Prison counselors are criminal justice and mental health professionals who play important roles in the correctional system. They help rehabilitate inmates during their stay in prison and prepare them to reintegrate into the real world once they are released.
There are more than 10 million individuals in prison at any given time with more than 30 million circulating through each year. Research has consistently shown that prisoners have high rates of psychiatric disorders, and in some countries there are more people with severe mental illness in prisons than psychiatric hospitals. Despite the high level of need, these disorders are frequently underdiagnosed and poorly treated.
Juveniles in prison have distinct mental health needs, and an overview of these is outside the scope of this review.Many primary studies and reviews have documented the high prevalence of most psychiatric disorders in prisoners
Self-report approaches to clinical diagnosis are problematic. In addition, prisoners assessed by lay interviewers have been associated with higher prevalences compared to diagnostic interviews conducted by clinically trained psychiatrists or psychologists.1 Certain disorders may be particularly prone to overestimation. Some prevalence studies of personality disorders in prisoners are problematic for similar reasons. Large high quality studies using clinically-based diagnoses have reported prevalences between 7-10%5,6compared to the 65% found in reviews of studies that have used diagnostic instruments.
A second problem is that many diagnostic instruments currently used have not been validated in prisons, and include items that may not be specific. For example, the MINI diagnostic interview is extensively used in newer prison studies, and without modification can lead to overestimating rates of mania and obsessive-compulsive disorder.
Despite these caveats, a number of prevalence findings are consistent. The evidence for major depression and psychotic illnesses is the strongest. A 2012 systematic review of around 33,000 prisoners and over 100 studies found very similar findings to a previous 2002 review
Recent research has also demonstrated high rates of comorbidity between mental illness and substance misuse.11 Such comorbidity worsens the prognosis of the individual psychiatric disorders, and has been shown to increase repeat offending and premature mortality following release.
A key issue in this field is the direction of causality for the high prevalence of psychiatric disorders, namely whether the excess in rates is caused by prison or whether they are imported into prison.
Many interventions aimed at prisoner mental health have been evaluated, though mostly on a small scale. The small sample size, and heterogeneity of prisoners and settings makes synthesis of the research difficult.
The number of medication trials conducted in prisons is particularly low. Some small RCTs have found evidence for ADHD medications in Swedish prisoners, including improved global functioning46 and increased likelihood of abstinence from amphetamine after release (as measured by negative urine samples).47 Work with other medications is limited
Compared with medication, there are more controlled trials of psychological therapies in prisoners, but these are typically small and involve a wide variety of interventions (e.g., cognitive behavioural [CBT], interpersonal, dialectical behavioural [DBT], meditation-based, and group therapies) with inconsistent findings
In summary, there is some evidence for these psychological interventions, but their effect sizes are not large, whether they would hold in better quality designs (e.g. using active controls and not waiting list or treatment as usual controls), and it is uncertain whether any improvements are sustained.
• All prisons should have systems in place for the identification of those with serious mental health problems, including case finding on arrival to prison and allocation to appropriate level of service (i.e. primary/secondary/transfer to hospital)
• All prisons should have a suicide prevention strategy that includes accurate screening and monitoring of risk after arrival into prison, multi-disciplinary management of high risk prisoners, and staff training
• Evidence-based psychological and pharmacological mental health treatments that are available in the community or developed for prison settings should be provided
• Provision of CBT for relapse prevention of substance misuse
• Prisons should consider provision of trauma-focused and gender-specific interventions to prisoners, particularly if unmet needs are identified
• Minimum standards for meaningful daytime activity (education/courses/training) should be developed that include the amount and range of these activities