Psychiatric morbidity in prisoners

Abstract

INTRODUCTION

It has been known that psychiatric disorders are highly prevalent among prisoners.[1] Many people with identifiable psychiatric illness do conflict with the law, often by no fault of their own but because of symptoms of their psychiatric illness and end up in jails. Such symptoms include impaired judgment, lack of impulse control, suspiciousness, disinhibition, paranoia, inability to trust others, delusions and hallucinations.

It is quite likely that act of incarceration may well exacerbate certain underlying psychiatric conditions. The effect of such incarceration may well be so severe as to precipitate mental abnormality in vulnerable individuals.[1] Different levels of stress during incarceration give rise to different incidence of psychiatric morbidity among remand prisoners.[2]

Somsundram[3] studied 53 criminal patients admitted to the Government Mental Hospital. They were acquitted of their criminal charges by reason of insanity at the time of commission of the crime under section 473 Cr. PC. It was found that 40 of them suffered from schizophrenia, 10 from affective disorders (3 mania and 7 depression), 1 epilepsy and 2 temporary insanity.

The criminal patients who were inpatients in the Government Mental Hospital Madras during 1972 were taken into consideration by Somsundram.[4] Only guilty but insane (19) out of total 79 inpatients were studied and he found that 18 were schizophrenic.

Jha[5] studied case records of criminal patients admitted in Ranchi Mansik Arogyashala and found 338 schizophrenic patients out of 1011 criminal patients admitted there during the years 1925 to 1963 giving an incidence of 33%.

Singh and Verma,[6] in an Indian Prison study, studied 50 consecutive subjects convicted of murder or attempt to murder and imprisoned at Central Jail Amritsar from January 1970 onwards. Fifteen (30%) of the subjects were found to have no evidence of psychiatric illness. The most common diagnosis was anxiety neurosis in 4 (8%) and depressive reaction in 8 (16%) cases. Psychopathic personality disorder was found in 8 (16%) cases, schizophrenia in 2 (4%), sexual deviation in 2 (4%), alcohol addiction in 6 (12%) and opium dependence in 5 (10%).

Mohan and Dhar[7] assessed 120 undertrials as per ICD-10 and 9% were diagnosed having different psychiatric disorder. Twenty eight percent suffered from schizophrenic psychosis, 13% from MDP, 14% from anxiety state and depression, 9% from malingering and 7% from seizure disorder in the assessed number of under trials. Pre-existing psychiatric illness before committing major crime was detected in 35% of undertrials referred.

Steadman et al.[8] studied a random sample of 3332 inmates representing 9.4% of New York's general prison population as well as 352 of the 360 inmates in the prison's mental health units. They found that 8% of the sample had severe psychiatric functional disabilities that clearly warranted some type of mental health intervention, and another 16% had significant mental disabilities that required periodic services (specific diagnoses were not given).

Agbahowe et al.[9] conducted a study to find prevalence of psychiatric morbidity among convicted inmates at a medium security prison in Nigeria. They assessed 100 inmates and found schizophrenia in 2, major depression in 2, recurrent mild depression in 21, generalized anxiety disorder in 8 and somatization disorder in 1.

Maden et al.[10] did retrospective, self-report survey of pre-arrest drug use in a representative sample of 1751 men serving a prison sentence. Reported drugs used were cannabis (34%), opiates (9%), amphetamines (9%) and cocaine (5%), including 1% ‘Crack’ users. Pre-arrest injecting was reported by 11% of inmates. Drug dependence was reported by 11%, including 7% dependent on opiates, 2% on amphetamines and 1% on cocaine.

Mason et al.[11] concluded that of 548 newly remanded prisoners studied, 57% men were using illicit drugs and 33% met DSM-IV drug misuse or dependence criteria. Thirty two percent met misuse or dependence criteria for alcohol.

There are limited studies on prevalence of psychiatric morbidity in prisoners housed in central jails. Most of the studies may be labeled as head counting in terms of socio-demographic attributes. So, it was decided to undertake a study on psychiatric and socio-demographic aspects of prisoners in order to fill this gap. It was with this aim that present study was planned.

AIMS

For the purpose of study, 500 convicted prisoners of Central Jail, Amritsar, were taken. The study was carried out in the period extending from 1^st April 2003 to 30^th September 2004. Sample was restricted to prisoners who were convicted before start of the study. The study was carried out with due permission of the Superintendent, Central Jail, Amritsar. The permission was refused for inclusion of prisoners in the maximum-security wing for security reasons. These included psychopathic killers, serial murderers, terrorists and foreign espionage agents. Prisoners with chronic psychiatric manifestations (including mental retardation and other chronic psychotic disorders) were kept in separate place named as prison psychiatric unit .They were excluded to avoid bias.

The inclusion and exclusion criteria were as follows:

TOOLS

RESULTS AND DISCUSSION

There is overrepresentation of the males in the sample. Male : Female ratio is 24 : 1. Mean age of the prisoners was 36.38 years, 36.6% of the prisoners were illiterate and 50% of the prisoners belonged to nuclear families. The above table shows that maximum number of prisoners (33.8%) belonged to socioeconomic status III and 73.6% of the prisoners belonged to socioeconomic status III, IV and V [Table 1].

Current diagnosis of psychiatric illness excluding substance abuse / dependence was found in 23.8% of the prisoners [Table 2].

Information on current substance abuse (inside the jail premises) could not be collected because respondents were not willing to disclose the information. 56.4% of the prisoners had history of substance abuse / dependence prior to incarceration, 39.8% of the prisoners met abuse / dependence criteria for alcohol and 5% were multiple substance abusers. 11.2% of the prisoners were dependent on various substances [Table 3].

Table 4 shows that among prisoners with psychiatric illness, maximum (34.45%) belonged to socioeconomic status III, 32.78% belonged to socio-economic status IV, 16.81% belonged to socio-economic status V, 12.60% belonged to socioeconomic status II and least 3.36% belonged to socioeconomic status I.

In prisoners without psychiatric illness, 33.60% belonged to socioeconomic status III, 27.82% belonged to socioeconomic status II, 25.98% belonged to socioeconomic status IV, 10.76% belonged to socioeconomic status V and 1.84% belonged to socioeconomic status I.

Statistically the data was not found to be significant (P>0.05) using Chi-square test.

Table 5 shows that among prisoners with psychiatric illness, 47.90% stayed for 3–6 years, 25.21% stayed for 6–9 years, 12.61% stayed for 1–3 years, 6.72% stayed for less than 1 year, 4.20% stayed for 9–12 year and 3.36% stayed for more than 12 years.

Among prisoners without psychiatric illness, 39.90% stayed for 3–6 years, 22.83% stayed for 1–3 years, 16.54% stayed for 6–9 years, 12.86% stayed for less than 1 year, 4.72% stayed for 9–12 years and 3.15% stayed for >12 years.

Statistically the data was not found to be significant (P>0.05) using Chi-square test.

In the present study, 500 convicted prisoners were interviewed, among which there was preponderance of male prisoners i.e. 480 males to 20 females in the ratio of 24:1. This finding is in accordance with the fact that majority of the crimes are committed by males.

In our study, 76% of the prisoners belonged to rural area which matches study by Sethi et al.[15] who concluded that majority of the prisoners came from rural areas (70%). But our finding is in contrast to study by Singh and Verma[6] who concluded that 92% of the criminals who committed murder were from a rural background. This variation may be due to difference in populations studied, as in their study prisoners committing only murder were included but in our study prisoners committing all the crimes were included.

Sethi et al.[15] concluded that majority of the convicts (77%) were illiterate or had their education up to primary which is in contrast to our study in which only 51.4% of the prisoners were illiterate or had their education up to primary. This variation may be due to vast time difference between the two studies. During the last 20 years, literacy rate has increased in India.

About 70% of the murderers were married in the study by Singh and Verma,[6] which is close to finding of our study in which 65.6% of the prisoners were married.

About 74% of the criminals came from lower and middle socio-economic classes (Grade III to V) in study by Singh and Verma.[6] In our study maximum number of prisoners belonged to socioeconomic status III (33.8%) and 73.6% of the prisoners belonged to socioeconomic status III, IV and V, which matches the study by Singh and Verma[6] (74%).

In our study 23.8% prisoner had psychiatric illness (excluding substance abuse). It is in agreement with the findings of Steadman et al.[8] and Birmingham et al.[16] who found psychiatric morbidity up to the extent of 24% and 26%, respectively. In terms of diagnostic breakup, depression was most common psychiatric disorder in this study (18% of the total sample). Agbahowe et al.[9] in Nigeria reported depression in 23% of the inmates. In study by Singh and Verma,[6] depressive reaction was found in 16% which matches our study. Dysthymia was found in 9 (1.8%) in our study, which matches the past literature. 2% prisoners had dysthymia in a study by Herrman et al.[17]

In our study, extent of schizophrenia was 0.4% while Herrman et al.[17] and Agbahowe et al.[9] reported schizophrenia in 2% of prisoners. Studies by Somsundram,[3,4] Jha,[5] Mohan and Dhar[7] had very high incidence of schizophrenia. This variation is due to different study design. Studies by Somsundram[3,4] and Jha[5] were done on criminals admitted in mental hospital and study by Mohan and Dhar[7] was done on undertrials who were referred to them in medical college, while our study was done in jail. The findings of our study are also in agreement with Coid's[1] observations that major psychosis was no more common in the majority of the studies of criminal population.

In our study, 56.4% of the prisoners had history of drug abuse / dependence prior to incarceration. 39.8% of the prisoners met abuse / dependence criteria for alcohol. 11.2% of the prisoners were dependent on various substances out of which 6.6% were dependent on alcohol. These findings are in agreement with findings of Mason et al.[11] who found 57% men were using illicit drugs and 32% met misuse or dependence criteria for alcohol. These findings differ from study done by Bushnell and Bakker,[18] who reported lifetime alcohol disorder up to extent of 81%. Findings of study by Bushnell and Bakker[18] are quite high as compared to our study and reasons for this might be lying in the roots of different socio-culture of these two countries.

11% of the prisoners were dependent on various substances in study done by Maden[9] et al., which is similar to the findings of our study but in their study cannabis (34%) was most commonly abused substance in contrast to our study in which alcohol (39.8%) was most commonly abused substance. Findings of this study differ from findings of study done by Kouri et al.[19] in which 95% obtained a diagnosis of dependence on one or more substances and these variations may be due to differences in social and geographical backgrounds.

CONCLUSION

The psychiatric morbidity among prison inmates is substantially higher than in the general population. We do, however, have insufficient knowledge about the extent of psychiatric treatment provided in our prisons. Most inmates have a number of defined problem areas, with substance use, depression and anxiety disorders most prevalent.

The high rate of common psychiatric disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of psychiatric inpatient facilities to care for the inmates who are too unwell to be treated in the prison. The burden of psychiatric illness in this vulnerable and marginalized population poses a serious challenge to researchers and clinicians alike.

LIMITATIONS

Footnotes

REFERENCES