As psychiatrists, we are well aware that all around the world people with serious mental health problems are in prison, where their condition is often unrecognised and untreated. In the UK there have been moves in recent years to provide more mental health support to the prison population. Louis Appleby and colleagues review the success of this initiative, introduced just over a decade ago; he was until recently the national clinical director for offender health. Their analysis points up some significant dilemmas, not least of which is the difficulty prison staff have in differentiating serious mental illness from pervasive but more minor mental disturbance. There clearly needs to be better identification of those most at risk, particularly of suicidal behaviour.
In Brazil, which incarcerates an exceptionally high proportion of its population, there are serious problems due to overcrowding and little support for prisoners with mental disorders, as discussed by Sergio Baxter Andreoli and fellow authors. Their recent research has shown that the prevalence of mental disorder is very high among prisoners, up to ten times greater than that in the general population. Most prison psychiatric hospitals lack mental health teams to run them. The authors question the logic by which individuals with a serious mental illness, whose offence was linked to their disorder, may end up in conventional prisons in Brazil, where they receive no adequate treatment. On their release, their chances of rehabilitation are seriously compromised as a consequence of the failure of the law to take appropriate account of their condition.
Finally, we have a fascinating study from Somaliland, where a novel in-reach service has been developed. The authors, Jibril Handuleh and Ronan McIvor, invite us to consider the project as providing a model for the development of in-reach services in other low-income countries. Their study was built on long-standing foundations, in terms of a collaborative venture between King’s College London, the Tropical Health and Education Trust, and Somaliland partners. Training was provided to prison guards and police officers in Borama Prison, working jointly with a local university. Benefits included a direct ban on khat use by prisoners, as well as an indirect influence on the awareness of mental illness among local judicial and governmental authorities. Given the country has no resident psychiatrists and no mental health legislation, this is a remarkable result.