INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int J Geriatr Psychiatry 2008; 23: 957962.

Published online 8 April 2008 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/gps.2017

Depression in elderly life sentence prisoners

Nicholas Murdoch 1*, Paul Morris 2 and Clive Holmes 1
1 2

Memory Assessment and Research Centre, University of Southampton, Southampton, UK Department of Psychology, University of Portsmouth, Portsmouth, UK

SUMMARY
Background The life sentence population is growing older and increasing in number. Despite the potential negative physical and social environment in prisons little is known about the prevalence or aetiology of depression in elderly lifers. Aims To determine the prevalence and associated risk factors of depression in elderly life sentence prisoners. Method One hundred and twenty-one elderly life/indeterminate sentence prisoners from two category B prisons in the United Kingdom were interviewed using the Geriatric Depression Scale and the relationship with prison and non prison specic variables analysed. Results Over half of the prisoners scored above the threshold for mild depression. The length of sentence served and other prison related variables were not associated with the depression score. However, the imported chronic physical ill health was strongly related to depression score. Conclusions Depression in long term prisoners is common and is related to the burden of imported chronic ill health as opposed to specic effects of imprisonment. Copyright # 2008 John Wiley & Sons, Ltd. key words Geriatric Depression Scale; depression; prisoners; physical health

INTRODUCTION It is widely accepted that the effects of imprisonment are detrimental to psychological well-being and prisoners are at risk from depression (Gibbs et al., 1991; Zamble and Porporino, 1992). Whilst there have been several surveys of psychiatric morbidity in the general prison population (Gunn et al., 1991; Fazel and Danesh, 2002), some important older prisoner studies (Colsher et al., 1992; Singleton et al., 1998; Fazel et al., 2001) and a scoping study on the elderly in prison (Howse, 2004), none have assessed the importance of prison or non prison specic variables in the aetiology of depression in elderly life sentence prisoners. This is despite concerns about the rising numbers of elderly prisoners and their complex physical and psychiatric needs (Fazel et al., 2001; Coid et al., 2002; Fazel and Benning, 2006).

METHODS Design This was a population-based survey of the prevalence and associated risk factors of depression in elderly life/indeterminate sentence prisoners.

Study population The study received ethical approval (Ref No:-p010204) and following the approved protocol a representative two-thirds (n 121) sample (in terms of type of sentence) of all (n 183) male elderly prisoners, dened as age 55 years and over, serving life or indeterminate sentences at either HM Prison Kingston or HM Prison Albany (Category B prisons) on 1 February 2004 were identied for interview. Over the period February 2004December 2005 all 121 male prisoners were approached, all of whom were interviewed, representing a 100% consent and response rate. Of the overall total, 35 were serving mandatory life sentences and 86 indeterminate sentences. The index
Received 16 July 2007 Accepted 15 February 2008

*Correspondence to: N. Murdoch, University of Southampton, Clinical Neurosciences Research Division, Memory Assessment and Research Centre, Moorgreen Hospital, Botley Road, Southampton, S030 3JB, UK. E-mail: kitnocks@zoom.co.uk Copyright # 2008 John Wiley & Sons, Ltd.

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offence for 92 (76%) prisoners was a sexual offence and the remaining 29 (24%) murder. Procedure Data collection took place during weekly visits to one or other of the prisons. All interviews and assessments were conducted in the medical centre at each prison, with the exception of one prisoner who was accommodated in the segregation block. A comprehensive medical history was taken from the inmate record le and a semi-structured clinical interview. All interviews were carried out by a clinician (NM) with long experience of assessment of the elderly and who was not a member of the prison staff. Measures Depressive symptoms were assessed using the Geriatric Depression Scale (GDS) (Yesavage et al., 1983). We modied question 12 (originalDo you prefer to stay at home, rather than going out and doing new things?) to more accurately reect the reality of the prisoners circumstances (modicationDo you go to association?). Mild depressive illness was dened as GDS scores 1120 points and severe depression 2130 points. A systematic review of the validity of the GDS against a range of clinical assessments of depression showed a sensitivity of 0.75 and a specicity of 0.77 (Wancata et al., 2006) with high testretest reliability (Yesavage et al., 1983). Cognitive function was measured using the Mini Mental State Examination (MMSE) (Folstein et al., 1975). A range of prison specic and non prison specic variables previously identied elsewhere

(Fazel et al., 2001; Crawley and Sparks, 2005; Liebling and Maruna, 2005), as inuencing the presence of depression in prison populations and the elderly were recorded (Table 1). Five health variables specically associated with ageing (i.e. the prevalence of ischaemic heart disease, hypertension, hypercholesterolaemia, number of illnesses in the last twelve months and whether they were regularly prescribed more than four medications) as dened in several community-based population surveys and the Medical Research Council (MRC CFAS, 2001; Harris et al., 2003), were also recorded. Statistical analyses Standard parametric tests including Pearsons product moment correlations, ANOVAs and t-tests were used in the analyses and multiple regression analysis to assess for confounders. We report standard measures of effect size associated with all statistical tests. Data were analysed using the SPSS package, Version 11. RESULTS Rates of depressive illness in the sample The GDS scores of the sample were normally distributed (mean 10.9 (SD 5.3) points). Fifty-nine (49%) prisoners scored below the threshold for depression (i.e. 10 or less), 58 (48%) prisoners scored in the mild depression range (i.e. 1120) and four (3%) prisoners scored in the severe depression range (i.e. 20 or above). Notably, of the 59 prisoners scoring below 11 points the majority (33 prisoners (56%) scored 10 points, i.e. at the border-line between no depression and mild depression.

Table 1. Prison specic, social demographic and health related variables recorded Prison specic variables Length of sentence Length of sentence served Previous time in prison Previous convictions In cell hobbies Attendance at gym or education programmes Being in prison work Friends in prison Good or bad relations with staff Satisfaction with food Complaints about noise Number of visits Letters sent or received Social/Demographic Age Marital status Number of children Religious belief Length of education Educational qualications Time served in armed forces Health Satisfaction with health care Psychiatric history Number of physical illnesses in past 12 months Hypertension Hypercholesterolaemia Ischaemic heart disease Medication history Mobility impairment Smoking status Hearing impairment Vision impairment

Copyright # 2008 John Wiley & Sons, Ltd.

Int J Geriatr Psychiatry 2008; 23: 957962. DOI: 10.1002/gps

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Likewise no relationship was found between the total prison sentence and GDS scores (r(121) 0.011, p 0.91), the time left to serve and GDS scores, (r(121) 0.017, p 0.85). Analysis of the presence or absence of other prison related variables as shown in Table 1 and GDS scores using t-tests also showed no signicant relationships.

Health variables Age showed a small signicant positive correlation with GDS score (r(121) 0.22, p 0.02). Information on the presence or absence of hypercholesterolaeamia was missing in 35 cases. Chronic illness in terms of hypercholesterolaemia, ischaemic heart disease, hypertension, illnesses in the past 12 months and whether they were prescribed more than four medications (excluding antidepressants) were all related to higher GDS scores (Table 2). These effects were not confounded with age or length of sentence served. The effect of the conrmed presence of any of the ve indicators on their own was to signicantly increase GDS, all with medium to large effect sizes. We combined these ill health indicators to produce a general index of illness (Table 3). Only ve prisoners had two ill health indictors thus this group were excluded from further analysis. An increase in the burden of illness had a clear cumulative negative effect on GDS score (F(4,111) 5.52, p 0.0005, E2 0.17) (Figure 2). Restriction of the analysis to include only those with complete data on cholesterol status (n 100) did not substantially change this relationship (F(4,87) 7.51, p 0.0001, E2 0.27). There were small non signicant relationships between the number of ill health indicators and age (r(121) 0.14, p 0.12), and ill health indicators and length of sentence served (r(121) 0.057, p 0.53).

Figure 1. GDS scores as a function of length of prison sentence served (r(120) 0.05, p 0.57)

Prison related variables and GDS GDS scores were unrelated to length of sentence served (r(121) 0.053, p 0.55). A group approach involving a comparison of GDS scores of prisoners who had served less than ve years, between ve and ten years and over ten years also revealed no signicant differences in GDS (Figure 1). The 95% Condence Intervals (CI) of the three groups were in fact closely overlapping (95% CI < 5 group 8.4811.32; 510 group 10.0213.49; > 10 group 9.8213.53). Hierarchical multiple regression analysis was used to assess the relative contribution of age, education years and length of sentence served to the GDS score. The only predictor variable that accounted for a statistically signicant amount of variance was age, t 2.12, p 0.036. The effect size of age was modest, standardised beta weight 0.19.
Table 2. Effects of health variables on GDS score Factor Hypercholesterolaemia Hypercholesterolaemia Ischaemic HD Ischaemic HD Hypertension Hypertension More than 2 illnesses* More than 2 illnesses More than 4 Meds* More than 4 Meds
*

N 70 30 72 49 87 34 108 13 70 51

Mean 11.30 8.46 11.92 9.42 11.80 8.62 15.31 10.37 12.15 9.19

SD 5.20 4.45 4.67 5.74 5.26 4.55 4.90 5.06 5.24 4.83

T-test results t 2.59, p 0.011, Cohens 0.72 t 2.62, p 0.01, Cohens d 0.43 t 3.10, p 0.002, Cohens d 0.43 t 3.33 p 0.001, Cohens 0.98 t 3.17, p 0.002, Cohens 0.43

95% CI of difference between means 0.664.99 0.604.36 1.155.21 1.997.86 1.114.80

in past 12 months.

Copyright # 2008 John Wiley & Sons, Ltd.

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Table 3. Prisoners with 05 ill health indicators Number of ill health indicators 0 1 2 3 4 5 ill ill ill ill ill ill health health health health health health indicators indicators indicators indicators indicators indicators Frequency 22 15 5 22 47 10

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Percentage 18.2 12.4 4.1 18.2 38.8 8.3

impairment) suggesting that a reduction in cognitive function is accompanied by an increase in GDS. Social and demographic variables and GDS There were no effects of marital status, parenthood, number of children, service in armed forces, on GDS scores. The small number of prisoners (n 17) who left school with qualications had signicantly lower mean GDS scores when compared to those without any qualications [7.41 c.f. 11.48 points; mean difference 4.07 (95% CI 1.46.7 points); p 0.003) although this effect is mediated by health factors; prisoners with qualications have signicantly fewer current ill health problems than those without qualications [1.73 c.f. 2.67 health problems; mean difference 0.94; (95% CI 0.261.97) p 0.006]. DISCUSSION A national survey across the prison estate in July 2007 showed that for the 1,523 lifers aged 50 years or more, 69% were imprisoned for violence against the person and 23% for sexual offences, other crimes being mainly robbery (personal communication, Department of Justice). Thus, this study had a disproportionate number of prisoners with sexual offences and should be viewed accordingly. Rates of depression, as rated by the GDS, were high in this population of elderly life sentence prisoners with just under half the sample (48%) scoring above the mildly depressed threshold and a further 3% diagnosed as being severely depressed. It should, however, be noted that this is a rate determined by sole use of the GDS which has its limitations since it is known to have less emphasis on physical symptoms that other scales and lower validity in a demented population (Burke et al., 1989). However, this rate is still higher in comparison to community based epidemiological studies using the GDS. Thus, in a general practice based survey of over 65 year olds, around 35% of the population fullled caseness for depression (DAth et al., 1994). Some studies have reported on levels of depression in elderly prisoners. A US population based survey of older male prisoners (Colsher et al., 1992) reported 15% as having depression. In a study of sentenced male prisoners aged 60 years and over, across 15 prisons in England and Wales (Fazel et al., 2001), 32% were identied as having a diagnosed psychiatric illness, the most common being depressive symptomatology (30%) and personality disorder (30%). When investigating the effects of imprisonment in a group of 81 Australian prisoners aged 18
Int J Geriatr Psychiatry 2008; 23: 957962. DOI: 10.1002/gps

Figure 2. GDS as a function of number of ill health indicators

GDS scores were higher for prisoners with restricted mobility however this effect was confounded with age. There was no relationship between smoking status, quality of vision or hearing and GDS scores. Prisoners who rated their health care as unsatisfactory had signicantly higher mean GDS scores than those who rated their health care as satisfactory [12.51 c.f. 10.17 points; mean difference 2.34 points; (95%CI 0.384.35); p 0.02]. Current and previous psychiatric history and GDS Those prisoners with a prior history of psychiatric illness (including depression, anxiety and substance abuse) had signicantly higher mean GDS scores than those without a prior history [12.00 c.f. 9.12 points; mean difference 2.88 (95% CI 1.04.8 points) p 0.003]. A prior history of depression had no more effect than any other prior psychiatric diagnosis. There was a signicant correlation between cognitive function as indexed by the MMSE and the GDS (r(121) 0.22, p 0.016) (it is a negative correlation as a lower MMSE score indicates greater
Copyright # 2008 John Wiley & Sons, Ltd.

depression in elderly life sentence prisoners 73 years (Gullone et al., 2000), 38% were reported as falling within the category of moderate to severe depression. There are, however, few studies examining the prevalence of depression in elderly lifers in prison. Maden et al. (2000) examines the lifetime prevalence of deliberate self harm in male prisoners but does not examine any relationship with depression. In a study of admissions to secure forensic psychiatric services (Coid et al., 2002) reported on 52 patients who were aged 60 years and over, 50% had committed homicide, and depressive illness was amongst the most prevalent diagnosis (42%) but this represents a highly selected group of prisoners. Curtice et al. (2003) in an 11-year elderly offender survey of referrals to a regional forensic psychiatry service in England reported the presence of mental disorder in 44% of referrals of which just 6% were diagnosed with depression. Thus, these are very selected studies for direct comparison. The theoretical ground for suggesting a putative link between depression and the direct effects of imprisonment is strong. Prolonged sentences gradually compromise adult competency (Birmingham, 2004), and the experience of long-term prisoners is predominantly characterised by exclusion, hence it is possible to envisage imprisonment, combined with the prospect of serving a long sentence, impacting adversely on mood. However, in contrast to the empirical ndings in several studies (Sapsford et al., 1978, 1983) showing a positive association between time served and affective atness in a group of long-termers the prevalence of depression was unrelated to length of sentence served. There was also no relationship between expected date of release and time left to serve and GDS scores. There was a clear and strong relationship between health and psychiatric variables and GDS scores. The majority of prisoners reported high rates of morbidity, with a combination of psychiatric and chronic physical health disorders. Those with previous psychiatric illnesses (including depression, anxiety and substance abuse) had signicantly higher GDS scores than those without, but a history of depression per se had no more effect than any other prior psychiatric diagnosis. Prisoners with reduced cognitive functioning as measured with the MMSE demonstrated increased levels of depression as indicated by GDS scores. Consistent with ndings reported following a series of community based studies examining the effect of specic chronic diseases on mood and cognition (Harris et al., 2006), the burden of physical health morbidity clearly had a cumulative negative effect on prisoners mood. Chronic illness, even after age the
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strongest potential confounder was adjusted, was related to higher GDS scores. In this study, overall GDS scores were elevated relative to general population norms. However, contrary to expectation, higher GDS scores were not related to the direct effects of imprisonment or to the length of sentence served or to be served. Rather the association was with the imported burden of chronic ill-health. This study offers hope that depression in elderly lifers is not an inevitable consequence of long term incarceration but rather the consequence of high levels of chronic ill health in elderly prisoners; something that equivalence of care can potentially address. CONFLICT OF INTEREST None known. DESCRIPTION OF AUTHORS ROLES N. Murdoch designed the study, collected the data and wrote the paper, C. Holmes supervised the data collection and wrote the paper and P. Morris was responsible for the statistical design of the study and for conducting the statistical analysis. ACKNOWLEDGEMENTS The authors would like to thank the staff and prisoners of HM Prison Kingston and HM Prison Albany. In addition we would like to thank Dr Luke Birmingham for useful comments. REFERENCES
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Int J Geriatr Psychiatry 2008; 23: 957962. DOI: 10.1002/gps