Services fail to treat prisoners with schizophrenia – increasing risk of violent reoffending
New research from Queen Mary University of London shows released prisoners with schizophrenia are three times more likely to be violent than other prisoners, but only if they receive no treatment or follow-up support from mental health services.
Maintaining psychiatric treatment both during imprisonment and after release can substantially reduce the risk of violent reoffending. Better screening and treatment of prisoners is therefore essential to prevent violence.
The research, funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research (PGfAR) and published in the American Journal of Psychiatry, investigated whether treated or untreated psychotic disorders were linked with increased risk of violent re-offending among prisoners.
The Prisoner Cohort Study* was conducted amongst 967 adult male and female offenders serving sentences of 2 years for more for sexual or violent offences.
Researchers compared the occurrence of violence among prisoners with schizophrenia, delusional disorder, or drug-induced psychosis, who 1) did not receive treatment whilst in prison or upon release 2) received treatment only during prison 3) received treatment during prison and after release. The same research was also carried out among prisoners with no psychosis as a baseline.
Prisoners with schizophrenia who remained untreated during and after imprisonment were more likely to be violent following release than other prisoners. Results revealed the cause of this violent behaviour was linked to delusional beliefs in individuals that someone or something is out to harm them – a symptom itself caused by lack of treatment.
Interestingly, there was no increase in risk of violence for untreated prisoners with delusional disorder. Drug-induced psychosis was linked with a nearly twofold risk of violence following release, but this became non-significant following adjustments for drug and/or alcohol dependence**.
Professor Jeremy Coid, Professor of Forensic Psychiatry, Queen Mary University of London (Barts and The London School of Medicine and Dentistry), comments: “Associations between major mental illness and violent behaviour are controversial, and many misconceptions remain in our society about what it means to have a psychotic disorder. Most people with schizophrenia are not violent and pose no danger to others. However, among those who have shown severe violent tendencies and been imprisoned as a result, the risk of future violence is greatly increased if they are not treated.
Schizophrenia Myths
#1
MYTH: Jail is an appropriate place for people with schizophrenia.
FACT: Jails and prisons are frequently used to warehouse the mentally ill and get them off the streets. The
mentally ill most often end up in prison because of vagrancy offenses, substance abuse, or minor property crimes.
They frequently fail to show up for court appearances, leading to further charges and jail time. Jails and prisons
typically have very inadequate psychiatric services. Mentally ill prisoners receive little or no treatment. If they are
housed with the general prison population, their abnormal behavior leads to beatings and abuse by other prisoners.
If they are segregated for their protection, they lose all social contact and the isolation often worsens their
symptoms.
#2
MYTH: Most people with schizophrenia can’t work.
FACT: Many people with schizophrenia can work—even if they have symptoms. Several studies have shown
that people with major mental illnesses fare better if they work. The ability to hold a job is not necessarily related
to the severity of the person’s illness. British and American studies have shown that people with schizophrenia are
more likely to stay out of hospital if they are employed. While many people with schizophrenia are able to work
successfully in competitive fulltime employment, for others part-time or volunteer work is best. Work is a vital
part of rehabilitation. It increases self esteem, reconnects the ill individual to the community, and provides
meaningful way to fill time.
#3
MYTH: People with schizophrenia are likely to be violent.
FACT: Mental disorders and violence are closely linked in the public mind. Sensationalized reporting by the
media bears much of the blame, as do television and movie portrayals of crazed axe murderers. Another
contributing factor is the popular misuse of psychiatric terms like “psychotic” and “psychopathic.” The stereotype
of the violent mental patient causes public fear and avoidance of the mentally ill. People with mental illness in
general are no more dangerous than healthy individuals from the same population. In fact, people with
schizophrenia are far more likely to be violent toward themselves than toward others. Forty to fifty percent of
people with schizophrenia attempt suicide; ten percent succeed.
#4
MYTH: People with schizophrenia have to be institutionalized.
FACT: In general, when inpatient and comprehensive outpatient programs are compared, people in the
community-based programs show better outcome for longer periods of time than those treated in the hospital.
Even people who are acutely psychotic can be treated effectively in carefully supervised and professionally
staffed community settings.
“Current risk assessment tools do not take treatment into account and we are therefore missing out on this vital part of the puzzle. We need to improve our screening methods and ensure the treatment of prisoners with psychosis, both in prison and following release, if the aim is to manage their risk of violence.”
Despite the high prevalence of mental disorders among prisoners, treatment is often less available in prison than in the outside world. A recent study found that mental health teams successfully identified only 25% of prisoners with severe mental illnesses and only 13% were accepted onto their caseloads. Furthermore, it is estimated in the UK, less than 25% of prisoners who screen positive for psychosis will subsequently receive an appointment with a mental health professional after release.
Professor Coid concludes: This is an important public health problem and at the moment we’re failing high-risk people with psychotic disorders and the public by not screening and treating people with severe mental disorders well enough, nor accurately evaluating risk when they’re released from prison.”
* The Prisoner Cohort Study (October 2002 to May 2006) was funded by the Ministry of Justice (formerly the Home Office). It was a large-scale study of a cohort of serious sexual and violent offenders who were about to be released from prison.
** These effects may therefore be the result of substance-related comorbidity. Findings did not differ according to treatment, which suggests that subsequent violence had little or no relationship with psychotic symptoms and instead may reflect re-engagement in the drug economy and criminal networks.
In 2000, 70 percent of prison inmates were diagnosed with mental disorders, and 15 percent with “severe” mental illnesses. From 1980 to 1992, the number of inmates with mental disabilities more than doubled.
In contrast, the number of inpatients in the old Department of Mental Hygiene was about 90,000 in the late 1950s, and that number has now dropped to 4,000 patients in the current State Office of Mental Health, Smith said.
“How did we end up with these huge numbers [of mentally disabled inmates]?” Smith asked.
According to the National Alliance on Mental Illness, as people are released from mental institutions, they are not given the proper resources to find jobs and acclimate to society. This leads to higher incarceration rates.
Smith pointed out trends over the years that support this theory. In 1955, there were 560,000 people with mental disabilities in state hospitals and only 200,000 in jails and prisons. In the 1960s and 1970s, the use of anti-psychotic drugs and cuts in state hospital budgets led to high rates of deinstitutionalization. No services were provided to help patients reintegrate into society, and by 2002, there were only 60,000 patients in state hospitals. However, the number of inmates with mental illnesses rose to two million.
Smith also gave a brief history of the current system, showing how we got to this point.
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Prof. Hal Smith, psychiatry professor at State University of New York
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Charli Scouller
Public Relations Manager
Queen Mary, University of London
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