Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review

BACKGROUND

High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison.

METHODS

Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text.

RESULTS

Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity.

CONCLUSIONS

It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

Preparing for end-of-life: learning from Do Not Attempt Cardiopulmonary Resuscitation decision-making during COVID-19

During the COVID-19 pandemic, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made differently. This included more prominent roles for specialties such as psychiatry and doctors in training. Concerns about inappropriate DNAR decisions led to anxiety for doctors, patients and the public. Positive outcomes may have included earlier and better-quality end-of life-discussions. However, COVID-19 exposed the need for support, training and guidance in this area for all doctors. It also highlighted the importance of effective public education about advanced care planning.

Equivalence, Justice, Injustice - Health and Social Care Decision Making in Relation to Prison Populations

Prisons represent sites of singular healthcare need-characterized by high levels of distress and disorder. In many jurisdictions, practitioners are ethically charged with delivering healthcare that is "equivalent" to that available in the wider community. This claim has been much debated-yet the emergence of a global coronavirus pandemic has highlighted the arguments in a particularly stark manner. In the following conceptual analysis, we explore the emergent discourse of the coronavirus and consider its particular significance for prison healthcare decision making and the concept of equivalence. For example, both the coronavirus pandemic and practice of prison incarceration induce a sense of varied temporality: The discourse of prison is replete in this area-such as the concept of "hard time." Alongside this, the discourse in relation to coronavirus has highlighted two competing modes of temporal understanding: The political-where the pandemic is conceptualized as has having a discrete "beginning and end", and the scientific-where the "new normal" reflects the incorporation of the "novel" coronavirus into the wider ecology. The impact of these disparate understandings on the prison population is complex: "Locking down" prisoners-to safeguard the vulnerable against infection-is relatively simple, yet it has traumatic repercussions with respect to liberty and psychosocial health. Easing lockdown, by contrast, is a difficult endeavor and risks collision between the temporalities of prison-where "hard time" is accentuated by separation from the "real world"-the political and the scientific. Whither then the concept of equivalence in relation to a field that is definitively non-equivalent? How can practitioners and policy makers maintain a just ethical stance in relation to the allocation of resources when it comes to a politically marginalized yet manifestly vulnerable population? We argue that further debate and consideration are required in this field-and propose a framework for such discussion.

The effects of COVID-19 on self-harm in UK prisons

Self-harm is a major international public health concern and is especially prevalent among prisoners. In this editorial, we explore recent trends in prisoner self-harm during the coronavirus lockdown, and consider strategies for improving the prevention and management of self-harm in prisons as we emerge from the pandemic.

Remote consultations in prison mental healthcare in England: impacts of COVID-19

Telemedicine has become increasingly used by prison mental health services throughout the COVID-19 pandemic. In this editorial, we explore the benefits and risks of the remote provision of forensic mental healthcare, with consideration of the clinical, financial, ethical and legal consequences.

OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis

Background

In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB.

Methods

A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting.

Results

For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction.

Conclusion

PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.