Psychiatry Research 225 (2015) 522–530

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Mental disorders in Italian prisoners: Results of the REDiMe study Annalisa Macciò a,n, Francesca Romana Meloni a,n, Davide Sisti b, Marco Bruno Luigi Rocchi b, Donatella Rita Petretto a,c, Carmelo Masala a,c, Antonio Preti a,d,e,nn a

Department of Education, Psychology, Philosophy, University of Cagliari, via Is Mirrionis 1, 09123 Cagliari, Italy Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino, Italy c Associazione Centro Studi Ricerche ed Intervento “Neuropsicopedagogia” Onlus, via Atene 9, 09047 Selargius (Cagliari), Italy d Center for Consultation-Liaison Psychiatry and Psychosomatics, University Hospital, University of Cagliari, via Ospedale 117, 09124 Cagliari, Italy e Centro Medico Genneruxi, via Costantinopoli 42, 09129 Cagliari, Italy b

art ic l e i nf o

a b s t r a c t

Article history: Received 28 January 2014 Received in revised form 16 September 2014 Accepted 26 November 2014 Available online 6 December 2014

The goal of the study was to estimate the prevalence of current and lifetime mental disorders in a consecutive sample (n ¼300) of detainees and prison inmates held in an Italian prison and compare it with the prevalence observed in a sample randomized from the community (n ¼ 300) within the same age interval (18–55 years) and sex proportion of prisoners, and with a similar socio-economic status. Psychiatric disorders were identified with the Mini International Neuropsychiatric Interview (MINI). Current psychiatric disorders were present in 58.7% of prisoners and 8.7% of the comparison group. Lifetime psychiatric disorders were present in 88.7% of prisoners and 15.7% of the comparison group. Current anxiety disorders and current stress-related disorders were related to prisoners serving their first-ever prison sentence. A variable fraction of prisoners with an ongoing psychopathology is not diagnosed or does not receive proper treatment. The provision of effective treatment to prisoners with psychiatric disorders might have potentially substantial public health benefits. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Affective disorders Addiction (consumption/abuse/ dependence) Anxiety disorders Antisocial personality disorder Epidemiology Psychometry and assessments in psychiatry

1. Introduction Poor health is not uncommon among detainees and prison inmates (Braithwaite and Arriola, 2003; Esposito, 2010; Fazel and Baillargeon, 2011). Most of this health burden depends on mental disorders (Kanato, 2008). Prisoners have high rates of mental disorders compared to the general population (Fazel and Danesh, 2002; Fazel and Seewald, 2012). Higher prevalence of mental disorders in prisoners involves a higher care burden and accounts for the increased risk of suicide and self-harm of prisoners while in custody (Preti and Cascio, 2006; Fazel et al., 2008, 2011), and their increased risk of premature mortality (Kariminia et al., 2007; Merrall et al., 2010; Pratt et al., 2010), and re-offending after release (Baillargeon et al., 2009; Fazel and Yu, 2011; Hall et al., 2012). Anxiety and stress-related mental disorders could be more frequent in detainees and prison inmates serving their first prison sentence than in the general population, because of the stress of the

n

Corresponding authors. Tel.: þ 39 070 6757501. Corresponding author at: Centro Medico Genneruxi, via Costantinopoli 42, 09129 Cagliari, Italy. E-mail addresses: [email protected] (A. Macciò), [email protected] (F.R. Meloni), [email protected] (A. Preti). nn

http://dx.doi.org/10.1016/j.psychres.2014.11.053 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

arrest and its consequences (Andersen, 2004). However, among detainees and prison inmates, most of the health burden attributable to a mental disorder precedes incarceration.

1.1. Mental disorders and risk of re-incarceration Generally, people with a mental disorder are at a higher risk of arrest and imprisonment than people without mental disorders (Teplin, 1984, 1994), and therefore they tend to be overrepresented in samples of detainees and prison inmates (Markowitz, 2011). People with substance abuse in particular are reported to have a higher risk of re-incarceration, especially when they have a cooccurring severe mental illness (Baillargeon et al., 2010; Colins et al., 2011). This may depend on substance abusers' being more likely to engage in drug-defined and drug-related offences after release from prison. Shortage of community-based mental health programmes able and willing to provide treatment to people released from prison may contribute to the higher risk of re-incarceration for the subjects with substance abuse problems (Baillargeon et al., 2010). Also comorbidity with antisocial personality disorder may increase the chance of re-incarceration of substance abusers (Fridell et al., 2008; van Horn et al., 2012). Antisocial personality disorder might be a

A. Macciò et al. / Psychiatry Research 225 (2015) 522–530

factor involved in re-incarceration per se, particularly for violent crimes (Yu et al., 2012). Beside substance abuse and antisocial personality disorder, severe mental disorders, such as bipolar disorder and schizophrenia and related psychotic disorders, were associated to an enhanced risk of crime recidivism (Fazel and Yu, 2011; Fazel et al., 2010). These disorders are also associated to less efficient social network and social support (Gayer-Anderson and Morgan, 2013), which increases the chance of arrest and incarceration simply because the psychosis sufferer is less able to escape police and justice investigations. 1.2. Goals of this study Despite their importance for first-time prisoners, few data are available on anxiety disorders and stress-related mental disorders among prisoners, which might contribute to the enhanced risk of suicide and self-harm of this population (Thibodeau et al., 2013). Past studies investigating the prevalence of mental disorders in detainees and prison inmates often used historical data from past surveys to evaluate differences with the general population (Fazel and Danesh, 2002). This may cause mismatch due to different methodologies and socio-demographic differences between samples. Sometimes, past investigations used no controls at all (Piselli et al., 2009; Zoccali et al., 2008). In this study a validated standardized interview was used to assess psychiatric morbidity in a sample (n¼300) of detainees and prison inmates held in an Italian prison by comparison with a sample randomized from the community (n¼300) within the same age interval (18–55 years), sex proportion of prisoners, and with a similar socio-economic status. This interview, the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998, 1997), provides diagnoses according to the DSM-IV (Sheehan et al.,1998, 1997; American Psychiatric Association, 1994). The MINI covers a wide range of current and lifetime diagnoses, including mood, anxiety, substance abuse-related, psychotic and stress-related disorders. The main aims of this study were: 1) to investigate current and lifetime psychiatric disorders in the sample; 2) to evaluate whether prisoners with current psychiatric disorders differ from those without current psychiatric disorders, and in particular to assess whether stress-related disorders were more prevalent in newly admitted prisoners; 3) to assess whether mental disorders known to be associated to a higher risk of re-incarceration (i.e., substance abuse disorders and antisocial personality disorder) were related to a specific type of crime (crimes against property versus crimes against the person). We hypothesised that: a) current and lifetime psychiatric disorders were more prevalent in the prison sample than in the community one; b) stress-related disorders were more prevalent in newly admitted prisoners than in recidivists; c) substance abuse disorders were more likely to be related to crimes against property, while antisocial personality disorders were more likely to be associated to crimes against the person.

2. Methods The “REDiMe: Rilevazione Epidemiologica dei Disturbi Mentali e del rischio di suicidio nella popolazione carceraria (Epidemiological survey on mental disorders and risk of suicide in the prison population)” was financed in 2010 by the Regional Authority of Sardinia, Italy, to investigate the prevalence of mental disorders in detainees and prison inmates of the prison of Cagliari (called “Buoncammino”), in order to gather information about the main risk factors for suicide, the most important of which is known to be a mental disorder (Yoshimasu et al., 2008; Hawton and van Heeringen, 2009). The “Buoncammino” prison of Cagliari is not a high security prison, and it hosts both detainees who are awaiting trial (remand detainees) and detainees who are

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serving a sentence. During the period of the study, the prison of Cagliari housed 532 males and 25 females. About quarter (24%) of the detainees were awaiting trial (detainees on remand); the rest (76%) were serving sentences. The study was carried out between Autumn 2010 and Spring 2012. All the people held in this prison from September 2010 to March 2011 were included in the study, provided that they were able to correctly understand the Italian language and to give informed consent. Among prisoners, none refused or withdrew consent during the interview. Enrolment was limited to n¼ 300. The comparison group was extracted from the community. A group of 300 individuals was selected within the same age interval of prisoners (18–55 years) and sex proportion (90% males). A rural sample was considered most likely to be similar to the prison sample in relation to the socio-economic status. A comparison group was therefore selected from three rural areas of inner Sardinia (Barbagia, Mandrolisai, and Sarcidano). The comparison group was drawn from telephone directories by applying randomisation to the phone numbers. After being introduced to the families chosen by lot, the investigators asked if someone complying with the enrolment criteria was willing to be interviewed. After replacing those who refused (n¼30), or withdrew consent during the interview (n ¼15), the enrolment was limited to n ¼300. Sample size was calculated on the basis of a priori estimates of opportunity of enrolment and of power analysis. In Italy, the 12-month prevalence of any psychiatric disorder was estimated at 7.3% (95% CI: 6.0–8.6), while the lifetime prevalence of any psychiatric disorder was estimated at 18.3% (16.0–20.4) (de Girolamo et al., 2006). We determined that for a prevalence of psychiatric disorders in the community sample as high as 20%, a sample of 300 participants per group would be needed to achieve 80% power to detect a difference with OR (Odds ratio)¼ 1.5 in the prevalence of disorder between inmates and community participants, at a 2-sided significance level of 0.05 and allocation ratio of 1:1. Over the period of the study we had 250 days of access per year for the interviews (500 in the whole period of the study), but some days no detainee was available. Overall, we were able to enrol the minimum required sample size to detect the minimum statistically significant difference in the sample (OR ¼ 1.5). The appropriate institutional review boards (of the local University Department performing the study and of the involved prison) approved the study protocol, which complies with the provisions of the 1995 Declaration of Helsinki (as revised in Tokyo, 2004).

2.1. Procedure In prison, interviews were conducted in a private area away from the distraction of the activities undertaken in the unit. In the community, interviews were carried out in a quiet, private room in the interviewed participant's house. Interviewers were licensed psychologists trained by a certified instructor at the University of Modena to administer the Structured Clinical Interview for DSM-IV, both SCID-I and II (Lobbestael et al., 2011). Interviewers received additional training to administer the MINI version 5 by qualified instructors of the University of Cagliari. After signing the informed consent form, each participant was administered a detailed interview including a section on background information, a section on criminal history, a section on psychosocial and environmental problems, and the MINI.

2.2. Measures The section on background information inquired about sex, age, nationality, civil status, occupational status (for prisoners: before the current incarceration), educational attainment of the subject and of his/her parents. The section on criminal history inquired about judicial status (whether the subject had ever been imprisoned); reason of incarceration based on the type of crime leading to the current incarceration; type of crime leading to the most recent past incarceration, if any; number of past sentences; duration of past incarcerations; and duration of the latest incarceration. The section on psychosocial and environmental problems inquired about problems with the main supportive group (the family: e.g., death of a close relative, separation or divorce, maltreatment or neglect, harsh discipline, conflicts with family members); problems within the social environment (e.g., death of a friend, inadequate social support, difficulties with acculturation, discrimination or stigmatisation); problems with school (including illiteracy and learning disabilities); problems with housing or living arrangement (being homeless, inadequate housing, dangerous neighbourhood); financial problems (including extreme poverty); and problems with access to health care services (including excessive distance from health care services and/or lack of transportation). The MINI is a structured interview that produces diagnoses for Axis I (psychiatric) and Axis II (personality) disorders according to the DSM-IV (Sheehan et al., 1998, 1997; American Psychiatric Association, 1994). The validity, reliability (interrater and test–retest), sensitivity and specificity indices of the MINI were proved to be good or very good (Sheehan et al., 1998; Amorim et al., 1998; Lecrubier et al., 1997). The MINI has already been used in prison samples, with satisfying results (Black et al., 2004; Gunter et al., 2008).

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2.3. Statistical analyses All data were coded and analysed using the Statistical Package for the Social Sciences (SPSS, Version 20.0 for Windows). All tests were two-tailed, with po0.05. Comparison of continuous data was by t-test or Mann–Whitney U-test (for non-normally distributed data). Categorical data were analysed in inter-group comparisons with χ2, with Yates' continuity correction when appropriate. The sample contained a large male prevalence and some age difference between the prisoners and the comparison sample (see Section 3). The role of possible confounders (e.g., sex, age, socio-economic status) was assessed using multivariable logistic regression. In the analysis of psychiatric disorders by judicial status (prisoners¼ 1 versus the comparison group¼ 0), the following variables were entered: sex (males¼ 1; females¼ 0); age (younger than 40 years old¼0; 40 years old and older¼ 1); highest parental educational attainment (as a proxy of the participants' socio-economic status: lower than compulsory school¼ 1; high school or higher¼ 0); and the targeted outcome (having a mental disorder in the major classes: present¼ 1; absent¼0). Participants' nationality, education, civil and employment status were not entered in the logistic regression for the following reasons: differences by nationality concerned a scant number of cases, unlikely to be relevant; differences by education were considered potentially related to the circumstances leading to the incarceration (e.g., substance abuse impacting on both educational attainment and risk of incarceration); differences by civil and employment status were considered a probable reflection of the judicial status. Since standard errors of parameters estimated by maximum likelihood method tend to be biased when one of the cells under comparison equals zero, the penalised maximum likelihood was used in estimating the fit of the logistic regression according to Firth (1993). Odds ratio (OR), with 95% confidence interval, the estimated z's p, and the variance explained by the model were reported for judicial status, taking into account sex, age and socio-economic status. Variance explained by the model (pseudo-R2) was calculated on the basis of Tjur's coefficient of discrimination (D), which is the difference in the average of the event probabilities between the groups of observations with observed events and nonevents (Tjur, 2009). The logistic regression and the associated analyses were carried out with the packages brglm (Kosmidis, 2013) and binomTools (Christensen and Hansen, 2011) running in R version 3.0.2 (R Core Team, 2013). After establishing that current psychiatric disorders were more prevalent in prisoners than in the comparison group, we compared inmates with and without current psychiatric disorders to evaluate whether they differed on some of the investigated characteristics. Multivariable logistic regression was used to investigate the relationship of first incarceration ever to current psychiatric disorders (see Section 3.4). In this analysis, first incarceration ever¼ 1; one or more past incarcerations ¼0. The following predictor variables were entered: any current mood disorder; any current anxiety disorder; any current substance use disorder; any current psychotic disorder; any current stress related disorder. They were entered simultaneously, since co-occurrence of disorders was frequent in prisoners, according to these codes: subject diagnosed with the disorder¼1, not diagnosed with the disorder¼ 0. Sex, age and socio-economic status were entered as before. The link between the number of past incarcerations (as a proxy for recidivism) and psychiatric disorders was assessed with Spearman's rho correlation coefficients. Multivariable logistic regression was then used to test the association of lifetime psychiatric disorders with crimes against property and crimes against the person (see Section 3.5). In this analysis, crime against the person was coded ¼1, crime against property was coded ¼ 0. As above, the following predictor variables were entered simultaneously: any lifetime mood disorder; any lifetime anxiety disorder; any lifetime substance use disorder; any lifetime psychotic disorder; and antisocial personality disorder (subject diagnosed with the disorder¼ 1; not diagnosed with the disorder¼ 0). Sex, age and socio-economic status were entered as above. Since there were no zero cells in the model, the maximum likelihood estimation was used in these analyses. Adjusted odds ratio (OR), with 95% confidence interval, and estimated Wald test's p were reported for each diagnosis. The variance explained by the model was estimated on the basis of Tjur's coefficient of discrimination (D), as above.

education, and their parents were more likely than the parents of the comparison group members not to have completed compulsory school (Table 1). Prisoners were less likely to be married or have a stable relationship with a partner than those in the comparison group. Overall, prisoners were statistically less likely to declare they had been in paid employment before the incarceration than those in the comparison group. None of the controls reported a current or past incarceration. Prisoners reported a higher proportion of psychosocial and environmental problems in the period before the incarceration than the comparison group (Table 1). 3.1. Current psychiatric disorders of prisoners and controls Current psychiatric disorders were present in 58.7% of prisoners and 8.7% of the comparison group. In both prisoners and the comparison group sex, age, and socio-economic status (as measured by highest parental educational attainment) were not related to the presence of current psychiatric disorders. Current psychiatric disorders were more prevalent in prisoners than in the comparison group for all the investigated categories but psychotic disorders (Table 2). Co-morbidity was substantial in prisoners but not in controls. Up to 21% of prisoners had two or more co-morbid disorders. Overall, variance explained by the multivariable logistic regression (as measured by Tjur's coefficient of discrimination) for the presence of any current psychiatric disorder in the sample was 28.1%, and entirely attributable to the judicial status (i.e., being in prison or not), since sex, age and socio-economic status were not statistically related to the presence of any current psychiatric disorder. 3.2. Lifetime psychiatric disorders Among prisoners, 266 (88.7%) were diagnosed with one or more lifetime psychiatric disorders. Lifetime psychiatric disorders were present in 47 members (15.7%) of the comparison group. About 20% of prisoners and none in the comparison group met the criteria for the diagnosis of antisocial personality disorder. In both prisoners and the comparison group sex, age, and socioeconomic status (as measured by highest parental education) were not related to the presence of lifetime psychiatric disorders. Lifetime psychiatric disorders were more prevalent in prisoners than in the comparison group for all investigated categories but psychotic disorders (Table 3). Variance explained by the multivariable logistic regression (as measured by Tjur's coefficient of discrimination) for the presence of any lifetime psychiatric disorder in the sample was 53.4%, and it was 39.9% for substance use disorders; it was entirely attributable to judicial status (i.e., being in prison or not), since sex, age and socioeconomic status were not statistically related to the presence of any lifetime psychiatric disorder. Table 4.

3. Results

3.3. Comparisons of prisoners with and without current psychiatric disorders

The sample included male participants mostly, with no gender difference by group. Prisoners were on average older than the members of the comparison group (Table 1). The sample of prisoners included 20 non-Italian subjects who were able to correctly understand the Italian language. All the members of the comparison group were born and raised in Italy. Prisoners were more likely than the comparison group to have low

Prisoners with a current psychiatric disorder did not differ from prisoners without a current psychiatric disorder regarding sociodemographic variables and criminal history. They had an, obvious, greater chance of receiving the diagnosis of a lifetime psychiatric disorder. Differences were statistically significant except for psychoses (merely because of the scarcity of cases) and antisocial personality disorder. The major difference concerned anxiety disorders.

A. Macciò et al. / Psychiatry Research 225 (2015) 522–530

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Table 1 General charateristics of prisoners (n ¼300) and the comparison group (n ¼300). Variable

Prisoners

Sex Males Females Age Mean (S.D.) Nationality Italian European Union (EU) Non-EU Civil status Married or with a partner Education Lower than compulsory school Compulsory school High school or higher Highest parental educational attainment Lower than compulsory school Occupation In stable or part-time paid employment Undemployed, including students and housewives Retired or disability pension Illegal activity Problems and difficulties Problems with the main supportive group Problems within the social environment Problems with school Problems with housing or living arrangement Financial problems Problems with access to healthcare services

275 (91.7%) 25 (8.3%)

Comparison group

274 (91.3%) 26 (8.7%)

Univariate analysis

χ2Yates ¼ 0.00, d.f. ¼ 1, p ¼ 1.00

37.9 (8.4)

33.3 (8.1)

t¼  6.85, d.f. ¼598, po 0.0001

280 (93.4%) 4 (1.3%) 16 (5.3%)

300 (100%)

χ2 ¼20.7, d.f. ¼2, po 0.0001

94 (31.3%)

136 (45.3%)

χ2Yates ¼ 11.58, d.f. ¼1, p ¼0.001

67 (22.3%) 202 (67.3%) 31 (10.3%)

9 (3.0%) 245 (81.7%) 46 (15.3%)

χ2 ¼6.22, d.f. ¼ 2, p ¼ 0.044

174 (58.0%)

124 (41.3%)

χ2Yates ¼ 16.00, d.f. ¼ 1, p o 0.0001

146 129 7 18

(48.7%) (43.0%) (2.3%) (6.0%)

250 49 1 0

(83.3%) (16.3%) (0.3%) (0%)

χ2 ¼85.76, d.f. ¼3, p o 0.0001

198 280 263 178 276 20

(66.0%) (93.3%) (87.7%) (59.3%) (92.0%) (6.7%)

65 31 151 8 228 5

(21.7%) (10.3%) (50.3%) (2.7%) (76.0%) (1.7%)

χ2Yates ¼ 117.9, d.f. ¼1, p o0.0001 χ2Yates ¼ 410.5, d.f. ¼ 1, p o 0.0001 χ2Yates ¼ 96.00, d.f. ¼ 1, p o 0.0001 χ2Yates ¼ 222.5, d.f. ¼1, p o0.0001 χ2Yates ¼ 27.39, d.f. ¼ 1, po 0.0001 χ2Yates ¼ 8.18, d.f. ¼1, p¼ 0.004

Table 2 Comparisons of current psychiatric disorders between prisoners (n ¼300) and the comparison group (n¼ 300). Variable

Prisoners

Comparison group

Univariate analyses

Odds ratio (95% CI)

103.3 (14.6–inf.) p o 0.0001 D ¼9.1%

Mood disorders Any

45 (15.0%)

0 (0%)

χ2Yates ¼ 46.51, d.f. ¼1, p o0.0001

Anxiety disorders Any

65 (21.7%)

5 (1.7%)

χ2Yates ¼ 56.29, d.f. ¼1, p o0.0001

13.7 (6.1–44.2) p o 0.0001 D ¼11.3%

108 (36.0%)

21 (7.0%)

χ2Yates ¼ 73.03, d.f. ¼ 1, p o 0.0001

7.4 (4.5–13.1) p o 0.0001 D ¼13.5%

4 (1.3%)

0 (0%)

χ2Yates ¼ 2.26, d.f. ¼1, p ¼0.132

7.3 (0.7–inf.) p ¼0.14 D ¼3.4%

41 (13.7%)

0 (0%)

χ2Yates ¼ 41.88, d.f. ¼1, p o0.0001

176 (58.7%)

26 (8.7%)

χ2Yates ¼ 165.6, d.f. ¼ 1, p o 0.0001

2þcurrent disorders

64 (21.3%)

0 (0%)

χ2Yates ¼ 69.42, d.f. ¼1, p o0.0001

3þcurrent disorders

23 (7.7%)

0 (0%)

χ2Yates ¼ 21.88, d.f. ¼ 1, p o 0.0001

105.1 (14.7–inf.) p o 0.0001 D ¼9.9% 13.7 (8.7–23.1) p o 0.0001 D ¼28.1% 164.0 (23.5–inf.) p o 0.0001 D ¼12.2% 57.1 (7.6–inf.) p o 0.001 D ¼8.0%

Substance use disorders Any

Psychotic disorders Any

Stress related disorders Any

Any current disorder

3.4. The relationship of first incarceration ever to current psychiatric disorders Among prisoners, 85 (28.3%) were serving their first-ever prison sentence. In the multivariable logistic regression model, current anxiety disorders (2.58; 1.15–5.08; p¼0.021) and current stress-related

disorders (3.15; 1.36–7.31; p¼0.007) were positively and independently related to the prisoner's being in jail for the first time ever; current substance use disorders were negatively related to the prisoner's being in jail for the first time (0.19; 0.09–0.40; po0.001), while a diagnosis of current mood disorder (0.81; 0.32–2.05; p¼0.66) or current psychosis (0.87; 0.08–9.04; p¼0.90) was not related to the

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Table 3 Comparisons of lifetime psychiatric disorders between prisoners (n¼ 300) and the comparison group (n¼ 300). Variable

Prisoners

Comparison group

Univariate analyses

Odds ratio (95% CI)

Mood disorders Any

74 (24.7%)

7 (2.3%)

χ2Yates ¼ 62.17, d.f. ¼ 1, p o 0.0001

12.0 (5.8–31.6) p o0.0001 D ¼11.4%

Anxiety disorders Any

67 (22.3%)

10 (3.3%)

χ2Yates ¼ 46.72, d.f. ¼1, p o0.0001

7.2 (3.8–16.1) p o0.0001 D ¼9.7%

30 (10.0%)

χ2Yates ¼ 229.1, d.f. ¼1, p o 0.0001

22.0 (14.1–36.9) p o0.0001 D ¼39.9% 12.6 (1.4–inf.) p ¼0.062 D ¼2.1% 175.9 (25.1–inf.) p o0.0001 D ¼14.5% 39.9 (25.0–69.8) p o0.0001 D ¼53.4% 448.6 (64.9– inf.) p o0.0001 D ¼28.3% 47.8 (6.5–inf.) p o0.01 D ¼5.7% 10.2 (1.1–inf.) p ¼0.083 D ¼11.4%

Substance use disorders Any

Psychotic disorders Any

Antisocial personality disorder

Any lifetime disorder

213 (71.0%)

6 (2.0%)

0 (0%)

χ2Yates ¼ 4.21, d.f. ¼1, p¼ 0.040

62 (20.7%)

0 (0%)

χ2Yates ¼ 66.93, d.f. ¼ 1, p o 0.0001

266 (88.7%)

47 (15.7%)

χ2Yates ¼ 317.4, d.f. ¼1, po 0.0001

2 þcurrent disorders

127 (42.3%)

0 (0%)

χ2Yates ¼ 158.5, d.f. ¼1, p o0.0001

3 þcurrent disorders

24 (8.0%)

0 (0%)

χ2Yates ¼ 22.96, d.f. ¼ 1, p o 0.0001

4 þlifetime disorders

5 (1.7%)

0 (0%)

χ2Yates ¼ 3.22, d.f. ¼ 1, p ¼ 0.072

condition of first-time inmate, as were no sex, age, and socio-economic status. Variance explained by the multivariable logistic regression (as measured by Tjur's coefficient of discrimination) was 19.0%. 3.5. The relationship of criminal history to current and lifetime psychiatric disorders The number of past sentences varied from none to 20 (median¼2). Lifetime substance use disorders (rho¼ 0.53, po0.0001) and antisocial personality disorders (Spearman' rho¼0.25, po0.0001) were positively related to past sentences; lifetime mood disorders (rho¼  0.21, po0.0001) and lifetime anxiety disorders (rho¼  0.27, po0.0001) were negatively related to past sentences. Psychotic disorders showed no link with past sentences (rho¼  0.06). For 179 prisoners (59.7%) the crime leading to the most recent past incarceration was against property, while for 121 (40.3%) it was a crime against the person. In the multivariable logistic regression model, lifetime substance use disorders were negatively related to the current reason of incarceration being a crime against the person (0.42; 0.24–0.74; p¼ 0.0029), while antisocial personality disorder was positively related to it (2.61; 1.43–4.77; p¼0.0018). Lifetime mood disorders (0.81; 0.43– 1.56; p¼0.54), anxiety disorders (0.73; 0.36–1.46; p¼ 0.37), and psychoses (0.72; 0.12–4.24; p¼0.71) were not related to the current reason of incarcerations' being a crime against the person. Variance explained by the multivariable logistic regression (as measured by Tjur's coefficient of discrimination) was 7.0%.

4. Discussion This study was based on the standardized direct interview of the participants. We found that prisoners had a statistically higher prevalence of current and lifetime psychiatric disorders than a

comparison sample drawn from the community for all the investigated classes of diagnosis and not merely for severe mental disorders; this was likely to increase the risk of offending. As expected, current anxiety disorders and current stress-related disorders were positively related to the prisoner's serving their firstever prison sentence, confirming that the first incarceration is a stressful event producing intense psychological distress. Prisoners with a current psychiatric disorder did not differ from prisoners without a current psychiatric disorder as far as sociodemographic variables and criminal history were concerned. However, those who were incarcerated for a crime against property were more likely to have been diagnosed with a substance use disorder, while those who were incarcerated for a crime against a person were more likely to have been diagnosed with antisocial personality disorder.

4.1. Prisoners' current and lifetime psychiatric disorders and recidivism The judicial status (being in prison or not) impacted on the distribution of lifetime psychiatric disorder in the sample, accounting for up to 53.4% of the variance explained by the multivariable logistic regression model; most of the explained variance (39.9%) was attributable to substance use disorders. Substance use disorders are a factor increasing the chance of incarceration, since the current Italian laws punish possession of illicit drugs per se. Moreover, substance use disorders were related to offending and re-offending, particularly for crimes against property. The scarcity of community-based mental health programmes able and willing to provide treatment to people released from prison has been suggested to contribute to the risk of re-incarceration in substance abusers (Baillargeon et al., 2010). Substance use disorders also negatively impact the chance of having a paid job, thus hampering the financial independence of those affected by them (Piselli et al., 2009).

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Table 4 Comparisons of prisoners with and without current psychiatric disorders. Variable

Sex Males Age Mean (S.D.) Nationality Non-Italian Civil status Married or with a partner Education Lower than compulsory school Highest parental educational attainment Lower than compulsory school Occupation In stable or part-time paid employment Undemployed, including students and housewives Retired or disability pension Illegal activity Criminal record Crime against property First incarceration ever Crime against the person Any violent crime in the past Number of past incarcerations Duration of past incarceration (years) Duration of current incarceration (years) Lifetime mood disorders Any Lifetime anxiety disorders Any Lifetime substance use disorders Any Lifetime psychotic disorders Any Antisocial personality disorder Any lifetime disorder 2þlifetime disorders 3þlifetime disorders 4þlifetime disorders

Prisoners with a mental disorder n¼ 176

165 (93.8%) 38.6 (8.1)

Prisoners without a mental disorder n¼ 124

Univariate analyses

115 (92.7%)

χ2Yates ¼0.01, d.f. ¼ 1, p ¼0.913

37.0 (8.7)

11 (6.2%)

9 (7.3%)

χ2Yates ¼0.01, d.f. ¼ 1, p ¼0.913

52 (29.5%)

42 (33.9%)

χ2Yates ¼0.44, d.f. ¼1, p ¼0.504

42 (23.9%)

25 (20.2%)

χ2Yates ¼0.38, d.f. ¼ 1, p ¼ 0.537

105 (59.7%)

69 (55.6%)

χ2Yates ¼0.33, d.f. ¼ 1, p ¼ 0.565

83 76 5 12

(47.2%) (43.2%) (2.8%) (6.8%)

63 53 2 6

(50.8%) (42.7%) (1.6%) (4.8%)

χ2 ¼ 1.14, d.f. ¼3, p ¼ 0.758

108 51 68 52 3.3 6.6 1.9

(61.4%) (29.0%) (38.6%) (29.5%) (3.5) (7.1) (2.7)

71 34 53 38 2.3 5.7 2.2

(57.3%) (27.4%) (42.7%) (30.6%) (2.6) (5.6) (2.9)

χ2Yates ¼0.35, d.f. ¼ 1, p ¼ 0.552 χ2Yates ¼0.02, d.f. ¼ 1, p ¼ 0.869 χ2Yates ¼0.35, d.f. ¼ 1, p ¼ 0.552 χ2Yates ¼0.01, d.f. ¼ 1, p ¼0.939 M–W: z ¼  1.9, p¼ 0.053 M–W: z ¼  0.29, p ¼ 0.767 M–W: z ¼  0.61, p ¼0.535 χ2Yates ¼10.80, d.f. ¼ 1, p ¼ 0.001

56 (31.8%)

18 (14.5%)

66 (37.5%)

1 (0.8%)

133 (75.6%)

80 (64.5%)

χ2Yates ¼3.79, d.f. ¼ 1, p ¼ 0.051

5 35 172 96 22 5

1 27 94 31 2 0

χ2Yates ¼0.67, d.f. ¼ 1, p ¼ 0.412 χ2Yates ¼0.06, d.f. ¼1, p¼ 0.800 χ2Yates ¼32.63, d.f. ¼ 1, p o 0.0001 χ2Yates ¼24.81, d.f. ¼ 1, p o 0.0001 χ2Yates ¼10.28, d.f. ¼ 1, p ¼ 0.001 χ2Yates ¼2.06, d.f. ¼1, p¼ 0.151

(2.8%) (19.9%) (97.7%) (54.5%) (12.5%) (2.8%)

Poverty is a factor related to committing crimes against property (Blau and Blau, 1982; Hooghe et al., 2011; Valdez et al. 2007). Antisocial personality disorder was related to offending and reoffending, too, particularly as far as violent crimes were concerned. In this case the disorder acts specifically as a factor increasing the risk of incarceration because it directly influences a person's behaviour (Yu et al., 2012; Hare, 1983; Pondé et al., 2014). However, people with antisocial personality disorder are statistically more likely to have a lifetime diagnosis of substance use disorder (Fenton et al., 2012; Glenn et al., 2013), which is per se a factor increasing the chance of incarceration (Baillargeon et al., 2010). Lifetime mood disorders and lifetime anxiety disorders were negatively related to the number of past sentences, and our proxy measure of re-offending. With the exception of bipolar disorder (Fazel et al., 2010), there is no evidence that mood or anxiety disorders are a factor involved in the risk of offending; in fact, they might be protective against this risk. Moreover, people with mood or anxiety disorders have a greater chance of receiving proper treatment than those with substance use disorders (Piselli et al., 2009), psychoses (Bradford et al., 2008), or antisocial personality disorder (National Collaborating Centre for Mental Health (UK), 2010). Available treatments for mood and anxiety disorders are also more effective than those available for the treatment of substance use disorders, psychoses or antisocial personality disorder (National Collaborating Centre for Mental Health (UK), 2010; Najt et al., 2011; Nasrallah et al., 2008). If any risk of offending is implied in having a mood or anxiety disorder, this risk might be reduced due to better access to, and

(0.8%) (21.8%) (75.8%) (25.0%) (1.6%) (0%)

χ2Yates ¼54.37, d.f. ¼ 1, p o 0.0001

effectiveness of treatment. In addition, current anxiety disorders and current stress-related disorders were related to the prisoner's serving the first-ever prison sentence, suggesting that some psychiatric disorders are a reaction to incarceration (Andersen, 2004), rather than a factor increasing its occurrence. 4.2. Strengths and limitations The study is based on a standardized assessment administered via the direct interview of the candidate. The interview used in the study, the MINI, was proved valid in both the general community (Faravelli et al., 2004), and the prison setting (Markowitz, 2011; Falissard et al., 2006). This tool has a relatively brief administration time, thus it is acceptable to participants (Sheehan et al., 1997; Amorim et al., 1998; Lecrubier et al., 1997). However, the motivation to provide frank answers to the queries might have differed between prisoners and controls. Many prisoners had long-standing psychiatric disorders and were accustomed to clinical evaluation. Many prisoners had substance use disorders, and had experienced the usefulness of revealing psychiatric symptoms to obtain treatment and other advantages, such as house arrest or community treatment order. For these reasons prisoners might have been more willing to disclose information on their psychiatric status than community controls, who might have concealed some information for fear of stigmatisation, which is felt more strongly by males (Holzinger et al., 2012). Despite advances in the effectiveness of the treatment of mental disorders, attitudes towards people with mental disorders have not changed

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in Western countries (Schomerus et al., 2012). To favour enrolment in the study, the investigators always tried to be introduced by a third person to the family chosen by the lot through the randomisation procedure. Participants might have inferred that some information could be disclosed to these third parties. It should be noted that prisoners are vulnerable subjects, so they might have felt pressured into participating in the study, as if they could not refuse to. Controls from the community certainly felt themselves freer to refuse to take part in the study. Despite these limitations, the findings concerning the comparison group were consistent with past investigations. In particular, both current and lifetime psychiatric disorders in the community-based group were strictly comparable to the findings of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project (Alonso et al., 2004). In this study, the current prevalence of any psychiatric disorder in the comparison sample was 8.7% as against 7.3% (95%CI: 6.0–8.6) in the Italian section of the ESEMeD study (de Girolamo et al., 2006). The lifetime prevalence of any psychiatric disorder was 15.7%, while the lifetime prevalence of any psychiatric disorder was estimated at 18.3% (16.0–20.4) in the Italian ESEMeD study (de Girolamo et al., 2006). Our figures perfectly matched also the lifetime prevalence of psychiatric disorders observed in male participants in a past Italian community sample investigated with the MINI (Faravelli et al., 2004). All these findings support the estimated higher prevalence of both current and lifetime psychiatric disorders in our sample of detainees and prison inmates. Additional limitations should be taken into account. Prisoners were on an average older and had a lower socio-economic status than the people in the comparison group. In past studies low socioeconomic status was related to an increased prevalence of psychological distress, and to a more chronic course of mental disorders (Kessler and Neighbors, 1986; Fryers et al., 2003). Nevertheless, sociodemographic variables were not related to the presence of current or lifetime psychiatric disorders in the sample. Other limitations of the study were: the MINI investigating antisocial personality disorder only and no other personality disorder; no independent sources about problems and difficulties were experienced by the participants. 4.3. Comparison with past studies All the prisoners were from a single prison establishment, so the generalisation of the findings to the entire country should be made with caution. However, findings are consistent with past studies carried out in Perugia (central Italy) and Messina (Sicily, the major island of Italy). In a study on 302 male detainees who were investigated 7 days after their imprisonment in Perugia, Piselli et al. (2009) found that 54.3% had a current psychiatric disorder. In a study on 142 prison inmates of the Casa Circondariale (District Penitentiary) of Messina who were evaluated with the Structured Clinical Interview for DSM-III-R Non-Patient Version (SCID I and SCID II), Zoccali et al. (2008) found that 85.2% had a lifetime psychiatric disorder, and 51.4% had requested psychiatric treatment during detention. Some differences were found with studies based on the MINI and conducted outside Italy, in countries with different sociocultural, judicial and correctional systems. A study carried out in France in 2002 and involving 799 prisoners from 20 randomly selected metropolitan French prisons, found that 28.6% met the criteria for a MINI mood disorder, 24% for a MINI anxiety disorder, 17.3% for a MINI psychotic disorder, and only 14.1% for a MINI substance-related disorder (Falissard et al., 2006). A study on 80 randomly selected remanded and sentenced prisoners in a Greek prison found that 78.7% had a mental disorder, and 37.5% had an antisocial personality disorder (Fotiadou et al., 2006). By using the MINI on 191 randomly selected prisoners admitted to the general

wards during the first weeks of their incarceration in the Dutch prison system, Bulten et al. (2009) found that 57% had one or more Axis I disorders, and 7 out of 10 of those affected by a psychopathology did not receive professional help. In the US, Black et al. (2004) found that 81% of prisoners were positive for a lifetime MINI disorder in their random sample of 67 offenders from the Iowa Department of Corrections, and 19% had a lifetime antisocial personality disorder. In a subsequent investigation including 320 randomly selected men and women detained in the Iowa prison system, Gunter et al. (2008) found that 90% were positive for a MINI-Plus disorder and 35% had a lifetime antisocial personality disorder. A study on 530 remanded and sentenced male prisoners from two New Zealand sites found that 51% met MINI criteria for one or more targeted major mental disorders (Evans et al., 2010). A study on 497 prisoners from closed and semi-open Brazilian prisons found that 17–18% (according to the setting) had a mood disorder, 7–4% had an anxiety disorder, 24–27% had an antisocial personality disorder, and 27–35% had alcohol or drug addiction (Pondé et al., 2011). A study on 193 convicts from a prison in Durban, South Africa, found that 55.4% had a MINI Axis I disorder, the commonest disorder being substance and alcohol use disorder (42%) and antisocial personality disorder (46.1%); the majority of the prisoners with psychopathology were untreated (Naidoo and Mkize, 2012). Differences in the prison and judicial system (for example, in the laws concerning the use of hashish/marijuana or in the laws that regulate capacity for discernment in people with psychosis), and in the prevalence of mental disorders across countries probably contribute to explaining some discrepancies between our study and past studies applying the MINI to the prison population. In a recent meta-analysis (Fazel and Seewald, 2012), rates of psychoses were estimated at 3.6% in male and 3.9% in female prisoners. In this study, a diagnosis of current psychosis was found in 1.3%, and lifetime psychosis was found in 2.0% of prisoners. Diagnosis of antisocial personality disorder was considerably less frequent than in past studies: 20.7%, against an estimated prevalence of 47% (Fazel and Danesh, 2002). The MINI might be more conservative in rating the presence of antisocial personality disorder than other diagnostic tools (e.g., SCID); moreover, in the prison of Cagliari violent prisoners with severe problems in adapting to the prison environment are transferred elsewhere. However, prevalence of antisocial personality disorder similar to the evidence found in this study had been reported in the past (Black et al., 2004; Coolidge et al., 2011). Overall, studies from other European countries found a similar prevalence of psychiatric disorders in prisoners to the prevalence reported in this study. For example, a cross-sectional survey carried out with the SCID on 707 Spanish male prisoners found that 84.4% had a lifetime psychiatric disorder, with substance use disorder being the most frequent diagnosis (Vicens et al., 2011). Studies from elsewhere reported different rates than in Europe. A study carried out in Australia and involving 916 prisoners admitted in 2001 found that the 12-month prevalence of any psychiatric disorder in the last year was 80% in prisoners, a higher rate than the 31% was found in the community during the 1997 Australian National Survey of Mental Health and Wellbeing (n¼8168) (Butler et al., 2006). Conversely, cross-sectional studies from Brazil and India found higher rates of substance use disorders and lower rates of psychoses or mood disorders than similar studies carried out in Western countries (Pondé et al., 2011; Goyal et al., 2011). In all countries, prisoners had a higher prevalence of psychiatric disorders than the expected prevalence in the general population. 4.4. Implications of the findings In this sample 58.7% of prisoners had a current psychiatric disorder. This causes a substantial burden of care. Given the limited

A. Macciò et al. / Psychiatry Research 225 (2015) 522–530

resources available to most prisons, since current government policies are further reducing resources to save on costs, there is a considerable risk that many prisoners might not receive the appropriate treatment they need. There is some evidence that mental health inreach teams identify and treat only a small proportion of prisoners with mental disorders (Bulten et al., 2009; Naidoo and Mkize, 2012; Senior et al., 2013). It is imperative to improve the screening procedures of prisoners in need of care and to promote effective care pathways to ensure appropriate access to treatment. Indeed, many diagnosable psychiatric disorders among prisoners can be treated. There is an evidence that treating substance abuse in patients with severe psychiatric disorders reduces the impact of symptoms and the burden of disability (Mullin et al., 2012). Some evidence suggests that drug treatment can lead to modest, but tangible reductions in criminal offending for drug-using criminal offenders (Nordstrom and Williams, 2012). There is also evidence that early treatment of first episode psychosis could reduce the incidence of severe violence committed by patients with psychosis (Nielssen and Large, 2010; Yee et al., 2011). This benefit might extend to all diagnosable psychiatric disorders, and it might reduce the associated risk of suicide and self-harm reported in people with severe mental disorders (Nielssen et al., 2012), and in prisoners (Fazel et al., 2008, 2011). Targeted intervention should be aimed at improving patients' adherence to treatment and at treating co-morbid substance abuse. Continuity of care should be assured to those who are about to be released (Baillargeon et al., 2009). Barriers to treatment of mental disorder in jail should be properly addressed, among others: confidentiality issues (and the need to share information for effective treatment); the frequent lack of case management; treatment providers' reluctance to work in jail; time constraints (since offenders are confined to jail for uncertain lengths of time); lack of funding for services; profound negative public perception of jail (which may negatively influence attitudes of jail staff about treatment, particularly as far as substance-related disorders are concerned).

4.5. Pathways for future research Like past studies on the topic, this was a cross-sectional investigation. Longitudinal studies are necessary to evaluate whether treatment can reduce the risk of re-offending in the population of prisoners with psychiatric disorders. New models of service delivery should also be investigated in the prison setting, to identify those with the greatest cost-saving effectiveness. In past studies, a relevant fraction of prisoners with an ongoing psychopathology was not detected or did not receive proper treatment (Bulten et al., 2009; Naidoo and Mkize, 2012; Senior et al., 2013). The provision of effective treatment to the prisoners with psychiatric disorders might have potentially substantial public health benefits, and possibly reduce re-offending rates.

Funding Dr. AM and Dr. FRM have received financial support from the Autonomous Region of Sardinia (Grant no. CRP1_261, in accordance with Regional Law L.R. 7/2007 “Promozione della ricerca scientifica e dell'innovazione tecnologica in Sardegna”). The Sardinia Region had no further role in the design of the study; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. No other forms of financial support were received for this study.

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