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Rates of prison populations per 100 000 inhabitants (1990-2019). a) Countries with rates higher than 180 per 100 000 population at the last data point; b) Countries with rates lower than 180 per 100 000 population at the last data point.
Source publication
Background
Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture...
Context in source publication
Context 1
... of prison populations increased in 18 countries, and decreased in 12 countries with a median increase of 36% (50 more prisoners per 100 000 population). This ranged from a decrease of 53% (86 fewer per 100 000 population) in Armenia to an increase of 629% (84 more per 100 000) in Kosovo (Fig. 2). Many countries that were formerly part of the Soviet Union, such as the Kyrgyz Republic, Latvia, Ukraine, and Uzbekistan, showed a decrease of over 35% in prison populations from a high rate at the early time points during the period of observation. The greatest increase was seen in countries formerly part of Yugoslavia (Kosovo, ...
Citations
... Despite these encouraging initial steps, tangible change proved to be slow and uneven, and the national rate of involuntary admission (IA) is still on the rise (Situatia internarilor nevoluntare 2020 -CNSMLA, 2021). While there was an initial trend towards reducing the number of inpatient beds (Mundt et al., 2021), resource allocation continues to favor state-run hospitals and, as of 2019, healthcare expenditure on inpatient services is about 15 times that on outpatient services (Radu, Pana, Pele, & Costea, 2021). As there are no privately-owned psychiatric hospitals in Romania, inpatient care, including involuntary admissions, is provided solely in state hospitals. ...
... Based on the few available studies, the Ukrainian mental health care system lacks financial resources [21,25,[44][45][46], workforce capacity and accessability of services [21,22,25,36,[45][46][47]. While insufficient funding for mental health services is common, in Ukraine this situation is dramatically worsened by the war and relicts from Soviet era including overfocus on inpatient care, high out-of-pocket payments and low staff wages leading to workforce shortages [21,46]. ...
The ongoing war in Ukraine is having profound impacts on both the local and global economy, as well as the infrastructure and overall well-being of the people. The prolonged duration of the conflict, coupled with its many related consequences such as total uncertainty, unfavorable economic conditions, and a distressing media backdrop, have a lasting impact on the mental health of the population. The ongoing war in Ukraine has exposed weaknesses in the national mental health care system and underscored the importance of mental health economics. To prevent further mental health problems, it is crucial to develop a comprehensive set of measures aimed at strengthening the capacity of the mental health care system in Ukraine. Currently, Ukraine’s mental health care system suffers from a lack of financial and human resources, which hinders its ability to provide adequate support to those in need. To address this issue, joint efforts between Ukrainian mental health stakeholders and the international governmental and non-governmental organizations are needed to provide support and capacity building for mental health services in Ukraine.
... times lower than recommended by international experts (20,21), suggesting a critical shortage of beds for acute care needs in the region (21). The prevalence of total psychiatric beds in Latin America was lower than in Eastern Europe and Central Asia, representing other middle-income regions (22), and only a little higher than the prevalence in sub-Saharan Africa (23), which has a lower average per capita income. Low prevalence of psychiatric beds has been associated with higher occupancy rates and overcrowding (24); increased readmission rates (25); longer stays in emergency departments (26,27); treatments in other general medical departments (28); increased rates of suicide, violent crime, early death, detention, and homelessness (29)(30)(31)(32); and other adverse social and health outcomes (33). ...
Objective:
Latin America has undergone major changes in psychiatric services over the past three decades. The authors aimed to assess the availability of service data and changes in psychiatric services in this region during the 1990-2020 period.
Methods:
The authors formed a research network to collect data on psychiatric service indicators gathered between 1990 and 2020 from national registries in Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, and Uruguay. Indicators included psychiatric beds in psychiatric and general hospitals overall, for children and adolescents, and for forensic populations; residential beds for substance use treatment; treatment slots in residential facilities and day hospitals; and outpatient facilities.
Results:
Data availability varied among countries, service indicators, and time points. The median prevalence of psychiatric beds decreased in psychiatric hospitals from 5.1 to 3.0 per 100,000 people (-42%) and in general hospitals from 1.0 to 0.8 (-24%). The median prevalence estimates of specialized psychiatric beds for children and adolescents (0.18) and for forensic populations (0.04) remained unchanged. Increases in prevalence were observed for residential beds for substance use treatment (from 0.40 to 0.57, 43% increase), available treatment slots in residential facilities (0.67 to 0.79, 17%), treatment slots in day hospitals (0.41 to 0.54, 32%), and outpatient facilities (0.39 to 0.93, 138%).
Conclusions:
The findings indicate that treatment capacity shifted from inpatient to outpatient and community care. Most countries had a bed shortage for acute psychiatric care, especially for children and adolescents and forensic patients. More comprehensive and standardized mental health service registries are needed.
... In the United States, mental health beds were reduced to 25 beds per 100,000 population, with an average LOS of only 6 days (3). The same trends have also been observed in Central and Eastern Europe (8). ...
... A primary concern in this regard, is the suggestion that this shift may lead to increased criminalization of behavior driven by mental illness, and in some cases to custodial remand as an alternative to inpatient treatment (2,8,15). The prison remand population in Aotearoa increased from 1,800 in 2012, to 3,409 in 2020 (16). ...
Introduction
Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years.
Methods
A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health.
Results
Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission.
Discussion
We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.
... Research involving larger numbers of countries has also yielded mixed results. A study of thirty Eastern European and Central Asian countries found a significant relationship between a decrease in psychiatric beds and increased prison populations in seventeen of these countries over the period 1990-2019; this effect appeared to be greater in countries with a lower per capita income and those which formerly belonged to the Soviet Union [22]; however, a study of twenty-six European countries, covering the period 1993-2011, found only a modest negative correlation between psychiatric beds and prison populations (ρ = −0.35), which was not significant after adjusting for socioeconomic factors [23]. ...
... Earlier studies that were designed specifically to test the Penrose effect found that national income-operationalized as gross national income per capita-was a significant confounder of associations between psychiatric bed strength and the prison population [14,22]. In addition to this, recent review articles on the social determinants of crime were consulted [34][35][36]. ...
The association between mental illness and violent crimes such as homicide is complex. In 1939, Lionel Penrose hypothesized that the availability of psychiatric hospital beds was inversely related to the prison population, presumably due to the hospitalization of potential offenders with a mental illness. Subsequent studies have found evidence for this association, but questions remain about the contributions of confounding factors. Moreover, there has been a move towards deinstitutionalization and community care of the mentally ill over the past six decades. In this study, the association between national homicide rates and three measures of the availability of psychiatric care—the numbers of psychiatrists, general hospital psychiatric beds, and psychiatric hospital beds per 100,000 population—was examined using a time-lagged correlation analysis. Associations between homicide rates and socioeconomic factors associated with crime were also examined. It was found that the availability of psychiatrists and of general hospital psychiatric beds were both negatively correlated with homicide rates, and that the association with general hospital psychiatric beds remained significant even after correction for confounding factors. These results suggest the need for a more nuanced interpretation of Penrose’s original formulation, involving the interplay of social, economic factors and psychological factors rather than linear causality.
... Policies regarding mental health care reforms have also been implemented with varying degrees of success [17,18]. A recent systematic review of expert arguments for changes of psychiatric bed rates reported few recommendations from LMICs and a majority of those arguing to increase rates [19]. The development of community-based public health services and primary health care has often been limited by a lack of resources [20], and some countries in SSA have not yet made transitions to community based mental health care systems. ...
... Several Western high-income countries and also middle-income regions have undergone substantial psychiatric bed removals in past decades [19,22,23], while expanding imprisonment. In Latin America, psychiatric bed removals and the increase of prison population rates were associated [23]. ...
... However, penal justice reforms are not a priority for most African governments and international donors [49]. Even though changes of incarceration rates were heterogeneous in SSA, they decreased on average over time as in Central Eastern Europe and Central Asia (CEECA) [19]. Changes of mean incarceration rates over time in SSA were in contrast with strongly increasing rates of imprisonment in Latin America (median increase of 181% per 100 000) [23]. ...
Background:
Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020.
Methods:
We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels.
Results:
Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries.
Conclusions:
SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.
... Research involving larger numbers of countries has also yielded mixed results. A study of thirty Eastern European and Central Asian countries found a significant relationship between a decrease in psychiatric beds and increased prison populations in seventeen of these countries over the period 1990-2019; this effect appeared to be greater in countries with a lower per capita income and those which formerly belonged to the Soviet Union [17]; however, a study of twenty-six European countries, covering the period 1993-2011, found only a modest negative correlation between psychiatric beds and prison populations (ρ = -.35), which was not significant after adjusting for socioeconomic factors [18]. The largest study of this sort, which included data from 158 countries (38 high-income countries and 120 low-and middle-income countries), found a significant effect of income group on the results: prison and psychiatric bed populations were positively correlated in low-and middle-income countries, but were not significantly correlated -either positively or negatively -in high-income countries [11]. ...
... Earlier studies that were designed specifically to test the Penrose effect found that national income -operationalized as gross national income per capita -was a significant confounder of associations between psychiatric bed strength and the prison population [11,17]. In addition to this, recent review articles on the social determinants of crime were consulted [27][28][29]. ...
The association between mental illness and violent crimes such as homicide is complex. In 1939, Lionel Penrose hypothesized that the availability of psychiatric hospital beds was inversely related to the prison population, presumably due to the hospitalization of potential offenders with a mental illness. Subsequent studies have found evidence for this association, but questions remain about the contributions of confounding factors. Moreover, there has been a move towards deinstitutionalization and community care of the mentally ill over the past six decades. In this study, the association between national homicide rates and three measures of the availability of psychiatric care – the numbers of psychiatrists, general hospital psychiatric beds, and psychiatric hospital beds per 100,000 population – was examined using a time-lagged correlation analysis. Associations between homicide rates and socioeconomic factors associated with crime were also examined. It was found that the availability of psychiatrists and of general hospital psychiatric beds were both negatively correlated with homicide rates, and that the association with general hospital psychiatric beds remained significant even after correction for confounding factors. These results suggest the need for a more nuanced interpretation of Penrose’s original formulation, involving the interplay of social, economic factors and psychological factors rather than linear causality.
... Individuals with mental health disorders may be arrested due to disorderly conduct or disruptive behaviors. Numerous studies have identified that as hospital [47] and psychiatric bed usage declines [16,33], incarceration rates tend to increase. ...
Background:
The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge.
Methods:
The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census.
Results:
Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate.
Conclusions:
Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.
... Cette situation est actuellement aggravée, d'un côté, par les procédures de jugement accélérées, telles que la comparution immédiate généralement réalisée sans aucune expertise psychiatrique, de l'autre, par la diminution de la durée de séjour en hospitalisation psychiatrique pour les personnes souffrant de troubles mentaux sévères. Plusieurs travaux ont pu montrer une corrélation inverse entre les taux d'incarcération et d'hospitalisation en psychiatrie [38][39][40]. Même si elle est discutée [41], notamment parce que les populations jadis hospitalisées et aujourd'hui incarcérées présentent des caractéristiques différentes [42], cette corrélation pourrait suggérer que les prisons remplissent aujourd'hui des fonctions d'institutionnalisation que les hôpitaux psychiatriques remplissaient autrefois (certains auteurs parlent de « transinstitutionnalisation ») [43,44]. ...
Résumé
La prise en charge des personnes souffrant de troubles psychiatriques et ayant commis une infraction pénale est extrêmement variable dans le monde. Cette problématique complexe vient, en effet, s’inscrire au croisement de la longue histoire du système pénal et du système de soins de chaque pays. Cet article propose une synthèse des liens entre santé mentale et justice pénale en France. Après une rapide contextualisation historique, les trajectoires possibles des personnes souffrant de troubles psychiatriques ayant commis une infraction sont décrites à partir de la décision judiciaire concernant la responsabilité pénale. L’organisation des soins psychiatriques aux personnes détenues est exposée ainsi que les dispositifs psychocriminologiques mis en place par l’administration pénitentiaire et les mesures de soins pénalement ordonnés. L’articulation complexe entre le système de santé mentale et la justice pénale mais aussi les nombreuses problématiques émergentes sont finalement abordées. La prévalence élevée des troubles psychiatriques sévères dans les prisons soulève, en effet, de multiples inquiétudes, en particulier en ce qui concerne la situation de l’expertise psychiatrique, le manque de formation des soignants et l’absence d’alternative à l’incarcération pour les personnes souffrant de troubles psychiatriques sévères. La reconnaissance de la psychiatrie légale dans la formation des psychiatres français pourrait constituer un facteur d’amélioration pour l’avenir.
... and international consensus is lacking on how many psychiatric beds should be available for optimal functioning of mental health systems. The bed rates in low (median 1.9 beds per 100,000), lower-middle (median 6.3 beds per 100,000), and upper-middleincome (median 24.3 beds per 100,000) countries (LMICs) are, on average, much lower than in high-income (median 52.6 beds per 100,000) countries (HICs) and in the OECD (mean 62 beds per 100,000) [1,2]. Variations in the provision of psychiatric beds, even among OECD member countries [3], can only partially be explained by geographical location and income levels [4]. ...
The required minimum number of psychiatric inpatient beds is highly debated and has substantial resource implications. The present study used the Delphi method to try to reach a global consensus on the minimum and optimal psychiatric bed numbers. An international board of scientific advisors nominated the Delphi panel members. In the first round, the expert panel provided responses exploring estimate ranges for a minimum to optimal numbers of psychiatric beds and three levels of shortage. In a second round, the panel reconsidered their responses using the input from the total group to achieve consensus. The Delphi panel comprised 65 experts (42% women, 54% based in low- and middle-income countries) from 40 countries in the six regions of the World Health Organization. Sixty psychiatric beds per 100 000 population were considered optimal and 30 the minimum, whilst 25–30 was regarded as mild, 15–25 as moderate, and less than 15 as severe shortage. This is the first expert consensus on minimum and optimal bed numbers involving experts from HICs and LMICs. Many high-income countries have psychiatric bed numbers that fall within the recommended range. In contrast, the number of beds in many LMIC is below the minimum recommended rate.
