Summary
In Uganda, mental illness affects over 30% of the population and fewer than 50% of these individuals seek intervention due to limited access to mental health services. Mental health problems and disorders are more prevalent in prisons than outside. This retrospective cross-sectional study utilizing secondary data aimed at establishing the trends and distribution of mental Illnesses among prisoners in Uganda (2015-2017) to support plans to improve mental health services among prisoners in Uganda. There was an increase in incidence among prisoners at Murchison Bay Hospital between July 2016 to December 2017(HIV Related Psychosis (13/1000 to 56/1000), Schizophrenia (0.24/1000 to 10.2/1000) and Epilepsy (1.7/1000 to 18/1000). 2015 (Females =150/1000, Males =81/1000), 2016 (Females =119/1000, Males =20/1000), 2017 (Females=1.6, Males =56/1000) and Depression; The biannual percentage change in incidence every six months was: Schizophrenia (OR=1.8, 95% CI=1.7-1.9), Depression ( OR=1.2, 95% CI=1.1-1.3), HIV Related Psychosis (OR=1.1, 95% CI=1.1-1.2), Bipolar disorders (OR=0.7, 95% CI=0.64-0.76), Dementia ( OR=0.85, 95% CI=0.79-0.91). Mental illnesses among prisoners is on the increase especially HIV related psychosis, Schizophrenia, Epilepsy and Depression. Women prisons should receive extra resources to support their mental health services
Background
Mental illnesses are disorders that affect the mood, thinking and behavior of a person. These include depression, anxiety disorders, schizophrenia, eating disorders, dementia, epilepsy, HIV related psychosis, bipolar disorders and addictive behaviors such as alcohol and drug abuse, etc.
It is estimated that the global burden of mental illness is 32·4% of years lived with disability (YLDs) and 13·0% of disability-adjusted life-years (DALYs). In 2013, mental illness ac-counted for 21·2% of global years lived with disability (YLDs) which is 3·5 times greater than that associated with all infectious diseases (6·0% of YLDs), 4 times greater than that for all injuries combined (5·0% of YLDs), 8 times greater than that associated with all cardiovascular and circulatory diseases (2·8% of YLDs), and 24 times greater than that associated with all cancers (0·9% of YLDs). Five types of mental illness appear in the top 20 causes of global burden of disease (GBD): major depression (2nd), anxiety disorders (7th), schizophrenia (11th), dysthymia (16th), and bipolar disorder (17th) were leading causes of years lived with disability (YLDs) (1). This study sought to determine the trends of Mental Illnesses among prisoners in Uganda, 2015 -2017 and describe the distribution of Mental Illnesses by sub population groups among prisoners in Uganda, 2015 -2017
Methods
Luzira Maximum prison is the largest prison in Uganda and was purposively selected for this study. The prison is in the Luzira parish, Nakawa Division in southeastern Kampala, the capital city of Uganda. It is also the only prison where a hospital-Murchison Bay Hospital is located. Murchison Bay Hospital is a National Prison Referral Hospital and thus receives patients referred from prison health facilities across the country. In addition, there are lower level healthcare facilities with-in Luzira prison such as the staff and upper prison clinics. We extracted data on all prisoners who were reported with mental illness and neurological disorders in DHIS2 by Murchison Bay Hospital for a period 2015 – 2017. Data from Murchison Bay prison Hospital is compiled using routine HMIS tools and re-ported electronically to Uganda MoH. The annual prison population data was used to identify bi-annual trends of mental illnesses by period, type, and person. We sought permission for using the data from Uganda Prisons Service and the MoH that own the HMIS data.
Results
From July 2016 to December 2017, there was a noticeable in-crease in incidence of HIV Related Psychosis among prisoners managed at Murchison Bay Hospital (Jul-Dec 2016 = 13/1000 and Jul-Dec 2017 = 56/1000). During January to July 2017, there was a sharp increase in Incidence of Schizophrenia among prisoners (61/1000). In addition, there was an increase in Epilepsy among prisoners from 7.7/1000 in Jan-Jun 2015 to 18/1000 during Jul-Dec 2017. The incidence in dementia among prisoners decreased from 7.5/1000 during Jan-Jun 2015 to 0.96/1000 in Jul-Dec 2017. (Figure 1).
Figure 1: Trends of Mental Illnesses among prisoners at Murchison Bay Hospital, Uganda, 2015-2017
For all years, HIV related psychosis was high in both sexes: 2015 (Females =150/1000, Males =81/1000), 2016 (Females =119/1000, Males =20/1000), 2017 (Females=1.6/1000, Males =56/1000). In 2015 and 2016, the incidence of dementia was high among women prisoners compared to that among male prisoners: 2015(Females=36/1000, Males=5.2/1000) and 2016(Females=90/1000, Males=9.1/1000). Depression was high among female prisoners compared to male prisoners for all the years: 2015(Females = 49/1000, Males=16/1000), 2016(Females=70, Males = 8.5), 2017 (Females=70, Males=3.3). (Figure 2).
Figure 2: Distribution of Mental Illnesses by sex among prisoners at Murchison Bay Hospital, Uganda, 2015 -2017
Bi-annual change in incidence of Mental Illnesses among prisoners at Murchison Bay Hospital, Uganda, 2015 -2017
Over the entire study period, we identified 4053 mental illness cases. The average increase in incidence over the three years was 461/1000 prisoners. For every additional six months from 2015-2017, the biannual percentage change in incidence was: Schizophrenia (OR=1.8, 95% CI=1.7-1.9), Anxiety Disorders ( OR=1.4, 95% CI=1.3-1.5), Epilepsy (OR=1.3, 95% CI=1.2-1.3), Depression (OR=1.2, 95% CI=1.1-1.3), HIV Related Psycho-sis ( OR=1.1, 95% CI=1.1-1.2), Bipolar disorders (OR=0.7, 95% CI=0.64-0.76), Dementia (OR=0.85, 95% CI=0.79-0.91).
Discussion
Mental illnesses among prisoners was on the increase especially HIV related psychosis, Schizophrenia, Epilepsy, and Depression. Female prisoners were affected more than males. Although there is on entry screening of all prisoners’ health conditions in all Uganda Prisons, mental health services are only provided in selected prisons health facilities.
During a systematic review by Fazel and Danesh, 2002, prisoners were several times more likely to have psychosis and major depression, and about ten times more likely to have antisocial personality disorder, than the general population. Yet still, Post Traumatic Stress Disorder (PTSD) prevalence among prisoners was 35% compared to prison staff at 15% in Uganda Prisons service (6, 9).
Conclusions
Mental illnesses among prisoners is on the increase especially HIV related psychosis, Schizophrenia, Epilepsy and Depression. Female prisoners are affected more than males. Our study confirms a disproportionate burden of mental illness problem among prisoners. Further studies should be conduct-ed to establish the cause of the high burden of mental illness-es among prisoners with focus on female prisoners.
Recommendations
The Uganda Prisons Service should enhance mental illness related health services in all prison facilities. HIV programming activities in Uganda Prisons Service should give more attention to Psychotic HIV patients to reduce on double jeopardy. Women prisons should receive extra resources to support their mental health services.
References
1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016;3(2):171–178.
2. World Health Organization, Regional Office for Eu-rope, United Nations Office on Drugs and Crimes. Good governance for prison health in the 21st century: a policy brief on the organization of prison health. S.l.]; Copenha-gen: UNODC, United Nations Office on Drugs and Crimes ; World Health Organization, Regional Office for Europe; 2013.
3. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. The Lancet. 2011;378(9802):1592–1603.
4. Murray JS, Ainslie L, Alpough M, Schramm C, Showalter C. The Scope of Mental Illness and Status of Psychiatric Care in Uganda. Issues Ment Health Nurs. 2015 Nov 2;36(11):877–83.
5. Ditton PM. Special report: Mental health and treatment of inmates and probationers. Wash DC US Dep Justice Bur Justice Stat. 1999;
6. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry. 2016;3(9):871–881.