International Journal of Law and Psychiatry 41 (2015) 82–88

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International Journal of Law and Psychiatry

Psychiatric needs of male prison inmates in Italy Massimiliano Piselli a,1, Luigi Attademo b,2, Raffaele Garinella b,2, Angelo Rella a,1, Simonetta Antinarelli c,3, Antonia Tamantini a,1, Roberto Quartesan b,d,2, Fabrizio Stracci e,4, Karen M. Abram f,⁎ a

Functional Area of Psychiatry, University of Perugia, AUSL Umbria 2, Ospedale San Giovanni Battista, Servizio Psichiatrico Diagnosi e Cura, Via Massimo Arcamone, 06034 Foligno, Italy School of Psychiatry, University of Perugia, Department of Medicine, Division of Psychiatry, Clinical Psychology and Psychiatric Rehabilitation, New Faculty of Medicine, Ellisse Edificio A Piano 8, Loc. Sant'Andrea delle Fratte, 06156 Perugia, Italy c Health District of Spoleto, AUSL Umbria 2, Palazzina Micheli Piazza D. Perilli 1, 06049 Spoleto, Italy d Department of Medicine, Division of Psychiatry, Clinical Psychology and Psychiatric Rehabilitation, New Faculty of Medicine, University of Perugia, Ellisse Edificio A Piano 8, Loc. Sant'Andrea delle Fratte, 06156 Perugia, Italy e Department of Experimental Medicine, Umbrian Population Cancer Registry, Division of Public Health, University of Perugia, Via Del Giochetto, 06122 Perugia, Italy f Department of Psychiatry and Behavioral Sciences, Health Disparities and Public Policy Program, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Suite 900, Chicago, IL 60611, USA b

a r t i c l e

i n f o

Available online 15 April 2015 Keywords: Prisoners Psychiatric disorders Substance use disorders Comorbidity

a b s t r a c t This paper presents data on the mental health needs of men in an Italian prison and examines if mental health needs of inmates differ across key correctional subpopulations. Interviewers conducted semi-structured clinical interviews with 526 convicted males incarcerated in the Spoleto Prison from October 2010 through September 2011. Nearly two thirds (65.0%) of inmates had an Axis I or Axis II disorder. About half (52.7%) had an Axis I disorder. Personality disorders were the most common disorders (51.9%), followed by anxiety (25.3%) and substance use disorders (24.9%). Over one third of inmates (36.6%) had comorbid types of disorder. The most common comorbid types of disorders were substance use disorders plus personality disorders (20.1%) and anxiety disorders plus personality disorders (18.0%). Findings underscore a significant need for specialized mental health services for men in Italian prisons. Moreover, as inmates return to the community, their care becomes the responsibility of the community health system. Service systems must be equipped to provide integrated services for those with both psychiatric and substance use disorders and be prepared for challenges posed by patients with personality disorders. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Prevalence studies of psychiatric morbidity among prisoners are important for determining the psychiatric treatment needs inside prisons, identifying inmates suffering from mental illness, and developing the best possible forensic psychiatric support (Andersen, 2004). Studies of mental illness among incarcerated populations in Great Britain (Singleton, Meltzer, Gatward, Coid, & Deasy, 1998), United States (Ditton, 1999; Lamb & Weinberger, 1999, 2001; Powell, Holt, &

Abbreviations: SCID, Structured Clinical Interview for DSM-IV; ASI-X, Addiction Severity Index-Expanded Version. ⁎ Corresponding author at: Karen M. Abram, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Suite 900, Chicago, IL 60611, USA. Tel.: +1 312 503 3500. E-mail addresses: [email protected], [email protected] (M. Piselli), [email protected] (S. Antinarelli), [email protected] (R. Quartesan), [email protected] (F. Stracci), [email protected] (K.M. Abram). 1 Tel.: +39 07423397360; fax: +39 07423397362. 2 Tel.: +39 0755784100/3194; fax: +39 0755783183. 3 Tel.: +39 0743210467. 4 Tel.: +39 0755857366.

http://dx.doi.org/10.1016/j.ijlp.2015.03.011 0160-2527/© 2015 Elsevier Ltd. All rights reserved.

Fondacaro, 1997), Canada (Brink, Doherty, & Boer, 2001), United Europe (Andersen, 2004; Blaauw, Roesch, & Kerkhof, 2000; Fazel & Danesh, 2002) and worldwide (Fazel & Seewald, 2012) have documented psychiatric needs of inmates. Comparison between studies is difficult because of differences in methodology, psychiatric classification systems, and modalities of assessment (Andersen, 2004; Brink et al., 2001); however, by all accounts, needs are substantial. Although many countries have examined rates of disorder among prison inmates, those rates may not generalize to prisoners in Italy. The prevalence of mental disorders among inmates may depend on many factors including incarceration policies. Italy has among the lowest incarceration rates in Europe (Elaborazioni Istat su dati Ministero della Giustizia, Anno, 2010, 2010, 2010, 2012). However, its prisons are among the most crowded, following tougher laws against crime enacted in 2006 (Elaborazioni Istat su dati Ministero della Giustizia, Anno 2010, 2012; International Centre for Prison Studies (ICPS), 2012). Recidivism rates are 70% (Leonardi, 2007), rivaling those in the United States (Bureau of Justice Statistics, 2002). More than one third of Italy's prisoners are serving time for drug offenses compared to 16% in the rest of Europe and 20% in the US (Aebi & Delgrande, 2010; West & Sabol, 2008).

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The responsibility for penitentiary health services in Italy has recently shifted from the Ministry of Justice to the Regional Health Service. In light of what we know about health care needs of prison populations, and the tendency of prisoners to avoid health services (Bridgwood & Malbon, 1994), it is critical to assess their mental health needs. Such data will allow us to implement suitable screening procedures aimed at better identifying inmates' needs, and to develop therapeutic plans for each responsible territorial service. This study has two aims: 1. To determine the mental health needs of men in an Italian prison; and 2. To determine whether mental health needs of inmates differ across key correctional subpopulations. 2. Methods 2.1. Design Interviewers conducted semi-structured clinical interviews with 526 convicted males incarcerated in the Spoleto Prison from October 2010 through September 2011. 2.2. Site This study was conducted at the Spoleto prison under an agreement with the Psychiatric Functional Area. The Spoleto Prison processes about 700 male detainees each year. Sociodemographic characteristics of detainees at the Spoleto Prison are representative of other medium and maximum security prisons in the Umbria region of Italy (Provveditorato Regionale Amministrazione Penitenziaria Regione Umbria, Italia).5 The Spoleto Prison is subdivided into 4 sections according to crime and inmate type: (1) common criminals section; (2) high surveillance section, for dangerous inmates sentenced for mafia crimes who are not, however, leading figures in organized crime; (3) protected section, for inmates whose personal safety would be endangered if allowed into the general prison population due to the nature of their offense (social censure for pedophilia and rape); their sexual orientation; or because they collaborated with criminal justice personnel; and (4) Section “41 bis”, for leading figures in organized crime. 2.3. Participants and sampling procedures This study was approved by Provveditorato Regionale dell'Amministrazione Penitenziaria per l'Umbria and by Società Italiana di Psichiatria. Eligible detainees were males at least 18 years of age, able to give informed consent, already sentenced and serving time. Interviewers were not permitted to interview inmates who were in Section 41 bis (leaders in organized crime). During the 12 months of the study period, 670 male detainees were incarcerated in the Spoleto Prison. Of these, 20 (3%) were awaiting trial and 82 (12.3%) were in Section 41 bis, and not eligible. Of the 568 eligible participants, 42 (7.4%) refused. The final sample was 526 (92.6% of eligible participants) comprised of 204 (38.8%) common criminals, 229 (43.5%) high surveillance offenders, and 93 (17.7%) protected inmates. The mean length of incarceration in the Spoleto Prison was 22.3 months (range 1–252). 5

The Italian prison system is currently regulated by: 1) LEGGE 26 Luglio 1975, n. 354: “Norme sull'ordinamento penitenziario e sulla esecuzione delle misure privative e limitative della libertà” (GU n. 212 del 9-8-1975 — Suppl. Ordinario); 2) D.P.R. 30 Giugno 2000, n. 230: “Regolamento recante norme sull'ordinamento penitenziario e sulle misure privative e limitative della libertà” (GU n. 195 del 22-8-2000 — Suppl. Ordinario n. 131); 3) Raccomandazione 11 Gennaio 2006, n. R/2006/2: “Raccomandazione R (2006) 2 del Comitato dei Ministri agli Stati Membri sulle Regole penitenziarie europee”; and 4) Ministero Giustizia, Dipartimento amministrazione penitenziaria, circolare n. 3479/ 5929 del 09.07.1998, circolare n. 20 del 09.01.2007 e circolare n. 3619/6069 del 21.04. 2009.

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Interviewers were doctors in their third year of residency at the University of Perugia, School of Psychiatry. They were trained to administer the Addiction Severity Index, Expanded Version, by certified instructors from the University of Pavia and University Catholic University of Rome. Interviewers also passed a course on the SCID-I and SCID-II at the University of Perugia, School of Psychiatry. All training interviews were reviewed by the lectors responsible for the SCID course. Interrater reliability Kappa ranged from 0.63–0.81, indicating substantial agreement (Landis & Koch, 1977). The head guard of the prison provided an updated list of inmates by section to the interviewers each month. Inmates were sampled in alphabetical order of their last name. Interviewers requested that the head guard call each inmate when it was their turn to be invited to be interviewed. Interviewers described the project and procedures to inmates and informed them that they would not receive any financial compensation, privileges, or any other special benefit, such as a reduced sentence, for participating in the study. Detainees who agreed to participate provided written informed consent. Interviews were conducted in a private area free from the distraction of other detainees and activities in the unit. 2.4. Measures 2.4.1. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) The SCID-I is a semi-structured interview that assesses DSM-IV Axis I disorders (American Psychiatric Association, 2000). It allows the clinician to probe inconsistencies in responses, paraphrase questions to fit a participant's understanding, and ask additional questions based on clinical judgment (Spitzer, Williams, Gibbon, & First, 1992). The SCID has been tested for reliability (Segal, Kabacoff, Hersen, Van Hasselt, & Ryan, 1995; Skre, Onstad, Torgersen, & Kringlen, 1991; Williams et al., 1992; Zanarini et al., 2000) and validity (Basco, Bostic, & Davies, 2000; Fennig, Craig, Lavelle, Kovasznay, & Bromet, 1994; Kranzler, Kadden, Babor, Tennen, & Rounsaville, 1996; Kranzler et al., 1995), and has shown less bias than other instruments in correctional settings (Arboleda-Florez, Holley, Williams, & Crisanti, 1994). Disorders assessed for this study include psychotic (schizophrenia; schizophreniform; schizoaffective; delusional; brief psychosis; shared psychosis; psychosis due to a general medical condition; and substance-induced psychosis); mood (dysthymia; major depression; bipolar I; bipolar II; cyclothymia; mood due to a general medical condition; substance-induced mood); anxiety (panic with or without agoraphobia; agoraphobia without panic; specific phobia; social phobia; obsessive–compulsive; generalized anxiety; acute stress; posttraumatic stress; anxiety due to a general medical condition; substance-induced anxiety); and substance use (dependence, abuse; intoxication, withdrawal) of alcohol; amphetamine; cannabis; cocaine; hallucinogen; inhalant; opioid; sedative-hypnotic or anxiolytic; and polysubstance. 2.4.2. Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) The SCID-II is a semi-structured interview that assesses the following Axis II disorders: avoidant, dependent, obsessive–compulsive, paranoid, schizotypal, schizoid, narcissistic, borderline, antisocial, passive–aggressive and depressive personality disorders. 2.4.3. Addiction Severity Index-Expanded Version (ASI-X; Oberg & Zingmark, 1999; Carrà, Restani, & Dal Canton, 2004) The ASI-X is a semi-structured interview that measures drug and alcohol use, suicidal ideation and behavior, and functioning in areas often affected by substance abuse: medical status, employment and support, legal status, family/social status and psychiatric status. The ASI-X is based on the “Expanded Female Version” (ASI-F) (Brown, Frank, & Friedman, 1997) interview of the semi-structured US Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O'Brien, 1980); it has been standardized and is comparable to the Europ-ASI (Kokkevi & Hertgers,

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1995). The reliability of the ASI has been demonstrated in numerous studies that emphasize its effectiveness in characterizing the problems of patients addicted to alcohol and drugs (Alterman et al., 2000; McLellan et al., 1980, 1992; Pozzi, Bacigalupi, & Tempesta, 1997), in selecting patients for specific treatments (McLellan, Woody, Luborsky, O'Brien, & Druley, 1983), and in comparing the results obtained with various interventions (Hodgins & el-Guebaly, 1992; Kosten, Rounsaville, & Kleber, 1983; McLellan et al., 1985). It can be used with general populations and with at-risk populations such as prisoners (Davis, Baer, Saxon, & Kivlahan, 2003; Peters et al., 2000). The ASI-X generates severity ratings (0–9) and composite scores (0–1) based on behavior during the previous 30 days. The severity scores range from 0–9; we defined “severe” impairment as a severity score of 6 or higher to indicate a need for services. The Easy-ASI software was used to score the data (Carrà et al., 2004). For this study, functioning was assessed for the 30 days preceding the interview unless otherwise specified. 2.5. Statistical analysis To compare means, we used one way analysis of variance for continuous variables and non-parametric Kruskal–Wallis-test for score variables. Categorical variables were analyzed by Chi Square tests and Fisher's exact tests when appropriate. The results for all tests were considered to be significant for p values of less than 0.05. Statistical analyses were conducted with a standard SPSS software package (version 12.0). 3. Results

High surveillance inmates were older and far more likely to be married (48.9%) than common criminals (37.7%) or protected inmates (35.5%). They were also more likely to be Italian (88.6%) than either common criminals or protected inmates (47.5% and 51.6%). Significantly more common criminals had been unemployed prior to their incarceration (80.4%) than high surveillance (69.4%) or protected (66.7%) inmates. 3.2. Psychiatric disorders Table 2 shows that nearly two thirds (65.0%) of inmates had an Axis I or Axis II disorder. Over half (52.7%) had an Axis I disorder. Personality disorders were the most common disorders (51.9%), followed by anxiety (25.3%) and substance use disorders (24.9%). Nearly one tenth had a mood disorder, and 4.2% had a psychotic disorder. Common criminals were more likely to have any disorder (72.1%) than high surveillance (62.0%) or protected (57.0%) inmates; they were also more likely to have an Axis I disorder (59.8% versus 48.0% and 48.4%) and substance use disorders than other groups (34.3% versus 18.3% and 20.4%). Common criminals and high surveillance inmates were more likely to have a personality disorder than protected inmates (57.8% and 53.3% versus 35.5%). Table 3 shows the profiles of the types of disorder for the sample. Over one quarter of the sample (28.3%) had only one type of disorder; half of these had personality disorders only (15.2%). Over one third of inmates (36.6%) had comorbid types of disorder. The most common comorbid types of disorders were comorbid substance and personality disorders (20.1%), comorbid anxiety and personality disorders (18.0%), and comorbid mood and personality disorders (8.9%).

3.1. Sociodemographic characteristics 3.3. Addiction severity and associated impairments Table 1 shows that the mean of age the sample was 41 years. Inmates tended to be poorly educated (7.5 years of schooling), unemployed prior to their incarceration (73.2%), and had held blue collar jobs when they had been employed (76.6%). Two fifths (42.2%) were married. One third (33.8%) were foreign nationals.

Table 4 shows that approximately two fifths of inmates had current medical problems that impaired their daily functioning (41.4%) and two fifths had seen a physician in the 6 months prior to their incarceration (38.0%); approximately one third were prescribed non-psychiatric

Table 1 Sociodemographic characteristics of men in Spoleto Prison.a

Age Years of schooling

Ethnicity Italy Africa Eastern Europe Other Occupation level Professional/business Clerical/sales/technical Manual labor/blue collar Employment Full time Part time Unemployed Otherd Marital status Married Never married Divorced/widowed a b c d e

Total (n = 526)

Common criminal (n = 204)

High surveillance (n = 229)

Protected (n = 93)

Mean (SD) 40.7 (11.6) 7.8 (3.1)

Mean (SD) 36.8 (10.7) 7.5 (3.1)

Mean (SD) 44.3 (11.0) 7.8 (3.2)

Mean (SD) 40.1 (12.1) 8.0 (3.1)

%

%

%

%

Differences across groups

HS N CC, P ns

HS N CC, Pb 66.2 12.5 16.2 5.1

47.5 19.6 27.5 5.4

88.6 4.8 3.5 3.1

51.6 16.1 22.6 9.7

8.4 15.0 76.6

5.4 14.2 80.4

10.0 18.3 71.6

10.8 8.6 80.6

4.6 14.0 73.2 8.2

5.4 9.3 80.4 4.9

4.8 16.6 69.4 9.2

2.2 18.3 66.7 12.9

42.2 41.8 16.0

37.7 48.0 14.2

48.9 34.5 16.6

35.5 46.2 18.3

ns

HS, P N CCc

HS N CC, Pe

HS = high surveillance; CC = common criminal; P = protected; ns = non-significant Italian versus non-Italian. Employed (full time, part time or other) versus unemployed. Irregular hours, day work, student, military service, retired or disabled. Married versus never married or divorced.

M. Piselli et al. / International Journal of Law and Psychiatry 41 (2015) 82–88

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Table 2 Psychiatric disorders of men in Spoleto Prison. Total (n = 526)

Any disorder Any Axis I disorder Any substance use disorder Any psychotic disorder Any mood disorder Any anxiety disorder Any Axis II (personality) disorder

Common criminal (n = 204)

High surveillance (n = 229)

Protected (n = 93)

p

n

%

n

%

n

%

n

%

342 277 131 22 50 133 273

65.0 52.7 24.9 4.2 9.5 25.3 51.9

147 122 70 8 21 47 118

72.1 59.8 34.3 3.9 10.3 23.0 57.8

142 110 42 9 23 60 122

62.0 48.0 18.3 3.9 10.0 26.2 53.3

53 45 19 5 6 26 33

57.0 48.4 20.4 5.4 6.5 28.0 35.5

medications (32.9%). Across the board, high surveillance inmates had the poorest functioning in the medical domain. Notably, 11.8% had hepatitis C compared to less than 6% of other inmate groups. 3.4. Psychosocial functioning Table 4 confirms extensive employment problems noted in Table 1, and particularly for the common criminals. One fifth of the inmates reports having two or more family members with significant legal, drug use or psychiatric problems, although this was less common among protected inmates. Approximately half of all inmates had prior arrests for either drug crimes, violent crimes or other crimes. Common criminals and high surveillance inmates were more likely to have prior arrests for drug crimes than protected inmates. Protected inmates were more likely to have prior arrests for violent crimes. Problems related to substance use affected at least one fifth of the sample and were particularly prevalent among common criminals. One fifth of inmates had prior detoxification services for substance use problems and two fifths of inmates had prior outpatient psychiatric treatment. Common criminals were more likely to have had detoxification services and less likely to have had outpatient psychiatric services than other inmates. 3.5. Suicidal ideation and behavior One-fifth of the inmates (20.5%) had ever had serious thoughts of suicide, and 10.5% had ever attempted suicide. In the past 30 days, 5.3% had seriously thought about suicide, and 1.1% had made an attempt.

b.05 b.05 b.01

b.01

4. Discussion Consistent with studies worldwide (Blaauw et al., 2000; Fazel & Danesh, 2002; Fazel & Seewald, 2012), our findings underscore a significant need for specialized mental health services for men in Italian prisons: Two-thirds of male inmates had a psychiatric disorder, and over half had an Axis I disorder. Worldwide, prevalence rates of psychiatric disorders among sentenced prisoners tend to be lower than among remand prisoners (Blaauw et al., 2000). Likewise, rates of Axis I disorders our sample appear lower than those among jail inmates in Italy; although rates of Axis 2 disorders were somewhat higher (Lusignani et al., 2006; Piselli, Elisei, Murgia, Quartesan, & Abram, 2009; Zoccali et al., 2008). It is difficult to compare prevalence rates of disorders across countries due to differences in methods and measurement. The overall prevalence rate of disorders in our sample appears higher than those reported for males in prisons in three European countries (37% to 54%) (Andersen, 2004; Gunn, Maden, & Swinton, 1991; Schoemaker & Van Zessen, 1997; Vicens et al., 2011). However, rates of substance use disorder are on the lower end of those reported prison populations worldwide: 24% to 61% (Andersen, 2004; Fazel, Bains, & Doll, 2006); and prevalence rates of affective, anxiety, and psychotic disorders are comparable to rates found in other countries (Andersen, 2004; Brugha et al., 2005; Fazel & Danesh, 2002; Fazel & Seewald, 2012; Schoemaker & Van Zessen, 1997; Vicens et al., 2011). Our rates of disorder are on the lower end of the range found among males in prisons in North America that assessed substance abuse/ dependence and personality disorders (usually antisocial) (46%–88%; Andersen, 2004); the difference is primarily due to lower rates of Axis II disorders (51.9%) than reported in western countries (65%; Fazel & Danesh, 2002).

Table 3 Comorbid types of disorder among males in Spoleto Prison. Total (n = 526)

No disorder Only one type of disorder Personality disorders Anxiety disorders Substance use disorders Mood disorders Psychotic disorders Any comorbid type of disorder Anxiety and personality Substance and anxiety Substance and personality Mood and personality Substance and mood Psychotic and personality Mood and anxiety Substance and psychotic

Common criminal (n = 204)

High surveillance (n = 229)

Protected (n = 93)

n

%

n

%

n

%

n

%

184 149 80 33 27 6 3 193 95 42 106 47 19 19 7 6

35.1 28.3 15.2 6.3 5.1 1.1 0.6 36.6 18.0 8.0 20.1 8.9 3.6 3.6 1.3 1.1

57 60 31 8 19 2 0 87 37 18 51 21 9 8 2 1

28.0 29.4 15.2 3.9 9.3 1 0 42.6 18.1 8.8 25.0 10.3 4.4 3.9 1 0.5

87 66 39 16 6 3 2 76 41 15 38 21 8 7 4 4

38.1 28.8 17 7 2.6 1.3 0.9 33.1 17.9 6.6 16.6 9.1 3.5 3 1.7 1.7

40 23 10 9 2 1 1 30 17 9 17 5 2 4 1 1

42.7 24.9 10.8 9.7 2.2 1.1 1.1 32.4 18.3 9.7 18.4 5.5 2.2 4.3 1.1 1.1

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Table 4 Addiction severity and associated impairments among men in Spoleto Prison.

Medical Current medical problems which interfere with functioning Hepatitis C Current regular use of non-psychiatric medications Medical problems treated by a physician, past 6 months Employment Valid driver's license Median split of longest period of unemployment N= 52 months Usually unemployed prior to incarceration Pension benefits or social security Debts Family/social Two or more family members with criminal records, drug problems or psychiatric disorders (lifetime) Legal (prior arrests) Drug-related crimes Violent crimes Other crimes Alcohol and drugs (prior to incarceration) Continuous use of alcohol Cocaine abuse More than one substance used per day Detoxification services (lifetime) Psychiatric Previous outpatient treatment Serious depression (lifetime) Hallucinations (lifetime)

Total (n = 526) %

Common criminal (n = 204) %

High surveillance (n = 229) %

Protected (n = 93) %

Differences across groups

41.4 8.4 32.9 38.0

32.4 5.9 24.0 33.8

54.1 11.8 45.0 45.0

30.1 5.4 22.6 30.1

b0.05 b0.05 b0.05 b0.05

34.2 45.2 73.2 5.5 13.3

48.0 36.3 80.4 2.5 18.1

23.6 54.1 69.4 6.1 12.7

30.1 43.0 66.7 10.8 4.3

b0.05 b0.05 b0.05 b0.05 b0.05

22.6

22.1

27.9

10.8

b0.05

45.4 55.5 41.1

53.9 38.2 22.3

49.8 57.2 68.3

16.1 89.2 17.2

b0.05 b0.05 b0.05

20.0 39.7 27.6 18.6

27.9 52.9 35.3 25.0

12.7 34.1 23.6 16.2

20.4 24.7 20.4 10.8

b0.05 b0.05 b0.05 b0.05

42.6 35.4 12.5

33.3 32.4 12.3

47.2 41.9 15.7

51.6 25.8 5.4

b0.01 b0.05 b0.05

Over one third of inmates (36.6%) had comorbid types of disorder. Notably 80% of inmates with substance use disorders had a comorbid psychiatric disorder; most commonly anxiety disorders and personality disorders. There are few data on comorbidity in men in prison; however, high rates of comorbid disorders have been reported among prisoners with substance use disorders in studies of those with identified mental health needs (Berto, Tartari, Tabacchi, Gerra, & Tamburino, 2005; Chiles, Von Cleve, Jemelka, & Trupin, 1990; Grella, Greenwell, Prendergast, Sacks, & Melnick, 2008; National Gains Center, 1997; Palijan, Muzinić, & Radeljak, 2009; Peters & Hills, 1993). Prevalence rates of affective, anxiety, and psychotic disorders were comparable across subgroups of inmates; however, there were notable differences in other psychiatric needs for key correctional subpopulations. Common criminals were significantly more likely to have substance use and personality disorders than either protected or high surveillance inmates. Substance use disorders may be lower among high surveillance inmates because they tend to be older than inmates in other groups. In addition, the code of conduct of Italian organized crime prohibits drug use among its affiliates (“uomo d'onore”). Some inmates are leaders who have already served time in isolation in 41 bis; their criminal lifestyle requires intellectual discipline. Protected inmates may have lower rates of substance use disorders because they are a more heterogeneous population (e.g., crimes against women and children, ex-law enforcement, justice system collaborators) and tend to be sequestered from other inmates. Two fifths of the sample reported medical problems that interfere with functioning, comparable to rates among men in state prison in the United States (Maruschak, 2008). However rates were far higher among high surveillance inmates, affecting over half of this oldest group. Common criminals, who were more likely than other inmate groups to have substance use disorders, were also more likely to have had detoxification services. They also; however, were less likely to have had outpatient psychiatric services than other inmates. This may reflect the higher rates of comorbid substance use disorder and personality disorders in this group: Such persons may be more likely to access detoxification services than psychiatric services.

Two-fifths (21%) of inmates had seriously thought about suicide; one in 10 had ever made a suicide attempt. Rates are lower than those reported in studies of prisoners in England and Wales (Singleton et al., 1998) and Australia (Larney, Topp, Indig, O'Driscoll, & Greenberg, 2012). Suicidal ideation and attempts are robust risk factors for suicide (Hayes, 1995) and must be taken seriously. Fazel, Grann, Kling, and Hawton (2011) examined prevalence rates of suicide among men in prisons across 12 countries. Despite variation in prevalence across countries, even the lowest rates were at least 3 times the rates in the general populations of the respective countries. As has been found in Italian jails and prisons across the globe, inmates tended to be poorly educated and unemployed prior to their incarceration (Fotiadou, Livaditis, Manou, Kaniotou, & Xenitidis, 2006; Harlow, 2003; Kraemer, Gately, & Kessell, 2009; Lusignani et al., 2006; Vicens et al., 2011; Zoccali et al., 2008). In our sample, common criminals had particularly poor socioeconomic status and were the most likely to have been unemployed prior to their incarceration. Several studies have documented particularly weak employment records for those prisoners with the poorest educational backgrounds (Committee on Ethical Considerations for Revisions to DHHS Regulations for Protection of Prisoners Involved in Research, 2006; Harlow, 2003). There are several limitations to this study. Although Italian prisons group inmates in similar sections (common criminals, high surveillance, protected, and “41 bis”), data were drawn from one prison; findings may not be generalizable to other Italian prisons. Data are subject to the limitations of self-report. The mental health needs of inmates may have affected their willingness to be interviewed by a psychiatrist; hence those who refused (7.4%) may have different psychiatric profiles than inmates who chose to participate. Finally, interviewers were not allowed access to “41 bis” inmates. Future research should adopt comparable diagnostic measures to replicate the study in other Italian prisons. Access to leaders of organized crime (“41 bis” inmates) would provide a more complete assessment of mental health needs of men in prison. Several studies suggest that criminal recidivism may be higher and occur more quickly for released prisoners with psychiatric disorders compared with those without (Baillargeon, Binswanger, Penn, Williams, & Murray, 2009; Cloyes,

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Wong, Latimer, & Abarca, 2010; Lovell, Gagliardi, & Peterson, 2002). Future studies should examine the effectiveness of services to inmates, and what types of services can affect rates of recidivism (Cloyes et al., 2010; Lovell et al., 2002). 5. Conclusions Findings underscore the importance of identifying the inmates' mental health needs across key correctional subpopulations, and the need for specialized mental health services for prison inmates. As inmates return to the community, their care becomes the responsibility of the community health system. Thoughtful linkage to community mental health services will facilitate a successful reintegration (Dumont, Brockmann, Dickman, Alexander, & Rich, 2012). Service systems must be equipped to provide integrated services for those with both psychiatric and substance use disorders and be prepared for challenges posed by patients with personality disorders. For countries with serious prison overcrowding, like Italy, we must also develop strategies to reduce unnecessary incarcerations and explore alternative means of addressing the needs of mentally ill offenders (Dumont et al., 2012). Acknowledgments We are grateful to the Azienda USL Umbria n.2 (216;01.06.2011) and to the Fondazione Cassa di Risparmio di Perugia (2013.0350.013) for their financial support of the research project. We also thank the Casa di Reclusione di Spoleto for their cooperation and support. References Aebi, M. F., & Delgrande, N. (2010). Council of Europe Annual Penal Statistics – Space I – Survey 2008. Switzerland: University of Lausanne. Alterman, A. I., McDermott, P. A., Cook, T. G., Cacciola, J. S., McKay, J. R., McLellan, A. T., et al. (2000). Generalizability of the clinical dimensions of the Addiction Severity Index to nonopioid-dependent patients. Psychology of Addictive Behaviors, 14(3), 287–294. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Milano: Tr. It. Masson. Andersen, H. S. (2004). Mental health in prison populations. A review — With special emphasis on a study of Danish prisoners on remand. Acta Psychiatrica Scandinavica, 424, 5–59 (Suppl.). Arboleda-Florez, J., Holley, H. L., Williams, J., & Crisanti, A. (1994). An evaluation of legal outcome following pretrial forensic assessment. Canadian Journal of Psychiatry, 39(3), 161–167. Baillargeon, J., Binswanger, I. A., Penn, J. V., Williams, B. A., & Murray, O. J. (2009). Psychiatric disorders and repeat incarcerations: The revolving prison door. The American Journal of Psychiatry, 166(1), 103–109. Basco, M. R., Bostic, J. Q., & Davies, D. (2000). Methods to improve diagnostic accuracy in a community mental health setting. American Journal of Psychiatry, 157, 1599–1605. Berto, D., Tartari, M., Tabacchi, B., Gerra, G., & Tamburino, G. (2005). Dual diagnosis within Italian prisons — Some preliminary data. International Journal of Prisoner Health, 1(1), 19–24. Blaauw, E., Roesch, R., & Kerkhof, A. (2000). Mental disorders in European prison systems. Arrangements for mentally disordered prisoners in the prison systems of 13 European countries. International Journal of Law and Psychiatry, 23(5–6), 649–663. Bridgwood, A., & Malbon, G. (1994). Survey of the physical health of prisoners. London: Her Majesty Stationery Office. Brink, J. H., Doherty, D., & Boer, A. (2001). Mental disorder in federal offenders: A Canadian prevalence study. International Journal of Law and Psychiatry, 24(4–5), 339–356. Brown, E., Frank, D., & Friedman, A. (1997). Supplementary administration manual for the expanded version of the Addiction Severity Index (ASI) instrument, the ASI-F (DHHS publication no. SMA 968056). Rockville: Centre for substance abuse treatment (49 pp). Brugha, T., Singleton, N., Meltzer, H., Bebbington, P., Farrell, M., Jenkins, R., et al. (2005). Psychosis in the community and in prisons: A report from the British National Survey of psychiatric morbidity. The American Journal of Psychiatry, 162(4), 774–780. Bureau of Justice Statistics (2002). Reentry trends in the US: Recidivism. Retrieved March 2, 2013, from http://bjs.ojp.usdoj.gov/content/reentry/recidivism.cfm Carrà, G., Restani, L., & Dal Canton, F. (2004). L'Addiction Severity Index (ASI-X) EasyASI. CD-ROM & software. www.eikondata.com Chiles, J. A., Von Cleve, E., Jemelka, R. P., & Trupin, E. W. (1990). Substance abuse and psychiatric disorders in prison inmates. Hospital & Community Psychiatry, 41(10), 1132–1134. Cloyes, K. G., Wong, B., Latimer, S., & Abarca, J. (2010). Time to prison return for offenders with serious mental illness released from prison: A survival analysis. Criminal Justice and Behavior, 37, 175–187.

87

Committee on Ethical Considerations for Revisions to DHHS Regulations for Protection of Prisoners Involved in Research (2006). Ethical considerations for research involving prisoners. Washington, DC: The National Academies Press. Davis, T. M., Baer, J. S., Saxon, A. J., & Kivlahan, D. R. (2003). Brief motivational feedback improves post-incarceration treatment contact among veterans with substance use disorders. Drug and Alcohol Dependence, 69(2), 197–203. Ditton, P. M. (1999). Mental health and treatment of inmates and probationers. Washington, DC: US Bureau of Justice Statistics. Dumont, D. M., Brockmann, B., Dickman, S., Alexander, N., & Rich, J. D. (2012). Public health and the epidemic of incarceration. Annual Review of Public Health, 33, 325–339. Elaborazioni Istat su dati Ministero della Giustizia, Anno 2010 (2012). Retrieved from http://noi-italia2012.istat.it/fileadmin/user_upload/allegati/59.pdf Fazel, S., Bains, P., & Doll, H. (2006). Substance abuse and dependence in prisoners: A systematic review. Addiction, 101(2), 181–191. Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23000 prisoners: A systematic review of 62 surveys. Lancet, 359(9306), 545–550. Fazel, S., Grann, M., Kling, B., & Hawton, K. (2011). Prison suicide in 12 countries: An ecological study of 861 suicides during 2003–2007. Social Psychiatry and Psychiatric Epidemiology, 46(3), 191–195 (Epub 2010 Feb 7). Fazel, S., & Seewald, K. (2012). Severe mental illness in 33,588 prisoners worldwide: Systematic review and meta-regression analysis. The British Journal of Psychiatry, 200(5), 364–373. Fennig, S., Craig, T., Lavelle, J., Kovasznay, B., & Bromet, E. J. (1994). Best-estimate versus structured interview-based diagnosis in first-admission psychosis. Comprehensive Psychiatry, 35(5), 341–348. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II). Washington, DC: American Psychiatric Press. Fotiadou, M., Livaditis, M., Manou, I., Kaniotou, E., & Xenitidis, K. (2006). Prevalence of mental disorders and deliberate self-harm in Greek male prisoners. International Journal of Law and Psychiatry, 29(1), 68–73 (Epub 2005 Nov 2). Grella, C. E., Greenwell, L., Prendergast, M., Sacks, S., & Melnick, G. (2008). Diagnostic profiles of offenders in substance abuse treatment programs. Behavioral Sciences & the Law, 26(4), 369–388. Gunn, J., Maden, A., & Swinton, M. (1991). Treatment needs of prisoners with psychiatric disorders. British Medical Journal, 303, 338–341. Harlow, C. W. (2003). Education and correctional populations Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice. Hayes, L. (1995). Prison suicide: An overview and a guide to prevention. The Prison Journal, 75, 431–456. Hodgins, D. C., & el-Guebaly, N. (1992). More data on the Addiction Severity Index. Reliability and validity with the mentally ill substance abuser. Journal of Nervous and Mental Disease, 180(3), 197–201. International Centre for Prison Studies (ICPS) (2012). Available at http://www. prisonstudies.org/info/worldbrief/wpb_country.php?country=147 Kokkevi, A., & Hertgers, C. (1995). EUROPASI: European adaptation of a multidimensional assessment instrument for alcohol and drug dependence. European Addiction Research, 1, 208–210. Kosten, T. R., Rounsaville, B. J., & Kleber, H. D. (1983). Concurrent validity of the addiction severity index. Journal of Nervous and Mental Disease, 171(10), 606–610. Kraemer, S., Gately, N., & Kessell, J. (2009). HoPE (Health of Prisoner Evaluation) pilot study of prisoner physical health and psychological wellbeing. Joondalup WA: Edith Cowan University. Kranzler, H. R., Kadden, R. M., Babor, T. F., Tennen, H., & Rounsaville, B. J. (1996). Validity of the SCID in substance abuse patients. Addiction, 91(6), 859–868. Kranzler, H. R., Kadden, R., Burleson, J., Babor, T. F., Apter, A., & Rounsaville, B. J. (1995). Validity of psychiatric diagnoses in patients with substance use disorders — Is the interview more important than the interviewer. Comprehensive Psychiatry, 36(4), 278–288. Lamb, H. R., & Weinberger, L. E. (1999). Persons with severe mental illness in jails and prisons: a review. Psychiatric Services, 49(4), 483–492. Lamb, H. R., & Weinberger, L. E. (2001). Persons with severe mental illness in jails and prisons: A review. New Directions for Mental Health Services, 90, 29–49. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174. Larney, S., Topp, L., Indig, D., O'Driscoll, C., & Greenberg, D. (2012). A cross-sectional survey of prevalence and correlates of suicidal ideation and suicide attempts among prisoners in New South Wales, Australia. BMC Public Health, 6, 12–14. Leonardi, F. (2007). Le misure alternative alla detenzione tra reinserimento sociale e abbattimento della recidiva. Rassegna Penitenziaria e Criminologica, 2, 7–26. Lovell, D., Gagliardi, G. J., & Peterson, P. D. (2002). Recidivism and use of services among persons with mental illness after release from prison. Psychiatric Services, 53(10), 1290–1296. Lusignani, G. S., Giacobone, C., Pozzi, F., Dal, Canton F., Alecci, P., & Carrà, G. (2006). Disturbi mentali in una casa circondariale: uno studio di prevalenza. Nóoς, 1, 23–34. Maruschak, L. M. (April 2008). Medical problems of prisoners Bureau of Justice Statistics Report. NCJ, 221740. McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance and Abuse Treatment, 9, 199–213. McLellan, A. T., Luborsky, L., Cacciola, J., Evans, F., Barr, H., & O'Brien, C. P. (1985). New data from the Addiction Severity Index. Reliability and validity in three centers. Journal of Nervous and Mental Disease, 173, 412–413. McLellan, A. T., Luborsky, L., Woody, G. E., & O'Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. Journal of Nervous and Mental Disease, 168(1), 26–33.

88

M. Piselli et al. / International Journal of Law and Psychiatry 41 (2015) 82–88

McLellan, A. T., Woody, G. E., Luborsky, L., O'Brien, C. P., & Druley, K. A. (1983). Increased effectiveness of drug abuse treatment from patient–program matching. NIDA Research Monografica, 43, 335–342. National Gains Center (1997). The prevalence of co-occurring mental and substance abuse disorders in the criminal justice system. Washington, DC: National Institute of Correction. Oberg, D., Zingmark, D., Sallmén,B. (1999). ASI-Xv1.11999-10-08. Edizione italiana a cura di Carrà, G., Restani, L., & Dal Canton, F. (2004a). Dipartimento di Scienze Sanitarie. Sezione di Psichiatria. Università di Pavia. Palijan, T. Z., Muzinić, L., & Radeljak, S. (2009). Psychiatric comorbidity in forensic psychiatry. Psychiatria Danubina, 21(3), 429–436. Peters, R. H., Greenbaum, P. E., Steinberg, M. L., Carter, C. R., Ortiz, M. M., Fry, B. C., et al. (2000). Effectiveness of screening instruments in detecting substance use disorders among prisoners. Journal of Substance and Abuse Treatment, 18(4), 349–358. Peters, R. H., & Hills, H. A. (1993). Inmates with co-occurring substance abuse and mental health disorders. In H. J. Steadman, & J. J. Cocozza (Eds.), Mental illness in America's prisons. Washington, DC: National Coalition for the Mentally Ill in the Criminal Justice System. Piselli, M., Elisei, S., Murgia, N., Quartesan, R., & Abram, K. M. (2009). Co-occurring psychiatric and substance use disorders among male detainees in Italy. International Journal of Law and Psychiatry, 32, 101–107. Powell, T. A., Holt, J. C., & Fondacaro, K. M. (1997). The prevalence of mental illness among inmates in a rural state. Law and Human Behavior, 21(4), 427–438. Pozzi, G., Bacigalupi, M., & Tempesta, E. (1997). Comorbidity of drug dependence and other mental disorders: A two-phase study of prevalence at outpatient treatment centres in Italy. Drug and Alcohol Dependence, 46(1–2), 69–77. Schoemaker, C., & Van Zessen, G. (1997). Psychische stoornissen bij gedetineerden: een verkennend onderzoek in Penitentiair Complex Scheveningen [Mental disorders among detainees: An explorative study in the penitentiary complex Scheveningen]. Utrecht: Trimbos-instituut.

Segal, D. L., Kabacoff, R. I., Hersen, M., Van Hasselt, V. B., & Ryan, C. F. (1995). Update on the reliability of diagnosis in older psychiatric outpatients using the Structured Clinical Interview for DSM-III-R. Journal of Clinical Geropsychology, 1, 313–321. Singleton, N., Meltzer, H., Gatward, R., Coid, J., & Deasy, D. (1998). Psychiatric morbidity among prisoners in England and Wales: A survey carried out in 1997 by the Social Survey Division of ONS on behalf of the Department of Health. London: Her Majesty's Stationary Office. Skre, I., Onstad, S., Torgersen, S., & Kringlen, E. (1991). High interrater reliability for the Structured Clinical Interview for DSM-III-R Axis I (SCID-I). Acta Psychiatrica Scandinavica, 84(2), 167–173. Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49(8), 624–629. Vicens, E., Tort, V., Dueñas, R. M., Muro, Á., Pérez-Arnau, F., Arroyo, J. M., et al. (Dec. 2011). The prevalence of mental disorders in Spanish prisons. Criminal Behaviour and Mental Health, 21(5), 321–332. http://dx.doi.org/10.1002/cbm.815 (Epub 2011 Jun 26). West, H. C., & Sabol, W. J. (2008). Prisoners in 2007. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice. Williams, J. B. W., Gibbon, M., First, M. B., Spitzer, R. L., Davis, M., Borus, J., et al. (1992). The Structured Clinical Interview for DSM-III-R (SCID) II. Multi-site test–retest reliability. Archives of General Psychiatry, 49, 630–636. Zanarini, M. C., Skodol, A. E., Bender, D., Dolan, R., Sanislow, C., Schaefer, E., et al. (Winter 2000). The collaborative longitudinal personality disorders study: Reliability of Axis I and II diagnoses. Journal of Personality Disorders, 14(4), 291–299. Zoccali, R., Muscatello, M. R., Bruno, A., Cambria, R., Cavallaro, L., D'Amico, G., et al. (Oct–Nov. 2008). Mental disorders and request for psychiatric intervention in an Italian local jail. International Journal of Law and Psychiatry, 31(5), 447–450 (Epub 2008 Sep 16).