Prison Is the First Mental Health Visit for Many in Spain

Spain has one of the highest incarceration rates in Europe, with 160 individuals imprisoned per 100,000 population. In 2020, 43,494 people were incarcerated in facilities not managed by regional health authorities — essentially all regions except Catalonia, the Basque Country, and Navarra. Among them, at least 1785 had significant mental health care needs, underscoring the urgent need for a more integrated, preventive, and humane approach in coordination with public health services.

Although precise data are difficult to determine, an estimated 4%-5% of inmates in Spain suffer from a severe mental disorder. Since the 1990s, multiple studies have shown that incarcerated individuals are four to six times more likely to develop psychotic disorders or major depression and up to 10 times more likely to have antisocial personality disorder compared with the general population.

Substance use is also a key factor. About 1 in 4 inmates with psychosis have symptoms related to drug intoxication or withdrawal. According to the European Monitoring Centre for Drugs and Drug Addiction, 30%-50% of European prisoners were regular users of illegal drugs prior to incarceration. While many reduce or discontinue use during imprisonment, approximately 27% continue using drugs while in custody.

Window for Mental Health Intervention

Around 70% of inmates with severe mental illness had no prior psychiatric care before incarceration, making prison an important point of contact for identifying and stabilizing mental health conditions. Within Spain’s prison system, some individuals require intensive psychiatric support. The most common profile includes young men (aged 18-30 years) with psychotic disorders and coexisting physical or mental health conditions that complicate their clinical picture.

These inmates often face significant structural and social disadvantages. They may lack financial resources, stable housing, and supportive social networks. Many come from marginalized environments and enter prison after periods of medical neglect and poor treatment adherence, contributing to clinical decompensation. Repeat offenses are common, partly due to the lack of access to community-based therapeutic and social support systems. For many, prison becomes one of the few places where they receive any form of psychiatric care — albeit limited.

Particularly vulnerable subgroups include women, unaccompanied foreign minors, and individuals with attention-deficit/hyperactivity disorder (ADHD), each of whom face unique clinical and social challenges within the prison environment.

Women at Fivefold Greater Risk

Although women represent only 7.1% of Spain’s prison population, they face distinct and heightened mental health challenges. Most incarcerated women are between 41 and 60 years old; 30% are Spanish nationals, and 40% belong to the Roma ethnic group. During incarceration, women are five times more likely to develop a mental health disorder compared with women in the general population.

Common conditions include anxiety, depression, and phobias, as well as more severe disorders: 3.9% have psychotic illnesses, 14.1% suffer from major depression, 21.1% are diagnosed with posttraumatic stress disorder, and between 30% and 60% have substance use disorders. Many have histories of gender-based violence and face compounded stigma — from both their criminalization and gender identity. Reintegration after release is often complicated by economic dependence, ongoing substance use, a lack of social support, and difficulty reentering the workforce or family life.

Unaccompanied Minor Migrants: Profound Vulnerability

Unaccompanied foreign minors — often from North Africa — form one of the most vulnerable groups in Spanish prisons. Although younger than 18 years, these adolescents frequently face uprootedness, social isolation, and behavioral problems. Lacking family support and originating from economically and socially disadvantaged environments, they are at an increased risk for both physical and psychological violence, both before and during incarceration. Substance use is common as a coping mechanism in response to abandonment and marginalization.

Young inmates diagnosed with ADHD have an estimated prevalence up to 10 times higher than that seen in the general population. These individuals often come from chaotic family environments and experience academic and social instability, leading to reduced cognitive and emotional resilience and increased vulnerability to abuse. Their prison behavior is frequently disruptive and poorly adapted, presenting additional challenges for rehabilitation efforts.

Forensic Psychiatric Hospitalization

Spain’s two forensic psychiatric hospitals primarily admit individuals who have committed serious offenses linked to psychiatric disorders. These patients often present with multiple comorbidities, including psychotic disorders, personality disorders, and substance misuse. Admission is typically based on legal criteria related to diminished criminal responsibility due to mental illness.

Models of Penitentiary Healthcare

While incarceration poses many limitations, it also presents a rare opportunity to diagnose, treat, and stabilize mental health conditions that often go unaddressed in community settings. However, this potential is constrained by Spain’s fragmented prison healthcare system, which is under-resourced and poorly integrated with regional health services.

Although a 2003 national healthcare law mandated the integration of prison healthcare into autonomous regional systems within 18 months, implementation has been incomplete. Only Catalonia, the Basque Country, and Navarra have complied with the legislation.

As a result, two models currently coexist in Spain:

• In 14 autonomous communities and in the territories of Ceuta and Melilla, healthcare in prisons is still managed by the central Ministry of the Interior through a nonmedical penitentiary directorate. This traditional, centralized model serves over 80% of the country’s incarcerated population and operates largely independently of the public healthcare system.
• In contrast, Catalonia (since 1983), the Basque Country (since 2011), and Navarra (since 2021) have adopted integrated healthcare models. These systems — covering about 17% of inmates — are better coordinated with regional health services and offer improved equity, continuity of care, and responsiveness to mental health needs.

Only Two Forensic Psychiatric Hospitals

Spain has just two forensic psychiatric hospitals — located in Alicante and Seville — both operated by the penitentiary system under nonclinical leadership. Psychiatric staffing levels in these facilities fall significantly below international standards, with only 0.8 full-time equivalent psychiatrists in Alicante and 2.6 in Seville. By comparison, countries like Germany, France, Italy, and the UK aim for approximately five psychiatrists per 100 inmates.

This shortage, combined with the geographic concentration of facilities, limits access to care, separates patients from their families, and undermines effective treatment, rehabilitation, and reintegration.

As of December 2020, these hospitals housed 393 patients — 151 in Seville and 242 in Alicante. The Seville hospital serves inmates from Andalusia, Extremadura, Melilla, Ceuta, and the Canary Islands. All other regions (excluding Catalonia, the Basque Country, and Navarra) refer their forensic psychiatric patients to Alicante.

Women with severe mental illness face particularly difficult conditions, as the Alicante facility is the only one equipped to admit them. This often results in geographical displacement, further hindering recovery. “Each region should have its own resources to offer more accessible and effective care,” said José Joaquín Antón Basanta, physician at the Albolote Penitentiary Center in Granada, Spain, and president of the Spanish Society of Penitentiary Healthcare, in an interview with El Medico Interactivo, a Medscape Network platform. “Long-term follow-up should be fully integrated into regional health services to ensure continuity of care in the community.”

‘Sadness, Frustration, and Burnout’

Physicians working in Spain’s prison system are at high risk for occupational stress and burnout. According to a systematic review by the Carlos III Health Institute, 1 in 4 physicians in Spain experience professional burnout. The analysis, based on 67 studies and more than 16,000 participants, highlights the severity of the issue across the medical profession — but prison doctors face even greater challenges.

Poor working conditions in the penitentiary setting have a significant emotional toll, leading to frustration, helplessness, and exhaustion. “Sadness, frustration, and burnout” is how Antón Basanta described the emotional state of many colleagues in his interview. In many prisons, medical care is limited to emergency interventions, and continuity of care is often disrupted. Due to staffing shortages, nurses frequently fill in for absent doctors and assume responsibilities outside their scope of training.

The lack of healthcare system integration across regions creates wide disparities in care delivery and working conditions. In regions where prison healthcare has not been transferred to the regional health system, professionals face job insecurity, fewer incentives, lower salaries, and a shortage of replacements. “In most regions, we’re still playing in a different league,” said Antón Basanta. “We’re not part of the regional health system; we earn less, have no career progression or incentives, and the majority of the workforce is over 60. Given the choice, younger professionals understandably opt for public health centers, where conditions are better. And with the broader shortage of physicians, very few choose to work in prison healthcare.”

As of December 2024, nearly 474 medical positions were needed across Spanish prisons, but only 140 were filled — meaning just 30% staffing coverage. Yet these professionals are responsible for the care of 80% of the national inmate population. “The system is on the brink of collapse,” Antón Basanta warned.

Commitment of Prison Doctors

Despite the significant social challenges, difficult living conditions, and high burden of physical and mental illness among incarcerated populations, many prison physicians remain deeply committed to delivering care with dignity and compassion. For them, this work is not only professional — it is profoundly ethical.

Antón Basanta described prison medicine as “almost unique.” “Being with patients full time, accessible at any moment and in any place, allows for a deep understanding not just of their medical conditions, but also of their life stories,” he said. “It’s reminiscent of traditional rural medicine, where the doctor knew each patient and their family. Here, we manage diabetes, HIV, and schizophrenia in the same individual — and view them as a whole person. This approach allows us to work on prevention, health education, and meaningful lifestyle change. It’s a privileged kind of medicine.”

Yet he noted with concern that neither prison healthcare professionals nor the patients they serve are a priority on Spain’s political agenda. “Today, those of us working in this setting face precarious conditions, invisibility, and burnout — with no institutional support. We have no political influence — and neither do the people we care for. That’s why we remain excluded from public debate. The phrase ‘let them rot in prison’ still lingers, and I’ve always fought against that mentality.”

Citing Nelson Mandela’s famous words — that you don’t truly know a country until you’ve been inside its prisons, and that a nation should be judged not by how it treats its highest citizens, but by how it treats its most vulnerable — Antón Basanta reflected: “Prisons mirror society. They are one of the clearest indicators of a nation’s progress. In Spain, prisons have seen major improvements over the past few decades, but today they are largely absent from public discussion.”

He called for renewed political will, sustainable investment, and a human rights-centered approach to prison healthcare. “Health — and healthcare in prison — must remain a guaranteed right for everyone.”

This story was translated from El Medico Interactivo.