Psychiatric problems of detainees under the Anti-Terrorism Crime and Security Act 2001

AIMS AND METHOD 

To provide a composite view of the impact of indefinite detention under the Anti-Terrorism Crime and Security Act 2001. Until recently, a number of detainees had been detained under this legislation since December 2001. The impact of this on eight detainees and three of their spouses is examined through qualitative analysis of 48 reports and documents compiled by 11 psychiatrists and 1 psychologist.

RESULTS 

Detention has had a severe adverse impact on the mental health of all detainees and the spouses interviewed. All were clinically depressed and a number had post-traumatic stress disorder. The indefinite nature of detention was a major factor in their deterioration.

CLINICAL IMPLICATIONS 

The use of indefinite detention without trial has severe adverse consequences that may pose insurmountable problems for the prison healthcare system.


RESULTS
Detention has had a severe adverse impact on the mental health of all detainees and the spouses interviewed. All were clinically depressed and a number had post-traumatic stress disorder. The indefinite nature of detention was a major factor in their deterioration.

CLINICAL IMPLICATIONS
The use of indefinite detention without trial has severe adverse consequences that may pose insurmountable problems for the prison healthcare system. From December 2001 until March 2005 a number of foreign nationals were detained indefinitely under the Anti-Terrorism Crime and Security Act 2001 on the grounds that they were a threat to national security. This was a unique situation. Previous published work on detention has been in relation to regimes which use torture during the process of detention. The closest analogue to the recent situation is the position of asylum seekers in detention awaiting immigration decisions, where a number of studies have highlighted the damaging impact that detention may have.
The Victorian Foundation for Survivors of Torture (1998) in Australia found high rates of mental illness in relation to detention of 17 East Timorese. They found that all had post-traumatic stress disorder (PTSD), 94% had depression and 65% severe anxiety. Clinically significant suicidal ideation was also reported. In a further group of 46 Cambodian asylum seekers detained for up to 2 years Steel et al (2004) found that 62% had PTSD, all were clinically depressed and 94% had clinical anxiety.
Silove et al (1998) surveyed 25 detained Tamil asylum seekers held in Victoria, Australia. Compared with community-based Tamil asylum seekers, detainees reported a greater level of trauma exposure, were more depressed, suicidal, and suffered more extreme posttraumatic and physical symptoms. Past trauma exposure did not entirely account for symptom differences across the groups, suggesting that detention was a cause of mental health problems among detainees.
In the UK, Bracken & Gorst-Unsworth (1991) carried out a file audit of ten detained asylum seekers, of whom six had documented physical evidence of torture. All reported depressed mood, appetite loss and somatic symptoms. Suicidal ideation was present in four, with two having a history of serious suicide attempts. This was similar to another UK study by Pourgourides et al (1995) of 15 detained asylum seekers. The majority gave histories of traumatic experience and presented with high levels of depressive and post-traumatic stress symptoms, profound despair and suicidal ideation. There were serious attempts at self-harm.
Sultan (2001), a physician who himself was held in detention, described the situation for 36 detainees held for over 12 months in detention in Australia. Thirty-three had clear evidence of severe depression, the remaining three experiencing mild depressive symptoms. Six developed clear psychotic symptoms and five had strong aggressive impulses and persistently self-harmed. Most displayed little if any of those symptoms prior to their detention. Sultan & O'Sullivan (2001) described deteriorating psychological well-being in 33 people held for over 9 months, with the immigration process being implicated in the deterioration. Of these, 85% were depressed and 32 out of 33 displayed significant symptoms during their detention. Keller et al (2003) in a survey of detainees in the USA found that 77% had clinically significant symptoms of anxiety, 86% depression and 50% PTSD. At follow-up they found that those released had a marked reduction in psychological symptoms but those still detained had deteriorated. There was a strong association between level of symptoms and length of detention.
These studies suggest that detention per se is a strong factor in causing deterioration in mental health over and above any mental health problems that are the result of pre-detention trauma. Although there are a number of parallels, immigration detainees always have hope of an end-point in terms of an immigration tribunal or court decision, something the Belmarsh detainees did not have during their imprisonment.

Method
This study concerns eight detainees under the 2001 Anti-Terrorism Crime and Security Act. It originated from a series of reports prepared at the request of solicitors and is based on the independent reports of 11 consultant psychiatrists and 1 consultant clinical psychologist. Concern grew with the realisation that there were a number of common features in the independent reports.
All detainees were seen on more than one occasion and by more than one clinician. In addition, reports by physicians, occupational therapists and social workers also informed the process. In total, 48 reports and documents were included in this analysis. The documents were subject to qualitative analysis, but only findings which were corroborated by more than one clinician were reported. The results of the analysis were circulated to all the authors for comments and verification and following a number of iterations were developed into the final report (Robbins et al, 2004). This paper represents an abbreviated version of that report.

Pre-migration factors
Six of the detainees were Algerian, one was Tunisian and one from Gaza. All were literate and educated, in some cases to university level. Four had a previous psychiatric history prior to their arrest and three had a clear family history of mental health problems. Several had serious physical health problems, including bilateral traumatic amputation of arms, the consequences of childhood polio, lower back injuries, etc., which interact with and influence mental state. Three had experienced previous detention and torture, but all had been in situations of political instability and unrest. All were devout Muslims and originate from countries where mental illness is highly stigmatised.

Presentation and progress following detention
All the detainees were found to have significant levels of clinical depression and anxiety and showed deterioration over time. In a number of cases there was also a diagnosis of PTSD. This was in relation to pre-migration events, their arrest and imprisonment or both working synergistically. There was a high level of suicidal ideation and attempts at self-harm. Deterioration in mood state was clearly linked to a sense of helplessness and hopelessness, which is an integral factor in indefinite detention. Concern with regard to their wives' mental state was exacerbating the mental health problems of some detainees.
On a number of occasions, detainees' behaviour had been interpreted by prison staff as manipulative, particularly where there was a failure to cooperate with the healthcare regimes. There is clearly a failure to perceive that this behaviour could reflect a deterioration in mental state. Where there were complex health needs, as for instance in the case of a polio survivor and amputee, these needs were not being adequately met within the prison system.
As their mood deteriorated a number developed significant psychotic symptoms which were not present prior to detention. In one detainee who was released on stringent conditions of house arrest, the psychotic symptoms receded within a short period following release, but the underlying depressive features were more slow to respond. In another case, although transfer to Broadmoor produced an initial improvement in clinical state, this has since fluctuated.
There is a strong consensus among the clinicians that indefinite detention per se is directly linked to deterioration in mental health and that fluctuations in mental state are related to the prison regime itself and to the vagaries of the appeal system. While indefinite detention continues there is agreement that it is highly unlikely that the prison healthcare team will be able to combat the deterioration in mental health. This is not a criticism of the prison psychiatric inreach team, rather it is an acknowledgement of the extent of the damage which indefinite detention without trial gives rise to.

Impact of detention on spouses
Three wives were seen by two clinicians whose reports show a high degree of congruence. There is clearly a high burden of stress imposed on wives and this is contributing negatively to their mental state. Whereas having a husband in prison may be seen as stressful for many women, their problems are seen as over and above what would normally be expected.
All three women were showing signs of clinical depression, with one showing signs of PTSD and another a phobic anxiety state. Their symptoms were related directly to the incarceration of their husbands and its indefinite nature, with their isolation compounding their difficulties. Their state fluctuated in relation to their husbands' problems and is unlikely to improve in the near future.

House of Lords decision
In December 2004, the Appellate Committee of the House of Lords (2004) delivered a judgment that found indefinite detention without trial to be contrary to fundamental legal principles. Lord Hoffmann one of the judges involved stated 'This is one of the most important cases which the House has had to decide in recent years. It calls into question the very existence of an ancient liberty of which this country has until now been very proud: freedom from arbitrary arrest and detention.The power which the Home Secretary wishes to uphold is a power to detain people indefinitely without trial or charge. Nothing could be more antithetical to the instincts and traditions of the people of the United Kingdom'.
The detainees were released in March 2005, but only after further powers were introduced in the form of control orders in the Prevention of Terrorism Act 2005.

Discussion
The detainees originated from countries where mental illness is highly stigmatised. For devout Muslims there is a direct prohibition against suicide, making the number who have attempted or are considering suicide very significant. All the detainees had serious mental health problems which were the direct result of, or were seriously exacerbated by, the indefinite nature of the detention. The mental health problems predominantly took the form of major depressive disorder and anxiety. A number of detainees developed psychotic symptoms as they deteriorated. Some experienced PTSD, as a result of their pre-migration trauma, their arrest and imprisonment or the interaction between the two.
Continued deterioration in their mental health was also affected by the nature of, and their mistrust in, the prison regime and the appeals process, as well as the underlying and central factor of the indefinite nature of detention. The prison healthcare system was unable to meet their health needs adequately. This is not a criticism of the healthcare system but is rather an acknowledgement of the causative role of the indefinite nature of the detention in the generation of mental illness. There was, however, a failure by prison staff to perceive self-harm and distressed behaviour as part of the clinical condition rather than being purely manipulative.
The mental health problems of the detainees did not resolve while they were maintained in detention. The detainees' problems were remarkably similar to those described in relation to immigration detention. There too, there are high levels of depression and anxiety, with the length of time in detention relating directly to the severity of symptoms. The indefinite nature of detention per se is acknowledged as causal in relation to psychiatric problems.
There is also evidence that this had a severe adverse effect on the wives of the men in detention. Their symptoms were related to the incarceration of their husbands and the indefinite nature of the detention. Their isolation exacerbated the impact of their husbands' detention and there was little improvement while their husbands were detained. The condition of the wives also had a corresponding effect on their husbands' mental state.
In conclusion, there is evidence from repeated clinical interviews carried out by expert clinicians that indefinite detention has a damaging impact on mental health. All of the detainees experienced major depressive disorder and anxiety, with some experiencing PTSD. Their healthcare needs could not be adequately met while they remained in detention. There was also a major impact on the wives of detainees. The problems of the current detainees are similar to those described in the literature for prolonged immigration detention with the caveat that in the case of immigration detainees there is always an end-point.
The process of indefinite detention has been deemed to be unlawful and the men have been released under control order restrictions but are still suffering adverse consequences of their detention. In come cases, this is being further aggravated by the restrictions inherent in the control orders.

Declaration of interest
All of the authors were initially instructed by solicitors and received payment for the preparation of the original independent reports on which this article is based. SILOVE, D., STEEL, Z., McGORRY, P., et al (1998)