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Severe mental illness in 33 588 prisoners worldwide: Systematic review and meta-regression analysis

  • Kriminologischer Dienst Berlin/Research & Development Berlin Prison Services

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High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low-middle-income countries compared with high-income ones. To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression. Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders. We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% (95% CI 3.1-4.2) in male prisoners and 3.9% (95% CI 2.7-5.0) in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low-middle-income countries reporting higher prevalences of psychosis (5.5%, 95% CI 4.2-6.8; P = 0.035 on meta-regression). The pooled prevalence of major depression was 10.2% (95% CI 8.8-11.7) in male prisoners and 14.1% (95% CI 10.2-18.1) in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA (P = 0.008). High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.
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10.1192/bjp.bp.111.096370Access the most recent version at DOI:
2012, 200:364-373.BJP
Seena Fazel and Katharina Seewald
review and meta-regression analysis
Severe mental illness in 33 588 prisoners worldwide: systematic
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There are over 10 million prisoners worldwide,
a population that
has been growing by about 1 million per decade. In 2008, the USA
had the largest number of people imprisoned at 2.3 million and
the highest rate per head of population (at 756 per 100 000 people
compared with a median of 145 per 100 000 worldwide), and
China, Russia, Brazil and India had more than a quarter of a
million prisoners each.
It has been widely reported that
prisoners have elevated rates of psychiatric disorders compared
with the general population, including for psychosis, depression,
personality disorder and substance misuse, which are risk factors
for elevated suicide rates,
premature mortality on release from
and increased reoffending rates.
It is estimated that
suicide rates within prison are increased four to five times
deaths within the first week of release 29-fold higher
than rates
in the general population. Further, a recent review found that
reoffending rates are increased by 40% in offenders with psychotic
disorders compared with non-mentally ill offenders.
A previous systematic review estimated that the prevalence of
psychosis was typically 4% in prisoners of both genders, and that
of major depression was 10% in men and 12% in women.
ever, this review is now a decade old, and, as many psychiatric
institutions have continued to reduce their bed numbers,
number of commentators have suggested that rates of severe
mental illness have been increasing over time in prisoners,
although empirical evidence in support of this is inconsistent
and experts have suggested that measures introduced by the World
Health Organization and other international humanitarian
agencies have improved prison care.
In addition, there has been
no review, to our knowledge, of the mental health of prisoners in
low–middle-income countries, although the vast majority of
prisoners now live in such countries.
As there is a substantial
body of new evidence,
we have conducted a new systematic
review and meta-analysis of the prevalence of psychosis and major
depression, and used subgroup analyses and meta-regression to
explore possible sources of heterogeneity between studies. We
hypothesise that there has been an increase in the rates of
psychosis and major depression over time, and that low–middle-
income countries have higher prevalences of these conditions
due to their less resourced community and prison healthcare
We identified publications estimating the prevalence of psychotic
disorders (including psychosis, schizophrenia, schizophreniform
disorders, manic episodes) and major depression among prisoners
that were published between 1 January 1966 and 31 December
2010. For the period 1 January 1966 to 31 December 2000,
methods are described in a previous systematic review conducted
by one of the authors (S.F.).
For the update and expanded review,
from 1 January 2001 to 31 December 2010, we used the following
databases: PsycINFO, Global Health, MEDLINE, Web of Science,
PubMed, National Criminal Justice Reference Service, EMBASE,
OpenSIGLE, SCOPUS, Google Scholar, scanned references and
corresponded with experts in the field (Fig. 1). Key words used
for the database search were the following: mental*, psych*,
prevalence, disorder, prison*, inmate, jail, and also combinations
of those. Non-English language articles were translated. We
followed PRISMA criteria.
Severe mental illness in 33 588 prisoners
worldwide: systematic review and meta-
regression analysis
Seena Fazel and Katharina Seewald
High levels of psychiatric morbidity in prisoners have been
documented in many countries, but it is not known whether
rates of mental illness have been increasing over time or
whether the prevalence differs between low–middle-income
countries compared with high-income ones.
To systematically review prevalence studies for psychotic
illness and major depression in prisoners, provide summary
estimates and investigate sources of heterogeneity between
studies using meta-regression.
Studies from 1966 to 2010 were identified using ten
bibliographic indexes and reference lists. Inclusion criteria
were unselected prison samples and that clinical examination
or semi-structured instruments were used to make DSM or
ICD diagnoses of the relevant disorders.
We identified 109 samples including 33 588 prisoners in
24 countries. Data were meta-analysed using random-effects
models, and we found a pooled prevalence of psychosis of
3.6% (95% CI 3.1–4.2) in male prisoners and 3.9% (95% CI
2.7–5.0) in female prisoners. There were high levels of
heterogeneity, some of which was explained by studies in
low–middle-income countries reporting higher prevalences of
psychosis (5.5%, 95% CI 4.2–6.8; P=0.035 on meta-
regression). The pooled prevalence of major depression
was 10.2% (95% CI 8.8–11.7) in male prisoners and 14.1%
(95% CI 10.2–18.1) in female prisoners. The prevalence of
these disorders did not appear to be increasing over time,
apart from depression in the USA (P=0.008).
High levels of psychiatric morbidity are consistently reported
in prisoners from many countries over four decades. Further
research is needed to confirm whether higher rates of
mental illness are found in low- and middle-income nations,
and examine trends over time within nations with large
prison populations.
Declaration of interest
The British Journal of Psychiatry (2012)
200, 364–373. doi: 10.1192/bjp.bp.111.096370
Review article
Inclusion criteria were the: (a) study population was sampled
from a general prison population; (b) diagnoses of the relevant
disorders were made by clinical examination or by interviews
using validated diagnostic instruments; (c) diagnoses met
standardised diagnostic criteria for psychiatric disorders based
on the ICD or the DSM; (d) prevalence rates were provided for
the relevant disorders in the previous 6 months.
In order to include unselected, representative and generalisable
prison samples we only selected studies that conducted a diagnostic
interview with a general prison population. We excluded those
studies that used a screening tool before conducting the diagnostic
(as this may lead to an underestimate if the
screening tool had poor sensitivity or overestimates if the tool
had poor specificity). We also excluded sampled selected
populations, for example by offence type
(as there is evidence
that selecting some offender groups may also lead to over-
estimates, which is particularly the case for murder and attempted
), or age group
(including solely juvenile prisoners
prisoners who were in healthcare settings
). For example, one
study that used a screening tool to identify mentally ill prisoners
and was excluded reported a prevalence of 32% for schizophrenia.
Studies that did not separate sentenced from remand prisoners
in their report
and duplicates were excluded. In this update,
we did not include personality disorder due to the high hetero-
geneity reported in the previous work.
For substance misuse
and post-traumatic stress disorder, there are more recent
and a substantial body of new work has not emerged
since their publication.
Data extraction
We extracted information on the year of interview, geographical
location, gender, remand/detainee (including jail inmates) or
sentenced prisoner, average age, method of sampling, sample size,
participation rate, type of interviewer, diagnostic instrument,
diagnostic criteria (ICD v. DSM), numbers diagnosed with
psychotic disorders (ICD-10: F20.xx–F29.xx, F30.xx; DSM-IV:
293.xx, 295.xx), and major depression (ICD-10, F 32.xx, F33.xx;
DSM-IV: 296.2x, 296.3x). Where there was schizophrenia and
other psychotic disorders reported separately, we combined them
to produce a single prevalence. For one publication,
we collated
´pression endoge
´lancolie’, ‘Etat de
´pressif chronique’ and
ˆmes psychotiques contemporains des e
´pisodes thymiques’
as indicating major depression. The data from each of the
identified publications were subdivided into four samples (men
v. women, remand/detainee v. sentenced prisoners). In contrast
to our previous review, we included data on low–middle-income
and whether the clinical diagnostic interview was
conducted within 2 weeks of arrival into the prison (which may
influence prevalence rates and also provides an estimate of mental
health needs on reception to prison). For the update, we examined
rates of comorbidity with substance misuse. The data extraction
was done by two researchers independently (K.S. and K.W.). For
further clarification about specific studies, we corresponded
directly with the authors of the studies.
Data analysis
We analysed sources of heterogeneity by subgroup and meta-
regression analysis using dichotomous and continuous variables.
The year that the interview was conducted and the average age
of the prisoners were analysed as continuous variables. Sample size
and response rate were analysed as both dichotomous and
continuous variables. As the median of reported response rates
was 81%, we defined ‘low’ as 480% v. ‘high’ as 480%). The
following were analysed only as dichotomous variables: gender,
prisoner type (detainees/remand v. sentenced prisoners),
reception status (interviewed in the first 2 weeks of reception v.
the rest), type of interviewer (psychiatrist v. non-psychiatrist),
diagnostic instrument (clinical examination v. semi-structured
interview using a diagnostic tool) and classification criteria
(ICD v. DSM). Geographical location was analysed as low–
middle-income v. high-income country.
We included the US
studies within the high-income country group. Also, we
conducted an additional separate analysis of US studies (v. rest
of world and v. rest of high-income countries) for three reasons:
first, there are over 2 million prisoners there (around a fifth of
the world prisoner population); second, they constituted 30% of
the included studies in the review; and third, mentally
disordered prisoners in the USA are less likely to be diverted
because of judicial and legal reasons, and hence this may
contribute to higher prevalence rates.
We used a recent method for further examination of hetero-
geneity, which involves removing up to four outliers and testing
whether this reduces I
values to below 50%, and then
investigating in more detail the study characteristics of these
We calculated pooled prevalence estimates and their 95%
confidence intervals and transformed the zero cells to 0.5 in order
to calculate prevalences as per standard methods.
for prevalences were conducted by gender and prisoner status. We
measured the heterogeneity between studies with Cochran’s Q
(reported with a chi-squared value and P-value) and the I
statistic (with 95% confidence intervals)
and used random-
effects models for summary statistics as heterogeneity was high
The I
is an estimate of the proportion of the total
variation across studies that is beyond chance. In situations with
high between-study heterogeneity, the use of random-effects
Severe mental illness in prisoners worldwide
Searching in databases
PsychINFO, Global Health, MEDLINE,
Web of Science, PubMed, National
Criminal Justice Reference Service,
Google Scholar
Records screened
Abstracts screened
Full-text articles
25 publications
included in final meta-analysis
Publications before
2001 excluded
Duplicates and reviews
excluded, title screened for
inclusion criteria
(e.g. offence type,
age group), removed:
Removed because screening
revealed exclusion criteria
(e.g. prison setting, specific
mental disorder):
Exclusion after full-text
screening for inclusion criteria
(e.g. priod of diagnoses,
breakdown for mood disorders)
and author correspondence:
Fig. 1 Flow diagram showing the different steps involved
in searching for relevant publications (2001–2010).
Fazel & Seewald
models is recommended as it produces study weights that
primarily reflect the between-study variation and thus provide
close to equal weighting. Univariate and multivariate meta-
regression analyses were used to explore possible sources of
heterogeneity among studies.
Factors in univariate meta-
regression with P-values of 50.1 were included in the final model.
We also conducted a test of funnel plot asymmetry (Egger’s test)
for publication bias using the publication (rather than the sample)
as the unit of measurement. A funnel plot is a plot of the
estimated prevalence against the sample size of the included
studies. Egger’s test can reveal a symmetric or asymmetric funnel
plot. The latter indicates the existence of a significant publication
bias or a systematic heterogeneity between studies.
All analyses
were done in STATA statistical software, version 11.1 on Windows.
Study characteristics
The final data-set consisted of 81 publications, 56 based on the
previous review from the period 1966–2001
and 25 new ones
(online Table DS1).
These publications provided data on
109 samples that included a total of 33 588 prisoners. Of these,
28 361 (84.4%) were male. The overall weighted mean age was
30.5 years. The studies were conducted in 24 different countries,
8 of which are classified as low–middle-income countries:
and Nigeria.
There were 72 studies from high-income countries. There were
25 studies from the USA,
3 from Canada,
5 from Australia,
1 from New Zealand.
The remaining studies were conducted
in Europe including eight in England and Wales,
six in Ireland,
three in Scotland,
and a number in The Netherlands,
and Sweden.
Nine studies reported results from interviews carried out
within 2 weeks of arrival into the prison,
two of them without giving information about the prisoner type
(remand/detainee or sentenced).
Psychotic illnesses
We identified 99 samples from 74 studies that reported
rates of psychotic illnesses and included a total of 30 635
Overall, we
calculated a random-effects pooled prevalence of 3.6% (95% CI
3.1–4.2) in male prisoners (1120 of 26 814 individuals), and
3.9% (95% CI 2.7–5.0) in female prisoners (182 of 3821
individuals) (Table 1). There was significant heterogeneity among
these studies in the male (w
= 416, P50.0001, I
= 83%, 95% CI
79–86) and female prisoners (w
= 86, P50.0001, I
= 68%, 95%
CI 54–79).
There was a significant difference in the prevalences in
low–middle-income countries (5.5%, 95% CI 4.2–6.8) compared
with high-income countries (3.5%, 95% CI 3.0–3.9) (Fig. 2),
confirmed by meta-regression (b= 0.0204, s.e.(b) = 0.0095,
P= 0.035) (Table 2). We did not find any difference in prevalences
between male and female prisoners, between detainees/remand
and sentenced prisoners, and no statistically significant change
in prevalence over time (b=70.0001, s.e.(b) = 0.0002, P= 0.84)
(Fig. 3). When we looked specifically at US studies (17 samples),
there also appeared to be no change over time (b=70.0006,
s.e.(b) = 0.0005, P= 0.24). There was evidence of an asymmetric
funnel plot (Egger’s test, t= 239.32, s.e.(t) = 0.0044, P50.001).
Major depression
We identified 54 publications that reported rates of major depression
in 20 049 prisoners.
Overall, 10.2% (95% CI 8.8–11.7) of male
prisoners (1686 of 16 021 individuals) and 14.1% (95% CI 10.2–
18.1) of female prisoners (605 of 4028) were diagnosed with major
depression (Fig. 4). There was significant heterogeneity among
these studies in males (w
= 541, P50.0001, I
= 91%, 95% CI
89–93) and also in females (w
= 307, P50.0001, I
= 93%, 95%
CI 90–94). Even after the exclusion of four outliers in both gen-
ders, the I
remained above 50%.
There was no significant difference in the prevalence of
depression between men and women. However, there appeared
to be higher prevalences in those studies using DSM criteria and
in low–middle-income countries, confirmed on univariate meta-
regression (Table 2). Whereas there was no evidence for rates of
major depression changing over time in the non-US samples,
the prevalence of depression appeared to be increasing over time
in the US samples, of which there were 17 from 1970 to 2010
(b= 0.0038, s.e.(b) = 0.0013, P= 0.008) (Fig. 5).
In a multivariate meta-regression analysis combining both
income group and classification criteria, the finding of a higher
prevalence rate in low–middle-income countries remained
significant only for women prisoners and was based on a single
Mexican study.
In the US studies, multivariate meta-regression
was not possible as all the samples that reported information on
classification criteria used DSM criteria. However in the non-US
and high-income samples, classification criteria still remained
significant when income group was included in the model
and DSM studies reported higher prevalences of depression
(b= –0.0645, s.e.(b) = 0.0282, P= 0.026). There was evidence of
an asymmetric funnel plot (t= 27.78, s.e.(t) = 0.0452, P50.001).
There were five publications since 2001 that reported rates of
comorbidity in prisoners.
These rates ranged from
20.4 to 43.5% in those with any mental disorder who had
comorbid substance misuse, from 13.6 to 95.0% in prisoners with
psychotic illnesses with comorbid substance misuse, and 9.2 to
82.5% in individuals with mood disorders and major depression
with concurrent substance misuse.
Main findings
We report a systematic review of the prevalence of psychosis and
depression in prisoners based on 109 separate samples (from 81
Table 1 Pooled prevalances for psychosis and major
depression in prisoners
Psychosis, %
(95% CI)
Major depression, %
(95% CI)
Overall 3.7 (3.2–4.1) 11.4 (9.9–12.8)
Gender of inmates
Male 3.6 (3.1–4.2) 10.2 (8.8–11.7)
Female 3.9 (2.7–5.0) 14.1 (10.2–18.1)
Prisoner status
Sentenced prisoners 3.7 (3.0–4.2) 10.5 (8.8–12.1)
Remand prisoners (detainees) 3.5 (4.2–6.8) 12.3 (9.5–15.1)
Low/middle income 5.5 (4.2–6.8) 22.5 (10.6–34.4)
High income 3.5 (3.0–3.9) 10.0 (8.7–11.2)
Severe mental illness in prisoners worldwide
publications) based on 33 588 prisoners. In addition, we have, for
the first time to our knowledge, reviewed research in low- and
middle-income countries (based on 5792 prisoners) and employed
meta-regression analyses to explore sources of heterogeneity
between studies. In particular, we have examined whether rates
of mental illness in prisoners have been increasing over time.
Our main findings were that rates of psychosis in prisoners
were significantly higher in low- and middle-income countries
than in high-income ones (5.5% in low–middle- v. 3.5% in high-
income nations). Contrary to expert opinion,
there were no
significant differences in rates of psychosis and depression
between male and female prisoners or between detainees (or
remand) and sentenced prisoners. In the 17 US samples included,
there appeared to be an increasing prevalence of depression over
the 31 years covered by these particular studies (1974–2005). In
addition, we found no differences in depression rates between
men and women, detainees (or remand) and sentenced prisoners,
or other study characteristics that may have explained hetero-
geneity. The overall prevalences of 3.7% of male and female
prisoners with a psychotic illness, and 11.4% with major
depression have not materially changed since a 2002 review based
on 56 publications of mental illness.
In contrast to one of our initial hypotheses, we did not find an
increase in rates of psychosis and depression over time. The
reasons for this are unclear but improvements in psychiatric care
in prison, increased diversion of mentally disordered offenders
from prison to hospital, and better living conditions may have
The role of international organisations, over the
past two decades, in improving prison health has also been
suggested to have a played a part.
Low/middle income
Fido & al-Jabally (1993)
Agbahowe et al (1998)
Arnab et al (2009)
Assadi et al (2006)
Ponde et al (2011)
Zahari et al (2010)
Sharma et al (2010)
Subtotal: I
52.3%, P= 0.050
High income
Hurwitz & Christiansen (1983)
Bluglass (1966)
Joukamaa (1995)
Robins & Reiger (1991)
Neighbors et al (1987)
Hyde & Seiter (1987)
Gunn et al (1991)
Motiuk & Porporino (1992)
Roesch (1995)
Teplin (1994)
Teplin et al (1996)
Joukamaa (1993)
Davidson et al (1995)
DiCataldo et al (1995)
Maden et al (1994)
Birmingham et al (1996)
Brooke et al (1996)
Powell et al (1997)
(male, sentenced)
Powell et al (1997)
(male, remand/detainee)
Parsons et al (2001)
Simpson et al (1999)
(male, sentenced)
Simpson et al (1999)
(male, remand/detainee)
Watzke et al (2006)
Duffy et al (2006)
Falissard et al (2006)
Curtin et al (2009)
(male, sentenced)
Curtin et al (2009)
(male, remand/detainee)
Trestman et al (2007)
Gunter et al (2008)
Piselli et al (2009)
Vicens et al (2011)
Alevizopoulus & Igoumenou (in press)
19 smaller studies (male, sentenced)
16 smaller studies (male, remand/detainee)
10 smaller studies (female, sentenced)
15 smaller studies (female, remand/detainee)
Subtotal: I
87.5%, P= 0.000
Overall: I
88.2%, P= 0.000
ES (95% CI) % WeightStudy ID
0.05 (0.00–0.09) 1.09
0.04 (0.00–0.08) 1.33
0.06 (0.05–0.06) 2.77
0.03 (0.01–0.05) 2.29
0.06 (0.04–0.08) 2.14
0.09 (0.06–0.11) 1.81
0.07 (0.02–0.11) 1.19
0.05 (0.04–0.07) 12.63
0.03 (0.01–0.05) 2.29
0.02 (0.00–0.04) 2.41
0.03 (0.02–0.04) 2.64
0.05 (0.03–0.07) 2.35
0.04 (0.02–0.07) 2.15
0.03 (0.02–0.05) 2.40
0.02 (0.01–0.03) 2.80
0.04 (0.03–0.04) 2.74
0.05 (0.03–0.06) 2.45
0.04 (0.03–0.06) 2.48
0.04 (0.03–0.05) 2.64
0.02 (0.00–0.03) 2.44
0.01 (0.00–0.03) 2.60
0.06 (0.04–0.09) 2.13
0.02 (0.00–0.03) 2.45
0.04 (0.03–0.06) 2.37
0.05 (0.03–0.06) 2.45
0.03 (0.02–0.05) 2.54
0.02 (0.01–0.03) 2.58
0.11 (0.08–0.14) 1.62
0.03 (0.02–0.04) 2.54
0.04 (0.02–0.05) 2.33
0.00 (70.00–0.01) 2.82
0.03 (0.02–0.05) 2.35
0.09 (0.06–0.11) 2.00
0.03 (0.01–0.04) 2.29
0.05 (0.03–0.08) 1.96
0.01 (0.00–0.03) 2.56
0.03 (0.01–0.05) 2.16
0.02 (0.00–0.03) 2.48
0.04 (0.03–0.06) 2.46
0.03 (0.01–0.04) 2.50
0.04 (0.03–0.05) 2.75
0.06 (0.05–0.07) 2.66
0.06 (0.04–0.08) 2.34
0.04 (0.02–0.05) 2.65
0.04 (0.03–0.04) 87.37
0.04 (0.03–0.04) 100.00
0 0.02 0.04 0.06 0.08 0.1 0.12
Fig. 2 Meta-analysis of the prevalence of psychotic illnesses in prisoners by country group (low–middle income
high income).
Weights are from random-effects analysis. Smaller studies: n5250. ES, prevalence.
Fazel & Seewald
Three main implications arise from these findings. First, the
substantial burden of treatable psychiatric morbidity is confirmed
by these findings. One in seven prisoners has depression or
psychosis, and treatment may confer additional benefits such as
reducing the risks of suicide
and self-harm
within custody,
and suicide
and drug-related deaths on release
as well as
As reoffending rates are high (at 50% in the USA
and UK within 2 years of release),
treatment of prisoners
may have a potentially large impact on public safety. In this
context, the lack of good-quality treatment evidence remains
The role of diversion away from prison at early
stages of the criminal process and other collaborations between
mental health and the justice system is underscored by our
particularly as repeat incarcerations are associated
with mental illness.
Second, the higher prevalence of psychosis in prisoners in low-
and middle-income countries is notable as rates of imprisonment
are increasing in more of these countries than in high-income
and possibly faster; also service provision is likely to be
worse. Health services in such countries can potentially use the
estimates reported in this review in developing prison medical
services, particularly in countries where resources are unlikely to
allow for local prevalence studies to be conducted. In poorer
countries, the role of explicit mental health budgets in ongoing
health programmes could be considered, particularly for
marginalised populations such as prisoners.
Our report does
not provide information on the causes of higher prisoner rates
of psychosis in low- and middle-income nations but possibilities
include fewer opportunities and services for diverting offenders
to health services, a stronger relationship between mental illness
and criminality, and different sociocultural factors that mean
more mentally ill people end up in prison. Poorer legal represen-
tation for the mentally ill may be one such factor. The increased
comorbidity with opioid use in prisoners found in some countries
and that form part of the illegal drug trade may be another.
A final implication from this review is that, although inter-
nationally the prevalence of depression does not appear to be
increasing in prisoners, in the USA, which has the largest prison
Table 2 Meta-regression analyses of sources of heterogeneity in the prevalence of psychosis and major depression in prisoners
Psychosis Major depression
Variable and study characteristic
Gender of inmates: male v. female 0.0016 0.063 0.800 0.0323 0.0222 0.151
Mean age of inmates (continuous) 70.0009 0.0009 0.334 0.0011 0.0033 0.735
Year of study (continuous) 50.0001 0.0003 0.889 0.0015 0.0013 0.340
Low/middle v. high income 0.0204 0.0095 0.035 0.1157 0.0318 0.001
USA v. rest of the world 0.0007 0.0060 0.902 70.0043 0.0241 0.859
Within the USA, over time 70.0006 0.0005 0.241 0.0038 0.0013 0.008
Prisoner status: sentenced prisoners v. detainees 0.0025 0.0038 0.504 0.0136 0.0159 0.396
On reception: first 2 weeks of reception v. rest 70.0016 0.0058 0.778 70.0131 0.0241 0.588
Participation rate
Continuous 70.0184 0.0333 0.585 70.0778 0.0998 0.441
Low (480%) v. high (480%) 72.637 3.0964 0.400 70.2786 1.1458 0.809
Sample size
Continuous 50.0001 0.0000 0.337 50.0001 0.0000 0.577
4500 v. 4500 0.0088 0.0062 0.156 70.0147 0.0275 0.594
Interviewer: psychiatrist v. other 70.0015 0.0053 0.784 0.0199 0.0231 0.391
Diagnostic criteria: ICD v. DSM 70.0021 0.0055 0.706 70.0590 0.025 0.021
Significant associations (P50.05) are in bold.
a. For comparisons the reference category is given first.
0.15 –
0.1 –
0.05 –
0.15 –
0.1 –
0.05 –
1960 1970 1980 1990 2000 2010
Year of interview
1970 1980 1990 2000 2010
Year of interview
Prevalence of psychotic illnessPrevalence of psychotic illness
Fig. 3 Prevalence of psychotic illness in prisoners over time in
(a) individual studies from all countries (including the USA) and
(b) studies conducted in the USA only.
The size of the circles is proportional to the sample size of each study.
Severe mental illness in prisoners worldwide
population worldwide, the rate of depression appears to have been
increasing over time. This was not found for psychosis in
prisoners internationally or in the USA, which may be partly
because the incidence of psychotic disorders has not increased
in the general population either.
In relation to increased
depression in US prisoners, further work could investigate the
possible contributions of the closure of large psychiatric hospitals,
the provision of community care, the funding of mental
health and the reported increase in major depression rates in
the general population.
Whatever the causes, the US houses
more than three times more mentally ill people in prison than
in all psychiatric hospitals,
and undertreatment for mental
illness in US prisons exacerbates these problems.
measures, including having policies and guidelines for the
transfer of severely mentally ill people to psychiatric hospitals,
training of prison staff and discharge planning, may improve these
Strengths and limitations
The high levels of heterogeneity between the studies are to be
expected as the studies were conducted by different groups in a
large variety of prisons using differing methods,
and this may
simply reflect real differences in prevalences over time and by
region. This may also be an explanation for the asymmetric funnel
plots we reported in addition to possible publication bias.
publication bias may explain the small number of studies in low-
and middle-income countries, and such bias is thought to
contribute in all mental health research from these countries.
Our approach to this was to identify causes of heterogeneity,
and two possible explanations were found. In depression, we
found that studies using DSM criteria had higher rates than those
using ICD criteria. Although such differences have occasionally
been found in community studies, and a lower congruence
between the two diagnostic systems for depression diagnoses
compared with some other psychiatric disorders has also been
Low/middle income
Fido & al-Jabally (1993)
Ghubash & El-Rufaie (1997)
Agbahowe et al (1998)
´dez et al (2007)
Assadi et al (2006)
Zahari et al (2010)
Ponde et al (2011)
Subtotal: I
98.0%, P= 0.000
High income
Neighbors et al (1987)
Hyde & Seiter (1987)
Roesch (1995)
Jordan et al (1996)
Teplin et al (1996)
DiCataldo et al (1995)
Brinded et al (1999)
Brooke et al (1996)
Powell et al (1997)
(male, remand/detainee)
Powell et al (1997)
(male, sentenced)
Parsons et al (2001)
Simpson et al (1999)
(male, sentenced)
Simpson et al (1999)
(male, remand/detainee)
Watzke et al (2006)
Duffy et al (2006)
Butler & Allnutt (2003)
(male, sentenced)
Butler & Allnutt (2003)
(male, sentenced)
Falissard et al (2006)
Curtin et al (2009)
(male, sentenced)
Curtin et al (2009)
(male, remand/detainee)
Gunter et al (2008)
Piselli et al (2009)
Vicens et al (2011)
Alevizopoulus & Igoumenou (in press)
13 smaller studies (male, sentenced)
10 smaller studies (male, remand/detainee)
8 smaller studies (female, sentenced)
12 smaller studies (female, remand/detainee)
Subtotal: I
91.0%, P= 0.000
Overall: I
94.7%, P= 0.000
Study ID ES (95% CI) % Weight
0.14 (0.07–0.22) 2.02
0.13 (0.08–0.19 2.40
0.21 (0.13–0.29) 1.93
0.62 (0.55–0.68) 2.21
0.29 (0.24–0.34) 2.57
0.13 (0.09–0.16) 2.84
0.86 (0.04–0.08) 3.01
0.23 (0.11–0.34) 16.97
0.13 (0.10–0.16) 2.82
0.07 (0.04–0.09) 2.99
0.10 (0.08–0.12) 3.01
0.11 (0.09–0.13) 3.00
0.14 (0.12–0.16) 3.03
0.09 (0.06–0.11) 2.96
0.14 (0.13–0.16) 3.04
0.10 (0.08–0.12) 3.01
0.08 (0.06–0.11) 2.97
0.12 (0.10–0.14) 2.98
0.14 (0.10–0.17) 2.81
0.06 (0.04–0.08) 3.04
0.10 (0.07–0.13) 2.91
0.03 (0.01–0.05) 3.04
0.05 (0.03–0.07) 3.02
0.05 (0.03–0.07) 3.02
0.13 (0.11–0.16) 2.97
0.18 (0.15–0.21) 2.85
0.06 (0.03–0.09) 2.94
0.05 (0.02–0.07) 2.98
0.17 (0.12–0.21) 2.62
0.06 (0.03–0.09) 2.93
0.08 (0.06–0.10) 3.02
0.04 (0.03–0.06) 3.04
0.13 (0.12–0.15) 3.05
0.09 (0.08–0.11) 3.07
0.11 (0.08–0.13) 2.94
0.12 (0.10–0.15) 2.99
0.10 (0.08–0.11) 83.03
0.12 (0.10–0.14) 100.00
0 0.5 0.1 0.15 0.2 0.25 0.3 0.35
Fig. 4 Meta-analysis of the prevalence of major depression in prisoners by country group (low–middle income
high income).
Weights are from random-effects analysis. Smaller studies: n5250. ES, prevalence. a. On early reception.
Fazel & Seewald
particular reasons for this difference in prisoners
are unclear. Possibilities include that in the diagnostic systems,
fatigability is included in the core criteria for depression in ICD,
but it is an associated (rather than a core) feature in DSM. In
addition, it may be that the distinction between melancholic
and non-melancholic forms of depression
is more important
in prisoners as the overlap between sadness and clinical depression
is more difficult to determine.
The strengths of this review include the large number of
samples and prisoners included, and therefore the ability to
examine prevalences by clinically relevant subgroups with some
degree of precision. However, we identified only eight studies in
low- and middle-income countries, and our findings should be
interpreted with caution. Furthermore, we have examined
heterogeneity using subgroup analyses and meta-regression, which
allowed us to investigate dichotomous and continuous variables
such as age, sample size and the date when the study was
conducted. One of the limitations of the review is that there
may be other explanations for the heterogeneity that we did not
test, such as comorbidity with other mental disorders, but
systematic data on this were lacking. Furthermore, the statistical
power of testing trends within nations was limited, and even
our findings on US trends were based on 17 studies.
Avenues for future research
A number of research implications arise from this review. First,
studying the epidemiology of mental illness and criminality in
low- and middle-income countries and how it compares with
high-income countries may provide some reasons for the
difference in psychosis prevalence. A recent review found no such
studies in low- and middle-income countries.
More research
into the treatment of mentally ill prisoners and the most effective
models of service delivery is pressing, and further comparison of
novel approaches needs closer examination.
Future prison
surveys should include information on comorbidity and
psychiatric history, suicide attempts within custody, treatment
received in prison and adherence to treatment, and length of
custody. In addition, the relationship between mental illness in
prisoners and recidivism rates needs further examination.
In summary, prison provides a unique public health
opportunity to treat mental illnesses that otherwise may not be
treated in the community. Almost all prisoners return to their
communities of origin, and effective treatment of mentally ill
prisoners will have potentially substantial public health benefits
and possibly reduce reoffending rates.
Seena Fazel, MD, Department of Psychiatry, University of Oxford, Warneford
Hospital, UK; Katharina Seewald, Bsc, Department of Psychiatry, University of
Oxford, Warneford Hospital, UK and Department of Psychology, University of
Konstanz, Germany
Correspondence: Seena Fazel, University Department of Psychiatry, Warneford
Hospital, Oxford OX3 7JX, UK. Email:
First received 10 May 2011, final revision 12 Dec 2011, accepted 17 Jan 2012
K.S. was funded by the German Friedrich-Ebert Stiftung.
We thank S. Agbahowe, H. Andersen, L. Birmingham, R. Bland, G. Cote, M. Davidson,
B. Denton, R. Ghubash, J. Haapsalo, H. Herrman, W. Hurley, K. Jordan, M. Joukamaa,
T. Maden, D. Mohan, B. Morentin, W. Narrow, K. Northrup, T. Powell, K. Rasmussen,
C. Schoemaker, N. Singleton, C. Smith and G. Walters for kindly providing additional data
from their studies for the initial review. We are grateful to T. Butler, B. Falissard,
H. Kennedy, M. Pereira Ponde
´, M. Piselli and R. Quartesan, C. E. von Schoenfeld,
R. Trestman and V. Tort for providing further information about their studies for the update.
In addition, K. Abram, D. Black, C. James, O. Nielssen, M. I. da Rosa and K. Wada helpfully
responded to queries. We are grateful to J. Baillargeon for comments on a previous draft.
Kat Witt assisted as the second data extractor.
1Walmsley R. World Prison Population List (8th edn). King’s College London
International Centre for Prison Studies, 2009.
2Baillargeon J, Penn JV, Thomas CR, Temple JR, Baillargeon G, Murray OJ.
Psychiatric disorders and suicide in the nation’s largest state prison system.
J Am Acad Psychiatry Law 2009; 37: 188–93.
3Fazel S, Cartwright J, Norman-Nott A, Hawton K. Suicide in prisoners: a
systematic review of risk factors. J Clin Psychiatry 2008; 69: 1721–31.
4Kariminia A, Law M, Butler T, Corben SP, Levy MH, Kaldor JM, et al. Factors
associated with mortality in a cohort of Australian prisoners. Eur J Epidemiol
2007; 22: 417–28.
5Fazel S, Yu R. Psychotic disorders and repeat offending: systematic review
and meta-analysis. Schizophr Bull 2011; 37: 800–10.
6Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ.
Psychiatric disorders and repeat incarcerations: the revolving prison
door. Am J Psychiatry 2009; 166: 103–9.
7Fazel S, Grann M, Kling B, Hawton K. Prison suicide in 12 countries: an
ecological study of 861 suicides during 2003–2007. Soc Psychiatry Psychiatr
Epidemiol 2011; 46: 191–5.
0.6 –
0.4 –
0.2 –
0.6 –
0.4 –
0.2 –
1970 1980 1990 2000 2010
Year of interview
1970 1980 1990 2000 2010
Year of interview
Prevalence of major depressionPrevalence of major depression
Fig. 5 Prevalence of major depression in prisoners over time
in (a) individual studies from all countries (including the USA)
and (b) studies conducted in the USA only.
The size of the circles is proportional to the sample size of each study.
Severe mental illness in prisoners worldwide
8Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al.
Release from prison – a high risk of death for former inmates. N Engl J Med
2007; 356: 157–65.
9Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic
review of 62 surveys. Lancet 2002; 359: 545–50.
10 Priebe S, Frottier P, Gaddini A, Kilian R, Lauber C, Martı
´nez-Leal R, et al.
Mental health care institutions in nine European countries, 2002 to 2006.
Psychiatr Serv 2008; 59: 570–3.
11 Dressing H, Kief C, Salize H-J. Prisoners with mental disorders in Europe.
Br J Psychiatry 2009; 194: 88.
12 Bradley-Engen MS, Cuddeback GS, Gayman MD, Morrissey JP, Mancuso D.
Trends in state prison admission of offenders with serious mental illness.
Psychiatr Serv 2010; 61: 1263–5.
13 Levy M. Health services for prisoners. BMJ 2011; 342: d351.
14 Moher D, Tsertsvadze A. Systematic reviews: when is an update an update?
Lancet 2006; 367: 881–3.
15 Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health:
scarcity, inequity, and inefficiency. Lancet 2007; 370: 878–89.
16 Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009; 6: e1000097.
17 O’Keefe ML, Schnell MJ. Offenders with mental illness in the correctional
system. J Offender Rehabil 2007; 45: 81–104.
18 Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of
serious mental illness among jail inmates. Psychiatr Serv 2009; 60: 761–5.
19 Kanyanya IM, Othieno CJ, Ndetei DM. Psychiatric morbidity among convicted
male sex offenders at Kamiti Prison, Kenya. E Afr Med J 2007; 84: 151–5.
20 Kugu N, Akyuz G, Dogan O. Psychiatric morbidity in murder and attempted
murder crime convicts: a Turkey study. Forensic Sci Int 2008; 175: 107–12.
21 Fazel S, Grann M. Psychiatric morbidity among homicide offenders: a
Swedish population study. Am J Psychiatry 2004; 161: 2129–31.
22 Fazel S, Hope T, O’Donnell I, Piper M, Jacoby R. Health of elderly male
prisoners: worse than the general population, worse than younger prisoners.
Age Ageing 2001; 30: 403–7.
23 Ajiboye PO, Yussuf AD, Issa BA. Current and lifetime prevalence of mental
disorders in a juvenile borstal institution in Nigeria. Res J Med Sci 2009; 3:
24 Morgan RD, Fisher WH, Duan NH, Mandracchia JT, Murray D. Prevalence of
criminal thinking among state prison inmates with serious mental illness.
Law Human Behav 2010; 34: 324–36.
25 Lamb HR, Weinberger EL, Marsh SJ, Gross HB. Treatment prospects for
persons with severe mental illness in an urban county jail. Psychiatr Serv
2007; 58: 782.
26 Segagni Lusignani G, Giacobone C, Pozzi F, Dal Canton F, Alecci P, Carra G.
Disturbi mentali in una casa circondariale: uno studio di prevalenza [Mental
disorders in a local prison: a prevalence study]. NO
´OS 2006; 1: 23–34.
27 Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a
systematic review. Addiction 2006; 101: 181–91.
28 Goff A, Rose S, Purves D. Does PTSD occur in sentenced prison populations?
A systematic literature review. Crim Behav Mental Health 2007; 17: 152–62.
29 Abdalla-Filho E, De Souza PA, Tramontina JF, Taborda JGV. Mental disorders
in prisons. Curr Opin Psychiatry 2010; 23: 463–6.
30 Falissard B, Loze J-Y, Gasquet I, Duburc A, de Beaurepaire C. Prevalence of
mental disorders in French prisons for men. BMC Psychiatry 2006; 6: 33.
31 The World Bank. How we Classify Countries: Country and Lending
Groups. The World Bank, 2011 (
32 Patsopoulos NA, Evangelou E, Ioannidis JP. Sensitivity of between-study
heterogeneity in meta-analysis: proposed metrics and empirical evaluation.
Int J Epidemiol 2008; 37: 1148–57.
33 Sweeting MJ, Sutton AJ, Lambert PC. What to add to nothing? Use and
avoidance of continuity corrections in meta-analysis of sparse data. Stat Med
2004; 23: 1351–75.
34 Ioannidis JPA, Patsopoulos NA, Evangelou E. Uncertainty in heterogeneity
estimates in meta-analyses. BMJ 2007; 335: 914–6.
35 Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis.
Stat Med 2002; 21: 1539–58.
36 Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency
in meta-analyses. BMJ 2003; 327: 557–60.
37 Ioannidis JPA, Patsopoulos NA, Rothstein HR. Reasons or excuses for
avoiding meta-analysis in forest plots. BMJ 2008; 336: 1413–5.
38 Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected
by a simple, graphical test. BMJ 1997; 315: 629–34.
39 Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, et al. Prevalence of ICD-10
psychiatric morbidity in random samples of prisoners on remand. Int J Law
Psychiatry 1996; 19: 61–74.
40 Bartholomew AA, Brain LA, Douglas AS, Reynolds WS. A medico-psychiatric
diagnostic review of remanded (without a request for a psychiatric report)
male minor offenders. Med J Aust 1967; 1: 267.
41 Birmingham L, Mason D, Grubin D. Prevalence of mental disorder in remand
prisoners: consecutive case study. BMJ 1996; 313: 1521–4.
42 Bland RC, Newman SC, Dyck RJ, Orn H. Prevalence of psychiatric disorders
and suicide attempts in a prison population. Can J Psychiatry 1990; 35:
43 Bluglass R. A Psychiatric Study of Scottish Convicted Prisoners. University
of St Andrews, 1966.
44 Brinded PMJ, Stevens I, Mulder RT, Fairley N, Malcolm F, Wells JE.
Christchurch Prisons Psychiatric Epidemiology Study: methodology and
prevalance rates for psychiatric disorder. Crim Behav Ment Health 1999;
9: 131–43.
45 Brooke D, Taylor C, Gunn J, Maden A. Point prevalence of mental disorder in
unconvicted male prisoners in England and Wales. BMJ 1996; 313: 1524–7.
46 Bulten B. Gevangen Tussen Straf en Zorg [Caught between Punishment and
Care]. Kluwer Academic Publishers, 1998.
47 Cooke DJ. Psychological Disturbance in the Scottish Prison System:
Prevalence, Precipitants, and Policy. Scottish Office, 1994.
48 Daniel AE, Robins AJ, Reid JC, Wilfley DE. Lifetime and six-month prevalence
of psychiatric disorders among sentenced female offenders. Bull Am Acad
Psychiatry Law 1988; 16: 333–42.
49 Davidson M, Humphreys MS, Johnstone EC, Owens DGC. Prevalence of
psychiatric morbidity among remand prisoners in Scotland. BMJ 1995; 167:
50 Denton B. Psychiatric morbidity and substance dependence among women
prisoners: an Australian study. Psychiatry Psychol Law 1995; 2: 173–7.
51 DiCataldo F, Greer A, Profit WE. Screening prison inmates for mental
disorder: an examination of the relationship between mental disorder and
prison adjustment. Bull Am Acad Psychiatry Law 1995; 23: 573–5.
52 Eyestone LL. An epidemiological study of attention-deficit hyperactivity
disorder and depression in a male prison population. Bull Am Acad
Psychiatry Law 1994; 22: 181–93.
53 Faulk M. A psychiatric study of men serving a sentence in Winchester prison.
Med Sci Law 1976; 16: 244.
54 Gibson LE, Holt JC, Fondacaro KM, Tang TS, Powell TA, Turbitt EL. An
examination of antecedent traumas and psychiatric comorbidity among male
inmates with PTSD. J Traum Stress 1999; 12: 473–84.
55 Gunn J, Maden A, Swinton M. Treatment needs of prisoners with psychiatric
disorders. BMJ 1991; 303: 338–41.
56 Gunn J, Robertson G, Dell S, Way C. Psychiatric Aspects of Imprisonment.
Academic Press, 1978.
57 Guy E, Platt JJ, Zwerling I, Bullock S. Mental health status of prisoners in an
urban jail. Crim Justice Behav 1985; 12: 29–53.
58 Haapasalo J. Vankien lapsuuden kaltoinkohtelu kaytosonogelmat ja aikuisian
psyykkiset hairiot truama [Childhood maltreatment, behavioral problems and
mental disorders among adult prisoners]. Psykologia 2000; 35: 45–57.
59 Harper D, Barry D. Estimated prevalence of psychiatric disorder in a prison
population. Abs Crim Pen 1979; 19: 237–42.
60 Herrman H, McGorry P, Mills J, Singh B. Hidden severe psychiatric morbidity
in sentenced prisoners – an Australian study. Am J Psychiatry 1991; 148:
61 Hurley W, Dunne MP. Psychological distress and psychiatric morbidity in
women prisoners. Aust N Z J Psychiatry 1991; 25: 461–70.
62 Hyde P, Seiter R. The Prevalence of Mental Illness among Inmates in the Ohio
Prison System. Department of Mental Health and the Ohio Department of
Rehabilitation and Correction Interdepartmenal Planning and Oversight
Committee for Psychiatric Services to Corrections, 1987.
63 James JF, Gregory D, Jones RK, Rundell OH. Psychiatric morbidity in prisons.
Hosp Comm Psychiatry 1980; 31: 674.
64 Jordan BK, Schlenger WE, Fairbank JA, Caddell JM. Prevalence of psychiatric
disorders among incarcerated women: II. Convicted felons entering prison.
Arch Gen Psychiatry 1996; 53: 513–9.
65 Joukamaa M. Psychiatric morbity among finnish prisoners with special
reference to sociodemographic factors – results of the health survey of
finnish prisoners (WATTU project). Forensic Sci Int 1995; 73: 85–91.
66 Joukamaa M. Mental health of Finnish prisoners – results of a survey.
J Forensic Psychiatr 1993; 4: 261–71.
67 Krefft KM, Brittain TH. A prisoner assessment survey: screenings of a
municipal prison population. Int J Law Psychiatry 1983; 6: 113–24.
Fazel & Seewald
68 Levander S, Svalenius H, Jensen J. Psykiska skador vanliga bland interner
[Common psychiatric disorders among inmates]. Lakartidningen 1997; 94:
69 Maden A, Taylor C, Brooke D, Gunn J. Mental Disorder in Remand Prisoners.
Home Office Research and Planning Unit, 1996.
70 Maden T, Swinton M, Gunn J. Psychiatric disorder in women serving a prison
sentence. Br J Psychiatry 1994; 164: 44–54.
71 Mohan D, Scully P, Collins C, Smith C. Psychiatric disorder in an Irish female
prison. Crim Behav Ment Health 1997; 7: 229–35.
72 Motiuk L, Porporino F. The Prevalence, Nature and Severity of Mental Health
Problems among Federal Male Inmates in Canadian Penitentiaries. Research
and Statistics Branch, Correctional Service, 1992.
73 Neighbors H, Williams D, Gunnings T, Lipscomb W, Broman C, Lepkowski J.
The Prevalence of Mental Disorder in Michigan Prisons. Michigan Department
of Corrections, 1987.
74 van Panhuis P. De Psychotische Patient in de TBS [The Psychotic Patient in
the TBS]. Gouda Quint, 1997.
75 Powell TA, Holt JC, Fondacaro KM. Prevalence of mental illness among
inmates in a rural state. Law Human Behav 1997; 21: 427–38.
76 Poythress N, Hoge S, Bonnie R, Monahan J, Eisenberg M, Feucht-Haviar T.
The competence-related abilities of women criminal defendants. J Am Acad
Psychiatry Law 1998; 26: 215–22.
77 Rasmussen K, Storsaeter O, Levander S. Psychiatric disorders in a Norwegian
prison population. Nord Psykiatr Suppl 1998; 41: 79–80.
78 Robertson G. Correlates of crime among women offenders. Med Sci Law
1990; 30: 165–74.
79 Robins R, Reiger D. Psychiatric Disorders in America: The Epidemiologic
Catchment Area Study. The Free Press, 1991.
80 Roesch R. Mental health interventions in pretrial jails. In Psychology and
Law: Advances in Research (eds GM Davies, S Lloyd-Bostock, M McMurran
& C Wilson): 520–31. De Greuter, 1995.
81 Schoemaker D, VanZessen G. Psychische Stoornissen bij Gedetineerden
[Psychiatric Disorders in Prisoners]. Trimbos-Instituut, 1997.
82 Schuckit MA, Hermann G, Schuckit JJ. Importance of psychiatric illness
in newly arrested prisoners. J Nerv Ment Dis 1977; 165: 118–25.
83 Simpson A, Brinded P, Laidlaw T, Fairley N, Malcolm F. The National Study
of Psychiatric Morbidity in New Zealand Prisons. Department of Corrections,
84 Smith C, O’Neill H, Tobin J, Walshe D, Dooley E. Mental disorders detected
in an Irish prison sample. Crim Behav Ment Health 1996; 6: 177–83.
85 Swank GE, Winer D. Occurence of psychiatric disorder in a county jail
population. Am J Psychiatry 1976; 133: 1331–3.
86 Teplin LA. Psychiatric and substance abuse disorders among male urban jail
detainees. Am J Public Health 1994; 84: 290–3.
87 Teplin LA, Abram KM, McClelland GM. Prevalence of psychiatric disorders
among incarcerated women: I. Pretrial jail detainees. Arch Gen Psychiatry
1996; 53: 505–12.
88 Washington P, Diamond RJ. Prevalence of mental illness among women
incarcerated in five California county jails. Res Community Ment Health 1985;
5: 33–41.
89 Watt F, Tomison A, Torpy D. The prevalence of psychiatric disorder in a male
remand population: a pilot study. J Forensic Psychiatr 1993; 4: 75–83.
90 Wilkins J, Coid J. Self-mutilation in female remanded prisoners: I. An indicator
of severe psychopathology. Crim Behav Ment Health 1991; 1: 247–67.
91 Agbahowe SA, Ohaeri JU, Ogunlesi AO, Osahon R. Prevalence of psychiatric
morbidity among convicted inmates in a nigerian prison community.
E Afr Med J 1998; 75: 19–26.
92 Fido AA, al-Jabally M. Presence of psychiatric morbidity in prison population
in Kuwait. Ann Clin Psychiatry 1993; 5: 107–10.
93 Ghubash R, El-Rufaie O. Psychiatric morbidity among sentenced male
prisoners in Dubai: transcultural perspectives. J Forensic Psychiatr 1997;
8: 440–6.
94 Hurwitz S, Christiansen K. Criminology (2nd edn). George Allen & Unwin,
95 Arnab B, Prativa S, Ray TK. Persons with major psychiatric illness in prisons
– a three years study. J Indian Med Assoc 2009; 107: 14.
96 Assadi SM, Noroozian M, Pakravannejad M, Yahyazadeh O, Aghayan S,
Shariat SV, et al. Psychiatric morbidity among sentenced prisoners:
prevalence study in Iran. Br J Psychiatry 2006; 188: 159–64.
97 Bermu
´dez CE, Romero Mendoza MP, Rodrı
´guez Ruiz EM, Durand-Smith AL,
´var Herna
´ndez GJ. Female depression and substance dependence in the
Mexico City penitentiary system. Salud Ment 2007; 30: 53–61.
98 Bulten E, Nijman H, van der Staak C. Psychiatric disorders and personality
characteristics of prisoners at regular prison wards. Int J Law Psychiatry
2009; 32: 115–9.
99 Butler T, Allnutt, S. Mental Illness among New South Wales Prisoners. NSW
Correction Health Service, 2003.
100 Curtin K, Monks S, Wright B, Duffy DM, Linehan SA, Kennedy HG. Psychiatric
morbidity in male remanded and sentenced committals to Irish prisons.
Ir J Psychol Med 2009; 26: 169–73.
101 Dudeck M, Kopp D, Kuwert P. Prevalence of psychiatric disorders in
prisoners with a short imprisonment: results from a prison in north
Germany. Psychiatr Prax 2009; 36: 219.
102 Duffy D, Linehan S, Kennedy HG. Psychiatric morbidity in the male
sentenced Irish prisons population. Ir J Psychol Med 2006; 23: 54–62.
103 Fotiadou M, Livaditis M, Manou I, Kaniotou E, Xenitidis K. Prevalence of
mental disorders and deliberate self-harm in Greek male prisoners. Int J Law
Psychiatry 2006; 29: 68–73.
104 Gunter TD, Arndt S, Wenman G, Allen J, Loveless P, Sieleni B, et al.
Frequency of mental and addictive disorders among 320 men and women
entering the Iowa prison system: use of the MINI-Plus. J Am Acad Psychiatry
2008; 36: 27–34.
105 Linehan SA, Duffy DM, Wright B, Curtin K, Monks S, Kennedy HG. Psychiatric
morbidity in a cross-sectional sample of male remanded prisoners.
Ir J Psychol Med 2005; 22: 128–32.
106 Parsons S, Walker L, Grubin D. Prevalence of mental disorder in female
remand prisons. J Forensic Psychiatr 2001; 12: 194–202.
107 Piselli M, Elisei S, Murgia N, Quartesan R, Abram KM. Co-occurring
psychiatric and substance use disorders among male detainees in Italy.
Int J Law Psychiatry 2009; 32: 101–7.
108 Ponde PP, Cruz Freire AC, Santos Mendonca MS. The prevalence of mental
disorders in detainees in the city of Salvador, Bahia, Brazil. J Forensic Sci
2011; 56: 679–82.
109 Sharma A, Nijhawan M, Sharma DK, Sushil CS. Psychosocial and psychiatric
aspect of criminal behavior. Indian J Psychiatr 2010; 52: S37.
110 Stompe T, Brandsta
¨tter N, Ebner N, Fischer-Danzinger D. Psychiatric
disorders in prison inmates [Psychiatrische Sto
¨rungen bei Haftinsassen].
J Neurol Neurochir Psychiatr 2010; 11: 20–3.
111 Vicens E, Tort V, Duen
˜as RM, Muro A
´rez-Arnau F, Arroyo JM, et al. The
prevalence of mental disorders in Spanish prisons. Crim Behav Ment Health
2011; 21: 321–32.
112 Trestman RL, Ford J, Zhang W, Wiesbrock V. Current and lifetime psychiatric
illness among inmates not identified as acutely mentally ill at intake in
Connecticut’s jails. J Am Acad Psychiatry Law 2007; 35: 490–500.
113 von Schoenfeld CE, Schneider F, Schroder T, Widmann B, Botthof U,
Driessen M. Prevalence of psychiatric disorders, psychopathology, and the
need for treatment in female and male prisoners. Nervenarzt 2006; 77: 830.
114 Watzke S, Ullrich S, Marneros A. Gender- and violence-related prevalence of
mental disorders in prisoners. Eur Arch Psychiatry Clin Neurosci 2006; 256:
115 Wright B, Duffy D, Curtin K, Linehan S, Monks S, Kennedy HG. Psychiatric
morbidity among women prisoners newly committed and amongst
remanded and sentenced women in the Irish prison system. Ir J Psychol
Med 2006; 23: 47–53.
116 Zahari MM, Hwan Bae W, Zainal NZ, Habil H, Kamarulzaman A, Altice FL.
Psychiatric and substance abuse comorbidity among HIV seropositive and
HIV seronegative prisoners in Malaysia. Am J Drug Alcohol Abuse 2010; 36:
117 Zoccali R, Muscatello MR, Bruno A, Cambria R, Cavallaro L. Mental disorders
and request for psychiatric intervention in an Italian local jail. Int J Law
Psychiatry 2008; 31: 447–50.
118 Alevizopoulus G, Igoumenou, A. Mental health problems in male prisoners
in Greece and their relation to the criminal history. Int J Law Psychiatry,
in press.
119 World Health Organization. Women’s Health in Prison. WHO, 2009.
120 Skeem J, Manchak S, Peterson J. Correctional policy for offenders with
mental illness: creating a new paradigm for recidivism reduction. Law Hum
Behav 2011; 35: 110–26.
121 Fraser A, Møller L, van den Bergh B. The health of prisoners. Lancet 2011;
377: 2002.
122 Lohner J, Konrad N. Risk factors for self-injurious behaviour in custody:
problems of definition and prediction. Int J Prison Health 2007; 3: 135–61.
123 Pratt D, Appleby L, Piper M, Webb R, Shaw J. Suicide in recently released
prisoners: a case-control study. Psychol Med 2010; 40: 827–35.
124 Bird SM. Changes in male suicides in Scottish prisons: 10-year study.
Br J Psychiatry 2008; 192: 446–9.
Severe mental illness in prisoners worldwide
125 Home Office. Probation Statistics England and Wales 2002. Home
Office Research, Development and Statistics Directorate, 2004.
126 Langan P, Lewin D. Recidivism of Prisoners Released in 1994.
Bureau of Justice Statistics, 2002 (
127 Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65.
128 Morrissey JP, Fagan JA, Cocozza JJ. New models of collaboration between
criminal justice and mental health systems. Am J Psychiatry 2009; 166:
129 Hassan L, Birmingham L, Harty MA, Jones P, King C, Lathlean J, et al.
Prospective cohort study of mental health during imprisonment. Br J
Psychiatry 2011; 198: 37–42.
130 Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health
without mental health. Lancet 2007; 370: 859–77.
131 McGrath J, Saha S, Welham J, El Saadi O, MacCauley C, Chant D. A
systematic review of the incidence of schizophrenia: the distribution of
rates and the influence of sex, urbanicity, migrant status and methodology.
BMC Medicine 2004; 2: 13.
132 Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The
epidemiology of major depressive disorder. JAMA 2003; 289: 3095–105.
133 Torrey E, Kennard A, Eslinger D, Lamb R, Pavle J. More Mentally Ill Persons
are in Jails and Prisons than Hospitals: A Survey of the States. Treatment
Advocacy Center, 2010.
134 Wilper AP, Woolhandler S, Boyd JW, McCormick D, Bor DH, Himmelstein DU,
et al. The health and health care of US prisoners: results of a nationwide
survey. Am J Public Health 2009; 99: 666–72.
135 Higgins JPT. Commentary: heterogeneity in meta-analysis should be
expected and appropriately quantified. Int J Epidemiol 2008; 37: 1158–60.
136 Singh D. Publication bias–a reason for the decreased research output
in developing countries. S Afr Psychiatr Rev 2006; 9: 153–5.
137 Cheniaux E, Landeira-Fernandez J, Versiani M. The diagnoses of
schizophrenia, schizoaffective disorder, bipolar disorder and unipolar
depression: interrater reliability and congruence between DSM-IV
and ICD-10. Psychopathology 2009; 42: 293–8.
138 Parker G. Classifying depression: should paradigms lost be regained?
Am J Psychiatry 2000; 157: 1195–203.
139 Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence:
systematic review and meta-analysis. PLoS Med 2009; 6: e1000120.
140 Raimer B, Stobo J. Health care delivery in the texas prison system: the role
of academic medicine. JAMA 2004; 292: 485–9.
doi: 10.1192/bjp.bp.111.096370, Fazel et al
Table DS1 Update: Details of included Studies since 2001
Study Year of
Country Income group Sampling Instrument Diagnostic criteria Psychiatric
Mean age
Participation Rate
Alevizopoulus, 2010 2010 Greece High Systematic ISPI DSM N26.9 Not stated
Arnab, 2009 2001 India Low-middle Not stated SCID DSM-IV Y 34.8 Not stated
Assadi, 2006 2002 Iran Low-middle Stratified random SCID DSM-IV Y32.7 88
Bermudez, 2009 2001 Mexico Low-middle Convenience MINI DSM-IV N 30.6 Not stated
Bulten,2009 2009 Netherlands High Simple random MINI DSM-III-R N30.4 81
Butler, 2005 2001 Australia High Consecutive CIDI DSM-IV N 29.6 85
Curtin, 2009 2004 Ireland High Consecutive SADS-L ICD-10 N29.8 92
Dudeck, 2009 2006 Germany High Not stated SCID DSM-IV Y 31.2 Not stated
Duffy, 2006 2001 Ireland High Systematic SADS-L ICD-10 Y37.1 64
Falissard, 2006 2003 France High Stratified random MINI DSM-IV Y 37 63
Fotiadou, 2004 2001 Greece High Systematic MINI DSM-IV N36.5 85
Gunter, 2008 2005 US High Simple random MINI DSM-IV N 31.1 Not stated
Linehan, 2009 2002 Ireland High Stratified random SADS-L ICD-10 N29.6 70
Parsons, 2001 1998 UK High Population SADS-L ICD-10 N 28.1 89
Piselli, 2009 2005 Italy High Consecutive SCID DSM-IV Y35.5 72
Ponde, 2010 2006 Brazil Low-middle Not stated MINI DSM-IV N 33 Not stated
Sharma, 2010 2010 India Low-middle Simple random Clinical interview Not stated NNot stated Not stated
Stompe, 2010 2008 Austria High Consecutive SCAN ICD-10 NNot stated Not stated
Trestman, 2007 2004 US High Systematic SCID DSM-IV N32 Not stated
Vicens, 2011 2007 Country High Simple random SCID DSM-IV NNot stated 90
von Schoenfeld, 2006 2003 Germany High Not stated SCID DSM-IV N34 82
Watzke, 2006 2000 Germany High Not stated SCAN ICD-10 Y31.6 Not stated
Wright, 2006 2002 Ireland High Population SADS-L ICD-10 Y27.4 76
Zahari, 2010 2009 Malaysia Low-middle Stratified random SCID DSM-IV Y35 Not stated
Zoccali, 2008 2003 Italy High Population SCID DSM-III-R Y35.8 Not stated
CIDI = Composite International Diagnostic Interview ; ISPI = Iowa Structured Psychiatric Interview; MINI =Mini-International Neuropsychiatric Interview ; SADS-L = Schedule for Affective Disorders and Schizophrenia; SCAN = Schedules
for Clinical Assessment in Neuropsychiatry; SCID = Structured Clinical Interview for DSM-IV
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (by the American Psychiatric Association),
ICD-10 = International Statistical Classification of Diseases and Related Health Problems (by the World Health Organization)
... First, incarcerated individuals are known to have a high prevalence of disability, including physical, intellectual, and developmental disabilities as well as mental health conditions and substance use disorders, which may contribute both to their becoming incarcerated and to their elevated risk of suicide mortality after release [30][31][32][33][34][35] . Second, the experience of incarceration and the prison environment itself can contribute to the development of new or exacerbation of existing mental health problems through solitude, lack of privacy, lack of meaningful activity, violence victimization, and insecurity about the future after release 21,32,36 . ...
We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people to the general population in North Carolina (NC). We conducted a retrospective cohort study of 266,400 people released from NC state prisons between January 1, 2000 and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people to the NC general population. We evaluated effect modification by race-ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for three years after release, with the highest rate of suicide mortality being in the two-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher non-firearm-involved suicide mortality rates than firearm-involved suicide mortality rates. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had greater elevation of suicide mortality compared to their general population peers than did other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups.
... A number of previous reviews of the literature have shown the prevalence of mental disorders in prisons is considerably higher than in the general population (1)(2)(3). This includes data from low and medium income countries as well as higher income countries. ...
... Reduced facial affect perception is documented among prison populations, 21 persisting in violent offenders, postincarceration, 22 and reduced ToM has been reported in persons convicted of sexual offenses. 23,24 Prison populations have elevated rates of psychopathology, 25 including psychopathy 26 or antisocial personality disorder, 27,28 conditions which are characterized by social cognitive impairment. 4 Individuals with psychopathy have impairments in facial affect perception 29,30 and appear to lack the implicit perspective-taking (ToM) that takes place in healthy people. ...
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Background and hypothesis: Reduced social cognition has been reported in individuals who have committed interpersonal violence. It is unclear if individuals with schizophrenia and a history of violence have larger impairments than violent individuals without psychosis and non-violent individuals with schizophrenia. We examined social cognition in two groups with violent offenses, comparing their performance to non-violent individuals with schizophrenia and healthy controls. Study design: Two social cognitive domains were assessed in four groups: men with a schizophrenia spectrum disorder with (SSD-V, n = 27) or without (SSD-NV, n = 42) a history of violence, incarcerated men serving preventive detention sentences (V, n = 22), and healthy male controls (HC, n = 76). Theory of mind (ToM) was measured with the Movie for the Assessment of Social Cognition (MASC), body emotion perception with Emotion in Biological Motion (EmoBio) test. Study results: Kruskal-Wallis H-tests revealed overall group differences for social cognition. SSD-V had a global and clinically significant social cognitive impairment. V had a specific impairment, for ToM. Binary logistic regressions predicting violence category membership from social cognition and psychosis (SSD status) were conducted. The model with best fit, explaining 18%-25% of the variance, had ToM as the only predictor. Conclusions: Social cognitive impairment was present in individuals with a history of violence, with larger and more widespread impairment seen in schizophrenia. ToM predicted violence category membership, psychosis did not. The results suggest a role for social cognition in understanding interpersonal violence.
... First, the now overwhelming evidence of the heightened risk that people leaving prison face of returning to substance use (and the poor outcomes associated with this) is not just present for the initial period after release from prison, but likely persists for a longer period of potentially up to several years. Given the multitude of complex health and social challenges that this group faces [21,67,68], multidisciplinary health treatment and support commencing during incarceration and continuing post-release is essential to reduce the risks of a return to substance use and poor associated outcomes. This is equally important for both the justice system, which often sees individuals who return to substance use cycle back through the system [69], and the health system, because it is already-strained public hospitals and EDs that are impacted by substance use requiring medical treatment. ...
Background and Aims Poor substance use‐related health outcomes after release from prison are common. Identifying people at greatest risk of substance use and related harms post‐release would help to target support at those most in need. The Alcohol Smoking and Substance Involvement Screening Test (ASSIST) is a validated substance use screener, but its utility in predicting substance‐related hospitalisation post‐release is unestablished. We measured whether screening for moderate/high‐risk substance use on the ASSIST was associated with increased risk of substance‐related hospitalisation. Design A prospective cohort study. Setting Prisons in Queensland and Western Australia. Participants Participants were incarcerated and within 6 weeks of expected release when recruited. A total of 2585 participants were followed up for a median of 873 days. Measurements Baseline survey data were combined with linked unit record administrative hospital data. We used the ASSIST to assess participants for moderate/high‐risk cannabis, methamphetamine and heroin use in the 3 months prior to incarceration. We used International Classification of Diseases (ICD) codes to identify substance‐related hospitalisations during follow‐up. We compared rates of substance‐related hospitalisation between those classified as low/no‐risk and moderate/high‐risk on the ASSIST for each substance. We estimated adjusted hazard ratios (aHR) by ASSIST risk group for each substance using Weibull regression survival analysis allowing for multiple failures. Findings During follow‐up, 158 (6%) participants had cannabis‐related, 178 (7%) had opioid‐related and 266 (10%) had methamphetamine‐related hospitalisation. The hazard rates of substance‐related hospitalisation after prison were significantly higher among those who screened moderate/high‐risk compared with those screening low risk on the ASSIST for cannabis (aHR 2.38, 95% confidence interval [CI] 1.74, 3.24), methamphetamine (aHR 2.23, 95%CI 1.75, 2.84) and heroin (aHR 5.79, 95%CI 4.41, 7.60). Conclusions Incarcerated people with an Alcohol Smoking and Substance Involvement Screening Test (ASSIST) screening of moderate/high‐risk substance use appear to have a significantly higher risk of post‐release substance‐related hospitalisation than those with low risk. Administering the ASSIST during incarceration may inform who has the greatest need for substance use treatment and harm reduction services in prison and after release from prison.
... In fact, DeHart (2008) found that many incarcerated women believed their traumatic experiences from childhood (sexual abuse) were connected with onset of deviant behavior (illicit drug use). BHDs, both internalizing (e.g., disorders characterized by emotions that are directed toward oneself, such as depression and anxiety; Zigler & Glick, 1986), and externalizing (e.g., disorders involving emotions that are directed towards others; Hoeve et al., 2015) have been linked to violent or aggressive behaviors (Okzan et al., 2019), and are also found at high rates among incarcerated individuals (Fazel & Seewald, 2012;Hofvander et al., 2017). Additionally, substance use has long been linked to increased criminal behavior (Bonta & Andrews, 2017), and also occurs at high rates among system-involved persons (Dalbir et al., 2022;Fazel et al., 2017). ...
The role of victimization in criminal behavior has been researched previously, particularly in justice-involved youth and prison samples. The contribution of such adversity in jail samples is less articulated. The current study examines the effect of physical abuse, sexual abuse, and polyvictimization (physical and sexual abuse) on behavioral health and substance use outcomes in a sample of individuals who went through the intake process at one jail. Through use of logistic regression models, we examined the impact of abuse on internalizing mental health issues, externalizing mental health issues, and substance use disorder. Findings demonstrated relationships between abuse and internalizing disorders, abuse and externalizing disorders, as well as between abuse and substance use disorder, with the effect of sexual abuse greater for women and the impact of polyvictimization larger for men. Policy implications are discussed.
Dysfunctional personality and psychopathological characteristics are increasingly studied in offenders separately, but only a few studies have analysed their relationship in this specific population. In this research, we focus on the so‐called Dark Triad personality, consisting of the Machiavellian, the narcissistic and the psychopathic personalities. The main objective of this study was to examine the association between Dark Triad personality and psychopathology and also to know the role of these mental health variables in recidivism. Participants were 63 offenders (44 men and 19 women) from two different penitentiary institutions. Sociodemographic data as well as clinical and personality characteristics were recorded. Psychopathology was assessed with the third version of the Millon Clinical Multiaxial Inventory and dark personality with the Short Dark Triad. Results of descriptive statistical analyses revealed a high prevalence of psychopathology in convicted participants and reincarcerated offenders. Correlational analyses showed a strong relation between the Dark Triad personality and psychopathology, being the psychopathic personality the one with the highest association. Finally, we found that the psychopathological variables contributing most to the discrimination of reincarcerated participants were substance and alcohol abuse disorders and in relation to dysfunctional personality were psychopathy and narcissism, the latter in negative direction. These data highlight the relevance of a necessity for research exploring long‐term patterns of re‐incarceration for both men and women, including mental health disorders and personality models. The importance of taking into account the relationship between variables in preventive and treatment interventions inside and outside penitentiary institutions is discussed.
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Chronic and violent juvenile offending. has been asslociated with adverse health, educational, vocational and interpersonal consequences with repercussion seen into adulthood. Youths with mental disorders pose a challenge for the juvenile system and after their release for the larger mental health system. This study investigated current and lifetime prevalence of mental disorders in a Borstal home in Nigeria. The study is a cross-sectional, descriptive one and reports exclusively on the 53 youths, aged 14-21 years, remanded at the Juvenile Borstal Institution in Ilorin, the Kwara state Capital. The inmates were interviewed using MINI-KID. The mean age±SD of the inmates was 17.3±2.1 years. Majority of them (52.8%) were between 18-21 years of age. Current psychiatric diagnoses were made in 67.6% of them and lifetime diagnoses made in 64.2% of the inmates. Recommendation is made for early detection and treatment of these psychiatric disorders.
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Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Prison inmates show a high burden with somatic illnesses like HIV or hepatitis; also the suicide rates are clearly higher than those of the general population. This paper presents for first time data on the mental condition of an Austrian prison population. 100 remand prisoners and 100 convicted prisoners were investigated with standardized instruments (AMDP, SCAN). Both groups showed statistically significantly higher rates of substance misuse/abuse and schizophrenia. Affective disorders were more prevalent in remand prisoners, neurotic disturbances in convicted prisoners. The prevalence rates of affective and neurotic disorders were comparable with the general population.
Background: No unbiased estimates of the rates of psychiatric disorder among women prison inmates are available. Nonetheless, available data suggest that some psychiatric disorders are prevalent in this population. The objective of the study was to determine the rates, risk factors, and outcomes of specific psychiatric disorders among women prison inmates. Methods: A virtual census of women felons (N=805) entering prison in North Carolina was assessed using in-person interviews. Assessments were conducted for 8 disorders, using the Composite International Diagnostic Interview as the primary assessment measure. For validation purposes, one quarter of the inmates were reassessed for 2 of these disorders, using structured clinical interviews. Results: Inmates were found to have high rates of substance abuse and dependence and antisocial and borderline personality disorders compared with women in community epidemiologic studies. Rates among inmates were also somewhat elevated for mood disorders but not for anxiety disorders. The rate of reports of lifetime exposure to traumatic events was also high. Rates of disorder tended to be higher among white than among African American women. Conclusion: High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.
Objective: The low level of mental health research from low and middle-income countries, as measured by the relative lack of publications in high impact journals is an inaccurate reflection of research being conducted in these countries. The number of manuscripts submitted for publication is a more accurate measure of the research activities. The study aimed to quantify the number of manuscripts submitted and accepted for publication in high impact psychiatric journals.Method: Editors of 8 psychiatric journals were requested information on the number of manuscripts submitted, the country of origin and the number of manuscripts accepted for publication from April to September 2005. Results: 5,2 % of all manuscripts submitted for publications were from low and middle income countries. The overall acceptance rate of manuscripts was 16,6 % but the acceptance rate for low and middleincome countries was 4,8 %. Manuscripts from high-income countries had a 5,8 times greater odds (2,5 - 4,9) of being accepted for publication than an article from a low and middle-income country. Conclusion: Both the quantity and quality of research from low and middle-income countries must be improved. Interventions to improve the quality of research must be directed towards capacity development, increasing international collaborations, mentoring of researchers and establishing formal psychiatric epidemiology training programs to equip researchers with skills to produce papers that meet the publication criteria of reviewers. Studies must become more innovative and include the changing paradigm in epidemiological research. Manuscripts that describe innovative studies have a greater chance of being published.