Wright, N., Walters, P. and Strang, J. (2016), "Dual diagnosis in prisons: management of co-existing substance use and mental health disorders", Advances in Dual Diagnosis, Vol. 9 No. 1. https://doi.org/10.1108/ADD-12-2015-0025Download as .RIS
Emerald Group Publishing Limited
Dual diagnosis in prisons: management of co-existing substance use and mental health disorders
Article Type: Guest editorial From: Advances in Dual Diagnosis, Volume 9, Issue 1.
Prevalence of mental ill health in prisons
There are over ten million prisoners worldwide, a population that has been growing by about 1 million per decade (Walmsley, 2009). In 2008, the USA had the largest number of people imprisoned at 2.3 million and the highest rate per head of population (at 756 per 100,000 people compared with a median of 145 per 100,000 worldwide). China, Russia, Brazil and India each had more than a quarter of a million prisoners (Walmsley, 2009). At the time of writing the UK has a prison population of 85,982 of which over 95 per cent are male gender (Ministry of Justice, 2015).
Worldwide mental and substance use disorders account for 184 million disability adjusted life-years lost, expressed as 8.6 million years lost to premature mortality, and 175.3 million years lost to disability. As such mental and substance use disorders are the leading cause worldwide of years lost to disability (Whiteford et al., 2013). Prisoners have elevated rates of psychiatric disorders compared with the general population, including psychosis, depression, personality disorder and substance misuse, which are all risk factors for elevated suicide rates (Baillargeon et al., 2009a; Fazel et al., 2008), premature mortality on release from prison (Kariminia et al., 2007) and increased reoffending rates (Fazel and Baillargeon, 2011). It is estimated that compared to the general population, suicide rates within prison are increased four to five times (Fazel and Baillargeon, 2011), and deaths within the first week of release increased 29 times (Baillargeon et al., 2009b).
Major interactions are also evident. For example reoffending rates are increased by 40 per cent in offenders with psychotic disorders compared with non-mentally ill offenders (Fazel and Yu, 2011). Self-inflicted deaths in the UK among inmates rose by 69 per cent in 2013-2014 – a total of 88 lives lost and the highest level for ten years, arguably related to fiscal constraints upon prison services (HMCIP, 2015). Prisoners are particularly vulnerable to developing mental health problems. Histories of abuse, deprivation, homelessness, unemployment and substance misuse are common. Many prisoners have numeracy and literacy problems and most prisoners have a lower than average IQ (Singleton et al., 1998).
Dual diagnosis in prisons
In the UK, more than 70 per cent of the prison population has two or more mental health disorders (Singleton et al., 1998). A review of 62 prison studies covering more than 23,000 prisoners worldwide found that 3.7 per cent of all male and 4 per cent of all female prisoners had a psychotic disorder, 10 per cent of all male and 12 per cent of all female prisoners suffered from major depression, 47 per cent fulfilled the criteria for an antisocial personality disorder, although there were also high rates of borderline personality disorder (Fazel and Danesh, 2002; Fazel and Seewald, 2012). A diagnosis of personality disorder in prisoner populations is strongly associated with substance misuse (Singleton et al., 1998).
In terms of co-morbid drug and alcohol addiction, there is a dearth of empirical data and therefore the study reported by Blaauw in this edition, “Dual diagnoses among detained female systematic offenders” makes an important contribution. The researchers quantified the prevalence of psychopathology including substance use disorders in a sample of detained female systematic offenders. Of 81 case files studies between 2004 and 2014, all except one woman were addicted to substances in the past year, with an average duration of addiction of 21 years. In addition, 53 per cent were diagnosed with another DSM Axis I disorder and 73 per cent were diagnosed with a personality disorder. Furthermore, 32-59 per cent were found to have intellectual dysfunctions. 12 per cent had one type of the above disorders, 43 per cent two types, 31 per cent three types and 14 per cent all four types.
Many prisoners continue with a pre-existing habit of dependent drug use while in prison. However, the prison context itself can contribute to the problem, with boredom and a lack of structured activity often cited as reasons for drug use among prisoners (Tompkins et al., 2009). Furthermore, the strained atypical environment of prison can also aggravate the problem, with some prisoners actually being initiated into drug use whilst in prison as evidenced by a report on a UK prison by Her Majesty’s Inspector of Prisons UK in 2011 which found that up to one in three prisoners tested positive in random tests, and 13 per cent developed a drug problem while in prison (HMCIP, 2014).
The availability of drugs in prison is a constant battle for any establishment with a quarter of prisoners surveyed by National Offender Monitoring System in England and Wales claiming that it was easy to obtain drugs in custody. An added challenge is the use of needles and syringes to inject drugs. In the prison environment, injecting is less common than in the community setting by virtue of the difficulty of smuggling and concealing needle and syringes and therefore needle exchange programmes are not available in UK prisons (Wright et al., 2015). However, the downside is that when injecting in prison does occur there is much less attention paid to hygienic precautions and also a greater degree of sharing of injecting equipment (with major resulting health implications). In addition, matters are compounded by Novel Psychoactive Substances (so-called “legal highs”) which present an additional significant challenge for the prison estate (HMCIP, 2015).
Dual diagnosis is not a new phenomenon. Nevertheless, there has been major change over the past two decades with a dramatic increase in the range and availability of street drugs (EMCDDA, 2007) and the high prevalence of dual diagnosis in prisoner populations (Department of Health, 2009). This can lead to damaging distortions regarding proper provision for vulnerable populations. For example, the US houses more than three times more mentally ill people in prison than in all psychiatric hospitals (Torrey et al., 2010), and under treatment for mental illness in US prisons exacerbates these problems (Wilper et al., 2009).
Management of dual diagnosis in prisons
Dual diagnosis clients have a higher than average risk of suicide (DH, 2009). Care of clients should be planned with this vulnerability in mind. Risk assessments should be made in accordance with the suicide assessment and monitoring procedures in place at the individual prison (known as the ACCT system). Empirical research is ongoing regarding developing screening tools for prison populations that have predictive validity regarding future episodes of self-harm to be administered at the point of considering opening an ACCT (Horton et al., 2014). These prisoners present as especially challenging because their substance abuse invariably impacts negatively upon their co-morbid mental health disorders.
The introduction of the integrated drug treatment system in prisons (HMPS, 2006) sought to bring together healthcare and drug treatment teams far more closely. It aimed to provide integrated care for prisoners with dual diagnosis, involving joint care planning, case reviews and co-ordinated through-care. The Patel Report, published in September 2010, highlighted some of the recent improvements in the field of treatment for drug addiction within prisons. In particular, it identified an apparent link between spending on drug treatment in prison, reduction in drug use and reduction in reoffending rates (Prison Drug Treatment Strategy Review Group, 2010). Importantly, if properly established and competently provided, drug treatment can be implemented effectively and safely in prisons at primary care level (Wright et al., 2014).
Integrated treatment models
Most prisons across the country practise a “parallel approach” to dual diagnosis. A parallel approach involves the provision of care by more than one treatment service to the patient at the same time. This is recognised as an accepted response to dual diagnosis (DH, 2009) since the patient receives specialist help for each of the different aspects of their problem. The main disadvantage of this system lies in the need for sharing important information between two or sometimes three treatment teams, and the potential that this holds for miscommunication. It can also be perceived as providing fragmented care to the patient. For example, there has been a longstanding belief of many mental health nurses and prison-based GPs that offering therapy for illicit drug use is not a part of their core role whilst they seek to deliver care to those who have mental ill-health. As a result, substance misuse and mental health teams often refer prisoners onto each other, rather than seeking to work together (Sainsbury Centre for Mental Health, 2007; Durcan and Knowles, 2006). Therefore, for it to meet the complex needs of prisoners, the parallel approach must be as fully integrated as possible.
The review by Moyes et al. “What can be done to improve outcomes for prisoners with a dual diagnosis?” reported in this edition contributes to our understanding of integrated treatment models by recommending they need to be coordinated and holistic, staged and gender responsive with an increased availability of “low level”, flexible interventions. Further recommendations include transitional support and continuity of care upon release with the utilisation of peer mentors; comprehensive assessments in conducive settings; mandatory dual diagnosis training for staff; and increased funding for female/gender responsive services. Such interventions, if properly implemented, would address longstanding barriers to effective treatment provision for prisoners with a dual diagnosis.
The area of psychological interventions for offenders with dual diagnosis remains an area requiring further research activity as the evidence base is extremely limited. This is evidenced by the findings of Melton et al. reported in this edition “Node-link mapping, an asset?” in which there was insufficient power to detect a significant difference in clinical outcomes, although participants were more likely to report the intervention as useful and instructive.
In addition to evidence-based pharmacological and psychological interventions for co-morbid mental ill-health and substance misuse, prisoners with dual diagnosis are likely to benefit from social interventions. For example, the evidence would suggest that a high level of purposeful activity appears to protect against the risk of suicide in prisons (Leese et al., 2006). The paper by Majer et al., “Comparative analysis of treatment conditions upon psychiatric severity levels at two years among justice involved persons”, showed that for those with a history of imprisonment, discharge from inpatient substance misuse services to community-based, residential treatment programmes led to improved clinical outcomes in terms of reduced psychiatric severity. Such findings of improved outcomes from community-based, residential treatment programmes concur with US-based trials that compared drug users released without any structured follow-up to those released from prison to a community residential unit. Key findings were that in the latter group there were lower rates of relapse into drug use and lower rates of re-imprisonment (Sacks et al., 2004; Wexler et al., 1999). Since currently there is a problem with prison over-crowding, yet also many unfilled beds in residential units, this could become an area for future development. The optimal time period for residential care appears to be between three and six months. However, this sort of “transitional release” from prison is not common at this point in time despite the pressure of overcrowding in prisons and a surplus in beds in the residential rehabilitation sector.
The prison environment presents both a challenge and also an opportunity. It offers significant opportunities for effective integrated working for the benefit of patients with dual diagnosis. The evidence suggests that drug treatment can be effectively delivered in prisons although the competent application of established risk assessment processes for those at risk of self-harm or suicide is vital. Threats to integrated working centre on poor communication between services or services inappropriately referring to each other rather than sharing care in a parallel model. We recommend that these are priority areas to address for those involved in prison healthcare delivery and organisation. There is a dearth of evidence pertaining to psychological interventions for prisoners with dual diagnosis and this forms an area for crucial future research activity.
Nat Wright, Pamela Walters and John Strang
Baillargeon, J., Penn, J.V., Thomas, C.R., Temple, J.R., Baillargeon, G. and Murray, O.J. (2009a), “Psychiatric disorders and suicide in the nation’s largest state prison system”, Journal of American Academy of Psychiatry Law, Vol. 37 No. 2, pp. 188-93
Baillargeon, J., Binswanger, I.A., Penn, J.V., Williams, B.A. and Murray, O.J. (2009b), “Psychiatric disorders and repeat incarcerations: th e revolving prison door”, American Journal of Psychiatry, Vol. 166 No. 1, pp. 103-9
Department of Health (2009), A Guide for the Management of Dual Diagnosis in Prisons, DoH, London
Durcan, G. and Knowles, K. (2006), Policy Paper 5: London’s Prison Mental Health Services: A Review, The Sainsbury Centre for Mental Health, London
EMCDDA (2007), “Annual report: the state of the drugs problem in Europe”, EMCDDA, Lisbon, November
Fazel, S. and Baillargeon (2011), “The Health of prisoners”, Lancet, Vol. 377 No. 9769, pp. 956-65. doi: 10.1016/S0140-6736(10)61053-7
Fazel, S. and Danesh, J. (2002), “Serious mental disorders in 23,000 prisoners: a systematic review of 62 surveys”, Lancet, Vol. 2002 No. 359, pp. 545-50
Fazel, S. and Seewald, K. (2012), “Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis”, The British Journal of Psychiatry, Vol. 200 No. 5, pp. 364-73
Fazel, S. and Yu, R. (2011), “Psychotic disorders and repeat offending: systematic review and meta-analysis”, Schizophreniar Bulletin, Vol. 37 No. 4, pp. 800-10
Fazel, S., Cartwright, J., Norman-Nott, A. and Hawton, K. (2008), “Suicide in prisoners: a systematic review of risk factors”, Journal of Clinical Psychiatry, Vol. 69 No. 11, pp. 1721-31
HMCIP (2014), Report on an Unannounced Inspection of HMP Durham, HMCIP, London
HMCIP (2015), HM Chief Inspector of Prisons for England and Wales Annual Report 2013-14, HMCIP 2014, London
HMPS (2006), “Clinical management of drug dependence in the adult prison setting”, DH, November, available at: www.dh.gov.uk/publications
Horton, M., Wright, N., Dyer, W., Wright-Hughes, A., Farrin, A., Mohammed, Z., Smith, J., Heyes, T., Gilbody, S. and Tennant, A. (2014), “Assessing the risk of self-harm in an adult offender population: an incidence cohort study”, Health Technology Assessment (Winchester, England), Vol. 18 No. 64, pp. 1-152
Kariminia, A., Law, M., Butler, T., Corben, S.P., Levy, M.H., Kaldor, J.M. and Grant, L. (2007), “Factors associated with mortality in a cohort of Australian prisoners”, European Journal of Epidemiology, Vol. 22 No. 7, pp. 417-28
Leese, M., Thomas, S. and Snow, L. (2006), “An ecological study of factors associated with rates of self-inflicted death in prisons in England and Wales”, International Journal of Law and Psychiatry, Vol. 29 No. 5, pp. 355-60
Ministry of Justice (2015), “Prison population figures: 2015 – population bulletin weekly 27 November 2015”, available at: www.gov.uk/government/statistics/prison-population-figures-2015 (accessed 3 December 2015)
Prison Drug Treatment Strategy Review Group (2010), The Patel Report: Reducing Drug-related Crime and Rehabilitating Offenders, Department of Health, London
Sacks, S., Sack, J., McKendrick, K., Banks, S. and Stommel, J. (2004), “Modified TC for MICA offenders: crime outcomes”, Behavioural Sciences and the Law, Vol. 22 No. 4, pp. 477-501
Sainsbury Centre for Mental Health (2007), Getting the Basics Right: Developing a Primary Care Mental Health Service in Prisons, Sainsbury Centre for Mental Health, London
Singleton, N., Meltzer, H. and Gatward, R. (1998), Psychiatric Morbidity among Prisoners in England and Wales, Office for National Statistics, London
Tompkins, C.N.E., Wright, N.M.J., Waterman, M.G., Sheard, L. and Bound, N. (2009), “Exploring buprenorphine misuse in prisons: a qualitative study of former prisoners”, International Journal of Prisoner Health, Vol. 5 No. 2, pp. 71-87
Torrey, E., Kennard, A., Eslinger, D., Lamb, R. and Pavle, J. (2010), More Mentally Ill Persons Are in Jails and Prisons than Hospitals: A Survey of the States, Treatment Advocacy Center, Arlington
Walmsley, R. (2009), World Prison Population List, 8th ed., King’s College London International Centre for Prison Studies, London
Wexler, H., De Leon, G., Thomas, G., Kressel, D. and Peter, J. (1999), “The amity prison TC evaluation: reincarceration outcomes”, Criminal Justice and Behaviour, Vol. 26 No. 2, pp. 147-67
Whiteford, H.A., Degenhardt, L., Rehm, J., Baxter, A.J., Ferrari, A.J., Erskine, H.E., Charlson, F.J., Norman, R.E., Flaxman, A.D., Johns, N., Burstein, R., Murray, C.J.L. and Vos, T. (2013), “Global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010”, Lancet, Vol. 382, November, pp. 1575-86
Wilper, A.P., Woolhandler, S., Boyd, J.W., McCormick, D., Bor, D.H., Himmelstein, D.U. and Lasser, K.E. (2009), “The health and health care of US prisoners : results of a nationwide survey”, American Journal of Public Health, Vol. 99 No. 4, pp. 666-72
Wright, N.M.J., French, C. and Allgar, V. (2014), “Methadone prescribing trends in prison: seven-year time-series analysis”, BMC Family Practice, Vol. 15 No. 64. doi: 10.1186/1471-2296-15-64, available at: http://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-15-64
Wright, N.M.J., Tompkins, C.N.E. and Farragher, T. (2015), “Injecting drug use in prison: prevalence and implications for needle exchange policy”, International Journal of Prisoner Health, Vol. 11 No. 1, pp. 17-29
Brooker, C., Repper, J., Beverley, C., Ferriter, M. and Brewer, N. (2002), Mental Health Services and Prisoners: A Review, ScHARR, University of Sheffield, Sheffield
Fazel, S., Benning, R. and Danesh, J. (2005), “Suicides in male prisoners in England and Wales, 1978-2003”, Lancet, Vol. 366 No. 9493, pp. 1301-2
Prisons and Probation Ombudsman for England and Wales (2011), Learning from PPO Investigations: Self-inflicted Deaths in Prison Custody 2007-2009, PPO, London
About the Guest Editors
Dr Nat Wright has worked with drug using prisoners for over 20 years. He has contributed to many national and international committees pertaining to healthcare delivery for offender populations and has published extensively in this area. Dr Nat Wright is the corresponding author and can be contacted at: mailto:email@example.com
Dr Pamela Walters consultant in forensic and addiction psychiatry of SWL and St Georges Mental Health Trust and South London & Maudsley Mental Health NHS Trust.
Professor John Strang is Head of Department for the Addictions academic activity of the IoPPN (Institute of Psychiatry, Psychology and Neuroscience), Kings College London, which includes conduct of diverse research studies and provision of educational activity in the Addictions. He is also Leader of the Addictions CAG (Clinical Academic Group), within the KHP AHSC (King’s Health Partners Academic Health Sciences Centre). He also holds an honorary appointment at, and is in a leadership position for, the Addictions clinical activity of the South London and Maudsley (SLaM) NHS Foundation Trust, which provides treatments in the drug, alcohol and smoking cessation fields (including in the prison environment). John Strang’s employer (King’s College London) has received, connected to his work, project grant support and/or honoraria and/or consultancy payments from Department of Health, NTA (National Treatment Agency), PHE (Public Health England), Home Office, NICE (National Institute for Health and Clinical Excellence), and EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) as well as research grants from (last three years) NIHR (National Institute on Health Research), MRC (Medical Research Council) and Pilgrim Trust. Has worked with WHO (World Health Organization), UNODC (United Nations Office on Drugs and Crime), EMCDDA, FDA (US Food and Drug Administration) and NIDA (US National Institute on Drug Abuse) and with other international government agencies. His employer (King’s College London) is registering intellectual property on an innovative buccal naloxone with which John Strang is involved, and John Strang has been named in a patent registration by a pharma company as inventor of a potential concentrated naloxone nasal spray. Along with his employer John Strang (King’s College London) has also received, connected to his work, research grant support and/or payment of honoraria, consultancy payments and/or travelling and/or accommodation and/or conference expenses from pharmaceutical companies (including, past three years, Martindale, Reckitt-Benckiser, MundiPharma, Braeburn/MedPace) and trial medication supply from iGen and also discussions with Alkermes, Fidelity International, Rusan, Titan, Indivior, Adapt, Camurus concerning medicinal products potentially applicable in the treatment of addictions and related problems and has argued for the development of improved formulations. This includes exploration of the potential for, and consideration of research trials of, improved medications with less abuse liability, longer duration of action (e.g. implant or depot formulations) and also novel non-injectable emergency medications. John Strang works closely with the charity Action on Addiction, and also with the Pilgrim Trust, and has received grant support from them. John Strang has previous close links with charitable funded providers, including Lifeline (Manchester), Phoenix House, KCA UK (Kent Council on Addictions), and Clouds (Action on Addiction). John Strang works (or has recently worked) with various drug policy organisations and advisory bodies including the UK Drug Policy Commission (UKDPC), the Society for the Study of Addiction (SSA), and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). For updated information see John Strang’s info on the Departmental website available at: www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx