Towards a health-informed approach to penal reform? Evidence from ten countries It’s awful watching people rot away on heroin in C [Category] prisons, locked up 23 hours a day looking out at an industrial estate and a KFC. Heroin is easy to get in prison, it’s everywhere. More people pick up drug habits than get clean in prison. Drugs get in over fences, in all kinds of ways, it’s unwavering, people are openly using. Male ex-prisoner, England The consequences of drug use in prison include drug-related deaths as well as suicide attempts, violence, intimidation and selfharm due to drug debts. Drug use tends to be more dangerous in prisons because of the scarcity of drugs themselves and the lack of sterile injecting equipment, which raises the risk of disease transmission. During the past decade, the use of synthetic cannabis and other novel psychoactive substances (NPS) has become widespread in prisons in some countries.13 In England and Wales, inspectors have reported that NPS use has led to increased violence, both as a direct result of the drugs’ effects and because of violence due to debts (Her Majesty’s Inspectorate of Prisons, 2015). European research suggests this is a matter of increasing concern in several other EU countries (European Monitoring Centre for Drugs and Drug Addiction, 2018). 3.1.5 Effects of incarceration on mental health It has long been recognised that psychological harm can result from the loss of liberty, separation from family and community, deprivation of autonomy and material deprivation – all factors that characterise imprisonment. Mentally, the effects of the sentence were to make my memory poor. My mental functioning was very slow after release. I had no confidence, low self-esteem. Technology was impossible for me. Even now I struggle, I have to get help. The often traumatic experience of being taken into custody (for Female ex-prisoner 2, Kenya the first time, in particular) can exacerbate pre-existing mental illness and can propel people with mental health vulnerability into violence, substance abuse, self-harm and even suicide. People with existing mental health conditions have been found to be more likely to be involved in violence, victimisation and prison rule infractions (Fazel et al, 2016). In the context of very long or indeterminate sentences, psychological harm may result from specific features of these, for example, when prisoners have no way of knowing how much longer they will be held once the tariff set by the court has been served (Crewe, 2011). Sentences of this kind often feature ongoing or regular psychological assessments designed to produce evidence to help inform parole boards or courts about whether someone is safe to be released. Prisoners serving such sentences have complained of the unpredictability and obscurity of the assessment and decision-making processes involved. These aspects of the sentence may have adverse effects on mental health and hinder prisoners’ efforts to come to terms with their offence and make sense of the sentence they are serving. I spent the first month in complete shock and I thought I would wake up and go home. It wasn’t real. … And it hurt - it felt like somebody was ripping my chest open. I saw no future, no point to tomorrow. It was the darkest time of my life. ‘Maria’, English prisoner (in Crewe et al, 2017) 3.1.6  Suicide and self-harm Suicide risk is considerably higher in prisoners than in people in the general population of similar age and gender. The relative risk of death by suicide in male prisoners is three to six times greater than that of the general population; and even higher than this for female prisoners (Fazel et al, 2017). Risks of suicide and attempted suicide and of the onset of psychiatric disorders are higher at the point of first entry into custody than later in the prison term: the ‘entry shock’ phenomenon (Jewkes, 2002: 2). 13 Novel psychoactive substances are a range of drugs that have been designed to mimic established illicit drugs such as cocaine, ecstasy and cannabis. Synthetic cannabis has been sold online since at least 2004. It has been reported to have various negative side effects. (Alcohol and Drug Foundation, Australia. https://adf.org.au/drug-facts/ne2w-psychoactive-substances/) 10