The mental health status of adolescents released from custody: a preliminary study

Predictors of rapid reincarceration in mentally ill young offenders

OBJECTIVE

Describe characteristics of mentally ill young offenders released from custody and predictors of those who rapidly returned to custody.

METHOD

Ambidirectional cohort study of 51 young males with mental disorders released from the largest New South Wales Juvenile Justice Centre (2005-2007), a health file audit at time of release and prospective determination of reincarceration.

RESULTS

Overall 47% were Aboriginal, 43% originated from regional communities, substance disorders were highly prevalent and only 12% accessed prior community mental health care. Over half (57%) satisfied diagnostic criteria for schizophrenia spectrum disorder. In custody, 39% were suicidal and 18% were homicidal. A majority (90%) returned to custody over a median of 28 months; half within five months of release. Schizophrenia/schizophreniform disorder (p<.001), bipolar disorder (p=.001) and schizoaffective disorder (p=.005) predicted rapid reincarceration, with shorter community survival than those without those diagnoses (p=.009). Antipsychotic treatment (p=.006) and treatment duration in custody (p=.006) predicted longer community survival. Aboriginality, younger age, prior incarceration and substance disorders were not predictive of rapid reincarceration.

CONCLUSIONS

Serious mental illness was a significant predictor of rapid reincarceration in young offenders. Treatment improved community survival. The findings highlight the need for optimal psychiatric treatment and post-release care for young offenders with mental illness.

A descriptive study of primary health care practices in Ontario's youth custody facilities

BACKGROUND

Adolescents admitted to youth custody facilities are often in need of physical and mental health care.

OBJECTIVES

To describe primary health care practices in Ontario's youth custody facilities.

METHOD

A questionnaire regarding facility characteristics and primary health care practices was distributed to the directors of all youth custody facilities in Ontario.

RESULTS

Most (87.8%) facilities obtained medical histories after the youth arrived, and 92% used health care professionals to perform that assessment. Intake medical examinations were performed on each youth admitted to custody at 94% of all facilities; however, only 57.2% of facilities reported that these examinations were performed by a doctor within 72 h of admission. Performing suicide assessments on all youth at intake was reported by 77.6% of facilities. Continuous health education was provided by 76% of facilities. Facility type and type of management appear to be related to some areas of health services provision.

CONCLUSIONS

Youth custody facilities in Ontario are providing primary health care services. Weaknesses are, however, evident, particularly in relation to untimely intake medical examinations, failure to provide continuous health education and failure to conduct suicide assessments on all youth at intake. Future research on barriers to health service provision in Canadian youth custody facilities is recommended.

Use of the Massachusetts Youth Screening Instrument to assess mental health problems in young people within an Australian youth detention centre

AIM

To screen for mental health problems in an Australian adolescent forensic population, evaluate the Massachusetts Youth Screening Instrument Version 2 (MAYSI-2) in providing a preliminary assessment of those needs, and to explore the level of mental health problems in vulnerable populations within detention.

METHODS

Over a 6-month period, all young people admitted into detention were referred for screening by the MAYSI-2, a 7-scaled instrument developed to identify young people within the youth justice system at greatest risk for serious mental, emotional or behavioural disorders.

RESULTS

High levels of mental health problems and trauma were reported, with 75.0% of males and 90.0% of females, and 81.2% of Indigenous and 75.0% of non-Indigenous youth screening above the clinical cut-off for at least one scale. Males screened highest on the Alcohol and Drug Use (58.9%), Angry-Irritable (28.2%) and Somatic Complaints (28.2%). Females screened highest on the Alcohol and Drug Use (67.5%), Somatic Complaints (45.0%), Depressed-Anxious (42.5%) and Suicide Ideation (30.0%) scales, with significantly higher rates than males on the Depressed-Anxious, Somatic Complaints and Suicide Ideation scales. No significant differences in screening rates were reported between Indigenous and non-Indigenous youth.

CONCLUSIONS

This study confirmed the high rates of mental health problems in adolescents within youth detention. Appropriate use of screening tools improves our understanding and targets treatment of mental health problems in this cohort. We have reservations in recommending the MAYSI-2 as a valid screening tool for Indigenous young people in youth detention and recommend the development of a more appropriate screening tool.

A preliminary case series on the use of quetiapine for posttraumatic stress disorder in juveniles within a youth detention center

Juveniles within the youth justice system have high rates of psychiatric morbidity, including posttraumatic stress disorder (PTSD). This case series describes 6 young people aged 15 to 17 years within a youth detention center who met the criteria for PTSD and reported an improvement in symptoms after 6 weeks of treatment with low-dose quetiapine. The primary outcome measure used was the Traumatic Symptom Checklist in Children. The dose of quetiapine ranged from 50 to 200 mg/d; T scores for PTSD symptoms decreased from 75 (SD, +/-5.2; range, 68-82) to 54 (SD, +/-7.4; range, 43-62) (P < 0.01). Significant improvements in symptoms of dissociation (P < 0.01), anxiety (P < 0.01), depression (P < 0.01), and anger (P < 0.05) were also noted over the 6-week evaluation period. Low-dose quetiapine was tolerated well, with no persisting side effects or adverse events. Nighttime sedation was reported, although this was viewed as beneficial. All young people opted to continue with treatment after the assessment period. This preliminary case series suggests that juveniles in detention who have PTSD may benefit from treatment with quetiapine. Caution is needed in interpreting these findings. Both larger open-label and blinded trials are warranted to define the use of quetiapine in the treatment of PTSD in the adolescent forensic population.

Predicting death in young offenders: a retrospective cohort study

OBJECTIVE

To examine predictors of death in young offenders who have received a custodial sentence using data routinely collected by juvenile justice services.

DESIGN

A retrospective cohort of 2849 (2625 male) 11-20-year-olds receiving their first custodial sentence between 1 January 1988 and 31 December 1999 was identified.

MAIN OUTCOME MEASURES

Deaths, date and primary cause of death ascertained from study commencement to 1 March 2003 by data-matching with the National Death Index; measures comprising year of and age at admission, sex, offence profile, any drug offence, multiple admissions and ethnic and Indigenous status, obtained from departmental records.

RESULTS

The overall mortality rate was 7.2 deaths per 1000 person-years of observation. Younger admission age (hazard ratio [HR], 1.4; 95% CI, 1.0-1.9), repeat admissions (HR, 1.8; 95% CI, 1.1-2.9) and drug offences (HR, 1.5; 95% CI, 1.0-2.1) predicted early death. The role of ethnicity/Aboriginality could only be assessed in cohort entrants from 1996 to 1999. The Asian subcohort showed higher risk of death from drug-related causes (HR, 2.5; 95% CI, 1.1-5.5), more drug offences (relative risk ratio [RRR], 13; 95% CI, 8.5-20.0) and older admission age (oldest group v youngest: RRR, 9.3; 95% CI, 1.3-68.0) than non-Indigenous Australians. Although higher mortality was not identified in Indigenous Australians, this group was more likely to be admitted younger (oldest v youngest: RRR, 0.31; 95% CI, 0.15-0.63) and experience repeat admissions (RRR, 1.6; 95% CI, 1.0-2.4).

CONCLUSIONS

Young offenders have a much higher death rate than other young Victorians. Early detention, multiple detentions and drug-related offences are indicators of high mortality risk. For these offenders, targeted healthcare while in custody and further mental healthcare and social support after release appear essential if we are to reduce the mortality rate in this group.

The psychosocial needs of young offenders and adolescents from an inner city area

To date, assessments of the prevalence of mental health problems in young offenders have largely focused on incarcerated samples. This paper describes a quantitative study of a sample of 47 male young offenders under the supervision of an inner city Youth Offending Team. A semi-structured interview, modified from previous studies, was used to investigate the type and frequency of psychosocial and health problems they experienced. The results were compared with data from a random community sample of 38 male adolescents interviewed in a comparable way. Young offenders reported more psychosocial problems at a statistically significant level (including depression/misery, excessive worry and problematic substance use), as well as higher life-time rates of head injury, than adolescents in the community sample. Levels of problematic substance use and exposure to head injury continued to differentiate the groups when offenders in custody were removed from the analyses. The findings are discussed in relation to previous research and implications for service delivery.

A transdisciplinary approach to adolescent forensic mental health

OBJECTIVE

To examine new strategies which may be implemented to address the significant mental health and substance abuse problems of young people within the juvenile justice system.

METHOD

Wide-ranging literature review of mental health problems within the juvenile justice population is given, illustrating the high prevalence of mental health problems within this cohort of young people. Reference is made to the differing demographics and agendas of the American justice system compared to that found in Australia.

RESULTS

It is suggested that new initiatives stemming from quality Australian studies are required in order to facilitate reform within adolescent forensic mental health. Psychiatrists need to be at the forefront of innovative policy delivery within the juvenile justice system.

CONCLUSIONS

A transdisciplinary approach is required to meet the changing needs of young people within the juvenile justice system. Such a system of care recognizes that these young people and their families have multiple needs that cross traditional boundaries and a collaborative approach across agencies is essential at both the policy and practical level. Psychiatrists have an important role to play in the development of these services. A systemic process to address such needs is offered.

Mortality in young offenders: retrospective cohort study

OBJECTIVES

To estimate overall and cause specific standardised mortality ratios in young offenders.

DESIGN

Comparison of mortality data in cohort of young offenders.

SETTINGS

State of Victoria, Australia.

SUBJECTS

Cohort of young offenders aged 10-20 years with a first custodial sentence from 1 January 1988 to 31 December 1999.

MAIN OUTCOME MEASURES

Deaths ascertained by matching with the national death index, a database containing records of all deaths in Australia since 1980. Death rates in the reference Victorian population used to calculate standardised mortality ratios.

RESULTS

The offender cohort comprised 2621 men and 228 women with 11 333 person years of observation. The median age of first detention was 17.9 years for men and 18.4 years for women. Median follow up was 3.3 years for men and 1.4 years for women. Overall standardised mortality ratio adjusted for age (expressed as a ratio) was 9.4 (95% confidence interval 7.4 to 11.9) for men and 41.3 (20.2 to 84.7) for women. Cause specific standardised mortality ratios for men were 25.7 (17.9 to 36.9) for drug related causes, 9.2 (5.8 to 15) for suicide, and 5.7 (3.6 to 9.2) for non-intentional injury. A quarter of drug related deaths in men aged 15-19 years were in offenders.

CONCLUSIONS

Social policies for young offenders should address both the prevalent drug and mental health problems as well the high levels of social disadvantage.

Mental health of adolescents in custody: the use of the "Adolescent Psychopathology Scale" in a Tasmanian context

OBJECTIVE

To investigate the incidence of mental health problems based on the DSM-IV [1] among adolescents in custody in Tasmania, using the Adolescent Psychopathology Scale (APS) [2].

METHODS

The APS was administered to 50 adolescents admitted consecutively to a youth detention centre in Tasmania, Australia, using a structured interview format.

RESULTS

In this sample 46% scored positively for a mood disorder, 36% for posttraumatic stress disorder (PTSD), and 32% for an anxiety disorder excluding PTSD.

CONCLUSIONS

Tasmania is no exception to the rule that adolescents in custody have a high proportion of mental health problems. This study confirmed findings of previous studies that detained adolescents had a roughly equivalent level of mental health problems as young people referred to mental health services and five times more than adolescents in the community. Therefore, all detained adolescents should be assessed for mental health problems as their risk is equivalent to that of young people referred to mental health services in the community. Youth detention centres are able to provide significant opportunities for individual therapy and group programmes for young people with mental health problems. However, to achieve a realization of this potential, detention facilities need to develop philosophies and procedures, which facilitate the development of therapeutic, as opposed to "punishing", environments.

The health of a group of young Australians in a New South Wales juvenile justice detention centre: a pilot study

OBJECTIVE

To consider the health profile of a sample of young, largely male Australians as assessed on their admission to a New South Wales Juvenile Justice Detention Centre.

METHOD

A retrospective analysis of primary care nurse health records for 100 sequential admissions.

RESULTS

Of the 97 males and three females (mean age = 15.9 years), 30 were Aboriginal and 39 did not live with either parent at the time of admission. Respiratory illness, such as bronchitis and asthma were common. These diagnoses were overshadowed by histories of significant physical injury. The sample was at high risk of sexually transmitted disease. Forty-six per cent had prior contact with a mental health professional, 26% reported they had thought of suicide and 9% reported having attempted suicide. There was a high prevalence of substance abuse.

CONCLUSION

The health of these young Australians is at risk from every perspective. Improving the quality of their health assessments is an important issue for the clinicians who attend them as individuals and for policy makers who aim to reduce the considerable social and economic cost of juvenile crime. The discussion of these results from one centre has revealed opportunities to make such improvements. There is a need for a gathering of expertise to address the issue, preferably on a national basis.