Mental disorder in federal offenders: a Canadian prevalence study

Chronic Psychotic Disorders and Correctional Involvement: A Population-Based Matched Case-Control Study in Ontario, Canada

OBJECTIVE

Individuals with chronic psychotic disorders are overrepresented in correctional facilities, but little is known about factors that increase the risk of correctional involvement. The objective of this study was to compare individuals with chronic psychotic disorders who were released from correctional facilities in Ontario to individuals with chronic psychotic disorders but no correctional involvement on sociodemographic, clinical, and prior mental health-related health service utilization characteristics.

METHOD

All individuals with chronic psychotic disorders who were released from a provincial correctional facility in Ontario in 2010 were matched (1:2) by age and sex to Ontario residents with chronic psychotic disorders and no correctional involvement. Covariates included sociodemographic (rural residence, marginalization such as residential instability quintile, material deprivation quintile, dependency quintile, and ethnic concentration quintile) and clinical (duration of chronic psychotic disorder and comorbidities) characteristics, and mental health-related health service utilization characteristics (primary care physician, psychiatrist and emergency department visits, and hospitalizations) 1 and 3 years prior to correctional involvement. The association between correctional involvement and prior health service utilization was measured by estimating incidence rate ratios using Poisson and negative-binomial regressions.

RESULTS

Individuals with correctional involvement (N = 3,197) lived in neighbourhoods with higher material deprivation and residential instability, and had a shorter duration of illness, and more psychosocial comorbidities (e.g., behavioural issues and depression) than individuals without correctional involvement (N = 6,393). Adjusting for sociodemographic and clinical variables, individuals with correctional involvement had a higher rate of mental health-related primary care physician visits, emergency department visits, and hospitalizations but a lower rate of psychiatrist visits prior to correctional involvement, compared to individuals without correctional involvement.

CONCLUSIONS

Despite higher mental health-related comorbidities and higher rates of accessing acute mental health services among individuals with chronic psychotic disorders and correctional involvement, visits to psychiatrists prior to involvement were low.

Addressing the Mental Health Needs of Inmates Through Education for Correctional Officers-A Narrative Review

INTRODUCTION

People with mental illness are overrepresented in correctional facilities. Correctional officers (COs) lack education to respond to inmates with mental illness. A review was conducted of mental health education programs for COs to identify factors related to effectiveness.

METHODS

Medical and criminal justice databases were searched for articles describing mental health education for COs. Studies including measurable outcomes were analyzed using an inductive analytic approach. The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Data were synthesized using Moore seven levels of outcomes for continuing professional development education. Findings were grouped by curriculum content and described according to levels of outcome.

RESULTS

Of 1492 articles, 11 were included in the analysis. Six described mental health programs, two described skill-specific programs, and three described suicide prevention programs. Programs reviewed content about mental illness, practical skills, included didactic and experiential teaching. The programs achieved level 5 on Moore taxonomy. Programs led to improvements in knowledge, skills, and attitudes among officers; however, improvements declined post-training. Officers were receptive to facilitators with correctional or lived mental health experience. Experiential teaching was preferred. Common themes related to programs' effectiveness included applicability to COs, information retention, program facilitators, and teaching methods.

DISCUSSION

There is limited, but positive literature suggesting that education programs are beneficial. The decline in improvements suggests need to ensure sustainability of improvements. This review can guide the planning of future education programs for COs based on continuing professional development best practices.

Prevalence of Mental Health and Addiction Service use Prior to and During Incarceration in Provincial Jails in Ontario, Canada: A Retrospective Cohort Study

OBJECTIVE

Individuals with mental illness and addiction are overrepresented in prisons. Few studies have assessed mental health and addiction (MHA)-related service use among individuals experiencing incarceration using health administrative data and most focus on service use after prison release. The objective of this study was to determine the prevalence of MHA-related service use in the 5 years prior to and during incarceration.

METHODS

We used linked correctional and administrative health data for people released from Ontario provincial jails in 2010. MHA-related service use in the 5 years prior to the index incarceration was categorized hierarchically into four mutually exclusive categories based on the type of service use: psychiatric hospitalization, MHA-related emergency department (ED) visit, MHA-related outpatient visit (from psychiatrist or primary care physician), and no MHA-related service use. Demographic, diagnostic, and incarceration characteristics were compared across the four service use categories. MHA-related service use during the index incarceration was assessed by category and length of incarceration.

RESULTS

A total of 48,917 individuals were included. Prior to incarceration, 6,116 (12.5%) had a psychiatric hospitalization, 8,837 (18.1%) had an MHA-related ED visit, and 15,866 (32.4%) had an MHA-related outpatient visit. Of the individuals with any MHA-related service prior to incarceration, 60.4% did not receive outpatient care from a psychiatrist prior to incarceration and 65.6% did not receive MHA-related care during incarceration.

CONCLUSION

Despite a high prevalence of mental illness and addiction among people experiencing incarceration, access to and use of MHA-related care prior to and during incarceration is poor. Increasing the accessibility and use of MHA-related services throughout the criminal justice pathway is warranted.

The prevalence of comorbid serious mental illnesses and substance use disorders in prison populations: a systematic review and meta-analysis

BACKGROUND

Comorbid mental illnesses and substance use disorders are associated with adverse criminal, social, and health outcomes. Yet, their burden is not reliably known among prison populations. We therefore aimed to estimate the prevalence of comorbid serious mental illnesses and substance use disorders (dual disorders) among people in prison worldwide.

METHODS

In this systematic review and meta-analysis, we searched 15 electronic databases (ASSIA, CAB Abstracts, Criminal Justice Database, Embase, Global Health, Global Index Medicus, IBSS, MEDLINE, NCJRS, PAIS Index, PsycINFO, Russian Science Citation Index, Scielo, Social Services Abstracts, and Web of Science) and the grey literature (Open Grey and ProQuest Dissertations & Theses Global) for studies reporting the prevalence of serious mental illnesses and substance use disorders in prison populations published between Jan 1, 1980, and Sept 25, 2021, and contacted the authors of relevant studies. Empirical studies among unselected adult prison populations that applied representative sampling strategies and validated diagnostic instruments, and either reported the prevalence of dual disorders or had authors who could provide prevalence data in correspondence, were included. Two reviewers (GB and SDL) independently extracted data from the eligible studies; both current (up to 1 year) and lifetime prevalence were extracted, if available. We sought summary estimates. Our primary outcomes were comorbid non-affective psychosis with substance use disorders and comorbid major depression with substance use disorders. We conducted a random-effects meta-analysis, explored between-sample heterogeneity with meta-regression, and calculated odds ratios (ORs) to assess bidirectional relationships between mental and substance use disorders. Risk of bias was assessed by use of a standard tool. The study protocol was registered with PROSPERO, CRD42020207301.

FINDINGS

Of 11 346 records screened, we identified 34 studies reporting the prevalence of dual disorders among individuals in prison and received unpublished prevalence data for 16 studies, totalling 50 eligible studies and 24 915 people. The mean quality score of included studies was 7·8 (SD 1·2). We found that 3·5% (95% CI 2·2-5·0) had current non-affective psychosis with any comorbid substance use disorder, representing 443 (49·2%) of 900 people with non-affective psychosis, and 9·1% (5·6-13·3) had current major depression and comorbid substance use disorders, representing 1105 (51·6%) of 2143 people with major depression. Between-sample heterogeneity was high (I2>80%). People in prison with current non-affective psychosis were significantly more likely to have substance use disorders compared with those without (OR 1·7, 95% CI 1·4-2·2). People with major depression had higher odds of substance use disorders than those without (1·6, 1·3-2·0).

INTERPRETATION

Around half of the prison population with non-affective psychosis or major depression have a comorbid substance use disorder. Consideration should be given to screening for dual disorders and implementing integrated and scalable treatments.

FUNDING

Economic and Social Research Council, Agencia Nacional de Investigación y Desarrollo (Chile), and the Wellcome Trust.

A retrospective records study of patterns in mental health and criminal justice service use by people found not criminally responsible on account of mental disorder

BACKGROUND

While the presence or absence of previous healthcare and criminal justice system (CJS) contacts in the histories of mentally ill offenders has been well-studied, the frequency of these contacts and when they occur in the period leading up to an index criminal event has received less research attention.

AIMS

To explore patterns of healthcare and CJS use in the year prior to a criminal act leading to a Not Criminally Responsible on Account of Mental Disorder (NCRMD) finding in Canada.

METHODS

In this 3-year retrospective records study, the case files of all patients newly admitted to the British Columbia forensic psychiatric system after a finding of NCRMD between 1st July 2012 and 31st July 2015 were reviewed. Data were extracted on healthcare and CJS use for the 12 months before the act leading to the NCRMD finding. Time-based descriptive statistics and two-step cluster analysis were used to investigate service use patterns.

RESULTS

Among 94 eligible patients, only four had no service contacts in the year leading up to the index event, leaving 90 in the cohort for further analysis. On average, these 90 patients had seven contacts with health or criminal justice services in the year prior to the index offence. Cluster analysis revealed a high healthcare pathway group who had had many healthcare and few CJS contacts; a limited service user group who had had few contacts of any kind and a heavy service user group who had had a high volume of contacts with both types of service providers.

CONCLUSIONS

The different patterns of patient contact prior to the index event imply that each practitioner-type has distinct and temporally relevant opportunities to provide preventative interventions to their patients or user groups.

A Qualitative Study of Success in Postrelease Federal Inmates With Mental Health Issues

Considerable research has focused on factors that put individuals at risk for recidivism after their release from incarceration. While recent research has increased the focus on protective factors and resilience, the experiences of people with mental health issues who successfully reintegrate into the community are not well-understood. The present study was conducted to determine which positive factors are implicated in the successful reintegration of people with mental health issues. In-depth, semi-structured interviews were conducted with four male former federal inmates on supervised release in Canada. The interviewees were nominated by staff who knew them to have previously been diagnosed with a mental disorder and perceived them to be doing well in the community. Volunteering and social support were found to be of the greatest importance in their successful outcomes. Additionally, all interviewees had access to mental health services, which likely influenced their success.

Is mental illness associated with placement into solitary confinement in correctional settings? A systematic review and meta-analysis

The aim of this meta-analysis was to examine the association between any mental health problem and the risk of being placed into solitary confinement in correctional settings. PubMed, PsycINFO, Web of Science and Google Scholar were searched from each database's inception date to November 2019. All publications assessing both mental health problems and placement into solitary confinement in a sample of adult inmates in correctional settings were included. The meta-analysis was performed using random-effects models. Heterogeneity among study point estimates was assessed with Q statistics and quantified with I² index. Publication bias was assessed with funnel plots. Guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed throughout. After screening 2777 potential studies, 11 studies were included amounting to a total of 163 414 inmates. Included studies comprised of a mix of mental disorders rather than a specific diagnosis per se. The odds ratio (OR) from the pooled studies was 1.62 (confidence interval (CI) = 1.21-2.15). The observed relationship remained unchanged regardless of the removal of outliers (OR = 1.63, CI = 1.47-1.80) and regardless of the adjustment of confounders (OR = 1.58, CI = 1.32-1.88). The present study shows a moderate association between any mental health problem and placement into solitary confinement within a considerable sample of inmates. As more individuals suffering from mental illness enter the correctional system, it is essential that correction officials create new safe interventions to manage these inmates and offer them proper mental health care to limit the use of solitary confinement, which may have deleterious effects.

Mental disorders in a forensic sample of sexual offenders

Objective

The present study examined the prevalence of DSM IV axis I disorders and DSM IV personality disorders among sexual offenders in Forensic State Hospitals in Germany.

Method

Current and lifetime prevalence rates of mental disorders were investigated based on clinical structured interviews among sexual offenders (n = 55). Additionally, subgroups were analyzed on the basis of diagnostic research criteria, with 30 sexual offenders classified as paraphiliacs and 25 sexual offenders as having an impulse control disorder (without paraphilia).

Results

Anxiety disorders, mood disorders, and substance use disorders were common among sexual offenders, as were cluster B and cluster C personality disorders. While social phobia was most common among paraphilic sexual offenders, major depression was most prevalent in impulse control disordered sexual offenders.

Conclusion

The results replicate recent findings of high psychiatric morbidity in sexual offenders placed in forensic facilities. Furthermore, differential patterns of co-morbid mental disorders were found in paraphiliacs and impulse control disordered sexual offenders. With regard to an effective therapy and relapse prevention co-morbid mental disorders should be a greater focus in the assessment of subgroups of sexual offenders.

The Unhappy Mental Health Triad: Comorbid Severe Mental Illnesses, Personality Disorders, and Substance Use Disorders in Prison Populations

BACKGROUND

Information on the comorbidity of mental health problems in prison populations is scarce. The aim of the present study was to assess the prevalence of comorbidities at intake to prison between three diagnostic groups: severe mental illnesses (SMIs), personality disorders (PDs), and substance use disorders (SUDs). The co-occurrence of those disorders in prison populations may require the integration of differential treatment approaches and novel treatment trials.

METHODS

A consecutive sample of N = 427 (229 male and 198 female) individuals committed to imprisonment in Santiago de Chile was assessed with the Mini Neuropsychiatric Interview and the Structured Clinical Interview for DSM-IV (module for borderline personality disorders) on arrival at prison. Diagnoses were a priori grouped as SMI including psychosis, bipolar disorder and major depression, PD including borderline and antisocial PD and SUD including alcohol and drug abuse or dependence. Sex stratified multivariate binary logistic regression analyses were conducted to assess sociodemographic, criminal and treatment characteristics of individuals with at least one diagnosis from each of the three diagnostic groups.

RESULTS

The triad of SMI, PD, and SUD was present in n = 138 (32.3%; 95% IC: 28.0-36.9) study participants, n = 105 (45.9%; 95% CI: 39.4-52.4) of the men and n = 33 (16.7%; 95% CI: 12.1-22.6) of the women. Among those with the disorder triad, n = 129 (30.2%; 95% CI: 26.0-34.8) had major depression, PD and SUD; n = 54 (12.6%; 95% CI: 9.8-16.2) had psychosis, PD and SUD. The disorder triad was more common in men (OR = 4.86; 95% IC: 2.63-8.95), younger age (OR = 0.94; 95% CI: 0.91-0.97), and participants with lower educational levels (OR = 1.69; 95% CI: 1.01-2.82). The disorder triad was significantly associated with previous incarcerations (OR 2.60; 95% CI: 1.55-4.34) and histories of psychiatric hospitalizations (OR 2.82; 95% CI: 1.27-6.28).

DISCUSSION

The complex triad of disorders from different diagnostic groups is common in prison populations, especially among young men. Successful treatment interventions may have the potential to break a cycle of repeat institutionalization in prisons and psychiatric institutions.

Prevalence of Posttraumatic Stress Disorder in Prisoners

People involved with criminal justice frequently are exposed to violence and traumatic experiences. This may lead to posttraumatic stress disorder (PTSD); however, no review, to our knowledge, has synthetized findings in this setting. We conducted a systematic review and meta-analysis to estimate prevalence rates of PTSD in prison populations. Original studies in which prevalence rates of PTSD in unselected samples of incarcerated people were reported were systematically searched between 1980 and June 2017. Data were pooled using random-effects meta-analysis, and sources of heterogeneity for prespecified characteristics were assessed by meta-regression. We identified 56 samples comprising 21,099 imprisoned men and women from 20 countries. Point prevalence of PTSD ranged from 0.1% to 27% for male, and from 12% to 38% for female prisoner populations. The random-effects pooled point prevalence was 6.2% (95% confidence interval: 3.9, 9.0) in male prisoners and 21.1% (95% confidence interval: 16.9, 25.6) in female prisoners. The heterogeneity between the included studies was very high. Higher prevalence was reported in samples of female prisoners, smaller studies (n < 100), and for investigations based in high-income countries. Existing evidence shows high levels of PTSD among imprisoned people, especially women. Psychosocial interventions to prevent violence, especially against children and women, and to mitigate its consequences in marginalized communities must be improved. Trauma-informed approaches for correctional programs and scalable PTSD treatments in prisons require further consideration.

Physician prescribing of opioid agonist treatments in provincial correctional facilities in Ontario, Canada: A survey

Background

Substance use and substance use disorders are common in people who experience detention or incarceration in Canada, and opioid agonist treatment (OAT) may reduce the harms associated with substance use disorders. We aimed to define current physician practice in provincial correctional facilities in Ontario with respect to prescribing OAT and to identify potential barriers and facilitators to prescribing OAT.

Methods

We invited all physicians practicing in the 26 provincial correctional facilities for adults in Ontario to participate in an online survey.

Results

Twenty-seven physicians participated, with representation from most correctional facilities in Ontario. Of participating physicians, 52% reported prescribing methadone and 48% reported prescribing buprenorphine/naloxone to patients in provincial correctional facilities. Nineteen percent of participants reported initiating methadone treatment and 11% reported initiating buprenorphine/naloxone for patients in custody. Participants identified multiple barriers to initiating OAT in provincial correctional facilities including concerns about medication diversion and safety, concerns about initiating treatment in patients who are not currently using opioids, lack of linkage with community-based providers and the Ministry of Community Safety and Correctional Services policy. Identified facilitators to initiating OAT were support from institutional health care staff and administrative staff, adequate resources for program delivery and access to linkage with community-based OAT providers.

Conclusions

This study identifies opportunities to improve OAT programs and to improve access to OAT for persons in provincial correctional facilities in Ontario.

The associations of poor psychiatric well-being among incarcerated men with injecting drug use histories in Victoria, Australia

BACKGROUND

Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome.

METHODS AND RESULTS

Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being.

CONCLUSIONS

Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.

The Nexus of Trauma, Victimization, and Mental Health Disorders Among Incarcerated Adults in Spain

Victimization and exposure to trauma, commonly linked to co-occurring mental health disorders, are prevalent among prison populations. The purpose of this study is to shed light on the prevalence of various kinds of victimization and trauma exposure at distinct life stages (childhood, adulthood and during prison) among incarcerated persons in Spain. The research team surveyed a random sample of 453 male and female inmates, serving time in two Spanish prisons, to gather information on experiences of physical and sexual victimization in both childhood and adulthood along with the presence or absence of in-prison treatment for a mental health disorder(s). More than 80% of participants reported experiencing some kind of traumatic/shocking life event - and this was significantly higher for those receiving in-prison mental health treatment than their non-treated counterparts (96.3 versus 83.3%, respectively). Logistic regression analyses revealed that inmates who were receiving in-prison treatment for a mental health disorder reported significantly higher rates of both physical and sexual victimization in prison, prior to prison, and during childhood. The results of this study strongly suggest the importance of comprehensive and accurate identification of inmates' traumatic, victimization, and mental health histories that necessitate treatment during incarceration. We discuss the implications of our study for correctional practice, policy and future research in order to reduce victimization in the Spanish Prison System.

The impact of a community mental health initiative on outcomes for offenders with a serious mental disorder

BACKGROUND

The Community Mental Health Initiative (CMHI) is mandated to assist offenders with serious mental disorders in their transition from institutions to the community, but this incorporates different styles of service. An important unanswered question is whether these are equivalent.

AIMS/HYPOTHESES

Our aim was to compare outcomes for different intervention styles within the CMHI, a programme for serious offenders in prison who also have at least one major mental disorder. Our specific research questions were as follows: do outcomes differ according to whether offenders with mental health difficulties receive (1) clinical discharge planning only; (2) community mental health services only; (3) the combined services or (4) none, although meeting criteria for any CMHI service?

METHODS

Survival analyses, controlling for variables with a significant effect on recidivism or return to prison, were used to test for differences in recidivism or return to prison rates between the intervention and no-intervention groups during a fixed follow-up period.

RESULTS

Men receiving only community mental health services had a significantly lower risk of returning to custody and of recidivism than men receiving discharge planning alone or no community mental health service at all, even after controlling for potential confounders including age, number of previous imprisonments and number of previous community failures. The advantages were apparent within 3-6 months and sustained for up to 4 years.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Provision of specialised community mental health services for higher-risk male offenders with a mental disorder may reduce recidivism in the short and longer term - within 3 months and up to 4 years respectively. Statistical modelling also pointed to the need to include treatment for substance abuse and assistance in identifying stable accommodation and brokerage of community services among the interventions and services. Copyright © 2016 John Wiley & Sons, Ltd.

The prevalence of depression and anxiety disorders in indigenous people of the Americas: A systematic review and meta-analysis

Indigenous populations are considered at higher risk of psychiatric disorder but many studies do not include direct comparisons with similar non-Indigenous controls. We undertook a meta-analysis of studies that compared the prevalence of depression and anxiety disorders in Indigenous populations in the Americas with those of non-Indigenous groups with similar socio-demographic features (Registration number: CRD42015025854). A systematic search of PubMed, Medline, PsycInfo, PsycArticles, ScienceDirect, EMBASE, and article bibliographies was performed. We included comparisons of lifetime rates and prevalence of up to 12 months. We found 19 studies (n = 250, 959) from Latin America, Canada and the US. There were no differences between Indigenous and similar non-Indigenous groups in the 12-month prevalence of depressive, generalised anxiety and panic disorders. However, Indigenous people were at greater risk of PTSD. For lifetime prevalence, rates of generalised anxiety, panic and all the depressive disorders were significantly lower in Indigenous participants, whilst PTSD (on adjusted analyses) and social phobia were significantly higher. Results were similar for sub-analyses of Latin America, Canada and the US, and sensitivity analyses by study quality or setting (e.g. health, community etc.). Risk factors for psychiatric illness may therefore be a complex interaction of biological, educational, economic and socio-cultural factors that may vary between disorders. Accordingly, interventions should reflect that the association between disadvantage and psychiatric illness is rarely due to one factor. However, it is also possible that assessment tools don't accurately measure psychiatric symptoms in Indigenous populations and that further cross-cultural validation of diagnostic instruments may be needed too.

National Prevalence of Mental Disorders among Incoming Canadian Male Offenders

OBJECTIVE

A current estimate of prevalence rates of mental disorder among Canadian federal offenders is required to facilitate treatment delivery and service planning.

METHOD

The study determined prevalence rates of major mental disorders among newly admitted male offenders entering the federal correctional system in Canada. Data were collected at each regional reception site on consecutive admissions for a 6-month period (N = 1110). Lifetime and current prevalence rates were estimated using the Structured Clinical Interview for DSM Axis I Disorders (SCID-I) and the SCID Axis II Disorders (SCID-II). Degree of impairment was estimated using the Global Assessment of Functioning (GAF) scale. Results were disaggregated by Aboriginal ancestry.

RESULTS

The national prevalence rate for any current mental disorder was 73%. The highest rates were for alcohol and substance use disorders; however, over half of participants met the lifetime criteria for a major mental disorder other than alcohol or substance use disorders or antisocial personality disorder. Thirty-eight percent met the criteria for both a current mental disorder and one of the substance use disorders. Fifty-seven percent of offenders with a current Axis I mental disorder were rated as experiencing minimal to moderate functional impairment based on the GAF, indicating that most participants do not require intensive psychiatric services.

CONCLUSIONS

These results underscore the challenge posed to Canadian federal corrections in providing the necessary mental health services to assist in the management and rehabilitation of a significant percentage of the offender population with mental health needs.

Psychiatric needs of male prison inmates in Italy

This paper presents data on the mental health needs of men in an Italian prison and examines if mental health needs of inmates differ across key correctional subpopulations. Interviewers conducted semi-structured clinical interviews with 526 convicted males incarcerated in the Spoleto Prison from October 2010 through September 2011. Nearly two thirds (65.0%) of inmates had an Axis I or Axis II disorder. About half (52.7%) had an Axis I disorder. Personality disorders were the most common disorders (51.9%), followed by anxiety (25.3%) and substance use disorders (24.9%). Over one third of inmates (36.6%) had comorbid types of disorder. The most common comorbid types of disorders were substance use disorders plus personality disorders (20.1%) and anxiety disorders plus personality disorders (18.0%). Findings underscore a significant need for specialized mental health services for men in Italian prisons. Moreover, as inmates return to the community, their care becomes the responsibility of the community health system. Service systems must be equipped to provide integrated services for those with both psychiatric and substance use disorders and be prepared for challenges posed by patients with personality disorders.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.

Probable posttraumatic stress disorder in a sample of urban jail detainees

This study examined the nature and extent of probable posttraumatic stress disorder (PTSD) among men in a substance abuse treatment program in a large urban jail. Specifically, it explored the prevalence of probable PTSD and other psychiatric problems among jail detainees, the types of trauma detainees experienced during different phases of their lives, and how those experiences might have contributed to the development of probable PTSD. Results showed that psychiatric problems were quite serious; nearly one-quarter of the sample reported previous psychiatric hospitalization, and nearly 10% were being currently treated with psychiatric medication. In addition, 21% of the sample met the criteria for probable PTSD, a rate five times greater than that in the general population. The current study suggests that the presence of probable PTSD among male detainees should be incorporated into the creation and implementation of jail-based behavioral healthcare services, including screening, assessment, and clinical interventions. Furthermore, in-custody drug treatment programs should adopt trauma-informed strategies for all program participants as the expected standard of care.

Pre-sentence mental health service use by adult offenders in Western Australia: baseline results from a longitudinal whole-population cohort study

BACKGROUND

Little is known about community mental health service use prior to offending.

AIM

This study aimed to investigate the 1-year community mental health service use by adult offenders (18-44 years) prior to their first ever criminal sentence in Western Australia.

METHODS

Administrative mental health service data were compared between all offenders (n = 23,755) commencing their first ever criminal sentence in Western Australia during 1985-1994 and a matched community group of 21,977 non-offenders.

RESULTS

Just over 8% of offenders had used mental health services prior to sentence compared with 1% of non-offenders. After adjusting for age, offenders were more likely to have used these services than non-offenders in all gender-race groups, but the effect was strongest for non-Indigenous women, who were over 12 times more likely to have used such services, and weakest among Indigenous men, who were about twice as likely to have used them as their non-offending peers. Service use for substance use disorder, the most common diagnosis, was about one and a half times more prevalent among Indigenous than non-Indigenous offenders, regardless of gender. For non-Indigenous offenders, prevalence of any mental health service contact was higher for violent than non-violent offenders, irrespective of gender. Service use was no different between offenders receiving custodial or non-custodial sentences in all gender-race groups.

CONCLUSION

The higher likelihood of mental health service use by offenders in the year prior to their first ever sentence than by non-offenders suggests that, insofar as the disorder was relevant to offending, there were some opportunities for preventive measures during that time. Differential service use according to gender and Indigenous/non-Indigenous status is of concern. It would be important to understand more about this apparently unequal service access, not least because Indigenous populations tend to be over-represented in prison.

Mental health screening tools in correctional institutions: a systematic review

BACKGROUND

Past studies have identified poor rates of detection of mental illness among inmates. Consequently, mental health screening is a common feature to various correctional mental health strategies and best practice guidelines. However, there is little guidance to support the selection of an appropriate tool. This systematic review compared the sensitivity and specificity of mental health screening tools among adult jail or prison populations.

METHODS

A systematic review of MEDLINE and PsycINFO up to 2011, with additional studies identified from a search of reference lists. Only studies involving adult jail or prison populations, with an independent measure of mental illness, were included. Studies in forensic settings to determine fitness to stand trial or criminal responsibility were excluded. Twenty-four studies met all inclusion and exclusion criteria for the review. All articles were coded by two independent authors. Study quality was coded by the lead author.

RESULTS

Twenty-two screening tools were identified. Only six tools have replication studies: the Brief Jail Mental Health Screen (BJMHS), the Correctional Mental Health Screen for Men (CMHS-M), the Correctional Mental Health Screen for Women (CMHS-W), the England Mental Health Screen (EMHS), the Jail Screening Assessment Tool (JSAT), and the Referral Decision Scale (RDS). A descriptive summary is provided in lieu of use of meta-analytic techniques due to the lack of replication studies and methodological variations across studies.

CONCLUSIONS

The BJMHS, CMHS-M, CMHS-W, EMHS and JSAT appear to be the most promising tools. Future research should consider important contextual factors in the implementation of a screening tool that have received little attention. Randomized or quasi-randomized trials are recommended to evaluate the effectiveness of screening to improve the detection of mental illness compared to standard practices.

Symptoms and treatment of mental illness among prisoners: a study of Michigan state prisons

This study reports on a representative sample of prisoners in Michigan correctional facilities to determine the prevalence of psychiatric illness and the delivery of mental health (MH) services. Mental health assessments were conducted with 618 incarcerated subjects using the interRAI Correctional Facilities (interRAI CF). Subjects were randomly sampled based on four strata: males in the general population, males in administrative segregation, males in special units, and females. The interRAI CF assessments were merged with secondary data provided by the Michigan Department of Corrections (MDOC) containing information on MH diagnoses or services that the subjects were receiving within the facilities, demographics, and sentencing. Study results show that 20.1% of men and 24.8% of women in Michigan prisons have a substantial level of MH symptoms and that 16.5% and 28.9%, respectively, are receiving MH services. However, when compared with Michigan Department of Corrections MH care records, 65.0% of prisoners who are experiencing symptoms of mental illness are not currently receiving any psychiatric services. The mis-match between symptoms and service delivery suggests the need for improved procedures for identifying and measuring psychiatric symptoms within Michigan correctional facilities to ensure that appropriate individuals receive needed care. It is recommended that a standardized assessment process be implemented and conducted at regular intervals for targeting and improving psychiatric care in the prison system.

PTSD and re-offending risk: the mediating role of worry and a negative perception of other people's support

BACKGROUND

Studies of posttraumatic stress disorder (PTSD) are mainly focused on victims of trauma. Very few studies explored the links between PTSD symptoms and re-offending risk in perpetrators of violence.

OBJECTIVE

The aim of the study was to assess the effect of PTSD symptoms on re-offending risk in prisoner populations with a focus on indirect effects of worry and a negative perception of other people's support on the relationship between PTSD and re-offending risk.

METHODS

75 prisoners (25 females, mean age: 44.36 years; 50 males, mean age: 34.7 years) were assessed for exposure to child abuse and neglect, PTSD symptoms, worry, a negative perception of other people's support and re-offending risk. Mediation analyses tested the indirect effects of worry and a negative perception of other people's support on the relationship between PTSD and re-offending risk.

RESULTS

72% participants presented PTSD symptoms and 30.7% were at risk of re-offending. Mediation analyses supported the hypothesis of a mediation pathway from PTSD to worry and a negative perception of other people's support to an increased risk of re-offending.

CONCLUSIONS

The results indicate that prisoners report high rates of PTSD symptoms; furthermore, they highlight an important relationship between PTSD and re-offending risk. Findings suggest that future research should test further the indirect effects of negative cognitive and emotional states on the relationship of PTSD and re-offending risk and explore more in depth the role of PTSD to assess and treat prisoners.

Collaboration du milieu hospitalier et du service de police : un réel partenariat

Certaines personnes atteintes de troubles mentaux présentent des problèmes d’itinérance, de toxicomanie ou de prostitution, surtout en milieu urbain. Le Centre hospitalier de l’Université de Montréal (CHUM) et le Service de police de la Ville de Montréal (SPVM) ont établi un protocole d’entente afin de mieux intervenir auprès de cette clientèle et d’éviter des conséquences malheureuses liées à la violence. Les défis sont toutefois nombreux. Santé mentale au Québec a rencontré M- Sandra D’Auteuil, adjointe au directeur des services professionnels et directeur adjoint aux affaires médicales et académiques du CHUM et Geneviève Gonthier, agente sociocommunautaire du SPVM.

Incentives for research participation: policy and practice from Canadian corrections

We explored current policies and practices on the use of incentives in research involving adult offenders under correctional supervision in prison and in the community (probation and parole) in Canada. We contacted the correctional departments of each of the Canadian provinces and territories, as well as the federal government department responsible for offenders serving sentences of two years or more. Findings indicated that two departments had formal policy whereas others had unwritten practices, some prohibiting their use and others allowing incentives on a case-by-case basis. Given the differences across jurisdictions, it would be valuable to examine how current incentive policies and practices are implemented to inform national best practices on incentives for offender-based research.

The prevalence of mental disorders in Spanish prisons

BACKGROUND

The prevalence of mental disorders among prisoners has been researched in a few countries worldwide but never previously in Spain.

AIM

Our aim was to estimate the lifetime and last month prevalence of mental disorders in a Spanish prison population.

METHODS

This is a descriptive, cross-sectional, epidemiological study of 707 male prisoners. Sociodemographic, clinical and offending data were collected by interviewers. Offending data were confirmed using penitentiary records. Mental disorders were assessed with the clinical version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition Axis I Disorders, and personality disorders were assessed through the Spanish version of the International Personality Disorders Examination.

RESULTS

The lifetime prevalence of mental disorder was 84.4%. Substance use disorder (abuse and dependence) was the most frequent disorder (76.2%) followed by anxiety disorder (45.3%), mood disorder (41%) and psychotic disorder (10.7%). The period (last month) prevalence of any mental disorder was 41.2%. Anxiety disorder was the most prevalent (23.3%) followed by substance use disorder (abuse and dependence; 17.5%), mood disorder (14.9%) and psychotic disorder (4.2%).

CONCLUSION

Although period prevalence figures, which are those generally provided in research into rates of mental disorder among prisoners, are useful for planning improvements to services within prisons, the fact that almost all of these men had a lifetime prevalence of at least one mental disorder suggests a much wider need for improving services, including community services, for this group.

Prevalence of mental disorder and related treatments in a local jail: a 20-month consecutive case study

Aims – To define the prevalence of mental disorder within an Italian local jail and to describe main psychiatric treatments provided. Methods – Cross-sectional study of consecutive male prisoners referred, over a twenty-month period, for a clinical psychiatric assessment, among population (N=990) of Casa circondariale “Torre del Gallo”, Pavia (I); clinical DSM-IV diagnostic assessment and retrospective analysis of provided psychiatric treatments (i.e. psychiatric visits and pharmacological prescriptions). Results – 191 men (19.3%) had one or more current mental disorders (excluding substance misuse), including 13 (1.3%) psychosis; 53 (5.4%) mood disorder; 24 (2.4%) anxiety disorder; 26 (2.6%) adjustment disorder; 40 (4.1%) personality disorder; 32 (3.2%) personality disorder plus mood disorder; 3 (0.3%) mental retardation. Substance- (N=89, 47%) and HIV-related (N=19, 10%) disorders comorbidity is recognised. Psychiatric visits are mainly provided to psychosis and personality disorder plus mood disorder subgroups. Off-label antipsychotics prescriptions are frequent. Conclusions – The prevalence of mental disorder in this population is higher than US and EU averages, and for particular diagnostic subgroups it could be underestimated. Psychiatric management in prison should be reorganized according to national and European health guidelines.

[Mental Health courts: therapeutic jurisprudence in action]

In Québec, as elsewhere in North America, psychiatric deinstitutionalization, lack of community mental health resources as well as legislative changes to civil and criminal codes have led to an increased probability that individuals with a mental illness come into contact with the criminal justice system. Based on the principle of therapeutic jurisprudence, mental health courts constitute emerging diversion programs, taking place within the court, implemented to offer an alternative to incarceration for individuals with a mental illness. This article offers a critical synthesis of the scientific literature on the topic. The authors first present the context in which mental health courts were developed ; describe their objectives and functioning ; and introduce the Montreal Mental Health Court pilot project, renamed PAJ-SM (Plan d'Accompagnement Justice et Santé) the first of its kind in Québec. The paper examines the research on mental health courts and tackles some of the stakes of diversion programs. The challenges and limits inherent to specialized courts are discussed as well as methodological obstacles related to the study of these complex intervention programs. The authors conclude that mental health courts offer promising intervention venues, but that they do not constitute a panacea to resolving all issues related to the contact of mentally ill individuals with the justice system. Mental health courts must be accompanied by other intervention strategies for persons with mental health problems at all stages of the criminal justice process.

Prevalence and screening of mental disorders in short-term correctional facilities

A majority of people incarcerated in correctional facilities have been affected by mental problems at least once in their lifetime. Among them, 12 to 25% suffer from severe and persistent mental disorders at the time of admission. Certain "profiles" are more likely to be detected than others. This is why the main objectives of this research are to establish, in both male and female offenders admitted in short-term detention facilities, the rate of those who have received medical diagnoses of mental disorders, the rate of screening for "mental health problems" at admission and the psychiatric diagnoses (last five years) most strongly associated with a positive screening. Using computerized medical and prison files, it can be established that 61% of the 671 offenders sent to a short-term correctional facility received, during 2002-2007, at least one diagnosis for mental disorder. A total of 227 subjects (33.8%) obtained a positive score to the indicator of mental health problem." In the case of men, correctional services workers identified as mental health problems: psychotic disorders, adjustment reactions, "neurotic"/anxiety disorders, being coupled to drug dependence. Positively detected women tend to exhibit problems of anxiety, personality disorder and substance related disorders. This study highlights, the difficulties faced by correctional services workers in detecting recent depressive disorders both in men and women offenders and also difficulties to detect recent affective psychoses.

La prescription de médicaments psychotropes aux personnes incarcérées dans les prisons provinciales du Québec

Dans cet article, les auteurs tentent de mieux cerner la pratique de la prescription de médicaments psychotropes auprès des personnes incarcérées dans les prisons provinciales du Québec. Bien que la prescription de ces médicaments s’avère le « traitement psychiatrique » le plus utilisée, rares sont les études qui portent sur sa prévalence. L’étude porte sur un échantillon de 671 personnes détenues, soit 500 hommes et 171 femmes. Globalement, 40,3 % des incarcérés ont reçu au moins une ordonnance de médicament psychotrope dans la période comprise entre 2002 et 2007. Les résultats démontrent que les femmes sont plus susceptibles d’avoir fait usage de médicaments que les hommes. Les personnes incarcérées ayant reçu au moins une prescription sont en moyenne plus âgés que les autres. Une majorité d’ordonnances a été émise par des omnipraticiens et les cas de polypharmacie sont nombreux. Sur une période de cinq ans, la classe de médicaments la plus prescrite est celle des anxiolytiques/hypnotiques, suivie des antidépresseurs et des antipsychotiques. Les auteurs concluent qu’il faudra analyser davantage les facteurs associés à la prescription de cette classe de médicaments auprès des personnes criminalisées.

Mental patients in prisons

Mental conditions usually affect cognitive, emotional and volitional aspects and functions of the personality, which are also functions of interest in law, as they are essential at the time of adjudicating guilt, labeling the accused a criminal, and proffering a sentence. A relationship between mental illness and criminality has, thus, been described and given as one of the reasons for the large number of mental patients in prisons. Whether this relationship is one of causality or one that flows through many other variables is a matter of debate, but there is no debating that prisons have become a de facto part, and an important one, of mental health systems in many countries. This paper deals with the issue of the relationship and provides estimates of prevalence of mental patients in prisons culled from many studies in different countries. It also provides some direction for the management of mental patients as they crowd correctional systems.

Mentally ill individuals in limbo: obstacles and opportunities for providing psychiatric services to corrections inmates with mental illness

For more than two millennia, prison reformers and inmate advocates have lamented the ethical and humanitarian injustices experienced by persons with mental illness in correctional settings; yet, we continue to see mentally ill individuals stuck in limbo between health care and custody. Using a case study that exemplifies the challenges that can prevent the provision of efficient mental health care in correctional settings, we identify the gaps and failures in service delivery, and provide specific strategies for streamlining inmates' access to psychiatric assessment and treatment. As a backdrop, we present a brief overview of the reasons why correctional centres experience difficulties in ensuring expedient care (e.g., competence, mental health legislation, waitlists) as well as reviewing the prevalence of mental health needs in correctional settings. Using the partnership and strategic alignment that have been developed for several years between our forensic psychiatric system and our provincial correctional system, we provide a roadmap to successfully reducing wait times and enhancing service delivery to mentally ill inmates. In our view, custody admissions provide a rare opportunity to provide mental health (and other services) to marginalized individuals who often slip through the cracks. imPROVE and related programs and strategies have been found to be effective means of preventing these opportunities from being lost.

A Prison Mental Health Screening Unit: a first for New South Wales

OBJECTIVE

The aims of this paper are to provide a description of a newly available service the Mental Health Screening Unit (MHSU), within the NSW prison system and to present the first 12 months in terms of the patients, its adaptations and its limitations.

METHODS

The first section of this paper provides a thorough description of the MHSU. The second looks at data collected for the period 1 July 2006 to 30 June 2007. A variety of databases were utilized as sources.

RESULTS

There were a total of 604 admissions. The most common primary diagnoses were schizophrenia-related disorders. There were relatively few adverse incidents, and 18% of the acute unit population were transferred to the Long Bay Prison Hospital.

CONCLUSION

The MHSU had a considerable throughput of patients and managed a range of severe mental illnesses. The initial objectives of the MHSU have broadly been achieved. There are several future areas of research discussed.

Co-occurring psychiatric and substance use disorders among male detainees in Italy

This paper presents data on the prevalence of co-occurring substance use and psychiatric disorders among newly imprisoned males in Italy. Interviewers conducted semi-structured clinical interviews with n=302 male detainees seven days after their admission to the prison of Perugia from August 2005 through July 2006. Over half of male detainees (54.3%) had either a substance use disorder or another psychiatric disorder. One of every five detainees (20.9%) had comorbid substance use and psychiatric disorders. Compared to detainees with psychiatric disorder only, substance use disorder only, or no disorder, detainees with comorbid substance use and psychiatric disorders were significantly more likely to have severe impairment in the areas of employment, substance abuse, family and social functioning, and psychiatric symptoms. Findings underscore the need for careful diagnostic screening at intake, access to treatment during detention, and an effective transition to services at the time of release.

Does PTSD occur in sentenced prison populations? A systematic literature review

BACKGROUND

A systematic review of the literature on mental disorder in prisoners, published in 2002, made no mention of post-traumatic stress disorder (PTSD), but indicators from other studies suggest that a history of serious and chronic trauma is common among offenders.

AIMS

To conduct a systematic review of the literature with the specific questions: does any epidemiological study of sentenced prisoners include data on prevalence of PTSD while in prison? If so, what is the prevalence in this group?

METHOD

Literature databases EMBASE, Medline, PsychInfo, PILOTS and SIGLE were searched. The Journal of Traumatic Stress was searched manually. Preliminary screening was conducted by reading abstracts of hundreds of papers. Ten exclusion criteria were then applied to the screened selection. Reference sections of all accessed papers were searched for any further studies.

RESULTS

One hundred and three potentially relevant papers were identified after preliminary screening. Four met all criteria for inclusion and suffered none of the exclusion criteria. PTSD rates ranged from 4% of the sample to 21%. Women were disproportionately affected.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

All four papers suggested that the prevalence of PTSD among sentenced prisoners is higher than that in the general population, as reported elsewhere. Overall the findings suggest a likely need for PTSD treatment services for sentenced prisoners.

Gender- and violence-related prevalence of mental disorders in prisoners

OBJECTIVES

To clarify the prevalence of mental diseases including personality disorders in a sample of German prisoners regarding delinquency and gender specificity.

METHOD

Crime history, present state and lifetime mental disorders, as well as personality disorders, were assessed amongst 415 inmates and compared regarding gender and type of delinquency.

RESULTS

Female offenders more often committed homicide while male offenders more frequently committed assault and robbery. Men had a higher prevalence of alcohol abuse and dissocial PD while women more often showed depression, anxiety disorders and Borderline PD. Violent offences were related to a higher prevalence of alcohol abuse and dissocial PD, as well as higher comorbidities of mental disorders.

CONCLUSION

Results emphasize the complexity of the needs and requirements of imprisoned offenders. Our findings reveal an urgent need for psychiatric-psychotherapeutic services to provide suitable care to inmates in order to contribute to a more favorable legal prognosis.

Schizophrenia and violence: a search for neurobiological correlates

PURPOSE OF REVIEW

Compelling evidence suggests that a small group of men who develop schizophrenia display a stable pattern of antisocial behaviour from childhood onwards, causing considerable suffering to victims and to themselves and imposing a significant financial burden on society. We reviewed the literature on the neurobiological correlates of antisocial behaviour and violence to further the understanding of this subgroup of persons with schizophrenia and develop testable hypotheses for future research.

RECENT FINDINGS

Few studies have been conducted, sample sizes are small and measures vary greatly. Taken together, the results suggest that among men with schizophrenia, those who have displayed a stable pattern of antisocial and aggressive behaviour since childhood, as compared with those with no such history, perform better on neuropsychological tests tapping specific executive functions and more poorly on assessments of orbitofrontal functions. We hypothesize that individuals in this subgroup are less compromised neurologically and display structural brain abnormalities in the amygdala-orbitofrontal system and in the prefrontal cortex and hippocampus.

SUMMARY

A better understanding of the distinctive neurobiological characteristics of this subgroup of men with schizophrenia will contribute to developing treatments tailored to their needs, to prevent antisocial behaviours and to reduce the symptoms of schizophrenia.

Neurobiological correlates of violent behavior among persons with schizophrenia

Men and women who develop schizophrenia are at increased risk, compared with the general population, to engage in violence toward others. The reasons for this robust finding remain obscure. We undertook a review of studies comparing neuropsychological test performance, neurological soft signs, and structural brain images of persons with schizophrenia with and without a history of violence. Our search identified 17 studies. The results are inconsistent and contradictory, mainly due to varying definitions of violence, differences in sample characteristics, and the use of diverse measures to tap the neurobiological correlates of violent behavior. The results suggest, however, that among men with schizophrenia, those who have displayed a stable pattern of antisocial and aggressive behavior since childhood, as compared with those with no such history, perform better on neuropsychological tests tapping specific executive functions and more poorly on assessments of orbitofrontal functions, show fewer neurological soft signs, and display larger reductions in volume of the amygdalae, more structural abnormalities of the orbitofrontal system, more abnormalities of white matter in the amygdala-orbitofrontal system, and smaller reductions in volumes of the hippocampus.

The psychometric properties of a psychosis screen in a correctional setting

Many people who go to gaol are mentally ill. Remandees, prisoner receptions or people in jails have a substantially higher rate of severe mental disorder than other prisoners and the general population. There are no completely satisfactory ways to screen for psychosis and few existing screening questionnaires are available for use in correctional establishments. The Screening Instrument for Psychosis (PS) was developed in the context of the Australian Mental Health Survey: Study of Low Prevalence Disorders. It can help indicate whether a person should be referred to mental health professional for a diagnostic evaluation and possible treatment and/or diversion. We trialled the PS in a high security remand and reception centre. Measures of validity and reliability are reported.

A comparison of Australian men with psychotic disorders remanded for criminal offences and a community group of psychotic men who have not offended

BACKGROUND

People remanded into custody by the courts have a substantially higher rate of severe mental disorder than other prisoners and the general population. Knowledge of their prevalence, needs and characteristics and an analysis of pathways to care may be necessary to provide mental health care effectively and efficiently. Previous prison studies focusing on psychotic offenders have suffered from the use of instruments not validated in a forensic setting and lack of a relevant comparison group.

METHOD

The Diagnostic Interview for Psychosis (DP) is a composite semi-structured standardized interview schedule. It combines social and demographic descriptors with measures of functioning adapted from the World Health Organisation Disability Assessment Schedule (DAS). The remand centre surveyed had 466 cells and is the main remand and reception centre for males for the southern region of the state of Queensland, Australia. Of the 621 men screened, 65 answered yes to at least one question in the DP and were interviewed.

RESULTS

Six hundred and twenty-one remandees were screened and of these 61 were interviewed as screened positive for psychotic disorder. Thirty-five per cent had been homeless for an average of 32 weeks during the previous year. Most had had little contact with families or close friends. Eighty-one per cent were receiving no treatment at the time of offence. Seventy-eight per cent were unemployed and in receipt of a pension. Eighty per cent were dependent on alcohol, cannabis or amphetamines. Statistical issues of power are detailed in the text.

CONCLUSIONS

The simplistic 'prison, hospital or community treatment' debate is misleading. Instead, the development of flexible preventative, management and accommodation services for people with severe mental disorder who have committed offences is a priority.

Mental disorders in Australian prisoners: a comparison with a community sample

BACKGROUND

The plight of those with mental health problems and the possible role of prisons in "warehousing" these individuals has received considerable media and political attention. Prisoners are generally excluded from community-based surveys and to date no studies have compared prisoners to the community.

OBJECTIVE

The objective was to examine whether excess psychiatric morbidity exists in prisoners compared to the general community after adjusting for demographics.

METHOD

Prison data were obtained from a consecutive sample of reception prisoners admitted into the state's correctional system in 2001 (n = 916). Community data were obtained from the 1997 Australian National Survey of Mental Health and Wellbeing (n = 8168). Mental health diagnoses were obtained using the Composite International Diagnostic Interview and a number of other screening measures. Weighting was used in calculating the 12-month prevalence estimates to control for demographic differences between the two samples. Logistic regression adjusting for age, sex and education was used to compare the prison and community samples.

RESULTS

The 12-month prevalence of any psychiatric illness in the last year was 80% in prisoners and 31% in the community. Substantially more psychiatric morbidity was detected among prisoners than in the community group after accounting for demographic differences, particularly symptoms of psychosis (OR = 11.8, 95% CI 7.5-18.7), substance use disorders (OR = 11.4, 95% CI 9.7-13.6) and personality disorders (OR = 8.6, 95% CI 7.2-10.3). Mental functioning and disability score were worse for prisoners than the community except for physical health.

CONCLUSIONS

This study found an overrepresentation of psychiatric morbidity in the prisoner population. Identifying the causes of this excess requires further investigation.

Psychiatric morbidity among sentenced prisoners: prevalence study in Iran

BACKGROUND

Information on psychiatric morbidity of prisoners has almost entirely been based on research in Western countries and it is uncertain whether these research findings are applicable to other settings.

AIMS

The primary objective was to investigate the prevalence of psychiatric disorders in Iranian prisoners.

METHOD

Through stratified random sampling, 351 prisoners were interviewed using the clinical version of the Structured Clinical Interview for DSM-IV Axis I Disorders and the Psychopathy Checklist: Screening Version.

RESULTS

The majority (88%) of prisoners met DSM-IV criteria for lifetime diagnosis of at least one Axis I disorder and 57% were diagnosed with current Axis I disorders. Opioid dependence (73%) had the highest prevalence among lifetime diagnoses, whereas major depressive disorder (29%) was the most common current diagnosis. Psychopathy was recorded in 23%. Prevalence rates of psychiatric disorders were significantly different among offence categories.

CONCLUSIONS

The results suggest that a substantial burden of psychiatric morbidity exists in the prison population of Iran, with treatment challenges that appear to be different from those observed in inmates in Western countries.

Epidemiology of mental illness in a correctional system

PURPOSE OF REVIEW

Reports of higher than community rates of mental disorder in incarcerated populations first appeared in the mid-1970s. These findings have been confirmed over the past three decades in numerous studies across a wide spectrum of forensic settings. Recent research has benefited from enhanced methodological sophistication, and reliable rates across clinical domains and divergent forensic population groups are now available. This article reviews the literature on the prevalence of mental illness in forensic settings over the past 10 years, with special reference to specific subgroups.

RECENT FINDINGS

Overall rates of any mental disorder, including personality disorder and addiction, remain high, in general ranging between 55% and 80%. The findings of recent, systematic surveys and of 22 studies reviewed here reveal rates of psychosis that are several times higher in correctional settings than in the community. Mood disorder rates are elevated also, with higher morbidity reported for women than for men. Findings in specialized populations indicate similarly elevated rates of mental disorder among adolescent and geriatric prisoners, while addiction rates rank highest across all population domains.

SUMMARY

The prevalence of psychiatric illness in correctional settings is significantly elevated, with higher than community rates reported for most mental disorders. It is estimated that in the USA one in five incarcerated persons is afflicted with major psychiatric illness; with an estimated 9-10 million persons imprisoned worldwide, the burden of psychiatric illness in this vulnerable and marginalized population poses a serious challenge to researchers and clinicians alike.

Conceptualizing nursing research with offenders: another look at vulnerability

In this article, vulnerability is examined as it applies to the conduct of nursing research with offenders. As a group, offenders present with a multitude of acute and chronic physical and mental health care needs; they are subject to discrimination, stigmatization, and marginalization; and as such, they often experience dual, multiple, or overlapping vulnerabilities. As research participants, they are especially vulnerable to coercion, as a direct consequence of their dependency status within the correctional system. Embracing a research agenda that focuses on offenders as a vulnerable population is fraught with ambiguities not generally encountered in other settings. The ethical conduct of research with vulnerable populations reflects a contemporary research problem that requires ongoing discourse within the nursing community and the health care community at large.