This study assessed the prevalence of psychiatric morbidity and associated factors among prisoners in Mbarara municipality, southwestern Uganda. The prevalence of a single diagnosis was 13% whereas the prevalence of more than one diagnosis was 73%. We also found a prevalence of 95% for one or more current episodes and 86% for lifetime, past and current episodes of mental disorders. Overall major depressive disorders (44%), post-traumatic stress disorders (31%) and antisocial personality disorders (21%) were the most common individual mental disorders diagnosed.

The prevalence of mental disorders in this study of 86% is quite high compared to that found in the general population of 30% [5] but similar to what has been reported in previous prison studies with similar trends in individual current diagnoses [1, 12, 22, 23]. A high rate of suicidality is also consistent with the published prison mental health literature [8, 24]. Suicidality was also demonstrated to occur more often in major depression than in psychotic disorders, a finding also in line with current literature [25]. And among the least diagnosed mental illnesses were psychiatric disorders due to a general medical condition (1.2%), bipolar affective disorders type I (9.7%) and substance use disorders (12.5%). Previous studies in prison populations have reported a high prevalence of alcohol and other substance use disorders in Uganda as well as other countries [9, 26, 27]. This difference might be attributed to the rigorous security checks that visitors are subjected to and the formidable security measures in place that limit access to such substances of abuse presently in Ugandan prisons. The other possible explanation for the difference could be the need to avoid the repercussions of being reported to use substances of abuse, and the desire to reform and deal with the guilty conscience among prisoners who actually committed the crimes that they are accused of.

Majority of the individuals with mental illness were young [11, 12, 28] and first time offenders [13]. They had a low education level [8, 11, 12], were alleged or convicted of committing violent crimes [29] and had a past history of traumatic brain injury [8]. Previous studies report similar findings but with some exceptions such as substance use [30], a prior history of mental illness and a history of past psychological trauma such as child abuse [26]. The possible explanation for the observed discrepancy could be due to the stigma and discrimination associated with substance use, mental illness and child abuse as well as the fact that Uganda is a low income country [14] with markedly different sociodemographic and economic characteristics while the vast majority of the findings from studies reviewed have been conducted in middle and upper income countries [1]. In addition, inadequacies in the judicial systems due to a variety of factors [31], as well as the inadequately equipped and overburdened health care systems [17] may also play a role.

The factors that were associated with mental illness in prisoners were low income status, incarceration under solitary confinement, past traumatic brain injury [8] and being raised by authoritarian parents or guardians. Prisoners with more than one diagnosis were more likely to have suffered a traumatic brain injury in the past [8] and to have been convicted but not sentenced, whereas inmates who were in solitary confinement, of a low income status and had been raised by authoritarian parents/guardians less likely to be diagnosed with two or more mental disorders.

The presence of a past traumatic brain injury was less likely among those diagnosed with a single mental disorder since fewer inmates had a single diagnosis. Traumatic brain injury is a known risk factor for mental illness and as such we expect it to be more likely in the majority i.e. those with more than one diagnosis. Most of the results from studies that were reviewed did not concur with the findings in this study and it can be postulated that the reason for this is the stark contrast attributed to differences in terms of study tools/instruments used, socioeconomic status, culture and judicial systems between Uganda and the other countries in which those studies were conducted.

The limitations encountered during the course of conducting this study include the fact that study participants comprised of only respondents incarcerated in the prison facilities in Mbarara municipality and so the findings cannot be generalized to other prisons. However given the fact that the living conditions and judicial system is similar, these findings would provide a basic insight into the nature and extent of the burden of mental illnesses in Ugandan prisons. Some respondents may have deliberately declined to disclose and/or falsified responses to some inquiries that they considered to be private, intimate, confidential and/or sensitive.

This could have been due to fear of reprisals and consequences by the prison authorities, anticipated exploitation of the sick role and the societal status and the ascribed privileges that accompanied it. This was mitigated by proper consenting of the study participants, sensitization of the non-professional psychiatric personnel, psychoeducation of the study participants, soliciting of psychiatric drugs and funds to provide mental health services in the correctional institutions. Any difficulties in obtaining accurate information about details in the past and long term symptoms were attributed to recall bias. Some inmates might have been malingering in order to assume the much coveted sick role and all its perceived benefits.

The lack of resources to confirm diagnoses of general medical conditions and ruling out psychiatric symptoms due to physical illnesses. Absence of some prisoners at the time of data collection due to prison scheduling e.g. community service, prison duties, court schedules and pending releases from prison may have also impacted the results. Aspiring to attain the mandated sample size while endeavoring to cater for potential data loss with the intension of getting a study population that is representative of the general prison population that I was planning to study went a long way to resolve these concerns.