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Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis

  • Seena Fazel (a1) and Katharina Seewald (a2)

High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low–middle-income countries compared with high-income ones.


To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression.


Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders.


We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% (95% CI 3.1–4.2) in male prisoners and 3.9% (95% CI 2.7–5.0) in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low–middle-income countries reporting higher prevalences of psychosis (5.5%, 95% CI 4.2–6.8; P=0.035 on meta-regression). The pooled prevalence of major depression was 10.2% (95% CI 8.8–11.7) in male prisoners and 14.1% (95% CI 10.2–18.1) in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA (P=0.008).


High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.

Corresponding author
Seena Fazel, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK. Email:
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K.S. was funded by the German Friedrich-Ebert Stiftung.

Declaration of interest


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Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis

  • Seena Fazel (a1) and Katharina Seewald (a2)
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Reply to Fazel and Sewald Severe Mental Illness in 33588 prisoners

Michael Fitzgerald, Consultant Child & Adult Psychiatrist
21 July 2012

Dear Editors,

Fazel and Sewald [1] make useful comments on psychosis and major depression in prisoners. The more serious mental disorders in prisoners responsible for much of imprisonment and re-offending are ADHD and it's comorbidities. It is time researchers focusing on mental disorder in prisoners focus on the common ADHD [2] and comorbidities and not exclusively on the rarer "severe mental illness" that is "psychosis and major depression". The major focus of forensic psychiatry is very out of date now and indeed excessively narrow in assessing prisoners.[3]


1. Fazel S. Sewald K. Severe mental illness in 33588 prisoners worldwide: Systematic review and meta regression analysis. Br. J. Psychiatry 2012; 200: 364/378

2. Curran S. Fitzgerald M. Attention Deficit Hyper Activity Disorder in prison population. American Journal of Psychiatry 1999; 156: 1664/1665

3. Fitzgerald M. Young, Violent and Dangerous To Know. Nova Science:New York 2010

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Conflict of interest: None declared

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Severe mental illness in prisoners worldwide

David J. Vinkers, Psychiatrist
24 June 2012

To the editor,

With much interest, we read the review article by Fazel and Seewald in the May issue of The Journal (1). The authors conclude that severe mental illness is more prevalent in prisoners in low- and middle-income countries than in high-income countries. This may be related to fewer opportunities and services for diverting offenders to health services, a stronger relationship between mental illness and criminality, and different socio-cutural factors, e.g. poorer legal representation for the mentally ill in low- and middle-income countries. We examined in an earlier study the relationship between mental illness and criminality in pre-trial reported Antillean defendants in the Netherlands and the Netherlands Antilles (2). Defendants who are suspectedto suffer from mental illness are pre-trial examined by a psychiatrist or psychologist both in the Netherlands and the Netherlands Antilles, before diversion to mental health services takes place. We found no significant difference in prevalence of psychotic disorders among pre-trial reported Antillean suspects in the Netherlands and the Netherlands Antilles (14.4 %vs. 15.1 %) and no significant difference in the prevalence of defendants deemed unaccountable due to a mental disorders (3.9 % vs. 4.0 %). There was, however, a much lower registered crime rate of Antilleans in the Netherlands Antilles than the Netherlands (11 vs. 113 offences per year per 1000 persons; p < 0.001) and a much higher rate of pre-trial reports in the Netherlands Antilles than the Netherlands (74 vs. 8 per 1000 Antillean defendants; p < 0.001). Antilleans living in the Netherlands Antilles thus have a low crime rate and a high pre-trial report rate when indicted of a crime as compared with Antilleans in the Netherlands, indicating that they are more frequently suspected to suffer from a mental illness. This finding is in line with the earlier formulatedrule of thumb that the frequency of mental illness is higher in countries with low crime rates (3,4). Indeed, the low- and middle-income countries included in the review of Fazel and Seewald have a combined prison population rate of 77 per 100,000, considerably less than the worldwide prison population rate of 145 per 100,000 (5). The higher prevalence of severe mental illness in prisoners in low- and middle-income countries maybe explained by lower rates of crime and imprisonment. If so, the relationship between mental illness and crime is not stronger in low- and middle- income countries, but weaker in high-income countries.

1. Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry2012; 200: 364-73.2. Vinkers DJ, Heytel FG, Matroos GM, Hermans KM, Hoek HW. Pre-trial psychiatric reports on Antillean suspected offenders in the Netherlands and on the Dutch Antilles. Tijdschr Psychiatr 2010; 52: 745-52.3. Large M, Smith G, Swinson N, Shaw J, Nielssen O. Homicide due to mentaldisorder in England and Wales over 50 years. Br J Psychiatry 2008; 193: 130-3.4. Coid J. The epidemiology of abnormal homicide and murder followed by suicide. Psychol Med 1983; 13: 855-6.5. Walmsley R. (2010). World Prison Population List?(8th ed.). International Centre for Prison Studies, Kings College: London.

David J. Vinkers, MD, PhDNetherlands Institute for Forensic Psychiatry and Psychology, the

Micha van de Vorst, MScPsychiaters Maatschappij Antillen, Curacao.

Hans W. Hoek, MD, PhDParnassia Bavo Psychiatric Institute, The Hague, the Netherlands.Department of Psychiatry, University Medical Center Groningen, University of Groningen, the Netherlands.Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States.

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Conflict of interest: None declared

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