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|Year : 2013
: 55 | Issue : 4 | Page
|Psychiatric morbidity in prisoners
Vinod Kumar1, Usha Daria2
1 Department of Psychiatry, Jhalawar Medical College, Jhalawar, Rajasthan, India
2 Department of Anesthesia, Jhalawar Medical College, Jhalawar, Rajasthan, India
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|Date of Web Publication||25-Oct-2013|
| Abstract|| |
Background: Prisoners are having high percentage of psychiatric disorders. Majority of studies done so far on prisoners are from Western countries and very limited studies from India.
Aim: Study socio-demographic profile of prisoners of a central jail and to find out current prevalence of psychiatric disorders in them.
Materials and Methods: 118 prisoners were selected by random sampling and interviewed to obtain socio-demographic data and assessed on Indian Psychiatric Interview Schedule (IPIS) with additional required questions to diagnose psychiatric disorders in prisoners.
Results: Mean age of prisoners was 33.7 years with 97.5% males, 57.6% from rural areas and 65.3% were married. Average education in studied years was 6.6 years and 50.8% were unskilled workers. 47.4% were murderers while 20.3% of drugs related crimes. 47.5% were convicted and history of criminal behavior in family was in 32.2% prisoners. Current prevalence of psychiatric disorders was 33%. Psychotic, depressive, and anxiety disorders were seen in 6.7%, 16.1%, and 8.5% prisoners respectively. 58.8% had history of drug abuse/dependence prior to imprisonment.
Conclusion: One prison of Hadoti region of Rajasthan is full of people with mental-health problems who collectively generate significant levels of unmet psychiatric treatment need. Prisons are detrimental to mental-health. Beginning of reforms is the immediate need.
Keywords: Drug abuse, prisoners, psychiatric morbidity, socio-demographic
|How to cite this article:|
Kumar V, Daria U. Psychiatric morbidity in prisoners
. Indian J Psychiatry 2013;55:366-70
| Introduction|| |
Prisoners live their life behind bars and this takes them away from their families, marriages, heterosexual contact, jobs, friends, communities, and religious activities and puts them in an extremely bad moral environment for years at a time. Social organization in prison revolves around vicious prison gangs and no good role models in jails to be followed. Many prisoners are beaten, raped, brutalized or made to live in fear. Overcrowding makes environment worse for prisoners. As per data of 2006 by National Human Rights Commission,  prisons of India having a total capacity of 248,439 while actual number of prisoners living in prisons was 358,177. Most of the prisons have limited sunlight and fresh air and full of bad odors and poor health services. Bland and unappealing food, clothing and extremely confining shelter makes life more measurable to prisoners. In a study published in 2003 Nurse et al.  examined the influence of environmental factors on the mental-health of people in prison found that participants reported lengthy periods of isolation with little mental stimulation contributing to poor mental-health and feelings of anger, frustration, and anxiety. Prisoners spend on average around 8-9 h unlocked, however, it is not uncommon to find in higher-security prisons that some prisoners spend 19-20 h and sometimes up to 23 h a day locked in their cells. According to Singleton et al.,  those who are male, on remand and psychotic are likely to be locked up longer than other inmates.
Prisons have high percentage of mentally-ill prisoners. ,,,, Firstly, mentally-ill persons are more frequently than others involved in crime due to symptoms like impaired judgment, lack of impulse control, suspiciousness, loss of inhibitions, paranoid ideas, inability to trust others, delusions, and hallucinations and most of them are less smart, so easily caught by police. Secondly, prisoner's living conditions in prison make them more susceptible to psychiatric disorders. Because conditions in prison are not conducive to good mental-health, prisoners with mental-illness are at risk of experiencing deterioration in their mental state. In 2004, Anderson  pointed in a review that psychiatric morbidity including, schizophrenia is higher and perhaps increasing in prison populations compared with general populations and also with dependence syndromes being the most frequent disorders. He further added that early phase of imprisonment is a vulnerable period with a moderately high incidence of adjustment disorders and twice the incidence in solitary confinement compared with non-solitary confinement. Finally, he concluded that there is a growing population of mentally ill prisoners being insufficiently detected and treated.
Relationship between psychiatric services and prison was studied by Penrose  in 1939 and found an inverse relationship between number of mental hospital beds and number of prisoners in any given society and the same relationship was further conformed by Billes and Mulligan  in 1979. In 2000 Gunn  found that studies carried out so far reported high prevalence of psychiatric disorders in prisoners. In 2003 Duffy et al.  also focused on screening prisoners for mental disorders. In 2004 Birmingham  concluded that prisons are full of people with serious mental problems and prison population is growing rapidly all over world. Studies carried out so far for psychiatric morbidity in prisoners are mostly from western countries. A systemic review in 2002 by Fazel and Danesh  of 62 surveys from 12 countries included 22,790 prisoners and found only three papers from non-Western societies with a combined sample of 326 prisoners only. Studies on psychiatric morbidity in Indian prisons are very limited and out of them only one study was from Rajasthan state by Bhojak et al.  who studied prisoner of Central Jail, Jaipur located in central area of Rajasthan. To fill this gap at some extent we took this study to examine prisoners of Central Jail, Kota located in south-east area of Rajasthan known as Hadoti region.
| Materials and Methods|| |
A written permission was obtained to carry out the study from the Director General, Prisons, Rajasthan and the Superintendent, Central Jail, Kota, Rajasthan. The plan of study was approved by ethical committee of Govt. Medical College, Kota. The jail was having a total of 1148 male prisoners including, 526 convicted males and 603 under-trial males and 19 under-trial female prisoners. Sample size required for study was calculated by the following formula (Daniel 1999). 
n = Z 2P (1-P)/d 2
where, n = sample size, Z = Z statistic for a level of confidence, P = expected prevalence in proportion of one and d = precision in proportion of one. For the level of confidence of 95%, which is conventional, Z value is 1.96. To calculate values for " P" and " d", studies done by Fazel and Danesh  and Singleton et al.  were used as reference for expected prevalence  of psychotic and other disorders. Using all above, sample size of more than 100 was considered as adequate for present study. Considering the fact of release of prisoner from jail before the interview and refusal by some prisoners to participate in the study, a total of 130 prisoners were decided to be selected for study. Then all the prisoners were numbered from 1 to 1148 as per serial number in register of jail and using simple random sampling method 130 prisoner were selected. Informed consent was obtained from selected prisoners to participate in study. Eight prisoners were released on or before the day of interview and four refused to participate in the study. Finally, 118 prisoners participated in the study.
The prisoners were interviewed in a room at jail provided by the jail administration. Interview included details for socio-demographic data, history of previous imprisonment, drug dependence, psychiatric disorders and family history of criminal behavior. For psychiatric disorders prisoners were assessed using Indian Psychiatric Interview Schedule (IPIS) and exploration of sign and symptoms in detail by additional questions and observation. IPIS is a structured instrument for investigating psychopathology in an Indian setting. It was developed and improved through a number of pilot studies conducted at National Institute of Mental Health and Allied Neural Sciences, Bangalore Out-Patient Department (Kapur et al., 1974).  The diagnoses for psychiatric disorders were made on criteria of 10 th revision of International Classification of Diseases (ICD-10) by World Health Organization. Since drugs are not supplied to prisoners of drug dependence in Indian jails, so to measure the magnitude of drug dependence detail history was taken from prisoners and questions for abuse or dependence were asked. The prisoners taking drugs prior to entry in jail and having dependence at that point of time were diagnosed as having history of drug abuse or dependence and presently absent in protracted environment.
The collected data was tabulated and presented in number, percentage, mean, and standard deviation. The results are compared with Indian, Western and non-Western countries.
| Results|| |
The prisoner's age was 19-66 years with mean age 33.7 years while at the time of crime it was 30.4 years seen in [Table 1]. Majority of prisoners were males (97.5%). More than half of prisoners (57.6%) were from rural areas. Average education in studied years was found 6.6 years with16.9% (20) illiterate and only 3.4% (4) prisoners having master's degree. Half of prisoners (50.8%) were unskilled workers and 16.9% were either in service or having their own business. Nearly two third (65.3%) of prisoners were married while 5.1% were widowed or divorced.
[Table 2] showing that maximum numbers of prisoners were murderers (47.5%) while 20.3% of prisoners carried out drugs related crimes like drug trafficking. Nearly half of the prisoners (47.5%) were convicted while 52.5% were under trial. Average stay of prisoners was found to be 30 months. One in 10 prisoners (9.3%) was having previous history of imprisonment and history of criminal behavior in family was found in every third (32.2%) prisoner.
Current prevalence of psychiatric disorders was found as 33% shown in [Table 3]. Psychotic disorders in prisoners were 6.7% including 3.4% schizophrenia and 2.5% bipolar affective disorders. Neurotic disorders were seen in 26.3% prisoners. Depressive disorder was seen in 16.1% prisoners. Anxiety disorders were seen in 8.5% including generalized anxiety disorder and obsessive compulsive disorder (OCD) as 6% and 2.5% respectively. Somatoform disorder was seen in 1.7% prisoners. History of drug abuse or dependence prior to imprisonment was found in 58.8% prisoners.
| Discussion|| |
The major limitation of our study was that we did not report current substance abuse and reported only history of substance abuse. It was likely that the prisoner's current use was underestimated. The reasons for this were, firstly, that all substance abuse populations under-report their use, and secondly, that there might be repercussions for inmates admitting they are using substances in prison. In our study, more than half of prisoners were having history of substance abuse. Similar results were reported by Indian and Western studies by Goyal et al.,  Mason et al.,  and Gavin et al. 
Our results suggest that prevalence of psychiatric disorders is much higher in prisoners than general Indian population. A review article  published in 2007 for psychiatric epidemiology in India including 16 studies from different part of India reported psychiatric morbidity in range of 9.5-102.8 per 1000. Our study found 33% prisoners having psychiatric disorder excluding current substance abuse. This finding was consistent with one previous study of Rajasthan state by Bhojak et al.  In another study of Punjab by Goyal et al.  reported psychiatric disorders in 23.8% prisoners. Comparative less percentage of psychiatric disorders in Goyal et al.  study was might be due to sampling and restriction by Jail administration. They included only convicted prisoners, excluding prisoners in prison psychiatric unit and in maximum-security unit. An Asian region study of Iran by Assadi et al.  found more than half inmates of Jails having psychiatric disorders. The high prevalence in Iranian prisoner might be due to law, religious, and cultural difference. Results of Western studies Birmingham et al.,  Steadman et al.  and Brooke et al.  were found consistent with our study.
Gavin et al.,  Maden et al.,  Brooke et al.  and Coid  reported high prevalence of psychotic disorders in prisoners and result of our study was consistent with them. Maden et al.  reported that one-fourth prisoners were having neurosis as repeated in our study. Same prevalence rate of depressive disorder of our study was reported in Indian and Western studies by Goyal et al.,  Gavin et al.,  Falissard et al.  Results of anxiety disorders of our study were in agreement with Davidson et al.  Agbahowe et al.  and Falissard et al.  OCD was found in 2.5% in our study while Simpson et al.  reported double prevalence of OCD.
The level of confinement and isolation experienced by some prisoners is detrimental to mental-health and people with a pre-existing psychiatric disorder deteriorate, and others who are vulnerable can become psychiatric patients. Long stay of prisoners in prison may be a contributing factor in high number of psychiatric prisoners and vice versa psychiatric persons more involved in unlawful activities and further easily caught by police. In our study, average stay of prisoners in prison was 2 years but it was difficult to establish its correlation with psychiatric disorders.
Every fifth prisoner of our study was involved in drug trafficking or related crimes. Our study reported high rate of history of drug abuse and family history of criminal behavior seems to be linked with unlawful activities. Prison population is dominated by low intelligence quotient (Birmingham et al.)  This fact was indirectly reflected in our study as low education studied years and half of the prisoners were unskilled workers.
Half of prisoners of our study sample were murderer. As per Indian law these were liable for life imprisonment or death sentence. These types of punishments give hopelessness in prisoners and may be a possible factor in higher rate of psychiatric disorders.
Prisoners who have a serious mental disorder should be transferred to psychiatric hospital, but this is often not done.  Whenever a prisoner is transferred, there are delays.  Prisoners who are potential candidates for hospital treatment may be rejected by psychiatric services because they are perceived as too disturbed or dangerous, or seen as criminals who are unsuitable for treatment (Coid).  As a result these prisoners remain untreated or undertreated leading to accumulation of psychiatric population in prisons and this is also seems a possible cause of high percentage of psychiatric morbidity in prisoners. This emphasizes the need for better training of prison staff and implies a need for increased specialist psychiatric input. Gunn et al.  and Maden et al.  demonstrated a significant level of unmet mental-health treatment needs among prisoners. Poor communication between the prison, court, and hospital systems hinders the assessment and management of the mentally disordered offender, and medical intervention can actually delay release from custody (Robertson et al.)  When communication breaks down altogether, the result can be the sudden and unpredicted release of someone with acute psychosis who is then lost to follow-up in the community. More often, however, mentally-ill prisoners receive no treatment or after-care when they are released because their treatment needs are not properly recognized (Birmingham et al.,  and Dell et al.) 
For remedial measures to be taken identification of magnitude of problem, preventable causes and treatment with proper compliance and follow-up is needed. Mental disorders are highly stigmatized conditions that many people want to keep private because of their embarrassment or fear of discrimination.  So jail records prepared by untrained staff may not be sufficient to identify the population of prisoner in treatment need.
Detection by screening may be performed by primary medical staff, psychologist or nursing staff and referral psychiatric evaluation. Ideal treatment would be assessment and treatment in prison by psychiatrists in liaison with prison health staff. Some of those with major depression will require inpatient care. Many should receive on going therapy, which may be psychological or by medication. Such a level of service provision is quite beyond the capacity of current psychiatric services. The same issues arise for substance misuse disorders. Without adequate detoxification programs, many inmates will continue to use drugs in prison. In some cases, this will be accompanied by the risk of needle sharing.
Staff recruitment, retention and training will be a real challenge for the prison health service, which has traditionally been seen as an unattractive place to work. Moreover, just improving the standards of health-care inside prisons will not be sufficient in itself but strengthening of community psychiatric services with sufficient beds and trained staff, and linking a quick accessible referral service to each prison or jail is real need.
Other possible cause for poor mental-health of prisoner is overcrowding, very few recreational and intellectual activities and sometimes unnecessary prolongation of under trial period due to lengthy judicial system of hearings. Increasing number of prisons, fast hearings in courts, religious activities, training of meditation, yoga, and other relaxation techniques may be fruitful for positive mental-health of prisoners.
In conclusion, it is readily apparent that one prison of Hadoti region of Rajasthan is full of people with mental-health problems who collectively generate significant levels of unmet psychiatric treatment need. Prisons are detrimental to mental-health, and the standards of psychiatric care are significantly lower than those for the general public. Certain remedial measures are to be implemented for a better future of prison and community because ultimately these prisoners will be released from prison and become a part of community. Beginning of reforms is the immediate need as a long journey ahead.
Limitations of study
Instead of current prevalence of substance abuse, past history of substance abuse was studied. Correlation of prison environment and psychiatric disorders are not studied. Convicted females were not kept in the prison and hence the number of females is less in this study. The study was carried out in a single prison and hence the results cannot be generalized on prison population of India. We suggest a larger multi-centric study involving all or several prisons of different areas of India to make a better planning for psychiatric services for prisoners.
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Department of Psychiatry, Jhalawar Medical College, Jhalawar 326 001, Rajasthan
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
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