Title: The Prevention Of Suicide Behaviour in Prison: Enhancing Access to Therapy (PROSPECT) Programme
Funder: Department of Health and Social Care

Abstract: Background The number of suicidal behaviours in prison reached a record high of 42,837 incidents in the 12 months to September 2017. Prison healthcare does not meet patients needs for evidenced-based psychological therapies for suicidal behaviour. To overcome this problem, we propose the PROSPECT therapy programme. Aims Through increasing access to PROSPECT therapy within prisons, we aim to improve patient and economic outcomes. Methods WP1: Working alongside Service User Consultants, we will refine our approach to enhance prisoners to take up of the PROSPECT therapy programme. In a series of co-production &ldquo;future&rdquo; workshops, we will critique current psychoeducation materials before producing a prototype workbook to be used in WP3. WP2. We will refine our proposed intervention to ensure that it is based on the best available evidence and acceptable to key stakeholders. This work will be informed by: (a) findings from WP1 workshops, (b) our existing treatment manual; (c) relevant systematic reviews; and (d) semi-structured interviews with 15-20 suicidal prisoners, 15-20 Samaritans-trained Listeners , and 15-20 prison staff. Findings will be synthesised using consensus methods to produce a logic model and a therapy manual. WP3. We will evaluate the effect of the PROSPECT therapy programme on patient and health economic outcomes using a randomised controlled trial. A target sample size of 360 participants from four host prisons will be recruited, which will have 90% power to detect an effect size of 0.36. Two co-primary outcomes will be the number of suicidal behaviours in past 6 months, and current suicidal ideation. Secondary outcomes include psychological correlates of suicide, symptoms of psychopathology, social functioning, quality of life and health economics. We will collect outcome measures at baseline, and 6-months. Following baseline assessments, participants will be randomised to the intervention arm plus treatment as usual, or usual care alone. Analysis will follow intention-to-treat principles and we will follow the CONSORT statement for non-pharmacological interventions. WP4. A mixed-methods process evaluation will be embedded within WP3 to identify contextual factors that promote/inhibit implementation and routine incorporation into everyday practice. We will record the number of patients who were offered and received the intervention and the number and quality of therapy sessions delivered. We will interview 30-40 prison-based staff and 30-40 prisoners about their experiences of the intervention, with transcripts examined using a framework analysis. Non-participant observation of staff and participant behaviour will inform our understanding of how the intervention is actually implemented. Timelines for delivery WP1: Months 1-18 WP2: Months 1-18 WP3: Months 7-48 WP4: Months 7-48 Anticipated Impact and Dissemination Improving access to effective, targeted psychological therapies in prison settings is likely to reduce the number of suicide attempts, as well as reduce distressing mental health symptoms, and improve patients well-being and resilience during imprisonment. Our key output will be a potentially clinically and cost-effective intervention that increases patient access to psychological therapy for suicidal prisoners, is feasible to deliver and is acceptable to service users and staff. A comprehensive dissemination strategy will be co-developed with key stakeholders.

Lay abstract: Background: Suicide behaviour refers to attempts made by someone trying to end their life, but who did not die. Suicide behaviour in UK prisons is a large problem, with more than 42,000 instances in the past year. In the UK, every suicidal patient should have access to targeted psychological treatments. However, this access is severely limited for prisoners. Additionally, the prison setting is designed to focus upon security rather than care with help-seeking often seen as vulnerability to be exploited. It has now been recognised that we need to know more about how suicidal prisoners should best be treated. To do this, we will look at how effective psychological therapy for suicidal prisoners is and if it offers good value for money. We need to bear in mind that prisoners often have multiple and complex mental health problems with very limited previous contact with health services. The new PROSPECT therapy therefore commences with a preparatory phase, to help the prisoner develop trust with the therapist and find new ways of managing difficult emotions. The second phase then targets the underlying thoughts and behaviours responsible for suicide behavior. Aims: The overall aim of this project is to increase access to psychological therapy for suicidal prisoners. Methods: We will complete four packages of work. WP1: Co-production of a workbook to help support prisoners access the preparatory phase of the PROSPECT therapy. WP2: Working alongside service users and staff, we will adapt the PROSPECT therapy to best fit prison settings. WP3: We will evaluate if the adapted PROSPECT therapy improves outcomes. Working across four prisons, we will recruit 360 suicidal prisoners. Half will receive their usual care and half will also access the PROSPECT therapy for 6 months. We will measure the effect of the therapy upon the number of suicidal thoughts and behaviours, patient wellbeing and quality of life. We will also assess if the PROSPECT therapy offers value for money. WP4: We will interview and observe prisoners and staff to find out how PROSPECT therapy is actually delivered in prison and what may prevent/encourage PROSPECT therapy becoming routine care. Patient and Public Involvement: We recognise the importance of in our research. Ex-offenders have been fundamentally involved in developing this project. Chaired by an ex-offender researcher, a group of ex-offenders and family/carers will provide ongoing advice to the project about participant recruitment, study materials, making sense of results and dissemination. Dissemination: If we want to offer the PROSPECT therapy to all suicidal prisoners in England and Wales, we need to tell a range of stakeholders about our research. We will share what we have learned via academic publications, conferences, press releases and with service user organisations.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH