Why this is important

There is limited evidence on the effective models for the training and supervision of practitioners working in the criminal justice system which could best support the identification of mental health problems in the criminal justice system. A series of experimental studies are required to assess the best methods to improve the recognition of the full range of mental health problems. These studies should be of adequate size and cover the full range of health, social and criminal justice staff.

There is insufficient evidence to determine the best methods to deliver effective training to improve the identification of mental health problems in the criminal justice system. Lack of adequate training leads to under-recognition and consequently sub-optimal treatment. Programmes need to be designed and evaluated which are specially developed with the needs of those working in the criminal justice system in mind. There is good evidence that the provision of training alone is unlikely to bring about substantial changes in staff behaviours without adequate service style change and the provision of high quality supervision. The nature of service style changes and the supervision training should also be evaluated.

Important outcomes could include:

• staff competence
• improved recognition of mental health problems
• improved access to and uptake of mental health interventions.

2.

What are the reliable and valid tools to identify cognitive impairment among people in contact with the criminal justice system (including people who have experienced physical trauma, neurodevelopmental disorders or other acquired cognitive impairment)?

Acquired cognitive impairment is common in criminal justice system populations and may be associated with poor social, occupational and interpersonal functioning. Also, people with acquired cognitive impairment have high risk of self-harm which is particularly prevalent in the prison population. Acquired cognitive impairment may arise as a result of, for example, traumatic brain injury, a stroke or other neurological conditions. Experts in this area have suggested that early identification of deficits and the implementation of effective management strategies could be important in limiting the long-term impact of acquired cognitive impairment. However, there is a lack of evidence on reliable and valid case identification tools and methods. It is important that research is developed to assist staff in the criminal justice pathway to help identify acquired cognitive impairment and support better understanding and management of acquired cognitive impairment.

3.

What is the prevalence of mental health problems and associated social problems for those in contact with the criminal justice system?

It is widely recognised that the people in contact with the criminal justice system have a high prevalence of a whole range of mental health problems and associated problems including unstable housing, long-standing unemployment, a lack of supportive social networks and debt. What is not clear, however, is how the mental and social functioning of this group of people has changed since the last major epidemiological study in the late 1990s. In order to plan for the effective mental health care of people in the criminal justice system, it is important to have a greater understanding of the prevalence of mental health problems and social functioning of this group of people. There are a number of factors which have changed since the last epidemiological study; these include a larger prison population, changing patterns of substance misuse, an aging prison population, changes in probation practice and sentencing policy as well as broader changes in society such as changes in mental health care and social care practice. A series of epidemiological studies of representative criminal justice system populations should be undertaken to address the above problems

4.

What factors are associated with suicide attempts and completed suicides?

There is high prevalence of suicide attempts among people in contact with criminal justice system. When developing interventions to prevent self-harm among these populations, it is important to identify and understand the factors related to successful suicide. A retrospective analysis of observational studies of suicidal attempts and completed suicides using suicide as a definitive and measurable outcome should be performed to identify the prognostic factors for successful prevention.

5.

What is the effectiveness of structured clinical (case) management in improving mental health outcomes using interventions within probation service providers?

Many people in contact with the community-based criminal justice services, have significant mental health problems, in particular, personality problems and interpersonal difficulties. Evidence from studies of people with such problems in general mental health services suggests that structured organisation and delivery of mental health interventions (structured clinical management) may be of benefit in improving mental health outcomes. A programme of research is needed which would first refine and develop structured clinical management for use in the community rehabilitation companies (CRCs) and the National Probation Service (NPS) and then test this in large scale randomised control trials in both CRCs and the NPS. The comparison should be against standard CRC and NPS care. The trial should consider both clinical outcomes and cost-effectiveness.

Important outcomes could include:

• mental health outcomes
• offending and re-offending rates
• service utilisation
• cost-effectiveness
• broader measures of social functioning

6.

What is the clinical effectiveness, cost-effectiveness and safety of specific psychological and pharmacological interventions both in and out of the prison among people with paraphilic disorders?

The limited evidence for pharmacological interventions (for example, medroxyprogesterone acetate) provides no clear evidence of benefit in people with paraphilias. A randomised trial with an adequate sample size is needed to examine the effectiveness of medroxyprogesterone acetate in these populations.

There is also insufficient evidence on the effectiveness of psychological interventions for people with paraphilias in the criminal justice system. An individual patient data analysis of existing large scale data sets of paedophiles who have been treated in the criminal justice system should be conducted to inform the choice of treatment and the design of any future research. Psychological interventions for paraphilias (such as sex offender treatment programme) should be tested in large randomised controlled trials in criminal justice populations. This research could have a significant impact upon updates of this guideline.

Important outcomes could include:

• offending and re-offending rates
• mental health problems
• cost-effectiveness
• service utilisation

While designing the trials, consideration should be given to the timing, intensity and duration of interventions in the context of the criminal justice system.

7.

What interventions are clinically effective and cost-effective for the remediation of difficulties associated with acquired brain injuries (including TBI) in adults with mental health problems within the criminal justice system?

Acquired brain injuries are common in adults in contact with the criminal justice system and are associated with an increased prevalence of mental health problems including increased suicidal risk and an increased risk of re-offending. Recognition of ACI is poor and there is currently no effective intervention used in the criminal justice system to address the problems presented by ACI. This leads to poor management in the criminal justice system and poor longer term outcomes in terms of mental health and offending. There is limited evidence on effective models to remediate the consequences of ACI in the general population but no evidence for remediative interventions in the adult criminal justice population. A programme of research and development is required which will (a) develop novel interventions for remediation specially to address the type of ACI commonly seen in the adult criminal justice system population (b) test these interventions in small pilot studies and (c) if the pilot studies show promise test the interventions in large scale randomised clinical trials in the criminal justice system.

Important outcomes could include:

• Improved adaptive functioning
• Improved cognitive performance
• Improved mental health
• Reductions in offending
• Service utilisation

8.

What psychosocial interventions are clinically and cost-effective for people with a personality disorder (other than ASPD or PBD) within the criminal justice system?

Personality disorders are common in adults in contact with the criminal justice system and are associated with an increased risk of re-offending, increased self-harm and suicidality and increased drug and alcohol misuse. Personality disorder may also contribute to significant management problems in the criminal justice system, these management problems may in part arise because the disorders are not recognised and potentially effective interventions are not made available. There are effective treatments for antisocial and borderline personality disorders and, in particular, antisocial personality disorder are available in the criminal justice system. However, although other types of personality disorder are also present in the criminal justice population there is very limited evidence to guide effective treatment for these problems. A programme of research and development is required which will (a) develop interventions for personality disorder (other than ASPD or PBD) within the criminal justice system specially for use in the adult criminal justice system population (b) test these interventions in a series of pilot studies and (c) if the pilot studies show promise, test the interventions in large scale randomised clinical trials in the criminal justice system

Important outcomes could include:

• Remission of the disorder
• Improved interpersonal performance
• Improved mental health
• Reductions in offending
• Service utilisation
• Cost effectiveness

9.

What models for the coordination and delivery of care for people in contact with the criminal justice system provide for the most effective and efficient coordination of care and improve access and uptake of services?

There is low quality evidence for a range of systems for the delivery and coordination of care in the criminal justice system (for example drug or mental health courts and case management). However, there is clear evidence of poor engagement, uptake and retention in treatment for people with mental health problems in contact with the criminal justice system. A number of models (for example, case management and collaborative care) have shown benefit for people with common and severe mental health problems in routine healthcare settings. A programme of research and development is needed, which will first develop and test different models of care coordination for the delivery of care in small feasibility studies and then test those models that have shown promise in the feasibility studies in large scale randomised clinical trials in the criminal justice system.

Important outcomes could include:

• improved mental health outcomes
• improved access and uptake of services
• reductions in offending and re-offending
• cost-effectiveness

10.

What is the best setting for treating people who have acute or significant ongoing psychotic illness within the prison system?

It is recognised that there is often a substantial delay in transferring patients with acute psychosis to a non-custodial hospital setting (currently identified as the preferred setting for such treatment). Currently approximately 1,000 prisoners per year are transferred to a hospital setting with an objective that this transfer be achieved within 14 days. However, this target is often not met and in certain circumstances and in some prisons, alternatives to hospital provision have had to evolve due to necessity. These include treatment in healthcare wings and segregation units. There are significant clinical concerns surrounding this practice and it warrants proper study to determine its feasibility, efficacy and safety.