Why prison mental health is important

Prisons are not healthy places. There is a high prevalence of mental health problems, including substance abuse disorders, and a higher prevalence of noncommunicable diseases. Unhealthy conditions such as overcrowding and poor hygiene are common in many prisons.

Prison health is part of public health and prisons are part of our society. One third of prisoners leave prison every year and the interaction between prisons and society is huge. We have to ensure that prisons are not becoming breeding places for noncommunicable diseases, and we must also seek to use the experience of imprisonment for the benefit of prisoners and society.

Why prison health is important

There are two compelling reasons for providing health care in prisons. First is the importance of prison health to public health in general. Prison populations contain a high prevalence of people with serious conditions. Sooner or later most prisoners will return to the community, carrying back with them new and untreated conditions that may pose a threat to community and add to the burden in the community. Thus there is a compelling interest on the part of society that this vulnerable group receive health protection and treatment for any ill health.
The second reason is society’s commitment to social justice. Healthy societies have a strong sense of fair play: those involved in the provision of health care are committed to reducing health inequalities as a significant contribution to health for all. It is a fact that the majority of prisoners come from the poorest parts of society, with deficiencies in education and employment experience. Their admission to prison can be the first time they have had a settled life with adequate nutrition and a chance to reduce their vulnerability to ill health and social failure. Prison health care can play an important role in reducing health inequalities.

Prevalence of poor mental health

Most prevalence studies have been conducted show consistently that a very high proportion of prisoners suffer from poor mental health. For example, the most exhaustive study in the United Kingdom found that 90% of prisoners aged over 16 years suffered from a mental illness, addiction or a personality disorder, and 70% of prisoners had two or more such problems. The prevalence of learning and communication difficulties and of addiction problems is also much higher than in the general population. In addition, prevalence studies show that 10–15% of the prison population suffer from severe and enduring mental illnesses such as schizophrenia, bipolar disorder and autism disorders, often complicated by comorbidity. The prevalence rates of poor mental health for young people in prison are very high, including over half with conduct disorders and around a third of young girls having a major depression. Studies have shown that the risk of suicide is much greater in a prison population, particularly in adolescent prisoners. Where studies of mental illness have been conducted, the prevalence has been consistently shown to be high.

Prisoners in the United Kingdom, in addition to having mental health problems, commonly experienced most if not all of the following problems concurrently:

• a history of unemployment
• poor education
• learning difficulties
• addiction or problematic substance misuse
• poor life and social skills
• poor access to stable housing
• debts both inside and outside prison
• poor general health
• past life trauma

Many, if not most, of the above are beyond the scope of health or mental health care services, and yet they are crucial to the health of prisoners and their recovery.

Illness and social focus

A focus needs to be adopted on both illness and wellness/ social health. The former characterizes much health care in many settings, certainly in many prison settings, but increasingly there is recognition of the importance of social interventions, although these are not standard in most services geared towards detecting and treating illness. Because resources are limited in prison systems, the risk of focusing on illness is that only those with the most severe problems are dealt with. High mental health service thresholds have to be set, leading inevitably to
frustration for the many prisoners who fall below this threshold.

Given the large number of prisoners who suffer from poor mental health, it seems wise to encourage all the
prison staff to recognize their responsibility in this area, rather than relying on a possibly small number of health
professionals.

Attempting to have a whole-prison focus on promoting and improving mental well-being can mean that the limited resources dedicated to mental health care can be put to the most effective use. It is also likely to have a positive impact on the regime in terms of safety and security. Additionally, it may result in improved outcomes for prisoners on release from prison, both for the risk of exacerbation of illness and in the recidivism risk for criminal offences.

The impact of prison on mental health and well-being

The following are factors that identify as negatively impacting on prison mental health:

• overcrowding;
• various forms of violence;
• enforced solitude;
• lack of privacy;
• lack of meaningful activity,
• isolation from social networks;
• insecurity about future prospects(work, relationships);
• inadequate health services, especially mental health services, in prisons.
• bullying by other inmates;
• concerns about family – difficulty in communicating with them;
• lack of a person they could trust to talk to;
• worries and concerns over release;
• substance misuse;
• incompatibility with cell-mates;
• poor diet;
• limited access to physical activity such as the gym;
• unresolved past life traumas;

Treatment in prison

The social structure in a prison is often relatively stable. Basic rules give safety and oversight, and basic needs (food, shelter) are met. For many inmates, this was not the case before they were imprisoned. This means that prison can be the place where disorders can be (re)detected, diagnosed and given basic treatment. It should be possible to give basic interventions, such as psychological support through counselling from a psychologist, nurse or stable peer, and psychotropic medications such as antipsychotics, as well as to motivate patients for treatment and medication during and after prison and to stabilize addiction problems.

For a limited number of severely psychiatric-disordered prisoners, it will also be necessary to have a crisis facility within or outside the national prison system, the latter depending on the relevant legislation. These facilities should be adequately staffed. They can also be used as a training facility for staff in other prisons.

References

  1. Houchin R. Social exclusion and imprisonment in Scotland: a report. Glasgow, Glasgow Caledonian University,
    2005 (http://www.scotpho.org.uk/downloads/SocialExclusionandImprisonmentinScotland.pdf).
  1. Blaauw E, van Marle H. Mental health in prisons. In: Møller L et al., eds. Health in prisons. A WHO guide to the essentials in prison health. Copenhagen, WHO Regional Office for Europe, 2007 (http://www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174. pdf).
  2. Standard minimum rules for the treatment of prisoners. New York, NY, United Nations, 1955 (http://www.unhcr.org/refworld/docid/3ae6b36e8.html).
  3. Convention on the Rights of the Child. Geneva, High Commissioner for Human Rights, 1989 (United Nations General Assembly resolution 44/25, 2 September 1990)(http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx).
  4. Lines R. From equivalence of standards to equivalence of objectives: the entitlement of prisoners to health
    care standards higher than those outside prisons. International Journal of Prisoner Health, 2006, 2(4):269–280.
  5. Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners in England and Wales.
    London, Office for National Statistics, 1998.
  6. Fazel S, Doll H, Långström N. Mental disorders among adolescents in juvenile detention and correctional
    facilities: a systematic review and metaregression analysis of 25 surveys. Journal of the American
    Academy of Child and Adolescent Psychiatry, 2008, 47(9):1010–1019.
  7. Fazel S, Benning R, Danesh J. Suicides in male prisoners in England and Wales, 1978–2003. The
    Lancet, 2005, 366:1301–1302.
  8. Durcan G. From the inside. Experiences of prison mental health care. London, Sainsbury Centre for Mental
    Health, 2008 (http://www.centreformentalhealth.org.uk/pdfs/From_the_Inside.pdf).
  9. Mental health and prisons. Geneva, World Health Organization, 2005 (Information Sheet) (http://www.
    who.int/mental_health/policy/mh_in_prison.pdf).
  10. Personality disorder: a briefing for people working in the criminal justice system. London, Sainsbury Centre for Mental Health, 2009 (http://www.centreformentalhealth.org.uk/pdfs/personality_disorder_briefing.pdf).

More information can be found on World Health Organisation Europe

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