The present study explored the prevalence and predictors of mental illness among inmates in Northwestern Ethiopia. This study is one of its kinds in the sense that it considers rehabilitation service use as predictors of mental illness alongside demographic and imprisonment related factors.
In the present study it was revealed that about two third of the inmates in Northwestern Ethiopia have mental illnesses. A similar mental illness prevalence rate was reported in Iran where a prevalence rate of 73.9% was reported among prisoners (20).
Slightly lower prevalent rates of mental illness among inmates were reported in Ethiopia and other African countries. The prevalence of mental illness among prisoners in Debremarkos correctional institute was found to be 67.6% (13) slightly lower than the prevalence rate in the present study. The prevalence rate of mental illnesses among inmates in Addis Ababa was 58.4% (10). The prevalence rate of mental illnesses in Jimma correctional institute was 62.7% (9). A 63.2% prevalence rate of mental illness was reported among inmates from a study in Kenya (4). In a systematic review among studies in Africa the pooled prevalence of mental illnesses among adults is 59% while it is 61% among the youth (8). Methodological differences and the characteristics of the respondents included in the studies are behind the differences in findings. For example in the study in Addis Ababa half of the respondents (50.1%) are females while only 7.8% of the participants in our study are female inmates.
Higher prevalence rates of mental illnesses among prisoners than the prevalence rate in the present study was reported in other studies. For instance, in a study in Southwestern Uganda mental illness was observed in 86% of the inmates (3). Likewise, a study in India reported a mental illness prevalence rate of 83.5% (21). Psychological distress was identified among 83.4% of inmates among prisons in Northwestern Ethiopia (6). The differences in findings are attributed to the tools used to measure mental illnesses. The studies in Southern Uganda and India used Mini-International Neuropsychiatric Interview (M.I.N.I.) that measured the prevalence of psychotic disorders while the study in Northwestern Ethiopia employed K10 that examined psychological distress.
Significantly lower mental illness prevalence rates are also reported in other African countries. The prevalence of mental illness rate reported in Zambia is 29.2% (7). Similarly, a mental disorder prevalence rate of 34.8% was reported from a study in a correctional prison in Yaoundè, Cameron (22). The differences are attributed to differences in the settings the data is collected and the tools used to assess mental illness. For example the study in Zambia is conducted in maximum security prisons among remanded, sentenced, and condemned inmates. Besides, the study in Cameron used M.I.N.I. to assess mental illness while our study employed SRQ-20.
Alongside to reporting the prevalence of mental illness, the present study depicted the most and the list reported mental illness symptoms by inmates. Feeling unhappy, difficulty to play important role in life, headaches and bad sleep were experienced by majority of the respondents. These symptoms were reported as high in the study among prisoners in Jimma correctional institute, southwestern Ethiopia (9). Handshakes, suicidal thoughts and crying more than usual were the symptoms least reported by inmates in the present study. These symptoms are also among the least reported symptoms in the study in Southwestern Ethiopia (9)(Adraro et al., 2019). These all could imply that the typical symptoms experienced by inmates are similar in different corners of the country.
Of all demographic variables considered, gender as an important predictor for inmates' mental illness was found in the present study. Unlike the findings from other studies, the present study found that male inmates have higher odds of having mental illness than their female counter parts.
Contrary to our findings the study at Debremarkos Correctional institute found that female inmates have higher probability of having mental illness than male inmates (13). In a study in Bonga town correction center female inmates were found to feel worthless and nervous than male inmates (23). Similarly in the study in Kenya female inmates were found to have higher chances of having mental illnesses than male inmates (4). The difference in the findings could be attributed to the high number of male inmates (92.2%) included in our study.
The present study highlights the important predictive effects of rehabilitation service use over inmates' mental illness. Of the 11 rehabilitation service use related variables considered in the study three of them were found to be important predictors of inmates' mental illness: life skill training program; educational training; and recreational and cultural activities.
In the present study inmates who participated in the life skill training programs were found to have lesser chances of developing mental illness. Likewise, in a study in Iran the mental health of women inmates who participated in anger management trainings were improved after the training (14) indicating the importance of life skill trainings. Another study in Iran found that inmates who participated in life skill trainings were found to have higher scores in positive mental adjustment (measured by assertiveness and self-esteem) and lower score in negative adjustment (measured by anxiety, depression, stress and aggressiveness) (15).
Participation in recreational and cultural activities are found to have a buffering effect against mental illness among prisoners. In line with our finding participation in recreational and cultural sport activities were reported as buffering against mental illnesses among inmates. For example in a study in the USA inmates who participated in group activities were found to have lower chances of experiencing anxiety. On the contrary the study depicted that being idle is associated with higher odds of anxiety and depression implying the importance of participation as a buffering against mental illnesses (17). In a study in Nigeria, inmates who participated in sport activities have better psychological and social wellbeing than inmates who don't participate (16). Likewise in a qualitative study in Northern Ireland it was depicted that participation in sport activities increases social interaction thereby improves inmates’ psychological wellbeing (18).
Surprisingly, in the present study, participation in educational training services was found to predict higher chances of having mental illness among inmates. In the literature participation in prison educational programs was associated with lower recidivism, higher employment chances after release, reduced misconduct while in prison and strong return on investment (24). Findings of the present study associates prison education with increased mental illnesses. This could be potentially attributed to the many challenges associated to prison education in Africa, for example in South Africa (25) or the low quality and relevance of the educational service provisions reported among prisons in Amhara National Regional State (26) or other additional covariates that need further investigations.
The cross-sectional nature of the present study is considered as the first limitation of the study. Moreover, the numbers of female respondents in the present study are small in that it would be difficult to generalize the results to female inmates in the region. In addition, mental illness is not clinically diagnosed with trained professionals and there could be recall bias and/or over reporting of symptoms.