Experiences of men who access NHS Talking Therapies from prison: 1 April 2018 to 31 March 2020

• A total of 3,485 referrals were identified as prison referrals to NHS Talking Therapies using information on the source of incoming referrals and the postcode of usual residence; these referrals corresponded to 2,930 individuals.

• The average wait time from the start date of a referral to the first appointment contact was one month (32 days), with 79% seen within six weeks of their referral date; average appointment time was 45 minutes and average total treatment contact time for a completed referral was 163 minutes.

• Of those referrals that attended at least one appointment where a therapy type was recorded, most referrals (70%) were treated with guided self-help using a book; 22% with Cognitive Behavioural Therapy and 2% with counselling for depression.

• Of those referrals that were assessed but not treated, 52% were suitable for NHS Talking Therapy but declined treatment; of those that moved into treatment 92% completed their treatment, with 8% dropping out.

• For those completing their NHS Talking Therapy treatment, 70% were assessed as having made a reliable improvement, 7% classed as having made a reliable deterioration and 23% were classed as no change; these are broadly in line with the average for all referrals to NHS Talking Therapies.

As a non-household population (NHP), prisoners were highlighted by the UK National Statistician’s Inclusive Data Task Force as a group that is often missed from data. This article adds to the limited evidence about treatment of common mental disorders (CMDs) among NHPs, specifically prisoners, and demonstrates how postcode information can be used to identify a non-household population in administrative data.

The HM Chief Inspector of Prisons for England and Wales Annual Report 2021 to 2022 found that 51% of male prisoners and 76% of female prisoners reported mental health difficulties (PDF 12.8 MB). Rates of self-harm and suicide in prison are well documented and are often used as a potential indicator for poor mental health of the prison population. For example, recorded self-harm incidents in prisons have more than doubled between 2010 and 2020.

There were also 677 deaths by suicide recorded in prison custody between 2008 and 2019. Male prisoners were also found to have an increased risk of dying by suicide compared with the general male population.

NHS Talking Therapies in prisons

The NHS Talking Therapies programme helps to treat common mental disorders such as depression and anxiety. A recent publication highlighted that older age groups, males, ethnic minorities, those with disabilities and those following a religious belief were all under-represented as receiving treatment in NHS Talking Therapies. It found that approximately 2% of adults in the Census 2011 population received treatment through NHS Talking Therapies from 1 April 2017 to 31 March 2018.

NHS England is responsible for commissioning healthcare in prisons in England, including mental health services. Prisoners can access NHS Talking Therapies if the service is available in the prison that they reside in. Prisoners can self-refer to NHS Talking Therapies or be referred through the justice system, a general practitioner (GP) or other services. While there is currently limited published data or research on the delivery of NHS Talking Therapies within prisons, the NHS Talking Therapies Manual (PDF, 6.63MB) notes that those in prison tend to be under-represented in NHS Talking Therapies.

The prisoners in the NHS Talking Therapies population used for this research come from the limited number of prisons in England that offer NHS Talking Therapies, and therefore these results are not representative of the wider prisoner population in England.

There are a wide range of other mental health services beyond NHS Talking Therapies that are on offer in prisons across England. The national specification for prison mental healthcare (PDF, 906KB) recommends that an integrated stepped care model is used. Provision of mental health care can vary across prisons but includes both primary and secondary care, as well as voluntary and community services. For example, Samaritans run a Listener scheme; this is a peer-support scheme aiming to reduce suicide and self-harm. These other services are beyond the scope of this report.

In this section, when we talk about prisoners, we are referring to individuals with referrals we have identified as residing in prison. Section 9: Data sources and quality explains how we identified this population. The statistics presented in this section are about individuals rather than referrals.

Of the prisoners that we identified in our data as being referred to NHS Talking Therapies from prison, 99% are male and 1% are female. The report covers findings for male prisoners only to minimise disclosure risk for female prisoners.

Demographic information on gender, age and source of referral were found to have high levels of valid information. However, data on ethnicity, religion, sexual orientation and long-term conditions were found to have high levels of missing data.

Most of the referrals identified as prisoners accessed NHS Talking Therapies through a referral from the Justice System (80%) while 15% referred themselves to the service and 5% were referred from other sources.

Our statistics suggest that the prisoners we identified in NHS Talking Therapies represent approximately 4% of the total male prisoner population in England between 1 April 2018 and 31 March 2020.

The age of male prisoners who have been referred to NHS Talking Therapies is slightly younger overall than all male referrals; 57% of male prisoners referred were aged between 18 and 35 years compared with 48% of all male referrals. This was calculated using publicly available annual activity data published for the whole NHS Talking Therapies programme between 1 April 2018 and 31 March 2020.

It is worth noting that 30% of the prisoners referred to NHS Talking Therapies were asked about their ethnicity but declined to state it and a further 21% were coded as not known.

Of the prisoners referred to NHS Talking Therapies, 10% were recorded as having one or more disability. Those who did not appear in the disability table in NHS Talking Therapies or were recorded as not having a disability are assumed not to have a disability (90%). Of those with valid information on long-term conditions, 63% did not have a long-term condition and 37% self-reported having a long-term condition.

Of those with valid religious information, 43% had no religion and 39% were Christian. Of those with valid information on sexual orientation, 94% identified as heterosexual, 3% as gay or lesbian and 3% as bisexual.

The rest of this article is about prison referrals. This is referral-level information from those who we identified as residing in prison. Where the same individual had multiple prison referrals during the research period each of their referrals is included in these statistics.

Most referrals (58%) do not specify a mental health condition. Among those that do specify a condition, 45% of those were for depression and 20% were for generalised anxiety disorder.

For each of the age groups, more than half of referrals were for an unspecified condition. This ranged from 52% for the subgroup aged 45 to 54 years to 62% for the subgroups aged 18 to 24 years and aged 25 to 34 years. For the subgroup aged 55 years and over, depression was the reason specified for 39% of the referrals, followed by an unspecified condition (38% of all referrals).

The average wait time from the start date of a referral to the first appointment contact was around one month (32 days). The average time that a prison referral was open was 67 days. Of referrals with at least one attended appointment, 79% were seen for their first appointment within six weeks of their referral date. An attended treatment appointment lasted on average for 45 minutes and the average total treatment contact time for an ended prison referral was 163 minutes.

To provide context from the whole NHS Talking Therapies programme, we used publicly available monthly activity data between 1 April 2018 and 31 March 2020, to calculate that for all NHS Talking Therapies referrals that began treatment in the period the average wait time was 21 days from referral to first treatment appointment.

Types of therapy delivered to those accessing the NHS Talking Therapies programme from prison

Of those that attended at least one appointment where a therapy type was recorded, the majority were treated with low-intensity therapy (76%), while 10% were treated with high-intensity therapy and 14% were treated with a combination of high- and low-intensity therapy.

Of those that attended at least one appointment where a therapy type was recorded, most referrals (70%) were treated with guided self-help using a book, 34% were treated with other low-intensity therapy and 6% were treated with a low-intensity therapy called Behavioural Activation. When it comes to high-intensity therapies, 22% of referrals were treated with Cognitive Behavioural Therapy (CBT) and 2% were treated with counselling for depression. A referral can be treated with multiple therapy types.

Attendance at NHS Talking Therapy appointments from prison

For all prison referrals that are marked as closed, the average experience consisted of two attended appointments and one missed appointment. The average attendance rate across all scheduled appointments was 62% among ended prison referrals.

The majority (57%) of referrals ended without any missed appointments while 42% of referrals ended with at least one missed appointment. Of those that missed appointments, it was most common to miss one appointment.

Just under half (47%) of referrals ended without any attended appointments while 52% ended with at least one attended appointment.

High-intensity therapies included CBT, counselling for depression and those categorised as other high-intensity therapy. Low-intensity therapies included guided self-help using a book, Behavioural Activation and those categorised as other low-intensity therapy. We consider referrals where both high- and low-intensity therapy types were recorded as "Mixed intensity".

Referrals to NHS Talking Therapies may end after assessment only or continue to treatment.

Of those referrals that were assessed only, 52% were suitable for NHS Talking Therapy but declined treatment. Of those referrals that also received treatment, 92% completed their scheduled treatment and 8% dropped out of treatment.

Completing NHS Talking Therapy from prison

Of those referrals that ended, we calculated that 29% had completed treatment according to the programme definition as defined in Section 9: Data sources and quality. For context, the average completion rate using monthly activity data for the whole NHS Talking Therapies programme for the period 1 April 2018 to 31 March 2020 was 38%.

"Caseness" is a referral that scores highly enough on measures of depression and anxiety to be classed as a clinical case. More information about its measurement can be found in Section 9: Data sources and quality.

Of the referrals that completed treatment, 9 in 10 (90%) referrals were considered to be at clinical "caseness" based on pre-treatment questionnaires. For context, among all NHS Talking Therapies referrals, 94% were at clinical "caseness" using published monthly activity data over the period from 1 April 2018 to 31 March 2020.

A referral is said to have recovered if their first questionnaire score was above or equal to the clinical threshold (at caseness) and their last score is below the clinical threshold (not at caseness). Of those completed referrals that started at caseness, 50% were classed as having recovered. For context, the average recovery rate was 52% among all NHS Talking Therapies referrals using published monthly activity data over the same period.

Rates of improvement, deterioration, or no change among those that completed NHS Talking Therapy from prison

If patients have completed treatment and have data for depression and anxiety questionnaire scores before and after treatment, they can be classed as either:

• reliably improved 

• reliably deteriorated

• no change

Of those eligible, 70% were classed as making a reliable improvement. Of those eligible, 7% were classed as making a reliable deterioration. Of those eligible, 23% were classed as no change.

For context, we used publicly available monthly activity data to calculate that for all referrals to NHS Talking Therapies on average, 67% reliably improved, 6% reliably deteriorated and 26% showed no change between 1 April 2018 and 31 March 2020.

Patient Health Questionnaire-9 (PHQ-9) can be used to measure depression symptoms. The scale ranges from 0 to 27, with a higher score indicating more severe symptoms. For those who ended their referral and had paired PHQ-9 scores, the mean for the first PHQ-9 score was 15 and the mean for the last PHQ-9 was 9.

Generalised Anxiety Disorder Questionnaire (GAD-7) can be used to measure anxiety symptoms. The scale ranges from 0 to 21, with a higher score indicating more severe symptoms. For those who ended their referral and had paired GAD-7 scores, the mean for the first GAD-7 score was 13 and the mean for the last GAD-7 score was 8.

NHS Talking Therapies

NHS Talking Therapies (previously known as Improving Access to Psychological Therapies) is an NHS service designed to offer psychological talking therapies to adults living in England who experience common mental health problems such as stress, anxiety disorders and depression. Patients need to be registered with a general practitioner (GP) in England to access the services, but they do not need referral from the GP to access it. NHS Talking Therapies offers a variety of different treatments such as guided self-help, Cognitive Behavioural Therapy (CBT), counselling, Interpersonal Therapy (IPT), mindfulness and many more. More information on NHS Talking Therapies can be found on the NHS website.

Non-household population

The non-private household (NPH) population includes people living in communal establishments, some core groups of homeless populations, as well as those who fall between institutions and households and have an "absent" or "temporary" household status. More specifically the NPH population includes people living in, for example, care homes, prisons and students in halls of residence. More information can be found in our article Alternative for including non-household populations in estimates of personal well-being and destitution.

Caseness

A referral that scores highly enough on measures of depression and anxiety to be classed as a clinical case. More information about its measurement can be found in Section 9: Data sources and quality.

Disability

An indication of whether a person is disabled. This could be where the person has been diagnosed as disabled or the person considers themself to be disabled. Under the Disability Discrimination Act (DDA), a disabled person is defined as "someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities".

Long-term condition

Long-term condition in the context of the NHS Talking Therapies dataset refers to a Long-Term Physical Health Condition (also known as a Chronic Condition) and is a health problem that requires ongoing management over a period of years or decades and is one that cannot currently be cured but can be controlled with the use of medication and/or other therapies.

Improving Access to Psychological Therapies (IAPT), currently known as NHS Talking Therapies

This article uses data from the NHS Talking Therapies (formerly known as Improving Access to Psychological Therapies or IAPT) in England, an administrative dataset owned by NHS Digital and NHS England, recording information about talking therapies offered for depression and anxiety. This article includes data from the reporting periods 1 April 2018 to 31 March 2020.

Identifying our population of interest – prison referrals in NHS Talking Therapies

To identify prison referrals in the NHS Talking Therapies dataset we used a combination of referral and postcode information. Firstly, we used NHS Talking Therapy service information about the referral source that is recorded at the point of referral. Any referrals that were recorded as coming from a prison were flagged as prisoners. Additionally, to ensure we also capture other referral routes of prisoners, such as self-referral, we carried out a postcode-matching method using a prison postcode as a proxy for a referral from a postcode containing a prison.

As patient postcode is self-reported and not collected longitudinally throughout a referral, this limits our population to those who self-report as residing in prison when postcode data was collected by the provider. For more information on the use of postcodes for this research please see Methods for identifying prisoners as a non-household population in NHS Talking Therapies.

Measuring completed treatment

Patients can be defined as completing treatment in the NHS Talking Therapies programme if they:

• attended at least two treatment appointments and

• ended their referral in the reporting period.

Measuring caseness

"Caseness" is used to describe a referral that scores highly enough on measures of depression and anxiety to be considered as a clinical case. It is measured using the assessment scores collected via questionnaires, such as Patient Health Questionnaire-9 (PHQ-9) or the Anxiety Disorder Specific Measure (ADSM).

To measure symptoms of depression, patients in NHS Talking Therapies will complete PHQ-9 whose scale ranges from 0 to 27, with a higher score indicating more severe symptoms. To measure symptoms on anxiety, patients in NHS Talking Therapies will also have an entry for an ADSM. The questionnaire used to determine this will vary depending on the anxiety disorder.

In our data, a referral is coded as "at caseness" if:

• a referral has "completed treatment" 

• the pre-treatment score on standardised depression or anxiety questionnaires passes the clinical threshold for that questionnaire

• the referral ended within the reporting period

Measuring rates of improvement, deterioration or no change among prisoners who completed treatment

A referral is said to have reliably improved if their last questionnaire score is "smaller" than their first score and the size of the change passes a reliable change threshold.

A referral is said to have reliably deteriorated if their last questionnaire score is "greater" than their first score and the size of the change passes a reliable change threshold.

A referral is said to show no change if the changes between the first and last questionnaire scores is "less" than the threshold for both scores, or one score improves and the other deteriorates.

More detailed information about the methodological approach can be found in our methodology article Methods for identifying prisoners as a non-household population in NHS Talking Therapies.