Mental disorder in the New South Wales prisoner population

OBJECTIVES: To determine the prevalence of mental illness among prisoners in New South Wales (NSW), Australia. METHOD: Mental illness was examined in two NSW prisoner populations: (i) new receptions to the correctional system; and (ii) sentenced prisoners. Reception prisoners were screened at four male centres and one female centre in NSW. The sentenced population was randomly selected from 28 correctional centres across the state. Reception prisoners were screened consecutively whenever possible while the sentenced group was randomly selected as part of the 2001 Inmate Health Survey. We adopted the same instrument, Composite International Diagnostic Interview - Auto (CIDI-A), for diagnosing mental illness as used in the Australian National Survey of Mental Health and Wellbeing. RESULTS: Overall, 43% of those screened had at least one of the following diagnoses: psychosis, anxiety disorder, or affective disorder. Reception prisoners suffered from mental illness to a greater extent than sentenced prisoners (46%vs. 38%). Women had higher levels of psychiatric morbidity than men (61%vs. 39%). Nine percent (9%) of all prisoners had experienced psychotic symptoms (due to any cause) in the prior 12 months. Twenty percent (20%) of all prisoners had suffered from at least one type of mood disorder and 36% had experienced an anxiety disorder. Posttraumatic stress disorder was the most common disorder, diagnosed in 26% of receptions and 21% of sentenced prisoners. CONCLUSIONS: These findings confirm that prisoners are a highly mentally disordered group compared with the general community. Given the high prevalence of mental illness identified by this study, it is essential that prison mental health services be adequately resourced to address the demand and, at minimum, ensure that mental health does not deteriorate during incarceration.     

Podiatric problems are associated with worse health status in persons with severe mental illness

The objective of this study was to determine the prevalence of self-reported podiatric impairments and their effect on health status in persons with severe mental illness. A sample of psychiatric outpatients (N=309) underwent interviews assessing medical conditions and health status with the Medical Outcomes Study Short Form-36 (SF-36). Podiatric health was assessed using nine items from the National Health Interview Survey (NHIS). Eighty percent of patients reported at least one podiatric problem. The most common problems were foot pain (48%), nail disorders (35%) and corns/calluses (28%). Prevalence rates were 4-11 times higher than those reported by the general population in the 1990 NHIS. The total number of podiatric problems was inversely related to eight self-reported health status domains and both summary SF-36 scores (all P<==.0001). After controlling for sociodemographic factors, psychiatric illness and medical conditions, the total number of podiatric limitations remained significantly associated with lower patient ratings in four of the eight SF-36 domains and both summary scores. We concluded that persons with severe and persistent mental illness have markedly elevated rates of podiatric problems when compared to the general population group. These problems are associated with worsened self-perceived health status. Addressing podiatric health may be a successful way to improve the overall health of this population.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.     

Community Mental Health Services and the Prevalence of Severe Mental Illness in Local Jails: Are They Related?

The excessive prevalence of severe mental illness noted in correctional settings has sometimes been attributed to the inadequacy of community based mental health services. This study examines the prevalence of severe mental illness in two jails situated within catchment areas featuring markedly different levels of community mental health services. We use these settings to test the hypothesis that greater levels of services in a community are associated with lower prevalence of severe mental illness in the community's jail. An epidemiologic approach, using standardized field instruments, was used to estimate the prevalence of major mental illness in detainees arriving at the two sites over a 6-month period. The hypothesis that greater levels of mental health resources in a community would be associated with lower prevalence of mental illness in the community's jail was not supported. These findings suggest that community-based mental health services by themselves do not affect the prevalence of mental illness in jail.     

Prevalence of psychiatric disorders among National Health Insurance enrollees in Taiwan

OBJECTIVE: About 96 percent of all residents of Taiwan were enrolled in the National Health Insurance (NHI) program in 2000. This study used claims data from the NHI database to determine the prevalence of and the demographic characteristics that are associated with psychiatric disorders. METHODS: A total of 200,432 persons, about 1 percent of Taiwan's population, were randomly selected from the NHI database. Persons under the age of 18 years and persons who were not eligible for NHI in 2000 were excluded, leaving 137,914 persons available for this study. Data for enrollees who had at least one service claim during 2000 for ambulatory or inpatient care for a principal diagnosis of a psychiatric disorder were classified into one of the psychiatric disorder categories according to ICD-9-CM diagnostic criteria. Data from the 2000 NHI study were compared with data from a 1985 community survey, the Taiwan Psychiatric Epidemiological Project, to determine how the prevalence of psychiatric disorders changed over the 15-year period. RESULTS: The one-year prevalence of any major psychiatric disorder, any minor psychiatric disorder, and any psychiatric disorder were 1.37 percent, 4.26 percent, and 5.30 percent, respectively. The differences in prevalence between the sexes were significant for five major and nine minor psychiatric disorders. The prevalence for eight psychiatric disorders were lower in the 2000 NHI study than in the 1985 community survey. However, the prevalence of schizophrenic disorder was found to be higher in the 2000 study and the prevalence of bipolar disorder was found to be the same in both studies. CONCLUSIONS: Because the prevalence of psychiatric disorders were generally lower in this study and in the 1985 community survey than those in other countries, it was concluded that both major and minor psychiatric disorders were undertreated in Taiwan. It is necessary for the public health department and the general population to emphasize mental illness education, prevention, and treatment in Taiwan.     

Critical time intervention for reentry from prison for persons with mental illness

Critical time intervention (CTI) is a nine-month, three-stage intervention that strategically develops individualized linkages in the community and seeks to enhance engagement with treatment and community supports through building problem-solving skills, motivational coaching, and advocacy with community agencies. It is an empirically supported practice shown to enhance continuity of care for people with mental illness after discharge from homeless shelters and psychiatric hospitals. This article describes CTI as a promising model to provide support for reentry from prison for people with mental illness. A conceptual model is presented for evaluating the impact of CTI on the transition from correctional settings to the community. The model is potentially useful for further development of mental health service-driven models of reentry process and outcome. Although CTI is a potentially useful model for reentry services for this population, challenges remain in adapting it to specific correctional facilities, justice systems, and community contexts.     

Current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake in Connecticut's jails

This study presents estimates of current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake into all five of Connecticut's adult jails (four male facilities and one female facility). Diagnoses were assessed with the Structured Clinical Interview for DSM-IV (SCID), Clinician-Administered PTSD Scale, and the Global Assessment of Functioning (GAF) and are reported by gender and race/ethnicity. The results showed that more than two of three inmates met the criteria for at least one lifetime psychiatric disorder, almost half for an anxiety disorder, and more than one-third for an affective disorder. Overall, estimates of psychiatric morbidity in the women were higher than those in the men, with the exception of antisocial personality disorder (ASPD). Of particular note, borderline personality disorder was diagnosed in 23.2 percent of women and 12.9 percent of men. An allegation of a violent offense was not associated with the presence of mental illness or with a specific diagnosis. Lifetime history of any mental illness was associated with significantly reduced scores (range, 12-15 points reduction) on the Global Assessment of Functioning. The study showed that current and lifetime psychiatric morbidity are elevated among newly incarcerated adults who do not exhibit obvious signs of severe mental illness and are associated with functional impairment. While such disorders do not necessarily require treatment, unrecognized mental illness may place offenders at greater risk while incarcerated than offenders without mental illness. This study reinforces the need for appropriate screening and referral for treatment at intake into jail.     

Treating incarcerated women: gender matters.

Research on incarcerated women has shown they have a high degree of comorbid psychopathology, including substance dependence, posttraumatic stress disorder (PTSD), antisocial personality disorder (ASPD), and major depression. Incarcerated women differ from their community peers by having more symptoms related to addiction, ASPD, and PTSD. At the same time, incarcerated women are every bit as likely as incarcerated men to be dependent on drugs and almost as likely to be dependent on alcohol. What emerges is a picture of the incarcerated woman far more likely to have had traumatic experiences, including early sexual and physical abuse, than her male peers but every bit as likely to have substance dependence and, in some correctional populations (eg, sentenced felons), antisocial personality disorder. Central to the discussion of how best to treat female offenders is the need to address how programs would best be structured for women with severe substance dependence, substantial trauma histories, and personality pathology, including ASPD. Incarcerated women are a population with complex medical and mental health needs and are likely to be high users of services within the correctional system. This poses challenges to a system already stretched thin in caring for these complex inmates. This article emphasizes that gender differences need to be appreciated, and that service delivery to male and female inmates needs to be structured with gender in mind. The article recommends case management, treatment in highly structured therapeutic communities, and emphasizing abstinence from substances and development of skill sets to engage in healthy relationships.A major future challenge lies in researching treatment interventions for women in the correctional system. There are few existing trials of treatment efficacy and, as previously noted, the incarcerated female population differs from populations of incarcerated men and women in the community. Opiate-dependent women undergoing treatment in the community may prove to be a reasonable comparison group in beginning to develop evidence-based treatment for female offenders in prisons and jails. Ultimately, the development of services for incarcerated women will consider gender, race, and psychopathology in determining treatment setting and modalities. We are on new ground. It is a promising and exciting time to be involved with treatment of female offenders.     

Parcours de soins et expertises psychiatriques pré-sentencielles : une étude descriptive au centre pénitentiaire de Château-Thierry

ContextThe high prevalence of psychiatric disorders among people in prison is well documented, and several hypotheses have been proposed to explain this overrepresentation. In France, the decrease in the number of people found by the judge to be not criminally responsible on account of mental disorder after a psychiatric expertise could play a crucial role. The Château-Thierry prison is a high-security correctional facility where prisoners whose integration into a “standard” prison is complicated because of behavioural problems, reside. We conducted the first study to describe the judicial and healthcare trajectories of people incarcerated in this facility.MethodAll the people incarcerated in the Château-Thierry prison between May and September 2019 were included in this cross-sectional study. In addition to sociodemographic characteristics, data on the psychiatric care before and during incarceration as well as information on the judicial and prison history were collected. We also analyzed all the pre-sentencing psychiatric reports in order to collect the degree of discernment determined by the psychiatrist expert for each included individual.ResultsSixty-eight (97%) of the 70 people detained at the Château-Thierry prison during the study period were included and 92 pre-sentencing psychiatric reports were analyzed. The population studied was exclusively male, with an average age of 40 years, low socio-economic status and frequent criminal history (79%). About half of them (46%) had already been hospitalized in a psychiatric community hospital prior to incarceration, and 79% have been hospitalized in a psychiatric facility during their incarceration. Disciplinary sanctions were frequent (72%) as well as convictions for offenses committed while in prison (57%). When at least one pre-sentencing psychiatric report was carried out (29 persons had a single psychiatric forensic evaluation and 27 ones had multiple evaluations), at least one psychiatric expert had concluded to a diminished (but not lack of) criminal responsibility in almost half of the cases (44%).ConclusionThis study shows the extent to which people incarcerated in the Château-Thierry prison are affected by psychiatric disorders. It also highlights the difficulties of coping with the prison environment for people suffering from psychiatric disorders. Finally, it raises the question of the lack of diversion programs for the individuals in France with mental health problems whose responsibility has been considered as full or diminished.     

Mental Health Problems in Recently Incarcerated Male Adult Drug Users in Taiwan: Patterns,Rates, and Implications for Treatment

This study aimed to explore the extent of association between the classes and patterns (single vs. multiple) of drug use and the psychiatric disorders among recently incarcerated male drug users to help formulate drug policies for correctional facilities and provide adequate treatment for incarcerated drug users. Data were recruited from 414 male first-time incarcerated illicit drug users in one detention center in Taiwan. Their lifetime historical profiles of illicit drug use were then assessed and their associations with current psychiatric disorders were compared with 257 community controls. Heroin and meth/amphetamine were the most commonly used drugs among single and combined users. Heroin users were more likely to exhibit major depression and social phobia; meth/amphetamine users showed more psychotic disorder and antisocial personality disorder than community controls. Multiple drug users were associated with two-thirds of the psychiatric disorders. This study suggests that heroin and meth/amphetamine users require specific treatments, which may effectively address associated psychopathologic conditions. Interventions for mental disorders for some detainees are also recommended.     

Psychiatric illness and comorbidity among adult male jail detainees in drug treatment

The prevalence of psychiatric disorders was examined in a sample of 204 pretrial jail detainees receiving standard drug treatment. More than half of the sample had at least one lifetime DSM-III-R axis I diagnosis, and the lifetime rates of serious mental illness were higher than reported prevalence rates for arrestees in general jail populations. Detainees with comorbid disorders were more likely than others to have more than one co-occurring psychiatric disorder, to have been arrested for property crimes, and to be dependent on alcohol, marijuana, or PCP. The findings argue for the expansion of integrated treatment services within criminal justice drug treatment settings.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Prevalence of somatic and psychiatric disorders among former prisoners of war

American former prisoners of war (POWs) are an aging group who seek health care with increasing frequency. To examine the prevalence of long-term physical and emotional consequences of captivity in this population, the authors analyzed medical and psychiatric examination data for 426 former POWs. Detailed psychiatric diagnostic criteria were used to assess the POWs' mental health. Compared with general population groups, POWs had moderately elevated lifetime prevalence rates of depressive disorders and greatly elevated rates of posttraumatic stress disorder (PTSD), although their rates of hypertension, diabetes, myocardial infarction, bipolar disorder, schizophrenia, and alcoholism were not elevated. POWs who lost more than 35 percent of their body weight during captivity had higher rates of anxiety disorder, depressive disorders, PTSD, and schizophrenia, compared with other POWs.     

Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys

ObjectiveTo systematically review and perform a meta-analysis of the research literature on the prevalence of mental disorders in adolescents in juvenile detention and correctional facilities.MethodSurveys of psychiatric morbidity based on interviews of unselected populations of detained children and adolescents were identified by computer-assisted searches, scanning of reference lists, hand-searching of journals, and correspondence with authors of relevant reports. The sex-specific prevalence of mental disorders (psychotic illness, major depression, attention-deficit/hyperactivity disorder [ADHD], and conduct disorder) together with potentially moderating study characteristics were abstracted from publications. Statistical analysis involved metaregression to identify possible causes of differences in disorder prevalence across surveys.ResultsTwenty-five surveys involving 13,778 boys and 2,972 girls (mean age 15.6 years, range 10–19 years) met inclusion criteria. Among boys, 3.3% (95% confidence interval [Cl] 3.0%-3.6%) were diagnosed with psychotic illness, 10.6% (7.3%-13.9%) with major depression, 11.7% (4.1%-19.2%) with ADHD, and 52.8% (40.9%-64.7%) with conduct disorder. Among girls, 2.7% (2.0%-3.4%) were diagnosed with psychotic illness, 29.2% (21.9%-36.5%) with major depression, 18.5% (9.3%-27.7%) with ADHD, and 52.8% (32.4%-73.2%) with conduct disorder. Metaregression suggested that surveys using the Diagnostic Interview Schedule for Children yielded lower prevalence estimates for depression, ADHD, and conduct disorder, whereas studies with psychiatrists acting as interviewers had lower prevalence estimates only of depression.ConclusionsAdolescents in detention and correctional facilities were about 10 times more likely to suffer from psychosis than the general adolescent population. Girls were more often diagnosed with major depression than were boys, contrary to findings from adult prisoners and general population surveys. The findings have implications for the provision of psychiatric services for adolescents in detention. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(9):1010–1019.     

The treatment of personality-disordered offenders in Germany

Offenders with mental illness challenge forensic systems throughout the world. Those with personality disorders present additional challenges. In this article, the authors describe relevant German legislation and the consequent forensic treatment of personality-disordered offenders in the German psychiatric and correctional systems, with a focus on the German state of Hessen. The development of laws and regulations are addressed, as are the parallels and distinctions between forensic hospitals and correctional settings. Current treatment approaches and programs are described. Research initiatives and future directions for the system, and comparisons with the system in the United States conclude the article.     

Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services

We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population.     

Prevalence and Correlates of Criminal Victimization Among New Admissions to Outpatient Mental Health Services in Hawaii

Adults with serious mental illness (SMI) experience criminal victimization at rates higher than the general population whether they reside in the community or correctional settings. This study examines the past-six month prevalence and correlates of criminal victimization among a large community sample (N = 2,209) of consumers with SMI newly admitted to outpatient mental health services during 2005 through 2008. A cross-sectional design was used with self-report and clinical data collected from administrative records. Victimization was determined by responses to direct questions about experiences in the previous 6 months with respect to victimization of a non-violent and/or violent crime. Socio-demographic, clinical and criminal correlates of victimization were abstracted from a quality of life survey and clinical assessment interview conducted at admission. Overall, 25.4 % of consumers reported being a victim of any crime (violent or non-violent) in the past 6 months, with 20.3 % reporting non-violent and 12.3 % violent victimization. The risk of victimization was elevated for those who were female, White, not taking atypical psychotropic medication, not feeling safe in their living arrangement, and were arrested or homeless in the six-months prior to engaging in mental health outpatient treatment. Policy and practice implications of these findings are discussed.