Unit III Literature Review
BDR
mentalhealth2.pdf
An Examination of Mental Health and Psychiatric Care among Older Prisoners in the United States Bryce Evan Stolikera and Phillip M. Gallib
aSchool of Criminology, Simon Fraser University, Burnaby, British Columbia, Canada; bDepartment of Sociology, Criminology & Anthropology, University of Wisconsin River Falls, River Falls, USA
ABSTRACT Despite that prisons in the United States (and other high-income countries) have witnessed an increase in the proportion of older inmates, and that prison populations exhibit high rates of psychiatric illness, there is limited knowledge on the nature of older inmates’ psychological health and use/provision of psychiatric care. The pre- sent study addresses these gaps, analyzing a nationally representa- tive sample of 1,907 male and female older inmates (age range = 50–84 years; M = 56) housed in U.S. state and federal prisons. The results highlight: (a) the prevalence of psychological issues among older prisoners; (b) factors associated with certain mental disorders and symptoms of mental health issues; (c) the prevalence of psychia- tric treatment before and during imprisonment for those with (and without) reported psychological health issues; (d) similarities and differences between male and female older inmates in relation to psychological health, factors associated with psychological issues, and the use/provision of psychiatric care. Discussion points toward recommendations for managing inmate mental health, as well as direction for further research on older inmate mental health and psychiatric care.
KEYWORDS Older prisoners; mental health; psychiatric care
Introduction
Although the United States’ prison population predominantly consists of younger inmates, the number of older prisoners (i.e., age 50 and older) has been steadily increasing (see Carson, 2018; West & Sabol, 2008). Researchers have referred to the increasing number of older inmates as the aging, or “graying”, of prison populations, which has been docu- mented in several high-income countries, such as Canada, the United States, and England and Wales (see Blowers & Blevins, 2015; Howse, 2003; Kakoullis, Le Mesurier, & Kingston, 2010; Reimer, 2008; Reviere & Young, 2004; Uzoaba, 1998). In the United States, in 2007, state and federal prisons housed 156,600 sentenced inmates aged 50 and older, compared to approximately 1.376 million under the age of 50 (West & Sabol, 2008). By comparison, in 2016, the estimated number of inmates aged 50 and older housed in U.S. state and federal prisons had nearly doubled (n = 288,987), while the number of inmates under the age of 50 had declined to 1.170 million (Carson, 2018). Therefore, there is reason to believe that by the year 2030 more than one-third of the prison population will consist of individuals aged 50 and older (Enders, Paterniti, & Meyers, 2005). In general, the rising
CONTACT Bryce Evan Stoliker [email protected] School of Criminology, Simon Fraser University, Saywell Hall, Burnaby, British Columbia V5A 1S6, Canada.
VICTIMS & OFFENDERS 2019, VOL. 14, NO. 4, 480–509 https://doi.org/10.1080/15564886.2019.1608883
© 2019 Taylor & Francis Group, LLC
number of older inmates has been linked to population aging, more crimes and arrests later in life, and “tougher” sentencing legislation (see Barry, Wakefield, Trestman, & Conwell, 2017; Blowers & Blevins, 2015; Luallen & Cutler, 2017; Regan, Alderson, & Regan, 2003; Uzoaba, 1998).
Mental health and psychiatric care
Alongside the issue of an aging inmate population, it is well-known that psychiatric illnesses pervade prison populations (see Fazel & Seewald, 2012; Fellner, 2006; Smith, 1999; Way, Sawyer, Lilly, Moffitt, & Stapholz, 2008) and that prisoners exhibit a higher rate of mental health issues compared to the general population, as well as other institu- tionalized populations (Diamond, Wang, Holzer, Thomas, & Cruser, 2001; Fazel, Hope, O’Donnell, & Jacoby, 2004; Way et al., 2008). Research suggests that older, and aging, individuals in the general population typically exhibit better psychological health and emotional well-being compared to those earlier in the lifespan (see Fiske & O’Riley, 2016; Van Orden & Conwell, 2016). Yet, it has been argued that older inmates are likely to experience more mental health issues compared to younger counterparts (Blowers & Blevins, 2015). Although inquiry and investigation into older inmate mental health and psychiatric care is still quite deficient, there has been some development in this area of research (e.g., see Caverley, 2006; Colsher, Wallace, Loeffelholz, & Sales, 1992; Fazel et al., 2004; Fazel, Hope, O’Donnell, & Jacoby, 2001a; Kakoullis et al., 2010; Koenig, Johnson, Bellard, Denker, & Fenlon, 1995; Regan et al., 2003; Stoliker & Varanese, 2017). There is some variability across older inmate samples with respect to the prevalence of psycholo- gical issues, however, studies have shown that 19% to 53% of older prisoners have a psychological issue (see Fazel & Jacoby, 2002; Koenig, 1995; Regan et al., 2003), with depression being the most commonly reported mental health problem among this group (Fazel et al., 2001a; Fazel & Jacoby, 2002; Koenig, 1995; Regan et al., 2003; Stoliker & Varanese, 2017). Along with depression, older inmates have also reported: anxiety dis- orders; personality disorders; schizophrenia or other psychotic disorders; neurocognitive illness/disorders (e.g., dementias); substance abuse/dependence; and, varying symptoms of mental health (Fazel et al., 2001a; Fazel & Jacoby, 2002; Koenig, 1995; Regan et al., 2003; Stoliker & Varanese, 2017).
Despite the high rates of psychiatric illness within prisons, there is limited scholarly knowledge on inmates’ mental health treatment needs and the extent to which these needs are being met (Fazel et al., 2004). In Fazel et al. (2001a) study on older prisoners in England and Wales, only 12% of inmates with depression were being treated with antidepressants, whereas approximately three-quarters of their sample were prescribed medication and were in regular contact with prison doctors for physical health needs. In a later study, Fazel et al. (2004) again found that medication needs for older inmates’ physical illnesses were mostly met, while medication needs for psychiatric illnesses were not. Only 18% of older inmates with any recorded psychiatric illness were prescribed psychotropic medication (for more detail, see Fazel et al., 2004). Koenig et al. (1995) also present evidence to suggest low rates of treatment (i.e., medication and counseling) for older inmates with psychiatric disorders. These findings suggest that a considerable number of older inmates with mental health issues are not receiving adequate psychiatric treatment (Fazel et al., 2001a; Stoliker & Varanese, 2017).
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Indeed, the World Health Organization (2005) has stated that those with mental disorders are often deprived of necessary treatment in prison. Though these researchers (i.e., Fazel et al., 2001a, 2004; Koenig et al., 1995) have provided some insight into the extent to which older prisoners with psychiatric illness are receiving mental health treatment while incarcerated, there is still very little known about the use/provision of psychiatric services for this group. For instance, Fazel et al. (2001a, 2004) had examined only one form of psychiatric treatment (i.e., medication), with Koenig et al. (1995) being the only other study that has analyzed more than one type of psychiatric treatment for older prisoners. In addition, no research has examined and compared older prisoners’ use/provision of psychiatric services before and during imprisonment – this provides comparative context for an inmate’s access to psychiatric treatment during incarceration.
Gender and mental health
Kakoullis et al. (2010) highlight that much of the research on older inmate mental health has focused primarily on male prisoners (see Allen et al., 2013; Allen, Phillips, Roff, Cavanaugh, & Day, 2008; Koenig, 1995; Koenig et al., 1995), with a limited number of studies which have examined female prisoners (see Jordan, Schlenger, Fairbank, & Caddell, 1996; Lynch, Fritch, & Heath, 2012; Martin & Hesselbrock, 2001) or both male and female prisoners (see Barry et al., 2017; Stoliker & Varanese, 2017). In a study on older inmates within the United States, results showed that females were significantly more likely than males to experience some, but not all, types of mental health symptoms and disorders (Stoliker & Varanese, 2017). These findings mirror gender patterns for psychological health found within offender populations in general. Research suggests there is a greater proportion of female offenders with psychological health issues when compared to males (Drapalski, Youman, Stuewig, & Tangney, 2009; Senior et al., 2013; Steadman, Osher, Robbins, Case, & Samuels, 2009). These gender differences in mental health may be attributed to variability in the experience of trauma by males and females (Moloney, van Den Bergh, & Moller, 2009), wherein female offenders are more likely to have experienced traumatic life events prior to incarceration (see Greenfeld & Minor-Harper, 1991; Wolf, Silva, Knight, & Javdani, 2007) and, therefore, psychological issues associated with trauma (see DeHart, Lynch, Belknap, Dass-Brailsford, & Green, 2014; Green, Miranda, Daroowalla, & Siddique, 2005). Given that female offenders exhibit higher rates of psycholo- gical issues, they are also more likely to utilize mental health services while incarcerated when compared to males (Drapalski et al., 2009; Dye, 2011). Despite this fact, there is a gap in knowledge on the use/provision of mental health services for male versus female older prisoners, as much of our understanding on older inmates’ psychiatric care is derived from research that has focused exclusively on male samples (see Fazel et al., 2001a, 2004).
Traumas/stressors and mental health
Researchers have emphasized the importance of examining the link between traumatic experiences/life stressors and the mental health of older prison inmates, especially given that traumas and life stressors are quite common among criminal justice populations in general (Haugebrook, Zgoba, Maschi, Morgen, & Brown, 2010; Stoliker & Varanese, 2017).
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Haugebrook et al. (2010) found that over three-quarters (n = 91) of older prisoners had reported a history of traumatic experiences and/or life-event stressors, whereas Beck et al. (1993) found 41% of elderly female prisoners reported a history of either physical or sexual abuse. Several studies have identified a relationship between trauma exposure and mental health issues within both male and female incarcerated popula- tions (see DeHart et al., 2014; Green et al., 2005; Greene, Ford, Wakefield, & Barry, 2014; Gunter, Chibnall, Antoniak, McCormick, & Black, 2012; Messina & Grella, 2006). However, there have been no empirical investigations on the association between pre- prison traumas/life stressors and the mental health of older inmates. For an older inmate, a long history of traumatic experiences and life stressors, along with exposure to the adversities of prison, could have considerable deleterious effects on mental health (Haugebrook et al., 2010). Exposure to traumas and stressors within prison can also play an important role in the psychological health and well-being of older inmates. Research has suggested older inmates are at risk of victimization by younger counter- parts, which is attributable to the fact that older inmates are vulnerable and attractive targets (Kerbs & Jolley, 2007). Kerbs and Jolley (2007) showed that older prisoners were most often subjected to psychological and property victimization, with fewer who have experienced physical and sexual victimization. It has also been found that older inmates who have experienced serious forms of physical victimization (i.e., resulting in injury) while incarcerated were more likely to have psychological issues (Stoliker & Varanese, 2017). For elderly female inmates, violence and the threat of violence within prison has been linked to poor psychological health (LaMere, Smyer, & Gragert, 1996; Smyer, Gragert, & LaMere, 1997).
Physical, behavioral, and mental health
Older inmate populations show high rates of physiological issues and tend to have poorer physical health compared to younger counterparts, as well as older persons in the general population (see Colsher et al., 1992; Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001b; Gallagher, 1990; Kakoullis et al., 2010). It has also been suggested that elderly female prisoners exhibit poorer overall health compared to male counterparts (Kratcoski & Babb, 1990). Researchers have highlighted the link between physical and psychological health among older inmates, where poor physical health is often linked to poor mental health (Fazel et al., 2001a; Koenig et al., 1995; Stoliker & Varanese, 2017). Older inmates are also known to experience limitations in physical function (see Colsher et al., 1992; Gallagher, 1990), which has been linked to mental health problems. Barry et al. (2017) found that older inmates experiencing disability in prison activities of daily living (e.g., dropping to the floor for alarms, climbing onto/off bunks, and hearing orders from staff) were at increased odds of experiencing symptoms of depression. However, Barry et al. (2017) reported that these effects were significant for males but not females. With respect to behavioral health (e.g., sub- stance abuse), studies have highlighted the link between psychiatric illness and substance abuse issues among older prisoners (Koenig et al., 1995; Stoliker & Varanese, 2017).
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Importation, deprivation, and the stress process
Researchers have often utilized the deprivation (Sykes, 1958) and importation (Irwin & Cressey, 1962) perspectives to examine and explain various issues within the prison setting, including the psychological health and well-being of inmates (see Armour, 2012; Dye, 2010; Dye & Aday, 2013; Stoliker, 2018; Stoliker & Varanese, 2017). Following the deprivation perspective, it is suggested correctional institutions impose a number of “pains” and stressors (Sykes, 1958; see also Dye, 2010; Goffman, 1961; Haney, Banks, & Zimbardo, 1973; Toch, 1977) and, therefore, inmates’ mental health is shaped by the prison environment and adverse experiences during imprisonment (see Armour, 2012). The importation perspective suggests that pre-existing issues and vulnerabilities are “carried” into prison by the inmate (Irwin & Cressey, 1962; see also Caroll, 1974; Jacobs, 1974; Wacquant, 2001) and, therefore, inmates’ psychological health is attributable to pre-prison life and long-standing individual character- istics (see Armour, 2012). Nevertheless, it is best to integrate the importation and deprivation perspectives (Armour, 2012; Dear, 2006; Dye, 2010; Dye & Aday, 2013; Liebling, 1999), as the psychological health of inmates is likely influenced by a combination of pre-prison and prison-based characteristics. To borrow from extant literature (see Armour, 2012; Dye, 2010; Stoliker, 2018; Stoliker & Varanese, 2017), pre-prison life shapes the development, or risk, of mental health problems among offenders. Offenders who enter prison with actual, or predisposed risk of, mental health issues are then likely to experience these adversities within the prison setting. During incarceration, the prison environment and inmate experiences have the potential to further shape psychological health (either positively or negatively).
Furthermore, the stress process theory (Pearlin, Menaghan, Lieberman, & Mullan, 1981) provides a suitable explanatory framework for the psychological health of older prisoners (see Barry et al., 2017). This theory suggests that adverse life events or chronic strains (i.e., the sources of stress) may elicit stress, which can ultimately lead to mental health issues (i.e., the manifestations of stress) – this process might also be dependent upon mitigating or aggravating individual and social factors (i.e., the mediators and moderators of stress).
The current study
The purpose of this study was to advance knowledge on older inmates’ mental health and use/provision of psychiatric care, with particular focus on (a) identifying factors associated with certain mental disorders and symptoms of mental health issues; (b) identifying the prevalence of psychiatric treatment before and during imprisonment for those with (and without) reported psychological health issues; and, (c) determining whether male and female older inmates exhibit differences in psychological health, factors associated with psychological issues, and the use/provision of psychiatric care.
Method
Data
The data for this study came from the latest wave of the Survey of Inmates in State and Federal Correctional Facilities (SISFCF; U.S. Department of Justice, Bureau of Justice Statistics, 2004). This cross-sectional survey was administered between October 2003
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and May 2004, and collected data from a nationally representative sample of 18,185 male and female inmates housed in 287 state and 39 federal correctional facilities throughout the United States. A two-stage multilevel sampling method was used to obtain the sample and conduct the survey, whereby prisons were selected in the first stage and inmates within sampled prisons were selected in the second stage. Computer-assisted personal interviewing was used to collect data from inmates.
For further detail on the survey and data collection, see the 2004 SISFCF codebook (U.S. Department of Justice, Bureau of Justice Statistics, 2004). Though in the past some researchers using the 2004 SISFCF have separated the state and federal data (see Blowers & Blevins, 2015; Horowitz, 2013), the current study merged and analyzed both state and federal data files.1 This analytic approach is justified in the fact that male and female older inmates show some variability in offense type (see Fazel & Jacoby, 2002), which has implications for the prison system/facility in which they are housed. Estimates from the current sample show that a significant proportion of male older inmates were housed in state facilities, whereas for female older inmates the proportion housed in state versus federal facilities was nearly equivalent (see Table 1). Considering that a central focus of this study was to provide a gender-based comparative analysis on psychological health and treatment, excluding federal (or state) data could potentially skew results.
Analytic sample
In the past there had been little consensus with respect to what defines an “older inmate” and, therefore, what age should be used as a standard threshold (i.e., cut-off point) when researching this population (Aday, 1994; Grant, 1999; see also Kakoullis et al., 2010; Stoliker & Varanese, 2017). Older inmates have most commonly been classified as individuals aged 50 years and older (Grant, 1999). Though a 50-year-old is not typically considered to be elderly, the use of such a low age cut-off is justified in the fact that inmates often display an “accelerated” physical age, which is attributable to pre-prison lifestyles/adversities and the conditions of prison (see Dawes, 2002, 1997; Grant, 1999; Kratcoski & Pownall, 1989; Maschi, Viola, & Sun, 2013; Reviere & Young, 2004; Williams et al., 2006). Studies have shown there is a 10- to 15-year differential between the overall health of prisoners and the general population (Grant, 1999; Kratcoski & Pownall, 1989; Maschi et al., 2013), and older inmates develop physiological issues/diseases earlier than persons in the general population (Williams et al., 2006).
Accordingly, an analytic sample was created following the abovementioned criterion for the classification of older inmates (Grant, 1999; Morton, 1992). Inmates aged 49 years or younger were excluded from the sample, keeping only those aged 50 years or older for analyses. The final analytic sample consisted of 1,537 male and 370 female older inmates (N = 1,907), with an age range of 50–84 for males (M = 56.22, SD = 5.88) and 50–75 for females (M = 55.45, SD = 5.28).
Measures
Considering that not all inmates will satisfy criteria for psychiatric disorders but could still be experiencing symptoms of psychological distress (Stoliker & Varanese, 2017), and the fact that it is not uncommon for mental disorders to go undiagnosed in prison
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Table 1. Sample characteristics. Full Sample Male Older Female Older
(N = 1,907) Inmates (n = 1,537) Inmates (n = 370) Test Statistic
% or M(SD) % or M(SD) % or M(SD) (χ2 or t-test)
Mental Disorder Diagnoses Depressive Disorder 16.2 13.5 27 40.857*** Mood Disorder 6.7 5.3 12.4 24.323*** Schizophrenia/Psychotic Disorder 3.7 3.5 4.3 0.613 PTSD 6.7 6.2 8.4 2.378 Anxiety/Panic Disorder 7.2 5.9 12.7 20.744*** Total Mental Disorder 23 19.8 35.4 41.925***
Mental Health Symptoms Depressiona 55.1 [55] 53.2 [53.2] 62.9 [62.7] 11.904*** Mania 36.2 33.6 47.3 24.787*** Schizophrenia/Psychosis 10.6 10.5 10.8 0.017 Total Mental Health Symptomsa 61.6 [61.5] 59.4 [59.4] 70.2 [70] 14.561***
Psychiatric Care Before Arrest/Imprisonment Medication 10.6 8.4 20 42.109*** Counselling/Therapy 7.4 5.5 15.4 42.977*** Hospitalization 2.2 2.1 2.7 0.531
Since Admission Medication 17.4 14.6 28.9 42.293*** Counselling/Therapy 12.4 10.2 21.4 34.107*** Hospitalization 2.3 2.4 1.9 0.351
Sociodemographic Characteristics Female = 1 19.4 - - - Race/Ethnicity Hispanic 14.3 13.6 17.3 3.327 Black 32.6 32.5 33 0.035 White 61.2 61 62.4 0.271 Other 6.7 7 5.4 1.162
Age 56.07 (5.78) 56.22 (5.88) 55.45 (5.28) −2.286* Education 11.49 (3.45) 11.33 (3.47) 12.17 (3.31) 4.165***
Life Stressors Sexual Victimization 9.1 5.0 25.9 160.169*** Physical Victimization 15.4 11.2 33.0 110.282***
Criminal History Prior Incarceration 41.3 44.8 26.8 42.323***
Physical Health/Disability Cancer 9.0 8.3 11.6 3.890* Paralysis 10.1 10.1 10.0 0.002 Stroke/Brain Injury 9.3 9.0 10.3 0.533 Heart Problems 22.9 21.7 27.8 6.946** Arthritis/Rheumatism 40.8 37.8 53.5 30.600*** Asthma 14.4 12.7 21.6 19.499*** Hypertension 47.4 44.8 58.1 21.307*** BADL Disability 32 32.1 31.6 0.011
Substance Use High Alcohol Use 19.9 22.1 11.1 22.567*** High Drug Use 26.1 26.3 25.4 0.120
Prison-based Characteristics State Inmate = 1 Time Served
71.3 75.6 53.2 72.797***
< 2 years 26.0 23.2 37.8 33.375*** 2 to 5 years 28.7 27.9 31.9 2.310 6 to 10 years 17.4 18.2 13.8 4.086* 11 years or more 22.8 25.4 11.9 31.084*** unknown 5.1 5.3 4.6 0.279
Victimization 10.7 12.0 5.1 14.823*** Segregation 15.0 16.8 7.6 19.879*** Isolation/Idleness 12.58 (5.44) 12.63 (5.51) 12.36 (5.14) −0.866
Test statistics for Pearson chi-square and independent samples t-test are provided in the far-right column to highlight statistically significant differences between the estimates provided by male and female older inmate sub-groups – † p< .10, *p< .05, **p< .01, ***p< .001; avariables containing measures with imputed values – original data are presented in square brackets; “Hospitalization” refers to admission to a mental hospital, unit or treatment program; “BADL” refers to “basic activities of daily living.”
486 B. E. STOLIKER AND P. M. GALLI
populations (Diamond et al., 2001), the current study examines older inmates with respect to both mental disorder diagnoses and mental health symptomatology. With respect to mental disorder diagnoses, the survey asked inmates if they had ever been told by a mental health professional, such as a psychiatrist or psychologist, they had: a depressive disorder; a mood disorder (e.g., manic-depression, bipolar disorder, or mania); schizophrenia or another psychotic disorder; post-traumatic stress disorder; or, an anxiety disorder other than PTSD (e.g., panic disorder). Each mental disorder variable was coded 1 if the inmate reported having the respective diagnosis, and 0 otherwise. The mental health symptom variables are dichotomous measures reflecting whether inmates had experienced symptoms consistent with depression, mania, or schizophrenia/psychosis within 12 months (or more) prior to data collection. The items that comprise each of the mental health symptom variables were derived from survey questions which reflect symptomatology and diagnostic criteria of pertinent mental illnesses as outlined in the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.; DSM-5; American Psychiatric Association, 2013). The measure of depressive symptoms was based on the aggregation of survey questions which reflected (a) depressed mood, (b) change in appetite, (c) sleep disturbance, (d) feelings of worthlessness, and (e) suicidal ideation or attempt.2 The measure of manic symptoms was based on the aggregation of survey questions which reflected (a) elevated or irritable mood, (b) racing thoughts, and (c) increased activity or agitation.3 The measure of schizophrenic/psychotic symptoms was based on the aggregation of survey questions which reflected (a) delusions and (b) hallucinations.4 For a similar approach to operationalizing and coding mental health symptoms using the 2004 SISFCF data cycle, see Houser, Belenko, and Brennan (2012). Each mental health symptom variable was coded 1 if inmates reported experiencing symptoms consistent with depression, mania, or schizophrenia/psychosis (0 otherwise). The mental disorder and symptom variables were further aggregated to create “Total Mental Disorder” and “Total Mental Health Symptoms” measures, which reflect whether an inmate has one or more of the measured mental disorders or mental health symptoms, respectively (coded 1 for yes, 0 otherwise). The survey included several measures which captured an inmate’s use/ provision of services for emotional or mental conditions, other than those related to drug or alcohol use, in the year prior to arrest/imprisonment and since current admission to prison. Inmates were asked if, at any time during the 12 months prior to arrest or since admission to prison, they had: taken medication for a mental or emotional problem; received counseling or therapy; been admitted to a mental hospi- tal, unit, or treatment program. Each measure was coded 1 for yes, and 0 otherwise.
A set of variables captured inmates’ sociodemographic characteristics, life stres- sors, criminal history, and physical and behavioral health. Female is coded as 1 (male = 0). Race/ethnicity was based on a series of dummy variables: White (referent category), Hispanic, Black, and “Other” (i.e., Native American, Hawaiian/ Pacific Islander, Asian). Age was a continuous measure, ranging from 50 to 84 years for the total sample. Education was a continuous measure that captured the years of education completed by the inmate prior to imprisonment, ranging from 0 to 18. Two measures were used to capture pre-prison life stressors: sexual and physical victimization. Sexual victimization was based on whether inmates had been pres- sured or forced into sexual contact against their will prior to admission to prison (1
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= yes, 0 otherwise). Physical victimization was based on whether inmates had been physically abused prior to admission to prison (1 = yes, 0 otherwise). Prior incar- ceration was coded 1 for yes, 0 for no.
With respect to physical health, inmates were asked whether they ever had: any type of cancer; experienced paralysis (not related to physical restraint); a stroke or brain injury; heart problems; arthritis/rheumatism; asthma; and, hypertension. Each variable was coded 1 if the inmate had experienced the physical condition, and 0 otherwise. Disability in basic activities of daily living (hereafter, BADL disability) was created by aggregating three survey questions, which asked inmates if they: experience difficulties seeing newsprint (even with glasses); experience difficulties hearing a normal conversation (even with a hearing aid); or, use an aid to help with daily activities (e.g., a cane, wheelchair, and walker). This measure was coded 1 based on a positive response (0 otherwise). In terms of behavioral health, two dichotomous measures were created to indicate inmates’ involve- ment in substance abuse prior to admission to prison. High alcohol use was coded 1 if inmates indicated they drank daily or almost daily in the year preceding their most recent offense. High drug use was created by aggregating several questions regarding how often offenders used specific drugs in the month before arrest (i.e., opiates, amphetamines, methaqualone, barbiturates, tranquilizers, crack/cocaine, phencyclidine, ecstasy, lysergic acid diethylamide or other hallucinogens, cannabis, inhalants, and other drugs), and was coded as 1 if inmates used any of the listed drugs once a week or more (0 otherwise).
A set of variables captured characteristics of the inmates’ incarceration. State inmates were coded as 1 (federal inmate = 0). Time served captured how long inmates had spent in prison since current admission, which was coded as a series of dummy variables: less than 2 years (referent category), 2 to 5 years, 6 to 10 years, 11 years or more, and unknown time (the latter dummy variable was used for descriptive purposes only). Victimization was based on whether inmates had been injured in a fight, assault, or incident in which someone tried to harm them since their admission to prison (1 = yes, 0 otherwise). Segregation was based on whether disciplinary action was taken against an inmate for violating prison rules, wherein those who indicated they received solitary confinement or were confined to their own cell/quarters as a result were coded 1 (0 otherwise). Isolation/ idleness captured the total amount of time an inmate spent where he or she sleeps in the 24hr period prior to the survey (including time spent sleeping and doing things other than sleeping), ranging from 1 to 24 h.
Analytic procedure
A “missing values analysis” was conducted on all study measures, which showed most variables contained less than 2.5% of missing cases. However, the measure of suicidal ideation, a component of the construct measuring depressive symptomatology, contained 10.5% (n = 201) missing cases. Results from Little’s MCAR test indicated that data were not missing completely at random [Little’s MCAR test χ2 (5) = 11.291, p = .046], with further analyses suggesting there was a greater likelihood data were missing at random (MAR) or missing not at random (MNAR). Multiple imputation was used to handle missing data on suicidal ideation, whereas variables having less than 5% of missing values were deemed as having ignorable “missingness” and listwise deletion was used. Multiple
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imputation is an appropriate method for managing missing data, as it often produces unbiased estimates if data are MAR or MNAR (see Schafer & Graham, 2002).
Descriptive analyses were conducted according to the full sample, as well as for male and female sub-samples; additionally, chi-square and independent samples t-test analyses were conducted to discern gender differences across the study variables (Table 1). Bivariate (Table 2) and multivariate (Tables 3 & 4) logistic regression analyses were conducted, regressing mental disorder and mental health symptomatology variables on independent measures for the full sample. Multivariate logistic regression was also used to examine the aggregated measures of mental disorder and mental health symptoms, stratified according to gender (Table 5).5 For hypothesis testing, we considered values of P< .10 as statistically significant. Furthermore, several figures were created to highlight the prevalence of older inmates’ use/provision of mental health services before arrest/impri- sonment and since admission to prison, stratified according to gender (see Figures 1–6). Specifically, older inmates’ use/provision of mental health services was examined accord- ing to mental disorder diagnoses (see Figures 1–3) and mental health symptoms (see Figures 4–6).
Results
Twenty-three percent of the sample had been diagnosed with one or more of the measured mental disorders, whereas 61.6% of the sample had reported experiencing symptoms of mental health issues (see Table 1). Both depressive disorder diagnoses (16.2%) and symptoms of depression (55.1%) were the most commonly reported psycho- logical issues for this sample (for prevalence of other measured psychological issues, see Table 1). Results from chi-square and bivariate analyses (see Tables 1 & 2) indicated females were significantly more likely than males to report having a depressive disorder, a mood disorder, an anxiety disorder other than PTSD, as well as symptoms consistent with depression and mania. Results from descriptive analyses (Table 1) further showed that, irrespective of whether inmates had reported a mental disorder diagnosis or symp- toms of psychological distress, a smaller proportion had used/received psychiatric care prior to arrest/imprisonment when compared to the use/access of these services during imprisonment. Specifically, 10.6% of inmates had taken medication prior to arrest/impri- sonment, whereas 17.4% had taken medication since admission to prison; 7.4% of inmates had received counseling/therapy prior to arrest/imprisonment, whereas 12.4% had received counseling/therapy since admission to prison. Very few inmates reported being admitted to a mental hospital, unit or treatment program both before arrest/imprisonment (2.2%) and since admission to prison (2.3%). Results from chi-square analyses (Table 1) indicated females were significantly more likely than males to report taking medication or receiving counseling/therapy both before arrest/imprisonment and since admission to prison.
Figures 1–3 summarize findings for the use/provision of mental health services before arrest/imprisonment and since admission to prison, according to mental disorder diag- nosis, for the male and female sub-samples. Results generally indicate that, for inmates who reported a mental disorder diagnosis, the proportion who used/received medication (Figure 1) or counseling/therapy (Figure 2) outside of prison was lower than that of the proportion who used/received these services in prison. Findings from Figures 1 and 2 also
VICTIMS & OFFENDERS 489
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M an ia
Sc h iz op
h re n ia /
Ps yc h os is
Ex p (b )
Ex p (b )
Ex p (b )
Ex p (b )
Ex p (b )
Ex p (b )
Ex p (b )
Ex p (b )
Fe m al e = 1
2. 39 3* **
2. 53 8* **
1. 25 5
1. 39 2
2. 32 9* **
1. 51 7* *
1. 79 6* **
1. 02 4
Ra ce /E th n ic it y (W
h it e)
H is p an ic
.8 44
.7 73
1. 09 5
.5 93 †
.7 92
.5 52 ** *
.5 60 ** *
.6 78
Bl ac k
.4 89 ** *
.5 84 *
.7 70
.5 44 **
.4 76 **
.8 94
1. 04 8
1. 54 1* *
O th er
.8 93
.7 46
.7 70
1. 33 7
.6 47
.8 46
1. 06 6
1. 96 2*
A g e
.9 65 **
.9 43 **
.9 75
.9 52 **
.9 90
.9 85 †
.9 79 *
.9 58 **
Ed uc at io n
1. 05 1* *
1. 01 0
.9 30 *
1. 11 0* **
1. 03 4
1. 02 5†
1. 00 5
.9 53 *
Se xu al V ic ti m iz at io n
4. 71 4* **
5. 71 9* **
1. 94 3†
3. 61 8* **
3. 31 5* **
3. 64 0* **
2. 18 1* **
2. 65 6* **
Ph ys ic al V ic ti m iz at io n
3. 37 7* **
3. 81 2* **
1. 95 2*
3. 05 3* **
3. 02 3* **
2. 52 6* **
1. 91 6* **
2. 03 2* **
Pr io r In ca rc er at io n
1. 05 2
1. 67 0* *
1. 69 6*
1. 01 5
1. 04 3
1. 25 8*
1. 48 4* **
1. 72 3* **
C an ce r
1. 09 2
1. 15 4
1. 52 5
.9 42
1. 03 5
1. 55 5* *
1. 22 1
.9 28
Pa ra ly si s
2. 54 9* **
1. 27 9
1. 49 4
2. 74 4* **
2. 30 3* **
3. 29 3* **
2. 15 2* **
2. 10 2* **
St ro ke /B ra in
In ju ry
2. 85 0* **
1. 99 9* *
3. 31 3* **
2. 04 3* *
2. 90 4* **
2. 16 6* **
2. 01 3* **
2. 29 7* **
H ea rt Pr ob
le m s
2. 25 3* **
1. 45 6†
1. 91 5*
2. 17 2* **
2. 41 1* **
2. 25 0* **
2. 02 9* **
1. 86 1* **
A rt h ri ti s/ Rh
eu m at is m
2. 08 9* **
2. 02 0* **
1. 26 9
1. 93 8* **
2. 33 2* **
2. 20 7* **
1. 96 6* **
1. 79 3* **
A st h m a
1. 56 0* *
1. 90 6* *
1. 26 7
1. 41 4
1. 75 1*
1. 53 1* *
1. 70 1* **
1. 74 9* *
H yp er te n si on
1. 76 7* **
1. 41 0†
1. 37 3
1. 85 4* *
1. 85 8* *
1. 49 7* **
1. 40 2* **
1. 23 5
BA D L D is ab ili ty
2. 06 9* **
2. 62 2* **
1. 57 4†
2. 00 1* **
2. 04 5* **
2. 22 6* **
2. 09 6* **
2. 20 3* **
H ig h A lc oh
ol U se
1. 63 5* *
2. 06 6* **
3. 32 0* **
1. 69 1*
1. 61 1*
1. 81 1* **
1. 38 7* *
1. 41 8*
H ig h D ru g U se
1. 13 3
1. 55 4*
1. 47 2
1. 15 5
1. 37 2†
1. 25 6*
1. 21 2†
1. 39 5*
St at e In m at e = 1
Ti m e Se rv ed
(< 2 ye ar s)
1. 04 0
1. 16 4
2. 19 2*
1. 31 4
.7 59
1. 38 7* *
1. 09 2
1. 28 4
2 to
5 ye ar s
.9 02
.7 38
.9 77
.6 82
.5 73 *
.9 58
.9 24
.9 81
6 to
10 ye ar s
.7 37
.7 12
1. 03 1
.8 05
.5 50 *
.8 25
.9 01
1. 21 4
11 ye ar s or
m or e
.4 87 ** *
.6 74
1. 67 3
.5 73 *
.4 53 **
.8 30
.9 32
1. 09 8
V ic ti m iz at io n
1. 64 8* *
1. 59 8†
2. 14 7*
1. 39 1
.9 24
1. 79 5* **
1. 56 0* *
2. 09 4* **
Se g re g at io n
.8 92
1. 03 5
1. 68 9†
.7 37
.9 41
1. 43 0* *
1. 45 8* *
1. 61 4*
Is ol at io n /I d le n es s
1. 03 5* *
1. 05 6* *
1. 09 6* **
1. 05 0* *
1. 04 2*
1. 05 8* **
1. 05 2* **
1. 04 0* *
† p<
.1 0,
*p < .0 5,
** p<
.0 1,
** *p < .0 01 .
490 B. E. STOLIKER AND P. M. GALLI
Ta b le
3. M ul ti va ri at e b in om
ia l lo g is ti c re g re ss io n p re d ic ti n g m en ta l d is or d er s, w it h ad ju st ed
od d s ra ti os
an d st an d ar d er ro rs
– fu ll sa m p le .
M od
el 1
M od
el 2
M od
el 3
M od
el 4
M od
el 5
D ep re ss iv e D is or d er
M oo d D is or d er
Sc h iz op
h re n ia /
Ps yc h ot ic D is or d er
PT SD
A n xi et y/
Pa n ic D is or d er
V ar ia b le s
Ex p (b )
SE Ex p (b )
SE Ex p (b )
SE Ex p (b )
SE Ex p (b )
SE
Fe m al e = 1
1. 54 8*
0. 18 5
1. 62 6†
0. 27 5
1. 57 5
0. 39 1
.6 96
0. 28 7
1. 52 0†
0. 24 9
Ra ce /E th n ic it y (W
h it e)
H is p an ic
1. 13 5
0. 21 7
1. 03 7
0. 34 3
1. 52 8
0. 39 6
.9 95
0. 32 7
1. 02 0
0. 30 3
Bl ac k
.4 90 ** *
0. 17 8
.5 23 *
0. 26 2
.5 58 †
0. 34 4
.5 56 *
0. 25 7
.4 66 **
0. 25 0
O th er
.7 82
0. 31 4
.4 58
0. 58 2
.8 19
0. 65 1
1. 30 4
0. 42 2
.4 06 †
0. 54 6
A g e
.9 54 **
0. 01 4
.9 45 *
0. 02 3
.9 71
0. 02 7
.9 33 **
0. 02 2
.9 88
0. 01 8
Ed uc at io n
1. 03 5
0. 02 3
1. 01 4
0. 03 5
.9 70
0. 04 2
1. 12 6* *
0. 03 5
1. 02 0
0. 03 1
Se xu al V ic ti m iz at io n
2. 69 0* **
0. 22 4
3. 57 0* **
0. 29 2
1. 31 8
0. 44 6
2. 28 1* *
0. 29 8
1. 52 1
0. 30 1
Ph ys ic al V ic ti m iz at io n
1. 73 6* *
0. 18 5
1. 63 4†
0. 26 0
1. 10 6
0. 35 9
1. 85 3*
0. 25 6
1. 69 9*
0. 24 9
Pr io r In ca rc er at io n
1. 13 4
0. 15 4
1. 92 4* *
0. 23 0
1. 25 9
0. 28 5
1. 00 4
0. 21 8
1. 19 2
0. 21 3
C an ce r
.7 04
0. 25 1
.7 23
0. 37 5
1. 16 7
0. 42 1
.8 45
0. 35 2
.6 75
0. 34 0
Pa ra ly si s
1. 26 5
0. 21 4
.5 51 †
0. 35 5
.8 07
0. 43 6
1. 42 2
0. 28 0
1. 20 6
0. 28 0
St ro ke /B ra in
In ju ry
1. 61 3*
0. 22 3
1. 44 5
0. 33 7
2. 92 0* *
0. 38 4
1. 09 3
0. 31 2
1. 59 5
0. 28 5
H ea rt Pr ob
le m s
1. 59 0* *
0. 16 8
1. 14 4
0. 25 6
1. 31 7
0. 32 5
1. 75 0*
0. 23 2
1. 43 7
0. 22 4
A rt h ri ti s/ Rh
eu m at is m
1. 30 9†
0. 15 2
1. 21 0
0. 23 1
.8 82
0. 29 8
1. 20 1
0. 21 8
1. 54 2*
0. 21 0
A st h m a
1. 06 4
0. 19 3
1. 24 5
0. 27 2
.9 79
0. 36 6
.8 91
0. 27 7
1. 20 5
0. 24 9
H yp er te n si on
1. 40 9*
0. 15 4
1. 02 8
0. 23 0
1. 01 6
0. 30 0
1. 53 9†
0. 22 1
1. 32 4
0. 21 2
BA D L D is ab ili ty
1. 56 6* *
0. 15 5
2. 23 8* **
0. 23 1
1. 17 6
0. 30 1
1. 60 7*
0. 21 8
1. 42 1†
0. 21 3
H ig h A lc oh
ol U se
2. 02 9* **
0. 16 7
2. 34 6* **
0. 23 5
3. 31 5* **
0. 28 5
1. 65 1*
0. 23 1
1. 83 7* *
0. 22 4
H ig h D ru g U se
.9 98
0. 17 0
1. 10 2
0. 23 8
1. 25 8
0. 30 4
1. 05 3
0. 24 0
1. 31 0
0. 22 7
St at e In m at e = 1
1. 16 7
0. 17 4
.8 64
0. 26 3
1. 86 9
0. 41 8
1. 49 0
0. 25 9
0. 79 3
0. 22 9
Ti m e Se rv ed
(< 2 ye ar s)
2 to
5 ye ar s
.9 62
0. 17 5
.6 82
0. 27 6
1. 11 7
0. 39 2
.7 69
0. 26 0
.5 99 *
0. 24 7
6 to
10 ye ar s
.7 42
0. 21 4
.7 72
0. 31 8
1. 11 4
0. 43 4
.9 06
0. 29 2
.6 14 †
0. 29 4
11 ye ar s or
m or e
.3 96 ** *
0. 23 5
.6 30
0. 32 5
1. 62 7
0. 39 7
.6 13
0. 31 4
.5 47 *
0. 30 4
V ic ti m iz at io n
2. 01 5* *
0. 22 1
1. 65 9
0. 30 9
1. 61 5
0. 36 5
1. 07 4
0. 31 3
.8 85
0. 33 1
Se g re g at io n
.8 87
0. 22 0
.9 17
0. 31 1
1. 21 1
0. 34 7
.6 83
0. 32 7
1. 21 0
0. 29 2
Is ol at io n /I d le n es s
1. 01 7
0. 01 3
1. 04 5*
0. 02 0
1. 05 8*
0. 02 4
1. 04 0*
0. 01 9
1. 02 2
0. 01 8
C on
st an t
.5 33
0. 90 8
.2 67
1. 44 3
.0 25 *
1. 75 9
.1 93
1. 35 6
.0 52 *
1. 19 8
N ag el ke rk e R 2
.2 17
.1 89
.1 36
.1 57
.1 40
H os m er -L em
es h ow
g oo d n es s- of -fi ta
.1 86
.8 14
.7 12
.3 17
.4 51
n = 17 63
n = 17 62
n = 17 61
n = 17 60
n = 17 63
† p<
.1 0.
*p < .0 5.
** p<
.0 1.
** *p < .0 01 ; a p -v al ue
is p re se n te d – n ot e th at
in si g n ifi ca n ce
of H os m er – Le m es h ow
te st fo r g oo d n es s- of -fi t su g g es ts th er e is an
ad eq ua te
fi t of
th e d at a to
th e
m od
el .
VICTIMS & OFFENDERS 491
indicate that a larger proportion of females (compared to males) with a mental disorder diagnosis used/received medication (Figure 1) or counseling/therapy (Figure 2) both before arrest/imprisonment and since admission to prison. Findings from Figure 3 indicate that, for male and female inmates with a mental disorder diagnosis, the propor- tion who were admitted to a mental hospital, unit or treatment program outside of prison was quite similar to that of the proportion who were admitted to these services in prison. For male inmates, a slightly greater proportion had been admitted to these services inside as compared to outside of prison – with the exception that proportions were equivalent for those with a mood disorder (Figure 3a). For female inmates, a slightly smaller proportion had been admitted to these services inside as compared to outside of prison – with the exception that proportions were equivalent for those with a diagnosis of schizophrenia/ psychotic disorder (Figure 3b).
Figures 4–6 summarize findings for the use/provision of mental health services before arrest/imprisonment and since admission to prison, according to mental health
Table 4. Multivariate binomial logistic regression predicting mental health symptomatology, with adjusted odds ratios and standard errors – full sample.
Model 1 Model 2 Model 3
Depression Mania Schizophrenia/
Psychosis
Variables Exp(b) SE Exp(b) SE Exp(b) SE
Female = 1 1.269 0.151 1.760*** 0.147 .804 0.245 Race/Ethnicity (White) Hispanic .660* 0.166 .641* 0.178 .807 0.291 Black 1.036 0.123 1.114 0.123 1.688** 0.189 Other .785 0.225 1.032 0.235 1.879† 0.336
Age .980* 0.010 .972** 0.010 .955** 0.017 Education 1.024 0.016 .999 0.017 .947* 0.027 Sexual Victimization 2.176** 0.233 1.366 0.200 1.999** 0.265 Physical Victimization 1.515* 0.172 1.204 0.159 1.398 0.223 Prior Incarceration 1.124 0.113 1.462** 0.114 1.414* 0.176 Cancer 1.278 0.194 1.024 0.186 .819 0.306 Paralysis 2.126*** 0.212 1.361† 0.182 1.298 0.246 Stroke/Brain Injury 1.032 0.210 1.246 0.193 1.658* 0.254 Heart Problems 1.742*** 0.141 1.544** 0.134 1.646* 0.198 Arthritis/Rheumatism 1.567*** 0.113 1.453** 0.113 1.424† 0.180 Asthma 1.059 0.157 1.266 0.149 1.365 0.212 Hypertension 1.134 0.113 1.038 0.114 .863 0.181 BADL Disability 1.606*** 0.122 1.615*** 0.118 1.639** 0.179 High Alcohol Use 1.900*** 0.136 1.476** 0.131 1.278 0.195 High Drug Use 1.193 0.126 1.044 0.126 1.178 0.187 State Inmate = 1 Time Served (< 2 years)
1.294* 0.125 .963 0.128 .934 0.208
2 to 5 years 1.023 0.136 .921 0.138 1.125 0.225 6 to 10 years .706* 0.161 .822 0.163 1.396 0.248 11 years or more .671* 0.156 .867 0.158 .993 0.252
Victimization 1.455* 0.186 1.286 0.175 1.724* 0.232 Segregation 1.388* 0.158 1.348† 0.154 1.154 0.219 Isolation/Idleness 1.044*** 0.010 1.038*** 0.010 1.018 0.015 Constant .603 0.632 .717 .649 .613 1.092 Nagelkerke R2 .201 .152 .131 Hosmer-Lemeshow goodness-of-fita .924 .782 .296
n = 1760 n = 1758 n = 1755
† p< .10. *p< .05. **p< .01. ***p< .001; ap-value is presented – note that insignificance of Hosmer–Lemeshow test for goodness-of-fit suggests there is an adequate fit of the data to the model.
492 B. E. STOLIKER AND P. M. GALLI
symptomatology, for the male and female sub-samples. Again, results generally indicate that, for inmates who reported experiencing psychological distress, the proportion who used/received medication (Figure 4) or counseling/therapy (Figure 5) outside of prison was lower than that of the proportion who used/received these services in prison. Findings from Figures 4 and 5 also indicate that a larger proportion of females (compared to males) with symptoms of psychological distress used/received medication (Figure 4) or counsel- ing/therapy (Figure 5) both before arrest/imprisonment and since admission to prison. Findings from Figure 6a indicate that, for males who reported psychological distress, the proportion who were admitted to a mental hospital, unit or treatment program outside of prison was equivalent to that of the proportion who were admitted to these services inside prison – with the exception being, for males who reported symptoms of schizophrenia/ psychosis, a slightly greater proportion were admitted to these services inside as compared to outside of prison. Results from Figure 6b indicate that, for female inmates who reported psychological distress, the proportion who were admitted to a mental hospital, unit or
Table 5. Multivariate binomial logistic regression predicting total mental disorder and total mental health symptoms, with adjusted odds ratios and standard errors – male and female sub-samples.
Total Mental Disorder Total Mental Health Symptoms
Model 1 Model 2
Male Female Male Female
Exp(b) SE Exp(b) SE Exp(b) SE Exp(b) SE
Race/Ethnicity (White) Hispanic 1.234 0.226 .387* 0.420 .663* 0.188 .316** 0.398 Black .571** 0.180 .467* 0.303 1.159 0.141 .989 0.319 Other 1.105 0.293 .857 0.631 .889 0.248 1.173 0.609 Age .960** 0.014 .954† 0.029 .980† 0.011 .969 0.028 Education 1.082** 0.023 .976 0.046 1.045* 0.018 .955 0.045 Sexual Victimization 2.058* 0.290 3.362** 0.349 2.877** 0.359 2.072† 0.442 Physical Victimization 2.248*** 0.205 1.155 0.319 1.464† 0.213 1.201 0.381 Prior Incarceration 1.353* 0.150 1.303 0.328 1.271† 0.123 1.244 0.368 Cancer .860 0.261 .647 0.417 1.186 0.224 1.323 0.483 Paralysis 1.316 0.220 .933 0.477 1.602* 0.231 1.841 0.683 Stroke/Brain Injury 1.459 0.236 1.736 0.469 1.198 0.239 1.441 0.674 Heart Problems 1.550* 0.177 1.473 0.303 1.436* 0.163 2.625** 0.371 Arthritis/Rheumatism 1.137 0.155 1.324 0.283 1.522** 0.129 1.568 0.293 Asthma 1.082 0.204 1.217 0.336 1.121 0.185 1.200 0.383 Hypertension 1.323† 0.156 1.753* 0.281 1.164 0.127 1.215 0.296 BADL Disability 1.590** 0.156 1.730† 0.298 1.710*** 0.137 2.630** 0.363 High Alcohol Use 1.833*** 0.163 1.730 0.398 2.109*** 0.150 4.779* 0.623 High Drug Use .895 0.172 1.660 0.333 1.196 0.141 .867 0.375 State Inmate = 1 1.155 0.182 .737 0.305 1.160 0.143 1.636 0.313 Time Served (< 2 years) 2 to 5 years .844 0.185 1.294 0.311 .987 0.158 1.238 0.327 6 to 10 years .739 0.217 1.287 0.409 .680* 0.180 .917 0.447 11 years or more .509** 0.222 .778 0.466 .725† 0.171 .231** 0.515 Victimization 1.774** 0.214 1.822 0.612 1.390 0.201 3.857 0.913 Segregation .829 0.209 1.390 0.493 1.361† 0.173 3.753† 0.714 Isolation/Idleness 1.026† 0.013 1.012 0.026 1.034** 0.011 1.041 0.030 Constant .345 0.878 2.842 1.800 .717 0.697 4.066 1.790 Nagelkerke R2 .176 .278 .173 .328 Hosmer-Lemeshow goodness-of-fita .105 .590 .117 .836
n = 1415 n = 348 n = 1409 n = 349
† p< .10. *p< .05. **p< .01. ***p< .001; ap-value is presented – note that insignificance of Hosmer–Lemeshow test for goodness-of-fit suggests there is an adequate fit of the data to the model; findings from this table should be interpreted with caution, as the outcome measures only indicate the presence or absence of one or more measured psychiatric issue(s) and, therefore, do not indicate more subtle nuances of the psychological issue(s).
VICTIMS & OFFENDERS 493
treatment program outside of prison was slightly greater than that of the proportion who were admitted to these services inside prison. For females who reported symptoms of schizophrenia/psychosis, a notably larger proportion were admitted to these services outside as compared to inside of prison (see Figure 6b).
Table 3 summarizes results for multivariate regressions predicting the likelihood of a reported mental disorder diagnosis. With respect to sociodemographic characteristics, females were at increased odds of reporting a diagnosis for a depressive disorder (OR =
Figure 2. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental disorder diagnosis – received counseling/therapy.
Figure 1. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental disorder diagnosis – use of psychotropic medication.
494 B. E. STOLIKER AND P. M. GALLI
1.548, p< .05), a mood disorder (OR = 1.626, p< .10), and an anxiety disorder other than PTSD (OR = 1.520, p< .10). Compared to White inmates, Black inmates were significantly less likely to report having a depressive disorder (OR = 0.490, p< .001), a mood disorder (OR = 0.523, p< .05), schizophrenia/psychotic disorder (OR = 0.558, p< .10), PTSD (OR = 0.556, p< .05), and an anxiety disorder other than PTSD (OR = 0.466, p< .01); those who identified as “other” race/ethnicity were significantly less likely to report having an anxiety
Figure 4. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental health symptoms – use of psychotropic medication.
Figure 3. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental disorder diagnosis – admission to a mental hospital, unit or treatment program.
VICTIMS & OFFENDERS 495
disorder other than PTSD (OR = 0.406, p< .10). A unit increase in age corresponds to decreased odds of reporting a diagnosis for a depressive disorder (OR = 0.954, p< .01), a mood disorder (OR = 0.945, p< .05), and PTSD (OR = 0.933, p< .01). A unit increase in education corresponds to increased odds of reporting a diagnosis for PTSD (OR = 1.126, p< .01). With respect to life stressors prior to incarceration, those who have been sexually victimized were at increased odds of reporting a diagnosis for a depressive disorder (OR =
Figure 6. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental health symptoms – admission to a mental hospital, unit or treatment program.
Figure 5. Psychiatric care before arrest/imprisonment and after current admission to prison according to mental health symptoms – received counseling/therapy.
496 B. E. STOLIKER AND P. M. GALLI
2.690, p< .001), a mood disorder (OR = 3.570, p< .001), and PTSD (OR = 2.281, p< .01). Those who have been physically victimized were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.736, p< .01), a mood disorder (OR = 1.634, p< .10), PTSD (OR = 1.853, p< .05), and an anxiety disorder other than PTSD (OR = 1.699, p< .05). With respect to criminal history, those who have had prior incarcerations were at increased odds of reporting a diagnosis for a mood disorder (OR = 1.924, p< .01).
When it comes to physical health, there were several significant findings. Inmates who have had a stroke/brain injury were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.613, p< .05) and schizophrenia/psychotic disorder (OR = 2.920, p< .01). Inmates who had heart problems were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.590, p< .01) and PTSD (OR = 1.750, p< .05). Those with arthritis/rheumatism were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.309, p< .10) and an anxiety disorder other than PTSD (OR = 1.542, p< .05). Those who have had hypertension were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.409, p< .05) and PTSD (OR = 1.539, p< .10). Inmates who reported having a BADL disability were at increased odds of reporting a diagnosis for a depressive disorder (OR = 1.566, p< .01), a mood disorder (OR = 2.238, p< .001), PTSD (OR = 1.607, p< .05), and an anxiety disorder other than PTSD (OR = 1.421, p< .10). When it comes to behavioral health, inmates who engaged in high alcohol use prior to incarceration were at increased odds of reporting a diagnosis for a depressive disorder (OR = 2.029, p< .001), a mood disorder (OR = 2.346, p< .001), schizophrenia/psychotic disorder (OR = 3.315, p< .001), PTSD (OR = 1.651, p< .05), and an anxiety disorder other than PTSD (OR = 1.837, p< .01). In terms of prison-based factors, inmates who had been victimized during the current incarceration were at increased odds of reporting a diagnosis for a depressive disorder (OR = 2.015, p< .01). A unit increase in “isolation/idleness” corresponds to increased odds of reporting a diagnosis for a mood disorder (OR = 1.045, p< .05), schizophrenia/psychotic disorder (OR = 1.058, p< .05), and PTSD (OR = 1.040, p< .05). Results from Table 3 also provide some indication that those who have served more time in prison (for the current sentence) were less likely to report having a diagnosis for a depressive disorder (see Model 1) and an anxiety disorder other than PTSD (see Model 5).
Table 4 summarizes results for multivariate regressions predicting the likelihood of reporting mental health symptoms. With respect to sociodemographic characteristics, females were at increased odds of reporting symptoms associated with mania (OR = 1.760, p< .001). Compared to White inmates, Hispanic inmates were less likely to report having symptoms of depression (OR = 0.660, p< .05) and mania (OR = 0.641, p< .05); Black inmates were more likely to report having symptoms of schizophrenia/psychosis (OR = 1.688, p< .01), as were inmates who identified as “other” race/ethnicity (OR = 1.879, p< .10). A unit increase in age corresponds to decreased odds of reporting symptoms associated with depression (OR = 0.980, p < .05), mania (OR = 0.972, p< .01), and schizophrenia/psychosis (OR = 0.955, p< .01). A unit increase in education corresponds to decreased odds of reporting symptoms associated with schizophrenia/psychosis (OR = 0.947, p< .05). With respect to life stressors prior to incarceration, those who have been sexually victimized were at increased odds of reporting symptoms associated with depres- sion (OR = 2.176, p< .01) and schizophrenia/psychosis (OR = 1.999, p< .01). Those who have been physically victimized were at increased odds of reporting symptoms associated
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with depression (OR = 1.515, p< .05). When it comes to criminal history, inmates with prior incarcerations were at increased odds of reporting symptoms of mania (OR = 1.462, p< .01) and schizophrenia/psychosis (OR = 1.414, p< .05).
With respect to physical health, there are several significant findings. Those who have experienced paralysis were at increased odds of reporting symptoms of depression (OR = 2.126, p< .001) and mania (OR = 1.361, p< .10). Inmates who have had a stroke/brain injury were at increased odds of reporting symptoms of schizophrenia/psychosis (OR = 1.658, p< .05). Inmates who have had heart problems were at increased odds of reporting symptoms of depression (OR = 1.742, p< .001), mania (OR = 1.544, p< .01), and schizophrenia/psychosis (OR = 1.646, p< .05). Inmates with arthritis/rheumatism were at increased odds of reporting symptoms of depression (OR = 1.567, p< .001), mania (OR = 1.453, p< .01), and schizophrenia/psychosis (OR = 1.424, p< .10). Inmates who reported having a BADL disability were at increased odds of reporting symptoms of depression (OR = 1.606, p< .001), mania (OR = 1.615, p< .001), and schizophrenia/psychosis (OR = 1.639, p< .01). When it comes to behavioral health, those who engaged in high alcohol use prior to incarceration were at increased odds of reporting symptoms of depression (OR = 1.900, p< .001) and mania (OR = 1.476, p< .01). In terms of prison-based factors, state inmates were at increased odds of reporting symptoms of depression (OR = 1.294, p < .05). Inmates who had been victimized during the current incarceration were at increased odds of reporting symptoms of depression (OR = 1.455, p< .05) and schizophrenia/ psychosis (OR = 1.724, p< .05). Inmates who had been segregated for disciplinary action were at increased odds of reporting symptoms of depression (OR = 1.388, p< .05) and mania (OR = 1.348, p< .10). A unit increase in “isolation/idleness” corresponds to increased odds of reporting symptoms of depression (OR = 1.044, p< .001) and mania (OR = 1.038, p< .001). Results also indicate that those who have served more time in prison (for the current sentence) were less likely to report having symptoms of depression (see Model 1).
Table 5 summarizes results for multivariate regressions predicting the likelihood of reporting any of the measured mental disorders or mental health symptoms (i.e., “total mental disorder” and “total mental health symptoms”; Models 1 and 2, respectively), stratified according to gender. The data suggest there are similarities between male and female older inmates with respect to the characteristics associated with mental disorder diagnoses (Model 1) or symptoms of mental health issues (Model 2). However, there are some noteworthy differences between genders when it comes to the factors associated with a mental disorder diagnosis (Table 5, Model 1). With respect to life stressors prior to incarceration, sexual victimization was a significant predictor of reporting a mental dis- order diagnosis for both males (OR = 2.058, p< .05) and females (OR = 3.362, p< .01), however, the effect size was greater for females. Physical victimization prior to incarcera- tion was significantly associated with reporting a mental disorder diagnosis for males (OR = 2.248, p< .001) but not females, as was education (OR = 1.082, p< .01), having a prior incarceration (OR = 1.353, p< .05), heart problems (OR = 1.550, p< .05), and high alcohol use (OR = 1.833, p< .001). In terms of prison-based factors, victimization (OR = 1.774, p< .01) and “isolation/idleness” (OR = 1.026, p< .10) were also significantly associated with a mental disorder diagnosis for males but not females.
There are also some noteworthy differences between genders when it comes to factors associated with symptoms of mental health issues (Table 5, Model 2). With respect to life
498 B. E. STOLIKER AND P. M. GALLI
stressors prior to incarceration, sexual victimization was significantly associated with symp- toms of mental health issues for both males (OR = 2.877, p< .01) and females (OR = 2.072, p< .10), however, the effect size was slightly greater for males. Physical victimization prior to incarceration was significantly associated with symptoms of mental health issues for males (OR = 1.464, p< .10) but not females, as was having a prior incarceration (OR = 1.271, p< .10), age (OR = 0.980, p< .10), education (OR = 1.045, p< .05), paralysis (OR = 1.602, p< .05) and arthritis/rheumatism (OR = 1.522, p< .01). Although both males (OR = 1.436, p< .05) and females (OR = 2.625, p< .01) with heart problems were significantly more likely to report symptoms of mental health issues, the effect size was notably larger for females. A similar trend is apparent in the effects of BADL disability and high alcohol use. The effect of BADL disability on symptoms of mental health issues was significant for males (OR = 1.710, p< .001) and females (OR = 2.630, p< .01), however, the effect size was larger for females. The effect of high alcohol use on symptoms of mental health issues was also significant for males (OR = 2.109, p< .001) and females (OR = 4.779, p< .05), however, the effect size for females was more than twice that of males. In terms of prison-based factors, “isolation/idleness” was significantly associated with symptoms of mental health issues for males (OR = 1.034, p< .01) but not females. Although both males (OR = 1.361, p< .10) and females (OR = 3.753, p< .10) who have been segregated were at increased odds of reporting symptoms of mental health issues, the effect size was notably larger for females.
Discussion
The purpose of the current study was to build upon extant knowledge of older inmates’ mental health and psychiatric care, with particular focus on (a) identifying factors associated with certain mental disorders and symptoms of mental health issues; (b) identifying the prevalence of psychiatric treatment before and during imprisonment for inmates with (and without) reported psychological issues; and, (c) determining whether male and female older inmates exhibit differences in psychological health, factors associated with psychological issues, and the use/provision of psychiatric care. There are several important findings and implications that can be extracted from this study.
Similar to patterns reported in extant literature (see Fazel et al., 2001a; Fazel & Jacoby, 2002; Koenig, 1995; Regan et al., 2003; Stoliker & Varanese, 2017), results suggest that psychological illness was quite prevalent among this sample of older inmates, with a diagnosis of depressive disorder or depressive symptomatology being the most com- monly reported (for both males and females). It was generally found that psychological issues were more common in female older inmates, which is consistent with previous studies on older inmate mental health (Stoliker & Varanese, 2017), as well as offender populations in general (see Drapalski et al., 2009; Senior et al., 2013; Steadman et al., 2009). However, this trend was not stable across all measures of psychological health (see Tables 1–4). Results further revealed that, although there were some similarities between male and female older inmates with respect to correlates of psychiatric illness, there were also some gender differences in this respect (see Table 5). Given the gendered patterns in psychiatric illness found among older prisoners, it is recommended that prisons consider the provision of gender-tailored psychological interventions (see Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016). This would require the identification of treatment needs/
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services most appropriate for male versus female older prisoners according to the nature of psychiatric illness and associated characteristics.
Furthermore, the present study finds support for the notion that traumatic experiences and life stressors play an important role in the psychological health of older inmates (see Haugebrook et al., 2010; Stoliker & Varanese, 2017), as physical and sexual victimization prior to admission to prison, as well as serious physical victimization during imprison- ment (i.e., resulting in injury), predicted increased odds of reported psychological issues in this sample of older prisoners.
Prisons should consider providing trauma-focused interventions (Fazel et al., 2016) to older inmates who have experienced traumatic life events or significant stressors, whether these issues have originated from pre-prison life or one’s experiences during incarceration. The treatment needs of those who have experienced traumas/stressors might depend on the nature of these issues (e.g., type, and frequency) and the associated psychological distress. Consistent with prior research (see Colsher et al., 1992; Fazel et al., 2001a, 2001b; Gallgher, 1990; Kakoullis et al., 2010; Koenig et al., 1995; Stoliker & Varanese, 2017), the results also showed that physiological illnesses were quite common among this sample of older inmates – especially for females (see Table 1) – and those with a history of physical health issues were generally more likely to report a mental disorder diagnosis or experience symptoms of psychological distress. Similar to Barry et al. (2017), it was found that older inmates with a BADL disability were more likely to report psychological issues. It was also determined that BADL disability was an important predictor of reported psychological illness for both male and female older inmates (see Table 5). Given the link between physical illness/disability and psychiatric illness, prisons should ensure older inmates are receiving adequate physical health services and that psychiatric services aim to address stresses surrounding the physical illnesses and disabilities of older inmates (Stoliker & Varanese, 2017). Similar to the findings from Koenig et al. (1995) and Stoliker and Varanese (2017), inmates with a history of alcohol abuse were at increased odds of reporting one of the mental disorder diagnoses, as well as depressive and manic symptomatology. Fazel et al. (2016) have provided several recommendations for the management of substance dependent inmates, such as: close monitoring; the provision of acute alcohol and drug detoxification (especially upon admission); the utilization of metha- done or alternative maintenance therapy; the provision of cognitive behavioral therapy for relapse prevention; and, continuity of care upon release. Finally, given there was a positive association between isolation/idleness and reported psychological issues, prisons should follow Fazel et al. (2016) recommendation for having minimum standards for meaningful activity.
With respect to psychiatric care, the findings generally showed that, for both male and female older inmates with (and without) a reported psychological issue, a greater proportion received psychotropic medication and counseling/therapy during the current period of incarceration when compared to the use/provision of these same services prior to incarcera- tion. When it comes to psychiatric hospitalization, estimates showed that the access/provision of this level of psychiatric care was quite similar during imprisonment as it was prior to incarceration. With exception to the access/provision of psychiatric hospitalization, these findings suggest older prisoners with mental health issues have better access to treatment services in prison compared to that in the community. It should be cautioned, however, that these results might also be a product of the sampling procedure for the SISFCF, as there was increased likelihood of a prison being selected for the survey if there was provision of mental
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health services (U.S. Department of Justice, Bureau of Justice Statistics, 2004). There is still limited understanding on the quality, duration, fidelity, and impact of psychological inter- ventions for older inmates. There should be further inquiry and investigation into whether psychological interventions are effectively addressing the specific mental health issues, and associated psychiatric needs, of older prison inmates. Fazel et al. (2016) present some evidence for the effectiveness of medication and psychotherapy interventions aimed at prisoner mental health; however, it is also stressed that there is need for further empirical investigation on the efficacy of psychological interventions within the prison setting. Furthermore, results support the notion that female offenders are more likely to utilize mental health services (Drapalski et al., 2009; Dye, 2011), as it was found that a larger proportion of older female prisoners reported taking medication or receiving counseling/therapy both before arrest/imprisonment and since current admission to prison. This pattern remained stable irrespective of whether the use/provision of mental health services was analyzed for the sample as a whole (see Table 1) or exclusively based on the report of a psychological issue (see Figures 1, 2, 4, & 5). These gender patterns were less consistent when considering older inmates’ admission to a mental hospital, unit, or treatment program before and during imprisonment (see Table 1, Figures 3, and 6).
Similar to findings of previous studies (Fazel et al., 2004, 2001a; Koenig et al., 1995), results provide some indication there is a sizable proportion of male and female older prisoners with a psychological issue that are not receiving some form of psychiatric care in prison (see Figures 1–6). It is understood that the psychiatric hospitalization of persons with mental health issues is often reserved for more extreme cases, which provides explanation for the large disparities in the proportion of inmates with mental health issues who receive this form of care versus those who do not. What is less justifiable are the disparities in the proportion of inmates with mental health issues who receive medication and counseling/therapy versus those who do not. Perhaps not all prisoners will consent to, or qualify for, certain types of treatment and the utilization of more than one form of treatment might not be necessary to effectively treat inmates with psychiatric illness. It could also be that, as previous researchers have indicated (see Fazel et al., 2004, 2001a; Koenig et al., 1995; Stoliker & Varanese, 2017), not all older inmates with mental health issues are receiving adequate psychiatric treatment in prison. More research is needed to substantiate or refute these claims.
It can be argued that the successful development and implementation of mental health intervention/prevention strategies require full institutional cooperation, from senior management to frontline workers (Slade & Forrester, 2015). Senior management should prioritize inmate mental health and adopt effective approaches to reduce inmates’ mental distress, as well as offer practical support to staff in mental health intervention and prevention strategies (see Slade & Forrester, 2015). When it comes to frontline workers, it can be argued that the management of inmate mental health should not solely be the responsibility of health-care staff and that the occupational role of correctional officers should be adapted to include this mandate (Forrester & Slade, 2014; World Health Organization, 2007). Correctional officers should, therefore, provide support for inmates with psychological illness, such as identifying individual risk, recognizing signs and symptoms of specific mental illnesses, calming distress, as well as monitoring and building relationships with inmates living with mental health issues (see Birmingham, 1999; Forrester & Slade, 2014; Slade & Forrester, 2015; World
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Health Organization, 2007). This would require specialized training for correctional officers, which could educate these personnel on mental health and the identification/ management of psychiatric illness (Birmingham, 1999; Forrester & Slade, 2014; Slade & Forrester, 2015), as well as aim to improve attitudes and behavioral responses sur- rounding interactions with inmates living with mental health issues (World Health Organization, 2007). Cross-professional collaboration and communication – between correctional officers, physicians, psychiatrists and psychologists, and other health-care staff – regarding inmate mental health status and concerns should also be implemented to foster more successful/efficient identification and management of inmates with mental health problems (Slade & Forrester, 2015; World Health Organization, 2007).
Most critical to the management of psychiatric illness within correctional facilities is the availability of high-quality psychiatric care (Munetz & Griffin, 2006). Maintaining or developing a high standard of psychiatric care within correctional facilities is, arguably, dependent upon identifying the composition of mental health issues among the inmate population and the specific treatment needs of inmates living with mental health issues, along with the availability of mental health-care staff and resources. In this initiative, it is important to administer psychiatric assessments by a trained professional upon an inmate’s admission to prison, as well as observe and assess inmates for psychiatric illness at regular intervals throughout their sentence (Fazel et al., 2016; World Health Organization, 2007; see also Gooding et al., 2017). Psychiatric assessments should aim to capture specific psychological disorder(s) and/ or mental health symptoms inmates might be living with or are currently experiencing, as well as take into consideration key characteristics associated with certain mental health issues to identify at-risk inmates. Information on the nature and composition of mental health issues/psychiatric needs within a prison population could be used to better allocate resources to necessary psychiatric care, as well as to tailor psychiatric treatment programs according to the psychiatric illnesses and other associated issues most prominent among the inmate population. In the event that prisons have limited resources and availability of psychiatric care, senior management should consider developing partnerships with community-based mental health programs (Fazel et al., 2016; World Health Organization, 2007).
This study is not without limitations. The survey data were collected in 2004 and, therefore, results do not necessarily reflect recent trends in mental health and psy- chiatric care among the older inmate population within United States’ state and federal prison systems. Since the data collection period, U.S. prisons have witnessed an increase in the number of older inmates (see Carson, 2018; West & Sabol, 2008). It is also possible that the nature of mental health issues, along with the use/provision of psychiatric care, among the older inmate population has shifted in U.S. prisons since the 2004 data collection period (Stoliker & Varanese, 2017). This suggests a possible disconnect between the findings of this study and contemporary application (Stoliker & Varanese, 2017). Despite this limitation, future research on older inmate mental health and psychiatric care (especially within the U.S. context) should use the results from the current study as a point of comparison. This survey was also cross-sectional in design, which limits the ability to make causal inferences on, and understand the temporal ordering of, relationships between independent and dependent measures. Another limitation relates to the issue of statistical “power” in regression analyses
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when stratifying and analyzing the sample according to gender. It is cautioned that a smaller sample size, especially for the female subsample, can increase the probability of false negative results (i.e., Type II error).
The mental health measures (i.e., mental disorder diagnosis and mental health symp- tomatology) also present some limitations. The variables that captured mental disorders were based on lifetime diagnoses, which is a less suitable measure compared to recent diagnosis considering that the nature and symptoms of mental disorders are likely to fluctuate over time (see Stoliker & Varanese, 2017). In addition, older inmates self- reported on mental disorder diagnosis, which could present some measurement error. This type of measure potentially overlooks inmates living with a mental disorder but who did not receive a formal diagnosis in the past. As mentioned above, it is not uncommon for mental disorders to go undiagnosed in prison populations (Diamond et al., 2001). With self-report measures, inmates might also neglect to report a previously diagnosed mental disorder or even report a disorder they do not truly have.
There is also the potential that the measures of mental disorder diagnosis bias results on the use/provision of psychiatric care before and since admission to prison (see Figures 1–3), as it is unclear whether inmates received a diagnosis prior to or during incarceration. Moreover, the mental health symptom variables were created according to the identification and aggregation of survey measures that are reflective of symptoms of certain mental health issues. Although this presented the opportunity to characterize and examine mental illnesses according to one or more symptoms, there is limited reliability and validity in these variables. In addition, the cross-sectional nature of the survey limits understanding of the stability of mental health symptoms over time. Symptoms might fluctuate, especially in relation to particular events experienced during imprisonment. The survey was also devoid of measures that capture neurocognitive illnesses (e.g., dementias). This is a significant limitation in the study of older inmate mental health considering that neurocognitive illness/disorders are common among the older prison demographic (Kakoullis et al., 2010) and might also be co-occurring with other mental health issues.
In conclusion, knowledge on older prisoners’ psychological health and well-being is improving; however, there are still many underexplored and unanswered questions. Research on older inmate mental health should aim to identify and explain in greater detail the underlying processes which link psychiatric illness to pertinent sociodemo- graphic characteristics, traumas/stressors, criminal history, physical health and disabil- ity, substance abuse, and characteristics of incarceration. The narrative should especially be developed on the nature of life in prison for older inmates with psycho- logical health issues, as there is a paucity of knowledge in this context. Researchers should also increase insight on the nature and quality of psychiatric assessment/ treatment of older prisoners with mental health issues. Finally, although the focus of the present study was specifically on older prisoners, future research must direct attention to comparative analyses of younger and older inmates to elucidate any age- based differences with respect to mental health and psychiatric needs/treatment. It is imperative to address these gaps if we are to advance scholarly knowledge and develop well-informed policy which aims to improve the mental health of older (and younger) inmates.
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Notes 1. Other researchers have also merged and analyzed both state and federal data included in
the 2004 SISFCF survey cycle. See Felson, Silver, and Remster (2012); Pare and Logan (2011); Stoliker (2018); Stoliker and Varanese (2017); Teasdale, Daigle, Hawk, and Daquin (2016).
2. “Depressed mood” was based on whether inmates had given up hope for life or the future, or if there were periods when they felt numb/empty inside. “Change in appetite” was based on whether inmates had noticeable increases or decreases in their appetite for a period of 2 weeks or more. “Sleep disturbance” was based on whether inmates had noticeable increases or decreases in the amount of time they slept. “Worthlessness” was based on whether there had been periods when inmates felt like no one cares about them. “Suicidal ideation or attempt” was based on inmates reporting whether they had ever considered or attempted suicide in their lifetime. Cronbach’s a = .694; mean inter-item correlation = .233; correlation with “depressive disorder,” rs = 0.265, p < .001. Because SPSS (version 24) does not provide Cronbach’s alpha or mean inter-item correlation for the aggregated imputed dataset, the estimates presented here were derived by averaging the values for the 10 separate imputed datasets.
3. “Elevated or irritable mood” was based on whether inmates have lost their temper easily and had a short fuse more often than usual, or had been angry more often than usual. “Racing thoughts” was based on whether inmates had experienced times when their thoughts raced so fast that they had trouble keeping track of them. “Increased activity or agitation” was based on whether inmates had experienced periods when they could not sit still. Cronbach’s a = .705; mean inter-item correlation = .375; correlation with “mood disorder,” rs = 0.205, p < .001.
4. “Delusions” was based on whether inmates believed other people could read their mind; believed other people had been able to control their brain or thoughts; or, felt that anyone other than corrections staff had been spying on, or plotting against, them. “Hallucinations” was based on whether inmates could see things other people say are not really there, or could hear voices other people cannot hear. Cronbach’s a = .719; mean inter-item correlation = .344; correlation with “schizophrenia/psychotic disorder,” rs = 0.215, p < .001.
5. The “total mental disorder” and “total mental health symptoms” measures were used in gender-based regression analyses in lieu of the disaggregated mental health measures, as cell counts for some mental health variables were quite low once the sample was further stratified according to gender.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
Aday, R. H. (1994). Golden years behind bars: Special programs and facilities for elderly inmates. Federal Probation, 58(2), 47–54.
Allen, R. S., Harris, G. M., Crowther, M. R., Oliver, J. S., Cavanaugh, R., & Phillips, L. L. (2013). Does religiousness and spirituality moderate the relations between physical and mental health among aging prisoners? International Journal of Geriatric Psychiatry, 28(7), 710–717. doi:10.1002/gps.v28.7
Allen, R. S., Phillips, L. L., Roff, L. L., Cavanaugh, R., & Day, L. (2008). Religiousness/spirituality and mental health among older male inmates. The Gerontologist, 48(5), 692–697. doi:10.1093/ geront/48.5.692
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
504 B. E. STOLIKER AND P. M. GALLI
Armour, C. (2012). Mental health in prison: A trauma perspective on importation and deprivation. International Journal of Criminology and Sociological Theory, 5(2), 886–894.
Barry, L. C., Wakefield, D. B., Trestman, R. L., & Conwell, Y. (2017). Disability in prison activities of daily living and likelihood of depression and suicidal ideation in older prisoners. International Journal of Geriatric Psychiatry, 32, 1141–1149. doi:10.1002/gps.4578
Beck, A., Gilliard, D., Greenfeld, L., Harlow, C., Hester, T., Jankowski, L., … Morton, D. (1993). Survey of state prison inmates, 1991. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Office of Justice Programs.
Birmingham, L. (1999). Prison officers can recognise hidden psychiatric morbidity in prisoners. British Medical Journal, 319, Article 853.
Blowers, A. N., & Blevins, K. R. (2015). An examination of prison misconduct among older inmates. Journal of Crime and Justice, 38(1), 96–112. doi:10.1080/0735648X.2014.924658
Caroll, L. (1974). Hacks, blacks and cons. Lexington, MA: Lexington Books. Carson, E. A. (2018). Prisoners in 2016. Washington, DC: Bureau of Justice Statistics, United States
Department of Justice. Caverley, S. J. (2006). Older mentally ill inmates: A descriptive study. Journal of Correctional Health
Care, 12, 262–268. doi:10.1177/1078345806295546 Colsher, P. L., Wallace, R. B., Loeffelholz, P. L., & Sales, M. (1992). Health status of older male
prisoners: A comprehensive survey. American Journal of Public Health, 82, 881–884. Dawes, J. (1997). Dying in prison: A study of deaths in correctional custody in South Australia, 1980-
1993 (doctoral dissertation). Flinders University, Adelaide, South Australia. Dawes, J. (2002). Dying with dignity: Prisoners and terminal illness. Illness, Crisis, & Loss, 10(3),
188–203. doi:10.1177/1054137302010003002 Dear, G. (2006). Preventing suicide and other self-harm in prison. Houndmills, UK: Palgrave
Macmillan. DeHart, D., Lynch, S., Belknap, J., Dass-Brailsford, P., & Green, B. (2014). Life history models of
female offending: The roles of serious mental illness and trauma in women’s pathways to jail. Psychology of Women Quarterly, 38(1), 138–151. doi:10.1177/0361684313494357
Diamond, P. M., Wang, E. W., Holzer, C. E., III, Thomas, C., & Cruser, D. A. (2001). The prevalence of mental illness in prison. Administration and Policy in Mental Health, 29(1), 21–40. doi:10.1023/A:1013164814732
Drapalski, A. L., Youman, K., Stuewig, J., & Tangney, J. (2009). Gender differences in jail inmates’ symptoms of mental illness, treatment history and treatment seeking. Criminal Behaviour and Mental Health, 19(3), 193–206. doi:10.1002/(ISSN)1471-2857
Dye, M. H. (2010). Deprivation, importation, and prison suicide: Combined effects of institutional conditions and inmate composition. Journal of Criminal Justice, 38(4), 796–806. doi:10.1016/j. jcrimjus.2010.05.007
Dye, M. H. (2011). The gender paradox in prison suicide rates. Women & Criminal Justice, 21(4), 290–307. doi:10.1080/08974454.2011.609400
Dye, M. H., & Aday, R. H. (2013). “I just wanted to die”: Preprison and current suicide ideation among women serving life sentences. Criminal Justice and Behavior, 40, 832–849. doi:10.1177/ 0093854813476266
Enders, S. R., Paterniti, D. A., & Meyers, F. J. (2005). An approach to develop effective health care decision making for women in prison. Journal of Palliative Medicine, 8(2), 432–439. doi:10.1089/ jpm.2005.8.432
Fazel, S., & Jacoby, R. (2002). Psychiatric aspects of crime and the elderly. In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (pp. 919–931). Oxford, UK: Oxford University Press.
Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). The mental health of prisoners: A review of prevalence, adverse outcomes and interventions. Lancet Psychiatry, 3(9), 871–881. doi:10.1016/S2215-0366(16)30142-0
Fazel, S., Hope, T., O’Donnell, I., & Jacoby, R. (2001a). Hidden psychiatric morbidity in elderly prisoners. The British Journal of Psychiatry, 179(6), 535–539. doi:10.1192/bjp.179.6.535
VICTIMS & OFFENDERS 505
Fazel, S., Hope, T., O’Donnell, I., & Jacoby, R. (2004). Unmet treatment needs of older prisoners: A primary care survey. Age and Ageing, 33(4), 396–398. doi:10.1093/ageing/afh113
Fazel, S., Hope, T., O’Donnell, I., Piper, M., & Jacoby, R. (2001b). Health of elderly male prisoners: Worse than the general population, worse than younger prisoners. Age and Ageing, 30, 403–407. doi:10.1093/ageing/30.5.403
Fazel, S., & Seewald, K. (2012). Severe mental illness in 33 588 prisoners worldwide: Systematic review and meta-regression analysis. The British Journal of Psychiatry, 200(5), 364–373. doi:10.1192/bjp.bp.111.100404
Fellner, J. (2006). A corrections quandary: Mental illness and prison rules. Harvard Civil Rights– Civil Liberties Law Review, 41(2), 391–412.
Felson, R. B., Silver, E., & Remster, B. (2012). Mental disorder and offending in prison. Criminal Justice and Behavior, 39(2), 125–143. doi:10.1177/0093854811428565
Fiske, A., & O’Riley, A. A. (2016). Toward an understanding of late life suicidal behavior: The role of lifespan developmental theory. Aging & mental health, 20(2), 123–130. doi:10.1080/ 13607863.2015.1078282
Forrester, A., & Slade, K. (2014). Preventing self-harm and suicide in prisoners: Job half done. The Lancet, 383, 1109–1111. doi:10.1016/S0140-6736(13)62571-4
Gallagher, E. M. (1990). Emotional, social, and physical health characteristics of older men in prison. The International Journal of Aging and Human Development, 31, 251–265. doi:10.2190/ QE9H-GV5T-KCJ6-EMJ4
Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York, NY: Anchor Books.
Gooding, P. A., Tarrier, N., Dunn, G., Awenat, Y., Shaw, J., Ulph, F., & Pratt, D. (2017). Psychological characteristics and predictors of suicide probability in high-risk prisoners. Criminal Justice and Behavior, 44, 321–335. doi:10.1177/0093854816650478
Grant, A. (1999). Elderly inmates: Issues for Australia. Trends and Issues in Crime and Criminal Justice (Series 115). Canberra, Australia: Australian Institute of Criminology.
Green, B. L., Miranda, J., Daroowalla, A., & Siddique, J. (2005). Trauma exposure, mental health functioning, and program needs of women in jail. Crime & Delinquency, 51(1), 133–151. doi:10.1177/0011128704267477
Greene, C. A., Ford, J. D., Wakefield, D. B., & Barry, L. C. (2014). Posttraumatic stress mediates the relationship between childhood victimization and current mental health burden in newly incar- cerated adults. Child Abuse & Neglect, 38(10), 1569–1580. doi:10.1016/j.chiabu.2014.07.006
Greenfeld, L. A., & Minor-Harper, S. (1991). Women in prison. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Office of Justice Programs.
Gunter, T. D., Chibnall, J. T., Antoniak, S. K., McCormick, B., & Black, D. W. (2012). Relative contributions of gender and traumatic life experience to the prediction of mental disorders in a sample of incarcerated offenders. Behavioral Sciences & the Law, 30(5), 615–630. doi:10.1002/bsl.2037
Haney, C., Banks, C., & Zimbardo, P. (1973). Interpersonal dynamics in a simulated prison. International Journal of Criminology & Penology, 1(1), 69–97.
Haugebrook, S., Zgoba, K. M., Maschi, T., Morgen, K., & Brown, D. (2010). Trauma, stress, health, and mental health issues among ethnically diverse older adult prisoners. Journal of Correctional Health Care, 16(3), 220–229. doi:10.1177/1078345809356536
Horowitz, V. (2013). Aging and inmate misconduct: A test of the importation theory. The International Journal of Aging and Society, 2, 53–69. doi:10.18848/2160-1909/CGP
Houser, K. A., Belenko, S., & Brennan, P. K. (2012). The effects of mental health and substance abuse disorders on institutional misconduct among female inmates. Justice Quarterly, 29(6), 799–828. doi:10.1080/07418825.2011.641026
Howse, K. (2003). Growing old in prison: A scoping study on older prisoners. London, England: Centre for Policy on Ageing and Prison Reform Trust.
Irwin, J., & Cressey, D. R. (1962). Thieves, convicts, and the inmate culture. Social Problems, 10(2), 142–155. doi:10.2307/799047
Jacobs, J. B. (1974). Street gangs behind bars. Social Problems, 21, 395–409. doi:10.2307/799907
506 B. E. STOLIKER AND P. M. GALLI
Jordan, B. K., Schlenger, W. E., Fairbank, J. A., & Caddell, J. M. (1996). Prevalence of psychiatric disorders among incarcerated women. II. Convicted felons entering prison. Archives of General Psychiatry, 53(6), 513–519.
Kakoullis, A., Le Mesurier, N., & Kingston, P. (2010). The mental health of older prisoners. International Psychogeriatrics, 22(5), 693–701. doi:10.1017/S1041610210000359
Kerbs, J. J., & Jolley, J. M. (2007). Inmate-on-inmate victimization among older male prisoners. Crime & Delinquency, 53(2), 187–218. doi:10.1177/0011128706294119
Koenig, H. G. (1995). Religion and older men in prison. International Journal of Geriatric Psychiatry, 10(3), 219–230. doi:10.1002/(ISSN)1099-1166
Koenig, H. G., Johnson, S., Bellard, J., Denker, M., & Fenlon, R. (1995). Depression and anxiety disorder among older male inmates at a federal correctional facility. Psychiatric Services, 46, 399–401. doi:10.1176/ps.46.4.399
Kratcoski, P., & Pownall, G. (1989). Federal Bureau of Prisons programming for older inmates. Federal Probation, 53(2), 28–35.
Kratcoski, P. C., & Babb, S. (1990). Adjustment of older inmates: An analysis by institutional structure and gender. Journal of Contemporary Criminal Justice, 6(4), 264–281. doi:10.1177/ 104398629000600407
LaMere, S., Smyer, T., & Gragert, M. (1996). The aging inmate. Journal of Psychosocial Nursing and Mental Health Services, 34(4), 25–29.
Liebling, A. (1999). Prison suicide and prisoner coping. Crime and Justice, 26, 283–359. doi:10.1086/449299
Luallen, J., & Cutler, C. (2017). The growth of older inmate populations: How population aging explains rising age at admission. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 72, 888–900.
Lynch, S. M., Fritch, A., & Heath, N. M. (2012). Looking beneath the surface: The nature of incarcerated women’s experiences of interpersonal violence, treatment needs, and mental health. Feminist Criminology, 7(4), 381–400. doi:10.1177/1557085112439224
Martin, M. E., & Hesselbrock, M. N. (2001). Women prisoners’ mental health: Vulnerabilities, risks and resilience. Journal of Offender Rehabilitation, 34(1), 25–43. doi:10.1300/ J076v34n01_03
Maschi, T., Viola, D., & Sun, F. (2013). The high cost of the international aging prisoner crisis: Well-being as the common denominator for action. The Gerontologist, 53(4), 543–554. doi:10.1093/geront/gns125
Messina, N., & Grella, C. (2006). Childhood trauma and women’s health outcomes in a California prison population. American Journal of Public Health, 96(10), 1842–1848. doi:10.2105/ AJPH.2005.082016
Moloney, K. P., van Den Bergh, B. J., & Moller, L. F. (2009). Women in prison: The central issues of gender characteristics and trauma history. Public Health, 123(6), 426–430. doi:10.1016/j. puhe.2009.04.002
Morton, J. (1992). An administrative overview of the older inmate. Washington, DC: U.S. Department of Justice, National Institute of Corrections.
Munetz, M. R., & Griffin, P. A. (2006). Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatric Services, 57(4), 544–549. doi:10.1176/ps.2006.57.4.544
Pare, -P.-P., & Logan, M. W. (2011). Risks of minor and serious violent victimization in prison: The impact of inmates’ mental disorders, physical disabilities, and physical size. Society and Mental Health, 1, 106–123. doi:10.1177/2156869311416828
Pearlin, L. I., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process. Journal of Health and Social Behavior, 22(4), 337–356. doi:10.2307/2136676
Regan, J. J., Alderson, A., & Regan, W. M. (2003). Psychiatric disorders in aging prisoners. Clinical Gerontologist, 26(1–2), 117–124. doi:10.1300/J018v26n01_10
VICTIMS & OFFENDERS 507
Reimer, G. (2008). The graying of the U.S. prisoner population. Journal of Correctional Health Care, 14(3), 202–208. doi:10.1177/1078345808318123
Reviere, R., & Young, V. D. (2004). Aging behind bars: Health care for older female inmates. Journal of Women & Aging, 16, 55–69. doi:10.1300/J074v16n01_05
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177. doi:10.1037/1082-989X.7.2.147
Senior, J., Birmingham, L., Harty, M. A., Hassan, L., Hayes, A. J., Kendall, K., & Shaw, J. (2013). Identification and management of prisoners with severe psychiatric illness by specialist mental health services. Psychological Medicine, 43(7), 1511–1520. doi:10.1017/S0033291712002073
Slade, K., & Forrester, A. (2015). Shifting the paradigm of prison suicide prevention through enhanced multi-agency integration and cultural change. The Journal of Forensic Psychiatry & Psychology, 26, 737–758. doi:10.1080/14789949.2015.1062997
Smith, R. (1999). Prisoners: An end to second class health care? British Medical Journal, 318 (7189), 954–955.
Smyer, T., Gragert, M. D., & LaMere, S. (1997). Stay safe! Stay healthy! Surviving old age in prison. Journal of Psychosocial Nursing and Mental Health Services, 35(9), 10–17.
Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60(6), 761–765. doi:10.1176/appi. ps.60.4.426
Stoliker, B. E. (2018). Attempted suicide: A multi-level examination of inmate characteristics and prison context. Criminal Justice and Behavior, 45(5), 589–611.
Stoliker, B. E., & Varanese, J. (2017). Spending the golden years behind bars: Predictors of mental health issues among geriatric prisoners. Victims & Offenders, 12(5), 718–740. doi:10.1080/ 15564886.2016.1170086
Sykes, G. M. (1958). Society of captives: A study of a maximum security prison. Princeton, NJ: Princeton University Press.
Teasdale, B., Daigle, L. E., Hawk, S. R., & Daquin, J. C. (2016). Violent victimization in the prison context: An examination of the gendered contexts of prison. International Journal of Offender Therapy and Comparative Criminology, 60, 995–1015. doi:10.1177/ 0306624X15572351
Toch, H. (1977). Living in prison: The ecology of survival. New York, NY: Free Press. U.S. Department of Justice, Bureau of Justice Statistics. (2004). Survey of inmates in state and federal
correctional facilities 2004 [codebook]. Ann Arbor, Michigan: Inter-university Consortium for Political and Social Research.
Uzoaba, J. (1998). Managing older offenders: Where do we stand? Ottawa, Canada: Correctional Services of Canada.
Van Orden, K. A., & Conwell, Y. (2016). Issues in research on aging and suicide. Aging & mental health, 20(2), 240–251. doi:10.1080/13607863.2015.1065791
Wacquant, L. (2001). Deadly symbiosis: When ghetto and prison meet and mesh. Punishment & Society, 3, 95–133. doi:10.1177/14624740122228276
Way, B. B., Sawyer, D. A., Lilly, S. N., Moffitt, C., & Stapholz, B. J. (2008). Characteristics of inmates who received a diagnosis of serious mental illness upon entry to New York state prison. Psychiatric Services, 59(11), 1335–1337. doi:10.1176/ps.2008.59.6.603
West, H. C., & Sabol, W. J. (2008). Prisoners in 2007. Washington, DC: Bureau of Justice Statistics Bulletin, United States Department of Justice.
Williams, B. A., Lindquist, K., Sudore, R. L., Strupp, H. M., Willmott, D. J., & Walter, L. C. (2006). Being old and doing time: Functional impairment and adverse experiences of geriatric female prisoners. Journal of the American Geriatrics Society, 54, 702–707. doi:10.1111/(ISSN)1532-5415
Wolf, A. M., Silva, F., Knight, K. E., & Javdani, S. (2007). Responding to the health needs of female offenders. In R. Sheehan, G. McIvor, & C. Trotter (Eds.), What works with women offenders (pp. 182–213). Portland, OR: Willan Publishing.
508 B. E. STOLIKER AND P. M. GALLI
World Health Organization. (2005). WHO resource book on mental health, human rights and legislation. Geneva, Switzerland: Author.
World Health Organization. (2007). Preventing suicide in jails and prisons. Geneva, Switzerland: Department of Mental Health and Substance Abuse.
VICTIMS & OFFENDERS 509
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- Abstract
- Introduction
- Mental health and psychiatric care
- Gender and mental health
- Traumas/stressors and mental health
- Physical, behavioral, and mental health
- Importation, deprivation, and the stress process
- The current study
- Method
- Data
- Analytic sample
- Measures
- Analytic procedure
- Results
- Discussion
- Notes
- Disclosure statement
- References
