Mental disorder prevalence and associated risk factors in three prisons of Spain

Mental disorder prevalence and associated risk factors in three prisons of Spain

MC Zabala-Baños1, A Segura1, C Maestre-Miquel1, M Martínez-Lorca2, B Rodríguez-Martín1, D Romero, M Rodríguez1

1Nursing, Physiotherapy and Occupational Therapy Department. Occupational Therapy, Logaoedics and Nursing School. University of Castilla la Mancha, Talavera de la Reina, Spain
2Department of Psychology. Occupational Therapy, Logaoedics and Nursing School. University of Castilla la Mancha, Talavera de la Reina, Spain



Aims: To determine the lifetime and monthly prevalence of people with mental disorders and its association with sociodemographic factors and criminal risk in three Spanish prisons (Ocaña, Madrid I, II and VI).

Method: Cross-sectional epidemiological study of a sample of 184 inmates. Socio-demographic and criminal data were collected by an ad hoc interview. Mental disorders were assessed with the clinical version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis I Disorders (SCID-I).

Results: Life prevalence of mental disorders was 90.2%. The most common mental disorders and substance abuse or dependence was 72.3%, followed by mood disorder (38.5%) and psychotic disorders (34.2%). Moreover, the prevalence of any mental disorder in the last month was 52.2%. The main psychotic disorder (20.7%) was followed by substance abuse or dependence (18.5%), and mood disorder state (13%). A socio-demographic profile as a risk for each disorder was found.

Discussion: The prevalence of people with mental disorders is very high in Spanish prisons, and is associated with a distinct demographic profile. It is essential to continue researching this reality, translating the results into therapeutic and preventive action adapted to the status of inmates to reduce social inequalities in this high priority public health situation.

Keywords: Prisons; Mental disorders; Prevalence; Epidemiology; Mental health; Street drugs; Substance-related disorders; Risk factors; Spain.



The imprisoned population has increased over the last twenty-five years in most of the countries1. In many of them, such as in the Netherlands or Greece, by 150%. In Spain, such population has grown up to 140 per every 100,000 inhabitants2. This escalation of the imprisoned population runs parallel with an increased prevalence of mental disorders among them, with higher rates than in the general public3-4. Epidemiological studies on the matter conclude that the rates of inmates with common mental disorders are twice as high and four times higher when considering severe mental disorders5. Hence, the importance of mental disorders in prisons as a key public health issue6, mainly associated with substance and alcohol abuse and dependence disorders.

A revision of studies7, concludes that the vast majority of people hosted in correctional facilities suffer from some type of mental disorder at some point, 61% of whom are formerly diagnosed with a mental disorder and 33.8% of whom present positive scores in mental health issues.

With regard to the most common mental disorders, the revision and meta-analysis8 carried out in 24 countries, suggests the prevalence of psychotic and major depression disorders, present in one of every seven inmates. Furthermore, they concluded high co-morbidity of such disorders with substance abuse, this being higher in patients with psychotic disorders (13.6% to 95%), prevailing in male offenders five years after their arrest in up to 27%, higher than among the general population, present un one of every six inmates9.

In our country, it is worth considering the PreCa4 study, the first multi-centre epidemiological study aimed at defining lifetime and month prevalence of mental disorders in prison. Its results show a lifetime prevalence for any mental disorder of 84.4%, the most common being substance abuse, followed by anxiety, mood and psychotic disorders. Month prevalence was 41.2%, the most common being anxiety disorder followed by substance abuse, mood and psychotic disorders.

In this context, the objective of the present study is to define lifetime and month prevalence of the main mental disorders in prison, as well as the sociodemographic profile of the male imprisoned population in two correctional facilities in Castilla-La Mancha and a facility in the Community of Madrid, by following the methodology described by the PreCa4 study.


This is a cross-sectional descriptive study, of nonexperimental design carried on convicted males hosted in the prisons of Ocaña I, Ocaña II (Castilla-La Mancha) and Madrid VI (Community of Madrid).

Study subjects

Inclusion criteria: 1) Males deprived of their freedom, serving their sentences in the correctional facilities under study. 2) Ages ranged between 18 and 75 years. 3) Spanish-speaking foreigners or with appropriate communication and comprehension skills. 4) Mentally able to provide signed informed consent.

Exclusion criteria: 1) Female inmates. 2) Inmates under preventive detention. 3) Inmates under security measures. 4) Foreigners with language difficulties. 5) Release in the next six months. 6) Inmates under open regimens. 7) Inmates with severe medical conditions unable to undergo the interview. 8) Inmates pending imminent transfer to other correctional facilities. 9) Inmates admitted to prison psychiatric units. 10) Inmates mentally unable to provide informed consent.

Sample Size

The sample included in the study (n=184) was selected from the list provided by each prison which included inmate identification numbers, by means of random stratified sampling techniques. Each selected participant had three alternates. Of the 184 individuals to whom the interview was administered, 5 alternates were selected and the response rate was 97.7%. The distribution of inmates was carried out proportionally to the population size of each prison.

Study variables

Sociodemographic variables were considered (age, nationality, marital status, maximum level of education achieved, working status and place of residence) along with criminal variables (type of offence, type of sentence, prison regimen, number of legal proceedings, arrests and admissions to prison) and clinical variables (mental disorders at some point and throughout the last month).

Evaluation tools

1. Structured interview on Socio-Demographic and Criminal data

2.Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis I Disorders (SCID-I), for the diagnosis of mental disorders according to DSM-IV criteria10. It is an interview protocol to diagnose the most important DSM-IV Axis I disorders11, by following a clinical diagnosis interview. It enhances diagnostic validity by providing a series of diagnostic criteria and the systematic inquiry into symptoms which could otherwise go unnoticed12.

The interview was individually and manually administered. Individuals took part voluntarily in the study, by providing signed written informed consent, prior information on the study. The authorization of corresponding prison administrations was necessary for the development of this study.

Statistical Analysis

Sociodemographic variables were described through absolute frequency and percentages. Prevalence has been expressed by absolute frequency and percentages with 95% confidence intervals. Raw and adjusted Odds-ratio was calculated for different mental disorders and sociodemographic variables through logistic regression models. Multivariate model includes all sociodemographic variables included in the table. All statistical significance tests are bilateral and consider a significance level of p<0.05. Data was analyzed through SPSS v.22.0 statistical software (SPSS for Windows, SPSS Inc., Chicago, IL, USA).



Table 1 depicts sociodemographic variables as well as variables on criminal record and recidivism of the subjects under study. The mean age was 39.6 years 54.9% were from Spain and 26.6% from South America. Only 28.8% were married or mated. 55.5% had finished primary school and only 12% had studied at university. 57.6% were employed prior to imprisonment. 41.8% were recidivists: crimes against public health (33.2%) and robbery (20.7%) being the most common. Last, 54.6% had been previously arrested.

Table 2 depicts lifetime and last-month prevalence of the main mental disorders. Lifetime prevalence of any mental disorder was 90.2%: substance abuse or dependence disorder (72.3%; 95%CI 65.8-78.7) being the most common, followed by mood disorders (38.5%; 95%CI 31.5-45.6) and psychotic disorders (34.2%; 95%CI 27.3-41.1).

As for the substances most commonly associated with abuse or dependence disorders throughout the subjects’ lives, alcohol was the leading cause (45.1%; 95% CI 37.8-52.3), followed by cocaine (39.6%; 95%CI 32.5-46.7).

On the other hand, last-month prevalence of any mental disorder was 52.2% (95%CI 44.9-59.4), the most common being psychotic disorders (20.7%; 95%CI 14.7-26.5) followed by substance abuse or dependence disorder (18.5%; 95%CI 12.8-24.1) and mood disorders (13%; 95%CI 8.1-17.9).

Table 3 shows the prevalence and raw and adjusted odds-ratio for suffering from mood or anxiety disorders according to sociodemographic factors. With regard to mood disorders, the main risk factors are associated to age, being twice as common at the age of 40 years and onwards (adjusted OR 1.92; 95%CI 0.65-5.6), university education (adjusted OR 2.68, 95% CI 0.69-10.14) in comparison with those who had not finished primary school; being born in Spain (adjusted OR 0.37; 95%CI 0.09-1.5for Africans adjusted OR = 0.07; 95%CI 0.02-0.2 for Latin Americans and adjusted OR 0.29, 95% CI 0.09-1 for the rest of Europe) and being unemployed (adjusted OR 1.69, 95% CI 0.79-3.6).

As for anxiety disorders, it is worth noting that we identified the following risk factors: older ages (adjusted OR=0.44; 95%CI 0.13-1.5 for individuals 50 and older), being married (adjusted OR = 1.44; 95% CI 0.62-3.3); low educational level (adjusted OR = 1.92; 95%CI 0.74-5.0 for those who had not finished primary school); place of birth, foreigners suffering less from anxiety disorder (adjusted OR 0.25; 95%CI 0.06-1 for Africans, adjusted OR = 0.42; 95% CI 0.18-1 for Latin-Americans and adjusted OR = 0.38; 95%CI 0.12-102 for the rest of Europeans), and last, being unemployed (adjusted OR= 1.82; 95%CI 0.87-3.8).

With regard to substance abuse or dependence disorders (see Table 4) the following risk factors were described: age ranged between 30 and 39 years (adjusted OR= 1.47; 95% CI 0.5-4.3),being single in comparison with being or giving been married (adjusted OR= 0.68; 95%CI 0.28-1.6 and 0.86; 95%CI 0.31-2.4 respectively), not having finished primary school (OR = 0.75; 95%CI 0.19-2.9), being unemployed (adjusted OR= 0.69; 95% CI 0.32-1.5) and Spanish nationality (adjusted OR=0.71; 95% CI 0.17-3.1 for Africans in comparison with inmates born in Spain).

The possibility of suffering from any mental disorder is associated to age, being more common among individuals with ages ranged between 20 to 29 years, having been previously married (adjusted OR = 3.02; 95%CI 0.52-17.4) and having unfinished or only complete primary education (adjusted OR 2.27; 95%CI 0.42-12.3). Foreign inmates presented lower probabilities (adjusted OR = 0.11; 95% CI 0.02-0.5 for Latin-Americans and adjusted OR = 0.16; 95% CI 0.02-1.1 for the rest of Europeans). Last, unemployment is also a risk factor (adjusted OR= 1.11; 95% CI 0.33-3.8).

Table 5 depicts how psychotic disorders are associated to the following risk factors: age ranged between 40 and 49 years (adjusted OR= 2.88; 95% CI 0.98-8); being single, primary education (adjusted OR 1.12; 95% CI 0.45-2.8), foreigners born in Africa or Latin America presented a lower probability (adjusted OR = 0.22; 95% CI 0.04-1.2 for Africans and adjusted OR = 0.37; 95% CI 0.14-1.0 for Latin-Americans) in comparison with those born in Spain and finally, being unemployed (adjusted OR = 0.69; 95% CI 0.32-1.5).



The profile of the sample includes male inmates with a mean age of 39.6 years, mostly from Spanish nationality, with primary education, single and unemployed at the time of imprisonment, with a high rate of recidivism and prior arrests. The most common crimes committed were offenses against public health and robbery. As for this aspect, our results run parallel with other studies13, where crimes against public health also account for the leading cause among male inmates. Our results on recidivism show lower rates than other Spanish studies4,14.

We concluded a high lifetime prevalence (90.2%), higher than other European studies which have results ranging between 27% and 78%15-16,7 and slightly higher than the prevalence concluded by the PreCa4 study and by the FAISEM14(Fundación Pública Andaluza para la Integración Social de personas con Enfermedad Mental) the Andalusian Public Fund for Social Integration of people with Mental Disorders, which found a prevalence of 82.6% with our same methodology. In comparison with the general public, our study concluded a prevalence 5.3 times higher. As for last-month prevalence, over half of our inmates presented some kind of mental disorder, a result which surpasses that of other European studies (32%)17, national publications (40%) 4 and the FAISEM study (25.8)14.

Regarding the type of disorder suffered throughout life, substance abuse or dependence disorder was the most common (72.3%) along with the results of Norwegian studies18, alcohol being the most common substance. This is in line with other studies4,19. Nevertheless, other authors suggest that substance abuse disorder among inmates is over 50%3,21-24, yet below our results20, and the most common substances cannabis and heroin although this has now dropped by 30%25. Although it is true that alcohol and drugs are frequently used in prisons26 it is also associated to sociodemographic variables, typically related to imprisonment and psychiatric co-morbidity27.

As for the other two most common disorders: mood and psychotic disorders, our data goes in line with other international publications3,8, which also place them as frequent disorders after substance abuse disorder. It is worth noting though that our study concludes higher lifetime and last-month prevalence rates, alike other studies28, which also raise awareness on the high risk of psychotic disorder in prison. This makes us believe that some of the reasons why these illnesses can go unnoticed during the criminal proceedings, are the features of the penitentiary environment itself and the lack of community resources for the implementation of their sentences, making prisons "a warehouse of severe mental patients"29.

The available data comes mostly from other countries where researchers alert on the high number of inmates who suffer from mental disorders and a lack of monitoring30. In Spain there is scarce literature on the issue. It is worth considering a longitudinal study31 which concludes a high rate of co-morbidity with substance abuse, personality, anxiety, depressive and psychotic disorders.

As for sociodemographic variables in our study, it is worth noting how all categories are higher than in the general Spanish population and lower in the foreign population, especially in comparison with Latin Americans. This could be due to the "Latino Paradox" whereby Hispanic communities do better in a series of physical and mental health indicators despite socioeconomic disadvantages32. Although the specific causes for this have not yet been identified, some authors33-34 suggest that there are distinctive features among Latin Americans such as extensive social support networks, pleasing social interaction based on reciprocal and non-competitive relationships, solid family ties and their sense of religiosity which may act as protective factors against psychosocial stress.

Previous studies suggest that substance abuse and mental disorders are more common among young male offenders under poorer socioeconomic circumstances35-36. Our results run parallel with this by reporting that the probability of substance abuse or dependence is lower among married foreign or highly educated inmates, and higher among inmates ranged between 30 and 39 years.

In an enclosed setting where inmates face adverse social circumstances and impaired future prospects, mental health issues rise significantly. Imprisonment entails a constant effort for psychosocial adaptation and we have observed that there are a series of sociodemographic factors such as age, nationality, marital status, employment or education, which make a difference in suffering certain mental disorders in prison. It is essential to ensure continuing research, to go further into the role of social status among inmates, as it is already being done in other countries37, and to translate results into real therapeutic and preventive actions, adapted to such status to reduce social inequality in this, a priority Public Health issue.

Our study has certain limitations, like the exclusion of female, senior and preventive inmates and those admitted to psychiatric units. On the other hand, the sample is somewhat limited although it contributes to know better this reality, by improving knowledge on the prevalence of mental disorders in Spanish prisons, such as the sociodemographic profile by replicating a previously validated methodology.



Carmen Zabala Baños
Email: Carmen
Universidad de Castilla la Mancha.



1. González Sánchez I. Aumento de presos y Código Penal: Una explicación insuficiente. Rev electrónica de ciencia penal y criminología [Internet]. 2011 [citado 2015 Mar 27]; 13: 1-22 [aprox. 20 p.]. Disponible en: − ISSN 1695-0194.

2. Institute for Criminal Policy Research [homepage on the internet]. London: ICPS; c1997-2016 [cited 2015 May 29]. ICPS, World Prison Brief 2015; [about 2 screens]. Available from: http: //www.

3. Fazel S, Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet. 2002; 16: 545-50.

4. Vicens E, Tort V, Dueñas RM, Muro A, PérezArnau F, Arroyo-Cobo JM , et al. The prevalence of mental disorders in Spanish prisons. Crim Behav Ment Health. 2011 Dec; 21 (5): 321-32. doi: 10.1002/cbm.815.

5. Arroyo-Cobo JM. Estrategias asistenciales de los problemas de salud mental en el medio penitenciario, el caso español en el contexto europeo. Rev Esp Sanid Penit. 2011; 13: 100-11.

6. Fazel S, Baillargeon J. The health of prisoners. Lancet. 2011; 377: 956-65.

7. Lafortune D. Prevalence and screening of mental disorders in short-term correctional facilities. International Journal of Law and Psychiatry. 2010; 33: 94-100.

8. Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis. BJP. 2012; 200: 364-73. doi: 10.1192/bjp.bp.111.096370.

9. Abram KM, Zwecker NA, Welty LJ, Hershfield JA, Dulcan MK, Teplin LA. Comorbidity and continuity of psychiatric disorders in youth after detention: a prospective longitudinal study. JAMA Psychiatry. 2015; 72 (1): 84-93. doi:

10.1001/jamapsychiatry.2014.1375. 10. First MB, Spitzer RL, Gibbon M, Williams JBW. Guía del usuario para la entrevista clínica estructurada para los trastornos del Eje I del DSM- IV. Version clínica SCID I. Barcelona: Masson; 1999.

11. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (DSM-IV). Washington DC: APA; 1994.

12. Vicens-Pons E, Arroyo-Cobo JM, Tort V, Pérez Arnau F, Muro A, Sardá P, et al. Aproximación a la metodología para el estudio de los trastornos mentales en población penitenciaria. El estudio PreCa. Rev Esp Sanid Penit. 2009; 11: 17-25.

13. González-Sánchez I. La cárcel en España: mediciones y condiciones del encarcelamiento en el siglo XXI. Rev D Penal y Crim. 2012; 8: 351-402.

14. Fundación pública andaluza para la integración social de personas con enfermedad mental. FAISEM. Prevalencia de problemas de salud mental en centros penitenciarios andaluces. Memoria 2012. Sevilla: Junta de Andalucía; 2013. 53 p.

15. Fotiadou M, Livaditi M, Manou I, Kaniotou E, Xenitidis K. Prevalence of mental disorders and deliberate self-harm in Greek male prisoners. International Journal of Law and Psychiatry. 2006; 29: 68−73.

16. Dressing H, Kief C, Salize HJ. Prisoners with mental disorders in Europe. The British Journal of Psychiatry. 2009; 194 (1), 88.

17. Brink JH, Doherty D, Boer A. Mental disorder in federal offenders: A Canadian prevalence study. International Journal of Law and Psychiatry. 2001; 24: 339-56.

18. Værøy H. Depression, anxiety, and history of substance abuse among Norwegian inmates in preventive detention: Reasons to worry? BMC Psychiatry. 2011; 11 (40): 1-7.

19. Casares- López MJ, González A, Torres M, Secades R, Fernández-Hermida JR, Álvarez M. Comparación del perfil psicopatológico y adictivo de dos muestras de adictos en tratamiento: en prisión y en comunidad terapéutica. International Journal of Clinical and Health Psychology. 2010; 10: 225-243.

20. Marín-Ballasote N, Navarro-Repiso C. Estudio de la prevalencia de trastorno mental grave (TMG) en los centros penitenciarios de Puerto I, II y III del Puerto de Santa María (Cádiz): nuevas estrategias en la asistencia psiquiátrica en prisiones. Rev Esp Sanid Penit. 2012; 14: 80-5.

21. Fazel S, Parveen B, Doll H. Substance abuse and dependence in prisoners: A systematic review. Addiction. 2006; 101: 181-91.

22. Tods S, Hariga F, Pouza M, Leclercq D, Gilbert P, Malessi MI. Drug use in Belgian prisons: Monitoring health risks. Final Report. Brussels: Modus Vivendi; 2006.

23. Dirección General de Instituciones Penitenciarias. Estudio Sobre Salud Mental en el medio penitenciario. Madrid: Dirección General de Instituciones Penitenciarias; 2007.

24. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Luxembourg: European Union; 2009.

25. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Luxembourg: European Union; 2013.

26. Rowell TL, Wu E, Hart CL, Haile R, Nabila ElBassel. Predictors of drug use in prison among incarcerated Black men. Am J Drug Alcohol Abuse. 2012; 38 (6): 593-7.

27. Lukasiewicz M, Falissard B, Michel L, Neveu X, Reynaud M, Gasquet I. Prevalence and factors associated with alcohol and drug-related disorders in prison: a French national study. Subst Abuse Treat Prev Policy. 2007; 2 (1).

28. Jarret M, Valmaggia L, Parrot J, Forrester A, Winton-Brown T, Maguire H, et al. Prisoners at ultrahigh-risk for psychosis: a cross-sectional study. Epidemiol Psychiatr Sci. 2015; Mar 3: 1-10.

29. Teplin, LA. La prevalencia de los trastornos mentales graves entre los detenidos de la cárcel urbanas masculinas: comparación con el Programa de Captación Epidemiológica Area. American Journal of Public Health . 1990; 663-9.

30. Shaw J, Baker D, Hunt IM, Moloney A, Appleby L. Suicide by prisoners: National clinical survey. Br J Psychiatry. 2004; 184: 5.

31. Arnau-Peiró F, García-Guerrero J, Herrero-Matías A, Castellano-Cervera JC, Vera-Remartínez EJ, Jorge-Vidal V, et al. Description of the Psychiatric Unit in prisons in the autonomous community of Valencia. Rev Esp Sanid Penit. 2012; 50-60.

32. Markides KS, Coreil J. The health of Hispanics in the south western United States: An epidemiologic paradox. Public Health Reports1986; 101: 253.

33. Marin G, Marin BV. Research with Hispanic populations. Newbury Park, CA: Sage; 1991.

34. Gallo LC, Penedo FJ, Espinosa de los Monteros K, Arguelles W. Resiliency in the face of disadvantage: do Hispanic cultural characteristics protect health outcomes? J Pers. 2009; 1707-46.

35. Steinbrimsson S, Sigurdsson MI, Gudmundsdottir H, Aspelund T, Magnusson. A. Mental disorder, imprisonment and reduced life expectancy — A nationwide psychiatric inpatient cohort study. Crim Behav Ment Health. 2015. doi: 10.1002/ cbm.1944 36 Pauly V, Frauger E, Rouby F, Sirere S, Monier S, Paulet C, et al. Analysis of additive behaviours among new prisoners in France using the OPPIDUM program. Encephale. 2010;36 (2): 122-31.

37. Friestad C. Socio-economic status and health in a marginalized group: the role of subjective social status among prison inmates. Eur J Public Health. 2009; 20 (6): 653-8.


  • No hay Refbacks actualmente.