Characteristics of the study sample
The sample consisted of 469 male and female prisoners (males 338, females 131). Participants’ ages ranged from 18 to 80 years (M = 35.95, SD 11.68; Mdn 34.00, IQR 26–43). The majority of participants were sentenced (90.2%), with the average sentence length reported at 260.45 weeks (range 1 to 1300 weeks, Mdn 184, IQR 52–386) (see Table 1 for full details of participant characteristics). The characteristics of the sample are broadly in line with that of the current general prison population in terms of age, ethnicity, average sentence length, and proportion on remand [19, 20].
Prior engagement with psychiatric services
Of the total sample, 48.8% (n = 229) of participants reported having had previous contact with mental services either in prison or in the community. Further, 42.4% (n = 199) of participants reported having previously received a diagnosis of a mental illness. Females were significantly more likely to report having had previous contact with mental health services than males, χ2 (1, N = 469) = 13.79, p = 0.000, and were also significantly more likely to report having previously received a diagnosis of a mental disorder, χ2 (1, N = 465) = 29.21, p = 0.000. In terms of diagnoses, females were significantly more likely than males to report having previously received a diagnosis of a personality disorder, mood disorder, obsessive compulsive disorder or an eating disorder. Males were significantly more likely than females to report having received a previous diagnosis of ADHD. Table 2 shows the prevalence of reported life time diagnosis of mental disorder by disorder type and gender.
Current mental disorder
Contact with mental health services
Of the total sample, around a quarter of participants reported that they were currently in contact with mental health services in prison (including Mental Health Inreach and the Offender Personality Disorder Pathway) (25.4%, n = 119). Of those who had reported having received a previous diagnosis of a mental disorder around half also reported currently being in contact with mental health services (49.7%, n = 99). Females were significantly more likely than males to report having current contact with mental health services, χ2 (1, N = 467) = 14.15, p = 0.000.
Screening measure outcomes
Table 3 details the point-prevalence for each mental disorder screened for by gender, including significant differences. Around two-thirds of participants screened positive for clinical symptoms of at least one type of mental disorder (i.e., above the clinical cut-off) (66.7%, n = 313). Just over half of all participants screened positive for at least one type of personality disorder (54.8%, n = 257). The most prevalent personality disorders screened positive for were depressive (28.1%, n = 132), masochistic (22.4%, n = 105), and schizoid (21.3%, n = 100). In terms of other mental health issues, the most common clinical syndromes screened positive for were substance dependence (42.2%, n = 198), anxiety (36.2%, n = 170), and risk of suicidal behaviour (27.3%, n = 128). Females were significantly more likely than males to screen positive for personality disorder; particularly avoidant, dependent, masochistic, schizotypal, borderline, and paranoid personality types. Females were also significantly more likely than males to screen positive for somatoform, mood disorders, PTSD, psychotic disorders, eating disorders, and risk of suicidal behaviour.
With regard to drug dependence, 66.1% (n = 310) of participants reported having used illicit substances prior to coming to prison. Men were significantly more likely than women to report having used drugs in the year prior to prison, χ2 (1, N = 469) = 10.06, p = 0.002. The most commonly reported drugs of preference were cannabis (53.2%, n = 165), cocaine (22.6%, n = 70), and heroin and crack combined (19.4%, n = 60). Women were significantly more likely than men to report heroin and crack as their combined drug of preference, χ2 (1, N = 309) = 34.63, p = 0.000, whereas men were significantly more likely than women to report cannabis, χ2 (1, N = 310) = 3.90, p = 0.048, or cocaine, χ2 (1, N = 310) = 8.87, p = 0.003, as their drug of preference. Just over a third of participants screened positive for drug dependence (52.6% of those who reported using drugs). There was no difference in the percentage of men and women who screened positive for drug dependence. With regard to alcohol use, 55.9% (n = 262) of participants screened positive for increasing/problematic alcohol consumption in the year prior to prison, including 33% (n = 155) for problem drinking, 9.2% (n = 43) for alcohol use disorders, and 13.6% (n = 64) for alcohol dependence. Men were significantly more likely than women to screen positive for some type of problematic alcohol use, χ2 (1, N = 468) = 6.55, p = 0.010.
Overall 27.3% (n = 128) of participants scored above the cut off for risk of suicidal behaviours. Significantly more women scored above the cut off for risk of suicidal behaviours than men, χ2 (1, N = 468) = 10.71, p = 0.001. Just over a quarter of participants reported having attempted suicide at least once in their life time (27.8%, n = 130) and 18.6% (n = 87) of participants reported that they had thought about killing themselves more than once in the past year. Further, 6.9% (n = 32) thought it was likely that they would attempt suicide in the future.
Just under half of participants (47.5%, n = 223) screened positive for two or more types of disorder, with participants screening positive on average for 2.07 disorders (SD 2.24). Women demonstrated significantly higher rates of comorbidity than men, χ2 (1, N = 469) = 16.50, p = 0.000 and screened positive for significantly more disorders overall than men, t(450) = − 3.81, p = 0.000, d = 0.42.
Met and unmet mental health need
How well current mental health need was being met for each disorder was calculated using cross-tabs (see Table 4). Met need was low across all disorders screened for. Excluding substance dependence (which is not directly treated by mental health services in the majority of prisons) the disorders with the lowest levels of met need were personality disorder, eating disorders and anxiety. Women’s current mental health needs were generally better met than men’s, with a higher proportion of participants with identified mental health needs currently reporting contact with prison mental health services. Males were significantly more likely than females to have unmet need in the areas of personality disorder, problematic alcohol use, drug dependence, PTSD, eating disorders and risk of suicidal behaviour.