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BRIEF COMMUNICATION

The Impact of Primary Mental Health Care in a Prison System in Brazil

José GV Taborda, MD¹, José M Bertolote², Rogério G Cardoso³, Paulo Blank⁴

Objective: To analyze the impact of a psychiatric service in a prison general hospital that refers prisoners with mental disorders to a separate forensic psychiatric hospital (FPH).

Method: Analysis of data on prison population and referrals to the FPH.

Results: Despite a 10.9% increase in the overall prison system population over 3 years, referrals from the prison general hospital with the new psychiatric service to the FPH were reduced by 36.5%, whereas referrals from other prisons increased by 120.4%.

Conclusion: Our results demonstrate the efficiency of the new primary health care approach.

(Can J Psychiatry 1999;44:180–182)

Key Words: forensic psychiatric care, primary health care, prison hospital

In May 1992, a psychiatric service (PS) was established at the prison hospital (PH) in Porto Alegre, Brazil, to provide both outpatient and inpatient short-term care to inmates of the Porto Alegre Central Prison (PACP). This paper describes some aspects of the impact of the new PS on the volume of prisoner referrals to various health facilities in the state prison system.

Porto Alegre is the capital city of the southernmost state in Brazil, Rio Grande do Sul. The state’s population is approximately 11 million, and its prison system is a network of institutions with diverse natures and aims that covers the whole state and hosts about 11 000 inmates. The PACP, its biggest facility, houses 1800 male inmates in high-security wards. Annexed to PACP is the PH, which provides clinical and surgical care to inmates state-wide. However, the recently established PS provides psychiatric care only to inmates of PACP.

Geographically and administratively independent from the PH, a forensic psychiatric hospital (FPH) is part of the prison system; its catchment area is the whole state. It provides inpatient care only to mentally ill offenders and to prisoners who develop mental disorders during their stay in prison (PMD). Under Brazilian law, PMDs must be transferred to the FPH until the clinical problem is resolved and then returned to the prison from which they came (1); this situation is strikingly different from what is found elsewhere (2). The FPH also receives offenders who were sent by courts for assessments and evaluations prior to or during civil or criminal law procedures.

Most patients were referred directly by prison agents to the PH either by request of the patients themselves or because the prison agents had noticed some behavioural abnormality: signs of alcohol withdrawal syndrome (more rarely, drug withdrawal), fits, psychomotor agitation, extreme suspiciousness, or aggressiveness. After an initial assessment by the general doctors from the PH, the psychiatrist is called in. Also, a few inmates who were under clinical or surgical care at the PH were referred by their doctors to the psychiatrists. The psychiatrist would decide whether to care for the inmate on an “outpatient” basis (that is, the inmate would be returned to his cell in the prison and would come regularly to the PH for treatment until discharge) or would remain in the PH, depending on the severity of the psychiatric and clinical conditions.

Admissions to the FPH usually have an extremely long duration; indeed, some of the patients admitted to the FPH remain there for the rest of their lives, particularly when they present with a chronic condition and have no relatives in the community. In fact, admission to the FPH, like to many similar forensic psychiatric institutions, can be characterized as a total institutionalization (3), which greatly diminishes the quality of life of inmates as well as the quality of health care provided.

Methodology

A monthly census based on official data was obtained for the prison population in the state from May 1, 1991, to April 30, 1992 (period I), and from May 1, 1993, to April 30, 1994 (period II). The year between April 30, 1992, and May 1, 1993, was discarded to allow the newly established PS at the PH to properly settle and organize itself.

Since, for confidentiality reasons, it was not possible to identify individuals, and since the same individual could be admitted more than once during those periods either to a prison or to the FPH, it was decided to consider the total population present at the end of each month in each prison. The total population for each period in PACP and in other prisons was a tally of the inmates at the end of each month; the same procedure was used for calculating total admissions to the FPH.

To account for fluctuation in the population base, those figures were also expressed in rates per 10 000 population. The chi-square test was used to analyze the difference between the number of cases originating from PACP and from all other prisons.

Results

Table 1 indicates an increase of 10.88% in the total prison population in Rio Grande do Sul during the periods under study. During the same periods, the global rate of admissions of PMDs to the FPH increased by 40.28%, despite a decrease in the number of FPH admissions of prisoners originating from PACP in the same period.

Table 1. Rio Grande do Sul prison population and psychiatric admission of prisoners with mental disorders^a
	State-wide prison system population			Admissions to forensic psychiatric hospital of prisoners with mental disorders^b
	Period I	Period II	Variation	Period I		Period II		Variation
	n	n	%	n	per 10 000	n	per 10 000	%
Porto Alegre Central Prison	18 645	20 493	+9.9	43	23.06	30	14.64	–36.5
Other prisons	98 114	108 973	+11.1	29	2.96	71	6.52	+120.3
Total	116 759	129 466	+10.9	72	6.17	101	7.8	+26.4

^aPeriod I: May 1, 1991, to April 30, 1992; period II: May 1, 1993, to April 30, 1994.
^bc² = 15.55, P < 0.05.

To reduce eventual distortions due to natural fluctuation of the population base, absolute values of the number of admissions of PMD were also expressed as an incidence of admissions per 10 000 prisoners (Table 1). Also, for the period under study, the PACP contribution to the number of FPH admissions was consistently higher (2 to 8 times) than was that from other penal establishments. It also shows that, despite a global increase of 26.42%, the rate of FPH admissions of PACP prisoners decreased by 36.51%, whereas the increase in the rate of prisoners from other prisons was 120.27%. The chi-square test is significant at P < 0.05.

Discussion

Analysis of the data indicates that between periods I and II the prison population in Rio Grande do Sul increased by 10.88%. During the same period, however, FPH admissions of PMDs increased by 40.28%, which would indicate an increase in the incidence of mental disorders (particularly of a psychotic nature) among prisoners. This finding could be explained by the overall deterioration observed by the authors in the conditions prevailing in prisons, which can be attributed to at least 2 interrelated factors: the increase in the absolute numbers of prisoners—which, in the absence of a room increase, results in an increased overcrowding of wards—and the observed limitation (and even reduction) of appropriate human and other resources—such as new and more spacious buildings—to deal with the already difficult situation of life in prison. As a result of this situation, several rebellions, riots, and hostage-takings have taken place in several prisons, widely commented on by the media.

However, although the population in PACP also increased proportionally to the global increase in the prison population all over the state throughout this period, maintaining 16% of the total population of prisoners, there was no increase in the number of admissions to FPH from the population of PACP. Indeed, there was a reduction of 36.71% in admissions to FPH from PACP, in both absolute figures (from 43 to 30) and relative values (from 60% to 30% of all admissions); in population terms, there was a reduction from 2306/10 000 to 1464/10 000.

In the absence of evidence of any other factor that might explain these findings, it is reasonable to believe that the opening of the PS in the PH had a positive impact on the reduction of referrals to FPH from PACP resulting in admissions.

This, in addition to a reduction of the already chronic overburden to which FPH has been submitted, also resulted in a benefit to the PACP population. The flexibility and promptness of the PS indicates an improved quality of mental health care (4). The fact that health care can be provided close to where people actually live—even though in this case the people are involuntarily institutionalized—is one of the elements of primary health care (5). This proximity facilitates care, at least in minimizing the delay between the identification of the need and its treatment, and expands the human resources with which prisoners come into contact (6).

Another positive aspect to be considered concerns the reduction of discrimination, a central element of human rights (7–9). Whereas it is known that both prisoners and nonprisoners with mental disorders are negatively discriminated against by society, patients from the FPH are exposed to a double stigma; namely, that of being prisoners and of being mentally ill; prisoners receiving care in the same prison are free from the second stigma associated with mental hospitals.

These findings agree with those of researchers of psychiatric reform (10) and will be further analyzed in future papers based on additional data obtained during the present study.

The continuing experience of the authors with the new system described here confirms these initial results. It is hoped that additional, ongoing studies will contribute to a better understanding of improved ways to provide mental health care to prisoners.

Clinical Implications

Access to care at the prison hospital psychiatric service (PHPS) is easier and faster than that provided by the forensic psychiatric hospital (FPH).
The quality of care provided by the PHPS is superior to that provided by the FPH.
The PHPS reduces stigma attached to people sent to the FPH.

Limitations

The study covers only 1 state in Brazil.
The time span of the study is only 3 years.
Detailed descriptions of procedures in both the PH and the FPH are not provided.

References

1. Jesus DE. Código de Processo Penal Anotado. São Paulo: Saraiva; 1981.

2. Morrissey JP, Swanson JW, Goldstrom I, Manderscheid RW. Overview of mental health services provided by state adult correctional facilities: United States, 1988. Ment Health Stat Note 1993;207:1–13.

3. Goffman I. Asylums: essays on the social situation of mental patients and other inmates. New York: Doubleday; 1961.

4. Bertolote JB. Quality Assurance in mental health care. In: Sartorius N, de Girolamo G, Andrews G, German GA, Eisemberg L, editors. Treatment of mental disorders. Washington (DC): American Psychiatric Press; 1993. p 443–61.

5. WHO-UNICEF. Primary health care: report of the international conference on primary health care. Alma-Ata, URSS, 6–12 September 1978. Geneva: World Health Organization; 1978.

6. Willmott Y. Prison nursing: the tension between custody and care. British Journal of Nursing 1997;9:333–6.

7. WHO. Guidelines for the promotion of human rights of persons with mental disorders (Doc: WHO/MNH/MND/95.4). Geneva: World Health Organization; 1996.

8. UN. Human Rights: a compilation of international instruments. New York and Geneva: United Nations; 1994.

9. Zaffaroni ER. Derechos humanos y sistemas penales en América Latina. In: Castro LA, editor. Criminologia en América Latina. Rome: UNICRI; 1990. p 39–48.

10. Desviat M. La reforma psiquiátrica. Madrid: Ediciones Dor; 1995.

Résumé

Objectif : Analyser les répercussions du service psychiatrique d’un hôpital général carcéral qui adresse les prisonniers souffrant de troubles mentaux à un hôpital psychiatrique médico-légal (HPML) distinct.

Méthode : Analyse des données sur la population carcérale et les demandes de consultation à l’HPML.

Résultats : Malgré une augmentation de 10,9 % de la population globale dans le système carcéral au cours des trois dernières années, le nombre des patients dirigés de l’hôpital général carcéral et de son nouveau service psychiatrique vers l’HPML a diminué de 36,5 %, tandis que les demandes de consultation en provenance d’autres prisons ont augmenté de 120,4 %.

Conclusion : Nos résultats démontrent l’efficacité de la nouvelle approche des soins de santé primaires.

Manuscript received January 1998, revised, and accepted June 1998.

¹Forensic psychiatrist, WHO Collaborating Centre for Research and Training in Mental Health, Porto Alegre, Rio Grande do Sul, Brazil.

²Medical Officer, Division of Mental Health and Prevention of Substance Abuse, World Health Organization, Geneva, Switzerland.

³Forensic psychiatrist, Psychiatric Service of the Porto Alegre Prison Hospital, Porto Alegre, Rio Grande do Sul, Brazil.

⁴Forensic psychiatrist, Forensic Psychiatric Hospital Dr Mauricio Cardoso, Porto Alegre, Rio Grande do Sul, Brazil.

Address for correspondence: Dr JGV Taborda, Rua Bororo, 55, 91900-540 - Porto Alegre, RS Brazil
email: taborda@conex.com.br

Can J Psychiatry, Vol 44, March 1999