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Institutionalised care for people with mental disorders in South America: indicators and trends (INCAS)

Centre for Psychiatry

Funding Body: Commission of the European Community
International Outgoing Fellow: Adrian Mundt
Project Investigator: Stefan Priebe


Marie Curie, FP7, European Flag

In the Caracas declaration of 1990, South American countries committed themselves to improve the human rights situation and social inclusion of people with mental disorders, de-institutionalise their care and develop community mental health services. There is however little evidence on the extent to which this has happened and what the current trends are. Indicators of institutionalised care include the provision of psychiatric hospital beds, forensic psychiatric beds, involuntary admission rates, supported housing, and residential homes. A particular question was how many people with mental disorders have been imprisoned, since the prison population increased substantially over the past decade.
The study had two aims

  1. to assess indicators of institutionalised care for people with mental disorders across South America since 1990 and identify possible relationships between psychiatric bed removals and increase of prison population rates;
  2. to establish the rate of people with mental disorders in a prison population in Chile in a consecutive sample of admissions to the penal justice system.

Sufficiently reliable data on psychiatric bed numbers and prison populations over time were obtained from six South American countries including Argentina, Bolivia, Brazil, Chile, Paraguay and Uruguay. The inverse relationship between psychiatric bed numbers and prison population rates was tested using country fixed effects panel data regression analysis. The relationship was highly significant. Prison population rates increased more, when and where more psychiatric beds were removed. There were on average 5.2 more prisoners for every psychiatric bed removed in the last two decades. The relationship was controlled for socio-economic indicators and in part but not fully explained by increases of per capita Gross National Income. The relationship remained unchanged when controlled for trends in income inequality
(Mundt et al. Psychiatric bed numbers and prison population rates in South America since 1990: Does the Penrose-Hypothesis apply? JAMA Psychiatry, 2015;72(2):112-8.)

A sample of 427 prisoners was assessed upon entry to the penal justice system in Santiago de Chile using a structured clinical interview. More than half of the sample had severe mental disorders including major depression and/or psychosis. Three quarter of the male prisoners and one third of the female prisoners additionally had a substance use disorder.
(Mundt et al. Prevalence of mental disorders at admission to the penal justice system in emerging countries: a study from Chile, Epidemiology and Psychiatric Sciences 2015 June 19. Epub ahead of print. Doi: 10.1017/S2045796015000554)

In all, our data support the hypothesis that severely mentally ill, especially those with comorbid substance use problems are increasingly institutionalized in the penal justice systems. Service development has to target people with mental health problems in prisons and link them with community care systems at the transition to community life. In the absence of large psychiatric hospitals and long-term psychiatric hospitalisation, new strategies are needed to prevent people with severe mental health problems to get imprisoned.

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