“Worse than when they came in”: dual diagnosis, prison health neglect and the structural violence of denied care

Schizophrenia and Co-Occurring Substance Use Disorder

Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence

Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail. Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups. Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis. The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.

Substance Abuse-Related Mortality Among Middle-Aged Male VA Psychiatric Patients

Objective-This retrospective cohort study examined the association between co-occurring serious mental illness and substance use disorders and parole revocation among inmates from the Texas Department of Criminal Justice, the nation's largest state prison system. Methods-The study population included all 8,149 inmates who were released under parole supervision between September 1, 2006, and November 31, 2006.An electronic database was used to identify inmates whose parole was revoked within 12 months of their release.The independent risk of parole revocation attributable to psychiatric disorders, substance use disorders, and other covariates was assessed with logistic regression analysis.Results-Parolees with a dual diagnosis of a major psychiatric disorder (major depressive disorder, bipolar disorder, schizophrenia, or other psychotic disorder) and a substance use disorder had a substantially increased risk of having their parole revoked because of either a technical violation (adjusted odds ratio [OR]=1.7,95% confidence interval [CI]=1.4-2.4) or commission of a new criminal offense (OR=2.8,95% CI=1.7-4.5) in the 12 months after their release.However, parolees with a diagnosis of either a major psychiatric disorder alone or a substance use disorder alone demonstrated no such increased risk.Conclusions-These findings highlight the need for future investigations of specific social, behavioral, and other factors that underlie higher rates of parole revocation among individuals with co-occurring serious mental illness and substance use disorders.Over the past four decades the widespread deinstitutionalization of persons with serious mental illness (1-3), the increase in drug-related arrests (4,5), and the reduction of community-based mental health care (1,2) have resulted in a substantial overrepresentation of persons with serious mental illness in the U.S. correctional system (1,2,6).Approximately 10% to 20% of U.S. prison inmates are estimated to have an axis I major mental disorder of thought or mood, such as major depressive disorder, bipolar disorder, or schizophrenia (7-12).Moreover, a majority of inmates with serious mental illness have a comorbid substance use disorder (7,(12)(13)(14)(15).A number of investigations have examined predictors of recidivism among released inmates (16)(17)(18)(19).Although results of these studies-conducted throughout a variety of criminal justice

Highlights of the 1998 Institute on Psychiatric Services. Issues in public-sector managed care.

Severe mental illness, substance use, and intimate partner violence have emerged as major intersecting public health problems that adversely and disproportionately impact the lives of women in the United States. This longitudinal study investigated the demographic and clinical correlates of intimate partner violence in a sample of 324 mothers with severe mental illness. A secondary analysis of longitudinal data was conducted by using multiple logistic regression. Participants were part of a longitudinal, community-based study of mothers with severe mental illness, which was aimed at understanding how these mothers viewed motherhood. The women were interviewed initially at baseline (interviews were conducted between 1995 and 1996) and then about 20 months later at follow-up (interviews were conducted between 1997 and 1998). At follow-up the prevalence rate of intimate partner violence was 19%. Multiple logistic regression analyses showed a significant positive relationship between alcohol and drug misuse at baseline and intimate partner violence at follow-up, indicating that women with a co-occurring diagnosis of a substance use disorder (dual diagnosis) were more likely than women without such a diagnosis to report intimate partner violence. The number of lifetime psychiatric hospitalizations and the number of symptoms related to psychiatric disability exhibited at baseline were positively associated with intimate partner violence at follow-up, and age was inversely associated with intimate partner violence. Mental health professionals serving mothers with mental health problems need to be aware of and prepared to assess the significant correlation between these intersecting public health problems in order to influence successful interventions. Particular attention must be given to the special treatment needs related to dual diagnosis and victimization and the impact of these factors on this vulnerable population.

A Longitudinal Investigation of Intimate Partner Violence Among Mothers With Mental Illness

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical by potbeses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.

Dual diagnosis: 15 years of progress.

This study compared the quality of treatment relationships and engagement in peer-based and regular case management. It also assessed the value of positive relationship qualities in predicting motivation for and use of community-based services for persons with severe mental illness. One hundred thirty-seven adults with severe mental illness participated in a 2x2 prospective longitudinal randomized clinical trial with two levels of case management intervention (peer and regular) and two interviews (six and 12 months). Self-report questionnaires assessed treatment relationships, motivation, and service use, and providers rated participants' initial engagement and monthly attendance in treatment. Participants perceived higher positive regard, understanding, and acceptance from peer providers rather than from regular providers at six months only, with initially unengaged clients showing more contacts with case managers in the peer condition and decreasing contacts in the regular condition. Six-month positive regard and understanding positively predicted 12-month treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings. Early in treatment, peer providers may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients and a facility for increasing treatment participation among the most disengaged, leading to greater motivation for further treatment and use of peer-based community services. Findings strongly suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system.

Executive summary The National Disability Insurance Scheme (NDIS) is not a health scheme. The NDIS funds disability support and a range of related services designed to maximise the independence of a person with a disability. Health care is a specific exclusion. The NDIS is organisationally separate from both the health system and the aged care sector. At the national level, the NDIS is the responsibility of the Minister for Social Services (and not the Minister for Health) and is being administered by the National Disability Insurance Agency (NDIA), which is an independent statutory agency. While the NDIS is not a health scheme, and health care is a specific exclusion, it will intersect with the health system on a number of levels. To ensure the NDIS does not lead to fragmented care for participants, the Department of Health, the Department of Social Services and the NDIA will need to work closely to monitor and resolve any issues that arise during the implementation phase. This will require active, joint collaboration to develop appropriate policy responses. Recommendations for action 1. Establish formal Department of Health, Department of Social Service and National Disability Insurance Agency tripartite working group with the following roles and responsibilities: Education and information for key targeted audiences regarding eligibility requirement and other key implications of the NDIS and the National Injury Insurance Scheme (NIIS) Workforce implications monitored and addressed in a coordinated manner Patient inequity issues monitored and coordinated policy responses undertaken Permanent and fluctuating impairment required coordinated care and active policy responses Mental health implications need to be better understood and coordinate actions to be taken to overcome barriers Service prevision boundary disputes between health and disability sectors require a resolution mechanism through negotiation rather than determined solely by the NDIA Timely access issues monitored and a fast track system for hospital referrals to/from the NDIS developed Inconsistency with the 2011 National Health Reform Agreement monitored and addressed as appropriate 2. While it is the responsibility of the Department of Social Services and the NDIA to work toward a nationally consistent approach as the scheme moves to full roll-out, the Department of Health should monitor roll-out to ensure health services are not negatively impacted. 3. Review the NDIS evaluation in order to inform the health system with applicable lessons. At the system level, the NDIS presents opportunities to learn more about individualised service planning and funding, and better ways to measure need and outcomes.

Editor's Note: In the commentary below, Francine Cournos, M.D., and Stephanie Le Melle, M.D., discuss the article on page 989, reprinted from the July 1981 issue of Hospital and Community Psychiatry. That article described a new group of chronic patients, young adults with poor social functioning who were draining the resources of public-sector programs. Drs. Cournos and Le Melle place the emergence of this patient group within a larger context of shifts in funding streams for social welfare programs and a lack of resources for community-based care. They describe studies published in this journal in the 1980s that examined many issues related to the treatment of young adult chronic patients—homelessness, outpatient commitment, and comorbid substance abuse—and they call on mental health professionals to advocate for more resources to improve patient care.

BackgroundThe prevalence of mental illness, substance use disorders, and their dual diagnosis is disproportionately high among people in prisons compared to the community. Accurate prevalence estimates are required to inform resourcing of prison health services and reduce the risk of harm to people experiencing these conditions. Existing estimates, where available, often rely on only one data source.MethodWe used three data sources – self-reported history of diagnoses, in-prison medical records, and administrative data to estimate the prevalence of mental illness, substance use disorder, and dual diagnosis among two large cohorts of non-Indigenous and Aboriginal and Torres Strait Islander people in Australian prisons. We calculated population-weighted proportions of the samples with each condition. Inter-rater reliability metrics inform data source agreement.ResultsThe prevalence of mental illness only, substance use disorder only, and dual diagnosis was 17.0% (95%CI 12.0–24.5), 14.8% (95%CI 9.6–18.1), and 44.2% (95%CI 33.2–54.7), respectively, for incarcerated, non-Indigenous adults. For incarcerated Aboriginal and Torres Strait Islander adults, our corresponding estimates were 7.0% (95%CI 4.3–11.5), 26.8% (95%CI 18.9–33.5), and 40.9% (95%CI 30.1–48.2). These estimates differed significantly from those derived from singular data sources. Individual data sources’ agreement was weakest for substance use disorder diagnoses and strongest for dual diagnoses.ConclusionsIndividual data sources likely have high specificity and low sensitivity, thus under-ascertaining diagnoses. We recommend using multiple data sources to estimate prevalence to ensure adequate ascertainment of these conditions among people in prison and to ensure in-prison and transitional health services are appropriately resourced.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12963-025-00408-7.

Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment. This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence. Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43). Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets. Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization. Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs. Self-reported abstinence from alcohol did not significantly differ between groups. Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43). One patient in ATM assaulted the therapist when his check had not arrived. ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.