This study examined psychiatric diagnoses and substance abuse disorders in 109 male prison inmates in Washington State. Nearly all (88%) inmates received at least one psychiatric diagnosis, which was much higher than rates in the general population. The most common diagnoses were antisocial personality disorder, depression, and dysthymia. Substance abuse disorders were very common among inmates, with 92% of those with antisocial personality disorder and 82% of those with depression also having alcohol or drug abuse diagnoses. Substance use was reported during incarceration by inmates with substance abuse disorders.
This study examined psychiatric diagnoses and substance abuse disorders in 109 male prison inmates in Washington State. Nearly all (88%) inmates received at least one psychiatric diagnosis, which was much higher than rates in the general population. The most common diagnoses were antisocial personality disorder, depression, and dysthymia. Substance abuse disorders were very common among inmates, with 92% of those with antisocial personality disorder and 82% of those with depression also having alcohol or drug abuse diagnoses. Substance use was reported during incarceration by inmates with substance abuse disorders.
This study examined psychiatric diagnoses and substance abuse disorders in 109 male prison inmates in Washington State. Nearly all (88%) inmates received at least one psychiatric diagnosis, which was much higher than rates in the general population. The most common diagnoses were antisocial personality disorder, depression, and dysthymia. Substance abuse disorders were very common among inmates, with 92% of those with antisocial personality disorder and 82% of those with depression also having alcohol or drug abuse diagnoses. Substance use was reported during incarceration by inmates with substance abuse disorders.
Brief Reports to make a diagnosis for each subject
aslong as the number of interviewers pen subject remains the same. A high level of internater reliability was found: .71 for dysthymia; .86 for al Substance Abuse and Psychiatric cohol abuse on dependence; .91 for depression; and 1.0 for drug abuse Disordersin Prison Inmates and dependence, mania, schizophre nia, schizophreniform disorder, and antisocial personality.
John A. Chiles, M.D. entering the Washington State pni Results
Elizabeth Von Cleve, Ph.D. son system. A total of 109 male of Psychiatric diagnoses.Ninety-six Ron P. Jemelka, Ph.D. fenders were interviewed. The study of 109 offenders in this study (88 Eric W. Trupin, Ph.D. was conducted in accordance with percent) received at least one psychi the institution's policy stipulating atric diagnosis. The prevalence of The numberofmentally ill offenders that inmates must give informed each diagnosis in the sample, shown in prison has risen dramatically oven consentto participate in any research in Table 1, was compared with life the past decade. Reasons for this in activity. time prevalence rates for the general crease include a drop in the number To determine if the sample was population available from recent of long-term psychiatric beds, de representative of the Washington literature (7,8). Although statistical creasing community support, and State inmate population, the group comparison between the data sets rigid criteria for civil commitment who were interviewed were corn was not possible, the prevalence of (1). In addition, certain character pared with a larger sample of 1,409 each diagnosis was higher in the of istics that are prevalent among men consecutive admissions to the necep fender group than in the general tally ill individuals increase the like iion center. No significant diffenenc population. Compared with the gen lihood of incarceration. These char es between the groups in age, eth enal population, offenders were five actenistics include use ofillicit drugs, nicity, marital status, offense, on IQ to 30 times more likely to be given failure to continue in treatment, and were found. In addition, no differ one of the psychiatric diagnoses violent behavior (2). Substance ences between groups were found in listed in Table 1. These results sup abuse among the offender popula scores on the Minnesota Multiphasic port the hypothesis that rates of the tion has beenwell documented (3,4). Personality Inventory, the Buss psychiatric illnesses studied are high The nature and extent of substance Durkee Hostility Inventory, the Sui en in an offender population than in abuse among the subpopulation of cide Probability Scale, the Veterans the community (1). mentally ill offenders have not been AlcoholScneeningTest,onthe Mon Substance abuse andmental ill as thoroughly explored and are the roe Dyscontrol Scale. Individuals ness. The prevalence ofchemical de subject of this report. who show extremely violent on psy pendency in inmates with a psychiat chotic behavior are sent directly to a tic diagnosis is reported in Table 1. Methods prison psychiatric ward. Thus in Symptoms of alcohol or drug abuse Subjects. Interviewers solicited vol mates with severe psychiatric distur on dependence were reported by 92 unteens for the study from among bance are probably undenrepresent percent of the inmates with antiso inmates at the Washington State ed in the sample discussed in this cial personality disorder and by 82 Corrections Reception Center, the paper. percent of the inmates with depres initial site of incarceration for more Measures. Responses to ques sion. All offenders with a diagnosis than 95 percent of male prisoners iions on the Diagnostic Interview of schizophrenia, schizophrenifonm Schedule (DIS) (5) were used to de disorder, dysthyrnia, on mania were tenmine lifetime prevalence of the given a diagnosis of drug or alcohol Dr. Chiles is associate professor, following DSM-IH-R axis I or axis II abuse on dependence. Dr. Von Cleve is clinical instruc diagnoses: depression, dysthymia, Inmates' responses to questions tor, Dr. Jemelka is assistant pro alcohol abuse on dependence, drug from the DIS sections on use of al fessor, and Dr. Trupin isprofessor abuse on dependence, schizophre cohol and drugs were analyzed to in the department of psychiatry nia, schizophreniform disorder, identify specific substance abuse and behavioral sciences at the mania, and antisocial personality dis problems. The responses of mentally University ofWashington School order. To assess intenraten reliability, ill offenders with substance abuse di of Medicine in Seattle. Address pairs of interviewers drawn from a agnoses were compared with ne correspondence to Dr. Chiles at group of five interviewed 24 in sponses of offenders without such Harborview Medical Center, ZA mates. The diagnoses made in each diagnoses. To reduce the likelihood 15, 325 Ninth Avenue, Seattle, joint interview were analyzed using ofa type I error, the probability level Washington 98104. an extension of kappa (kappa v) (6), was set at .001.
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Table 1 also had a diagnosis ofalcohol abuse Lifetime prevalence of selected psychiatric aAlcoholAlcoholAll andalcohol and drugabuse in or dependence or drug abuse on de sample ofmale prison inmates (N = 109)diagnoses pendence. Previous studies have found that drugs and alcohol are available in Alcohol drug drug prison, and substance abusers have abusersDiagnosis inmates' abusersDrug abusersand abusersor reported frequent use of alcohol on %N%Schizophrenia N % N %N %N drugs while incarcerated. In one study, drug abusers reported being 5 5 100Schizophreniformdisorder 4 803 602 405 in a chemically altered state of mind during about 25 percent of their in 100Antisocial 2 2 1 502 1001 502 carcenation (9). Intoxicants are not person alitydisorder 92Depression 47 44 38 8135 7430 6443 only prime contraband in prisons but 82Dysthymia 33 30 2 1 6422 6716 4827 are the product of a significant cot 100Mania 16 15 13 8114 8811 6916 tage industry. In the Washington 04100Alcohol 4 4 1253750 prison system, fruits and vegetables abuseor are often combined with yeast and dependence —¿Drug 72 66 —¿ —¿50 69— —¿â€” sugar and fermented in toilet bowls abuseordependence to produce “¿pruno,― an alcoholic 66 61 50 76— —¿â€” —¿â€” —¿ mainstay. It is almost impossible for 1Percents sum to more than 100 because some inmates had more than one diagnosis. a chemically addicted mentally ill person to maintain sobriety in an en A significant difference between compared with those who did not vironment where drugs and alcohol the groups was found on nine of the have this diagnosis, a significant dif areavailable andused. 36 items in the DIS section on al fenence was found on only one of the The finding that substance abuse 23 items in the DIS section on drug and dependency are part ofthe lives cohol use. Compared with offenders use. Ninety-seven percent of the of of most mentally ill offenders has who did not have a diagnosis of al fenders with drug abuse diagnoses important implications for the devel cohol abuse on dependence, of butonly 4 percent of other offenders opmcnt of policies about compul fenders with this diagnosis were answered yes to the question, Do sory substance abuse treatment of more likely to see themselves as cx drugs interfere with your life a lot? incarcerated offenders and for the cessive drinkers (x2 = 18.28, df= 1, design oftreatmcnt plans for mental p = .0000),to report drinking large (x2=49.52,df=1,p=.0000). ly ill prison inmates. Connectional of amounts in one day (x2 = 26.25, Subjects were asked to identify ficers need training in the areas of df= 1, p = .0000), to report drinking the three drugs that they had used substance abuse, mental illness, and excessively at least once a week most frequently or that had caused dual diagnosis. Further attention to (X2=13.2, df=1, p=.0003), to them the most difficulty in their substance abuse as a contributor to have their drinking objected to by lives. Fifteen offenders (14 percent) incarceration of the mentally ill is family members (x2 = 19.09, df= 1, indicated that they did not use drugs needed. In addition, substance abuse p = .0000), to have health care pro or that they used them very infre should be addressed in community fessionals tell them they drink too quently. A total of 94 inmates (86 based mental health programs that much(@2= 15.45,df= l,p=.000l), percent) reported some regular drug provide services to former prison in to go on binges that last for days use, and 66 (6 1 percent of the sam mates who are mentally ill. (x2=12.78,df=1,p=.0004),and pie) were given a diagnosis of drug to suffer blackouts (x2 = 14.21, abuse or dependence. Marijuana, df= 1, p= .0002). Offenders with a cocaine, and amphetamines were the References diagnosis ofalcohol abuse or depen three drugs used most extensively dence were more likely to have been both by offenders with a diagnosis of 1. Jemelka R,Trupin E, ChilesJ: The men arrested for drinking (x2 = 14.27, drug abuse or dependence and by tally ill in prisons: a review. Hospital and df= 1, p = .0002) and to have gotten those who did not have this diag Community Psychiatry 40:481—491, nosis. An offender who used cocaine 1989 into physical fights while drinking 2. SheetsJL, PrevostJA, ReihmanJ: Young (x2=30.93,df=1,p=.0000). Both or heroin was significantly more like adult chronic patients: three hypothe mentally ill offenders with a diag ly than users ofothendrugs to receive sized subgroups. Hospital and Commu nosis of alcohol abuse on depen a diagnosis of drug abuse or depen nityPsychiatry 33:194—203,1982 dence and those without that diag dence. 3. Collins JJ: Preliminary Findings: Drug Use Among Arrestees in Three Urban nosis hadproblemswith alcohol atan Areas. Research Triangle Park, NC, early age. About half of each group Conclusions Center for Social Research and Policy reported that they had problems Of the 96 mentally ill offenders in Analysis, 1988 with drinking before age ten. the sample, 64 had a diagnosis other 4. Wish ED, Brody E, Cuadrado M: Urine testing of arrestees: findings from Man When offenders with a diagnosis than a substance abuse disorder, and hartan. Presented at a conference on of drug abuse on dependence were of these offenders, 54 (84 percent) drugs and crime, sponsored by National
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Institute of Justice, Washington, DC, orders in three communities. Archives of well as a variety of residential pro June 5, 1986 General Psychiatry 41:959—967,1984 grams. Because of restrictive licens 5. Robins LN, HelzerJE, RatcliffT, et a!: 8. Robins L, HelzerJ, Weissman M, et a!: ing and reimbursement regulations, Validity of the Diagnostic Interview Lifetime prevalence of specific psychiat Schedule, version II: DSM-III diagno nc disorders in three sites. Archives of many ofthese services (especially in ses. Psychological Medicine 12:855— General Psychiatry 4 1:949—958,1984 patient and residential programs) are 870,1982 not available to dual diagnosis pa 6. FleissJL:Measuringnormalscaleagree 9. SobellLC,SobellMB, MaistoSA,et a!: Alcoholanddrugusebya!coholand drug tients unless their psychiatric illness ment among many raters. Psychological Bulletin16:378—382,1971 abusers when incarcerated: clinica! and is clearly predominant. Even so, 7. MyersJ, Weissman M, Tischler M, et a!: research implications. Addictive Behav acute intoxication on a known history Six-month prevalence ofpsychiazric dis iors8:88—92, 1983 of chronic severe substance abuse may result in dismissal from on refusal of treatment. Psychiatric services are provided primarily by staff therapists with minimal formal training on expeni ence in the treatment of substance Barriers to Community Treatment abuse (7,8). Similarly, the psychia trists providing supervision and con of Patients With Dual Diagnoses sultation may not have an extensive background in substance abuse. Sub stance abuse services are provided by a drug and alcohol agency that is Robert H. Howland, M.D. services for mental health treatment independent of community mental and those for substance abuse treat health in its funding and legislative There is a growing awareness of a ment. Given the extent of problems mandate. A variety of programs, subpopulation of mental health pa faced by dual diagnosis patients and from education to treatment, are tients with coexistent substance their relatively poor fit in either the maintained and staffed primarily by abuse and psychiatric disorders. Al mental health on the substance abuse persons who have been certified in though various surveys have found systems alone, specialized services substance abuse counseling but who that this comonbidity may be quite would seem appropriate. However, have little training in mental health. high in some populations (1,2), the few community programs exist to Although psychiatric consultation literature addressing clinical aspects provide such specialized services, may be available, treatment usually of the dual diagnosis patient—from and those that do probably could not is offered by referral to the mental phenomenology to treatment—is adequately serve the large number of health system. not extensive. What little literature patientswho might benefit. An alter Programs that might serve dual there is suggests that patients with native would be to coordinate exist diagnosis patients are not typical in dual diagnoses are more problematic ing services from each system, a these systems, nor is coordination of to work with, frequently use emer practice that is unfortunately the ex services that might benefit these pa gency services, are difficult to ception rather the rule (6). This tients. Referrals are made blindly be evaluate and often misdiagnosed, are paper describes some of the barriers tween the agencies; because of issues less responsive to treatment, fre to the adequate provision of clinical surrounding patient confidentiality, quently resist available services, and services for dual diagnosis patients no clinical information is shared on are at higher risk for suicide and vio and recommends ways of ovencorn follow-up contact made to ensure lence (3—5). These characteristics ing these barriers. that services are provided. Likewise, thus define a heterogeneous group if patients are seen jointly by each of patients with special needs who Barriers to treatment agency, it is unusual for clinical infor pose particular problems for a sen When describing the characteristics mation to be shared or for contact vice delivery system. of a service delivery system, it must between the treating clinicians to Historically, an artificial division be recognized that although impor occur. There are generally no has stood between the provision of tant general principles may apply, provisions for joint training, educa not all systems or programs are alike. iion, or treatment programs that Dr. Howland is clinical research Barriers to treatment of patients with could help inexperienced clinical fellow in the department of psy dual diagnoses have been described staffin working with these patients. chiatry at theWestern Psychiatric elsewhere (6,7); the description used Barriers to treatment also stem Institute andClinic ofthe Univer in this paper is based on the general from philosophical differences be sity of Pittsburgh School of Mod organization of mental health sen tween the two systems. Because no icine. Address correspondence to vices in Pennsylvania. systematic effort to identify patients him at the clinic, 381 1 O'Hara In most areas, the community as dually diagnosed exists, where and Street, Pittsburgh, Pennsylvania mental health system provides in whattype oftneatrnent these patients 15213. patient and outpatient services as receive may depend on the pencep
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