Mapping the forensic mental health ecosystem in Australia: A national audit
In 2013 the National Mental Health Commission (NMHC) dedicated a chapter of its national Report Card to articulating the importance of the justice system, in analysis of Australia’s mental health systems and services. This identified an urgent need for research and analysis to provide a nationally consistent picture of the different approaches to the mental health needs of justice-involved people:
We do not have a national reporting system or consistent framework across the criminal justice, police and court system in Australia. It is therefore not surprising that being able to see a national picture is difficult.…
It is of the utmost importance to have a criminal justice system that gives justice to people with mental illness. Underlying this principle is the need to have a strong evidence base upon which to plan and deliver services, interventions and supports.
- This is consistent with emerging recognition internationally that ‘prisoner health is public health’,1 that addressing the mental health needs of justice-involved populations is critical to reducing health inequalities at the population level,2 and that a ‘prison health in all policies’ framework is appropriate. This recognition that prisons are critical sites for reducing health inequalities draws on the 2013 WHO Helsinki Statement on Health in All Policies, and aligns with the WHO Trenčín Statement on Prisons and Mental Health, which asserts that “promoting mental health and well-being should be central to a prison’s health care policy”, and that effective leadership and adequate resources are essential to achieving this.3
- Consistent with these international frameworks, our group recently undertook the first ever national prison mental health benchmarking project,4 documenting both marked heterogeneity in prison mental health systems and structures, and significant mental health staffing limitations in almost all jurisdictions. Comparable benchmarking projects for youth detention, and for police watchhouses, are urgently needed.
- There has also been considerable research demonstrating the critical role of the justice system for achieving public mental health objectives, and the very high prevalence of mental disorder among justice-involved populations, including among those who come into contact with the police5, 6, courts7, 8, prisons9, 10, and the youth justice system.11-13 This heavy burden of mental disorder among justice-involved populations manifests in elevated rates of morbidity and mortality, both in custody and in the community, notably including high rates of self-harm14-16 and suicide.17-19 These poor outcomes are compounded by inadequate engagement with community mental health services,20 and heavy utilisation of acute and tertiary health services, often due to co-occurring substance use and mental illness.16, 21-23
- Mental health services in Australian justice settings appear to be under-funded and poorly coordinated, and lack accountability.4 The approach to mental health treatment in prisons is heavily biomedical in character, and does little to empower consumers. One tangible manifestation of this is a very high rate of psychotropic medication dispensing, coupled with extremely poor medication knowledge.24
- Primarily due to resource constraints, public mental health services for individuals in the criminal justice system focus largely on acute care for the most severely unwell. However, this is not the only publicly-funded system relevant to the mental health of justice-involved populations. Other key systems that interact with justice-involved people with mental health problems include community mental health and AOD treatment, hospitals (particularly emergency departments), and primary care. The role of these systems in responding to the mental health needs of justice-involved populations is not sufficiently recognised in policy.
- Although there is growing epidemiological evidence regarding the mental health and patterns of health service utilisation among justice-involved populations, the fundamental gap that the NMHC identified in 2013 – the lack of a national picture about specific policy approaches to mental health and the justice system – remains. The significance of this knowledge gap is evident in key documents within the National Mental Health Strategy. For example, criminal justice plays a key role in all eight of the priority areas of the Fifth National Mental Health Plan:
- Achieving integrated regional planning and service delivery;
- Effective suicide prevention;
- Coordinating treatment and supports for people with severe and complex mental illness;
- Improving Aboriginal and Torres Strait Islander mental health and suicide prevention;
- Improving the physical health of people living with mental illness and reducing early mortality;
- Reducing stigma and discrimination;
- Making safety and quality central to mental health service delivery;
- Ensuring that the enablers of effective system performance and system improvement are in place.
- However, the Plan contains scant reference to the criminal justice system, and the role of criminal justice settings is largely absent from the indicators tracked in the NMHC’s implementation report on the Plan. Although the forensic mental health system requires specific attention, greater focus on justice-involved populations in future iterations of the National Mental Health Plan would facilitate a more strategic, coordinated approach, and would be consistent with the WHO Helsinki Statement on Health in All Policies.
- A key first step in this regard is to map national, state and territory strategies, policies and plans relevant to the mental health of justice-involved people. A national map would provide information that would directly assist with several key areas of work for the NMHC, such as:
- Informing the development of the National Suicide Prevention Implementation Strategy and relevant indicators;
- Providing greater clarity about policy consistencies and inconsistencies between mental health systems, criminal justice systems, and the NDIS, as they pertain to the mental health of justice-involved people; and
- Improving the evidence base for the NMHC’s work of monitoring the implementation of the Fifth National Mental Health Plan.
- Identify and source all national and state/territory (including Primary Health Network) policies, strategies, action plans, and related documents relevant to the mental health of justice-involved populations in Australia.
- Critically review these documents, identifying key synergies and gaps in how they meet the mental health needs of justice-involved people, and in their consistency with relevant national and international guidelines.
- Produce a report that can be used to support the NMHC’s work, and to provide a basis for future national consultation.
1. WHO. Declareation on prison health as part of public health. Moscow: World Health Organization; 2003.
2. Kinner SA, Southalan S, Janca E, Butler A, Young JT, Lindner SR, et al. The role of prisons, jails and youth detention centres in addressing health inequalities in the Americas: Submission to the PAHO Commission on Equity and Health Inequalities in the Americas. Melbourne, Australia: University of Melbourne; 2018.
3. WHO. Trencin statement on prisons and mental health. Available at http://www.euro.who.int/document/e91402.pdf. Copenhagen: World Health Organisation, Regional Office for Europe; 2008.
4. Clugston B, Perrin M, Davidson F, Heffernan E, Kinner S. Prison mental health services: A comparison of Australian jurisdictions. Brisbane: Queensland Centre for Mental Health Research; 2018.
5. Heffernan EB, Finn J, Saunders JB, Byrne G. Substance-use disorders and psychological distress among police arrestees. Medical Journal of Australia. 2003;179(8):408-11.
6. Rekrut-Lapa T, Lapa A. Health needs of detainees in police custody in England and Wales. Literature review. Journal of Forensic and Legal Medicine. 2014;27:69-75.
7. Vanny KA, Levy MH, Greenberg DM, Hayes SC. Mental illness and intellectual disability in Magistrates Courts in New South Wales, Australia. Journal of Intellectual Disability Research. 2009;53(3):289-97.
8. Davidson F, Heffernan E, Greenberg D, Butler T, Burgess P. A Critical Review of Mental Health Court Liaison Services in Australia: A first national survey. Psychiatry, Psychology and Law. 2016;23(6):908-21.
9. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. The Lancet. 2002;359(9306):545-50.
10. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet Psychiatry. 2016;3(9):871-81.
11. Fazel S, Doll H, Langstrom N. Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1010-19.
12. Teplin LA, Welty LJ, Abram KM, Dulcan MK, Washburn JJ. Prevalence and persistence of psychiatric disorders in youth after detention: A prospective longitudinal study. Archives of General Psychiatry. 2012;69(10):1031-43.
13. Kinner SA, Degenhardt L, Coffey C, Sawyer S, Hearps S, Patton G. Complex health needs in the youth justice system: A survey of community-based and custodial offenders. Journal of Adolescent Health. 2014;54(5):521-6.
14. Borschmann R, Young JT, Moran P, Spittal MJ, Kinner SA. Self-harm in the criminal justice system: A public health opportunity. The Lancet Public Health. in press.
15. Borschmann R, Coffey C, Moran P, Hearps S, Degenhardt L, Kinner S, et al. Self-harm in young offenders. Suicide and Life-Threatening Behavior. 2014.
16. Borschmann R, Thomas E, Moran P, Carroll M, Heffernan E, Spittal MJ, et al. Self harm following release from prison: A prospective data linkage study. Australian and New Zealand Journal of Psychiatry. 2017;51(3):250-9.
17. Fazel S, Ramesh T, Hawton K. Suicide in prisons: an international study of prevalence and contributory factors. The Lancet Psychiatry. 2017;4(12):946-52.
18. Spittal MJ, Forsyth S, Pirkis J, Alati R, Kinner SA. Suicide in adults released from prison in Queensland, Australia: a cohort study. Journal of Epidemiology and Community Health. 2014;68(10):993-8.
19. Kinner SA, Spittal MJ, Borschmann R. Suicide and the criminal justice system: A more complete picture [Letter to the Editor]. Lancet Psychiatry. in press.
20. Thomas EG, Spittal MJ, Heffernan EB, Taxman FS, Alati R, Kinner SA. Trajectories of psychological distress after prison release: implications for mental health service need in ex-prisoners. Psychological Medicine. 2016;46(3):611-21.
21. Borschmann R, Young JT, Moran P, Carroll M, Heffernan E, Spittal M, et al. Ambulance attendances resulting from self-harm after release from prison: a prospective data linkage study. Social Psychiatry and Psychiatric Epidemiology. 2017;52(10):1295-305.
22. Andrade Dd, Spittal MJ, Snow K, Taxman F, Crilly J, Kinner SA. Emergency health service contact and reincarceration after release from prison: a prospective cohort study. Criminal Behaviour and Mental Health. in press.
23. Young JT, Heffernan E, Borschmann R, Ogloff JRP, Spittal MJ, Kouyoumdjian FG, et al. Dual diagnosis and injury in adults recently released from prison: A prospective cohort study. The Lancet Public Health. in press.
24. Carroll M, Heffernan EB, Kinner SA. Medication use and knowledge in a large sample of Indigenous and non-Indigenous prisoners. Australian and New Zealand Journal of Public Health. 2014;38(2):142-6.
25. de-Pinho H. Systems tools for complex health systems: A guide to creating causal loop diagrams Columbia University, Mailman School of Public Health: Columbia University; 2015 [Available from: http://www.who.int/alliance-hpsr/resources/publications/Session_1_Intro_to_systems_thinking_Presentation_FV.pdf.
26. Young JT, Kinner SA. Prisoners are excluded from the NDIS — here’s why it matters. The Conversation. 2017 14th March.
27. Plueckhahn T, Kinner SA, Sutherland G, Butler T. Are some more equal than others? Challenging the basis for prisoners’ exclusion from Medicare. Medical Journal of Australia. 2015;203(9):359-61.
28. Cumming C, Kinner SA, Preen D. Closing the gap in Indigenous health: Why section 19(2) of the Health Insurance Act 1973 matters [Letter to the Editor]. Medical Journal of Australia. 2016;205(6):283.
In-kind support is provided from the University of Melbourne, the Queensland Centre for Mental Health Research, and the Murdoch Children’s Research Institute.