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

manuela.jarrett@kcl.ac.uk