Mental Health Experiences Among Inmates Serving Life Sentences in Ghana Prisons

In Ghana, a convicted person is not entitled to parole. The only hope for their return into the community is either completing the sentence or government amnesty. However, recidivists on life sentences are completely denied the chance of returning into the community. This coupled with the demand of adjusting to the country’s prison conditions affects the mental well-being of life-sentenced inmates. This study explored the mental health experiences of life-sentenced inmates. An interpretive phenomenological approach guided the analysis of qualitative data collected from 21 life-sentenced inmates who were serving terms in three selected prisons. We employed the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases 11th Revision (ICD-11) mental disorder symptomologies to situate the participants’ narration of their experiences. The participants reported feeling sad, hopelessness, and having sleepless days and nights due to thinking about their perceived spoiled plight. They also experienced stress and were fearful of uncertainties due to perceived prison officer apathy and harsh prison conditions. Additionally, the participants resorted to drug use as a means to cope with their mental health experiences. The participants’ descriptions of their experiences were consistent with some symptomologies of mental disorders as provided in the DSM-5 and ICD-11 and call for the creation of mental health treatment services in the country’s prisons to improve the mental health of inmates.

, life-sentenced inmates face lifelong liberty deprivation, coupled with prison hardships and family neglect, and there is a need for researchers and policy makers prioritize their well-being. Butler (2019) argued that prison visitation is important for inmates' adjustment and lack of it affects the mental well-being and behaviors of inmates.
To date, almost all studies conducted on inmates' health in the Ghanaian context have looked at inmates who were serving discharged sentences-leaving a void to be filled on those serving life sentences. For example, the few studies have focused on the risk assessment of criminal offenders (Adjorlolo & Chan, 2019), psychiatric nurses' attitudes toward offenders (Adjorlolo et al., 2018), quality health care accessibility by prison inmates (Sarpong et al., 2015), HIV/AIDS, Hepatitis B and C, and syphilis infections among inmates (Adjei et al., 2008), and mental health legislations of offenders standing trial (Adjorlolo et al., 2016). These studies in the Ghanaian context, although significant contributions, have still left questions on inmates' mental health experiences unanswered.
A study conducted by Ibrahim et al. (2015) was the only peer-reviewed study that focused on inmates' mental health in Ghana. However, Ibrahim et al.'s quantitative study highlighted the prevalence of mental health disorders among inmates in a prison facility in Ghana, but without specific coverage of life-sentenced inmates. To date, the question of what contributed to their mental health experiences, especially for those serving life sentences, is yet to be answered. The current study, however, will build upon Ibrahim et al.'s work by broadening and deepening the knowledge base through a qualitative study that explored the mental health causes and experiences of 21 lifesentenced inmates in three prisons in Ghana. This study is therefore needed to enhance the understanding of how life-sentenced inmates experienced mental health and to put their experiences into perspective by interpreting them within the spectrum of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases 11th Revision (ICD-11) mental disorder symptomologies (American Psychiatric Association [APA, 2013]; WHO, 2019). This will broaden knowledge and guide policy interventions on life-sentenced inmates' mental health in Ghana.

Method
Data presented in this study were obtained from three prison sites in Ghana, West Africa. Ghana is a nation that shares boundaries with Burkina Faso (North), Togo (East), Cote d'Ivoire (West), and the Gulf of Guinea (South). According to the Ghana Statistical Service (2019), Ghana's population is estimated at 30,280,811 and has an incarcerated inmate population of 15,203 (World Prison Brief [WPB], 2019). The 43 prison facilities around the country, however, only have a collective capacity to house 9,945 inmates (WPB, 2019), thereby creating an overpopulation of 5,258 inmates. This present study focused on collecting data from inmates who were serving terms at the maximum prison at Ankaful, the Medium Security Prison at Nsawam, and Kumasi Central Prison, a minimum security prison.
These specific prison facilities were selected for this study because they provided a crosssectional sample of inmates incarcerated in the three main security levels of correctional institutions in the country (maximum, medium, and minimum). The three prison facilities are scattered in three different regions (Ashanti, Central, and Eastern) of Ghana. In the Ashanti Region, the central prison is located at the regional capital in the central business district of Kumasi, opposite the Ashanti Regional Police Headquarters. The maximum security prison is situated on the outskirts of Ankaful, adjacent to the psychiatric hospital in the Central Region. The medium security prison in the Eastern Region is located at Nsawam Township on the Nsawam-Accra Road.
This present study is phenomenological in nature which encourages researchers to uncover the lived experiences of the participants through the use of a qualitative methodology (van Manen, 2017). Thus, a phenomenological qualitative design is a particularly suitable framework to employ when attempting to elicit the deeply personal experiential narratives of mental health issues among inmates (Bevan, 2014). In Ghana, mental health expressions such as trauma, depression, schizophrenia, anxiety, and the like do not have direct local meanings. For example, a person experiencing recurring distress or unhappiness that may be due to a past traumatic experience will simply narrate his or her condition as feeling sad. Even though this could be a symptomology of either depression or anxiety (WHO, 2019), it will not be referred to as such in local expression. However, these are all complex medical concepts that include an equally complex array of symptoms that the prison inmates may not be conversant with.
As such, it is unreasonable to expect the inmates to be able to articulate their mental health conditions in such terms. Consequently, a methodology that was sensitive enough to facilitate communication of such deeply personal mental health afflictions was needed. One that would facilitate the recounting of vivid expressions and interpretations of what they were experiencing-fear, hopelessness, trauma, and stress (Creswell, 2007). Using a phenomenological approach, participants were asked to describe their experiences and how they impacted their mental well-being (van Manen, 2017). The results of the study are from the perspective and the meanings the participants make out of their experiences (Frechette et al., 2020).
When the present study received approval to proceed from the GPS (the institution that manages prison and inmates' well-being in Ghana) as well as from James Cook University's Human Research Ethics Committee, qualitative data were then collected using individual in-depth interviews and field observations. The study purposively sampled and collected data from 21 (after reaching saturation) consenting male participants who (1) were serving life sentences and (2) had previously served two or more terms in any Ghana prison. This category of inmates was considered appropriate because during the first author's initial field observation and interactions with life-sentenced and nonlife-sentenced inmates, the former was more concerned about their missed opportunity to protect their perceived damaged plight (the perception that imprisonment had damaged their identity) and their inability to return into the community to redeem it. Additionally, we focused on life-sentenced inmates because there is no existing study in the Ghanaian context that has explored their mental health experiences. Further, as they were going to spend the rest of their life in a prison where there is no psychiatric service (Afari et al., 2015) made them more suitable to provide data that addressed the purpose of this study, to explore the mental health experiences of inmates serving life sentences.
Using this inclusion criteria, we selected seven participants each from the Kumasi Central Prison, Ankaful Maximum Security Prison, and Nsawam Medium Security Prison. The age of the participants' sample ranged from 24 to 43 (with the median age being 33.5). Thirteen of the participants had been previously imprisoned from between four and 11 occasions, while the remaining eight had served between two and three prior prison sentences. The participants who were provided with the following pseudonyms: Adam, Adoma, Adu, Akwasi, Ali, Ansa, Appiah, Atta, Fiifi, Kubi, Kwabena, Kwadwo, Kwaku, Kwame, Oman, Onana, Oti, Owu, Patey, Tutu, and Yaw were asked various questions about their mental health experiences, included queries like: (1) Do you think about your sentence and why? (2) If so, how does that make you feel? (3) How did you feel when the judge made the pronouncement that you were going to serve the rest of your life in the prison? All of these interviews were conducted in the Akan language (a dominant Ghanaian language). The duration of interviews ranged from between 1 hr and 1 hr 17 min, and they were audiotaped with the consent of the participants. These interviews were informed by the first authors prior field observation over a period of 3 months. Things that were observed during this period included prison conditions and participants' day-to-day behaviors and actions in the prisons.
To ensure rigor throughout the process of this study, reflexivity during data collection and analysis was prioritized. Even though we acknowledged our biases and presuppositions, we remained conscious throughout data collection and analysis and conducted ourselves in a way that ensured that the data presented for this study reflected the original views of the study participants (Jewkes, 2014). In doing so, after the data had been collected and analyzed by the first author, the original data and analysis were sent to the other authors where a meeting was held to discuss the rigor of the process and whether the themes generated for the study were representation of the original data. In addition to the coresearchers' debriefing, we ensured external peer debriefing where the process and findings of the study were presented at the James Cook University College of Art, Society, and Education's annual students conference in front of larger audience from different disciplines. The contributions and criticisms from experts in the field and nonexperts were addressed to ensure that the findings were credible. Additionally, the researchers employed a triangulation of different data collection methods (interviews and field observation; Williams & Morrow, 2009). Given the emotionally sensitive nature of the subject matter, more time was spent with the participants before the interviews and during the observation phase so as to build rapport between the first author and the participants. The rapport was established to increase the likelihood of more forthcoming and candid interviews, as well as a reduced likelihood of "staged responses" on the part of the participants.
In this study, the definition of mental health was adopted from the DSM-5 (APA, 2013) and ICD-11 revised (WHO, 2019) classification of mental disorders. As a result, we describe mental health difficulties to include any significant disturbance in an individual prisoner's behavior that undermines the effective functioning of his psychosocial functioning and usually causes the feeling of distress, which impedes personal and interpersonal functioning. Given that this study did not set out to conduct a clinical assessment of the inmates, using the DSM-5 and ICD-11 helped us to provide sufficient precision to the symptoms described by the participants and what they meant for example, by feeling sad, hopeless, distressed, and fear.

Data Analysis
An interpretive phenomenological analysis was employed to examine the qualitative data that were produced from this study. It allowed for a more critical and nuanced examination and interpretation of how the participants made sense of their experiences of mental health and subsequent rigorous interpretation to enhance understanding of data (Smith et al., 2009). Such an interpretive phenomenological analysis has been profitably used by other scholars when attempting to better understand the mental health experiences of participants (Albert & Simpson, 2015) and has been touted as appropriate when studying lived experience (Finlay, 2011). This lies in its ability to allow the researcher to analyze and make meanings out of how the inmates' past and present experiences influenced their mental well-being (Conroy, 2003). In addition, given that it was beyond the scope of the study to conduct a clinical assessment on the inmates, we relied on interpretation of their experiences (symptoms) to suggest how consistent they were with a particular mental health complication.
Transcription of data was time-consuming because interviews were conducted in the Akan language. This therefore required a careful and slow translation of the audio recordings from Akan to the English language. To limit data loss due to this translation process, the original audiotape had to be listened to several times before and after the transcription was done. To further improve upon the accuracy of the translated transcript, both the audiotapes and the transcripts were given to a local high school language tutor (who was fluent in the Akan and English languages) to compare them for consistency and quality of translation (as recommended by Stewart et al., 2017). Further, field notes taken through observation were transcribed and used to complement the interviews during data analysis. The four protocols of interpretive phenomenology analysis were then applied in the following way (Smith et al., 2009): (a) multiple readings of and writing down notes from the transcripts, (b) transforming the notes into initial themes, (c) seeking out relationship and grouping the themes, and finally (d) writing-up.

Results
The phenomenological analysis of the data (interviews and observations) produced one overarching theme: mental health experiences of life-sentenced inmates and three subthemes: (1) difficulties coping with prison hardships, (2) constantly thinking about their plight-causing sleepless nights, and (3) lack of mental health services and substance use and suicide attempt. The themes reflected the first author's field observation, and participants' narratives of how their perceived damaged plight and prison conditions have brought about symptoms consistent with mental health issues such as depression, anxiety, and addictive disorders.

Exploring the Mental Health Experiences of Life-Sentenced Inmates
The 21 participants' narrations of their experiences were consistent with some symptoms of mental disorders. For example, expressions such as thinking too much, always feeling sad, I struggle to sleep, I am afraid of what will happen next, and I rely on weed to cope with my worries are symptoms that are consistent with depression, anxiety, or substance addictive disorders as stipulated in the DSM-5 and ICD-11 (APA, 2013; WHO, 2019). It is important to state that all the inmates perceived that their current symptoms started manifesting and recurring after they had received their life sentence. While some of the participants answered succinctly that their mental health experiences were unique to their life sentences, others took the opportunity to explain why their previous sentences did not give them a lot of reasons to worry or feel sad. Patey, in particular, explained: I have been to the prison before, but at the time I consoled myself that I was not going to stay here forever . . . this time is different; when I think about the fact that I am not going home again, that alone keeps me awake all night and leaves me to think.
Another participant, Tutu, explained: All the time I came to the prison I did not spend more than one year, so I did not feel it-this time I am not going to spend 2 or 5 years, the rest of my life will be spent as a prisoner . . . this is something I am struggling to control and the reason I tried to kill myself during the early days of this sentence.

Exploring How Difficulties Coping With Prison Hardships Affected Inmates' Mental Health
Feeling of stress. It is certainly arguable that prison conditions in Ghana are indeed harsh and challenging (Ibrahim et al., 2015). This therefore is a constant source of worry to the participants when they think about how such a lamentable and disheartening environment is going to be their home for the rest of their lives. The prisons are overcrowded, which results in insufficient resources being allocated to the inmates, including medical and psychiatric services. The field data and observational notes revealed that the inmates were provided insufficient food and were living in areas with poor sanitation and sleeping facilities. In this condition, coupled with knowing that they were being imprisoned for life, the participants expressed how significant their levels of stress were. Atta explained how: The environment alone makes you feel stressed out, in the afternoon the prison is crowded, and in the night, it is worse. There is nothing in this prison that will keep you engaged; we spend all our time doing one thing, which is staying in the cells. This is what I have been doing throughout my time here and now it is more stressful than ever-I am not okay.
International Criminal Justice Review 32 (1) The poor prison conditions appear to compound the participants already vulnerable state of mental health. As Kwadwo acknowledged: I am serving a life sentence, which is very difficult to take, but I think my situation will be better if the prison is good for humans to live in. You get worried anytime you think about where we sleep, the food they give us and those who are very sick and there is no one to care for them.
Fear of the uncertainty. In addition to their feeling of stress, most of the participants were living in fear. Occurrences such as a sudden death of a fellow inmate instilled excessive fear among the participants. The participants became traumatized after witnessing disease outbreaks that had claimed lives in the prison. Further, the way the dead were treated in the prisons compounded the participants fear by making them perceive the prison authorities as being apathetic and uncaring. For example, Patey explained that: I have witnessed disease outbreaks that led to a lot of deaths among inmates. That time was very difficult; you wake up in the morning and you see a fellow inmate being wrapped in the blanket to be taken to the cemetery . . . I felt the prison officers were not concerned and this makes me think about what will happen to me in the next morning.
Thinking about the unknown instilled excessive fear among participants, with some of them revealing in their interviews that they feared for their lives. Fear thus became a recurring and major discussion topic during the interviews. Oti disclosed: I am afraid for my life because in this prison everything is possible, you can die at any time . . . everybody has in mind that his or her life is not important to the officers. What happens to us is nobody's business . . . if you have witnessed how they wrap the dead it is a pitiful and heartbreaking. This constant fear for one's life significantly impacted upon the quality of sleep among the participants, and Kwame noted how: Here a lot of us sleep to death, in the morning when it is time for us to wake up some will not-they are dead. These people I am talking about were very active the night before, this makes you fearful that you can also die in your sleep. There are times I have tried not to sleep because I felt I will die before the next day.
Another participant explained how the death of his best friend has become something he cannot forget and has left an indelible memory over the years. Kwaku sadly disclosed: I witnessed the death of my friend and it has left me to think about it all the time. It puts fear in me and sometimes I dream about him more than twice in a night-these dreams come and go but when it comes, I cannot do anything but to become overly concerned about my life.
In addition to witnessing the death of a fellow inmate, the participants narrated experiences of getting frightened and anxious over a relatively trivial issue. According to one of the inmates, a fall of an item and unexpected shout by an officer or fellow inmates cause him to experience intense panic that may take days to get over: "I get frightened easily and I know it is not normal-this started a few months into this sentence, a little noise and shout get me feel frightened for days or weeks to get over" (Kubi).
The field observation notes confirm the issue raised by the participants about the harsh conditions that the inmates were living in. At the Kumasi Central and Nsawam Medium Security Prisons, there was evidence of congestion as there were more inmates than the prisons' capacity. During the time of data collection, the daily updated total inmate population including those awaiting trial was displayed on the main notice board at the Nsawam Medium Security Prison. It was always above 4,005. Given that the prison was originally established to accommodate not more than 700 inmates, the excess could create congestion and may cause stress among the inmates. In addition to this, the first author witnessed an inmate who appeared to be sick and a follow-up with some of the inmates revealed that he had been unwell for weeks without any medical intervention or response from the prison officers. Conditions like this, coupled with the participants' status as life-sentenced inmates, were perceived to be overburdening and may give the participants reasons to fear for their lives.

Constantly Thinking About Their Plight
Having a prison record in Ghanaian society is an indelible stain on an inmate's reputation and tarnishes an individual's image and self-esteem. However, inmates find solace in the fact that they will be discharged back into the community to make amends by behaving in a socially acceptable way. While a majority of inmates expect to go back into the community at some point in their lives, others have to adjust to spending the rest of their lives behind prison walls. As a result, the participants of this study were constantly thinking of their plight (there being no reprieve and redemption in sight), which increased the likelihood of them feeling sad, hopeless, and having sleepless nights. These lifesentenced inmates faced significant problems in adjusting to the thought of a lifelong stay in prison and the negative reactions from their families and friends when they visited them at the prison (or, when family and friends refused to visit them at the prison because they were ashamed). The pervasive reason behind the participants' constantly thinking about their plight was their inability to return to their community to correct what had led to their imprisonment. For example, Oman explained that: Most times what I do is to think, think, and think-I feel I have let my family down, after my first release from the prison, I thought coming back to prison will be the last thing that will ever happen to me . . . now I find myself here again and this time I am not going home again . . . I cannot change anything in my community, I am going to spend the rest of my life here and this leaves me thinking all the time.
Feelings of sadness and hopelessness. The participants found it extremely discouraging to realize that the rest of their lives will be spent in prison. This led to the inmates indulging in even more thoughts about their plight. For example, Adu noted: Now I am serving a life sentence and it leaves me to think all day. It is very sad to wake up, only to think you will never step foot outside the prison again. It is something I am trying to get over, but you know it is not easy.
Some of the participants also found it difficult to adjust to their new situation as a life-sentenced inmate-because they had unsupportive family members who were ashamed of them. According to some participants, their family members were intolerant of their imprisonment. In Ghana, the imprisonment of a family member can lead to stigma and discrimination directed at other family members. Such family members disassociate themselves from the offender and offence by publicly expressing disavowal. In this study, some of the participants' family members went to the extent of disowning them due to their imprisonment. This negatively affected the inmates and resulted in them feeling sad and distressed. As Kwabena said: Knowing that I was going to serve the rest of my life in the prison has not been easy . . . the other side that makes me feel sad the most has to do with my family-my uncle came here to fuel my problems by letting me know that they will have nothing to do with me again . . . I have been in the prison for almost 20 years, all these years I have not set eyes on any family member, not even my own siblings.
Akwasi, another participant, likewise had a similar experience and stated that: I have been here for the past 10 years-none of my family members, not even my wife and children have visited me during this time. I struggle to survive, and everything seems not to go on well with me here . . . I used to be big in size, but look at me, I am now very lean and always decreasing in size, and this leaves me thinking and feeling sad all the time-you have no hope of going back home.
In addition to the pervasive feeling of sadness, some of the participants said that they had lost hope in life. As Yaw lamented: Appiah, another participant narrated how he developed and lost interest in playing and watching soccer which used to be his favorite sport. He explained: During the early days of my sentence I developed a keen interest in playing football . . . I was the first to be on the field and when people were not coming, I will go to each of the blocks and call others to join me. For some time now, I don't even enjoy watching it-I do not feel like I used to . . . I don't enjoy spending every minute of my life in the prison, I feel sorry for myself all the time and I am longing to go home again, even though it might never happen.
Sleepless nights and days. In addition to feelings of sadness and hopelessness, the participants expressed their inability to sleep during day and night. The pervasiveness of their sadness and hopelessness that resulted from excessive thinking of their plight was not a short-term malady, but rather it continued and made them struggle to have a good sleep. Adoma acknowledged that: Sometimes I think I am stressing myself too much by thinking all day and night. I struggle to have a good sleep during that day and night-this has continued for years and I can see that it has given me a lot of health problems. Some of the participants actually attributed their excessive thinking and sleepless nights to the poor conditions they have had to endure in the prisons. For example, Onana questioned: How can you be happy if you are spending the rest of your life in this condition? This place is not good for us-sometimes you tell yourself that the thinking is not going to reduce the sentence, but you quickly get reminded by the hardship here and you realize there is nothing you can do than to think and find a way to console yourself. The place we sleep is not good-in the nights we are packed like canned fish and we have got no fan. You cannot sleep in the night, but to stay awake and think.
The above findings are supported by the observational field notes. The first author witnessed three of the inmates crying on different occasions (one at the Kumasi Central Prison and two at the Nsawam Medium Security Prison), who subsequently became participants of this study. On those instances that I saw them, they appeared to be worried about their situations. During the interviews, one of them revealed to me how he had lost hope in life due to his current status and attributed his weight loss to his sleeping difficulties over the years. A majority of the participants looked tired and stressed which they attributed to their sleeping difficulties. At the Kumasi Central Prison, Yaw, one of the participants dozed off twice in less than 20 min into the interview. When I asked him to go and get some rest so we can continue with the interview the following day, he replied: "No! let's continue, I sleep well when I don't mean to, if I go and lie down the sleep will never come again."

Lack of Mental Health Services and Substance Use and Suicide Attempts
In this study, due to lack of mental health services in the prisons, the participants were made to deal with their experiences by themselves. For example, Adam lamented: "There is no clinic here; when you are not feeling well, you find a way to deal with it." In fact, some of the participants suggested that a majority of the inmates were experiencing significant mental health disorders but have been left untreated. For example, Ansa tragically recounted that: I know people who came to meet me in jail and died after few weeks of their stay here. They couldn't cope with the hardships in the prison; a lot of the inmates are mentally ill in the cells-their conversations are not on point, if you talk to them, they give wayward answers; answers that do not have anything to do with what you asked them. Some spend all their time at the lavatory, picking trashes like a mad person.
Some of the participants who were experiencing significant stress levels resorted to abusing substances as a coping mechanism. This would naturally further impair their mental health experiences. Owu disclosed that: This is my great secret, but to the inmates who have been here for long it is not a secret. During the early months of my sentence I was relying on marijuana . . . the cells were too hot for me and I was convinced by other inmates that smoking marijuana will make me have a good sleep-I started smoking and, on several occasions, I was found by the officers and other inmates talking to myself and hoarding rubbish . . . most of the time I could feel somebody was talking to me and I became aggressive to deal with. I was fighting other inmates and became troublesome . . . the officers locked me up for more than a month on several occasions . . . through the church service and the help of the pastor I stopped smoking and now there is a major change in my behaviour.
Owu continued by explaining that: There are a majority of inmates who abuse drugs. If you go to the backyard you can count more than 200 inmates. A majority of the guys there who smoke can be very aggressive to deal with and when a fight breaks out among them it becomes violent and difficult for the officers to even calm them down.
Fiifi, another participant explained how he became addicted to cannabis and sedatives which he is struggling to quit: Even though I used to smoke when I was at home, I had never smoked in the prison during my early sentences. For this current sentence, I was able to stay in this prison for 3 years without smoking, I could not resist it anymore because I thought smoking was going to help me manage my problems-now I am struggling to stop; if I don't get it in large quantity to smoke I started to shiver and become aggressive.
Fiifi continued by making a request: Now when I do not have money to buy the weed or when they are in shortage I have to stick to tramadol or blue-blue to get high and prevent myself from shaking and behaving badly . . . initially, I was using with the intention to overcome my problems but I have rather invited a more difficult one in the smoking-I want to stop and will be happy if you can help me.
Even though the majority of the participants showed a lack of interest in responding to past or present substance use and related experiences questions posed to them by the researcher, field observational notes support Owu's claim that some of the inmates were using substances in the prison. This was confirmed when one of the participants who I was interviewing clearly smelled like he had smoked an illegal substance and was under the influence of an illicit drug. For any question that I asked him, he initially responded on top of his voice and lowered his voice until I could not hear a word but saw him miming on his lips. This continued and so we had to end the interview and continue the next morning where he admitted that he had been "high" the previous day and was not aware of anything that went on.
Suicide ideation and attempts were additional serious issues that were raised by the participants. Some became overly concerned about their plight which led to them thinking too much, feeling stressed and hopeless, and experiencing difficulty sleeping. With no access to services that could help them address their experiences, many of the participants who could not cope with their situation considered suicide as a remedy to their situation. Adam, in particular, explained: After the judge told me that I was going to spend the rest of my life in the prison, I have never been the same. Sometimes, I feel like ending it all . . . at the early days of my sentence, I tried to kill myself more than twice. One of them resulted in me being in the hospital for days and now I feel pain in my tummy all the time.
Other participants indicated they thought about it too but did not follow through. In this study, almost all of the 21 participants had thought about committing suicide at some point in their life sentences. Nevertheless, most of the participants revealed their resilience and hope for the future and that this made them think twice about committing suicide. Ali noted how: At one point, during the early days of my life-sentence, I thought about killing myself . . . at the time I told myself that to spend the rest of my life living in the prison, it is better to die than spending the most part of my life in the prison . . . I gave it a second thought and I always console myself that life is priceless, and you would not know what will happened tomorrow.
Another participant narrated how hope for a change in his situation prevented him from committing suicide. Tutu described how: Earlier I thought of ending my life, but I reflected on it for some time . . . I came to the realization that there is the possibility that my situation will change. I know a guy who was in the condemned block, after filing for an appeal he got his sentence reduced and he was discharged later-this increased my hope that if I get somebody to help me file for an appeal my situation too may change.

Discussion
The findings presented above have illuminated the mental health experiences among lifesentenced inmates in selected Ghana prisons. Using the DSM-5 and ICD-11 mental disorder definitions, the participants' narrations of their experiences appeared to show some consistency with classified mental disorder symptoms such as depression, anxiety, and substance-related and addictive disorders. The participants' narrations of their mental disorders revealed a continuous feeling of sadness and sleepless nights and days due to their excessive thinking about a perceived damaged plight. The fact that they were living in harsh prison conditions had resulted in the feeling of stress and fear for one's life. The findings have therefore demonstrated the impact that life sentence and untreated mental health complications may have on the participants. Immediate policy interventions are needed to address mental health difficulties among this population of inmates.
Even though we anticipated that the prison conditions could affect the participants' mental health experiences based on the first author's preliminary observational field notes, we did not anticipate the role their plights might have played. The participants constantly related their feeling of sadness and hopelessness to excessively thinking about their plight. This finding on how perceived damaged plight contributed to participants mental health experiences is novel and illuminates the need for bringing all stakeholders together especially the community to address mental health issues among prison inmates.
Early studies have reported experiences of mental health issues among life-sentenced inmates (Fedock, 2018;Leigey, 2010). In this study, the uniqueness of our findings has been reinforced. For example, Leigey's (2010) study showed that when a person was given a life sentence it led to a negative effect on inmate's mental health. In this study, even though the life sentence played a part in the participants' experiences of mental health, there were other major mediating factors such as harsh prison condition, neglect by family and friends, and damaged plight (due to their inability to return to their communities to correct what had let to their imprisonment). This finding may largely be due to the nature of the Ghanaian context where the (extended) family prioritizes communal living and places a significant emphasis on reciprocity and holds members accountable for their behaviors (Agyemang et al., 2018).
In Ghana, a life sentence deprives inmates the liberty to return to their communities. The only hope for a life-sentenced inmate to have physical contact with family and friends was through prison visitation. However, due to the stigma attached to the prisons in Ghana, family and friends openly disowned their members as soon as they received prison sentences (Dako-Gyeke & Baffour, 2016). The double jeopardy (spending the rest of one's life in a harsh prison condition and participants' inability to return to their respective communities to redeem their image) of life-sentencing became unbearable, leading inmates to think too much. Participants felt disappointed and considered themselves as useless due to their inability to return and contribute to the development of their communities and right their wrongs. These and other factors such as harsh prison conditions and a perceived prison officer apathy made the participants think during days and nights. Consequently, they felt sad, distressed, and struggled to have better sleep during day and night. Similar findings have been reported by Leigey (2010). Chong and Fellows (2014) explained that prison conditions that are suppressive and emotionally draining negatively impact inmates' mental health.
Moreover, previous studies in other jurisdictions have observed the negative impacts that prison hardships may have on inmates' mental health (Dye, 2010;Haney, 2017). In this study, prison hardships in the selected prisons had created unbearable scenes-causing fear among the study participants. Among these scenes were sudden deaths and poor burial arrangements of deceased inmates. Some of the participants lamented that they got frightened and overanxious by relatively trivial issues. Inmates expressed a lasting development of fear for their lives, which sometimes prevented them from having a decent sleep in the day and night due to the fear of dying in their sleep.
While the study did not set out to look at the mental health treatments available in the selected prisons, observational field notes, and the participants' responses revealed that there was no structured intervention designed to address mental health in the prisons. In fact, the participants had to deal with their mental health experiences by themselves. The explanation to this finding could be traced to a 2017 study by Walker and Osei (2017) who reported that mental health service accessibility for the general public is insufficient. As supported by our findings, specialized mental health services are nonexistent for vulnerable groups in Ghana: inmates included (Roberts et al., 2014). The Lancet Commissions' report (Patel et al., 2018) stated that mental health funding in developing countries, including Ghana, was less than 1% of national health budgets. The report further added that the funding is distributed to the main mental health hospitals, leaving institutions such as the prison with no financial allocation. The lancet report was consistent with the MoH's (2013) report which highlighted that Ghana was spending US$0.12 on each mental health patient. This was the lowest among the 42 low-and middle-income countries that were compared. Unlike physical ailments, mental health within the general community does not receive the same level of institutional support and attention from governments (Patel et al., 2018). Hester (2017) explained that untreated mental illness intensifies mental health conditions and eventually increases the occurrences of suicide ideations and attempts. Therefore, given that the participants were made to deal with their experiences of mental health issues by themselves due to the lack of a structured mental health service in the prisons, there is an urgent need for policy intervention. In effect, the study has provided initial information on inmates' mental health when serving life sentences and seeks to create awareness and influence policy outcomes that will be aimed at remedial measures.

Policy and Program Implications
The analysis of the life-sentenced inmates' experiences of mental health has illuminated the magnitude of one of the challenges confronting inmates in Ghana's prisons. The study has highlighted four significant problems that mediated mental health experiences among the participants: (1) poor prison conditions, (2) family/friends neglect and perceived damaged plight, (3) lack of mental health treatment (lack of psychiatrics in the prisons), and (4) drug use among inmates.
For this study to yield the anticipated impact and improve the well-being and living conditions of life-sentenced inmates, we have suggested these policy recommendations. First and foremost, in the short term, the GPS should enforce the Prisons Regulation 134 (1) which mandates the service to ensure that at least a medical officer (psychiatrist) visits each prison facility daily to respond to inmates physical and mental health needs. We believe that due to overcrowding and inadequate medical facilities in the prisons a full implementation of this legislation will be difficult. However, given the findings of the current study, there is the need for mental health services for those with a life sentence to better serve the challenges they face.
We suggest that, in the long term, the GPS should create a prison mental health treatment service department that prioritizes inmates' mental health needs. In order to prevent the escalation of mental health experiences that may result from lack of identification, the study recommends that the GPS prioritize inmates' mental health by establishing mental health treatment departments in the country's prisons. The department should recruit psychiatrics, social workers, and psychologists who will be tasked with the responsibility of early identification and treatment, and when necessary refer mental health cases in the prisons. This may ensure proper management of mental health issues in the country's prisons.
Create drug treatment services in the selected prisons. In this study, a majority of the participants resorted to illicit drugs as a coping mechanism. There is the need for the GPS to introduce drug treatment program that will help inmates serving life sentences to manage their addictive challenges. Counseling service must be directed at life-sentenced inmates to serve as remedial measures.
It is further recommended that GPS create aftercare units in the prison facilities. The aftercare unit must be resourced to ensure a proper liaison between the prions, life-sentenced inmates, and their families. Doing this will help demystify imprisonment and encourage families to stick with their wards during incarceration. Further, this will encourage prison visitation where life-sentenced inmates may fulfill their desire to reunite with family and friends and restore their perceived damaged plight.

Limitations and Recommendations for Future Research
This study was not intended to provide a clinical diagnosis of mental health conditions, therefore, application of the findings must be done with care since some of the descriptions, when gone through a clinical text, might not accurately match the mental health conditions as provided in the DSM-5 and ICD-11. The study focused on life-sentenced inmates who were recidivists. Therefore, the findings cannot be generalized to cover the experiences of other prison populations. Nevertheless, the evidence provided for the study took account of the cultural context that influenced participants' experiences of mental health in the selected prisons, which could enhance transferability on the part of readers (Li, 2004).
Further, due to financial constraints, the researchers could not go back to the participants in the various prisons to confirm the accuracy of the voices presented in this study. Consultation with the study participants could have increased the validity of analysis and the presentation of results. Additionally, given that some of the inmates' statements were about the community and prisons' management, seeking the prisons administrators' and community members' views would have provided additional insights for the study.
Based on the above limitations, and for effective consideration and implementation of the policy recommendations outlined in this study, future research that will provide broader scope of lifesentenced inmates is needed. As a result, researchers need to conduct a similar qualitative study as the current one but focus on identifying what prison-based strategies would be useful for improving the mental health experiences of life-sentenced inmates in the Ghanaian context. Other studies should look at the impact of prison conditions and prison visitation on life-sentenced inmates' mental health experiences. There is also the need for a clinical diagnostics study of inmates' mental health. Last but not least, future study should investigate the coping strategies adopted by lifesentenced inmates to deal with their experiences of mental health issues since there is currently no such study conducted in the Ghanaian context. The researchers believe these recommended studies if undertaken will provide a broader information regarding life-sentenced inmates' mental health and comprehensive policies needed to address it.

Conclusions
The findings of the study have demonstrated the poor mental health among life-sentenced inmates in three selected prisons in Ghana. The life sentence gave the participants no hope of returning to their respective communities and this, coupled with poor prison conditions, affected their mental well-being. WHO's (1999) report on prison mental health promotion highlighted the need for state parties to pay attention to inmates' mental health. This is due to the high psychological distress associated with the deprivation of a person's liberty during incarceration. In this study, aside from the psychological distress that comes with a life sentence, other issues that contributed to affect the mental health of the participants were harsh prison conditions, family neglect and perceived damaged plight, drug use by inmates, and lack of psychiatrists-leading to a lack of identification and treatment of inmates' mental health difficulties.
The issues identified above as the antecedents to mental health among the participants are crucial to their well-being and fundamental human rights and calls for immediate intervention by stakeholders. Locally, the Kampala Declaration on Prison Health and conditions in Africa (1996Africa ( , 1999, and internationally, the United Nations Office on Drugs and Crime (n.d.) on the standard minimum rules for the treatment of prisoners underscore a conducive prison environment that promotes inmates' welfare and well-being. Ghana as a signatory to the above declaration and convention needs to maintain decent accommodation for its prison inmates and improve mental health care