Criminal Behaviour and Mental Health 25: 220–225 (2015) Published online 31 March 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cbm.1952
A total population-based cohort study of female psychiatric inpatients who have served a prison sentence
STEINN STEINGRIMSSON1,4, MARTIN I. SIGURDSSON2, HAFDIS GUDMUNDSDOTTIR3, THOR ASPELUND2 AND ANDRES MAGNUSSON1, 1Department of Psychiatry, Landspitali University Hospital, Reykjavik, Iceland; 2Faculty of Medicine, University of Iceland, Reykjavik, Iceland; 3Prison and Probation Administration of Iceland, Reykjavik, Iceland; 4Centre of Ethics, Law and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ABSTRACT Background Studies of the overlap between severe mental disorder and criminality tend to focus on prison populations rather than psychiatric populations. Aims Our aims were to establish the prevalence of previous imprisonment among female psychiatric inpatients and test relationships between diagnoses, mortality and imprisonment. Methods A nationwide cohort of 18–65-year-old women who had been hospitalised for psychiatric disorder between January 1983 and March 2008 was identified from a hospital records database and linked to the database of the Prison and Probation Administration of Iceland as well as the National Register of causes of death at Statistics Iceland from January 1985. Results Six thousand and ninety-four women had had at least one psychiatric hospitalisation, 102 of them had been imprisoned on 172 occasions between them, giving an imprisonment rate of 118 per 100,000 over the 24 year period of study. The crude imprisonment proportion was 1.7% during a 20-year follow-up period; it was at its peak (5%) among 18–30 year-olds at index admission. Substance use and personality disorders were the most common diagnoses associated with imprisonment. Mortality rates were not statistically different between those imprisoned and not (hazard ratio = 1.3, 95% confidence interval 0.5–3.5). Conclusion and implications for practice Women admitted to a psychiatric hospital have higher rates of imprisonment than the general population. Because admission predated imprisonment in most cases, this may be seen as an opportunity for early intervention to reduce later criminality. Copyright © 2015 John Wiley & Sons, Ltd.
Copyright © 2015 John Wiley & Sons, Ltd.
25: 220–225 (2015) DOI: 10.1002/cbm
Imprisonment among female psychiatric inpatients
Introduction An association between mental illness and criminality is well established. Among female prisoners, around 4% suffer from a psychotic illness, 14% from major depression, 10–24% alcohol use disorder and 30–60% other substance use disorder (Fazel et al., 2006; Fazel & Seewald, 2012). Some symptoms of personality disorder are present in about 42%; about 25% fulfil the criteria of borderline personality disorder (Fazel & Danesh, 2002). Conversely, a history of criminal convictions is common among psychiatric inpatients, both men and women (Hodgins et al., 2007). In general, the risk of imprisonment decreases with age, and women have a lower risk of imprisonment compared with men (Steffensmeier & Motivans, 2000) as well as a different pattern of diagnoses (Steingrimsson et al., 2012), making it important to study women in their own right and to allow for age. Both psychiatric patients (Wahlbeck et al., 2011) and prisoners (Zlodre & Fazel, 2012) have been shown to have a shorter life expectancy, and therefore it is important to study any interaction between hospitalisation and imprisonment on life expectancy. Our aims were to calculate the 20-year cumulative incidence of prison sentences among women admitted to a psychiatric hospital and to compare discharge diagnoses and survival rates of ever prison sentenced women with those never so sentenced. Our hypotheses were that personality disorder diagnoses would be more common among the ever imprisoned who would also tend to live shorter lives.
Methods The National Bioethical Committee of Iceland (registration number: 08-051) and the Data Protection Authority of Iceland (2008/189) reviewed the study protocol; additional ethical approval was granted from Landspitali University Hospital, Akureyri Hospital, Statistics Iceland and the Prison Administration of Iceland. Using unique personal identifying numbers assigned to each individual in Iceland, we constructed a nationwide database of women aged 18–65 years using three sources: the discharge diagnoses register from all psychiatric centres in Iceland, the database of the Prison and Probation Administration of Iceland and the National Register of causes of death at Statistics Iceland. The first database contains information on all women admitted to psychiatric hospitals in Iceland between January 1983 and March 2008 and the second information on all episodes of imprisonment from 1985. The index diagnosis was defined as the discharge diagnosis after the first admission during the study period. Diagnoses were categorised into the following groups according to the ICD-9 and ICD-10 codes: (1) schizophrenia and related disorders (F20-F29); (2) bipolar affective disorder (F30-31); (3) unipolar affective disorder (F32-33); (4) substance use disorders (SUDs) (F10-F19); (5)
Copyright © 2015 John Wiley & Sons, Ltd.
25: 220–225 (2015) DOI: 10.1002/cbm
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personality disorders (F60); and (6) other organic mental disorder (F00-09) and anxiety-related disorders (F40-48). A diagnosis of one disorder did not exclude another. Descriptive statistics were calculated for women between 18 and 65 years of age at index admission. The 20-year cumulative imprisonment incidence was estimated and plotted using the Kaplan–Meier method. To compare difference in incidence of diagnoses at index admission between those imprisoned and not, an Χ2-test was used. Because age and diagnoses differed between the two groups, a nested case-control (1:3) design was used to study the difference in mortality between those imprisoned and not. The controls were matched for sex, age at index admission (±1 year) and year of index admission (±1 year). The two groups were compared using the Cox-proportional hazard model. Follow-up was censored at 15 years and only all cause mortality reported. All models had to fulfil the proportional hazard assumption to be considered statistically significant. In all calculations, a two tailed p-value
A total population-based cohort study of female psychiatric inpatients who have served a prison sentence
STEINN STEINGRIMSSON1,4, MARTIN I. SIGURDSSON2, HAFDIS GUDMUNDSDOTTIR3, THOR ASPELUND2 AND ANDRES MAGNUSSON1, 1Department of Psychiatry, Landspitali University Hospital, Reykjavik, Iceland; 2Faculty of Medicine, University of Iceland, Reykjavik, Iceland; 3Prison and Probation Administration of Iceland, Reykjavik, Iceland; 4Centre of Ethics, Law and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ABSTRACT Background Studies of the overlap between severe mental disorder and criminality tend to focus on prison populations rather than psychiatric populations. Aims Our aims were to establish the prevalence of previous imprisonment among female psychiatric inpatients and test relationships between diagnoses, mortality and imprisonment. Methods A nationwide cohort of 18–65-year-old women who had been hospitalised for psychiatric disorder between January 1983 and March 2008 was identified from a hospital records database and linked to the database of the Prison and Probation Administration of Iceland as well as the National Register of causes of death at Statistics Iceland from January 1985. Results Six thousand and ninety-four women had had at least one psychiatric hospitalisation, 102 of them had been imprisoned on 172 occasions between them, giving an imprisonment rate of 118 per 100,000 over the 24 year period of study. The crude imprisonment proportion was 1.7% during a 20-year follow-up period; it was at its peak (5%) among 18–30 year-olds at index admission. Substance use and personality disorders were the most common diagnoses associated with imprisonment. Mortality rates were not statistically different between those imprisoned and not (hazard ratio = 1.3, 95% confidence interval 0.5–3.5). Conclusion and implications for practice Women admitted to a psychiatric hospital have higher rates of imprisonment than the general population. Because admission predated imprisonment in most cases, this may be seen as an opportunity for early intervention to reduce later criminality. Copyright © 2015 John Wiley & Sons, Ltd.
Copyright © 2015 John Wiley & Sons, Ltd.
25: 220–225 (2015) DOI: 10.1002/cbm
Imprisonment among female psychiatric inpatients
Introduction An association between mental illness and criminality is well established. Among female prisoners, around 4% suffer from a psychotic illness, 14% from major depression, 10–24% alcohol use disorder and 30–60% other substance use disorder (Fazel et al., 2006; Fazel & Seewald, 2012). Some symptoms of personality disorder are present in about 42%; about 25% fulfil the criteria of borderline personality disorder (Fazel & Danesh, 2002). Conversely, a history of criminal convictions is common among psychiatric inpatients, both men and women (Hodgins et al., 2007). In general, the risk of imprisonment decreases with age, and women have a lower risk of imprisonment compared with men (Steffensmeier & Motivans, 2000) as well as a different pattern of diagnoses (Steingrimsson et al., 2012), making it important to study women in their own right and to allow for age. Both psychiatric patients (Wahlbeck et al., 2011) and prisoners (Zlodre & Fazel, 2012) have been shown to have a shorter life expectancy, and therefore it is important to study any interaction between hospitalisation and imprisonment on life expectancy. Our aims were to calculate the 20-year cumulative incidence of prison sentences among women admitted to a psychiatric hospital and to compare discharge diagnoses and survival rates of ever prison sentenced women with those never so sentenced. Our hypotheses were that personality disorder diagnoses would be more common among the ever imprisoned who would also tend to live shorter lives.
Methods The National Bioethical Committee of Iceland (registration number: 08-051) and the Data Protection Authority of Iceland (2008/189) reviewed the study protocol; additional ethical approval was granted from Landspitali University Hospital, Akureyri Hospital, Statistics Iceland and the Prison Administration of Iceland. Using unique personal identifying numbers assigned to each individual in Iceland, we constructed a nationwide database of women aged 18–65 years using three sources: the discharge diagnoses register from all psychiatric centres in Iceland, the database of the Prison and Probation Administration of Iceland and the National Register of causes of death at Statistics Iceland. The first database contains information on all women admitted to psychiatric hospitals in Iceland between January 1983 and March 2008 and the second information on all episodes of imprisonment from 1985. The index diagnosis was defined as the discharge diagnosis after the first admission during the study period. Diagnoses were categorised into the following groups according to the ICD-9 and ICD-10 codes: (1) schizophrenia and related disorders (F20-F29); (2) bipolar affective disorder (F30-31); (3) unipolar affective disorder (F32-33); (4) substance use disorders (SUDs) (F10-F19); (5)
Copyright © 2015 John Wiley & Sons, Ltd.
25: 220–225 (2015) DOI: 10.1002/cbm
221
222
Steingrimsson et al.
personality disorders (F60); and (6) other organic mental disorder (F00-09) and anxiety-related disorders (F40-48). A diagnosis of one disorder did not exclude another. Descriptive statistics were calculated for women between 18 and 65 years of age at index admission. The 20-year cumulative imprisonment incidence was estimated and plotted using the Kaplan–Meier method. To compare difference in incidence of diagnoses at index admission between those imprisoned and not, an Χ2-test was used. Because age and diagnoses differed between the two groups, a nested case-control (1:3) design was used to study the difference in mortality between those imprisoned and not. The controls were matched for sex, age at index admission (±1 year) and year of index admission (±1 year). The two groups were compared using the Cox-proportional hazard model. Follow-up was censored at 15 years and only all cause mortality reported. All models had to fulfil the proportional hazard assumption to be considered statistically significant. In all calculations, a two tailed p-value
