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3. OVERVIEW OF SEVERE AND ENDURING MENTAL HEALTH PROBLEMS IN PRISONS IN SCOTLAND

THE POLICY CONTEXT

3.1 It is likely that people with severe and enduring mental health problems will come into contact with the criminal justice system at some time. There is a range of policy and legislative safeguards in place to ensure that their welfare is considered.

Legislation

3.2 The most relevant piece of legislation relating to this inspection is the Mental Health (Care and Treatment) (Scotland) Act 2003 [the Act]. The Act provides a number of means for the identification and treatment of people with mental health problems involved in criminal proceedings. Where there is a concern about an individual's mental health ( e.g. from the police, Procurator Fiscal, court, defence solicitor, etc.), a mental health assessment can be requested to help identify whether or not there is a need for treatment, and how to deal with the case.

3.3 A court has the option to impose a prison sentence without examination of mental health issues, and may not identify a concern with this. There are, however, a number of options available under the Act for the imposition of orders relating to care and treatment which do not involve imprisonment. These provide for a range of options before and after trial which require that the individual undergoes an assessment or some form of treatment in a hospital, rather than a prison setting. In some cases, where such an order has been imposed, the order must be kept under review, and the result of this may be that an offender is returned to prison to complete his or her sentence.

3.4 Where an offender is remanded in custody, or receives a custodial sentence, and there are concerns about his or her mental health, there is a clear expectation in the Act (and in national policy set out below) that their mental health will be kept under review. Where an offender requires this, he/she can be transferred to a specified hospital for assessment or treatment. The procedure governing this is set out in the Act, and is the basis for all transfers between prison and hospital regardless of the location of the prison or the hospital. Remand prisoners may be transferred on either an Assessment Order (Section 52D) or a Treatment Order (Section 52M). The arrangements for convicted prisoners are set out in Section 136 of the Act. This is described as a Transfer for Treatment Direction, and specifies issues such as eligibility of prisoners for transfer to hospital, the way in which the decision on the need for transfer should be reached and the approval processes required. It also sets out the specific criteria which apply to admission to the State Hospital. A protocol governing the detailed liaison arrangements to apply between SPS and the NHS was agreed in 2006. ¹

3.5 While in hospital, the mental health of the patient must continue to be reviewed and, if the circumstances which required transfer to hospital no longer apply, the individual may be returned to prison to complete his sentence. A parallel protocol was also agreed in 2006, covering these transfers.

The Use of Prison as a "Place of Safety"

3.6 Although the Act allows an individual to be taken to a "place of safety" for up to 24 hours when a police officer has significant concerns for their welfare, it appears that prisons are not being used to provide this. However, Sheriffs have the power to require that an accused person be detained for a period of seven days to allow an assessment to be made of his mental health. While the accused person would normally be detained in hospital, it is clear that some people are being detained in prison ( e.g. where a hospital bed is not available). Although this is commonly referred to within prisons as a "place of safety order", it is in fact an "assessment order" (although it specifies detention in a "place of safety"). In this context, the Act states that:

"An assessment order may include such directions as the court thinks fit for the removal of the person subject to the order to, and detention of the person in, a place of safety pending the person's admission to the specified hospital." [Section 52D(9)]

National Policy in Relation to Severe and Enduring Mental Health Problems

3.7 Overall policy for forensic mental health in Scotland is guided by "Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland". ² The policy sets out the basis for a multi-agency, multi-disciplinary approach to work with mentally disordered offenders, and encompasses all stages from investigation, through court processes, imprisonment and care in the community.

3.8 The overall aim of the policy is:

"... to co-ordinate care and support for the benefit of the individual and to ensure public safety."

3.9 The overall approach of the policy is that:

... Mentally disordered offenders should be cared for:

• With regard to quality of care and proper attention to the needs of individuals.
• As far as possible in the community rather than in institutional settings.
• Under conditions of no greater security than is justified by the degree of danger they present to themselves or to others.
• In such a way as to maximise rehabilitation and their chances of sustaining an independent life.
• As near as possible to their own homes or families if they have them.

3.10 Overall, the policy sets out the range of services which should be available to mentally disordered offenders through relevant providers within the NHS and local authorities. It also sets out clearly the roles of the partners, and the ways in which they should work together. The policy also sets out a clear direction for SPS in terms of the identification of mental health problems, and the responses which it should make. Key to this is the direction that prisoners who do not meet the criteria for hospital admission need to be treated in prison. It suggests the development of service level agreements with health and social work services and notes that:

"So far as possible within the constraints of resources and of imprisonment, the Scottish Prison Service aims to provide or commission services for prisoners with mental health problems in line with best practice in the wider community."

3.11 In 2003, the Forensic Network was established as a means of bringing together all agencies with a relevant interest in mentally disordered offenders (including the Scottish Executive, the NHS, local authorities and SPS).

3.12 In July 2006, the Scottish Executive issued a new policy on Forensic Mental Health Services, which set out a new structure for the delivery of in-patient services, and established a set of standards for various aspects of this care (referred to as HDL (2006) 48). ³

3.13 The structure of in-patient services is relevant to this inspection as this sets out where, and under what conditions, prisoners will be held if they are transferred to hospital. Essentially, there are three levels of facility: national, regional and local. Within this, there are three basic levels of security: high, medium and low. HDL48 sets out clear guidance on the component parts of these three levels of security, designed to protect the patient and the public, but to do so in a way which subjects the patient to the minimum level of security required.

3.14HDL48 also sets out the pattern of services for women, and for adults with learning disabilities. In relation to women, there were to be no beds in high secure conditions, and a limited number in medium and low secure units. In relation to learning disabilities, some beds were to be retained in high secure conditions, with additional provision in medium and low secure units.

3.15 The implementation of this policy was underway at the time of the inspection. This requires a new hospital to be built on the site of the State Hospital at Carstairs, the commissioning of new medium secure beds in Perth and Glasgow, and the redevelopment of low secure beds in a number of locations. In addition, a number of new beds for adults with learning disabilities are being created. This is, therefore, a transitional period for forensic mental health services.

3.16 At an individual patient level, the Care Programme Approach, first introduced in 1991, is used across the NHS to provide a co-ordinated approach to the assessment, planning and review of care for people with a range of mental health problems, including all of those who would be covered by a diagnosis of severe and enduring mental health problems. This is not currently mandatory in Scotland.

3.17 In April 2007, eight Community Justice Authorities ( CJAs) were established across Scotland. They have been established as a means of taking a co-ordinated approach to the planning and delivery of services to offenders. Their overall aim is to contribute to the reduction in re-offending. The CJAs are at an early stage in their development, but it is expected that they will consider policy and practice relating to mentally disordered offenders in due course.

Policy in SPS

3.18 The key aims of SPS are:

• To keep in custody those committed by the courts.
• To maintain good order in each prison.
• To care for prisoners with humanity.
• To provide prisoners with a range of opportunities to exercise personal responsibility and to prepare for release.
• To play a full role in the integration of offender management services.

3.19 Overall, all healthcare within SPS prisons is governed by the agency agreement between Scottish Ministers and SPS. Healthcare in HMP Kilmarnock is governed by the contract between SPS and SERCO.

3.20 There is a recently established Mental Health Steering Group within SPS, which is intended to provide a strategic direction for mental health and to consider practical policy issues.

3.21 In terms of policy direction, there is a number of policies which impact on the identification, treatment and management of prisoners with severe and enduring mental health problems.

3.22 Mental health well-being is an important part of the SPS policy on the "Health Promoting Prison". ⁴ The policy is based on four main principles: empowerment; partnership; equity and sustainability. In relation to mental health well-being specifically, the policy sets out five broad areas of work:

• Creating a supportive environment.
• Involving prisoners, communities and partners.
• Developing personal skills.
• Integrating healthcare services.
• Monitoring and reviewing progress.

3.23 Following this, SPS published a policy statement "Positive Mental Health" ⁵ which remains current. It aims:

"... to provide a setting which encourages positive mental health in all aspects of prisoner management and care, which responds to the mental health and care needs of prisoners, and arranges specialist healthcare provision for those with mental illness within the prison population as appropriate."

3.24 To achieve this, the policy recognises that a range of factors should be emphasised within the regime relating to: a secure and well ordered environment; supportive relationships and modelling of good interpersonal skills by well-trained staff and management; purposeful activities to promote self esteem; drug and alcohol detoxification, rehabilitation and relapse prevention programmes; healthcare services responsive to prisoner needs and liaison with community agencies.

3.25 The policy recognises that a range of outcomes would be required relating to staff understanding and responses, the interventions provided, continuity of care, management information systems and the adoption of multi-disciplinary team working, evidence-based approach.

3.26 Within SPS, the delivery of mental health policy is overseen by the Mental Health Steering Group and is taken forward locally by multi-disciplinary mental health teams ( MDMHTs).

3.27 At a broader level, in 2006, the Scottish Executive set out a series of outcomes for offenders. Although these relate to reoffending, and to all services working with offenders, these have been adopted by SPS, and overall healthcare policy takes account of these. Of the outcomes, a number are directly relevant to prisoners with severe and enduring mental health problems, including:

• Sustained or improved physical and mental well-being.
• The ability to access and sustain suitable accommodation.
• Reduced or stabilised substance misuse.
• Maintained or improved relationships with families, peers and community.
• The ability to access and sustain community support, including financial advice and education.
• The ability to live independently if they choose.

3.28 The national Choose Life strategy also has relevance to work with prisoners with severe and enduring mental health problems. It is worth noting that, as a result of SPS participation in Choose Life, an approved national training programme, Mental Health First Aid, has been introduced in a number of prisons. This provides basic awareness of mental health issues particularly related to the risk of suicide and self-harm, and provides participants with information about how best to address these issues in a prison setting. The SPS anti-suicide strategy Act2Care is clearly also relevant, as it sets out procedures which staff must follow in the event of concerns being raised. These procedures should lead to the identification of, or at least a suspicion of, severe and enduring mental health problems where these exist.

3.29 At the time of inspection, the SPS was conducting a scoping exercise to look at the feasibility of transferring the provision of prison healthcare to a contracted out arrangement by the NHS. Prisoners with mental health problems should have the same quality of healthcare, and access to it, as anyone else.

3.30 At a broader level, the liberation of prisoners with severe and enduring mental health problems is generally covered by the same policies as other prisoners. For all prisoners, throughcare arrangements apply, and for longer-term prisoners, parole and license conditions may also be relevant. Integrated Case Management ( ICM) arrangements would also apply to designated prisoners with severe and enduring mental health problems (as with any other prisoner falling within its scope). For sexual offenders, MAPPA (multi-agency public protection arrangements) would apply, as a result of the potential risk to the public. ⁶

THE NATURE OF MENTAL HEALTH PROBLEMS

3.31 The Mental Health Foundation notes that the term "mental health problem" is used to encompass a wide range of problems and it is important to identify the types of behaviour covered by this. There are a number of diagnostic and classification frameworks and, amongst these, the most common is the World Health Organisation's "International Statistical Classification of Diseases and Related Health Problems" (the ICD-10) which classifies mental health problems in a number of categories.

3.32 Mental health "disorders" are subdivided into "organic" or "functional", within which there is a range of individual disorders. Organic disorders involve identifiable brain malfunction and include issues such as acute confusion or delirium; dementia (including Alzheimer's disease); and learning disability. Functional disorders are those which are not due to simple structural abnormalities of the brain and include disorders such as: schizophrenia; mood disorders (including bi-polar affective disorder); mania and depression. There are also "neurotic mental disorders" (including obsessive compulsive disorder and post traumatic stress disorder); eating disorders; substance misuse disorders (such as drug-induced psychosis); personality disorders and conduct disorders.

3.33 The Mental Health (Care and Treatment) (Scotland) Act 2003 defines mental disorder as:

"… any mental illness, personality disorder or learning disability, however caused or manifested."

3.34 As such, the Act includes both organic and functional disorders.

Severe and Enduring Mental Health Problems

3.35 Mental health problems exist on a spectrum from mild to severe, and from common to less common. In terms of the identification of "severe and enduring mental health problems", "common" mental health problems include anxiety, depression, phobias, obsessive compulsive and panic disorders, while "severe and enduring" mental health problems include those such as psychotic disorders (including schizophrenia) and bi-polar affective disorder (manic depression). ⁷ "Personality disorder" is also identified as a mental disorder under the Mental Health (Care and Treatment) (Scotland) Act 2003. This has been defined as "an enduring pattern of inner experience and behaviours that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment". ⁸

THE PREVALENCE OF MENTAL HEALTH PROBLEMS

3.36 It is worth considering the general prevalence of mental health problems in the wider population as a whole, before considering the findings of this review in relation to the prison population in Scotland.

Prevalence of Mental Health Problems

3.37NHS Quality Improvement Scotland (2005) has identified the high prevalence of mental health problems in Scotland and the impact of this on the quality of life of those affected. The "Framework for Mental Health Services in Scotland" identifies that more than 20% of adults are affected by mental health problems at any one time, and that 30% of general practice consultations involve mental health problems. Amongst those experiencing mental health problems, the proportion of people experiencing severe and enduring mental health problems is much smaller. For example, 0.4% of people living at home have been found to have schizophrenia, and 0.5-1% have bi-polar affective disorder. ⁹ A recent report by SAMH¹⁰ estimated the social and economic costs of mental health problems in Scotland at £8.6 billion (and this did not include the costs borne by the criminal justice system).

3.38 The Sainsbury Centre for Mental Health identified considerable overlap between the populations who have contact with mental health services and those who have contact with criminal justice services. ¹¹ Tickle (2005) ¹² stated that more than 60% of offenders entering prison in Scotland had a mental illness (compared to 16% of the general population). The Mental Health Foundation has suggested that nine out of 10 prisoners have a mental disorder, and the Sainsbury Centre for Mental Health (2007) identified that around 70% of sentenced prisoners in England and Wales experience two or more mental health problems, and 20% of male and 15% of female prisoners have previously had a psychiatric acute admission to hospital. ¹³

3.39 Data from an unpublished inspection on High Risk Offenders identified that 30% of prisoners (from sample) presented with a history of mental ill health on admission, with 41% going on to receive some form of support for mental health whilst in prison.

3.40 International studies suggest that 3-7% of prisoners have severe and enduring mental health problems, and Tickle suggested that around 5% of the prison population experience such issues, a prevalence identified as four times that within the wider community. The Sainsbury Centre for Mental Health (2007) ¹⁴ identified that, while most of the mental health problems in prison are common conditions such as depression or anxiety, some have more severe problems such as psychosis. Singleton et al (1998) ¹⁵ suggested that, in England and Wales, 10-20% of prisoners are in the group with the most serious mental health problems.

3.41 There are many difficulties in measuring the actual prevalence of severe and enduring mental health problems in prisons, including problems in terms of identifying "severe and enduring" mental health problems as a distinct group, and in taking account of those prisoners who may have undiagnosed or less visible problems. For these reasons, the figures from this inspection cannot be seen to be definitive, but provide an estimate of the scale of the problem in Scotland.

Severe and Enduring Mental Health Problems in Prisons in Scotland

3.42 There are prisoners with mental health problems throughout the prison system in Scotland. As in the wider population, however, prisoners with severe and enduring mental health problems in prison make up a relatively small proportion of prisoners with mental health problems. People with severe and enduring mental health problems also constitute a relatively small proportion of the total number of prisoners receiving medication for some form of mental health problem.

3.43 Some MDMHTs commented on the high number of prisoners overall with some form of mental health problem. One, for example, noted that almost all exhibited some form of personality disorder, while another suggested that about 70% of prisoners had some form of mental health issue (similar to the figure quoted by Tickle in 2005, and representing a much higher proportion than in the population as a whole).

3.44 In terms of severe and enduring mental health problems, although there were some issues with the means of classification, at least 315 prisoners were identified as having some form of diagnosed condition. This figure excludes those in Polmont, as psychiatrists there are generally reluctant to reach a formal diagnosis on young people (an issue discussed later). A further eight prisoners were identified who were, at that time, undergoing assessment in a hospital facility.

3.45 Excluding Polmont, this represents around 4.5% of all prisoners. As with the figure for mental health problems overall, this is again similar to the figure quoted by Tickle in 2005, and represents a much larger proportion of people with severe and enduring mental health problems in prison than in the wider community. Some prisoners' behaviour suggested that they may have undiagnosed severe and enduring mental health problems, and prisoners with personality disorders may be amongst those most likely to be within this group.

3.46 Only a very small proportion of prisoners with severe and enduring mental health problems were found to be subject to the anti-suicide strategy Act2Care.

Changing Trends

3.47 Although there is a relatively low number of prisoners with severe and enduring mental health problems, prisons felt that the number has been increasing in recent years, along with the severity and complexity of the problems. Additionally, 10 prisons indicated that the number of prisoners with severe and enduring mental health problems had risen in the last three years.

3.48 Although there was seen to have been a general increase in severe and enduring mental health problems, some particular mental health problems were identified as having increased specifically, and those highlighted included: drug-related problems; learning disabilities; Post Traumatic Stress Disorder ( PTSD); Attention Deficit Hyperactivity Disorder ( ADHD); and autistic spectrum disorder. However, this increase may be due to a greater knowledge of these conditions resulting in increased assessment and diagnosis.

3.49 A number of hospitals, however, stated that they had not seen a particular change in the types of severe and enduring mental health problems which prisoners who were referred to them experienced and it was suggested that many of the problems facing prisoners would be dealt with in prison. One hospital stated explicitly that its experience was mostly of prisoners with "psychotic" disorders: the rest remaining in prison.

3.50 Five possible reasons for the perceived increase in the number of prisoners with severe and enduring mental health problems in prisons were highlighted:

• The rising number of prisoners overall.
• The closure of long-stay psychiatric hospitals and a perceived lack of sufficient support in the community.
• The increase in long-term substance misuse problems.
• An increase in the elderly population.
• A greater awareness of mental health disorders supported by increased assessment and diagnosis.

3.51 However, the increasing visibility of these problems may not necessarily reflect an actual increase. Instead, it was suggested this could be as a result of improvements in the recognition of mental health problems, and the availability of mental health assessment in prison, accessibility of support, and individuals' willingness to seek help. One of the hospitals also suggested that there had been changes to the perception of the need for transfer of prisoners to hospital, rather than an actual increase in the number experiencing severe and enduring mental health problems.

3.52 Whatever the reason for the changing patterns, there is an increasing requirement for prisons to respond to these issues.

Types of Severe and Enduring Mental Health Problems in Prisons

3.53 Amongst severe and enduring mental health problems experienced by prisoners, most of the prisoners spoken to stated that they had experienced their mental health problems for a long period of time, and most had had problems before they came into the prison.

Common Issues

3.54 The majority of participants were able to identify the severe and enduring mental health problems which they considered to be particularly prevalent amongst prisoners. The most common types of problems highlighted were those which would be classed as "functional" mental disorders, with the most prevalent seen to be schizophrenia and bi-polar affective disorder.

3.55 There were also some examples of organic mental disorder highlighted, such as prisoners with learning disabilities, and some instances of dementia. "Neurotic" mental disorders, such as anxiety, obsessive compulsive disorder ( OCD) and PTSD were also identified as amongst the types of severe and enduring mental health problems experienced. Some prisoners also described specific symptoms of mental disorder, such as hallucinations, insomnia, paranoia or self-harm.

3.56 Included within the group of prisoners with severe and enduring mental health problems were a number with a personality disorder.

3.57 Some of the differences of view of whether or not the inclusion of personality disorder was appropriate became apparent during the inspection, and it was suggested that it was unusual, for example, for hospitals to accept patients with a sole diagnosis of personality disorder. It was clear, however, that there are difficulties in identifying some mental health problems such as "severe and enduring" (as distinct from less severe), and the point at which a problem becomes severe and enduring was often difficult to establish.

Co-morbidity

3.58 The term "co-morbidity" refers to the presence of more than one mental health disorder, and there is clear evidence of co-morbidity relating to substance misuse and mental health problems. Grant ¹⁶ (2004) noted that up to three in four people who use drugs have mental health problems, up to one in two patients with alcohol problems may also have mental health problems and up to two in five people with mental health problems, may have a drug and/or alcohol problem.

3.59 This issue of co-morbid substance misuse and mental health problems was also identified in this inspection. The large majority of prisoners with mental health problems also have substance misuse issues. Prisoners confirmed this. Estimates varied, but the commonest were that co-morbid substance misuse is an issue for around 80% of prisoners with severe and enduring mental health problems. Hospital and voluntary sector participants were also clear that a very high proportion of these prisoners have co-morbidity issues, with several hospitals suggesting that this was "virtually all".

3.60 Although it is recognised that there is not a simple causal relationship between substance misuse and mental health problems, substance misuse was seen to impact upon mental health problems in a number of ways, such as drug-induced psychosis. The point was also raised that substance misuse leads to considerable physical damage and cognitive impairment, which were seen to be high amongst the prison population. Similarly, mental health problems were seen to increase the likelihood of substance misuse, with some prisoners stating that they had "self-medicated" with alcohol or other non-medicinal drugs. One MDMHT also suggested that the high level of drug use in prison could mask a lot of mental health problems.

Issues for Particular Groups

3.61 Some groups of prisoners experience specific issues relating to their mental health. The majority of prisons believed that there were some groups of prisoners amongst whom severe and enduring mental health problems were particularly prevalent. Those identified included: those with substance misuse issues; those with personality disorders; "vulnerable prisoners"; prisoners in particular age groups; survivors of childhood sexual abuse; short-term prisoners; and prisoners with a blood borne virus.

3.62 As well as groups for which there was seen to be a higher prevalence of mental health problems, it was also suggested that some groups faced particular issues. For example, particular issues were highlighted amongst young offenders, in terms of the types of mental health problems they experienced and their general "vulnerability". Some disorders of childhood, adolescence and development affect this group particularly, such as Attention Deficit Hyperactivity Disorder ( ADHD), autistic spectrum disorder, communication problems and learning disabilities.

3.63 In terms of co-morbidity, the issue of co-morbidity for young people often relates to alcohol, rather than to other drugs. An issue also arose with the diagnosis of young people, with the suggestion that many young people have symptoms of severe and enduring mental health issues, but are not yet diagnosed, as psychiatrists are unwilling to do so.

3.64 A further group identified as experiencing specific mental health issues was women. One hospital had seen an increase in the number of women patients, and that women prisoners would generally have more complex needs and issues, with particular experiences of abuse, emotional damage and substance misuse issues. Family dynamics and complex social situations can also have an impact on their mental health. One MDMHT identified particular issues for women with severe and enduring mental health problems with babies, noting that there could be fears for the safety of the baby. It was also identified, however, that being separated from the baby could also have an impact on a woman's mental health.

3.65 There are also issues for women prisoners relating to experiences of rape and sexual abuse, and some women themselves identified these issues as contributing to their symptoms and experiences of mental health problems.

3.66 A small number of participants also identified that there were specific difficulties for disabled prisoners in coping both with a physical disability and mental health problems in prison. It was also suggested that there could be problems for prisoners with communication difficulties.

3.67 Specific mental health issues were also identified for older prisoners, with the suggestion that there is an ageing population of long-term prisoners and that this group has their own set of problems.

3.68 It was also suggested that ethnic minority prisoners may have specific needs relating to their health and mental health, as well as having a need for access to information in an appropriate language. Cultural issues may impact upon the identification of mental health problems.

3.69 The point was raised that there may be severe and enduring mental health issues for Transgender prisoners, although mental health issues affecting Lesbian, Gay, Bisexual and Transgender ( LGBT) people were generally not highlighted frequently.

3.70 Sex offenders and prisoners who require protection from other prisoners may also have specific mental health needs, and one MDMHT noted the receipt of a significant number of referrals from protection prisoners.

3.71 There were also issues identified relating to a prisoner's length of sentence. For example, it was noted that short-term prisoners and those on remand can experience a lot of adjustment issues, stress and social issues. Amongst long-term prisoners, a lack of progression and lack of activity may impact upon mental health. One prison suggested that some long-term prisoners could have a very long history of substance misuse, which impacts upon their mental health, while another suggested that long-term prisoners could reach a stage in their sentence when their mental health becomes poor. Long-term prisoners may also experience mental health problems at the start and towards the end of a long sentence.

3.72 More generally, prisoners with severe and enduring mental health problems often have common experiences of poverty, social problems, communication problems and a lack of support and that many have come through the care system.

3.73 All of these issues have implications for the identification of needs, and the treatment of these groups, and will be addressed later in this report.

THE IMPACT OF MENTAL HEALTH PROBLEMS

3.74 Almost all prisons stated that having prisoners with severe and enduring mental health problems has an impact on the establishment as a whole, on staff and on other prisoners, and that this impacts in a range of ways.

Impact on Prisons

3.75 Prisoners with severe and enduring mental health problems have an impact on the general running of a prison in a number of ways:

• Prisoners with complex needs, or who require frequent checking, are resource-intensive. Other activities may be restricted as a result.
• Disruption by one person with a severe and enduring mental health problem can require disproportionate staff input and time.
• Where prisoners need to be located alone, this can make extra demands on staff resources.
• Where prisoners are located in the segregation unit this impacts on the other resources available.
• There may be a lack of appropriate facilities for people with severe and enduring mental health problems.

3.76 By contrast, most hospitals did not suggest that the presence of prisoners had any particular impact on their facilities.

Impact on Staff

3.77 There is also an impact on prison staff:

• Officers often have to manage difficult behaviour and respond to complex needs.
• Staff may feel that they are not appropriately skilled or resourced for the tasks required.
• Staff may be the subject of allegations by people with mental health problems.
• There can be assaults on staff.
• Working with prisoners with severe and enduring mental health problems is stressful, emotionally demanding and can be upsetting, particularly for staff in single posts: "something that's never considered is the impact on staff mental health and well-being".

Impact on Other Prisoners

3.78 There is a number of ways in which prisoners with severe and enduring mental health problems impact on other prisoners, particularly in terms of their actions and behaviour:

• There can be noise and disruption (including at night) and a general "lack of peace" (with one example given of a prisoner who banged his door rhythmically for hours on end).
• Tension and stress can increase the risk of unpredictable behaviour from other prisoners.
• Some behaviours may pose a threat to other prisoners.
• Other prisoners may not be able to access staff resources, with disproportionate time taken up by prisoners with severe and enduring mental health problems.
• Prisoners may not wish to share a cell with others with mental health problems, but there can be perceptions of favouritism and pressure on such accommodation if those with mental health problems are moved to a single cell.
• In one prison a recent suicide was seen to have had a particular impact on other prisoners, with everyone "on a downer".
• Sometimes the prison needs to be locked down to deal with issues for people with severe and enduring mental health problems, and this can lead to loss of recreation and interaction time for others.

The Impact of Imprisonment on Prisoners with Severe and Enduring Mental Health Problems

3.79 The fact and nature of imprisonment itself can have a negative impact on people with severe and enduring mental health problems:

• The environment is not seen as conducive to recovery.
• Factors such as separation from family and social support can have a detrimental effect.
• Other prisoners may bully or "rile" people with mental health problems, and lack understanding of these issues.
• Staff attitudes can affect mental health, and there can be stigma.
• Prisoners may be singled out and ostracised.
• Poor conditions can impact on mental health. Segregation in particular can impact on this.
• Other aspects of the living conditions, and a lack of activity, can lead to worsening of specific symptoms.
• Prisoners may well worry about family issues - particularly women.
• The nature of the regime, boredom and "time to think" can exacerbate mental health problems.
• Prisoners may experience difficulties in adjusting and sleeping.
• Prisoners with severe and enduring mental health problems can be a threat to themselves.
• There can be a lack of progress for some prisoners with severe and enduring mental health problems, and a dependency on nursing staff and officers.

Interaction with Overcrowding

3.80 Overcrowding may exacerbate the challenge of managing prisoners with severe and enduring mental health problems. Overcrowding may:

• Make extra demands on staff resources and compound the difficulties identified.
• Affect prisoners' mental health directly.
• Contribute to behaviour (such as bullying) which can impact on mental health.
• Make it more difficult to identify mental health issues and provide support.
• Make it too easy for prisoners to stay in their cells and focus on their problems.

CONCLUSIONS

3.81 In terms of the prevalence of severe and enduring mental health problems, the main conclusions are as follows:

3.81.1 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 with severe and enduring mental health issues were identified by prisons (not counting Polmont). A further eight prisoners were identified who were at the time, undergoing assessment in a hospital facility. Excluding Polmont, this represents around 4.5% of all prisoners.

3.81.2 The number of prisoners with severe and enduring mental health problems appears to be rising, although it was not clear if the numbers themselves are increasing, or if the visibility of mental health problems is increasing. Whatever the reason for the changing patterns, there is an increasing requirement for prisons to respond to these issues.

3.81.3 The most common types of severe and enduring mental health problems in Scottish prisons are schizophrenia and bi-polar affective disorder. There is also a significant number of prisoners with a personality disorder. The majority of prisoners with mental health problems also have substance misuse issues. Smaller numbers of prisoners with other mental health problems were also reported.

3.81.4 There are some groups amongst whom severe and enduring mental health problems are seen to be particularly prevalent, as well as some groups which experience specific issues relating to their mental health, including: young people; women with babies; disabled people; older people; ethnic minority people; sex offenders and protection prisoners; and prisoners serving particularly long or short sentences.

3.82 In terms of the impact of severe and enduring mental health problems in prison, the main conclusions are as follows:

3.82.1 Prisoners with severe and enduring mental health problems have an impact on the general running of an establishment, with this group seen as being both resource-intensive and a cause of disruption.

3.82.2 There is also an impact on prison staff, in terms of the physical and emotional demands of being required to manage difficult behaviour and respond to complex needs. This is exacerbated by a lack of training and guidance.

3.82.3 The impact on other prisoners is general disruption; hampering access to staff and facilities; and affecting the overall atmosphere.

3.82.4 The fact and nature of imprisonment itself does real harm to people with severe and enduring mental health problems.

3.82.5 These impacts are exacerbated by overcrowding.

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