TYPE Original Research PUBLISHED 12 January 2023 DOI 10.3389/fpsyg.2022.1039099 Psychiatric disorders and OPEN ACCESS comorbidity in a Spanish sample EDITED BY Eric García-López, Universidad de Castilla-La Mancha, of prisoners at the end of their Spain REVIEWED BY sentence: Prevalence rates and Joseph Sadek, Dalhousie University, Canada Martha Frías Armenta, associations with criminal University of Sonora, Mexico *CORRESPONDENCE history Mireia Pagerols mireia.pagerols@sjd.es Mireia Pagerols1,2*, Sergi Valero3,4 , Lourdes Dueñas5 , SPECIALTY SECTION This article was submitted to Rosa Bosch1,6 and Miquel Casas1,7 Forensic and Legal Psychology, 1 a section of the journal Programa MIND Escoles, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Frontiers in Psychology Esplugues de Llobregat, Spain, 2 Unitat de Farmacologia, Facultat de Medicina i Ciències de la Salut, Departament de Fonaments Clínics, Universitat de Barcelona (UB), Barcelona, Spain, 3 Ace RECEIVED 07 September 2022 Alzheimer Center Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain, 4 Networking ACCEPTED 20 December 2022 Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, PUBLISHED 12 January 2023 Spain, 5 Programa Reincorpora “la Caixa”, Departament de Justícia, Centre d’Iniciatives per a la Reinserció (CIRE), Generalitat de Catalunya, Barcelona, Spain, 6 CIBER de Salud Mental (CIBERSAM), CITATION Instituto de Salud Carlos III, Madrid, Spain, 7 Departament de Psiquiatria i Medicina Legal, Universitat Pagerols M, Valero S, Dueñas L, Autònoma de Barcelona (UAB), Bellaterra, Spain Bosch R and Casas M (2023) Psychiatric disorders and comorbidity in a Spanish sample of prisoners at the end of their sentence: Prevalence rates and associations with criminal history. Introduction: This study examined, for the first time, the prevalence of mental Front. Psychol. 13:1039099. disorders and comorbidities among inmates who were about to be released, doi: 10.3389/fpsyg.2022.1039099 and their association with criminal history. COPYRIGHT © 2023 Pagerols, Valero, Dueñas, Methods: A Spanish sample of 140 prisoners at the end of their Bosch and Casas. This is an sentence was recruited from an occupational program. Psychiatric disorders open-access article distributed under the terms of the Creative Commons were determined according to the Diagnostic and Statistical Manual Attribution License (CC BY). The use, of Mental Disorders criteria. Bivariate analyses followed by multivariate distribution or reproduction in other forums is permitted, provided the regression models were conducted to identify significant variables for repeat original author(s) and the copyright incarceration and violent offending. owner(s) are credited and that the original publication in this journal is Results: The lifetime prevalence of Axis I disorders was 81.4%, with substance cited, in accordance with accepted academic practice. No use, distribution use disorders (SUD) and attention deficit/hyperactivity disorder (ADHD) being or reproduction is permitted which the most common diagnoses (51.4 and 31.4%, respectively). The current does not comply with these terms. prevalence of Axis I disorders was 59.0%, including learning disorders (38.6%), ADHD (16.4%), and SUD (5.71%) among the most frequent syndromes. Thirty- six (26.5%) participants met criteria for a current Axis II disorder, which commonly was an antisocial personality disorder (12.5%). The majority of the sample (60.8%) suffered from two or more comorbid disorders during their lifetime, although the current prevalence fell to 23.3%. Childhood ADHD increased the number of imprisonments, while inmates convicted of a violent crime were more likely to present a learning disorder. Having a lifetime diagnosis of SUD or multiple psychiatric disorders appeared to be associated with both repeat incarceration and violent offending. Frontiers in Psychology 01 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 Conclusion: Given the high rate of mental disorders still present among subjects completing prison sentences and the challenges they may encounter to benefit from vocational programs, our results suggest that appropriate psychiatric care should be provided during imprisonment and after release to facilitate their community reintegration. KEYWORDS substance use disorders (SUD), attention deficit/hyperactivity disorder (ADHD), learning disorders (LD), repeat incarceration, violent offending, community reintegration Introduction Young et al., 2015). Additionally, mental health problems are often found to coexist and subjects with multiple conditions According to the Council of Europe Annual Penal Statistics feature more severe symptoms, greater functional impairment, (SPACE I), on 31st January 2020 there were 1,528,343 inmates less social competence, higher public service utilization, and in the penal institutions of the Council of Europe member states worse treatment outcome (van Buitenen et al., 2020). Likewise, (Aebi and Tiago, 2021). About 95% of them will eventually incarcerated offenders who present co-occurring disorders be released, although research suggests that nearly half return usually show more serious offending behaviors, are at higher to correctional systems within the first year because they lack risk of recidivism or repetition of criminal activity after the skills to successfully transition from prison to community release, and thus may struggle to achieve successful community (Hughes and Wilson, 2002; Petersilia, 2005; Eggers et al., 2006). reintegration (Chang et al., 2015; White et al., 2016; Kim et al., Employment has proven to be one of the most effective means 2017; Garofalo et al., 2018; van Buitenen et al., 2020). In this for promoting the reintegration of offenders as it provides sense, Fazel and Seewald (2012) reported that up to 43.5% of individuals with a legitimate source of income, a structured prisoners with any mental illness suffered from a comorbid routine, certain status, and the opportunity to associate with SUD, although comorbidity estimates range between 9 and 95% law-abiding peers (Bahr et al., 2010; Peled-Laskov et al., 2019). according to a recent meta-analysis (Fazel and Seewald, 2012; Therefore, rehabilitation programs focused on professional Baranyi et al., 2022). training and developing the necessary skills for workplace With regard to Spain, which has one of the largest prison settings are highly popular in the Western world and have been population rates compared to the European median (Aebi associated with multiple benefits, including higher self-esteem, and Tiago, 2021), only a single study has investigated the better jobs opportunities upon release, and lower recidivism prevalence of psychiatric disorders among male prisoners so far rates (Peled-Laskov et al., 2019; Zhao et al., 2019). (Vicens et al., 2011). The lifetime and last month prevalence However, psychiatric disorders, which frequently entail of mental disorders was 84.4 and 41.2%, respectively, including emotional disturbances and cognitive limitations, such as SUD (76.2 vs. 17.5%), anxiety disorder (45.3 vs. 23.3%), mood attention deficits and learning difficulties, can significantly disorder (41.0 vs. 14.9%), and psychotic disorder (10.7 vs. 4.2%) jeopardize a prisoner’s ability to successfully engage in among the most frequent ones (Vicens et al., 2011). On the interventions intended to increase employability (Lee et al., other hand, over 80% of the men had at least one personality 2018). Of note, epidemiological studies have consistently disorder, which was commonly a cluster B personality disorder, demonstrated that mental illnesses are highly overrepresented although the rate of antisocial personality disorder (23.0%) among incarcerated adults (Fazel and Danesh, 2002; Fazel was lower than that reported in the literature (47.0%) (Fazel and Seewald, 2012). Indeed, a previous meta-analysis, based and Danesh, 2002; Vicens et al., 2011). Importantly, the on pooled data from 33,588 prisoners in 24 countries, authors did not evaluate ADHD, despite the elevated rates estimated that 65.0% of the male inmates were diagnosed consistently observed among juvenile offenders worldwide, with a personality disorder, which commonly was an antisocial the evidence that symptoms persist into adulthood for most personality disorder, 10.2% had major depression, and 3.6% children, and the high comorbidity with other mental disorders experienced psychotic disorders (Fazel and Seewald, 2012). (Haavik et al., 2010; Young et al., 2015; Solberg et al., 2018). Attention deficit/hyperactivity disorder (ADHD) and substance Likewise, numerous studies report a notable overrepresentation use disorders (SUD) also appear to be overrepresented of other neurodevelopmental disabilities, such as dyslexia, in adult prison populations, with prevalence rates around among detained adolescents and incarcerated young people 25.0 and 50.0%, respectively (Mumola and Karberg, 2006; but the prevalence of learning disorders in Spanish inmates Frontiers in Psychology 02 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 is not available (Einat and Einat, 2008; Elbeheri et al., 2009; Mohr-Jensen and Steinhausen, 2016; Román-Ithier et al., 2017; Hughes et al., 2012; Borschmann et al., 2020). Besides, there are Philipp-Wiegmann et al., 2018). no reliable data on comorbidity within Spanish prisons, since Vicens et al. (2011) focused on male inmates with co-occurring SUD and Axis I psychiatric disorders (Vicens et al., 2011). Materials and methods Previous epidemiological investigations, however, have reported a wide variability in prevalence rates (Fazel and Study population Danesh, 2002; Fazel and Seewald, 2012; Baranyi et al., 2022; Heller et al., 2022). This heterogeneity may reflect distinct Participants were consecutively recruited over a 1-year research methodologies, diagnostic criteria, assessment tools, period from an occupational program aimed at promoting sample characteristics, and information sources (Young and the fully integration into society of inmates who are ending Cocallis, 2019). For instance, most of the research has relied their sentence (Reincorpora Program; Fundació “la Caixa”). on screening measures, medical records or self-reports, which The program was restricted to subjects with a valid Spanish might have yielded unreliable estimates (Martin et al., 2013). ID card or an employment authorization for offenders, who Thus, there is a call for the use of standardized clinical indicated their willingness to initiate the rehabilitation process interviews based on the Diagnostic and Statistical Manual of and were at the lowest category within the prison system, which Mental Disorders (DSM) or the International Classification of allows day release privileges. Otherwise, they had to be on Diseases (ICD) criteria to improve the diagnostic validity (Slade parole or convicted with alternative measures to imprisonment. and Forrester, 2013; Hofvander et al., 2017). Indeed, accurate Eligible candidates were required to be at least 18 years and prevalence estimates are crucial for planning and implementing have sufficient language skills to give informed consent and appropriate rehabilitation services during imprisonment. Yet, complete the clinical assessment. The participation was totally to the best of our knowledge, the prevalence of mental voluntary at all times and prisoners were reassured that their disorders and comorbidities among offenders completing prison personal details would not be identifiable. Of the 179 subjects sentences has never been examined. Given that the majority do who met inclusion criteria, 39 (21.8%) refused to participate, not receive adequate mental health care during incarceration which yielded a study sample of 140 (78.2%) inmates. (Bowler et al., 2018), we hypothesize that inmates who are about to be released are still characterized by a high rate of psychiatric disorders, which can undermine the effectiveness of vocational Procedure programs aimed at promoting their successful reintegration into society. The present study was conducted in cooperation with the Considering this knowledge gap and the above-mentioned Department of Justice of the Catalan Government and the weaknesses of prior studies, the present research used Center for Reintegration Initiatives (CIRE), a public enterprise standardized diagnostic methods based on the DSM criteria to that facilitates the social integration of inmates through training evaluate the prevalence of current and lifetime mental disorders programs and job opportunities. After obtaining authorization among 140 inmates (93.6% male, 39.5 ± 10.4 years) at the end from the directors of the centers where subjects were serving of their sentence who participated in an occupational program. their sentence, all potential participants were informed about Moreover, we aimed to determine, for the first time in Spain, the nature and purpose of the study. Only those who provided the comorbidity rates within this adult prison population and their informed consent were interviewed for the assessment whether specific mental disorders were related to a higher risk of mental disorders with the Structured Clinical Interview for of repeat incarceration or violent crimes. In this sense, previous DSM-IV Axis I and II Disorders (SCID-I and SCID-II) (First investigations from other countries suggest that personality and et al., 1997a,b), the Diagnostic Interview for ADHD in adults neurodevelopmental disorders (i.e., ADHD, reading problems) (DIVA 2.0) (Kooij, 2012), the Battery for the Evaluation of are positively related to violent offenses, while subjects with Reading Processes in Junior and Senior High-School Students, SUD, depression, or generalized anxiety disorder are more likely Revised (PROLEC-SE-R) (Cuetos et al., 2016), and the Battery to be incarcerated for a non-violent crime (Lewis et al., 1980; for the Evaluation of Writing Processes (PROESC) (Cuetos et al., Lindgren et al., 2002; Simonoff et al., 2004; Harris et al., 2006; 2002). Interviews were carried out during three sessions in the Macciò et al., 2015; Alevizopoulos and Igoumenou, 2016; Scott CIRE facilities, where the inmates received the occupational et al., 2016; Román-Ithier et al., 2017; Nacher et al., 2018). On program. A suitable place was arranged so that psychiatrists the other hand, antisocial personality disorder, SUD, bipolar and psychologists from the Hospital Universitari Vall d’Hebron, disorder, depression, psychotic disorders, and ADHD have been in Barcelona, could perform the clinical assessment away from significantly associated with recidivism, especially when co- the distraction of other ongoing activities. Participants first occurring disorders are being present (Baillargeon et al., 2009, met a psychiatrist of the research team, who conducted a 2010; Yu et al., 2012; Gaïffas et al., 2014; Macciò et al., 2015; clinical interview including the SCID-I, SCID-II, and DIVA Frontiers in Psychology 03 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 2.0, and were then granted an additional appointment with a Students, Revised (PROLEC-SE-R) (Cuetos et al., 2016) and psychologist who administered the neuropsychological battery the Battery for the Evaluation of Writing Processes (PROESC) for the evaluation of learning disorders. All researchers had (Cuetos et al., 2002). extensive experience in the administration of the instruments The most prevalent psychiatric disorders were grouped used as they are part of the assessment protocol from the Adult into broader categories for analyses: Mood disorders (i.e., ADHD Program at the Department of Psychiatry, and did not major depressive disorder, mood disorder due to a general require special training to perform the diagnostic interviews. medical condition, and substance-induced mood disorder), The study protocol received formal approvals from the Ethics psychotic disorders (i.e., schizophrenia, delusional disorder, Committee of the Vall d’Hebron Hospital Universitari, the and substance-induced psychotic disorder), SUD (i.e., alcohol, Department of Justice, and the involved penitentiary centers. hallucinogens, amphetamines, cannabis, cocaine, opioids, sedatives, and other substances), anxiety disorders (i.e., social phobia, post-traumatic stress disorder, generalized Measures anxiety disorder, substance-induced anxiety disorder, and anxiety disorder not otherwise specified), ADHD, Sociodemographic and criminal characteristics learning, and personality disorders (i.e., paranoid, schizoid, The CIRE provided information on the sociodemographic antisocial, borderline, narcissistic, avoidant, dependent, and and criminal characteristics of prisoners who took part of obsessive-compulsive). the study. It included gender (men, women), age, nationality, civil status (single, in a relationship), educational level (less than compulsory education, compulsory education or higher), Statistical analyses employment situation prior to imprisonment (unemployed, employed), age of first conviction, number of imprisonments, All analyses were performed in SPSS version 25.0 (IBM), reason for incarceration, and length of stay. Based on the type with a two-tailed p-value ≤ 0.05 as significance threshold. of offense leading to incarceration, participants were classified Descriptive statistics were calculated to summarize the in two major crime categories: violent crimes and non-violent sociodemographic and criminal characteristics of prisoners, crimes. Violent crimes included robbery with violence, property and to estimate the prevalence rates of mental disorders. crimes with violence, bodily harm, domestic violence, organized Multivariate regression analyses were then performed crime, attempted homicide, and murder. Non-violent crimes to identify significant variables for repeat incarceration were defined as robbery, vandalism, traffic offenses, tax evasion, (continuous variable) and violent offending (yes, no). Potential computer crimes, obstruction of justice, parole violation, drug predictors included factors which have been previously possession, and trafficking. addressed in the literature (Lewis et al., 1980; Lindgren et al., 2002; Harris et al., 2006; Macciò et al., 2015; Alevizopoulos Psychiatric disorders and Igoumenou, 2016; White et al., 2016; Kim et al., 2017; Current and past psychiatric disorders were determined Krona et al., 2017; Román-Ithier et al., 2017; Garofalo et al., with the Spanish version of the Structured Clinical Interview 2018; Nacher et al., 2018; Fernández-Pacheco Alises et al., for DSM-IV (SCID-I and SCID-II), a semi-structured diagnostic 2022; Karlsson and Håkansson, 2022; Streb et al., 2022); interview that assesses Axis I and Axis II disorders according namely, gender (men, women), age (continuous variable), to the DSM-IV criteria (First et al., 1997a,b). The procedure nationality (Spanish, foreign origin), educational level (less consists of an open-ended overview that includes questions than compulsory education, compulsory education or higher), about demographic information, past and present periods of number of lifetime diagnoses (continuous variable), history psychopathology, treatment history and current functioning, of any mood disorder (yes, no), psychotic disorder (yes, no), followed by separate diagnostic modules. The Diagnostic SUD (yes, no), anxiety disorder (yes, no), and ADHD (yes, Interview for ADHD in adults (DIVA 2.0), which is available no), any current learning disorder (yes, no), and personality and validated in Spanish, was administered to diagnose ADHD, disorder (yes, no). However, given its limited sample size, the both at current time (adulthood) and retrospectively (childhood, present study was not sufficiently powered to test all potential before the age of seven) (Kooij, 2012; Ramos-Quiroga et al., predictors simultaneously. Therefore, bivariate analyses were 2019). It evaluates the presence of ADHD symptoms as reported first conducted, using Fisher’s exact tests, Chi-square tests, in the DSM-IV and the impairment caused in five areas of Student’s t-tests or Pearson’s correlation coefficients, and daily life (i.e., work and education, relationships and family variables with p-values < 0.1 were subsequently entered in the life, social contacts, free time and hobbies, self-confidence, final models, as described in previous investigations (Fazel and and self-image) by providing several specific examples, for Seewald, 2012; Kim et al., 2017). Last, we undertook sensitivity each age period, to facilitate recognition. Additionally, learning analyses by entering all potential predictors in the models to disorders were examined with the Battery for the Evaluation assess the robustness of the findings and minimize the instances of Reading Processes in Junior and Senior High-School of p-hacking (Raj et al., 2018). Frontiers in Psychology 04 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 TABLE 1 Sociodemographic and criminal characteristics of the TABLE 1 (Continued) study population. Total sample Total sample (n = 140) (n = 140) Computer crimes 1 (0.72) Sociodemographic characteristics Obstruction of justice 1 (0.72) Gender (n, %) Parole violation 2 (1.44) Men 131 (93.6) Drug possession 20 (14.4) Women 9 (6.43) Drug trafficking 11 (7.91) Age, years (M, SD) 39.5 (10.1) Differences in sample sizes across variables are due to missing data. Nationality (n, %) Spain 86 (61.4) Results Europe 7 (5.00) Latin America 28 (20.0) Sample characteristics Africa 17 (12.1) Asia 2 (1.43) The sample included 131 (93.6%) men and 9 women (6.43%), with ages ranging from 20 to 66 years (M = 39.5, Civil status (n, %) SD = 10.1). Most of the participants (87.9%) completed Single 77 (55.0) compulsory education or had a higher degree, 55.1% had been Married or with a partner 63 (45.0) employed prior to incarceration, and 45% were in a relationship. Education level (n, %) Subjects were predominantly Spanish (61.4%) and those of Less than compulsory education 17 (12.1) foreign origin (38.6%) came mostly from Spanish-speaking countries (20.0%) and Morocco (11.4%). Approximately 60% Compulsory education or higher 123 (87.9) of the inmates were sentenced for a violent crime (e.g., Employment status prior to imprisonment (n, %) robbery with violence, domestic violence, bodily harm, and Unemployed 31 (22.5) murder) and 43 (30.7%) had already been incarcerated for Employed 76 (55.1) previous convictions, including at least one violent act in most Other 31 (22.5) cases. Overall, the average number of imprisonments varied from 1 to 12 (M = 1.62, SD = 1.47) and the age of first Criminal record conviction was 30.6 years (SD = 11.0, range = 16–59). Table 1 Age of first conviction (M, SD) 30.6 (11.0) presents the sociodemographic and criminal characteristics of Previous imprisonment (n, %) the sample. No 97 (69.3) Yes 43 (30.7) Number of imprisonments (M, SD) 1.62 (1.47) Lifetime prevalence of mental Length of last imprisonment, months (M, SD) 79.5 (65.2) disorders and comorbidities Type of offenses (n, %) A large majority of prisoners (81.4%) met criteria for at Robbery with violence 44 (31.7) least one Axis I disorder according to the DSM-IV. The most Property crimes with violence 3 (2.16) common diagnoses were SUD (51.4%), followed by ADHD Bodily harm 9 (6.47) (31.4%) (Table 2). In particular, subjects suffering from SUD mainly had problems with cocaine (32.1%), alcohol (27.9%), and Domestic violence 10 (7.19) cannabis (18.6%) misuse, and most of them abused multiple Organized crime, terrorist organization 4 (2.88) substances during their lifetime. With regard to ADHD, a total Attempted homicide 4 (2.88) of 21 (15.0%) participants were diagnosed with the combined Murder 9 (6.47) subtype, 8.57% met criteria for the hyperactive-impulsive Robbery 9 (6.47) subtype, and 7.86% had the inattentive subtype. Furthermore, 24 (17.1%) prisoners were found to meet criteria for a lifetime Vandalism 1 (0.72) psychotic disorder, mostly induced by substance use (15.7%), Traffic offenses 3 (2.16) while 13.6% suffered from internalizing disorders, including Tax evasion, fraud 8 (5.76) any anxiety and mood disorder (7.14 and 6.43%, respectively) (Continued) (Table 2). Frontiers in Psychology 05 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 TABLE 2 Lifetime and current prevalence of mental disorders. TABLE 2 (Continued) Lifetime Current Lifetime Current prevalence % prevalence % prevalence % prevalence % (n/N) (n/N) (n/N) (n/N) Axis I disorders 81.4 (105/129) 59.0 (72/122) Cluster B Mood disorders 6.43 (9/140) 1.43 (2/140) Antisocial personality disorder 12.5 (17/136) Major depressive disorder 4.29 (6/140) 1.43 (2/140) Borderline personality disorder 0.74 (1/136) Mood disorder due to a general 0.71 (1/140) 0.00 (0/140) Narcissistic personality disorder 0.74 (1/136) medical condition Cluster C Substance-induced mood 2.14 (3/140) 0.71 (1/140) Avoidant personality disorder 1.47 (2/136) disorder Dependent personality disorder 0.74 (1/136) Substance use disorders 51.4 (72/140) 5.71 (8/140) (dependence/abuse) Obsessive-compulsive personality 4.41 (6/136) disorder Alcohol 27.9 (39/140) 2.14 (3/140) Comorbid disorders Hallucinogens 3.57 (5/140) 0.00 (0/140) No mental disorder 13.3 (16/120) 28.3 (34/120) Amphetamines 4.29 (6/140) 0.00 (0/140) One mental disorder 25.8 (31/120) 48.3 (58/120) Cannabis 18.6 (26/140) 3.57 (5/140) Two mental disorders 33.3 (40/120) 18.3 (22/120) Cocaine 32.1 (45/140) 0.71 (1/140) Three mental disorders 15.8 (19/120) 5.00 (6/120) Opioids 15.0 (21/140) 0.00 (0/140) Four or more mental disorders 11.7 (14/120) 0.00 (0/120) Sedatives 3.57 (5/140) 1.43 (2/140) Differences in sample sizes across variables are due to missing data. NA, not applicable; Other substances 0.71 (1/140) 0.00 (0/140) NOS, not otherwise specified. Psychotic disorders 17.1 (24/140) 0.71 (1/140) Schizophrenia 0.71 (1/140) 0.71 (1/140) As shown in Table 2, there was a high rate of comorbidity Delusional disorder 0.71 (1/140) 0.00 (0/140) (60.8%), ranging from two to five disorders. Specifically, 33.3% Substance-induced psychotic 15.7 (22/140) 0.00 (0/140) of the inmates were diagnosed with two mental illnesses during disorder their lifetime, 15.8% had three diagnoses, and 11.7 met criteria Anxiety disorders 7.14 (10/140) 2.86 (4/140) for at least four disorders. Social phobia 0.71 (1/140) 0.71 (1/140) Post-traumatic stress disorder 0.71 (1/140) 0.00 (0/140) Current prevalence of mental disorders Generalized anxiety disorder 1.43 (2/140) 1.43 (2/140) and comorbidities Substance-induced anxiety 1.43 (2/140) 0.00 (0/140) disorder Axis I disorders were currently present in 59.0% of Anxiety disorder NOS 2.86 (4/140) 0.71 (1/140) the sample, including learning disorders (38.6%), ADHD Attention deficit/hyperactivity 31.4 (44/140) 16.4 (23/140) (16.4%), and SUD (5.71%) among the most frequent clinical disorder syndromes (Table 2). Particularly, almost half of the inmates Inattentive 7.86 (11/140) 3.57 (5/140) who were diagnosed with a learning disorder had difficulties Hyperactive-impulsive 8.57 (12/140) 7.86 (11/140) in reading and written expression, which represented 21.7% Combined 15.0 (21/140) 5.00 (7/140) of the entire sample. Eleven (7.86%) participants suffered from the ADHD hyperactive-impulsive subtype, 7 (5.00%) Learning disorders NA 38.6 (54/120) met criteria for the combined subtype, and 5 (3.57) had Reading 6.67 (8/120) the inattentive subtype. With regard to SUD, cannabis- and Written expression 16.7 (20/120) alcohol-related disorders were the most prevalent categories Reading and written expression 21.7 (26/120) (3.57 and 2.14%, respectively). A current psychotic disorder was Axis II disorders NA 26.5 (36/136) only found in one (0.71%) subject, who received a diagnosis of schizophrenia. Anxiety disorders were detected in four Cluster A (2.86%) prisoners, half of whom had generalized anxiety Paranoid personality disorder 4.41 (6/136) disorder, and the prevalence rate of mood disorders (i.e., major Schizoid personality disorder 1.47 (2/136) depressive disorder, substance-induced mood disorder) was (Continued) 1.43% (Table 2). Frontiers in Psychology 06 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 TABLE 3 Variables associated with repeat incarceration in the TABLE 4 Variables associated with violent offending in the multivariate linear regression analysis. multivariate logistic regression analysis. Independent variables β SE P-value Independent variables OR 95% CI P-value Age 0.031 0.012 0.008 Gender (ref. women) 10.3 1.08–98.0 0.043 Nationality −0.23 0.27 0.403 Lifetime SUD (ref. no) 3.39 1.45–7.95 0.005 Lifetime SUD 0.54 0.25 0.034 Lifetime ADHD (ref. no) 1.68 0.67–4.22 0.274 Lifetime ADHD 0.70 0.26 0.009 Current LD (ref. no) 2.69 1.13–6.36 0.025 ADHD, attention deficit/hyperactivity disorder; SE, standard error; SUD, ADHD, attention deficit/hyperactivity disorder; CI, confidence interval; LD, learning substance use disorders. disorders; OR, odds ratio; SUD, substance use disorders. Moreover, 36 (26.5%) participants met criteria for a significant when both factors were taken into account [men: current Axis II disorder, which commonly was an antisocial odds ratio (OR) = 10.2, 95% confidence interval (CI) = 1.18– personality disorder (12.5%), a paranoid personality disorder, 88.1, p = 0.035; comorbidities: OR = 1.59, 95% CI = 1.12–2.27, or an obsessive-compulsive personality disorder (both 4.41%) p = 0.010] and were not affected by the adjustment for all (Table 2). potential covariates (men: OR = 13.1, 95% CI = 1.39–122.9, Overall, 48.3% of the inmates had only one mental illness, p = 0.024; comorbidities: OR = 1.54, 95% CI = 1.05–2.26, 18.3% were diagnosed with two psychiatric disorders, and 5.00% p = 0.027). Regarding the main diagnostic categories, only SUD suffered from three comorbid disorders. [63.2 vs. 32.1%, χ2 (1, N = 140) = 12.8, p < 0.001], ADHD [36.8 vs. 22.6%, χ2 (1, N = 140) = 3.06, p = 0.080], and learning disorders [53.9 vs. 29.5%, χ2 (1, N = 120) = 6.70, p = 0.010] Association between psychiatric were overrepresented among violent offenders. In the adjusted disorders and criminal history model, significant predictors included gender, having a lifetime diagnosis of SUD and current learning disorders, while ADHD Bivariate analyses indicated that repeat incarceration was was no longer associated with violent offending (Table 4). These significantly associated with age, nationality, and comorbidity. results seem to be robust, since the risk estimates hardly changed Specifically, the number of imprisonments was higher among with sensitivity analysis (men: OR = 14.7, 95% CI = 1.36–159.2, older inmates (r(139) = 0.225, p = 0.008), Spanish (1.91 vs. 1.17, p = 0.027; SUD: OR = 4.05, 95% CI = 1.50–10.9, p = 0.006; t (138) = 2.98, p = 0.003), and subjects who received multiple learning disorders: OR = 2.63, 95% CI = 1.02–6.76, p = 0.045). diagnoses during their lifetime (r(120) = 0.253, p = 0.005). The influence of nationality did not remain significant (p = 0.134) in the multivariate linear regression model, whereas age (β = 0.039, p = 0.005) and comorbidity (β = 0.28, p = 0.016) increased the Discussion number of imprisonments, even when all potential predictors were considered (age: β = 0.037, p = 0.007; comorbidity: The current research investigates for the first time the β = 0.26, p = 0.029). Furthermore, when we examined the prevalence of mental disorders and comorbidities in Spanish main diagnostic categories, we found a significant relationship inmates who are about to be released, and their association with between the number of imprisonments, ADHD (2.18 vs. 1.36, repeat incarceration and violent offending. Using standardized t (138) = −3.15, p = 0.002), and SUD (2.00 vs. 1.22, t (138) = −3.24, diagnostic instruments, our findings demonstrate that prisoners p = 0.002), even after controlling for age and nationality. at the end of their sentence are still characterized by a high Indeed, prisoners with a lifetime diagnosis of ADHD or SUD prevalence of psychiatric disorders, which can significantly had higher odds of being in jail more than once (Table 3). jeopardize the effectiveness of occupational programs aimed Mood disorders, psychotic disorders, anxiety disorders, learning at promoting their successful reintegration into society. disorders, and personality disorders, by contrast, showed no link Specifically, almost half of the participants (48.3%) met criteria with repeat incarceration (p > 0.1). Sensitivity analysis showed for a current Axis I or Axis II disorder and 23.3% suffered consistent results, indicating the robustness of these findings from two or more comorbid disorders, including learning (age: β = 0.041, p = 0.003; SUD: β = 0.68, p = 0.026; ADHD: disorders, personality disorders, ADHD, and SUD among the β = 0.64, p = 0.034). most common diagnoses. In addition, the present study showed On the other hand, inmates convicted of at least one that older age and a history of ADHD increased the number violent act were more frequently men (97.7 vs. 2.30%, χ2 (1, of imprisonments. On the other hand, inmates convicted of at N = 140) = 6.52, p = 0.027) and met criteria for more lifetime least one violent crime during their lifetime were more likely to psychiatric disorders (2.18 vs. 1.43, t (118) = −3.23, p = 0.002), be men and present a current learning disorder. Finally, having according to bivariate analyses. These associations remained a lifetime diagnosis of SUD or multiple psychiatric disorders Frontiers in Psychology 07 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 appeared to be associated with both repeat incarceration and with a 1-month prevalence of 82.3, 23.3, 14.9, and 4.2%, violent offending. respectively (Vicens et al., 2011). Nevertheless, only 36 (26.5%) Overall, the results confirmed the high prevalence of of our participants met criteria for a current Axis II disorder, psychiatric disorders previously identified among prisoners four (2.86%) suffered from anxiety disorders, and mood across different countries, although estimates have been shown disorders were present in two (1.43%) inmates. Finally, although to vary widely (e.g., 41–90%) (Vicens et al., 2011; Macciò et al., considerably lower, our rates of psychotic disorders (i.e., 0.71%) 2015; Alevizopoulos and Igoumenou, 2016; Garofalo et al., 2018; are grossly elevated compared with those within the community, Nacher et al., 2018; Heller et al., 2022). Of note, the only where the prevalence for schizophrenia and related disorders previous study conducted in Spanish male prisoners reported a is estimated to be 0.4% (Moreno-Küstner et al., 2018), and 1-month prevalence of 41.2% for any Axis I disorder according echo the values provided by Macciò et al. (2015) in Italian to the SCID-I (Vicens et al., 2011), which is particularly close prisoners (i.e., 1.3%). Likewise, Bulten et al. (2009) showed to our figures (i.e., 59%). More specific, SUD was one of the that only one (0.5%) of 191 inmates admitted to the general most frequent diagnoses (17.5%) and 76.2% of the inmates ward of a Dutch correctional institution was diagnosed with appeared to have a history of drug misuse (abuse and/or such disorders. In contrast, the lifetime prevalence for psychotic dependency), with cocaine, cannabis, and alcohol being the disorders in the present study was 17.1%, most of whom (91.7%) primarily consumed substances (Vicens et al., 2011). Likewise, were substance-induced, which confirms that substance use is a SUD were highly overrepresented in the present study, where factor increasing the chance of incarceration (Baillargeon et al., 72 (51.4%) subjects received a lifetime diagnosis, and the 2010) and demonstrates the effectiveness of the prison system in most commonly used drug was cocaine, followed by alcohol detecting and monitoring drug users. and cannabis. The current prevalence of SUD, on the other Interestingly, Vicens et al. (2011) did not evaluate ADHD, hand, fell to 5.71%, which could be partly explained by the despite the elevated rates consistently observed among juvenile institutional bans and detoxification programs implemented in offenders worldwide and the evidence that symptoms persist prison. Indeed, a considerable body of evidence suggests that into adulthood for most children. Indeed, a meta-analysis imprisonment may represent a unique opportunity to identify based on 42 studies provided a prevalence of 25.5% among individuals with a history of substance use and initiate addiction youth and adult incarcerated populations when using diagnostic treatments that significantly improve their health (Degenhardt clinical interviews (Young et al., 2015). More recently, Vélez- et al., 2014; de Andrade and Kinner, 2016; Mundt et al., 2018; Pastrana et al. (2020) conducted a cross-sectional study in 500 Bukten et al., 2020). However, the majority of interventions fail Latino male prisoners aged 18–74 and found that 17% met to produce long-term benefits and most prisoners return to use DSM diagnostic criteria for adult ADHD. Similarly, Hamzeloo substances upon release (Puljević et al., 2017). In this sense, et al. (2016) reported a prevalence of 16.2% among adult male it should be noted that while the observed current prevalence inmates in Iran. Consistent with these previous investigations, was considerably low compared to lifetime prevalence, SUD 23 (16.4%) of our participants suffered from ADHD, which is were still five times more frequent among prisoners who were substantially higher than the rate detected in adult community ending their sentence than in the general Spanish population samples (i.e., 2.5–4.4%) (Kessler et al., 2006; Fayyad et al., 2007; (Navarro-Mateu et al., 2015). Moreover, our research showed Simon et al., 2009). Besides, 44 (31.4%) subjects received a that having a history of SUD was related to repeat incarceration lifetime diagnosis of ADHD and childhood ADHD was found and increased the risk of being convicted for a violent crime, to be associated with a greater number of imprisonments which is consistent with previous studies (Steadman et al., as described elsewhere (Gaïffas et al., 2014; Mohr-Jensen 1998; Baillargeon et al., 2010; Young et al., 2011; Macciò and Steinhausen, 2016; Román-Ithier et al., 2017; Philipp- et al., 2015; White et al., 2016; Nacher et al., 2018). Taken Wiegmann et al., 2018). Research also suggests that ADHD together, the present findings emphasize the need to promote may negatively impact rehabilitation and educational programs, detoxification treatments both in prison and as individuals with and inmates with ADHD are more likely to exhibit poorer SUD transition back to the community in order to facilitate their outcomes following release (Cahill et al., 2012; Scott et al., 2016). reintegration and employability (Bukten et al., 2020). Indeed, Specifically, according to longitudinal studies subjects who Bahr et al. (2010) examined the extent to which drug treatment present the hyperactive-impulsive subtype, which was the most was associated with the reentry of parolees after release and currently frequent in the present sample (i.e., 7.86%), may be at found that those who succeeded were more likely to have taken greater risk of ending up in prison as a result of behaviors such as a substance abuse class while in prison (Bahr et al., 2010). fast driving, illegal drug use, impulsive gambling, and a variety On the other hand, the prevalence of personality, anxiety, of antisocial activities (Barkley et al., 2004; Satterfield et al., mood, and psychotic disorders in our sample contrasts starkly 2007; Cahill et al., 2012). Given the disproportionately high rate with estimates reported by Vicens et al. (2011). Particularly, of ADHD still present among prisoners who are in the final these authors found that personality, anxiety, mood, and stage of their sentence and the increased probability of further psychotic disorders were among the most common diagnoses, incarcerations, our results highlight that providing appropriate Frontiers in Psychology 08 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 mental health care within the prison setting and after release is Overall, the significant prevalence of neurodevelopmental crucial to reduce recidivism, enhance the rehabilitation process disorders found among prisoners who are ending their of inmates, and facilitate their successful integration in the sentence questions the effectiveness of the practices used community. In this vein, effective management of ADHD has within the justice system to identify and support these shown to improve psychiatric symptoms and comorbidities, vulnerable individuals. For instance, current approaches tend decrease violent and delinquent behavior, increase participation to assume typical levels of verbal and cognitive competence, in social, vocational, and/or educational programs, and promote and may be inappropriate for people with such conditions employability after release (Scott et al., 2016). given their specific developmental needs and learning styles. Furthermore, there is significant evidence that a high Thus, a lack of identification or insufficient awareness of the proportion of adults with ADHD may also have a comorbid varied needs associated with neurodevelopmental disorders condition, including other neurodevelopmental disorders. can lead to poor engagement in interventions intended However, studies examining the prevalence of such disabilities to address offending behavior, promote rehabilitation, and within the prison system are still limited. Therefore, one salient increase employability (Hughes et al., 2017; Borschmann et al., finding of the current research concerns the high frequency of 2020). Conversely, programs that recognize the difficulties learning disorders identified among inmates who are about to be of the individual typically yield better learner achievement released. In particular, the rate of learning disorders was 38.6%, (Reid and Kirk, 2001). with reading difficulties being present in 28.3% of the sample, Finally, another key finding was related to psychiatric while the prevalence for dyslexia in the general population comorbidities, given the sparse research and wide variability stands at 10% (Hughes et al., 2012). In accordance with our in prevalence rates observed across countries and specific results, previous investigations from several Western criminal settings. In this sense, previous investigations, including justice systems have reported a notable overrepresentation that from Vicens et al. (2011), have mainly examined of learning disorders among incarcerated adults, although co-occurring SUD and Axis I disorders, with estimates estimates strongly vary (e.g., 30–76%) as a result of differences ranging between 6 and 95% (Vicens et al., 2011; Fazel and in the definitions and assessment procedures used (Einat and Seewald, 2012; Baranyi et al., 2022). Of note, 60.8% of Einat, 2008; Elbeheri et al., 2009; Hughes et al., 2012). Indeed, the participants had multiple psychiatric disorders during research that identifies disproportionately large rates of dyslexia their lifetime and 23.3% were currently diagnosed with two within prisons may be confounding specific learning difficulties or more comorbid conditions, suggesting that comorbidity with more generalized learning disabilities derived from low represents more a rule than an exception among the intelligence (Elbeheri et al., 2009). On the other hand, this study incarcerated population (Bebbington et al., 2017; Garofalo revealed that inmates convicted of at least one violent crime et al., 2018; Heller et al., 2022). Furthermore, our study during their lifetime were more likely to present a learning revealed that the risk for repeat incarceration and violent disorder, which provides further evidence for the contribution offending increased with the number of lifetime diagnoses. of these disabilities to criminality. Similarly, reading problems Consistently, the presence of psychiatric comorbidities has have been found to be associated with antisocial or aggressive been related to less social competence, worse treatment behaviors, violence, and recidivism (Lewis et al., 1980; Lindgren outcomes, and higher odds of relapse into crime, especially et al., 2002; Simonoff et al., 2004; Harris et al., 2006). As violent reoffending (Chang et al., 2015; Kim et al., 2017; learning difficulties manifest early in life, subjects whose dyslexia van Buitenen et al., 2020). goes undiagnosed or receive inappropriate educational support might experience considerable pain, social stigma, harassment, and denigration in the school environment, which might turn Strengths and limitations into forms of deviant behavior as a way of responding to their low self-esteem and achieve peer recognition (Elbeheri The findings of this first attempt to estimate the prevalence et al., 2009). Besides, this environment may discourage many of mental disorders and comorbidities among offenders people with such problems from attending school and eventually completing prison sentences should be interpreted in lead to drop-out, thus increasing the risk of engagement in light of several limitations. First, the assessment of past criminal activity as suggested by earlier studies that indicate a disorder symptoms based on participants’ recall might have causal relationship between quitting school, lack of education, undercounted lifetime prevalence, since we were unable and offending behavior (Einat and Einat, 2008). Finally, to corroborate this information with collateral reports or language impairments are common among adults with learning medical records (Navarro-Mateu et al., 2015). However, the disabilities (Vogel, 1997) and poor communication skills may semi-structured design of the diagnostic instruments used, result in difficulties understanding the perspective of others or which were administered by experienced clinicians, have the use of challenging behavior, including reactive aggression, as shown to diminish this recall bias (Knäuper et al., 1999). a means to express feelings (Hughes et al., 2017). Some potential confounders, including life events, financial Frontiers in Psychology 09 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 problems or parental psychopathology, were not available in the community. However, further epidemiological and either. Therefore, the retrospective and cross-sectional design longitudinal studies, with larger representative samples, are of the study prevents from establishing conclusions on causality required to provide accurate prevalence estimates and fully between variables, although retrospective studies may be validate our results. Future research should also determine an important tool to investigate rare phenotypes, such as whether rehabilitation services tailored to fit the abilities, repeat incarceration or violent offending, on relatively large learning styles, and needs of offenders with mental disorders samples from neurodevelopmental and lifetime mental health can ultimately change their trajectory and improve outcomes perspectives (Hofvander et al., 2017; Talari and Goyal, 2020). following release. Besides, the relatively small sample size may have limited the power of our analyses to determine additional significant correlations. Lastly, participants were recruited from an Data availability statement occupational program aimed at promoting the integration into society of inmates. In particular, the program was restricted The raw data supporting the conclusions of this article will to subjects with a valid Spanish ID card or an employment be made available by the authors, without undue reservation. authorization for offenders, who indicated their willingness to initiate the rehabilitation process and were at the lowest category within the prison system, which allows day release Ethics statement privileges. Otherwise, eligible candidates had to be on parole or convicted with alternative measures to imprisonment. The studies involving human participants were reviewed Therefore, findings are not representative of the entire Spanish and approved by the Ethics Committee of the Vall d’Hebron prison population and may not generalize to other regions Hospital Universitari, the Department of Justice (Generalitat de or samples. By contrast, the main strengths include the Catalunya, Spain), and the involved penitentiary centers. The involvement of women as study participants, the availability patients/participants provided their written informed consent to of official offending history from criminal records, and the participate in this study. use of standardized clinical interviews based on the DSM criteria, such as SCID-I and SCID-II, which leads to more replicable and valid diagnoses (Segal et al., 2012). Nevertheless, Author contributions the SCID does not provide information on the severity of the evaluated disorders and some psychiatric diagnoses (e.g., MP and SV: study conception and design, data analysis, and intellectual disabilities, autism spectrum disorders, oppositional interpretation of results. LD: data collection. SV: data curation. defiant disorder, sexual disorders) are not covered. Finally, RB and MC: study supervision. MC: funding acquisition. the assessment of both lifetime and current prevalence gives a MP: writing—draft manuscript preparation. SV, RB, and MC: wider view of the mental health problems among incarcerated writing—review and editing. All authors read and approved the adults. final version of the manuscript. Conclusion Funding Our results demonstrate that inmates who are about This work was funded by Fundació “la Caixa” and Vall to be released are still characterized by a higher rate of d’Hebron Institut de Recerca (VHIR). The funders were not psychiatric disorders than the general population, including involved in the study design, collection, analysis, interpretation neurodevelopmental disorders and SUD among the most of data, the writing of this article or the decision to submit it common diagnoses. On the other hand, childhood ADHD for publication. was found to be associated with a greater number of imprisonments and subjects convicted for a violent crime were more likely to present a learning disorder, while a Acknowledgments history of SUD was related to both repeat incarceration and violent offending. Given the increased risk of recidivism We are grateful to Fundació “la Caixa,” Departament de among mentally ill inmates and the challenges they confront Justícia and Departament de Salut (Generalitat de Catalunya, to benefit from occupational programs, the present research Spain), Vall d’Hebron Institut de Recerca (VHIR), and Institut highlights the need for early identification and provision of MIND (Hospital Sant Joan de Déu) for their support. We also appropriate psychiatric care within the prison setting and thank Paola Sancho and M. Carmen Calderón from Centre after release in order to facilitate their successful reintegration d’Iniciatives per a la Reinserció for their cooperation in initiating Frontiers in Psychology 10 frontiersin.org Pagerols et al. 10.3389/fpsyg.2022.1039099 the project. Last, we express our gratitude and our respects to relationships that could be construed as a potential conflict Marina Comin, who passed away in February 2021, for her of interest. assistance with data collection. Conflict of interest Publisher’s note MC has received travel grants and research support from All claims expressed in this article are solely those of the Eli Lilly and Co., Janssen-Cilag, and Shire. He was on the authors and do not necessarily represent those of their affiliated advisory board and served as a consultant for Eli Lilly and Co., organizations, or those of the publisher, the editors and the Janssen-Cilag, and Shire. reviewers. Any product that may be evaluated in this article, or The remaining authors declare that the research was claim that may be made by its manufacturer, is not guaranteed conducted in the absence of any commercial or financial or endorsed by the publisher. References Aebi, M. F., and Tiago, M. M. (2021). 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