language 115 refused115 refused Measuring functioning in prisonMeasuring functioning in prison Difficult to engage once they leave prisonDifficult to engage once they leave prison No follow up No follow up
ConclusionConclusion
Screening identifies prisoners wanting help Screening identifies prisoners wanting help – useful for triage– useful for triage
Prevalence: 5% ARMS & 3% psychosisPrevalence: 5% ARMS & 3% psychosis
Comparison prison vs community groupsComparison prison vs community groupsIntroduction of service – in progressIntroduction of service – in progress
AcknowledgementsAcknowledgements
Lucia Valmaggia (PI)Lucia Valmaggia (PI) Tom CraigTom Craig Andrew ForresterAndrew Forrester Janet ParrottJanet Parrott Toby Winton-Brown Toby Winton-Brown Majella Byrne Majella Byrne David Ndegwa David Ndegwa Philip McGuirePhilip McGuire
HMP Brixton Prisoners HMP Brixton Prisoners and Staffand Staff
OASIS TeamOASIS Team Helen McGuireHelen McGuire Philipe WuytPhilipe Wuyt