Mortality, Criminal Sanctions, and Court Diversion in People With Psychosis.

Importance: People living with psychosis experience excess premature mortality and are overrepresented in criminal legal systems, but little is known about mortality associated with criminal sanctions or diversion in this population. Objective: To examine associations of different types of recent (past 2 years) criminal sanction, including court diversion, with mortality among people with psychosis. Design, Setting, and Participants: This population-based, retrospective, data-linkage cohort study was conducted using 6 routinely collected administrative data collections from New South Wales, Australia, relating to health, court proceedings, imprisonment, and mortality. Participants (adults aged ≥18 years hospitalized for psychotic disorders) entered observation at the time of discharge from their first psychosis-related hospital admission (or their 18th birthday if aged <18 years) between July 2001 and November 2017 and were followed-up until May 2019. Data were analyzed between February 2023 and April 2024. Exposures: Recent (past 2 years) criminal sanction type, a time-varying variable with 5 categories: no recent criminal sanction, recent mental health court diversion, recent community sanction, current imprisonment, and recent prior imprisonment (ie, recent prison release). Main Outcomes and Measures: Causes of death were described, and age- and sex-specific mortality rates by recent criminal sanction type were calculated. In those younger than 65 years, Cox regression was used to examine associations of all-cause and external-cause mortality with recent criminal sanction type, adjusting for sociodemographic, health-related, and offense-related confounders. Results: The cohort included 83 071 persons (35 791 female [43.1%]; 21 208 aged 25-34 years [25.5%]; median [IQR] follow-up, 9.5 [4.8-14.2] years), of whom 25 824 (31.1%) received a criminal sanction. There were 11 355 deaths. In those aged younger than 65 years, recent mental health court diversion, community sanctions, and prior imprisonment were associated with increased hazards of all-cause and external-cause mortality compared with no recent sanction, with the largest adjusted hazard ratios (aHRs) observed for recent prior imprisonment (all-cause mortality: aHR, 1.69; 95% CI, 1.50-1.91; external-cause mortality: aHR, 2.64; 95% CI, 2.27-3.06). Conclusions and Relevance: In this cohort study of people with psychosis, recent criminal sanctions were associated with increased mortality irrespective of sanction type. These findings suggest that future research should develop strategies to improve health and safety in people with psychosis who have criminal legal system contact.

Self-reported traumatic brain injury in a sample of impulsive violent offenders: neuropsychiatric correlates and possible "dose effects".

Background: Traumatic brain injury (TBI) is a major public health problem that may be associated with numerous behavioral problems, including impulsivity, aggression and violence. Rates of self-reported TBI are high within offender populations, but the extent to which TBI is causally implicated in causing illegal behavior is unclear. This study examined the psychological and functional correlates of histories of traumatic brain injury in a sample of impulsive violent offenders. Methods: Study participants, all men, had been recruited to participate in a randomized controlled trial of sertraline to reduce recidivism. Study entry criteria were an age of at least 18 years, a documented history of two or more violent offenses and a score of 70 or above on the Barratt Impulsiveness Scale. An extensive list of standardized questionnaires was administered to obtain information on previous TBI and other neuropsychiatric conditions or symptoms. Results: In the sample of 693 men, 66% were aged between 18 and 35 years old, and 55% gave a history of TBI ("TBI+"). Overall, 55% of study participants reported at least one TBI. High levels of neuropsychiatric symptomatology were reported. In 75% of TBI+ individuals, their most severe TBI (by self-report) was associated with loss of consciousness (LOC) < 30 min. Compared to TBI- (those without history of TBI) participants, TBI+ individuals were more impulsive (Eysenck Impulsivity), irritable, angry, and reported higher levels of assaultive behavior, depressive symptomology, alcohol use disorder, suicidal ideation, suicide attempts, and lower quality of life. Potential "dose effects" of TBI severity and frequency in terms of neuropsychiatric symptomatology were identified. Conclusion: Like other studies of offender populations, single and multiple TBIs were very common. The associations of TBI, TBI severity, and TBI frequency (i.e., TBI "burden") with adverse neuropsychiatric phenomena suggest TBI contributes importantly to offender morbidity but the select nature of the sample and cross-sectional study design constrain the interpretation of these findings.

Mental health service utilisation and reoffending in offenders with a diagnosis of psychosis receiving non-custodial sentences: A 14-year follow-up study.

OBJECTIVE: While psychosis is considered a risk factor for offending, little is reported about mental health service utilisation in offenders with psychosis and its relationship with reoffending. We examined the association between contact with mental health services and reoffending in those diagnosed with psychosis. METHODS: We linked health and offending records in New South Wales (Australia) and identified all individuals with a diagnosis of psychosis and a subsequent offence resulting in a non-custodial sentence between 2001 and 2012. We examined the incidence and risk factors for reoffending, and time to reoffending between 2001 and 2015 using Cox regression and Kaplan-Meier survival methods. We specifically examined the association between clinical contact with community mental health services following the index offence and reoffending. RESULTS: Of the 7393 offenders with psychosis, 70% had clinical contact and 49% reoffended. There was a linear relationship between an increased number of clinical contacts and reduced risk of reoffending: those with no clinical contact had more than a fivefold risk of reoffending compared to those with the highest number of contacts (adjusted hazard ratio = 5.78, 95% confidence interval = [5.04, 6.62]). Offenders with substance-related psychosis and those convicted of non-violent offences had fewer clinical contacts and higher rates of reoffending when compared with controls (adjusted hazard ratio = 1.29, 95% confidence interval = [1.13, 1.47] and adjusted hazard ratio = 1.26, 95% confidence interval = [1.18, 1.35], respectively). CONCLUSION: This study supports an association between more frequent mental health service use and reduced risk of reoffending. Efforts to enhance mental health service utilisation in those with psychosis who are at a higher risk of reoffending should be promoted.

Mental health service contact following release from prison or hospital discharge in those with psychosis.

Background: An association exists between psychosis and criminal offending, which evidence suggests can be reduced by effective mental health care for this vulnerable population. However mental health services often lose contact with people after diagnosis. The association between the first episode of psychosis and criminal offending highlights the need for effective mental health care for this vulnerable population. Aims: To investigate the association between the first diagnosis of psychosis (FDP) in prison or hospital and subsequent mental health service contact following release from prison or discharge from hospital. Materials and methods: Individuals with a FDP either in prison (n = 492) or hospital setting (n = 24,910) between July 2006 and December 2011 in NSW (Australia), were followed post-release or discharge until their first mental health service contact in the community, the occurrence of an offence, death, or completion of the study period at the end of December 2012. Cox regression models were used to examine the predictors for the mental health service contacts following release or discharge. Results: Over 70% of those with a FDP in prison or hospital had a psychosis-related or any community-based mental health service contact following release or discharge between July 2006 and December 2012. Those with a FDP in prison were more likely to have no contact with mental health services than those in hospital with no prior offence record (hazard ratio, HR = 3.14, 95% CI: 2.66-3.72 and adjusted hazard ratio, aHR = 3.05, 95% CI: 2.56-3.63) within a median follow-up time of 25 days for the prison group and 26 days for hospital group. Males, individuals of Aboriginal heritage and individuals diagnosed with substance-related psychoses compared to those with schizophrenia and related psychoses were less likely to have a mental health service contact following release or discharge in both the univariable and multivariable analysis. Conclusion: This study suggests that prior offending or a previous prison episode represents a barrier to mental health service contact in the community for those with a FDP. Effective rehabilitation planning while exiting prison and discharge planning from hospital are essential to the successful reintegration of these individuals with a FDP.

Sertraline hydrochloride for reducing impulsive behaviour in male, repeat-violent offenders (ReINVEST): protocol for a phase IV, double-blind, placebo-controlled, randomised clinical trial.

INTRODUCTION: Considerable evidence supports an association between poor impulse control (impulsivity) and violent crime. Furthermore, impulsivity and aggression has been associated with reduced levels of serotonergic activity in the brain. Selective serotonin reuptake inhibitors (SSRIs) are a class of anti-depressants that aim to regulate brain serotonin concentrations. Several small studies in psychiatric populations have administered SSRIs to impulsive--aggressive individuals, resulting in reduced impulsivity, anger, aggression and depression. However, no clinical trial has been undertaken in a criminal justice population. This protocol describes the design and implementation of the first systematic study of the potential benefits of SSRIs in impulsive---violent offenders who are at high risk of reoffending. METHODS AND ANALYSIS: A randomised, double-blinded, multicentre trial to test the clinical efficacy of an SSRI, sertraline hydrochloride, compared with placebo on recidivism and behavioural measures (including impulsivity, anger, aggression, depression and self-reported offending) over 12 months. 460 participants with histories of violence and screening positive for impulsivity are recruited at several local courts and correctional service offices in New South Wales, Australia. ETHICS AND DISSEMINATION: Results will be submitted for publication in a peer-reviewed journal. Possible implications of the effectiveness of this pharmacological intervention include economic benefits of reducing prison costs and societal benefits of improving safety. This study has received ethical approval from the University of New South Wales, Aboriginal Health & Medical Research Council, Corrective Services NSW and the NSW Justice Health and Forensic Mental Health Network. TRIAL REGISTRATION NUMBER: ACTRN12613000442707.

Association Between Early Contact With Mental Health Services After an Offense and Reoffending in Individuals Diagnosed With Psychosis.

Importance: Psychosis is a known risk factor for offending behavior, but little is known about the association between clinical contact with mental health services after an offense and reoffending. Objective: To examine the association between early contact with mental health services and reoffending after an index offense in individuals with psychosis. Design, Setting, and Participants: In this cohort study, individuals diagnosed with psychosis before their index offense from July 1, 2001, to December 31, 2012, and who received a noncustodial sentence were identified by linking health and offending databases in New South Wales, Australia. The incidence of and risk factors for reoffending and time to reoffending within 2 years from the index offense were examined using Cox proportional hazards regression and Kaplan-Meier survival estimates. Specifically, the association between contact with mental health services within 30 days after an offense and reoffending was examined. Data were analyzed from July 1, 2019, to March 5, 2020. Exposures: Hospital admission, emergency department presentation, and contact with community mental health services associated with psychosis. Main Outcomes and Measures: Reoffending within 2 years of the index offense was compared in individuals with and without clinical contact with mental health services within 30 days after an offense, with adjustment for potential confounders. Results: Of the 7030 offenders with psychosis (4933 male [70.2%]; median age at the index offense, 34 [interquartile range, 26-42] years), 2605 (37.1%) had clinical contact with mental health services within 30 days after the index offense. The risk of reoffending was significantly lower in those with vs without clinical contact (adjusted hazard ratio [AHR], 0.83; 95% CI, 0.76-0.91). The risk of reoffending was 30% less in male offenders with 5 or more clinical contacts compared with male offenders with no clinical contact (AHR, 0.71; 95% CI, 0.59-0.84). Reoffending in both male and female offenders was associated with younger age (eg, AHR for male offenders aged <18 years, 3.31 [95% CI, 2.39-4.59]; AHR for female offenders aged <18 years, 2.60 [95% CI, 1.69-3.99]) and offending history (eg, AHR for male offenders with ≥4 prior offenses, 2.28 [95% CI, 1.98-2.64]; AHR for female offenders with ≥4 prior offenses, 2.22 [95% CI, 1.67-2.96]). Conclusions and Relevance: In this cohort, early and frequent clinical contact with mental health services after an offense in individuals with psychosis was associated with reduced risk of reoffending in this group. More support may be needed for early treatment of those with serious mental illness who are at risk of reoffending.

Disengagement from mental health treatment and re-offending in those with psychosis: a multi-state model of linked data.

BACKGROUND AND AIMS: Individuals with psychosis are over-represented in the criminal justice system and, as a group, are at elevated risk of re-offending. Recent studies have observed an association between increased contacts with mental health services and reduced re-offending, as well as reduced risk of re-offending in those who are ordered to mental health treatment rather than punitive sanctions. In furthering this work, this study examines the effect of disengagement from mental health treatment on probability of re-offence in offenders with psychosis over time. METHODS: Data linkage was conducted with judicial, health and mortality datasets from New South Wales, Australia (2001-2015). The study population included 4960 offenders with psychosis who received non-custodial sentences and engaged with community-based mental health treatment. Risk factors for leaving treatment and/or reconviction were examined using multivariate cox regression. Further, a multi-state model was used to observe the probabilities associated with individuals moving between three states: conviction, disengagement from mental health treatment and subsequent re-conviction. RESULTS: A threefold increase was observed in the risk of re-offending for those who disengaged from treatment compared to those who did not (aHR = 2.76, 95% CI 1.65-4.62, p < 0.001). The median time until re-offence was 195 days, with the majority (67%) being convicted within one year of leaving treatment. A higher risk of leaving treatment was found for those born outside of Australia, with substance-related psychosis, and a history of violent offence. CONCLUSIONS: The findings argue for an emphasis on continued engagement with mental health services following release for offenders with psychosis and identify subgroups within this population for whom concentrated efforts regarding treatment retention should be targeted.

First diagnosis of psychosis in the prison: results from a data-linkage study.

BACKGROUND: Psychosis is more prevalent among people in prison compared with the community. Early detection is important to optimise health and justice outcomes; for some, this may be the first time they have been clinically assessed. AIMS: Determine factors associated with a first diagnosis of psychosis in prison and describe time to diagnosis from entry into prison. METHOD: This retrospective cohort study describes individuals identified for the first time with psychosis in New South Wales (NSW) prisons (2006-2012). Logistic regression was used to identify factors associated with a first diagnosis of psychosis. Cox regression was used to describe time to diagnosis from entry into prison. RESULTS: Of the 38 489 diagnosed with psychosis for the first time, 1.7% (n = 659) occurred in prison. Factors associated with an increased likelihood of being diagnosed in prison (versus community) were: male gender (odds ratio (OR) = 2.27, 95% CI 1.79-2.89), Aboriginality (OR = 1.81, 95% CI 1.49-2.19), older age (OR = 1.70, 95% CI 1.37-2.11 for 25-34 years and OR = 1.63, 95% CI 1.29-2.06 for 35-44 years) and disadvantaged socioeconomic area (OR = 4.41, 95% CI 3.42-5.69). Eight out of ten were diagnosed within 3 months of reception. CONCLUSIONS: Among those diagnosed with psychosis for the first time, only a small number were identified during incarceration with most identified in the first 3 months following imprisonment. This suggests good screening processes are in place in NSW prisons for detecting those with serious mental illness. It is important these individuals receive appropriate care in prison, have the opportunity to have matters reheard and possibly diverted into treatment, and are subsequently connected to community mental health services on release. DECLARATION OF INTEREST: None.

Court diversion for those with psychosis and its impact on re-offending rates: results from a longitudinal data-linkage study.

BACKGROUND: With significant numbers of individuals in the criminal justice system having mental health problems, court-based diversion programmes and liaison services have been established to address this problem.AimsTo examine the effectiveness of the New South Wales (Australia) court diversion programme in reducing re-offending among those diagnosed with psychosis by comparing the treatment order group with a comparison group who received a punitive sanction. METHOD: Those with psychoses were identified from New South Wales Ministry of Health records between 2001 and 2012 and linked to offending records. Cox regression models were used to identify factors associated with re-offending. RESULTS: A total of 7743 individuals were identified as diagnosed with a psychotic disorder prior to their court finalisation date for their first principal offence. Overall, 26% of the cohort received a treatment order and 74% received a punitive sanction. The re-offending rate in the treatment order group was 12% lower than the punitive sanction group. 'Acts intended to cause injury' was the most common type of the first principal offence for the treatment order group compared with the punitive sanction group (48% v. 27%). Drug-related offences were more likely to be punished with a punitive sanction than a treatment order (12% v. 2%). CONCLUSIONS: Among those with a serious mental illness (i.e. psychosis), receiving a treatment order by the court rather than a punitive sanction was associated with reduced risk for subsequent offending. We further examined actual mental health treatment received and found that receiving no treatment following the first offence was associated with an increased risk of re-offending and, so, highlighting the importance of treatment for those with serious mental illness in the criminal justice system.

Managing aggression and violence: the clinician's role in contemporary mental health care.

OBJECTIVE: From time to time misconceptions about violence risk assessment raise debate about the role mental health professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This paper will address some of the misconceptions about risk assessment in those with serious mental illness. METHODS: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowledge and discussion they have reviewed the literature to form their opinions. RESULTS: This paper reflects the authors' views. CONCLUSION: There is a modest yet statistical and clinically significant association between certain types of mental illness and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of case-specific factors to inform appropriate management interventions to reduce the identified risk.

Co-occurring mental illness and substance use disorder among Australian prisoners.

INTRODUCTION AND AIMS: Estimate the prevalence of co-occurring substance use disorder and mental illness in a sample of Australian prisoners, and describe patterns of co-occurring substance use disorder and mental illness. DESIGN AND METHODS: The sample comprised 1478 individuals (1208 men, 270 women) from two surveys of prisoners' mental health: the 2001 New South Wales Inmate Health Survey, and a consecutive sample of prison receptions. Individuals were drawn from all of the state's 29 prisons. Mental health and substance use disorders were assessed using the Composite International Diagnostic Interview. RESULTS: The overall prevalence of any mental disorder was 42.7% and the prevalence of any substance use disorder was 55.3%. With the exception of alcohol use disorder, women had higher rates than men of mental illness and substance use disorders. The prevalence of a co-occurring mental illness and substance use disorder in the past 12 months was 29% (46% among women vs. 25% among men). The association between cannabis use disorder and psychosis was significant for men only [odds ratio (OR)=2.4]. Among women there was a significant association between affective disorder and co-occurring alcohol use disorder (OR=2.4), and stimulant use disorder (OR=2.4). DISCUSSION AND CONCLUSION: The results highlight the high prevalence of co-occurring substance use and mental illness among prisoners. These results indicate that mental health services in prisons need to be adequately resourced to address co-occurring mental health and substance use problems, and these services need to be appropriately structured to effectively screen, manage and treat this group.

A survey of the conditionally released forensic patient population in New South Wales.

OBJECTIVE: The purpose of this study was to describe the demographic and clinical variables of the conditionally released forensic patient population in New South Wales. METHOD: Data were gathered from 74 conditionally released forensic patients. RESULTS: Of this population, 37% had committed homicides and 50% had committed serious violent offences (attempted murder, grievous bodily harm or robbery). Approximately two-thirds had their first admission to a psychiatric hospital before the age of 30. The majority (83%) of patients were diagnosed with schizophrenia and 55% had a history of substance use disorders; 24% were deemed to have been intoxicated at the time of the offence. CONCLUSIONS: Conditionally released forensic patients in NSW show similar characteristics to those in other jurisdictions. Areas identified for further evaluation are comorbid substance use and rehabilitation, longer term outcomes and the under representation of indigenous persons.

Reducing impulsivity in repeat violent offenders: an open label trial of a selective serotonin reuptake inhibitor.

BACKGROUND: The association between serotonergic dysfunction and aggression has prompted the use of selective serotonin re-uptake inhibitors (SSRIs) as a means of controlling impulsive violent behaviour. The aim of the current study was to examine the feasibility of using an SSRI to treat impulsivity in a group of repeat violent offenders. METHODS: Potential participants were recruited from three magistrates' court complexes in the Sydney metropolitan area and all had histories of violent offending (at least one prior conviction for a violent offence). Those who scored highly on the Barratt Impulsivity Scale (BIS-11), passed medical and psychiatric evaluations and consented to treatment were prescribed sertraline (Zoloft) over a three month period. RESULTS: Thirty-four individuals commenced the trial, with 20 completing the three month intervention. Reductions were observed across a range of behavioural measures from baseline to 3 months: impulsivity (35%), irritability (45%), anger (63%), assault (51%), verbal-assault (40%), indirect-assault (63%), and depression (62%). All those who completed the three month trial requested to continue sertraline under the supervision of their own medical practitioner. CONCLUSION: Our findings suggest that treating impulsive violent individuals in the criminal justice system with an SSRI is a potential treatment opportunity for this population. An adequately powered randomized control trial of this intervention is warranted.

The harassment and stalking of plastic surgeons by their patients in Australasia.

Abstract Medical professionals come into direct contact with the public. The relationships are often personal. The aim of the survey is to examine the prevalence of harassment of plastic surgeons by their patients. Survey questionnaires were mailed to all plastic surgeons listed in the 1999 Australasian Society of Aesthetic Plastic Surgery List of Members. A very wide definition of harassment was then provided and information in regard to the nature of the harassment was obtained. This was a descriptive survey of plastic surgeons' experiences of harassment by patients in Australia and New Zealand. More than half of the plastic surgeons in Australia and New Zealand who responded to the questionnaire reported having been a victim of harassment at some point of their careers. One quarter had been harassed in the previous year. Over 20% of cases met the legal criteria for stalking. These estimates are in excess of those reported in the other studies of the general community. Harassment persisted in the majority of cases for at least a month and in a third of cases for up to 5 years. The recognition of psychiatric disorder, particularly personality dysfunction, prior to embarking on surgery may limit the likelihood of harassment by difficult patients. Formal teaching may be helpful to surgical registrars and consultants. Expert intervention could assist in reducing clinician anxiety.

Temperament, substance use and psychopathology in a prisoner population: implications for treatment.

OBJECTIVE: The association between temperament and drug use or temperament and psychopathology has previously been restricted to community clinical or non-clinical samples. The aim of the present study was therefore to examine these associations in a large cohort of Australian offenders using Cloninger's Temperament and Character Inventory (TCI). METHODS: A total of 1322 prisoners from New South Wales (NSW) who completed all dimensions of the TCI and were screened for mental illness using the Australian National Survey of Mental Health and Wellbeing were included in the study. RESULTS: A total of 15% of the sample fulfilled the criteria for a diagnosis for depression, 36% for anxiety disorders and 54% for a substance abuse disorder. Using logistic regression analysis, the TCI dimensions of harm-avoidance and low self-direction predicted depression. Being female, a poly-substance user and having high harm-avoidance, persistence, self-direction and self-transcendence predicted anxiety disorders. Significant stepped trends across age, gender, and type of drug use were found for all TCI dimensions. CONCLUSIONS: The TCI is useful in identifying prisoners with a history of psychopathology and substance misuse. This tool also provides clinically relevant information about at-risk individuals and has the potential to guide the development of intervention programmes for inmates.

When killing isn't murder: psychiatric and psychological defences to murder when the insanity defence is not applicable.

OBJECTIVE: This paper describes psychiatric and psychological defences to murder where the defence of insanity is not applicable. The charges of murder and manslaughter are outlined. Self-defence, sane and insane automatism, provocation, diminished responsibility, duress, necessity and novel defences are discussed. CONCLUSIONS: The complexities of psychological and psychiatric expert evidence are highlighted as well as the fact that legal decisions are not always consistent with medical or scientific theory. It is concluded that this is a controversial and evolving area of mental health law and mental health professionals have an educative role and a responsibility to provide testimony that is supported by the best possible evidence.

The insanity defence: from wild beasts to M'Naghten.

OBJECTIVE: This paper provides an overview of the insanity defence. An historical context is offered and each element of the M'Naghten Rules is discussed, highlighting differing interpretations within various jurisdictions. Discussion is offered on the role of expert evidence in addressing the 'ultimate issue' before the courts. Significant case law in relation to the insanity defence is highlighted. CONCLUSIONS: Psychiatrists have an important role to play in addressing issues central to the M'Naghten Rules and making these accessible and comprehensible to court and jurors in particular. Insanity is a legal construct designed to determine the extent to which a person may be deemed criminally responsible for a criminal act and is often difficult to reconcile within medical and public paradigms of mental illness and justice. Principles are offered to guide psychiatrists who are called to give evidence in cases where the mental illness defence has been raised.

Fitness issues in the context of judicial proceedings.

OBJECTIVE: This paper provides a conceptual, historical and legislative overview of fitness issues. These include fitness to be interrogated or charged, to plead, to be tried and to be sentenced in the context of Australia and New Zealand. CONCLUSIONS: Legislation regarding fitness issues needs to strike a balance between protecting the rights of mentally impaired defendants to a fair trial process and recognizing that mental illness in itself does not absolutely preclude participation in a trial process or necessarily diminish criminal responsibility. Although the key determinants of fitness seem to be the ability to cope with court processes and communicate with counsel, the application of clinical judgement to legal criteria is not always straightforward.

Mental health status of Aboriginal and non-Aboriginal Australian prisoners.

OBJECTIVE: To compare the mental health of Aboriginal and non-Aboriginal prisoners in New South Wales. METHODS: The sample consisted of a cross-sectional random sample of sentenced prisoners, and a consecutive sample of reception prisoners. The sample was drawn from 29 correctional centres (27 male, two female) across New South Wales. Overall, 1208 men (226 Aboriginal), and 262 women (51 Aboriginal) participated in the study. Mental illness was detected using the Composite International Diagnostic Interview (CIDI-A) and a number of other screening measures incorporated into the programme. RESULTS: No differences were detected in mental illness between Aboriginal and non-Aboriginal men, apart from depression, which was lower in the latter group. Aboriginal woman were more likely than non-Aboriginal women to screen positive for symptoms of psychosis in the prior 12 months and have a higher 1 month and 12 month prevalence of affective disorder; they also had higher psychological distress scores. Suicidal thoughts and attempts were the same in both groups. CONCLUSIONS: These findings confirm that the demand for mental health services in prisons is considerable, and that Aboriginal women are one of the most vulnerable groups. Services and programmes providing an alternative to incarceration are needed, as are culturally sensitive approaches to treatment.

Mental disorders in Australian prisoners: a comparison with a community sample.

BACKGROUND: The plight of those with mental health problems and the possible role of prisons in "warehousing" these individuals has received considerable media and political attention. Prisoners are generally excluded from community-based surveys and to date no studies have compared prisoners to the community. OBJECTIVE: The objective was to examine whether excess psychiatric morbidity exists in prisoners compared to the general community after adjusting for demographics. METHOD: Prison data were obtained from a consecutive sample of reception prisoners admitted into the state's correctional system in 2001 (n = 916). Community data were obtained from the 1997 Australian National Survey of Mental Health and Wellbeing (n = 8168). Mental health diagnoses were obtained using the Composite International Diagnostic Interview and a number of other screening measures. Weighting was used in calculating the 12-month prevalence estimates to control for demographic differences between the two samples. Logistic regression adjusting for age, sex and education was used to compare the prison and community samples. RESULTS: The 12-month prevalence of any psychiatric illness in the last year was 80% in prisoners and 31% in the community. Substantially more psychiatric morbidity was detected among prisoners than in the community group after accounting for demographic differences, particularly symptoms of psychosis (OR = 11.8, 95% CI 7.5-18.7), substance use disorders (OR = 11.4, 95% CI 9.7-13.6) and personality disorders (OR = 8.6, 95% CI 7.2-10.3). Mental functioning and disability score were worse for prisoners than the community except for physical health. CONCLUSIONS: This study found an overrepresentation of psychiatric morbidity in the prisoner population. Identifying the causes of this excess requires further investigation.