Mental health in prisons around the world

BY ANASTASIA REPOULIOU

Show me your prisons and I shall say in which society you live.
~Winston Churchill

The Problem

Let’s start with the numbers: According to the World Prison Population List, 11th edition, by Roy Walmsley, more than 10.35 million people are held in penal institutions throughout the world. Taking into account that figures for Eritrea, Somalia, and the DPRK are not available, that figures for China and Guinea-Bissau are incomplete, and that prisoners held in not fully recognized international jurisdictions and pre-trial prisoners were not included in the report, the total can be estimated to be higher than 10.35 million and may well be in excess of 11 million.

The world prison population rate, based on United Nations estimates of national population levels, is 144 prisoners per 100,000 of the national population. Trends vary largely internationally. Since about the year 2000, the total prison population has increased by about 60% in Oceania, 14% in Central America, and 145% in South America.  In Europe it has decreased by 21% largely because of falls in prison populations in Russia and central-eastern Europe.

Now that we’ve established that we are dealing with a large and quickly growing part of the world’s population, let’s look at this population’s profile.

According to the World Health Organization (WHO), there is a disproportionately high rate of mental disorders in prisons. These mental illnesses are often present before admission to prison and exacerbated by the stress of imprisonment, but sometimes they are developed during imprisonment as a consequence of the prison environment and possibly torture or other human rights violations. The main causes identified pertain to:

• The specific prison environment – overcrowding, violence, enforced solitude, lack of privacy, lack of meaningful activity, isolation, insecurity about future prospects, and inadequate health services (especially mental health services)
  
• Societal perceptions affecting the judicial and penal system – the misconception that people with mental disorders are a danger to the public, the intolerance of many societies to difficult or disturbing behavior, the failure to promote treatment, care, and rehabilitation, and the lack of, or poor access to, mental health services
• The practice of inappropriately locking people with severe mental disorders up in prisons because of the lack of mental health services.

The Challenges

Anasseril E. Daniel, a psychiatrist in Columbia, identifies psychotic illness, major depression, personality disorder, psychosis, anxiety disorders including post-traumatic stress disorder (PTSD), organic disorders, suicidal behaviors, and attention deficit hyperactivity disorder (ADHD) as some of the main mental health issues in prisons. Dr. Daniel also identifies some issues that arise when we examine mental health provisions in prisons.

One consideration is the privatization of mental health and medical care, which started due to increasing healthcare costs, staff expense, lack of qualified health care professionals to work in prisons, general lack of visionary correctional leadership, and increasing litigation. There are multiple health care models including services provided by the state, large private vendors providing medical and mental health services, separate small or large specialist mental health vendors, public medical institutions, and medical school-private vendor partnership.

Even though it is unclear which of these models work best, it seems to be true that the profit motive may trump quality and compromise ethics standards and practice.

Another issue that makes mental health in prisons an important issue for the public is that, as Dr. Anasseril puts it: “Compared with the public, offenders may seem less cooperative, less appealing, and even less ‘human.’ Yet U.S. courts have clearly established that prisoners have a constitutional right to receive medical and mental health care that meets minimum standards.”

Finally, pharmaceutical costs are of course a significant component of the overall mental health care costs in corrections, and therefore an important challenge in improving the mental health services in prisons. A tactic we need to put an end to is that of establishing a restricted formulary of older generation psychotropics and generic agents that are less expensive from which formulary physicians are required to preferentially prescribe medications. This is especially important in drug-abusing prisoners, who should be treated with anti-craving and relapse-prevention medications beginning two to four weeks before release and until 30 to 60 days after release.

The Goals

The importance of dealing with these issues should be clear. The WHO summarizes the benefits of responding to mental health issues in prisons in terms of utilitarian calculations with regard to the three main stakeholders:

1. Prisoners: enhanced health and quality of life, increased probability of successful rehabilitation, and decreased re-offense likelihood
2. Prison staff: reasonably decreased demands placed upon staff
3. Society: decreased re-offense incidents, reduced high costs of prisons.

Additionally, the WHO provides a set of possible solutions, including but not limited to diverting people with mental disorders towards the mental health system, access to appropriate mental health treatment, including acute mental health care in psychiatric wards, psychosocial support, and rationally prescribed psychotropic medication, trained staff, information, and education to prisoners and their families on mental health issues, and adoption of mental health legislation that protects human rights.

Assuming a fair and functional judicial system, society through the executive action of the government has the right to restrict the rights of serious offenders, for its own protection, as well as the ultimate goals of deterrence and rehabilitation.

Prisoners lose many of their civil rights such as self-determination and liberty of movement and action. They do however retain their basic rights as human beings.

Prisoners have a right to be healthy and to be provided with adequate treatment. Major steps have been accomplished in that respect when it comes to physical health, but mental health remains a big issue that is largely ignored.

References

Daniel, Anasseril E. “Care of the Mentally Ill in Prisons: Challenges and Solutions.” Journal of the American Academy of Psychiatry and the Law Online. American Academy of Psychiatry and the Law., Dec. 2007. Web. 13 Feb. 2016. <http://www.jaapl.org/content/35/4/406.full>.

“Mental health and prisons Information Sheet.” World Health Organization. ICRC. Web. 13 Feb. 2016. < http://www.who.int/mental_health/policy/mh_in_prison.pdf >.

Walmsley, Roy. “World Prison Population List Eleventh Edition.” World Prison Brief (n.d.): n. pag. Institute for Criminal Policy Research, Birkbeck University of London. Web. 13 Feb. 2016. <http://www.icpr.org.uk/media/41356/world_prison_population_list_11th_edition.pdf>.

Image Reference

Murray, Stuart J. “Prisons & Mental Health: Violence & Truth-telling.” CHAIM Centre. Carleton University, n.d. Web. 13 Feb. 2016. <http://carleton.ca/chaimcentre/2015/prisons-truth-telling/>.