According to articles 40 and 41 of the Prison Regulations, the prison is directly responsible for identifying and treating patients with mental disorders. The effects of imprisonment and confinement in closed spaces, isolation from friends and family, and lack of healthy recreational activities on mental health are not hidden. The aim of this article is to explain and describe the effects of imprisonment on the mental health of prisoners, the conditions of patients with mental disorders in prisons, and the quality of psychiatric services in Iranian prisons.

This article is based on interviews with three sources who have had direct or indirect experience with mental illness in Ward 209 of the Ministry of Intelligence, Tehran’s Great Prison, Evin Women’s Ward, and Qarchak Women’s Prison. The limited number of sources is understandable but unfortunate, as individuals with mental disorders generally do not have a desire to revisit or share their painful and difficult personal experiences while in prison. This is a common issue for individuals with mental disorders and is one of the contributing factors to the lack of personal narratives and lived experiences in this subject.

The first source, “Nazanin”, a 30-year-old (pseudonym, confidential identity with the peace line) spoke to us about her experience with mental illness in ward 209. Nazanin, who has been detained in this ward for 11 months, explains that despite the undeniable role of the individual conditions and the highly secure atmosphere of ward 209 in her physical and mental decline, she has not been dissatisfied with the quality of care, services, and medications provided to her in this ward. According to Nazanin, upon her initial arrest and entry into the ward and the initial examination by the general practitioner, she explained her mental illness and declared her medications, and also presented the prescription she had with her. Her medications were given to her according to the prescription until her visit with the psychiatrist inside ward 209 was arranged within a week, and the psychiatrist, after a relatively accurate examination, prescribed an additional medication for her that was beneficial for her condition and was

Nazanin explains that the process of entering cell 209 includes being blindfolded, taking off personal clothing, and being placed in an empty individual cell with only a closed package that is opened solely at the will of the prison guard for interrogation, giving food, or going to the bathroom. This is enough to cause severe stress and anxiety in any healthy individual and can worsen symptoms in a sick person.

Losing complete control over a prisoner in solitary confinement throws them into a deep mental well, where they may question their deepest beliefs about themselves and experience doubts in their various identities. Considering the fact that the ability of different individuals to tolerate solitary confinement varies based on their background, mental and personal strength, past traumas, physical conditions, contact or lack of contact with the outside world, and the presence or absence of family or legal support, as well as the type of case and level of concern about its outcome, the type, technique, and duration of interrogation, and the pressure imposed during interrogation, and the behavior of prison guards, it is not possible to expect a uniform “resistance” or “strength” from individuals in this regard.

Nazanin explained that despite not having any history of suicidal thoughts, under the security conditions of cell 209 and the fear of the unknown and the possibility of being stuck there for a long time, she was intensely preoccupied with thoughts of suicide and sought ways to end her life during the first few months. She believes that being forced to sleep in the constant light of cell 209, or being required to wear a blindfold when moving between the cell and the bathroom, having all external identifying markers such as jewelry and clothing taken away, wearing the uniform of cell 209 and a chador, not knowing the time in solitary confinement, having no information about the interrogation or any control over time or food, constantly being moved between cells with other inmates while trying to maintain friendly and supportive relationships, and the presence of terrifying and discouraging writings on the walls (written by previous cellmates) about the length of time others have spent in the cell or the techniques used to break them, being held

The second source, Maryam, 35 years old (alias, identity kept confidential by the peace line) who has been in Evin and Qarchak women’s prisons for a year and a half, spoke to us about the general conditions of these two prisons and the way mental health services are provided. Maryam says that when she entered the women’s ward of Evin prison with a poor mental state and under treatment for a chronic mental illness, and declared her psychiatric illness and medications to the medical staff during the initial visit, her appointment with a psychiatrist was scheduled for two weeks later and she was given her medications during this time, as she had stated. The possibility of being visited by a psychologist was also available upon request by the prisoner, either monthly or a maximum of twice a month, but Maryam did not take advantage of this option.

Maryam says that during her continued stay in Evin Women’s Prison, she was visited twice more by her requested psychiatrist. Although these visits were spaced two to three weeks apart from the time of her request, and the quality of the psychiatrist’s visits was not up to Maryam’s expectations, as she had been receiving specialized treatment outside of prison for years, overall they were acceptable and her general and mental health improved during her time in Evin. Maryam emphasizes that a significant part of this improvement is owed to the environment of Evin Women’s Prison, which is better than many other prisons, including the minimal presence of guards inside the ward, the role and agency of prisoners in managing the ward, the presence of extracurricular and cultural activities planned by prisoners, and the availability of a library and other facilities for healthy use of prisoners’ time. Maryam says, for example, that the presence of newspapers, the possibility of in-person visits, and the ability to cook inside the

Maryam says that although she has not experienced any inappropriate treatment from the prison guards regarding her mental illness, she has noticed the prevalence of stigma and discrimination towards mental illness and the use of psychiatric medication among her fellow inmates. For example, her fellow inmates would always advise her with compassion and kindness to “stop taking those pills” and “a good girl like her shouldn’t be medicated.” Maryam specifically says, “I felt that some of my fellow inmates’ respect for me decreased because of being ‘medicated’ and instead gave way to a sympathetic attitude, which was upsetting and insulting for me as someone who was more aware of my own illness than they were.”

Maryam also narrates a story of being hospitalized at Razi Psychiatric Hospital (Aminabad) for one to two weeks. She says that she was not aware of her illness, but she knew that she was suffering from mental disorders and distress. Maryam says that she was told by her fellow inmates that one of the reasons for her deteriorating condition was that they suspected her of passing information to the prison staff without any solid evidence, which led to them mistreating her individually and collectively, resulting in her hospitalization. She also witnessed one of her fellow inmates becoming extremely agitated and hysterical when another inmate was referred to as “mentally ill” by others, and she protested against the use of this term to degrade people. According to Maryam, this particular inmate had been traumatized and had unpleasant memories from her time at Razi Psychiatric Hospital (Aminabad), and she rarely spoke about that period.

The importance of Maryam’s narrative is doubled in that it opens up and highlights the issue of discrimination and prejudice towards mental illness in prison environments, which is often carried out under the guise of “goodwill” and kindness, and due to lack of trust in the prison’s medical services by inmates. Maryam says that she has unfortunately witnessed that the behavior of guards towards inmates with mental illness is often more compassionate and understanding, perhaps because the guards do not want to add to the already confined, stressful and overwhelming environment of the prison, and only intervene in times of crisis or out of human compassion, taking extra time out of their organizational duties to talk to and calm down these sick inmates.

Maryam says that another factor that caused problems in the treatment and use of medication for prisoners was the drug distribution system. It was necessary to go to the prison staff daily or nightly and receive and consume the medication in the presence of a guard. This caused some prisoners to be reluctant to take their medication. Maryam understands that making a large amount of medication available to prisoners inside the prison raises certain concerns from a prison management perspective. She believes that intermittent solutions such as providing daily, weekly, or biweekly doses of medication could also be used to solve this problem.

Maryam, who was imprisoned in the women’s prison of Evin, was also imprisoned in the women’s prison of Qarchak. She refers to Qarchak as “the end of the world” and emphasizes that her mental state has rapidly deteriorated in Qarchak. She says that being visited by a psychiatrist in Qarchak was more time-consuming, with shorter and lower quality sessions, and the prescription of medication was much more compassionate compared to Evin, where prisoners were only given sleeping pills and sedatives upon request and without any medical justification. Maryam describes the conditions in Qarchak, including the significantly higher number and density of prisoners in a much smaller space, a small or dirty courtyard with inadequate sports facilities, lack of any form of entertainment inside the cell except for a few uninteresting books and a television in the middle of the cell, occasional group music playing with a CD player or watching a maximum of one movie per week, small “cabins” and lack

Maryam says that discrimination and inequality in mental illness by fellow inmates in Qarchak prison was similar or even worse than Evin prison, perhaps because of the larger number of inmates and lower quality of psychiatric services and excessive prescription of sedatives and sleeping pills. The inmates felt they had to protect each other from the systematic “pill-pushing” system in the prison – which may have been aimed at “controlling and managing” the inmates. Due to her deteriorating mental state, Maryam received a higher and stronger dosage of medication three times and was eventually prescribed Largactil, at which point the concerns of her fellow inmates reached their peak and turned into interference. Her lawyer directly spoke to her several times and warned her about the dangers of Largactil and its effects on other inmates, saying “I won’t let you become a victim.” While Maryam sees these concerns and interferences as influenced by discrimination and inequality, she also sees them as a result of mistrust towards

Maryam and Nazanin, based on their direct experience of managing mental illness in prison, both believed that special counseling and guidance should be provided to prisoners with mental disorders by the prison staff, psychiatrists, and psychologists. Simple methods such as regular medication, managing a regular sleep pattern, healthy nutrition as much as possible, regular exercise or occasional walks in the fresh air, making efforts to establish supportive friendships with other prisoners or even guards, forming small support groups among prisoners, maintaining connections with the outside world and preferably on positive and uplifting topics, avoiding getting involved in peripheral issues and internal stressors, not allowing fellow prisoners to interfere and give negative opinions about the illness and treatment process, making efforts to create and maintain recreational activities, writing daily journals, reading books or engaging in creative hobbies and activities, maintaining personal daily routines and order, regularly cleaning the individual cell or bed, and in short, anything that can give the prisoner a sense of agency and minimal control over their situation. Nazanin

Nazanin and Maryam both spoke to us about the long-lasting effects of their prison experience on their mental health, even after their release. Maryam says that one of the first and most destructive effects of this “transition”, especially for her who was transferred from Evin Women’s Prison to Qarchak Women’s Prison and then released, was the sudden severing of emotional ties with friends and fellow inmates in Evin and later Qarchak. She says, “It was very difficult to live with a group of people for months, to establish friendly, supportive, and emotional relationships with them, and then suddenly have those ties cut off when you are transferred to another prison or even released. But in any case, those strong and vital connections that were crucial for my mental health were suddenly severed and broken. The memory of saying goodbye to my friends in Evin is still painful and bitter for me, and for the first few weeks in Qarchak, I would cry almost every day

Maryam also says that despite all the stress and anxiety in prison, there was “less” need or urgency to think about fundamental life issues such as income, job, or marriage after freedom (because even thinking about these matters wouldn’t change anything for a prisoner and the focus was more on their case and the time of release). This kept her in a low-stress mental bubble. She says that after being released, she experienced heavy anxiety in the process of returning to normal life and thinking and making decisions about these issues. It is logical that this anxiety is even greater for those who have spent more years in prison, and many of them may feel that while everyone else has been moving forward and progressing, they are the only ones left behind in prison and now have to “catch up” with their lives, while the experience and stigma of prison and their “criminal record” weigh them down and make it harder for them to catch up.

Nazanin explains that a former prisoner cannot simply forget

Nazanin and Maryam both agree that the support of friends and family, talking about prison and the memories and emotions associated with it, seeking professional help, and even writing about it in a personal journal or safe online space, can be helpful in returning to a less tense “free world”.

The fourth source, Ebrahim Allahbakhshi, from his experience of 6 months of detention in the public crimes prison and what he witnessed there, as well as his experience of being close to Behnam Mahjoubi, a prisoner who lost his life in suspicious circumstances in Bahman 1399, has spoken to us.

Ibrahim says that during his 6 months in exile in the public crimes section, he witnessed the widespread and uncontrolled use of sedative, tranquilizer, and sleeping pills prescribed by the prison psychiatrist. These drugs were usually prescribed during short and imprecise visits, and were given generously to prisoners who claimed to have trouble sleeping, while other essential and simple medications such as cold or stomach pills were not available or were difficult to obtain. Every prisoner could receive high doses of sleeping pills by visiting the doctor and claiming to have trouble sleeping, mainly consisting of Largactil 100 and Clonazepam. According to Ibrahim, prisoners would “fall” minutes after taking these pills and would generally become lethargic and inactive throughout the day. The most dangerous aspect was that the distribution of these drugs was done by a prisoner who worked as a “health liaison” without any supervision from guards or prison staff, creating an environment for abuse where this liaison would give or take away medication from prisoners

It is not known what percentage of these prisoners actually had problems with insomnia or more severe psychological issues, and how many resorted to these medications for relief from the hardships of prison, escaping from intrusive thoughts and daily worries, or due to the inability to obtain drugs. What is certain is the lack of serious concern for the mental health of prisoners in this section, and the compassionate use of sedatives and painkillers for the “control” of prisoners and management of their behaviors by relevant authorities.

Although there is no precise knowledge to describe how many of the prisoners in this ward have had mental disorders, it has been observed that four patients with severe mental disorders, who had no control over their behavior and had lost their mental and emotional balance, exhibited behaviors such as screaming, aimless running, talking to themselves or imaginary objects or people, or getting into fights with each other. They were kept in a separate room called “Room 15” and eventually transferred to Razi Psychiatric Hospital (Aminabad) for treatment, with a legal medical letter. There is no information about the management of the health of these prisoners before and after their transfer to Aminabad, the conditions that led to this level of severity of illness, and how they are being kept in Aminabad.

Ibrahim says that many of the prisoners in this ward, who either truly had addiction or did not have it at all, used the free methadone allocation upon entering the prison because they did not have the ability to buy drugs that were smuggled into the prison and accessible to prisoners. Even the delivery of this allocation was used as a tool to control and manage the behavior of prisoners, meaning that in certain situations, the dosage of methadone was increased or decreased to harass and torment prisoners, or the time of delivery of methadone by prison staff was changed, leading to the deterioration of prisoners’ health and the emergence of tension in the ward.

Ibrahim says that a type of addiction-breaking pill called B-2 or “buprenorphine” was smuggled into prisons by prisoners or prison guards and used by prisoners through inhalation via the nose. Generally, the inhalation of painkillers or psychotropic drugs has a more severe and destructive effect on the nervous system and can lead to a general decline in a person’s overall condition.

Regarding the case of “Parab Cheshm” by Behnam Mahjoubi, Ibrahim explained that Behnam’s illness was not initially severe and acute. In December 2017, after losing a loved one, Behnam became anxious, stressed, and sleepless and went to see a doctor. The doctor prescribed medication and advised him to avoid stressful situations to prevent his condition from worsening and the need for increasing the dosage of medication. After Behnam was sentenced to imprisonment, the doctor wrote a letter stating that Behnam’s mental state was not suitable for enduring imprisonment. However, after the letter was delivered to the supervising judge of the prison, Mr. Vaziri, it was not considered valid. Mr. Mohammadi, the head of the execution of sentences, promised a visit by a legal doctor inside the prison for Behnam.

On the day of Behnam’s introduction for execution, he was not allowed to bring his medications inside the prison. After expressing his problem to the prison authorities, he was prescribed painkillers and sleeping pills. About a month after taking these medications, Behnam reported an increase in stress, insomnia, weakness, and numbness on the left side of his body. The doctor (outside of prison) ordered him to stop taking the medications prescribed by the prison and prescribed new ones for him. These medications were given to Behnam by the prison authorities for a while, but as soon as his symptoms improved, they were stopped and he was told to take the medications prescribed by the prison. Until this point, three months after the start of his imprisonment, Behnam had not been referred to a legal physician. After resuming the use of prison medications, Behnam had a seizure and was sent to Razi Psychiatric Hospital (Aminabad) instead of a public hospital. He was kept there

Ibrahim reports from Behnam that in his first stay at Aminabad, for the first two days, Behnam was kept in an isolated room with another patient and was restrained to the bed in a crucifix position. Isolated rooms in psychiatric hospitals are special rooms for patients who have a potential for self-harm or harm to others. This room is somewhat similar to a solitary cell, in that it contains minimal objects and the objects are designed in a way that they cannot be used to harm oneself or others. The other patient in this room suffered from severe delusions and once believed that Behnam was a “demon” and hit him with a strong broomstick, causing a tear in Behnam’s earlobe. Another time, in an uncontrollable state, the patient urinated on Behnam’s restrained body. Behnam did not even open the bed to fulfill his bodily needs or go to the bathroom, and due to lack of timely attention, he lost control of his

After two days, Behnam was transferred to the Aburayhan ward, which was specifically for patients with neurological and psychiatric disorders. The patients there were much worse off than Behnam, who only suffered from depression, anxiety, and sleep problems. In this ward, Behnam witnessed scenes of uncontrollable behavior from patients, such as fighting or self-harm in public, which had a negative impact on the mental state of even the healthiest individuals. Behnam told Ibrahim that the staff would force these patients to strip naked and take them to the bathroom, where they would mock and humiliate them and even physically abuse them. After seeing these scenes, Behnam said, “In Aminabad, I saw the decline of humanity.” According to Behnam, he was injected with unknown drugs, possibly strong sedatives and tranquilizers, which caused him to experience dizziness and loss of consciousness.

According to Ibrahim, after being discharged from the hospital and returning to prison, sending to Razi Psychiatric Hospital (Aminabad) became a tool of threat and pressure in Behnam’s case. He was threatened with being sent to Aminabad for writing a repentance letter, cutting off communication with Ibrahim, or breaking his hunger strike, especially since Ibrahim had published audio files of his conversation with Behnam about his experience at Razi Hospital (Aminabad).

After being discharged from the hospital for the first time, Behnam’s main medications (prescribed by his doctor outside of prison) were discontinued and he was given alternative medications. He once again complained of numbness in his left hand and left side of his body and initiated a 10-day hunger strike to demand his medications. Behnam’s medications were intermittently obtained and sent to him from outside the prison with permission, but even this process of discontinuing and resuming his medications had become a form of harassment and pressure.

A few days before the suspicious death of Behnam, his medication had run out and due to fatigue and headaches, he went to the infirmary for the second time. Upon insistence of the doctor, he took the prison medication and upon returning to his cell, he experienced severe weakness and nausea. The next day, Behnam was transferred to the poisoning ward of Loghman Hospital, and in the following days, while in a coma and restrained with handcuffs and leg cuffs (which were later removed after the intervention of friends and family), he passed away under suspicious circumstances that are beyond the scope of this report. The results of the autopsy, which was performed based on Behnam’s physical condition, have not yet been communicated to his family.

What is clear in the tragic case of Behnam Mahjoubi is that his mental illness (anxiety, depression, and insomnia) and the medications he was taking (Topiramate, Trankopin, Citalopram, Gabapentin, Depakine, and Pranol) were not of a nature that would require him to be hospitalized and isolated twice at Razi Hospital (Aminabad); or to result in his current state of semi-paralysis and numbness in half of his body. The worsening of his condition and the loss of Behnam Mahjoubi are a direct result of the mismanagement of his mental health and safety by the prison authorities; and a clear example of the use of mental health or illness and psychological torture for “management”, threatening and intimidating prisoners. Behnam Mahjoubi is gone; and besides regret, the only thing that can be done is to raise awareness of the role of the Islamic Republic in this tragedy and monitor

Article 40 – Prison psychologists and vocational and employment centers are obliged to, in cooperation with social workers and the Deputy for Rehabilitation and Consideration of Personal Files, examine the mental incompatibilities and abnormalities of convicts and report their findings to the Classification Council. They must take necessary actions to promote compatibility and, if necessary, provide treatment for them.

Article 41 – The responsible person for the maintenance of vocational and employment centers or prisons is obliged to collaborate with relevant experts such as a psychiatrist, physician, or psychologist to hospitalize mentally ill patients for treatment. If the illness of these individuals is diagnosed as leading to insanity or emotional disorders, the matter must be reported to the legal physician by the head of the institution or prison as soon as possible, and the judicial authorities must be informed. If necessary, appropriate legal measures must be taken for their transfer and treatment in a medical and welfare institution.