All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-Analysis

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The global prison population in 2008 was estimated at 9.8 million with a median rate of imprisonment of 145 prisoners per 100 000 persons, most of whom are aged between 18 and 44 years. More than 2.3 million of these prisoners reside in the United States, which has the highest rate of imprisonment of 756 per 100 000 population. Natural cause mortality inside prison has been reported to be lower than that of the general population in France, Russia, England and Wales, and the United States. However, it is well-established that prisoner suicide rates are elevated compared with age-matched general populations. For example, the suicide rate of male prisoners in England and Wales between 1973 and 2003 was found to be 5 times higher than that of the general population, and in US jails, it has been reported to be 8 times higher. The odds of chronic medical conditions are increased by up to 4 times in US prisons. As prison populations are drawn from socioeconomically deprived backgrounds with reduced access to health care and health-seeking behavior when living in the community, prison provides an opportunity to provide public health interventions including health education and improving engagement with health services following release. For example, targeted health interventions such as medication review and HIV health education have been proposed.

Objectives: We systematically reviewed studies of mortality following release from prison and examined possible demographic and methodological factors associated with variation in mortality rates.

Methods: We searched 5 computer-based literature indexes to conduct a systematic review of studies that reported all-cause, drug-related, suicide, and homicide deaths of released prisoners. We extracted and meta-analyzed crude death rates and standardized mortality ratios by age, gender, and race/ethnicity, where reported.

Results: Eighteen cohorts met review criteria reporting 26 163 deaths with substantial heterogeneity in rates. The all-cause crude death rates ranged from 720 to 2054 per 100 000 person-years. Male all-cause standardized mortality ratios ranged from 1.0 to 9.4 and female standardized mortality ratios from 2.6 to 41.3. There were higher standardized mortality ratios in White, female, and younger prisoners.

Conclusions: Released prisoners are at increased risk for death following release from prison, particularly in the early period. Aftercare planning for released prisoners could potentially have a large public health impact, and further work is needed to determine whether certain groups should be targeted as part of strategies to reduce mortality.

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References:

Zlodre J, Fazel S. Am J Public Health. 2012 Dec;102(12):e67-75. doi: 10.2105/AJPH.2012.300764.