MENTAL HEALTH SERVICES AND PRISONERS: A REVIEW

Transcription

1 MENTAL HEALTH SERVICES AND PRISONERS: A REVIEW Commissioned by Prison Health, Department of Health Brooker,C., Repper, J., Beverley, C., Ferriter, M* and Brewer, N (all at ScHARR, University of Sheffield apart from Dr M Ferriter who is based at Rampton Hospital and who is honorary research fellow at ScHARR) December 2002

2 INTRODUCTION The initial tender The broad aim of the review was outlined in the briefing paper that accompanied the call for tenders as follows: To carry out a systematic review of primary/secondary research, including the grey literature, to appraise work related to the mental health problems of prisoners, relevant to the development of: prison primary care services; NHS community mental health services in-reaching into prisons; the clients to be referred and the services provided The original brief confirmed that the purpose of the review was to identify gaps in knowledge to inform the development of a prison mental health services research agenda. The proposal that the team from ScHARR submitted originally argued that a three phase approach was required which included: A review of reviews with particular emphasis on systematic review which met strict quality criteria defined by the Centre for Reviews and Dissemination (CRD) A review of the effectiveness literature according to CRD guidelines (Centre for Reviews and Dissemination, 2001) A review of models of good practice according to methods, at the time, being developed by the NHS SDO programme (Fulop et al,2001) The team also proposed the design of a final stakeholder event where the findings would be accorded some sense of priority. Our successful tender stated that: this will provide a forum for the presentation of the results of the review of existing research and a number of focus groups will be facilitated to elicit the views of experts about areas in which further research is needed and methodologies that might yield the most useful findings Steering Group modifications Despite the original intentions outlined above, as in much research, the initial proposal evolved as the review progressed under the guidance of the Steering Group. At an early stage in the implementation of the study, it was agreed that the report should include an epidemiological review of mental disorders in prisons to clarify the prevalence of major mental disorders in prisons. This would provide a context against which the findings of the review could be assessed. In addition, it was determined that the adequacy of research into interventions for prisoners with mental disorders of interventions could best be assessed in relation to interventions used to treat mental disorders in the general population. This further piece of work was therefore introduced, with the intention to provide an overview, not a comprehensive review of the evidence. These two sections, along with an account of current policy for prisoners with mental disorders would provide a background to the review and a rationale for the questions addressed by the review. The stakeholder consultation day proceeded as planned in November. It proved helpful in providing clarity about research priorities and ii

3 in progressing ideas about the involvement of prisoners themselves in the mental health research agenda. The structure of the review itself also developed as the literature search proceeded. Over 2,502 papers were identified in total. Blind selection by at least three reviewers led to 392 papers being obtained, all of which specifically referred to mental disorders in prison. Two researchers then sorted these papers into the sections identified in the proposal: reviews, interventions and good practice (those papers falling into more than one category were copied so that they could be included in all relevant sections of the review). This led to the further changes in the proposed review. First, owing to the nature of the papers obtained, the proposed good practice section was broadened to reflect the areas covered by research to become a review of literature on service delivery and organisation. Second, given the paucity of review papers, the proposed review of reviews was abandoned and those reviews that existed are dealt with in the relevant section. Review Structure The review is presented in 5 sections. The first describes the aims, objectives and an overview of methods. It is, however, important to note that detailed search and review methods differed for each aspect of the review and are therefore included in the relevant sections of the report. Section 2 provides the background to the review including the strategic context, an epidemiological review of mental disorders in prisons and an overview of interventions used to treat mental disorders in the general population. It concludes with a brief summary. Section 3 reviews research into interventions for prisoners with mental disorders, summarising the findings by diagnostic categories and making recommendations for future research. Section 4 reviews research into service delivery and organisational issues relating to prisoners who have mental disorders. The findings are discussed in Section 5 followed by recommendations for a new mental health prison research agenda. References for each section are given separately for each section, and a report of the consultation day and all Tables are given in the appendices. iii

4 ABBREVIATIONS USED IN THE TEXT APA APHA AUDIT BDI BPD BPRS CBT CCETSW CCTR CDSR CIS CIS-R CJS CMHT CPA CPN CRD CRiB DARE DBT DEC DofH DSM-IV DSPD EED GP HAC HAS HMIC HMP HoNOS HTA MAOI MDO MHA NACRO NCCHC NeLMH NGC NHS NICE NIMH(E) NRR NSF - American Psychiatric Association - American Public Health Association - Alcohol Use Disorders Identification Test - Beck s Depression Inventory - Borderline Personality Disorder - Brief Psychiatric Rating Scale - Cognitive Behavioural Therapy -.Central Council for the Education &Training of Social Workers - Cochrane Controlled Trials Register - Cochrane Database of Systematic Reviews - Clinical Interview Schedule - Clinical Interview Schedule Revised - Criminal Justice System - Community Mental Health Team - Care Programme Approach - Community Psychiatric Nurse - Centre for Reviews and Dissemination - Current Research in Britain - Database of Abstracts of Reviews and Effectiveness - Dialectical Behavioural Therapy - Development and Evaluation Committees - Department of Health - Diagnostic and Statistical Manual of Mental Disorders - Dangerous and Severe Personality Disorder - Economic Evaluation Database - General Practitioner - Health Advisory Committee - Health Advisory Standards - Health Management Information Consortium - Her Majesty s Prison - Health of the Nation Outcome Scales - Health Technology Assessment - Mono-amine Oxidase Inhibitors - Mentally Disordered Offender - Mental Health Act - National Association for the Care and Resettlement of Offenders - National Commission on Correctional Health Care - National electronic Library for Mental Health - National Guidance Clearinghouse - National Health Service - National Institute of Clinical Excellence - National Institute for Mental Health (Executive) - National Research Register - National Service Framework iv

5 ONS OPCS PST ReFeR SCAN ScHARR SCID-II SDO SIGN SSRI TCA TRIP US WHO - Office of National Statistics - Office for Population, Census and Surveys - Problem Solving Therapy - Research Findings Register - Schedules for Clinical Assessment in Neuropsychiatry - School of Health and Related Research, Sheffield University - Structured Clinical Interview for DSM-IV - Service and Delivery Organisation - Scottish Inter-Collegiate Guidelines Network - Selective Serotonin Reuptake Inhibitors - Tri-cyclic Antidepressants - Turning research Into Practice - United States - World Health Organisation v

6 CONTENTS Introduction Abbreviations used in the Text Contents Executive Summary - Mental Health Services and Prisoners: a review Page ii iv vi x 1. Research Protocol Aims and objectives of the review Method References 2 2. Background to the Review Strategic Context An Epidemiological Review of Mental Disorders in Prisons Introduction Methods Used for Epidemiological Reviews The Prevalence of Mental Disorders Within British Prisons The Prevalence of Mental Disorders in the General Population The Prevalence of Mental Disorders in Prisons Internationally The Prevalence of Mental Disorders Amongst Minority Groups 13 in Prisons Organisational Issues effecting estimation of prevalence Implications for Prison Mental Health Services Overview Overview of the Interventions Used to Treat the Major Mental 15 Disorders in a General Population Introduction Methods Used for This Overview Overview of the Literature The Effectiveness of Mental Health Services Application of the Findings to a Prison Setting Overview References Review of Interventions for Prisoners with Mental Disorders Introduction Method Inclusion Criteria Search Strategy Sources 29 vi

7 Search Terms Search Restrictions Assessment of Quality: Reviews Assessment of Quality: Individual Studies Analysis of Studies Summary of Results by Diagnostic Category Mental and Behavioural Disorders Due to Psychoactive 32 Substance Abuse Schizophrenia, Schizotypal and Delusional Disorders Affective Disorders Neurotic, Stress-related and Somatoform Disorders Disorders of Adult Personality and Behaviour Other Categories Discussion Overview Recommendations References to Included Material (Reviews and Studies) References to Rejected Studies General References Review of Service Delivery and Organisation for Prisoners with 42 Mental Disorders 4.1. Introduction Method Search Strategy Sources Search Terms Search Restrictions Inclusion / Exclusion Criteria Quality of Evidence Contained in the Study Relevance to the Review Theoretical Orientation of the Study Categorisation of References Included Papers Excluded Papers Results Theoretical Papers Therapeutic Communities Reviews Evaluation of Services Audit of Services Pathway Research Organisational Research Needs Assessment Screening for Mental Disorders Studies of Specific Groups Roles and responsibilities of different professional groups 55 vii

8 4.4. Discussion Limitations of This Part of the Review Overall Comments Recommendations Included Papers Theoretical Papers Therapeutic Communities Review Papers Evaluation of Services Audit Pathways Research Organisational Research Needs Assessment Screening for mental health problems Studies of Specific Groups Roles and responsibilities of different professionals Excluded Papers Description of Problems/Needs Papers that do not refer to people in prison OR do not refer to people with mental illness Service descriptions Ethics/Rights of prisoners Opinion/viewpoints/commentary Policy papers and DoH/HMP Reports Guidelines/ standards/recommendations General References Discussion Recommendations 94 A B C D E F G H Methodology Services Delivery and organisation Organisational research Intervention Public Health Reviews Epidemiology Training viii

9 Appendices Appendix A - The Research Team 97 Appendix B - Sample Medline Search Strategy 98 List of Tables Table 1 Prevalence of Mental Disorders in Sentenced Prisoners in Britain 8 Table 2 Prevalence of Mental Disorders in Remand Prisoners in Britain 8 Table 3 Prevalence of Mental Disorders Among British Sentenced and Remand Prisoners 10 Table 4 Table 5 Table 6 Overview of the Effectiveness of Different Treatment Options for the Major Mental Disorders in the General Population As Reported in Evidence-based Digests, Guidelines or Systematic Reviews 16 Table of Rejected Reviews, Overviews and Studies (Effective Interventions for Prisoners) Summary of Inclusion / Exclusion Criteria for Studies of Service Delivery and Organisation ix

10 EXECUTIVE SUMMARY MENTAL HEALTH SERVICES AND PRISONERS: A REVIEW x

11 EXECUTIVE SUMMARY MENTAL HEALTH SERVICES AND PRISONERS: A REVIEW Introduction The broad aim of the review, as originally commissioned, was to undertake a systematic review of the primary and secondary research related to the mental health of prisoners. This was to appraise work relevant to the development of prison primary care services, NHS community mental health services in-reaching into prisons, the clients to be referred and the services provided. The review was to identify gaps in knowledge that might inform a prison mental health services research agenda. The original proposal had suggested a three-phase approach to include a review of reviews; a review of the effectiveness literature and a review of models of good practice. The Steering Group modified this approach to include an epidemiological review of mental disorders in prisons and a review of effective mental health interventions to be obtained from relevant up to date review and syntheses. In addition, a stakeholder conference was arranged to consult on the findings and to add clarity to the recommendations. The review s final structure emerged as the literature search proceeded. Over, 2,500 papers were identified and following blind selection by three reviewers 392 papers were obtained, reviewed and categorised. This led to further changes. The review of reviews was abandoned due to insufficient material. The section on Good Practice was extended and renamed Service delivery and organisation. 1. Research Protocol Aims and Objectives The purpose of this review is to provide a rigorous, systematic and comprehensive review of the relevant primary and secondary mental health literature in order to: a) inform the development of services for prisoners with mental disorders b) identify gaps in the current state of knowledge to inform a new mental health prison research agenda. Method A systematic review of the literature on mental disorders in prisons was undertaken. Due to the nature of the topic under investigation, a four-phase approach was adopted. This included: a) A (traditional) review of the epidemiology of mental health problems in prisons to supplement the background of the report. b) A brief overview of the effectiveness of specific interventions for mental health problems within the general population (at the evidence-based guideline and systematic review level only) again to provide overall context for the report. xi

12 c) A review of literature on interventions used to treat mental disorders in prisons, following the NHS Centre for Reviews and Dissemination (CRD) guidelines (NHS CRD, 2001) d) A review of the literature on service delivery and organisational issues relating to mental disorders in prisons, following the methods currently being developed by the NHS SDO Programme (Fulop et al., 2001) Specific search, selection and structuring strategies were used and each of these are reported in each relevant section of the report. 2. Background to the review Strategic context The publication of The future organisation of prison health care and The national service framework for mental health (1999) strengthened efforts to improve the quality of mental health care received by prisoners. This is an enormous challenge with 72,000 people in prison at any given time and as many as 90% having some kind of mental disorder (Singleton et al, 1998). The key principle of policy as been that prisoners should receive the same level of community mental health care within prisons as they would receive in the wider community. More recent policy Changing the outlook (2001) recognises the need to plan more effective mental health services for prisoners that are locally commissioned, based on the assessment of health need, and which acknowledge the needs of particular groups, for example, young offenders. The document anticipates that by 2004, there will be 300 more staff providing in-reach services leading to 5,000 more prisoners receiving comprehensive care and treatment. However, there remain questions about the type of care and treatment for prisoners that is likely to be most effective and the precise way in which future services should be organised. This review will provide a valuable context for the commissioning of new research that will help to answer some of these questions. Epidemiological review A traditional review of the epidemiology of the prison population was undertaken in order to provide background to the subsequent systematic review of effective interventions for prisoners and service development and organisational issues. The search strategy is outlined fully in section of the main report. Key data were extracted from the major British-based prevalence studies and these findings are tabulated in Tables 1 and 2 of the appendix. Although the focus was on the UK literature key findings from the international literature are also presented and important differences between sentenced and remand and male and female prisoners are highlighted. Perhaps the most influential and comprehensive cross-sectional study to date has been the ONS Survey of Psychiatric Morbidity among prisoners in England and Wales (Singleton, 1998). Unlike previous epidemiological surveys the study was targeted at remand and sentenced prisoners and men and women. The results from this study are presented in some detail in this review but under the main various diagnostic headings. However, where relevant, the results from other studies are also presented to demonstrate the range of reported prevalence of major disorders. This variation can be explained by the use of various diagnostic tools employed in the studies but also by the unreliability of self-report for say the misuse of substances. xii

13 The overview of this traditional review summarises the key findings as follows: it is clear that prisoners with mental disorders are significantly over-represented in the prison population; as many as 12-15% of all prisoners have 4/5 co-existing mental disorders; 30% of all prisoners have a history of self-harm; and the incidence of mental health disorder is higher for women, older people and those from ethnic minority groups. Although cross-sectional studies are clearly important they are not able to pinpoint causality an issue that reverberates across this review. Overview of the interventions used to treat the major mental health disorders in the general population The aim of this section was to give an overview of effective mental health interventions for the general population thus providing greater contextual clarity to the review as a whole. The review focused on the most prevalent mental disorders established in the previous review, namely, personality disorder, neurotic disorders, alcohol and drug dependency, suicide and self-harm and schizophrenia. The review methods are laid out clearly in section Although no formal appraisal of the included studies was undertaken relevant checklists were employed to assess the quality of the selected publications (see section ). The conclusion reached is that there is large variation in both the quantity and the quality of review literature that pertains to the most prevalent mental disorders in prisons. The greatest volume of high quality literature has been published on anxiety disorders, schizophrenia and depressive disorders; followed by personality disorder, panic disorder and bipolar disorder. There is, however, very little evidence-based information on drug and alcohol abuse, self-harm and suicide. The results are presented by each major diagnostic sub-heading thus revealing significant gaps in the evidence that might be used to agree future research priorities In addition, the effectiveness of mental health service provision was examined. Here the only interventions that could be shown to be demonstrably effective from primary research were community mental health teams and assertive outreach. Interestingly, the care programme approach was not considered to be an effective intervention. Clearly there is an urgent need to consider separately interventions found to be effective for the general population that might be applicable in prisons. Some interventions will clearly not be practical (family work in schizophrenia for example), others might not transfer outcomes to a prison setting (improvement in social functioning), finally some interventions of possible benefit, such as anger management, might not have been even considered. 3. Review of interventions for prisoners with mental disorders The introduction to this systematic review points out that even when high quality evidence can be found for effective mental health interventions with the general population [see above] - mentally disordered offenders (MDOs) might differ in important ways. As we have seen a major issue for MDOs is co-morbidity and in most general population-based RCTs this might well lead to exclusion from a trial. It is also important to be clear whether for MDOs the aim of an intervention is to alleviate the mental disorder or reduce criminality or both (although little is understood about the relationship between the two). Hence in this review only those interventions that have been designed to improve health status have been included. The full method for this review is detailed in section 3.2 with included reviews being assessed using the DARE criteria whereas included individual papers were assessed using a hierarchy of evidence (Sutton at al, 1998). The results, which are xiii

14 presented by diagnostic category, are disappointing with only one reported trial using randomisation and two others that report the use a con-current control group of some description. Some reasons are postulated for the lack of controlled studies in prison settings. First that it might be problematic to obtain informed consent. Second, that prison environments might not lend themselves to the organisation of controlled trials, indeed, participants at the consultation day argued that prison context was a significant confounding variable. 4. Review of service delivery and organisation for prisoners with mental disorders Further reasons for the lack of evidence for effective interventions for individual prisoners with mental health disorders are revealed by the review of service development and organisation (SDO). It has become clear that there are large numbers of MDOs in prisons, but interventions can only be employed if mental disorders are detected. Prisons are closed institutions in which repeated reports have emphasised the lack of skills, resources and appropriate culture to provide adequate mental health care. It is not surprising therefore that recent policy has stressed systems-wide change over the development of interventions for individuals. The method for this aspect of the review is outlined in section 4.1. All included papers were selected independently by two reviewers and selected papers had to take the form of research, inquiry, investigation or study. Commentaries or simple descriptions were excluded (see section 4.7). A total of 72 papers were included which were categorised as follows: reviews (12), needs assessment (3), Screening for mental health problems (9), evaluation (11), audit (4), pathways research (1), roles/training of different professionals (10), service delivery for specific groups (6), organisational research (2), therapeutic communities (5) and theoretical papers (9). The breadth of the subject area and the variety of research methods employed makes it difficult to draw one overarching conclusion. However, almost all studies give recommendations that support current prison mental health policy and numerous papers provide more detailed guidelines or standards. Only a small amount of research however has addressed the impact of implementing these standards. Theoretical papers have illustrated the contradictory cultures of mental health and the criminal justice system. There is, however, little research into the organisation, culture and service systems within prisons. The identification of MDOs in prisons is a crucial first step in providing effective mental health care with the secondary benefit of raising the awareness of prison staff through training. More generally, little is known about the impact of training prison staff (in any area) and the effect this has on the mental health outcomes of prisoners. Finally, mental disorders are over-represented in certain minority groups (women, older people and ethnic minority groups) whose needs are not met. More research is needed into what works for whom. 5. Discussion The review aimed to elicit literature relating to mental disorder and prisons in order to inform future research priorities that will underpin policy development in this area. The review is divided into three main sections; a background paper (policy, epidemiology and a review of effective mental health interventions for the general population), a review of xiv

15 effective interventions for prisoners with mental disorder and a review of research focusing on service delivery and organisation of mental health services for prisoners. The original search strategy generated 2,502 references from which 392 full papers were obtained. The traditional review of epidemiology clearly demonstrated that there is a much higher prevalence for all mental disorders for prisoners when compared with the general population. This was especially true for sub-groups within the prison population including women, older people, and members of particular ethnic minority groups. The high levels of co-morbidity in the prison population are also a significant issue. However, point prevalence studies are cross-sectional, and provide us with no understanding about the aetiology of mental disorder in prisoners. Do prisoners arrive at reception with a mental disorder already established or does it develop in the prison environment? This a key question, with important implications for policy, that warrants further rigorous examination. The review of effective mental health interventions for the general population illustrated the variation in the quality and quantity of available evidence (in the key diagnostic groups that are most represented in prisons). Whilst it might appear to be clear that certain interventions will have a demonstrable impact on prisoner s mental health status this cannot always be taken for granted. First, prisoner s high levels of co-morbidity will complicate this picture. Second, outcomes achievable in community settings might not be so readily achievable in prisons, for example, improvements in social functioning. The review of effective interventions for prisoners themselves was illuminating. There is a paucity of high quality research in this area with only one randomised controlled trial ever undertaken. It is possible to speculate on the reasons: focus on systems-level policy initiatives; little development of appropriate outcome measures; problems with obtaining informed consent; and a lack of prison ownership of the research agenda. Whatever the reasons, prison effectiveness research, in the context of the MRC Framework for Complex Interventions, is at a very early phase of development. This is true too of the prison mental research agenda in the field of SDO the largest and most complex area of the review. Here, one focus was on the provision of theoretical frameworks that demonstrate the ways in which mental health service provision and the criminal justice system exist in parallel universes. In this area of the review (as in the other areas), a whole series of practical recommendations are given about future research which might be commissioned that include: the impact on mental health status of the implementation of guidelines/standards; the development of a routine outcome measure for prisons (Prison HONOS); and the impact of different training packages on outcome. Finally, it has become clear that user involvement is as important area to address in prison mental health research as it is elsewhere. There is not one paper included in this review that so much as describes the service user perspective let alone evaluates it. The consultation day that was held to feed back the early findings to an expert group identified some practical steps for taking this agenda forward and these are outlined in the appendix. 6. Summary of recommendations A Methodology A1 A2 How should prisoners with mental health problems be encouraged to participate meaningfully in research? Consider in detail the organisational commitment and incentives that would need to be in place for the conduct of RCTs. As in the general population researchers have a major task in educating potential participants in the need for research and also xv

16 why specific research designs might be used to answer specific questions. In addition there is a need to also educate those charged with the care of prisoners so that both staff and prisoners are motivated to facilitate research of potential benefit to the participants and to the functioning of the prison service. A3 A4 A5 Agree that in a number of instances, other designs (especially those that employ case-controls) will provide an acceptable surrogate to the use of RCTs where RCTs are either not feasible or might not be the best design to answer the research question. There are quality checklists available for non-random designs that can be used to provide guidance and reporting of such studies. Primary research to develop valid and sensitive prisoner-specific outcome measures across a range of major mental disorders that are likely to be the most prevalent in prisons. More systematic local evaluation, giving details of input and process (to allow replication) and using selected outcome measures (not only routinely collected data). B B1 B2 B3 B4 B5 Service delivery and organisation The swift identification at reception of those with a mental disorder and the routine subsequent screening of the prison population in order to identify those that develop mental disorders as a consequence of being imprisoned. Identify the effectiveness research that is likely to be relevant for prisoners with mental disorders that is derived from general population studies. This would include pragmatic studies of participants with co-morbidity. Some interventions might need to be developed and evaluated that are prisonspecific, for example, the use of computerised cognitive behavioural psychotherapy. Identify potential models of service delivery taking into account different agencies and locations of providers and examine the relationship between models and outcome. How do different stakeholders perspectives of needs of prisoners with mental health problems differ? What effect does this have on the support that different professional/provider groups provide? In particular, how do prisoners themselves identify their needs? How does their perspective differ from other groups? C C1 C2 Organisational research Organisational research into ways to integrate the cultures and values of criminal justice and mental health services in prisons. Develop organisational research methods to determine factors effecting organisational culture and effect of culture on prisoners mental health. xvi

17 D D1 D2 D3 Intervention There is a clear need for specific treatment outcome studies to be carried out on prisoners with mental disorders. There is also a need to recognise that prisoners represent a significant minority group of the mentally disordered population. Where feasible, general treatment outcome studies in mental health should contain cohorts drawn from the mentally disordered prison population. Identify the effectiveness research that is likely to be relevant for prisoners with mental disorders that is derived from general population studies. This would include pragmatic studies of participants with co-morbidity. Co-morbidity is a significant issue in epidemiological studies of prisoners especially in relation to substance misuse. Very little is known about effective interventions for this group. E E1 E2 Public Health The needs of significant minority groups in pirsons, such as women, older and younger people, and members of ethnic minority groups, who will have a higher prevalence of mental health disorder, should be studied further. Development of an indicator of need from the perspective of prisoners using mental health services. E3 Continued evaluation and development of reception health screening questionnaire. F F1 F2 Reviews More focussed reviews into specific issues or groups. Reviews have culminated in many lists of guidelines, recommendations and standards. Can these be implemented? Are they being implemented? Do they make a difference? Is their implementation related to prisoner well-being and health status, staff satisfaction, better co-ordination etc? G G1 Epidemiology More research into individuals pathways between prisons, health-care services and discharge. H H1 Training The effect of large-scale training of health-care staff to use a screening xvii

18 questionnaire (on beliefs, behaviour, culture). Implications of promoting user involvement in research into mental disorders and prisoners (Ex)/prisoners who have experienced mental health problems need to be recruited, trained in research skills and provided with appropriate support to enable them to contribute to: - the establishment of research priorities, - the selection of projects to fund, - the design of interview schedules, - the conduct of interviews, - the analysis of information and the dissemination of findings. User involvement in prison research should be evaluated to assess the effect of such involvement on definition of priorities, the nature of questions asked, the response (and response rates) of prisoners/research subjects. It will also be important to monitor the process of user involvement in research to identify potential barriers and ways of over-coming them. At the very least, all projects submitted for ethical approval must demonstrate appropriate consumer involvement. The Principles of Successful Consumer Involvement developed by Sheffield University, and currently being piloted in general mental health research, should be piloted in a prison setting to find out just where the problems lie and generate ideas for overcoming them. xviii