Mental health facts and statistics

About this information

Introduction

Mental health is a broad topic, and understanding some of the facts and figures associated with it can help to put individual experiences in context.

This information is targeted at mental health professionals, journalists and students. However, it is also our aim to present statistics in a way that makes this factsheet accessible to all those who are interested in mental health.

Note: The language used in these pages reflects the sources referred to. The use of such language does not imply Mind's automatic acceptance of it.

Understanding the figures

The frequency of mental health problems is well documented statistically. However, these figures need to be treated with some caution.

Often widely differing figures will be given for the same mental health problem, making it difficult to determine exactly how common it is. This is partly because these figures are not always measuring the same thing. For example, in order to reflect the fact that mental health is not fixed but likely to change over time, a variety of different figures are used. The most common are:

Prevalence: this measures the number of people with a particular diagnosis at a given time.

Lifetime prevalence: this measures the number of people who have experienced a particular mental health problem at any time in their lives.

Incidence: this measures the number of new cases of a particular mental health problem that appear in a given time period.

Often these figures are compared to provide further information about a mental health problem. For example, comparing the number of new cases, (the incidence) with the number who are ill at any one time (the prevalence) can give us a rough idea of the average amount of time a mental health problem is likely to last.

Another important factor is the kind of sample used to arrive at a particular figure. Often the number of people treated by health professionals is used to determine how common a mental health problem is. However, this is likely to ignore all those who have not come into contact with services. Furthermore, psychiatric diagnosis is often far from straightforward - a person's diagnosis may be changed several times in the course of their treatment. An alternative is to take a sample of the whole population and interview people, according to a standard set of criteria, to see if they have a mental health problem. This approach, known as a community survey, although expensive and time consuming, is usually the most reliable.

How common are mental health problems?

The 1 in 4 statistic

1 in 4 people will experience a mental health problem in any given year.

This is the most commonly quoted statistic, and the one which has the most research evidence to support it. It came initially from a large scale study published first in 1980, then updated again 1992[i]. This figure is further supported by the results of all three Adult Psychiatric Morbidity Surveys[ii]

The breakdown below gives an overview of what treatment those who experience mental health problems are likely to seek and get:

• around 300 people out of 1,000 will experience mental health problems every year in Britain
• 230 of these will visit a GP
• 102 of these will be diagnosed as having a mental health problem
• 24 of these will be referred to a specialist psychiatric service
• 6 will become inpatients in psychiatric hospitals.

Common mental health problems

This chart shows the prevalence of common mental health problems since 1993[iii] Please click on the image to enlarge

Note: People may have more than one type of common mental disorder, so the percentage with any disorder is not the sum of those with specific disorders.

Individual Conditions

Depression

• Depression with anxiety is experienced by 9.7 per cent of people in England, and depression without anxiety by 2.6 per cent.[iv]

• Women have a higher prevalence of mixed anxiety and depressive disorder than men. The ONS figure for women is 11.8 per cent of the population in England and for men 7.6 per cent.[v]

• Overall, depression occurs in 1 in 10 adults or 10 per cent of the population in Britain at any one time, according to the ONS, closely matching figures from other studies.[vi] [vii]

• Around 1 in 20 people at any one time experience major or ‘clinical’ depression.[viii]

Obsessive compulsive disorder

Around 1.3 per cent of the population of England have obsessive compulsive disorder (OCD) at any one time according to the NHS Information Centre.[x]

• Other studies suggest that up to 3 per cent of the population will experience OCD at some time in their life.[xi]

• Several studies suggest a lifetime prevalence of 2 to 3 per cent. However, NICE suggests that these figures are too high and that some studies may have over-diagnosed people participating in the studies.[xii]

• Studies are divided over whether this is more common for women: one survey gives a female to male ratio of 15:11[xiii], whereas other studies have suggested no clear gender difference in diagnostic rates for OCD.

Eating disorders

• The incidence of anorexia nervosa is around 19 per 100,000 of the population per year for women and 2 per 100,000 per year for men, according to NICE.[xiv]

• The prevalence for bulimia nervosa is between 0.5 and 1.0 per cent for young women, suggests NICE.

• Around 90 per cent of those diagnosed with bulimia are thought to be girls, according to NICE.

• Beating Eating Disorder (beat) suggests that the prevalence rates for anorexia might be around 1 –2 per cent.[xv] For bulimia they suggest a prevalence rate of 1-3 per cent.

• As many cases of eating disorder are unreported or undiagnosed, the actual figures are likely to be much higher. beat suggests that as many as 1.5 million people in the UK might be experiencing some form of eating disorder.[xvi]

Postnatal depression

• The most common form of postnatal disturbance is the ‘baby blues’ which is said to be experienced by at least half of all mothers in the western world.

• However, different studies suggest different figures for the number of women affected by ‘baby blues’, and estimates vary between 15 and 85 per cent.[xvii]

• Baby blues usually lasts for a few hours or a few days.[xviii] The condition is so common that it is considered as normal.

• Some women have a much more severe change in mood after the birth of their child and may be assessed as experiencing postnatal depression (PND). A number of studies indicate that 10-15 per cent of new mothers will experience PND.[xix]

• Puerperal psychosis is a severe and relatively rare form of postnatal depression affecting between 0.1 and 0.2 per cent of all new mothers.[xx]

Phobias

• Around 2.6 per cent of adults in England experience phobias.[xxi]

• One study, it is shown that women are twice as likely as men to experience phobias.

• Other studies show widely differing rates: one author quotes two community surveys - one in Canada, giving a prevalence rate of 7.7 per cent; and another very large US survey, giving a rate of 13.3 per cent.[xxii]

Personality disorders

• In Britain the prevalence of personality disorder ranges from 2 per cent to 13 per cent according to different studies.

• The concept of a personality disorder is controversial and use of this diagnosis is often questioned. Some diagnoses are applied more commonly to men (such as dissocial personality disorder), while others are applied more commonly to women (such as borderline personality disorder).[xxiii]

• ONS reports that the prevalence rate for personality disorder in the UK is around 5.4 per cent for men and 3.4 for women.[xxiv]

Bipolar disorder (Manic Depression)

• Most studies give a lifetime prevalence of 1 per cent for bipolar disorder and equal prevalence rates for men and women.[xxv]

• However, hospital admission rates are much higher owing to the recurrent nature of the illness.[xxvi]

• It is estimated that 20 per cent of people who have a first episode of manic depression do not get another.[xxvii]

Schizophrenia

• Most studies show a lifetime prevalence for schizophrenia of just under 1 per cent.

• ONS suggests a per year prevalence rate of around 5 per 1000 of the population (0.5 per cent)[xxviii].

• It is estimated that the prevalence at any one time is about 2 per 1000 (0.2 per cent).[xxix]

• While prevalence rates are the same for men and women, age and gender together is an important factor: one study shows incidence for men aged 15-24 is twice that for women, whereas for those between 24-35, it is higher among women. This reflects a common late onset of the illness for women.[xxx]

• One estimate suggests that around 37-40 per cent of people diagnosed with psychosis will fit the diagnostic criteria for schizophrenia.[xxxi]

[i] Goldberg, D. & Huxley, P., (1992), 'Common mental disorders ­ a bio-social model', London: Routledge

[ii] Meltzer et al (1995) ‘Surveys of psychiatric morbidity in Great Britain: Report 1’ HMSO: London

[iii] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey [Table 2.4, Pg 41]

[iv] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey

[v] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey

[vi] Healy, D. 1998, ‘Gloomy days and sunshine pills’ Openmind, 90, March/April.

[vii] Hale, A. 1997, ‘ABC of mental health: depression’ British medical journal, 315, 5 July pp. 43-46.

[viii] Hale, A. 1997, ‘ABC of mental health: depression’ British medical journal, 315,  5 July pp. 43-46.

[x] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey

[xi] De Silva, P. & Rachman, S. 1992, OCD - the facts, OU Press, Oxford.

[xii] NICE, 2006, Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder, The British Psychological Society and The Royal College of Psychiatrists

[xiii] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey

[xiv] NICE, 2004, Eating Disorders, Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders, National Clinical Practice Guideline Number CG9, developed by, National Collaboration Centre for Mental Health, commissioned by NICE, The British Psychological Society and Gaskell

[xv] beat, 2007, Understanding eating disorders and how you can help, Some Statistics, downloaded 27 Feb 2008, from http://www.b-eat.co.uk/NewsEventsPressMedia/PressMediaInformation/Somestatistics

[xvi] beat, 2007, Understanding eating disorders and how you can help, Some Statistics, downloaded 27 Feb 2008, from http://www.b-eat.co.uk/NewsEventsPressMedia/PressMediaInformation/Somestatistics

[xvii] BMJ Best Treatments. 2008, Postnatal depression, The baby blues, BMJ Publishing Group Ltd, downloaded 27 Feb 2008, from http://besttreatments.bmj.com/btuk/conditions/1000691238.html

[xviii] BMJ Best Treatments. 2008, Postnatal depression, The baby blues, BMJ Publishing Group Ltd, downloaded 27 Feb 2008, from http://besttreatments.bmj.com/btuk/conditions/1000691238.html

[xix] Lee, D, Yip, A, Leung, T and Chung, T, 2004, Ethnoepidemiology of postnatal depression, The British Journal of Psychiatry 184; 34-40

[xx] Comport, M 1987.

[xxi] The Health & Social Care Information Centre, 2009, Adult psychiatric morbidity in England,   Results of a household survey

[xxii] Stern, R. 1995, Mastering phobias - cases, causes and cures, Penguin, London.

[xxiii] Marlowe, M. &  Sugarman, P. 1997,  ‘ABC of mental health: disorders of personality’ British medical journal,  315, 19 July, pp.176-179.

[xxiv] ONS 2000, Psychiatric morbidity among adults living in private households in Great Britain.

[xxv] Goodwin, F. & Jamison, K. 1990, Manic-depressive illness, OU Press, Oxford.

[xxvi] Thompson, D. 1993, Mental illness: the fundamental facts, Mental Health Foundation.

[xxvii] Wing, J. & Marshall, P. 1994, ‘Protocol for visiting teams: standards for clinical and social care in schizophrenia’, Clinical Standards Advisory Group, quoted in Bird, L. 1999, The fundamental facts, Mental Health Foundation.

[xxviii] ONS 2000, Psychiatric morbidity among adults living in private households in Great Britain

[xxix] Mangalore,R. and Knapp, M., 2006, Cost of Schizophrenia in England, PSSRU Discussion Paper 2376

[xxx] Warner, R. 1994, Recovery from schizophrenia - psychiatry and political economy, Routledge, London.

[xxxi] Mangalore, R and Knapp, M, 2006, Cost of Schizophrenia in England, PSSRU Discussion Paper 2376

Dangerousness

Introduction

This page explores the nature of dangerousness and the differing perceptions of dangerousness, how literature and the media influence these perceptions, and how these perceptions can impact different groups of people, particularly those with mental health problems. The page also provides statistics relating to dangerousness and its links with mental health problems, propensity to violence and predictors of dangerousness.

What is dangerousness?

Although “dangerousness” is an emotive term that is widely used in the mental health field and the media, there is no consensus on its meaning. [1] Dangerousness has been described as: "an unpredictable and untreatable tendency to inflict or risk serious, irreversible injury or destruction, or to induce others to do so" [2] and "a propensity to cause serious physical injury or lasting physical harm". [3]

In his article ‘Defining the terms’ in Dangerousness, psychiatric assessment and management, Gunn states that the term dangerousness is made up of three elements – destructiveness, prediction and fear. “The latter, fear, makes it at least partially subjective, therefore it can never be entirely objective." [4] Prediction is also highly subjective.

Perceptions of dangerousness vary, and literature and the media influence these perceptions. The most common perception of dangerousness is in the form of one person presenting a danger to others. More often than not, however, dangerousness presents in the form of people being a danger to themselves, through suicide or deliberate self-harm.

Public perceptions of dangerousness can impact on different groups of people, particularly people with mental health problems and people from minority ethnic groups. The effects of such stigmatisation can be extremely negative, and in some cases has even led people from these groups to become victims of violent crime.

These issues are discussed in more detail below.

Key facts about violence

• Out of 1,564 people convicted for homicide in England and Wales between April 1996 and April 1999, 164 (10 per cent) were found to have had symptoms of mental health problems at the time of the offence. [5] A later study looking at homicides committed between January 1997 and December 2005 found that the same proportion, 10 per cent (510 of 5,189), were by individuals known to have had mental health problems at the time of the offence. [6]
• In 2009, the total population in England and Wales aged 16 or over was just over 43 million. It has been estimated that about one in six of the adult population will have a significant mental health problem at any one time, [7], [8] which amounts to more than 7 million people. Given this number and the 50–70 cases of homicide a year involving people known to have a mental health problem at the time of the murder, [9] clearly the statistics data do not support the sensationalised media coverage about the danger that people with mental health problems present to the community.
• The majority of violent crimes and homicides are committed by people who do not have mental health problems. In fact, 95 per cent of homicides are committed by people who have not been diagnosed with a mental health problem.[10]
• Contrary to popular belief, the incidence of homicide committed by people diagnosed with mental health problems has stayed at a fairly constant level since the 1990s. [11]
• The fear of random unprovoked attacks on strangers by people with mental health problems is unjustified. This has been highlighted by a US finding that patients with psychosis who are living in the community are 14 times more likely to be the victims of a violent crime than to be arrested for such a crime. [12]
• According to the British Crime Survey, almost half (47 per cent) of the victims of violent crimes believed that their offender was under the influence of alcohol and about 17 per cent believed that the offender was under the influence of drugs. [13] Another survey suggested that about 30 per cent of victims believed that the offender attacked them because they were under the influence of drugs or alcohol. In contrast, only one per cent of victims believed that the violent incident happened because the offender had a mental illness. [14]
• People with mental health problems are more dangerous to themselves than they are to others: 90 per cent of people who die through suicide in the UK are experiencing mental distress. [15]
• People with serious mental illness are more likely to be the victim of a violent crime than the perpetrator. One study found that more than one in four people with a severe mental illness had been a victim of crime in one year. [16]
• It is also worth keeping in mind that many cases of violence in the community get reported three times – the event, the court case, and the inquiry report – thus greatly exaggerating the number of cases in the public’s mind.

Historical background

In recent history, people with mental health problems were housed in large institutions, isolated from the rest of the community. However, psychiatric hospitals have been closing down since the early 1950s. The 1980s saw large-scale closures , forming part of the government's policy of care in the community, and large numbers of former psychiatric patients were discharged into the community.

The main intention of de-institutionalisation was to increase the freedom of people with mental health problems by promoting the principle of ‘least restrictive alternative’. The ’’least restrictive’‘ philosophy underpins the principles of care outlined in the Reed Report, [17] which states that care arrangements for people with mental health problems should “have proper regard to the quality of care and the needs of individuals; as far as possible, in the community, rather than in institutional settings; under conditions of no greater security than is justified by the degree of danger; so as to maximise rehabilitation and the chances of sustaining an independent life; as close as possible to their own homes and families.”

The main recommendation of the Reed report was that “ …mentally disordered offenders should, wherever possible, receive care and treatment from health or social services rather than in the criminal justice system” and that “…we see community services as providing wherever possible for the majority of mentally disordered offenders”.

Until 1981, inquiries had addressed scandals in hospitals on behalf of an angry public, almost invariably showing patients as helpless victims and staff as abusers. A shocking event in July 1984 had major repercussions for mental health care, and eventually, public attitudes. Sharon Campbell, a former inpatient, killed Isabel Schwartz, her former social worker, at Bexley Hospital. From then on, community care became associated with danger. [18]

In 1992, there were a cluster of tragic cases involving people with mental health problems. Michael Buchanan, Christopher Clunis and Erhi Inweh were all experiencing serious mental health illness when they attacked and killed strangers. [19] The publicity around these events created a sense that random irrational acts of violence were increasing. However, this is far from the case.

There is a common perception that people with mental health problems are likely to behave in a violent way – a view that is supported repeatedly by films, novels and the media. The facts demonstrate how exaggerated and unfair this view is. Figures from 2007–08 show that about 1.2 million people were treated by secondary mental health services in England and Wales in one year. [20], [21], [22] More than 110,000 people were admitted to hospital for a mental health problem, [23], [24], [25] and close to 34,000 people spent some time as formally detained inpatients. [26], [27], [28] In this same period, there were 662 homicides in England and Wales, [29] of which little more than 10 per cent would have involved people known to have a mental illness.

Violent behaviour and mental disorder

Press coverage focusing on crimes of violence committed by people with a diagnosis of schizophrenia has led some commentators to seek a link between psychosis and violence. Although there is research suggesting a modest link between psychosis and violence, it emphasises that the majority of such crimes are associated with drug and alcohol abuse. [30]

The public perception is that community care policy has failed and that there are now more people with mental health problems on the streets. Many believe that this has increased the risk of being harmed by someone diagnosed with a mental health problem.  However, research shows otherwise. Rates of homicide committed by people with a mental illness peaked in the 70s and have since reached historically low rates. [31]

The MacArthur Foundation’s Community Violence Risk Study was set up to compare the rates of violence by former mental patients and other members of the community. [32] The study reported the following findings.

• People with a diagnosis of a major mental disorder but without a diagnosis of substance abuse are involved in significantly less community violence than people with both diagnoses.
• The prevalence of violence among people who have been discharged from a psychiatric hospital but who do not have symptoms of substance abuse is about the same as that among people living in their communities who have not spent time in psychiatric hospitals and who do not have symptoms of substance abuse.
• The prevalence of violence is higher among people who have symptoms of substance abuse (discharged psychiatric patients and non-patients). People who have been discharged from a psychiatric hospital are more likely than other people living in their communities to have symptoms of substance abuse.
• The prevalence of violence for the first few months after discharge from a psychiatric hospital among patients who have symptoms of substance abuse is significantly higher than among other people living in their communities who have symptoms of substance abuse.
• Violence committed by people discharged from a psychiatric hospital is very similar to violence committed by other people living in their communities in terms of type (hitting), target (family members), and location (at home).

Homicide

In their annual report, published in 2009, The National Confidential Inquiry into Homicides and Suicides by People with Mental Illness received statistics and information from the Home Office about 5,189 homicide offences committed between January 1997 and December 2005.  [33] The report focuses on the number of homicides committed by people with mental health problems – or with a previous history of mental illness.

• Of the total number of homicides committed in the nine- year period covered by the study, a total of 510 (10 per cent of the total) were identified as patient homicide. This means that the person charged with the offence had been in contact with mental health services in the 12 months before committing the homicide.
• A total of 550 individuals were found to have had symptoms of mental illness at the time of the offence. Symptoms included hypomania, depression, delusions, hallucinations and other psychotic symptoms.
• Among the people found to have a mental illness, 289 were diagnosed as psychotic. Of these, 226 were diagnosed with schizophrenia.

The National Confidential Inquiry suggests that there has been an increase in recent years in the number of murders committed by people who were later found to have had symptoms of mental illness at the time of the offence. [34] Because these individuals were not in contact with mental health services when the crime was committed, and were only interviewed after the homicide, it is possible that the increase is due to assessors using assessment tools that allow them to identify more symptoms of mental illness than were able to be identified in previous years. It is important to note that some mental disorders, for example antisocial personality disorder, are associated with crime and violence. This means that when someone is known to have been violent and to have committed homicide they are also likely to meet the criteria for a mental disorder such as antisocial personality disorder.

Another study looked into homicide due to mental disorder in England and Wales over a 50- year period, from 1946 to 2004. [35] The researchers found that the total rate of homicide in the general population and the rate of homicide by people with mental illness rose until the mid-1970s. Since then the rate of homicide in the general population has continued to rise, while the number of homicides committed by people with mental illness has fallen to historically low levels. Although the rates may vary from one year to another, the pattern has been that the risk of being killed by someone with a mental illness has declined and remained very low.

The researchers suggest that the decrease in the number of killings by people with mental illness is due to better treatment, including use of antipsychotic medication and increased awareness of the treatment of psychosis in primary care.

Suicide

In most Western countries, close to 90 per cent of those who die by suicide have a mental disorder. This proportion is much smaller in some Asian countries, but there is still a strong link between mental illness and suicidal behaviour. [36] More than 60 per cent of those who die by suicide are thought to have been experiencing a depressive illness at the time. Bipolar disorder, alcohol and substance abuse and schizophrenia are also linked to an increased risk of suicide.

It is important to be aware that the majority of people with a mental disorder will never attempt suicide. [37]

A UK study found that about 10 per cent of people with no mental disorder have had suicidal thoughts at some time in their life, [38] and about 2 per cent have attempted suicide. The study showed that rates were much higher among people with mental disorders. As expected, the researchers found that people who had experienced a depressive episode had high rates of suicidal thoughts. About 52 per cent of those with depression had a lifetime prevalence of suicidal thoughts, and 25 per cent had attempted suicide at some stage in their life. People with obsessive-compulsive disorder had the highest rate of suicidal thoughts, with a 64 per cent lifetime prevalence.

The most common methods of suicide in men are hanging, strangulation and suffocation (44 per cent), drug-related poisoning (20 per cent) and ‘other poisoning’, including motor vehicle exhaust gas (10 per cent). The most common methods of suicide in women are drug-related poisoning (46 per cent), hanging, strangulation and suffocation (27 per cent) and drowning (7 per cent). [39]

Relationship with victims

There is a common misconception that homicides by people with mental health problems tend to be random unprovoked attacks on complete strangers. Although this type of attack does happen occasionally, figures from the National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness show that the majority of victims are family members or otherwise acquainted with the aggressor. [40]

Mental health and the media

The media frequently draws links between mental illness and crime, particularly violent crime such as homicide. [41] In one survey, homicide and crime were the most common stories covered in relation to mental health. [42] The sources most frequently used in reporting on mental health were the police and the courts. One journalist said that ”there is no sexiness in mental health unless someone has committed a terrible crime.” [43]

People who have personal experience of mental illness are rarely quoted in the media: one survey showed that they were quoted in only six per cent of articles covering topics relating to mental health. [44]

References

[1] Jones, D 1995, ‘Prediction of dangerousness’, in B Kidd and C Stark (eds), Management of Violence and Aggression in Health Care, Gaskell.
[2] Scott PD 1977, ‘Assessing dangerousness in criminals’, British Journal of Psychiatry, vol. 131, pp. 127–142.
[3] Butler Report. 1975, ‘Report of the Committee on Mentally Abnormal Offenders’, London, The Stationery Office.
[4] Gunn J 1982, ‘Defining the terms’, in JR Hamilton and H Freeman (eds), Dangerousness: Psychiatric Assessment and Management, Gaskell.
[5] Department of Health 2001, Safety First, Report of the National Confidential Inquiry (NCI) Into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales. Department of Health.
[6] Large M, et al., 2008, ‘Homicide due to mental disorder in England in Wales over 50 years’, British Journal of Psychiatry, vol. 193, pp. 130–133.
[7] The Health & Social Care Information Centre, 2009, Adult Psychiatric Morbidity in England, 2007, Result of a household survey
[8] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009
[9] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales, 2009
[10] Kings College London, Institute of Psychiatry, 2006, Risk of violence to other people,
[11] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[12] Walsh E et al. 2003, ‘Prevalence of violent victimisation in severe mental illness’, British Journal of Psychiatry, vol. 183, pp. 233–238.
[13] Home Office, 2009, Crime in England and Wales 2008/09, Vol. 1, Findings from the British Crime Survey and police recorded crime, Statistical Bulletin, 11/09, vol. 1.
[14] Coleman K, Hird C, Povey D. 2006, ‘Violent Crime Overview, Homicide and Gun Crime 2004/2005’, Home Office Statistical Bulletin,
[15] Hall D et al. 1998, ‘Thirteen-year follow-up of deliberate self-harm, using linked data’, British Journal of Psychiatry, vol. 172: pp. 239–242.
[16] Teplin L, McClelland M, Abram K, Weiner D, 2005, ‘Crime victimization in adults with severe mental illness’, Archives of General Psychiatry, vol. 62, pp. 911–921.
[17] Reed DJ. 1992, Review of Health and Social Services for Mentally Disordered Offenders and Others Requiring similar Services, Final Summary Report, Home Office.
[18] Muijen M. 1995, ‘Scare in the community: Britain in moral panic’, in Heller T, et al (eds), Mental Health Matters, MacMillan Press.
[19] Searl, Liz, 1995, Living in fear of a man who could strike again, The Independent, 25/08/95.
[20] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[21] STATSWALES, 2009, Consultant lead out-patient clinics, summary date, by speciality group.
[22] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[23] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[24] Health Statistics Wales, 2009, Chapter 10, Hospital Statistics for people with a mental illness.
[25] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[26] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[27] STATSWALES, 2009, Admission of patients to NHS Mental Health Facilities by status.
[28] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[29] British Crime Survey, 2009, table 2.04, Recorded crime by offence, 1997 to 2008/09 and percentage change between 2007/08 and 2008/09, revised figures.
[30] Fazel S, Långström N, Hjern A, Grann M, and Lichtenstein P, 2009, Schizophrenia, substance abuse and violent crime, JAMA 2009;301(19):2016-23.
[31] Large M, Smith G, Swinson N, Shaw J. and Nielssen O, 2008, Homicide due to mental disorder in England and Wales over 50 years, The British Journal or Psychiatry (2008) 193, 130-133. doi: 10.1192/bjp.bp.107.046581
[32] MacArthur Violence Risk Assessment Study, Executive Summary September 2005, available at: www.macarthur.virginia.edu/risk.html#_ftnref1 Accessed 12/01/10.
[33] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[34] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[35] Large M, Smith G, Swinson N, Shaw J. and Nielssen O, 2008, Homicide due to mental disorder in England and Wales over 50 years, The British Journal or Psychiatry (2008) 193, 130-133. doi: 10.1192/bjp.bp.107.046581
[36] International Association for Suicide Prevention (IASP) 2006, Co-sponsored by the World Health Organization (WHO), World Suicide Prevention Day.
[37] International Association for Suicide Prevention (IASP) 2006, Co-sponsored by the World Health Organization (WHO), World Suicide Prevention Day.
[38] Meltzer H, et al. 2002, Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain, Office of National Statistics.
[39] Brock A., Griffiths C., 2003, ‘Trends in suicide by method in England and Wales, 1979 to 2001’, Health Statistics Quarterly, vol. 20, Office of National Statistics.
[40] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009.
[41] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[42] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[43] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[44] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.

Race and culture

Note on terminology: where terms such as 'Black' and 'White' have been capitalised in this publication, it has been done so to express the categorisation of ethnicity as described in the cited research.

How to define ethnicity

Ethnic monitoring only became mandatory in publicly funded mental health services in 1995. [1] Therefore, little reliable data has been available on how minority ethic groups are treated by mental health services in England and Wales. The Healthcare Commission concludes in its 2005 Count me in report [2] that poor ethnic monitoring ‘shows both lack of understanding of the value of having such data for planning services, and removes from services information that is needed to ensure that individual patients receive culturally sensitive and relevant care.’

However, people who do record and monitor ethnicity frequently find it a complex task. One reason for this is that individuals’ and groups’ perceptions of what group they belong to will vary according to views and perceptions held by the individual and by society. [3] For example, some people of African origin who are born in the UK might perceive themselves as Black African; others might prefer to classify themselves as Black British. People from the Indian subcontinent might want to define themselves as, for example, Gujaratis or Punjabis; but in the 2001 Census they were offered the options of ‘Indian’, ‘Pakistani’, ‘Bangladeshi’ or ‘other Asian’.

How ethnicity is defined will change over time because of social and political attitudes; for example, in 1976, Office of Population Censuses and Surveys referred to the minority ethnic population as ‘the population of New Commonwealth and Pakistan ethnic origin.’ [4]

As perceptions and attitudes change it is important to note that an ethnic group classification can only be valid and meaningful for the time and context in which it is used. [5]

An individual’s perception of what ethnic group he or she belongs to may be different to the perception of what group that person is seen as belonging to by the person who is recording and monitoring ethnicity. In A practical guide to ethnic monitoring in the NHS and social care the Department of Health suggest that a person should assign their own ethnic group. People should not be assigned their ethnicity by staff. [6]

Ethnicity, rates of mental illness and admission to psychiatric hospitals

Both past and recent research suggests that some groups – notably Black Caribbean, Black African and other Black groups – are over-represented in psychiatric hospitals. [7]

The high number of African Caribbean people being diagnosed with schizophrenia is well documented, with some studies reporting between two to eight times higher rates of diagnosis compared to the White population. [8]

The ‘Count me in’ census was introduced in England in 2005 and designed to support the Department of Health’s five year action plan ‘Delivering Race Equality in Mental Health Care’. The census also aimed to support the Welsh Assembly Government’s ‘Raising the Standard: Race Equality Action Plan for Adult Mental Health Services in Wales’. Key goals were to reduce rates of admission, detention and seclusion among black and minority ethnic groups. Unfortunately the figures show that these goals have not been achieved. [9]

Data from the 2005 ‘Count me in’ census showed that men from Black and White/Black mixed groups had the highest rates of admission to psychiatric hospitals. They were three or more times likely than the general population to be admitted. Women from the Black and mixed White/Black groups were two or more times likely than the general population to be admitted to psychiatric hospitals. Unfortunately, figures from the later surveys, including the 2009 ‘Count me in’ census, suggest the situation is still the same. [10]

White British, Chinese and Indian men were less likely than the average population to be admitted according to figures from all the five Count me in census reports. [11]

Men from Black Caribbean, Black African, and other Black groups were more likely than other groups to have been detained under the Mental Health Act 1983. The figures follow the same pattern in all the ‘Count me in’ reports from 2005 to 2009. [12]

Studies have shown that Irish people have higher rates of mental illness than the general population. [13] The Irish are often overlooked because they are White. Yet studies have found that Irish-born people living in the UK have a higher rate of suicide than any other minority ethnic group living in the country. [14]

The reliability of statistics on ethnicity and mental health

Statistics can appear very convincing, simply because most people interpret numbers as facts. However, the story behind the numbers may be more obscure than the figures indicate.

Some research suggests that although more Black Caribbean people are treated for psychosis, this may not indicate that they are more likely to have such an illness. Rather, it could be that the way they express their symptoms is interpreted in such a way that they are more likely than others to be prescribed treatment for these symptoms. [15]

Further, research indicates that more African Caribbean and other Black people with psychosis are being admitted to hospital for treatment because of the way they initially got in contact with the mental health services. Evidence suggests that they are more likely to have been in contact with the police or other forensic services prior to admission. They are also more likely to have been referred to treatment by a stranger rather than by a relative or a neighbour. It is important to note that this happens despite the fact that they are less likely than White people to show evidence of self harm and are no more likely to be aggressive to others before admission to a mental health hospital. [16]

Research also suggests that although there is no evidence indicating that African Caribbean people are more likely to be aggressive than their White counterparts, staff in mental health hospitals are more likely to perceive them as potentially dangerous. Evidence also suggests that psychiatrists are more likely to consider this group as potentially dangerous to others. It is therefore possible that African Caribbean people are more likely to be diagnosed with psychosis because of bias among those who treat them. [17] Research in the US shows similar results. [18]

Ethnic origin and psychosis

 Psychotic illness affects a very small portion of the population – around one person in 200 in the UK. [19] Because of the small numbers, it has been difficult to produce statistics that accurately reflect any differences between ethnic groups. Although the figures below indicate some differences in the prevalence of psychosis, it is important to note that only the difference between Black Caribbean women and White women can be considered as statistically significant. [20] 

Estimated annual prevalence of psychosis by gender [21]

	Percentage of UK population
	White	Irish	Black Caribbean	Bangla-deshi	Indian	Pakistani
Men	1.0	1.0	1.6	1.6	0.9	1.4
Women	0.7	1.0	1.7	0.6	1.3	1.3
Total	0.8	1.0	1.6	0.6	1.1	1.3

The above figures are from the Fourth National Survey of Ethnic Minorities (FNS). As expected, it shows a higher rate of psychotic illness for Black Caribbean people than for White people, with Black Caribbean people being twice as likely as White people to be diagnosed with psychosis.

However, the difference is much lower than previous studies have indicated. More importantly, previous studies have indicated that the rate of psychosis is particularly high among Black Caribbean men. The FNS study suggests that the difference was largely due to higher rates of psychosis among Black Caribbean women.

The study further showed that those from a poorer background were more likely to suffer from a psychotic illness. This was the case for Black people as well as for White people. It also emerged that those living in inner cities seemed at higher risk. [22] These findings support the theory that mental illness is related to living conditions rather than ethnicity or race.

Ethnic origin and common mental disorders

Common mental disorders include disorders such as depression and anxiety. Many more people are likely to experience these disorders than psychosis. As the table below indicates, there are some differences between different ethnic groups.

Any common mental disorder in past week for men and women by ethnic group [23]

	Percentage of UK population
	White	Irish	Black Caribbean	Bangla- deshi	Indian	Pakistani
Any common mental disorder Men Women Total	11.6 19.9 15.8	18.4 18.6 18.5	13.8 19.8 17.3	12.9 12.3 12.3	12.1 23.8 18.1	12.6 26.0 19.6
Depressive episode Men Women Total	2.4 3.3 2.9	1.8 3.5 2.8	2.2 2.5 2.4	2.1 1.6 1.9	1.7 5.7 3.8	2.4 6.3 4.5
Any Anxiety Disorder Men Women Total	3.0 3.9 3.6	5.9 5.4 5.6	4.7 4.0 4.3	3.6 1.9 2.8	1.4 7.3 4.4	4.4 5.4 4.9
Obsessive Compulsive Disorder Men Women Total	0.3 1.4 0.9	0.6 1.2 1.0	0.6 1.2 1.0	1.0 0.9 1.0	0.6 1.7 1.2	2.1 1.4 1.7
All Phobias Men Women Total	1.8 1.7 1.8	1.9 2.3 2.1	0.9 1.9 1.5	1.0 0.4 0.7	0.3 1.3 0.8	2.5 1.7 2.1
Panic Disorder Men Women Total	0.5 0.5 0.5	2.0 1.5 1.7	1.8 1.0 1.3	1.7 0.9 1.3	1.7 3.5 2.1	0.6 1.8 1.2
Generalised Anxiety Disorder Men Women Total	1.5 1.4 1.4	2.9 3.0 3.0	2.0 0.8 1.3	0.5 0.6 0.6	0.2 2.0 1.2	1.4 1.3 1.4
Mixed anxiety & depressive disorder Men Women Total	7.4 13.7 10.9	11.5 11.7 11.6	8.3 14.5 12.0	8.7 9.4 9.0	9.7 14.1 11.9	7.1 17.0 12.3

Common mental disorders such as depression and anxiety are not considered as serious or disabling for the individual as psychotic disorders such as schizophrenia or bipolar disorder. However, as the disorders are far more common, they affect more people, and have a much greater impact on the community. One estimate suggested that they account for one third of days lost from work due to ill health. [24] The Labour Force Survey suggests that common mental disorders such as depression and anxiety plus stress accounts for more than 40 per cent of days lost to ill health. [25]

Although many more people will experience a common mental disorder – more than 15 per cent of the population in the UK may be affected at any time – few studies have attempted to find out how different minority groups have been affected by these disorders. Most research has focused on the rarer psychotic disorders.

Depressive episodes

The above table indicates that, among men, White and Pakistani subjects reported depressive episodes most often (2.4 per cent). However, it is important to note that as the numbers reported are small, the differences between the groups cannot be considered statistically significant.

Irish men reported the highest level of common mental disorders (18.4 percent); however, they reported fewer depressive episodes (1.8 percent) than men from all other groups, except Indians.[26]

The highest levels of depressive episodes were reported by Pakistani women (6.3 per cent) and Indian women (5.7 per cent). Both these groups show a much higher rate that their male counterparts. In other ethnic groups there was no significant gender difference. Bangladeshi women showed the lowest rate (1.6 per cent).

Anxiety disorders

The highest rates of anxiety reported were from Irish men (5.9 per cent) and Indian women (7.3 per cent).

Mixed anxiety depressive disorder

The lowest rate of mixed anxiety depressive disorder among men was found in the White (7.4 per cent) and Pakistani (7.1 per cent) groups. However, the differences between the men were not statistically significant.

Pakistani women reported the highest rate (17.0 per cent) and Bangladeshi women reported the lowest rate (9.4 per cent) of mixed anxiety depressive disorder. The differences between women in the other groups were not statistically significant.

Self harm

Figures from all five ‘Count me’ in census shows that the White British group have a higher than average rate of self harm. Black and South Asian groups have a lower than average level of self harm. [27]

 

References

[1] Commission for Healthcare Audit and Inspection, 2005, Count me in, Results of a national census of inpatients in mental health hospitals and facilities in England and Wales, November 05,
[2] Commission for Healthcare Audit and Inspection, 2005, Count me in, Results of a national census of inpatients in mental health hospitals and facilities in England and Wales, November 05,
[3] ONS, 2002, Population projections by ethnic group, a feasibility study.
[4] ONS, 2002, Population projections by ethnic group, a feasibility study.
[5] ONS, 2002, Population projections by ethnic group, a feasibility study.
[6] DH, 2007, A practical guide to ethnic monitoring in the NHS and social care
[7] Commission for Healthcare Audit and Inspection, 2005, Count me in, Results of a national census of inpatients in mental health hospitals and facilities in England and Wales.
[8] Harrison, G., 2002, ‘Ethnic minorities and the Mental Health Act’, The British Journal of Psychiatry (2002) 180: 198-199
[9] Care Quality Commission, 2009, Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales
[10] Care Quality Commission, 2009, Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales
[11] Care Quality Commission, 2009, Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales
[12] Care Quality Commission, 2009, Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales
[13] Fitzpatrick, M., 2005, Profiling mental health needs: what about your Irish patients?, British Journal of General Practice, October 2005.
[14] NIMH, 2003, Inside outside, improving mental health services for black and minority ethnic communities in England, DH.
[15] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[16] Nazroo, J.Y, 2001, Ethnicity, Class and Health, Policy Studies Institute
[17] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[18] ‘Mental Health: Culture, Race, and Ethnicity’ (supplement), 2001, Chapter 3: Mental Health Care for African Americans, from Reports of the Surgeon General, National Library of Medicine
[19] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[20] Nazroo, J.Y, 2001, Ethnicity, Class and Health, Policy Studies Institute
[21] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[22] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[23] Weich, S., McManus, S, 2002, ‘Common Mental Disorders’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[24] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[25] HSE, 2009, Health and Safety Statistics 2008/09, Health and Safety Executive
[26] Nazroo, J., King M., 2002, ‘Psychosis – symptoms and estimated rates’, in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[27] Care Quality Commission, 2009, Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales

The Criminal Justice System

Prisoners and mental health

Number of prisoners with mental health problems

According to the ONS (the Office of National Statistics), a large proportion of prisoners in England and Wales have a mental health problem.

In one survey they found that in the week before the interview, 39 per cent of sentenced males and 75 per cent of female remand prisoners had significant neurotic problems, such as anxiety, depression and phobias. Rates for all groups were much higher than the 12 per cent of men and 18 per cent of women found to have significant levels of neurotic symptoms in a similar household survey carried out by the ONS.

Differences between remand prisoners and sentenced prisoners

Remand prisoners (prisoners awaiting trial) have higher rates of neurotic disorder than sentenced prisoners and women have higher rates than men. ONS suggest that 58 per cent of men and 75 per cent of women remand prisoners experience significant neurotic symptoms . The figures are lower for sentenced prisoners, with 39 per cent of men and 62 per cent of women showing some form of neurotic disorder.

Another survey found that 45 per cent of suicides in prisons were by people held on remand and who were still waiting to go to trial.

Self-harm among prisoners

ONS has found that self-harm during the current prison term, without the intention of suicide, is just under 10 per cent for female prisoners and just under 6 per cent for males. The rates reported by remand and sentenced prisoners were similar; however, two thirds of remand prisoners had been in prison for less than three months compared with only about a quarter of the sentenced prisoners.

Women represent more than 50 per cent of all self-harm cases in prison. This is worrying as women represent only 5 per cent of the prison population. The rate of self-harm is particularly high among women under 21. At two women's prisons they have reported around 10 cases of self-harm per day.

Between 2004 and 2008, incidents of self-harm in prisons increased by 25 per cent. In female prisons the increase was 42 per cent in the same period. The total number of self-harm cases in 2008 was 10,466 for men and 12,560 for women - a total of 23,026.

Attempted suicide among prisoners

ONS has found that a high number of prisoners have tried to take their own lives, particularly women and remand prisoners. Just under one in four men and nearly two in five women reported a suicide attempt at some time in their life. In one survey, over a quarter of female remand prisoners reported attempting suicide in the year before the interview.

Suicide among prisoners

 The suicide rate among prisoners went down from 92 in 2007 to 61 in 2008. However, it is important to note that this followed a sharp increase in the numbers from 67 in 2006 to 92 in 2007. Although the numbers are going down, the suicide rate for prisoners is still alarmingly high with 91 suicides per 100,000 in the prison population compared with 8.5 per 100,000 in the general population.[ This means that the risk of suicide is more than 10 times higher for a prisoner than for the general population.

Psychosis among prisoners

In an ONS survey, a random sample of one in five prisoners interviewed previously were selected for an additional interview by a clinician to assess personality disorder and functional psychoses, such as schizophrenia and manic depression (but not organic psychoses such as dementia). In this follow-up interview, 14 per cent of all the women, 10 per cent of the men on remand and 7 per cent of the sentenced men were assessed as having a functional psychosis, in the year prior to interview. These rates for psychosis are much higher than for the general population, where the figure is only 0.4 per cent.

Mental health in-reach teams (MHIRT) confirms high rates of psychosis among prisoners. A survey of clinical records of prisoners treated by the MHIRTs showed that 18 per cent had a diagnosis of schizophrenia and another 18 per cent had a diagnosis of psychosis.  

Personality disorders among prisoners

ONS suggests that over three quarters of the men on remand, nearly two thirds of the males sentenced, and half of the women sentenced fitted a diagnosis of personality disorder. Another survey shows that, among prisoners treated by MHIRT, around 17 per cent have a diagnosis of personality disorder, usually in combination with another diagnosis.

Antisocial personality disorder (ASPD)
The most common type of personality disorder seen in prisons, according to the ONS, is antisocial. This has been found in 63 per cent of males on remand, 49 per cent of males sentenced and 31 per cent of all female prisoners. This would be expected, since the category of ASPD requires the presence of antisocial behaviour before the age of 15 years and persisting into adulthood. Criminal behaviour is often seen as antisocial, so many prisoners are therefore likely to be diagnosed with this disorder. The figures are broadly in line with the results of studies carried out within the United States prison system.

Paranoid and borderline personality disorders
Paranoid and borderline personality disorders are the next most common types of disorder seen in prison, according to ONS. A total of 29 per cent of male remand, 20 per cent of male sentenced and 16 per cent of female prisoners were assessed as having paranoid personality disorder. The equivalent figures for borderline personality disorder were 23 per cent, 14 per cent and 20 per cent respectively.

According to the ONS, paranoid personality disorder is often combined with ASPD in criminal populations and is characterised by pervasive mistrust and suspiciousness. People with borderline personality disorder are considered to be highly impulsive, experience brief mood swings, have a poor sense of self-image and have difficulty in sustaining close relationships. They are the group most often seen by psychiatric services in prisons.

Another survey also found that prisoners in England and Wales have very high rates of mental illness, substance misuse and personality disorder.

Prevalence of personality disorder 

	Male	Male	Female
	Remand	Sentenced	All
	Per cent
Type of personality disorder
Antisocial	63	49	31
Paranoid	29	20	16
Borderline	23	14	20
Avoidant	14	7	11
Obsessive-compulsive	7	10	10
Narcissistic	8	7	6
Schizoid	8	6	4
Dependent	4	1	5
Schizotypal	2	2	4
Histrionic	1	2	1
Any personality disorder	78	64	50
Base (sample size)	181	210	105

Hazardous alcohol use by prisoners

ONS says that the prevalence of hazardous drinking, in the year prior to coming to prison, is higher in men than in women. This applied to over half the men they interviewed regarding this: 58 per cent on remand and 63 per cent sentenced. This compared to 36 per cent of female remand prisoners and 39 per cent of female sentenced prisoners.

Prisoners who have problems with alcohol are often also addicted to drugs. Over 25 per cent of male prisoners and around 20 per cent of female prisoners who are hazardous drinkers are also dependent on one or more illegal drugs.

In 2002/03 around 6,400 prisoners took part in alcohol detoxification programmes. Another 7,000 prisoners joined detoxification programmes for combined alcohol and drug addiction.

The Prison Service published an alcohol strategy for prisoners in 2004. Key aims of the strategy are to balance treatment and support with measures that can reduce supply. Although, it is clear that alcohol misuse is a big problem for prisoners, the government has not been able to provide treatment for those who want it. One report on arrestees showed that of the 27 per cent who wanted treatment, only 9 per cent had been offered treatment.

Drug dependence among prisoners

ONS suggests that drug dependence (as shown by the use of a drug every day for two weeks or more and, for cannabis, some other sign of dependence), in the year before coming to prison, is very common. Drug dependence was reported by 51 per cent of male remand, 43 per cent of male sentenced, 54 per cent of female remand and 41 per cent of female sentenced prisoners.

According to the ONS, the rates of all types of mental disorder - especially drug and alcohol dependency - are higher for prisoners than for the general population.

Remand prisoners are more likely than sentenced prisoners to report dependence on opiates (heroin or non-prescribed methadone) alone or in combination with other drugs, in the year before coming to prison. Opiate dependence has been reported by 41 per cent of females on remand and 26 per cent of males on remand, but only 23 per cent of females sentenced and 18 per cent of males sentenced.

Offenders who are sent to residential drug treatment centres are 45 per cent less likely to commit crimes after release compared to offenders who are sent to prison. Many offenders who are sent to prisons and who want treatment are not offered this. The greatest gap is for those addicted to crack (cocaine). One survey showed that 67 per cent of arrestees had wanted treatment for crack addiction, but only 9 per cent had been offered treatment. The survey also showed that 60 per cent of arrestees who took heroin five or more days a week had not been offered treatment in the past 12 months. HM Chief Inspector of Prisons has said that they get 60 per cent less funding than they had hoped for new integrated drug treatments.

The Home Office suggests that for every £1 spent on drug treatment saves society £9.50.

Prisoners and the Mental Health Act

People sent to hospital (rather than prison) under Part III of the Mental Health Act

During 2007/08, the courts in England sent a total of 1,400 people to hospital for treatment under the Mental Health Act (Part III). Some were sent by the courts at the time of sentencing, while others were transferred from prison to hospital. During 2007/08 the courts in Wales sent 103 people to hospital. 

People detained in high security hospitals under Part III of the Mental Health Act

In England, a total of 7,500 people were sent to secure hospitals (Place of Safety Orders) during 2007/08 - most of these were to an NHS hospital. That means the figures have trebled since 1997/98 when the number of Place of Safety Orders was 2,483.   In Wales, a total of 367 people were put on Place of Safety detention in 2007/08. The figures have increased since 2003/04 when 262 people in Wales were sent to secure hospitals.

Crime and risk in the community

Risk of being killed by someone with a mental heath problem

The public perception is that community care policy has failed and that there are now more people with mental health problems on the streets. Many believe that this means an increased risk of being harmed by somebody diagnosed with a mental health problem. A report by the Audit Commission points out that most people with schizophrenia live relatively normal lives in the community and the risk to the public has actually decreased since the community care reforms. The report cites evidence that the number of homicides by people with mental health problems has not increased, while the number committed by others has more than doubled.

In January 1999, psychiatrists carried out a study based on Home Office Figures. The study shows that the majority of homicides are not linked to care in the community. Contrary to popular belief, the number of homicide convictions of people considered to be mentally disordered has fallen to half that reached in 1979 - before the rush to close old asylums. Compared with all killings, the number committed by people with mental health problems has fallen even faster. The proportion has dropped from almost half in the 1960s, to little more than one in ten today. Although homicide convictions have multiplied fivefold since the late 1950s to more than 500 annually, the number involving a mentally disordered offender has fallen to around 60.

According to the psychiatrists who carried out the study, the likelihood of someone being killed by somebody with a mental disorder is probably less than that of winning the National Lottery outright. Even then, victims are likely to be someone known to the killer, rather than a stranger. Although people today are at slightly increased risk of being killed by a stranger, according to the psychiatrists, that person is highly unlikely to have a mental disorder.

There were 699 homicides in 1995. In 423 cases, the victim was known to the suspect; in 169 the suspect was a stranger; in 88 cases no suspect was identified. In only 32 cases (4.6 per cent) was the suspect 'mentally disturbed'.

The Confidential Enquiry into Homicides and Suicides by Mentally Ill People   shows that serious mental disorders are rare, and affect only four out of every 1,000 adults. Serious violence is even more rare - there are between 600 and 700 homicides each year, but few of them are carried out by people with mental health problems. The enquiry, which took place over a period of 33 months, identified only 39 homicides in England by people in contact with specialist mental health services in the previous year (between five and six per cent of all homicides).

In 2004, The British Medical Journal published a study which concluded: 'Stranger homicides have increased in the recent years, but the increase is not the result of homicides by mentally ill people and therefore the "care in the community" policy. Stranger homicides are more likely to be related to alcohol or drug misuse by young men.'

People with mental health problems are, in fact, at far greater risk of harming themselves than other people and are at increased risk of suicide.

References

---

[1] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[2] Meltzer, H et al. 1995, OPCS Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity among adults living in private households, HMSO.
[3] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[4] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[5] Prison Reform Trust, 2008, The Cruellest Wait
[6] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[7] HM Chief Inspector of Prisons for England and Wales, 2009, Annual report 2007-08
[8] HM Chief Inspector of Prisons for England and Wales, 2009, Annual report 2007-08
[9] The Howard League for Penal Reform, 2009, downloaded from www.howardleague.org , June 2009
[10] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[11] Ministry of Justice, 2009, Deaths in prison custody 2008
[12] Royal College of Psychiatrists, 2009, Multi-agency working needed to tackle 'worryingly high' prison deaths
[13] Meltzer, H et al. 1995, OPCS Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity among adults living in private households, HMSO.
[14] HM Inspectorate of prisons, 2007, The mental health of prisoners, A thematic review of the care and support of prisoners with mental health needs
[15] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[16] HM Inspectorate of prisons, 2007, The mental health of prisoners, A thematic review of the care and support of prisoners with mental health needs
[17] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[18] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[19] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London.
[20] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[21] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[22] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[23] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[24] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[25] HM Prison Service, 2004, Addressing Alcohol Misuse: A Prison Service Alcohol Strategy for Prisoners
[26] Home Office, 2006, Home Office Statistical Bulletin, The Arrestee Survey Annual Report: Oct 2003-Sept 2004
[27] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[28] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[29] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[30] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[31] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[32] NHS Evidence, National Library for Public Health, 2009, 2009 Annual Update - Drugs - Drugs misuse treatment in Offender population
[33] Health and Social Care Information Centre, 2008, In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England 1997-98 to 2007-08
[34] Statistical Directorate, 2008, Admission of patients to mental health facilities in Wales, 2007/08 (including patients detained under the Mental Health Act 1983) National Assembly for Wales, SDR 167/2008. Available from http://new.wales.gov.uk/statsdocs/health/sdr167-2008.pdf
[35] Health and Social Care Information Centre, 2008, In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England 1997-98 to 2007-08
[36] Statistical Directorate, 2008, Admission of patients to mental health facilities in Wales, 2007/08 (including patients detained under the Mental Health Act 1983) National Assembly for Wales, SDR 167/2008. Available from http://new.wales.gov.uk/statsdocs/health/sdr167-2008.pdf
[37] Reed, J. 1997, 'Risk Assessment and Clinical Risk Management: The Lessons from Recent Enquiries', British Journal of Psychiatry, 170, supplement 32, pages 4-7.
[38] Taylor, P. and Gunn, J., Institute of Psyhiatry Research, quoted in The Guardian, Wednesday January 6 1999.
[39] Taylor, P. and Gunn, J. 1999.
[40] Parliamentary Written Answers, 14 October 1996.
[41] Royal College of Psychiatrists, 1996, Confidential Enquiry into Homicides and Suicides by Mentally Ill People, London.
[42] BMJ 2004;328:734-737 (27 March), doi:10.1136/bmj.328.7442.734, available at: http://bmj.bmjjournals.com/cgi/content/full/328/7442/734

Key Facts and Trends

The Mental Health Network has produced a short factsheet summarising key facts and trends related to mental health problems (September 2011). It brings together data from major national surveys and reports covering:

• Key trends in morbidity and behaviour
• Wider societal changes and challenges
• NHS budget and spending projections
• Service activity
• Quality, safety and user experience

View Key facts and trends in mental health