INTRODUCTION

Based on global data there are 11 million people in prison globally an increase of about 8 percent over the last 10 years. Prisons are operating at above capacity in 119 countries, and measures to reduce prison populations are inadequate ⁽¹⁾. Mental disorders are often experienced by prisoners, these disorders are often undiagnosed and not handled properly. Generally, mental health problems experienced by many of these prisoners are depression, hopelessness, alcohol consumption, and drug use. Mental health problems are a challenge for mental health nurses because if left untreated they can lead to poor adjustment to health conditions and life in prison. In addition, life in prison is also a challenge for inmates who have poor mental health conditions ⁽²⁾.

The elderly are a population that is vulnerable to mental health impacts, especially in prison environments. Research conducted by Tarbuck ⁽³⁾. explains that older inmates will be at higher risk of experiencing violence than other inmates which result in high levels of chronic stress and can worsen physical and mental health problems. The United States has the highest number of incarcerated individuals worldwide, as well as its elderly inmates who reached 200,000 incarcerated people aged 55 and over in 2017. Therefore, the elderly are at risk of developing mental health problems ⁽⁴⁾.

Mental health in the elderly generally occurs with dementia. When mental health problems affect elderly prisoners, more complex health problems will arise including depression, Alzheimer's, anxiety, bipolar disorder, schizophrenia, and alcohol use ⁽⁵⁾. Mental health problems in elderly prisoners should be addressed as soon as possible. So that further research is needed on interventions for mental health problems in the elderly and the factors that influence them, especially to prevent more serious mental disorders. Meanwhile, research or literature review studies on mental health problems in elderly prisoners are still minimal. Therefore, the authors conducted a scoping review study to identify mental health in elderly prisoners.

METHODS

Study selection

We carried out the study selection process using the PRISMA Flow Diagram (Figure 1). From the results of the selection of articles according to keywords, then we validated according to the inclusion criteria, namely free full-text articles, English, types of research: qualitative and quantitative study, research design with publication time from 2000 to 2023, and focuses on the population of elderly prisoners. The exclusion criteria were documents, and review article. Four authors (NOH, AF, RHP, RRNA) mapped and created extraction table. The data listed in the extraction table were: authors and year of publication, research design, country, sample size, and instruments (Table 1). Furthermore, the results of performed analysis were reviewed by three authors (NOH, EFW, IA).

Figure 1: PRISMA Flow Diagram. 

Table 1: Summary of studies^{(7) (8) (9) (10) (11) (12) (13) (14) (15)}. 

RESULTS

A total of 465 articles were located using databases and search engines, and after removing duplicates and doing preliminary screening, 82 of these papers were examined against the exclusion criteria, with nine being declared eligible for inclusion.

Mental health problems of elderly prisoners

Depression and suicide attempts

Based on the results of a literature study, depression is a mental health problem that most often occurs in elderly prisoners. Of the nine articles, eight of them stated that elderly inmates were depressed when they were in prison. Sixty prisoners (50%) had a diagnosable mental disorder, with depression being the most common ⁽⁷⁾. Research conducted by Regan et al ⁽⁸⁾ had the highest result where out of 671 elderly inmates in Tennessee state prisons 33% of them experienced depression. Over half of the prisoners scored above the threshold for mild depression ⁽⁹⁾. More than half of the elderly prisoners had a psychiatric diagnosis ⁽¹⁰⁾. Depression is the most common disorder in elderly prisoners that is associated with the risk of suicide. The risk of suicide is the most prevalent disorder in elderly prisoners (80%) in 138 elderly samples⁽¹¹⁾. As for other studies, a history of attempted suicide was found (15.7%) in 166 samples ⁽¹²⁾.

Anxiety and agoraphobia

The second most common mental health problem that occurs in elderly prisoners in this literature study is anxiety. Research conducted by Baidawi ⁽¹²⁾ in Australia resulted in the prevalence of elderly prisoners experiencing anxiety was 27 (16.3%) (n = 166), while Regan’s research ⁽⁸⁾ mentions that the prevalence of elderly prisoners experiencing anxiety was 13%. While the research conducted by Combalbert et al ⁽¹¹⁾ and Allen et al ⁽¹³⁾ said that anxiety is a mental health problem that often occurs in elderly prisoners. Another thing related to this anxiety is agoraphobia, which is one of the most common disorders in elderly prisoners in the study. Agoraphobia occurred (19%) in men over 50 years of age who were on probation at Probation Services Berkshire, Oxfordshire, and Buckinghamshire, England ⁽¹⁴⁾.

Post-traumatic stress disorder

In addition, two articles found post-traumatic stress disorder or post-traumatic stress disorder as a mental health problem found in elderly prisoners. In the study of Combalbert et al ⁽¹¹⁾, the prevalence of PTSD was higher (9.4%) when compared to the results of the study by Baidawi ⁽¹²⁾ which was (2.4%).

Bipolar

Two articles also discuss bipolar of some elderly inmates at 9 (18%) ⁽¹⁵⁾. While research conducted by Baidawi ⁽¹²⁾ in Australia, there were 6 (3.6%) of 166 elderly prisoners who experienced bipolar.

Schizophrenia

As many as 12 elderly (24%) of the 360 samples were diagnosed with schizophrenia. In this study, the incidence of schizophrenia in elderly inmates was higher than the rates of community-dwelling adults found in other studies ⁽¹⁵⁾. Meanwhile, Baidawi ⁽¹²⁾ found in 7 elderly (4.2%) out of 166 samples experienced psychosis/schizophrenia.

Alcohol and drug dependence

Fitton et al ⁽¹⁴⁾ found (19%) of 32 elderly people had alcohol dependence. A history of alcohol dependence and drug use was also found in 36 elderly (20.9%) of the total sample of 172 elderly prisoners ⁽¹²⁾.

Personality and mood disorders

While the prevalence of mental disorders is relatively small based on literature studies, namely personality disorders and mood disorders. Research conducted by Baidawi ⁽¹²⁾ found that elderly prisoners may have personality disorders with a prevalence of 6 (3.6%) out of a total of 166 elderly prisoners. Meanwhile, Combalbert et al ⁽¹¹⁾ said that mood disorders were also the most common disorder in elderly prisoners aged 50 years and over, but the prevalence was not stated.

Elderly prisoners characteristics

Participants who were included in the study were elderly prisoners, most of whom were aged 50 years and over, with a total number of participants from all articles amounting to 1,895.

Table 2: Cecklist mental health problems among elderly prisoners^{(7) (8) (9) (10) (11) (12) (13) (14) (15)}. 

PD: Personality disorder; PTSD: Post-traumatic stress disorder

DISCUSSION

This review study aims to analyze various mental health problems that arise in elderly prisoners. Based on the analysis of nine articles, it was found that mental health problems of elderly prisoners include anxiety, agoraphobia, depression, bipolar, personality disorders, post-traumatic stress disorder, risk of suicide, mood disorders, psychosis or schizophrenia spectrum disorders, and alcohol abuse or dependence.

From the results of a literature review, mental health problems that often occur in elderly prisoners are depression with anxiety. Depression and anxiety are psychological symptoms of stress ⁽¹⁶⁾. Approximately 85% of patients with depression may experience significant symptoms of anxiety, while comorbid depression occurs in up to 90% of patients with anxiety disorders ⁽¹⁷⁾. Mental health in the elderly is an indicator of achievement of the quality of life lived by the elderly ⁽¹⁶⁾. Elderly prisoners usually have poor stress coping compared to other inmates so the risk of experiencing health problems is more likely to occur in elderly prisoners ⁽¹⁸⁾. Research conducted by Baidawi ⁽¹²⁾ resulted that female prisoners over 50 years of age experienced more mental health problems. While the research conducted by Regan et al ⁽⁸⁾ resulted in the number of elderly prisoners who were male, experiencing more mental health problems.

Of all the articles analyzed, eight of them stated that elderly inmates were depressed when they were in prison. Depression is most common in elderly prisoners ^(7,9,10). This is in line with a study from Hayes et al ⁽¹⁹⁾ that the majority of elderly prisoners in the UK (34%) suffer from major depression and 19% experience anxiety disorders). In several studies, Combalbert et al ⁽¹¹⁾ observed that this disorder is often not detected and is not specifically intervened by health services in prisons. The high prevalence of depression in the prison environment can generally be associated with support from strong family problems and personal problems, or because of the loss of social relationships with the closest people who act as support systems. In addition, this is because older inmates tend to have difficulty adapting to changes (in this case changes in life patterns and the environment before and after staying in prison) than younger inmates which has an impact on increasing levels of stress and anxiety.

In addition, based on the analysis of the articles conducted, there is a positive relationship between the measure of religiosity/spirituality with negative mental conditions. In particular, positive religious coping was associated with increased feelings of depression. This is due to the possibility of depressed prisoners trying to overcome their negative emotional state by drawing closer to God. From the various works of literatures that have developed, there is a relationship between religious participation and the improvement of better mental health among the elderly. Religiosity/spirituality can reduce the number of stressors, provide meaning or coherence that counteracts stress and helps to cope with stress, and provide a relationship of like-minded people who can serve as a support system and promote psychological development, including self-esteem and a sense of personal worth ⁽¹³⁾.

Depression faced by elderly prisoners is often associated with the risk of suicide. The risk of suicide is also a disorder with the greatest prevalence in elderly prisoners, which is as much as (80%) ⁽¹¹⁾. A history of attempted suicide was found (15.7%) ⁽¹²⁾. Another study found that between 2000 and 2013 the suicide rate of prisoners in Germany aged 50 years and over was higher than the suicide rate of prisoners under 50 years of age. Relevant factors related to this include female gender, detention status, and life sentences. These factors were shown to be independent predictors in the group of elderly inmates who committed suicide. The increased risk of suicide in elderly prisoners is also an expression of hopelessness and unmet social needs ⁽²⁰⁾.

Liem & Kunst ⁽²¹⁾ introduced the idea that elderly prisoners often exhibit a range of mental health problems related to post-traumatic stress disorder. Two articles found post-traumatic stress disorder prevalence of PTSD (9.4%) ⁽¹¹⁾, and (2.4%) ⁽¹²⁾. Most prisoners are exposed to potentially traumatic events during childhood ⁽²²⁾.

Based on review studies related to psychiatric problems in elderly prisoners that have been carried out, several articles have their advantages and disadvantages. In terms of shortcomings, most of the articles include participants who are classified as few, Fitton's study only took a sample of 32 ⁽¹⁴⁾. Related to this shortcoming was that some participants did not agree to participate in the study, and elderly prisoners tended to spend more time in detention. Some articles have a large sample of 671 elderly prisoners ⁽⁸⁾, but the research uses secondary data.

Other shortcomings and limitations of the articles studied include some studies that do not consider dependence disorders or abuse of alcohol or illegal drugs, the number of prisoners is disproportionate to sexual offenses and must be reviewed for suitability, some instruments are less accurate and relatively new, one of which (level depression determined by the use of the actual GDS instrument has limitations because it is known to lack emphasis on physical symptoms), and the study did not analyze treatment interventions for psychiatric disorders that occur in elderly prisoners.

Of the various shortcomings above, there are also advantages found in the various articles analyzed. One of these is from Baidawi’s study ⁽¹²⁾, which is the first quantitative study of elderly inmates in Australia and could cover two states which together hold a significant portion of the prison population in Australia. The sampling strategy in this study also included female prisoners who were often excluded or minimally represented in research related to elderly prisoners. In addition, a study from Allen et al ⁽¹³⁾ used a measure that showed adequate internal consistency to the good category in its research sample.

Of all the articles, most of them use several types of mental disorder instruments in conducting their research for measuring results, explanations related to the comparison of results between instruments or between research variables are presented clearly and in detail according to their classification, as well as many research articles that include the results of previous research.

CONCLUSIONS

Based on the results of this literature study, research that discusses mental health problems in elderly prisoners is still in the small category when compared to research conducted on general/adult prisoners. Of the nine articles that discuss mental health problems in elderly prisoners, only one article uses a qualitative approach. Research in several articles was carried out in various countries but no research came from Asia. There are recommendations for further research more focused on handling or providing appropriate interventions for elderly prisoners who experience mental health problems and identifying the extent of mental health services for elderly prisoners in prison. In addition, there is a need for research with a qualitative approach to further explore the mental health problems of elderly prisoners and how to solve them.