By  Catriona Connell , Mary Birken, Hannah Carver, Tamara Brown, and Jessica Greenhalgh

Abstract Background People released from prison experience complex health challenges in addition to challenges resettling into the community. Consequently, employment rates are low. Participating in good quality employment can support good health and is protective against future reofending. Multiple interventions are provided to support people into employment on release. The efectiveness of interventions for improving employment outcomes has not previously been evaluated in a meta-analysis. Aim Our objective was to examine the efectiveness of interventions to improve employment following release from prison. Method We searched seven databases and three trial registries for peer reviewed randomised controlled trials (RCTs), published since 2010, that included adults and measured an employment outcome(s). We conducted meta-analysis using random efects models with sub-group and sensitivity analyses. We appraised bias risk per outcome, and incorporated this into an assessment of the certainty estimates for each outcome. A group of people with experience of imprisonment met with us throughout the project to inform our search strategy and interpretation of results. Results We included 12 RCTs (2,875 participants) which were all conducted in the USA. Few outcomes were of low risk of bias. Intervention participants were 2.5 times more likely to work at least one day (95% CI:1.82–3.43) and worked more days over 12 months (MD=59.07, 95% CI:15.83–102.32) compared to controls. There was no efect on average employment status or employment at study end. There is moderate certainty in these estimates. Conclusion Interventions can improve some employment outcomes for people released from prison. More evidence is required to establish efective interventions for sustaining quality employment, particularly outside the USA, and which consider outcomes for diferent groups of people released, such as women or those with health or substance use needs

  Health & Justice (2023) 11:17

By Christina Emilian, Noura Al-Juffali, Seena Fazel

Prison populations have been increasing worldwide. Previous studies suggest that there is a high burden of psychiatric morbidity in people in prison, but, to our knowledge, the last published meta-analysis of prevalence is more than a decade old. We aimed to describe the pooled prevalence of depression, psychosis, bipolar disorder, and schizophrenia spectrum disorders for people who are incarcerated. Methods In this updated systematic review and meta-analysis, we searched six databases and grey literature published from database inception until Aug 8, 2024, with no language or geographical restrictions. We included primary quantitative studies that reported the prevalence of depression and psychotic disorders in the unselected prison population, based their diagnoses on clinical examination or from interviews and by the use of validated diagnostic instruments, met standardised criteria of the ICD or the Diagnostic and Statistical Manual of Mental Disorders for the diagnoses, and provided pooled prevalences for psychosis in the previous 6 months and clinical depression in the previous 2 weeks to 1 month. We excluded studies that used selected samples or were only qualitative. We investigated bipolar and schizophrenia spectrum disorders as separate diagnostic subcategories. We synthesised studies using random-effects meta-analysis and explored heterogeneity with meta-regression and subgroup analyses. The protocol is registered with PROSPERO, CRD42022378568. Findings We identified 131 publications reporting the prevalence of mental illness in 58838 people in prison in 43 countries. We estimated that the prevalence of depression was 12·8% (95% CI 11·1–14·6) and for any psychosis was 4·1% (3·6–4·7). For diagnostic subcategories, we found that the prevalence of bipolar disorder was 1·7% (1·0–2·6) and schizophrenia spectrum disorders was 3·6% (1·3–7·1). Between-study heterogeneity was substantial for these estimates (I² 69–97%) with few explanations. However, subgroup analyses revealed that people in prison in lowincome and middle-income countries had higher prevalences for depression (16·7% [95% CI 13·6–20·0]) than in high-income countries (10·8% [9·0–13·0]), and that, for people with psychosis who are incarcerated, psychiatrists were less likely to diagnose (3·5% [2·8–4·3]) than were non-psychiatrists (4·7% [3·9–5·5]). Interpretation Our study indicates that the prevalence of severe mental illness in people who are incarcerated worldwide is considerable. Meeting the treatment needs of people in prison who have mental ill health remains an ongoing challenge for public mental health. More evidence on how to improve the assessment, treatment, and linkage to services on release, which will require more research-friendly prison services, is now needed.

Lancet Public Health 2025; 10:, pages 97–110