From positive screen to engagement in treatment: a preliminary study of the impact of a new model of care for prisoners with serious mental illness

Abstract

BackgroundThe high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources.MethodThe PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care.ResultsThe number of prisoners in the study in the year before the PMOC (n = 19,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = −7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment.ConclusionsThe PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison.

Decision curve analysis as a framework to estimate the potential value of screening or other decision‐making aids

“…The net benefit of screening with multiple cut‐offs which has sensitivity (75%) and specificity (71%) comparable to the best studied tools ranged from 7 to 13% over the range of thresholds for which it was the optimal strategy. However, as discussed in the introduction, observational studies have reported approximately 3 to 5% increases in uptake of treatment following screening (Evans et al, ; Pillai et al, ), and some of these increases may be through greater provision of services to those who do not require treatment (Martin et al, ). Given these gaps from potential to actual impacts of screening, results of our subgroup analyses warrant attention to better understand the limitations of screening as currently practiced.…”

“…Although there are no RCTs of mental health screening in prisons, two observational studies have reported 3–5% increases in the proportion of inmates accessing treatment (Evans et al, ; Pillai et al, ). Neither study looked at duration of care or accuracy of treatment decisions.…”

Mental health in the criminal justice system: A pathways approach to service and research design

“…The organisation of these processes into a particular model—the STAIR model —is one easily understandable way of signifying what should happen within the prison health care pathway and when. It includes five key elements—screening, triage, assessment, intervention, and reintegration (STAIR) (Forrester et al, ; McKenna et al, ; Pillai et al, ). Although this model is broadly in keeping with guidelines for the management of adults who are in contact with the criminal justice system, which particularly emphasise screening processes, further research is needed to refine existing models to ensure they are sensitive to the wide range of mental disorders seen (National Institute for Health and Care Excellence, ).…”

Human rights and mental health in post-apartheid South Africa: lessons from health care professionals working with suicidal inmates in the prison system

“…Our participants also drew attention to the need to address contextual factors within the prison system and to create a caring culture in which prisoners feel safe. The importance of creating communities of care within prisons and establishing systems for screening and appropriate referrals of mentally ill prisoners have been highlighted in studies from high-income countries [ 47 ]. There is growing acknowledgment in the international literature of the need for correctional centers to be transformed into “psychologically informed planned environments” [ 48 ] (p. 84) and “therapeutic communities that target specific behaviors, such as drug and alcohol abuse and violent behavior” [ 49 ] (p.4), in an attempt to bridge gaps between therapy and custody.…”