The prevalence of psychiatric morbidity was much higher in the study sample (46.1%) than that reported for the general population (8.8%).23
Notably, among the five symptoms measured by the BSRS-5, the most prevalent was insomnia (46.6%), followed by depression (31.3%). Insomnia (3.9%) was also the only symptom prevalent among the non-cases group. This may be partly due to the uncomfortable incarceration environment as well as the co-occurring psychiatric symptoms, e.g. depression.
Many factors must be taken into consideration when dealing with prisoners and mental health, e.g. international differences, prison settings, demographics and methodological issues.24
All inmates (including injection drug users) are screened for HIV upon incarceration in Taiwan. Individuals found to be seropositive are separated from HIV seronegative prisoners. What impact such segregation has on inmates’ psychological well-being has not yet been determined. However, it is reasonable to argue such separation, though effective in the prevention of HIV transmission among inmates, is a form of stigmatization, and can be an additional stressor for HIV-positive prisoners.
Previous research has shown that HIV-related stigma can have a strong negative impact on individual social support, physical health, and psychological well-being.25,26
Gonzalez et al27
also found a significant interaction between the awareness of HIV/AIDS-related stigma and anxiety symptoms. Future research is needed to further assess the impact of stigma on inmate mental health.
Furthermore, inmates who had used drugs exhibit more health problems and greater rates of chronic health problems than prisoners who have not used drugs.28
As 98.1% of inmates in this survey admitted using illicit drugs, this is a critical warning sign. The relationship between drug use, mental disorders, and HIV infection clearly merits further study.
Of the inmates who were in the BSRS-5 defined case group (n
= 221), 23.1% had serious thoughts of suicide and 8.1% had once attempted suicide, perhaps due to the combined negative impact of imprisonment and HIV-related physical and mental health problems. Furthermore, as indicated in the multivariate analysis (), suicidal ideation (OR = 6.69) was the strongest predictor of the BSRS-5 defined cases. In other words, after controlling for other variables, those with suicidal ideation were 6.69 times more likely to be BSRS-5 defined psychiatric cases than their counterparts. As previously reported, BSRS-5 could be used as a suicide ideation screening instrument.21
Lifetime prevalence of serious anxiety or tension (OR = 4.05) was also noted as another strong predictor of the BSRS-5 defined cases. This may also be, in part, due to their incarceration status. Given that people living with HIV are aging,29
new challenges will arise in the future for those mental health professionals working with incarcerated.
There are several limitations to this study. First, a cross-sectional analysis prevents us from making causal inferences in predicting psychiatric morbidity. Second, the BSRS-5 defined psychiatric morbidity is important for screening but it does not allow us to make diagnostic classifications. Third, this study is based on self-reported data. Recall bias and related factors may affect measurement, although the use of anonymous questionnaires may have minimized the risk of deliberated misreporting. Finally, this study only focused on HIV-infected adult male inmates and therefore lacks the generalizability to reflect female HIV-infected adult inmates, who have been reported to be quite different.30,31
Despite these limitations, to the best of our knowledge, this study is the first to use extensive samples from various geographic areas to explore the psychiatric morbidity among HIV-infected male inmates in Taiwan.
In conclusion, psychiatric morbidity is prevalent among HIV-infected male prisoners. The present study identified multiple psychosocial factors associated with psychiatric morbidity among HIV-positive inmates in Taiwan. Being a recidivist, having a poor self-rated health status, and having experienced certain psychiatric symptoms in one’s lifetime were significantly correlated to a participant’s psychiatric morbidity. It is suggested that tailored HIV/AIDS education related to mental health should be included as part of the comprehensive HIV/AIDS training program for those treating incarcerated populations.