Abstract
This commentary discusses the main findings of the research study by Friedman et al. entitled, “Gender Differences in Criminality: Bipolar Disorder with Co-occurring Substance Abuse.” Moreover, it shows that the role of substance use should be determined in studies that assess outcomes among co-occurring disorders, such as bipolar disorder and criminal behavior. High rates of substance-related problems were recorded in the study by Friedman et al. Fifty-six percent of the patients with dual-diagnosis, rapid-cycling bipolar disorder had been charged with drug- or alcohol-related offenses. Significantly more men (69%) had incurred substance-related charges than had women (38%). Women who abused cocaine were more likely to be charged with a crime than were those who had not. Sixty-five percent of the women in the study who abused cocaine had been previously charged with a crime, compared with 38 percent of the women who did not; but this finding did not hold true for the men. The number of crimes committed by the men who abused cocaine and by those who did not was about the same. This article also provides an overview of the role of substance use in criminal behavior and how substances of abuse can affect bipolar disorder and criminal outcomes.
In a sample of community defendants with dual diagnosis and rapid-cycling bipolar disorder, Friedman and colleagues1 report in this issue of the Journal the following results of their study: (1) Sixty-eight percent of their study sample had been charged with a legal offense at some point in their lives. (2) Of those charged with an offense, 55 percent were convicted and 46 percent were incarcerated. (3) These investigators found gender differences across legal offenses. For example, significantly more men received a charge for a legal offense at some point in their lives (79%) than did women (53%). (4) There were no significant differences between men and women in the number of convictions or amount of incarceration.
Regarding violent and nonviolent outcomes, Friedman et al. report that men were more likely to be arrested for violent and nonviolent offenses. For example, the investigators report that men were more likely to have been charged with a nonviolent offense in the past (71%) than were women (42%). In terms of the outcomes that pertain to felony and misdemeanor arrests, they report the following findings: (1) Men were more likely to be charged with felony offenses than were women, and (2) men were more likely than women to be charged with misdemeanor offenses.
In terms of substance-related outcomes, Friedman and colleagues1 report the following: (1) Fifty-six percent of the population of patients with dual-diagnosis, rapid-cycling bipolar disorder had been charged with drug- or alcohol-related offenses. Significantly more men (69%) had substance-related charges than did women (38%). However, the investigators found an interesting result across the gender and drug categories. For example, they reported that women who abused cocaine were more likely to be charged with a crime than those who had not. Moreover, their data illustrated that 65 percent of women who abused cocaine had been charged with a crime, compared with women who did not abuse cocaine (38%), whereas this finding did not hold true for men (i.e., there was no difference between men who abused cocaine and those who did not in the numbers of those who had been charged with crimes).
As the authors note,1 the findings highlight the need for early identification of bipolar disorder with co-morbid substance abuse, especially among those individuals in prison who have dual diagnoses. Moreover, the women in this latter population may have specific treatment needs, as they were four times more likely to have been arrested in their lifetimes than were women in the general population. In addition to the authors' comments, it is important to assess the severity and frequency of cocaine use and more specific legal characteristics among the women who abuse cocaine.
There are other important points to consider when interpreting these findings across both male and female dually diagnosed populations. For example, how do the following questions influence the results of this study and the interpretation of gender differences among patients with dually diagnosed bipolar disorder and substance abuse, with and without criminal histories?
1. What is the specific role of substance use in criminal behavior?
2. How does substance use affect bipolar disorder?
Underestimating the Role of Substance Abuse in Criminal Behavior
The drug, violence, and criminal behavior relationship exists, is strong, and has pervasive effects on society.2 At times, the relationship among the three can be murky and confounding. For example, Hoaken and Stewart3 have shown that drugs can have direct and indirect effects on criminal behavior. The pharmacologic effects of drugs can have a direct impact on the induction of violence (e.g., intoxicating doses of alcohol have been shown to be related to aggressive behavior, such as domestic violence and disorderly conduct).4,5 Drugs can also have indirect effects on violence and criminal behavior, because individuals with drug abuse or dependence often commit crimes or engage in violence to obtain drugs (e.g., robbery, theft, prostitution, and possession and selling of narcotics). The drug/violence relationship is further complicated by the intoxicating doses and neurotoxic and/or withdrawal effects of specific drugs of abuse (e.g., alcohol, cocaine, heroin, benzodiazepine, or PCP).3
Substance Use and Bipolar Disorder
When assessing and diagnosing substance abuse disorders and/or bipolar disorders among male and female populations, it is crucial to differentiate between a true Rapid-Cycling Bipolar Disorder with Co-occurring Substance Abuse and a Substance-Induced Bipolar Disorder, as the treatment implications and potential for future relapse into criminal behavior could be affected by misdiagnosis and inappropriate treatment planning.
Conclusions
In sum, the authors found gender differences across criminal history and type of legal charge. Men consistently had significantly more arrests during their lifetimes and had significantly more arrests for violent and nonviolent offenses, felonies, and misdemeanors than did women. However, an interesting finding that emerged was the cocaine abuse in women versus men and how it related to being charged for a crime. Women who abused cocaine were more likely to be charged with a crime than were women who had not abused cocaine, but the same result was not found among men who abused cocaine.
It is important to highlight the central role that substance use plays in criminal behavior, as rates of substance use are extremely high in mental health5 and criminal justice6 populations. Substance use has been shown to play a facilitative role in violent and criminal behavior.7 For example, substance use has been shown to lead to male-against-female violence, with the physical violence occurring within 2 hours after the intoxicating dose of the substance takes effect.7 In fact, in one study in which men were arrested for a domestic violence charge against a female partner, 92 percent were found to have some substance in their systems at the time of their offenses.8 In addition, substance use can induce a variety of psychiatric disorders,9 including psychosis, depression, and bipolar disorder, and we have specific diagnostic criteria for distinguishing among these disorders.9 Moreover, substance use alone can lead to noncompliance with treatment (e.g., lack of attendance, participation in psychotherapy, or compliance with medication).
This commentary suggests the importance of assessing gender differences and criminality among patients with dual diagnoses, but it also uncovers the importance of addressing the specific role of substance use among men and women with criminal histories. Substance use plays a role in violence and criminal behavior, but research is still needed to show how gender differences play into this equation.
- American Academy of Psychiatry and the Law
