Mental Health Reform & Forensic Psychiatric Services The Past, The Present and The Future

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Mental Health Reform Forensic Psychiatric
ServicesThe Past, The Present and The Future

• Dr. Myo Kyaw Oo
• Senior Medical Officer/Consultant Psychiatrist
• Bellevue Hospital
• December 2, 2011

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Mission

• To improve the mental health of the people of
  Jamaica so that individuals will attain a state
  of well being, where the individual will rely on
  his/her own abilities, be able to cope with life,
  work productively, make a contribution to his/her
  community and live harmoniously with others
• Mental Health Reform The reallocation of
  services and phasing out Bellevue Hospital June
  2003

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Principles of Mental Health Reform

• Decentralization
• Deinstitutionalization
• De-stigmatization

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Decentralization

• Four Health Regions 1997
• Regional Parish Psychiatrists
• Regional Community Mental Health Services
• Community Mental Health Staffs
• Mental Health Act 1997, Amendment Bill 1999
• Strategic Mental Health Plan 1999
• Strategic Mental Health Plan 2009-2014

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Common Principles Mental Health Policy

• Equity
• Human rights
• Role of scientific evidence
• integration

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Psychiatric Specialty Services

• General Adult Psychiatry
• Child Adolescent Psychiatry
• Addiction Psychiatry
• Forensic Psychiatry
• Disaster Psychiatry
• Geriatric Psychiatry
• Consultation-liaison Psychiatry

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Forensic Psychiatric ServicesJamaica

• History of Forensic Psychiatry
• King George III, Queen Victoria, MNaghten
• Role of psychiatry and the Law
• Role of Psychiatry and defense
• Role of psychiatry and sentencing
• Role of psychiatry and disposal

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Jamaica Landmarks in psychiatry

• Mental Hospital Act 1873
• Community mental health services 1960s
• Closure of Forensic ward BVH 1975
• Mental Health Act 1997
• Mental Health Strategic Plan 1999
• Bill to amend Mental Health Act 1999
• Amendment to Criminal Justice (Administration)
  Act 2005

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Forensic Psychiatric Services

• Regional Psychiatrists
• Bellevue Hospital
• UHWI
• DCS
• Community Mental Health Centers
• Psychiatrists in private practice

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Treatment services, assessment experts opinion

• Fitness to plea
• Fitness to stand trial
• Fitness for sentencing
• Diminished responsibility
• Fitness to be executed

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Mental Health Reform

• Cabinet approved reform on March 20, 2006
• The Development of Community Mental Health
  Services and De-Institutionalization.
• Mandated Ministry of Health to pursue further
  consultations and community involvement.

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Facilities for Forensic patients

• Forensic ward closed in 1975
• Criminal Justice (Administration) Act (Amendment)
  2005
• Cabinet Approval Decentralization Development
  of Community Mental Health Services 2006
• Bellevue Hospital
• Police jails
• Department of Correctional Services
• Tower Street ACC
• St. Catherine ACC
• South Camp ACC
• Fort Augusta ACC
• Juveniles facilities

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Bellevue Hospital

• 3000 inpatients in 1965
• 1500 inpatients in 1990
• 800 inpatients in 2011
• policy decision made closure of forensic
  psychiatric ward in 1975
• Transfer of patients to TSACC
• Bellevue is under reform

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What do we have between Bellevue and Prisons ???
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Balanced?

• Bellevue

• Community Mental Health Services
• Acute psychiatric wards in general hospitals
• Facilities for chronic mentally ill to offer
  rehabilitation and occupational therapy
• Child Adolescent psychiatric services

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What we do not want to see

• Criminalization of mentally ill
• Trans-institutionalization
• Strategic Mental Health Plan
• Amendment to Criminal Justice (Administrative)
  Act 2005

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UK, US, Singapore

• What are the challenges?
• What model of care for forensic psychiatric
  patients?

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Woodbridge Hospital SG

• 1851 built facility, fully restructured
• 2000 psychiatric beds on 25 hectare campus
• Range of psychiatric facilities, adult, child
  adolescent, geriatric, addiction, forensic,
  community, special clinics
• National Mental Health Blue Print 2007-2012
• 88 millions in 2007, 35 millions in 2009

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Caribbean/Regional

• Barbados
• Trinidad Tobago

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What do we have??

• What commitment ?
• What have we invested?

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Mentally ill Offenders

• Jails Remand Centre
• Prisons
• Other institutions community

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What do we have?What do we need?
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Mental Health Services

• Ministry of Health for police jails
• Bellevue General Hospitals
• University Hospital
• Health Centers

• Prison Psychiatric Services
• Sessional Psychiatrists
• Psychologists
• Nursing staff
• Probation officers
• Chaplain
• Child Development Agency

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Mental Health Reform Justice Reform

• Inter-agencies or multi-agencies involvement
• Investment begins with a vision

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Justice Reform Principle of Therapeutic
Jurisprudencein Criminal Justice

• Criminal Responsibility
• Actus Reus Mens Rea
• Jail Diversion
• Drug Court
• Mental Health Court

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Objective is ..

• There should be NO mentally ill in prison.
• To provide a comprehensive rehabilitation
• To reduce recidivism

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Mental illness in prisons

• Disorders present before admission and
  exacerbated by incarceration
• Disorders develops during incarceration

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Factors related

• Widespread misconception that all with mental
  illness are a danger to society
• General intolerance of people to difficult and
  disturbing behaviour
• Sensational stories in the media of some charged
  with offences
• Failure to promote treatment rehabilitation
• Lack of mental health services/ poor and
  inefficient access to services

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• Poor physical conditions
• Situational crises
• Violence, harassment
• Discrimination, stigmatization
• Victimization
• Abuse and human right violations

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Mentally ill in prisons

• Psychotic
• Non-psychotic

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Psychotic Group

• GG pleasure with or without court date
• RM pleasure, unfit to plea with court date
• Convicted Sentenced
• Diminished responsibility
• psychotic during incarceration
• Majority Schizophrenia Drug Psychosis

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Non-psychotic group

• Adjustment disorder
• Depression suicide
• Personality disorder
• Gender identity disorder
• Substance abuse disorder
• Conduct disorder
• DUAL DIAGNOSIS

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Prevention

• No drugs No abusers
• No precursorsNo manufacturing process
• How are you going to make prisons safe?
• How do inmates receive their supply?
• Zero Tolerance Policy?

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Demand Reduction

• Educational Approach, school education, public
  education, sport culture
• Health medical Measure, treatment and
  rehabilitation programs
• Community involvement
• Economic empowerment
• Regional International Cooperations Caribbean
  OAS

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Causes of Drug Addiction

• Moral/Spiritual
• Biological
• Psychodynamic
• Behavioural
• Socio-cultural
• Individual-drug-environment
• INTEGRATIVE

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Integrative

• No single cause
• Interaction of range of causes
• Bio-Psycho-Social
• Bio-Psycho-Socio-Cultural

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General outline of demand reduction

• Treatment Rehabilitation
• Prevention follow-up

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Models of Treatment facilities

• Residential based
• Hospital or centres
• Short, medium, long term

• Outpatient based
• Drug Court Treatment
• Prison based

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Treatment Approaches

• Individual therapy
• Group therapy
• Family therapy
• Special program ( juvenile, Drug court, prison
  based, combined HIV,STI, TB, therapeutic
  communities, cultural)

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Changing Model of Care

• Recovery is not an event but the process
• Incarceration by itself does little to break the
  cycle of illegal drug use and crime
• Offenders sentenced to Incarceration exhibit high
  rate of RECIDIVISM once they are released

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Drug Abuse Prevalence in prisons

• Drug Abuse in prison is very common
• Estimated 22 - 86
• Most frequently used illicit drug Cannabis
  8 - 60
• British Study 60 heroin user reported use in
  prison, more than 25 initiated use in prison

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Factors associated with substance abuse in prison

• Age, Ethnicity, Conduct disorder, abuses, school
  difficulties
• Psychiatric disorders
• Antisocial personality
• Support system
• Length of sentence

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Jamaica

• Proposal to establish Drug Abuse Facility 1998
• OAS/CICAD Belize City Drug Abuse workshop 2001
• OAS/CICAD St. Lucia Drug Abuse workshop 2004
• DCS Drug Abuse Survey 2005
• DCS Drug Abuse Training Seminar 2006

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Drug Abuse Survey in Jamaican Prisons

• 2005

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Methodology

• 4 maximum security prisons
• Sampling Frame of 3434 inmates
• Stratified sampling method used
• Estimated prevalence rate 45 5
• A total of 440 inmates
• 42 items, 4 sections Questionnaire used

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Results - Age

• A Total of 440 inmates
• Male 82 (360), Female 18 (80)
• Age range 18 to 73 years
• Majority 53 (Age range 23-34)

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Results Age group by Gender
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Results Education by gender
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Results Literacy level
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Knowledge

• Ganja is a drug 72
• Ganja smoking is harmful 61
• Alcohol, tobacco beady are drugs 78
• Ganja improves sexual performance 33
• Alcohol improves sexual performance 38
• Addiction is drug dependency 85
• A link between drug abuse STI 73

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Prevalence
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Prevalence

• Drug abuse before incarcerated 62
• Drug abuse during incarceration 46

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Type of Substances abused(N305)
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Pattern of Abuse
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Factors affecting frequency
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Reason for Drug use

• To feel more relaxed 119 27
• To meditate 99 23
• To cope with prison 84 19
• To sleep 65 15
• Curiosity 46 11
• Lonely 36 8
• Peer pressure 26 6
• Addiction 22 5
• Religion 8 2

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Source of supply in prison

• Fellow inmates 189 43
• Correctional officers 13 3
• Over prison wall/fence 8 2
• Family/friends 5 1

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Motivation for change

• Want to stop drug abuse 150 34
• Request assistance to stop 113 26
• Interest to participate in program 348 79

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Best group to sensitize drug abuse program
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Survey Summary

• Prevalence of drug abuse 46
• Ganja is most commonly abused 39
• 34 of inmates are motivated to quit and 26
  requested assistance.
• 79 showed interest to participate in the drug
  abuse program in prison.

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Principle of Therapeutic Jurisprudence

• Prof. Bruce Winnick
• Prof. David Wexler

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Application of TJ

• Offenders with underlying drug abuse problems
• Incarceration alone does not help or reduce
  recidivism
• Therapeutic principle is applied in Judicial
  process
• Diversion Programme Drug Court Mental Health
  Court
• Prison Based Programme
• Parallel Model

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Diversion Programme

• Drug Court Treatment Rehabilitation
• May 2001 Kingston, July 2001 Montego Bay
• Drug Court Act 1999
• Offenders with Minor Offences who meet eligible
  criteria
• Bail offered
• Six months outpatient programme under court
  supervision and weekly urine testing

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What about those ineligible Offenders?
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Prison Based Programme

• Prison based Program
• ? Legislation
• Political will
• Budget commitment

• Outpatient Drug Court
• Legislation
• Court supervision
• Probation period after graduation
• Criminal offence not recorded

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to address ALL Mental Health Issues including
substance abuse

• Punitive Model without Rehabilitation does not
  solve underlying issues
• Try innovative methods and programs

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What we need?

• Forensic Psychiatric Hospitals
• Community Forensic Psychiatric Services
• Faculty of Forensic Psychiatry Law, UWI
• Ongoing combined or cross training of Law
  Psychiatry
• Professionals with special interest
• Partnership building networking
• Legal Mental Health Reform
• Proper enumeration classification
• Research evaluation
• Legislation

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There is no good health without a good mental
health

• nobody is immune to mental illness

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Making mental health a Jamaican Priority,
investing in development of forensic psychiatric
services through advocacy and actions
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Policy direction

• Secured Forensic psychiatric hospital
• Community Forensic Services
• HR legislatives
• Quality assurance guidelines
• Training Research
• Inter-agencies co-ordination (Ministries of
  Health/Justice/National Security
• Advocacy support groups
• Budgetary commitment

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Plan includes..(not limited to)

• Promotion prevention
• Detection screening
• Proper treatment
• Referral upon released
• Non-discriminatory
• Respect with human right principles
• Consultation, inclusion of inmates/staff/community
  for strategic planning
• HR issues, training
• Research Evaluation
• Net working, inter-agencies, Regional and Global
  partnership

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To ensure development of forensic psychiatric
services and to stop mentally ill entering to
prisons
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We need a change

• Political will commitment
• Philosophical concept with a vision
• budgetary

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• There is no good health without a good mental
  health
• Lets make Mental health a priority through your
  action and advocacy
• A great push, a great investment
• Nobody is immune to mental illness

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The Great PushInvesting in Mental
HealthTimely investment in Forensic Services

• Healthy minds, Healthy people, Healthy Nation
• One Nation, One People, One Love

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Thank You

• Dr. Myo Kyaw Oo
• MBBS, DPM, DM Psych.
• December 2, 2011
• Norman Manley Law School UWI