Prevalence of Psychosis and Associated Factors among Prisoners in Jimma Correctional Institution, Southwest Ethiopia, 2017 (RETRACTED)
Received Date: Sep 13, 2018 / Accepted Date: Sep 28, 2018 / Published Date: Oct 05, 2018
Introduction: Psychosis is the most prevalent, severe and disabling psychiatric syndrome among prisoners in the world. People with lowest socio economic status (SES) have eight times greater relative risk for psychosis than those of the highest SES. Studies shows the high prevalence/magnitude of psychosis among prisoners is related to low socio-economic status of most prisoners, untreated mental illness and prison environment related factors. However the prevalence of psychosis and associated factors among prisoners in our study area is not known.
Objective: This study therefore aimed to assess the prevalence and associated factors of psychosis among prisoners in Jimma correctional institution in 2017.
Method: Institution based cross-sectional study design was conducted among 336 prisoners selected by systematic random sampling method. Data was collected by a face to face interview using Psychosis Screening Questionnaire. Data analysis was done using SPSS version 21.0. Multivariable logistic regression was computed to identify independent factors associated with psychosis.
Results: The response rate of the study was 319(95%). The prevalence of psychosis among prisoners was 80[24.8%]. Having poor social support [AOR=2.91 CI: 1.11-7.66], common mental disorders [AOR= 5.41 CI: 2.65 -11.03], stressful life events [AOR=2.30 CI: 1.22-4.33], lifetime use of alcohol [AOR=2.51 CI: 1.13-5.57] and lifetime use of nicotine [AOR=3.02 CI: 1.28-7.10] had significant association with psychosis in final regression model.
Conclusion: This study has shown large number of prisoners who had psychosis but remained undetected in the correctional institution. Psychosis is significantly associated with poor social support, having common mental disorders, and one or more stressful life events. The lifetime use of alcohol and nicotine also significantly associated with psychosis. To improve the mental health status of the prisoners; there is a need to be screening mechanism and management practice for psychosis in correctional institutions which involves all concerned bodies.
Keywords: Psychosis; Prisoners; Ethiopia
Psychosis is a devastating, alienating experience that mystifies and terrifies everyone it touches . As stated in Diagnostic and Statistical Manual of Mental Disorders-fifth edition, the causes of psychosis can vary but presentations are usually characterized by unshakeable pathological beliefs (delusions), distorted perceptions of reality (hallucinations) and impaired judgment .
The cumulative global impact of mental disorders including psychosis in terms of lost economic output will amount to US$ 16 000 billion over the next 20 years . The WHO 2001 report estimated that over 21 million people suffer from schizophrenia, which is one of the severe psychotic illnesses, making it one of the top ten causes of disability worldwide .
Incarceration in prisons is common occurrences for people with psychosis, which exacerbate their marginalization and instability. Prisoners with psychosis are misbehave due to the illness and allowed for disciplinary infractions at higher rates than other prisoners . In developing countries, people with psychosis are inappropriately locked up in prisons simply because of the lack of mental health services and people have committed minor offences are often sent to prison rather than treated for their mental illness. Psychosis therefore continues to go unnoticed, undiagnosed and untreated [6,7]. The cumulative effects result in increment of prison population rate which reached 124 per 100,000 in Ethiopia .
The magnitude of psychosis is higher among prisoners around the world when compared to general population. In US, approximately 24% of jail inmates, 15% of State prisoners, and 10% of Federal prisoners reported at least one symptom of psychotic disorder . The prevalence of psychosis in Britain in 2014 was 2.72% . In Brazil State of Sao Paulo prison population in 2014, the prevalence of severe mental disorders including psychosis, 12-month prevalence rates were, 14.7% among women and 6.3% among men . In India among psychiatric patients seen in a jail hospital over a period of three months, the rate of psychosis was 26% . In Nigeria, 41.2% of peoples who were arrested for violent crimes had paranoid schizophrenia .
Psychosis significantly impairs work, family and social functioning . People with the lowest socio-economic status (SES) have 8 times greater relative risk for psychosis than those of the highest SES . People with psychosis are also 4 times more likely to be unemployed or partly employed, one-third more likely not to have graduated from high school and 3 times more likely to be divorced .
Literacy is poor  and prisoners generally come from a background of family problems and multiple disadvantages . The evidence from different studies shows, all forms of psychiatric morbidity was increased, and co-morbidity is so common as to be typical of the prison population [18-20]. Prisoners have a high rate of suicides and self-injury due to untreated psychotic illness and situational difficulties . Apart from these, mental health is one of the most disadvantaged health programmers’ in Ethiopia, both in terms of basic services and skilled manpower especially among prison population .
Even though there are studies done in prevalence and associated factors of psychosis commonly schizophrenia in community and health institutions in Ethiopia, there is no published study conducted in local jails and correctional institutions. Therefore the current study assessed the prevalence of psychosis and associated factors among prisoners in Jimma Correctional Institution.
Materials and Methods
Study setting and period
Institution based cross-sectional study design was used at Jimma zone correctional institution, southwest Ethiopia from June 1-25, 2017.
All prisoners during data collection period were included in the study. Those prisoners who were critically sick during data collection were excluded from the study.
Sample size determination
The sample size was calculated by using single population proportion formula by considering the following assumptions; prevalence p=50% because no similar study done in our country among prison population, 95%CI, margin of error 5%, non-response rate 10%. The calculated sample size was 384. Since the population size is less than 10,000(i.e. 1460) we used population correction. Therefore, the final sample size taken was 336.
A systematic random sampling technique was used to select study participants at correctional institution during the study period. A sampling frame was created. The sampling interval (K) was calculated by dividing the study population with the final sample size as follow K=N/n, i.e. 1460/336~4. Therefore, we used to draw the actual participant randomly every 4 interval in the sampling frame until the required sample size was reached. The first study subject was selected by lottery method from 1-4. Therefore, participants was selected every 4 interval starting from the first study unit.
A structured questionnaire had the following five sections. Section 1: Socio-demographic questionnaire to assess the prisoners’ background information. Section 2: The psychosis screening questionnaire (PSQ) was used to determine the presence or absence of psychosis. This tool has sensitivity of 96.9%, specificity of 95.3% . The Inter-rater reliability (κ) of PSQ in this study is 0.87. Section 3: The Self Reporting Questionnaire 20 (SRQ-20) was used to screen the presence of common mental disorders (CMD). This tool was developed by WHO primarily to screen CMD in developing countries . Inter-rater reliability (κ) of SRQ in this study is 0.79. Section 4: The Oslo-3 three item scale (OSS-3) was used to assess level of social support . In this study, Inter-rater reliability (κ) of OSS-3 is 0.820. Section 5: The Life Events Checklist for DSM-5 (LEC-5) was used to screen stressful life events .
The questionnaire was translated to local languages Amharic and Afan Oromo and back to English by independent person to check for consistency and understandability of the tool and the questionnaire was pretested one week prior to the actual data collection on 10% in Agaro prison center for clarity of questioners. Based on this some modification were done. Six data collectors and two supervisors who have psychiatry background were selected from the different institution and were given training for three days. Data was collected using face to face interview.
Operational definition and definition of terms
Psychosis: assessed by endorsement of at least one psychotic symptom in Psychosis Screening Questionnaire from thought interference, paranoia, strange experience, hallucinations and hypomania .
Common Mental Disorders (CMD): The total SRQ-20 score of greater than 7 was considered as having CMD .
Social support: Based on Oslo social support scale; prisoners who scored 3-8 had poor support, 9-11 had moderate support and 12-14 had strong support .
Stressful life event: Based on Life Event Checklist of DSM-5; Prisoners having at one least one stressful life event .
Life time substance use: use of at least one specific substance for non-medical purpose with in their life time (alcohol, nicotine, khat and cannabis use) was assessed by Yes/No answers of respondents.
Solitary confinement: Ever placed alone in a cell alone or with other prisoners with little human contact or interaction, reduced or no natural light for at least one day .
Correctional Institution: Place designated by law for the keeping of persons held in custody under process of law, or under lawful arrest primarily for the purposes of punishment and correction following conviction of a criminal offense.
Lowest Socio-Economic Status (SES): Gaur’s Socio-economic Classification of class V with total score of less than 10 .
Data processing, analysis and interpretation
The entire questionnaire was checked for completeness. The data were entered in to Epi-data then exported to SPSS 21 version statistical software for analysis. Socio-demographic characteristics of respondents were analyzed by descriptive statistics (percentage, mean and standard deviations). Bivariate analysis was undertaken to identify candidate variables for the final multiple logistic regression model and variables with p-value less than 0.25 were taken as eligible for the final model. Finally multiple logistic regression analysis was conducted and significance was declared at p-value<0.05 with 95% confidence interval. Adjusted odds ratio (AOR) was used to interpret significantly associated variables. Results were presented in the form of tables and figure using frequency and description along with them.
The study was conducted after ethical clearance was obtained from the ethical review board of Institute of Health in Jimma University. Then official letter from the postgraduate coordinating office of institute of health was written to head office of prison administration. Each respondent was informed about the objective of the study. Confidentiality was ensured to all participants. Participation was completely voluntary and each participant gave informed written consent for their participation. Prisoners with paranoid and hallucination who are in need of mental health care were linked to psychiatric clinic in Jimma University Medical Center.
Socio-demographic characteristics of prisoners in Jimma Correctional Institution
The response rate the study was 319(95%). Out of 319 respondents, majority 298(93.4 %) were males. The mean (± SD) age of respondents was found to be 30.40 (± 11.60) year with minimum and maximum age of 18 and 86 years respectively. More than half of respondents were single 170(53.3%) in marital status and Muslim 177 (55.5%) in religion while the majority 204 (63.9%) were Oromo in ethnicity. Majority 204 (63.9%) of the respondents reported that they live in urban area prior to imprisonment and more than half 173 (54.2%) of them had attended primary education. One third, 107 (33.5%), of the respondents had private work prior to imprisonment. About half 157 (49.2%) of the prisoners have poor social support (Table 1).
|Educational status||No formal education||44||13.8|
|Level of Social Support||Poor support||157||49.2|
Table 1: Socio-demographic characteristics of prisoners in Jimma Correctional Institution; Southwest Ethiopia, 2017 (n=319).
Prison environment characteristics of prisoners in Jimma Correctional Institution
Among prisoners, 33(10.3%) had history of solitary confinement. Majority of prisoners, 232(72.7%) had no work in the prison and 266(83.4%) committed violent crimes. Regarding court’s decision, 293(91.8%) was sentenced and 37(11.6%) had history of prior incarceration (Table 2).
|Work in prison||No||232||72.7|
|Type of crime||Violent||266||83.4|
Table 2: Prison related factors of prisoners in Jimma Correctional Institution, Southwest Ethiopia 2017 (n=319).
Substance use among prisoners in Jimma Correctional Institution
Out of the total 319 study respondents, 185(55.7%) had lifetime use of at least one substance (alcohol, khat, nicotine and cannabis). About half, 168(50.6%) of prisoners had lifetime use of khat and 110(33.1%) had alcohol use. About 105(31.6%) had nicotine use and, 41(12.3%) had cannabis use.
Clinical factors among prisoners in Jimma Correctional Institution
Out of the total 319 study participants, 53(16.6%) of the respondents reported at least one chronic physical illness. About 51 (16.0%) of the respondents reported family history of mental illness, 32(10.0%) had past history of mental illness and 29(9.1%) had past admission to psychiatric clinic. About half 162(50.8%) of the respondents had CMD. Among study participants, 126(39.5%) reported one or more stressful life events (Table 3).
|Chronic Physical illness||No||266||83.4|
|Common Mental Disorder||No||157||49.2|
|Family Mental Illness||No||268||84|
|Past Mental Illness||No||287||90|
|Past admission to psychiatric clinic||No||290||90.9|
|Stressful life event||No||193||60.5|
Table 3: Clinical factors among prisoners in Jimma Correctional Institution, Southwest Ethiopia 2017(n=319).
Prevalence of psychosis among prisoners in Jimma Correctional Institution
The prevalence of psychosis among prisoners in Jimma correctional institution is found to be 80 (24.8%, 95%CI: 20.4-29.8%). According to the PSQ, the commonest psychotic symptoms among prisoners were paranoia 44(13.8%) and thought interference 29(9.1%) (Figure 1).
Factors Associated with Psychosis among prisoners in Jimma Correctional Institution
The following factors are significantly associated with psychosis in bivariate logistic regression analysis. These are poor social support, no work in prison, lifetime use of alcohol and cigarette, having one or more stressful life event, having past mental illness, family mental Illness, chronic physical illness, past admission to psychiatric clinic and having CMD (Table 4). These variables are candidates for multiple logistic regression after checking the assumptions like multi collinearity (VIF<10), meaningful coding, no outliers, linearity and large sample. The Hosmer Lemeshow goodness of fit statistic (p=0.689) and log likelihood statistics was used to assess whether the necessary assumptions for the application of multiple logistic regression are fulfilled.
|Variables||COR (95% C.I.)||P value|
|Marital Status||Single||1.275 (0.738-2.202)||0.384|
|Educational Status||Higher education||1|
|No formal education||5.200(1.652-16.369)||0.005*|
|Private work||1.095(0.435-2.755 )||0.848|
|Level of Social Support||Poor||3.344(1.490-7.506)||0.003*|
|Work in Prison||No||1.780(1.038-3.053)||0.036*|
|Type of crime committed||Violent||1.440(0.688-3.017)||0.334|
|Lifetime Alcohol Use||Yes||3.702(2.018-6.794)||0.000**|
|Lifetime nicotine use||Yes||3.966(2.055-7.652)||0.000**|
|Lifetime Khat Use||Yes||1.601(0.963- 2.662)||0.07|
|Lifetime Cannabis use||Yes||7.424(2.880-19.142)||0.000**|
|Stressful Life events||Yes||2.953(1.760-4.953)||0.000**|
|Family Mental Illn||Yes||2.807(1.508-5.225)||0.001*|
|Chronic Physical illness||Yes||3.495(1.897-6.439)||0.000**|
|Past Mental Illness||Yes||5.295(2.513-11.159)||0.000**|
|Past Admission to psychiatric clinic||Yes||6.361(2.857-14.161)||0.000**|
|Common Mental Disorders(CMD)||Yes||5.104(2.826-9.219)||0.000**|
Note: 1=constant **=p<0.001 *=p<0.05
Table 4: Bivariate logistic regression analysis result among selected prisoners in Jimma Correctional Institution Southwest Ethiopia, 2017(n=319).
In multiple logistic regression analysis: Poor social support, lifetime use of alcohol and nicotine, having CMDs and presence one or more stressful life events were significantly associated with psychosis (p<0.05). The odds of having psychosis was 2.92 times (AOR=2.91 CI: 1.11-7.66) higher among prisoners with poor social support than the odds of moderate and strong social support. The odds of having psychosis was 5.10 times (AOR= 5.10(CI: 2.53-10.27) higher among prisoners with CMD. The odds of having psychosis was 2.3 times (AOR=2.30 CI: 1.22- 4.33) higher among prisoners who had one or more stressful life events. The odds of having psychosis was 2.5 times (AOR=2.51 CI: 1.13-5.57) higher among prisoners who had lifetime use of alcohol and 3 times (AOR=3.02 CI: 1.28-7.10) higher among prisoners who had lifetime use of nicotine (Table 5).
|Variables||COR (95% C.I.)||AOR (95% C.I.)||P-value|
|Level of Social Support||Poor||3.34(1.49 -7.50)||2.92 (1.11-7.66)||0.030*|
|Moderate||2.18 (0.90- 5.23)||1.45(0.51-4.35)||0.457|
|Work in prison||No||1.78(1.03-3.05)||1.80(0.93-3.46)||0.078|
|Lifetime Alcohol use||Yes||3.70(2.01-6.79)||2.51 (1.13-5.57)||0.023*|
|Lifetime Nicotine use||Yes||3.96(2.05-7.65)||3.02(1.29-7.10)||0.011*|
|Stressful life events||Yes||2.95(1.76-4.95)||2.30(1.22-4.33)||0.010*|
|Family history of mental illness||Yes||2.80(1.50-5.22)||0.78(0.33-1.82)||0.57|
|Chronic physical illness||Yes||3.49(1.89-6.43)||1.55(0.68-3.49)||0.291|
|Past mental illness||Yes||5.29(2.51-11.16)||0.58(0.09-3.68)||0.566|
|Past admission to psychiatric clinic||Yes||6.36(2.85-14.16)||6.60(0.96-45.18)||0.054|
|Common Mental Disorders||Yes||5.10(2.82-9.21)||5.10(2.53-10.27)||0.000**|
Note: 1.00=constant **=p<0.001 *=p<0.05 CMD=Common Mental Disorders Model: Chi-square =96.10, df=12, and Sig.<0.001.
Table 5: Multivariate Logistic regression analysis of factors associated with psychosis among prisoners in Jimma Correctional Institution Southwest Ethiopia, 2017 (n=319).nbsp;
Untreated psychosis ends up with a long-standing morbidity and psychological trauma for children, friends and relatives and the loss of economic productivity for the nation. The underlying reason for assessing psychosis in prison is to ensure that treatment plans and evaluations focus on prisoners’ risk factors. Hence this institutional based cross sectional study was conducted to assess psychosis and associated factors among prisoners.
The prevalence of psychosis among prisoners in Jimma correctional institution is found to be 24.8%. It is found to be consistent to the prevalence studies done among prisoners in India which was 26%  and in Brazil with the similar study population, which was 25.8% . But lower than the study conducted in Nigeria which was 40.2% . The difference might be due to the inclusion of prisoners with only violent crimes and police stations in Nigerian study. The study which assessed the prevalence of mental disorders in South Africa Durban prison reported that 4.7% had new psychotic episode . The difference might be due to small sample size (n=193), the study assessed incidence rather than prevalence of psychosis.
Prisoners having poor social support were nearly three times more likely to develop psychosis. This finding agrees with the study conducted in Turkey in which people with poor social support were four and half times more likely to develop psychotic symptoms . Similarly, selfreported psychotic symptoms using PSQ in Britain were significantly associated with small primary support group (few close friends or relatives) . It is plausible that poor social support in addition to social isolation might contribute to the development of negative schemas in these prisoners as a psychosocial risk factor. Prevalence of psychosis using PSQ was elevated most significantly among immigrants living in Italy with poor social support and having poor social integrity . This might be due to features of psychosis, including both negative and positive symptoms, may cause individuals to withdraw from social networks or create difficulty in maintaining relationship. Therefore, individuals living with psychosis may be vulnerable to low social support or reduced network size.
Prisoners having CMD in SRQ-20 were about five and half times more likely to develop psychosis than who had not CMD. This is consistent with the study conducted in Kenya  and Tanzania . Similarly in British study, the self-reported psychotic symptoms were significantly associated with CMD . In a study of adult primary care patients, psychotic symptoms were associated with anxiety and depression, and these were all clinical consequences of psychosis . On the other hand, CMD have been reported in excess in those adults who later develop psychosis . Due to this, it had been identified as part of the initial prodrome in psychosis. Longitudinal studies have found that adolescent males with CMD are more likely to develop schizophrenia in later life , and that CMD (with prominent anxiety symptoms) increases the risk for subsequent onset of psychotic symptoms . Other study argue that, the frequent occurrence of emotional disorder like anxiety and mood disorders prior to and accompanying psychosis suggests that CMD contributes to the development of the positive symptoms of psychosis like delusions and hallucinations .
Prisoners having one or more stressful life events were 2.3 times more likely develop psychosis. Study abroad showed that psychosis were associated with stress related to relationship problems, manmade and natural disaster, employment, financial crises and victimization experiences [13,28]. The possible mechanism is that stressful events are regarded as an important component influencing the biological functioning of the brain. This is due to stress induced abnormally activated HPA axis causes neurotoxicity in the central nervous system. This effect is related to the increased level of the glucocorticoid hormones .
This study found that prisoners who had lifetime alcohol and nicotine use were nearly four times more likely to had psychosis. Similarly, it has been reported that alcohol use is five times more risk for psychotic symptoms compared to people who had no use of alcohol [13,29]. The possible mechanism is that alcohol use related to dopamine mediated brain reward pathways in the mesocorticolimbic tracts  and induced psychotic symptoms by increasing dopamine in the mesolimbic areas of the brain of people whose brains had been sensitized due to the genetic and neurodevelopmental factors .
Strength of the study: The symptom of psychosis in addition to the prevalence was determined. The tool we used is standardized and internationally recognized screening tool with high reliability to screen psychosis regardless of population characteristics.
Limitation of this study: The study however could suffer from the following limitations. This study was cross-sectional study design; it did not allow establishing a temporal relationship between psychosis and associated factors. The study was institution based which could limit its generalizability to normal population and clinical setting. Recall bias regarding lifetime substance use and question to assess factors like chronic illness were asked by single generated questions which have no internationalized cut of point or no Likert scale. The areas yet to be studied in this population are socioeconomic and prison environment characteristics of respondents have no association with depression. The other important things that are yet to be studied which we saw during this study but are not included in our study are life style conditions of prisoners in correctional institution like food, reception and recreational activity. These are other areas that need further investigation.
The high prevalence of Psychosis was found in this study and significantly associated among prisoners with poor social support, having common mental disorders, one or more stressful life events and, lifetime use of alcohol and nicotine. Therefore, psychosis is major public health problem in Jimma Correctional Institution.
To improve the mental health status of the prisoners, there is a need to psychosis screening mechanism and management practice in correctional institutions which involves all concerned bodies. Further research is recommended to assess prevalence of psychosis by using standardized diagnostic tools at correctional institution around the country. Above all, further research detailing the availing of mental health care services for prisoners must be undertaken to achieve sustainable development through the involvement of prisoners by addressing their mental health needs.
The authors acknowledge Institute of Health, Jimma University for financial and technical support. Jimma Correctional Institution Administration, data collectors, and all the study participants are also highly acknowledged.
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Citation: Alenko A, Kerebih H, Yeshigeta E, Nigussie A (2018) Prevalence of Psychosis and Associated Factors among Prisoners in Jimma Correctional Institution, Southwest Ethiopia, 2017. J Psychiatry 21: 459. DOI: 10.4172/2378-5756.1000459
Copyright: © 2018 Alenko A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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