Department of Psychological Medicine, St Bartholomew's Hospital, London
Department of Psychiatry and Behavioural Science, Royal Free and University College Medical School, London
Department of Psychiatry, University of Leicester, Leicester
Institute of Psychiatry, London
South London and Maudsley NHS Trust Addiction Resource Centre, London
Division of Psychiatry, University of Bristol, Bristol
Office for National Statistics, London
Correspondence: Professor Jeremy Coid, Forensic Psychiatry Research Unit, St Bartholomew's Hospital, William Harvey House, 61 Bartholomew Close, London ECIA 7BE, UK. Tel: 020 7601 8138; fax: 020 7601 7969; e-mail: J.W.Coid{at}qmul.ac.uk
Funded by the Department of Health.
See part 2, pp.
481487, this issue.
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ABSTRACT |
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Aims To estimate population-based rates of imprisonment in different ethnic groups, and compare criminal behaviour and psychiatric morbidity.
Method We examined Home Office data on all persons in prison, and carried out a two-stage cross-sectional survey of 3142 remanded and sentenced, male and female, prisoners in all penal establishments in England and Wales in 1997.
Results We confirmed high rates of imprisonment for Black people and lower rates for South Asians. Different patterns of offending and lower prevalence of psychiatric morbidity were observed in Black prisoners.
Conclusions Despite increased risks of imprisonment, AfricanCaribbeans show less psychiatric morbidity than White prisoners. This contrasts with the excess of AfricanCaribbeans in secure hospitals, an inconsistency possibly in part due to the effects of ethnic groups on admission procedures.
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INTRODUCTION |
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METHOD |
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Survey of psychiatric disorders among prisoners
The survey design has been described in a previous report
(Singleton et al,
1998). All prisons in England and Wales were included in the
survey, and samples of inmates were taken from all locations within each
prison. It was intended to provide separate prevalence estimates for different
types of prisoner remand and sentenced, male and female. To ensure
that persons in all prisons had an equal chance of being selected, a fixed
sampling fraction was obtained, proportional to numbers in each prison.
Sampling was based on 61 944 prisoners in 131 penal establishments at the end of July 1997 (all ages), including 46 872 male sentenced prisoners, 12 302 male remand prisoners (including civil prisoners) and 2770 women prisoners. To obtain the required number of interviews for each type of prisoner, different sampling fractions were obtained for each group, that is 1 in 34 male sentenced prisoners, 1 in 8 male remand prisoners, and 1 in 3 women prisoners (whether remand or sentenced). The sampling fraction for the male sentenced prisoner group was changed to 1 in 50 for the last 4 weeks of the survey because a large number of male sentenced prisoners than expected was obtained in the early part of the fieldwork. To ensure that the correct number of interviews was obtained, replacement of those leaving (for example transfers or releases) with new arrivals was carried out for remand but not sentenced prisoners.
The survey was carried out in two stages: the first involved initial interviews by lay interviewers who asked questions and entered the prisoners' responses using laptop computers. Parts were self-administered by prisoners using computers, unless unable to read or unlikely to do this reliably. The second stage included every fifth person interviewed in the first, and comprised a follow-up interview by a clinician.
Response
All 131 prison establishments agreed to participate, 3563 prisoners were
selected, and 3142 (88%) were interviewed in the first phase. A further 37
agreed to take part but failed to complete the interview. Only 198 (6%)
refused, 53 (1%) were unable to participate (mainly because of language
difficulties), and the interviewers could not contact 118 (3%) prisoners.
Interviewers were advised not to see 15 prisoners. Response was good in all
prisons, and below 80% in only 12.
In the second phase, 505 (76%) of 661 prisoners selected for follow-up were interviewed: 105 (16%) could not be contacted as most had left prison. A further 50 (8%) refused. The mean interval between the first and second phase interviews was 2 weeks.
Assessment instruments (stage 1)
Lay interviewers administered questionnaires using laptop computers and
establishing sociodemography, general health, use of services in prison,
service use before current prison term, and lifetime experience of services.
The distribution of neurotic disorders and symptoms was established using the
Clinical Interview Scale Revised (CISR;
Lewis et al, 1992).
The Psychosis Screening Questionnaire (PSQ;
Bebbington & Nayani, 1995)
identified probable psychosis. Lay interviews also elicited histories of
deliberate self-harm, key life events and post-traumatic stress, difficulties
with daily living, alcohol consumption, drug use, and carried out the Quick
test (Ammons & Ammons,
1962). Information on criminal charges or convictions was obtained
from each prison. A previous history of convictions was obtained from
self-report. Subjects were also administered the Structured Clinical Interview
Revised (SCIDII) questionnaire for DSMIV Personality
Disorders (First et al,
1997).
Assessment instruments (stage 2)
The 1 in 5 subsample was interviewed by clinicians using the Schedules for
Clinical Assessment in Neuropsychiatry (SCAN;
World Health Organization,
1992a) and the SCIDII. SCAN is a detailed
semi-structured clinical interview that applies algorithms to the elicited
symptoms to establish diagnoses according to DSMIV
(American Psychiatric Association,
1994) and ICD10 (World
Health Organization, 1992b) criteria. SCIDII was
chosen because it covers each personality disorder category in turn and,
within each category, each component criterion is evaluated by specified
questions and subsequent probes. The SCIDII can usually be completed in
under 60 minutes, an important consideration for a survey covering many
disorders and several other topics.
Ethnicity
The subjects assigned themselves to 1 of 9 ethnic groups
(Government Statistical Service,
1996). For the study analysis, this classification was simplified
into 4 categories: White, Black (including Black Caribbean, Black African,
Black other), South Asian (including Indian, Pakistani, Bangladeshi), or Other
(all other categories). Data were also available on whether the subject was
non-UK born.
Statistical analysis
Data analysis was performed using SAS statistical software (SAS Institute
Inc., Cary, North Carolina, USA). Data were obtained from the Home Office for
all prisoners in penal establishments in England and Wales for the year 1997
according to age, gender and ethnic grouping, and UK nationality. National
imprisonment rates according to age and gender were calculated. These were
taken as the expected imprisonment rates for the population as a whole. They
were then applied to the age and gender structures of each ethnic population
group to calculate the numbers of imprisonments in each ethnic group that
would have been expected if the national rates had applied. The comparison of
actual with expected imprisonments was then used to calculate a standardised
imprisonment ratio for each of the ethnic groups according to gender.
Logistic regression was used to model the prevalence of different outcomes of interest among prisoners according to gender using the survey data. The independent variables included marital status, age, whether UK-born, qualifications, social class and prisoner type. Odds ratios (OR) with 95% confidence intervals (CI) were used to measure relative differences between the Black and South Asian ethnic groups compared with the White ethnic group, adjusting for the above independent variables.
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RESULTS |
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Survey sample
A total of 3142 prisoners were interviewed in the first phase of the
survey, 2371 (75%) men and 771 (25%) women. The subjects were 80% White, 13%
Black (8% Black Caribbean; 4% Black African; 1% Black other), 3% South Asian,
and 4% Other. Among the interviewed prisoners 39 (1%) were foreign
nationals.
Table 2 indicates marked demographic differences between Black and South Asian prisoners and White prisoners. Compared with White prisoners, those in the Black ethnic subgroup were more likely to be female, single and non-UK born, but less likely to have been unemployed or living off the proceeds of crime before imprisonment. They were also more likely to have educational qualifications. There were no differences in social class, prisoner type, age or whether they had children. Compared with Whites, South Asian prisoners were less likely to be female, unemployed, living off crime before imprisonment or to have children. They were more likely to be non-UK born and of higher social class. There were no differences in marital status, educational qualifications, prisoner type or age.
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Logistic regression criminal histories
Table 3 compares index
offences (i.e. charges leading to remand or convictions) of the Black and
South Asian ethnic groups with those of the White group, according to gender,
after adjusting for age, UK birth, prisoner type, social class, marital status
and qualifications. Black male prisoners were more likely to be charged with
or convicted of robbery and firearm offences; burglary and theft were less
likely. There were no differences for homicide offences, major violence (e.g.
wounding), minor violence (e.g. common assault, affray), major sex offences
(rape and indecent assault), other sex offences, false imprisonment, fraud and
forgery, criminal damage, drug offences, breach of suspended sentences or
probation, etc. Black women were also less likely to be charged with or
convicted of theft; drug offences were more likely. South Asian women showed
no differences in any crime categories; South Asian men showed no differences
except for fewer burglaries and thefts. Numbers were too small to examine
other offences.
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Independent comparisons of patterns of previous criminality and imprisonment between Black and South Asian ethnic groups and Whites are shown in Table 4. Black male prisoners were less likely to have previous convictions, specifically for violence, arson, burglary, fraud and deception, or to have previously escaped from custody. Black women were also less likely to have previous convictions, specifically those of burglary, drug offences, fraud/deception, or to have escaped from custody. South Asian prisoners appeared similar to White prisoners in most categories of previous criminality, although fewer South Asian men had been convicted of violence or burglary, or had escaped from custody. Stratified according to gender, there were no differences between ethnic groups when comparing previous experiences of imprisonment.
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Severe mental disorder, hazardous drinking and deliberate
self-harm
Univariate analyses of severe mental disorder (schizophrenia, delusional
disorder, affective psychosis or other functional psychosis) were carried out
using diagnostic data from SCAN. No significant differences were found between
the Black and White subgroups, whether for both genders combined or for males
and females separately. Owing to the small numbers, these comparisons could
only be carried out for South Asians and Whites by combining both genders. No
differences were found.
Table 5 compares Black and South Asian ethnic subgroups separately with the White subgroup in terms of probable psychosis (based on the PSQ), hazardous drinking and deliberate self-harm derived from self-report instruments. Black men and women were less likely to be rated as having probable psychosis, and Black women were less likely to be rated as having post-traumatic stress. Table 5 also demonstrates that both male and female Black prisoners were less likely to have attempted suicide, to have harmed themselves during the current prison term, or to have engaged in hazardous drinking before imprisonment. South Asian men were also less likely to have previously attempted suicide. No differences were found between South Asian and White women.
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Neurotic disorders
Ethnic subgroups were compared in terms of the frequency of neurotic
symptoms identified from the CIS-R. Few differences were found. However, Black
males were less likely to report forgetfulness/loss of concentration, and
South Asian males less likely to report irritability, than White males. Black
women prisoners were more likely to report worries about physical health, and
less likely to report anxiety, than White women prisoners. There were no
differences between either Black or South Asian subgroups and White prisoners,
according to gender, for an overall measure of neurotic symptoms using a CIS-R
cut-off score of 12.
Drug use
Table 6 compares reported
drug use, including injecting behaviour. Black male and female prisoners were
less likely to report having used most illicit drugs, or to have injected,
compared with White prisoners. However, more Black male prisoners reported
cannabis use. There were no differences between Black and White prisoners in
their use of crack cocaine. South Asian prisoners showed few differences from
White prisoners, except that fewer men had used amphetamines or injected.
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Personality disorder
Table 7 compares categories
of personality disorder derived from the SCIDII questionnaire between
Black and South Asian prisoners and White ethnic subgroups. Overall, more
female Black prisoners received a diagnosis of personality disorder than White
females, but there were no differences between other subgroups. However, there
were some differences relating to individual categories of personality
disorder.
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DISCUSSION |
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Differences observed between the criminal histories of the different ethnic subgroups are the outcome of complex processes operating within the criminal justice system: the reporting and detection of crime by the police, decisions to prosecute by the Crown Prosecution Service, subsequent verdicts in courts and sentencing. For those with mental disorder, identification by prison health care staff, the referral of prisoners for second opinions and gatekeeping by mental health professionals all influence the prevalence of prisoners with severe mental disorder. None of these factors can be adequately explored using a cross-sectional design.
Nevertheless, it is of concern that the rate of imprisonment in England and Wales remains markedly higher for Black than for White men and women. This phenomenon has been observed in previous criminological studies both in the UK and USA (Home Office, 1992; Donziger, 1996; Home Office, 2000). It is not accounted for by the number of foreign nationals in the Black subgroup of prisoners. Imprisonment ratios were slightly increased for Black men when this factor was controlled for. However, there was a fall in the ratio of imprisoned Black men when compared with the 1992 Home Office study. The rate of imprisonment was somewhat lower for South Asian men than White men, and for South Asian women it was less than a quarter that for White women; these trends are generally similar to those observed for admissions to secure forensic psychiatry services of patients who have committed serious offences (Coid et al, 2000), except that such admissions among South Asian men with mental disorders were even lower than their rates of imprisonment.
Criminal histories
The criminal histories of the Black and White ethnic subgroups showed
important differences. More Black men were imprisoned following robberies and
firearm offences, but fewer for burglaries and theft; more Black women for
drug offences, but fewer for thefts. Serious sexual offences by Black males
were not more common, contrasting with previous observations of offenders with
mental illness (Coid et al,
2000) and with previous UK prison studies
(Smith, 1997). This suggests
that patterns of sexual offending, or the processing of Black defendants
charged with sexual offending, may have changed over time. Other differences
may be partially explained by the fact that convictions for robbery and
firearm and certain drug offences carry heavy penalties, and that more Black
defendants elect for trial in the Crown Court, where longer sentences may be
imposed following a conviction. It was of some concern that, despite an
absence of overall differences between ethnic subgroups in previous experience
of imprisonment, more Black male and female prisoners reported that they had
no previous convictions. This study is unable to explore further the question
of whether Black defendants had been treated more harshly in the courts.
It is of considerable interest that the criminal histories of Black prisoners were characterised by fewer acquisitive offences. This is reflected in the findings that more White prisoners reported living off the proceeds of crime before imprisonment. Moreover, extensive acquisitive offending is often associated with drug misuse, especially opiate dependence (Coid et al, 2000), and with antisocial personality disorder, which were both more common in White prisoners. In contrast, the drug-related offending of Black women may have differed, in that it involved offences of supplying and trafficking rather than possession.
Although South Asians were relatively unlikely to be imprisoned, the patterns of offending and the factors relevant to offending behaviour appeared largely the same as for White prisoners.
Psychiatric morbidity
We found that ethnic minority subgroups made no excess contribution to the
high levels of psychiatric morbidity in the overall prisoner population
(Singleton et al,
1998). This is in contrast with the results of local studies of
prisons in England and Wales (Brooke et
al, 1996), and the over-representation of
AfricanCaribbeans transferred from prison to psychiatric hospital
(Banerjee et al, 1995;
Bhui et al, 1998).
Considerable credence should be given to the current nationwide study. Few
differences were found between South Asians and Whites of either gender for
any measure of psychopathology. This would suggest that the level of exposure
to risk factors for both criminal behaviour and psychiatric morbidity were
very similar. However, the lower rates of imprisonment among South Asians must
put into question whether the risk factors leading to criminal behaviour are
less prevalent among South Asians in the general population, especially women,
and whether certain protective factors operate within this ethnic
subgroup.
However, despite their higher rates of imprisonment, Black male and female prisoners demonstrated lower levels of psychopathology on most measures except personality disorders. These findings contrast with those from psychiatric services in England and Wales. Black patients are more likely to have had contact with the police and forensic services (McGovern & Cope, 1987), to be treated in intensive care facilities if detained under the Mental Health Act (Moodley & Thornicroft, 1988), to have criminal convictions (Wessely et al, 1994) and to be admitted more frequently to secure forensic psychiatry services (Coid et al, 2000). These discrepancies in psychiatric hospital admissions are explained by higher rates of major mental disorder, primarily schizophrenia, in the AfricanCaribbean subgroup. In contrast, Black prisoners in this study demonstrated no differences in unadjusted measures of functional psychosis from the SCAN interview, and a reduced adjusted risk of probable psychosis derived from the PSQ. The high prevalence of functional psychosis observed in prisoners in England and Wales (Singleton et al, 1998) is not therefore accounted for by an excess of AfricanCaribbeans with these conditions, and contrasts markedly with the situation in psychiatric services. The question whether independent processes are in operation, leading to disproportionate numbers of AfricanCaribbeans with psychosis in psychiatric hospitals, and disproportionate numbers in prison despite lower levels of psychiatric morbidity, requires further study. This phenomenon might be the outcome of a generally increased tendency for AfricanCaribbeans to be criminalised to an extent that out-weighs the tendency for people with mental illnesses to be imprisoned. An increased likelihood of Black people with psychosis being identified and diverted to secure psychiatric facilities at an early stage runs counter to evidence from other sources.
Personality disorder
Black inmates of secure psychiatric hospitals are considerably less likely
than their White counterparts to have a primary diagnosis of personality
disorder (Coid et al,
1999). This could represent true differences in the prevalence of
personality disorders in different ethnic groups or the result of clinical
selection by gatekeepers (Coid et
al, 2000). The current study suggests differences in the
profile of personality disorders between Black and White male prisoners, but
no difference in overall rate. Black women prisoners appear to have a higher
overall prevalence than Whites of personality disorder, mainly paranoid,
schizoid and narcissistic personality disorder.
If this is the case, why are Black women not found more frequently in secure psychiatric hospitals? One reason may be that Black prisoners do not have an excess of borderline and antisocial personality disorders, the disorders most commonly seen in patients in secure units (Coid et al, 1999). There are thus no differences in the prevalence of personality disorders that could account for the lower proportion of Black people in secure units. This is more likely to involve the effect of ethnic group on the treatment-seeking behaviour of prisoners or the gatekeeping process governing access to treatment.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication October 5, 2001. Revision received July 1, 2002. Accepted for publication July 16, 2002.
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