| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
|
|
|
||||||||||
|
||||||||||||
Department of Psychiatry and Psychiatric Research Centre, Tehran University of Medical Sciences, Iran
Tehran Institute of Psychiatry, Iran University of Medical Sciences, Iran
Department of Psychiatry, University of Oxford, Oxford, UK
Correspondence: Dr Seyed Mohammad Assadi, Roozbeh Psychiatric Hospital, South Kargar Avenue, Tehran 13337, Iran. Tel: +98 21 5541 2222; fax: +98 21 5541 9113; e-mail: assadism{at}sina.tums.ac.ir
Funding detailed in Acknowledgements.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Aims The primary objective was to investigate the prevalence of psychiatric disorders in Iranian prisoners.
Method Through stratified random sampling, 351 prisoners were interviewed using the clinical version of the Structured Clinical Interview for DSM–IV Axis I Disorders and the Psychopathy Checklist: Screening Version.
Results The majority (88%) of prisoners met DSM–IV criteria for lifetime diagnosis of at least one Axis I disorder and 57% were diagnosed with current Axis I disorders. Opioid dependence (73%) had the highest prevalence among lifetime diagnoses, whereas major depressive disorder (29%) was the most common current diagnosis. Psychopathy was recorded in 23%. Prevalence rates of psychiatric disorders were significantly different among offence categories.
Conclusions The results suggest that a substantial burden of psychiatric morbidity exists in the prison population of Iran, with treatmentchallenges that appear to be different from those observed in inmates in Western countries.
|
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
METHOD |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Participants
Prisoners were recruited using stratified random sampling. The sample was
stratified by type of index offence to ensure adequate representation of all
offence categories. According to official Iranian statistics, offences are
classified into five categories: violent crimes (murder, kidnapping and armed
robbery), non-violent crimes (such as fraud, pickpocketing and burglary),
drug-related offences (drug use, possession or trafficking), ‘immoral
acts’ (such as fornication, prostitution, and alcohol use or trading)
and financial crimes (mainly bounced cheques). People convicted of
drug-related crimes constitute the majority (about 50%) of inmates
(State Prisons Organization and Security
and Corrective Measures, 2004). This high proportion reflects the
increasing rates of drug use in the general population. Official reports
indicate that Iran has at least 1 200 000–2 000 000 cases of drug
dependency or abuse, constituting 1–2% of the general population
(Mokri, 2002). About 20% of
prisoners are sentenced for non-violent crimes and more than 10% for violent
offences. An additional 10% of prisoners have been incarcerated for financial
crimes; they are usually individuals whose financial forecasts have proved
wrong during economic fluctuations
(Islamic Republic News Agency,
2001). Prisoners with ‘immoral act’ sentences are the
smallest group, constituting 4% of inmates. Although some drug-related
offenders recruited in this study were sentenced primarily for drug smuggling
and trading, most of them also had previous or current sentences for drug use,
which is a criminal offence in Iran. Offenders from each category were housed
in separate units of Qasr prison. Preliminary evaluations indicated that these
units had different environments and should be sampled separately. We used the
current sentence for classifying prisoners into the five aforementioned
categories. The sample was composed only of men. Women generally constitute a
small proportion of prisoners in Iran (3.6% in mid-2002;
State Prisons Organisation and Security
and Corrective Measures, 2004).
The study was designed to recruit 80 prisoners from each category, to reach a total sample size of 400. However, 49 individuals (12%) refused to participate. Therefore, the final sample consisted of 351 prisoners. The individuals who refused to participate did not differ from those who participated in terms of age (non-consenters’ mean age 33.1 years, s.d.=10.1), level of education (mean 9.4, s.d.=4.8 years) and number of previous prison sentences (mean 1.4, s.d.=1.8).
Measures
Demographic data were obtained from official prison records. Prisoners were
interviewed using the Clinical Version of the Structured Clinical Interview
for DSM–IV Axis I Disorders (SCID–CV;
First et al, 1997)
and the Hare Psychopathy Checklist: Screening Version (PCL–SV;
Hart et al,
1995).
The SCID–CV is a semi-structured interview for making the major DSM–IV Axis I diagnoses (American Psychiatric Association, 1994). It has six modules, covering some 40 psychiatric disorders (First et al, 1997). The SCID–CV allows assessment of current and lifetime diagnoses, and has been used for assessing prevalence rates of mental disorders in prison populations (Herrman et al, 1991; Rasmussen et al, 1999; Brink et al, 2001).
The PCL–SV is a 12-item rating scale and is derived from the Hare Psychopathy Checklist – Revised (PCL–R; Hart et al, 1995). It is a relatively quick way of assessing psychopathic traits. Its total score can be used either as a dimensional measure or for categorical diagnosis. For the first purpose, the raw total score is used, which ranges from 0 to 24; for the latter purpose, a cut-off score of 18 has been recommended (Hart et al, 1995). The scale is composed of two factors: factor 1 reveals interpersonal and affective symptoms of psychopathy, whereas factor 2 reflects the severity of social deviance and antisocial lifestyle. Both factors are scored from 0 to 12. Previous studies have used the PCL–SV for assessing psychopathy in offenders (Dolan & Anderson, 2003; Ullrich et al, 2003; Hill et al, 2004).
Prisoners were interviewed alone by one of four interviewers. Each interview took about 90 min on average. All interviewers were third-year psychiatric trainees (M.P., O.Y., S.A. and S.V.S.), who went through a 5-day study-specific training programme. In addition, all interviewers had prior experience with structured diagnostic interviews and had participated in a study adapting and validating the SCID–CV in Iran. Interviewers were regularly supervised by a board-certified psychiatrist (S.M.A.) who was trained in the use of the SCID, and difficult diagnostic issues were resolved in such meetings.
Statistical analysis
Data were analysed using the Statistical Package for the Social Sciences,
SPSS version 11.5. As the sample was stratified by type of offence, all
prevalence estimates were weighted to reflect the actual offence
characteristics of the prison population. The weights were the inverse of the
sampling fraction in each stratum. Comparisons between groups were performed
by likelihood ratio 
2-test and analysis of variance (ANOVA).
All statistical tests were two-sided and were considered significant at
P<0.05.
|
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
Prevalence of psychiatric disorders
Table 2 lists the current
and lifetime prevalence rates of Axis I diagnostic categories in the sample.
Current mental disorders were diagnosed in 57.2% of participants, with mood
disorders having the highest prevalence. Of the whole sample, 29.1% met the
diagnostic criteria for major depressive disorder and 1.5% for dysthymic
disorder. Of those with major depressive disorder, 17.8% met the criteria for
mild depressive episode, 39.6% for moderate episode, 38.5% for severe episode
without psychotic features, and 4.1% for severe episode with psychotic
features. No one met the diagnostic criteria for bipolar disorder. Regarding
psychotic disorders, 2.0% of participants had schizophrenia, 0.3% delusional
disorder and 0.8% psychotic disorder not otherwise specified. Opioids were the
principal substance of abuse. Current opioid abuse and dependence were
diagnosed in 9.5% of participants; cannabis and sedative, hypnotic or
anxiolytic use disorders were seen in 0.8% and 0.9% respectively. No one met
the diagnostic criteria for current alcohol abuse or dependence. Anxiety
disorders were diagnosed in 7.7% of participants, with generalised anxiety
disorder (5.7%) being the most prevalent diagnosis. Specific phobia,
post-traumatic stress disorder, social phobia and obsessive–compulsive
disorder were diagnosed in 1.0%, 0.7%, 0.6% and 0.3% of participants
respectively. Only one prisoner with hypochondriasis (0.4%) was observed.
Based on interviewers’ impressions, the current diagnosis of substance
use disorders was thought to be an under estimate. Moreover, drugs and alcohol
are generally less available in prison, and current rates of substance use
disorders in cross-sectional samples of prisoners will probably underestimate
the true prevalence (Maden et al,
1994; Fazel et al,
2001; Andersen,
2004). Thus, we decided to use the lifetime diagnoses in comparing
subgroups and estimating the extent of Axis I disorders comorbidity.
|
Eighty-eight per cent of prisoners met DSM–IV lifetime criteria for at least one Axis I disorder. Substance use disorders had the highest lifetime prevalence (78%), followed by mood disorders (48.7%). Lifetime opioid dependence was diagnosed in 72.7% of participants, alcohol dependence in 8.8% and dependence on other substances in 0.4%. The lifetime rate of opioid abuse was 0.1%, alcohol abuse 13.3% and abuse of other substances 2.4%.
Overall, psychiatric disorders were less prevalent in the financial offences group. In addition, offence groups had different rates of psychiatric morbidity in three out of the six diagnostic categories: psychotic disorders, substance use disorders and anxiety disorders (Table 2).
Comorbidity rates are presented in Table 3. Substance use disorders were the main comorbid disorders in diagnostic categories. Mood disorders were highly prevalent in participants with anxiety, substance use and somatoform disorders. Comorbid anxiety disorders were seen in a quarter of participants with mood disorders and about half of participants with somatoform disorders.
|
According to the data collected in the overview section of the SCID, only 10.5% of prisoners with current Axis I diagnoses were receiving psychiatric treatment, and the majority of prisoners with psychiatric diagnoses (89.5%) did not receive any psychiatric intervention.
Prevalence of psychopathy
Table 2 shows the prevalence
of psychopathy according to the PCL–SV. Using the standard cut-off
score, about a quarter of prisoners met the criteria for psychopathy. The
offence groups were significantly different in this regard: those imprisoned
for drug-related offences had the highest rate of psychopathy, whereas those
imprisoned for financial offences had the lowest. The same pattern emerged
with both factors of the checklist: the mean scores for factor 1 and factor 2
were significantly different between the offence groups
(Table 4).
|
The majority of participants categorised as psychopathic (98.8%) had at
least one Axis I disorder, and there was a significant difference between the
psychopathic and non-psychopathic groups in this regard
(2(1, n=349)=9.26, P<0.01).
Specifically, rates of substance use disorders were higher in the psychopathic
group (92.7%) compared with the non-psychopathic group (73.0%;
2(1, n=349)=16.63, P<0.01),
whereas rates of anxiety disorders were lower (6.1% and 19.1% respectively;
2(1, n=349)=9.33, P<0.01).
There was no significant difference between these two groups with regard to
the other diagnostic categories.
Characteristics of prisoners with psychiatric disorders
Table 5 shows the
association between selected demographic and criminological characteristics
and psychiatric disorders. Mood disorders and psychopathy were most prevalent
in the youngest age-group, whereas substance use disorders appeared to be most
prevalent in those aged 25–44 years. Psychotic and substance use
disorders were most prevalent among those with low education. In addition,
psychotic disorders, substance use disorders and psychopathy were more
prevalent in unmarried prisoners, whereas anxiety disorders were higher in
married inmates. Overall, the prevalence of psychiatric diagnoses was
significantly lower among those who were born in the capital city of Tehran
than among those born in the provinces. Finally, prisoners with a history of
previous sentences had significantly higher prevalence of psychiatric
morbidity compared with those who did not.
|
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Comparison with the Iranian general population
Our results suggest that rates of psychiatric morbidity in prisoners in
Iran are much higher than in the general population. Two recent surveys
respectively estimated the prevalence of current psychiatric disorders at 21%
and 17% in the general Iranian population
(Mohammadi et al,
2003; Noorbala et al,
2004), which implies that the rate of psychiatric morbidity is
around three times higher in prisoners. This finding is consistent with the
results of recent reviews that the prevalence of psychiatric disorders in
prisoners is higher than in the general population
(Fazel & Danesh, 2002;
Andersen, 2004).
Comparison with non-Western studies
Previous non-Western studies (Fido &
al-Jabally, 1993; Ghubash
& El-Rufaie, 1997; Agbahowe
et al, 1998) reported varying rates of psychosis, ranging
from 0% to 5%. Regarding depression, Agbahowe et al
(1998) reported two cases of
psychotic depression (2% of prisoners). The two other studies
(Fido & al-Jabally, 1993; Ghubash & El-Rufaie, 1997)
found depression in 13% and 9% of prisoners respectively – rates lower
than that found in our study. Differences across studies may be explained by
various methodologies used.
Comparison with Western studies
Compared with Western countries, the rate of psychosis is similar in
Iranian prisoners, but rates of depression and substance use disorders appear
to be higher. The review by Fazel & Danesh found an overall prevalence of
3.7% for psychotic illnesses and 10% for major depression among male prisoners
in Western countries (Fazel & Danesh,
2002). The prevalence of substance use disorders has been
estimated at between 25% and 50% in most Western studies
(Andersen, 2004). The high
rates found in our investigation suggest that prison health services have
additional challenges in low-income countries, particularly where there is a
large prison population related to illegal drug trafficking and use. Models of
effective prison healthcare that could be used in the Iranian setting need to
incorporate these additional challenges.
We found different prevalences of psychiatric diagnoses among offence categories. In particular, financial offenders had lower rates of psychiatric illness. The most detailed study of risk factors for prisoners found that those convicted of sexual offences had increased scores for mood disorders, but did not include a separate category for those convicted of financial offences, as the numbers of such inmates are relatively small in English and Welsh prisons (Singleton et al, 1998).
Psychopathy
The prevalence rate for psychopathy in Iran appears to be similar to rates
reported in North American prisoners (25–30%) and higher than those
found in European countries (Andersen,
2004). There is evidence that treatment of Axis I disorders in
people with psychopathy is more complicated
(Alterman et al,
1998). Therefore, a high prevalence of psychopathy would pose
additional challenges for psychiatric services.
Limitations of the study
Our study has a number of limitations. The participants were recruited from
one prison located in the metropolitan city of Tehran. However, there is no
evidence that the study prison was different from other Iranian prisons. In
addition, the study did not examine Axis II disorders and therefore
underestimated the extent of comorbidity. We used the PCL–SV for
assessing psychopathy, which has not been validated for use in the Iranian
prison population, and the findings on its use must be interpreted cautiously.
A further limitation was that although we used the prison’s criminal and
health records to confirm or deny self-reported statements, some aspects of
PCL–SV scores need more detailed historical information that we were not
able to corroborate.
Implications for healthcare
The study found that over half of Iranian prisoners suffered from a
treatable mental disorder, and a third had a current psychotic or major
depressive disorder. The need for improving psychiatric services in prison
settings is an international public health burden
(Fazel & Danesh, 2002), and
non-Western countries may face additional challenges in meeting this need.
|
|
Clinical Implications and Limitations |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
LIMITATIONS
|
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Alterman, A. I., Rutherford, M. J., Cacciola, J. S., et al (1998) Prediction of 7 months methadone maintenance treatment response by four measures of antisociality. Drug and Alcohol Dependence, 49, 217 –223.[CrossRef][Medline]
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). Washington, DC: American Psychiatric Association.
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, 110, 5 –59.
Brink, J. H., Doherty, D. & Boer, A. (2001) Mental disorder in federal offenders: a Canadian prevalence study. International Journal of Law and Psychiatry, 24, 339 –356.[Medline]
Dolan, M. C. & Anderson, I. M. (2003) The relationship between serotonergic function and the Psychopathy Checklist: Screening Version. Journal of Psychopharmacology, 17, 216 –222.[Abstract]
Fazel, S. & Danesh, J. (2002) Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet, 359, 545 –550.[CrossRef][Medline]
Fazel, S., Hope, T., O’Donnell, I., et al
(2001) Hidden psychiatric morbidity in elderly prisoners.
British Journal of Psychiatry,
179, 535
–539.
Fido, A. A. & al-Jabally, M. (1993) Presence of psychiatric morbidity in prison population in Kuwait. Annals of Clinical Psychiatry, 5, 107 –110.[Medline]
First, M. B., Spitzer, R. L., Gibbon, M., et al (1997) User’s Guide for the Structured Clinical Interview for DSM-I Axis I Disorders – Clinical Version (SCID–CV). Washington, DC: American Psychiatric Press.
Ghubash, R. & El-Rufaie, O. (1997) Psychiatric morbidity among sentenced male prisoners in Dubai: transcultural perspectives. Journal of Forensic Psychiatry, 8, 440 –446.
Hart, S. D., Cox, D. N. & Hare, R. D. (1995) The Hare Psychopathy Checklist: Screening Version (PCL:SV). New York: Multi-Health Systems.
Herrman, H., McGorry, P., Mills, J., et al
(1991) Hidden severe psychiatric morbidity in sentenced
psychiatric morbidity in sentenced prisoners: an Australian study.
American Journal of Psychiatry,
148, 236
–239.
Hill, C. D., Neumann, C. S. & Rogers, R. (2004) Confirmatory factor analysis of the psychopathy checklist: screening version in offenders with axis I disorders. Psychological Assessment, 16, 90 –95.[CrossRef][Medline]
Islamic Republic News Agency (2001) The Check Prisoners. http://www.payvand.com/news/01/nov/1084.html.
Maden, T., Swinton, M. & Gunn, J. (1994)
Psychiatric disorders in women serving a prison sentence. British
Journal of Psychiatry, 164, 44
–54.
Mohammadi, M. R., Davidian, H., Noorbala, A. A., et al (2003) An epidemiological study of psychiatric disorders in Iran, 2001. Hakim Research Journal, 6, 55 –64.
Mokri, A. (2002) Brief overview of the status of drug abuse in Iran. Archives of Iranian Medicine, 5, 184 –190.
Noorbala, A. A., Bagheri Yazdi, S. A., Yasamy, M.T., et
al (2004) Mental health survey of the adult population
in Iran. British Journal of Psychiatry,
184, 70
–73.
Rasmussen, K., Storsæter, O. & Levander, S. (1999) Personality disorders, psychopathy, and crime in a Norwegian prison population. International Journal of Law and Psychiatry, 22, 91 –97.[CrossRef][Medline]
Singleton, N., Meltzer, H. & Gatward, R. (1998) Psychiatric Morbidity Among Prisoners in England and Wales. London: Stationery Office.
State Prisons Organisation and Security and Corrective Measures (2004) Ettelaat-e amari-e zendanian-e mojood dar khordad-e 1381 [Statistical data of prisoners in May 2002]. Tehran: http://www.prisons.ir/farsi/reports.php.
Ullrich, S., Paelecke, M., Kahle, I., et al (2003) Categorical and dimensional assessment of ‘psychopathy’ in German offenders. Prevalence, gender differences and age factors [in German]. Der Nervenarzt, 74, 1002 –1008.[CrossRef][Medline]
Walmsley, R. (2003) Findings 188. World Prison Population List (4th edn). London: Home Office Research Development and Statistics Directorate. http://www.homeoffice.gov.uk/rds/pdfs2/r188.pdf
Received for publication October 29, 2004. Revision received February 28, 2005. Accepted for publication March 16, 2005.
Related articles in BJP:
This article has been cited by other articles:
|
|
 |
|
  S. M. Assadi, M. Noroozian, S. V. Shariat, O. Yahyazadeh, M. Pakravannejad, and S. Aghayan Neurological Soft Signs in Mentally Disordered Offenders J Neuropsychiatry Clin Neurosci, November 1, 2007; 19(4): 420 - 427. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Tyrer The British Journal of Psychiatry, February 1, 2007; 190(2): 188 - 188. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
