Prevalence of mental illness among Australian and New Zealand people in prison: A systematic review and meta-analysis of studies published over five decades.

BACKGROUND: The higher rate of mental illness, including severe psychotic disorders, among people in prisons compared to the general community is well-established. However, there have been no reviews or attempts to pool data on the reported prevalence of mental illness across prisons in Australia and New Zealand. METHODS: A systematic search of electronic databases from 1966 to the end of 2020 was conducted to identify studies reporting rates of 'any' mental illness, and separately rates of psychotic illness, among adult men and women in Australian and New Zealand prisons. A meta-analysis was performed according to PRISMA guidelines (PROSPERO ID: CRD42021241946), with separate analyses conducted for lifetime and current prevalence rates. RESULTS: Seventeen studies, with a total of 10,209 people in prison, met inclusion criteria. The pooled lifetime prevalence of 'any' mental illness was 69.0% (95% confidence interval = [0.56, 0.79]), and the pooled lifetime prevalence for psychosis was 9.1% (95% confidence interval = [0.07, 0.12]). Meanwhile, the pooled prevalence for 'any' current mental illness was 54.0% (95% confidence interval = [0.39, 0.68]) and for any current psychosis was 6.4% (95% confidence interval = [0.04, 0.10]). There was substantial heterogeneity between studies, with evidence that lifetime rates of psychosis have increased over time, with true prevalence estimates in 95% of all comparable populations falling between 2.7% and 26.4%. CONCLUSION: The prevalence of mental illness, including severe psychotic illness, is high in Australian and New Zealand prisons. Furthermore, there is evidence that the prevalence of psychosis may be increasing over time, indicating more effort is needed to ensure diversion of people with mental illness away from the criminal justice system and into healthcare pathways.

The full spectrum of clinical stages of psychosis at prison entry: prevalence and concurrent validity of symptom screening.

PURPOSE: Despite the high rates of psychotic disorders amongst people in prison, current prison mental health screening approaches have not included assessment of the full psychosis spectrum to capture those at-risk of an emerging psychosis as well as those with established illness nor assessed the concurrent validity of psychosis symptom screening. METHODS: Using a clinical staging approach to establish the prevalence of Ultra High Risk (UHR), first episode of psychosis (FEP) and established psychosis (EP) groups, 291 adults entering custody in two prison reception centres in NSW completed a two-stage (screening and validation) interview process. The Comprehensive Assessment of At-Risk Mental States (CAARMS) was used to determine the clinical stages of psychosis and concurrent validity of symptom screening in identifying individuals on the psychosis spectrum was formally assessed. RESULTS: Amongst men and women entering prison, almost one quarter (24.1%) met UHR criteria, 5.1% met the FEP threshold and 10.6% had an established psychosis. Those on the psychosis spectrum reported greater disadvantage across sociodemographic and justice factors. The presence of perceptual disturbance and paranoid beliefs emerged as the two best screening items for identifying those with an underlying psychosis spectrum illness. CONCLUSION: The prevalence of psychosis spectrum illness, including the UHR state, amongst those entering prison is high. Current prison mental health approaches should include screening for the presence of perceptual disturbances and paranoid beliefs to improve the detection of psychosis spectrum illness.

The prevalence of self-reported mental illness among those imprisoned in New South Wales across three health surveys, from 2001 to 2015.

OBJECTIVE: The prevalence of mental illness among those in prison is much higher than in the community; however, very few studies have examined whether rates have changed over time, in line with increasing self-reported rates in the community. METHODS: This study compares the prevalence of self-reported mental illness, self-harm and suicidal thoughts/behaviours, and drug and alcohol use across three waves (2001, 2009 and 2015) of health surveys involving men and women in New South Wales prisons and compared these rates with published community-level findings. RESULTS: The prevalence of those reporting any mental health diagnosis increased significantly across the three surveys, even after adjustment for socio-demographic and criminal justice variables that also changed over time. Individuals surveyed in 2015 were more likely to report a mental health diagnosis than those surveyed in 2001 (adjusted odds ratio = 2.66, 95% confidence interval = [2.16, 3.27]). The prevalence of self-harm and suicidal thoughts and behaviours remained stable across the three surveys, while self-reported regular drug use decreased over the period. Women experienced a far greater burden of mental illness than men across all three surveys and experienced more growth in the prevalence of most psychiatric disorders. CONCLUSION: These findings have important implications for public and prison health systems given the poor social, health and criminal justice outcomes of those imprisoned with mental illness, both in custody and post-release.

Self-harm risk screening on prison entry: assessing the predictive validity of self-harm history and recent ideation in men and women.

PURPOSE: Rates of self-harm are elevated in prison, and there is limited evidence to support the efficacy of brief risk screening at reception to predict and prevent self-harm. This study aims to examine the predictive validity of the self-harm/suicide screening items embedded in a prison mental health screening tool from two key domains strongly associated with risk: previous suicidal/self-harm behaviour, and recent ideation. DESIGN/METHODOLOGY/APPROACH: A sample of men and women were screened on entry to prison, with eight screening items covering the two key domains of risk. Follow-up data on self-harm incidents were collected for 12 months post-screening. The predictive validity of individual screening items, item combinations and cumulative screening score was examined for the overall sample and for men and women separately. FINDINGS: Individual screening items across the two domains were all strongly associated with self-harm in the follow-up period, with odds ratios varying from 2.34 to 9.24. The predictive validity of both individual items, item scores and item combinations demonstrated high specificity but low to moderate sensitivity, and modest area under the curves (AUCs). Predictive validity was generally better for men than women; however, differences were not statistically significant. PRACTICAL IMPLICATIONS: Identifying those at risk of self-harm in prisons remains challenging and brief universal screening at prison entry should be only one component of a broader prison risk assessment and management strategy. ORIGINALITY/VALUE: To the best of the authors' knowledge, this study is one of very few to prospectively examine self-harm behaviour following risk screening. Predictive validity was examined in a representative sample of individuals in custody, and for men and women separately.

Continuity of mental health care during the transition from prison to the community following brief periods of imprisonment.

Purpose: The prison-to-community transition period is one of high risk and need, particularly for those with mental illness. Some individuals cycle in and out of prison for short periods with little opportunity for mental health stabilization or service planning either in prison or the community. This study describes the socio-demographic, clinical and criminal justice characteristics of individuals with mental illness and frequent, brief periods of imprisonment, examines continuity of mental health care between prison and the community for this group, and reports on their post-release mental health and criminal justice outcomes. Design/methodology/approach: This study examined a sample of 275 men who had recently entered prison in New South Wales (NSW), Australia, who had been charged with relatively minor offenses and had been identified on reception screening as having significant mental health needs. Baseline demographic and mental health information was collected via interview and file review and contacts with the prison mental health service were recorded for the period of incarceration. Follow-up interviews were conducted 3 months post-release to determine level of health service contact and mental health symptoms. Information on criminal justice contact during the 3 month period was also collected. Findings: The majority (85.5%) of the sample had contact with a mental health professional during their period of incarceration. Mental health discharge planning was, however, lacking, with only one in 20 receiving a referral to a community mental health team (CMHT) and one in eight being referred for any kind of mental health follow-up on release. Of those followed up 3 months post-release (n = 113), 14.2% had had contact with a CMHT. Of those released for at least 3 months (n = 255), one in three had received new charges in this period and one in five had been reincarcerated. Conclusion: Continuity of mental health care for those exiting prison is poor, particularly for those with mental health needs experiencing brief periods of imprisonment, and rates of CMHT contact are low in the immediate post-release period. These findings suggest a need for early identification of individuals in this group for timely commencement of intervention and release planning, and opportunities for diversion from prison should be utilized where possible.