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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 23
| Issue : 1 | Page : 43-51 |
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Ending up in prison healthy and getting out mentally ill: Prevalence and risk factors of psychiatric illnesses among jail inmates at the Kondengui Central Prison (Yaoundé-Cameroon)
Eric Clement Lele Nkoagne, H Blaise Nguendo Yongsi
Department of Public Health, School of Health Sciences, Catholic University of Central Africa, Yaoundé, Cameroon
| Date of Web Publication | 2-Nov-2018 |
Correspondence Address:
H Blaise Nguendo Yongsi
Institute of Training and Research in Population Studies (IFORD), University of Yaounde II, Post Box 1556, Yaounde
Cameroon
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_20_18
Background: Mental disorders are a matter of great concern worldwide. The situation is particularly challenging in the developing countries given the substandard detention conditions of prisoners. This appears to be an obstacle to achieve the triple economic, social, and security goals of prisons of this 21st century. Objectives: This study aims at determining the prevalence and risk factors associated with mental disorders among inmates in Cameroon. Subjects and Setting: The study focuses on 230 convicted and unconvicted inmates being held at the Central Correctional Prison of Kondengui in Yaoundé. Materials and Methods: A cross-sectional study of a random sample was conducted to assess psychiatric disorders using a Mini-International Neuropsychiatric Interview. The Chi-square test was used to determine associations at the 5% significance level, and magnitude of association was estimated using the odds ratio and its 95% confidence interval. Results: Of the 230 inmates, 80 (34.8%) were diagnosed as suffering from a mental illness, and identified disorders were related to psychotic disorders (66.67%) to mood disorders (54.29%), borderline personality (38.57%), and suicidal thoughts (24.29%). Risk factors associated with those mental disorders were mostly environmental (the general prison environment), sociological and individual (regimes governing daily life inside prison). Conclusion: Mental disorders are common among inmates. Extrapolation of our results suggests that inmates in Cameroon need transfer to hospital for specialized psychiatric treatment and services and that environmental condition of detention must be improved.
Keywords: Cameroon, jail inmates, Kondengui Central Prison, mental disorders, risk factors
How to cite this article:
Lele Nkoagne EC, Nguendo Yongsi H B. Ending up in prison healthy and getting out mentally ill: Prevalence and risk factors of psychiatric illnesses among jail inmates at the Kondengui Central Prison (Yaoundé-Cameroon). J Mental Health Hum Behav 2018;23:43-51 |
How to cite this URL:
Lele Nkoagne EC, Nguendo Yongsi H B. Ending up in prison healthy and getting out mentally ill: Prevalence and risk factors of psychiatric illnesses among jail inmates at the Kondengui Central Prison (Yaoundé-Cameroon). J Mental Health Hum Behav [serial online] 2018 [cited 2023 Jun 1];23:43-51. Available from: https://www.jmhhb.org/text.asp?2018/23/1/43/244910 |
| Introduction | |  |
The issue of mental illness among people in prisons has been highlighted in several studies. While some raised the problem of its existence[1] and magnitude which varies from 26% in developed countries to 11% in the developing countries,[2] other drew attention either on type of mental illnesses[3],[4] or to the lack of improvement despite numerous inquiries into the management of mentally disordered people in prison.[5],[6] In any case, mental disorders account for almost 14% of the global burden of disease, and up to 85% of people with severe mental disorders receive no treatment in low- and middle-income countries, compared with 35%–50% in high-income countries.[7] The deprivation of liberty constitutes a significant risk of mental disorder, given the conditions of detention that are not always optimal. Although it is widely acknowledged that most of the detainees have weakened mental health, mental disorders seem to be the most frequent pathologies experienced by prisoners. There is much debate in the literature about the very large numbers of persons with mental illness in jails. Many mental health, law enforcement, and legal professionals are concerned that the criminal justice system in western countries and the judiciary system in whole in developing societies are at the grassroots of the predominant numbers of persons with mental disorders who are in need of not, of treatment.[8],[9] The prevalence data about psychiatric disorders in the course of detention are very wide between countries: 6% in Italy, 13% in France, 29,2% in Zambia, 64% in the United States, and 74% in Australia.[10],[11],[12] These high prevalence rates reflect the extent of psychiatric problems in custody compared to the general population, and mirror that it is a serious disturbance that can immediately lead to enormous social, security, and physiological problems, and later to the disruption of the social, economic, and political balance of a nation;[13] a situation which goes against the declared goals of imprisonment, that is “neutralization, punishment, prevention, and cure.”[14] Although a number of studies have not been able to establish factors associated with mental illness in inmate populations, there is a number of contributing factors which can be identified to help explain the high rates of prisoners with mental illnesses. These factors include the limited capacity or none functionality of community-based mental health services to address the needs of mentally ill offenders, deinstitutionalization of mentally ill people, and an increase in the use of drugs and alcohol. In Cameroon, anecdotal evidence from staff working in the correctional system has always suggested a high prevalence of mental illness among the prisoner population. According to this staff, 78 nation's prisons held over 33,000 inmates as of December 2017. The latest methodologically sound estimates of the percentages of persons diagnosed as having a severe mental illness. By using the lower percentages to avoid overstating this phenomenon, Amnesty International estimates that as of December 2016, the number of inmates with mental illness in jails was 30,000. However, it is still unclear how much of the mental disorders are recognized by prison health-care services. With such a large number of this population incarcerated in the criminal justice system as opposed to being treated in the mental health system, it is important to have more detailed information about their psychiatric status, what psychiatric services they used while incarcerated, and eventually what challenges they might present in psychiatric treatment after release. We then conducted this study to explore these issues in detail, specifically to assess the magnitude of mental health in prison, to find out the types of disorders and to identify risk factors associated with the occurrence of those mental illnesses.
| Materials and Methods | | |
Setting and participants
This cross-sectional study was conducted at Kondengui Central Prison, located in Yaoundé between 03°831 N and 11°519 E. Among the 78 functional prisons over the 88 prisons throughout the Cameroonian territory [Figure 1], Kondengui is a maximum security prison in Yaoundé constructed in 1967 to hold only 500 inmates. She is the largest in terms of number of inmates (about 4500 whereas the maximum capacity is 1500 prisoners).[15] It is a mixed prison as she holds both males and females from various statuses (remands, condemned). However, she is made up of 14 yards with two known as “Kosovo yards” hosting nearly 3000 inmates. Although the facility has 16 toilets and 400 beds, she has been the subject of numerous international criticisms for its overcrowding and poor conditions. Participants included remanded, sentenced, and condemned inmates. The sample did not include violent offenders and those requiring maximum security placement because they could not be easily moved into the testing area. In fact, stays in special programming units were generally brief, so that most inmates were unavailable for testing. A sample size of 230 was derived after using the formula: Sample size = z2 × p (1 − p)/m2.
Whereby “m” was margin of error that was set at 10%, “z” was confidence level at 95% (1.96) and “p” was postulated prevalence of mental illness. Given the configuration of the premise (14 yards hosting inmates distributed according to the gender and to their social status) and since we were looking for statistical representativeness, participants were selected proportionally, based on the number of inmates in each yard. A sampling frame was constructed by enumerating all the names of the inmates with their corresponding numbers on the register and hosting yard. Using the systematic random sampling technique, a Windows excel function was used to generate a list of random numbers which was used to select inmates from the sampling frame.
Data collection and instrument
To diagnose mental disorders, we used the psychometric tool called Mini International Neuropsychiatric Interview (MINI). The MINI is a standard open access psychometric tool used by health professionals to explore the major Axis I of the DSM-IV psychiatric disorders. As well as the self-reported questionnaire developed by the World Health Organization to screen for psychiatric disorders especially in the developing countries,[16] MINI is a structured diagnostic interview made up of questions with modalities to check responses and a space provided for the final diagnosis. The different categories of mental disorders explored were: personality and behavioral disorders (specific personality disorders, mixed disorders, and other personality disorders), mood disorders and affective disorders (manic disorders, depressive episodes, recurrent depressive disorder, and persistent affective disorder), anxiety disorders, (phobic anxiety disorder, other anxiety disorders, obsessive–compulsive disorder (OCD), reactions to a severe stressor and adjustment disorders, delusional disorder, and other neurotic disorders), suicidal risk (mild, moderate, and severe), addiction to alcohol and drugs. The MINI was then administered by ourselves,[17] and MINI diagnoses were characterized by good or very good kappa values. Sensitivity was 0.70 for all disorders except dysthymia and OCD. The instrument assesses suicide risk by combining several relevant items (current or past suicidal thoughts, and attempts), addictions (tobacco, alcohol, and drugs).
In addition to this, a structured questionnaire was used to explore demographic features of prisoners, environmental characteristics of the premise, criminal history of inmates, daily financial expenses, reintegration activities, recidivism of detention, overcrowding, respect for the dignity of the person, and existence of other social and emotional factors.
Interviewer training
Five end-of-year medical students interviewers were trained for phase I (administration of the MINI), and five master students in population studies were trained for phase II (collection of demographic and environmental information). During each phase, interviewers participated in 2-day on-site training in the administration of the questionnaires by a certified MINI instructor. Interviewers practiced with acquaintances and volunteer psychiatric patients.
Data processing and analysis
Data processing and analysis were conducted using a Statistical Package for Social Sciences version 18.0 (SPSS 18.0, SPSS Inc, IBM, Chicago, USA). Data were edited using range checks. Associations were established using the uncorrected Chi-square test at the 5% significance level. The Fisher's exact test for association was used to test for the association when a cell in a two by two contingency table had an expected frequency of <5. The magnitude of association was estimated using odds ratio (OR) and its 95% confidence interval to determine associations between sociodemographic factors and mental disorders.
Ethical considerations
The research proposal was approved by the Institutional and Ethics Review Board of the School of Health Sciences of the Central Africa Catholic University. Permission to conduct the study was granted by the General Director of Kondengui Prison. Participation to the study was absolutely voluntary. Participants were informed that they were free to decide whether or not to participate and were also free to withdraw at any time from the study. Both verbal and written consent were obtained from the participants before taking part in the study. Confidentiality was upheld by use of codes on the questionnaires. Given their diminished autonomy and in accordance with the General Director of the setting, participants' interviews were limited to 30 min and were carried out in privacy. Consent forms and questionnaires were only accessible to the investigator. Participants were informed that the decision to participate would not affect their stay in the jail, and a brief quiz was administered to assess competency to consent.
| Results | | |
Demographic characteristics
A total of 230 participants participated, including 159 (69.1%) male and 71 (30.9%) female. Associated demographic characteristics of the sample are shown in [Table 1]. The mean (standard deviation) age of offenders was 42.1 years, and more than half of the sample was married or was living in a couple (61.7%). There was no great differences.
Context of confinement
The most frequent charge for which an offender was incarcerated was burglary (36.1%), followed in order of frequency by Public funds embezzlement, sexual abuse, and crimes against persons (11.7%). Most of them were already convicted (66.1%) whereas some were still on pretrial detention (16.1%). Inmates are secured in different wards and mostly in the overcrowded one called “Kosovo” (31.7%), followed by the temporary cell (23.9%). Offenders jailed for embezzlement are secured in the special cell (36.1%) females have their separate ward (30.8%). The occupancy rate per cell is higher as we recorded at least between 10 and 50 inmates per cell. The majority does not have access to facilities such as water for the shower and improved toilets, as well as to any assistance [Table 2].
Prevalence rate and current mental disorders
Out of the 230 participants, 80 met the criteria for at least one-lifetime disorder when assessed with the MINI, that is, a prevalence rate of 34.78%.
In examining the prevalence of current disorders [Table 3], severe psychiatric disorders are the most common, whereas suicidal thoughts and the borderline personality disorders are the less common. Factors associated to those mental illnesses include penal status, cell occupancy rate, repeat offences, and use of psychoactive substances among others. Thus, the fact of “having already been incarcerated twice or more,” is statistically associated with the risk of developing a mental disorder. For example, 36.96% of inmates with severe psychotic disorder were incarcerated more than once (OR = 3.83, Sig = 0.03). Environmental factors also affect the health of prisoners. The study shows that cohabitation and social cohesion actions reduce by almost 75% the risk of developing mood disorders (OR = 0.24) compared to those incarcerated in isolation (special cell). Respect of privacy and having access to sanitary facilities reduce the risk of developing a mood disorder by 65%–80% and the risk of developing a suicidal risk by 96% and (OR = 0.22). People with no socioeconomic occupation within the prison are twice as likely to have a personality disorder (OR = 2.85). With regard to sociological factors, it appears that family ties and the frequency of family assistance reduce by 76% the risk of developing mood disorders and personality disorders (OR = 0.23; Sig = 0.01). However, with no family assistance, the risk of developing borderline personality disorders increases thrice (OR = 3.43%). Vulnerability to mental disorders also comes from psychological characteristic and addiction to drugs. For example, living in fear increases the risk of developing severe psychotic disorders by four times and more (OR = 4.37, Sig = 0.00). In 45% of cases, the use of drugs increases the risk of developing a personality disorder by more than three times (OR = 3.21). | Table 3: Current mini international neuropsychiatric interview-plus disorders in the offenders
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| Discussion | | |
The prevalence rate of mental disorders in this study was 34.78%. This prevalence rate is lower than 56% obtained in the state maximum security prisons in the USA, or than 63.1% and64% obtained in the medium security prison respectively in Zambia and Australia.[18],[19] However, these findings are synonymous to those by Loeb et al. that show a pattern of lower prevalence rate prisons.[20] The study confirms the high frequency of mental disorders in incarcerated offenders, findings generally consistent with reports from other prison-based studies.[21],[22] Within the Cameroonian context, this prevalence rate seems to be increasing and is in accordance with the increase trend in all the prisons throughout the country [Figure 2]. | Figure 2: Tends in penal population at Kondengui-Yaoundé Central Prison and in Cameroonian Prisons
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As seen, several inmates met criteria for at least one lifetime MINI disorder. Compared with community rates, severe psychotic disorders, mood and anxiety disorders, borderline personality disorders, and suicidal thoughts were all more frequent as reported by Diamond et al.[23]
The high frequency of mental disorders is fairly dependent of gender, type of offense, education level, and age. Females' inmates were less likely to have mental illness compared to males. This situation may be explained by the fact that, women are given a preferential treatment as, for example, they are secured in separate cells of not more than 100 inmates. However, our expectations regarding the distribution of disorders were not confirmed, because male inmates in this study, according to focus group discussions held, had a number of social amenities such as sports, religious activities as well as communication facilities which were contributing positively to their mental well-being.
Of importance, the study shows that current disorders are common among persons newly committed. The distinction between current and lifetime disorders has generally been ignored or omitted in prior prevalence studies. While it is necessary to understand lifetime rates, data for the current disorders are more important in terms of planning because these are conditions that may require urgent attention.[24] The presence of these disorders suggests that women may need special programs to address their needs. For example, women may have more difficulty adjusting to their conviction and incarceration than men and may benefit from counseling that addresses this transition.
The finding that most offenders screened positive for a lifetime severe psychotic disorder merits discussion. Taken at face value, the percentage appears much too high, yet when placed into context, it seems less. First, most anxiety disorders were current widespread anxiety (20%), agoraphobia (20%), and OCD (70%). Our results are not similar to those of Senior et al.,[25] but they seem to be higher than those got by Butler et al.[26] The duration of incarceration and living conditions in cells may explain this high rate at Kondengui. The following testimonials reflect the living conditions in Cameroonian prisons:
“Taking into consideration the reality of arbitrary pretrial detention in Cameroon which does not amount to 'lawful sanctions', we are inclined to hold that the conditions in some prisons and detention cells in Cameroon, characterized by overcrowding, sleep deprivation, poor sanitation, and nutrition, which inflict physical and mental suffering on detainees, tantamount to torture. Such treatment may cause detainees to suffer mental breakdown and even permanent psychological trauma.”[27]
“In prison, he (Bertrand Teyou) shared his days with prisoners referred to as 'penguins,' who're permanently crouching by the walls of the prison yard, and who eat from makeshift buckets placed on the floor, sleep on filthy rags, and cram into every nook and cranny when it rains-a one-way mirror on the suffering of a people held hostage.”[28]
“The hygienic conditions of the female quarters are deplorable. When I just got into prison, the latrine that had and still has 3 toilets pots was all cracked. These 3 toilets had to serve over 150 and at times 200 women. They were constantly blocked…There was no water most of the time. Some make the place deliberately filthy and take much joy from doing so. It is beyond horrible. I still develop goose pimples just thinking about this.”[29]
Because psychotic features are commonly observed in people constantly down in dungeon, a high rate of OCD is not surprising [Table 4].[30] Another possible explanation of these high prevalence figures is that the MINI over diagnoses psychotic disorders. Leon et al. (1997) and Sheehan et al.[31],[32] each reported a relatively high rate of false-positive diagnoses of psychotic disorders with the MINI. Nor has the MINI been standardized in the setting of criminal prosecution and incarceration, unusual experiences that could contribute to elevations in instruments designed to measure strange experiences.
With regard to mild/moderate mood disorders, our estimate of 54.3% is five times higher than that obtained by Esposito[33] among prisoners in Italy (9.87%). As for suicidal thoughts, our prevalence rate of 24.29% is much higher than that reported by Fazel et al.[2] whose estimation was 17 suicidal thoughts over 10,000 inmates in France. Borderline personality disorders reported here are statistically associated with occupational status in prison: More than half of the inmates (51.2%) who developed a personality disorder were those with no occupation in prison (P = 0.01). This can be purely explained by idleness. The mild/moderate mood disorders reported in our study were essentially episodes of major depression whose prevalence is twice as high as that obtained in the general population by Nguendo Yongsi.[34] Whatever it is, these mood disorders are statistically associated with the overcrowding factor. It comes out that detainees living in cells of 10 square meters with more than 50 other inmates were three times more likely to develop major depression (68.6%) than those secured in cells with <10 inmates (22.2%) (P = 0.01). This is probably due to sleep disorders as space in cell is too small, and the discomfort generates promiscuity. In fact, the imposed narrowing of the living space and the prison overcrowding simultaneously establish a “proxemia” peculiar to the institution: “The inmates wake up to line up behind each other and take turns urinating on the little mountain of feces in one corner of the cell, chipping it off and scattering the pieces onto the floor. There is something unique about uncomfortable prisons. Sometimes, the heat helps detainees forget the prison and sometimes, the prison helps them forget the heat.”[35]
The permanent stress here can also be attributed to the disruption of the life social rhythms in an environment different from the house since in prison inmates are by regulation obliged to live together, which implies confrontation with postural, gestural, corporal styles, physiological rhythms, and different lifestyle habits. In addition to confinement, there is continual encroachment of privacy under the combined effect of promiscuity and close watch of co-inmates.[36] While examining our results, it appears that lack of intimacy in prison is associated with mood disorder (60.4%, P = 0.02).
Two kinds of temporality external to the prison affect the mental health of prisoners at Kondengui: The judicial temporality in a relationship with the procedure rhythm and the length of the sentence. From our study, inmates convicted for property offenses were 12 times (12.5%) more exposed to dysthymia disorders than those convicted for personal injury (P = 0.02). Moreover, inmates sentenced <12 months' detention (52.8%) were at greater risk than those who already completed more than 12 months' imprisonment (P = 0.03. Looking beyond the temporal sequence which runs from the cells closing till the sunrise, there is a long period of confinement, and for prison warders, it does not matter whether inmates are claustrophobic or not. Sleeping all the time, the brain never completely sleeps, lack of privacy during the night, common showers, toilets/restrooms installed at the center of the cell, of course intensify anxiety and generate stress. In short and according to Maschi et al.,[37] various protective barriers which filter and regulate relations with others are cracked to the last bulwark that constitutes the body envelope.
The rate of suicide thoughts (34.29%) mostly among inmates aged 40 years and more should also raise concerns. The disorder has gained increasing attention, as it has become clear that it is common and widespread in the general population, yet few prison-based studies have been conducted to investigate this concern. Our results differ from those of Ferriera et al.[38] where the youngest adults appear to be the most vulnerable. Nevertheless, various studies conducted in the USA do not necessarily agree on the effect of age, meaning that age is not clearly recognized as a risk factor.[39],[40] However, length of imprisonment has appeared to be correlated to suicide risk in prison: More than half of the prisoners with sentence <5 years were likely to commit suicide. This situation can be explained by the fact that suicidal thoughts are based on several situations: Death by suicide in the neighboring cell, death of a close inmate, personal desire to die rather than to be deprived of liberty or to be tortured permanently by prison guards, as it is revealed by an ex-convict who share the indignity and mental torture and inhuman condition of inmates: We were treated like common criminals. “I witnessed young men beaten and degraded beyond any human imagination. Passing one through the balançoire and beating of the soles of the feet were common features for the treatment meted out to the detainees.”[41] According to this category of inmates, prison is a “little death, a slow death,” and rather to that, it is preferable to die fast by committing suicide. The fact that the disorder leads to death should lead to discussions regarding the merits and emergency of providing appropriate care/counseling in correctional settings.
| Conclusion | | |
The prison environment is particularly favorable to mental disorders. At Kondengui Correctional Prison, we found a diversity of mental disorders including borderline personality disorders, mood disorders, suicidal risk, and severe psychotic disorders. For most inmates with severe psychiatric disorders, their prevalence is higher in the overcrowded wards, which host formerly social and economic disadvantaged convicted inmates. Risk factors associated with mental disorders are environmental, sociological, and individual. They include lack of privacy, amenities insufficiency, overcrowding, lack of family assistance and social support, and inadequacies in the social reintegration system. These findings should raise concerns about the adequacy of the current screening programs for mental disorders in state prisons and the response of correctional personnel in providing adequate treatment services. Both screening and treatment are legally mandated yet in consistently implemented throughout the 78 state prisons. Due to the large burden created by mental disorders, it is urgent that correctional facilities face the growing challenges of providing treatment services to incarcerated offenders. While the MINI proved to be useful in this study, its length, complexity, and requirement for interviewer training suggest that it is not appropriate as a screening tool in prisons. Its developers have devised a quick screener for use in primary care estimated to take 5 min to administer that should be studied for its utility in the correctional system.
Limitations
There are several limitations to this study. First, the study was relatively small, and the power may be insufficient to detect significant differences between the men and women. Second, because the study was exploratory, we chose not to correct for the number of comparisons made. Third, data or this study is limited to the self-report of the offender and available public information from the IDOC. The diagnoses are based on the MINI, and no medical records or laboratory data were available. Finally, while it appeared that participants were forthright in self-reporting symptoms of mental illness, some degree of underreporting of antisocial behaviors and over-reporting of symptoms of mental illness is possible.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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