University Department of Psychiatry, Warneford Hospital, Oxford, UK
Departments of Public Health and Primary Care, Institute of Health Sciences, University of Oxford, UK
Institute of Criminology, Faculty of Law, University College Dublin, Ireland
University Department of Psychiatry, Warneford Hospital, Oxford, UK
Correspondence: Dr S. Fazel, University Department of Psychiatry, Warneford Hospital, Oxford OX37JX, UK
Declaration of interest Funding was provided by the Wellcome Trust.
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ABSTRACT |
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Aims To determine the prevalence of psychiatric morbidity in elderly sentenced prisoners.
Method A stratified sample of 203 male sentenced prisoners aged over 59 years, from 15 prisons in England and Wales, representing one in five men in this age group, was interviewed using semistructured standardised instruments for psychiatric illness and personality disorder.
Results More than half of the elderly prisoners had a psychiatric diagnosis. The most common diagnoses were personality disorder and depressive illness.
Conclusions The prevalence of depressive illness was five times greater than that found in other studies of younger adult prisoners and elderly people in the community. Underdetected, undertreated depressive illness in elderly prisoners is an increasing public health problem.
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INTRODUCTION |
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METHOD |
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Instruments
The following standardised instruments were used.
(i) The Geriatric Mental State (GMS) schedule is a semi-structured clinical interview designed to assess the mental state of the elderly in the community. The computerised diagnostic schedule that processes GMS data (AGECAT) reduces unreliability, supports diagnoses of a wide range of disorders and has been shown to accord with the diagnoses made by experienced psychiatrists (Copeland et al, 1988). Cases of organic disorder and depression generated by GMS-AGECAT correlate well with DSM-III diagnoses of dementia, and combined major depression, dysthymia and adjustment disorder, respectively (American Psychiatric Association, 1980; Copeland, 1990; Ames et al, 1994). Data on mood disorders in this study were converted to DSM-IV criteria for major depressive episode (American Psychiatric Association, 1994) using a standard algorithm at the University of Liverpool's Institute for Human Ageing.
(ii) The Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II) was administered after the GMS (First et al, 1997). This covers each personality disorder category in turn; within categories, each component is evaluated by a specified question (or questions) and subsequent probes. It is one of the few personality interviews that have been used in published studies in a range of research centres. This measure has the advantages that it was developed to assess DSM criteria and can usually be completed in under 60 minutes, unlike other instruments which take considerably longer (Zimmerman, 1994). The screening questionnaire was omitted because it leads to a considerable number of false positives (Coid, 1993). Two categories of personality disorder, depressive and passive-aggressive, which are omitted from the formal version of the DSM-IV, were not assessed in the study reported here.
After the interview, each individual's medical records and reception health screen data were studied for major illness and current medication, and criminological information was gathered from the local prison database. Monthly meetings were held with a steering committee of senior academic psychiatrists (R.J. and T.H.), where diagnostic issues were reviewed.
Statistical analysis
Data were entered into the Statistical Package for the Social Sciences
(SPSS, 1998), which generated
descriptive statistics and relative risks. The test for independent
proportions was used to compare characteristics of consenters with
non-consenters, and participants in this study with the total population of
elderly men in prison.
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RESULTS |
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Psychiatric illness according to the GMS-AGECAT was diagnosed in 64 men (31.5%, 95% confidence interval 25.1-37.9%) (Table 2). The most common diagnosis was depressive disorder, which was found in 60 individuals (29.6%, 95% CI 23.3-35.9%). Of these, 7 (11.7%) were being treated with antidepressant medication at the time of the interview, and 24 (40.0%) had a past or present history of depression noted in their medical records. Altogether, 156 (76.8%) men were taking prescribed medication of some kind. The two men with dementia experienced its onset while in prison.
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Personality disorder
Personality disorder was diagnosed using the SCIDII in 61 men
(30.0%, 95% CI 23.7-36.3%) (Table
3). There was comorbid personality disorder and GMSAGECAT
psychiatric illness in 19 individuals (9.4%). Prisoners were interviewed about
their history of substance misuse in the preceding month, using the questions
in the GMS. Overall, 10 prisoners (4.9%) reported current substance misuse or
dependence: 6 misused alcohol and 4 misused drugs. A lifetime history of
alcohol misuse was documented in the medical records of 23 prisoners (11.3%),
with comorbid drug misuse in one case. There was one documented case of
learning disability (of moderate severity). There was comorbidity of substance
misuse or dependence with personality disorder or psychiatric illness in eight
cases. Therefore, in total, 108 men (53.2%, 95% CI 46.3-60.1%) were given a
psychiatric diagnosis.
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Risk factors for depression
Risk factors for depressive illness were explored. The risk of being
diagnosed with depression at interview was greater both in those with a past
history of psychiatric illness (relative risk 2.2, 95% CI 1.2-4.3) and in
those with bad or very bad self-reported general health (RR=2.1, 95% CI
1.1-3.8). The following were not associated with an increased risk of being
assigned a diagnosis of depression: present conviction for a sexual offence
(RR=1.0, 95% CI 0.5-1.8); present conviction for murder (RR=1.2, 95% CI
0.6-2.6); being currently widowed, divorced or separated (RR=0.9, 95% CI
0.5-1.7); paid employment at the time of the offence (RR=0.7, 95% CI 0.4-1.4);
having a comorbid personality disorder (RR=1.0, 95% CI 0.5-2.0); age at
interview (aged 60-69 years, RR=1.3, 95% CI 0.5-3.0; aged 70-79 years, RR=1.0,
95% CI 0.4-2.4; aged 80 years or more, RR=1.0, 95% CI 0.9-1.0); or the length
of time spent in prison (less than 12 months, RR=0.7, 95% CI 0.4-1.3; 12-47
months, RR=1.0, 95% CI 0.5-1.9; 48-119 months, RR=0.5, 95% CI 0.2-1.6; 120
months or over, RR=0.9, 95% CI 0.4-2.1).
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DISCUSSION |
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Service implications
Five per cent of the elderly prison population represents a large number of
inmates with psychosis, more than the prevalence of psychosis in some other
surveys of younger sentenced male prisoners, such as the 2% reported in the
largest study in England and Wales (Gunn
et al, 1990). If the sample described in this
investigation were to be extrapolated to the total elderly prison population,
at any one time in prisons in England and Wales 52 (95% CI 21-83) elderly
sentenced men would be psychotic, most with a depressive psychosis. Most
psychiatrists would wish to see these individuals moved to a specialist
treatment centre. Similarly, 312 (95% CI 243-380) elderly inmates of English
and Welsh prisons would be depressed. We found that only 12% of the depressed
prisoners were being treated with antidepressants, which suggests that there
are large unmet treatment needs. This situation appears to be worse than that
reported in an earlier study of younger sentenced prisoners in England and
Wales: 27% of those diagnosed with neurosis were receiving treatment
(Gunn et al, 1990).
We also found that three-quarters of our sample were being prescribed
medication, and elderly prisoners were therefore in regular contact with
prison doctors for their physical health needs. These contacts should provide
ample opportunity for assessment and treatment of psychiatric illness.
Personality disorder
The rates of personality disorder in this study fall between those found in
younger adult prisoners and estimates in community samples. The SCIDII
has been used to diagnose personality disorders in sentenced men in England
and Wales: 64% of sentenced men aged 18-65 years had a personality disorder,
and 23% had an antisocial personality disorder in the age group 45-65 years
(Singleton et al,
1998), in comparison with 30% with personality disorder and 8%
with antisocial personality disorder in this study. Little is known about
personality disorders in old age community settings, but one meta-analysis in
the over-50 age group found community rates of around 10% with personality
disorder (Abrams & Horowitz,
1996). The Epidemiologic Catchment Area study included 2106
community-dwelling elderly people, of whom 0.2-0.8% were diagnosed as having
antisocial personality disorder (Robins
et al, 1984).
Dementia
Community rates of GMS dementia in men aged 65-69 years are 1.3-1.4%
(Medical Research Council Cognitive
Function and Ageing Study, 1998), similar to the low rate of
dementia in this study (1%). This is considerably lower than the rates found
in studies of elderly offenders at other stages of the criminal justice
system. We suggest two main reasons for this. Those arrested who show signs of
dementia are successfully diverted before sentencing. In addition, it is
likely that prisoners are a selected population, in that those with dementia
do not have the capacity to commit some of the types of serious crime for
which people are imprisoned.
Risk factors for depression
We found that the relative risk for depressions was increased in prisoners
with a past psychiatric history, and in those with poor self-reported physical
health. A study of younger adult prisoners showed that the risk of neurotic
disorders was increased in those who were economically inactive at the time of
their offence and in those who had spent less time in prison
(Singleton et al,
1998). In contrast, we found no relationship between having a
diagnosis of depression and paid employment at the time of the index offence
or the length of time spent in prison. Studies of younger prisoners have not
explored the association between physical illness and depression. However, a
large community study of elderly individuals with GMS-related depression found
that physical illness at the time of interview was predictive of depression,
as was being widowed, divorced or separated
(Copeland et al,
1999).
Methodological issues
Although the instruments we used allow valuable comparisons to be made,
they have limitations. Psychiatric illness in the elderly is ideally diagnosed
using an informant in addition to a clinical interview, although there is no
study that has shown that personality disorder diagnoses based on informant
information are more valid than those based on patient interview alone
(Skodol, 1997). The GMS has
not been used in prison settings, and does not give lifetime diagnoses of
substance dependence or misuse, or assess learning disability.
The difficulties in diagnosing depression in the elderly are compounded by problems in the prison system, including lack of resources, training of medical and nursing staff, the security-dominated culture of prisons and sentencing policy. However, on the grounds of human rights and public health, it is important that the high rates of psychiatric morbidity, particularly depression, be recognised and that systems be put in place for its detection and treatment. Virtually every elderly prisoner will eventually be released, and a clearer understanding of their health care needs is necessary to plan community treatment and support. The greying of the prison population is an international trend and it is likely that developments in Britain will have wide application.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication December 5, 2000. Revision received May 29, 2001. Accepted for publication June 8, 2001.