Abstract
In this commentary, we discuss the main findings of the research study by Gunter et al., “The Frequency of Mental Health and Addictive Disorders Among 320 Men and Women Entering the Iowa Prison System: Use of the MINI-PLUS.” This commentary provides an overview on the use of standardized assessments with prison populations; prevalence rates of mental and addictive disorders within prisons; substance use disorders, as opposed to substance-induced psychiatric disorders, among prison populations; and research on diversion treatment programs within the community for nonviolent mentally ill and substance-using offenders.
In their article, Gunter et al.,1 highlight several important points that are psychiatric, forensic, and ethics-related. However, although the article raises concerns that are inherent within the findings, these concerns are not fully discussed. In this commentary, we address the following: the use of standardized assessments within prisons, as well as the related problems in reported prevalence rates of mental and addictive disorders; treatment needs and suicide risk in individuals within prisons; complications of distinguishing co-occurring substance use disorders from substance-induced psychiatric disorders; and the diversion, through statutes and mental health and drug courts, of nonviolent psychiatric and substance-abusing offenders from corrections to community-based treatments.
The Use of Standardized Assessments
Gunter and colleagues1 utilized a standardized assessment instrument, the Mini International Neuropsychiatric Interview-Plus (MINI-Plus), which provides for coding of more than 60 variables, including DSM-IV2 diagnoses and suicide risk assessment. The MINI has shown appropriate psychometric properties through direct comparisons to the Structured Clinical Interview for DSM-IV (SCID).3 Through the use of the MINI-Plus, the authors found that 90 percent of offenders in their sample met criteria for a current or lifetime psychiatric disorder. The most frequent were substance use disorders (90%), mood disorders (54%), psychotic disorders (35%), antisocial personality disorder (35%), and attention deficit hyperactivity disorder (22%). Offenders had a mean of 4.2 disorders, and two-thirds had 3 disorders or more. Results also showed few gender-based differences. Moreover, 30 percent of the offenders were rated at risk for suicide. The authors concluded that mental and addictive disorders are common among incarcerated offenders and that these individuals are at risk for suicide.
Using standardized assessments among prison samples is needed, yet dissemination of this research into clinical practice is still limited across much of the United States. There are several potential reasons for the lack of dissemination and lag in prison research: an increase in mental health workers' caseloads that limits the amount of time in which to administer standardized assessments; widespread understaffing, which results in a lack of time for any assessment; lack of funding to support state-of-the-art diagnostic assessments within prisons; a dogmatic belief in the superiority of familiar approaches (i.e., “The old way is the best way”); and institutional review boards (IRBs) and funding agencies that are hesitant and generally cautious when research involves prisoners, thus slowing the process of obtaining IRB approval to perform the needed research and follow-through with replication studies.
Prevalence Rates of Mental and Addictive Disorders Within Prisons, as Determined by the MINI-Plus
A comparison of the findings of Gunter and colleagues1 with other research within prison systems showed similar prevalence rates.4–7 However, as can be expected, the prevalence rates for their study are higher than those found in the National Epidemiological Surveys on Alcohol and Mental Health Disorders, which focuses on the general population.8 For example, Grant and colleagues8 reported general population rates of past-year alcohol use as low as 9 percent and independent mood and anxiety disorders at 9 and 11 percent, respectively. In general, one can surmise that there would be an increase in mental and addictive disorders within prison populations, as in many cases, it is the mental health and/or addiction problems that are causally related to the legal problems. It is also important to point out that individuals in the general population may be underreporting mental disorders and substance use, whereas the prisoners may be overreporting their mental health problems and addictions if they are in the presentencing phase. In addition, it is unclear whether the MINI-Plus independently rules out mental disorders caused by substance use, as do other standardized assessments.2,3 There are added complications in obtaining a clear picture of mental illness, co-occurring disorders, or substance-induced disorders when individuals are at the beginning stages of incarceration, especially when the effects of substance use have not had time to clear. Finally, when comparing prevalence of disorders in different samples, it is also important to ascertain whether the researchers are reporting on current, past-year, or lifetime endorsements of mental and addictive disorders.
In comparisons with the general population, the findings of Gunter et al.1 are largely similar to other findings on prevalence rates of mental and substance use disorders among incarcerated offenders. For example, Teplin and colleagues4 and Parsons et al.6 found that more than 80 percent of male prisoners met criteria for at least one lifetime psychiatric disorder, and 70 percent were symptomatic within 6 months of the interview. As found by Gunter et al.,1 the most prevalent disorder was substance abuse or dependence. However, post-traumatic stress disorder was also highly prevalent in the findings of Teplin et al.,4 which is consistent with findings in other incarcerated samples,7 rather than prison populations as a whole.
It is not surprising that high prevalence rates (35%) of ASPD were recorded in both studies. Legal problems tend to be interwoven with the use of alcohol and drugs, hence increasing the offenders' likelihood of meeting criteria (adult symptoms/criteria) for ASPD. Kelly and Petry9 found rates of ASPD to be as high as 42 percent in their substance use population.
With regard to gender, Gunter and colleagues1 found few gender differences in prevalence of mental and addictive disorders among female and male offenders. However, other researchers5 have found that approximately 72 percent of female prisoners with severe mental disorders had a co-occurring substance use disorder, as opposed to men. Findings also showed that the lifetime prevalence of psychiatric disorders in female prisoners ranged from 64 to 81 percent. Moreover, they found that the prevalence of current or past-6-month psychiatric disorders in female prisoners was between 48 and 71 percent, but was only as high as 31 percent in male offenders.5 Again, it is possible that psychiatric diagnoses will differ depending on the point at which an offender is assessed during his or her prison sentence, as well as the adequacy of the assessment instrument at distinguishing substance-induced disorders from substance use and independent, co-occurring disorders. Different results may also be obtained depending on whether the clinicians performing the evaluations are highly trained professionals who are skilled at performing diagnostic assessments. There may be some discrepancies in the prevalence rates of mental and substance use disorders in male and female offenders reported in the various studies, but the high prevalence rates of psychiatric and substance disorders, the widespread suicide risk, and the high need for offenders to receive appropriate treatment are clear and straightforward findings.
Substance Use Disorders AmongPrison Populations
Researchers postulate that the influx of offenders incarcerated for drug-related offenses has led to increases in the prison population.10 There is a strong relationship between drug use and criminal behavior. Along with the illegality of the drug use itself, such substance use also increases the likelihood of additional criminal behavior and continued use in prisons.10 However, continued drug use can greatly complicate the diagnostic picture, and substance use in prison is associated with misconduct and suicide attempts.10 Thus, when administering diagnostic assessments within the prison population, it is important to consider the following: utilization of objective indicators of substance use to rule out ongoing use in prison; re-evaluations to rule out psychiatric symptoms associated with withdrawal or continued use; and re-evaluations several months into the sentence, as some drug users (e.g., chronic PCP users) can take up to one year to become free of PCP-induced symptoms.
Diversion Programs for Nonviolent Mentally Ill and Substance-Abusing Offenders
In sum, we stress not only the need for standardized diagnostic assessments and treatments for offenders in prisons, but also the need for forensic professionals to be aware of the various mental health and drug diversion programs available for offenders. For example, many states have statutes in which offenders with mental health and/or substance abuse problems are court ordered to evaluations (e.g., forensic substance dependency evaluations) for appropriate treatment within the community (i.e., outpatient or residential). These nonviolent mentally ill and/or substance-using offenders are vulnerable, in that they can face lengthy sentences that are often secondary to untreated mental illness or substance dependency. The literature clearly states that diversion programs, mental health courts, and drug courts11,12 are effective in decreasing recidivism rates in this population.
In conclusion, it is the obligation of forensic psychiatry not only to be cognizant of standardized assessments and appropriate timing of the application of the assessments, but also to be familiar with statutes and court systems that utilize mental health and drug courts, to help this population obtain successful treatments within the community when appropriate.
- American Academy of Psychiatry and the Law
