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

The Effectiveness of Schema Therapy in Individuals Who Committed Crimes: A Systematic Review

Research suggests that individuals who commit crimes often exhibit various early maladaptive schemas (EMSs). EMSs are a broad and pervasive theme or pattern consisting of memories, emotions, cognitions, and bodily sensations concerning oneself and one's relationships with others. Furthermore, EMSs play a crucial role in the onset and maintenance of different types of offending behaviors, highlighting the need to implement schema therapy (ST) for perpetrators. Therefore, the present systematic review assesses the effectiveness of ST for individuals who committed crimes. Four databases (PubMed, Scopus, Web of Science, and Scielo) were searched for studies examining the effectiveness of ST for individuals who committed crimes. Seventeen studies were identified, but only 15 met the criteria for inclusion. Results showed that ST can lead to beneficial effects in EMSs, schema modes, personality symptoms, and risk factors to commit crimes (e.g., cognitive distortions). However, the studies, besides being scarce, revealed some methodological limitations. ST is a promising therapy for individuals who committed crimes, despite the studies' methodological shortcomings, which prevent us from drawing more firm conclusions. Although promising, more research is needed to enhance our understanding of the impact of ST therapies in forensic settings.

Women in acute forensic psychiatric care: comparison of clinical, sociodemographic, and detention-related characteristics in pretrial detention, sentence execution, and court-ordered treatment

Compared to men inmates, women display decreased prevalence of severe mental disorder but increased occurrence of substance use disorders (SUD) and higher rates of previous contacts with mental health services. The group of women in detention is highly heterogeneous according to the status of incarceration (pre-trial detention (PTD), sentence execution (SE) and court ordered treatments (COT)). Studies focusing on the comparison of sociodemographic patterns, detention-related and clinical variables between these groups are still lacking. We explored these parameters in 136 women admitted for acute psychiatric care in the sole Geneva forensic unit during a nine year period (2014-2023). Sociodemographic and detention-related data included age, nationality, marital status, presence of children, education attainment, most frequently speaking language, social support, employment before conviction and type of offenses. Clinical variables included the main ICD-10 diagnosis, presence of concomitant SUD, type of personality disorders, presence of suicidal thoughts and attempts at admission, as well as number and mean duration of stays. PTD and SE women had at least 9 years of formal education in 38.9% and 30.3% of cases. Most women in PTD (77.7%), SE (56.6%) and COT (56.2%) groups were Swiss or European citizens. The level of French knowledge was excellent in most of the cases. 43.8% of COT women had at least one child and this percentage is even higher for PTD and SE cases. The employment rate before conviction was also quite high, mainly for PTD and SE (61.1% and 60.6%) and, in a lesser degree, for COT (43.8%) women. Significant social support was present in the vast majority of women without any significant group difference. The distribution of type of offenses did not differ between the three types of detention with a predominance of physical violence, and drug trafficking. The number of stays during the period of reference was significantly higher in COT compared to both SE and PTD women. History of previous inpatient care was also significantly more frequent in COT that SE and PTD women. Adjustment and affective disorders were more often found in SE and PTD cases, these diagnoses were absent in the COT group. In contrast, a main diagnosis of psychotic disorders was found in 62.5% of COT cases compared to only 21.2% in SE and 24.1% in PTD cases. The number of stays, history of inpatient care and diagnosis of psychosis were independent predictors of COT status. In conclusion, the present data reveal the good social integration and emotional support of women needing acute psychiatric care in prison independently of the type of detention. Clinically, women in PTD and SE display more often emotional distress whereas those in COT suffer from acute psychotic symptoms with previous history of psychiatric care and multiple inpatient stays.

Types of Psychiatric Beds and Mental Health Services in 16 Latin American Countries, 1990-2020

OBJECTIVE

Latin America has undergone major changes in psychiatric services over the past three decades. The authors aimed to assess the availability of service data and changes in psychiatric services in this region during the 1990-2020 period.

METHODS

The authors formed a research network to collect data on psychiatric service indicators gathered between 1990 and 2020 from national registries in Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, and Uruguay. Indicators included psychiatric beds in psychiatric and general hospitals overall, for children and adolescents, and for forensic populations; residential beds for substance use treatment; treatment slots in residential facilities and day hospitals; and outpatient facilities.

RESULTS

Data availability varied among countries, service indicators, and time points. The median prevalence of psychiatric beds decreased in psychiatric hospitals from 5.1 to 3.0 per 100,000 people (-42%) and in general hospitals from 1.0 to 0.8 (-24%). The median prevalence estimates of specialized psychiatric beds for children and adolescents (0.18) and for forensic populations (0.04) remained unchanged. Increases in prevalence were observed for residential beds for substance use treatment (from 0.40 to 0.57, 43% increase), available treatment slots in residential facilities (0.67 to 0.79, 17%), treatment slots in day hospitals (0.41 to 0.54, 32%), and outpatient facilities (0.39 to 0.93, 138%).

CONCLUSIONS

The findings indicate that treatment capacity shifted from inpatient to outpatient and community care. Most countries had a bed shortage for acute psychiatric care, especially for children and adolescents and forensic patients. More comprehensive and standardized mental health service registries are needed.

Mental health intervention research in Latin American correctional settings: A scoping review

BACKGROUND

The Latin American prison population has grown faster than anywhere else globally over the past two decades, reaching a total of 1.7 million people at any given time. However, research on mental health prevention and treatment interventions in Latin American prisons remains scarce.

AIMS

This study aimed to systematically review and synthesize research on prison mental health interventions conducted in the region.

METHODS

We used a two-stage scoping review design guided by the JBI Manual for Evidence Synthesis. Searches took place in December 2021 in nine databases using descriptors and synonyms. First, all prison mental health research in Latin America was retained. Secondly, using title and abstract screening, all research possibly related to interventions was retained for full text evaluation. Studies reporting interventions were assessed by country, language, institution, population, intervention type, intervention focus and outcomes.

RESULTS

N = 34 studies were included in this review. These were 13 case reports, seven expert consensus papers and 14 quantitative studies (four randomized controlled trials, nine cohort studies, one quasi-experimental study). Fourteen interventions were targeted at promoting prosocial behavior, seven studies each aimed to improve mental health and to treat substance use disorders. Six studies involved the treatment of sexual offending behavior, and 3 focused on reducing criminal recidivism. Psychoeducation (n = 12) and motivational interviewing (n = 5) were the most frequent intervention types studied. Promising data from trials showed that anger management, depression, substance use and reoffending could be successfully addressed through interventions.

CONCLUSIONS

Implementation and effectiveness research of mental health interventions in Latin American prisons is scarce. Addressing mental health, substance use and prosocial behavior outcomes should be considered in future research. There is a particular dearth of controlled trials describing quantifiable outcomes.

The Co-occurrence of Personality Disorders and Substance Use Disorders

PURPOSE OF REVIEW

Despite significant negative outcomes, the co-occurrence of personality disorders (PDs) and substance use disorders (SUDs) continues to be underrecognized, and the mechanisms contributing to this co-occurrence remain unclear. This review summarizes recent work on PD-SUD co-occurrence, with a focus on borderline and antisocial PDs, general substance use patterns among those with PDs, and the association of personality traits with SUDs.

RECENT FINDINGS

The prevalence of co-occurring PD-SUD is generally high, with estimates ranging depending on the type of PD and SUD, the population assessed, and the sampling methods and measures used. Current theoretical explanations for co-occurrence include shared etiology and predisposition models, with research highlighting the importance of transactional processes. Potential underlying mechanisms include personality traits and transdiagnostic characteristics. Recent research has increased focus on substances besides alcohol, dimensional models of personality pathology, and transactional explanations of co-occurrence, but more research is needed to disentangle the nuanced PD-SUD relationship.

[The transitional mobile team, psychiatric care upon release from prison]

The "transitional mobile team" has been developed to optimize the management of the transition from prison to the community for people with psychiatric disorders in France. The objectives are to limit the risk of relapse and death during this high-risk period and to ensure the links between psychiatry in prison and community psychiatry.

Admission to jail and psychotic symptoms: a study of the psychotic continuum in a sample of recently incarcerated men

PURPOSE

We sought to measure the prevalence of psychotic symptoms (PSs) and psychotic disorders (PDs) in a sample of men entering jail and to compare these prevalences with those observed in the general population. We also aimed to explore the sociodemographic and clinical factors associated with PSs and PDs.

METHODS

The Mental Health in the Prison Population (MHPP) survey interviewed 630 incarcerated men upon admission to jail, using the Mini International Neuropsychiatric Interview. We looked for associations between sociodemographic and clinical characteristics and the presence of lifetime PSs and PDs in the MHPP and Mental Health in the General Population (MHGP) surveys, which used the same methodology to collect data from the jail and general populations of the same geographical area.

RESULTS

A higher proportion of PSs without PDs was found in the MHGP group (25.3% vs. 17.8%, p < 0.001), whereas a higher prevalence of PDs was found in the MHPP group (7.0% vs. 2.6%, p < 0.001). The multivariable model indicated that subjects who were single or separated/divorced/widowed and had a history of trauma exposure were at joint risk of PSs and PDs, whereas entering jail was not associated with either PSs or PDs after adjustment for all covariates.

CONCLUSION

The present study shows that PDs, but not PSs, are more prevalent in men entering jail than in the general population. This overrepresentation could be further explained by the exposure to vulnerability factors found in this population rather than by any specificity related to entering jail.

Sex differences in borderline personality disorder: A scoping review

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

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.

The health of detainees and the role of primary care: Position paper of the European Forum for Primary Care

This position paper aims to increase awareness among primary care practitioners and policymakers about the specific and complex health needs of people who experience incarceration. We focus on the importance of primary care and of continuity of care between prison and community. We highlight what is known from the literature on the health of people who experience incarceration, on the organisation of prison health care, and on the role of primary care both during and after detention. We present three case descriptions of detainees' encounters with the organisation of prison health care in three European countries. Finally, we describe the position that the European Forum for Primary Care takes. Prisoners and ex-prisoners have a worse physical and mental health compared with a cross-section of the population. However, access to good quality treatment and care is often worse than in the outside situation. In particular, well-organised primary care in the prison context could benefit prisoners and, indirectly, society at large. Moreover, continuity of care between the community and the prison situation needs improvement.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis

Background

Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period.

Methods

We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels.

Findings

Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings.

Interpretation

Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries.

Funding

Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.