International Journal of Mental Health & PsychiatryISSN: 2471-4372

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.

Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 2

Prevalence of Common Mental Disorders and Associated Factors among Prisoners in Debre Markos Town Correctional Institution, North-West, Ethiopia

Yigrem Ali1*, Neguse Yigzaw2, Lulu Bekana3 and Semahegn Mekonen4
1Depratment of Psychiatry, College of Health sciences and Medicine, Dilla University, Dilla Ethiopia
2Depratment of Psychiatry, College of Health and Medical sciences, University of Gondar, Gondar, Ethiopia
3Department of psychiatry, Amanuel Mental Specialized Hospital, Research and Training Director, Addis Ababa, Ethiopia
4Department of Anesthesia, College of Health Sciences and Medicine, Addis Ababa University, Addis Ababa Ethiopia
Corresponding author : Yigrem Ali
Depratment of Psychiatry, college of health sciences and Medicine, Dilla University, Dilla, Ethiopia
E-mail: [email protected]
Received: November 02, 2015 Accepted: March 22, 2016 Published: March 26, 2016
Citation: Ali Y, Yigzaw N, Bekana L, Mekonen S (2016) Prevalence of Common Mental Disorders and Associated Factors among Prisoners in Debre Markos Town Correctional Institution, North-West, Ethiopia. Int J Ment Health Psychiatry 2:2. doi:10.4172/2471-4372.1000118

Abstract

Background: worldwide more than 10.1 million people are currently being held in penal institutions. Surprisingly those mental health problems are common in prisons because prisoners live with extensive surveillance, security controls in the absence of ordinary social interaction and abnormal environmental stimulus. They are more likely to be demoralized and victimized by the community and other prisoners. Therefore this study aimed to assess the prevalence of Common Mental Disorders and Associated Factors Among Prisoners in Debre Markos Town Correctional Institution, North West, Ethiopia, 2014.

Methods: Institutional based cross-sectional study was conducted the research from April 28 - May 28. Data was collected by face to face interview. Data was coded and entered in to Epi-info Version 7 and was exported to SPSS version 20. Crude and adjusted OR were analyzed using logistic regression and the level of significance of association was determined at P- value<0.05.

Result: A total of 423 participants were interviewed with a response rate of 97.9%. The prevalence of common mental disorder was found to be 67.6%. Statistically higher level of common mental disorders was found among female prisoners than male prisoners (AOR=3.27, 95% CI: 1.05, 10.22). Divorced/ widowed (AOR=3.79, 95% CI:1.54, 9.30) and having history of mental illness (AOR=7.30, 95% CI: 2.96, 18.01), loss of loved one (AOR=3.03, 95% CI: 1.34, 6.85), relationship problems (AOR=2.07, 95% CI: 1.26, 3.40) and traumatic stress (AOR=2.02, 95% CI: 1.23, 3.37) were also found to be significantly associated with common mental disorders.

Conclusion: The prevalence of common mental disorders was high among prisoners at Debre Markos town correctional institution. Therefore, early prevention, detection and alleviating common mental disorder should be implemented in prison.

Keywords: Common mental disorders; Prevalence; Prisoners; Ethiopia

Keywords

Common mental disorders; Prevalence; Prisoners; Ethiopia

Introduction

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcoholuse and substance-use disorders, and psychoses [1].
Common mental disorders are groups of distress states manifesting with anxiety, depression and somatic symptoms, which occur together over time [2].
Prison is a correctional institution in which prisoners have limited liberty, autonomy, and communication with family and friends. This can devastate their physical, psychological and social wellbeing [3]. It is a violent place for persons with mental disorders and eight times more likely to be victims of sexual abuse than none mentally ill prisoners [4].
There are many hundreds of men and women remanded in prison for long periods of time, many of whom suffer from longstanding mental disorder, current mental illness, or both [5,6].
They live with extensive surveillance and security controls, the absence of ordinary social interaction, abnormal environmental stimulus, a few hours a week of “recreation” alone in caged enclosures, and little educational, vocational, or other purposeful activities [7].
These conditions can be psychologically harmful to prisoners, and provoke anxiety, depression, anger, cognitive disturbances, perceptual distortions, obsessive thoughts, paranoia, and psychosis. The stress, lack of meaningful social contact, and unstructured days can exacerbate symptoms of illness or provoke a reoccurrence [7].
It has been known that psychiatric disorders are highly prevalent among prisoners [8]. Many people with identifiable psychiatric illness do conflict with the law, often by no fault of their own but because of symptoms of their psychiatric illness and end up in jails. Such symptoms include impaired judgment, lack of impulse control, suspiciousness, disinhibition, paranoia, inability to trust others, delusions and hallucinations.
It is quite likely that act of incarceration may exacerbate and precipitate certain underlying psychiatric conditions [8]. Different levels of stress during incarceration give rise to different incidence of psychiatric morbidity among prisoners [9].
Forensic psychiatry has been able to provide treatment program that are both effective and able to enhance public safety [10].
Prisoners have rates of mental illness-including such serious disorders as schizophrenia, bipolar disorder, and major depression-that are two to four times higher than members of the general public [11].
A large number of mentally ill individuals who do not meet criteria for civil commitment are left in the community, at times unwilling or unable to pursue outpatient treatment, which increases the likelihood of engaging in behaviour that could result in incarceration [12].
Even though the national health policy of Ethiopia prioritize health care delivery at the community level, still it is not possible to address those who are suffering from mental health problem at the primary health care setting, even at the particular institutions, like prisons. Most studies in Ethiopia in the field of mental health mainly focused at the community level. Therefore, assessing and showing the significance of common mental disorder at the prisoner’s institutions might be important to enforce policy makers and different stakeholders to integrate mental health service within the prisons to manage common mental disorders [13,14].

Methods

Study area and period
The Institutional based cross sectional study was conducted at Debre Markos Town Correctional institution from Apr 28 - May 28, 2014. Debere Markos is one of the oldest cities in Ethiopia located 300 km North West of Addis Abba. Debre Markos (Markos) has been the capital of Gojjam province or state and now it is the capital of East Gojjam. Debre Markos is best known for producing Teff, Corn, honey, butter, onion, potato, barley, Bean, peace, sheep, goat, chicken, charcoal, and other agricultural products which are the main source for the central and northern part of Ethiopia.
Debere Markos is a central resting area for travelers from Addis Ababa to Bahir Dar or Gonder. Also Deber Markos is best known producing Ethiopian homemade beer Tala, homemade liquor Araque and the famous Honey Wine or Tej. The food and drink in Deber Markos is fresh and natural, in Westener Lingo it is called “Organic Food”. Long time ago Markos was one of the cheapest place to live. It was named the “Feeding Basket” of Ethiopia. Now, because of whole sellers and merchants from big cities and neighboring countries and states jacked the price too high. Locals are blaming the outsiders for making the city more expensive.
About 90% Debre Markos residences are christians. The name Debre Markos derived from the biggest church in town called St. Marcos or Debre Markos. The church believed to host more than 44 saints. Abima Mariam (Abima ST Mary) Endimata Eyesu (Endimata Jusus) Kidane Mihret, Abun Sefer,Kahin Sefer, Shew Ber, Sindegom, Ferse Bet, Dibza, Gimija Bet, Yebbo, Kebi, Daligaw, Weoka, Police Camp, Chemoga, Yeraba, Gim Wiha, Kidamin, Mota Sefer, Weseta, Witren, and several others are the names of neighborhoods in the town.
Also Debere Markos is the breeding ground for Ethiopian intellectuals, writes artist and athletes. Namely Haddis Alemayeh the author of Fiket Eseke Mekabir, Efprame Tamiru the legendary Ethiopian Singer, Engidazer Nega the Ethiopian comedy Icon, and Drs, engineers and educators who are abroad and in the country. Unfortunately most of these native golden boys and girls are not leaving in Markos/Gojam rather they are living in the Capital or in excel for better life.
Debere Markos is one of few Ethiopian cities who are growing by its own native people without federal or foreign aid. Debere Markos has one Correctional institution which has approximately 1593 prisoners.
Sample size determination and technique
It was determined by Level of significance (0.05), Power (0.50) with z=95% confidence internal and the value of ‘’p’’( p= proportion of prevalence) was taken as 50% due to the absence of previous study that indicates the prevalence of Common Mental Disorders and Associated Factors among prisoners. Then by adding 10% of non respondents then, total sample size for this study is 423.
The study also used to select the sampling prisoners by systematic sampling technique from 1593 prisoners.
Data collection and analyses procedures
Data collection instruments: A structured questionnaire was used to collect socio demographic, substance use, clinical and psychosocial characteristics. The presence of Common Mental disorders was assessed using the 20-item version of the Self- Reporting Questionnaire (SRQ-20). In addition to detecting so-called ― major mental disorders, the SRQ-20 also identifies sub-clinical spectrums, which are highly important because they are associated with functional and social impairment [15,16].
The self reporting questionnaire SRQ-20,a psychiatric case finding instrument designed by WHO for developing countries was tested in Ethiopia [17].
This study focused on the SRQ-20, which consists of 20 yes/no questions to assess presence of common mental disorders symptoms: anxiety, depression, and psychosomatic.
The SRQ-20 has been tested in numerous settings. Depending on the setting, community surveys or primary care, varied cut-off points have been used, where SRQ-20 has been validated in other sub-Saharan countries, the optimal cut-off for defining caseness for CMD has also varied widely from ≥ 4 in Sudan to ≥ 10 in South Africa. Population surveys in Ethiopia have used various cut-off points to define cases of CMD, ≥ 6 in Addis Ababa and ≥ 11 in two rural settings. Mental illness will be measured using the locally validated Self-Reported Questionnaire (score of ≥ six indicating high levels of CMD).it is designed to give an estimation of illness, and has previously been translated into Amharic and validated in Ethiopia, and it has been used for community surve [18].
Data collection technique and Data quality control: Data was collected by interviewing technique. Four (three diploma and one BSc) nurses were involved to collect and guide the data collection process. Prior to involvement to the data collection training was given for data collectors for one day by the investigator on how to use the questionnaire, ethical principles of confidentiality, data management, how participants identify and referral process [19,20].
Training was given to the data collectors on the data collection tool and sampling techniques for one day. Close Supervision was held regularly during data collection period. Each data was checked for completeness by supervisors and principal investigator and the necessary feedback were offered to data collectors [21-23].
Data processing and analysis: The coded Data was checked, cleaned by entering into epi.info version 7.1 and then exported into Statistical Package for the Social Sciences (SPSS window version 20).
The Descriptive summary using frequencies, percentage and median were used to present study results.
A Bivariate analysis was performed to determine the effect each of factors on the outcome variable. Only factors with p.value <0.2 on Bivariate analyses were kept for multivariate analyses and a p value of <0.05 on multivariate analyses was considered as statistically significant [24,25].
Ethical consideration
Ethical clearance was obtained from the Institutional Review Board (IRB) of University of Gondar and from Amanuel Specialized Mental hospital ethical committee. Formal permission was also obtained from prisoner’s administrative bureau and finally written consent was obtained from each participant during data collection. All participants were well informed about the aims and purpose of the study, its contribution to the future development of health system; especially to mental health intervention in the country. The right was given to the study participants to refuse or withdraw from participation at any time during data collection without loss of any entitlement. Three participants were found to have CMDs. the principal investigator have seen the three CMD cases and referred to D/ markos referral hospital for further management.

Result

A total of 423 participants were studied, Out of 423 participants 414 participants responded for questionnaires and the overall response rate was 97.9%.
Description of socio-demographic characteristics
Most of the study subjects were in the age group of 18-27 years old 181 (43.7%), and the median age of participants was 28.00 with interquartile Range of age 14.00 and the minimum and maximum 18 and 70 respectively.
Majority of the participants were males 375 (90.6%) and were orthodox Christians 399 (96.4%). About half of the participants were married 214 (51.7%) and had attained primary level of education 127 (30.7%).
Of the study participants 151 (36.5%) were farmers by occupation and had done 170 (40.1%) of killing crime.
Stressful life events and clinical factors of the respondents
Regarding stressful life events, among the total of the study participants 197 (47.6%) of them had experienced relationship problems while the remaining 176 (42.5) of traumatic stress, 106 (25.6%) of health risk, 102 (24.6%) of financial stress and 53 (12.8%) of the respondents loss of loved one stress.
Of the respondents 61 (14.7%) reported history of mental illness while 50(12.1%) of the respondents had family history of mental illness and the remaining 52 (12.6%) had chronic physical illness. Altogether, 196 (47.3%) of the participants had <1 year length of sentences or stays.
Substance use history of the participant
As illustrated in Figure 1 out of 414 study subjects 211 (51.0%) had used alcohol once in their life.
Figure 1: Distribution of substance use among prisoners in Debre Markos Town Correctional Institution, North West, Ethiopia, 2014.
Prevalence of common mental disorders among participants
The overall prevalence of CMDs was found to be 280 (67.6%) (Figure 2).
Figure 2: Prevalence of common mental disorders among prisoners in Debre Markos Town Correctional Institution, North West, Ethiopia, 2014.
Factors associated with common mental disorders among prisoners
In Bivariate analyses, age, sex, marital status, religion, ethnicity, occupation, type of crime, health risk, loss of loved one, relationship problems, financial stress, traumatic stress, length of stay /sentences, history of mental illness, family history of mental illness, chronic physical illness and substance use were analyzed (Table 1).
Table 1: Socio-demographic characteristics of respondents in Debre Markos Town, Correctional Institution, North West, Ethiopia, 2014.
Multivariate logistic regression was also used to analyze associations between variables which have p value of <0.2 in Bivariate logistic regression. After adjusting for possible covariates, sex, marital status, loss of loved one, relationship problems, traumatic stress and history of mental illness were significant associated variables with common mental disorders among prisoners with p-value<0.05.
Females were about 3.27 times more likely to have CMD as compared to males (AOR=3.27, 95% CI: 1.05, 10.22).
The study revealed that prisoners who are divorced/widowed 3.79 times more likely to have common mental disorders as compared to prisoners who are married (AOR= 3.79, 95% CI: 1.54, 9.30).
A Statistically significant higher rate of CMD was seen among prisoners who reported history of mental illness (AOR=7.30, 95% CI: 2.96, 18.01) when compared to those who did not report.
Also, prisoners who had loss of loved one (AOR=3.03, 95% CI: 1.34, 6.85), relationship problems (AOR=2.07, 95% CI: 1.26, 3.40) and traumatic stress (AOR=2.02, 95% CI: 1.22, 3.37) had CMD symptoms than those who had no these symptoms.

Discussion

The study has tried to determine the prevalence of Common Mental Disorder among 414 prisoners and associated factors using a cross sectional study design by using SRQ 20 instrument. The prisoners were predominantly males (90.6%) which were similar to previous studies [26,27]. The overall prevalence of common mental disorder for prisoners was found to be 67.6%.
According to this study the prevalence of common mental disorder among prisoners was in line with Zambia which is almost 63.1% [27].
Similarly, our finding was also higher than studies conducted in Durban, South Africa (55.4%); the possible difference might be due to the instrument they used and socio-economical status of the study setting (CIS-R) [16].
Our finding was less than study conducted in Nigeria (87.8%) and (85.3%) on the GHQ - 30 and the HADS - Depression Sub-scale respectively [28].
Our finding was high study conducted in US the range of 45%- 64% [29].
Our study finding is low from a nationally representative survey 73% of the inmate was reported mental health problems during screening in US [30]. The possible difference might be due to the instrument they assessed (GHQ - 30 and the HADS).
In this study, the respondents (14.7%) reported that have had experiencing history of mental illness. However, a study in Australian suggested that almost (50%) of prisoners may have a diagnosable mental disorder at the time of arrest (23). In England and wolves, 21% of prisoners had received help before entering prison and 15% of them had received help since coming to prison [31]. The high prevalence might be due to the instrument, sample size and population difference.
Prevalence of lifetime substance use was (54.1%) with alcohol was the highest (51.0%). A study conducted in Nigeria prisons, prevalence of Lifetime substance use was (85.5%) with alcohol being the highest (77.5%) [32]. Lifetime prevalence of substance use study In Kenya was 66.1%, while that of alcohol use was 65.1% [33]. The discrepancy might be due to habit, the possible of accessibility and availability of substance and low cost.
Reasons why they use substances include relaxing, to relieve stress, to feel normal, to be accepted by peers, easy availability of the substances and the confidence to commit a crime [33].
Female prisoners were about 3.27 times more likely to have common mental disorder when compared to male prisoners. BJS reported on Washington DC 24% of men and 36% of women prisoners surveyed reported receiving mental health services at some point in their lives, whereas 10% of men and 20% of women reported receiving them since admission [29,34,35]. BJS on US showed that 73% and 75% women in state prisons and local prisons respectively have symptoms of mental disorder compared to 12% of women in the general population [36]. These finding might be due to hormonal difference which may play important role. Women are more vulnerable for gender discrimination, neglect, violence, physical and sexual abuse. The influence of increased stressors and adverse life events, such as overcrowded, cultural influence, formal or informal rules, limited liberty, polluted environments and reduced social support are the possible reasons. Long periods of isolation, poor mental health care and feelings of intense anger, frustration and anxiety are also the possible explanation.
The study found that prisoners who are divorced/ widowed are 3.79 times developing common mental disorder than those do not divorced/widowed [27,28]. This might be due to decreasing of family and friend support with being in a prison.
Common mental disorder was 7.30 times more among those participants who reported history of mental illness as compared those participants who did not report (AOR=7.30,95% CI:2.96, 18.01). This might be due to fear of the social stigma and discrimination that the prisoners obsessed and likely to experience distress, the guilt feeling for their illness and lack of social support many more stressors. As WHO supported that the act of incarceration may exacerbate certain underlying psychiatric conditions. The effect of incarceration is so severe to precipitate mental abnormality in vulnerable individuals. Different levels of stress during incarceration give rise to different incidence of psychiatric morbidity among remand prisoners [8,9].
There were a strong association between Loss of loved one, relationship problems and traumatic stress and CMDs in the study among those individuals who had experienced these stressful life events were about 3.03, 2.07 and 2.02 times respectively more likely to develop common mental disorder as compared to those who had no these stressful life events (Table 2). The study also revealed that health related risk, like a serious illness, injury or assault 25.6%, financial stress 24.6%, lose of loved one 15.0%, relationship problems, like marital problems 47.6% and traumatic stress were 42.6% reported (Table 3). The possible explanation may be due to limited liberty, autonomy, and lack of communication with family and friends. As WHO reported that mental disorders may develop during imprisonment itself as a consequence of prevailing condition like social exclusion, disadvantage, and traumatic adversities prior to imprisonment precipitate mental illness in prison populations [37].
Table 2: Stressful life event and Clinical related factors of the respondents in Debre Markos Town Correctional Institution, North West, Ethiopia, 2014.
Table 3: Bivariate and Multivariate analysis of factors associated with common mental disorders.
The variables educational status and occupational status have no association with common mental disorder, unlike some previous studies where those variable differences were observed [27,28,38]. Majority of prisoners are farmers and do not worry about their educational status since majority of them are primary level of education.
Thus, Common mental disorder of prisoners likely to be impacted by genders, divorced/ widowed, history of mental illness, loss of loved one ,relationship problems and traumatic stress which in turn, establish platform for the development of distressed feelings, destructive thoughts, interpersonal relationship problems, and many more non-identified mental and behavioral disorders.

Limitation of the Study

A cross- sectional study design is unable to know Cause and effect relationship. The prisoners pretending as having CMD symptoms (malingering) may have an influence on the findings and increase prevalence of CMD.

Conclusion

The prevalence of common mental disorder is high in the study among prisoners. Of great concern is the large numbers of prisoners who have common mental disorder remain undetected in the prison.
Being female, divorced/widowed, history of mental illness, loss of loved one, relationship problems and traumatic stress were associated with common mental disorder.

Recommendations

To zonal health offices
• Should incorporated mental health care services in primary health care services.
• Trainings of screening and managing CMD for health professionals working in prison should be designed and implemented.
To health professionals
• Professionals should be alert while they are giving care for those prisoners having the possible higher risk for CMD specially females, divorced/widowed, history of mental illness, loss of loved one, relationship problems and traumatic stress to detect and manage CMD symptoms early.
To prison administration
• Trainings of screening and managing CMD for health professionals working in prison should be designed and implemented.
• The office should give special attention and psychosocial support and living environment for those vulnerable people to alleviate possible stressors.
•The office should integrate and strengthen prison mental health care services with Debre Markos Referral Hospital.
To researchers
• It is better to conduct further longitudinal research in prisons to know the temporal relationship of common mental disorders.

Acknowledgments

This study was funded by jointly University of Gondar and Amanuel Mental specialized Hospital, they covered all the financial and material support for the research.
We also want to acknowledge Debre Markos Prison Administration and participants (prisoners) for providing us important materials and for giving us relevant information.

References







































Track Your Manuscript