Portugal's Prisons: Too Many Patients, Too Few Psychiatrists
The number of healthcare professionals working in Portuguese prisons is insufficient to provide adequate care — particularly for individuals with psychiatric conditions — according to recent findings that underscore a growing public health concern within the country's correctional system.
Key barriers include overcrowded prison facilities and a shortage of medical staff, which hinder incarcerated individuals from accessing care equivalent to that provided through Portugal's public healthcare system, the Serviço Nacional de Saúde. Mental health care is particularly affected.
A 2023 report by the World Health Organization (WHO) on healthcare in European prisons identified mental health access as the most urgent concern. The report estimated that 32.8% of people in custody across the European region have a mental disorder — more than twice the 13.1% prevalence found in the general population.
Portugal did not submit detailed data on the mental health of its incarcerated population for the WHO report. Among the 36 countries surveyed, Portugal was one of 16 that did not respond to that portion of the questionnaire. However, a separate report from the Portuguese government titled Health Plan in the Context of Deprivation of Liberty provided a more comprehensive overview of healthcare services in the nation's prisons, along with proposals for improvement. Developed by a multidisciplinary expert group, the report cited data from the World Mental Health Survey showing that 22.3% of the Portuguese population experiences psychiatric disorders — above the European average of 14.2%. It also suggested that prevalence may be even higher within prison populations.
'This population has significantly higher rates of mental illness and psychiatric disorders compared to the general population, as multiple studies have shown — and for a variety of reasons,' said Susana Pinto Almeida, MD, psychiatrist at São João de Deus Prison Hospital in Caxias, Portugal.
Almeida, a subspecialist in forensic psychiatry, emphasized that incarceration itself is a major risk factor for mental illness. The structure and constraints of the prison environment can worsen existing psychiatric conditions or precipitate new ones. She also highlighted two critical moments for mental health deterioration: entry into the prison system and the delivery of a court sentence. Both are associated with an increased risk for suicide.
Suicide remains the leading cause of death in European prisons, according to the WHO. In Portugal, the inmate suicide rate is also higher than that of the general population. In 2022, 14 out of 64 deaths recorded in Portuguese prisons (21.9%) were due to suicide — corresponding to a crude mortality rate of 117 per 100,000 inmates. By contrast, the suicide rate in the general Portuguese population was 8.9 per 100,000 in 2021.
Preventive Programs and Ongoing Gaps
Portugal has implemented several initiatives aimed at improving mental health care in prisons. One key intervention occurs at the time of entry into the correctional system — a moment widely recognized as critical for identifying individuals at risk.
Under current legislation, all newly admitted inmates must undergo a comprehensive health assessment. This initial screening is designed to detect psychiatric disorders, suicide risk factors, withdrawal syndromes, signs of physical or sexual abuse, communicable diseases, and chronic conditions. The assessment must be conducted by a nurse within 24 hours of admission and by a physician within 72 hours. If suicide risk indicators are identified, the individual is referred for urgent evaluation by a psychiatrist.
In addition, Portugal has established the Integrated Suicide Prevention Program, which includes a two-step screening process: an initial checklist completed by a correctional officer to identify warning signs, followed by a questionnaire administered by the facility's educational staff.
Despite these protocols, the government's own reporting acknowledges that implementation may be inconsistent. 'According to the European Prison Observatory, suicide risk assessments during intake — and the associated prevention plans — are often only activated in response to public concern. In practice, statutory requirements are frequently overlooked,' said Almeida.
Staff Shortages and Operational Barriers
Workforce shortages remain a significant obstacle to providing adequate healthcare in Portuguese prisons. According to 2020 data from both the WHO report and the Portuguese government's prison health improvement plan, 382 healthcare professionals — including external contractors — were working across the national correctional system. Nurses made up the majority (318), followed by physicians (33).
Despite Portugal having 49 correctional facilities, only 17 psychiatrists were reported to be working in prisons at the time — equating to a ratio of 1.7 psychiatrists per 1000 inmates. While this is higher than the ratio in the general population (0.7 per 1000), it is still considered insufficient to meet the complex mental health needs of the incarcerated population.
A 2019 report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment also deemed the number of healthcare professionals in Portuguese prisons inadequate to ensure proper medical care. The report highlighted not only staffing shortages but also high turnover rates among prison healthcare workers.
Further, the Portuguese government's own data point to a substantial gap between projected and actual staffing levels. In 2021, for example, only 23 of the 64 planned physician positions were filled. In addition to clinical staff, inmates also interact with senior rehabilitation technicians — nonclinical professionals who work closely with incarcerated individuals and are trained to recognize signs of mental health issues.
Almeida emphasized that the limited number of psychiatrists significantly impedes early detection and proper treatment of severe psychiatric disorders such as schizophrenia and bipolar disorder. 'Most inmates are young adults under the age of 35. Among men, who make up the majority of the prison population, serious mental illnesses often emerge during early adulthood,' she said. 'These conditions are frequently underdiagnosed or misdiagnosed in this setting.'
While Portuguese legislation has introduced important reforms to improve prison mental health care and sets out standards for appropriate treatment, Almeida believes these guidelines have yet to be fully implemented.
She called for increased public attention to both the mental health needs of incarcerated individuals and the working conditions of the professionals who care for them. 'Prison psychiatry must be treated with the dignity and respect it deserves,' she said.
'It's painful to confront a reality shaped by indifference toward an ultra-vulnerable population,' she added. 'If living with a mental illness is already a vulnerability, then individuals who are both mentally ill and incarcerated face compounded hardship — they've lost their mental clarity and their freedom. It's a double loss.'
Medscape's Portuguese edition reached out to Portugal's Directorate-General for Reintegration and Prison Services, the agency under the Ministry of Justice responsible for prison healthcare, but did not receive updated data or comment.
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Portugal's Prisons: Too Many Patients, Too Few Psychiatrists
The number of healthcare professionals working in Portuguese prisons is insufficient to provide adequate care — particularly for individuals with psychiatric conditions — according to recent findings that underscore a growing public health concern within the country's correctional system. Key barriers include overcrowded prison facilities and a shortage of medical staff, which hinder incarcerated individuals from accessing care equivalent to that provided through Portugal's public healthcare system, the Serviço Nacional de Saúde. Mental health care is particularly affected. A 2023 report by the World Health Organization (WHO) on healthcare in European prisons identified mental health access as the most urgent concern. The report estimated that 32.8% of people in custody across the European region have a mental disorder — more than twice the 13.1% prevalence found in the general population. Portugal did not submit detailed data on the mental health of its incarcerated population for the WHO report. Among the 36 countries surveyed, Portugal was one of 16 that did not respond to that portion of the questionnaire. However, a separate report from the Portuguese government titled Health Plan in the Context of Deprivation of Liberty provided a more comprehensive overview of healthcare services in the nation's prisons, along with proposals for improvement. Developed by a multidisciplinary expert group, the report cited data from the World Mental Health Survey showing that 22.3% of the Portuguese population experiences psychiatric disorders — above the European average of 14.2%. It also suggested that prevalence may be even higher within prison populations. 'This population has significantly higher rates of mental illness and psychiatric disorders compared to the general population, as multiple studies have shown — and for a variety of reasons,' said Susana Pinto Almeida, MD, psychiatrist at São João de Deus Prison Hospital in Caxias, Portugal. Almeida, a subspecialist in forensic psychiatry, emphasized that incarceration itself is a major risk factor for mental illness. The structure and constraints of the prison environment can worsen existing psychiatric conditions or precipitate new ones. She also highlighted two critical moments for mental health deterioration: entry into the prison system and the delivery of a court sentence. Both are associated with an increased risk for suicide. Suicide remains the leading cause of death in European prisons, according to the WHO. In Portugal, the inmate suicide rate is also higher than that of the general population. In 2022, 14 out of 64 deaths recorded in Portuguese prisons (21.9%) were due to suicide — corresponding to a crude mortality rate of 117 per 100,000 inmates. By contrast, the suicide rate in the general Portuguese population was 8.9 per 100,000 in 2021. Preventive Programs and Ongoing Gaps Portugal has implemented several initiatives aimed at improving mental health care in prisons. One key intervention occurs at the time of entry into the correctional system — a moment widely recognized as critical for identifying individuals at risk. Under current legislation, all newly admitted inmates must undergo a comprehensive health assessment. This initial screening is designed to detect psychiatric disorders, suicide risk factors, withdrawal syndromes, signs of physical or sexual abuse, communicable diseases, and chronic conditions. The assessment must be conducted by a nurse within 24 hours of admission and by a physician within 72 hours. If suicide risk indicators are identified, the individual is referred for urgent evaluation by a psychiatrist. In addition, Portugal has established the Integrated Suicide Prevention Program, which includes a two-step screening process: an initial checklist completed by a correctional officer to identify warning signs, followed by a questionnaire administered by the facility's educational staff. Despite these protocols, the government's own reporting acknowledges that implementation may be inconsistent. 'According to the European Prison Observatory, suicide risk assessments during intake — and the associated prevention plans — are often only activated in response to public concern. In practice, statutory requirements are frequently overlooked,' said Almeida. Staff Shortages and Operational Barriers Workforce shortages remain a significant obstacle to providing adequate healthcare in Portuguese prisons. According to 2020 data from both the WHO report and the Portuguese government's prison health improvement plan, 382 healthcare professionals — including external contractors — were working across the national correctional system. Nurses made up the majority (318), followed by physicians (33). Despite Portugal having 49 correctional facilities, only 17 psychiatrists were reported to be working in prisons at the time — equating to a ratio of 1.7 psychiatrists per 1000 inmates. While this is higher than the ratio in the general population (0.7 per 1000), it is still considered insufficient to meet the complex mental health needs of the incarcerated population. A 2019 report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment also deemed the number of healthcare professionals in Portuguese prisons inadequate to ensure proper medical care. The report highlighted not only staffing shortages but also high turnover rates among prison healthcare workers. Further, the Portuguese government's own data point to a substantial gap between projected and actual staffing levels. In 2021, for example, only 23 of the 64 planned physician positions were filled. In addition to clinical staff, inmates also interact with senior rehabilitation technicians — nonclinical professionals who work closely with incarcerated individuals and are trained to recognize signs of mental health issues. Almeida emphasized that the limited number of psychiatrists significantly impedes early detection and proper treatment of severe psychiatric disorders such as schizophrenia and bipolar disorder. 'Most inmates are young adults under the age of 35. Among men, who make up the majority of the prison population, serious mental illnesses often emerge during early adulthood,' she said. 'These conditions are frequently underdiagnosed or misdiagnosed in this setting.' While Portuguese legislation has introduced important reforms to improve prison mental health care and sets out standards for appropriate treatment, Almeida believes these guidelines have yet to be fully implemented. She called for increased public attention to both the mental health needs of incarcerated individuals and the working conditions of the professionals who care for them. 'Prison psychiatry must be treated with the dignity and respect it deserves,' she said. 'It's painful to confront a reality shaped by indifference toward an ultra-vulnerable population,' she added. 'If living with a mental illness is already a vulnerability, then individuals who are both mentally ill and incarcerated face compounded hardship — they've lost their mental clarity and their freedom. It's a double loss.' Medscape's Portuguese edition reached out to Portugal's Directorate-General for Reintegration and Prison Services, the agency under the Ministry of Justice responsible for prison healthcare, but did not receive updated data or comment.
