Psychiatric aspects of imprisonment

In 1997 the prison population in England and Wales rose to a new level of 61 000 and is expected to reach 83 000 by 2005. (49 Prisons contain two distinct populations of people. Remanded or pretrial prisoners (detainees in the United States) are those held in prison while they await trial or sentencing. Convicted or sentenced prisoners (felons) are those found guilty and who are serving a sentence imposed by the court. The former is a relatively unsifted population, while the latter will, depending on local services, have passed through screening processes likely to have selected out and removed prisoners with major psychiatric disorders requiring treatment. This process of selecting-out mentally ill offenders will also depend on the available legislation. For example, since 1959 courts in the United Kingdom have been able to order hospital admission as an alternative to imprisonment for mentally ill offenders convicted of any imprisonable offence except murder. In countries where that court disposal is unavailable, prisons are likely to contain larger numbers of mentally ill prisoners.

Psychiatric surveys in prisons are essentially epidemiological in type. They reveal very little about the relationship between psychiatric disorder and offending, but a great deal about the use of one type of institutional resource for the containment of mentally disordered offenders. (41) Traditionally, prison surveys of psychiatric morbidity were hampered by sampling problems, and a lack of uniformity in defining psychiatric disorders and measuring their severity. More recent studies (42,43,4 and 45) have addressed these problems with large (sometimes census) surveys and more refined assessment procedures. The results from recent studies in the United Kingdom, including a comprehensive survey by the Office for National Statistics, (46) and the United States'4 48 and 49) reveal a consistent picture (Table 1 and Table..?).


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Table 1 United Kingdom studies of psychiatric disorder in male prisoners

Table 1 United Kingdom studies of psychiatric disorder in male prisoners


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Table 2 Studies of psychiatric disorder in female prisoners

Table 2 Studies of psychiatric disorder in female prisoners

• The prevalence rate for psychotic disorder is between 2 and 15 per cent and approximately 20 times greater than for adults in the general population.

• While it is impossible to prove that this results from deinstitutionalization of the mentally ill and reductions in inpatient bed numbers, observation and impression point in that direction.'50)

• In both the United Kingdom and the United States there is a crisis in the proper provision of community and hospital resources suitable for the treatment of mentally ill offenders; by default they drift into prison.

• Misuse of alcohol and drugs, prior to and during imprisonment, is the most common psychiatric feature. More than a third of prisoners in Scotland have injected drugs, and the majority of these have injected in prison.(51) An outbreak of HIV infection has occurred in a Scottish prison.(52)

• Neurotic symptoms and disorders are common and may be a factor in the large numbers of prisoners with histories of self-harm and suicide attempts prior to imprisonment.'46)

• The high prevalence of personality disorder, particularly antisocial in type, poses huge problems for prison authorities in the management and provision of regimes.

• Co-occurrence of disorders is common. Approximately 25 per cent of the remanded population (of both sexes) in the Office of National Statistics ( ONS) study'46' had four or five psychiatric disorders.

Suicide in prisons

Prison suicides are a major problem facing prison authorities and governments. The rate of prison suicides has risen sharply in United Kingdom in recent years (as elsewhere). Several key factors have emerged from studies in England(53) and Scotland(54)

• Suicide is rare among female prisoners, though there has been a recent spate of seven in 30 months in Scotland's only women's prison. (55)

• The most common method is hanging from a window bar or other ligature point using torn bed linen, with death resulting from asphyxia or carotid artery compression.

• The majority occur within 6 months of imprisonment.

• Life-sentence prisoners are over-represented.

• Psychiatric morbidity is common, with alcohol and substance misuse being the most likely.

Many prisoners possess the personal, social, and psychological characteristics that typify those who commit suicide in the community. Identifying those at risk, and instituting appropriate measures for managing them, are often difficult tasks in a prison setting. In the past, suicide prevention regimes have been strongly criticized for providing little more than passive, remote observation of prisoners located in bare ligature-proof strip cells. There is now increased emphasis on personal interaction, observation through therapeutic activity, and more humane environments. Prison suicide has acquired medico-legal importance with law suits commonly initiated against the prison authority by a bereaved family. (56>

Female prisoners

The imprisonment of women in the United Kingdom is rising at a faster rate than for men; the sentenced population in particular rose by more than 20 per cent between 1996 and 1997.(4°) Black women are over-represented in prison by a factor of 10. Women are less likely than men to have committed a crime of violence or of burglary and more likely to have committed a drug offence, theft, fraud, or deception. There has been a significant rise in the number of women from overseas imprisoned for drug-carrying.

The mental health of female prisoners is more likely to be impaired than that of males. In a survey of sentenced prisoners, Maden et al.(57> found that two-thirds of women, compared with one-third of men, received a psychiatric diagnosis. Drug misuse and personality disorder were the most common. Women more commonly have histories of psychiatric treatment before imprisonment: 40 per cent of women compared with 20 per cent of men in the ONS study.(46) Of female remand prisoners in the ONS study, 22 per cent had a previous psychiatric admission, 6 per cent for longer than 6 months and 11 per cent in locked wards. Suicide attempts in the year before imprisonment (27 per cent), and episodes of non-suicidal self-harm during imprisonment (9 per cent), are more common in women than in men (15 per cent and 5 per cent respectively).(46) These phenomena were more common in white than in black women and those from other ethnic groups. The management in prison of self-mutilating women, frequently with borderline personality disorders, poses serious problems.

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