MENTAL ILLNESS AMONG NEW SOUTH WALES PRISONERS - Tony Butler  Stephen Allnutt  - August 2003

I I

Copyright NSW Corrections Health Service

State Health Publication No: (CHS) 030147

ISBN: 0 7347 3559 6

Suggested citation:

Butler T, Allnutt S. Mental Illness Among New South Wales’ Prisoners. NSW

Corrections Health Service, 2003. ISBN: 0 7347 3559 6.

Copies of the report are available from:

NSW Corrections Health Service

PO Box 150

Matraville NSW 2036

Australia

Tel: +61 2 9289 2977

Fax: +61 2 9311 3005

Cover illustration: “Whispers” by Zig Jaworowski

II I

Contents

List of Tables..................................................................................................... V

List of Figures .................................................................................................. VI

FOREWORD......................................................................................................1

EXECUTIVE SUMMARY...................................................................................2

ACKNOWLEDGEMENTS..................................................................................5

INTRODUCTION ...............................................................................................6

METHODS.........................................................................................................8

Overview ........................................................................................................8

Study 1 (Reception Prisoners) .......................................................................8

Study 2 (Sentenced Prisoners) ......................................................................9

Interviewers ....................................................................................................9

Screening Instruments ................................................................................ 10

Data Analysis .............................................................................................. 11

RESULTS........................................................................................................ 12

Overall Prevalence Estimates..................................................................... 13

Any Psychiatric Disorder ............................................................................. 15

Comment ................................................................................................. 16

Any Mental Disorder (psychosis, anxiety or affective disorder).................. 17

Demographic Correlates of Any Mental Disorder.................................... 17

Comment ................................................................................................. 18

Psychosis .................................................................................................... 19

Demographic Correlates of Psychosis .................................................... 19

Comment ................................................................................................. 21

Affective Disorders ...................................................................................... 22

Demographic Correlates of Affective Disorders ...................................... 23

Comment ................................................................................................. 24

Anxiety Disorders ........................................................................................ 25

Demographic Correlates of Anxiety Disorders ........................................ 26

Comment ................................................................................................. 27

Suicidal Ideation .......................................................................................... 28

Comment ................................................................................................. 28

Substance Use Disorders ........................................................................... 30

Demographic Correlates of Substance Use Disorder ............................. 31

Comment ................................................................................................. 32

Personality Disorders .................................................................................. 34

Demographic Correlates of Personality Disorder.................................... 35

Comment ................................................................................................. 36

Neurasthenia ............................................................................................... 37

Demographic Correlates of Neurasthenia............................................... 37

Comment ................................................................................................. 38

Health Service Usage ................................................................................. 39

Comment ................................................................................................. 39

Disability ...................................................................................................... 40

Comment ................................................................................................. 41

One-month Prevalence Estimates .............................................................. 42

Comment ................................................................................................. 43

Substance Use disorder and Psychiatric Diagnosis ................................... 45

Comment ................................................................................................. 45

Mental Illness And Offence Category ............................................................. 46

IV

DISCUSSION.................................................................................................. 48

REFERENCES ............................................................................................... 52

V

List of Tables

Table 1: Number and proportion of inmates screened at reception sites in Study 1. ..............12

Table 2: Comparison of screened and non-screened inmates for selected characteristics in

Study 1 (reception) and Study 2 (sentenced). ....................................................................13

Table 3: Twelve-month and one-month ICD-10 prevalence estimates of major disorders

among male and female prisoners, New South Wales (Australia)......................................14

Table 4: Prevalence (%) of ‘any psychiatric disorder’ among male and female prisoners by

marital status, country of birth, income, and highest qualification (twelve-month diagnosis).

...........................................................................................................................................16

Table 5: Prevalence (%) of any psychosis, anxiety or affective disorders among male and

female prisoners by marital status, country of birth, income, and highest qualification

(twelve-month diagnosis). ..................................................................................................18

Table 6: Prevalence (%) of psychosis among male and female prisoners by marital status,

country of birth, income, and highest qualification (twelve- month diagnosis). ...................20

Table 7: Twelve-month ICD-10 prevalence estimates of affective disorder. ...........................22

Table 8: Prevalence (%) of affective disorders among male and female prisoners by marital

status, country of birth, income, and highest qualification (twelve-month diagnosis). .........24

Table 9: Twelve-month ICD-10 prevalence estimates of anxiety disorders. ...........................25

Table 10: Prevalence (%) of anxiety disorders among male and female prisoners by marital

status, country of birth, income, and highest qualification (twelve-month diagnosis). .........27

Table 11: Suicidal ideation plans and attempts. .....................................................................28

Table 12: Twelve-month ICD-10 prevalence estimates for substance use disorders. ............31

Table 13: Prevalence (%) of any substance use disorder among male and female prisoners

by sex, marital status, country of birth, income, and highest qualification (twelve-month

diagnosis). .........................................................................................................................32

Table 14: Personality disorders..............................................................................................34

Table 15: Prevalence (%) of any personality disorder among male and female prisoners by

marital status, country of birth, income, and highest qualification (twelve-month diagnosis).

...........................................................................................................................................36

Table 16: Prevalence (%) of any personality disorder among male and female prisoners by

marital status, country of birth, income, and highest qualification (twelve-month diagnosis).

...........................................................................................................................................38

Table 17: Mean score on the Brief Disability Questionnaire (BDQ). .......................................40

Table 18: Number of days in previous month affected by disability. .......................................41

Table 19: One-month ICD-10 prevalence estimates of major disorders among male and

female reception prisoners, New South Wales (Australia)..................................................43

Table 20: Twelve-month ICD-10 prevalence estimates of major disorders among prisoner with

and without a substance use disorder diagnosis. ...............................................................45

Table 21: Most serious offence and ICD-10 twelve-month diagnosis for reception and

sentenced prisoners (combined). .......................................................................................47

V I

List of Figures

Figure 1: Prevalence of ‘Any Psychiatric Disorder’ (% positive) by age and sex (twelve-month

diagnosis). .........................................................................................................................16

Figure 2: Prevalence of any mental disorder (anxiety disorder, affective disorder or psychosis)

...........................................................................................................................................18

Figure 3: Prevalence of psychosis (% positive) by age and sex (twelve-month diagnosis).....20

Figure 4: Prevalence of any affective disorder (% positive) by age and sex (twelve-month

diagnosis). .........................................................................................................................23

Figure 5: Prevalence of any anxiety disorder (% positive) by age and sex (twelve-month

diagnosis). .........................................................................................................................26

Figure 6: Prevalence of any substance use disorder (% positive) by age and sex (twelvemonth

diagnosis)................................................................................................................32

Figure 7: Prevalence of any personality disorder (% positive) by age and sex (twelve-month

diagnosis). .........................................................................................................................35

Figure 8: Prevalence of neurasthenia (% positive) by age and sex (twelve-month diagnosis).

...........................................................................................................................................38

Figure 9: Health service usage for a mental health problem in the previous twelve months by

‘any psychiatric disorder’ (twelve-month diagnosis). ..........................................................39

FOREWORD

Anecdotal evidence from staff working in the New South Wales’ correctional

system has always suggested a high prevalence of mental illness among the

prisoner population. However, hard evidence has been lacking and generated

the impetus for the projects described in this document. Planning effective

services for mentally ill prisoners is problematic in the absence of accurate

information on the extent and the types of disorders.

Institutionalised populations are routinely excluded from community surveys

such as the National Survey of Mental Health and Wellbeing, hence the need

to survey them separately to provide comparative data and to ensure that key

population groups are not forgotten.

Two groups of prisoners are considered in this report: those entering the

correctional system either for the first time or as repeat offenders, and those

who have been sentenced and may have been detained for some time.

What is clear from this report is that the mental health needs of the prisoner

population are considerable compared with those of the general community

and that a large unmet need exists. These data provide a solid basis on which

to plan appropriately targeted mental health services within the correctional

system and ensure that appropriate screening and treatment programmes

exist both at the point of reception and for those who are sentenced.

Psychiatric problems rarely exist in isolation, however in this group the comorbidities are formidable.

While this survey provides benchmark data on mental illness in NSW prisons,

it leaves a number of questions unanswered. Of particular importance is the

role of community mental health services in keeping the mentally ill out of gaol

and the contribution of mental illness to offending behaviour.

The dedication and determination of key mental health and research staff

ensured the success of the projects reported in this document. They should

be considered as pilot studies which will hopefully be repeated with adequate

resources to expand their scope and minimise the number who could not be

screened. It would also be appropriate to consider a national survey to

examine differences between the various states and to promote national

collaboration on prison mental health.

Dr Richard Matthews

Chief Executive Officer

July 2003.

EXECUTIVE SUMMARY

Anecdotal evidence from staff working in the New South Wales’ correctional system has always suggested a high prevalence of mental illness among the prisoner population. This perception, along with the lack of reliable epidemiological data on mental illness prompted Corrections Health to conduct two studies to examine this issue.

Limited information on mental illness among NSW prisoners was collected as part of the 1996 Inmate Health Survey. The main reason for undertaking these two projects was to enhance this information and provide more detail in relation to specific psychiatric disorders among the reception and sentenced prisoner populations. The information arising from these surveys can be used to inform service planning and provision.

Study 1 was a sample of male and female inmates screened on reception to the NSW correctional system over a three-month period.

Study 2 screened a sample of sentenced inmates from across the state as part of the 2001 Inmate Health Survey.

The same instrument used in the National Survey of Mental Health and Wellbeing was adopted to enable comparisons with the wider community. This instrument is essentially a modified version of the Composite International Diagnostic Interview (CIDI), which yields twelve-month and one-month ICD-10 and DSM-IV diagnoses.

Key Findings

The prevalence of mental illness in the NSW correctional system is substantial and consistent with international findings.

The twelve-month prevalence of ‘any psychiatric disorder’ (psychosis, anxiety disorder, affective disorder, substance use disorder, personality disorder, or neurasthenia) identified in the NSW inmate population is substantially higher than in the general community (74% vs. 22%).

Almost half of reception (46%) and over one-third (38%) of sentenced inmates had suffered a mental disorder (psychosis, affective disorder, or anxiety disorder) in the previous twelve months.

Female prisoners have a higher prevalence of psychiatric disorder than male prisoners.

Psychiatric morbidity was higher among reception prisoners compared with sentenced prisoners.

There was comparatively little difference between the one-month and twelve month prevalence estimates of mental disorder.

Two-thirds of reception prisoners had a twelve-month diagnosis of substance use disorder.

The high rate of mental disorder among inmates cannot be attributed to substance use disorder alone.

40% of reception prisoners had a twelve-month diagnosis of opioid use disorder.

Almost one in ten inmates reported experiencing symptoms of psychosis in the twelve months prior to interview.

An estimated 4% to 7% of reception inmates suffer from a functional psychotic mental illness.

The twelve-month prevalence of psychosis in NSW inmates was thirty times higher than in the Australian community.

14% of male receptions and 21% of female receptions had a one-month diagnosis of depression.

The most common group of mental disorders were anxiety disorders with over one-third of those screened experiencing an anxiety disorder in the previous twelve months.

Post-traumatic stress disorder (PTSD) was the most common anxiety disorder (24%).

One in twenty prisoners had attempted suicide in the twelve months prior to interview.

Females were more likely than males to utilise health services for mental health problems.

Prisoners with a psychiatric diagnosis had higher levels of disability.

Recommendations

Current screening procedures for reception prisoners should be reviewed and, if necessary updated to improve diagnostic accuracy at the point of reception.

There should be a case management approach towards mentally ill inmates with high levels of need. Interventions should be adapted to the psychiatric needs of the prisoner with an evidence-based justification.

There should be co-ordinated pre-release planning involving external agencies in the community.

Current treatment and rehabilitation programmes for mentally ill prisoners within the prison system should be reviewed to assess whether or not treatment guidelines are adequate.

Resources should be made available to conduct a more comprehensive survey of prisoners’ mental health covering disorders such as, schizophrenia and attention deficit disorder.

Drug and alcohol rehabilitation should be integrated into the treatment of mentally ill offenders.

Residential treatment units should be developed within the correctional setting to house mentally ill prisoners who require a therapeutic environment but not hospitalisation. These units should be staffed by skilled mental health workers and appropriately trained custodial officers.

Social and psychological programmes, such as cognitive behavioural therapy, should be made available to inmates. Treatment should be multidisciplinary and commensurate with that provided in the community.

Current transportation practices of inmates with severe mental illness should be reviewed

Establish a forensic mental health directorate to coordinate the treatment, care and rehabilitation of forensic patients in NSW.

The NSW Forensic Mental Health Strategy should be adopted by CHS to guide service development and resource allocation.

Court liaison services in NSW should be expanded to include all magistrate courts to facilitate the diversion into mental health care of those with a mental illness who have been charged with minor crimes.

The number of secure forensic psychiatric beds in the community should be increased.

All forensic patients should be transferred out of the criminal justice system and into a community forensic mental health system for care, containment, and rehabilitation.

ACKNOWLEDGEMENTS

This project would have been impossible to complete without the dedication

and commitment of the nurse interviewers – David Cain, Dale Owens, Chris

Muller, Lee Trevathan, Michael Harris, Alison Lee, Peter Sadler, Rebecca

Gibson, and Eli Baxter.

We wish to thank A/Professor Carolyn Quadrio for her encouragement to

pursue this project and Ms Anne Doherty for her support.

We wish to thank the NSW Department of Corrective Services for providing

custodial staff to assist with retrieving inmates, particularly Mr Brian Kelly from

the MRRC, and Ms Lee Downes from Mulawa.

NSW Health provided financial support to cover the cost of writing this report

and for providing laptop computers (Mr George Fisher) necessary to

administer the questionnaire. The Department of Corrective Services also

provided financial support for the 2001 Inmate Health Survey.

Professor Gavin Andrews for encouraging us to use the NSMHWB screening

instrument. Mr Tim Slade from CRUFAD was helpful in preparing the data for

analysis. Mr Lucas Milner and Ms Azar Kariminia provided invaluable

assistance in checking the data contained in the document. Imelda Butler and

Ms Anne Cummins provided editorial assistance.

INTRODUCTION

Prisoner populations are comprised of some of the most disadvantaged and

stigmatised individuals in the community. People from disadvantaged

backgrounds, poor educational attainment, histories of unemployment, and

indigenous populations are over-represented among prisoner populations in Australia.

International studies have found an over-representation of those with a mental

illness in prison.1-5 A recent meta-analysis of sixty-two prison mental health

surveys found that inmates were substantially more likely to have a psychotic

illness, major depression, and a personality disorder than the general population.6

There are few Australian studies measuring the prevalence of mental illness

among prisoners. Those which have been conducted have had comparatively

small sample sizes and therefore limited generalisability. All found a high

prevalence of mental disorder in correctional communities studies.5;7;8

In 1996, a wide-ranging survey conducted by the NSW Corrections Health

Service (CHS) found that 50% of females and 33% of males self-reported that

they had been diagnosed with a mental illness at some time in the past with

significant numbers scoring positive for depression according to the Beck

Depression Inventory.9 Using the Referral Decision Scale which was

developed by Teplin (1989) to identify prisoners with sufficient symptomology

to require further psychiatric assessment, 56% of females and 30% of males

were recommended for referral for major depression, 20% of females and

12% of males required referral for manic-depression, and 33% of females and

18% of males required referral for schizophrenia.10 While the schizophrenia

referral rate is high, it is important to be aware that this instrument was

designed to include false-positives rather than false-negatives, thus the

prevalence of schizophrenia is likely to be somewhat inflated.

This initial survey shed some light on the unknown demand for mental health

services in NSW; however it was subject to the limitations of self-report. A

decision was made to undertake a more formal assessment to examine the

prevalence of mental illness in the NSW correctional system using a

recognised psychiatric diagnostic tool.

Further justification for conducting these assessments is that institutionalised

populations such as prisoners are routinely excluded from community surveys

such as the National Survey of Mental Health and Wellbeing (NSMHWB) and

the National Health Survey.11;12

The reception assessment, which is conducted on all new admissions into the

correctional system ascertains the specific health needs of the inmate in three

key health areas: medical status, drugs and alcohol, and mental health

including suicide and self-harm. Notably, it does not involve any formal tool for

diagnosing mental illness. Concerns had been expressed that the current

approach to assessment was biased towards identifying psychosis and

overlooked conditions such as mood and anxiety disorders.

This report presents the results from two correctional populations: (1) those

admitted to the correctional system (receptions); and (2) those already serving

a custodial sentence (sentenced) as part of the 2001 Inmate Health Survey.13

METHODS

Overview

The initial intention of the reception assessment project was to screen all

consecutive prison receptions over a one-month period. However, in the male

group this was not feasible for a number of reasons: lack of interview staff to

screen all new receptions especially on days with large numbers of new

intakes, inmates transferred to other gaols before they could be interviewed,

lack of custodial staff to assist with inmate retrieval, ‘lock downs’1, inmates

who were too mentally unwell to be screened, and those released to freedom

prior to screening. In contrast, the female sample presented fewer logistical

challenges given the reduced numbers.

Bearing in mind that prisoners could be released following bail appearances

or transferred to other gaols at short notice, it was decided to interview

prisoners within twenty-four hours of being received into custody.

It was assumed that new receptions place a higher demand on health

resources. It was decided to screen all reception inmates rather than just

those on remand. The latter group can be held for considerable time in gaol

and were deemed to have more in common with sentenced inmates who were

to be screened as part of the 2001 Inmate Health Survey (Study 2).

The NSW Inmate Health Survey is a broad based assessment of the physical

and mental health status of the state’s prisoner population. It was first

conducted in 1996 and was repeated in 2001. The design is a cross-sectional,

random sample of inmates, stratified by sex, age and Aboriginality. The

sample represents approximately 11% of male and 40% of female prisoners.9

The 1996 survey did not utilise a formal psychiatric screening instrument but

relied on self-reported histories of mental illness. It was decided that the 2001

undertaking should incorporate the same approach to mental health

assessment as used in Study 1.

Study 1 (Reception Prisoners)

The main reception site used in Study 1 was the Metropolitan Remand and Reception Centre (MRRC) in western Sydney. Over three-quarters of the state’s reception prisoners are processed at the MRRC. A number of remote reception sites (Bathurst, Cessnock and Goulburn) also process reception prisoners and were included in Study 1 (Table 1). Almost all female reception prisoners are processed at Mulawa Correctional Centre which is located on the same complex as the MRRC in Sydney.

Each day, the team leader contacted the duty officer from the Department of Corrective Services and obtained a list of receptions processed on the previous night. At the main reception site, prisoners can arrive between 4pm

and midnight with the number of new admissions varying between 0 and 50

on any one day. The assessors would systematically work through the list of

reception prisoners. This was a particularly difficult task at the MRRC as

inmates are held in a series of ‘pods’ across the complex and therefore

required the assistance of custodial officers to escort subjects to the study

area for the interview.

Once located, the inmates were given an explanation of the project and

invited to participate. Those agreeing to participate were interviewed in a

private office by a team member using the screening instruments described above.

The sample of reception prisoners therefore represents a consecutive

convenience sample of inmates over a three month period. This approach is

not ideal but was the only practicable approach available. A process of

randomisation would have been impractical.

Study 2 (Sentenced Prisoners)

In contrast to Study 1, Study 2 screened inmates from all NSW gaols as part

of the 2001 Inmate Health Survey.13 The Metropolitan Reception and Remand

Centre (MRRC) was not included in Study 2 as it had been the main centre

used in Study 1.

The study sample is designed to be representative of the sentenced prisoner

population and to provide prevalence estimates across a wide range of health

conditions.9 Details of the methodology are described elsewhere.13

Following the completion of the Inmate Health Survey, a list of participants

was forwarded to the project manager who organised for the mental health

assessment to be administered to all available inmates within two to three

weeks. Inmates were remunerated $5 for participating in the survey as many

had to miss work and would have forfeited pay.

Interviewers

Study 1 used CHS mental health nurses to screen inmates. All interviewers

received training in the use of the screening instruments from senior CHS

mental health staff. Interviewers in Study 2 included both CHS nurses and

forensic psychology master’s degree students. Security awareness training

was provided for those not currently working within the correctional system.

Furthermore, students were also paired with an experienced team leader who

was able to resolve any issues should they arise in the course of the

interview.

Page 10

Screening Instruments

The Composite International Diagnostic Interview (CIDI)

Making diagnostic comparisons with epidemiological studies conducted in the

general community, other correctional communities, both nationally and

internationally, was a priority. The recent National Survey of Mental Health

and Wellbeing (NSMHWB) and the study of psychiatric morbidity in New

Zealand prisons had both used the Composite International Diagnostic

Interview (CIDI).12;14

Following discussions with the developers of the NSMHWB, it was decided to

utilise this instrument. This is essentially a modified version of the CIDI-A,

which yields both DSM-IV and ICD-10 diagnoses.12;15-17 This instrument also

incorporates several measures of disability (SF-12, BDQ), personality disorder

(the International Personality Disorder Examination - IPDE), general

psychiatric morbidity (GHQ-12), and psychological distress (K10). Psychosis

was diagnosed using a short screener, incorporated into the program. The

CIDI is relatively inaccurate in diagnosing particular types of psychotic illness.

For the purpose of this report the psychosis screener data is to be regarded

as ‘any psychosis’.

The psychosis screener is sensitive to the presence of psychotic symptoms

due to any cause, but does not differentiate between the different types of

psychotic disorders (drug induced psychosis, brief episodic psychosis, and

functional psychotic illness). Thus it was not possible to determine the

prevalence of functional psychotic mental illness (schizophrenia,

schizophreniform psychosis, schizoaffective disorder, delusional and affective

psychosis), using the psychosis screener alone. To address this, two

clinicians assessed a sub-group of reception inmates who were psychosis

screener positive or psychotic according to clinical impression. They applied

the Longitudinal history, Expert [interview by a psychiatrist], All available Data

(LEAD) protocol. This assessment includes a clinical interview, a review of all

documentation and longitudinal history. Those with a ‘definite’, ‘possible’

diagnosis or ‘no diagnosis’ of a functional psychotic mental illness were

identified using this protocol.

The BDQ was scored according to the Medical Outcomes Study (MOS) as the

individual items used to generate the score were regarded as more relevant to

the prisoner population.

The advantages of using the NSMHWB instrument are threefold: (1) it enables

direct comparisons to be made with both national and international community

samples, and (2) it generates both ICD-10 and DSM-IV diagnoses, and (3) it

is computer-based and can be administered by a layperson following training.

The 144-item version of Cloninger’s Temperament Character Inventory (TCI)

was also administered as a measure of personality.18 This is a dimensional

measure which attempts to overcome the limitations of categorical measures

of personality disorder. Categorical measures produce multiple diagnoses with

Page 11

overlapping traits and have limited clinical utility when considering the types of

interventions to implement. Dimensional measures of personality are clinically

more helpful in that they better describe the nature of the traits that are

present in the population and thus better inform treatment needs. The TCI

data are not presented in this report.

Data Analysis

Data from the CIDI were imported into SPSS 11 using a program written by

staff at the Clinical Research Unit for Affective Disorders, St Vincent’s

Hospital, Sydney.19 This program imports the raw data from the automated

interview into SPSS and runs a scoring algorithm, which generates the ICD-10

and DSM-IV diagnoses.

Some of the demographic questions administered to the community sample

were inappropriate for a prisoner population and phrased in such a way that

they could not be used in the analysis. For example, the community group

were interviewed in their homes and questions regarding accommodation

pertained to the house in which the assessment took place eg. was it being

rented or mortgaged? Similarly, the employment questions asked about job

seeking in the recent past - it is unlikely that someone facing a prison

sentence would be actively seeking work.

For the purposes of this report, demographic data (age, education status,

country of birth and source of income) were combined across the reception

and sentenced groups. Tables presenting the demographic data use the

twelve-month ICD-10 diagnoses.

For the purpose of this report, ‘any psychiatric disorder’ refers to any

psychosis, anxiety disorder, affective disorder, substance use disorder,

personality disorder or neurasthenia diagnosed by the CIDI.

Summary statistics presented in this report were calculated in SPSS 11.

Page 12

RESULTS

Between March and June of 2001, 953 inmates (777 males and 176 females)

were screened at four of the five male reception centres and the one female

reception centre in NSW. Across male reception centres, over 30% of all

reception inmates were screened during the period, and 56% of females.

Table 1: Number and proportion of inmates screened at reception sites in Study 1.

Reception site

Eligible reception

inmates

Number

screened

%

Screened

Site 1 (MRRC) 2310 676 29.3

Site 2 (Bathurst) 146 44 30.1

Site 3 (Cessnock) 67 22 32.8

Site 4 (Goulburn) 86 35 40.7

Female site (Mulawa) 312 176 56.4

Total 2921 953

To determine whether the inmates who were screened were broadly

representative of prison admissions during the assessment period,

comparisons were made between both reception and sentenced inmates

across a range of characteristics (Table 2).

In the reception group, the only significant differences between the screened

and non-screened groups were among men in terms of a slightly lower

proportion of indigenous inmates (11.5% vs. 15.1%), and those had been

referred to the mental health team (13.0% vs. 17.3%). There were no

significant differences between the screened and non-screened female

reception prisoners.

For the sentenced group, the profile of those screened and those not

screened was similar in terms of age, Aboriginality, proportion committing a

violent offence, and self-reported history of a previous psychiatric illness for

both males and females. For males, however, the median sentence length

was longer in the screened group. A likely explanation for this is probably the

release of those with short sentences before they could be interviewed. The

2001 Inmate Health Survey is designed to be representative of the NSW

prison population.

Based on these data, the sample of reception prisoners is broadly

representative of inmates received into the NSW correctional system. Those

referred for mental health assessment biased our results in favour of a lower

rate of mental illness.

We evaluated the prevalence of all psychiatric disorders present in both the

one month and one year prior to assessment. Those with a positive diagnosis

in the last month can be regarded as unwell at the time of the assessment and

reflects the immediate burden of illness on the service. The prevalence of

mental illness in the year prior would be more relevant to those sentenced and

reflects the burden of illness over time.

Page 13

Table 2: Comparison of screened and non-screened inmates for selected characteristics in

Study 1 (reception) and Study 2 (sentenced).

Characteristic Screened

Nonscreened

p-value

Number 777 1832

Mean age (years) 29.61 29.82 0.57

Aboriginality (%) 11.5 15.1 0.02

Referrals for detoxification (%) 40.1 43.2 0.19

Male

Mental health referrals* (%) 13.0 17.3 0.014

Number 176 136

Mean age (years) 29.10 29.46 0.7

Aboriginality (%) 29.0 21.9 0.21

Referrals for detoxification (%) 43.2 37.9 0.44

Female

Mental health referrals* (%) 16.6 21.6 0.36

Study 1 (Reception)

Number 469 279

Mean age (years) 33.8 32.2 0.07

Aboriginality (%) 30.1% 30.1% 0.94

Median sentence length 2.15 1.49 0.001

Violent offence (%) 52.6 48.2 0.36

Male

Previous psychiatric treatment 41.4% 39.6% 0.69

Number 110 58

Mean age (years) 32.7 33.9 0.42

Aboriginality (%) 16.4% 19.0% 0.83

Median sentence length 1.5 0.91 0.18

Violent offence (%) 35.6% 30.3% 0.81

Female

Previous psychiatric treatment 53.3% 54.3% 0.96

Study 2 (Sentenced)

* Mental health referral data available for MRRC only

Overall Prevalence Estimates

Table 3 shows the twelve-month and one-month prevalence of mental illness

for male and female, reception and sentenced prisoners.

Page 14

Table 3: Twelve-month and one-month ICD-10 prevalence estimates of major disorders among male

and female prisoners, New South Wales (Australia).

RECEPTION SENTENCED

MALE (N=756) FEMALE (N=165) MALE (N=458) FEMALE (N=108)

12 Month 1 Month 12 Month 1 Month 12 Month 1 Month 12 Month 1 Month

ICD-10 Diagnosis N % N % N % N % N % N % N % N %

Psychosis 81 10.7 - - 25 15.2 - - 19 4.2 - - 6 5.7 - -

Affective Disorders

Depression1 121 16.0 102 13.5 39 23.6 34 20.6 43 9.5 23 5.1 15 14.4 8 7.7

Dysthymia 54 7.2 46 6.1 16 9.7 15 9.1 17 3.8 15 3.4 6 5.8 4 3.8

Manic episode2 21 2.8 10 1.3 13 7.9 9 5.5 6 1.3 0 0.0 2 1.9 2 1.9

Any Affective Disorder 158 21.1 128 17.1 56 33.9 50 30.3 55 12.4 31 7.0 21 20.4 12 11.8

Anxiety Disorders

Post traumatic stress disorder 164 21.7 128 16.9 72 43.6 62 37.6 73 16.2 43 9.5 46 43.8 30 28.6

Generalised anxiety disorder 101 13.4 94 12.4 37 22.4 33 20.0 56 12.4 40 8.8 16 15.2 13 12.4

Panic disorder 55 7.3 35 4.6 28 17.0 14 8.5 31 6.9 12 2.7 17 16.2 5 4.8

Agoraphobia 23 3.0 22 2.9 5 3.0 4 2.4 9 2.0 6 1.3 6 5.7 4 3.8

Obsessive compulsive disorder 20 2.7 17 2.3 4 2.4 3 1.8 7 1.6 6 1.4 2 2 1 1.0

Social phobia 11 1.5 8 1.1 1 0.6 1 0.6 4 0.9 4 0.9 1 1.0 1 1.0

Any Anxiety Disorder 250 33.9 206 28.0 92 55.8 78 47.3 126 28.4 80 18.1 56 54.4 39 37.9

Any Mental Disorder (above) 314 42.0 273 36.5 102 61.8 89 53.9 147 33.0 97.0 21.8 61 59.2 45 43.7

Substance Use Disorders2

Alcohol dependence 142 19.2 59 8.0 27 16.5 10 6.1 50 11.3 3.0 0.7 5 4.9 0 0.0

Alcohol abuse 24 3.3 17 2.3 3 1.8 2 1.2 10 2.3 0 0.0 3 2.9 1 1.0

Cannabis dependence 136 18.7 108 14.9 37 23.0 28 17.4 54 12.4 7 1.6 17 16.8 2 2.0

Cannabis abuse 18 2.5 13 1.8 4 2.5 3 1.9 5 1.1 1 0.2 1 1.0 0 0.0

Opioid dependence 251 34.5 189 26.0 86 53.4 60 37.3 64 14.6 7 1.6 38 37.6 2 2.0

Opioid abuse 13 1.8 6 0.8 1 0.6 0 0.0 2 0.5 0 0.0 1 1.0 0 0.0

Sedative dependence 83 11.4 72 9.9 46 28.6 28 17.4 25 5.7 2 0.5 23 22.8 3 3.0

Sedative abuse 2 0.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.0 0 0.0

Stimulant dependence 202 27.8 166 22.8 77 47.8 55 34.2 47 10.8 3 0.7 29 28.7 0 0.0

Stimulant abuse 21 2.9 7 1.0 4 2.5 3 1.9 4 0.9 0 0.0 1 1.0 0 0.0

Any Substance Use Disorder 466 63.7 339 46.6 120 74.5 92 57.1 147 33.6 15 3.4 58 57.4 6 5.9

Personality Disorders

Impulsive 162 21.4 - - 52 31.5- - 86 19.0- - 14 13.3 - -

Paranoid 150 19.8 - - 46 27.9- - 68 15.0- - 16 15.2 - -

Borderline 149 19.7 - - 51 30.9- - 60 13.3- - 14 13.3 - -

Anxious 144 19.0 - - 38 23.0- - 52 11.5- - 19 18.1 - -

Schizoid 123 16.3 - - 37 22.4- - 47 10.4- - 16 15.2 - -

Anankastic 110 14.6 - - 31 18.8 - - 11.1 11.1 - - 17 16.2 - -

Dependent 83 11.0 - - 35 21.2 - - 22 4.9 - - 9 8.6 - -

Histrionic 50 6.6 - - 19 11.5 - - 14 3.1 - - 3 2.9 - -

Dissocial 19 2.5 - - 4 2.4 - - 12 2.7 - - 3 2.9 - -

Any Personality Disorder 303 40.1 - - 94 57.0 - - 166 36.7 - - 40 38.1 - -

Neurasthenia4 27 3.6 24 3.2 17 10.3 13 7.9 7 1.5 5 1.1 8 7.6 7 6.7

Any Psychiatric Disorder 583 78.2 496 66.7 146 90.1 137 84.6 272 61.0 172 38.7 81 78.6 56 54.9

1 Includes mild, moderate and severe depression.

2 Includes Mania, hypomania, and bipolar affective disorder.

Page 15

Any Psychiatric Disorder1

Overall, the majority of male and female reception prisoners were found to

have had a psychiatric disorder in the twelve months prior to interview (78%

vs. 90%).

The twelve-month prevalence of ‘any psychiatric disorder’ was higher among

females than males in both the reception and sentenced groups (86% vs.

72%) and higher among reception prisoners compared with those currently

serving a sentence (80% vs. 64%).

Age

In both males and females, the prevalence of ‘any psychiatric disorder’

declined with age. The highest prevalence of ‘any psychiatric disorder’ was in

females under 25 years old and was lowest was for men over 40 years of age

(Figure 1).

Marital Status

For males, the prevalence of ‘any psychiatric disorder’ was similar across all

categories of marital status. In females, the prevalence of ‘any psychiatric

disorder’ was highest amongst the married/defacto group (Table 4).

Country of Birth

The prevalence of ‘any psychiatric disorder’ was highest in men and women

born in Australia.

Source of Income

The prevalence of ‘any psychiatric disorder’ was lowest in males reporting

other sources of income compared with females in which it was highest.

Highest qualification

Overall, females with post-school qualifications had the highest levels of ‘any

psychiatric disorder’ and for males the lowest prevalence was among those

with a secondary school qualification.

1 Note: this refers to any psychosis, anxiety disorder, affective disorder, substance use

disorder, personality disorder or neurasthenia.

Page 16

Figure 1: Prevalence of ‘Any Psychiatric Disorder’ (% positive) by age and sex (twelve-month

diagnosis).

Table 4: Prevalence (%) of ‘any psychiatric disorder’ among male and

female prisoners by marital status, country of birth, income, and highest

qualification (twelve-month diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married/ defacto 70.6 90.0

Divorced / separated/ widowed 73.5 85.5

Never married 71.8 81.3

Country of Birth

Australia 74.4 87.7

Other English speaking country 66.7 81.8

Other country 66.4 77.8

Source of Income

Wage or salary 62.6 81.5

Pension or benefit 80.2 88.2

Other source of income 50.8 92.3

Highest qualification

No qualification 72.3 84.7

Secondary school qualification 50.0 80.0

Post-school qualification 71.5 87.3

Comment

These data support the view that inmates in NSW are an extremely

psychologically disturbed group. The overall burden of mental illness that

these findings suggest for both the Corrections Health Service and the

Department of Corrective Services is staggering.

72.4%

76.6%

58.2%

91.7%

83.7%

79.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 17

Any Mental Disorder (psychosis, anxiety or affective

disorder)1

Almost half (46%) of the receptions and 38% of the sentenced group had at

least one mental disorder in the year prior to interview. Anxiety disorder was

the most common complaint in both the reception and sentenced groups (38%

and 33%). Affective disorder was the second most common mental disorder

(23% among receptions and 14% among sentenced). Psychosis prevalence

among reception and sentenced prisoners was 12% and 5% respectively.

Demographic Correlates of Any Mental Disorder

Age

The prevalence of any mental disorder was higher for women than men

across all age groups. For women, the rate slightly increased after the age of

40 but decreased for men over 40 years (Figure 2).

Marital Status

The prevalence of any mental disorder was similar across all categories in

males. In women, the prevalence of mental disorder was highest in those who

were divorced/separated/widowed (Table 5).

Country of Birth

The lowest prevalence of any mental disorder in both males and females was

found in those born in non-English speaking countries.

Source of Income

In males, the lowest prevalence of any mental disorder was found among

those with other sources of income whereas the opposite was true for

females. Approximately two-thirds of women with other income sources had

an anxiety disorder, affective disorder or psychosis.

Highest qualification

The prevalence of any mental disorder was similar across educational groups

in females whereas for males it was lowest among those with secondary

school qualifications.

1 Note: ‘any mental disorder’ refers to any of the following: psychosis, anxiety disorder or

affective disorder.

Page 18

Figure 2: Prevalence of any mental disorder (anxiety disorder, affective disorder or psychosis)

(% positive) by age and sex (twelve-month diagnosis).

Table 5: Prevalence (%) of any psychosis, anxiety or affective disorders

among male and female prisoners by marital status, country of birth,

income, and highest qualification (twelve-month diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married/ defacto 40.0 54.5

Divorced / separated/ widowed 40.7 73.9

Never married 36.7 58.2

Country of Birth

Australia 40.9 62.6

Other English speaking country 31.7 72.7

Other country 30.0 22.2

Source of Income

Wage or salary 34.6 61.5

Pension or benefit 44.1 61.6

Other source of income 27.9 69.2

Highest qualification

No qualification 37.8 59.5

Secondary school qualification 28.6 60.0

Post-school qualification 40.0 62.7

Comment

The prevalence of ‘any mental disorder’ is very high and significantly higher

than in the general community.12 It is possible that concurrent/co-morbid

substance abuse and dependence contributes to the high prevalence of

mental disorder amongst prisoners in NSW. Nonetheless, this reflects the

reality for this population group and, at minimum reflects the degree of

suffering due to psychiatric disturbance, from any cause. Females had the

highest prevalence of mental disorder compared with males.

36.7%

41.2%

35.9%

60.5% 60.1%

64.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 19

Psychosis

Psychotic disorders are extremely disabling and are characterised by

symptoms such as hallucinations, delusions and a severe inability to make

realistic and rational decisions. These kinds of symptoms can have a profound

effect on judgement. Individuals with psychosis are vulnerable to exploitation

in environments that are not therapeutic. Psychosis can occur briefly (for

example when the person is high on certain drugs) or can remain for the

duration of a person’s life (for example in people who suffer from chronic schizophrenia).

There are many types of psychotic disorders including schizophrenia,

schizoaffective disorder, mood disorders with psychosis, and drug induced

psychosis. Schizophrenia is a chronic, recurrent and debilitating mental illness

from which a minority recover. Psychosis, whether induced by drugs or

caused by mental illness is the most severe form of psychological

disturbance.

Overall, 9% of respondents (receptions and sentenced) had experienced

psychotic symptoms in the year prior to interview. Psychosis was more

common among reception prisoners than sentenced inmates (12% vs. 5%).

Psychosis was higher among females than males (12% vs. 8%).

Eighty-seven inmates who screened positive for psychosis were assessed

using the LEAD protocol described above. The prevalence of ‘definite’ and

‘probable’ schizophrenia among those screening positive for psychotic mental

illness was estimated to be between 4% and 7%.

Demographic Correlates of Psychosis

Age

The prevalence of psychosis was higher in females under 25 and over 40

compared with males in the same age groups, but similar to males in the 25-

40 year old group. There was a marked decline in the prevalence of psychosis

in males over 40 years of age (Figure 3).

Marital status

The prevalence of psychosis was similar across all marital categories within

the male and female groups (Table 6).

Country of Birth

Among females, the prevalence of psychosis was highest among those born

in Australia. The lowest rate of psychosis was found among males and

females from non-English speaking countries.

Page 20

Source of income

In males, those who were receiving a pension or benefit had the highest

prevalence of psychosis whereas for females, the highest prevalence was

found in those with other income sources.

Highest Qualification

In the female group, those with post-school qualifications had the highest

prevalence of psychosis. In the male group, those with secondary school

qualifications had the lowest prevalence of psychosis. No one with symptoms

of psychosis was found among those reporting secondary school

qualifications.

Figure 3: Prevalence of psychosis (% positive) by age and sex (twelve-month diagnosis).

Table 6: Prevalence (%) of psychosis among male and female prisoners by

marital status, country of birth, income, and highest qualification (twelvemonth

diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married/ defacto 8.7 11.9

Divorced / separated/ widowed 5.6 11.4

Never married 9.2 11.1

Country of Birth

Australia 8.6 12.1

Other English speaking country 9.0 11.1

Other country 6.3 5.6

Source of Income

Wage or salary 3.7 7.6

Pension or benefit 11.1 13.8

Other source of income 9.7 15.4

Highest qualification

No qualification 9.3 10.3

Secondary school qualification 0.0 0.0

Post-school qualification 7.0 13.6

8.7%

9.6%

4.0%

13.8%

10.1%

11.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 21

Comment

Psychotic inmates can make significant demands on resources within the

correctional environment and are difficult to manage as a consequence of

their unique needs.

The prevalence of psychosis, as described above, may include psychosis

caused by substance use and/or mental illness. One in ten people received

into the correctional system had experienced psychotic symptoms in the

previous year. Seven percent of receptions probably had schizophrenia

according to the follow-up using the LEAD protocol. In NSW 18,000

receptions occur annually meaning that on an average day around four people

suffering schizophrenia will enter ‘the system’.

One in twenty sentenced inmates had been actively psychotic in the previous

year. While some of these sentenced inmates may have been in the

community, many would have been in prison at the time they were unwell.

The higher prevalence of psychosis among females with post-school

qualifications may reflect the later onset of psychosis in females in general

who are thus able to complete tertiary studies prior to onset.

The twelve-month prevalence of psychosis in NSW inmates was 30 times

higher than in the Australian community. The prevalence of schizophrenia and

related disorders approximates that found in the New Zealand survey of

prisoners (6%) but higher than reported in a recent meta-analysis of

psychiatric illness among prisoner populations (3.7% - 4.0%).6

Page 22

Affective Disorders

Affective disorders are disturbances of mood and include depression,

dysthymia and mania. It is normal for a person’s mood to fluctuate with ‘highs’

and ‘lows’. When a high or low mood persists and affects functioning at home,

work or socially then the person has a mood disorder.

Depressive disorder is a mood disturbance that is persistently and markedly

low or sad, as compared to normal. It persists for at least two weeks, and

affects the person’s appetite, sleeping patterns, concentration, motivation,

drive and energy levels. Dysthymia is a longstanding lower grade mood

disturbance than depression that has persisted for years. It is distinguished

from depression by its long-term presence with relatively less severe

disturbance in functioning. Mania is an elevated mood persisting for at least

one week and can affect appetite, sleeping patterns, concentration,

motivation, drive and energy levels in an opposite way to depression. It can

occur alone or can alternate with low moods in patterns of extreme highs and

lows and is often known as Manic Depression or Bipolar Disorder.

Twenty percent (20%) of all those surveyed reported suffering at least one

type of mood disorder in the prior twelve months (Table 7). The prevalence of

any affective disorder was higher among females than males (29% vs. 18%).

Mood disorders were more common among reception prisoners than

sentenced (23% vs. 14%).

The most common type of mood disorder in both the reception and sentenced

groups was depression (17% and 10%). Any depressive illness was 1.5 times

more common for reception males and females than those who had been

sentenced.

Mania was the least prevalent mood disorder. Four percent of the reception

group reported at least one manic episode compared with 1% in the

sentenced group.

The prevalence of dysthymia was higher among reception prisoners

compared with sentenced (8% vs. 4%).

Table 7: Twelve-month ICD-10 prevalence estimates of affective disorder.

RECEPTION SENTENCED

Male Female Total Male Female Total

Affective Disorder % % % % % %

Depression1 16.0 23.6 17.4 9.5 14.4 10.4

Dysthymia 7.2 9.7 7.7 3.8 5.8 4.2

Manic episode2 2.8 7.9 3.7 1.3 1.9 1.4

Any Affective Disorder 21.1 33.9 23.4 12.4 20.4 14.0

1 Includes mild, moderate and severe depression.

2 Includes mania, hypomania, and bipolar affective disorder.

Page 23

Demographic Correlates of Affective Disorders

Age

The prevalence of affective disorders across all age groups showed the same

patterns for females and males. The prevalence was highest in the 25-40 age

group (Figure 4).

Marital Status

In men and women those who were divorced/separated/widowed had the

highest prevalence of mood disorders (Table 8).

Country of Birth

The lowest rate of mood disorders was in males born in non-English speaking

countries and highest in women born in other English speaking countries.

Source of Income

For males, the prevalence of mood disorders was highest among those

receiving pensions or benefits, and for females it was highest in those with

other sources of income. Conversely, for males mood disorders were lowest

among those with other income sources.

Highest Qualification

Interestingly, males and females with post-school qualifications had the

highest prevalence of affective disorder. There was a large difference

between males and females in the proportion of those with secondary school

qualifications who had a mood disorder diagnosis.

Figure 4: Prevalence of any affective disorder (% positive) by age and sex (twelve-month

diagnosis).

14.8%

20.3%

17.7%

23.3%

32.4%

26.5%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 24

Table 8: Prevalence (%) of affective disorders among male and female

prisoners by marital status, country of birth, income, and highest

qualification (twelve-month diagnosis).

Comment

Incarceration results in the loss of many personal freedoms taken for granted

in the community, including social supports, inter-personal relationships,

employment, social status, and social role. These losses are commonly

correlated with depressive disorder. At the time of reception almost onequarter

were diagnosed with a mood disorder, which is more severe than

simply feeling ‘down’ about their circumstances.

Along with schizophrenia, depression is associated with an increased risk for

suicide and could be ameliorated through effective screening, diagnosis and

treatment.

Having had any affective disorder in the year prior to interview was 3.4 times

more common among NSW prisoners than in the Australian community (20%

vs. 5.8%).

The low rate of mania is similar to that reported in a recent study of New

Zealand prisoners.14

Demographic Characteristic Male Female

Marital Status % %

Married / defacto 17.2 27.7

Divorced / Separated / Widowed 24.4 31.9

Never married 15.5 27.6

Country of Birth

Australia 19.0 30.0

Other English speaking country 16.7 36.4

Other country 13.5 22.2

Source of Income

Wage or salary 17.3 23.1

Pension or benefit 19.5 30.4

Other source of income 9.8 38.5

Highest qualification

No qualification 17.7 26.1

Secondary school qualification 0.0 20.0

Post-school qualification 18.6 32.7

Page 25

Anxiety Disorders

Anxiety is a common experience in everyday life. Feeling anxious about

certain things is normal and important for adaptation and survival. However,

the degree of anxiety that some people feel is sometimes excessive and

impacts on their functional capacity and can be debilitating. Anxiety disorders

are diagnosed when anxiety is either persistent or persistently recurrent, and

affects a person’s ability to work, have relationships or interact with others in

social situations.

Over 36% of all those screened experienced an anxiety disorder in the twelve

months prior to interview (Table 9). The prevalence was substantially higher

among females than males in both the reception (56% vs. 34%) and

sentenced (54% vs. 28%) groups. Interestingly, the prevalence of anxiety

disorders did not differ markedly between the reception and sentenced

prisoners in both males and females (34% vs. 28% for receptions, and 56%

vs. 54% for sentenced).

Post-traumatic Stress Disorder (PTSD) was the most common anxiety

disorder, with 26% of reception prisoners and 21% of sentenced prisoners

meeting the diagnostic criteria in the previous twelve months.

Generalised Anxiety Disorder (GAD) was the second most common disorder,

occurring in 15% of reception and 13% of sentenced prisoners. Panic disorder

was more common in females than males (17% vs. 7% for reception

prisoners; and 16% vs. 7% for sentenced prisoners). Agoraphobia, obsessivecompulsive

disorder (OCD), and social phobia were relatively rare (3%, 2%

and 1%).

Table 9: Twelve-month ICD-10 prevalence estimates of anxiety disorders.

RECEPTION SENTENCED

Male Female Total Male Female Total

Anxiety Disorder % % % % % %

Post traumatic stress disorder 21.7 43.6 25.6 16.2 43.8 21.4

Generalised anxiety disorder 13.4 22.4 15.0 12.4 15.2 12.9

Panic disorder 7.3 17.0 9.0 6.9 16.2 8.6

Agoraphobia 3.0 3.0 3.0 2.0 5.7 2.7

Obsessive compulsive disorder 2.7 2.4 2.7 1.6 2.0 1.7

Social phobia 1.3 0.6 1.3 0.9 1.0 0.9

Any Anxiety Disorder 33.9 55.8 37.9 28.4 54.4 33.3

Page 26

Demographic Correlates of Anxiety Disorders

Age

Among males, the prevalence of anxiety disorder was similar across all age

groups. However, in females the prevalence increased with age from 52% in

those under 25 to 65% in those over 40 years (Figure 5).

Marital Status

In males, the prevalence of anxiety disorders did not differ between categories

of marital status; however, in the female group those who were widowed/

divorced/separated had a highest prevalence (Table 10).

Country of Birth

Males and females born in non-English speaking countries were less likely to

have had an anxiety disorder in the previous twelve months.

Source of Income

In males, anxiety disorder was highest in those receiving a pension or benefit

and lowest among those with other sources of income. In females the

prevalence was similar across all income groups.

Highest Qualification

In males, the prevalence of anxiety disorder was similar across all levels of

education. For women it was lower in those with no qualifications.

Figure 5: Prevalence of any anxiety disorder (% positive) by age and sex (twelve-month

diagnosis).

31.1% 32.5% 31.5%

52.3%

54.7%

64.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 27

Table 10: Prevalence (%) of anxiety disorders among male and female prisoners

by marital status, country of birth, income, and highest qualification (twelvemonth

diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married / defacto 31.7 50.5

Divorced / Separated / Widowed 33.9 68.1

Never married 31.0 51.0

Country of Birth

Australia 34.5 57.0

Other English speaking country 20.0 63.6

Other country 21.1 22.2

Source of Income

Wage or salary 30.1 56.9

Pension or benefit 35.3 55.8

Other source of income 23.3 53.8

Highest qualification

No qualification 31.3 53.6

Secondary school qualification 28.6 60.0

Post-school qualification 32.6 57.3

Comment

These data suggest that almost every second NSW inmate has experienced

some form of anxiety disorder in the previous twelve months.

The prevalence of anxiety disorders did not differ markedly between the

reception and sentenced prisoners.

The twelve-month prevalence of PTSD in NSW inmates (24%) was

substantially higher than that found in the general Australian community (3%).

This is interesting because most people view prisoners as ‘traumatisers’

rather than having been traumatised themselves. It also supports the notion

that inmates are more vulnerable to having experienced serious psychological

trauma in the past, likely associated with their upbringing, lifestyle and

temperament.

The high rate of Generalised Anxiety Disorder (GAD) confirms that this

population are burdened by substantial anxiety and worry about their life

circumstances.

It is likely that both PTSD and GAD are under-diagnosed in the prisoner

population. Both conditions are difficult to treat with medication alone and

require a combination of both medication and psychological intervention over

a fairly lengthy period of time.

Page 28

Suicidal Ideation

Suicide is a fatal outcome associated with mental illness. Risk factors for

suicide are common among prisoner populations including: younger age,

male, psychological distress, recent substance abuse, history of violence,

single marital status, multiple losses, poor social supports, and previous

suicide attempts. There are different motives for self-harm including attempts

to make others take notice, to relieve internal psychological tension, and intent

to actually take one’s life. Self-harm behaviour, driven by the intent to take

one’s own life, is suicidal intent and behaviour. It can be difficult to distinguish

between self-harm behaviour driven by other motives and suicidal behaviour.

Overall, 16% of all inmates had suicidal thoughts in the previous twelve

months, 10% had made a suicide plan and 5% had attempted suicide.

Among receptions, 18% had thought about suicide in the previous twelve

months, 59% of these had made a plan to commit suicide with over half of the

planners attempting suicide. In the sentenced group, 11% had thought about

suicide in the previous twelve months, 67% of these had made a plan to

commit suicide with almost half of the planners attempting suicide.

Between 1999 and 2002, the rate of completed suicide in NSW prisons was

approximately 80 per 100,000 compared with approximately 12 per 100,000

for all ages in the NSW community.

Suicidal ideation, plans and attempts in the twelve months prior were all more

common among reception prisoners, and more common among females than

males (Table 11).

Table 11: Suicidal ideation plans and attempts.

RECEPTION SENTENCED

Male Female Total Male Female Total

% % % % % %

Suicidal ideation 15.3 31.5 18.2 9.7 17.3 11.1

Suicide plan 7.8 24.2 10.8 6.8 10.6 7.5

Suicide attempts 5.3 9.7 6.1 3.2 5.8 3.7

Comment

The prevalence of suicidal thoughts and behaviours among NSW inmates are

approximately four times higher than in the general population (16% and

3.4%).20

Based on the number of successful suicides in NSW correctional centres,

these data suggest that, proportional to the number of inmates that report

thoughts of suicide, fewer attempt suicide and even fewer are successful.

Nonetheless, the rate of completed suicide among NSW prisoners is

Page 29

significantly higher than the general population, suggesting that this is a highrisk

population

The presence of suicidal thoughts and plans were higher in the reception

group in both sexes and higher in females than males.

Page 30

Substance Use Disorders

Substance use disorders describe abuse of, and dependence on substances.

They refer to the misuse of substances to the extent that the person’s

functioning is effected. People who abuse substances are preoccupied with

thinking, procuring and using substances such that relationships, work

performance and social interaction suffer. Substance use disorders exclude

moderate use of drugs (ie. casual, experimental or social). Substance

dependence means that over time the person has become tolerant (ie.

requires larger quantities of the substance to have the same effect) to, or

dependent on (unable to cope without), the substance or both tolerant and

dependent. Abuse and dependence are on a spectrum with each other. Abuse

precedes dependence. Dependence creates a drive to obtain substances to

avoid withdrawal symptoms. This drive often forms the basis of the motives for

general offending in this population thus increasing the risk of arrest often for

minor property crimes.

Substance use disorders were the most common diagnostic group among

male and female prisoners (55%). Two-thirds (66%) of receptions and 38% of

sentenced prisoners were diagnosed with a substance use disorder in the

previous twelve months (Table 12). Substance use disorders were more

common among females than males in both the reception (75% vs. 64%) and

sentenced groups (57% vs. 34%). Further, the majority of those with a

diagnosis of a substance use disorder were dependent on substances rather

than just abusing them, indicating the severity of drug problems among

prisoners.

Opioid use disorders were the most common substance use disorder among

both reception and sentenced prisoners (40% and 20%). Stimulant use

disorders were the second most common diagnosis (34% and 15%). In both

the reception and sentenced groups, alcohol use disorders were higher in

males than females, whereas use of cannabis, opioids, sedatives, and

stimulants were higher among females.

Page 31

Table 12: Twelve-month ICD-10 prevalence estimates for substance use disorders.

RECEPTION SENTENCED

Male Female Total Male Female Total

Substance use disorder % % % % % %

Alcohol dependence 19.2 16.5 18.7 11.3 4.9 10.1

Alcohol abuse 3.3 1.8 3.0 2.3 2.9 2.4

Cannabis dependence 18.7 23.0 19.5 12.4 16.8 13.2

Cannabis abuse 2.5 2.5 2.5 1.1 1.0 1.1

Opioid dependence 34.5 53.4 38.0 14.6 37.6 19.0

Opioid abuse 1.8 0.6 1.6 0.5 1.0 0.6

Sedative dependence 11.4 28.6 14.5 5.7 22.8 8.9

Sedative abuse 0.3 0.0 0.2 0.0 1.0 0.2

Stimulant dependence 27.8 47.8 31.4 10.8 28.7 14.1

Stimulant abuse 2.9 2.5 2.8 0.9 1.0 0.9

Any Substance Use Disorder 63.7 74.5 65.7 33.6 57.4 38.0

Demographic Correlates of Substance Use Disorder

Age

The prevalence of any substance use disorder declined with age in females.

For men it slightly increased for those aged 25-40 and then decreased

markedly for persons over 40 years (Figure 6).

Marital Status

In females and males, the prevalence of substance use disorders were lowest

among those who were divorced/separated/widowed (Table 13).

Country of Birth

For both males and females, substance use disorders were higher among

those born in Australia, particularly among females.

Source of Income

In both sexes, the prevalence of substance use disorders were higher in those

receiving a pension or benefit.

Highest Qualification

In both sexes, the lowest prevalence of substance use disorders occurred in

those with secondary school qualifications.

Page 32

Figure 6: Prevalence of any substance use disorder (% positive) by age and sex (twelvemonth

diagnosis).

Table 13: Prevalence (%) of any substance use disorder among male and female

prisoners by sex, marital status, country of birth, income, and highest qualification

(twelve-month diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married/ defacto 52.4 73.7

Divorced / separated/ widowed 45.4 60.9

Never married 55.6 67.0

Country of Birth

Australia 55.9 73.7

Other English speaking country 54.2 36.4

Other country 45.9 44.4

Source of Income

Wage or salary 41.2 60.3

Pension or benefit 65.0 73.3

Other source of income 33.3 69.2

Highest qualification

No qualification 55.2 69.1

Secondary school qualification 21.4 40.0

Post-school qualification 49.4 67.6

Comment

Substance use disorder was the most common psychiatric diagnosis among

NSW inmates. Incarceration results in the sudden limitation of access to

substances. Thus, withdrawal from substances is common and places

significant demand on resources in terms of detoxification and maintenance.

In addition, dependence creates an internal market for illicit substances within

the prison environment.

57.5%

60.1%

23.6%

80.7%

66.2%

44.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 33

According to these data, approximately one-half of inmates received into

prison are at risk of substance withdrawal and require treatment. Considering

there are about 18,000 receptions into the NSW correctional system each

year, this suggests that each day twenty five new receptions are likely to

require detoxification.

When compared with the Australian community, the reception population had

an extraordinarily high prevalence of opioid (40% vs. 1%) and stimulant (34%

vs. 1%) use disorders. The high levels of stimulant use disorder may reflect

the well-recognised and recent heroin drought that was a feature of the

Australian drug scene in 2001.

The prevalence of substances commonly used in the Australian community

(alcohol and cannabis) was markedly higher among reception prisoners.

Approximately one-fifth (22%) of those received into the correctional system

had a twelve-month diagnosis of an alcohol use disorder, compared with 6.5%

in the Australian community.21 The twelve-month prevalence of cannabis use

disorder was 22% which was higher than that reported in the Australian

community (1.7%).

The large difference in the twelve-month diagnosis of substance use disorders

between males and females in the sentenced group likely reflect the shorter

sentences in the female group and also reflect the incarceration of females

primarily for drugs related offences.

Predictably, the prevalence of substance use disorders in the sentenced

group was lower than among receptions due to limited access to drugs such

as heroin and amphetamine during incarceration.

Page 34

Personality Disorders

Personality disorder is not a mental illness but is regarded under the broad

definition of psychiatric disorder. Personality describes a collection of

relatively fixed traits that are difficult to change and in combination define the

person. These traits are patterns of thinking, feeling, behaving and interacting

with others that are fixed and inflexible. When these traits manifest as

difficulties in functioning and are maladaptive the person may have a

personality disorder. These difficulties generally become evident in

adolescence, continue through life and occur in a wide range of situations.

Personality disorder diagnoses are therefore lifetime rather than twelve or

one-month. People with a personality disorder exhibit a wider range of

emotional expression, have more difficulty controlling their impulses and

delaying gratification of needs. They have more difficulty managing

interpersonal relationships and often their behaviour causes distress to others.

The overall lifetime prevalence of ‘any personality disorder’ in this survey was

41% (Table 14). Personality disorder was higher among females than males

(50% vs. 39%) and higher in the reception than the sentenced groups (43%

vs. 37%).

Common personality disorders in males and females were impulsive (21%

and 24%), borderline (17% and 24%), paranoid (18% and 23%), anxious

(16% and 21%) and schizoid (14% and 20%).

Notably, dissocial personality disorder, which relates to antisocial personality

in the DSM IV, had a surprisingly low prevalence suggesting the IPDE

screener is poor in identifying this disorder. Previous studies have shown a

high prevalence of antisocial personality among prisoner populations.22 It is

interesting to note that in the Australian National Survey of Mental Health and

Wellbeing, nobody received a diagnosis of dissocial personality.23

Table 14: Personality disorders.

RECEPTION SENTENCED

Male Female Total Male Female Total

Affective Disorder % % % % % %

Impulsive 21.4 31.5 23.2 19.0 13.3 18.0

Paranoid 19.8 27.9 21.3 15.0 15.2 15.1

Borderline 19.7 30.9 21.7 13.3 13.3 13.3

Anxious 19.0 23.0 19.8 11.5 18.1 12.7

Schizoid 16.3 22.4 17.4 10.4 15.2 11.3

Anankastic 14.6 18.8 15.3 11.1 16.2 12.0

Dependent 11.0 21.2 12.8 4.9 8.6 5.6

Histrionic 6.6 11.5 7.5 3.1 2.9 3.1

Dissocial 2.5 2.4 2.5 2.7 2.9 2.7

Any Personality Disorder 40.1 57.0 43.1 36.7 38.1 37.1

Page 35

Demographic Correlates of Personality Disorder

Age

The prevalence of any personality disorder remained fairly constant over the

age groups in both males and females (Figure 7).

Marital Status

The prevalence of personality disorder was higher among persons who were

separated, divorced or widowed (Table 15).

Country Of Birth

The prevalence of any personality disorder was lowest in those born in non-

English speaking countries.

Source of Income

For males and females, the prevalence of personality disorder was highest

among those receiving a pension or benefit. Among females, the lowest

prevalence was in the wage/salary group.

Highest Qualification

In males, the prevalence of any personality disorder was similar across

qualification categories. However, in females, it was lowest in the secondary

school qualification group and highest among those with post-school

qualifications.

Figure 7: Prevalence of any personality disorder (% positive) by age and sex (twelve-month

diagnosis).

40.4% 39.4%

34.4%

47.1%

51.7%

47.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 36

Table 15: Prevalence (%) of any personality disorder among male and female

prisoners by marital status, country of birth, income, and highest qualification

(twelve-month diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married / defacto 37.6 50.5

Divorced / separated/ widowed 43.1 54.3

Never married 37.8 45.5

Country of Birth

Australia 42.0 50.2

Other English speaking country 31.7 58.3

Other country 24.8 44.4

Source of Income

Wage or salary 34.1 37.9

Pension or benefit 43.4 55.8

Other source of income 27.4 53.8

Highest qualification

No qualification 40.9 44.5

Secondary school qualification 35.7 20.0

Post-school qualification 36.0 58.2

Comment

As expected, the prevalence of personality disorder was high in the prisoner

population and was higher in females. This supports the view that prisoners

are a difficult population group to manage even in the absence of serious

mental illness. While the IPDE screener probably under-diagnosed

antisocial/dissocial personality disorder in this study, there is an extensive

literature confirming high rates of this personality disorder among prisoners.22

What is interesting is the high prevalence of other personality disorders such

as paranoid, anxious and schizoid.

Page 37

Neurasthenia

Neurasthenia is a condition characterised by persistent feelings of fatigue

after quite minor mental and physical effort. Common symptoms are muscular

aches, dizziness, tension headaches, sleep problems, an inability to relax,

and irritability.

Overall, 4% of NSW inmates were diagnosed with Neurasthenia in the twelve

months prior to interview. The prevalence was higher in females than males in

both the reception (10% vs. 4%) and sentenced (8% vs. 2%) groups.

Demographic Correlates of Neurasthenia

Age

The highest prevalence of neurasthenia was found among females aged 25-

40 years. In males, the prevalence of neurasthenia was similar across all age

groups (Figure 8).

Marital Status

Neurasthenia was highest in the divorced/separated/widowed group in both

males and females (Table 16).

Country of Birth

The prevalence of neurasthenia was similar in all categories of country of birth

in both males and females.

Source of Income

The prevalence of neurasthenia was lowest in those with another source of

income in both males and females.

Highest Qualification

Among males, the prevalence of neurasthenia was highest in those with a

secondary school qualification whereas in female it was lowest in this

category.

Page 38

Figure 8: Prevalence of neurasthenia (% positive) by age and sex (twelve-month diagnosis).

Table 16: Prevalence (%) of any personality disorder among male and female

prisoners by marital status, country of birth, income, and highest qualification

(twelve-month diagnosis).

Demographic Characteristic Male Female

Marital Status % %

Married / defacto 1.4 8.9

Divorced / separated/ widowed 5.2 12.9

Never married 2.8 7.1

Country of Birth

Australia 3.1 9.1

Other English speaking country 2.6 11.1

Other country 1.7 11.1

Source of Income

Wage or salary 2.3 10.6

Pension or benefit 4.0 10.1

Other source of income 1.6 0.0

Highest qualification

No qualification 3.2 10.3

Secondary school qualification 7.1 0.0

Post-school qualification 2.2 8.2

Comment

Neurasthenia was found to be the higher in the prisoner population (4%) than

in the Australian community 0.5%.24

2.8%

2.3%

4.0%

6.9%

11.4%

5.9%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Under 25 yrs 25-40 yrs Over 40 yrs

Age Group

Percent

Male

Female

Page 39

Health Service Usage

Overall, sentenced prisoners were more likely to have utilised health services

for mental health problems than reception prisoners in the previous twelve

months (Figure 9). This suggests that prisons have a role to play in treating

those with a mental illness during incarceration.

Females were more likely than males to utilise services for mental health

problems in both the reception and sentenced groups. This was most notable

in the sentenced group, suggesting that females have greater access than

males to mental health services during incarceration.

Sentenced females were more likely than reception females to have seen

either a psychiatrist (37% vs. 14%) or a psychologist (34% vs. 9%) in the

previous twelve months. Sentenced males were more likely to have seen a

drug and alcohol counsellor than reception males (39% vs. 21%). This

suggests that for many males, prison represents an opportunity to address

drug and alcohol issues.

In contrast to the general pattern of male health service usage, reception

males were more likely to have consulted with a GP about a mental health

problem than sentenced males. This could reflect either a greater access to

GPs in the community for this group or that GPs are the preferred point of

contact with community health services for men with mental health problems.

Figure 9: Health service usage for a mental health problem in the previous twelve months by

‘any psychiatric disorder’ (twelve-month diagnosis).

Comment

Females tend to use mental health services more than males. Sentenced

females were more likely than sentenced males to have seen a mental health

professional.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

GP Psychiatrist Psychologist D&A Counsellor Counsellor Nurse Mental Health

Team

Social Worker

Health Professional

Percent

Reception males

Reception

females

Sentenced males

Sentenced

females

Note: 'Any psychiatric disorder' includes: psychosis, anxiety, affective, substance abuse, personality disorder and neurasthenia

Page 40

Disability

The Brief Disability Questionnaire (BDQ) was used to assess the degree to

which respondents are limited by health problems in a number of activities,

and the degree to which they have cut down or stopped activities they were

expected to do as part of their normal routine. This screener also asks how

many days in the previous four weeks respondents were unable to carry out

their usual activities (days out of role) because of illness.

Overall, those with a psychiatric diagnosis were more likely to have higher

disability scores than those without a diagnosis (Table 17). Males tended to

have similar disability scores in both the reception and sentenced groups,

whereas female receptions had higher scores than sentenced females.

Table 17: Mean score on the Brief Disability Questionnaire (BDQ).

Reception Sentenced

ICD-10 Diagnosis Male Female Male Female

Psychosis Positive 4.3 5.0 3.8 3.0

Negative 2.5 3.3 2.1 3.1

Affective disorder Positive 4.4 4.4 4.7 3.1

Negative 2.4 3.2 1.9 3.1

Anxiety disorder Positive 4.3 4.7 4.3 2.8

Negative 2.1 2.6 1.6 3.6

Any mental disorder* Positive 4.1 4.7 4.4 3.5

Negative 2.0 2.3 1.4 2.7

Substance use disorder Positive 3.0 3.8 3.4 2.3

Negative 2.5 3.2 2.0 3.1

Personality disorder Positive 3.8 4.2 3.2 4.0

Negative 2.0 2.8 1.8 2.7

Neurasthenia Positive 6.4 5.7 7.8 6.0

Negative 2.6 3.4 2.1 2.9

Any psychiatric illness** Positive 3.3 3.9 3.2 3.5

Negative 1.6 1.9 1.4 2.6

* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.

** ‘Any psychiatric illness’ refers to any psychosis, anxiety disorder, affective disorder, substance use disorder,

personality disorder or neurasthenia.

Overall, those with psychiatric diagnoses had more days out of role than those

with no diagnosis (Table 18). This was consistent for both males and females

and reception and sentenced prisoners. Male and female receptions,

irrespective of whether a disorder was present or not, had more days out of

role than the sentenced group.

Page 41

Table 18: Number of days in previous month affected by disability.

Reception Sentenced

ICD-10 Diagnosis Male Female Male Female

Psychosis Positive 11.1 10.3 5.9 2.5

Negative 5.5 6.5 1.7 1.6

Affective disorder Positive 11.3 8.2 5.4 3.7

Negative 5.1 6.6 1.6 1.4

Anxiety disorder Positive 10.0 8.5 3.4 3.1

Negative 4.6 5.9 1.5 0.8

Any mental disorder* Positive 10.0 7.8 3.7 3.0

Negative 4.0 6.3 1.4 0.7

Substance use disorder Positive 8.4 8.4 2.1 3.2

Negative 4.0 5.3 1.8 1.6

Personality disorder Positive 10.0 8.6 3.3 3.1

Negative 3.6 5.2 1.3 1.1

Neurasthenia Positive 13.8 10.5 26.6 5.5

Negative 5.9 6.8 1.6 1.4

Any psychiatric disorder Positive 8.0 7.8 2.9 2.4

Negative 2.3 3.2 1.2 0.8

* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.

** ‘Any psychiatric illness’ refers to any psychosis, anxiety disorder, affective disorder, substance use disorder,

personality disorder or neurasthenia.

Comment

As expected, those with a mental illness manifest greater levels of disability

and more days out of role. Sentenced inmates had lower levels of disability

than reception inmates and fewer days out of role, possibly reflecting

improved access to treatment services in prison and abstinence from drugs.

Page 42

One-month Prevalence Estimates

The data presented above reports the twelve-month prevalence estimates.

However, the CIDI can also generate a one-month diagnosis. The twelvemonth

diagnosis is valuable in terms of describing the overall level of

psychiatric morbidity in this population. The one-month estimates are more

likely to reflect the direct burden of illness exerted on the correctional system

at the time of reception.

The psychosis screener used in this study does not generate a one-month

diagnosis. Similarly, the personality disorder diagnosis is based on the

presence of long-term traits and therefore does not generate a one-month

diagnosis.

Among male receptions, 67% had a one-month diagnosis of ‘any psychiatric

disorder’, 17% affective disorder, 28% anxiety disorder, and 47% substance

use disorder (Table 19). In female receptions, 85% had a one-month

diagnosis of ‘any psychiatric disorder’, 57% substance use disorder, 47%

anxiety disorder, and 30% affective disorder.

Overall, the one-month prevalence of ‘any psychiatric disorder in both male

and female receptions was similar to the twelve-month estimates (67% vs.

78% in males, and 85% vs. 90% in females). Similarly, in male and female

reception inmates, the one and twelve-month estimates were similar for

anxiety disorder (28% vs. 34%, and 47% vs. 56%), and affective disorder

(17% vs. 21%, and 30% vs. 34%).

Predictably, for substance use disorders the twelve-month and one-month

prevalence estimates differed. For both male and female reception and

sentenced inmates, the twelve-month prevalence was higher than the onemonth

prevalence (47% vs. 64%, and 57% vs. 75%).

Page 43

Table 19: One-month ICD-10 prevalence estimates of major disorders among

male and female reception prisoners, New South Wales (Australia).

ICD-10 One-month Diagnosis MALE FEMALE

Affective Disorders N % N %

Depression 102 13.5 34 20.6

Dysthymia 46 6.1 15 9.1

Manic episode 10 1.3 9 5.5

Any Affective Disorder 128 17.1 50 30.3

Anxiety Disorders

Post traumatic stress disorder 128 16.9 62 37.6

Generalised anxiety disorder 94 12.4 33 20.0

Panic disorder 35 4.6 14 8.5

Agoraphobia 22 2.9 4 2.4

Obsessive compulsive disorder 17 2.3 3 1.8

Social phobia 8 1.1 1 0.6

Any Anxiety Disorder 206 28.0 78 47.3

Any Mental Disorder* 273 36.5 89 53.9

Substance Use Disorders2

Alcohol dependence 59 8.0 10 6.1

Alcohol abuse 17 2.3 2 1.2

Cannabis dependence 108 14.9 28 17.4

Cannabis abuse 13 1.8 3 1.9

Opioid dependence 189 26.0 60 37.3

Opioid abuse 6 0.8 0 0.0

Sedative dependence 72 9.9 28 17.4

Sedative abuse 0 0.0 0 0.0

Stimulant dependence 166 22.8 55 34.2

Stimulant abuse 7 1.0 3 1.9

Any Substance Use Disorder 339 46.6 92 57.1

Neurasthenia4 24 3.2 13 7.9

Any Psychiatric Disorder** 496 66.7 137 84.6

* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.

** ‘Any psychiatric disorder’ refers to any psychosis, anxiety disorder, affective disorder,

substance use disorder, personality disorder or neurasthenia.

Comment

Overall, there was comparatively little difference between the twelve-month

and one-month prevalence estimates among reception prisoners. Over threequarters

of females and two-thirds of males were diagnosed with at least one

psychiatric disorder in the month prior to interview. At reception, over one-third

of males and over half of the females had either an anxiety or affective

disorder in the previous month. This suggests that the demand for psychiatric

services at the point of reception is likely to be high.

Predictably, the prevalence of certain substance use disorders, particularly

current use, was higher in the reception group in both sexes for alcohol

dependence, opioid dependence, and in women alone: sedative and stimulant

dependence.

Page 44

The similarity of the one-month and twelve-month prevalence estimates

provides support for the assumption that, in this population, the twelve-month

diagnosis can be used as a reasonable estimate of recent mental illness.

Page 45

Substance Use disorder and Psychiatric Diagnosis

Given the high rates of psychiatric disorder reported above, particularly

substance use, it is reasonable to suggest that some mental illness may have

been due to drug use. The twelve-month prevalence estimates of mental

illness (psychosis, affective disorder and anxiety disorder) in those with and

without a substance use disorder diagnosis are shown in the Table 20. Mental

illness among those with no diagnosis of substance use disorder was lower

than those with co-morbid substance use disorder. However, the prevalence

remained high in the absence of drug use.

Table 20: Twelve-month ICD-10 prevalence estimates of major disorders among prisoner with

and without a substance use disorder diagnosis.

No Substance Use

Disorder Diagnosis

Substance Use Disorder

Diagnosis

MALE

(N=265)

FEMALE

(N=41)

MALE

(N=466)

FEMALE

(N=120)

ICD-10 Diagnosis N % N % N % N %

Psychosis 17 6.4 5 12.2 60 12.9 20 16.7

Affective Disorders

Depression 29 10.9 11 26.8 86 18.5 28 23.3

Dysthymia 13 4.9 3 7.3 39 8.4 13 10.8

Manic episode 6 2.3 3 7.3 14 3.0 10 8.3

Any Affective Disorder 42 15.8 15 36.6 108 23.2 41 34.2

Anxiety Disorders

Post traumatic stress disorder 41 15.5 12 29.3 123 26.4 59 49.2

Generalised anxiety disorder 27 10.2 12 29.3 70 15.0 24 20.0

Panic disorder 12 4.5 5 12.2 38 8.2 23 19.2

Agoraphobia 3 1.1 0 0.0 18 3.9 5 4.2

Obsessive compulsive disorder 2 0.8 1 2.4 18 3.9 3 2.5

Social phobia 2 0.8 0 0.0 9 1.9 1 0.8

Any Anxiety Disorder 47 23.4 18 46.3 183 39.4 72 60.0

Any Mental Disorder* 79 29.8 21 51.2 221 47.5 80 66.7

* ‘Any mental disorder’ refers to any psychosis, anxiety disorder or affective disorder.

Comment

The high rate of mental disorder among inmates cannot be attributed to

substance use disorder alone.

Page 46

Mental Illness And Offence Category

Overall, males were more likely than females to have been convicted for

violent offences (homicide and assault) (Table 21). The most common

convictions for both males and females were assaults, robbery and property

offences. Homicide, sexual and driving offences were less common among

females than males.

Overall, females convicted of either a violent or non-violent crime had a higher

prevalence of psychiatric disorder than males across all diagnostic categories.

The exception was among females with psychosis convicted of non-violent

crimes that had a prevalence of psychosis similar to that of males convicted of

a non-violent crime. This suggests that females with psychosis charged with a

non-violent crime may be less likely to be incarcerated than males with

psychosis charged with a non-violent crime.

Among females, there was a higher prevalence of mental disorder (psychosis,

affective disorder, and personality disorder) in those convicted for violent

crimes compared with non-violent offenders. However, among males there

was little difference in the levels of mental disorder between violent and nonviolent

offenders. The exception was substance use disorder, which was

more commonly associated with non-violent crimes in males.

In both males and females, anxiety disorder was the most common mental

disorder (ie. psychosis, anxiety or affective disorder) across all offence

categories except for fraud in the males.

Males with a diagnosis of substance use disorder were most likely to have

been convicted for property, robbery and assault. Among females, substance

use disorder was most common in those convicted for property and driving

offences. Personality disorder in males and females was common among

those with a conviction for property offences which is consistent with the

notion that many property offenders are incarcerated for drug related crimes.

.

Page 47

Table 21: Most serious offence and ICD-10 twelve-month diagnosis for reception and sentenced prisoners (combined).

Psychosis

Affective

Disorder

Anxiety

Disorder

Substance use

disorder

Personality

disorder

Male Female Male Female Male Female Male Female Male Female Male Female

Offence N*** % N*** % N % N % N % N % N % N % N % N % N % N %

Homicide 59 5.0 7 2.7 2 3.4 1 14.3 8 13.6 0 0.0 18 31.0 6 85.7 7 12.1 3 42.9 22 37.3 3 42.9

Assault 223 19.0 39 15.3 20 9.0 8 20.5 46 20.9 18 47.4 63 29.6 23 60.5 124 58.5 27 71.1 87 39.0 27 69.2

Sexual 61 5.2 4 1.6 6 9.8 1 25.0 16 26.7 2 50.0 23 39.0 3 75.0 7 12.3 3 75.0 19 31.1 3 75.0

Robbery 262 22.3 54 21.2 24 9.2 7 13.0 33 12.7 11 20.4 74 28.8 32 59.3 155 60.3 34 68.0 102 38.9 27 50.0

Fraud 32 2.7 15 5.9 3 9.4 1 6.7 10 31.3 5 33.3 9 28.1 7 46.7 11 35.5 9 64.3 10 31.3 5 33.3

Property 187 15.9 57 22.4 16 8.6 3 5.3 35 19.1 13 23.2 66 35.9 28 50.0 118 65.2 47 83.9 86 46.0 31 54.4

Driving 132 11.3 13 5.1 10 7.6 2 15.4 20 15.2 3 23.1 45 34.6 8 61.5 72 55.4 11 84.6 52 39.4 7 53.8

Drugs 97 8.3 37 14.5 8 8.2 1 2.7 9 9.4 7 18.9 23 24.0 18 48.6 42 44.2 14 37.8 32 33.0 8 21.6

Order 120 10.2 29 11.4 8 6.7 4 13.8 27 23.1 11 37.9 40 33.9 14 48.3 61 53.0 22 78.6 45 37.5 15 51.7

Violent* 282 23.4 46 17.3 22 7.8 9 19.6 54 19.4 18 40.0 81 29.9 29 64.4 131 48.5 30 66.7 109 38.7 30 65.2

Non-Violent** 830 68.8 205 77.1 69 8.3 18 8.8 134 16.4 50 24.5 257 31.5 107 52.5 459 56.7 137 69.2 327 39.4 93 45.4

* Homicide and assault. ** Robbery, fraud, property, driving, drugs, and order offences.

*** Note: percentages may not be exact due to missing offence data in certain diagnostic categories.

Page 48

DISCUSSION

This is the first large-scale survey of the prevalence of psychiatric disorder

among Australian prisoners.

Overall, 74% of those assessed had at least one psychiatric disorder

(psychosis, affective disorder, anxiety disorder, substance use disorder,

personality disorder or neurasthenia) in the twelve-months prior to interview.

For most diagnostic categories, the prevalence of ‘any psychiatric disorder’

was higher in those recently received into custody (80% vs. 64% in the

sentenced group) and higher among females than males (86% vs. 71%).

Forty-six percent (46%) of reception and 38% of sentenced inmates were

diagnosed with having had at least one ‘mental disorder’ (psychosis, affective

disorder, or anxiety disorder) in the twelve months prior to interview.

Substance use disorder was the most common diagnostic group with 66% of

reception inmates and 38% of sentenced inmates meeting the diagnostic

criteria in the previous twelve months.

The prevalence of psychiatric disorder was significantly higher than that found

in the Australian community using the same diagnostic tool (the CIDI). In the

National Survey of Mental Health and Wellbeing (NSMHWB) the twelve-month

prevalence for ‘any psychiatric disorder’ was 22% (vs. 77% among inmates),

for ‘any mental disorder’ it was 15% (vs. 42% among inmates), for psychosis it

was 0.42% (vs. 9% among inmates), for affective disorder it was 6% (vs. 22%

among inmates), for anxiety disorder it was 10% (vs.. 43% among inmates),

for substance use disorder it was 5% (vs. 57% among inmates), for

personality disorder it was 7% (vs. 43% among inmates), and for neurasthenia

it was 2% (vs. 6% among inmates).

Given the number of full-time inmates in NSW in 2000/2001 was 7,735, it is

possible to extrapolate the diagnostic data to the wider prisoner population to

ascertain the number of inmates with a psychiatric disorder.25 The number of

sentenced inmates who would have been diagnosed with ‘any psychiatric

disorder’ in the previous month would have been approximately 3,077 and

1,799 with ‘any mental disorder’ in the previous month. Three hundred and

thirty three (333) would have reported having experienced psychotic

symptoms in the previous twelve months.

While the static population was 7,735, approximately 12,483 males and 1,566

females were received into the NSW correctional system in 2000/2001. Based

on these figures, 9,693 would have been diagnosed with having had ‘any

psychiatric disorder’ in the previous month; 5,427 with ‘any mental disorder’;

and 6,739 with a substance use disorder in the previous month.

Approximately 1,581 reception inmates would have reported experiencing

psychotic symptoms in the previous twelve-months.

The use of the psychosis screener prevented the accurate measurement of

the different psychotic disorders. However, we utilised a separate clinical

Page 49

assessment protocol (the LEAD) to provide further insight into the prevalence

of functional psychotic illness in a sub-set of reception prisoners. We are

satisfied that the prevalence of functional psychotic illness is in the order

between 4% and 7%.

Following cardiovascular disease and cancer, mental disorder ranks third in

terms of disability adjusted life years (DALYs) in NSW for both males and

females in the general community.26 Given the relatively higher rates of

mental disorder in the NSW inmate population, this suggests that a substantial

‘burden of disease’ due to mental disorder exists in this population.

Further investigation is warranted into the possible unmet mental health needs

of the NSW prisoner population to identify those suffering from less severe

forms of mental illness who would nonetheless benefit from psychiatric

treatment. The data also makes a cogent argument for the need for screening

systems and diagnostic instruments to better identify inmates with these

problems at the point of reception. Once identified, there will likely be an

increased demand for multidisciplinary mental health services to manage

these conditions and to co-ordinate linkage with community mental health

services on release to freedom.

Mentally ill inmates are more disabled than those with no mental illness.

However when resources are allocated there is little distinction made between

the needs of the mentally ill inmate and the non-mentally ill. Inmates suffering

mental illness and forensic patients have different and frequently greater need

and in many cases require management in specialist units.

There are numerous probable explanations for the high number of mentally ill

people in prison including: homelessness, a lack of adequate diversionary options

in the community, inadequate specialist community forensic psychiatric services,

deinstitutionalisation of the mentally ill, inadequate rehabilitation of forensic

psychiatric in-patients, the high threshold for admission to general psychiatric

facilities, the reluctance of general psychiatric services to accept mentally ill

patients from the courts, society’s intolerance of deviant behavior by the mentally

ill, and the greater likelihood of the mentally ill being arrested. The increased use

of illicit substances in the general population and among the mentally ill has likely

made a significant contribution to an increase in all types of offending.2;27

The most common offences are those associated with substance misuse

highlighting the link between drugs and incarceration. There is also a relationship

between mental illness and offending.3-5;28-30 Substance abuse can mimic, trigger

or exacerbate symptoms of mental illness. Co-morbid substance abuse and

mental illness substantially increases the risk of offending. Among the mentally ill,

substance abuse may increase the risk of non-compliance to medication and

interfere with the effectiveness of medication.

Further, incarceration results in a sudden disruption in the individual’s life,

characterised by loss of freedom and liberty, loss of social and family support,

exposure to an unfamiliar and sometimes threatening environment, frequent

and unexpected transfers to new correctional environments, loss of control,

Page 50

and a highly regimented daily routine. Such an environment poses a

challenge, particularly for those inmates with a mental illness who have a

higher likelihood of cognitive disability, poor insight, and problem solving skills.

Mentally ill inmates may experience increased feelings of paranoia, anxiety,

and despair, which can exacerbate a mental illness. They may have difficulty

accessing regular psychiatric follow-up due to frequent transfers, and in some

cases, less likely to assert themselves to obtain treatment out of fear of

stigmatisation.31

The mentally ill often revolve through prisons, with periods of incarceration

interspersed with spells in the community and place high demand on

services.32 Mentally ill prisoners are doubly stigmatised, suffering from a

psychiatric illness in addition to labelling as an ‘offender’. They are often

disenfranchised, frequently itinerant, suffer chronic illness with acute

symptoms, have poor physical health, lack social supports, have co-morbid

substance abuse, and are frequently without community care.

The majority of mental health providers within the NSW correctional

environment are obligated to operate in accordance with the correctional

ethos. This is fertile ground for conflicting priorities between clinical needs (the

health priority) and security (the custodial priority). The correctional approach

to the management of difficult behaviour can be the antithesis of the mental

health approach.

An examination of those inmates who either declined to be interviewed or

were unavailable for interview and those who were screened failed to identify

any significant differences between the two groups. However, in the

sentenced group, males with longer sentences were more likely to be

screened. There was an under-representation in the reception sample of

indigenous males and those males who had been referred to the mental

health team for assessment. This latter group were not assessed because

they were determined to be too mentally unwell. This is likely to have

produced slight underestimates of the prevalence of mental illness.

Notwithstanding these considerations we believe that the sample is generally

representative of the NSW prisoner population.

Using the same version of the CIDI as the National Survey of Mental Health

and Wellbeing (NSMHWB) prevented the collection of certain demographic

data. The substance use module did not include a diagnosis of possible

cocaine use disorder which is likely to be fairly common in this population.

Internationally and nationally, strategies have been adopted to address the

seemingly disproportionately high number of offenders with a mental illness.33

These include: diverting mentally ill offenders out of the criminal justice

system who have been charged with relatively minor offences, admission of

inmates requiring involuntary psychiatric treatment, admission of those found

‘not guilty by reason of mental illness’ and admission of those found ‘unfit to

stand trial’ to secure forensic mental health facilities, and follow-up in the

community of ‘high risk’ and forensic psychiatric patients. Screening new

Page 51

receptions for mental illness and developing targeted treatment programmes

in correctional centres is essential.

Mental health services in NSW are delivered under the ‘Charter for Mental

Health Care in New South Wales’. This charter outlines the mental health care

entitlements of people in NSW. It stipulates fostering positive attitudes to

mental health, effective treatment, and accessibility to appropriate care,

cultural sensitivity, and the promotion of quality of life. This includes prison inmates.

The NSW Forensic Mental Health Strategy outlines plans for the development

of forensic psychiatric services across the state. Currently, a new, secure

forensic psychiatric hospital is being planned. This will provide a more

appropriate environment for the rehabilitation and treatment of forensic

patients and inmates requiring involuntary psychiatric treatment. Court liaison

services have been developed with mental health expertise provided to eleven

magistrate courts throughout NSW. This enables magistrates to divert

offenders with minor offences into community psychiatric care.

While specialised community forensic psychiatric services are yet to be

developed in NSW, general community psychiatric services provide ongoing

oversight to high-risk patients. However, given the level of public concern

about high-risk and forensic patients and the medico-legal complexities

associated with this group of offenders, specialised services need to be

developed. Establishing a forensic mental health directorate and the

realisation of the NSW Forensic Mental Health Strategy will, in all likelihood

address many of the current demands on correctional mental health

resources.

Arrest and detention can provide an opportunity for intervention and

treatment, and in some cases may be the only time certain individuals receive

mental health care.34 This treatment needs to be consistent with international

best practice.

Page 52

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