Mental health in prisons in Latin America: The effects of COVID-19.

Latin America is a vast region of the world. In 2022, it is estimated that nearly 620 million people live in 33 countries spanning almost 20 million km across North, South and Central America, and the Caribbean. These countries are united by their common historic cultural origins. It is estimated that Spanish is spoken by 400 million, and Portuguese by 200 million people in the region. Quechua is the most widely spoken indigenous language in the region, with around 8 million speakers; smaller numbers speak around 560 other indigenous languages such as Mayan, Guarani, and Nahuatl. The region was described as having a total gross domestic product (GDP) of almost 4.7 trillion US dollars in 2020, with substantial contributions from the four largest economies—Brazil, Mexico, Argentina, and Chile. However, Latin American countries are mainly considered developing nations. Meanwhile, it is thought that nearly 12 million people were detained in prisons throughout the world in 2019, of which at least 1.6 million were held in prisons in Latin America (1.163 million in South America, 340,000 in Central America, and 122,000 in the Caribbean). These numbers have been increasing throughout the twenty-first century, as the world’s prison population has risen by 24% since the year 2000. However, the prison population growth in Latin American countries has been extreme, with reported increases of 77% in Central America, and 200% in South America. In 2022, prison population rates were 478–605 prisoners per 100,000 people in the Latin American countries with the highest occupancy (El Salvador, Cuba, and Panama). In Bolivia, with a rate of 175 prisoners per 100,000, the level of overcrowding in some prisons was nonetheless as high as 891% of capacity in 2018. The reasons are linked to multiple factors, including increasing levels of crime and insecurity along with the rise of penal populism and zero tolerance policies, contributing to longer prison sentences. Decreases in psychiatric beds have also been found to correlate significantly with increases in the prison population in Latin American countries. People in prison present with very high levels of mental ill-health and substance misuse. For example, the global estimated prevalence of psychosis is 3.6% amongst male, and 3.9% amongst female prisoners, while the estimated prevalence of depression is 10.2% amongst male and 14.1% amongst female prisoners. Neurodevelopmental conditions also feature prominently in this group, with intellectual disabilities said to be present in around 2.9% of prisoners, and attention-deficit hyperactivity disorder in 26.2%. Prisoners have a high level of maltreatment in childhood, with almost half reporting four or more adverse childhood experiences. Unsurprisingly, prisoners therefore present with high reported levels of post-traumatic stress disorder, amongst 6.2% of male and 21.1% of female prisoners, and personality disorder in an estimated 65%. Similarly, high levels of drug and alcohol misuse or dependence are described—66.1% and 55.9% respectively in one 2019 UK sample. To date, however, most research in this area has been done in high-income countries, reflecting the greater level of resources available. Yet throughout the world, most prisoners are detained in lowand middle-income countries, with different cultural and legal considerations, and resource allocations. In Latin America, some important prevalence studies have been conducted in Brazil, Chile, and Ecuador, but most states have no such estimates available. The available research has confirmed high lifetime and 12-month prevalence rates for all mental disorders, with high rates of depression, personality disorder, and alcohol and drug addiction amongst prisoners in Brazil,23–25 and very high levels of depression and psychosis—50.2% and 25.9% respectively—in Ecuador. In Chile, very high rates of depression and drug/alcohol use disorders have also been described, with substantial levels of suicide risk—amongst male (28%) and female (15%) prisoners. Substance misuse disorders are the most commonly presenting health issue, with many exhibiting co-morbidities across three domains—the triad of severe mental illness, personality disorder, and substance misuse. These high levels of morbidity signify a need for services that are appropriate to the task at hand, both in terms of absolute staff numbers provided and assessments and treatments offered. However, many prisoners in Latin America do not receive these treatments, and even when they do, they are often inadequate, or arrive too late. Further, mental health presentations are often compounded by serious shortcomings in prison systems, with failures to meet agreed international standards—including harsh, Editorial