956 www.thelancet.com Vol 377 March 12, 2011 Review Lancet 2011 377: 956���65 Published Online November 19, 2010 DOI:10.1016/S0140- 6736(10)61053-7 See Editorial page 876 Department of Psychiatry, University of Oxford, Oxford, UK (S Fazel MD) and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA (J Baillargeon PhD) Correspondence to: Dr Seena Fazel, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK seena.fazel@psych.ox.ac.uk The health of prisoners Seena Fazel, Jacques Baillargeon More than 10 million people are incarcerated worldwide this number has increased by about a million in the past decade. Mental disorders and infectious diseases are more common in prisoners than in the general population. High rates of suicide within prison and increased mortality from all causes on release have been documented in many countries. The contribution of prisons to illness is unknown, although shortcomings in treatment and aftercare provision contribute to adverse outcomes. Research has highlighted that women, prisoners aged 55 years and older, and juveniles present with higher rates of many disorders than do other prisoners. The contribution of initiatives to improve the health of prisoners by reducing the burden of infectious and chronic diseases, suicide, other causes of premature mortality and violence, and counteracting the cycle of reoff ending should be further examined. Introduction More than 10 million people are imprisoned worldwide, with 2��3 million in the USA, 1��6 million in prison and another 0��9 million in administrative detention in China, and 0��9 million in Russia. India, Thailand, Iran, Indonesia, Turkey, Brazil, Mexico, South Africa, and Ukraine all have prison populations exceeding 100 000 people.1 The USA has the highest number of prisoners per head of population at 756 per 100 000 people, compared with a mean of 145 per 100 000 worldwide. The number of people in prisons has been increasing in more than two-thirds of countries worldwide in the past decade and rose by more than 1 million from the late 1990s to 2006���08 (fi gure 1).1,2 Rates of imprisonment have also risen in north and central America, Asia, and Oceania (fi gure 1). Prisoners bear a substantial burden of physical and psychiatric disorders relative to the general population. However, most evidence on the health of prisoners comes from high-income nations. Long-standing concerns about the care and treatment of prisoners, such as the use of capital punishment for mentally ill prisoners in some countries, are widespread.4���6 The health disparity between prisoners and the general population has been attributed to various behavioural and socioeconomic factors, including high rates of intravenous drug use in prisoners, which leads to increased risk of infectious diseases and increased alcohol misuse and smoking. These behaviours in turn raise the risk of cardiovascular disease and some cancers. Mental illness, which increases the risk of crime and repeat off ending,7���9 is common in prisoners. The extent to which the prison itself raises the risk of illness has only been investigated in relation to infectious diseases and is unknown in relation to most other disorders. In this Review, we discuss the prevalence and risk factors for some of the major physical and psychiatric diseases in prisoners, and the challenges to provide health-care services for this population. We fi rst discuss the prevalence of mental disorders and evidence-based treatments for them, the prevalence, transmission, and prevention of infectious diseases, and the prevalence of chronic diseases. We then review mortality rates in prisoners and discuss populations with particular health needs. Finally, we present information on health-care services and make several recommendations for improvements. Where possible, we use the term prison apart from in the USA, where jails (detention centres before trial or remand centres that house prisoners on sentences shorter than 1 year) and state prisons (for sentenced prisoners) are distinguished. Jails tend to have higher turnover rates than do prisons, and hence provide fewer opportunities to diagnose and treat disease. Prevalence of mental disorders Since a landmark study of admissions to Sing Sing prison in New York in 1918 highlighted the large number of mentally ill people in custody,10 a great body of evi- dence has shown high rates of psychiatric morbidity, although these data are almost entirely based on research done in high-income countries. Around one in seven prisoners has a treatable mental illness. In a systematic review and meta-analysis of 62 surveys of 23 000 prisoners, the pooled prevalence of psychosis was around 4%, major depression 10���12%, and personality disorder 40���70%.11 Drug and alcohol problems are also common. A review of reception studies noted that 17���30% of men and 10���24% of women were diagnosed with alcohol misuse or dependence.12 10���48% of men and 30���60% of women misused or were dependent on illegal drugs on reception to incarceration. Post-traumatic stress disorder is also thought to aff ect up to a fi fth of prisoners,13 and Search strategy and selection criteria We searched Medline, PubMed, the Cochrane Library, EMBASE, and the National Criminal Justice Reference Service database for all article types from Jan 1, 1990, to Nov 31, 2009. All languages were included. Key search terms used were ���prison���, ���prisoner���, and ���inmate���. These terms were combined with specifi c medical and psychiatric disorders and conditions. We largely selected articles published in the past 5 years in peer-reviewed journals, but did not exclude often referenced and highly regarded older publications. We also searched the reference lists of articles identifi ed by this search strategy and selected additional publications that we deemed relevant.

Review www.thelancet.com Vol 377 March 12, 2011 957 prisoners of both sexes report histories of severe trauma and abuse.14 Women seem to have higher rates of most psychiatric disorders than do men.15 By comparison with the general population of similar ages, the highest proportionate risks are estimated to be for substance misuse and dependence, antisocial personality disorder, and psychosis (table 1).11,12,17 Prevalence of intellectual disabilities is typically in the range of 0��5���1��5%,16 much the same as that of many community surveys. Rates of deliberate self-harm in the year preceding imprisonment are 7���15% in men and 17���27% in women.18 Solitary confi nement seems to exacerbate symptoms of mental illness, and recommendations have been made to avoid its use in those with pre-existing psychiatric disorders.19 The high prevalences of mental illness and substance misuse in prisoners might result from an association with violent crime,7,8 a shortage of inpatient psychiatric beds20 and failure to divert appropriately from court to hospital,21 high rates of mental illness in homeless people,22 and failure to identify mental disorders on prison reception23 and poor subsequent care. Some of these factors are clearly indications of the eff ectiveness of community mental health services. Cornford and colleagues24,25 found that a third of English and Welsh prisons in 2005 were not able to off er any cognitive behavioural therapy, and that no systems were in place for transfer of medical information on admission or release in more than 70% of prisons.24 Data from a national US survey from 2002���04 showed that a third of prisoners with diagnoses of schizophrenia and bipolar disorder were not treated with psychiatric drugs.26 Of 80 jails in North Carolina, none used evidence-based screening tools for mental illness, 35% never contacted mental health services when mentally ill prisoners were released, and 42% had to transport prisoners to a community provider for mental health assessments.27 Most prisoners with mental health problems return to their home communities, and treatment of their illnesses is therefore an important public health opportunity because treatment seems to decrease rates of repeat off ending.9 However, many patients have di��� culty accessing appropriate medical care in the community, and prognosis is associated with the duration of untreated illness. Few studies of psychiatric morbidity, however, have been done in non-western countries, and whether prevalences of mental illness are diff erent elsewhere is unknown. Data suggest potentially important diff er ences that merit further examination. In Iran, with the ninth largest prison population worldwide, Assadi and colleagues28 reported that around 70% of male prisoners were dependent on opioids, which is a substantially higher proportion than in western prison populations. High rates of drug addiction in prisoners might be a feature of countries that form part of the illegal drug trade. In China, the prevalence of post-traumatic stress disorder, although common in female prisoners,29 was lower than that estimated in imprisoned women in western countries. In India, however, rates of severe mental illness seem to be close to those in other countries.30 Randomised controlled trial evidence for treatment of mental health disorders in prisoners is scarce. For substance misuse, trial evidence suggests that therapeutic community interventions with aftercare programmes might decrease rates of repeat off ending, and results from one trial of methadone maintenance treatment showed some evidence of lowered drug use after a few months.31 To be eff ective the dose of methadone should be high (eg, 60 mg) and prescribed for the whole duration of imprisonment.32 Furthermore, prisons should assess all new inmates for drug withdrawal and provide detoxifi cation services. Relapse prevention courses should be developed for inmates before release, and linking with community services should be prioritised.33 Evidence from a randomised controlled trial in prisoners with a history of heroin addiction before incarceration has underlined the importance of methadone maintenance in prison and continued on release.34 The Figure 1: Prison population by continent Data is collated from national prison administrations.1���3 500 000 0 1 000 000 1 500 000 2 000 000 2 500 000 3 000 000 3 500 000 4 000 000 Total prison population Asia North and Central America Europe (including Russia) A 1996 2002 Year 2007 0 100 200 300 400 500 600 Prisoners per 100 000 of population B Africa South America Oceania