Abstract
SummaryBackgroundHigh mortality rates have been reported in people released from prison compared with the general population. However, few studies have investigated potential risk factors associated with these high rates, especially psychiatric determinants. We aimed to investigate the association between psychiatric disorders and mortality in people released from prison in Sweden.MethodsWe studied all people who were imprisoned since Jan 1, 2000, and released before Dec 31, 2009, in Sweden for risks of all-cause and external-cause (accidents, suicide, homicide) mortality after prison release. We obtained data for substance use disorders and other psychiatric disorders, and criminological and sociodemographic factors from population-based registers. We calculated hazard ratios (HRs) by Cox regression, and then used them to calculate population attributable fractions for post-release mortality. To control for potential familial confounding, we compared individuals in the study with siblings who were also released from prison, but without psychiatric disorders. We tested whether any independent risk factors improved the prediction of mortality beyond age, sex, and criminal history.FindingsWe identified 47 326 individuals who were imprisoned. During a median follow-up time of 5·1 years (IQR 2·6–7·5), we recorded 2874 (6%) deaths after release from prison. The overall all-cause mortality rate was 1205 deaths per 100 000 person-years. Substance use disorders significantly increased the rate of all-cause mortality (alcohol use: adjusted HR 1·62, 95% CI 1·48–1·77; drug use: 1·67, 1·53–1·83), and the association was independent of sociodemographic, criminological, and familial factors. We identified no strong evidence that other psychiatric disorders increased mortality after we controlled for potential confounders. In people released from prison, 925 (34%) of all-cause deaths in men and 85 (50%) in women were potentially attributable to substance use disorders. Substance use disorders were also an independent determinant of external-cause mortality, with population attributable fraction estimates at 42% in men and 70% in women. Substance use disorders significantly improved the prediction of external-cause mortality, in addition to sociodemographic and criminological factors.InterpretationInterventions to address substance use disorders could substantially decrease the burden of excess mortality in people released from prison, but might need to be provided beyond the immediate period after release.FundingWellcome Trust, Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.
Highlights
Every year more than 30 million people circulate through prisons,[1] and most will eventually return to their communities
The period after release is associated with high risk for various health outcomes,[2] and many studies have provided an epidemiological description of high mortality in people released from prison compared with the general population.[3,4,5,6,7,8,9,10]
Whether substance use disorders and other psychiatric disorders are causally associated with post-release mortality is uncertain, because prisoners are usually from deprived socioeconomic backgrounds,[4] and both criminal behaviour and most psychiatric disorders tend to cluster in families
Summary
Every year more than 30 million people circulate through prisons,[1] and most will eventually return to their communities. Substance use disorders and psychiatric disorders are important potential risk factors that are highly prevalent in prisoners and potentially treatable.[15,16] a few studies of post-release mortality have reported data for these disorders,[3,17] none has fully examined the association between them and differentiated the contribution of individual diagnoses. Mortality from drug overdose has been reported to be high after release from prison.[18] whether substance use disorders and other psychiatric disorders are causally associated with post-release mortality is uncertain, because prisoners are usually from deprived socioeconomic backgrounds,[4] and both criminal behaviour and most psychiatric disorders tend to cluster in families. Whether substance use and other psychiatric disorders can be used to predict postrelease mortality is unknown
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