Department of Forensic Psychiatry, Institute of Psychiatry, London
Correspondence: Deborah Brooke, The Bracton Centre, Bexley Hospital, Old Bexley Lane, Bexley, Kent DA5 2BW,UK. Tel: 01322 294300; fax: 01322 293595
Declaration of interest The study was funded by the Home Office Research and Planning Unit, for the Directorate of Health Care. The views expressed are the authors' own.
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ABSTRACT |
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Aims To examine differences between prisoners on remand with substance misuse problems and other prisoners on remand.
Method Random selection and interview of unconvicted male prisoners (n=750, a 9.4% sample), plus examination of the prison medical record.
Results Of the sample of 750,253 subjects (33.7%) reported either drug- or alcohol-related health problems or dependency. Compared with other prisoners on remand, they reported more childhood adversity, conduct disorder, self-harm, past psychiatric treatment and current mood disorder, and had fewer qualifications, were more likely to be unemployed and have more housing difficulties.
Conclusions One-third of unconvicted men in prison report substance-related problems, and these are a marker for vulnerability within a disadvantaged population. Health care providers should involve this group in treatment and rehabilitation, both inside prison and following release.
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INTRODUCTION |
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METHOD |
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On the basis of these data, subjects were grouped into two categories.
Problem users Use over 3-4 times per week (except cannabis); all those subjects whose substance use caused health problems and all dependencies, including alcohol.Comparison group All other remanded prisoners: moderate drinkers without alcohol-related harm to health; cannabis up to and including daily use; if other drugs, no more often than 3-4 times per week; the abstinent.
Subjects completed the SF36 questionnaire (Ware & Sherbourne, 1992; McHorney et al, 1993) to give an indication of their general health.
Comparisons between the two groups were carried out using 2
and t-tests, as appropriate, in SPSS for Windows. (Copies of the
interview schedule are available from the first author upon request.)
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RESULTS |
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Ninety-one subjects (12%) were solely dependent on alcohol. A further 162 (22%) described themselves as heavy users of, or dependent on, one or more substances. These 253 subjects comprise the problem users subsample. Seven subjects were unable to describe their levels of drug use.
Demographic characteristics
Of the 750 men, 585 (78%) were Caucasian. The average age of the comparison
subjects was 28.0 years (s.d.=9.58), so that they were older than the problem
users (average age 26.5 years; s.d.=7.31; t=2.32, d.f.=638.9,
P=0.021). Of the whole sample, 350 (47%) had never married; 211 (28%)
described themselves as married or cohabiting. Problem users were less likely
to have been living in their own home, or with their own family, before
arrest, and were less likely to be returning to their own home or family after
release (194 of 253 (77%) problem users previously living thus, compared with
420 of 490 (86%) comparison subjects: 2=9.49,
P=0.0021; 161 of 253 (64%) problem users expected to return, compared
with 349 of 490 (71%) comparison subjects:
2=4.46,
P=0.035). There were differences in occupational characteristics
between the two subsamples; only 84 (33%) and 64 (25%) of 253 problem users,
respectively, had gained any qualification or were currently employed,
compared with 222 (45%) and 175 (36%) of 490 in the comparison sample
(
2 for any qualification=11.11, P=0.0009;
2 for employed=8.30, P= 0.004). The average age of
the problem users on leaving school was 15.3 years (s.d.=1.15), as opposed to
15.6 years (s.d.=1.20) for the social users (t=4.04, d.f.=733,
P<0.0001).
Clinical characteristics
Problem users were more likely to report childhood adversity, antisocial
behaviour in adolescence and previous self-harm (childhood adversity: 115 of
253 (46%) problem users, compared with 178 of 490 (36%) others on remand,
2=4.95, P=0.026; significant truancy: 168 of 253
(66%) problem users, compared with 217 of 490 (44%) others on remand,
2=30.05, P<0.0001; deliberate self-harm: 83 of 253
(33%) problem users, compared with 102 of 490 (21%) others on remand,
2=12.85, P=0.0003). Similar proportions reported
literacy difficulties. Half of the problem users (124 of 252, 49%) reported
past psychiatric treatment, compared with 169 of 490 (35%) comparison subjects
(
2= 17.35, P<0.0001). The comparison group
reported consulting the prison medical officer marginally more often about
their physical health than the problem users. The average number of such
attendances in the preceding month was 0.90 (s.d.=2.52) for the comparison
group (n=474), and 0.57 (s.d.=1.23) for the problem users
(n=241; t=1.93, d.f.=713, P=0.054). Similar
proportions in both groups had received night sedation since imprisonment. The
prevalence of mental disorders among all subjects, irrespective of substance
misuse, exceeded the figure found in the community
(Brooke et al, 1996). There was a difference between the two groups in the prevalence of mood
disorder: comparison subjects (n=453) reported any depressive
illness in 43 cases (9.5%); problem users (n=239) reported
any depressive illness in 36 cases (15.1%);
2=11.35, d.f.=5, P=0.045. We diagnosed a psychotic
illness in 36 male prisoners on remand, that is, 4.8%. Of these, 12 were in
the problem substance use group, of whom seven had alcohol
dependency. These figures suggest that prisons contain significant numbers of
unconvicted men with severe and complex psychiatric disorders.
Current well-being
The SF36 gave an indication of current well-being; it was not administered
to the 206 subjects who were under 21 years old. In all the SF36 domains,
problem users perceived themselves to be worse than other remand prisoners. In
the areas of general health and vitality, these
differences were significant. (Mean scores for general health: social users,
68.2, s.d.=21.2, n=284; problem users, 62.1, s.d.=25.3,
n=156; t=2.57, d.f.=275.9, P=0.011. Mean scores for
vitality: social users, 54.9, s.d.=21.1, n=284; problem users, 48.7,
s.d.=21.2, n=156; t=2.96, d.f.=437, P=0.003.)
Patterns of offending; different histories of convictions and
imprisonment
Nearly twice as many problem users had been charged with burglary (70 of
253 (28%) problem users, compared with 73 of 490 (15%) others on remand,
2=17.51, P<0.0001), and their offences were more
severe. The mean age at first conviction was younger among the problem drug
users (14.1 years for comparison cases, s.d.=2.30, n=286; 13.6 years
for problem users, s.d.=2.0, n=184; t=2.43, d.f.=468,
P=0.016). Problem users were overrepresented among those who had
served two or more custodial sentences (comparison cases, n=172
(36.1%), problem users, n=141 (59.0%);
2=38.1,
d.f.=2, P<0.0001).
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DISCUSSION |
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This study did not attempt to assess subjects' levels of dependence on cannabis, which, in the light of current understanding about cannabis dependency, would have made a more complete assessment of subjects' difficulties with street drugs.
Vulnerability among prison populations
In this paper, we drew a distinction between those prisoners who were
social users and those whose substance use caused problems. This
was a pragmatic choice, because of the difficulty in being more precise about
a state, such as dependency, with blurred boundaries. This is,
perhaps, an artificial distinction; many subjects would have been in a
different group if we had interviewed them at a different time. The levels of
childhood adversity, disadvantage and instability were high in both
groups.
However, the problem users were clearly worse off than their peers. They were a younger group with disproportionate levels of educational failure, unemployment and housing difficulties. Their average ages at first conviction and on leaving school were younger. These findings are in agreement with the most recent large survey of psychiatric morbidity among prisoners (Singleton et al, 1998), which showed that subjects with drug dependency were less likely to be married and less likely to be educated to A-level standard. Problems with substance misuse may be a marker of special susceptibility in this already vulnerable population. Substance misuse has been associated with suicide in prison (Leibling, 1992) and with violence among mentally disordered offenders (Monahan & Steadman, 1994).
Are substance misusers in the criminal justice system different?
The severity of dependence among our subjects who were addicted to opiates
equalled that of patients entering in-patient detoxification
(Brooke et al, 1998),
and imprisonment is a frequent experience among addicts, so it is likely that
they are essentially the same population of drug misusers. With reference to
those who were dependent on alcohol, Tam et al
(1996) showed that problem
drinkers who were known only to the criminal justice system (and not to
treatment facilities) tended to be younger men who were less dependent. This
finding suggests that early intervention packages with controlled drinking
guidelines would be appropriate.
Clinical variables
Half of the remand prisoners with substance problems reported having
received psychiatric treatment in the past. Some of this treatment was in
substance misuse services. This agrees with previous estimates that half of
the addicts in contact with probation services are new to treatment
(Advisory Council on the Misuse of Drugs,
1991), despite the efficacy of substance misuse services
(Task Force to Review Services for Drug
Misusers, 1996).
Within the sample of remand prisoners, the SF36 scores showed that problem users perceived themselves to be less well than other prisoners on remand. Despite this, they were not consulting the prison doctor more often for emotional or physical complaints. They were not receiving night sedation more often. This suggests that their expectations of the services were lower, or that they were not good at making use of them. Bearing in mind that the problem users group contained many prisoners with multiple diagnoses, perhaps those with the greatest need were not using the services enough.
Implications for practice
Problem users on remand need a range of psychiatric, educational and social
interventions. Hodgins & Lightfoot
(1988) divided prisoners with
histories of alcohol and drug use into five groups with different social and
clinical needs. They suggested specific treatment packages for each group,
including general life skills development. The Home Affairs Committee
(1999) has stated that these
measures are especially relevant to remand and short-term prisoners, because
they are more likely to be in prison for drug-motivated crimes, and treatment
is more urgent because they will be released sooner. Other recommendations
included improved assessment procedures on induction, and urine screening for
all prisoners on reception.
The difficulties reported by the problem users were long-standing. Time in prison can only offer a window of opportunity to start to change. The depth of need and the large numbers imply that prison health care services alone cannot address these problems: a response right across the institution is required. Furthermore, recovery needs to be consolidated after release, so there should be close liaison between services inside and outside prison. This may be facilitated by implementing the recommendation that local health authorities should take into account the health needs of prisoners in their area when commissioning services (HM Prison Service & the NHS Executive, 1999).
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication November 5, 1999. Revision received February 8, 2000. Accepted for publication February 10, 2000.
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