Welcome to the Oxford University Psychology Podcast series. My name is Daniel Maun and I have Professor Seina Faizal here with me this morning. Good morning, Siena. Good morning, Professor Sceneries and is an expert in forensic psychiatry in understanding about mental health in prisons and suicide risk in prisons. And that's quite a diverse research field. Could you tell us a bit about how you got into that? Yes, well, I think like many researchers, it's partly a matter of chance.
I was training as a junior psychiatrist here in Oxford and invited to be the research work on a study of older prisoners and on the prisoners had been studied much before. And I was interested in mental health on the prisoners and interviewed over 200 older prisoners over a couple of years or so. And that really sparked an interest.
And then I trained in prison for perjury and then ended up working as a consultant for the psychiatrist and now predominantly doing research, but also still work clinically in a prison as a as a psychiatrist, as a visiting psychiatrist in a local prison. Your research field is actually received some national interest from the media both last year and this year. Well, increasingly over the past few years, particularly around the area of suicide in prisons.
Now, why is that the case? Well, I think it's I think it's noted as an international problem, particularly in high income countries. So there's always been a lot of media coverage around the world, particularly in the UK. And I think the UK has been partly, I think because of the Howard League for Reform and and other third sector organisations, has raised this as an important issue, as a litmus test really about health generally. Public health and public health should include prisoners.
So I think that's part of it. The other reason why it's perceived as a national interest recently is because the numbers have gone up, the numbers of deaths in custody have got up. They went up 30 individuals more than the previous year. And also there's quite a large burden of self-harm in prisons. So there's a lot of interest, obviously, in deaths. But actually there's over 20000 incidents every year in prisons of self-harm.
And that's been going up, particularly amongst men. There's there's a number of reasons, not only the international context, but a local context where the numbers have gone up and the self-harm rates are very high. And you've done some interesting work in the internationally and looking at mental health rates and suicide rates in prison. Tell us a bit about that. Yeah, well, one of the things we wanted to do is try and synthesise the evidence around the world about prison mental health.
So, I mean, the the one of the best approaches to that is reviewing the evidence and in a transparent, quantitative way, trying to pull studies which can be pooled to some extent together to get a picture of what are the main mental disorders and what's their prevalence, what explains variation between different preferences that are reported around the world. So what have you found? Well, I think the the the most stark figure is that one in seven prisoners have a major treatable mental illness.
By that would mean a major depression or psychotic illness, such as schizophrenia, bipolar disorder. So that's that that's helpful because it helps policymakers, people in public health to think about the burden of disease in mental illness, in person as treatable mental illness. Um, we've also done some work on substance abuse subsequently, which was very high rates, particularly amongst women going into prison.
And that's focussed very much around drug and alcohol problems, obviously, particularly drug problems and women. You mentioned that number one in seven prisoners have a major treatable mental illness. And this is internationally and presumably there's going to be quite a variation in the quality of psychiatric management in prisons. That's right. Yes. And one of the big differences is, is who actually administers the health care?
So there's been two different models. One is the equivalent of the national health system runs prison health care. The other model has been justice departments around the world employ their own health care systems. And there's been a gradual move towards the national health running prison systems and and the UK has been at the fore. In front of that today, the NHS now runs prison health care.
It's been difficult to know to what extent that's actually improved things, but there is some evidence that particularly if it's aligned with good quality care. So it's not just a question of who runs it, but it needs to be backed by having good quality standards, accountability. The involvement of academic medicine is very helpful. So if that if that all comes into the mix, then it does seem to health to to help health outcomes.
Right. And you've done some research not only into the mental health of people in prison, but the suicide risk of people in prison. You made some interesting observations about the fact that they aren't the suicide risk isn't necessarily linked to the general population suicide risk. What's that all about? Yes, that's right. So, I mean, one thing about that is that it seems to firmly research that we've done, the suicide risk is elevated compared to the general population.
So even if you compare prisoners with people of the same age in the general population, you find it's elevated somewhere like between about five or six times. Compared to women, it's even higher than women. It goes up to 10 to 20 times competitor. So we have this quite large differential with the general population, excess risk population. And one of the things we did is we try to look at risk factors and we've done this in different ways.
But was you saying one of the interesting findings of the first piece of work that we did on risk factors was that there are some risk factors that are different than the general population. In the general population, for instance, marriage is thought to be a protective factor, but it seems in prisoners it's a risk factor. And there was also an indication, but not so strong an indication employment was a risk factor in prisons. Of course, it's a protective factor in the general population.
And one of the theories that we've had about this is that it's something to do with the number of loss events. So you have more to lose than prison time and actually be in your suicide risk, elevate your suicide risk. So people who come in married, who've got jobs, plus a lot of them have underlying mental disorders, who have all sorts of other psychosocial problems going on. I mean, put all that together. The accumulation of those risk factors, unfortunately, does lead to elevated suicide risk.
Is there more that we could be doing in prisons to help manage this risk and help treat these these people with mental health problems? Well, I think there is one of the things that we've been trying to demonstrate is the importance of treatable mental illnesses and their contribution to suicide risk, not just suicide or self-harm risk as well.
That will have a huge impact because of the I mean, the extent of the morbidity of self-harm is so large in prisons, the effects it must have on prison staff and also other prisoners. I mean, there's a bit of contagion. So when people self-harm, it may spread in prison wings. When you talk about self-harm. What's that look like? Is it sort of is it cutting on the arms or what is it? It is cutting on the arms mainly. And there is also some overdose of medication.
People store their medication overdose and people use other methods as well. There are certain other ways as well, but it's often ligatures as well. The time things around necks in particular. But cutting is sort of, as you say, a prominent way of doing it. So what else can people do? So I think it serves not just to treat the treatment of mental illness. What we have also shown is that it's often people have multiple mental disorders.
So it's someone may have a depressive illness and those who have alcohol problems as well. Well, they may have some other problem on top of that. And we've shown it in women prisoners in particular. It also comes from trauma. Many of these women have had bereavements in their immediate family, but also very traumatic experiences growing up, being in care, being abused. So you put all that together. You create quite complex psycho psychological needs and probably requires complex solutions.
But it's not just a question of primary care and medication. It's more than that. So that's one of the things and the other thing. Is is is probably something to do with the environment as well, and that we know a little bit that there are things like if you increase meaningful daytime activity, if you increase or improve relationships between prison officers and prisoners, they may also have a more difficult study. But there's definitely something about the environment and good relationships.
And people talk about healthy prisons. And I part of it that that whole way of thinking is, is it's it's the prisoners live in very sexual contexts and want us to be aware of the wider context. So one of the things that we we've argued when we studied self-harm is it's if you know, an individual self harms, in a way, you have to be aware.
You have to think about the people that we are vulnerable because of the contagious effect, the possible contagious effects of it, and maybe things you can do to to mitigate the risk in other prisoners who may be considering it but haven't actually self-harm. What about psychiatrists who are working in prisons? They're called in reach services. That's right, isn't it? Yes. These psychiatrists, who how do they actually manage this suicide risk?
What do they do in the prisons? What does their candidate like? Well, I think there isn't there's a moral question, I think partly because prisons are very different. So some prisons have a lot of prisoners who are not sentenced. And so it's much more chaotic and and there is much more difficult to do anything because people are doing for sure. You have to move. They're going back and forth to court. So how are you supposed to actually intervene effectively?
It's a real big challenge. The real challenge of the the psychiatrist do. Well, I mean, I think it's good, good, good practise following, you know, evidence based treatment to to treat mental illnesses. There is there are there are protocols in prison societies, management protocols, which are mainly administered by prison officers. And I think that's right, because most of the care is actually the psychosocial campus and this is given out by prison officers.
I mean, they're there all the time. They make this sort of close relationships with prisoners. The health care staff just can't because they're not there to that extent. So there is also in that context, the work of psychiatrists liaising with different other people in prison, particularly primary care, but also prison officers to some extent. And I think just sort of helping helping the prison develop its policies, develop its guidelines and think about how to deal with high risk individuals.
But actually, I think quite rightly so, a lot of the suicide risk management is run by by prison officers in conjunction with primary care, with the nursing staff. That's really interesting to hear. We are facing a lot of constraints in our country at the moment. And we've noticed that in psychiatry in general that are acute inpatient beds are reducing and that's putting a lot of pressure on the system.
And and if you look back, you noticed there is a spezza decreasing if mental health, prison numbers are potentially increasing. And and if we look at the number of mental health problems in prison that you've suggested, is that a concern? Are we we moving people from one from one place to another? It is a concern. And there is some evidence to suggest that there is a phenomenon going on called trans institutionalisation.
So the idea was from the 50s onwards that these large asylums would gradually closed down and you would get deinstitutionalisation. But actually, there is some evidence that it's been people have just shifted and unfortunately, we've shifted. Some of these people shift to the prisons. A lot of them shifted to becoming homeless.
So, you know, the worst possible context in some to some ways, in some respects, for people to go into ending up in the criminal justice system and actually homeless when we know there are very high rates of mortality and of disease. Um, so there is that in countries like the U.S., that's a particular concern because the seven bed numbers have gone down by about 95 percent and the three largest institutions hold psychiatric patients are prisons. And so the number of men in prison.
In American prisons, it's more than the hospitals, so there is, I think in the U.K. and in in in Western Europe, that's less a little less stark because our prison numbers are much lower. But in some countries, it does seem to be quite a lot of transition utilisation going on. A recent piece of work in South America, actually, where they found a very close correlation between decreasing bed numbers, psychiatric bed numbers and increasing numbers.
Of course, there are lots of secular trends that want us to take account of a difficult study. But but it's just the absolute numbers of people in prison is very high in some countries. And the absolute number of people mental lose as a consequence, very high. So really fascinating narrative actually, as a society advances a on that note, do you have any plans for future research in this area that that that looks at new ways or novel ways of managing people with mental health in prisons?
Yes. So we're trying to develop ways of identifying high and medium risk groups. So a piece of work I'm involved in currently is funded by the Wellcome Trust is is really developing what we call clinical protection rules. So ways of prognostic rules and a way of trying to identify people that might benefit from more interventions, more management, closer management to their problems, particularly maybe prison.
We've been very interested in the link between mental illness and reoffending and and and and what can be done to reduce the risk of reoffending and patients with with with mental health problems or prisoners with their health problems. Finding a system that's improving identification of these high risk individuals within prisons, absolutely within prisons are released from prisons and finding a way that scalable, simple, not very expensive.
That would be the aim. And that's part of the work involved. Thank you, Professor CNR. It's been great speaking to you this morning. Thanks for your time. Thank you. And thank you for tuning in to the Oxford University Psychology Podcast series. Please do tune in again. Thank you.