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Mental Illness Among New South Wales Prisoners

Authors:
MENTAL ILLNESS
AMONG NEW SOUTH WALES
PRISONERS
Tony Butler
Stephen Allnutt
August 2003
II
Copyright NSW Corrections Health Service
State Health Publication No: (CHS) 030147
ISBN: 0 7347 3559 6
Suggested citation:
Butler T, Allnutt S. Mental Illness Among New South Wales’ Prisoners. NSW
Corrections Health Service, 2003. ISBN: 0 7347 3559 6.
Copies of the report are available from:
NSW Corrections Health Service
PO Box 150
Matraville NSW 2036
Australia
Tel: +61 2 9289 2977
Fax: +61 2 9311 3005
Cover illustration: “Whispers” by Zig Jaworowski
III
Contents
List of Tables..................................................................................................... V
List of Figures .................................................................................................. VI
FOREWORD......................................................................................................1
EXECUTIVE SUMMARY ...................................................................................2
ACKNOWLEDGEMENTS..................................................................................5
INTRODUCTION ...............................................................................................6
METHODS .........................................................................................................8
Overview ........................................................................................................8
Study 1 (Reception Prisoners) .......................................................................8
Study 2 (Sentenced Prisoners) ......................................................................9
Interviewers ....................................................................................................9
Screening Instruments ................................................................................ 10
Data Analysis .............................................................................................. 11
RESULTS........................................................................................................ 12
Overall Prevalence Estimates ..................................................................... 13
Any Psychiatric Disorder ............................................................................. 15
Comment ................................................................................................. 16
Any Mental Disorder (psychosis, anxiety or affective disorder).................. 17
Demographic Correlates of Any Mental Disorder.................................... 17
Comment ................................................................................................. 18
Psychosis .................................................................................................... 19
Demographic Correlates of Psychosis .................................................... 19
Comment ................................................................................................. 21
Affective Disorders ...................................................................................... 22
Demographic Correlates of Affective Disorders ...................................... 23
Comment ................................................................................................. 24
Anxiety Disorders ........................................................................................ 25
Demographic Correlates of Anxiety Disorders ........................................ 26
Comment ................................................................................................. 27
Suicidal Ideation .......................................................................................... 28
Comment ................................................................................................. 28
Substance Use Disorders ........................................................................... 30
Demographic Correlates of Substance Use Disorder ............................. 31
Comment ................................................................................................. 32
Personality Disorders .................................................................................. 34
Demographic Correlates of Personality Disorder.................................... 35
Comment ................................................................................................. 36
Neurasthenia ............................................................................................... 37
Demographic Correlates of Neurasthenia............................................... 37
Comment ................................................................................................. 38
Health Service Usage ................................................................................. 39
Comment ................................................................................................. 39
Disability ...................................................................................................... 40
Comment ................................................................................................. 41
One-month Prevalence Estimates .............................................................. 42
Comment ................................................................................................. 43
Substance Use disorder and Psychiatric Diagnosis ................................... 45
Comment ................................................................................................. 45
Mental Illness And Offence Category ............................................................. 46
IV
DISCUSSION.................................................................................................. 48
REFERENCES ............................................................................................... 52
V
List of Tables
Table 1: Number and proportion of inmates screened at reception sites in Study 1...............12
Table 2: Comparison of screened and non-screened inmates for selected characteristics in
Study 1 (reception) and Study 2 (sentenced). ....................................................................13
Table 3: Twelve-month and one-month ICD-10 prevalence estimates of major disorders
among male and female prisoners, New South Wales (Australia)......................................14
Table 4: Prevalence (%) of ‘any psychiatric disorder’ among male and female prisoners by
marital status, country of birth, income, and highest qualification (twelve-month diagnosis).
...........................................................................................................................................16
Table 5: Prevalence (%) of any psychosis, anxiety or affective disorders among male and
female prisoners by marital status, country of birth, income, and highest qualification
(twelve-month diagnosis). ..................................................................................................18
Table 6: Prevalence (%) of psychosis among male and female prisoners by marital status,
country of birth, income, and highest qualification (twelve- month diagnosis). ...................20
Table 7: Twelve-month ICD-10 prevalence estimates of affective disorder. ...........................22
Table 8: Prevalence (%) of affective disorders among male and female prisoners by marital
status, country of birth, income, and highest qualification (twelve-month diagnosis)..........24
Table 9: Twelve-month ICD-10 prevalence estimates of anxiety disorders. ...........................25
Table 10: Prevalence (%) of anxiety disorders among male and female prisoners by marital
status, country of birth, income, and highest qualification (twelve-month diagnosis)..........27
Table 11: Suicidal ideation plans and attempts. .....................................................................28
Table 12: Twelve-month ICD-10 prevalence estimates for substance use disorders. ............31
Table 13: Prevalence (%) of any substance use disorder among male and female prisoners
by sex, marital status, country of birth, income, and highest qualification (twelve-month
diagnosis). .........................................................................................................................32
Table 14: Personality disorders..............................................................................................34
Table 15: Prevalence (%) of any personality disorder among male and female prisoners by
marital status, country of birth, income, and highest qualification (twelve-month diagnosis).
...........................................................................................................................................36
Table 16: Prevalence (%) of any personality disorder among male and female prisoners by
marital status, country of birth, income, and highest qualification (twelve-month diagnosis).
...........................................................................................................................................38
Table 17: Mean score on the Brief Disability Questionnaire (BDQ)........................................40
Table 18: Number of days in previous month affected by disability. .......................................41
Table 19: One-month ICD-10 prevalence estimates of major disorders among male and
female reception prisoners, New South Wales (Australia)..................................................43
Table 20: Twelve-month ICD-10 prevalence estimates of major disorders among prisoner with
and without a substance use disorder diagnosis................................................................45
Table 21: Most serious offence and ICD-10 twelve-month diagnosis for reception and
sentenced prisoners (combined)........................................................................................47
VI
List of Figures
Figure 1: Prevalence of ‘Any Psychiatric Disorder’ (% positive) by age and sex (twelve-month
diagnosis). .........................................................................................................................16
Figure 2: Prevalence of any mental disorder (anxiety disorder, affective disorder or psychosis)
...........................................................................................................................................18
Figure 3: Prevalence of psychosis (% positive) by age and sex (twelve-month diagnosis).....20
Figure 4: Prevalence of any affective disorder (% positive) by age and sex (twelve-month
diagnosis). .........................................................................................................................23
Figure 5: Prevalence of any anxiety disorder (% positive) by age and sex (twelve-month
diagnosis). .........................................................................................................................26
Figure 6: Prevalence of any substance use disorder (% positive) by age and sex (twelve-
month diagnosis)................................................................................................................32
Figure 7: Prevalence of any personality disorder (% positive) by age and sex (twelve-month
diagnosis). .........................................................................................................................35
Figure 8: Prevalence of neurasthenia (% positive) by age and sex (twelve-month diagnosis).
...........................................................................................................................................38
Figure 9: Health service usage for a mental health problem in the previous twelve months by
‘any psychiatric disorder’ (twelve-month diagnosis). ..........................................................39
Page 1
FOREWORD
Anecdotal evidence from staff working in the New South Wales’ correctional
system has always suggested a high prevalence of mental illness among the
prisoner population. However, hard evidence has been lacking and generated
the impetus for the projects described in this document. Planning effective
services for mentally ill prisoners is problematic in the absence of accurate
information on the extent and the types of disorders.
Institutionalised populations are routinely excluded from community surveys
such as the National Survey of Mental Health and Wellbeing, hence the need
to survey them separately to provide comparative data and to ensure that key
population groups are not forgotten.
Two groups of prisoners are considered in this report: those entering the
correctional system either for the first time or as repeat offenders, and those
who have been sentenced and may have been detained for some time.
What is clear from this report is that the mental health needs of the prisoner
population are considerable compared with those of the general community
and that a large unmet need exists. These data provide a solid basis on which
to plan appropriately targeted mental health services within the correctional
system and ensure that appropriate screening and treatment programmes
exist both at the point of reception and for those who are sentenced.
Psychiatric problems rarely exist in isolation, however in this group the
comorbidities are formidable.
While this survey provides benchmark data on mental illness in NSW prisons,
it leaves a number of questions unanswered. Of particular importance is the
role of community mental health services in keeping the mentally ill out of gaol
and the contribution of mental illness to offending behaviour.
The dedication and determination of key mental health and research staff
ensured the success of the projects reported in this document. They should
be considered as pilot studies which will hopefully be repeated with adequate
resources to expand their scope and minimise the number who could not be
screened. It would also be appropriate to consider a national survey to
examine differences between the various states and to promote national
collaboration on prison mental health.
Dr Richard Matthews
Chief Executive Officer
July 2003.
Page 2
EXECUTIVE SUMMARY
Anecdotal evidence from staff working in the New South Wales’ correctional system
has always suggested a high prevalence of mental illness among the prisoner
population. This perception, along with the lack of reliable epidemiological data on
mental illness prompted Corrections Health to conduct two studies to examine this
issue.
Limited information on mental illness among NSW prisoners was collected as part of
the 1996 Inmate Health Survey. The main reason for undertaking these two projects
was to enhance this information and provide more detail in relation to specific
psychiatric disorders among the reception and sentenced prisoner populations. The
information arising from these surveys can be used to inform service planning and
provision.
Study 1 was a sample of male and female inmates screened on reception to the
NSW correctional system over a three-month period. Study 2 screened a sample of
sentenced inmates from across the state as part of the 2001 Inmate Health Survey.
The same instrument used in the National Survey of Mental Health and Wellbeing
was adopted to enable comparisons with the wider community. This instrument is
essentially a modified version of the Composite International Diagnostic Interview
(CIDI), which yields twelve-month and one-month ICD-10 and DSM-IV diagnoses.
Key Findings
The prevalence of mental illness in the NSW correctional system is substantial
and consistent with international findings.
The twelve-month prevalence of ‘any psychiatric disorder’ (psychosis, anxiety
disorder, affective disorder, substance use disorder, personality disorder, or
neurasthenia) identified in the NSW inmate population is substantially higher than
in the general community (74% vs. 22%).
Almost half of reception (46%) and over one-third (38%) of sentenced inmates
had suffered a mental disorder (psychosis, affective disorder, or anxiety disorder)
in the previous twelve months.
Female prisoners have a higher prevalence of psychiatric disorder than male
prisoners.
Psychiatric morbidity was higher among reception prisoners compared with
sentenced prisoners.
There was comparatively little difference between the one-month and twelve-
month prevalence estimates of mental disorder.
Two-thirds of reception prisoners had a twelve-month diagnosis of substance use
disorder.
The high rate of mental disorder among inmates cannot be attributed to
substance use disorder alone.
Page 3
40% of reception prisoners had a twelve-month diagnosis of opioid use disorder.
Almost one in ten inmates reported experiencing symptoms of psychosis in the
twelve months prior to interview.
An estimated 4% to 7% of reception inmates suffer from a functional psychotic
mental illness.
The twelve-month prevalence of psychosis in NSW inmates was thirty times
higher than in the Australian community.
14% of male receptions and 21% of female receptions had a one-month
diagnosis of depression.
The most common group of mental disorders were anxiety disorders with over
one-third of those screened experiencing an anxiety disorder in the previous
twelve months.
Post-traumatic stress disorder (PTSD) was the most common anxiety disorder (24%).
One in twenty prisoners had attempted suicide in the twelve months prior to interview.
Females were more likely than males to utilise health services for mental health
problems.
Prisoners with a psychiatric diagnosis had higher levels of disability.
Recommendations
Current screening procedures for reception prisoners should be reviewed and, if
necessary updated to improve diagnostic accuracy at the point of reception.
There should be a case management approach towards mentally ill inmates with
high levels of need. Interventions should be adapted to the psychiatric needs of
the prisoner with an evidence-based justification.
There should be co-ordinated pre-release planning involving external agencies in
the community.
Current treatment and rehabilitation programmes for mentally ill prisoners within
the prison system should be reviewed to assess whether or not treatment
guidelines are adequate.
Resources should be made available to conduct a more comprehensive survey of
prisoners’ mental health covering disorders such as, schizophrenia and attention
deficit disorder.
Drug and alcohol rehabilitation should be integrated into the treatment of mentally
ill offenders.
Page 4
Residential treatment units should be developed within the correctional setting to
house mentally ill prisoners who require a therapeutic environment but not
hospitalisation. These units should be staffed by skilled mental health workers
and appropriately trained custodial officers.
Social and psychological programmes, such as cognitive behavioural therapy,
should be made available to inmates. Treatment should be multidisciplinary and
commensurate with that provided in the community.
Current transportation practices of inmates with severe mental illness should be
reviewed
Establish a forensic mental health directorate to coordinate the treatment, care
and rehabilitation of forensic patients in NSW.
The NSW Forensic Mental Health Strategy should be adopted by CHS to guide
service development and resource allocation.
Court liaison services in NSW should be expanded to include all magistrate
courts to facilitate the diversion into mental health care of those with a mental
illness who have been charged with minor crimes.
The number of secure forensic psychiatric beds in the community should be
increased.
All forensic patients should be transferred out of the criminal justice system and
into a community forensic mental health system for care, containment, and
rehabilitation.
Page 5
ACKNOWLEDGEMENTS
This project would have been impossible to complete without the dedication
and commitment of the nurse interviewers – David Cain, Dale Owens, Chris
Muller, Lee Trevathan, Michael Harris, Alison Lee, Peter Sadler, Rebecca
Gibson, and Eli Baxter.
We wish to thank A/Professor Carolyn Quadrio for her encouragement to
pursue this project and Ms Anne Doherty for her support.
We wish to thank the NSW Department of Corrective Services for providing
custodial staff to assist with retrieving inmates, particularly Mr Brian Kelly from
the MRRC, and Ms Lee Downes from Mulawa.
NSW Health provided financial support to cover the cost of writing this report
and for providing laptop computers (Mr George Fisher) necessary to
administer the questionnaire. The Department of Corrective Services also
provided financial support for the 2001 Inmate Health Survey.
Professor Gavin Andrews for encouraging us to use the NSMHWB screening
instrument. Mr Tim Slade from CRUFAD was helpful in preparing the data for
analysis. Mr Lucas Milner and Ms Azar Kariminia provided invaluable
assistance in checking the data contained in the document. Imelda Butler and
Ms Anne Cummins provided editorial assistance.
Page 6
INTRODUCTION
Prisoner populations are comprised of some of the most disadvantaged and
stigmatised individuals in the community. People from disadvantaged
backgrounds, poor educational attainment, histories of unemployment, and
indigenous populations are over-represented among prisoner populations in
Australia.
International studies have found an over-representation of those with a mental
illness in prison.
1-5
A recent meta-analysis of sixty-two prison mental health
surveys found that inmates were substantially more likely to have a psychotic
illness, major depression, and a personality disorder than the general
population.
6
There are few Australian studies measuring the prevalence of mental illness
among prisoners. Those which have been conducted have had comparatively
small sample sizes and therefore limited generalisability. All found a high
prevalence of mental disorder in correctional communities studies.
5;7;8
In 1996, a wide-ranging survey conducted by the NSW Corrections Health
Service (CHS) found that 50% of females and 33% of males self-reported that
they had been diagnosed with a mental illness at some time in the past with
significant numbers scoring positive for depression according to the Beck
Depression Inventory.
9
Using the Referral Decision Scale which was
developed by Teplin (1989) to identify prisoners with sufficient symptomology
to require further psychiatric assessment, 56% of females and 30% of males
were recommended for referral for major depression, 20% of females and
12% of males required referral for manic-depression, and 33% of females and
18% of males required referral for schizophrenia.
10
While the schizophrenia
referral rate is high, it is important to be aware that this instrument was
designed to include false-positives rather than false-negatives, thus the
prevalence of schizophrenia is likely to be somewhat inflated.
This initial survey shed some light on the unknown demand for mental health
services in NSW; however it was subject to the limitations of self-report. A
decision was made to undertake a more formal assessment to examine the
prevalence of mental illness in the NSW correctional system using a
recognised psychiatric diagnostic tool.
Further justification for conducting these assessments is that institutionalised
populations such as prisoners are routinely excluded from community surveys
such as the National Survey of Mental Health and Wellbeing (NSMHWB) and
the National Health Survey.
11;12
The reception assessment, which is conducted on all new admissions into the
correctional system ascertains the specific health needs of the inmate in three
key health areas: medical status, drugs and alcohol, and mental health
including suicide and self-harm. Notably, it does not involve any formal tool for
diagnosing mental illness. Concerns had been expressed that the current
Page 7
approach to assessment was biased towards identifying psychosis and
overlooked conditions such as mood and anxiety disorders.
This report presents the results from two correctional populations: (1) those
admitted to the correctional system (receptions); and (2) those already serving
a custodial sentence (sentenced) as part of the 2001 Inmate Health Survey.
13
Page 8
METHODS
Overview
The initial intention of the reception assessment project was to screen all
consecutive prison receptions over a one-month period. However, in the male
group this was not feasible for a number of reasons: lack of interview staff to
screen all new receptions especially on days with large numbers of new
intakes, inmates transferred to other gaols before they could be interviewed,
lack of custodial staff to assist with inmate retrieval, ‘lock downs’
1
, inmates
who were too mentally unwell to be screened, and those released to freedom
prior to screening. In contrast, the female sample presented fewer logistical
challenges given the reduced numbers.
Bearing in mind that prisoners could be released following bail appearances
or transferred to other gaols at short notice, it was decided to interview
prisoners within twenty-four hours of being received into custody.
It was assumed that new receptions place a higher demand on health
resources. It was decided to screen all reception inmates rather than just
those on remand. The latter group can be held for considerable time in gaol
and were deemed to have more in common with sentenced inmates who were
to be screened as part of the 2001 Inmate Health Survey (Study 2).
The NSW Inmate Health Survey is a broad based assessment of the physical
and mental health status of the state’s prisoner population. It was first
conducted in 1996 and was repeated in 2001. The design is a cross-sectional,
random sample of inmates, stratified by sex, age and Aboriginality. The
sample represents approximately 11% of male and 40% of female prisoners.
9
The 1996 survey did not utilise a formal psychiatric screening instrument but
relied on self-reported histories of mental illness. It was decided that the 2001
undertaking should incorporate the same approach to mental health
assessment as used in Study 1.
Study 1 (Reception Prisoners)
The main reception site used in Study 1 was the Metropolitan Remand and
Reception Centre (MRRC) in western Sydney. Over three-quarters of the
state’s reception prisoners are processed at the MRRC. A number of remote
reception sites (Bathurst, Cessnock and Goulburn) also process reception
prisoners and were included in Study 1 (Table 1). Almost all female reception
prisoners are processed at Mulawa Correctional Centre which is located on
the same complex as the MRRC in Sydney.
Each day, the team leader contacted the duty officer from the Department of
Corrective Services and obtained a list of receptions processed on the
1
‘Lock downs’ are periods of time when inmates are locked in their cells and access is limited
to emergency needs only.
Page 9
previous night. At the main reception site, prisoners can arrive between 4pm
and midnight with the number of new admissions varying between 0 and 50
on any one day. The assessors would systematically work through the list of
reception prisoners. This was a particularly difficult task at the MRRC as
inmates are held in a series of ‘pods’ across the complex and therefore
required the assistance of custodial officers to escort subjects to the study
area for the interview.
Once located, the inmates were given an explanation of the project and
invited to participate. Those agreeing to participate were interviewed in a
private office by a team member using the screening instruments described
above.
The sample of reception prisoners therefore represents a consecutive
convenience sample of inmates over a three month period. This approach is
not ideal but was the only practicable approach available. A process of
randomisation would have been impractical.
Study 2 (Sentenced Prisoners)
In contrast to Study 1, Study 2 screened inmates from all NSW gaols as part
of the 2001 Inmate Health Survey.
13
The Metropolitan Reception and Remand
Centre (MRRC) was not included in Study 2 as it had been the main centre
used in Study 1.
The study sample is designed to be representative of the sentenced prisoner
population and to provide prevalence estimates across a wide range of health
conditions.
9
Details of the methodology are described elsewhere.
13
Following the completion of the Inmate Health Survey, a list of participants
was forwarded to the project manager who organised for the mental health
assessment to be administered to all available inmates within two to three
weeks. Inmates were remunerated $5 for participating in the survey as many
had to miss work and would have forfeited pay.
Interviewers
Study 1 used CHS mental health nurses to screen inmates. All interviewers
received training in the use of the screening instruments from senior CHS
mental health staff. Interviewers in Study 2 included both CHS nurses and
forensic psychology master’s degree students. Security awareness training
was provided for those not currently working within the correctional system.
Furthermore, students were also paired with an experienced team leader who
was able to resolve any issues should they arise in the course of the
interview.
Page 10
Screening Instruments
The Composite International Diagnostic Interview (CIDI)
Making diagnostic comparisons with epidemiological studies conducted in the
general community, other correctional communities, both nationally and
internationally, was a priority. The recent National Survey of Mental Health
and Wellbeing (NSMHWB) and the study of psychiatric morbidity in New
Zealand prisons had both used the Composite International Diagnostic
Interview (CIDI).
12;14
Following discussions with the developers of the NSMHWB, it was decided to
utilise this instrument. This is essentially a modified version of the CIDI-A,
which yields both DSM-IV and ICD-10 diagnoses.
12;15-17
This instrument also
incorporates several measures of disability (SF-12, BDQ), personality disorder
(the International Personality Disorder Examination - IPDE), general
psychiatric morbidity (GHQ-12), and psychological distress (K10). Psychosis
was diagnosed using a short screener, incorporated into the program. The
CIDI is relatively inaccurate in diagnosing particular types of psychotic illness.
For the purpose of this report the psychosis screener data is to be regarded
as ‘any psychosis’.
The psychosis screener is sensitive to the presence of psychotic symptoms
due to any cause, but does not differentiate between the different types of
psychotic disorders (drug induced psychosis, brief episodic psychosis, and
functional psychotic illness). Thus it was not possible to determine the
prevalence of functional psychotic mental illness (schizophrenia,
schizophreniform psychosis, schizoaffective disorder, delusional and affective
psychosis), using the psychosis screener alone. To address this, two
clinicians assessed a sub-group of reception inmates who were psychosis
screener positive or psychotic according to clinical impression. They applied
the Longitudinal history, Expert [interview by a psychiatrist], All available Data
(LEAD) protocol. This assessment includes a clinical interview, a review of all
documentation and longitudinal history. Those with a ‘definite’, ‘possible’
diagnosis or ‘no diagnosis’ of a functional psychotic mental illness were
identified using this protocol.
The BDQ was scored according to the Medical Outcomes Study (MOS) as the
individual items used to generate the score were regarded as more relevant to
the prisoner population.
The advantages of using the NSMHWB instrument are threefold: (1) it enables
direct comparisons to be made with both national and international community
samples, and (2) it generates both ICD-10 and DSM-IV diagnoses, and (3) it
is computer-based and can be administered by a layperson following training.
The 144-item version of Cloninger’s Temperament Character Inventory (TCI)
was also administered as a measure of personality.
18
This is a dimensional
measure which attempts to overcome the limitations of categorical measures
of personality disorder. Categorical measures produce multiple diagnoses with
Page 11
overlapping traits and have limited clinical utility when considering the types of
interventions to implement. Dimensional measures of personality are clinically
more helpful in that they better describe the nature of the traits that are
present in the population and thus better inform treatment needs. The TCI
data are not presented in this report.
Data Analysis
Data from the CIDI were imported into SPSS 11 using a program written by
staff at the Clinical Research Unit for Affective Disorders, St Vincent’s
Hospital, Sydney.
19
This program imports the raw data from the automated
interview into SPSS and runs a scoring algorithm, which generates the ICD-10
and DSM-IV diagnoses.
Some of the demographic questions administered to the community sample
were inappropriate for a prisoner population and phrased in such a way that
they could not be used in the analysis. For example, the community group
were interviewed in their homes and questions regarding accommodation
pertained to the house in which the assessment took place eg. was it being
rented or mortgaged? Similarly, the employment questions asked about job
seeking in the recent past - it is unlikely that someone facing a prison
sentence would be actively seeking work.
For the purposes of this report, demographic data (age, education status,
country of birth and source of income) were combined across the reception
and sentenced groups. Tables presenting the demographic data use the
twelve-month ICD-10 diagnoses.
For the purpose of this report, ‘any psychiatric disorder’ refers to any
psychosis, anxiety disorder, affective disorder, substance use disorder,
personality disorder or neurasthenia diagnosed by the CIDI.
Summary statistics presented in this report were calculated in SPSS 11.
Page 12
RESULTS
Between March and June of 2001, 953 inmates (777 males and 176 females)
were screened at four of the five male reception centres and the one female
reception centre in NSW. Across male reception centres, over 30% of all
reception inmates were screened during the period, and 56% of females.
Table 1: Number and proportion of inmates screened at reception sites in Study 1.
Reception site
Eligible reception
inmates
Number
screened
%
Screened
Site 1 (MRRC) 2310 676 29.3
Site 2 (Bathurst) 146 44 30.1
Site 3 (Cessnock) 67 22 32.8
Site 4 (Goulburn) 86 35 40.7
Female site (Mulawa) 312 176 56.4
Total 2921 953
To determine whether the inmates who were screened were broadly
representative of prison admissions during the assessment period,
comparisons were made between both reception and sentenced inmates
across a range of characteristics (Table 2).
In the reception group, the only significant differences between the screened
and non-screened groups were among men in terms of a slightly lower
proportion of indigenous inmates (11.5%
vs.
15.1%), and those had been
referred to the mental health team (13.0% vs. 17.3%). There were no
significant differences between the screened and non-screened female
reception prisoners.
For the sentenced group, the profile of those screened and those not
screened was similar in terms of age, Aboriginality, proportion committing a
violent offence, and self-reported history of a previous psychiatric illness for
both males and females. For males, however, the median sentence length
was longer in the screened group. A likely explanation for this is probably the
release of those with short sentences before they could be interviewed. The
2001 Inmate Health Survey is designed to be representative of the NSW
prison population.
Based on these data, the sample of reception prisoners is broadly
representative of inmates received into the NSW correctional system. Those
referred for mental health assessment biased our results in favour of a lower
rate of mental illness.
We evaluated the prevalence of all psychiatric disorders present in both the
one month and one year prior to assessment. Those with a positive diagnosis
in the last month can be regarded as unwell at the time of the assessment and
reflects the immediate burden of illness on the service. The prevalence of
mental illness in the year prior would be more relevant to those sentenced and
reflects the burden of illness over time.
Page 13
Table 2: Comparison of screened and non-screened inmates for selected characteristics in
Study 1 (reception) and Study 2 (sentenced).
Characteristic Screened
Non-
screened p-value
Number 777 1832
Mean age (years) 29.61 29.82 0.57
Aboriginality (%)
11.5 15.1 0.02
Referrals for detoxification (%) 40.1 43.2 0.19
Male
Mental health referrals* (%) 13.0 17.3 0.014
Number 176 136
Mean age (years) 29.10 29.46 0.7
Aboriginality (%) 29.0 21.9 0.21
Referrals for detoxification (%) 43.2 37.9 0.44
Female
Mental health referrals* (%) 16.6 21.6 0.36
Study 1 (Reception)
Number 469 279
Mean age (years) 33.8 32.2 0.07
Aboriginality (%) 30.1% 30.1% 0.94
Median sentence length 2.15 1.49 0.001
Violent offence (%) 52.6 48.2 0.36
Male
Previous psychiatric treatment
41.4% 39.6% 0.69
Number 110 58
Mean age (years) 32.7 33.9 0.42
Aboriginality (%) 16.4% 19.0% 0.83
Median sentence length 1.5 0.91 0.18
Violent offence (%) 35.6% 30.3% 0.81
Female
Previous psychiatric treatment
53.3% 54.3% 0.96
Study 2 (Sentenced)
* Mental health referral data available for MRRC only
Overall Prevalence Estimates
Table 3 shows the twelve-month and one-month prevalence of mental illness
for male and female, reception and sentenced prisoners.
Page 14
Table 3: Twelve-month and one-month ICD-10 prevalence estimates of major disorders among male
and female prisoners, New South Wales (Australia).
RECEPTION SENTENCED
MALE (N=756) FEMALE (N=165) MALE (N=458) FEMALE (N=108)
12 Month 1 Month 12 Month 1 Month 12 Month 1 Month 12 Month 1 Month
ICD-10 Diagnosis
N % N % N % N % N % N % N % N %
Psychosis 81 10.7 - - 25 15.2 - - 19 4.2 - - 6 5.7 - -
Affective Disorders
Depression
1
121 16.0 102 13.5 39 23.6 34 20.6 43 9.5 23 5.1 15 14.4 8 7.7
Dysthymia 54 7.2 46 6.1 16 9.7 15 9.1 17 3.8 15 3.4 6 5.8 4 3.8
Manic episode
2
21 2.8 10 1.3 13 7.9 9 5.5 6 1.3 0 0.0 2 1.9 2 1.9
Any Affective Disorder 158 21.1 128 17.1 56 33.9 50 30.3 55 12.4 31 7.0 21 20.4 12 11.8
Anxiety Disorders
Post traumatic stress disorder 164 21.7 128 16.9 72 43.6 62 37.6 73 16.2 43 9.5 46 43.8 30 28.6
Generalised anxiety disorder 101 13.4 94 12.4 37 22.4 33 20.0 56 12.4 40 8.8 16 15.2 13 12.4
Panic disorder 55 7.3 35 4.6 28 17.0 14 8.5 31 6.9 12 2.7 17 16.2 5 4.8
Agoraphobia 23 3.0 22 2.9 5 3.0 4 2.4 9 2.0 6 1.3 6 5.7 4 3.8
Obsessive compulsive disorder 20 2.7 17 2.3 4 2.4 3 1.8 7 1.6 6 1.4 2 2 1 1.0
Social phobia 11 1.5 8 1.1 1 0.6 1 0.6 4 0.9 4 0.9 1 1.0 1 1.0
Any Anxiety Disorder 250 33.9 206 28.0 92 55.8 78 47.3 126 28.4 80 18.1 56 54.4 39 37.9
Any Mental Disorder (above) 314 42.0 273 36.5 102 61.8 89 53.9 147 33.0 97.0 21.8 61 59.2 45 43.7
Substance Use Disorders
2
Alcohol dependence 142 19.2 59 8.0 27 16.5 10 6.1 50 11.3 3.0 0.7 5 4.9 0 0.0
Alcohol abuse 24 3.3 17 2.3 3 1.8 2 1.2 10 2.3 0 0.0 3 2.9 1 1.0
Cannabis dependence 136 18.7 108 14.9 37 23.0 28 17.4 54 12.4 7 1.6 17 16.8 2 2.0
Cannabis abuse 18 2.5 13 1.8 4 2.5 3 1.9 5 1.1 1 0.2 1 1.0 0 0.0
Opioid dependence 251 34.5 189 26.0 86 53.4 60 37.3 64 14.6 7 1.6 38 37.6 2 2.0
Opioid abuse 13 1.8 6 0.8 1 0.6 0 0.0 2 0.5 0 0.0 1 1.0 0 0.0
Sedative dependence 83 11.4 72 9.9 46 28.6 28 17.4 25 5.7 2 0.5 23 22.8 3 3.0
Sedative abuse 2 0.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.0 0 0.0
Stimulant dependence 202 27.8 166 22.8 77 47.8 55 34.2 47 10.8 3 0.7 29 28.7 0 0.0
Stimulant abuse 21 2.9 7 1.0 4 2.5 3 1.9 4 0.9 0 0.0 1 1.0 0 0.0
Any Substance Use Disorder 466 63.7 339 46.6 120 74.5 92 57.1 147 33.6 15 3.4 58 57.4 6 5.9
Personality Disorders
Impulsive 162 21.4 - - 52 31.5 - - 86 19.0 - - 14 13.3 - -
Paranoid 150 19.8 - - 46 27.9 - - 68 15.0 - - 16 15.2 - -
Borderline 149 19.7 - - 51 30.9 - - 60 13.3 - - 14 13.3 - -
Anxious 144 19.0 - - 38 23.0 - - 52 11.5 - - 19 18.1 - -
Schizoid 123 16.3 - - 37 22.4 - - 47 10.4 - - 16 15.2 - -
Anankastic 110 14.6 - - 31 18.8 - - 11.1 11.1 - - 17 16.2 - -
Dependent 83 11.0 - - 35 21.2 - - 22 4.9 - - 9 8.6 - -
Histrionic 50 6.6 - - 19 11.5 - - 14 3.1 - - 3 2.9 - -
Dissocial 19 2.5 - - 4 2.4 - - 12 2.7 - - 3 2.9 - -
Any Personality Disorder 303 40.1 - - 94 57.0 - - 166 36.7 - - 40 38.1 - -
Neurasthenia
4
27 3.6 24 3.2 17 10.3 13 7.9 7 1.5 5 1.1 8 7.6 7 6.7
Any Psychiatric Disorder 583 78.2 496 66.7 146 90.1 137 84.6 272 61.0 172 38.7 81 78.6 56 54.9
1
Includes mild, moderate and severe depression.
2
Includes Mania, hypomania, and bipolar affective disorder.
Page 15
Any Psychiatric Disorder
1
Overall, the majority of male and female reception prisoners were found to
have had a psychiatric disorder in the twelve months prior to interview (78%
vs. 90%).
The twelve-month prevalence of ‘any psychiatric disorder’ was higher among
females than males in both the reception and sentenced groups (86% vs.
72%) and higher among reception prisoners compared with those currently
serving a sentence (80% vs. 64%).
Age
In both males and females, the prevalence of ‘any psychiatric disorder’
declined with age. The highest prevalence of ‘any psychiatric disorder’ was in
females under 25 years old and was lowest was for men over 40 years of age
(Figure 1).
Marital Status
For males, the prevalence of ‘any psychiatric disorder’ was similar across all
categories of marital status. In females, the prevalence of ‘any psychiatric
disorder’ was highest amongst the married/defacto group (Table 4).
Country of Birth
The prevalence of ‘any psychiatric disorder’ was highest in men and women
born in Australia.
Source of Income
The prevalence of ‘any psychiatric disorder’ was lowest in males reporting
other sources of income compared with females in which it was highest.
Highest qualification
Overall, females with post-school qualifications had the highest levels of ‘any
psychiatric disorder’ and for males the lowest prevalence was among those
with a secondary school qualification.
1
Note: this refers to any psychosis, anxiety disorder, affective disorder, substance use
disorder, personality disorder or neurasthenia.
Page 16
Figure 1: Prevalence of ‘Any Psychiatric Disorder’ (% positive) by age and sex (twelve-month
diagnosis).
Table 4: Prevalence (%) of ‘any psychiatric disorder’ among male and
female prisoners by marital status, country of birth, income, and highest
qualification (twelve-month diagnosis)
.
Demographic Characteristic Male Female
Marital Status % %
Married/ defacto 70.6 90.0
Divorced / separated/ widowed 73.5 85.5
Never married 71.8 81.3
Country of Birth
Australia 74.4 87.7
Other English speaking country 66.7 81.8
Other country 66.4 77.8
Source of Income
Wage or salary 62.6 81.5
Pension or benefit 80.2 88.2
Other source of income 50.8 92.3
Highest qualification
No qualification 72.3 84.7
Secondary school qualification 50.0 80.0
Post-school qualification 71.5 87.3
Comment
These data support the view that inmates in NSW are an extremely
psychologically disturbed group. The overall burden of mental illness that
these findings suggest for both the Corrections Health Service and the
Department of Corrective Services is staggering.
72.4%
76.6%
58.2%
91.7%
83.7%
79.4%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 17
Any Mental Disorder (psychosis, anxiety or affective
disorder)
1
Almost half (46%) of the receptions and 38% of the sentenced group had at
least one mental disorder in the year prior to interview. Anxiety disorder was
the most common complaint in both the reception and sentenced groups (38%
and 33%). Affective disorder was the second most common mental disorder
(23% among receptions and 14% among sentenced). Psychosis prevalence
among reception and sentenced prisoners was 12% and 5% respectively.
Demographic Correlates of Any Mental Disorder
Age
The prevalence of any mental disorder was higher for women than men
across all age groups. For women, the rate slightly increased after the age of
40 but decreased for men over 40 years (Figure 2).
Marital Status
The prevalence of any mental disorder was similar across all categories in
males. In women, the prevalence of mental disorder was highest in those who
were divorced/separated/widowed (Table 5).
Country of Birth
The lowest prevalence of any mental disorder in both males and females was
found in those born in non-English speaking countries.
Source of Income
In males, the lowest prevalence of any mental disorder was found among
those with other sources of income whereas the opposite was true for
females. Approximately two-thirds of women with other income sources had
an anxiety disorder, affective disorder or psychosis.
Highest qualification
The prevalence of any mental disorder was similar across educational groups
in females whereas for males it was lowest among those with secondary
school qualifications.
1
Note: ‘any mental disorder’ refers to any of the following: psychosis, anxiety disorder or
affective disorder.
Page 18
Figure 2: Prevalence of any mental disorder (anxiety disorder, affective disorder or psychosis)
(% positive) by age and sex (twelve-month diagnosis).
Table 5: Prevalence (%) of any psychosis, anxiety or affective disorders
among male and female prisoners by marital status, country of birth,
income, and highest qualification (twelve-month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married/ defacto 40.0 54.5
Divorced / separated/ widowed 40.7 73.9
Never married 36.7 58.2
Country of Birth
Australia 40.9 62.6
Other English speaking country 31.7 72.7
Other country 30.0 22.2
Source of Income
Wage or salary 34.6 61.5
Pension or benefit 44.1 61.6
Other source of income 27.9 69.2
Highest qualification
No qualification 37.8 59.5
Secondary school qualification 28.6 60.0
Post-school qualification 40.0 62.7
Comment
The prevalence of ‘any mental disorder’ is very high and significantly higher
than in the general community.
12
It is possible that concurrent/co-morbid
substance abuse and dependence contributes to the high prevalence of
mental disorder amongst prisoners in NSW. Nonetheless, this reflects the
reality for this population group and, at minimum reflects the degree of
suffering due to psychiatric disturbance, from any cause. Females had the
highest prevalence of mental disorder compared with males.
36.7%
41.2%
35.9%
60.5%
60.1%
64.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 19
Psychosis
Psychotic disorders are extremely disabling and are characterised by
symptoms such as hallucinations, delusions and a severe inability to make
realistic and rational decisions. These kinds of symptoms can have a profound
effect on judgement. Individuals with psychosis are vulnerable to exploitation
in environments that are not therapeutic. Psychosis can occur briefly (for
example when the person is high on certain drugs) or can remain for the
duration of a person’s life (for example in people who suffer from chronic
schizophrenia).
There are many types of psychotic disorders including schizophrenia,
schizoaffective disorder, mood disorders with psychosis, and drug induced
psychosis. Schizophrenia is a chronic, recurrent and debilitating mental illness
from which a minority recover. Psychosis, whether induced by drugs or
caused by mental illness is the most severe form of psychological
disturbance.
Overall, 9% of respondents (receptions and sentenced) had experienced
psychotic symptoms in the year prior to interview. Psychosis was more
common among reception prisoners than sentenced inmates (12% vs. 5%).
Psychosis was higher among females than males (12% vs. 8%).
Eighty-seven inmates who screened positive for psychosis were assessed
using the LEAD protocol described above. The prevalence of ‘definite’ and
‘probable’ schizophrenia among those screening positive for psychotic mental
illness was estimated to be between 4% and 7%.
Demographic Correlates of Psychosis
Age
The prevalence of psychosis was higher in females under 25 and over 40
compared with males in the same age groups, but similar to males in the 25-
40 year old group. There was a marked decline in the prevalence of psychosis
in males over 40 years of age (Figure 3).
Marital status
The prevalence of psychosis was similar across all marital categories within
the male and female groups (Table 6).
Country of Birth
Among females, the prevalence of psychosis was highest among those born
in Australia. The lowest rate of psychosis was found among males and
females from non-English speaking countries.
Page 20
Source of income
In males, those who were receiving a pension or benefit had the highest
prevalence of psychosis whereas for females, the highest prevalence was
found in those with other income sources.
Highest Qualification
In the female group, those with post-school qualifications had the highest
prevalence of psychosis. In the male group, those with secondary school
qualifications had the lowest prevalence of psychosis. No one with symptoms
of psychosis was found among those reporting secondary school
qualifications.
Figure 3: Prevalence of psychosis (% positive) by age and sex (twelve-month diagnosis).
Table 6: Prevalence (%) of psychosis among male and female prisoners by
marital status, country of birth, income, and highest qualification (twelve-
month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married/ defacto 8.7 11.9
Divorced / separated/ widowed 5.6 11.4
Never married 9.2 11.1
Country of Birth
Australia 8.6 12.1
Other English speaking country 9.0 11.1
Other country 6.3 5.6
Source of Income
Wage or salary 3.7 7.6
Pension or benefit 11.1 13.8
Other source of income 9.7 15.4
Highest qualification
No qualification 9.3 10.3
Secondary school qualification 0.0 0.0
Post-school qualification 7.0 13.6
8.7%
9.6%
4.0%
13.8%
10.1%
11.8%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 21
Comment
Psychotic inmates can make significant demands on resources within the
correctional environment and are difficult to manage as a consequence of
their unique needs.
The prevalence of psychosis, as described above, may include psychosis
caused by substance use and/or mental illness. One in ten people received
into the correctional system had experienced psychotic symptoms in the
previous year. Seven percent of receptions probably had schizophrenia
according to the follow-up using the LEAD protocol. In NSW 18,000
receptions occur annually meaning that on an average day around four people
suffering schizophrenia will enter ‘the system’.
One in twenty sentenced inmates had been actively psychotic in the previous
year. While some of these sentenced inmates may have been in the
community, many would have been in prison at the time they were unwell.
The higher prevalence of psychosis among females with post-school
qualifications may reflect the later onset of psychosis in females in general
who are thus able to complete tertiary studies prior to onset.
The twelve-month prevalence of psychosis in NSW inmates was 30 times
higher than in the Australian community. The prevalence of schizophrenia and
related disorders approximates that found in the New Zealand survey of
prisoners (6%) but higher than reported in a recent meta-analysis of
psychiatric illness among prisoner populations (3.7% - 4.0%).
6
Page 22
Affective Disorders
Affective disorders are disturbances of mood and include depression,
dysthymia and mania. It is normal for a person’s mood to fluctuate with ‘highs’
and ‘lows’. When a high or low mood persists and affects functioning at home,
work or socially then the person has a mood disorder.
Depressive disorder is a mood disturbance that is persistently and markedly
low or sad, as compared to normal. It persists for at least two weeks, and
affects the person’s appetite, sleeping patterns, concentration, motivation,
drive and energy levels. Dysthymia is a longstanding lower grade mood
disturbance than depression that has persisted for years. It is distinguished
from depression by its long-term presence with relatively less severe
disturbance in functioning.
Mania
is an elevated mood persisting for at least
one week and can affect appetite, sleeping patterns, concentration,
motivation, drive and energy levels in an opposite way to depression. It can
occur alone or can alternate with low moods in patterns of extreme highs and
lows and is often known as Manic Depression or Bipolar Disorder.
Twenty percent (20%) of all those surveyed reported suffering at least one
type of mood disorder in the prior twelve months (Table 7). The prevalence of
any affective disorder was higher among females than males (29% vs. 18%).
Mood disorders were more common among reception prisoners than
sentenced (23% vs. 14%).
The most common type of mood disorder in both the reception and sentenced
groups was depression (17% and 10%). Any depressive illness was 1.5 times
more common for reception males and females than those who had been
sentenced.
Mania was the least prevalent mood disorder. Four percent of the reception
group reported at least one manic episode compared with 1% in the
sentenced group.
The prevalence of dysthymia was higher among reception prisoners
compared with sentenced (8% vs. 4%).
Table 7: Twelve-month ICD-10 prevalence estimates of affective disorder.
RECEPTION SENTENCED
Male Female Total Male Female Total
Affective Disorder
% % % % % %
Depression
1
16.0 23.6 17.4 9.5 14.4 10.4
Dysthymia 7.2 9.7 7.7 3.8 5.8 4.2
Manic episode
2
2.8 7.9 3.7 1.3 1.9 1.4
Any Affective Disorder 21.1 33.9 23.4 12.4 20.4 14.0
1
Includes mild, moderate and severe depression.
2
Includes mania, hypomania, and bipolar affective disorder.
Page 23
Demographic Correlates of Affective Disorders
Age
The prevalence of affective disorders across all age groups showed the same
patterns for females and males. The prevalence was highest in the 25-40 age
group (Figure 4).
Marital Status
In men and women those who were divorced/separated/widowed had the
highest prevalence of mood disorders (Table 8).
Country of Birth
The lowest rate of mood disorders was in males born in non-English speaking
countries and highest in women born in other English speaking countries.
Source of Income
For males, the prevalence of mood disorders was highest among those
receiving pensions or benefits, and for females it was highest in those with
other sources of income. Conversely, for males mood disorders were lowest
among those with other income sources.
Highest Qualification
Interestingly, males and females with post-school qualifications had the
highest prevalence of affective disorder. There was a large difference
between males and females in the proportion of those with secondary school
qualifications who had a mood disorder diagnosis.
Figure 4: Prevalence of any affective disorder (% positive) by age and sex (twelve-month
diagnosis).
14.8%
20.3%
17.7%
23.3%
32.4%
26.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 24
Table 8: Prevalence (%) of affective disorders among male and female
prisoners by marital status, country of birth, income, and highest
qualification (twelve-month diagnosis).
Comment
Incarceration results in the loss of many personal freedoms taken for granted
in the community, including social supports, inter-personal relationships,
employment, social status, and social role. These losses are commonly
correlated with depressive disorder. At the time of reception almost one-
quarter were diagnosed with a mood disorder, which is more severe than
simply feeling ‘down’ about their circumstances.
Along with schizophrenia, depression is associated with an increased risk for
suicide and could be ameliorated through effective screening, diagnosis and
treatment.
Having had any affective disorder in the year prior to interview was 3.4 times
more common among NSW prisoners than in the Australian community (20%
vs. 5.8%).
The low rate of mania is similar to that reported in a recent study of New
Zealand prisoners.
14
Demographic Characteristic Male Female
Marital Status % %
Married / defacto 17.2 27.7
Divorced / Separated / Widowed 24.4 31.9
Never married 15.5 27.6
Country of Birth
Australia 19.0 30.0
Other English speaking country 16.7 36.4
Other country 13.5 22.2
Source of Income
Wage or salary 17.3 23.1
Pension or benefit 19.5 30.4
Other source of income 9.8 38.5
Highest qualification
No qualification 17.7 26.1
Secondary school qualification 0.0 20.0
Post-school qualification 18.6 32.7
Page 25
Anxiety Disorders
Anxiety is a common experience in everyday life. Feeling anxious about
certain things is normal and important for adaptation and survival. However,
the degree of anxiety that some people feel is sometimes excessive and
impacts on their functional capacity and can be debilitating. Anxiety disorders
are diagnosed when anxiety is either persistent or persistently recurrent, and
affects a person’s ability to work, have relationships or interact with others in
social situations.
Over 36% of all those screened experienced an anxiety disorder in the twelve
months prior to interview (Table 9). The prevalence was substantially higher
among females than males in both the reception (56% vs. 34%) and
sentenced (54%
vs.
28%) groups. Interestingly, the prevalence of anxiety
disorders did not differ markedly between the reception and sentenced
prisoners in both males and females (34% vs. 28% for receptions, and 56%
vs. 54% for sentenced).
Post-traumatic Stress Disorder (PTSD) was the most common anxiety
disorder, with 26% of reception prisoners and 21% of sentenced prisoners
meeting the diagnostic criteria in the previous twelve months.
Generalised Anxiety Disorder (GAD) was the second most common disorder,
occurring in 15% of reception and 13% of sentenced prisoners. Panic disorder
was more common in females than males (17% vs. 7% for reception
prisoners; and 16% vs. 7% for sentenced prisoners). Agoraphobia, obsessive-
compulsive disorder (OCD), and social phobia were relatively rare (3%, 2%
and 1%).
Table 9: Twelve-month ICD-10 prevalence estimates of anxiety disorders.
RECEPTION SENTENCED
Male Female Total Male Female Total
Anxiety Disorder
% % % % % %
Post traumatic stress disorder 21.7 43.6 25.6 16.2 43.8
21.4
Generalised anxiety disorder 13.4 22.4 15.0 12.4 15.2
12.9
Panic disorder 7.3 17.0 9.0 6.9 16.2
8.6
Agoraphobia 3.0 3.0 3.0 2.0 5.7 2.7
Obsessive compulsive disorder 2.7 2.4 2.7 1.6 2.0 1.7
Social phobia 1.3 0.6 1.3 0.9 1.0 0.9
Any Anxiety Disorder 33.9 55.8 37.9 28.4 54.4 33.3
Page 26
Demographic Correlates of Anxiety Disorders
Age
Among males, the prevalence of anxiety disorder was similar across all age
groups. However, in females the prevalence increased with age from 52% in
those under 25 to 65% in those over 40 years (Figure 5).
Marital Status
In males, the prevalence of anxiety disorders did not differ between categories
of marital status; however, in the female group those who were widowed/
divorced/separated had a highest prevalence (Table 10).
Country of Birth
Males and females born in non-English speaking countries were less likely to
have had an anxiety disorder in the previous twelve months.
Source of Income
In males, anxiety disorder was highest in those receiving a pension or benefit
and lowest among those with other sources of income. In females the
prevalence was similar across all income groups.
Highest Qualification
In males, the prevalence of anxiety disorder was similar across all levels of
education. For women it was lower in those with no qualifications.
Figure 5: Prevalence of any anxiety disorder (% positive) by age and sex (twelve-month
diagnosis).
31.1%
32.5%
31.5%
52.3%
54.7%
64.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 27
Table 10: Prevalence (%) of anxiety disorders among male and female prisoners
by marital status, country of birth, income, and highest qualification (twelve-
month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married / defacto 31.7 50.5
Divorced / Separated / Widowed 33.9 68.1
Never married 31.0 51.0
Country of Birth
Australia 34.5 57.0
Other English speaking country 20.0 63.6
Other country 21.1 22.2
Source of Income
Wage or salary 30.1 56.9
Pension or benefit 35.3 55.8
Other source of income 23.3 53.8
Highest qualification
No qualification 31.3 53.6
Secondary school qualification 28.6 60.0
Post-school qualification 32.6 57.3
Comment
These data suggest that almost every second NSW inmate has experienced
some form of anxiety disorder in the previous twelve months.
The prevalence of anxiety disorders did not differ markedly between the
reception and sentenced prisoners.
The twelve-month prevalence of PTSD in NSW inmates (24%) was
substantially higher than that found in the general Australian community (3%).
This is interesting because most people view prisoners as ‘traumatisers’
rather than having been traumatised themselves. It also supports the notion
that inmates are more vulnerable to having experienced serious psychological
trauma in the past, likely associated with their upbringing, lifestyle and
temperament.
The high rate of Generalised Anxiety Disorder (GAD) confirms that this
population are burdened by substantial anxiety and worry about their life
circumstances.
It is likely that both PTSD and GAD are under-diagnosed in the prisoner
population. Both conditions are difficult to treat with medication alone and
require a combination of both medication and psychological intervention over
a fairly lengthy period of time.
Page 28
Suicidal Ideation
Suicide is a fatal outcome associated with mental illness. Risk factors for
suicide are common among prisoner populations including: younger age,
male, psychological distress, recent substance abuse, history of violence,
single marital status, multiple losses, poor social supports, and previous
suicide attempts. There are different motives for self-harm including attempts
to make others take notice, to relieve internal psychological tension, and intent
to actually take one’s life. Self-harm behaviour, driven by the intent to take
one’s own life, is suicidal intent and behaviour. It can be difficult to distinguish
between self-harm behaviour driven by other motives and suicidal behaviour.
Overall, 16% of all inmates had suicidal thoughts in the previous twelve
months, 10% had made a suicide plan and 5% had attempted suicide.
Among receptions, 18% had thought about suicide in the previous twelve
months, 59% of these had made a plan to commit suicide with over half of the
planners attempting suicide. In the sentenced group, 11% had thought about
suicide in the previous twelve months, 67% of these had made a plan to
commit suicide with almost half of the planners attempting suicide.
Between 1999 and 2002, the rate of completed suicide in NSW prisons was
approximately 80 per 100,000 compared with approximately 12 per 100,000
for all ages in the NSW community.
Suicidal ideation, plans and attempts in the twelve months prior were all more
common among reception prisoners, and more common among females than
males (Table 11).
Table 11: Suicidal ideation plans and attempts.
RECEPTION SENTENCED
Male Female Total Male Female Total
% % % % % %
Suicidal ideation
15.3 31.5 18.2 9.7 17.3
11.1
Suicide plan
7.8 24.2 10.8 6.8 10.6
7.5
Suicide attempts
5.3 9.7 6.1 3.2 5.8
3.7
Comment
The prevalence of suicidal thoughts and behaviours among NSW inmates are
approximately four times higher than in the general population (16% and
3.4%).
20
Based on the number of successful suicides in NSW correctional centres,
these data suggest that, proportional to the number of inmates that report
thoughts of suicide, fewer attempt suicide and even fewer are successful.
Nonetheless, the rate of completed suicide among NSW prisoners is
Page 29
significantly higher than the general population, suggesting that this is a high-
risk population
The presence of suicidal thoughts and plans were higher in the reception
group in both sexes and higher in females than males.
Page 30
Substance Use Disorders
Substance use disorders describe abuse of, and dependence on substances.
They refer to the misuse of substances to the extent that the person’s
functioning is effected. People who abuse substances are preoccupied with
thinking, procuring and using substances such that relationships, work
performance and social interaction suffer. Substance use disorders exclude
moderate use of drugs (ie. casual, experimental or social). Substance
dependence means that over time the person has become tolerant (ie.
requires larger quantities of the substance to have the same effect) to, or
dependent on (unable to cope without), the substance or both tolerant and
dependent. Abuse and dependence are on a spectrum with each other. Abuse
precedes dependence. Dependence creates a drive to obtain substances to
avoid withdrawal symptoms. This drive often forms the basis of the motives for
general offending in this population thus increasing the risk of arrest often for
minor property crimes.
Substance use disorders were the most common diagnostic group among
male and female prisoners (55%). Two-thirds (66%) of receptions and 38% of
sentenced prisoners were diagnosed with a substance use disorder in the
previous twelve months (Table 12). Substance use disorders were more
common among females than males in both the reception (75% vs. 64%) and
sentenced groups (57% vs. 34%). Further, the majority of those with a
diagnosis of a substance use disorder were dependent on substances rather
than just abusing them, indicating the severity of drug problems among
prisoners.
Opioid use disorders were the most common substance use disorder among
both reception and sentenced prisoners (40% and 20%). Stimulant use
disorders were the second most common diagnosis (34% and 15%). In both
the reception and sentenced groups, alcohol use disorders were higher in
males than females, whereas use of cannabis, opioids, sedatives, and
stimulants were higher among females.
Page 31
Table 12: Twelve-month ICD-10 prevalence estimates for substance use disorders.
RECEPTION SENTENCED
Male Female Total Male Female Total
Substance use disorder % % % % % %
Alcohol dependence 19.2 16.5 18.7 11.3 4.9 10.1
Alcohol abuse 3.3 1.8 3.0 2.3 2.9 2.4
Cannabis dependence 18.7 23.0 19.5 12.4 16.8 13.2
Cannabis abuse 2.5 2.5 2.5 1.1 1.0 1.1
Opioid dependence 34.5 53.4 38.0 14.6 37.6 19.0
Opioid abuse 1.8 0.6 1.6 0.5 1.0 0.6
Sedative dependence 11.4 28.6 14.5 5.7 22.8 8.9
Sedative abuse 0.3 0.0 0.2 0.0 1.0 0.2
Stimulant dependence 27.8 47.8 31.4 10.8 28.7 14.1
Stimulant abuse 2.9 2.5 2.8 0.9 1.0 0.9
Any Substance Use Disorder 63.7 74.5 65.7 33.6 57.4 38.0
Demographic Correlates of Substance Use Disorder
Age
The prevalence of any substance use disorder declined with age in females.
For men it slightly increased for those aged 25-40 and then decreased
markedly for persons over 40 years (Figure 6).
Marital Status
In females and males, the prevalence of substance use disorders were lowest
among those who were divorced/separated/widowed (Table 13).
Country of Birth
For both males and females, substance use disorders were higher among
those born in Australia, particularly among females.
Source of Income
In both sexes, the prevalence of substance use disorders were higher in those
receiving a pension or benefit.
Highest Qualification
In both sexes, the lowest prevalence of substance use disorders occurred in
those with secondary school qualifications.
Page 32
Figure 6: Prevalence of any substance use disorder (% positive) by age and sex (twelve-
month diagnosis).
Table 13: Prevalence (%) of any substance use disorder among male and female
prisoners by sex, marital status, country of birth, income, and highest qualification
(twelve-month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married/ defacto 52.4 73.7
Divorced / separated/ widowed 45.4 60.9
Never married 55.6 67.0
Country of Birth
Australia 55.9 73.7
Other English speaking country 54.2 36.4
Other country 45.9 44.4
Source of Income
Wage or salary 41.2 60.3
Pension or benefit 65.0 73.3
Other source of income 33.3 69.2
Highest qualification
No qualification 55.2 69.1
Secondary school qualification 21.4 40.0
Post-school qualification 49.4 67.6
Comment
Substance use disorder was the most common psychiatric diagnosis among
NSW inmates. Incarceration results in the sudden limitation of access to
substances. Thus, withdrawal from substances is common and places
significant demand on resources in terms of detoxification and maintenance.
In addition, dependence creates an internal market for illicit substances within
the prison environment.
57.5%
60.1%
23.6%
80.7%
66.2%
44.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 33
According to these data, approximately one-half of inmates received into
prison are at risk of substance withdrawal and require treatment. Considering
there are about 18,000 receptions into the NSW correctional system each
year, this suggests that each day twenty five new receptions are likely to
require detoxification.
When compared with the Australian community, the reception population had
an extraordinarily high prevalence of opioid (40% vs. 1%) and stimulant (34%
vs. 1%) use disorders. The high levels of stimulant use disorder may reflect
the well-recognised and recent heroin drought that was a feature of the
Australian drug scene in 2001.
The prevalence of substances commonly used in the Australian community
(alcohol and cannabis) was markedly higher among reception prisoners.
Approximately one-fifth (22%) of those received into the correctional system
had a twelve-month diagnosis of an alcohol use disorder, compared with 6.5%
in the Australian community.
21
The twelve-month prevalence of cannabis use
disorder was 22% which was higher than that reported in the Australian
community (1.7%).
The large difference in the twelve-month diagnosis of substance use disorders
between males and females in the sentenced group likely reflect the shorter
sentences in the female group and also reflect the incarceration of females
primarily for drugs related offences.
Predictably, the prevalence of substance use disorders in the sentenced
group was lower than among receptions due to limited access to drugs such
as heroin and amphetamine during incarceration.
Page 34
Personality Disorders
Personality disorder is not a mental illness but is regarded under the broad
definition of psychiatric disorder. Personality describes a collection of
relatively fixed traits that are difficult to change and in combination define the
person. These traits are patterns of thinking, feeling, behaving and interacting
with others that are fixed and inflexible. When these traits manifest as
difficulties in functioning and are maladaptive the person may have a
personality disorder. These difficulties generally become evident in
adolescence, continue through life and occur in a wide range of situations.
Personality disorder diagnoses are therefore lifetime rather than twelve or
one-month. People with a personality disorder exhibit a wider range of
emotional expression, have more difficulty controlling their impulses and
delaying gratification of needs. They have more difficulty managing
interpersonal relationships and often their behaviour causes distress to others.
The overall lifetime prevalence of ‘any personality disorder’ in this survey was
41% (Table 14). Personality disorder was higher among females than males
(50% vs. 39%) and higher in the reception than the sentenced groups (43%
vs. 37%).
Common personality disorders in males and females were impulsive (21%
and 24%), borderline (17% and 24%), paranoid (18% and 23%), anxious
(16% and 21%) and schizoid (14% and 20%).
Notably, dissocial personality disorder, which relates to antisocial personality
in the DSM IV, had a surprisingly low prevalence suggesting the IPDE
screener is poor in identifying this disorder. Previous studies have shown a
high prevalence of antisocial personality among prisoner populations.
22
It is
interesting to note that in the Australian National Survey of Mental Health and
Wellbeing, nobody received a diagnosis of dissocial personality.
23
Table 14: Personality disorders.
RECEPTION SENTENCED
Male Female Total Male Female Total
Affective Disorder
% % % % % %
Impulsive 21.4 31.5 23.2 19.0 13.3 18.0
Paranoid 19.8 27.9 21.3 15.0 15.2 15.1
Borderline 19.7 30.9 21.7 13.3 13.3 13.3
Anxious 19.0 23.0 19.8 11.5 18.1 12.7
Schizoid 16.3 22.4 17.4 10.4 15.2 11.3
Anankastic 14.6 18.8 15.3 11.1 16.2 12.0
Dependent 11.0 21.2 12.8 4.9 8.6 5.6
Histrionic 6.6 11.5 7.5 3.1 2.9 3.1
Dissocial 2.5 2.4 2.5 2.7 2.9 2.7
Any Personality Disorder 40.1 57.0 43.1 36.7 38.1 37.1
Page 35
Demographic Correlates of Personality Disorder
Age
The prevalence of any personality disorder remained fairly constant over the
age groups in both males and females (Figure 7).
Marital Status
The prevalence of personality disorder was higher among persons who were
separated, divorced or widowed (Table 15).
Country Of Birth
The prevalence of any personality disorder was lowest in those born in non-
English speaking countries.
Source of Income
For males and females, the prevalence of personality disorder was highest
among those receiving a pension or benefit. Among females, the lowest
prevalence was in the wage/salary group.
Highest Qualification
In males, the prevalence of any personality disorder was similar across
qualification categories. However, in females, it was lowest in the secondary
school qualification group and highest among those with post-school
qualifications.
Figure 7: Prevalence of any personality disorder (% positive) by age and sex (twelve-month
diagnosis).
40.4%
39.4%
34.4%
47.1%
51.7%
47.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 36
Table 15: Prevalence (%) of any personality disorder among male and female
prisoners by marital status, country of birth, income, and highest qualification
(twelve-month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married / defacto 37.6 50.5
Divorced / separated/ widowed 43.1 54.3
Never married 37.8 45.5
Country of Birth
Australia 42.0 50.2
Other English speaking country 31.7 58.3
Other country 24.8 44.4
Source of Income
Wage or salary 34.1 37.9
Pension or benefit 43.4 55.8
Other source of income 27.4 53.8
Highest qualification
No qualification 40.9 44.5
Secondary school qualification 35.7 20.0
Post-school qualification 36.0 58.2
Comment
As expected, the prevalence of personality disorder was high in the prisoner
population and was higher in females. This supports the view that prisoners
are a difficult population group to manage even in the absence of serious
mental illness. While the IPDE screener probably under-diagnosed
antisocial/dissocial personality disorder in this study, there is an extensive
literature confirming high rates of this personality disorder among prisoners.
22
What is interesting is the high prevalence of other personality disorders such
as paranoid, anxious and schizoid.
Page 37
Neurasthenia
Neurasthenia is a condition characterised by persistent feelings of fatigue
after quite minor mental and physical effort. Common symptoms are muscular
aches, dizziness, tension headaches, sleep problems, an inability to relax,
and irritability.
Overall, 4% of NSW inmates were diagnosed with Neurasthenia in the twelve
months prior to interview. The prevalence was higher in females than males in
both the reception (10% vs. 4%) and sentenced (8% vs. 2%) groups.
Demographic Correlates of Neurasthenia
Age
The highest prevalence of neurasthenia was found among females aged 25-
40 years. In males, the prevalence of neurasthenia was similar across all age
groups (Figure 8).
Marital Status
Neurasthenia was highest in the divorced/separated/widowed group in both
males and females (Table 16).
Country of Birth
The prevalence of neurasthenia was similar in all categories of country of birth
in both males and females.
Source of Income
The prevalence of neurasthenia was lowest in those with another source of
income in both males and females.
Highest Qualification
Among males, the prevalence of neurasthenia was highest in those with a
secondary school qualification whereas in female it was lowest in this
category.
Page 38
Figure 8: Prevalence of neurasthenia (% positive) by age and sex (twelve-month diagnosis).
Table 16: Prevalence (%) of any personality disorder among male and female
prisoners by marital status, country of birth, income, and highest qualification
(twelve-month diagnosis).
Demographic Characteristic Male Female
Marital Status % %
Married / defacto 1.4 8.9
Divorced / separated/ widowed 5.2 12.9
Never married 2.8 7.1
Country of Birth
Australia 3.1 9.1
Other English speaking country 2.6 11.1
Other country 1.7 11.1
Source of Income
Wage or salary 2.3 10.6
Pension or benefit 4.0 10.1
Other source of income 1.6 0.0
Highest qualification
No qualification 3.2 10.3
Secondary school qualification 7.1 0.0
Post-school qualification 2.2 8.2
Comment
Neurasthenia was found to be the higher in the prisoner population (4%) than
in the Australian community 0.5%.
24
2.8%
2.3%
4.0%
6.9%
11.4%
5.9%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
Under 25 yrs 25-40 yrs Over 40 yrs
Age Group
Percent
Male
Female
Page 39
Health Service Usage
Overall, sentenced prisoners were more likely to have utilised health services
for mental health problems than reception prisoners in the previous twelve
months (Figure 9). This suggests that prisons have a role to play in treating
those with a mental illness during incarceration.
Females were more likely than males to utilise services for mental health
problems in both the reception and sentenced groups. This was most notable
in the sentenced group, suggesting that females have greater access than
males to mental health services during incarceration.
Sentenced females were more likely than reception females to have seen
either a psychiatrist (37%
vs.
14%) or a psychologist (34%
vs.
9%) in the
previous twelve months. Sentenced males were more likely to have seen a
drug and alcohol counsellor than reception males (39% vs. 21%). This
suggests that for many males, prison represents an opportunity to address
drug and alcohol issues.
In contrast to the general pattern of male health service usage, reception
males were more likely to have consulted with a GP about a mental health
problem than sentenced males. This could reflect either a greater access to
GPs in the community for this group or that GPs are the preferred point of
contact with community health services for men with mental health problems.
Figure 9: Health service usage for a mental health problem in the previous twelve months by
‘any psychiatric disorder’ (twelve-month diagnosis).
Comment
Females tend to use mental health services more than males. Sentenced
females were more likely than sentenced males to have seen a mental health
professional.
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
GP Psychiatrist Psychologist D&A Counsellor Counsellor Nurse Mental Health
Team
Social Worker
Health Professional
Percent
Reception males
Reception
females
Sentenced males
Sentenced
females
Note: 'Any psychiatric disorder' includes: psychosis, anxiety, affective, substance abuse, personality disorder and neurasthenia
Page 40
Disability
The Brief Disability Questionnaire (BDQ) was used to assess the degree to
which respondents are limited by health problems in a number of activities,
and the degree to which they have cut down or stopped activities they were
expected to do as part of their normal routine. This screener also asks how
many days in the previous four weeks respondents were unable to carry out
their usual activities (days out of role) because of illness.
Overall, those with a psychiatric diagnosis were more likely to have higher
disability scores than those without a diagnosis (Table 17). Males tended to
have similar disability scores in both the reception and sentenced groups,
whereas female receptions had higher scores than sentenced females.
Table 17: Mean score on the Brief Disability Questionnaire (BDQ).
Reception Sentenced
ICD-10 Diagnosis Male Female Male Female
Positive
4.3 5.0 3.8 3.0
Psychosis
Negative 2.5 3.3 2.1 3.1
Positive
4.4 4.4 4.7 3.1
Affective disorder
Negative 2.4 3.2 1.9 3.1
Positive 4.3 4.7 4.3 2.8
Anxiety disorder
Negative
2.1 2.6 1.6 3.6
Positive 4.1 4.7 4.4 3.5
Any mental disorder*
Negative
2.0 2.3 1.4 2.7
Positive 3.0 3.8 3.4 2.3
Substance use disorder
Negative 2.5 3.2 2.0 3.1
Positive 3.8 4.2 3.2 4.0
Personality disorder
Negative 2.0 2.8 1.8 2.7
Positive
6.4 5.7 7.8 6.0
Neurasthenia
Negative 2.6 3.4 2.1 2.9
Positive 3.3 3.9 3.2 3.5
Any psychiatric illness**
Negative
1.6 1.9 1.4 2.6
* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.
** ‘Any psychiatric illness’ refers to any psychosis, anxiety disorder, affective disorder, substance use disorder,
personality disorder or neurasthenia.
Overall, those with psychiatric diagnoses had more days out of role than those
with no diagnosis (Table 18). This was consistent for both males and females
and reception and sentenced prisoners. Male and female receptions,
irrespective of whether a disorder was present or not, had more days out of
role than the sentenced group.
Page 41
Table 18: Number of days in previous month affected by disability.
Reception Sentenced
ICD-10 Diagnosis Male Female Male Female
Positive 11.1 10.3 5.9 2.5
Psychosis
Negative 5.5 6.5 1.7 1.6
Positive 11.3 8.2 5.4 3.7
Affective disorder
Negative 5.1 6.6 1.6 1.4
Positive
10.0 8.5 3.4 3.1
Anxiety disorder
Negative 4.6 5.9 1.5 0.8
Positive 10.0 7.8 3.7 3.0
Any mental disorder*
Negative 4.0 6.3 1.4 0.7
Positive 8.4 8.4 2.1 3.2
Substance use disorder
Negative
4.0 5.3 1.8 1.6
Positive 10.0 8.6 3.3 3.1
Personality disorder
Negative
3.6 5.2 1.3 1.1
Positive 13.8 10.5 26.6 5.5
Neurasthenia
Negative 5.9 6.8 1.6 1.4
Positive 8.0 7.8 2.9 2.4
Any psychiatric disorder
Negative 2.3 3.2 1.2 0.8
* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.
** ‘Any psychiatric illness’ refers to any psychosis, anxiety disorder, affective disorder, substance use disorder,
personality disorder or neurasthenia.
Comment
As expected, those with a mental illness manifest greater levels of disability
and more days out of role. Sentenced inmates had lower levels of disability
than reception inmates and fewer days out of role, possibly reflecting
improved access to treatment services in prison and abstinence from drugs.
Page 42
One-month Prevalence Estimates
The data presented above reports the twelve-month prevalence estimates.
However, the CIDI can also generate a one-month diagnosis. The twelve-
month diagnosis is valuable in terms of describing the overall level of
psychiatric morbidity in this population. The one-month estimates are more
likely to reflect the direct burden of illness exerted on the correctional system
at the time of reception.
The psychosis screener used in this study does not generate a one-month
diagnosis. Similarly, the personality disorder diagnosis is based on the
presence of long-term traits and therefore does not generate a one-month
diagnosis.
Among male receptions, 67% had a one-month diagnosis of ‘any psychiatric
disorder’, 17% affective disorder, 28% anxiety disorder, and 47% substance
use disorder (Table 19). In female receptions, 85% had a one-month
diagnosis of ‘any psychiatric disorder’, 57% substance use disorder, 47%
anxiety disorder, and 30% affective disorder.
Overall, the one-month prevalence of ‘any psychiatric disorder in both male
and female receptions was similar to the twelve-month estimates (67% vs.
78% in males, and 85% vs. 90% in females). Similarly, in male and female
reception inmates, the one and twelve-month estimates were similar for
anxiety disorder (28% vs. 34%, and 47% vs. 56%), and affective disorder
(17% vs. 21%, and 30% vs. 34%).
Predictably, for substance use disorders the twelve-month and one-month
prevalence estimates differed. For both male and female reception and
sentenced inmates, the twelve-month prevalence was higher than the one-
month prevalence (47% vs. 64%, and 57% vs. 75%).
Page 43
Table 19: One-month ICD-10 prevalence estimates of major disorders among
male and female reception prisoners, New South Wales (Australia).
ICD-10 One-month Diagnosis MALE FEMALE
Affective Disorders
N % N %
Depression 102 13.5 34 20.6
Dysthymia 46 6.1 15 9.1
Manic episode 10 1.3 9 5.5
Any Affective Disorder 128 17.1 50 30.3
Anxiety Disorders
Post traumatic stress disorder 128 16.9 62 37.6
Generalised anxiety disorder 94 12.4 33 20.0
Panic disorder 35 4.6 14 8.5
Agoraphobia 22 2.9 4 2.4
Obsessive compulsive disorder 17 2.3 3 1.8
Social phobia 8 1.1 1 0.6
Any Anxiety Disorder 206 28.0 78 47.3
Any Mental Disorder* 273 36.5 89 53.9
Substance Use Disorders
2
Alcohol dependence 59 8.0 10 6.1
Alcohol abuse 17 2.3 2 1.2
Cannabis dependence 108 14.9 28 17.4
Cannabis abuse 13 1.8 3 1.9
Opioid dependence 189 26.0 60 37.3
Opioid abuse 6 0.8 0 0.0
Sedative dependence 72 9.9 28 17.4
Sedative abuse 0 0.0 0 0.0
Stimulant dependence 166 22.8 55 34.2
Stimulant abuse 7 1.0 3 1.9
Any Substance Use Disorder 339 46.6 92 57.1
Neurasthenia
4
24 3.2 13 7.9
Any Psychiatric Disorder** 496 66.7 137 84.6
* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.
** ‘Any psychiatric disorder’ refers to any psychosis, anxiety disorder, affective disorder,
substance use disorder, personality disorder or neurasthenia.
Comment
Overall, there was comparatively little difference between the twelve-month
and one-month prevalence estimates among reception prisoners. Over three-
quarters of females and two-thirds of males were diagnosed with at least one
psychiatric disorder in the month prior to interview. At reception, over one-third
of males and over half of the females had either an anxiety or affective
disorder in the previous month. This suggests that the demand for psychiatric
services at the point of reception is likely to be high.
Predictably, the prevalence of certain substance use disorders, particularly
current use, was higher in the reception group in both sexes for alcohol
dependence, opioid dependence, and in women alone: sedative and stimulant
dependence.
Page 44
The similarity of the one-month and twelve-month prevalence estimates
provides support for the assumption that, in this population, the twelve-month
diagnosis can be used as a reasonable estimate of recent mental illness.
Page 45
Substance Use disorder and Psychiatric Diagnosis
Given the high rates of psychiatric disorder reported above, particularly
substance use, it is reasonable to suggest that some mental illness may have
been due to drug use. The twelve-month prevalence estimates of mental
illness (psychosis, affective disorder and anxiety disorder) in those with and
without a substance use disorder diagnosis are shown in the Table 20. Mental
illness among those with no diagnosis of substance use disorder was lower
than those with co-morbid substance use disorder. However, the prevalence
remained high in the absence of drug use.
Table 20: Twelve-month ICD-10 prevalence estimates of major disorders among prisoner with
and without a substance use disorder diagnosis.
No Substance Use
Disorder Diagnosis
Substance Use Disorder
Diagnosis
MALE
(N=265)
FEMALE
(N=41)
MALE
(N=466)
FEMALE
(N=120)
ICD-10 Diagnosis N % N % N % N %
Psychosis 17 6.4 5 12.2 60 12.9 20 16.7
Affective Disorders
Depression 29 10.9 11 26.8 86 18.5 28 23.3
Dysthymia 13 4.9 3 7.3 39 8.4 13 10.8
Manic episode 6 2.3 3 7.3 14 3.0 10 8.3
Any Affective Disorder 42 15.8 15 36.6 108 23.2 41 34.2
Anxiety Disorders
Post traumatic stress disorder 41 15.5 12 29.3 123 26.4 59 49.2
Generalised anxiety disorder 27 10.2 12 29.3 70 15.0 24 20.0
Panic disorder 12 4.5 5 12.2 38 8.2 23 19.2
Agoraphobia 3 1.1 0 0.0 18 3.9 5 4.2
Obsessive compulsive disorder 2 0.8 1 2.4 18 3.9 3 2.5
Social phobia 2 0.8 0 0.0 9 1.9 1 0.8
Any Anxiety Disorder 47 23.4 18 46.3 183 39.4 72 60.0
Any Mental Disorder* 79 29.8 21 51.2 221 47.5 80 66.7
* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.
Comment
The high rate of mental disorder among inmates cannot be attributed to
substance use disorder alone.
Page 46
Mental Illness And Offence Category
Overall, males were more likely than females to have been convicted for
violent offences (homicide and assault) (Table 21). The most common
convictions for both males and females were assaults, robbery and property
offences. Homicide, sexual and driving offences were less common among
females than males.
Overall, females convicted of either a violent or non-violent crime had a higher
prevalence of psychiatric disorder than males across all diagnostic categories.
The exception was among females with psychosis convicted of non-violent
crimes that had a prevalence of psychosis similar to that of males convicted of
a non-violent crime. This suggests that females with psychosis charged with a
non-violent crime may be less likely to be incarcerated than males with
psychosis charged with a non-violent crime.
Among females, there was a higher prevalence of mental disorder (psychosis,
affective disorder, and personality disorder) in those convicted for violent
crimes compared with non-violent offenders. However, among males there
was little difference in the levels of mental disorder between violent and non-
violent offenders. The exception was substance use disorder, which was
more commonly associated with non-violent crimes in males.
In both males and females, anxiety disorder was the most common mental
disorder (ie. psychosis, anxiety or affective disorder) across all offence
categories except for fraud in the males.
Males with a diagnosis of substance use disorder were most likely to have
been convicted for property, robbery and assault. Among females, substance
use disorder was most common in those convicted for property and driving
offences. Personality disorder in males and females was common among
those with a conviction for property offences which is consistent with the
notion that many property offenders are incarcerated for drug related crimes.
.
Page 47
Table 21: Most serious offence and ICD-10 twelve-month diagnosis for reception and sentenced prisoners (combined).
Psychosis
Affective
Disorder
Anxiety
Disorder
Substance use
disorder
Personality
disorder
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Offence N
***
% N
***
%
N
%
N
%
N
%
N
%
N
%
N % N % N % N % N %
Homicide
59
5.0
7
2.7
2 3.4 1 14.3 8 13.6 0 0.0 18 31.0 6 85.7 7 12.1 3 42.9 22 37.3 3 42.9
Assault
223
19.0
39
15.3
20 9.0 8 20.5 46 20.9 18 47.4 63 29.6 23 60.5 124 58.5 27 71.1 87 39.0 27 69.2
Sexual
61
5.2
4
1.6
6 9.8 1 25.0 16 26.7 2 50.0 23 39.0 3 75.0 7 12.3 3 75.0 19 31.1 3 75.0
Robbery
262
22.3
54
21.2
24 9.2 7 13.0 33 12.7 11 20.4 74 28.8 32 59.3 155 60.3 34 68.0 102 38.9 27 50.0
Fraud
32
2.7
15
5.9
3 9.4 1 6.7 10 31.3 5 33.3 9 28.1 7 46.7 11 35.5 9 64.3 10 31.3 5 33.3
Property
187
15.9
57
22.4
16 8.6 3 5.3 35 19.1 13 23.2 66 35.9 28 50.0 118 65.2 47 83.9 86 46.0 31 54.4
Driving
132
11.3
13
5.1
10 7.6 2 15.4 20 15.2 3 23.1 45 34.6 8 61.5 72 55.4 11 84.6 52 39.4 7 53.8
Drugs
97
8.3
37
14.5
8 8.2 1 2.7 9 9.4 7 18.9 23 24.0 18 48.6 42 44.2 14 37.8 32 33.0 8 21.6
Order
120
10.2
29
11.4
8 6.7 4 13.8 27 23.1 11 37.9 40 33.9 14 48.3 61 53.0 22 78.6 45 37.5 15 51.7
Violent
*
282 23.4 46 17.3 22 7.8 9 19.6 54 19.4 18 40.0 81 29.9 29 64.4 131 48.5 30 66.7 109 38.7 30 65.2
Non-Violent
**
830 68.8 205 77.1 69 8.3 18 8.8 134 16.4 50 24.5 257 31.5 107 52.5 459 56.7 137 69.2 327 39.4 93 45.4
*
Homicide and assault.
**
Robbery, fraud, property, driving, drugs, and order offences.
***
Note: percentages may not be exact due to missing offence data in certain diagnostic categories.
Page 48
DISCUSSION
This is the first large-scale survey of the prevalence of psychiatric disorder
among Australian prisoners.
Overall, 74% of those assessed had at least one psychiatric disorder
(psychosis, affective disorder, anxiety disorder, substance use disorder,
personality disorder or neurasthenia) in the twelve-months prior to interview.
For most diagnostic categories, the prevalence of ‘any psychiatric disorder’
was higher in those recently received into custody (80% vs. 64% in the
sentenced group) and higher among females than males (86% vs. 71%).
Forty-six percent (46%) of reception and 38% of sentenced inmates were
diagnosed with having had at least one ‘mental disorder’ (psychosis, affective
disorder, or anxiety disorder) in the twelve months prior to interview.
Substance use disorder was the most common diagnostic group with 66% of
reception inmates and 38% of sentenced inmates meeting the diagnostic
criteria in the previous twelve months.
The prevalence of psychiatric disorder was significantly higher than that found
in the Australian community using the same diagnostic tool (the CIDI). In the
National Survey of Mental Health and Wellbeing (NSMHWB) the twelve-month
prevalence for ‘any psychiatric disorder’ was 22% (vs. 77% among inmates),
for ‘any mental disorder’ it was 15% (vs. 42% among inmates), for psychosis it
was 0.42% (vs. 9% among inmates), for affective disorder it was 6% (vs. 22%
among inmates), for anxiety disorder it was 10% (vs.. 43% among inmates),
for substance use disorder it was 5% (vs. 57% among inmates), for
personality disorder it was 7% (vs. 43% among inmates), and for neurasthenia
it was 2% (vs. 6% among inmates).
Given the number of full-time inmates in NSW in 2000/2001 was 7,735, it is
possible to extrapolate the diagnostic data to the wider prisoner population to
ascertain the number of inmates with a psychiatric disorder.
25
The number of
sentenced inmates who would have been diagnosed with ‘any psychiatric
disorder’ in the previous month would have been approximately 3,077 and
1,799 with ‘any mental disorder’ in the previous month. Three hundred and
thirty three (333) would have reported having experienced psychotic
symptoms in the previous twelve months.
While the static population was 7,735, approximately 12,483 males and 1,566
females were received into the NSW correctional system in 2000/2001. Based
on these figures, 9,693 would have been diagnosed with having had ‘any
psychiatric disorder’ in the previous month; 5,427 with ‘any mental disorder’;
and 6,739 with a substance use disorder in the previous month.
Approximately 1,581 reception inmates would have reported experiencing
psychotic symptoms in the previous twelve-months.
The use of the psychosis screener prevented the accurate measurement of
the different psychotic disorders. However, we utilised a separate clinical
Page 49
assessment protocol (the LEAD) to provide further insight into the prevalence
of functional psychotic illness in a sub-set of reception prisoners. We are
satisfied that the prevalence of functional psychotic illness is in the order
between 4% and 7%.
Following cardiovascular disease and cancer, mental disorder ranks third in
terms of disability adjusted life years (DALYs) in NSW for both males and
females in the general community.
26
Given the relatively higher rates of
mental disorder in the NSW inmate population, this suggests that a substantial
‘burden of disease’ due to mental disorder exists in this population.
Further investigation is warranted into the possible unmet mental health needs
of the NSW prisoner population to identify those suffering from less severe
forms of mental illness who would nonetheless benefit from psychiatric
treatment. The data also makes a cogent argument for the need for screening
systems and diagnostic instruments to better identify inmates with these
problems at the point of reception. Once identified, there will likely be an
increased demand for multidisciplinary mental health services to manage
these conditions and to co-ordinate linkage with community mental health
services on release to freedom.
Mentally ill inmates are more disabled than those with no mental illness.
However when resources are allocated there is little distinction made between
the needs of the mentally ill inmate and the non-mentally ill. Inmates suffering
mental illness and forensic patients have different and frequently greater need
and in many cases require management in specialist units.
There are numerous probable explanations for the high number of mentally ill
people in prison including: homelessness, a lack of adequate diversionary options
in the community, inadequate specialist community forensic psychiatric services,
deinstitutionalisation of the mentally ill, inadequate rehabilitation of forensic
psychiatric in-patients, the high threshold for admission to general psychiatric
facilities, the reluctance of general psychiatric services to accept mentally ill
patients from the courts, society’s intolerance of deviant behavior by the mentally
ill, and the greater likelihood of the mentally ill being arrested. The increased use
of illicit substances in the general population and among the mentally ill has likely
made a significant contribution to an increase in all types of offending.
2;27
The most common offences are those associated with substance misuse
highlighting the link between drugs and incarceration. There is also a relationship
between mental illness and offending.
3-5;28-30
Substance abuse can mimic, trigger
or exacerbate symptoms of mental illness. Co-morbid substance abuse and
mental illness substantially increases the risk of offending. Among the mentally ill,
substance abuse may increase the risk of non-compliance to medication and
interfere with the effectiveness of medication.
Further, incarceration results in a sudden disruption in the individual’s life,
characterised by loss of freedom and liberty, loss of social and family support,
exposure to an unfamiliar and sometimes threatening environment, frequent
and unexpected transfers to new correctional environments, loss of control,
Page 50
and a highly regimented daily routine. Such an environment poses a
challenge, particularly for those inmates with a mental illness who have a
higher likelihood of cognitive disability, poor insight, and problem solving skills.
Mentally ill inmates may experience increased feelings of paranoia, anxiety,
and despair, which can exacerbate a mental illness. They may have difficulty
accessing regular psychiatric follow-up due to frequent transfers, and in some
cases, less likely to assert themselves to obtain treatment out of fear of
stigmatisation.
31
The mentally ill often revolve through prisons, with periods of incarceration
interspersed with spells in the community and place high demand on
services.
32
Mentally ill prisoners are doubly stigmatised, suffering from a
psychiatric illness in addition to labelling as an ‘offender’. They are often
disenfranchised, frequently itinerant, suffer chronic illness with acute
symptoms, have poor physical health, lack social supports, have co-morbid
substance abuse, and are frequently without community care.
The majority of mental health providers within the NSW correctional
environment are obligated to operate in accordance with the correctional
ethos. This is fertile ground for conflicting priorities between clinical needs (the
health priority) and security (the custodial priority). The correctional approach
to the management of difficult behaviour can be the antithesis of the mental
health approach.
An examination of those inmates who either declined to be interviewed or
were unavailable for interview and those who were screened failed to identify
any significant differences between the two groups. However, in the
sentenced group, males with longer sentences were more likely to be
screened. There was an under-representation in the reception sample of
indigenous males and those males who had been referred to the mental
health team for assessment. This latter group were not assessed because
they were determined to be too mentally unwell. This is likely to have
produced slight underestimates of the prevalence of mental illness.
Notwithstanding these considerations we believe that the sample is generally
representative of the NSW prisoner population.
Using the same version of the CIDI as the National Survey of Mental Health
and Wellbeing (NSMHWB) prevented the collection of certain demographic
data. The substance use module did not include a diagnosis of possible
cocaine use disorder which is likely to be fairly common in this population.
Internationally and nationally, strategies have been adopted to address the
seemingly disproportionately high number of offenders with a mental illness.
33
These include: diverting mentally ill offenders out of the criminal justice
system who have been charged with relatively minor offences, admission of
inmates requiring involuntary psychiatric treatment, admission of those found
‘not guilty by reason of mental illness’ and admission of those found ‘unfit to
stand trial’ to secure forensic mental health facilities, and follow-up in the
community of ‘high risk’ and forensic psychiatric patients. Screening new
Page 51
receptions for mental illness and developing targeted treatment programmes
in correctional centres is essential.
Mental health services in NSW are delivered under the ‘Charter for Mental
Health Care in New South Wales’. This charter outlines the mental health care
entitlements of people in NSW. It stipulates fostering positive attitudes to
mental health, effective treatment, and accessibility to appropriate care,
cultural sensitivity, and the promotion of quality of life. This includes prison
inmates.
The NSW Forensic Mental Health Strategy outlines plans for the development
of forensic psychiatric services across the state. Currently, a new, secure
forensic psychiatric hospital is being planned. This will provide a more
appropriate environment for the rehabilitation and treatment of forensic
patients and inmates requiring involuntary psychiatric treatment. Court liaison
services have been developed with mental health expertise provided to eleven
magistrate courts throughout NSW. This enables magistrates to divert
offenders with minor offences into community psychiatric care.
While specialised community forensic psychiatric services are yet to be
developed in NSW, general community psychiatric services provide ongoing
oversight to high-risk patients. However, given the level of public concern
about high-risk and forensic patients and the medico-legal complexities
associated with this group of offenders, specialised services need to be
developed. Establishing a forensic mental health directorate and the
realisation of the NSW Forensic Mental Health Strategy will, in all likelihood
address many of the current demands on correctional mental health
resources.
Arrest and detention can provide an opportunity for intervention and
treatment, and in some cases may be the only time certain individuals receive
mental health care.
34
This treatment needs to be consistent with international
best practice.
Page 52
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Occupational therapy is well equipped to help people with mental illness in criminal justice contexts. Criminal court mental health initiatives, meanwhile, have emerged as a “rehabilitative response” to disproportionate numbers of people with mental illness caught in the criminal justice system. These initiatives—namely, mental health courts and mental health diversion—belong to a family of problem-solving courts animated by the theoretical concept of therapeutic jurisprudence. Occupational therapy is on the periphery of these developments, but this article argues that the growing emergence of these initiatives presents an important and expanding new area of practice for occupational therapy.