Background
Worldwide, there are about 10 million people in prisons. Worldwide, prison population is being raised by around one million per decade. The majority of the world prison population were observed at low- and middle-income countries [
1]. According to Penal Reform International (PRI) 2015 report, since 2004, the size of the world prison population has increased by approximately 10%. Accordingly, Over the last 15 years, prison populations have indicated sharp rises by 150, 125 and 53% in Brazil, Colombia and Mexico respectively. US showed 16% increment in between 2001 and 2012, while also in Asia steep rises have been seen particularly in Indonesia (183%), Vietnam (136%), and China (modest rise). In Europe, since 2000, prison populations have fallen in Russia (particularly in Baltic States) and in some Eastern countries (e.g. Romania) even though it began to rise again after 2010. In UK and France increments have also been seen continuously. In Africa, while data are less completed, large percentages of increment have been seen in some Northern African countries like Algeria (i.e. it was 76% between 2001 and 2013) and Morocco. In South Africa prison numbers was raised to maximum in 2004 and then decreased to 158,000 in 2014. The number of detainees have been risen in some, but not in all, East African countries; from 55,000 in 2000 to 93,000 in 2011 in Ethiopia [
2].
Estimated 450 million people worldwide suffered from mental or behavioral disorders [
3]. The problems were especially prevalent in prison populations [
4]. About 11% of prisoners world-wide were suffering from common mental health problems such as depression and anxiety [
5]. Mental health presents one of the greatest health problem that current and future generations will face [
6]. Epidemiological studies conducted among prisoners in many countries have shown a high prevalence of psychiatric morbidity. The magnitude of severe mental disorders was five to ten times higher among prisoners compared to the general population [
7]. Other studies added that mental problem was more common among the prison population [
4,
8]. In European prisons, the prevalence of psychotic disorders was about 5%, depressive or anxiety disorders was estimated to be 25%, and substance-related disorders was approximately 40% [
9] while study among women’s prison in Sa˜o Paulo revealed that the prevalence of common mental disorders was reported as 26.6% [
10]. Many of these disorders might be present before admission to prison, and might be further exacerbated by being detained [
11,
12]. However, mental disorders might also be developed during imprisonment itself as a result of prevailing conditions, possibly due to torture or other human rights violations [
12].
World Health Organization (WHO) forecasted, in 2001, that by 2020 depression will be the second leading contributor to the global burden of disease [
13]. Additionally, according to the 2009 discussion paper released by World Health Organization, out of 66 million people suffering from depression; 85% live in low and middle income countries [
14]. An extensive literature review done in 24 countries revealed rates of depression of around 10 and 14% in males and females prisoners respectively [
15]. Many studies reported different levels of depression among detainees; 46.1% among Norwegian inmates [
16], 59.4% among incarcerated women in Central Prison of Peshawar, Pakistan [
17], 29% among sentenced prisoners in Iran [
18], 18% among prisoners of England and Wales (including anxiety) [
19], 10 and 12% among men and women prisoners respectively [
20], 23.3% among prisoners of Durban, South Africa (including psychotic and anxiety disorders) [
21], and 49% among prisons and jails according to special reports of U.S. department of Justice [
22]. In Kaliti Federal Prisons, Addis Ababa, Ethiopia, 61.9% of prisoners were found to have high levels of mental distress in general [
23].
There were many factors in prisons that have contribution on mental health, particularly on depression including; overcrowding, various forms of violence, enforced solitude or conversely, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects (work, relationships, etc.), inadequate health services, especially mental health services in prisons, luck of social support, dissatisfaction before and after imprisonment, older ages and status of prison. The increased risk of suicide in prisons (often related to depression) was, unfortunately, one common manifestation of the cumulative effects of these factors [
11,
12,
24‐
28].
In Ethiopia, approximately 1.7% of the national health expenditure was spent on mental health in 2004. So, in order to tackle mental health problem the Government of Ethiopia launched a National based Mental Health Strategy that can enable the government to deliver comprehensive and integrated service to mental health needs of Ethiopians [
29,
30].
Majority of the population in the prison was found in the productive age category that will be returned to their community after they complete the time at jail. The government gives high attention to the prisoners to create productive mentality through implementation of different strategies that lead to the production of entrepreneur prisoners of the future country. However, the emphasis given to mental health was very low across the globe in general and for prisoners in particular. This is even more in countries with limited resource and still there is no accurate magnitude of prisoners with mental disorder who were incarcerated in Ethiopia, particularly in Northwest of Amhara Regional state and information about prisoners’ health conditions is scarce. Even though health care service for mental disorder was designed in the national health policy of Ethiopia, interventions against the problem were very limited, which might be due to limited information about the problem. Thus, establishing the prevalence rates of mental disorders, particularly depression, is of great importance [
31]. As a result, this study aimed to assess magnitude of depression and its attributes among prisoners detained in prisons of Northwest Amhara regional state, Ethiopia which will serve as an input for policy makers, health service planners and strategy designers.
Discussion
This study disclosed the level of depression and associated factors among prisoners in the prisons of Northwest Amhara regional state. The study revealed that more than eight out of 19 internees were identified with depression (43.8%). The result goes with the reports of study done among Norwegian inmates (46.1%) [
16]. This result also in line with results reported by studies conducted on different types of populations, a systematic literature review of depression among Australian women, which reported prevalence ranging from 2.6 to 43.9% [
36], report’s of study done in Hamadan, Iran among population over 65 years old (48.3%) [
37], and in Netherland; among older persons (48.4%) [
38]. However, It is higher than results of study in Iran among sentenced prisoners (29%) [
18], reports of Bureau of Justice Statistics among State prisoners (23%) and jail inmates (30%) [
22], systematic review of 62 studies from 12 countries; which reported 10% among men and 12% among females [
20], study conducted in Agaro town (15%) [
39], in low- to middle-income countries which ranges from 5.9 to 11.1% [
28], and northern Uganda (29.2%) [
40]. On the other hand it is lower than results reported on Woman in Central Prison, Peshawar, Pakistan (59.4%) [
17], by studies done in Germany among general adults [
41]. The possible explanation for the differences might be socio-demographic, socio-economic and cultural difference between our study population and the listed studies. There were also measurement (like cut off value, and tool difference) and prison status difference which might be the other possible explanations.
The study showed that detainees who were not satisfied with their day to day life before imprisonment were 56% more likely to show signs of depression when compared to their counterpart [AOR = 0.44; 95% CI: 0.26, 0.63]. In line with this study, many studies among different population suggested that satisfaction had strong association with depression; which stated strong positive association between low satisfaction and depression [
42]. Aligned with this, respondents who thought that they would face difficulty of running life as before after being free of imprisonment were 47% more likely to develop depression when compared to their counterpart [AOR = 1.87; 95% CI: 1.30, 2.69]. The possible reason could be as the prisoners worry about their future life they become more depressed; they are also the most stigmatized segment of the population in the society because of the crime they have done previously.
On the other way, the odds of developing depression among prisoners who had plan to commit suicide were more than four times more likely when compared with prisoners who hadn’t plan to commit suicide [AOR = 4.16; 95% CI: 2.56, 6.77]. This finding in lined with earlier reports of world health organization and American Psychiatric Association which showed that mental health disorders (specially depression) were related with more than 90% of all cases of suicide [
43] and major depressive disorder alleviate the risk of suicidal ideation, attempted suicide and death by completed suicide [
25]. A study conducted on inmates of New South Wales, Australia also confirmed this association [
44]. Another study also showed the evidence of strong positive association between depression and suicide [
40]. However, prisoners who had social support were 62% less likely to be with depression’s signs when compared to those who hadn’t social support [AOR = 0.62; 95% CI: 0.44, 0.89]. Many studies on the different population showed that depression was high among individuals who had poor social support. The possible reasons stated were lack of (poor) social support which may lead to increased psychological distress; on the other hand, good social support is vital for the prevention of anxiety, both of which have relation with depression [
45]. Other studies added that loneliness has adverse consequences for mental health including depression [
40,
46‐
49].
The study showed that prisoners in the Gondar and Debre Tabor prisons were more likely to be imitated by depression when compared to Bahir Dar prison with [AOR = 1.54; 95% CI: 1.04, 2.29] and [AOR = 2.27; 95% CI: 1.46, 3.51] respectively. This finding was strengthened by the result from Jos maximum Security Prison, Plateau State which indicated a strong association between depression and status of prison [
27]. The possible explanation for this could be age distributions of the prisoners as the distribution of old ages were higher in the Gondar and Dabre Tabor prisons. Even though age is not associated to depression in our study; studies supported that depression were more likely to occur among old ages [
28,
36,
40,
49‐
55]. The other possible reason could be as Bahir Dar’s prison is regional level; there may be facility difference, which might improve the satisfaction level of the prisoners.
Even though the study indicated very important factors associated with depression, the study is not free of the limitations of cross sectional study design like lack of indicating the strong cause and effect relationship. Additionally, the study is not still free of social desirability bias because subjects were systematically more likely to provide a socially acceptable response since data was collected through self report. Furthermore, the study did not collect information on the injury and trauma as they might be other factors associated with depression.
Acknowledgements
We are very grateful to University of Gondar for the approval of the ethical clearance and for their technical and financial support of the study. We are also indebted to Gondar, Bahir Dar and Debre Tabor prisons’ administrators for the permission as well as information they provided us to undertake this study. Finally, we would like to thank all prisoners who participated in this study and for their commitment in responding honest response to our interviews.