We searched Medline, PubMed, the Cochrane Library, EMBASE, and the National Criminal Justice Reference Service database for all article types from Jan 1, 1990, to Nov 31, 2009. All languages were included. Key search terms used were “prison”, “prisoner”, and “inmate”. These terms were combined with specific medical and psychiatric disorders and conditions. We largely selected articles published in the past 5 years in peer-reviewed journals, but did not exclude often referenced and highly
ReviewThe health of prisoners
Introduction
More than 10 million people are imprisoned worldwide, with 2·3 million in the USA, 1·6 million in prison and another 0·9 million in administrative detention in China, and 0·9 million in Russia. India, Thailand, Iran, Indonesia, Turkey, Brazil, Mexico, South Africa, and Ukraine all have prison populations exceeding 100 000 people.1 The USA has the highest number of prisoners per head of population at 756 per 100 000 people, compared with a mean of 145 per 100 000 worldwide. The number of people in prisons has been increasing in more than two-thirds of countries worldwide in the past decade and rose by more than 1 million from the late 1990s to 2006–08 (figure 1).1, 2 Rates of imprisonment have also risen in north and central America, Asia, and Oceania (figure 1).
Prisoners bear a substantial burden of physical and psychiatric disorders relative to the general population. However, most evidence on the health of prisoners comes from high-income nations. Long-standing concerns about the care and treatment of prisoners, such as the use of capital punishment for mentally ill prisoners in some countries, are widespread.4, 5, 6 The health disparity between prisoners and the general population has been attributed to various behavioural and socioeconomic factors, including high rates of intravenous drug use in prisoners, which leads to increased risk of infectious diseases and increased alcohol misuse and smoking. These behaviours in turn raise the risk of cardiovascular disease and some cancers. Mental illness, which increases the risk of crime and repeat offending,7, 8, 9 is common in prisoners. The extent to which the prison itself raises the risk of illness has only been investigated in relation to infectious diseases and is unknown in relation to most other disorders.
In this Review, we discuss the prevalence and risk factors for some of the major physical and psychiatric diseases in prisoners, and the challenges to provide health-care services for this population. We first discuss the prevalence of mental disorders and evidence-based treatments for them, the prevalence, transmission, and prevention of infectious diseases, and the prevalence of chronic diseases. We then review mortality rates in prisoners and discuss populations with particular health needs. Finally, we present information on health-care services and make several recommendations for improvements. Where possible, we use the term prison apart from in the USA, where jails (detention centres before trial or remand centres that house prisoners on sentences shorter than 1 year) and state prisons (for sentenced prisoners) are distinguished. Jails tend to have higher turnover rates than do prisons, and hence provide fewer opportunities to diagnose and treat disease.
Section snippets
Prevalence of mental disorders
Since a landmark study of admissions to Sing Sing prison in New York in 1918 highlighted the large number of mentally ill people in custody,10 a great body of evidence has shown high rates of psychiatric morbidity, although these data are almost entirely based on research done in high-income countries. Around one in seven prisoners has a treatable mental illness. In a systematic review and meta-analysis of 62 surveys of 23 000 prisoners, the pooled prevalence of psychosis was around 4%, major
HIV infection
Since the first reports of HIV/AIDS in prisoners were published more than 25 years ago,35 this prison health issue has been the most highly researched worldwide. Epidemiological studies of prison populations in most countries have consistently reported rates of HIV infection that exceed those in the general population.36, 37 A review of HIV prevalence in prisons in low-income and middle-income countries reported that, of the 75 countries for which such data were available (of a total of 152),
Non-infectious diseases and cancer
In contrast to infectious diseases, few studies have assessed the prevalence of non-infectious diseases in prisoners. Most chronic disorders seem to be more common in prisoners than in the general population, although epilepsy prevalence seems to be similar in both.76 Results from a US survey have shown higher age-adjusted rates of hypertension, diabetes, asthma, and arthritis in prisoners than in the general population,26 findings replicated in other developed countries (figure 2), even though
During custody
Suicide is the leading cause of death in prisons, accounting for about half of all prison deaths. National suicide prevention strategies from the UK,86 USA,87 and some other countries have highlighted the importance of suicide prevention in prisons. In a study of 12 western countries in 2003–07, rates of suicide were estimated to be between 50 and 150 suicides per 100 000 male prisoners per year on average, with higher rates in northern European countries and lower rates in Canada, Australia,
Older adults
In this section, the term older adults mostly refers to people aged 55 years and older, although some studies, particularly those from the UK, have used 60 years as the age threshold. The number of older men in prison has greatly increased in many developed countries. In the USA, for example, about 74 000 men and 3700 women aged 55 years or older were being held in prisons at the end of 2008.108 This trend has been attributed to various factors such as the imposition of longer sentences, more
Medical services
As a result of burgeoning prison populations and an increasing number of disease epidemics, prison health-care services have become increasingly complex. According to WHO recommendations, national and regional governments should provide prisoners with the best possible health care free of charge, even in times of substantial economic difficulty.127 The UN Basic Principles for the Treatment of Prisoners128 states that prisoners “shall have access to the health services available in the country
Improvement of prison medical services
Prison medical services need improvement. First, greater health-care resources should be targeted at prisons since they provide a rare public health opportunity to screen and treat a young, marginalised, and diseased group.134, 135 Second, where public health systems are adequately resourced, the administrative responsibility for health in prisons should be handed over to public health systems because the values of the criminal justice system, which prioritise security, are unlikely to
Conclusion
From a public health viewpoint, the disproportionate burden of physical and psychiatric disease in prisoners presents both a challenge and an opportunity. In many countries throughout the world, prisons are an important venue of contact with millions of individuals who are out of the reach of conventional community-based health systems. For these individuals, prison provides an opportunity for diagnosis, disease management education, counselling, and treatment that they would not receive in the
Search strategy and selection criteria
References (140)
- et al.
Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys
Lancet
(2002) - et al.
The prevalence of intellectual disabilities among 12,000 prisoners—a systematic review
Int J Law Psychiatry
(2008) - et al.
Prevalence and detection of serious psychiatric disorder in defendants attending court
Lancet
(1999) - et al.
Prevalence and characteristics of trauma and posttraumatic stress disorder in female prisoners in China
Compr Psychiatry
(2006) - et al.
The impact of substitution treatment in prisons—a literature review
Int J Drug Policy
(2007) - et al.
A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease
J Subst Abuse Treat
(2009) - et al.
HIV in prison in low-income and middle-income countries
Lancet Infect Dis
(2007) - et al.
The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey
Aust N Z J Public Health
(2007) - et al.
Heterogeneity in hepatitis B virus (HBV) seroprevalence estimates from U.S. adult incarcerated populations
Ann Epidemiol
(2009) - et al.
Interventions to reduce HIV transmission related to injecting drug use in prison
Lancet Infect Dis
(2009)
The self-reported health status of prisoners in New South Wales
Aust N Z J Public Health
The disease profile of Texas prison inmates
Ann Epidemiol
Suicides in male prisoners in England and Wales, 1978–2003
Lancet
World prison population list
World prison population list
World prison population list
Shackled, shameful, and shoddy
Lancet
Health care for prisoners: implications of “Kalk's refusal”
Lancet
Execution of prisoners with mental illnesses in Japan
Lancet
Serious criminal offending and mental disorder: case linkage study
Br J Psychiatry
Schizophrenia and violence: systematic review and meta-analysis
PLoS Med
Psychotic disorders and repeat offending: systematic review and meta-analysis
Schizophr Bull
A study of 608 admissions to Sing Sing prison
Ment Hyg
Substance abuse and dependence in prisoners: a systematic review
Addiction
Does PTSD occur in sentenced prison populations? A systematic literature review
Crim Behav Ment Health
Childhood trauma, psychiatric disorders, and criminal behavior in prisoners in Germany: a comparative study in incarcerated women and men
J Clin Psychiatry
Gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates
Am J Public Health
Mental disorders in Australian prisoners: a comparison with a community sample
Aust NZ J Psychiatry
Psychiatric and social aspects of suicidal behaviour in prisons
Psychol Med
The psychological effects of solitary confinement on prisoners in supermax units: reviewing what we know and recommending what should change
Int J Offender Ther Comp Criminol
Mental health care institutions in nine European countries, 2002 to 2006
Psychiatr Serv
The prevalence of mental disorders among the homeless in Western countries: systematic review and meta-regression analysis
PLoS Med
Mental health care in prisons
Br J Psychiatry
A survey of the delivery of health care in prisons in relation to chronic diseases
A survey of primary and specialised health care provision to prisons in England and Wales
Prim Health Care Res Dev
The health and health care of US prisoners: results of a nationwide survey
Am J Public Health
Screening and access to services for individuals with serious mental illnesses in jails
Community Ment Health J
Psychiatric morbidity among sentenced prisoners: prevalence study in Iran
Br J Psychiatry
Persons with major psychiatric illness in prisons—a three year study
J Indian Med Assoc
Interventions for drug-using offenders in the courts, secure establishments and the community
Cochrane Database Syst Rev
Opportunities and obstacles for effective treatment of drug misusers in the criminal justice system in England and Wales
Br J Criminol
Acquired immunodeficiency syndrome in male prisoners. New insights into an emerging syndrome
Ann Intern Med
AIDS epidemic update: December 2009
Publications & products: HIV in prisons and jails
Correlates of HIV, HBV, and HCV infections in a prison inmate population: results from a multicentre study in Italy
J Med Virol
Prevalence and incidence of bloodborne viral infections among Danish prisoners
Eur J Epidemiol
HIV in prisons, 2007–08. Bureau of Justice Statistics Bulletin
HIV/AIDS among inmates of and releasees from US correctional facilities, 2006: declining share of epidemic but persistent public health opportunity
PLoS One
Viral hepatitis in incarcerated adults: a medical and public health concern
Am J Gastroenterol
Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention
AIDS
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