For personal use. Only reproduce with permission from The Lancet Publishing Group.
ARTICLES
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545
Summary
Background About 9 million people are imprisoned
worldwide, but the number with serious mental disorders
(psychosis, major depression, and antisocial personality
disorder) is unknown. We did a systematic review of
surveys on such disorders in general prison populations in
western countries.
Methods We searched for psychiatric surveys that were
based on interviews of unselected prison populations and
included diagnoses of psychotic illnesses or major
depression within the previous 6 months, or a history of any
personality disorder. We did computer-assisted searches,
scanned reference lists, searched journals, and
corresponded with authors. We determined prevalence
rates of serious mental disorders, sex, type of prisoner
(detainee or sentenced inmate), and other characteristics.
Findings 62 surveys from 12 countries included 22 790
prisoners (mean age 29 years, 18 530 [81%] men, 2568
[26%] of 9776 were violent offenders). 3·7% of men
(95% CI 3·3–4·1) had psychotic illnesses, 10% (9–11)
major depression, and 65% (61–68) a personality disorder,
including 47% (46–48) with antisocial personality disorder.
4·0% of women (3·2–5·1) had psychotic illnesses, 12%
(11–14) major depression, and 42% (38–45) a personality
disorder, including 21% (19–23) with antisocial personality
disorder. Although there was substantial heterogeneity
among studies (especially for antisocial personality
disorder), only a small proportion was explained by
differences in prevalence rates between detainees and
sentenced inmates. Prisoners were several times more
likely to have psychosis and major depression, and about
ten times more likely to have antisocial personality
disorder, than the general population.
Interpretation
Worldwide, several million prisoners
probably have serious mental disorders, but how well
prison services are addressing these problems is not
known.
Lancet 2002; 359: 545–50
Department of Psychiatry, University of Oxford, Warneford
Hospital, Oxford OX3 7JX, UK (S Fazel MRCPsych); and Department of
Public Health and Primary Care, Institute of Public Health,
University of Cambridge, Forvie Site, Cambridge CB2 2SR, UK
(Prof J Danesh DPhil)
Correspondence to: Dr Seena Fazel
Introduction
About 9 million people are imprisoned worldwide,
including 2 million in the USA and 70 000 in the UK.1
Many psychiatric surveys have been done in prisons, but
they have generally been small, have often included
selected populations (such as prisoners referred to
psychiatric services), and have not been assessed
systematically. Indeed, three reviews included a total of
only ten studies in general prison populations.2–4
More
reliable estimates of the prevalence rates of serious
mental disorders in prisoners, such as psychotic
illnesses, major depression, and antisocial personality
disorder should help inform public policy and prison
health services. We have done a systematic review of
psychiatric surveys of people in general prison
populations in western countries (with results
subdivided by disorder, sex, and type of prisoner).
Methods
We searched for studies of the prevalence of psychotic
illnesses, major depression, or any personality disorder in
general prison populations of western countries
published between January, 1966, and January, 2001.
We did computer-based searches (EMBASE,
PsycINFO, MEDLINE, US National Criminal Justice
Reference System Abstract Database), scanned relevant
reference lists, searched forensic psychiatry and other
relevant journals by hand, and discussed and
corresponded with authors.5–71
We have not included
diagnoses of substance abuse because prevalence in
prisoners is likely to be substantially affected by various
reporting and ascertainment biases. We used
combinations of keywords relating to psychiatric illnesses
(eg, mental*, psych*, depress*, personality) and to
prisoners (eg, inmate, sentenced, remand, detainee,
felon). Non-English articles were translated. We
included surveys that did not sample prisoners referred
for psychiatric assessment; that related diagnoses of
psychotic illnesses or major depression to symptoms in
the previous 6 months, or a diagnosis of personality
disorder to lifelong behaviour; and involved diagnoses
made by clinical examination or interviewers using
diagnostic instruments (hence, surveys that used only
self-report instruments, such as the depression
component of the UK Office for National Statistics��
study, were ineligible60). Moreover, to reduce variability
in diagnosis of personality disorders, we only included
surveys in which validated instruments had been used. A
few studies were not included because they were done in
non-western populations (314 prisoners from Dubai,
Kuwait, and Nigeria72–74), reported substance abuse as
the main diagnosis,75
or used a hierarchy of exclusive
diagnoses.76
For every eligible study, we independently determined
(with a fixed protocol supplemented by correspondence
with authors; any discrepancies were resolved by further
Serious mental disorder in 23 000 prisoners: a systematic
review of 62 surveys
Seena Fazel, John Danesh
Articles
For personal use. Only reproduce with permission from The Lancet Publishing Group.
review) geographical location, year of interview, number
of prisoners interviewed, sampling method, type of
prisoner (detainee
vs sentenced inmate), response rate,
diagnostic instruments and criteria, type of interviewer,
number diagnosed with relevant disorders, mean age,
proportion male, number charged with violent offences,
and mean duration of imprisonment at time of interview.
Psychotic illnesses included mainly schizophrenia but
also schizophreniform disorder, manic episodes, and
delusional disorder. Major depression included
diagnoses of unipolar affective disorder (symptoms had
to be present for at least 2 weeks). Any reported
personality disorder was recorded, with particular
emphasis given to antisocial (or dissocial) personality
disorder because of its prognostic value and potential
treatability.77
If possible, results were tabulated
separately by prisoners�� status (ie, detainees [remand
prisoners in the UK]
vs sentenced inmates). Several
studies did not provide separate results for detainees and
sentenced prisoners; they were combined in analyses and
called mixed studies.23–26,51,52,69
As previously described,78,79 prevalence rates of various
disorders were combined from different studies by direct
summation of numerators and denominators (providing
weighted averages), subdivided by sex and by prisoners��
status. The results from smaller studies—those with less
than 250 prisoners—were combined in figures 1–3 and
when displaying the results from separate studies and
calculating standard ��2
tests of heterogeneity. Possible
sources of heterogeneity were investigated by grouping
studies according to potentially relevant characteristics
and by ��2 tests. To make some allowance for multiple
comparisons, 99% CIs were used for individual studies
(or aggregations of smaller studies), and 95% CIs for
subtotals and overall totals.
Role of the funding source
The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report.
Results
Study and baseline characteristics
62 relevant surveys, reported in 66 publications, included
a
total
of
22 790
prisoners
of
whom
18530 (81%) were men. In 47 surveys (12 859
prisoners) that included information on age, weighted
mean age of prisoners was 29 years. 2568 (26%) of
9776 prisoners were charged with, or convicted
of, violent offences (27 surveys included these data).
These baseline characteristics varied little by disorder.
The
studies
were
from
Australia
(598
prisoners),18,39,50,52,61,69
Canada (3196),5,27,37,59,67,68
Denmark
(583),12,32
Finland (1317),23,25,55
Ireland (280),15,49
Netherlands (450),14,21,35
New Zealand (1431),10,19,20
Norway (41),43,66
Spain (99),65
Sweden (103),40
UK (5548),6,8,11,22,26,28,33,41,42,46,47,51,53,60
and the USA
(9144).7,9,13,16,17,24,29–31,34,36,38,44,45,48,54,56–58,62–64,70,71
28 of the 62
surveys (11 071 prisoners) were done before
19907,13,16–18,23-25,27,28,30-33,36-39,41,42,44,50,51,57-59,62,70,71
but, with the
exception of female antisocial personality disorder, the
overall prevalence rates did not differ significantly by
whether surveys were done before or after 1990. Reported
sampling strategies included complete sampling of entire
prisons (1478 prisoners),8,29,40,50,52,66,67
simple random
sampling (3768),11,15,17,18,20–23,25,33,34,36,37,41,44,47,51,54
stratified
random sampling (10 563),7,9,13,24,27,28,31,38,39,45,46,53,60,70 inclusion
of consecutive prisoners (3144),14,16,35,42,49,56-59,62,64,68,69
sampling of various prisoner subgroups (482),12,55,61 and
various combinations of such strategies (2374).5,10,26 Apart
from seven studies that included only 13% (2876
prisoners) of the total sample,27,34,36,40,55
the reported
response rates were higher than 80%; in five27,34,36,40,55 of the
seven surveys with lower participation rates, rates were
still higher than 65%.
In some studies, diagnoses of psychotic illnesses and
major depression were based solely on clinical
examination, but in most studies trained interviewers had
made diagnoses using validated questionnaires.
For psychotic illnesses and depression, the
instruments
included:
Diagnostic
Interview
Schedule,5,7,9,24,27,29,34,35,37,45,57,62
Composite International
Diagnostic Interview,10,20,56
Structured Clinical Interview
for the Diagnostic and Statistical Manual,30,31,39,50,52,66
Clinical Interview Schedule,6,8,11,28,46,53
Present State
Examination-10,12,60
Schedule for Affective Disorders,26
Diagnostic Interview for Children and Adolescents—
Adolescent Version,55
and Schedule for Clinical
Assessment in Neuropsychiatry.49 The following validated
questionnaires were used by interviewers in studies of
personality disorder: the Diagnostic Interview
Schedule,5,7,9,24,27,31,34,35,37,45,56-59,61,62,65
Structured
Clinical
Interview
for
Diagnostic
and
Statistical
Manual Personality Disorders,19,43,60,69 Personality Disorder
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Abbreviated
reference
Detainees
Men
Prevalence
of illness
Prevalence
and 99% Cls
0
2
4
6
8
10
Percentage (%)
Roesch, 19955
Brooke, 19966
Teplin, 19947
Birmingham, 19968
Powell, 19979
Simpson, 199910
Davidson, 199511
10 smaller studies*
4 mixed studies23–26†
Subtotal
Sentenced
Sentenced
39/790 (5%)
35/750 (5%)
30/728 (4%)
24/569 (4%)
10/500 (2%)
16/441 (4%)
5/371 (1%)
60/1038 (6%)
60/2006 (3%)
279/7193 (4%)
69/1925 (3%)
34/1769 (2%)
26/750 (3%)
19/645 (3%)
33/514 (6%)
15/464 (3%)
17/379 (4%)
10/335 (3%)
80/1773 (5%)
309/8854 (3%)
Motiuk, 199227
Women
Detainees
51/1272 (4%)
Teplin, 199645
15/440 (3%)
7 smaller studies��
20/448 (5%)
6 mixed studies†¶
86/2160 (4%)
Subtotal
4/258 (2%)
Maden, 199453
29/546 (5%)
7 smaller studies||
33/804 (4%)
Subtotal
119/2964 (4%)
Total
Gunn, 199128
Powell, 19979
Simpson, 199910
DiCataldo, 199529
Hyde, 198730
Neighbors, 198731
Hurwitz, 198332
6/300 (2%)
Bluglass, 196633
14 smaller studies‡
Subtotal
588/16047 (4%)
Total
Figure 1: Prevalence of psychotic illnesses in 49 prison surveys
Size of black areas is proportional to number of prisoners. Open
diamonds=subtotals; shaded diamonds=grand totals. *References
12–18, 20–22. †Mixed studies=surveys that did not report results
separately for detainees and sentenced inmates. ‡ References 15, 20,
21, 34–44. ��References 11, 12, 46–50. ¶References 23–26, 51, 52.
||References 10, 20, 36, 39, 49, 50, 57.
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Questionnaire,10
and Personality Disorder Examination.67
There was generally no substantial heterogeneity within
groupings of studies with fewer than 250 prisoners, and
most studies reported insufficient detail to enable reliable
assessments of the extent of psychiatric comorbidity.
Psychotic illnesses
49 relevant surveys on psychotic illnesses included a total
of 19011 prisoners.5-18,20-53,57
Overall, 3·7% (95% CI
3·3–4·1, figure 1)—or 588 of 16 047 male prisoners—were
diagnosed with a psychotic illness. There was substantial
heterogeneity among these studies (��2
18=68, p<0·0001),
and only a small part of it was explained
by possible differences between studies that used validated
diagnostic instruments and those that did
not (3·5
vs 4·3%, respectively; ��2
1=6·2, p=0·01). There
were significant differences between studies done in the
USA and those done elsewhere (4·5
vs 3·3%, respectively;
��2
1=13·7, p=0·0002). Overall, 4·0% (3·2–5·1, figure 1)—
or 119 of 2964 female prisoners—were diagnosed with a
psychotic illness. There was no significant heterogeneity
between these studies (��2
4=7·1, p>0·10).
Major depression
We identified 31 relevant surveys that reported on
major depression including a total of 10 529
prisoners.5,6,9,10,12,13,20-22,24,29-31,34,35,37,39,42,43,45,47-50,52,54-57,71
Overall,
10% (9–11, figure 2)—or 743 of 7631 male prisoners—
were diagnosed with major depression. There was
substantial heterogeneity between these studies (��2
11=64,
p<0·0001), and this was only partly explained by
differences between detainees and sentenced prisoners
(9
vs 11%, respectively; ��2
1=10·0, p=0·002), between
studies in which interviews were done by psychiatrists or
not (7
vs 10%, respectively; ��2
1=14·2, p=0·0002), and
between larger and smaller studies (9
vs 11%,
respectively; ��2
1=6·2, p=0·008). Overall, 12% (11–14,
figure 2)—or 350 of 2898 female prisoners—were
diagnosed with major depression. Again, there was no
significant heterogeneity between these studies (��2
4=7·0,
p>0·10).
Personality disorder
We identified 28 relevant surveys that reported on
antisocial personality disorder including a total of 13 844
prisoners.5,7,9,10,12,19,21,27,31,34,35,37,43,45,56-65,67-70
Overall, 47%
(46–48, figure 3)—or 5113 of 10 797 male prisoners—
were diagnosed with antisocial personality disorder.
There was substantial heterogeneity between these
studies (��2
11=438, p<0·0001), and this was partly
explained by differences between studies done in the
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547
Figure 2: Prevalence of major depression in 31 prison surveys
Size of black areas is proportional to number of prisoners. Open
diamonds=subtotals; shaded diamonds=grand totals.*References 12, 13,
20–22. †Mixed studies=surveys that did not report results separately for
detainees and sentenced inmates. ‡References 20, 21, 34, 35, 37, 39,
42, 43, 54, 55. ��References 12, 47–50, 71. ¶References 10, 20, 39, 49,
50, 57.
Figure 3: Prevalence of antisocial personality disorder in
28 prison surveys
Size of black areas is proportional to number of prisoners. Open
diamonds=subtotals; shaded diamonds=grand totals. *References 12, 19,
21, 59, 60. †Mixed studies=surveys that did not report results separately
for detainees and sentenced inmates. ‡References 19, 21, 34. 35, 37,
60–66. ��References 12, 50, 67, 68. ¶References 24, 60, 69.
||References 24, 50, 60, 67–69.
Abbreviated
reference
Prevalence
of illness
Prevalence
and 99% Cls
0
4
8
12
16
20
Percentage (%)
Roesch, 19955
Brooke, 19966
Powell, 19979
Simpson, 199910
5 smaller studies*
1 mixed study24†
Subtotal
Sentenced
Sentenced
80/790 (10%)
73/750 (10%)
42/500 (8%)
45/441 (10%)
28/550 (5%)
44/604 (7%)
312/3635 (9%)
89/750 (12%)
38/645 (6%)
46/514 (9%)
35/464 (8%)
49/379 (13%)
174/1244 (14%)
431/3996 (11%)
Women
Detainees
174/1272 (14%)
Teplin, 199645
27/292 (9%)
6 smaller studies��
11/105 (10%)
2 mixed studies24,52†
212/1669 (13%)
Subtotal
87/805 (11%)
Jordan, 199656
51/424 (12%)
6 smaller studies¶
138/1229 (11%)
Subtotal
350/2898 (12%)
Total
Powell, 19979
Simpson, 199910
DiCataldo, 199529
Hyde, 198730
Neighbors, 198731
10 smaller studies‡
Subtotal
743/7631 (10%)
Total
Detainees
Men
Abbreviated
reference
Men
Detainees
Prevalence
of illness
Prevalence
and 99% Cls
0
20
40
60
80
Percentage (%)
Roesch, 19955
Teplin, 19947
Powell, 19979
Simpson, 199910
5 smaller studies*
1 mixed study24†
Subtotal
Sentenced
Sentenced
508/790 (64%)
344/728 (47%)
206/500 (41%)
181/405 (45%)
279/690 (40%)
191/604 (32%)
1709/3717 (46%)
1095/1925 (57%)
325/1149 (28%)
533/1035 (51%)
388/750 (52%)
243/592 (41%)
820/1629 (50%)
3404/7080 (48%)
Women
Detainees
174/1272 (14%)
Teplin, 199645
123/239 (51%)
4 smaller studies��
51/202 (25%)
3 mixed studies†¶
348/1713 (20%)
Subtotal
96/805 (12%)
Jordan, 199656
187/529 (35%)
6 smaller studies||
283/1334 (21%)
Subtotal
631/3047 (21%)
Total
Motiuk, 199227
Collins, 198858
Neighbors, 198731
Powell, 19979
Simpson, 199910
12 smaller studies‡
Subtotal
5113/10797 (47%)
Total
For personal use. Only reproduce with permission from The Lancet Publishing Group.
USA and those done elsewhere (43
vs 52%, respectively;
��2
1=93, p<0·0001). In a subsidiary analysis of the four
studies in which investigators reported on any
personality disorder in men, 65% (61–68)—or 989 of
1529 male prisoners—were diagnosed with some
personality disorder (including antisocial personality
disorder).10,60,64,66 Overall, 21% (19–23, figure 3)—or 631
of 3047 female prisoners—were diagnosed with
antisocial personality disorder. There was substantial
heterogeneity between these studies (��2
4=285,
p<0·0001), much of which was accounted for by
differences between larger and smaller studies (13
vs
37%, respectively; ��2
1=236, p<0·0001) and between
studies done before and after 1990 (39
vs 17%,
respectively; ��2
1=125, p<0·0001). There were also
differences between studies done in the USA and those
done elsewhere (18
vs 33%, respectively; ��2
1=64,
p<0·0001) and between studies in which interviews were
done by psychiatrists or not (42
vs 19%, respectively;
��2
1=67, p<0·0001). In a subsidiary analysis of the seven
studies in which investigators reported on any
personality disorder in women, 42% (38–45)—or 532 of
1281 female prisoners—were diagnosed with some
personality disorder (including antisocial personality
disorder).10,23,25,50,56,60,69
In the five studies in which
borderline personality disorder was reported, this
diagnosis was made in 25% (22–29)—or 307 of 1208—
female prisoners.10,50,56,60,69
Discussion
Our results suggest that typically about one in seven
prisoners in western countries have psychotic illnesses or
major depression (disorders that might be risk factors for
suicide),80
and about one in two male prisoners and
about one in five female prisoners have antisocial
personality disorders. These findings might have several
implications.
First, they indicate that the risks of having serious
psychiatric disorders are substantially higher in prisoners
than in the general population. Compared with the
general American24,81 or British82 population of similar age,
prisoners have about two-fold to four-fold excesses of
psychotic illnesses and major depression, and about a
ten-fold excess of antisocial personality disorder. More
research is needed to elucidate to what extent these
excesses are causes, consequences, or both, of
imprisonment (for example, the effect of substance abuse
on the prevalence of psychosis in prisoners is not known).
Second, our findings suggest that the burden of
treatable serious mental disorder in prisoners is
substantial. For example, application of these typical
prevalence rates to the prison population of the USA
suggests that a few hundred thousand prisoners might
have psychotic illnesses, major depression, or both—an
amount that is twice the number of patients in all
American psychiatric hospitals combined.83
Given the
limited resources of most prisons, however, it seems
doubtful whether most prisoners with these illnesses
receive appropriate care, such as that mandated by the
European Convention on Human Rights and other
international charters.84
Finally, although only about one-third of the world��s
prisoners live in western countries, about 99% of
available data from prison surveys are derived from
western populations, which underscores the need for
greater forensic psychiatric research in non-western
populations.
Even though our review was restricted to surveys done
in western countries, it included data gathered during
several decades from different prison populations in
12 countries. The prevalence of psychiatric disorders
might, therefore, have been expected to vary
substantially as a result of such differences, as well as
because of differences in medical and judicial systems
and in survey methods. But, although we noted that
estimates of prevalence of antisocial personality disorder
varied considerably, there was much less variation in
psychotic illnesses and major depression (perhaps, in
part, because of greater diagnostic consensus for these
two disorders). Despite the likelihood that there are
some real differences in the prevalence of psychiatric
disorders in different prison circumstances, our
summary estimates can help inform public policy and
public health initiatives, particularly in areas where
reliable local information is lacking.
Since a few million prisoners worldwide probably have
serious mental disorders (including several hundreds of
thousands with potentially treatable psychosis or
depression), the ability of prison health services in some
countries to address these problems may well require
review.
Contributors
S Fazel and J Danesh drafted the report and were involved in study
design, conduct, analysis, and interpretation.
Conflict of interest statement
None declared.
Acknowledgments
J Coid, M Fazel, R Huxley, C Meux, and G Whitlock gave helpful
comments. P Appleby plotted the figures. E Blaauw, S Doostdar,
M Grann, M Hughes, O Pickering, I Sieracka, B Vollm, and
Zhenming Chen assisted with translations. The following investigators
kindly provided additional data from their studies: S Agbahowe,
H Andersen, L Birmingham, R Bland, G Cote, M Davidson,
B Denton, R Ghubash, J Haapsalo, H Herrman, W Hurley, K Jordan,
M Joukamaa, T Maden, D Mohan, B Morentin, W Narrow,
K Northrup, T Powell, K Rasmussen, C Schoemaker, N Singleton,
C Smith, and G Walters. S Fazel was supported by a grant from the
Wellcome Trust. J Danesh was supported by the Frohlich Trust, a
Merton College fellowship, and the Raymond and Beverly Sackler
Research Award in the Medical Sciences.
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