Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries : a systematic review and meta-analysis of prevalence studies

Abstract

Background: Although more than two thirds of the world's incarcerated individuals are based in low-income and middle-income countries (LMICs), the burden of psychiatric disorders in this population is not known. This review provides estimates for the prevalence of severe mental illness and substance use disorders in incarcerated individuals in LMICs. Methods: For this systematic review and meta-analysis, we searched 17 electronic databases to identify prevalence studies of psychiatric disorders in prison populations in LMICs, published between January, 1987, and May, 2018. We included representative studies from general prison samples, providing information about four major psychiatric diagnoses: psychosis, major depression, alcohol use disorders, and drug use disorders. We pooled data from studies using random-effects meta-analyses and assessed the sources of heterogeneity by meta-regression. We extracted general population estimates from the Global Burden of Diseases 2016 database to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42015020905. Findings: We identified 23 publications reporting prevalence estimates of severe mental illness and substance use disorders for 14 527 prisoners from 13 LMICs. In this population, the estimated pooled 1 year prevalence rates for psychosis were 6·2% (95% CI 4·0–8·6), 16·0% (11·7–20·8) for major depression, 3·8% (1·2–7·6) for alcohol use disorders, and 5·1% (2·9–7·8) for drug use disorders. We noted increased prevalence at prison intake and geographic variations for substance use disorders. For alcohol use disorders, prevalence was higher in the southeast Asian region than in the eastern Mediterranean region; and drug use disorders were more prevalent in the eastern Mediterranean region than in Europe. Prevalence ratios indicated substantially higher rates of severe mental illness and substance use disorders among prisoners than in the general population (the prevalence of non-affective psychosis was on average 16 times higher, major depression and illicit drug use disorder prevalence were both six times higher, and prevalence of alcohol use disorders was double that of the general population). Interpretation: The prevalence of major psychiatric disorders is high in prisoners in LMIC compared with general populations. As these findings are likely to reflect unmet needs, the development of scalable interventions should be a public health priority in resource-poor settings. Funding: CONICYT of the Chilean government and the Wellcome Trust.