Mental health of incarcerated people in Africa

“It’s an embarrassing backlog: you would find somebody sitting in prison for 10 years, and they are still waiting for that mental health assessment”

A Zimbabwean policymaker told us. As our organization Kushinga interviewed leaders within Zimbabwe’s mental health system to understand the country’s challenges and priorities, we were struck by how many respondents mentioned the mental health of incarcerated people. Our qualitative interview guide included nothing on forensics or prisons, but our respondents, both clinicians and policymakers, would return to the issue of prisons.  Many people with mental illness, they explained, ended up in the criminal justice system and would be detained for months or years, awaiting administrative review, often without being formally charged with a crime. In the prison system, patients were housed in deplorable conditions with minimal access to hygiene, food, or mental health care until Médecins Sans Frontières began to alleviate the dire situation. The prison system absorbed some of the most severely ill patients and the human and financial resources devoted to mental health care.

In the United States, there are over 2.2 million people in jail and prison, a disproportionate number of whom are black or brown. In her groundbreaking book, The New Jim Crow, Michelle Alexander notes that there is poor evidence for the effectiveness of prisons, that they actually create crime rather than prevent it, and that they feed into a system that benefits private organizations that run for-profit prisons on government contracts (“the Prison Industrial Complex”). Due to the ineffectiveness of the criminal justice system and its disproportionate impact on communities of color, an entire movement spearheaded by prominent activists such as Angela Davis and Ruth Wilson Gilmore has arisen argues for an end to mass incarceration.

The idea of the “revolving door” between incarceration and the mental healthcare system— that people with mental illness often cycle in and out of jail or prison, because of inadequate community resources—is gaining increasing attention in high-income countries, particularly the US. Mass incarceration in the US far outstrips other countries, but our joint Zimbabwean-American team was surprised by how the Zimbabwean situation mirrored some issues in the American criminal justice system. Despite these similarities, we noticed that the mental health of incarcerated people in low- and middle- income countries was left out of many conversations within the global mental health movement. Incarceration features minimally in the Mental Health Atlas, is not mentioned in mhGAP, and has not been part of major research priorities. Shocked by the human rights abuses we had heard in Zimbabwe, our team sought to learn more. 

To better understand what was already known, we conducted a systematic review on the mental health of incarcerated people in Africa, including individuals in jail, prison, or forensic units.

What did we learn?

We identified a total of 80 studies, the majority of which measured the prevalence of mental health disorders at a single jail, prison, or forensic unit. Unsurprisingly, the pooled prevalence of mental disorders was high: 38% of people had a substance use disorder and 33% had a psychotic disorder. We identified only three studies of interventions, two of which assessed interventions based on cognitive behavioral therapy principles and showed promising results, though with small samples in single settings. The complete study is available here.

A few lessons stuck out to us from our review and qualitative interviews with stakeholders in Zimbabwe:

• There is a poor evidence base for mental health interventions in jail or prison in high-income countries, but there are even fewer for LMICs. Adaptation and evaluation of interventions for incarceration, diversion from incarceration, and transition back into communities are needed.

• The majority of participants in 36% of studies had never been convicted of a crime. We found a similar pattern in Zimbabwe—many people with mental illness would be incarcerated for minor crimes (stealing a loaf of bread) and detained without a formal court hearing, speaking to the stigma of mental illness and and inadequacy of the criminal justice system to cater to the needs of people with mental illness.

• Research that includes people who are incarcerated can be ethically complex, particularly if interventions are being tested.  35% of studies did not report ethical review board approval, speaking to a need for strong ethical oversight in future research.

• In Zimbabwe, as may be the case in many other countries, responsibility for mental health services in prisons is split between the Ministry of Health and the Ministry of Justice, leading to complex funding streams and neither party taking full responsibility.

• A number of studies included or focused on youth who were incarcerated, an extremely vulnerable population about which little is known.

What should happen next?

Fundamentally, jail and prison have not been shown to reduce crime or improve mental health outcomes. There is great need for research on and implementation of transformative and restorative justice approaches and development of programs that provide therapeutic options other than punitive incarceration for people with mental illness. However, as we work toward a world that provides alternatives to incarceration, we cannot forget the people who are currently imprisoned and must also work to improve prison conditions.

Accordingly, our work allows us to make a number of specific recommendations:

• International organizations, such as the World Health Organization, should do more to incorporate incarceration into their guidelines on clinical care and mental health system strengthening and should advocate for funding streams that are specific to mental health care within the justice system.

• The research community should help us continue to grow the knowledge base on the mental health of incarcerated people worldwide, with particular attention to including the voices of service users, a group that is largely absent from existing literature. We are already starting to see growth in this area. We hope that more research will focus on restorative and transformative justice approaches, perhaps following some of the work of the Sycamore Tree Project, a restorative justice group that works worldwide, including in Rwanda, Senegal, South Africa, Nigeria, and Zambia.

• People with a history of incarceration are a vulnerable population with specific needs and traumatic experiences to which clinicians should be attuned. For practitioners working directly in prisons, there are a number of organizations, including the Africa Prisons Project, that are doing direct service in this area and from which researchers and clinicians can learn. 

We encourage the global mental health community to join us and elevate the voices and needs of people who are incarcerated, bringing attention to this uniquely vulnerable population that has for too long been silenced.