Recognising vulnerability in the prison population

Professor Paul Bebbington
Thursday, 1 April 2021

The very high levels of psychiatric disturbance and suicidal thinking in prisoners are well established.

In Britain, they have been confirmed by large surveys of psychiatric disorder carried out in the general population and in prisons, using the same methods of assessment. This picture has recently been emphatically confirmed by the World Health Organisation, which examined the physical and mental health of the 1.5 million people incarcerated in Europe on any given day. This report also identified a context of 'entrenched and intergenerational social disadvantage'. Until recently no-one has ever identified ex-prisoners in representative population samples in order to establish their comparative levels of psychiatric and social need. Such information would have clear implications for shaping the responses of both psychiatric and social services.

Since 1993, there has been a UK programme of National Surveys of Psychiatric Disorder, carried out at seven-year intervals. The most recent one in 2014 covered a representative English sample, aged 16 and above and living at home. It used standardised ways of assessing their psychiatric problems and social circumstances. People were chosen randomly, and interviewed at home in great detail; over 7,000 individuals took part in the survey. For the first time in the National Survey programme they were asked, as part of the interview, if they had ever been in prison. This made it possible to evaluate the mental state and social circumstances of a representative sample of ex-prisoners living at home, and to compare them with the rest of the population.

The results of this comparison have recently been published by Bebbington and colleagues in the scientific journal Social Psychiatry and Psychiatric Epidemiology. The authors found that, out of every seventy participants, one (1.4 per cent) reported having been in prison. These ex-prisoners suffered greatly increased rates of current psychiatric problems, including anxiety and depression, psychotic disorder, post-traumatic disorder, substance dependence, and suicide attempts. They had twice the rate of anxiety and depression seen in the rest of the sample, even after adjusting for trauma and current socioeconomic adversity. They also appeared to have experienced difficulties dating back to childhood: deficits in attention, hyperactivity, autistic traits. These difficulties were compounded by relatively low verbal IQ, and a lack of qualifications. The ex-prisoners also reported extremely high rates of childhood adversity, including physical and sexual abuse, and spending time in local authority care.


Prison experience is a marker of enduring psychiatric vulnerability. Accordingly, it identifies an important target population for intervention and support on humanitarian grounds. However, these psychiatric attributes of ex-prisoners also create a context for recidivism. Liaison between the criminal justice system and mental health services has not been very effective, but without it, the vulnerability of ex-prisoners to relapse and to reoffending will continue, along with the grievous personal and societal costs.

Professor Paul Bebbington is Emeritus Professor of Social and Community Psychiatry at UCL. Published widely, in particular using epidemiological surveys to examine the social context and causes of psychiatric disorders, Paul has also been involved in trials of social and psychological treatments.