Mental Health Held Hostage Behind Bars

Medscape

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This article launches a new series on prison psychiatry, produced in collaboration with Univadis Italy , a Medscape Network platform. All the published articles are grouped on an exclusive page and updated over time.
Every time a violent incident involving an inmate with a mental illness creates headlines, it tends to overshadow the work of correctional mental health professionals. This was the case at Bollate Prison near Milan, Italy, where an inmate on semi-liberty fatally stabbed one coworker, seriously injured another, and died by suicide after jumping from the Duomo terrace. Although convicted of homicide in 2016, the patient showed no overt psychiatric symptoms. However, a former fellow inmate later claimed that he exhibited signs of distress in an article published in Il Manifesto.
System Reform
This tragic story is part of the broader context of mental health protection in prisons, which has evolved since the 2008 reform that transferred responsibility for inmate healthcare from the Ministry of Justice to the Ministry of Health. The reform culminated a decade ago in the final closure of judicial psychiatric hospitals nearly 50 years after Franco Basaglia's landmark 1978 reform, which abolished all psychiatric hospitals in Italy.
'Integrating prison healthcare into the national health system took years, but it introduced the concept of clinical responsibility — so inmates are treated as patients,' said Antonella D'Ambrosi, a psychologist who has worked in Italian prisons since 1996, to Univadis Italy .
Since 2020, she has led the Dependencies and Psychopathology Unit in the Frosinone Penitentiary Institutions, primarily intended for the custody of people awaiting trial and for the execution of prison sentences of < 5 years), and a prison (a penitentiary institution intended for those definitively sentenced to medium-long prison sentences, generally > 5 years).
A 2019 Constitutional Court ruling confirmed this paradigm shift, affirming that all citizens, including prisoners, have the right to physical and mental healthcare.
Psychiatric Prevalence
However, despite these reforms, overcrowding remains a serious problem. By the end of 2024, 62,153 people had been detained in Italy — approximately 2000 more than in 2023 — against an official capacity of around 47,000.
In San Vittore, Milan, the actual overcrowding has reached 225%; in Brescia Canton Monbello, 205%; in Como and Lucca, 200%; in Taranto, 195%; and in Varese, 194%, the report stated. 'There are now 59 institutions with an overcrowding rate higher than 150%, mainly the large metropolitan prisons, those with the highest number of admissions and the greatest tensions.'
Mental illness is far more common in the prison population than in the general population.
A 2015 study in the journal Psychiatry Research of 300 inmates in Cagliari found that 58.7% had a psychiatric disorder compared to 8.7% in healthy individuals. Another 2016 epidemiological study of 15,751 inmates across 57 facilities in six regions of Italy found that 67.5% had at least one clinical diagnosis. Of them, 41.3% (27.9%) had a psychiatric diagnosis. Other common health conditions included gastrointestinal disorders (14.5%), infectious diseases (11.5%), cardiovascular diseases (11.4%), endocrine, metabolic, and immunological disorders (8.6%), and respiratory illnesses (5.4%).
Parma Initiative
Another in-depth investigation into prison mental health was conducted in Parma by Lorenzo Pelizza, MD, PhD, a professor at the Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy. He began working in the prison system by chance and returned to his hometown for family reasons. 'When I asked for a transfer, they told me, 'We are happy to have you, but you will need to work in the prison — no one else wants to go there,'' Pelizza told Univadis Italy . 'I agreed.'
A few months after his arrival, the team leader left for another position, and Pelizza was offered this role. 'I found myself working with many non-health professionals inside the prison — security personnel, social workers, and educators — and I kept hearing the same concern: The psychiatrist's hours needed to increase. Thus, there is a clear need for psychiatric support. Therefore, data were gathered to better understand these needs, particularly in relation to the types of diagnoses.
The idea of this study was simple: To systematically assess all new inmates upon entry, including transfers from other institutions, and then follow them for 1 year. The rollout was delayed by the COVID-19 pandemic; however, despite concerns regarding contagion, this study continued. 'We evaluated about 400 admissions ourselves, using consistent diagnostic criteria,' Pelizza said. 'We found that the main issue, affecting more than half of the cases, was addiction.'
Among the psychiatric needs, most disorders are linked to depression and anxiety, which are often driven by detention. 'We classify these as adjustment disorders, which can sometimes present with significant depressive symptoms,' he explained. 'Serious mental disorders — the kind typically managed by community mental health services — made up only about 10% of cases.'
The findings, according to Pelizza and colleagues, challenge the common perception that more psychiatrists are urgently needed in prison, except for medication prescriptions, for which they caution that it is not always appropriate.
The findings revealed that 63.1% of the inmates received at least one anxiolytic prescription, 20.3% received antidepressants, and 19.9% received antipsychotics. One third of the inmates received at least one psychiatric consultation during detention, averaging 1.4 visits per inmate per year.
'Even the visits we doctors make outside of prison often lead to a prescription of drugs because this is what the patient expects. This also occurs in prisons, where the request for drugs is often excessive compared to needs, and not only in cases of addiction. Prescriptions often have the purpose of reassurance and sedation to immediately deal with a new situation. In many cases, it could be possible to reassure even by listening to the needs of prisoners who are not strictly medical,' Pelizza said.
Intake Stressors
These stressors are countless, especially in remand prisons, where many inmates await sentencing in a state of extreme uncertainty. 'There are people who are suddenly taken into custody and thrown into prison with no warning. They arrive without a suitcase, without a change of clothes — completely unprepared,' Pelizza explained. 'They sit in their cells, not even understanding where they are. They don't know the rules, how to request basic items, or how to get in touch with their families.'
Pelizza vividly recalled one case: A Swedish man in his early twenties who was arrested on the highway while riding in a taxi that he had taken from Bologna to Milan. Previously, he had attempted to steal a woman's car by grabbing her. The attempt failed, and he fled, but the woman was injured when she fell during the incident.
'When the boy arrived in prison, his mental state was completely altered. Only after a few days were we able to get him to tell his story — in English because he did not speak Italian — and we concluded that the trip he had suddenly decided to take to Italy was already linked to an alteration in his mental state, probably a manic phase in a bipolar disorder,' Pelizza recalled.
'In addition to trying to start a treatment inside, I was concerned with building an alternative path outside the prison, since, among other things, he was in pretrial detention. It took 3-4 months, but we managed to bring him to our residence in Parma, where he remained for almost a year, until the trial,' continued Pelizza.
At trial, the young man was deemed unfit to stand trial because he was incapable of understanding or intending his actions at the time of the crime. He was released after being judged no longer to be in danger to himself or others, thanks to the therapy he had undergone in the interim. 'This is a classic example: In prison, he could not have been treated, whereas in the residential facility, he received care and experienced no further clinical relapses,' Pelizza concluded.
Residence for the Execution of Security Measures (REMS) Network
The Parma experience is also unique in many ways, not only because of the high standards of Emilia Romagna's public health system but also because the same Department of Mental Health that operates within the prison oversees two therapeutic communities for the general population and a REMS. REMS facilities, introduced in the 2015 reform, replaced old judicial psychiatric hospitals (OPGs). They are intended for individuals who commit crimes but are deemed not prosecutable due to mental incapacity at the time of the offence — people who cannot simply return home because they may pose a danger to themselves or others.
Currently, there are 32 REMS facilities in Italy. Each region is required by law to have at least one, although Calabria and Umbria have yet to establish their own. In total, 630 locations are available, as each REMS is legally limited to a maximum of 20 beds. An exception exists at Castiglione delle Stiviere, once home to the last remaining OPG, where 160 patients are housed, although they are formally divided into eight separate REMS units.
Capacity Challenges
According to a document approved in February 2025 by the Superior Council of the Judiciary, around 700 individuals meet all the criteria for transfer to an REMS but are still waiting for a place — 45 of them are currently held in prison. The Ministry of Health has opposed the creation of additional REMS facilities, citing the principle summarized in the CSM report : 'The more containers there are, the more they are filled.' However, the ministry is still evaluating the possibility of increasing the total number of places by 20%.
Giuseppe Nese, MD, is the director of the Multispecialty Department for Prison Health Services, Local Health Authority (ASL) Caserta; he also serves as the coordinator of the Regional Inter-Institutional Group for Prison Mental Health and Secure Psychiatric Care (REMS) in the Campania Region, which oversees four prison facilities, including a REMS, and has long collected and analyzed data to assess psychiatric needs. He believes that the current number of REMS places is sufficient and argues that a cultural shift across the entire system is needed. Despite the closure of the OPGs, he said that courts continue to favor detention, even though the spirit of the reform law is to reintegrate into society those who can be treated within the regular healthcare system.
'There is a widespread tendency in Italy to assign patients subject to temporary security measures to REMS,' noted the Antigone Association's report on REMS, edited by Nese. 'Yet the law stipulates that such measures should be applied only when alternative options are inadequate in addressing both clinical needs and potential social risk.' He also pointed out that both the European Court of Human Rights and Italy's Constitutional Court have repeatedly emphasized the need to find alternatives to forced hospitalization — whether in former OPGs or REMS — stressing the importance of balancing care with public safety.
A common scenario, he explained, is that of a person who commits a serious crime without any apparent mental illness, only for psychiatric issues to emerge after their incarceration. 'Sometimes it becomes clear that the individual may have committed the offense while mentally incapacitated,' Nese told Univadis Italy . 'In such cases, even before sentencing, a judge can order the provisional application of a security measure in a REMS. However, the judge must also assess whether that person, though deemed not legally responsible due to mental illness, is socially dangerous. If they are not, no security measure should be applied.'
In essence, if a person is not considered a danger to society, they should remain in prison only if there is a risk of escape or reoffending. Otherwise, they await trial in freedom. However, Nese noted that this critical evaluation often arrives too late in the judicial process.
The challenges of mental healthcare in the prison system in Italy are also evident in the numbers — numbers that appear high for another reason linked to the legal assessments that determine criminal responsibility. According to Nese, approximately 1 in 5 people on the REMS waiting list would not be eligible for admission as they are involved in more than one legal proceeding. It is not uncommon for someone to be deemed not criminally responsible in one case but responsible in another based on differing psychiatric evaluations.
A promising initiative launched approximately 18 months ago in Ficarolo, Veneto, on the border with Emilia-Romagna and Lombardy, aimed to ease REMS waiting lists, reduce inconsistencies in psychiatric assessments, and improve the appropriateness of care. Psychologist Stefano Rambelli explained that the Criminological Profiling and Analysis Center (CePAC) is a facility dedicated to the observation and assessment of individuals with psychiatric disorders who have committed crimes.
The multidisciplinary team at CePAC, a private facility accredited by the National Health System, assists court-appointed experts by observing individuals, up to a maximum of 20 at a time, over several months.
In some cases, these individuals return to prison, where the most severe psychiatric cases are managed in specialized units known as ATSM (mental health protection units). These sections provide more continuous medical care, and inmates often participate in group activities during the day, although they return to their cells at night. Currently, 32 ATSM units operate within 17 penitentiary institutions, one per region, housing approximately 300 prisoners with serious mental health conditions.
'The shift to REMS created parallel systems of care, but the overall response remains inadequate,' said Ines Testoni, PhD, a professor of social psychology at the University of Padua, Padua, who has conducted extensive research on prison mental health and suicide prevention. 'Many people with psychiatric conditions still end up in prison, where they cannot be properly managed.' Suicide is a sentinel event, an extreme signal of unmanageable psychological distress.
Estimates of suicide in prisons vary depending on the source. According to the National Guarantor for the Rights of Persons Deprived of Liberty, which compiled data from penitentiary authorities, there were 83 suicides in 2024, compared to 68 in 2023 and 84 in 2022. However, Ristretti Orizzonti, a long-standing publication by inmates at Padua Prison, reported that 2024 saw 91 suicides. The magazine also estimated that total prison deaths from all causes reached an unprecedented 246 in 2024, up from 241 in 2023 and 212 in 2022.
The psychological toll extends beyond inmates. 'Prison staff face the difficult task of balancing punitive, rehabilitative, and therapeutic roles, creating conflicting expectations and emotional strain,' Testoni explained. She has also studied suicides among prison officers, for whom it is difficult to obtain reliable data. According to Ristretti Orizzonti, 148 prison officers died by suicide between 1997 and 2018.
Testoni led a qualitative study involving focus groups and semi-structured interviews with staff at eight prisons in northeastern Italy. The goals were to understand their perspectives, identify systemic challenges, and explore the need for more collaboration with external services. This study also highlights the urgent need for enhanced training, greater staffing, and improved infrastructure.
'We need to invest in radically new solutions, which currently do not exist. Whenever a mental health issue emerges in prison, external care pathways must be available, even for those already convicted. For prison officers, we must create opportunities for them to process the relational and emotional challenges they face, free from stigma. Mental illness is a kind of 'contagious' suffering,' Testoni concluded.
Testoni also emphasized that community doctors should pay close attention to the mental health of people who have been in prison or work there.
Fabio Turone is an Italian science journalist, founder of Agenzia Zoe, president of the Science Writers of Italy, and a board member of the European Federation for Science Journalism. He has reported for the BMJ , Nature , and Research Professional and was a 2016-2017 Knight Science Journalism Program Fellow at Massachusetts Institute of Technology, Boston.
Chiara Sabelli earned a PhD in particle physics in 2012 and later completed a master's in science communication at the International School for Advanced Studies in Trieste. She has worked in science communication since 2017 and has been a journalist since 2019. She contributes to Nature Italy and Scienza in Rete.