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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.23 no.11 Rio de Janeiro Nov. 2018

http://dx.doi.org/10.1590/1413-812320182311.30372016 

ARTICLE

Common mental disorder among incarcerated women: a study on prevalence and associated factors

Transtorno mental comum entre mulheres encarceradas: estudo de prevalências e fatores associados

Celene Aparecida Ferrari Audi1 

Silvia Maria Santiago1 

Maria da Graça Garcia Andrade1 

Priscila Maria Stolses Bergamo Francisco1 

1Departamento de Saúde Coletiva, Faculdade de Ciências Médicas, Universidade Estadual de Campinas. R. Tessália Vieira de Camargo 126, Cidade Universitária Zeferino Vaz. 13083-887 Campinas SP Brasil. celenefaudi@yahoo.com.br


Abstract

Mental disorders are present in four of the ten main causes of incapacity across the world. This article aims to analyze the prevalence of Common Mental Disorders (CMD) in incarcerated women and associated factors. A cross-sectional study was conducted with a population of 1,013 women incarcerated in a female prison. The prevalence of CMD was assessed by the SRQ-20. The hierarchical logistic regression was the method of analysis used to search for independent associations between sociodemographic, lifestyle, morbidity and violence variables with CMD and strength of association. The prevalence of CMD was 66.7%. The following variables were independently and positively associated with CMD: lack of income, hypertension, tranquilizers, physical inactivity, smoking, scabies/pediculosis, psychological violence in the year before being arrested, and having witnessed psychological violence in the family in childhood/adolescence. Interdisciplinary activities among health, justice and education institutions can contribute to a qualified assessment of women before admission into the prison system. This can enable an approach that does not exacerbate or trigger the onset of CMD, contributing to the improvement in living conditions and for better health and recovery strategies.

Key words: Women’s health; Mental health; Common mental disorder; Violence; Prison

Resumo

Método

Transtornos mentais estão presentes em quatro das dez principais causas de incapacidade em todo o mundo. O objetivo deste artigo é analisar a prevalência e os fatores associados ao transtorno mental comum entre mulheres encarceradas. estudo transversal realizado com uma população de 1.013 mulheres encarceradas em uma prisão feminina. A prevalência de TMC foi avaliada através do SQR-20. O modelo de regressão logística hierárquica foi o método de análise utilizado para verificar associações independentes entre as variáveis sociodemográfica, estilo de vida, morbidade e violência com TMC e sua força de associação. A prevalência de TMC foi de 66,7%. Foram de forma independente e positivamente associadas com TMC as variáveis: falta de renda, hipertensão, uso de tranquilizantes, sedentarismo, tabagismo, sarna/pediculose, violência psicológica no ano antes de ser presa e ter testemunhado violência psicológica na família quando criança/adolescente. Atividades interdisciplinares entre as instituições de saúde, justiça e educação podem contribuir para uma avaliação qualificada das mulheres antes da admissão no sistema prisional, assim como contribuir para a melhoria das condições de vida e de melhores estratégias de saúde e recuperação.

Palavras-Chave: Saúde da mulher; Saúde mental; Trantorno mental comum; Violência; Prisão

Introduction

Mental and behavioral disorders are a set of diseases defined by the International Classification of Diseases (ICD-10). Although the symptoms vary considerably, such behaviors are characterized, generally speaking, by a combination of abnormal ideas, emotions, behaviors and relationships with other people. The dichotomy between the biological and psychosocial dimensions has been an obstacle to the understanding of mental and behavioral disorders1.

Ordinary mental disorders are characterized by non-psychotic psychiatric symptoms, as insomnia, fatigue, irritability, forgetfulness, difficult concentration, anxiety and somatic complaints2. In fact, these disturbances are similar to many physical diseases that result from a complex interaction of all these factors1.

Mental disorders are present in four of the ten main causes of incapacity across the world, a situation that represents high costs in terms of human suffering, work disability and economic losses1.

This condition can be aggravated among incarcerated individuals. Today, approximately nine million people worldwide are held in prisons. At least half of them have personality disorders and one million prisoners or more across the world suffer from severe mental disorders, like psychosis or depression. Furthermore, each year millions of prisoners try to end their lives while they are in prison3-5.

A systematic review that evaluated 62 studies conducted in 12 countries, including 22,790 prisoners, has found that 3.7% of men had psychotic disorders, 10% had major depression, and 65% had personality disorder, including 47% who suffered from antisocial personality disorder. Among women, 4% had psychotic disorders, 12% had major depression, and 42% had personality disorder, including 21% who suffered from antisocial personality disorder6.

In a study carried out by Meltzer and Petticrew7, only one prisoner out of ten did not show evidences of having mental disorders, and not more than two out of ten had only one disorder.

The reasons for this high prevalence have been discussed by Reed8 and include: higher risk of incarceration for people with mental disorder, insufficient assessment by courts, inefficient healthcare services, and non-identification of mental problems in the moment of imprisonment.

Among TMC associated factors stand out to be women, low education level, physical inactivity, alcoholic consumption, smoking, medication use, stressful events in life and social isolation9,10.

Thus, prisons are clearly associated with mental health problems, either because many imprisoned individuals already had such disorders, or because people without mental disorders may develop emotional problems during the incarceration period due to the regime and conditions of the prison environment5,10,11.

In view of the scarce scientific production on the theme in Brazil and of its epidemiologic relevance, it has become pertinent to investigate it, especially in the population of incarcerated women, besides that, to identify these factors can guide relevant interventions.

The aim of the present study was to assess the prevalence of Common Mental Disorder (CMD) among incarcerated women and to investigate its association with sociodemographic characteristics, self-reported morbidity and weight gain, variables related to lifestyle, use of tranquilizers and prior use of illicit drugs, as well as types of violence suffered before incarceration.

Methods

Study design

A cross-sectional study was conducted from August 2012 to July 2013 with total of inmates (n = 1,013) at a Female Prison (FP) located in the county of Campinas, São Paulo State. This study is part of a larger research that investigated health conditions of incarcerated women and workers at the institution.

Questionnaire, instrument, measurements and variables

The information was collected by means of a questionnaire that was divided into modules, administered by trained interviewers and answered face-to-face by the incarcerated women. The questionnaire addressed demographic characteristics (age, religion, marital status, race/skin color), socioeconomic characteristics (level of schooling, occupation in the FP and income), length of imprisonment, health-related behaviors, life and health conditions in the prison, and prior situation of violence, among others.

In the present study, the dependent variable was Common Mental Disorder (CMD), assessed by means of the Self-Reporting Questionnaire 20 (SRQ-20), an instrument developed by the World Health Organization (WHO)12 to detect common mental disorders in the general population. Validated by Mari and Willians13 in the city of São Paulo, SRQ-20 is recommended by the WHO1 to be used in developing countries and it has proved to be efficient to screen and detect common mental disorders.

An advantage of using SRQ-20 is that the instrument has been validated in Brazilians living in urban environments and has presented high sensitivity and specificity. The instrument is composed of 20 questions with dichotomous answers (yes/no) about depressive-anxious mood, somatic symptoms, decline in vital energy and depressive thoughts. Each answer “yes” is scored the value “1”, and the final score is the sum of positive answers, ranging between 0 and 2012.

The score used to assess CMD in this study was ≥ 8. A study that evaluated the performance of SRQ-20 as a psychiatric screening instrument has shown an ideal cut-off point of 7/8, with sensitivity of 86.33% and specificity of 89.31%. The SRQ-20’s discriminating power for psychiatric diagnosis was 0.91. Cronbach’s alpha coefficient was 0.86, the positive predictive value was 76.43% and the negative predictive value was 94.21%13.

The following independent variables were considered:

  • Sociodemographic: age group (≤ 39 years; ≥ 40 years), is currently studying (yes/no), has completed primary education (yes/no), marital status (married/stable union, other), children (yes/no), skin color (white, non-white), religion (Catholic, other), works (yes/no), receives income (yes/no), length of permanence in the Prison (≤ 1 year, >1 year), length of imprisonment (≤ 1 year, >1 year).

  • Self-reported morbidity: It was asked women if they had arterial hypertension, diabetes mellitus, heart problem, gynecological problem, vaginal bleeding, urinary tract infection, fractures, tuberculosis, Hansen’s disease, IST/AIDS, scabies/pediculosis. Considering overweight or obesity, they were calculated by the measure of height and weight (BMI = kg/m2).

  • Lifestyle: practice of physical activity ≥ 150 minutes weekly, smoking, use of tranquilizers, risky sexual behavior (to have sex without condom and have multiple partners), and prior use of illicit drugs (dichotomized as yes/no).

  • Types of violence suffered before imprisonment: psychological, physical, sexual (dichotomized as yes/no). In the assessment of prior violence, the questions referred to childhood or adolescence (before the age of 15) and the indicators were ‘has witnessed physical aggression in the family’ (yes/no) and ‘has suffered physical aggression in the family scope’ (yes/no).

Statistical analyses

The collected information was keyboarded in the statistical package Epi Info 2000. Subsequently, the consistency of the database was analyzed, and whenever necessary, the questionnaires referring to the interviews were revisited. The software SPSS version 17.0 (SPSS Chicago, Illinois, USA) was employed for the statistical analyses. Initially, descriptive analyses were carried out, and the prevalence and bivariate association tests were calculated by means of the chi-square test, with a level of significance of 5%.

Analyses were performed using a hierarchical multiple logistic regression model developed in four stages.

In the first stage, we introduced the socioeconomic, biological, sociodemographic, and length of imprisonment variables that presented a level of significance lower than 20% (p < 0.20) in the test of association with the dependent variable. The variables with p < 0.05 remained in the model.

In the second stage, besides the variables that had remained in the previous stage, the self-reported morbidity variables were added, and those with p < 0.05 remained in the model.

In the third stage, the variables concerning health-related behaviors were included, and those with p < 0.05 remained in the model.

In the fourth and last stage, the variables related to situations of violence experienced by the inmates before the incarceration were included, and those with p < 0.05 remained in the model.

The strength of the association between the independent variables and the dependent variables was expressed in Odds Ratio values, with a 95% confidence interval. Model adjustment was verified by the Hosmer-Lemeshow Test.

The Project was submitted to the Research Ethics Committee of the Prisons Administration Department on October 27, 2011 and was approved on June 21, 2012. The consent document was read to all the interviewees. The document explained the aims of the study, the themes that would be approached and the procedures that would be followed. Voluntary participation was guaranteed, as well as the secrecy of participants’ identity and the possibility of abandoning the study at any time, without any penalization or need of justification.

Results

The prevalence of common mental disorder (CMD) found in the women incarcerated at the institution considered in the present study was 66.7%.

The average age of the 1,013 researched women was 30.8 (sd = 9.3) years. According to Table 1, the majority of the women were aged 39 years or younger 82.0%, were single 65.0%), reported that their skin color was non-white 51.9%, had not completed primary education 63.0% with up to three years of study), was not studying in the Prison 95.8%, was not receiving any income 64.0%, and did not have any occupational activity in the Prison 88.5%. Among the interviewees, 3.0% were pregnant and 80.3% of them reported being mothers. Length of permanence in the Prison was lower than or equal to 1 year for 60.8% of the interviewees. In the simple analysis, the women who reported absence of income received for working in the FP presented higher prevalence of CMD.

Table 1 Sociodemographic characteristics, length of imprisonment and prevalence of common mental disorder (CMD) among female inmates of a prison in the interior of the State of São Paulo, 2011/2013. 

Variables and categories Inmates (n = 1,013) CMD (≥ 8) P-value*

n % n %
Age group* 0.095
≤ 39 years 826 82.0 560 67.8
≥ 40 years 181 18.0 111 61.3
Studies in prison 0.588
No 969 95.8 647 66.8
Yes 43 4.2 27 62.8
Has completed primary education 0.841
No 622 63.0 413 66.4
Yes 391 37.0 262 67.0
Marital status 0.620
Married/stable union 355 35.0 233 65.6
Other 658 65.0 442 67.2
Children 0.964
No 200 19.7 133 66.5
Yes 813 80.3 542 66.7
Skin color* 0.205
White 487 48.1 315 64.7
Non-white 526 51.9 360 68.4
Catholic religion 0.637
No 613 60.5 405 66.1
Yes 400 39.5 270 67.5
Works in prison 0.786
No 897 88.5 599 66.8
Yes 116 11.5 76 65.5
Receives income 0.020
No 646 64.0 447 69.2
Yes 363 36.0 225 62.0
Length of permanence in prison 0.150
< 1 year 616 60.8 421 68.3
≥ 1 year 397 39.2 254 64.0
Length of imprisonment 0.673
< 1 year 838 82.7 556 63.3
≥ 1 year 175 17.3 119 68.0

* P-value from chi-square test.

In relation to the prevalence of common mental disorder (CMD) according to self-reported morbidity and weight gain, a higher prevalence was observed among hypertensive women (p < 0.001), women with scabies/pediculosis (p = 0.002), and women with overweight/obesity (p = 0.039) (Table 2).

Table 2 Prevalence of common mental disorder (CMD) according to self-reported morbidity and weight gain among female inmates of a prison in the interior of the State of São Paulo, 2011/2013. 

Variables and categories Inmates (n = 1,013) CMD (≥ 8) P-value*

n % n %
Arterial hypertension* < 0.001
No 785 78.3 498 63.4
Yes 217 21.6 168 77.4
Diabetes* 0.781
No 970 96.8 644 66.4
Yes 32 3.2 22 68.8
Heart problem 0.933
No 906 91.0 600 66.2
Yes 90 9.0 60 66.7
Gynecological problem 0.901
No 668 65.9 446 66.8
Yes 343 34.1 229 66.4
Vaginal bleeding 0.415
No 947 93.5 628 66.3
Yes 66 6.5 47 71.2
Urinary tract infection 0.322
No 695 68.8 456 65.6
Yes 314 31.2 216 68.8
Fractures 0.158
No 656 64.8 427 65.1
Yes 357 35.2 248 69.5
Tuberculosis 0.496
No 981 97.1 651 66.4
Yes 29 2.9 21 72.4
Hansen’s disease 0.838
No 998 98.7 664 66.5
Yes 13 1.3 9 69.2
IST/AIDS 0.104
No 895 88.5 588 65.7
Yes 116 11.5 85 73.3
Scabies/Pediculosis 0.002
No 761 75.2 488 64.1
Yes 251 24.8 187 74.5
Overweight/obesity 0.039
No 404 39.9 254 62.9
Yes 609 60.1 421 69.1

* P-value from chi-square test.

Table 3 shows higher prevalence of CMD among women who do not practice physical activity on a daily basis (p = 0.001) and among smokers (p = 0.006). The prevalence observed in those who reported using tranquilizers was 81.9% (p < 0.001).

Table 3 Prevalence of common mental disorder (CMD) according to lifestyle, use of tranquilizers and illicit drugs among female inmates of a prison in the interior of the State of São Paulo, 2011/2013. 

Variables and categories Inmates (n = 1,013) CMD (≥ 8) P-value*

n % n %
Physical activity ≥ 30 min/day 0.001
No 712 70.3 497 69.8
Yes 301 29.7 178 59.1
Smoking 0.006
No 309 30.5 187 60.6
Yes 704 69.5 488 69.3
Use of tranquilizers in prison* < 0.001
No 816 80.6 514 63.0
Yes 193 19.1 158 81.9
Risky sexual behavior* 0.960
No 740 73.2 493 66.7
Yes 271 26.8 181 66.8
Use of illicit drugs before imprisonment 0.481
No 381 37.6 259 68.0
Yes 632 62.4 416 65.8

*P-value from chi-square test.

Table 4 presents the prevalence of CMD according to types of violence suffered in the year before incarceration. Except for physical aggression in childhood/adolescence, it is possible to see that all the variables were positively associated with presence of common mental disorder (p < 0.05).

Table 4 Prevalence of common mental disorder (CMD) according to types of violence suffered before imprisonment among female inmates of a prison in the interior of the State of São Paulo, 2011/2013. 

Variables and categories Inmates (n = 1,103) CMD (≥ 8) P-value*

n % n %
Psychological violence in the year before being imprisoned < 0.001
No 605 59.7 366 60.5
Yes 408 40.3 309 75.7
Physical violence in the year before being imprisoned < 0.001
No 695 68.6 434 62.4
Yes 318 31.4 241 75.8
Sexual violence in the year before being imprisoned 0.020
No 934 92.2 613 65.6
Yes 79 7.8 62 78.5
Before the age of 15 she witnessed physical aggression in the family 0.013
No 592 58.4 376 63.5
Yes 421 41.6 299 71.0
Before the age of 15 she suffered physical aggression in the family 0.870
No 740 73.1 492 66.5
Yes 273 26.9 183 67.0

* P-value from chi-square test.

Through the multiple logistic regression analysis of the factors associated with CMD presented on Table 5, it was possible to verify that the following variables showed an independent and positive association with CMD: absence of income, arterial hypertension, scabies/pediculosis, smoking, physical inactivity, use of tranquilizers, having witnessed violence in the family during childhood/adolescence, and having suffered psychological violence in the year before being incarcerated.

Table 5 Multiple logistic regression analysis of the factors associated with common mental disorder (CMD) among female inmates of a prison in the interior of the State of São Paulo, 2011/2013. 

Variables First Stage Second Stage Third Stage Fourth Stage

OR 95% CI P-value OR 95% CI P-value OR 95%CI P-value OR 95%CI P-value
Receives income
No 1.37 1.04-1.80 0.023
Yes 1
Arterial Hypertension
No 1
Yes 1.99 1.38-2.86 <0.001
Scabies/ Pediculosis
No 1
Yes 1.65 1.19-2.89 0.003
Smoking
No 1
Yes 1.58 1.18-2.11 0.002
Physical Activity
No 1
Yes 1.56 1.19-2.13 0.002
Use of Tranquilizer
No 1
Yes 2.41 1.61-3.61 <0.001
Witnessed violence in the family in childhood/adolescence
No 1
Yes 1.40 1.05-1.86 0.021
Suffered psychological violence in the year before imprisonment
No 1
Yes 1.89 1.14-2.53 <0.001

Hosmer-Lemeshow Test= 0.88

Discussion

The prevalence of symptoms related to common mental disorder (CMD) affects more than half of the incarcerated women investigated in the present study (66.7%).

A study carried out in 2006 in the State of São Paulo identified a significant prevalence of mental disorders in the incarcerated population: 61.7% of the inmates had at least one occurrence of mental disorder during their lifetime, and approximately 25% of the ones who were in the closed prison system met diagnostic criteria for at least one mental disorder in the year before the study. Approximately 11.2% of the male inmates and 25.5% of the women presented severe mental disorders14,15.

The participants’ profile in the present study was: young, single, non-white women with low social and/or economic status, incomplete primary education, low professional qualification, informal and low-income labor activity previously to the imprisonment. Specific studies with the incarcerated population have confirmed these findings and have showed that a large part of the sample of incarcerated women, in addition to these characteristics, had a life history marked by material, educational and affective insufficiency12,16-18.

The factors that were associated with CMD were: prior psychological violence, witnessed violence in the family in childhood/adolescence use of tranquilizers, self-reported arterial hypertension and scabies/pediculosis, being a smoker, physical inactivity and absence of income.

The environment in prisons is usually precarious and unhealthy. Overcrowded cells, poor diets, lack of hygiene, sedentary lifestyle, drug use and conflicts of many types configure conditions that favor the proliferation of epidemics and other sickening situations. There is a considerable prevalence of cases of IST/AIDS, tuberculosis, pneumonia, dermatosis, hepatitis, traumas, infectious diarrhea, arterial hypertension, diabetes and mental disorders. Corroborating the literature, this study found that the living conditions before incarceration and the experience in the prison contribute to the high prevalence of common mental disorder5,18,19.

Studies have shown that more than half of all prisoners use licit and/or illicit drugs, have mental illness, or both the conditions apply. This increases their risk of sexually transmitted diseases and other infections, all of them highly prevalent in the incarcerated population. Furthermore, it is estimated that around 40% of all prisoners have at least one chronic disease, like diabetes or arterial hypertension, although it is a population that is predominantly composed of youths6,8,10,20.

The prevalence of tobacco use is high in the FP and positively associated with CMD; however, no action has been carried out in order to control the incarcerated women’s tobacco use, despite the existence of resources in the public networks of healthcare services21,22.

A study conducted in the United States with people who received a psychiatric diagnosis found that their chance of smoking was 3.23 (95%CI 3.11-3.35) times higher when compared to those without this diagnosis. Improving the approach to psychiatric comorbidities - smoking among them - can be a task to be undertaken with the incarcerated population, considering that prisons can become adequate places for the implementation of actions of health promotion and disease prevention3.

With regard to the practice of physical activity, only one third of the women practiced some modality on a daily basis. The evidences of the benefits of physical activities during at least thirty minutes in the major part of the weekdays are clear and consistent, as they contribute to mental health, not to mention their physical-functional and socialization benefits23.

The bibliographic review has not found studies that assessed the relationship between physical activity and common mental disorder among incarcerated women. Nevertheless, population-based studies have found an inverse relationship between practice of physical activity and presence of CMD24,25.

The prison where the study was conducted has a yard for the common use of the inmates. This yard can be used for daily, systematic and guided physical activities, in the perspective of acquisition of new behaviors that enhance physical and mental health.

Violence seems to be part of the incarcerated women’s history and produces negative experiences throughout their lives. The women who reported having suffered psychological violence in the year before being imprisoned and having witnessed psychological violence in the family during adolescence had a chance almost twice as high of manifesting common mental disorder when compared to the other women. This corroborates the findings of a study in which personal history of psychological violence was also associated with CMD25. Therefore, incarcerated women may present a psychological condition that is even more vulnerable due to the history of violence and to the current condition of imprisonment3,25.

Historically, prisons have been organized to shelter men, who represent the majority in the prison system. Until recently, incarcerated women were admitted to the same institutions constructed for men. These were transformed into female prisons, as is the case of the prison studied here. The fragile adaptation of the old structures has not met the needs of the population of incarcerated women, and this has been aggravating the conditions of permanence in prison and, due to this, the health of the women26,27.

The incarcerated population’s extremely precarious conditions of life and health make us reflect that, although the objective is ensuring their return to social life, the hazardous conditions of confinement become an obstacle to rehabilitation and prevent the imprisoned people’s access to health in an effective way27,28.

Among the study’s limitations, we would like to mention that the data may be underestimated and the prevalence may be even higher. Many participants may not have reported stories of abuses or may have denied involvement with drugs and alcohol, fearing that the study might negatively affect their legal situation. Another limitation is the fact that it was a cross-sectional study, a condition that prevents the establishment of implicit causality relations among the variables. Moreover, we did not have access to the women’s mental health conditions before their imprisonment.

Final remarks

The study has shown the difficult mental health situation of women incarcerated in the researched institution and corroborates other studies related to this population profile. The identification of the presence of mental problems when the individuals are admitted to prisons is a necessary task that may guide the adoption of measures to reduce suffering beyond the penalty of deprivation of freedom.

In this perspective, basic actions targeted at the treatment of common diseases, like arterial hypertension and dermatological complaints, the possibility of practicing physical activities on a regular basis, and the opportunity to work while serving the sentence need to be implemented. In addition, the treatment of mental disorders must be adequately conducted, including drug administration. These approaches need to be included in a health policy for the incarcerated population, in the context of a broader policy of reorganization of the prison system in Brazil.

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Received: August 17, 2016; Revised: March 22, 2017; Accepted: March 24, 2017

Collaborations

CAF Audi participated in the study’s conception and planning, coordinated and participated in the collection and analysis of the empirical data, wrote the paper and approved its final version. SM Santiago participated in the study’s conception and planning, supervised data collection and analyses, reviewed the paper critically and approved its final version. MGG Andrade participated in the paper’s conception, in the critical review and approved the final version of the paper. PMSB Francisco participated in the statistical analysis and interpretation of the data, and approved the final version of the paper.

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