Michelle DentonManager: Forensic MHSSouthern and Central QldPhD Candidate Uni of Qld

Andrew HockeyProject Officer

“Back on Track”: Transition from prison to community for people with a serious mental illness.

What we know

• High prevalence of mental illness, substance use disorder, health and social issues

• 8-14% psychosis, • 40 -60% some mental disorder, • 70% SUD

• Post release high risk time for unnatural deaths: suicide, overdose, accident (higher MI)

• Poverty, homelessness, lack of social supports, unemployment, stigma

• Cycle of arrest, incarceration, release, relapse, re-offending, re-incarceration

arrest

povertyunemploymentsubstance usehomelessness

stigma

incarcerationrelapse/

re-offending

release

transition phase

Cycle of Mental Illness and Offending

Policy context

• Transition phase - a key point of intervention for MI• Few MH transition services in Australia• Sparse information internationally• USA trend for MH transition support programs funded and managed within CJS rather than health • Concerns that a CJS framework may lack mental health/recovery focus

QUEENSLAND FORENSIC MENTAL HEALTH SERVICEState-Wide Team

COMMUNITY

District Mental Health Services

Court Liaison Service

Community Forensic

Outreach Service

High Secure Hospital

Prison Mental Health In-reach + Transition

Evaluation PMHS Transition

Phase 1 • Evaluation (completed)

– Retrospective study all available data 2007-08

Phase 2• Evaluation (current)

– Prospective study all participants 2010 – outcome data at 4 points – in partnership with RFQ

Phase 3• PhD in-depth qualitative study 25 ‘typical’ cases (current)

– Young men< 40– Psychosis + SUD– < 1 year incarcerated

Aims of Phase 1

• Evaluate 12 months of service activity (July 2007 – June 2008)

• Identify suitable data sources for analysis• Build a demographic and diagnostic profile

of clients receiving transition support• Attempt to evaluate continuity of care

outcomes • Develop a method for future evaluation

Method Phase 1

• Retrospective • Ethics approval QH• Data collection;

• Queensland Health data bases• CIMHA , program data, case note

review • Queensland Corrective Services.

• IOMS• Cross tab analysis.

Program participants

How many• 96/ ~ 3000 releases open clients received

support 1-7-07 and 31-6-08• 80% referred RFQ (NGO)Who• Acutely unwell or relatively complex

– Hospital admission or recommendation– Involuntary Ax during incarceration– Ax as potentially benefiting from program

support

Demographics• 26 females / 70 males.• Mean Age = 32.26 years

28.5

29

29.5

30

30.5

31

31.5

32

32.5

33

33.5

34

Indigenous Non IndigenousAvera

ge A

ge (

Years

)

Female

Male

Primary Diagnosis

0

10

20

30

40

50

60

70A

ntis

ocia

l Per

sona

lity

Dis

orde

r

Bip

olar

Affe

ctiv

e D

isor

der

Bor

derli

ne P

erso

nalit

y D

isor

der

Dep

ress

ive

Epi

sode

Dru

g In

duce

d P

sych

osis

Dys

thym

ia

Pol

y S

ubst

ance

Abu

se

Pos

t Tra

umat

ic S

tres

s D

isor

der

Sch

izoa

ffect

ive

Dis

orde

r

Sch

izop

hren

ia

Male

Female

Additional Diagnoses

0

10

20

30

40

50

60

Acquired Brain Injury

Adjustment Disorder

Intellectual Impairment

Nil. Personality Disorder

Affective Disorder

Drug and Alcohol

Psychosis Anxiety Disorder

Male

Female

Dual Diagnoses (SUD)

0

10

20

30

40

50

60

70

Alc

ohol

Dep

ende

nce

Am

phet

amin

e A

buse

and

D

epen

denc

e

Ben

zodi

azep

ine

Dep

ende

nce

Nil.

Opi

ate

Dep

ende

nce

Pol

y S

ubst

ance

Abu

se

Sol

vent

Abu

se

Male

Female

Previous Psychiatric Admissions

0

10

20

30

40

50

60

No Unknown Yes

FemaleMale

Previous Community MH Treatment

0

5

10

15

20

25

30

35

40

45

50

No Unknown Yes

FemaleMale

Self-Harm History

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

History of Self-harm

History ofSuicide

Attempts

No History

Perc

en

tag

e

Female

Male

Social Support

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Limited Social Support Socially Supported

Per

cent

age Female

Male

Planned Housing Pre-release

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Per

cen

tag

e

Female

Male

Planned Employment Pre-release

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

DSP PSPProgram

NSAllowance

Employed Retired Unknown

Per

cen

tag

e

Female

Male

Incarceration

This intervention• 26 on remand, 52 sentenced, 9 missing• Average length incarceration

– (~ 10 mths) males – (~ 8 mths) females

History– Average 4 times incarcerated (range = 1

to 16) since 1990

Re-incarceration

• 27% re-incarcerated within 6 months (25% M 35%F)

• Av length in the community before re-incarceration was 102 days (~3 mths)(Range 15 to 181 days)

Profile Young <40Schizophrenia + SUD / poly-substancePrevious Psychiatric Admissions Previous Community MH services Self harm + suicide attempts Limited social supportsHousing issues Low employmentMultiple incarcerations

Continuity of Care

• Attended face to face appointment @ local CMHS within 2 weeks post release ?– 73% of males – 61.5% of females

• Who attended 1st appointment?• Who continued attending?

1st appointment attendance

0

20

40

60

80

100

AffectiveDisorder

AnxietyDisorder

PersonalityDisorder

Psychosis SubstanceUse Disorder

Did Not Attend

Attended%

1st appointment attendance X incarceration history

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 >5

Prior Incarcerations

Did notattendAttended

%

Ongoing appointments X prior incarcerations

0

2

4

6

8

10

12

LOW (1-2) AVERAGE (3-6) HI (>6)

Prior Incarcerations

Ave

rag

e n

um

ber

of

con

sult

atio

ns

Female

Male

Ongoing appointments X diagnosisAverage number of consultations

0

2

4

6

8

10

12

14

Affective

Dis

ord

er

Anxie

ty

Dis

ord

er

Pers

onalit

y

Dis

ord

er

Psychosis

Substa

nce U

se

Dis

ord

er

Avera

ge n

um

ber

of

co

nsu

ltati

on

s

Female

Male

Summary

• Complex, high need, multi incarceration • 70% attended first MH assessment 2 weeks• Most maintained engagement 6 months

• Transition support may improve continuity of care

• ↑QOL• ↓ relapse• ↓ recidivism• ↓ mortality and morbidity

Are we getting it right ?Comprehensive assessment Individual plans / personalised deliveryHealth and wellbeing focusPre & post release engagementContinuity of staff across continuumFacilitate access to services? Partnership with communityCross agency collaboration

Just the beginning. More work to be done!