Ethnic differences in prisoners. 1: criminality and psychiatric morbidity

Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK

Objective

The review aims to identify the extent and nature of research on mental disorders and their care in immigrant populations in three major European countries with high levels of immigration, i.e. Germany, Italy, United Kingdom (UK).

Methods

Peer-reviewed publications on the subject from the three countries between 1996 and 2004 were analyzed. The research questions addressed, the methods used, and the results obtained were assessed.

Results

Thirteen papers reporting empirical studies were found from Germany, four from Italy and 95 from the UK. Studies addressed a range of research questions and most frequently assessed rates of service utilization in different immigrant groups. The most consistent finding is a higher rate of hospital admissions for Afro-Caribbean patients in the UK. Many studies had serious methodological shortcomings with low sample sizes and unspecified inclusion criteria.

Discussion

Despite large scale immigration in each of the three studied countries, the numbers of relevant research publications vary greatly with a relatively high level of empirical research in the UK. Possible reasons for this are a generally stronger culture of mental health service research and a higher number of researchers who are themselves from immigrant backgrounds in the UK.

Conclusion

Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.

Mental health of jail inmates within the prison of Ducos, Martinique - a cross-sectional descriptive study

BACKGROUND

Prisoners' sociocultural backgrounds and prison environments have an influence on detainees' psychopathology; complex judicial and public policies are also to be taken into account in the dynamics of that environment. Scientific literature shows a wide range prison inmates' profiles across the world. However, very little data about the mental health of Caribbean jail inmates has been published. Martinique is a French overseas administrative district in the Caribbean, with a population of about 400,000 inhabitants. Its only prison is located in the city of Ducos. Our study proposes a description of the psychiatric characteristics of jail inmates in Martinique with epidemiological tools. Its objectives are to highlight their specific features and compare them to mainland France's jail population.

METHODS

The initial study was a multicenter cross-sectional survey conducted in 18 French prisons. The selection was done using a two-stage stratified sampling strategy. For the purpose of our study, two groups were defined and compared: the detainees from the prison of Ducos (n=100) were compared to inmates from mainland France (n=698). Current psychiatric diagnoses were rigorously collected, through clinical and semi-structured interviews. We conducted a multiple logistic regression for each assessed mental disorder. Each prisoner gave us his oral and written informed consent.

RESULTS

In terms of sociodemographic characteristics, we found more children per prisoner in the Martinican group and a better educational status in the mainland France group. The inmates from Martinique had significantly more adverse experiences in their childhood and the length of incarceration at the time of the interview was longer in the Martinique sample. Major depressive disorders (aOR=0.51; 95% CI=0.26-0.95) and psychotic disorders (aOR=0.24; 95% CI=0.08-0.57) were significantly less frequent in the Martinique sample. The data concerning substance-related disorders showed significant differences in bivariate analysis but this link was no longer statistically significant in the multiple logistic regression analysis.

CONCLUSION

Even if imprisonment conditions are extremely tough, the inmates carry the heavy burden of difficult family histories, and the use of cannabis seems to be a major problem, it appears that Martinique's jail inmates have lower rates of mental illness than their counterparts from mainland France. We think this could be due to the benefit of greater proximity to their relatives and a united community, both which may contribute to lower prevalence of mental disorders.

Assessing needs for psychiatric treatment in prisoners: 1. Prevalence of disorder

BACKGROUND

High levels of psychiatric morbidity in prisoners have important implications for services. Assessing Needs for Psychiatric Treatment in Prisoners is an evaluation of representative samples of prisoners in a male and a female prison in London. This paper reports on the prevalence of mental disorders. In a companion paper, we describe how this translates into mental health treatment needs and the extent to which they have been met.

METHODS

Prisoners were randomly sampled in a sequential procedure based on the Local Inmate Data System. We interviewed roughly equal numbers from the following groups: male remand; male sentenced prisoners (Pentonville prison); and female remand; female sentenced prisoners (Holloway prison). Structured assessments were made of psychosis, common mental disorders, PTSD, personality disorder and substance abuse.

RESULTS

We interviewed 197 male and 171 female prisoners. Psychiatric morbidity in male and female, sentenced and remand prisoners far exceeded in prevalence and severity than in equivalent general population surveys. In particular, 12% met criteria for psychosis; 53.8% for depressive disorders; 26.8% for anxiety disorders; 33.1% were dependent on alcohol and 57.1% on illegal drugs; 34.2% had some form of personality disorder; and 69.1% had two disorders or more. Moreover, in the year before imprisonment, 25.3% had used mental health services.

CONCLUSIONS

These rates of mental ill-health and their similarity in remand and sentenced prisoners indicate that diversion of people with mental health problems from the prison arm of the criminal justice system remains inadequate, with serious consequences for well-being and recidivism.

Assessing needs for psychiatric treatment in prisoners: 2. Met and unmet need

BACKGROUND

In a companion paper, we established high levels of psychiatric morbidity in prisoners (Bebbington et al. Soc Psychiatry Psychiatr Epidemiol, 2016). In the current report, we evaluate how this morbidity translates into specific needs for treatment and the consequent implications for services. Mental health treatment needs and the extent to which they had been met were assessed in a representative sample of prisoners in a male and a female prison in London (Pentonville and Holloway).

METHODS

Prisoners were sampled at random in a sequential procedure based on the Local Inmate Data System. We targeted equal numbers of male remand, male sentenced, female remand, and female sentenced prisoners. Following structured assessment of psychosis, common mental disorders, PTSD, personality disorders and disorders of abuse, we used the MRC Needs for Care Assessment (NFCAS) to establish whether potential needs for care in ten areas of mental health functioning were met, unmet, or incapable of being met by services.

RESULTS

Data on treatment experience were provided by 360 inmates. Eighty percent of females and 70% of males had at least one need for treatment. Over half (53.7%) of the needs of female prisoners were met, but only one third (36.5%) in males. Needs for medication were unmet in 32% of cases, while those for psychological treatment were unmet in 51%.

CONCLUSIONS

Unmet needs for mental health treatment and care were common in the two prisons. This has adverse consequences both for individual prisoners and for the effective functioning of the criminal justice system.

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK

Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants' cultural beliefs and practices.

Psychotic disorders are more common in ethnic minority than in Dutch native defendants

PURPOSE

The prevalence of psychotic disorders among prisoners from racial or ethnic minority groups remains uncertain. We therefore compared the frequency of psychotic disorder in ethnic minority and Dutch native defendants using the nationwide database of elaborate pre-trial reports.

METHODS

Analysis of a nationwide database of pre-trial reported defendants in the Netherlands between 2000 and 2006 (n = 12,752).

RESULTS

A diagnosis of a psychotic disorder was more common in ethnic minority than in Dutch native defendants (21.1 vs. 10.2%). The odds ratio of this diagnosis, adjusted for age, gender, IQ below 85 and abuse of cannabis or hard drugs, was 2.6 (95% CI 2.2-3.0). This odds ratio was highest for African defendants (OR = 5.2; 95% CI 3.7-7.4).

CONCLUSIONS

Psychotic disorders were more common among pre-trial reported defendants from ethnic minorities than among their Dutch native counterparts.

Pathways to forensic mental health care in Toronto: a comparison of European, African-Caribbean, and other ethnoracial groups in Toronto

OBJECTIVE

To describe pathways taken to care by a sample of patients in a secure forensic unit who have been found not criminally responsible or unfit to stand trial, and to investigate the pathways taken by patients within 3 ethnoracial subgroups of origin: European, African or Caribbean, and Other.

METHOD

Fifty patients from secure forensic units were interviewed using the Encounter Form developed for pathways mapping undertaken in the World Health Organization field trials. Differences in the types of caregivers seen, the total number of caregivers seen, and the time taken to reach forensic psychiatric services were compared across the 3 ethnoracial groupings.

RESULTS

Most people committed their index offence after they had already had contact with general mental health services. Few significant differences were observed in the pathways to secure forensic units across the European, African-Caribbean, and Other ethnoracial groups.

CONCLUSIONS

These findings suggest that improvements in general mental health services may be a key to decreasing the use of forensic psychiatric services. Further research is required to explore factors that may predict and prevent offending. Larger studies are needed to examine ethnoracial differences in pathways to care.

Ethnicity, violent offending, and vulnerability to schizophrenia: a pilot study

Previous research has highlighted increased risk for schizophrenia in Afro-Caribbeans as well as over-representation in the prison population. This small-scale study examined the relationship between criminality, ethnicity, and psychosis-proneness in a male prison sample. Twenty British Caucasian and 20 Afro-Caribbean prisoners were divided into equal sub-groups of violent and non-violent offenders. Participants completed measures of schizotypy, delusional ideation, and hostility. Afro-Caribbean offenders scored more highly on negative schizotypy and delusional ideation than their Caucasian counterparts. Violent offenders scored more highly on the positive symptoms of schizotypy than non-violent prisoners. Both ethnicity and violent offending may be relevant factors when considering vulnerability to psychosis in the offending population.

Assessments and admissions during the first 6 years of a UK medium secure DSPD service

BACKGROUND

Offenders with personality disorder represent a considerable burden on mental health and criminal justice services. Millfields Unit was one of the pilot medium secure units (MSUs) established by the UK Department of Health and Ministry of Justice to provide dedicated services for such individuals.

AIMS

Our study aimed to describe a complete cohort of referrals made to the service and to explore decisions on admissions to the Unit.

METHODS

File review was used to collect a structured data set of information on the first 158 referrals. These were then analysed descriptively and inferentially.

RESULTS

Previous psychological treatment in prison and evidence of motivation for further treatment were the strongest predictors of admission to the service. People admitted showed evidence of more extensive criminal histories, prior treatment failure and higher level of risk than those accepted into conventional medium secure units. Despite the stated purpose of the units being for people with personality disorder, a high number of patients with a primary diagnosis of psychotic illness were referred.

CONCLUSION

The new service accepted a high-risk group of people with personality disorder whose needs would not otherwise have been met.

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.

A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment

BACKGROUND

Although psychoses and ethnicity are well researched, the importance of culture, race and ethnicity has been overlooked in Personality Disorders (PD) research. This study aimed to review the published literature on ethnic variations of prevalence, aetiology and treatment of PD.

METHOD

A systematic review of studies of PD and race, culture and ethnicity including a narrative synthesis of observational data and meta-analyses of prevalence data with tests for heterogeneity.

RESULTS

There were few studies with original data on personality disorder and ethnicity. Studies varied in their classification of ethnic group, and few studies defined a specific type of personality disorder. Overall, meta-analyses revealed significant differences in prevalence between black and white groups (OR 0.476, CIs 0.248 - 0.915, p = 0.026) but no differences between Asian or Hispanic groups compared with white groups. Meta-regression analyses found that heterogeneity was explained by some study characteristics: a lower prevalence of PD was reported among black compared with white patients in UK studies, studies using case-note diagnoses rather than structured diagnostic interviews, studies of borderline PD compared with the other PD, studies in secure and inpatient compared with community settings, and among subjects with co-morbid disorders compared to the rest. The evidence base on aetiology and treatment was small.

CONCLUSION

There is some evidence of ethnic variations in prevalence of personality disorder but methodological characteristics are likely to account for some of the variation. The findings may indicate neglect of PD diagnosis among ethnic groups, or a true lower prevalence amongst black patients. Further studies are required using more precise cultural and ethnic groups.

Psychopathy among prisoners in England and Wales

Most research into psychopathy among prisoners is based on selected samples. It remains unclear whether prevalences are lower among European populations. This study aimed to measure the prevalence of psychopathy, and the distribution and correlates of psychopathic traits in a representative national sample of prisoners. Psychopathy was measured using the revised Psychopathy Checklist (PCL-R) in a second stage, cross-sectional survey of prisoners in England and Wales in 1997 (n=496). Poisson regression analysis was carried out to examine independent associations between correlates and PCL-R total and factor scores. The prevalence of categorically diagnosed psychopathy at a cut off of 30 was 7.7% (95%CI 5.2-10.9) in men and 1.9% (95%CI 0.2-6.9) in women. Psychopathic traits were less prevalent among women. They were correlated with younger age, repeated imprisonment, detention in higher security, disciplinary infractions, antisocial, narcissistic, histrionic, and schizoid personality disorders, and substance misuse, but not neurotic disorders or schizophrenia. The study concluded that psychopathy and psychopathic traits are prevalent among male prisoners in England and Wales but lower than in most previous studies using selected samples. However, most correlates with psychopathic traits were similar to other studies. Psychopathy identifies the extreme of a spectrum of social and behavioral problems among prisoners.

Prevalence and correlates of hepatitis A among adult drug users: The significance of incarceration and race/ethnicity

This report examines associations between hepatitis A virus (HAV) infection prevalence and a history of incarceration in jail or a correctional facility among a population of drug users in Baltimore stratified by African American and white racial/ethnic status. The study sample consisted of 509 non-injection and injection drug users recruited from inner-city neighborhoods of the Baltimore metropolitan region. The baseline prevalence of HAV infection was 36.9% (N=188). One-fourth (25.5%) of the sample reported no lifetime history of incarceration, 44.6% reported incarceration in a local jail in their lifetime, and 29.9% reported incarceration in a correctional facility in their lifetime. In the multivariate logistic analysis, HAV infection prevalence was higher for whites (44.3%) [adjusted odds ratio (AOR)=2.3, 95% CI=1.5-3.5] when compared to African Americans (30.5%) adjusting for gender, age, and education. In the analysis stratified by race/ethnicity, as anticipated, jail incarceration and correctional facility incarceration were each independently associated with elevated HAV prevalence among white drug users. African American drug users with a high school diploma had significantly lower HAV infection prevalence when compared to African American drug users who did not graduate from high school. Heightened HAV prevalence among white drug users compared to African American drug users is noteworthy given the opposite association of HAV infection prevalence and these two racial/ethnic groups in the general population. Since millions of incarcerated drug users in the US return to society each year, the results suggest that incorporating systematic HAV screening, prevention, and treatment programs within correctional systems represents a vital yet underutilized strategy to reduce HAV transmission in society as a whole.

Health needs of prisoners in England and Wales: the implications for prison healthcare of gender, age and ethnicity

This paper aims to provide evidence of the healthcare needs of prisoners in relation to gender, age and ethnicity, drawing from a larger systematic overview of the policy and research literature concerning primary care nursing in prisons in England and Wales. The literature overview shaped the initial stages of a research project funded by the Department of Health to examine the views and perspectives of prisoners and nurses working in prisons, and to identify good primary care nursing in the prison environment. At total of 17 databases were searched using search terms related to primary healthcare in prisons (health, nurs*, primary care, healthcare, family medicine, prison*, offender*, inmate*) with terms truncated where possible in the different databases. Following this, a sifting phase was employed using inclusion/exclusion criteria to narrow and focus the literature perceived as relevant to the research questions. All papers were critically appraised for quality using standardised tools. Findings from the literature overview show that prisoners are more likely to have suffered some form of social exclusion compared to the rest of society, and there are significantly greater degrees of mental health problems, substance abuse and worse physical health in prisoners than in the general population. Women, young offenders, older prisoners and those from minority ethnic groups have distinct health needs compared to the prison population taken as a whole, with implications for the delivery of prison healthcare, and how these needs are met effectively and appropriately.

Ethnic differences among patients in high-security psychiatric hospitals in England

BACKGROUND

Black (Black Caribbean and Black African) patients are over-represented in admissions to general adult and medium-security psychiatric services in England.

AIMS

To describe the sociodemographic, clinical and offence characteristics of patients in high-security psychiatric hospitals (HSPHs) in England, and to compare admission rates and unmet needs by ethnic group.

METHOD

A total of 1255 in-patients were interviewed, and their legal status, socio-demographic characteristics and individual treatment needs were assessed.

RESULTS

Black patients in HSPHs are over-represented by 8.2 times (range 3.2-24.4,95% CI 7.1-9.3), are more often male (P=0.037), and are more often diagnosed with a mental illness and less often diagnosed with a personality disorder or learning disability (P<0.001) than White patients. Unmet needs were significantly less common among White than among Black patients (mean values of 2.22 v. 2.62, difference=0.40,95% CI 0.06-0.73).

CONCLUSIONS

Compared with the proportion of Black patients in the general population in their region of origin, a much higher proportion of Black patients were admitted to HSPHs, and fewer of their needs were met.

Ethnic differences in prisoners. 2: risk factors and psychiatric service use

BACKGROUND

The high rates of psychiatric morbidity in prisoners vary between ethnic groups.

AIMS

To compare early environmental risks, stressful daily living experiences and reported use of psychiatric services in prisoners from different ethnic groups.

METHOD

Cross-sectional survey of 3142 prisoners in all penal establishments in England and Wales in 1997.

RESULTS

Fewer Black and South Asian male prisoners reported childhood traumas and conduct disorder, and fewer Black prisoners experienced stressful prison experiences, than White prisoners. Fewer Black women had received previous psychiatric treatment, and fewer Black men had their psychiatric problems identified in prison. Black prisoners were less likely to have received psychiatric treatment than Whites.

CONCLUSIONS

The lower prevalence of psychiatric morbidity observed in Black prisoners corresponds with reduced exposure to risk factors. Higher rates of imprisonment might be explained by higher rates of conduct disorder, adolescent-onset criminality and disadvantage within the criminal justice system.