Iran Red Cres Med J. 2014 January; 16(1): e15205. DOI: 10. 5812/ircmj. 15205 Research Article Published online 2014 January 5. Prevalence of Psychiatric Disorders and Related Factors in Male Prisoners 1 1,* 1 1 Zahra Sepehrmanesh ; Afshin Ahmadvand ; Goudarz Akasheh ; Rezvan Saei 1Department of Psychiatric, Kashan University of Medical Sciences, Kashan, IR Iran *Corresponding Author : Afshin Ahmadvand, Department of Psychiatric, Kashan University of Medical Sciences, Kashan, IR Iran. Tel: +98-3615559111, Fax: +98-3615550036, E-mail: psychiatric. [email protected] Received: ; Revised: ; Accepted: October 2, 2013 November 12, 2013 December 7, 2013 Background: Prisoners are at risk of mental disorders. Therefore attention to mental health of prisoners is important. Objectives: This study aimed determine to the prevalence of mental disorders among Kashan prisoners. Patients and Methods: This cross sectional study was carried out in Kashan prison (Iran). 180 Subjects were selected by using stratified random sampling and evaluated with Symptoms Check List-90-Revised (SCL-90-R) questionnaire and clinical interview based on Diagnostic Statistical Manual of Disease-IV (DSM-IV) check list by two psychiatrists. Data were analyzed by SPSS-16 software and Chi square, Kolmogrov Smirnov, Mann-whiteny and Leven tests. Results: The mean age of prisoners was 31.9 ± 8.96. The prevalence of psychiatric disorders in prisoners was 43.4 %. The most frequent disorders were major depressive disorders (27.9 %), Post traumatic Stress Disorder (17.4%) and substance use disorder (17.4 %). 28.3% of prisoners had personality disorders, that the most prevalent were antisocial personality and borderline personality. The comorbidity of psychiatric disorders was (36 %) in axis I. Suicidal thoughts there were in 44.6 % of prisoners. History of head trauma in Prisoners with psychiatric disorders was (52.2 %). There was significant difference between head trauma and psychiatric disorders (P = 0.05). Significant difference was between marital status and duration of imprisonment with psychiatric disorders P < 0.05. There was not significant difference between type of crime and educational level with psychiatric disorders. Conclusions: About half of all prisoners suffered from psychiatric disorders; therefore treatment psychiatric disorder in this group is essential for prevention of crime. Prisoners are at risk of mental disorders. Therefore attention to mental health of prisoners is important. Keywords: Prevalence; Mental Disorders; Prisoners 1. Background (8, 9). The majority of studies represent that personality disorders and substance abuse disorders are the most Mental disorders are one of the most common disor- frequent disorders in prisoner populations (10-12). The ders in the world and prisoner's mental health is a major prevalence of personality disorders in Sanandaj prison concern of public health in today society (1). Numerous was reported 88 % (13). These Studies demonstrate that a studies have shown that mental disorders can be found many prisoners experience mental health problems. significantly more frequently in prisoners in compari- son to normal populations (2). Moore (2013) reported the 2. Objectives prevalence of mental disorders is 17% among prisoners (3). Prisoners do not seek help for their psychiatric problems As mental disorders have an essential role in the inci- and therefore their needs less assessed and so suicidal be- dence of crime and since no study has been conducted havior in them is common (1, 4). The World statistics in- about prevalence of mental disorder and some risk fac- dicate that more than 9 million people live on prisons of tors in Kashan (Iran) this research was designed. This the world (1). According to the reports; more than 163000 study evaluates mental disorders in men prisoners in- prisons are in Iran (2). This issue that prison populations cluding prevalence mental disorders in axis I and person- have less mental health than the general population has ality disorders in axis II and some risk factors of psychiat- been identified in the research of Brinded (2004) (4). ric disorders. Nilsson and Misrachi in their study found that 5.1 % of 3. Materials and Methodes prisoners had psychosis disorders (5). Brugha (2002) re- ported the prevalence of mental disorders in prisoners is 10 times more than their staff (6). The prevalence of men- 3.1. Subjects and Sampling Method tal disorders is %66 in prisoners of England and 85 % in Finland (7). The prevalence of mental disorders in Iran's This cross sectional study was conducted on men pris- prisons has been reported; 75 % in Shiraz, 88% in Tehran oners in Kashan city /Iran (2011-2012). The sample number Implication for health policy/practice/research/medical education: Prevention of consequences and vicious cycle of mental disorder and crime. Copyright © 2014, Iranian Red Crescent Medical Journal; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Com- mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sepehrmanesh Z et al. (n = 180) was determined with (z = 1.96, q = 0.25, d = 0.05, mental retardation and organic mental disorders (16). P = 0.75). The subjects were selected by stratified random- The Data were processed by SPSS software version 16 and ized sampling among prison's wards (N = 535). Inclusion analyzed via statistical tests include Chi -square, Kolmo- and exclusion criteria were male sex, duration of impris- grov Smirnov, Mann-whitney, independent sample t test onment at least 3 months, lack of mental retardation, and Leven tests. lack of delirium, dementia and physical disability. After 3.3. Ethical Consideration taking formal consent from administrator of prison, the list of prisoners was provided by clinical psychologist This study was approved by the Ethics Committee of the of Kashan prison. The proportion of each ward was de- ni = ki / N × n Kashan University of Medical Sciences, project number termined via . The participants filled ques- 8704. Formal consent was obtained from the prison ad- tionnaires after written consent. The information was ministrator .The study protocol conformed to the ethical kept secret. Prisoners who their scores were above cut guidelines of the 1975 Declaration of Helsinki. off point in the SCL-90 test, were referred for clinical in- terview by two psychiatrists based on DSM-IV check list. 4. Results Based on SCL-90 questionnaire results, 131 subjects based on inclusion criteria were referred to the psychiatrist for In this study, 180 subjects participated in the first stage evaluation of mental disorders based on DSM-IV check- (screening). Based on SCL-90 questionnaire results, 131 list. 21 cases were excluded because of freedom and other subjects were referred to the psychiatrist for evaluation problems, therefore 159 subjects were interviewed by two of mental disorders based on DSM-IV checklist. Out of 180 psychiatrists. subjects, 21 cases were excluded because of freedom and other problems, therefore 159 subjects were interviewed 3.2. Tools by two psychiatrists. Demographic characteristic of pris- oners are presented in Table 1. 3.2.1. Symptom Checklist 90 Revised (SCL-90-R) Table 1. Frequency of Demographic Characteristics in Male Psychopathological features were assessed with the Prisoners symptom checklist 90 revised , a self- administered Frequency Percentage questionnaire used to evaluate the symptoms of psy- Age chopathology experienced by individuals even beyond clinically relevant mental disorders. The questionnaire is 15-25 40 68 appropriate for use in both normal and distressed indi- 26-36 68 42.7 viduals. The questionnaire consist of 90 items concern- 36-50 51 32.7 ing an individual's symptom distress. Each item is related Marriage status on a five-point Iikert scale (0-4). The nine subscales that can be derived from the SCL-90 are: Single 65 40.8 Somatization (som, 12 items), obsessive compulsive Married 78 49.1 (OBS, 10 items), interpersonal sensitivity (SENS, 9 items), Divorced 16 10.1 depression (DEP, 13 items), anxiety (ANX, 10 items), anger Occupation hostility (HOS, 6 items), phobic anxiety (PHOB, 7 items), Unemployed 9 5.7 Paranoid ideation (PAR, 6 items) and psychotic (PSYC, 10 items). The final score of the GSI, which represents the Worker 37 23.3 average severity score of all the 90 items of the question- Staff 7 4.4 naire, is thought to be a reliable measure of psychologi- Open 105 66.5 cal distress. The cut off point for GSI used in this study Retired 1 0.06 is 0.7, as indicated by the existing literature. (14, 15). Re- Education liability of this scale has been reported 0.90 in Iran and 0.85 in foreign study (8, 14). Illiterate 5 3.2 Primary 93 58.4 3.2.2. DSM-IV Check List Secondary 61 38.4 DSM-IV check list was used simultaneously by two psy- and higher chiatrists to agree on the same diagnosis. Its Kappa coef- History of substance ficient was 0.87. Clinical interview check list has been provided by Noorbala and colleagues based on DSM-IV Yes 142 89.4 criteria. This structural questionnaire includes 149 symp- No 17 10.6 toms of mental disorders such as: symptom of mood Total 159 100 disorders, anxiety, psychotic, psychosomatic, epilepsy, 2 Iran Red Cres Med J. 2014;16(1):e15205 Sepehrmanesh Z et al. The mean age of prisoners was 31.9 ± 8.96. Duration of 30 imprisonment was 6.68 ± 11.82 and the frequency of im- 27.6 prisonment was at least 3 times. In this study between 25 age and mental disorder there was not significant dif- ferences while, between Duration of imprisonment and 20 17.4 17.4 17.3 mental disorder there was significant differences (Table 15 2). Type of crime in prisoners was selling drug (opioid substance) 67 (42.1 %), robbery and theft 47 (29.3 %), vio- 10 10.2 lence and disrupting social order 21 (13.2 %), and 24 (15.0%) 5.8 had other crimes. Regarding to suicidal behaviors, 71 5 4.3 (44.6 %) prisoners had suicidal thoughts and 62 (38.9 %) 0 history of suicidal attempt. The married prisoners had Majer Post substance General Obsessive cyclotimic psychotic depression traumatic abuse anxiety compulsive disorder disorder more prevalence suicidal thoughts (47.4 %) than the sin- disorder stress disorder disorder disorder disorder gle prisoners. The prisoners with low level of education (elementary school) (49.5 %) had higher suicidal thought Figure 2. Frequency of Mental Disorders in 69 Male Prisoners Based on than the prisoners with high level of education. Clinical Interview Table 2. Frequency of Mental Disorder Based on Quantitative Prisoners who had history of head trauma had more Variables (Mean age, Duration of Imprisonment) mental disorder than the others. History of head trauma Mental Disorder Age, Mean ± SD Duration of in Prisoners with psychiatric disorders was 52.2 %. There Imprisonment, was significant difference between head trauma and Mean ± SD mental disorders (P = 0.05) (Table 3). Divorced prison- Yes ers had the most prevalent mental disorder (75 %). There 32.26 ± 869 8.7 ± 13.79 No was significant difference between mental disorder and 31.65 ± 9.2 4.05 ± 7.96 marital status (P = 0.01). In this study, there was not Signif- P value 0.67 0.009 icant differences between mental disorder and occupa- tional status, educational level, type of crime and history The Prevalence of psychiatric disorders in the prison- of mental disorder in the prisoners and their family (P > ers was 43.4%. Mood disorders were the most prevalent 0.05) (Table 2). psychiatric disorders. The most frequent disorder in sub- group of mood disorders was major depressive disorder 5. Discussion (27.6 %). The prevalence of other psychiatric disorders re- spectively was post-traumatic stress disorder (17.4 %), sub- The present research was designed to determine the stance disorder (17.4 %), general anxiety disorder (13 %), prevalence of psychiatric disorders in prisoners. In the obsessive compulsive disorder (10.2 %), bipolar spectrum present study, the prevalence of psychiatric disorders disorders (5.8 %) and psychotic disorder (4.3 %). Regarding was 43.4 %. This prevalence is consistent with Shariat comorbidity, we found high comorbidity of psychiatric Study in Tehran prison and Abram’s study in America disorders in the prisoners (36 %) (Excluding personality prison with 46. 9 %, 45. 9 % respectively (8, 17). The preva- disorders). Personality disorder was found in 45 (28.3 %) lence of mental disorders in this study are less than these based on clinical interview by two psychiatrists. Antiso- studies; Tihonen and Hakula (1994) in Finland (85 %), cial personality (62.2 %) and borderline personality disor- Linda and Teplin (1997) in America (75 %), Langveld (2001) der (31.2 %) were the most prevalent personality disorders in Norway (80 %), Butler (2006) in Australia (80 %), Von (Figures 1 and 2). Schonfeld (2006) in Germany (83.5 %), Dudeck (2009) in Germany (83 %), Brooke (1996) in England (63%), Bulten 70 (2009) in The Neterland (57 %), Vicence (2011) in Spain 62.2 (84.4%) While, in Kielsberg study (2006) the prevalence of 60 mental disorders in Norwegian prisoners was 25 % which 50 is less than the present study (3, 18-26). 40 In the present study the most prevalent mental disor- 31.2 ders were major depressive disorder, post-traumatic 30 stress disorder, substance disorder and general anxiety 20 disorder which are consistent with these studies Shariat (2006) and Ashkani (2002) in Iran, Brinded (2004) in New 10 6.6 Zealand, Abram (2003) in USA, Fazel (2002) in England, 0 Clayer (1995) in Australia, Vergheese (1973), Medianson Antisocial Personality Borderline Personality Hysterionic Personality (1985), Bart (1998) and Hamdi (1992) (5, 7-9, 17, 27-32). According to the results of the present study the most Figure 1. Frequency of Personality Disorders in Male Prisoners prevalent personality disorders were antisocial person- 3 Iran Red Cres Med J. 2014;16(1):e15205 Sepehrmanesh Z et al. ality and borderline personality. These findings are con- compatible with present study (8). There was significant firmed by Modaber Arasteh (2008) in Iran, Langeveld between marital status and mental disorders so that (2001) in Norway, Von Schonfeld (2006) and Dudeck widow Prisoners had higher mental disorders compared (2009) in Germany, Aghbahowe (1998) in Nijeriya, Brind- with married and single subjects (P = 0. 01). This result ed (2004) in New Zealand and Fazel (2002) in Western is not compatible with Modaber Arasteh study (2008) in countries (5, 13, 19, 21, 22, 33, 34). Significant difference was Iran (13). Jang study (2009) reported that divorced or wid- not between mental disorders and age of prisoners (P = 0. 67). In Ashkani research (2002) subjects who were older owed men are at high risk of depression more than other than 65 years had more mental disorders that this is not men (35). Table 3. Frequency of Mental Disorders in Male Prisoners Based on Demographic Factors Mental Disorder Yes, No.(%) No, No.(%) Total P value Marriage Status 0.01 Single 22 (38.8) 43 (66.2) 65 Married 35 (44.9) 43 (55.1) 78 Divorced 12 (75) 4 (25.0 ) 16 Mental disorders in family 0.7 Yes 34 (44.7) 4 (55.3) 76 No 35 (42.2) 4 (57.8) 83 Head trauma 0.05 Yes 36 (52.2) 33 (47.8) 69 No 33 (36.7) 57 (63.3) 90 Education 0.3 Illiterate 2 (40.0) 3 (60.0) 5 Primary 36 (38.7) 57 (61.3) 93 Higher 31 (50.8) 30 (49.2) 61 Crime 0.12 Robbery 15 (31.9) 32 (68.1) 47 Violence 9 (42.9) 12 (57.1) 21 Substance dealer 36 (53.7) 31 (46.3) 67 Other 9 (37.5) 15 (62.5) 124 In our study the association of mental disorders and explained by prison environment and long isolation. In educational level, history of substance use, family history evaluation type of crime and mental disorders, although of mental disorders and type of crime was not found substance dealers had higher mental disorders than the (P > 0.05) (Table 2). This is in agreement with Modaber other offenders but this difference was not significant. Arasteh study (2008). Suicidal ideation there was in 44. This result is confirmed by Aghbahowe study (1998) (33). 6 % of prisoners and 38. 9 % of prisoners had history of This study clearly indicates that many of prisoners have suicidal attempts (13). Prisoners are at high risk of suicide mental health problems. Nearly half of prisoners who because they do not seek help for their problems and were drug dealer had mental disorder. Substance crime their mental health needs were recognized less by health and mental disorder have intricate relationship and each professional (1, 4). In addition mood and personality one can cause other. This issue requires that prison ser- disorders in prisoners and other factors such as; be young, vices more attention to improving mental health of pris- lack of social resources, substance abuse, environmental oners and prison staff and focused on the role of mental factors can be mentioned as effective factors for suicidal health professionals including psychiatrists, psycholo- tendencies. This finding was confirmed by Fazel (2008), gists, psychiatric nurses, social workers for detection and Sarchiapone (2009), Joukemaa (1997), Jenkins (2005), treatment of psychiatric disorders in prison population. Lekka (2006) and Bland (1990) (34, 36-40). The present This study suggests that high risk prisoners are recog- study indicates prevalence of mental disorders in nized and treated for prevention of consequences and prisoners with longer duration of imprisonment vicious cycle of mental disorder and crime. In this regard was higher than others. (P = 0.009). 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