Abstract
Objectives:
Mental illness is a very common issue in the prison population. This study set out to analyse the prevalence of mental disorders among inmates at Zuera Prison (Zaragoza).
Material and method:
A descriptive cross-sectional study was conducted in September 2023, including inmates undergoing active treatment with psychotropic drugs. The sample included 598 prisoners (560 men and 38 women), with a mean age of 39.3 years for men and 41.3 years for women.
Results:
The results showed that neurotic disorders were the most prevalent in both sexes (47% men, 55.30% women), followed by disorders due to psychoactive substance use (35.40% men, 23.70% women) and, in third place, personality disorders. Significant differences were observed in the distribution of diagnoses according to gender, nationality and recidivism: repeat offenders had a higher prevalence of drug-related disorders, while first-time offenders had more neurotic disorders. The foreign population showed a lower association with drug-related pathologies than the Spanish population.
Discussion:
The high prevalence of mental health disorders observed, and the differences found according to sociodemographic and prison-related characteristics, highlight the need to strengthen strategies for early detection, prevention and comprehensive mental health care within the prison system, particularly for individuals with a history of reoffending and substance-use disorders.
Keywords: prisons, mental health, substance abuse, psychotropic drugs, nursing, recidivism
Resumen
Objetivos:
La enfermedad mental constituye un problema altamente prevalente en la población privada de libertad. El objetivo de este estudio fue analizar la prevalencia de los trastornos mentales en las personas privadas de libertad del Centro Penitenciario de Zuera (CPZ) (Zaragoza).
Material y método:
Se llevó a cabo un estudio descriptivo transversal en septiembre de 2023, incluyendo internos en tratamiento activo con psicofármacos. La muestra incluyó 598 personas privadas de libertad (560 hombres y 38 mujeres), con edad media de 39,3 años en hombres y 41,3 en mujeres.
Resultados:
Los resultados mostraron que los trastornos neuróticos fueron los más prevalentes en ambos sexos (47% hombres, 55,30% mujeres), seguidos de los trastornos debidos al consumo de sustancias psicoactivas (35,40% hombres, 23,70% mujeres) y, en tercer lugar, de los trastornos de personalidad. Se observaron diferencias significativas en la distribución de diagnósticos en función del sexo, nacionalidad y reincidencia: los internos reincidentes presentaron mayor prevalencia de trastornos vinculados al consumo de drogas, mientras que los primarios presentaron más trastornos neuróticos. La población extranjera mostró menor asociación con patologías relacionadas con drogas que la población española.
Discusión:
La elevada prevalencia de trastornos mentales observada y las diferencias encontradas según las características sociodemográficas y penitenciarias ponen de manifiesto la necesidad de reforzar las estrategias de detección precoz, prevención y atención integral en salud mental en el ámbito penitenciario, especialmente en personas con antecedentes de reincidencia y trastornos asociados al consumo de sustancias.
Palabras clave: prisiones, salud mental, sustancias de abuso por vía oral, psicotrópicos, enfermería, reincidencia
Introduction
The prevalence of mental disorders amongst the Spanish adult population stands at 10.70%, and of those, between 0.5 and 1% suffer from a serious mental illness1,2. According to the World Health Organisation (WHO), approximately one in eight people worldwide present some kind of mental disorder3.
The prevalence of mental illness in the prison setting is significantly higher than it is in the general population4. Psychotic disorders, severe depression and personality disorders are between four and ten times more common amongst prison inmates5. This phenomenon is caused by many factors, such as the lack of resources in community mental health services, which are unable to cover the needs of patients with more serious disorders6.
This leads to a phenomenon known as “transinstitutionalisation”, where the penal system functions as a last resort. There is also a two-way process between social exclusion and mental illness, with the added factors of substance abuse and the impact of the prison setting, which can aggravate or trigger mental disorders due to the chronic stress caused by imprisonment6.
Mental health can be affected by socioeconomic factors such as poor education, social class, unemployment and lack of social support. The Spanish National Health Survey for 2017 revealed that the lower the social class and educational background, the greater the increase in diagnoses of depression and anxiety7.
Significant gender inequalities have also been observed: mental disorders tend to be more common amongst women, especially when they belong to disadvantaged social classes. Female immigrants also show a higher risk of presenting poor mental health than Spanish women, although it is not a determining factor amongst male immigrants7. Similar gender and health issues are also very marked amongst female inmates. According to Añaños et al. (2017), 80.90% of women in prison present self-perceived undiagnosed psychiatric symptoms, mostly related to mood disorders8.
A multicentre study in Norway, Denmark and Sweden found a very high proportion of inmates with diagnoses of mental disorders along with an increase in the number of this type of patient in recent decades. Substance use and depressive disorders were found to be amongst the most common conditions9. In British prisons, a significantly higher prevalence of mental disorders was found amongst women than in men10.
In 2023, a study in Sweden showed that psychiatric disorders are linked to a higher risk of recidivism, especially where persons with substance use disorders are concerned, which explained the higher overall proportion of repeat offenders11.
Mental disorders in prison are characterised by their complexity and chronicity, and are affected by social factors and an institutional setting that emphasises control, discipline, forced cohabitation and isolation, along with factors that place obstacles in the way of building adequate therapeutic spaces for dealing with them12.
To respond to these issues, the Prison Institution developed the Spanish Comprehensive Care Program for the Mentally Ill in Prisons (PAIEM)4. This multidisciplinary program is designed for inmates with severe mental disorders and sets out specialised guidelines for care, with particular emphasis on therapeutic and occupational activities. There are also two psychiatric centres mainly for persons undergoing judicial internment measures13.
Prison nursing units are key factors in the provision of comprehensive care for inmates as they offer prevention, care and rehabilitation service, including complete evaluation, administration of treatment, crisis intervention, health education and also foster coping skills, communication and emotional support14.
Several European studies point out that the complex issue of health in the prison population creates a need for highly specialised nursing staff, especially in mental health care15. The characteristics of the prison setting impose obstacles on therapeutic approaches and require specific intervention strategies16.
Although some highly relevant studies have been carried out in Spain on the prevalence of mental disorders in the prison population, such as the 2011 PRECA report17 and later research18, such studies did not go further into the relation between psychiatric diagnosis and recidivism. There is also a shortage of recent studies that analyse sociodemographic variables in a large prison.
This study therefore sets out to analyse the prevalence of mental disorders and their association with sociodemographic variables in Zuera Prison, providing relevant information for prison nursing units to develop prevention and promotion strategies and comprehensive care for prison inmates.
Materials and method
Cross-sectional descriptive study that set out to analyse the prevalence of mental disorders in the prison population of Zuera Prison, according to age, sex, nationality and recidivism.
The population of the study were the prison inmates that were being treated with psychiatric drugs in September 2023. Persons belonging to the Social Rehabilitation Centre (CIS) in Zaragoza and Huesca were excluded since they did not receive treatment from the prison healthcare service.
The information was obtained via the IT System for Prison Healthcare Digital Clinical Records.
Operational definitions and variables
Table 1 shows the sociodemographic variables that were analysed: sex, age, nationality and recidivism.
Table 1. Variables included in study.
| Variable | Definition | Categorisation procedure |
|---|---|---|
| Age | Inmate’s age when data was collected (September 2023) | Quantitative variable categorized into groups: 18-25 years, 26-35 years, 36-45 years and >45 years |
| Nationality | Nationality registered in identity document (national identity card [DNI] or foreign resident’s identity number [NIE]) | Dichotomous qualitative variable: Spanish/foreign |
| Recidivism | Number of previous admissions in prisons | Dichotomous qualitative variable: first offenders (first prison sentence) /repeat offenders (two or more sentences) |
| Mental disorder | Active psychiatric diagnosis recorded in the OMI360 system when data was collected | Qualitative variable grouped according to diagnostic category of the ICD-10, chapters V and VI |
Note. ICD-10: tenth edition of the International Classification of Diseases.
The diagnoses recorded in the digital clinical records by physicians at the centre were compiled and grouped in accordance with chapters V and VI of the tenth edition of the International Classification of Diseases (ICD-10)19.
A normal data distribution was assumed, given that the sample size was over 30 cases (for men and woman). The mean and typical deviation were calculated in the quantitative variables. Frequency and interquartile range were calculated for the qualitative variables.
To establish differences between the population groups, Student’s t test was calculated for the quantitative variables, while the chi-squared test was used for the qualitative variables. All the statistical significance tests were considered from p <0.05 onwards.
This study was approved by the Clinical Research Committee of Aragon (CEICA, C.P.- C.I, EPA 23-033) and the General Secretary of Prisons. All participants signed an informed consent to participate in the study.
Results
There were 1,153 persons in Zuera Prison when the data was gathered: 1,080 men (93.7%) and 73 women (6.3%). The final sample included 598 inmates receiving active treatment with psychotropic medication: 560 men (93.6%) and 38 women (6.4%).
The figures for the sociodemographic and penitentiary characteristics of the population (Table 2) showed that the average age of the male participants 39.3 years (standard deviation: 12.4), and 41.3 for women (standard deviation: 11.5). The most representative age group was from 36 to 45 years.
Table 2. Descriptive table of the study population.
| Men | Women | Total | |
|---|---|---|---|
| Age groups | |||
| 18-25 years | 84 (15%) | 2 (5.3%) | 86 (14.4%) |
| 26-35 years | 152 (27.1%) | 10 (26.3%) | 162 (27.1%) |
| 36-45 years | 164 (29.3%) | 16 (42.1%) | 180 (30.1%) |
| >46 years | 160 (28.6%) | 10 (26.3%) | 170 (28.4%) |
| Nationality* | |||
| Spanish | 385 (68.7%) | 33 (86.8%) | 418 (69.9%) |
| Foreign | 175 (31.2%) | 5 (13.1%) | 180 (30.1%) |
| Recidivism | |||
| First offenders | 395 (70.5%) | 31 (81.5%) | 426 (71.2%) |
| Repeat offenders | 165 (29.4%) | 7 (18.4%) | 172 (28.7%) |
Note. *Nationality: Spanish citizens. Foreign: other nationalities. †First offenders: first prison sentence. Repeat offenders: two or more prison sentences.
The most broadly represented nationality was Spanish (68.75% men, 86.48% women). The data showed 37 different nationalities in Zuera Prison at the time of the study. The most representative nationalities amongst men were Morocco (9.82%) and Algeria (4.82%), while the most common once amongst women was Romania (5.40%).
The figures for recidivism in sentencing showed that 70.53% (n = 395) of men were first offenders (81.57% for women).
The data for observed psychiatric diagnoses according to the gender variable (Figure 1) showed that the most predominant group in both sexes was neurotic stress-related and somatoform disorders (ICD-10, codes F40-F48), with a prevalence of 47.00% in men and 55.30% in women. These were followed by mental and behavioural disorders caused by psychoactive substance use (F10-F19), with 35.40% in men and 23.70% in women. Third place was occupied by adult personality and behavioural disorders (F60-F69), with 5.40% amongst men and 5.30% amongst women.
Figure 1. Diagnoses according to gender variable.
Note. *F00-09: organic, including symptomatic, mental disorders; †F10-19: mental and behavioural disorders due to psychoactive substance use; ‡F20-29: schizophrenia, schizotypal and delusional disorders; §F30-39: mood (affective) disorders; ||F40-48: neurotic, stress-related and somatoform disorders; ¶F50-59: behavioural syndromes associated with physiological disturbances and physical factors; **F60-69: disorders of adult personality and behaviour; ††F70-79: intellectual disabilities; ‡‡F90-98: behavioural and emotional disorders with onset usually occurring in childhood and adolescence; §§G40-47: epilepsy and recurrent seizures.
Analysis of the diagnostic groups according to age (Table 3) brought to light no significant differences between them. The most prevalent group was neurotic disorders, followed by psychoactive substance use disorders.
Table 3. Diagnoses according to age group.
| Age groups | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Men | Women | Men | Women | Men | Women | Men | Women | Men | Women | Men | Women | |
| Diagnosis | (18-25 years) | (26-35 years) | (36-45 years) | (>46 years) | Total | Total | P (c2)* | P (c2)* | ||||
| F00-09† | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (0.6%) | 0 (0.0%) | 3 (1.9%) | 1 (10.0%) | 4 (0.7%) | 1 (2.6%) | 0.190 | 0.411 |
| F10-09‡ | 32 (38.1%) | 1 (50%) | 52 (34.2%) | 3 (30%) | 60 (36.6%) | 3 (18.8%) | 54 (33.8%) | 2 (20%) | 198 (35.4%) | 9 (23.7%) | 0.884 | 0.734 |
| F20-29§ | 4 (4.8%) | 0 (0.0%) | 12 (7.9%) | 0 (0.0%) | 4 (2.4%) | 1 (6.3%) | 5 (3.1%) | 0 (0.0%) | 25 (4.5%) | 1 (2.6%) | 0.091 | 0.703 |
| F30-39|| | 0 (0.0%) | 0 (0.0%) | 3 (2.0%) | 0 (0.0%) | 5 (3%) | 0 (0.0%) | 6 (3.8%) | 1 (10.0%) | 14 (2.5%) | 1 (2.6%) | 0.314 | 0.411 |
| F40-48¶ | 44 (52.4%) | 1 (50%) | 67 (44.1%) | 5 (50.0%) | 77 (47.0%) | 10 (62.5%) | 75 (46.9%) | 5 (50%) | 263 (47.0%) | 21 (55.3%) | 0.683 | 0.900 |
| F50-59** | 1 (1.2%) | 0 (0.0%) | 2 (1.3%) | 0 (0.0%) | 4 (2.4%) | 0 (0.0%) | 9 (5.6%) | 0 (0.0%) | 16 (2.9%) | 0 (0.0%) | 0.084 | NaN†† |
| F60-69‡‡ | 2 (2.4%) | 0 (0.0%) | 10 (6.6%) | 1 (10.0%) | 11 (6.7%) | 1 (6.3%) | 7 (4.4%) | 0 (0.0%) | 30 (5.4%) | 2 (5.3%) | 0.422 | 0.766 |
| F70-79§§ | 0 (0.0%) | 0 (0.0%) | 1 (0.7%) | 0 (0.0%) | 0 (0.0%) | 1 (6.3%) | 0 (0.0%) | 1 (10.0%) | 1 (0.2%) | 2 (5.3%) | 0.422 | 0.766 |
| F90-98|||| | 0 (0.0%) | 0 (0.0%) | 3 (2.3%) | 0 (0.0%) | 2 (1.2%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 5 (0.9%) | 0 (0.0%) | 0.221 | NaN |
| G40-47¶¶ | 1 (1.2%) | 0 (0.0%) | 2 (1.3%) | 1 (10.0%) | 0 (0.0%) | 0 (0.0%) | 1 (0.6) | 0 (0.0%) | 4 (0.7%) | 1 (2.6%) | 0.524 | 0.411 |
| Total | 84 (100%) | 2 (100%) | 152 (100%) | 10 (100%) | 164 (100%) | 16 (100%) | 160 (100%) | 10 (100%) | 560 (100%) | 38 (100%) | ||
Note. F: Chapter V of ICD-10 (Mental and behavioural disorders); G: Chapter VI of ICD-10 (Diseases of the nervous system). *χ2: chi squared; †F00-09: organic, including symptomatic, mental disorders; ‡F10-19: mental and behavioural disorders due to psychoactive substance use; §F20-29: schizophrenia, schizotypal and delusional disorders; ||F30-39: mood (affective) disorders; ¶F40-48: neurotic, stress-related and somatoform disorders; **F50-59: behavioural syndromes associated with physiological disturbances and physical factors; ††NaN: not a Number; ‡‡F60-69: disorders of adult personality and behaviour; §§F70-79: intellectual disabilities; ||||F90-98: behavioural and emotional disorders with onset usually occurring in childhood and adolescence; ¶¶G40-47: epilepsy and recurrent seizures.
The data for nationalities and the representative nature of the psychiatric diagnoses showed that neurotic disorders were the most common amongst both Spanish and foreign groups (42.90% in men and 56.00% in women), presenting statistically significant differences of p <0.005 (Table 4).
Table 4. Diagnoses according to nationality.
| Men | Women | |||||||
|---|---|---|---|---|---|---|---|---|
| Diagnosis | Spanish | Foreign | Total | P (χ2)* | Spanish | Foreign | Total | P (χ2)* |
| F00-09† | 2 (0.5%) | 2 (1.1%) | 4 (0.7%) | 0.417 | 1 (3.0%) | 0 (0.0%) | 1 (2.6%) | 0.693 |
| F10-09‡ | 150 (39.0%) | 48 (27.4%) | 198 (35.4%) | 0.008 | 8 (24.2%) | 1 (20.0%) | 9 (23.7%) | 0.835 |
| F20-29§ | 17 (4.4%) | 8 (4.6%) | 25 (4.5%) | 0.934 | 0 (0.0%) | 1 (20.0%) | 1 (2.6%) | 0.009 |
| F30-39|| | 12 (3.1%) | 2 (1.1%) | 14 (2.5%) | 0.165 | 1 (3.0%) | 0 (0.0%) | 1 (2.6%) | 0.693 |
| F40-48¶ | 165 (42.9%) | 98 (56%) | 263 (47.0%) | 0.004 | 18 (54.5%) | 3 (60.0%) | 21 (55.3%) | 0.819 |
| F50-59** | 8 (2.1%) | 8 (4.6%) | 16 (2.9%) | 0.101 | NaN†† | NaN | NaN | NaN |
| F60-69‡‡ | 24 (6.2%) | 6 (3.4%) | 30 (5.4%) | 0.172 | 2 (6.1%) | 0 (0.0%) | 2 (5.3%) | 0.572 |
| F70-79§§ | 0 (0.0%) | 1 (0.6%) | 1 (0.2%) | 0.138 | 2 (6.1%) | 0 (0.0%) | 2 (5.3%) | 0.572 |
| F90-98|||| | 5 (1.3%) | 0 (0.0%) | 5 (0.9%) | 0.13 | NaN | NaN | NaN | NaN |
| G40-47¶¶ | 2 (0.5%) | 2 (1.1%) | 4 (0.7%) | 0.417 | 1 (3.0%) | 0 (0.0%) | 1 (2.6%) | 0.693 |
| Total | 385 (100%) | 175 (100%) | 560 (100%) | 33 (100%) | 5 (100%) | 38 (100%) | ||
Note. F: Chapter V of ICD-10 (Mental and behavioural disorders); G: Chapter VI of ICD-10 (Diseases of the nervous system). *χ2: chi squared; †F00-09: organic, including symptomatic, mental disorders; ‡F10-19: mental and behavioural disorders due to psychoactive substance use; §F20-29: schizophrenia, schizotypal and delusional disorders; ||F30-39: mood (affective) disorders; ¶F40-48: neurotic, stress-related and somatoform disorders; **F50-59: behavioural syndromes associated with physiological disturbances and physical factors; ††NaN: not a Number; ‡‡F60-69: disorders of adult personality and behaviour; §§F70-79: intellectual disabilities; ||||F90-98: behavioural and emotional disorders with onset usually occurring in childhood and adolescence; ¶¶G40-47: epilepsy and recurrent seizures.
The most predominant diagnostic groups in male first offenders were neurotic disorders and those caused by psychoactive substance use. However, psychoactive substance use disorders were found to be more common amongst both male and female repeat offenders.
Discussion
This study evinces the high prevalence of mental disorders amongst the prison population of Zuera Prison. Neurotic disorders were the most common diagnostic group in both sexes, in all the age groups and in Spanish and foreign inmates. However, further analysis of the repeat offenders showed a higher prevalence of mental disorders related to psychoactive substance use, which suggests that there may be a link between recidivism and drug use.
Comparisons with the literature
The 2011 PRECA report17 states that anxiety is the most common disorder (23.30%), followed by substance use disorder (17.50%), affective disorder (14.90%) and psychotic disorder (4.20%). These results match the findings obtained in the Region of Valencia in 2012, where symptoms of anxiety and depressed mood were the main causes of psychiatric consultations20. In 2016, a study carried out at Soria Prison showed that the most prevalent disorder was anxiety18, which backs up our own results.
The prevalence of psychotic disorders in Europe is similar to the one found in our study, although personality disorders are more common21. This difference could be explained by high comorbidity with affective disorders, anxiety (especially major depression and post-traumatic stress disorder) and substance use. This may lead to underdiagnosis if structured evaluations or specific clinical interviews are not carried out22.
As regards the age variable, the United Nations Global Report (2022) used time series and found that substance use is more frequent amongst young people, and that current levels exceed those of the previous generation23. Since this study has a cross-sectional design, our results do not allow us to establish time trends. These results suggest that there may be a need to study this issue in greater depth in future research to ascertain if disorders caused by substance use increase in these age groups.
The data for nationality showed significant differences in diagnoses of neurotic and substance use disorders, in which the latter is more prevalent amongst Spanish inmates. This result could be explained by higher drug consumption amongst Spaniards compared to foreign inmates in the prison population. A study carried out in 2014 on prisons in Murcia concluded that drug use was more common amongst the Spanish prison population than amongst foreign inmates24. Similar data was found in the study by Rincón-Moreno, which observed that heroin use was four times higher amongst Spanish inmates than amongst foreigners25. This higher level of exposure may be the result of a higher load of mental illness associated with substance use amongst Spanish inmates.
Main findings
The main finding of this study is the relationship between recidivism and psychiatric diagnoses. Disorders caused by psychoactive substance use predominate amongst persons with a higher number of prison admissions, while first offenders show a greater tendency towards neurotic disorders. This relationship can be explained by an increase in drug use linked to prolonged prison sentences, which tend to encourage a process where addictive disorders can appear or become chronic, especially in large prisons such as Zuera. Caravaca-Sánchez makes special mention of this phenomenon26.
Our conclusions were backed up by a recent study in Sweden, in which substance use disorder was the most common diagnosis, with a higher absolute proportion of recidivism10.
Limitations and strengths
The limitations of this study include the low representation of women, caused by the higher number of men in prison. This low representation imposes situations of inequality and higher vulnerability in this group26. Another limitation is that we may have created a selection bias, since we only included patients that were being treated with psychiatric drugs at the time of the study. There may be patients whose lack of awareness of being ill or whose fear of recognising the signs or symptoms stopped them from requesting medical attention.
Despite the above limitations, the main strength of this study is the representative nature of the sample, as the sociodemographic profile of Zuera Prison is comparable to the Spanish prison population as a whole, the data for which was obtained from the 2022 Report of the Ministry of the Interior, and which enabled the results to be extrapolated13.
Implications for clinical practice and nursing
This study reaffirms that fact that the prison population is a particularly vulnerable group in biophysical terms, and marked by factors such as social exclusion, immigration, low educational and economic levels, unemployment, lack of family support and drug use. Added to this is the limited access to quality primary healthcare due to the lack of human resources, which leads to underdiagnosis and makes a more comprehensive treatment approach more difficult to achieve.
In such a context, nursing units play a key role in the early detection, clinical monitoring and emotional support of persons with mental illness, and in health education, promotion of healthy habits and relapse prevention. A quality therapeutic relationship is therefore essential for fostering adherence to treatment, acceptance of a disease and developing coping strategies for situations of vulnerability.
Future lines of research
Future lines of action should be geared towards developing personalised care plans, implementing specific prevention and treatment programs for drug users - especially repeat offenders - and improving coordination between prison mental health teams and community services.
To conclude, mental disorders in prisons represent a public health issue despite institutional efforts through programs such as the PAIEM. The results obtained enable clinical interventions in the prison setting to be more precisely oriented. The high prevalence of neurotic and substance use disorders, especially amongst repeat offenders, highlights the need to implement early detection strategies from the moment inmates are admitted into prison, along with monitoring programs adapted to each inmate’s risk profile.
In this context, a comprehensive approach applied by nursing units takes on even greater importance, since evaluation, monitoring and health education can help in early detection, increase treatment adherence and prevent relapses.
Footnotes
*Award for best presentation at the mental health panel, presented at the SESP Congress, Vitoria, 2024.
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