Post-imprisonment healthcare contacts for mental health and substance use: A Scottish cohort study

Abstract

Background Mental health (MH) and substance use (SU) problems are prevalent in the prison population. People released have high rates of emergency service use, suicide, and SU-related deaths. Healthcare contacts are opportunities to provide MH/SU support that prevents more severe outcomes, but little is known about post-release contacts for MH/SU in Scotland. We aimed to compare post-release MH/SU contact rates to general population rates in a range of services. Methods We conducted a retrospective cohort study using Scottish linked administrative data. The cohort included all people released from Scottish prisons in 2015, and a randomly selected general population sample who were not in prison in the five years prior, and were matched on age, sex, postcode and area deprivation level. We used fixed-effects Poisson models with cluster-robust standard errors to estimate adjusted incidence rate ratios (aIRRs) for MH/SU contacts with community prescribing, outpatient, inpatient, and emergency services. We stratified models by MH, SU and dual-diagnosis (DD) and adjusted a 4-year follow-up for time-in-community and deaths. Models controlled for time-in-community pre/post-index date, pre-index MH/SU service contacts, and comorbidities. Results Post-release contact rates were higher in all services for MH, SU and DD compared to general population. aIRRs increased as services addressed more serious or urgent needs. Lowest aIRRs were community prescriptions (MH: 1.80[95% CI = 1.67-1.94], SU: 5.95[95% CI = 4.83-7.32], DD: 5.33[95% CI = 3.70-7.68]). The highest aIRR for MH was ambulance callouts (7.75[95% CI = 5.76-10.42]); SU was psychiatric inpatient care (10.64 [95% CI = 6.12-18.84]); and DD was general inpatient care (13.11[95% CI = 7.95-21.61]). Conclusions Despite elevated community contact rates, people released from prison had far higher emergency MH/SU contact rates. Enhanced access to appropriate post-release MH/SU care is urgently needed to improve individual and public health. Key messages • Imprisonment does nothing to reduce the health inequalities that drive a disproportionate contribution to population preventable death rates by people released from prison. • Post-imprisonment mental health and substance use services require urgent attention to increase access to effective early intervention.