Mental health in the prison ecosystem
The high frequency of mental health problems among people incarcerated in prisons is well known, with a higher percentage of affected individuals compared to the general civilian population (Bebbington, McManus, Coid, Garside, & Brugha, 2021). Furthermore, as in the community, a growing trend of mental health problems is observed in the prison environment, conditioned and modulated by the specific characteristics, situations, and circumstances of incarceration.
The prevalence of mental disorders and addictions in the prison population is estimated to be more than double that of the general population.
Reviews published in The Lancet in 2016 and 2019 (Baranyi et al., 2019; Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016) highlight the significant heterogeneity in the design and methodologies of the different studies. Nevertheless, they conclude that there is an overall higher prevalence, with psychotic, depressive, and alcohol and drug use disorders being particularly prevalent. These and other studies on the subject also acknowledge the significant clinical complexity and high comorbidity among mental disorders themselves and with medical conditions in other fields.
Is stigma present among mental health professionals?
Closer to home, national studies have also observed a high prevalence of mental disorders in prisons, with 40% in analyses limited to the month prior to incarceration and up to 80% lifetime prevalence (M López, FJ Saavedra, A López, & M Laviana, 2016; Vicens et al., 2011). These studies also highlight substance use disorders (affecting up to 80% of male and female inmates) and personality disorders; virtually all those affected had comorbidity or a dual diagnosis. In general, a greater psychopathological burden is observed in women, and another particularly vulnerable group is the geriatric population, which often appears early in the prison environment. Another psychopathological condition that is overrepresented in prisons is intellectual disability, observed in up to 30% of inmates when considering both intellectual disability and borderline intellectual functioning.
The main importance of this close relationship between prison and the impact on mental health lies in the consequences that arise from it, since people with mental disorders in prison have greater difficulties adapting and complying with rehabilitation and treatment programs related to their criminal sphere, are also more vulnerable to suffering the psychological and emotional consequences derived from social isolation, are more prone to victimization and, in addition and as a consequence of all this, present higher rates of recidivism and criminality when community reintegration is carried out (Bebbington et al., 2021; Skar et al., 2019).
Another point of particular relevance and media interest is the high suicide rate among the prison population . Statistics from recent years show an increase in the number of suicides; in 2020, the rate was 10.3 per 100,000 inmates, higher than the rate in previous years and compared to the general population. The suicide rate is higher among inmates with some form of mental health condition or addiction (Zhong et al., 2021), and pretrial detention poses a particular risk , with the highest rate observed (16.3 per 100,000). Suicide in prisons shares similar conditions and difficulties with the community, with some nuances, such as the very nature of incarceration, especially in cases of long sentences; shared psychosocial factors associated with violent behavior and poorer functional adjustment; and the difficulty in establishing a comprehensive and specific approach that considers self-harm and self-inflicted injury without suicidal intent.
From a holistic perspective, the relationship between prison and mental health can be considered bidirectional and reciprocal, without implying that having a mental disorder is directly related to criminality or violence. It is worth noting that violence is not an inherent trait of mental disorders, although some can lead to aggressive behavior or present it as part of their symptomatic range, particularly when left untreated and in critical situations.
In summary, the turning points between the two are:
Common risk factors
The prison population is a group at risk of social exclusion. A large proportion of incarcerated individuals come from troubled and marginalized backgrounds, have lived in dysfunctional family environments, or have suffered adverse situations such as mistreatment or abuse. In general, their socioeconomic level of origin is low, and there is a connection to migration, particularly irregular migration. This sociobiographical profile is the breeding ground for various psychological and emotional conditions that, in certain circumstances and environments, lead to disruptive, maladaptive, and criminal behaviors.
Special mention should be made of the analysis of the traumatic burden in the prison population and its relationship to mental disorders. In this respect, the female population stands out, as they not only exhibit a higher psychopathological burden and a history of psychiatric problems, but also tend to have fewer resources and therapeutic options.
Prison as a risk factor
Incarceration is a source of psychological stress and an independent factor in the development of cognitive and emotional problems (Porter, Kozlowski-Serra, & Lee, 2021). On the one hand, there is the experience of imprisonment itself, which causes a disruption and a change in the rhythm of life, even if that rhythm was previously constructed and followed along conflictive, destructive, or traumatic paths. This, like any other radical change of environment, requires adaptation, and in the prison world, other stressors are added, such as subjection to strict rules and regulations, the loss of autonomy and dependence for certain routine activities, and uncertainty regarding the judicial process or the review and progression of the sentence. Another point to highlight is the coexistence among inmates, regulated by particular relationships, dynamics, and even a specific language.
Prison ultimately leads to a "reduction of oneself." Adaptation and mental and emotional suffering are determined by psychopathological history and an overload of adversity, as well as by the specific stage of imprisonment. A higher risk of anxiety, depression, and suicide is observed in the initial stages and when adversities or setbacks arise, whether personal, familial, or related to the legal process.
In this sense, and supported by the literature (Porter, Kozlowski-Serra, & Lee, 2021), the construction of a more respectful, kind, close and communicative environment is fundamental to improving both mental health and rates of violence among hospitalized people.
Prevention and community care capacity
As previously noted, there is currently a growing trend in the incidence of mental health problems and greater instability among those with a prior diagnosis. The reasons and triggers for this phenomenon are beyond the scope of this paper, but they are complex and related to various factors, such as evolving lifestyles and relationships in the modern world, as well as the community's capacity to promote, prevent, and address mental health disorders. Regarding this last point, the strategies implemented and their evolution seem to indicate an insufficient response, not in quantity (the benefits of a universal system), but certainly in quality. It can be observed that the capacity of community mental health assistance has been overwhelmed by the increase in specialized care for minor psychiatric problems (referring to adjustment disorders and others mainly linked to psychosocial circumstances) and therefore those people with severe mental disorders may have been left without the necessary approach and intervention, leading to greater social exclusion, an accumulation of adverse circumstances and ultimately, clinical instability and decompensation, which may sometimes be related to criminal behavior or aggression and violence.
Aspects related to the judicial and forensic field
Article 20 of the Penal Code outlines the grounds for exemption from criminal liability and for which alternative measures to imprisonment should be imposed, the fundamental principle being the appropriate treatment and care of the underlying problem that led to the crime. While this can occur and be effectively implemented in most cases, there are situations where ambiguity, disparity, or arbitrariness arises in determining the need for specific treatment and the type of therapeutic resource offered as an alternative to imprisonment. This may be due to a lack of knowledge or communication among the various agents involved in the implementation and monitoring of these alternative penal measures, and also (as mentioned in the previous point) to the capacity and therapeutic approach of community mental health services.
The aim of this article is not to be definitive or to draw conclusions on such a complex and dynamic topic, one that welcomes and is enriched by readings and approaches from different perspectives and schools of thought. Rather, it seeks to establish a starting point and offer some initial insights to stimulate reflection on a socially intrinsic issue, though one that is often outside our understanding.
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