Incidence of Depression among Incarcerated Woman in Central Prison , Peshawar , Pakistan

This study aimed to determine the prevalence of depression among women prisoners in Peshawar, Pakistan. This was a cross-sectional study carried out at the female barracks of Central Prison, Peshawar, Pakistan. A total of n=64 female prisoners aged 16–65 years were interviewed. Face-to-face interviews were conducted using the Hamilton Depression Rating Scale (HAMD). Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 13.0. Odds ratios were also determined. An alpha value of less than 0.05 was considered significant. Out of the 64 female prisoners, 38 (59.4%) were found to be suffering from depression. Of these 38, a total of 73.7% met the criteria for mild depressive episodes, 21.1% for moderate episodes and 5.3% for severe depressive episodes. Middle-aged women (31–40 years) were mainly affected. Depression was more common among urban-dwelling (60.5%) and low-income (64.5%) prisoners. The incidence of depression was also found to be higher among married women. Middle-aged, married women with a low socio-economic status were found to be at a higher risk of depression. In addition, smoking may have had some effect on the mood state of patients.


INTRODUCTION
According to the statistics provided by the U.S. Home Department, approximately 8.75 million persons are held in penal institutions across the world.The highest numbers of prisoners are reported in the USA (1.96 million), followed by China (1.46 million) and Russia (0.92 million) (1).It is estimated that the imprisonment rate in most countries at any given time is about 150 per 100 000 of the general population.Worldwide, the overall prison environment, living conditions and the availability of health facilities are the most important issues relating to penal institutions.In other words, it is appropriate to say that the prison environment is one of the main challenges to the overall health of prisoners.In the past the health of prisoners has been a neglected issue, and Smith (2,3) was the first to highlight the need to monitor the mental health of prisoners.Latter, Bluglass (4) reported the incidence of depression among prisoners and criticized the ineffective management of mental disorders among the prison population.The UK Health Advisory Committee raised further concerns for the health of prisoners in 1997 for the Prison Service (5).The main issue raised was the need to provide prisoners with the same health facilities that are available to the public.Fazel and Danesh (6) gave an insight into the incidence of mental disorders among prisoners, reporting that one in seven prisoners suffer from some type of mental or psychiatric disorder (7,8) .Current or past drug abuse, unemployment and homelessness are the common risk factors found to be associated with the incidence of psychiatric disorders (9).Overall, the incidence of psychiatric problems was found to be higher among men; according to the findings of Fazel and Danesh (2002) about 50% of male prisoners and one in five women prisoners were diagnosed with some type of mental disorder (5).However, a different study found that women who were remanded in custody were at higher risk; 59% had some incidence of mental disorder and about 11% had psychosis (10).

The situation in Pakistan
Pakistan is the second most populous country in South Asia, with an estimated population of 170 million.In the general population the estimated incidence of mental disorders is about 34% (11).The main risk factors for mental disorders are socio-political instability, economic uncertainty, violence, regional conflict and dislocation for at least the past three decades (12).Overall it is seen that the incidence of depression is higher among women than in men.Financial, interpersonal and family problems are the main factors playing a vital role in the poor mental health of Pakistani women (13,14).Focusing on Pakistani prisoners in particular, most prisons in Pakistan are overcrowded with poor living conditions, and health has always been a neglected issue.A study by Khan et al. (2009) reported a higher incidence of depression among male prisoners, and drug abuse was one of the main issues found to be associated with the incidence of mental disorders (15).However, there have been no studies reporting the overall and mental health of female prisoners in Pakistan.The aim of this study was to assess female prisoners in a prison in Peshawar for the incidence of depression and to highlight the factors associated with its incidence.

MATERIALS AND METHODS
In May 2008 a cross-sectional study was conducted among the female prisoners at the Central Prison in Peshawar, Pakistan.All the female prisoners were invited to participate; those willing to take part were interviewed face to face using the 17-item Hamilton Depression Rating Scale (HAMD) (16).To test reliability and internal consistency a pilot study was conducted on a group of 10 prisoners.A reliability scale was applied and the internal consistency of the tool was estimated based on Cronbach's alpha statistic (=0.66).For the 17item questionnaire, the range of possible scores is 0-54.The evaluation for the incidence of depression was conducted on the basis of the score attained by the respondents.Those who scored 0-6 were considered normal.Those with a score of 7-17 were rated to have minor depression, those scoring 18-24 as having moderate depression and those with scores of more than 24 were defined as having severe depression on the Hamilton Depression Scale.Statistical analysis was conducted by using Statistical Package for the Social Sciences (SPSS®) version 13.0.Odds ratios (ORs) were also determined to identify the groups at risk, with a confidence interval of 95%.

RESULTS
A total of n=140 female prisoners were approached for their participation in this study.Of these, n=64 female prisoners were willing to participate, giving a response rate of 47.5%.A total of 26 (40.6%) were normal, while 28 (43.8%)prisoners were found to have mild depression, eight (12.5%) had moderate depression and two (3.1%) had severe depression.Most of the prisoners were middle-aged (defined here as 31-40 years of age), with low socio-economic status.Demographic details of the prisoners are listed in Table 1.In addition, questioning about social history revealed that 39 (60.1%) of the prisoners smoked cigarettes and that four (6.3%) had abused drugs.During the interview it was revealed that somatic symptoms were very frequently reported among the prisoners.About 32 (84.2%) shared that they often had headaches followed by disturbed sleep pat-tern, 31 (81.6%) said that they had experienced changes in appetite and 30 (78.9%) reported agitated behavior (Table 2).
To identify the prisoners at higher risk of depression, odd ratios were calculated.It was revealed that women who were middle-aged (OR 1.31, confidence interval CI 1.02-1.60),married (OR 1.80, CI 1.36-2.23)and with a low socio-economic status (monthly income <5000 rupees; OR 1.71, CI 1.46-1.96)were more likely to suffer from depression in comparison to others (Table 3).Furthermore, female prisoners reporting that they smoked between one and five cigarettes per day were at a higher risk (OR 1.53, CI 1.20-1.87) in comparison to those smoking more than five cigarettes a day.

DISCUSSION
The general health and quality of life of prisoners is a neglected issue in Pakistan.No efforts are ever made in this regard highlighting the need to examine this issue.In addition, the prison system in Pakistan suffers from administrative, financial and legal problems, of which overcrowding is one of the most crucial.In Pakistan at    (17).Furthermore, there are no separate jails for women and most of the prisons are in a deplorable situation.Overall living conditions are the worst, hardly giving someone a proper place to sleep.The majority of prisoners are kept in groups in a cell and are made to sleep on the floor, which is one of the main sources of infectious disease.
Particularly for children and women in these jails there is a scarcity of proper health, sanitation, food and medical facilities.Besides, the foundations of the mental health concept for prisoners do not even exist in the Pakistani prison system.This study will be a first step towards drawing the attention of the authorities towards the value of mental health among prisoners in Pakistan.
Overall findings revealed that the incidence of depression in the Central Prison in Peshawar was 59.4%.So far in Pakistan no other studies have been conducted on this topic, so this figure and these findings will act a baseline for future studies to compare between different prison settings in Pakistan.However, our findings can be compared with those from prisons in other countries.The incidence of depression was higher among women prisoners in some other regions.Radloff reported an incidence of 70% among women prisoners at a prison in North Carolina (18), USA.However, among British women prisoners the incidence was 31.0%, which is much lower than in American and Pakistani women prisoners (19).A possibility for this comparatively low incidence may be a better prison environment in the UK and the supply of proper health care services to the prisoners.This is one of the essential factors which might contribute in the incidence of depression among women prisoners in Pakistan.While evaluating the risk factors for the incidence, it was revealed that middle-aged, married women were found to be at a higher risk in comparison to others (Table 3).However, those who smoked between one and five cigarettes a day were more likely to report depression in comparison to non-smokers and those smoking more five cigarettes a day.Other possible factors that may result in depression could be the number of children and the type of locality in which the prisoners usually live.It was seen that women with four or five children were more likely to suffer from depression.Similarly, the locality of the patient was another demographic factor that could be a possible cause of depression.Prisoners from urban areas were found at a higher risk of depression compared to those from rural areas.The lower boundary of the confidence intervals for these particular variables (number of children and locality) were less than one (Table 3), and comparison of the lower boundaries for confidence interval may be a possible way to decide the groups at risk.

Limitations
A limited sample size could have been a possible limitation of the study.Furthermore, the current study did not cover the inmate medical history.It might be possible that the prisoners were suffering from medical conditions like hypertension, diabetes mellitus etc. that have induced the depression symptoms among the students.Future studies should address these limitations to draw a better conclusion about the risk factors for depression among prisoners.
In conclusion; middle-aged, married women with a low socio-economic status were found to be at higher risk of depression among women prisoners in Peshawar.
Similarly, smoking may be another factor that has some effect on the mood state of patients.

Table 1 .
Demographic Profile of Female Prisoners Note: percentages are calculated for individual column not for row

Table 2 .
Frequent symptoms of depression among female prisoner

Table 3 .
Incidence of depression and demographic correlatesthe time of the study there are 97 prisons with an authorized capacity of 41873, but with a prison population of 92,013 (as of 31 December 2008)