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And we have to ask who really starts to talk on this subject.

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So we are really, really lucky. Professor Keith Horton, who is a governing body here at the college,

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is professor of Psychiatry and Director of the Centre for Researcher, sorry for Suicide Research at Oxford University.

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You have his bias and your pants. I'm not going to take up their time in the presentation to read that to you, but just see how much work he's done.

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He's prolific. He really is the leading expert on this.

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And he's coming along here today with Professor Stephen Facile from who's a Wellcome Trust senior research fellow,

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again here at Oxford and an honorary consultant in forensic psychiatry.

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So if you were in any doubt as to whether we have the leading expert in this final session, you are no longer in doubt.

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I would share cuts that he's helped us out to water and hand over the floor to.

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I think he's going to start right things. Well.

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Thanks very much, Caroline. I hope you haven't had too many muffins.

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We don't want you dozing off. And I'm glad you called us the Centre for Suicide Research and the BBC programme recently.

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They present some of our data and they called us the Centre for Suicide, which was very, very helpful.

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So we're actually going to talk beyond just near lethal self-harm.

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So we're going to try and give you an overview about suicide and self-harm in prisoners based particularly on some of our work.

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I'm as Karen has said, I'm very much involved in suicide research.

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I'm not a prisons expert, although I've done quite a bit of research on prisoners,

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whereas Senior is very much the forensic expert as well as generally,

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as well as having a lot of experience in relation to suicide and self-harm in prisoners.

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So just by way of introduction, seen is going to talk about the extent of suicide and self-harm in prisons and trends in these over time,

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and also about risk factors for both self-harm and suicide in prisoners.

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And then I'm going to focus on some joint studies we did using the near lethal suicide attempt, approached John to explain later.

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And then I'm going to say a bit about prevention of self-harm and suicide in prisons.

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So I'm going to hand over to Athena to tell you more about trends in suicide and self-harm.

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Thank you. So just to put everything in context, this is a map of incarceration rates around the world.

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I mean, I suppose it would be interesting to compare it to what we know about mortality in prisons.

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We don't know enough about mortality in prisons,

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but it's just important just to see where the just to see where the prison populations are larger snaps.

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The numbers, as you can see, is the US and China UK also slightly overrepresented,

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as you know, the largest prison population per head in Western Europe.

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Many prisons come and come up quite a lot in the media today.

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I mean, if you listen to Women's Hour,

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but I did and there was a long section on some of the work being done to reduce reoffending among prisoners was very interesting actually,

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and had a number of experts on and it comes up repeatedly actually in in in that program but also many

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programs and here's a great piece new reviewed books review of a couple of you know statistics and reports

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essentially but and fantastically review just to highlight the problem in the states of particularly

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victimisation of and highlights the the problem of victimisation in people with mental health problems as well.

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I mean, the other area, the other sort of wider context is increasing awareness that yeah, a lot of people in prison who shouldn't be.

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I mean that was a big theme today and in the piece on women's prisons and has been for decades about women in prison.

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But now it's also moving over to many men also in prison who shouldn't be there.

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And often it's because there's a lack of alternatives.

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Sometimes that may be one way of interpreting sentencing policy.

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And so a couple of questions I'm going to tackle in the first part of my presentation.

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What we just know about suicide rates, I mean, compared to the general population.

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And then how do they compare across different countries where we have reliable information?

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And what can that tell us about some of the factors associated with suicides?

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So, I mean, we we we first looked at this about ten years ago.

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We did a piece where we looked at England.

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Wales, we find found that it was five times higher than the general population and it had been going up compared to the general population over time.

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The BBC reported it, no one else reported. I remember the BBC reporting is Adam BRIMELOW.

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He's still the guy, the health guy. He said. He said that because I was about to go easy.

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Don't go away. Because there'll be lots of press interest and there wasn't any. It's just him.

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And I remember cancelling my flight because I was forced to go away to have dinner with him.

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Nothing was just silence. Bernie. There was the one piece, so.

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What's happened recently is there's been an increase in self-inflicted deaths.

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I mean that's has defined in in England Wales is a slightly broader definition in some other countries.

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So there was a little bit of a decrease and then it seems to have gone up.

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And that actually is also consistent. If you look at out per head of prisoner, security has a rates rather than absolute numbers.

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S.M. is a relative relative to general population.

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So here you would take one as. As there being no difference with the general population.

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And as you can see, these are a selection of countries.

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Keith and I did some work on these countries because we had reliable information on the deaths in custody and suicide rates in custody.

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And also, we were able to get reliable information on general population suicide rates for the same age bands.

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So quite narrow age fans to reflect the age structure of prisons.

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So as you can see, I mean, it it's around 4 to 6.

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This is in men and women, actually.

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And there are some differences.

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And what's interesting is, is is what explains those differences.

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So why, for instance, does Finland, Ireland, New Zealand, possibly Canada,

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Australia have slightly lower rates than maybe Norway in Wales, in women prisoners, like I just mentioned, it's it's higher.

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So you can see the scale is different. Previously the scale was was up to ten and now the scale is is intense.

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And that reflects the fact that in in the general population, the rates of suicide on women are low.

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And so any any suicides in in prisoners will be reflected in quite a large excess compared to the general population.

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And you can't take you can't read too much into differences between countries here because we're not talking matter of numbers, and that's relative.

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There's some uncertainty about the differences between these countries.

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But the general picture there is one that it's it's higher as a as a proportion as a as a comparison to general population, as it is in men.

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And I just I put up some more recent numbers, this ugly slide I'm sorry.

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This is the European Union project where they're trying to compile suicide information on all European projects, all European prisons.

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And what's interesting about this is, I mean, I don't trust all the numbers,

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but but what's interesting is it gives you sort of where where countries are on

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a sort of percentile basis for deaths in custody and the suicide in custody.

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And I just I bring up the UK because it's it's it's in the the top half possibly the top quarter as of this is 10,000 prisoners.

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And you can see France, Belgium, even even higher rates than the UK.

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And then some other countries have lower rates.

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And it doesn't say that there may be some problems about how these deaths in custody are classified in those countries.

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So another way of looking at it, I mean, if if you're not very efficient, if you're uncertain about how people classify suicides in other ways,

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looking at mortality and the the issue about mortality is that actually a lot of mortality, you can see the darker boxes are higher mortality rates.

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I mean, a lot of that will be explained by infectious diseases rather than by misclassification of suicides as as as as natural deaths.

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It's sort of helpful, but it isn't helpful the same time. It's an alternative.

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I mean, you want to take us to a European picture of deaths in custody.

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It gives you some impression, but I'm not sure how easy it is to interpret.

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So you see Belgium and Portugal have an excess of deaths in custody.

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And is that is that because actually there's there's a problem of suicide, which tends to be about half the deaths in custody?

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Or is that because there's something else going on in those prisons?

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And so the did the next step really in our work is trying to understand why there's a difference between these countries.

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And one of the hypothesis is that it's related to suicide in general populations.

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So if you have a high suicide rates in the general population, that's reflected with a higher suicide rates than other countries in prisons.

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And this is one way of putting it. So here's the suicide rates in the general population and hence suicide rates in prisons.

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And if that was true, everything would would fit very neatly on the slide.

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It doesn't. So actually, that. That's a bit.

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That's actually a bit messy. And that suggests that it isn't associated with general population suicide.

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Right. So it's not just people importing risk into prison.

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There's also something else going on. So that's that's on a sort of on a broad sort of national level.

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What do we know about individual level factors and individual level factors?

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We did a review a few years ago. I don't think it's been updated.

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And the what's interesting is that the idea on an individual level, the sum of the risk factors are modifiable,

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so that they're often things which can be changed and therefore potentially could reduce suicide rates in prison.

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The the single cell, previous suicide attempts, psychiatric diagnosis, being on medications,

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this is just a marker of having a psychiatric diagnosis and having a history of alcohol problems.

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So some of them are potentially modifiable, and that's good news in some ways.

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The things that are inversely associated with suicide are things you can't change really the history and the sentence you get given.

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And a couple of interesting things that were different from what you'd expect.

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So we know in the general population being married and being employed a protective factors,

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but actually in prison there were risk factors that increase your risk.

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And that's sort of interesting because another view is that it's probably something

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to do with the number of loss events you experience when you go to prison.

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So the more things you lose the high risk element, very strong risk factors.

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So they were they were not as strong as these.

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But they are interesting because they differ. They they're in a different direction where everything else was in the same direction as you'd expect.

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And finally, self-harm, as you just mentioned here, I mean, previous attempts because of because I'm going to go on talking about self-harm now.

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And I think the whole issue, I mean, one of the big things,

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which is obviously is the fact that psychiatric diagnosis and psychiatric problems is risk factors important.

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And that's and you know, again, the increasing interest in this area about mentally ill people being wrongly placed in prisons.

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Guardian piece, which I'm not sure about the title of it,

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I think people are more in the states is function as there's this there's many more times more people

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with severe mental illness in prisons than there are in all public and private hospitals in America.

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And that's very clear. And you can look at state by state. People have worked it out in the new not.

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I'm not so sure about that. I mean, it's actually this this this married business that I told you about, that risk factor was very strong.

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I mean, the BBC picked up on that one. I didn't change my holiday plans at that point.

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An interesting number, again, it was the only only means you have really picked up on this story.

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So I may go and then I can talk about self-harm because I think it's it was a neglected area which causes quite a lot of morbidity in prisons.

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And we did a study that was published now about a couple of years ago looking at self-harm in England and Wales.

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I mean, in summary, I'm not going to talk about all the findings, but in summary it was quite common.

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It was often repeated and it wasn't linked to suicide mortality, like I said,

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and that there are some implications for prevention, which which Keith will touch on,

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which I think are important in terms of not just reducing self-harm, suicide,

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mortality, in terms of the numbers, I mean, the absolute numbers are huge.

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So, I mean, the the impact on obviously on individuals, but also on the prison and on public health hospitals is enormous.

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So about 140,000 episodes every year.

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We looked at every six year period. What that means is if you take in a year about one in five women prisoners and about

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5 to 6% of male prisoners were self-harming in a 12 month period inside prison.

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So really quite, quite high rates. And that was picked up.

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I mean, you know, we're one of the few slightly sort of more.

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What kind of how can I produce more caring stories in the mail about prisoners came out of this research.

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You know is actually it had a a positive spin on the importance of health.

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Yeah. I think you're talking about self-harming.

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Can you give an idea of the range of different activities? What are these accounts?

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Yeah. So it's things like cutting, hang love to sell strangulation, some overdoses.

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And then the main ones, if I remember correctly, um, this is over time actually since I mean,

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we work with the prison service and one of the things that came out of our work

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is that there's a small group of women that self-harm over 100 times a year.

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And actually that focusing on that high risk population, we reduce numbers.

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And interesting, our numbers in women went down. Numbers of men have actually gone up, have continued to go up.

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Gradually, the number of women went down quite a bit.

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And it may be the prison service actually did focus on this high risk population of women as the ratio of number of episodes a prisoner.

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So this is much more prominent in women's state.

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So there was no more than 100 episodes a year to women.

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So that's a good, you know, pretty important targeted approach to reduce self-harm could focus on this group of women.

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So here's your question about the methods being used cutting and scratching, strangulation, ligature, and there's some gender differences.

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Ingestions, overdoses and hanging and other methods.

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Who's most at risk? What are the risk factors? In our study, we did not have information on health.

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We didn't have health records in most of these sociodemographic and chronological factors.

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But what that does is it at least, you know, can provide some information about high risk populations.

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And also is you'll see some population who goes on to die from suicide as well.

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So who is the highest at risk of suicide?

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The other interesting thing was there's quite a bit of clustering so that the there was a discussion in the women's state,

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but also in the mental state. There was some clustering of self-harm episodes across space and time.

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And that also has implications about how you manage self-harm, because obviously on a on a wing,

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if someone's self-harm and you need to think about the other people who are vulnerable but haven't self-harmed yet,

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it's not just the person who's self-harming in terms of suicide.

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What it means is a suicide. Well, they're in this in the cohort we looked at, there were 109 suicides.

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And among people who self-harm, there's a very high risk of suicide.

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And there are some factors which distinguish the group who die from suicides, from those who didn't.

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And I think the one that is probably easiest to remember is the fact that there's more than five episodes a year in women,

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and that's a group at high risk of dying from suicides in prison.

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What about the location of the prison? I was thinking especially about segregation units.

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Yeah, I don't I don't think we had a lot of information on that.

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So people I mean, they don't spend a lot of time in segregation units as well.

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So it'd be quite difficult to know actually the impact it has in probably need even longer periods and we had to really study that.

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I'm not sure actually the using racial law and women's prisons, I'm not sure someone else would have to help me with that.

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And a lot of the women in segregation had cell phone just really.

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Yeah, but but is it used widely in women?

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Is they I mean, it's obviously used in the men's estate, but I do not know the extent to which it's used in the States.

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It's it's used as it's called, let's put it that way. It is.

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Okay. So summary, self harm, common, possibly neglected, at least from a research perspective, it seems neglected.

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Repetition is common. There's some evidence of contagion and associated risk of self-harm and suicide.

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There was Keith. Cale, thanks very much.

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We we were thinking about what work we might be able to do to understand the problem of suicide in prisoners with a bit more depth.

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And one of the approaches that has been used in studying suicide in general is to study people who,

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if you like, were as close to suicide as they could be but didn't die.

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So that you're able to actually talk to them, ask them about their histories event and investigate their psychology and so on and so forth.

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So we call that the near lethal suicide attempt approach, and we decided to apply this within prisons.

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It's actually quite a difficult approach to use in the community in general.

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Actually locating people who have made very high risk suicide attempts and getting them into studies proves very difficult, surprisingly difficult.

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But of course, prisons have an advantage in terms of research,

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and people are there and staying there and are generally relatively willing to be involved in all these sorts of studies.

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So we did two studies using this approach.

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Okay. The first one was study of men.

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Second, the study of women. And we used exact more or less exactly the same approach for the two gender studies.

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So we looked at 60 men who had made nearly full attempts and 60 controls, who had not made nearly full attempts while in prison.

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That was a study that Adrienne Rivlin worked on with this for her dphil and then a study of women, similar design.

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And this was what the main work on this was Dr. Lisa Marzano, her post-doc, who came with already quite a bit of experience of prisons research.

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And what we did was to try and interview the prisoners within a month of their near lethal acts.

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The recruitment process was often a bit clunky, hence we had to allow up to a month two to get.

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It would be nice to have seen them closer to the time of the act if possible, but what with getting consent and so on,

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a month was reasonable and we just included people who were prisoners who were aged 18 years and over.

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Okay. So just I'm just going to summarise the the methods very, very briefly.

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It was based on interviews, index interviews.

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We asked about a lot about what had happened to the prisoners before they came into prison,

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getting right back to their family backgrounds, their family history.

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Family history of suicidal behaviour, suicide, attempted suicide.

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We asked about life events, both early life events and more recent ones that had occurred before coming to prison,

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such as abuse, violence and bereavements and so on, was very high rate of bereavement in this group, particularly in the women.

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We asked about criminal obviously about their criminal history and about their psychiatric history in terms of them being in prison.

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We we wanted to get a good idea about the psychiatric disorder.

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So we used a clinical diagnostic schedule to screen for various psychiatric disorders and also for antisocial personality disorder.

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And then we looked at a range of psychological and personality factors as well, using interview standardised interviews, schedules.

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We asked them about their the social environment of being a social environmental factors in terms of being in prison,

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for example, where they bullied in prison and so on.

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And then we tried to build up a picture of what we call the suicidal process,

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which is rather than thinking about a suicidal act, as you know, something just occurs in time to be thinking longitudinally.

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How does suicidal ideation develop? What leads up to to a suicidal act?

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What determines choice of method and so on and so forth?

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So that's a very brief overview of the of the way we we did the study.

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So I'm going to summarise some of the results.

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And so these are comparisons between the prisoners who made near lethal attempts and the control prisoners.

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And what I would present is just differences which were statistically significant.

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So prisoners who made near lethal attempts were mostly white,

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single and under 30 years of age they tended to be on an than normal prison wing location rather than segregated settings.

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They generally had high suicidal intents, by which we mean when they carried out the act.

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How determined did they seem to be that the act would end in death?

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And we used this particular scale of the suicide suicide intent scale to assess this.

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And they usually attempted. They used hanging, mostly hanging and self strangulation.

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Now, so this is just the characteristics of the nearly lethal cases rather than

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differences between them in the case and the controls outcomes in the moment.

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Now they have in prison, as you probably know, this policy called act SCC t, which you can see down the bottom here.

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If it means assessment, care in custody and teamwork, which is the policy approach,

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this use for prisoners who are thought to be at risk in the prison setting so

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they may be en act for a period of time while they're thought to be at risk.

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Now, of the men who engaged in near lethal suicide attempts, 40% were considered to be at risk.

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In other words, 70%, 60% hadn't been identified as being at risk prisoners,

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whereas for the women, nearly all of them were on an act at the time of their self-harm episodes.

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88% of them. So a very high proportion.

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Okay. So now comparing the the individuals who made the near lethal suicide attempts compared to the controls and just looking at both gender,

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these are findings we found in both genders. The cases were more likely to have prior convictions.

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So they had a multiple forensic history, if you like, compared with the control item in multiple forensic history.

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Compared with the controls, they were more likely to have engaged in violent means, committed for violent offences.

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On the other hand, they spent less time in prison than the controls and in the camps and also in their current prison.

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And we know that suicides, one period of risk of suicide in prisons is early after reception,

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and it looks as though the same applied for these near lethal episodes rather rather than later on.

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They're also more likely than controls to have had a history at any time of self-harm or suicide attempts,

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and to have a history of prior suicide attempts or self-harm in prison.

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But don't forget, we selected the controls as not having a history of nearly who suicide attempts.

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But they they they the cases had more often self-harmed or attempted suicide or both outside prison.

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That looks like they they also more often receive psychiatric inpatient care prior to coming to prison and also outpatient psychiatric treatment.

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And this is sort of one of the main findings in that is that all of the female prisoners who engaged in near

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lethal self-harm and all but not one of the males had at least one current psychiatric disorder diagnosis.

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Often there were multiple diagnoses, as you see, seen in moment.

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So psychiatric disorder is a is a very major factor in this.

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Of course, we know in relation to suicide in the community, psychiatric disorder is very important.

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It isn't the sole determinant of suicide, but it is an important component.

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And if you look across studies that have been done of people who've died by suicide, an average.

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The results, excluding China.

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Interestingly, then you have a figure around 93% of people who die by suicide are thought to have a psychiatric disorder,

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be it with what, irrespective of whether it was diagnosed before they died.

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Or is a diagnosis made when, after talking to relatives and so on and getting information about their state before death?

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But it seems even even more common in people engaging in these near lethal suicide attempts in prison,

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and therefore we assume in people who die by suicide in prison.

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Now, looking at the two genders separately, the findings are very similar to males and females,

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but the males who engaged in near lethal suicide attempts were more likely than their controls to have a diagnosis of depression, psychosis,

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anxiety disorder, drug misuse disorder, and to have multiple dying diagnoses as two or more diagnoses,

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the women were more likely to have a ms. Depression Anxiety Disorder, and a major feature here was post-traumatic stress disorder.

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Over half had a diagnosis of post-traumatic stress disorder, often related to being on the receiving end of violence attacks.

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Prior to coming into into prison abuse experiences, sexual abuse experiences were extremely common.

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They're also more likely to have a diagnosis of psychosis and again, multiple diagnoses compared with the with the controls.

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Also in terms of psychosis of psychological characteristics,

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the both the males and the females had had a significantly higher levels measured on on psychometric scales of aggression,

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impulsivity, hostility, hopelessness and childhood trauma.

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And they had they also had significantly lower self-esteem and self reported social support.

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So generally, the the individuals engaging in near lethal suicide attempts differed markedly in terms of their psychology as well as their psychiatry,

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if you like, from from the controls in terms of prior life events, the males who engaged in nearly four attempts,

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nearly two thirds of them had a history of being bullied.

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60% had a family history of suicide or self-harm, which is incredibly high compared with what you find in people in the general population.

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6% had a 58% had a history of homelessness, and 43% of them had been in local authority care at some time in terms of life events.

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And the women four out of five had a history of sexual abuse, incredibly high rates of sexual abuse, three quarters, a history of domestic violence.

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Over half had been in local authority care.

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A third had experienced an extraordinary high figure, the death of a partner and or a child, their own child.

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Extraordinarily high, high figures and a quarter had a family history of suicide.

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It's not self-harm, it's just the suicide, which again is extraordinarily high compared to what you find not only in their controls,

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but in the obviously much, much higher than you'd find in the general population.

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So one can sort of generate a model. I don't know how helpful it is of pathways for suicidal behaviour in prisoners and this is

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based on a model we use in the in relation to suicide and self-harm in the general population.

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I'm not going to go over all the points, but one obviously has to think about genetic factors being relevant,

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genetic factors related to maybe aggression, impulsivity, psychiatric disorder, early life events and traumas.

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And so one pathway may be through psychiatric disorder another way and one may be through psychological

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characteristics of individuals which make them at higher risk of engaging in suicide or self-harm when exposed to.

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A psychiatric disorder or other are the factors.

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Down the bottom, the you will see it. It's important obviously to think about negative life events, as I've just highlighted, and poor social support,

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which may again may contribute to psychiatric disorder and to psychological experiences.

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Obviously, a history of previous self-harm is very important and is seen as said, exposure to suicidal behaviour in other people.

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We know this from a lot of studies now that can be extremely important and when seen it talked about the clustering we found for self-harm.

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Some of you may have seen a note that it was particularly relevant to first episodes of self-harm.

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In other words, people were likely to engage in a first episode of self-harm when exposed to self-harm by other people.

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So it may be exposure in prison in the family. We also know in the general population that exposure through the media,

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dramatic reporting or portrayal of suicidal behaviour in the media can be extremely important.

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So all of this may lead to thoughts of self-harm or suicide, and then the availability of method becomes crucial and very,

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very simply, if the method that's available is chosen is more dangerous, more lies die.

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And if it's less dangerous, then you're more likely to survive.

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And this is interesting in relation to the prison environment. This is a very controlled environment,

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but people tend to use methods because they can't very easily get hold of medication is seen as said ingestions.

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While they're quite common, they're not nearly as common as we find the self-harm in the general population.

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So they tend to turn to methods that they can use.

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And this may be cutting, which might be very dangerous,

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cutting or strangulation and hanging using materials that they can get hold of in the prison setting.

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Okay. So just to briefly summarise the study of near lethal attempts,

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so there appears to be a I'm I'm always worried about this because you find a figure of, you know,

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44% of men were on act which means that you know what it 50 whatever it is 56% weren't that you one can

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say well suicide risk IDs Paul but it you know there's a gap there if you don't just put it like that,

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whereas the women,

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most of them were identified as at risk and there's obviously a problem of management of self-harm in women is and I'll come back to that in a moment.

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Once dealing with people with a comp, with complex needs and co-morbidity of psychiatric and personality issues, I mean,

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one can think in terms of unmet need in relation to psychiatric disorder in any

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just over a third of the male prisoners who were prescribed antidepressants sorry,

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who had a diagnosis of depression had been prescribed antidepressants,

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whereas most of the women who we identified as having a depressive disorder were actually receiving antidepressants.

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And of the women who engaged in in near lethal self-harm and had a psychiatric disorder,

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which they all did, only 43% had regular contact with a mental health professional.

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So there's a there's another gap there between the psychopathology, if you like,

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and and what we found out about and what not was actually being provided.

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Okay. So to finish with Juliette, I'll just say a bit about prevention of self-harm and suicide in the prison setting.

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I'm sorry to cover this fairly briefly, but as you saw from the figures, that's seen a percentage too.

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Unfortunately, the suicide prevention and prevention of self-harm is way from being achieved

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in the prison setting and things at the moment because they're getting worse,

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which is something we might pick up in the discussion because I think there's some important issues as to why that may be happening.

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So if you think about approaches to. Prevention.

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Put very simply, you can think about things that you can do for all prisoners that might reduce risk in the prison population.

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So what we might call population approaches and then if you can identify the high risk prisoners,

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what you can do in terms of targeted interventions focussed on that group.

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It's also very important to think about CNS and what happens before going into

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prison and whether people are going to the right place given their needs.

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And then of course, it's also very important to think about what happens after people leave prison because that's another time of high risk.

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So if we think about population approach is one thing we certainly need is needed is very accurate,

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reliable and and transparent data collection on self-harm and suicide.

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And I must say, I think the prison service has done well on this in this country.

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The suicide, the way that recorded suicides as six self inflicted deaths is seen.

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As said, that means they don't wait until there's a coroner's inquest.

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They make a judgement as to whether it's likely to be a self-inflicted death.

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And because a coroner's inquest may not take place to several months later.

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So they have good up to date immediate data on likely suicides.

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And I'm pleased also they claim pretty good data on self-harm.

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And I'm very pleased with this because we've been monitoring self-harm for several decades now up at the John Radcliffe Hospital here,

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where we collect information on all and people presenting with self-harm and the prisons and people from the prison service came to me and said,

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Can you help us set this up in the prison service? You know, I'm very pleased that they've they've continued doing that pretty well.

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One of the issues in this field is the whole issue about prediction, risk assessment.

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We we we we you know, we continue searching for the the Holy Grail in terms of risk assessment.

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But it particularly when it comes to suicide, we have to remember we're dealing with even in a high risk population like in prisons,

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we're actually dealing with, fortunately, a low event rate and prediction of who is really at risk is quite difficult.

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Having said that, I think nobody would say that screenings not important.

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So screening at the time of reception and during the prison stay, not just at the time reception, things can change.

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And so there may be key events such as moving prison.

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There may be life events outside the prison which may change a prisoner's risk.

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And that so ideally this should be an ongoing process depending on the circumstances.

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And seen her and I are involved at the moment with helping with a project in London prisons aimed at

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trying to sharpen up their screening process and will be interesting to see how successful that is.

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And then, of course, there's the central importance of mental health issues, just to repeat it again.

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Mental health issues in prisons is obviously common, and treating an adequate detection and of course,

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treatment of these is has got to be a core part of prevention.

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This is a slide from a study that CNN did, a systematic review of data.

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Is it right? Yes. Comparing prevalence of various disorders in in May of prisoners in the male and

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the male general population and female prisoners and the general population.

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And you can see virtually all diagnoses.

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I hope you can read the figures and if you can at the back that there's there's a much higher trend of a higher prevalence,

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if particularly marked, of course, for personality disorder, which is not very surprising, and especially antisocial personality disorder,

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mild for alcohol misuse, independence, drunk drug misuse, independence.

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And of course, depression is more commonly the population psychosis, intellectual disability.

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Interesting. A little difference between the prisoners and the general population, but higher rates of PTSD.

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And as I said, particularly in female prisoners that.

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In the general population. So it's just again emphasised this issue.

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So while improved detection and management of psychiatric disorders in prisoners really has to be a central part of prevention.

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Unfortunately, current provision of mental health care in prisons is often rather poor,

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and this is in spite of the sort of prison service and NHS psychiatric services having to come together.

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I think things are often pretty inadequate and here's a report from a few years

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ago now from the Sainsbury Centre about the spending on prison mental health care,

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which is way out of proportion downwards compared to the prevalence of psychiatric disorder in the prison population.

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When you compare with with what's happening in the general population,

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where it's also inadequate, as you've seen from recent stuff in the in the press.

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Okay. A bit more about population approaches.

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One thing we know is that the most effective way or that's known of of reducing suicides in the general population is reducing access to means.

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Now, this isn't getting of the causes. Well, access to means can can be a contributory factor in the suicidal process.

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But we know that through numerous studies in the general population that this is the most effective approach.

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And as I as I said, the hanging and strangulation are particularly common methods of suicide in the prison setting.

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Now, this is not a prison setting. This is this is based on data for psychiatric hospitals in England and Wales.

393
00:48:15,540 --> 00:48:25,890
And this shows the what's happened to in-patient suicides in mental health hospitals in England and Wales.

394
00:48:26,250 --> 00:48:32,190
And you will see there has been a huge drop in suicides.

395
00:48:32,190 --> 00:48:36,330
This is since 2001 through 2011.

396
00:48:36,780 --> 00:48:46,950
And one thing that will have contributed to this, because these numbers of suicides is a decline in the psychiatric hospital population.

397
00:48:47,520 --> 00:48:54,569
But that isn't the whole story, because when people convert this to rates, then you still get evidence of a decline.

398
00:48:54,570 --> 00:48:57,150
Obviously not quite as sharp as shown here.

399
00:48:57,450 --> 00:49:06,120
And one of the key factors, as you can see down to the bottom here, is what's happened in relation to hanging or strangulation actually on the ward.

400
00:49:06,360 --> 00:49:14,850
A lot of these deaths in overall deaths in patients who are inpatients actually occur off the ward when people go on leave.

401
00:49:15,990 --> 00:49:21,660
But quite a few of them do. But these are actually hangings that have occurred in the ward setting.

402
00:49:21,660 --> 00:49:28,230
And you see these have dropped from 40 here to just I think it's ten in 2011.

403
00:49:28,740 --> 00:49:35,700
And what happened was that there was a general policy to make wards much safer, to cover up types,

404
00:49:36,810 --> 00:49:43,560
you know, thing any any sorts of parts of the building where people could easily use these.

405
00:49:43,560 --> 00:49:48,540
They used to hang themselves. And that seems to have been relatively effective.

406
00:49:48,540 --> 00:49:54,090
So that sort of approach can can work, can help.

407
00:49:54,450 --> 00:49:57,989
And of course, in the prison setting now, we have many more sort of course,

408
00:49:57,990 --> 00:50:06,750
safer cells which are made sort of as hanging proof as is possible, which is is quite difficult.

409
00:50:06,870 --> 00:50:12,899
There's quite a lot of imagination to think of all the places you could actually try and hang yourself,

410
00:50:12,900 --> 00:50:16,080
and you don't have to be suspended in the air to die by hanging.

411
00:50:17,490 --> 00:50:25,110
You know, people can just put something around their neck tied to a radiator, whatever, door knob and flop down.

412
00:50:25,110 --> 00:50:28,979
And it doesn't take much for people to hang themselves.

413
00:50:28,980 --> 00:50:37,469
So these safer cells have all these sorts of in-built safety measures to prevent those issues.

414
00:50:37,470 --> 00:50:44,010
And undoubtedly those help a lot. I don't care what proportion of cells are safe, the cells seen as a unit now and if there was,

415
00:50:44,070 --> 00:50:47,790
you know, increasing the number of it's not very many still.

416
00:50:47,790 --> 00:50:51,060
So the idea that they don't have to be very oppressive in design also.

417
00:50:51,330 --> 00:50:53,200
Well, that's that's that's right.

418
00:50:53,230 --> 00:50:59,219
I was going to say that, you know, being one of these rooms, which is going to be featureless in a sense, which makes it.

419
00:50:59,220 --> 00:51:03,930
Yeah. And a pretty unpleasant environment. Okay.

420
00:51:04,710 --> 00:51:12,090
So it's reducing access to means. Obviously improving training for prison officers is very important.

421
00:51:12,110 --> 00:51:16,070
Improving training in terms of understanding.

422
00:51:16,790 --> 00:51:26,600
First of all, I mean, attitudes is is a key issue here in terms of people's attitudes towards individuals with mental health problems,

423
00:51:27,380 --> 00:51:31,070
people who may be at risk man gains in self-harm.

424
00:51:31,730 --> 00:51:36,740
Improving detection of people who maybe have mental health issues.

425
00:51:39,530 --> 00:51:46,140
You know, it's all extremely important and being willing to provide support to such individuals.

426
00:51:46,160 --> 00:51:52,310
Now, unfortunately, a lot of prison officers will not see that as what they came into the job to do.

427
00:51:53,720 --> 00:52:03,590
And I think there's a sort of conflict between the mental health needs in prisons and what many prison officers would see as their role,

428
00:52:04,490 --> 00:52:10,940
particularly in current times of austerity, which maybe will come back to this time for discussion.

429
00:52:13,040 --> 00:52:21,320
Another point to make is enough is that prisons, which we believe should become much more research friendly environments.

430
00:52:24,230 --> 00:52:28,850
I mean, we actually have pretty good cooperation in the studies that we did.

431
00:52:30,290 --> 00:52:34,610
I think it's become a bit less easy to do these sorts of studies now.

432
00:52:36,260 --> 00:52:45,260
And I guess what is particularly noticeable is the gulf between, you know, what people find out through research,

433
00:52:45,260 --> 00:52:49,760
what the implications are and what actually is applied within the prison setting.

434
00:52:50,150 --> 00:52:53,180
Unfortunately, that also happens in the general community.

435
00:52:54,680 --> 00:53:01,070
But, you know, I think it would help a lot if prisons could be more research friendly.

436
00:53:01,940 --> 00:53:11,840
What about targeted approach? What approaches or seen senior highlighted the women, particularly who engage in repetitive self-harm?

437
00:53:12,140 --> 00:53:16,280
And clearly, that's an important group to focus on.

438
00:53:18,200 --> 00:53:26,749
One thing that has happened is seen a surge in the number of self-harm episodes in women seem to have dropped quite a bit,

439
00:53:26,750 --> 00:53:28,520
although they picked up a little bit again.

440
00:53:28,880 --> 00:53:38,300
And one reason for that was quite a lot of them were women at risk were being diverted from going to prison to go into other settings.

441
00:53:38,300 --> 00:53:46,730
So you only you saw that figure of the hundred orders was 102 women and 17,000 self-harm episodes.

442
00:53:47,180 --> 00:53:53,850
You know, you need to move the small proportion of those women to another setting and you reduce the amount of self-harm within.

443
00:53:53,870 --> 00:53:57,349
And then there is then the same amount of self-harm in other settings.

444
00:53:57,350 --> 00:54:01,610
Another question, but hopefully they receive better care for their problems.

445
00:54:02,840 --> 00:54:08,989
And obviously, you know, it's just that where prisoners are identified as high risk,

446
00:54:08,990 --> 00:54:12,410
we know they're going to have many most of them will have mental health problems.

447
00:54:12,860 --> 00:54:16,520
And ensuring good mental health input to them is absolutely crucial.

448
00:54:16,910 --> 00:54:26,660
I've already talked about screening, but screening for mental illness is obviously crucial, particularly depression, PTSD.

449
00:54:26,660 --> 00:54:33,680
I think I think our finding on PTSD was a relatively new finding in terms of its high prevalence,

450
00:54:33,680 --> 00:54:41,230
particularly in women, and it's relatively easy to screen for very discrete PTSD.

451
00:54:42,110 --> 00:54:46,099
The other issue is around treatment of co-morbidity, of disorders.

452
00:54:46,100 --> 00:54:55,460
And this is one of the big challenges. You know, treating depression, straightforward depression, if I can call it that, can be relatively simple.

453
00:54:55,820 --> 00:55:02,750
But when you've got co-morbidity, particularly with substance misuse and other disorders, it becomes much more complicated.

454
00:55:04,190 --> 00:55:09,259
And then psychological treatments for those with a history of of severe trauma or abuse.

455
00:55:09,260 --> 00:55:14,240
And this will apply particularly to many of the women.

456
00:55:15,290 --> 00:55:19,250
Delivering psychological treatments in the prison setting is very difficult,

457
00:55:19,730 --> 00:55:29,180
and often what people will need will be fairly intensive treatment of relatively long duration for these sorts of issues,

458
00:55:29,190 --> 00:55:38,690
issues they're going to be effective, and that may not be terribly compatible with the prison setting and then treatment

459
00:55:38,690 --> 00:55:45,290
guidelines for mental health problems and so on that are prison specific.

460
00:55:46,250 --> 00:55:51,500
I mentioned about screening before or at reception,

461
00:55:51,710 --> 00:56:00,470
but also before that and the whole issue of whether people with major mental health problems should be

462
00:56:00,470 --> 00:56:06,950
getting to prison rather than going to perhaps forensic psychiatrist setting or some other psychiatric.

463
00:56:07,240 --> 00:56:12,030
Setting where they can receive more appropriate treatment.

464
00:56:12,040 --> 00:56:21,910
As I said, this may have been a factor which resulted in the incidence of self-harm in women having dropped quite markedly recently.

465
00:56:22,480 --> 00:56:27,010
And then there's the whole issue of what happens when people are leaving prison.

466
00:56:28,180 --> 00:56:38,860
As I said, we know this is a time of high risk. So there's the whole issue around linking up between prison and community mental health services.

467
00:56:39,820 --> 00:56:51,820
I think you can see this very well. But this is a figure this is these are figures for the standardised mortality rate from all causes.

468
00:56:51,820 --> 00:57:00,760
But this would include a lot of suicides in various studies where prisoners were just released,

469
00:57:00,760 --> 00:57:05,800
comparing them with the risk for death in the general population.

470
00:57:06,040 --> 00:57:14,649
And you can see they're all between two and just around eight times the risk of three.

471
00:57:14,650 --> 00:57:24,280
Sorry. And you see it two and nine times the risk of death in the general population over the sort of 13 exposure period.

472
00:57:24,290 --> 00:57:26,889
So a big risk of death on discharge.

473
00:57:26,890 --> 00:57:34,660
And this is some of this would be related particularly to drug abuse and people going back into using drugs and using to higher doses and so on.

474
00:57:34,870 --> 00:57:38,140
But a lot of those are also suicides.

475
00:57:38,500 --> 00:57:47,170
Now, I think whether you can read this at the moment, this is just the summary thinking about prevention in and of suicide behaviour in prisons,

476
00:57:47,320 --> 00:57:52,780
pre reception at reception during their time in prison and on release.

477
00:57:54,460 --> 00:57:58,840
Here we've got active diversion of offenders with severe mental illness to other settings,

478
00:57:59,150 --> 00:58:10,560
screening at reception and and first night ticking first night centres which and then repeated screening at times of perhaps changed risk.

479
00:58:10,690 --> 00:58:18,579
Ongoing monitoring and risk and then various targeted approaches in relation to mental health problems we've added.

480
00:58:18,580 --> 00:58:21,910
In addition, here is what are called listeners.

481
00:58:22,090 --> 00:58:27,100
These are people who are specially trained to talk to prisoners and Samaritans really listen.

482
00:58:27,250 --> 00:58:32,350
Samaritans runs a listening service for prisoners,

483
00:58:32,800 --> 00:58:48,520
reducing access to means and then any changes that can be made to the environment which might make it less oppressive and also safer anti-bullying.

484
00:58:48,530 --> 00:58:50,660
I haven't said much about bullying in prisons.

485
00:58:50,710 --> 00:58:59,710
That's a major issue is anti-bullying interventions and then of course refer to that's prior to release,

486
00:59:00,430 --> 00:59:07,960
ensuring that people who are in need because of psychiatric problems are going to be picked up by community health service,

487
00:59:08,530 --> 00:59:13,180
mental health services and proper resettlement and aftercare.

488
00:59:13,600 --> 00:59:20,110
And in terms of general aspects of this staff training and support is crucial

489
00:59:21,340 --> 00:59:25,510
evidence based practice learning from what's happened in previous instance,

490
00:59:25,510 --> 00:59:28,690
learning from research that I underline that again,

491
00:59:29,650 --> 00:59:38,830
and ensuring there's good information flow as people go through the system and particularly around the time of discharge.

492
00:59:39,700 --> 00:59:46,389
So just summarise again, mental health issues, very important that thinking about prevention,

493
00:59:46,390 --> 00:59:55,660
one needs to think about the combination of population strategies targeted at the whole prison population and targeted approach is focussed on

494
00:59:55,660 --> 01:00:06,430
those who are thought to have particular needs or risk and finally keep the good surveillance going and encourage research in the prison setting.

495
01:00:07,480 --> 01:00:16,270
Okay, so thanks very much. The.