The border between prison and the outside community appears to be particularly open to people with mental health problems.
In 1997, the Office of National Statistics (ONS) published a landmark report on the mental health of prisoners. This took samples from all prisons in England and Wales, eventually interviewing over 3,000 prisoners.
It used methods that allowed direct comparison with surveys of the general population. The findings were striking.
Schizophrenia and similar psychotic disorders are the most severe form of mental disorder. Their frequency ('prevalence') in Britain is around a half a per cent, while ten per cent of prisoners had such disorders.
Mental disorders in prisoners are linked to increased rates of victimisation, both violent and sexual. Unsurprisingly they have major consequences in terms of suicidal thoughts and behaviour and deliberate self-harm.
Criminal justice inertia
It has been acknowledged for a long time that the way prisons are run obstructs the rehabilitation of prisoners with serious mental health problems. Good medical care should be provided on humane grounds, but also has a role in reducing recidivism. Moreover, imprisonment is plainly inappropriate for many offenders with mental disorders and, where possible, diversion at various stages of the justice process is accepted as more productive.
The findings of the 1997 survey produced an upsurge of good intentions. However, the inertia of the criminal justice system made implementation difficult. Initiatives were unsuccessful or short-lived, falling foul of other imperatives and developments in the prison and probation services.
The Bradley review of 2009 called for a repeat of the 1997 ONS survey in order to provide up-to-date data for treatment provision strategies. The government accepted this recommendation, but no such study has been commissioned.
Recently, however, a psychiatric survey was carried out in two local London prisons (HMPs Holloway and Pentonville – the former closed and scheduled for redevelopment, the latter in line for possible closure). These surveys were partly designed to evaluate the prison mental health service, but they used methods virtually identical to the 1997 survey, and so can be used to comment on the prevalence of mental disorders 15 years on.
The findings are strikingly similar to the 1997 national survey. For example the prevalence of psychotic disorders was twelve per cent. In both surveys the prevalence of mood disorders was not only very high but was also skewed towards the more severe types. So, while in the general population mild disorders are nearly four times as common as severe disorders, they are only 1.4 times as common in the recent prison sample.
Similar levels of alcohol dependence were found in male and female prisoners. Compared with the general population, the rates were three times as high in males and ten times in females. Drug dependence was equally widespread, with figures starkly in contrast to the general population: 12 times as high in men, 26 times in women.
As might be expected, personality disorder was also very common, with borderline personality disorder 33 times, and antisocial personality disorder 73 times more frequent than in the general population.
Finally, prisoners were considerably more likely than people in the population at large to suffer from multiple disorders.
More prevalent, more severe
Overall the results of the survey suggest that people in prisons are not only more likely to have mental disorders, but their disorders are also more severe.
This ties in with their very high rates of recent pre-imprisonment contact with mental health services: a quarter had been in touch with mental health services and around seven per cent had been admitted to a psychiatric hospital. This is ten and 42 times the population rate respectively.
Many participants had a key worker in the community prior to their imprisonment, especially female and sentenced prisoners. This contact had clearly not been enough to keep them out of the criminal justice system.
Comparison between the 1997 national prisons psychiatric survey and this more recent survey indicates continuously high levels of mental disorders in prisons over a 15 year gap.
Nothing appears to have changed in the propensity of people with mental disorders to end up in prison. However, the English prison population rose by 64 per cent between 1993 and 2011. This implies there has been a considerable absolute increase in the numbers of people with mental disorders in prison.
Increasing the well-being of people with mental disorders at risk of entering the criminal justice system and reducing rates of crime and recidivism converge on the need for providing them with effective treatments. The prison environment is not (and probably never will be) conducive to mental wellbeing, despite the contribution of medical, mental health and prison staff.
Treatment, not punishment
Treatment should as far as possible be located outside prison, through diversion procedures, although this will require more governmental commitment than has so far been apparent over the last 20 years.
However, in the interval since the recent survey, the funding of prisons has been further reduced. The Home Office and Ministry of Justice budgets (which cover criminal justice in England and Wales) fell by 19 per cent and 29 per cent respectively between 2010 and 2014, paralleled by a reduction in overall UK spending on criminal justice by 12 per cent.
This can only have a detrimental effect on the general suitability of the prison environment for managing prisoners with mental health problems, particularly as prisoner numbers remain high despite declining crime rates.
It has also been compounded by the savaging of the probation service in the UK.