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In recent years, concerns have been raised about the availability of mental health care in prisons. While there are substantial international variations in prison populations, mental disorders are consistently common. There are limited resources to address mental health and criminological needs, and a fundamental change in prison mental health care is needed.
During her presentation at the International Forensic Psychiatry Lecture Series, Dr. Lindsay Thomson shared some of the work done in Scotland’s prison system. She and her co-authors looked at both research and service development and then put the results into an international context. Dr. Thomson also discussed the results of a randomized controlled trial that looked at the treatment of attention-deficit hyperactivity disorder (ADHD) symptoms.
(In her lecture and this article, the term “prison” is used in the European context to mean all correctional facilities and detention centres.)
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Prevalence of Mental Disorders in Prisons
People in prison are often up to twice as likely to have a mental disorder as people in the general population. However, the current models of care do not adequately address the high levels of need in prisons.
There is an arbitrary variation in available mental health service resources between prisons. For example, different health boards cover different drugs. This means that medication that had been working for an individual can become inaccessible when that person is moved from one prison to another, which can lead to destabilization.
Challenges to Improving Service Delivery
Funding and service provision are very limited. There are consistent issues with staffing, recruitment, and retention, particularly among nursing staff. There is often a lack of office space and other logistical issues associated with clinical work.
In addition, there is much room for improvement in the partnerships between clinicians and their allied health professionals, such as prison staff, social workers, nonprofit organizations, and volunteers.
Substance misuse among prisoners is an ongoing problem. Language can be a barrier, with non-English speakers being significantly disadvantaged in their recovery. Also, effective management of transition points (for example, between prisons or from prison to the community) is lacking despite being crucial to the individuals’ well-being.
Financial difficulties have hampered change in most areas, and there are still many issues to resolve in the mental health care system for prisoners. However, there has been steady improvement in the average number of transfers from prison settings to forensic mental health services, and average times for those referrals are decreasing.
Recommendations
Dr. Thomson suggests that the common goal be to help people leave prison in a better state than when they started their sentence.
Other recommendations are to adopt a single model of care and a more therapeutic approach with a greater focus on meaningful activity. This would include a common approach across prisons with respect to prescribing medication. Also recommended are increased funding and formalized partnerships with allied professionals.
These changes would help with consistent information sharing to streamline a more effective approach to improving care overall. It would also be helpful to address staff shortages and increase the space and time available for treatment.
Treatment of ADHD in the Prison Setting
Dr. Thomson also discussed a separate prison study, which focused specifically on the treatment of ADHD. In this study, Dr. Thomson and Dr. Phillip Asherson conducted a randomized controlled trial of the short-term effects of an osmotic-controlled drug delivery system (OROS) methylphenidate on symptoms and behavioural outcomes in young adult male prisoners.
While all the men showed improvement after the trial, no differences were found between those who were given the medication and those who received the placebo. This surprised Dr. Thomson and her colleague because multiple trials had shown that this first-line medication effectively treated ADHD. She said this is why this type of research is important; we now know that people in the prison system respond differently.
One proposed explanation is that increased placebo effects in the prison population might be associated with high engagement of the patients in the absence of other areas of focus.
Dr. Thomson highlights various limitations of the trial, but the general conclusion does not support routine treatment with OROS-methylphenidate in this population. Further research is needed to look at the possible other factors.
For more details, watch the recording of the May 22, 2025 lecture, “Optimising Mental Healthcare for People in Prison: Recipes for Care and Research in this Setting” on our website.
Written by Carolyn Johnstone and approved by Dr. Lindsay Thomson.
