Benavides et al. BMC Psychiatry (2019) 19:248 https://doi.org/10.1186/s12888-019-2227-z RESEARCH ARTICLE Open Access Depression and psychosis related to the absence of visitors and consumption of drugs in male prisoners in Ecuador: a cross sectional study Andrés Benavides1, Juan Chuchuca1, David Klaic2, William Waters3, Miguel Martín2,4,5 and Natalia Romero-Sandoval2,4* Abstract Background: Major mental disorders in prison populations have been recognised as a long-term problem with an important impact on public health. Despite this, screening activities in prisons are still weak in Latin America. We proposed to estimate the prevalence of depression and psychosis and associated factors in the largest Ecuadorian prison for male inmates. Methods: Cross-sectional study with 309 prisoners chosen at random between January and February 2017, who were administered two structured questionnaires. The first examined socio-demographic and occupational characteristics prior to incarceration and presence of social support networks; the second was the Mini International Neuropsychiatric Interview version in Spanish 5.0.0. We used maximum likelihood tests and multiple logistic regression to assess associations between depression, psychosis and study factors. Results: The prevalence of depression and psychosis were 50.2% (95% CI 44.6–55.8) and 25.9% (95% CI 21.0–30.8), respectively. The two conditions occurred together in 22.0% of the cases (95% CI 14.8–29.2), and depression or psychosis (D/P) was found in 54.0% (95% CI 48.4–59.6). Consuming drugs while in prison was found in 41.4% (95% CI 35.9–46.9). When age was considered among those consuming drugs, the prevalence of D/P were 72.2, 88.0, and 92.3%, respectively for the age-groups 18–29, 30–39 and 40 years or over (p-value < 0.001). Using a multivariate model, we found that not receiving visits (AOR 3.15 95%CI 1.42–6.96) and consuming drugs while in prison (AOR 5.85 95%CI 3.06–11.16) were associated with D/P, while the age effect disappears. Inmates who stopped drug consumption in prison or who had never consumed did not present any significant differences. Conclusions: Depression and psychosis in prisoners are strongly affected by the absence of visitors and by consumption of drugs in prison. Greater presence of social support networks and preventive actions targeting drug abuse would contribute to improving the mental health of prison inmates. Background Although in prisons, priority is given to treating acute Depression and psychotic illness are among the most rather than chronic problems, the prevalence of the latter common mental disorders in prisons [1] and have been is much higher than in the general population. Prison recognized as a public health problem for several reasons. inmates generally come from socially disadvantaged segments of the community and the presence of mental * Correspondence: nromero@uide.edu.ec disorders, along with other communicable and non-com- 2 School of Medicine, Universidad Internacional del Ecuador, Av. Jorge municable diseases, should provoke society’s commitment Fernández s/n and Simon Bolívar, 170113 Quito, Ecuador 4 to justice in order to fight against this inequity [2, 3]. Fi- Red GRAAL - Grups de Recerca d’Amèrica i Àfrica Llatines, Barcelona, Spain. Edifici M, Avinguda de Can Domènech, 08193 Bellaterra (Cerdanyola del nally, social isolation, extreme overcrowding, deficient Vallès), Barcelona, Spain sanitation, lack of health services, inadequate security Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Benavides et al. BMC Psychiatry (2019) 19:248 Page 2 of 7 measures, and violence in prisons can exacerbate or pro- type of crime, although highly dangerous prisoners are held long psychiatric symptoms among inmates with mental in other prisons. disorders, even among those with no history of mental illness [4]. Inclusion criteria A recent systematic review of information from over Eligible subjects were the 2375 male Ecuadorian or other 24 countries and a population of 33,588 prison inmates Spanish-speaking prisoners between 18 and 75 years of found that the prevalence of depression and psychosis age who were held in the prison during the first 3 was 10.2 and 3.6%, respectively [3]. Data for South months of 2017, who had been in the prison for at least America are scarce; however, Andreoli and colleagues 12 months prior to the interview, and whose release was (2014) found depression in 12.3% of 1192 male prisoners not expected within the next 6 months. Inmates with se- in the state of Sao Paolo, Brazil between 2006 and 2007 vere somatic pathologies or security measures prevent- [5] and Pondé and colleagues obtained figures of 17.6, ing the interview were excluded. 1.4, and 27.9% for depression, psychosis, and drug abuse, respectively, in 497 prison inmates in the city of Salvador, Brazil, using the Mini International Neuropsychiatric Sample size and sample procedure Interview [6]. Sample size calculations were performed assuming a Since 2009, responsibility for health in prisons has prevalence of psychosis of 10% [11], requiring a preci- been transferred from ministries of justice to ministries sion of 3% at the 95% confidence level, and a dropout of health in various developed countries [4]. In 2014, rate of 10%. This yielded a sample size of 362. The per- this process took place in Ecuador and clinical exams for centage of refusal to participate was 14.6%. The reason prisoners became obligatory [7]. given for refusal was the unwillingness to participate. The incarceration rate in Ecuador, based on United The characteristics of the prison and the authorizations Nations figures for an estimated national population of to conduct the study made it difficult to complete the 16.89 million in March 2018, was 222 per 100,000 in- sample size with replacement and we obtained a sample habitants [8]. Ecuador thus ranks 60th among the 222 of 309 prisoners (84.5%). Participants were selected by countries for which information is available. In 2011, the simple random selection. average incarceration rate for South American countries was 202 per 100,000 inhabitants, which is one of the Methods of data collection highest in the world [9], compared to 145 per 100,000 Prisoners were invited to participate in this study in inhabitants worldwide [3]. February 2017 in coordination with the Ministry of In Ecuador, surveillance of diseases related to human Justice. They were transferred from their pavilions to behaviour includes alcoholism, dementia, drug depend- the health unit of the prison and those who agreed to ence, homicide, suicide, and victims of violence, but not participate remained in the doctors’ offices. Each day 20 depression or psychosis [10]. Consequently, no figures prisoners were invited. Data were collected by a group of or studies assessing the risk factors are available. five psychologists with experience in psychological inter- viewing. The interview was conducted face-to-face with each participant. The purpose of the interview was first Methods explained, and it was made clear that participation was Aims voluntary and that responses would be treated as confi- We proposed to quantify the prevalence of depression dential. Informed consent was obtained before ques- or psychosis and relationships with demographic, social, tionnaire administration was begun and privacy was and drug abuse factors among male prison inmates in maintained during the interview. the Ecuadorian prison with the largest male population, Two structured questionnaires were used. One col- through a cross-sectional study, with the aim of contrib- lected social demographic information as well as visits uting epidemiological information to the mental health by family members, place of family residence, and drug system in a penitentiary setting that was recently incor- abuse history. The second questionnaire was the Spanish porated into the new health model for prisons. version of the Mini International Neuropsychiatric Inter- view, version 5.0.0 (MINI), screening tool, which was Study setting and design used to assess current status regarding depression, We carried out a cross-sectional study among male inmates psychosis, and drug abuse (nonalcohol). The latter is aged over 18 years in a prison in the city of Guayaquil, defined as consumption in the last month [12] . Depres- Ecuador. Both the prison and the city are the most densely sion module is related to Major Depressive Episode and populated in the country. Prisoners are grouped in areas Major Depressive Disorder, and Psychosis module based on availability of cells rather than by security level or include current Any Psychotic Disorder. Benavides et al. BMC Psychiatry (2019) 19:248 Page 3 of 7 Operational definitions Table 1. Of the 204 prisoners whose families resided in Age was grouped into three categories: 18 to 29 years, Guayaquil (where the prison is located), 178 (87.3%) 30 to 39 years, and 40 years or more. Educational level stated that they received visits, compared to 80/96 was categorized as primary school or less and second- (83.3%) of those whose families resided in another city, ary school or higher. Participants were asked about and 5/9 (55.6%) of those whose families lived outside the the place of residence of their family (in the city, out- country. side the city, or overseas), whether they had children, whether they had a job prior to incarceration, any Estimation of the prevalence of depression, psychotic past incarceration, and family visits received in the illness and drug consumption past 3 months. Responses indicating having consumed Overall, the prevalence of depression was 50.2% (95% CI drugs and current drug abuse according to the MINI 44.6–55.8), and of psychosis, 25.9% (95% CI 21.0–30.8); were combined to yield three categories: (i) never the prevalence of the two disorders simultaneously was consumed drugs, (ii) stopped drug consumption dur- 22.0% (95% CI 14.8–29.2), and D/P was present in 54.0% ing imprisonment, and (iii) consumes drugs in the (95% CI 48.4–59.6). The latter condition was found in prison. Depression and psychosis were ascertained 95/158 (60.1%) of participants aged 18 to 29 years, in 39/ using DSM-IV criteria. Finally, we generated a new 77 (50.6%) of the group aged 30 to 39, and in 33/74 variable to reflect the presence of at least one of the (44.6%) of the group aged 40 or over. Differences were two mental disorders (D/P), which was used as the not significant (p > 0.05), though. Consuming drugs dependent variable. while in prison was found in 41.4% (95% CI 35.9–46.9) of participants. However, among those who reported Statistical analysis drug consumption, the corresponding figures in the Data were entered with Microsoft Excel 2010 software three age groups were 65/90 (72.2%), 22/25 (88.0%) and and analyzed in the Statistical Package for Social Sciences 12/13 (92.3%), respectively, which demonstrates that age (SPSS, version 21). The variables are described in terms of interacts with consumption of drugs in the presence of relative and absolute frequencies. Associations between the disorders studied (p < 0.001). presence of at least one of the two mental disorders and factors under study were assessed using binary logistic re- Factors associated with depression or psychotic illness gression. The results are expressed in terms of crude and D/P was found in 86/153 (56.2%) of participants with a adjusted OR and their 95% CI. A p-value of 0.05 was con- primary education or less, in 125/230 (54.3%) of those sidered as the cut-off point for statistical significance. who had children, and in 95/170 (55.9%) of those who were unemployed prior to incarceration, as well as in Ethical considerations 112/204 (54.9%) of those who had family in the same The data were managed by the team of interviewers dur- city as the prison, in 51/96 (53.1%) of those who had ing the process of data collection, who ensured confidenti- family outside the city, in 4/9 (44.4%) of those whose ality by using an individual alpha-numeric code. Privacy families lived overseas. was guaranteed by conducting individual interviews with Table 2 presents associations between depression or each participant in a consulting room in the prison’s psychosis and the factors included in the study. After health unit. The door was closed; a guard waited outside, performing multivariate adjustments, we observed sig- but this person had no access to any of the information nificant adjusted OR values for absence of family visits collected during the application of the evaluation (AOR 3.15 95%CI 1.42–6.96) and consumption of drugs instruments. in prison (AOR 5.85 95%CI 3.06–11.16). Stopping drug The printed copies of the completed evaluation instru- consumption upon incarceration and never having con- ments were removed from the prison each day. Access to sumed drugs behaved similarly. Having a prison history the data was restricted to members of the research team. lost its significance after adjusting for the other factors. Under no circumstance was any of the information given to prison personnel or officials of the Ministry of Justice, Discussion Ministry of Health, or any other institution. The study was In penitentiary settings, maintenance and protection of approved by the Human Subject Research Ethics Commit- mental health is difficult and availability of resources for tee of the Universidad San Francisco de Quito. diagnosis of mental disorders in prisons is limited [13]. In the present study, we found that one of five partici- Results pants presented both depression and psychosis, while Demographic and social characteristics one of two presented one or the other. The prevalence Demographic and social characteristics and data on past rate of depression, as well as that of psychosis that we incarceration and patterns of drug use are presented in found, seem to be among the highest reported [3]. Benavides et al. BMC Psychiatry (2019) 19:248 Page 4 of 7 Table 1 Description of the sociodemographic factors of the prisoners in the masculine prison, Ecuador Variable Categories Frequency (n) Percentage (%) Age (years) 18–29 158 51.1 30–39 77 24.9 ≥ 40 74 23.9 Education Primary or less 153 49.5 High school or college 156 50.5 Place of family residence In the city were the prison is located 204 66.0 Outside the city were the prison is located 96 31.1 Out of the country 9 2.9 Children No 79 25.6 Yes 230 74.4 Labor situation before imprisonment Had a job 139 45.0 Underemployment or unemployment 170 55.0 Previous imprisonments No 156 50.5 Yes 153 49.5 Visits No 46 14.9 Yes 263 85.1 Drugs Never 109 35.3 Stopped using in jail 72 23.3 Consumes in jail 128 41.4 Some studies conducted in other settings show that Ecuadorian prisons, or in the general population. It has rates of common mental disorders in the prison popula- been recognized that some prison inmates present mental tion are double those found in the general population, disorders prior to incarceration [18], or in other cases that and quadruple in the case of severe mental disorders it is in prison where the initial diagnosis is made [19]. [11, 14–16]. Recent studies have reported rates of 8.7 We also found a higher prevalence of depression or and 20.7% respectively, for depression and psychosis psychosis among prisoners between 18 and 29 years of among male prison inmates in Spain [11]; and 6.3 and age; however, a change was observed in this prevalence 12.3%, respectively in Brazil [9]. Similarly, rates of 6.1% upon associating age and consumption of drugs. In this for depression were found in Chile [16], and 38. 6% in case, we found a very high prevalence of these mental Colombia [17]. We have not identified any studies pub- disorders studied among prisoners over 40 years of age lished in indexed journals that investigate these topics in who consumed drugs (92.3%). In the logistic regression Table 2 Factors associated with depression or psychosis by bivariable and multivariable logistic regression among masculine prisoners, Ecuador Variable Category n (%) Crude OR 95%CI Adjusted OR 95%CI a Visits No 36 (78.3) Yes 131 (49.8) 3.62 1.73–7.63 3.15 1.42–6.96 a Previous imprisonments No 73 (46.8) Yes 94 (61.4) 1.81 1.15–2.85 1.21 0.72–1.99 a Drugs Never 37 (33.9) Stopped using in jail 31 (43.1) 1.47 0.80–2.71 1.34 0.71–2.55 Consumes in jail 99 (77.3) 4.51 2.42–8.42 5.85 3.06–11.16 Age (years) 18–29a 95 (60.1) 30–39 39 (50.6) 0.68 0.39–1.78 1.03 0.54–1.99 ≥ 40 33 (44.6) 0.53 0.03–0.93 1.03 0.51–2.08 a Basal category Benavides et al. BMC Psychiatry (2019) 19:248 Page 5 of 7 model, however, the age effect disappeared, not being information to physicians. In this regard, several authors significant in explaining the variability in the rate of the have reiterated the need for early diagnosis and timely two mental disorders studied following adjustment for treatment of mental disorders in prisons in order to the other factors. Even so, systematic reviews suggest avoid fatal consequences [28–30]. that older prisoners have a higher risk of presenting a We used the Spanish version of the MINI because of single psychiatric disorder [20, 21]. It is known that its appropriateness and easy application by psycholo- people with some mental disorder who have committed gists, because it includes the variables of interest in this crimes but who do not receive appropriate treatment, study (which have been replicated) [31, 32], and because can enter a cycle of re-incidence involving both the it has been applied to young offenders, for example in mental disorders and criminal acts [22]. Moreover, in Chile [33]. A mental health screening tool should con- low and middle-income countries, prison inmates with sider important contextual factors in the implementation mental disorders tend to have such poor access to re- of screening. Although there are other tests for screen- sources that the risk of suffering abuse and violations of ing for mental illness [34], they have not been validated human rights is higher [9]. in Spanish-speaking countries in Latin America, which One systematic review found a prevalence of drug is an important limitation to addressing mental health in abuse and dependence of 25% among 90,000 prisoners prisons in the region. in low and middle-income countries [23] and a figure of We recognize several limitations of the present 27.1% was found among inmates in prisons in Sao Paulo study. First, in the selection of participants, we did [5], independently of whether they had mental disorders not consider aspects such as duration of prison sen- or not. An updated systematic review and meta-regression tence, general health status, or time still to be served. analysis in 18,388 prisoners, 64% of whom were male, These factors could have influenced the mental health found prevalences of drug abuse of between 10 and 61% test results. Second, the evaluation used in this study [24]. A recent study in 336 prisoners in Ethiopia (2017) did not consider potential differences in prisoners’ found a prevalence of substance use disorder of 55.9%; un- mental health on admission to prison, compared with like our study, this analysis included alcohol abuse and prisoners already incarcerated. A study conducted in nicotine dependence with an instrument other than the Chile found a higher prevalence among those evalu- MINI. This study found that lack or poor social sup- ated at the time of admission [16]. Third, the variable port, living in urban areas, psychopathy, and family his- of interest (depression or psychosis) was based on a tory of substance use was associated with substance use single measurement. An addition to a standardized disorder [25]. diagnostic interview could modify the prevalence rates We found that among prisoners who consumed drugs founded. Fourth, prison regulations imposed limita- in the prison, seven out of ten presented depression or tions on the administration of the mental health test psychosis. We also observed a relationship between not and in obtaining our intended sample size: these limi- receiving visits and presenting depression or psychosis; tations included the place for the application of the 78.3% of prisoners who did not receive visits presented test, the impossibility of contacting prisoner again, depression or psychosis, and the relationship remained and the time authorized for applying the test. Finally, significant after adjusting for the other factors. In the possibility that drug consumption and not receiv- Ethiopia, a significant association was found between ing visits might result from mental health problems not having any social support and depression among 727 should be considered. prisoners [26]. However, Prins (2014) found difficulties in diagnosing these problems in high-income Western countries with sample surveys using interviews and clin- Conclusions ical instruments [15]. Consumption of drugs in prison and the absence of visi- Mental health service providers and the justice system tors were associated with the mental health of prison in prison settings should discuss and agree on oper- inmates. A higher frequency of visits and actions to pre- ational priorities related to custody, care, security issues vent consumption and abuse of drugs would contribute to and treatment of prison inmates with mental conditions, improved mental health of prisoners. and should reflect on the system for organizing visits or social support for those who do not receive visits [27]. Abbreviations D/P: Depression or Psychosis; MINI: Mini International Neuropsychiatric Falissard and colleagues called for in-depth, collective re- Interview flection to answer questions about the diagnosis of men- tal health in prisons [14]. In particular, it is important to Acknowledgements access a user-friendly instrument that can be applied by The authors would like to express their thanks to the Ecuador Ministry health technical personnel, who must transfer reliable of Justice for facilitating the development of this study. Benavides et al. BMC Psychiatry (2019) 19:248 Page 6 of 7 Authors’ contributions 8. Ecuador | World Prison Brief. http://www.prisonstudies.org/country/ecuador. DK and NRS conducted the literature search. AB, JC and WW drafted the Accessed 30 June 2018. sections on prevalence of mental disorders and recommendations. NRS and 9. Almanzar S, Katz CL, Harry B. Treatment of Mentally Ill Offenders in Nine MM drafted the sections on epidemiological analysis, and special Developing Latin American Countries. J Am Acad Psychiatry Law. 2015;43: populations. WW supervised the study. All authors made a critical revision of 340–9. the manuscript for important intellectual content and contributed to final 10. Dirección Nacional de Vigilancia Epidemiológica. Comportamiento Humano_ manuscript. All authors read and approved the final manuscript. 1994-2017. https://public.tableau.com/profile/vvicentee80#!/vizhome/ ComportamientoHumano_2014_0/ANUARIO. Accessed 30 June 2018. Funding 11. Zabala-Baños MC, Segura A, Maestre-Miquel C, Martínez-Lorca M, This research received no specific grant from any funding agency, commercial Rodríguez-Martín B, Romero D, et al. Mental disorder prevalence and or not-for-profit sectors. None of the authors’ affiliation institutions had any associated risk factors in three prisons of Spain. Rev Espanola Sanid influence on the design, implementation, analysis or interpretation of the data Penit. 2016;18:13–23. in this study. 12. Hergueta T, Baker R, Dunbar GC. The MINI-international neuropsychiatric interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IVand ICD-10. J Clin Psychiatry. 1998;59(Suppl Availability of data and materials 20):2233. The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. 13. Fazel S, Baillargeon J. The health of prisoners. Lancet. 2011;377:956–65. 14. Falissard B, Loze J-Y, Gasquet I, Duburc A, De Beaurepaire C, Fagnani F, et al. Prevalence of mental disorders in French prisons for men. BMC Psychiatry. Ethics approval and consent to participate 2006;6:33. Research was performed in accordance with the Declaration of Helsinki and 15. Prins SJ. Prevalence of mental illnesses in US state prisons: a systematic was approved by the Human Subject Research Ethics Committee from review. Psychiatr Serv. 2014;65:862–72. Universidad San Francisco de Quito. Written consent to participate was 16. Mundt AP, Kastner S, Larrain S, Fritsch R, Priebe S. Prevalence of mental received from each prisoner. disorders at admission to the penal justice system in emerging countries: a study from Chile. Epidemiol Psychiatr Sci. 2016;25:441–9. Consent for publication 17. Vélez-Álvarez C, Barrera-Valencia C, Benito-Devia AV, Figueroa-Barrera M, Not applicable. Franco-Idarraga SM. Study of depressive symptoms according to Zung’s self-rating scale on men deprived of freedom in a city of Colombia. Rev Competing interests Espanola Sanid Penit. 2016;18:43–8. AB and JC are employed in the Ecuador Ministry of Health. The other 18. World Health Organization-AIMS, Panamerican American Health authors declare that they have no conflicts of interest. Organization. Regional report on mental health systems in Latin America and the Caribbean. 2013. Author details 19. Al-Rousan T, Rubenstein L, Sieleni B, Deol H, Wallace RB. Inside the nation’s 1 National Department of Penitentiary Mental Health, National Direction of largest mental health institution: a prevalence study in a state prison the First Level of Attention. Ministerio de Salud Pública de Ecuador, Av. system. BMC Public Health. 2017;17:342. Quitumbe Ñan y Av. Amaru Ñan. Plataforma Gubernamental de Desarrollo 20. Di Lorito C, Vӧllm B, Dening T. Psychiatric disorders among older prisoners: Social, 170146 Quito, Ecuador. 2School of Medicine, Universidad Internacional a systematic review and comparison study against older people in the del Ecuador, Av. Jorge Fernández s/n and Simon Bolívar, 170113 Quito, community. Aging Ment Health. 2018;22:1–10. Ecuador. 3Instituto de Investigación en Salud y Nutrición, Universidad San 21. Davoren M, Fitzpatrick M, Caddow F, Caddow M, O’Neill C, O’Neill H, et Francisco de Quito, Diego de Robles y Vía Interoceánica, 170901 Cumbayá, al. Older men and older women remand prisoners: mental illness, Ecuador. 4Red GRAAL - Grups de Recerca d’Amèrica i Àfrica Llatines, physical illness, offending patterns and needs. Int Psychogeriatr. 2015; Barcelona, Spain. Edifici M, Avinguda de Can Domènech, 08193 Bellaterra 27:747–55. (Cerdanyola del Vallès), Barcelona, Spain. 5Unidad de Bioestadística, Facultad 22. Macciò A, Meloni FR, Sisti D, Rocchi MBL, Petretto DR, Masala C, et al. de Medicina, Universidad Autónoma de Barcelona, Edifici M, Avinguda de Mental disorders in Italian prisoners: results of the REDiMe study. Psychiatry Can Domènech, 08193 Bellaterra (Cerdanyola del Vallès), Barcelona, Spain. Res. 2015;225:522–30. 23. Mundt AP, Baranyi G, Gabrysch C, Fazel S. Substance use during imprisonment Received: 11 November 2018 Accepted: 30 July 2019 in low- and middle-income countries. Epidemiol Rev. 2018;40(1):70–81. 24. Fazel S, Yoon IA, Hayes AJ. Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated References men and women. Addiction. 2017;112(10):1725–39. 1. Baranyi G, Scholl C, Fazel S, Patel V, Priebe S, Mundt AP. Severe mental 25. Yitayih Y, Abera M, Tesfaye E, Mamaru A, Soboka M, Adorjan K. Substance illness and substance use disorders in prisoners in low-income and middle- use disorder and associated factors among prisoners in a correctional income countries: a systematic review and meta-analysis of prevalence institution in Jimma, Southwest Ethiopia: a cross-sectional study. BMC studies. Lancet Glob Health. 2019;7:e461–71. Psychiatry. 2018;18:314. 2. de Viggiani N. Unhealthy prisons: exploring structural determinants of 26. Beyen TK, Dadi AF, Dachew BA, Muluneh NY, Bisetegn TA. More than eight prison health. Sociol Health Illn. 2007;29:115–35. in every nineteen inmates were living with depression at prisons of 3. Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: Northwest Amhara regional state, Ethiopia, a cross sectional study design. systematic review and meta-regression analysis. Br J Psychiatry J Ment Sci. BMC Psychiatry. 2017;17:31. 2012;200:364–73. 27. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of 4. Durcan G, Zwemstra JC. Mental health in prison. In: Enggist S, Møller L, prisoners: prevalence, adverse outcomes, and interventions. Lancet Galea G, Udesen C, editors. Prisons and health. Copenhagen: WHO Regional Psychiatry. 2016;3:871–81. Office for Europe; 2014. p. 87–95. 28. Begun AL, Early TJ, Hodge A. Mental health and substance abuse service 5. Andreoli SB, Dos Santos MM, Quintana MI, Ribeiro WS, Blay SL, Taborda JGV, engagement by men and women during community reentry following et al. Prevalence of mental disorders among prisoners in the state of Sao incarceration. Admin Pol Ment Health. 2016;43:207–18. Paulo, Brazil. PLoS One. 2014;9:e88836. 29. Brown GP, Hirdes JP, Fries BE. Measuring the prevalence of current, severe 6. Pondé MP, Freire AC, Mendonça MS. The prevalence of mental disorders in symptoms of mental health problems in a Canadian correctional prisoners in the city of Salvador, Bahia, Brazil. J Forensic Sci. 2011;56:679–82. population: implications for delivery of mental health services for inmates. 7. Ministerio de Salud Pública de Ecuador, Ministerio de Justicia, Derechos Int J Offender Ther Comp Criminol. 2015;59:27–50. Humanos y Cultos. Acuerdo Interministerial 00004906. 2014. https:// 30. Ayhan G, Arnal R, Basurko C, About V, Pastre A, Pinganaud E, et al. Suicide aplicaciones.msp.gob.ec/salud/archivosdigitales/documentosDirecciones/ risk among prisoners in French Guiana: prevalence and predictive factors. dnn/archivos/ac_00004906_2014%2026%20jun.pdf. BMC Psychiatry. 2017;17:156. Benavides et al. BMC Psychiatry (2019) 19:248 Page 7 of 7 31. Nacher M, Ayhan G, Arnal R, Basurko C, Huber F, Pastre A, et al. High prevalence rates for multiple psychiatric conditions among inmates at French Guiana’s correctional facility: diagnostic and demographic factors associated with violent offending and previous incarceration. BMC Psychiatry. 2018;18:159. 32. Baier A, Fritsch R, Ignatyev Y, Priebe S, Mundt AP. The course of major depression during imprisonment - a one year cohort study. J Affect Disord. 2016;189:207–13. 33. Gaete J, Labbé N, Del Villar P, Allende C, Araya R, Valenzuela E. Mental health and associated factors among young offenders in Chile: a cross- sectional study. Crim Behav Ment Health. 2018;28:13–27. 34. Martin MS, Colman I, Simpson AI, McKenzie K. Mental health screening tools in correctional institutions: a systematic review. BMC Psychiatry. 2013;13:275. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.