High prevalence rates for multiple psychiatric conditions among inmates at French Guiana’s correctional facility: diagnostic and demographic factors associated with violent offending and previous incarceration

High prevalence rates for multiple psychiatric conditions among inmates at French Guiana’s... Background: French Guiana has the highest incarceration rate among French territories, it is higher than that of Brazil, Colombia or Venezuela. It is well known that mental health problems are over-represented in correctional facilities. Our objectives were to describe the prevalence of various psychiatric conditions and to study factors associated with violence and repeated offenses among arriving detainees at the sole correctional facility of French Guiana. Methods: The study was cross-sectional. All consenting new adult prisoners incarcerated between 18/09/2013 and 31/12/2014 at the penitentiary centre of French Guiana were included. The Mini International Neuropsychiatric Interview (MINI) was used to screen for psychiatric diagnoses. In addition sociodemographic data was collected. Results: Overall 647 men and 60 women were included. The participation rate was 90%.Overall 72% of patients had at least one psychiatric diagnosis (Fig. 2). Twenty percent had three or more diagnoses. Violent index offences were not more frequent among those with a psychiatric diagnosis (crude odds ratio 1.3 (95%CI = 0.9–2), P = 0.11. Multivariate analysis showed that after adjusting for sex and age, psychosis, suicidality and post-traumatic stress disorder were independently associated with violent offences. Generalized anxiety disorder was less likely to be associated with incarceration for violent offences. Having a history of a previous incarceration was significantly associated with a psychiatric condition in general (any diagnosis) OR = 3 (95%CI = 2–4.3), P < 0.0001. Calculations of the population attributable risks showed that in the sample 31.4% of repeat incarcerations were attributable to antisocial personality disorder, 28.3% to substance addiction, 17.3% to alcohol addiction, 8.7% to depression and 7% to psychosis. (Continued on next page) * Correspondence: mathieu.nacher66@gmail.com Centre d’Investigation Clinique CIC INSERM 1424, Centre Hospitalier de Cayenne, 97300 Cayenne, French Guiana Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nacher et al. BMC Psychiatry (2018) 18:159 Page 2 of 9 (Continued from previous page) Conclusions: The very high prevalence of psychiatric disorders observed in our sample, and the relative lack of psychiatric facilities, suggest that part of the problem of very high incarceration rate may be explained by transinstitutionalization. Improving psychiatric care in prison and coordination with psychiatric care in the community after release is likely to be important. Background Methods French Guiana is a French overseas territory located be- The study was cross-sectional. All consenting new adult tween Brazil and Suriname, and thus a part of the European prisoners incarcerated between 18/09/2013 and 31/12/ Union. It has the highest GDP per capita on the Latin 2014 at the penitentiary centre of French Guiana at American continent and therefore attracts numerous immi- Cayenne were included. grants in search of a better life (https://www.insee.fr/fr/sta- This is slightly different from the study on suicide risk tistiques/2011101?geo=DEP-973). However, unemployment factors [9] because the questionnaire and case record form is high and much of the population lives in precarious used was modified after a test phase; we only used data social conditions. The soil is rich in gold and attracts large collected with the finalized version of the data collection numbers of illegal gold miners [1]. French Guiana is also a tool. hub for cocaine trafficking towards France and Europe. Inmates with an assigned legal guardian were excluded Drugs are relatively cheap and there are high rates of in order not to compromise the incarceration procedures substance use, impacting on HIV rates [2]. A quarter of for our study because the presence of the legal guardian families are single parent families, and one in five families would have been logistically very difficult given the includes four children or more, demographic conditions restricted access to the mental health ward [9]. that further increase social vulnerability (https://www.in- After incarceration, all new arrivals are seen for physical see.fr/fr/statistiques/2011101?geo=DEP-973). examination by a doctor of the “Unité de consultation et de The natural population growth in French Guiana is soinsambulatoires(UCSA)”, the ambulatory care unit of 2.45% per year, the second highest in Latin America on a the prison and then by a psychiatrist or psychiatric nurse in par with Guatemala [3]. This very rapid growth com- the “Unité fonctionnelle de psychiatrie intra-carcérale pounds social problems and challenges the French social (UFPI)” (the psychiatric ward). Patients had a 15 day win- system, which struggles to keep up in terms of education, dow after arrival in which they could be included. health infrastructure, and appropriate housing. These In addition to this normal procedure upon admission difficult social conditions and the illegal “opportunities to for the purpose of our study we added the Mini Inter- make money” may fuel the high crime rate and lead national Neuropsychiatric Interview (MINI). The MINI is French Guiana to have the highest incarceration rate (328 a short diagnostic structured interview (DSI) developed in per 100,000) among French territories, a rate that is higher France and the United States to explore 17 disorders than that of Brazil (319 per 100,000), Colombia (231 per according to the Diagnostic and Statistical Manual 100,000) or Venezuela (173 per 100,000) [4]. (DSM)-V diagnostic criteria. The validity and reliability of As for other government services, the judiciary and the MINI has been confirmed in several studies [10, 11]. penitentiary systems struggle to keep up. The only The MINI is structured to allow administration by correctional facility in French Guiana is thus saturated non-specialized interviewers for the research of current and its overpopulation and poor living conditions have disorders. It is currently one of the most used psychiatric been repeatedly described [5, 6]. diagnostic tools [12]. For each mental illness, one or two screening questions rule out the diagnosis when answered It is well known that mental health problems are negatively. The MINI is thus adapted for epidemiological over-represented in correctional facilities [7, 8]. Psychiatric studies requiring a short but robust tool. The estimated illnesses often increase the risk of suicide, the risk of death time for the interview is 15 min. The MINI has been after release from incarceration, and the risk of new of- translated and validated in 46 languages, including the fences and reincarceration. Until recently, there had never main languages found in French Guiana: French, English, been any study of the mental health issues of detainees in Portuguese, Dutch and Spanish. this particular territory at the crossroad between France and Latin America. A first study showed focused on the All psychiatrists and nurses performing the MINI were risk of suicide and its predictors among arriving detainees trained in order to correctly use the questionnaire. [9]. The objective of the present study was to describe the Socio-demographic questions were added (age, birthplace, relation between various psychiatric conditions and vio- residence, languages, presence of a translator, family status, lence or repeated offenses among arriving detainees at the children, siblings, position among siblings, professional situ- sole correctional facility of French Guiana. ation), history of detention (reason for detention, previous Nacher et al. BMC Psychiatry (2018) 18:159 Page 3 of 9 imprisonment) and psychiatric history. A training period A similar procedure was used for bivariate and multi- preceded our study in order to test the feasibility of the variate analysis of variables associated with repeated MINI and to familiarize staff with the protocol and to incarcerations. verify that the staff was proficient with the tool before Principal component analysis was performed and a starting the study. Since there were 2 phases with some loading plot of the different diagnoses was performed. changes in the ancillary questionnaire, we only analyzed Stata13 (College Station, Texas, USA) was used. the data collected with the final questionnaire in order to obtain a homogenous data set. Ethical and regulatory aspects The study was approved by the Ethical committee of Inclusion criteria Bordeaux (Comité de Protection des Personnes, CPP) Incarcerated adults accepting to participate were only (reference number DC 2012/115). The study was also included. approved by the Ethical committee of INSERM CEEI in 2013 (IRB00003888). Inmates gave informed consent (oral Exclusion criteria and written) to participate in the study. Minors, persons with a legal guardian, or persons refusing to participate were not included. Results General results Statistical analysis th Between September 18 2013 and December 31st 2014, 785 Descriptive analysis of qualitative and quantitative vari- new prisoners were registered. The survey participation rate ables was followed by bivariate analysis in order to identify was 90% (707/785) [9]. Overall 647 men and 60 women significant variables for incarceration for violent index were included. The mean age was 30 years (SD = 10.7 years) offences. Variables were included in a multivariate model for men and 27.7 years (SD 10 years) for women. Figure 1 for logistic regression in order to identify independent shows the over-representation of younger age groups. diagnoses at increased risk for incarceration for violent index offences. The modelling strategy was purely exploratory and the variables were retained in the model Birth place and spoken language except obsessive compulsive disorder, anorexia and Overall 47.8% of persons were born in French Guiana, bulimia which were too rare to be included in a multivari- 3% in other French territories, 15.1% were born in ate model (respectively, 15, 5 and 3 persons). Collinearity neighboring Suriname, 14.3% were born in Guyana, was tested using the Collin package (STATA, College 10.6% in Brazil, 3.1% in Haiti, and the rest were born Station, Texas) and verifying that variance inflation factors elsewhere or missing. 57.3% spoke French, 14% spoke were < 4. The Hosmer-Lemeshow goodness-of-fit test was English, 9.1% spoke Portuguese, 7.4% spoke Nengue used to test the model. Tongo, and 7% spoke Haitian Creole. Fig. 1 Age of incarcerated persons included in the study at the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 4 of 9 Marital status Overall 36 of 51 (70.6%) persons with psychosis also Regarding their marital status 48.4% were single, and had substance addictions. Conversely, 36 of 235 41.02% lived in a couple, 6.3% were married and 1% persons with substance addictions (15.3%) were also were divorced or widowed. Sixty percent (368/613 psychotic. Among the study population, 307 took respondents) of inmates had parents who were separated cannabis (43%), 58 took crack cocaine (8.2%) and 15 (13.3% of non response). cocaine (2.1%). The individual prevalence for individual diagnoses is shown in Fig. 3. Work Overall, 2% reported past sexual trauma (95%CI = Among respondents (92%) to the work status question, 1–3.5%) and 5.9% (95%CI = 4.2–8%) reported a family 22.4% of men and 48% of women were unemployed; 46% history of psychiatric problems. of men and 26% of women declared having odd jobs; and 24.6% of men and 10% of women had a work contract. Principal component analysis Trauma Figure 4 shows a loading plot after the principal com- Nearly 2% (11/564 respondents) declared having experi- ponent analysis of the different diagnoses obtained by enced prior sexual trauma with 18.2% not responding to the MINI. A cluster of depressive signs is found on the question. A third of respondents declared the death the lower right part, the bottom center is mostly of a close family member (233/691 respondents). linked to a cluster of neurotic manifestations; the top center cluster pertains to addictions, which lie close Incarceration motives to antisocial disorder. Incarceration resulted from violent offences in 28% of cases (assault 7.9%, homicide without intent 2.2%, intentional homicide 3.5%, rape 4.5%, violence 9.8%) and drugs in Incarceration for violence 34.4% of cases. Table 1 shows the proportion of patients for listed MINI- diagnoses who had been charged with violent Psychiatric diagnoses and non-violent crimes. Multivariate analysis showed Overall 72% of patients had at least one psychiatric that after adjusting for sex and age, psychosis, suicidal- diagnosis (Fig. 2). Twenty percent had three or more ity, and post-traumatic stress disorder were independ- diagnoses. Violent offences were not more frequent ently associated with violent offences for incarceration. among those with a psychiatric diagnosis (crude odds Generalized anxiety disorder was less likely to be ratio 1.3 (95%CI = 0.9–2), P=0.11, Median1inboth associated with incarceration following a violent index groups, p = 0.49). offence. Fig. 2 Number of psychiatric diagnoses among inmates incarcerated in the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 5 of 9 Fig. 3 Prevalence and 95% confidence intervals of different psychiatric conditions in Prisoners in French Guiana using the MINI 5.0 screening tool at the time of incarceration Repeat offenders 28.3% to substance addiction, 17.3% to alcohol addiction, Overall, 48.6% of inmates had already been previously 8.7% to depression and 7% to psychosis. incarcerated. Having a history of a previous incarcer- ation was significantly associated with a psychiatric con- Discussion dition in general (any diagnosis) OR = 3 (95%CI = 2–4.3), The present study emphasizes the high prevalence of P < 0.0001. Table 2 shows the detail by psychiatric diag- mental illness among detainees in French Guiana [9]. Over- nosis. Calculations of the population attributable risks all, 512/707 inmates (72%) presented at least 1 psychiatric showed that in the sample 31.4% of repeat incarcerations disorder. The most common diagnoses were antisocial were attributable to antisocial personality disorder, personality disorder (34.6%), substance addiction (33.2%), Fig. 4 Principal component analysis of the different psychiatric diagnoses among inmates incarcerated in the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 6 of 9 Table 1 Variables associated with violent and non violent crimes, bivariate and multivariate analysis Total Incarceration linked Incarceration not linked Crude odds Adjusted odds ratio to violence N(%) to violence N(%) ratio (95% CI) (95% CI), P Age in years Mean [SD] 707 29.6 [10.3] 31 [11.2] 1 (0.99–1.02) 1(0.98–1.02), P = 0.5 Sex Male 647 195 (98.5) 452(88.8) 8.2(2.5–26.5) 8 (2.4–26.4), P = 0.001 Female 60 3(1.5) 57(11.2) Antisocial disorder Yes 245 67(33.8) 178 (35) 0.9 (0.67–1.3) 0.9 (0.6–1.3), P = 0.5 No 462 131 (66.2) 331(65) Generalized anxiety disorder Yes 182 39(19.7) 143(28.1) 0.6 (0.4–0.9) 0.5 (0.3–0.8), P = 0.006 No 525 159(80.3) 366(71.9) Psychosis Yes 51 23(11.6) 28(5.5) 2.2 (1.2–4) 2.4 (1.2–4.6), P = 0.01 No 656 175(88.4) 481(94.5) Substance addiction Yes 235 61(30.8) 174(34.2) 0.8(0.6–1.2) 0.7 (0.4–1), P = 0.05 No 230 197 (69.2) 33(65.8) Alcohol addiction Yes 144 39(19.7) 85(16.7) 1.2 (0.8–1.8) 1.4 (0.86–2.2), P = 0.19 No 583 159(80.3) 424(83.3) PTSD Yes 107 40(20.2) 67(13.1) 1.7(1.1–2.6) 1.8 (1.08–3), P = 0.02 No 600 158(79.8) 442(86.8) Social phobia Yes 63 15(7.6) 48(9.4) 0.8 (0.4–1.44) 0.7 (0.4–1.5), P = 0.4 No 644 183(92.4) 461(90.6) Agoraphobia Yes 76 28(14.1) 48(9.4) 1.6 (0.96–2.6) 1.6 (0.9–2.9), P = 0.1 No 631 170(85.9) 461(90.6) Panic attacks Yes 48 15(7.6) 33(6.5) 1.2 (0.6–2.2) 1 (0.5–2), P = 0.9 No 659 183(92.4) 476(93.5) Mania Yes 26 5(2.5) 21(4.1) 0.6 (0.2–1.6) 0.4 (0.1–1.2), P = 0.1 No 681 193(97.5) 488(95.9) Mood disorders Yes 38 11(5.5) 27(5.3) 1 (0.5–2.1) 0.9 (0.4–2.2), P = 0.9 No 669 187(94.5) 482(94.7) Suicidality Yes 93 35(17.7) 58(11.4) 1.7 (1.05–2.6) 2.1 (1.2–3.8), P = 0.009 No 614 163(82.3) 451(88.6) Depression Yes 101 28(14.1) 73 (14.3) 1 (0.6–1.6) 0.8 (0.4–1.5), P = 0.5 No 606 170(85.9) 436(85.7) generalized anxiety disorder (25.7%), alcohol addiction depression was also higher. This may reflect the use of the (17.5%), post traumatic stress disorder (15.1%), and major MINI, rather than the use of other diagnostic instruments depression (14.3%) (Fig. 3). in other studies in the literature. Although antisocial per- Prevalence of psychosis was greater in our sample (7.6%) sonality disorder was the most frequent diagnosis, its preva- than in large meta-analyses (3.7–4%) [8, 13]. Prevalence of lence was less frequent than in the largest meta-analysis of Nacher et al. BMC Psychiatry (2018) 18:159 Page 7 of 9 Table 2 Variables associated with previous incarcerations, bivariate and multivariate analysis Total Previously First incarceration Crude odds Adjusted odds ratio incarcerated N(%) N(%) ratio (95% CI) (95% CI), P Age in years Mean [SD] 707 32 [10.5] 28.1 [10.3] 1 (0.99–1.02) 1.04(1.02–1.06), P < 0.001 Sex Male 647 333(96.8) 314 86.5) 4.7(2.4–9.2) 4.3 (2–9.1), P < 0.001 Female 60 11(3.2) 49(13.5) Antisocial disorder Yes 245 162(47.1) 83 (22.9) 3 (2.2–4.1) 2.6 (1.8–3.7), P < 0.001 No 462 182 (52.8) 280(77.1) Generalized anxiety disorder Yes 182 92(26.7) 90(24.8) 1.1 (0.8–1.5) 0.8 (0.5–1.3), P = 0.4 No 525 252(73.3) 273(75.2) Psychosis Yes 51 37(10.7) 14(3.9) 3 (1.6–5.7) 1.4 (0.7–2.9), P = 0.01 No 656 307(89.3) 349(96.1) Substance addiction Yes 235 153(44.5) 82(22.6) 2.7(2–3.8) 1.9 (1.3–2.7), P = 0.001 No 472 191 (55.52) 281(77.4) Alcohol addiction Yes 124 88(25.6) 36(9.9) 3.1 (2–4.7) 1.7 (1.1–2.8), P = 0.02 No 583 256(74.4) 327(90.1) PTSD Yes 107 64(18.6) 43(11.9) 1.7(1.1–2.6) 1.3 (0.8–2.2), P = 0.3 No 600 280(81.4) 320(88.1) Social phobia Yes 63 34(9.9) 29(8) 1.2 (0.74–2.1) 1.2 (0.6–2.3), P = 0.6 No 644 310(90.1) 334(92) Agoraphobia Yes 76 46(13.4) 30(8.2) 1.7 (1.05–2.8) 1.1 (0.6–2.1), P = 0.6 No 631 298(86.4) 333(91.8) Panic attacks Yes 48 27(7.9) 21(5.8) 1.4 (0.7–2.5) 0.8 (0.4–1.6), P = 0.5 No 659 317(92.1) 342(94.2) Manic Yes 26 18(5.2) 8(2.2) 2.56 (1.05–5.7) 1.3 (0.5–3.6), P = 0.5 No 681 326(94.8) 355(97.8) Mood disorders Yes 38 19(5.5) 19(5.2) 1.1 (0.5–2) 0.5 (0.2–1.2), P = 0.13 No 669 325(94.5) 344(94.8) Suicidality Yes 93 54(15.7) 39(10.7) 1.5 (0.99–2.4) 1.2 (0.7–2), P = 0.6 No 614 290(84.3) 324(89.3) Depression Yes 101 63 (18.3) 38 (10.53) 1.9 (1.2–3) 1.7 (0.96–3), P = 0.06 No 606 281(81.7) 325(89.5) cross-sectional prevalence rates of mental illness among has a profile that is closer to low and middle income prisoners internationally [13]. It has been observed that in countries [8]. In low and middle income countries, lower lowtomiddleincome countries theprevalenceofpsychosis budgets for psychiatric care of psychoses may lead to a shift and major depression is higher than in high income coun- from mental health care towards incarceration. Another tries. French Guiana, despite being a French territory thus hypothesis pertains to different social and cultural norms Nacher et al. BMC Psychiatry (2018) 18:159 Page 8 of 9 regarding mental illness, and possible poor legal representa- The transinstitutionalization hypothesis posits that tions of mentally ill patients in the justice system [8]. mentally ill persons without proper care will be When comparing our results with the study in French over-represented in the criminal justice system. This prisons, which used the MINI and examination by a hypothesis is debated. Some authors argue that this is re- psychiatrist, there were some differences between main- ductionist and that psychiatric desinstitutionalization does land France and the French territory of French Guiana. A not necessarily lead to a direct increase in the number of striking difference was the weight of addictions in French prisoners with mental health issues, and that increasing Guiana (33.2% for drugs and 17.5% for alcohol) relative to psychiatric facilities will not necessarily reduce numbers mainland France (8.9 and 8.7%, respectively). This level of of detainees with mental health issues [7, 21–25]. addictions was comparable to what is observed in neigh- French Guiana has a structural lag in health care boring Brazil [14, 15]. PTSD and generalized anxiety personnel, notably in terms of specialized physicians. In seemed more frequent in French Guiana than in mainland terms of the density of psychiatrists French Guiana is six France (15.1 and 25.7%, versus 6.6 and 15.4%) whereas de- times lower than in mainland France [26]. The number of pression was less frequent in French Guiana than in main- beds per capita is much lower than in mainland France land France (14.3 versus 22.9%). Some of these differences and even than other French overseas territories [27]. In may be due to methodological differences, but others may terms of psychiatric care, the number of beds per 100,000 be due to the “Latin American socio economic and persons in French Guiana is lower than in other territories cultural context” in French Guiana. Thus what applies in (90 in France, in Martinique, 70 in Guadeloupe, and 40 in mainland France may not apply in French Guiana, and French Guiana). When we compare the incarceration rate French-trained mental health professionals require some and the psychiatric facilities, the contrast between French adaptation of their epidemiological assumptions. territories is even more salient: in France there are 1.12 in- After adjusting for age, males, antisocial personality mates per psychiatric bed, in Guadeloupe 3, in Martinique disorder, substance and alcohol addictions, depression 3.3 and in French Guiana 8.2. and psychoses were significantly associated with repeat It is noteworthy that in early 2017, following a wave of offenses as described elsewhere [16, 17]. We did not find violent crime, French Guiana erupted in mass protests any association with bipolar disorder. It may be that our over notably security issues and deficient health infra- sample size was insufficient to detect any effect because structures [28]. When looking at the very high prevalence the crude odds ratio, but not the adjusted one, was of psychiatric disorders observed in our sample, and when significantly associated with repeat incarceration. The looking at the relative lack of psychiatric facilities, it is calculation of population-attributable fractions is tempting to hypothesize that part of the problem can be arguable in this cross-sectional design. It was meant to explained by transinstitutionalization and the Penrose estimate, what proportion of repeat offenses could be hypothesis [21, 29]. At least, we hope these data will help attributed to the psychiatric conditions, and thus what fuel strategic debates in French Guiana. could theoretically be gained if they were controlled. We There are several limitations to our study: The cross believe it emphasizes the importance of enhancing sectional design and the use of declarative data in a con- psychiatric and social care in prison. text of incarceration may have led to biased estimates. The variables significantly associated with incarcer- The MINI scale is a validated screening tool but it may ation for violent crimes were male sex, psychosis, suicide not always be sufficiently sensitive notably for certain risk. Generalized anxiety disorder on the contrary was borderline personality disorders which are associated associated with a lower probability of incarceration for a with incarceration. Finally the inclusion of study partici- violent crime. The direction of causality is not clear with pants directly after incarceration– a stressful period- regard to suicide risk: perhaps remorse explained the may have impacted responses to the questions. association, but hetero-aggressive behavior in persons with suicidal thought is also a possible explanation. We Conclusions have previously described predictive factors for suicide Mentally ill detainees should benefit from effective risk for this population [9]. screening, case identification and psychiatric care on Substance addiction has been reported to be associated arrival [9], ongoing care during the period of incarcer- with violence [18]. However, here we did not find any ation and pre-release arrangements for ongoing care in significant association perhaps because violence between the community following release from custody. The drug users may be less frequently reported to the police goals of the correctional facilities and the psychiatric and less frequently prosecuted. Prison is likely to repre- system are different but they may not always be antag- sent an opportunity to initiate addiction treatment and onistic. Improved recognition and care of persons with medical services that should aim for a smooth transition mental illness in prison settings may improve outcomes with the services outside of prison [19, 20]. for affected individuals and for public security [30]. Nacher et al. BMC Psychiatry (2018) 18:159 Page 9 of 9 Abbreviations 8. Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide: CEEI: Comité d’Evaluation Ethique de L’INSERM; CNIL: Commission Nationale systematic review and meta-regression analysis. Br J Psychiatry. 2012; Informatique et Libertés; GDP: Gross Domestic Product; HIV: Human 200(5):364–73. immunodeficiency virus; INSERM: Institut National de la Santé et de la 9. Ayhan G, Arnal R, Basurko C, Pastre A, Pinganaud E, Sins D, Jehel L, Falissard Recherche Médicale; UCSA: Unité Carcérale de Soins Ambulatoires B, Nacher M. Suicide risk among prisoners in French Guiana: prevalence and predictive factors. BMC Psychiatry. 2017;17(1):156. 10. Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan KH, Janavs Availability of data and materials J, Dunbar GC. The MINI international neuropsychiatric interview (MINI). A Data may be made availability upon request to Pr Nacher Cayenne Hospital, short diagnostic structured interview: reliability and validity according to the and with additional permission from the Commission Nationale Informatique CIDI. Eur Psychiatry. 1997;12(5):224–31. et Libertés (CNIL) 3 Place de Fontenoy, 75007 Paris, France. 11. Sheehan D, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, Schinka J, Knapp E, Sheehan M, Dunbar G. The validity of the MINI international Authors’ contributions neuropsychiatric interview (MINI) according to the SCID-P and its reliability. RA, CB, MN designed the protocol; RA, GA, VA, AP collected data; MN Eur Psychiatry. 1997;12(5):232–41. analyzed the data and wrote first draft of the manuscript; VA, RA, GA, CB, BF, 12. Aboraya A. Use of structured interviews by psychiatrists in real clinical settings: LJ, FH, AP critically reviewed the manuscript. All authors read and approved results of an open-question survey. Psychiatry (Edgmont). 2009;6(6):24. the final manuscript. 13. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet. 2002;359(9306):545–50. Ethics approval and consent to participate 14. Andreoli SB, dos Santos MM, Quintana MI, Ribeiro WS, Blay SL, JGV T, de The study was approved by the Ethical committee of Bordeaux (Comité de Jesus Mari J. Prevalence of mental disorders among prisoners in the state of Protection des Personnes, CPP) (reference number DC 2012/115). The study Sao Paulo, Brazil. PLoS One. 2014;9(2):e88836. was also approved by the Ethical committee of INSERM CEEI in 2013 15. Pondé MP, Freire AC, Mendonça MS. The prevalence of mental disorders in (IRB00003888). Inmates gave informed consent (oral and written) to prisoners in the city of Salvador, Bahia, Brazil. J Forensic Sci. 2011;56(3):679–82. participate in the study. 16. Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Consent for publication Psychiatr. 2009;166(1):103–9. All persons included gave informed consent for publication of aggregated 17. Yu R, Geddes JR, Fazel S. Personality disorders, violence, and antisocial results. behavior: a systematic review and meta-regression analysis. J Personal Disord. 2012;26(5):775–92. Competing interests 18. 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High prevalence rates for multiple psychiatric conditions among inmates at French Guiana’s correctional facility: diagnostic and demographic factors associated with violent offending and previous incarceration

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Medicine & Public Health; Psychiatry; Psychotherapy
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Abstract

Background: French Guiana has the highest incarceration rate among French territories, it is higher than that of Brazil, Colombia or Venezuela. It is well known that mental health problems are over-represented in correctional facilities. Our objectives were to describe the prevalence of various psychiatric conditions and to study factors associated with violence and repeated offenses among arriving detainees at the sole correctional facility of French Guiana. Methods: The study was cross-sectional. All consenting new adult prisoners incarcerated between 18/09/2013 and 31/12/2014 at the penitentiary centre of French Guiana were included. The Mini International Neuropsychiatric Interview (MINI) was used to screen for psychiatric diagnoses. In addition sociodemographic data was collected. Results: Overall 647 men and 60 women were included. The participation rate was 90%.Overall 72% of patients had at least one psychiatric diagnosis (Fig. 2). Twenty percent had three or more diagnoses. Violent index offences were not more frequent among those with a psychiatric diagnosis (crude odds ratio 1.3 (95%CI = 0.9–2), P = 0.11. Multivariate analysis showed that after adjusting for sex and age, psychosis, suicidality and post-traumatic stress disorder were independently associated with violent offences. Generalized anxiety disorder was less likely to be associated with incarceration for violent offences. Having a history of a previous incarceration was significantly associated with a psychiatric condition in general (any diagnosis) OR = 3 (95%CI = 2–4.3), P < 0.0001. Calculations of the population attributable risks showed that in the sample 31.4% of repeat incarcerations were attributable to antisocial personality disorder, 28.3% to substance addiction, 17.3% to alcohol addiction, 8.7% to depression and 7% to psychosis. (Continued on next page) * Correspondence: mathieu.nacher66@gmail.com Centre d’Investigation Clinique CIC INSERM 1424, Centre Hospitalier de Cayenne, 97300 Cayenne, French Guiana Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nacher et al. BMC Psychiatry (2018) 18:159 Page 2 of 9 (Continued from previous page) Conclusions: The very high prevalence of psychiatric disorders observed in our sample, and the relative lack of psychiatric facilities, suggest that part of the problem of very high incarceration rate may be explained by transinstitutionalization. Improving psychiatric care in prison and coordination with psychiatric care in the community after release is likely to be important. Background Methods French Guiana is a French overseas territory located be- The study was cross-sectional. All consenting new adult tween Brazil and Suriname, and thus a part of the European prisoners incarcerated between 18/09/2013 and 31/12/ Union. It has the highest GDP per capita on the Latin 2014 at the penitentiary centre of French Guiana at American continent and therefore attracts numerous immi- Cayenne were included. grants in search of a better life (https://www.insee.fr/fr/sta- This is slightly different from the study on suicide risk tistiques/2011101?geo=DEP-973). However, unemployment factors [9] because the questionnaire and case record form is high and much of the population lives in precarious used was modified after a test phase; we only used data social conditions. The soil is rich in gold and attracts large collected with the finalized version of the data collection numbers of illegal gold miners [1]. French Guiana is also a tool. hub for cocaine trafficking towards France and Europe. Inmates with an assigned legal guardian were excluded Drugs are relatively cheap and there are high rates of in order not to compromise the incarceration procedures substance use, impacting on HIV rates [2]. A quarter of for our study because the presence of the legal guardian families are single parent families, and one in five families would have been logistically very difficult given the includes four children or more, demographic conditions restricted access to the mental health ward [9]. that further increase social vulnerability (https://www.in- After incarceration, all new arrivals are seen for physical see.fr/fr/statistiques/2011101?geo=DEP-973). examination by a doctor of the “Unité de consultation et de The natural population growth in French Guiana is soinsambulatoires(UCSA)”, the ambulatory care unit of 2.45% per year, the second highest in Latin America on a the prison and then by a psychiatrist or psychiatric nurse in par with Guatemala [3]. This very rapid growth com- the “Unité fonctionnelle de psychiatrie intra-carcérale pounds social problems and challenges the French social (UFPI)” (the psychiatric ward). Patients had a 15 day win- system, which struggles to keep up in terms of education, dow after arrival in which they could be included. health infrastructure, and appropriate housing. These In addition to this normal procedure upon admission difficult social conditions and the illegal “opportunities to for the purpose of our study we added the Mini Inter- make money” may fuel the high crime rate and lead national Neuropsychiatric Interview (MINI). The MINI is French Guiana to have the highest incarceration rate (328 a short diagnostic structured interview (DSI) developed in per 100,000) among French territories, a rate that is higher France and the United States to explore 17 disorders than that of Brazil (319 per 100,000), Colombia (231 per according to the Diagnostic and Statistical Manual 100,000) or Venezuela (173 per 100,000) [4]. (DSM)-V diagnostic criteria. The validity and reliability of As for other government services, the judiciary and the MINI has been confirmed in several studies [10, 11]. penitentiary systems struggle to keep up. The only The MINI is structured to allow administration by correctional facility in French Guiana is thus saturated non-specialized interviewers for the research of current and its overpopulation and poor living conditions have disorders. It is currently one of the most used psychiatric been repeatedly described [5, 6]. diagnostic tools [12]. For each mental illness, one or two screening questions rule out the diagnosis when answered It is well known that mental health problems are negatively. The MINI is thus adapted for epidemiological over-represented in correctional facilities [7, 8]. Psychiatric studies requiring a short but robust tool. The estimated illnesses often increase the risk of suicide, the risk of death time for the interview is 15 min. The MINI has been after release from incarceration, and the risk of new of- translated and validated in 46 languages, including the fences and reincarceration. Until recently, there had never main languages found in French Guiana: French, English, been any study of the mental health issues of detainees in Portuguese, Dutch and Spanish. this particular territory at the crossroad between France and Latin America. A first study showed focused on the All psychiatrists and nurses performing the MINI were risk of suicide and its predictors among arriving detainees trained in order to correctly use the questionnaire. [9]. The objective of the present study was to describe the Socio-demographic questions were added (age, birthplace, relation between various psychiatric conditions and vio- residence, languages, presence of a translator, family status, lence or repeated offenses among arriving detainees at the children, siblings, position among siblings, professional situ- sole correctional facility of French Guiana. ation), history of detention (reason for detention, previous Nacher et al. BMC Psychiatry (2018) 18:159 Page 3 of 9 imprisonment) and psychiatric history. A training period A similar procedure was used for bivariate and multi- preceded our study in order to test the feasibility of the variate analysis of variables associated with repeated MINI and to familiarize staff with the protocol and to incarcerations. verify that the staff was proficient with the tool before Principal component analysis was performed and a starting the study. Since there were 2 phases with some loading plot of the different diagnoses was performed. changes in the ancillary questionnaire, we only analyzed Stata13 (College Station, Texas, USA) was used. the data collected with the final questionnaire in order to obtain a homogenous data set. Ethical and regulatory aspects The study was approved by the Ethical committee of Inclusion criteria Bordeaux (Comité de Protection des Personnes, CPP) Incarcerated adults accepting to participate were only (reference number DC 2012/115). The study was also included. approved by the Ethical committee of INSERM CEEI in 2013 (IRB00003888). Inmates gave informed consent (oral Exclusion criteria and written) to participate in the study. Minors, persons with a legal guardian, or persons refusing to participate were not included. Results General results Statistical analysis th Between September 18 2013 and December 31st 2014, 785 Descriptive analysis of qualitative and quantitative vari- new prisoners were registered. The survey participation rate ables was followed by bivariate analysis in order to identify was 90% (707/785) [9]. Overall 647 men and 60 women significant variables for incarceration for violent index were included. The mean age was 30 years (SD = 10.7 years) offences. Variables were included in a multivariate model for men and 27.7 years (SD 10 years) for women. Figure 1 for logistic regression in order to identify independent shows the over-representation of younger age groups. diagnoses at increased risk for incarceration for violent index offences. The modelling strategy was purely exploratory and the variables were retained in the model Birth place and spoken language except obsessive compulsive disorder, anorexia and Overall 47.8% of persons were born in French Guiana, bulimia which were too rare to be included in a multivari- 3% in other French territories, 15.1% were born in ate model (respectively, 15, 5 and 3 persons). Collinearity neighboring Suriname, 14.3% were born in Guyana, was tested using the Collin package (STATA, College 10.6% in Brazil, 3.1% in Haiti, and the rest were born Station, Texas) and verifying that variance inflation factors elsewhere or missing. 57.3% spoke French, 14% spoke were < 4. The Hosmer-Lemeshow goodness-of-fit test was English, 9.1% spoke Portuguese, 7.4% spoke Nengue used to test the model. Tongo, and 7% spoke Haitian Creole. Fig. 1 Age of incarcerated persons included in the study at the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 4 of 9 Marital status Overall 36 of 51 (70.6%) persons with psychosis also Regarding their marital status 48.4% were single, and had substance addictions. Conversely, 36 of 235 41.02% lived in a couple, 6.3% were married and 1% persons with substance addictions (15.3%) were also were divorced or widowed. Sixty percent (368/613 psychotic. Among the study population, 307 took respondents) of inmates had parents who were separated cannabis (43%), 58 took crack cocaine (8.2%) and 15 (13.3% of non response). cocaine (2.1%). The individual prevalence for individual diagnoses is shown in Fig. 3. Work Overall, 2% reported past sexual trauma (95%CI = Among respondents (92%) to the work status question, 1–3.5%) and 5.9% (95%CI = 4.2–8%) reported a family 22.4% of men and 48% of women were unemployed; 46% history of psychiatric problems. of men and 26% of women declared having odd jobs; and 24.6% of men and 10% of women had a work contract. Principal component analysis Trauma Figure 4 shows a loading plot after the principal com- Nearly 2% (11/564 respondents) declared having experi- ponent analysis of the different diagnoses obtained by enced prior sexual trauma with 18.2% not responding to the MINI. A cluster of depressive signs is found on the question. A third of respondents declared the death the lower right part, the bottom center is mostly of a close family member (233/691 respondents). linked to a cluster of neurotic manifestations; the top center cluster pertains to addictions, which lie close Incarceration motives to antisocial disorder. Incarceration resulted from violent offences in 28% of cases (assault 7.9%, homicide without intent 2.2%, intentional homicide 3.5%, rape 4.5%, violence 9.8%) and drugs in Incarceration for violence 34.4% of cases. Table 1 shows the proportion of patients for listed MINI- diagnoses who had been charged with violent Psychiatric diagnoses and non-violent crimes. Multivariate analysis showed Overall 72% of patients had at least one psychiatric that after adjusting for sex and age, psychosis, suicidal- diagnosis (Fig. 2). Twenty percent had three or more ity, and post-traumatic stress disorder were independ- diagnoses. Violent offences were not more frequent ently associated with violent offences for incarceration. among those with a psychiatric diagnosis (crude odds Generalized anxiety disorder was less likely to be ratio 1.3 (95%CI = 0.9–2), P=0.11, Median1inboth associated with incarceration following a violent index groups, p = 0.49). offence. Fig. 2 Number of psychiatric diagnoses among inmates incarcerated in the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 5 of 9 Fig. 3 Prevalence and 95% confidence intervals of different psychiatric conditions in Prisoners in French Guiana using the MINI 5.0 screening tool at the time of incarceration Repeat offenders 28.3% to substance addiction, 17.3% to alcohol addiction, Overall, 48.6% of inmates had already been previously 8.7% to depression and 7% to psychosis. incarcerated. Having a history of a previous incarcer- ation was significantly associated with a psychiatric con- Discussion dition in general (any diagnosis) OR = 3 (95%CI = 2–4.3), The present study emphasizes the high prevalence of P < 0.0001. Table 2 shows the detail by psychiatric diag- mental illness among detainees in French Guiana [9]. Over- nosis. Calculations of the population attributable risks all, 512/707 inmates (72%) presented at least 1 psychiatric showed that in the sample 31.4% of repeat incarcerations disorder. The most common diagnoses were antisocial were attributable to antisocial personality disorder, personality disorder (34.6%), substance addiction (33.2%), Fig. 4 Principal component analysis of the different psychiatric diagnoses among inmates incarcerated in the sole correctional facility of French Guiana Nacher et al. BMC Psychiatry (2018) 18:159 Page 6 of 9 Table 1 Variables associated with violent and non violent crimes, bivariate and multivariate analysis Total Incarceration linked Incarceration not linked Crude odds Adjusted odds ratio to violence N(%) to violence N(%) ratio (95% CI) (95% CI), P Age in years Mean [SD] 707 29.6 [10.3] 31 [11.2] 1 (0.99–1.02) 1(0.98–1.02), P = 0.5 Sex Male 647 195 (98.5) 452(88.8) 8.2(2.5–26.5) 8 (2.4–26.4), P = 0.001 Female 60 3(1.5) 57(11.2) Antisocial disorder Yes 245 67(33.8) 178 (35) 0.9 (0.67–1.3) 0.9 (0.6–1.3), P = 0.5 No 462 131 (66.2) 331(65) Generalized anxiety disorder Yes 182 39(19.7) 143(28.1) 0.6 (0.4–0.9) 0.5 (0.3–0.8), P = 0.006 No 525 159(80.3) 366(71.9) Psychosis Yes 51 23(11.6) 28(5.5) 2.2 (1.2–4) 2.4 (1.2–4.6), P = 0.01 No 656 175(88.4) 481(94.5) Substance addiction Yes 235 61(30.8) 174(34.2) 0.8(0.6–1.2) 0.7 (0.4–1), P = 0.05 No 230 197 (69.2) 33(65.8) Alcohol addiction Yes 144 39(19.7) 85(16.7) 1.2 (0.8–1.8) 1.4 (0.86–2.2), P = 0.19 No 583 159(80.3) 424(83.3) PTSD Yes 107 40(20.2) 67(13.1) 1.7(1.1–2.6) 1.8 (1.08–3), P = 0.02 No 600 158(79.8) 442(86.8) Social phobia Yes 63 15(7.6) 48(9.4) 0.8 (0.4–1.44) 0.7 (0.4–1.5), P = 0.4 No 644 183(92.4) 461(90.6) Agoraphobia Yes 76 28(14.1) 48(9.4) 1.6 (0.96–2.6) 1.6 (0.9–2.9), P = 0.1 No 631 170(85.9) 461(90.6) Panic attacks Yes 48 15(7.6) 33(6.5) 1.2 (0.6–2.2) 1 (0.5–2), P = 0.9 No 659 183(92.4) 476(93.5) Mania Yes 26 5(2.5) 21(4.1) 0.6 (0.2–1.6) 0.4 (0.1–1.2), P = 0.1 No 681 193(97.5) 488(95.9) Mood disorders Yes 38 11(5.5) 27(5.3) 1 (0.5–2.1) 0.9 (0.4–2.2), P = 0.9 No 669 187(94.5) 482(94.7) Suicidality Yes 93 35(17.7) 58(11.4) 1.7 (1.05–2.6) 2.1 (1.2–3.8), P = 0.009 No 614 163(82.3) 451(88.6) Depression Yes 101 28(14.1) 73 (14.3) 1 (0.6–1.6) 0.8 (0.4–1.5), P = 0.5 No 606 170(85.9) 436(85.7) generalized anxiety disorder (25.7%), alcohol addiction depression was also higher. This may reflect the use of the (17.5%), post traumatic stress disorder (15.1%), and major MINI, rather than the use of other diagnostic instruments depression (14.3%) (Fig. 3). in other studies in the literature. Although antisocial per- Prevalence of psychosis was greater in our sample (7.6%) sonality disorder was the most frequent diagnosis, its preva- than in large meta-analyses (3.7–4%) [8, 13]. Prevalence of lence was less frequent than in the largest meta-analysis of Nacher et al. BMC Psychiatry (2018) 18:159 Page 7 of 9 Table 2 Variables associated with previous incarcerations, bivariate and multivariate analysis Total Previously First incarceration Crude odds Adjusted odds ratio incarcerated N(%) N(%) ratio (95% CI) (95% CI), P Age in years Mean [SD] 707 32 [10.5] 28.1 [10.3] 1 (0.99–1.02) 1.04(1.02–1.06), P < 0.001 Sex Male 647 333(96.8) 314 86.5) 4.7(2.4–9.2) 4.3 (2–9.1), P < 0.001 Female 60 11(3.2) 49(13.5) Antisocial disorder Yes 245 162(47.1) 83 (22.9) 3 (2.2–4.1) 2.6 (1.8–3.7), P < 0.001 No 462 182 (52.8) 280(77.1) Generalized anxiety disorder Yes 182 92(26.7) 90(24.8) 1.1 (0.8–1.5) 0.8 (0.5–1.3), P = 0.4 No 525 252(73.3) 273(75.2) Psychosis Yes 51 37(10.7) 14(3.9) 3 (1.6–5.7) 1.4 (0.7–2.9), P = 0.01 No 656 307(89.3) 349(96.1) Substance addiction Yes 235 153(44.5) 82(22.6) 2.7(2–3.8) 1.9 (1.3–2.7), P = 0.001 No 472 191 (55.52) 281(77.4) Alcohol addiction Yes 124 88(25.6) 36(9.9) 3.1 (2–4.7) 1.7 (1.1–2.8), P = 0.02 No 583 256(74.4) 327(90.1) PTSD Yes 107 64(18.6) 43(11.9) 1.7(1.1–2.6) 1.3 (0.8–2.2), P = 0.3 No 600 280(81.4) 320(88.1) Social phobia Yes 63 34(9.9) 29(8) 1.2 (0.74–2.1) 1.2 (0.6–2.3), P = 0.6 No 644 310(90.1) 334(92) Agoraphobia Yes 76 46(13.4) 30(8.2) 1.7 (1.05–2.8) 1.1 (0.6–2.1), P = 0.6 No 631 298(86.4) 333(91.8) Panic attacks Yes 48 27(7.9) 21(5.8) 1.4 (0.7–2.5) 0.8 (0.4–1.6), P = 0.5 No 659 317(92.1) 342(94.2) Manic Yes 26 18(5.2) 8(2.2) 2.56 (1.05–5.7) 1.3 (0.5–3.6), P = 0.5 No 681 326(94.8) 355(97.8) Mood disorders Yes 38 19(5.5) 19(5.2) 1.1 (0.5–2) 0.5 (0.2–1.2), P = 0.13 No 669 325(94.5) 344(94.8) Suicidality Yes 93 54(15.7) 39(10.7) 1.5 (0.99–2.4) 1.2 (0.7–2), P = 0.6 No 614 290(84.3) 324(89.3) Depression Yes 101 63 (18.3) 38 (10.53) 1.9 (1.2–3) 1.7 (0.96–3), P = 0.06 No 606 281(81.7) 325(89.5) cross-sectional prevalence rates of mental illness among has a profile that is closer to low and middle income prisoners internationally [13]. It has been observed that in countries [8]. In low and middle income countries, lower lowtomiddleincome countries theprevalenceofpsychosis budgets for psychiatric care of psychoses may lead to a shift and major depression is higher than in high income coun- from mental health care towards incarceration. Another tries. French Guiana, despite being a French territory thus hypothesis pertains to different social and cultural norms Nacher et al. BMC Psychiatry (2018) 18:159 Page 8 of 9 regarding mental illness, and possible poor legal representa- The transinstitutionalization hypothesis posits that tions of mentally ill patients in the justice system [8]. mentally ill persons without proper care will be When comparing our results with the study in French over-represented in the criminal justice system. This prisons, which used the MINI and examination by a hypothesis is debated. Some authors argue that this is re- psychiatrist, there were some differences between main- ductionist and that psychiatric desinstitutionalization does land France and the French territory of French Guiana. A not necessarily lead to a direct increase in the number of striking difference was the weight of addictions in French prisoners with mental health issues, and that increasing Guiana (33.2% for drugs and 17.5% for alcohol) relative to psychiatric facilities will not necessarily reduce numbers mainland France (8.9 and 8.7%, respectively). This level of of detainees with mental health issues [7, 21–25]. addictions was comparable to what is observed in neigh- French Guiana has a structural lag in health care boring Brazil [14, 15]. PTSD and generalized anxiety personnel, notably in terms of specialized physicians. In seemed more frequent in French Guiana than in mainland terms of the density of psychiatrists French Guiana is six France (15.1 and 25.7%, versus 6.6 and 15.4%) whereas de- times lower than in mainland France [26]. The number of pression was less frequent in French Guiana than in main- beds per capita is much lower than in mainland France land France (14.3 versus 22.9%). Some of these differences and even than other French overseas territories [27]. In may be due to methodological differences, but others may terms of psychiatric care, the number of beds per 100,000 be due to the “Latin American socio economic and persons in French Guiana is lower than in other territories cultural context” in French Guiana. Thus what applies in (90 in France, in Martinique, 70 in Guadeloupe, and 40 in mainland France may not apply in French Guiana, and French Guiana). When we compare the incarceration rate French-trained mental health professionals require some and the psychiatric facilities, the contrast between French adaptation of their epidemiological assumptions. territories is even more salient: in France there are 1.12 in- After adjusting for age, males, antisocial personality mates per psychiatric bed, in Guadeloupe 3, in Martinique disorder, substance and alcohol addictions, depression 3.3 and in French Guiana 8.2. and psychoses were significantly associated with repeat It is noteworthy that in early 2017, following a wave of offenses as described elsewhere [16, 17]. We did not find violent crime, French Guiana erupted in mass protests any association with bipolar disorder. It may be that our over notably security issues and deficient health infra- sample size was insufficient to detect any effect because structures [28]. When looking at the very high prevalence the crude odds ratio, but not the adjusted one, was of psychiatric disorders observed in our sample, and when significantly associated with repeat incarceration. The looking at the relative lack of psychiatric facilities, it is calculation of population-attributable fractions is tempting to hypothesize that part of the problem can be arguable in this cross-sectional design. It was meant to explained by transinstitutionalization and the Penrose estimate, what proportion of repeat offenses could be hypothesis [21, 29]. At least, we hope these data will help attributed to the psychiatric conditions, and thus what fuel strategic debates in French Guiana. could theoretically be gained if they were controlled. We There are several limitations to our study: The cross believe it emphasizes the importance of enhancing sectional design and the use of declarative data in a con- psychiatric and social care in prison. text of incarceration may have led to biased estimates. The variables significantly associated with incarcer- The MINI scale is a validated screening tool but it may ation for violent crimes were male sex, psychosis, suicide not always be sufficiently sensitive notably for certain risk. Generalized anxiety disorder on the contrary was borderline personality disorders which are associated associated with a lower probability of incarceration for a with incarceration. Finally the inclusion of study partici- violent crime. The direction of causality is not clear with pants directly after incarceration– a stressful period- regard to suicide risk: perhaps remorse explained the may have impacted responses to the questions. association, but hetero-aggressive behavior in persons with suicidal thought is also a possible explanation. We Conclusions have previously described predictive factors for suicide Mentally ill detainees should benefit from effective risk for this population [9]. screening, case identification and psychiatric care on Substance addiction has been reported to be associated arrival [9], ongoing care during the period of incarcer- with violence [18]. However, here we did not find any ation and pre-release arrangements for ongoing care in significant association perhaps because violence between the community following release from custody. The drug users may be less frequently reported to the police goals of the correctional facilities and the psychiatric and less frequently prosecuted. Prison is likely to repre- system are different but they may not always be antag- sent an opportunity to initiate addiction treatment and onistic. Improved recognition and care of persons with medical services that should aim for a smooth transition mental illness in prison settings may improve outcomes with the services outside of prison [19, 20]. for affected individuals and for public security [30]. Nacher et al. BMC Psychiatry (2018) 18:159 Page 9 of 9 Abbreviations 8. Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide: CEEI: Comité d’Evaluation Ethique de L’INSERM; CNIL: Commission Nationale systematic review and meta-regression analysis. Br J Psychiatry. 2012; Informatique et Libertés; GDP: Gross Domestic Product; HIV: Human 200(5):364–73. immunodeficiency virus; INSERM: Institut National de la Santé et de la 9. Ayhan G, Arnal R, Basurko C, Pastre A, Pinganaud E, Sins D, Jehel L, Falissard Recherche Médicale; UCSA: Unité Carcérale de Soins Ambulatoires B, Nacher M. Suicide risk among prisoners in French Guiana: prevalence and predictive factors. BMC Psychiatry. 2017;17(1):156. 10. Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan KH, Janavs Availability of data and materials J, Dunbar GC. The MINI international neuropsychiatric interview (MINI). A Data may be made availability upon request to Pr Nacher Cayenne Hospital, short diagnostic structured interview: reliability and validity according to the and with additional permission from the Commission Nationale Informatique CIDI. Eur Psychiatry. 1997;12(5):224–31. et Libertés (CNIL) 3 Place de Fontenoy, 75007 Paris, France. 11. Sheehan D, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, Schinka J, Knapp E, Sheehan M, Dunbar G. The validity of the MINI international Authors’ contributions neuropsychiatric interview (MINI) according to the SCID-P and its reliability. RA, CB, MN designed the protocol; RA, GA, VA, AP collected data; MN Eur Psychiatry. 1997;12(5):232–41. analyzed the data and wrote first draft of the manuscript; VA, RA, GA, CB, BF, 12. Aboraya A. Use of structured interviews by psychiatrists in real clinical settings: LJ, FH, AP critically reviewed the manuscript. All authors read and approved results of an open-question survey. Psychiatry (Edgmont). 2009;6(6):24. the final manuscript. 13. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet. 2002;359(9306):545–50. Ethics approval and consent to participate 14. Andreoli SB, dos Santos MM, Quintana MI, Ribeiro WS, Blay SL, JGV T, de The study was approved by the Ethical committee of Bordeaux (Comité de Jesus Mari J. Prevalence of mental disorders among prisoners in the state of Protection des Personnes, CPP) (reference number DC 2012/115). The study Sao Paulo, Brazil. PLoS One. 2014;9(2):e88836. was also approved by the Ethical committee of INSERM CEEI in 2013 15. Pondé MP, Freire AC, Mendonça MS. The prevalence of mental disorders in (IRB00003888). Inmates gave informed consent (oral and written) to prisoners in the city of Salvador, Bahia, Brazil. J Forensic Sci. 2011;56(3):679–82. participate in the study. 16. Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Consent for publication Psychiatr. 2009;166(1):103–9. All persons included gave informed consent for publication of aggregated 17. Yu R, Geddes JR, Fazel S. Personality disorders, violence, and antisocial results. behavior: a systematic review and meta-regression analysis. J Personal Disord. 2012;26(5):775–92. Competing interests 18. Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, The authors declare that they have no competing interests. Roth LH, Silver E. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998;55(5):393–401. Publisher’sNote 19. Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a Springer Nature remains neutral with regard to jurisdictional claims in systematic review. Addiction. 2006;101(2):181–91. published maps and institutional affiliations. 20. Huber F, Merceron A, Madec Y, Gadio G, Pastre A, Coupez I, Adenis A, Adriouch L, Nacher M. High mortality among male HIV-infected patients Author details after prison release: ART is not enough after incarceration with HIV. PLoS Centre d’Investigation Clinique CIC INSERM 1424, Centre Hospitalier de One. 2017;12(4):e0175740. Cayenne, 97300 Cayenne, French Guiana. Service de Psychiatrie, Centre 21. Banks SM, Stone JL, Pandiani JA, Cox JF, Morschauser PC. Utilization of local Hospitalier de Cayenne, 97300 Cayenne, French Guiana. Hôpital de Jour jails and general hospitals by state psychiatric center patients. J Behav Heal Adultes, Centre Hospitalier de Cayenne, 97300 Cayenne, French Guiana. Serv Res. 2000;27(4):454–9. Unité de Consultations Ambulatoires Carcérales, 97300 Cayenne, French 22. Guy G. Community-based care: deinstitutionalization or Guiana. CESP- INSERM U1178 Equipe IPSOM, Centre Hospitalier Universitaire Transinstitutionalization? Except Child. 1985;32(3):137–47. de Martinique, BP632, 97261 Cedex fort de France, France. CESP/INSERM 23. Primeau A, Bowers TG, Harrison MA, XuXu. Deinstitutionalization of the U1018 (Centre de Recherche en Epidémiologie et Santé des Populations), mentally ill: evidence for transinstitutionalization from psychiatric hospitals 75679 Paris cedex 14, France. to penal institutions. Compr Psychol. 2013;2:16.02. 13. CP. 12.12. 24. Prins SJ. Does transinstitutionalization explain the overrepresentation of Received: 21 July 2017 Accepted: 11 May 2018 people with serious mental illnesses in the criminal justice system? Community Ment Health J. 2011;47(6):716–22. 25. Stavis PF. Why prisons are brim-full of the mentally ill: is their incarceration References a solution or a sign of failure. Geo Mason UCRLJ. 2000;11:157. 1. Douine M, Musset L, Corlin F, Pelleau S, Pasquier J, Mutricy L, Adenis A, 26. Breton-Lerouvillois L. Atlas de la démographie médicale en France. In: Djossou F, Brousse P, Perotti F. Prevalence of Plasmodium spp. in illegal Conseil National de l'ordre des médecins; 2014. gold miners in French Guiana in 2015: a hidden but critical malaria 27. DREES. Les établissements de santé dans les départements et régions reservoir. Malar J. 2016;15(1):1. d’outre-mer : activité et capacités. In: DREES; 2016. 2. Parriault M-C, Van-Melle A, Basurko C, Valmy L, Hoen B, Cabié A, Goerger- 28. A. B. Strikes shut down French Guiana, with effects resonating in Paris. In: Sow M-T, Nacher M. Sexual risk behaviors and predictors of inconsistent New York times; 2017. condom use among crack cocaine users in the French overseas territories in 29. Mundt AP, Chow WS, Arduino M, Barrionuevo H, Fritsch R, Girala N, the Americas. Int J STD AIDS. 2017;28(13):1266–74. Minoletti A, Mitkiewicz F, Rivera G, Tavares M. Psychiatric hospital beds and 3. Liste des pays et territoires par taux de croissance démographique [https:// prison populations in South America since 1990: does the Penrose fr.wikipedia.org/wiki/Liste_des_pays_et_territoires_par_taux_de_croissance_ hypothesis apply? JAMA Psychiatry. 2015;72(2):112–8. d%C3%A9mographique]. Accessed 25 May 2018. 30. Skeem JL, Manchak S, Peterson JK. Correctional policy for offenders with 4. Prison population rate region taxonomy [http://www.prisonstudies.org/ mental illness: creating a new paradigm for recidivism reduction. 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BMC PsychiatrySpringer Journals

Published: May 29, 2018

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