Commentary: implications for assessment and treatment of addictive and mentally disordered offenders entering prisons

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.     

Mental disorders in a forensic sample of sexual offenders.

OBJECTIVE: - The present study examined the prevalence of DSM IV axis I disorders and DSM IV personality disorders among sexual offenders in Forensic State Hospitals in Germany. METHOD: - Current and lifetime prevalence rates of mental disorders were investigated based on clinical structured interviews among sexual offenders (n = 55). Additionally, subgroups were analyzed on the basis of diagnostic research criteria, with 30 sexual offenders classified as paraphiliacs and 25 sexual offenders as having an impulse control disorder (without paraphilia). RESULTS: - Anxiety disorders, mood disorders, and substance use disorders were common among sexual offenders, as were cluster B and cluster C personality disorders. While social phobia was most common among paraphilic sexual offenders, major depression was most prevalent in impulse control disordered sexual offenders. CONCLUSION: - The results replicate recent findings of high psychiatric morbidity in sexual offenders placed in forensic facilities. Furthermore, differential patterns of co-morbid mental disorders were found in paraphiliacs and impulse control disordered sexual offenders. With regard to an effective therapy and relapse prevention co-morbid mental disorders should be a greater focus in the assessment of subgroups of sexual offenders.     

Mental health and associated factors among young offenders in Chile: a cross‐sectional study

Background

Few studies in Latin America have explored mental disorder among young offenders, or variables associated with it.

Aims

Our aim was to test for associations between childhood adversity or substance misuse and psychiatric disorders among young offenders.

Methods

Sentenced adolescent offenders were recruited from young offenders' institutions or community centres provided by the Chilean National Service for Minors. Psychiatric disorders were assessed using the Mini International Neuropsychiatric Interview, conducted by trained psychologists. A trained sociologist used an ad hoc interview to collect information about childhood experiences, including parenting, trauma, education and substance misuse. Multivariable logistic regressions were used to analyse data.

Results

The most prevalent psychiatric disorders among the 935 participants were marijuana dependence disorder, major depressive disorder, and anxiety disorders. Substance use disorders were less frequent among young offenders who were serving their sentence in young offenders' institutions than among those serving in community centres and more frequent among those who started to use marijuana at an earlier age. Among other variables, childhood maltreatment was related to major depressive disorder, and maternal death to anxiety disorders. Higher educational status was related to a lower frequency of depressive and anxiety disorders.

Conclusions

Our findings suggest that greater efforts must be made to identify vulnerable young people much earlier. Few of these young offenders with mental health problems had been well adjusted in health, education or socially before this period of detention. © 2017 The Authors. Criminal Behaviour and Mental Health Published by John Wiley & Sons Ltd     

Prevalence of psychiatric disorders in an urban community in Bangladesh

There is a critical lack of information on the epidemiology of mental health problems in Bangladesh. The present study aimed at assessing the prevalence and pattern of psychiatric disorders in an urban community in Dhaka, Bangladesh, and identifying associated socio-demographic factors. A total of 1145 respondents aged 18 years and above were screened for psychiatric disorders using the Self Reporting Questionnaire (SRQ), a stratified random sub-sample that were assessed by a psychiatrist. A structured questionnaire was also used to collect socio-demographic information. We found that the prevalence of psychiatric disorders was 28%. Somatoform disorders were the most common among the respondents, followed by mood, sleep, anxiety, and substance related disorders. Females and persons from the higher socio-economic classes were more likely to have a psychiatric disorder. Psychiatric morbidity is a significant and unrecognized public health problem in urban Bangladesh.     

Psychopathology in adolescent and young adult criminal offenders (15–21 years) in Sweden

Background This study examined rates of psychopathology among adolescent and young adult serious offenders referred to pre-sentence forensic psychiatric services and compared patterns of psychiatric morbidity with adult forensic referrals and age-matched general psychiatric inpatients. Methods In Sweden, criminal offenders can be referred for an extensive court-ordered pre-sentence inpatient forensic psychiatric examination (FPE). Data on all 3,058 of these offenders (90% male, mean age = 35.3 years) during 1997–2001 were obtained from the National Board of Forensic Medicine. We compared DSM-IV psychiatric diagnoses across age bands 15–17 years (N = 60), 18–21 years (N = 300) and 22 years and older (N = 2,698). Comparative data by age bands were also obtained for inpatient diagnoses among individuals admitted to general psychiatric hospitals. Results Compared with the adult forensic psychiatric examinees, those aged 15–17 years and 18–21 years had higher rates of depression, and childhood and developmental disorders but lower rates of psychosis, bipolar disorder, and substance use disorders. Compared with general psychiatric inpatients, offenders aged 15–17 years had higher prevalences of depression and attention-deficit or disruptive disorders and lower ones of alcohol and drug misuse disorders. Conclusions There are significant differences in patterns of psychiatric morbidity in adolescent and young adult offenders that come into contact with psychiatric services compared with older offenders and adolescent psychiatric inpatients. This suggests that the development of health services addressing the psychiatric needs of younger offenders needs to draw on information on their specific mental health needs.     

Evaluation of Quality of Life of Primary Health Care Patients in Brazil: Influence of Drug Interactions,Common Mental Disorders,and Use of Psychiatric Medication

The objectives of this study were to identify the interaction between drug interaction risk, common mental disorders, use of psychiatric medication and quality of life in patients treated in primary health care settings in Brazil. In this quantitative research, 452 patients were interviewed in ten basic Brazilian health units. Sociodemographic and pharmacotherapeutic questionnaires, use of psychiatric medication, prevalence of common mental disorders, and quality of life were utilised. The structural equation model was used to evaluate the relationships among the variables. The prevalence of drug interaction risk was 66.59%. The variables associated with drug interaction risk were polypharmacy and income. The use of psychiatric medication was associated with diagnosis of common mental disorders, income and gender. The use of psychiatric medication and common mental disorders negatively influenced quality of life.

     

The prevalence of mental health disorders amongst offenders on probation: A literature review

Background There is increasing focus on addressing the mental health needs of offenders throughout the criminal justice system. However, there is currently a gap in the literature for a review of research into the prevalence of mental health disorders amongst offenders on probation. Aims To review existing literature on the prevalence of mental health disorders in probation populations in order to inform the provision of health services to this group. Method A comprehensive review of the literature on the topic to date across ASSIA, Web of Science, IBSS, CINAHL and MEDLINE databases. Results A total of 18 papers were identified. Four of these studies were based on probation approved premises, six on probation psychiatric services and eight on broader probation populations. The prevalence of mental illness reported varies widely across these papers. Conclusion One can tentatively conclude that there is a high prevalence of mental illness and high rates of co-morbidity in offenders on probation. However, variation in study settings and methodology make it difficult to reach firm conclusions on the likely prevalence of mental illness in probation populations from the existing literature. There is a need for further high-quality research in this area.     

Mental, physical and functional status in primary care attenders

OBJECTIVE: The purpose of the present study was to analyze the association, in primary care attenders, between psychiatric disorders, medical comorbidity, and impairment in mental and physical function status. METHODS: The study had a two-stage design. The GHQ-12 was used to screen 1647 patients, and 323 of them were then interviewed using the CIDI-PHC to obtain ICD-10 diagnoses. Severity of mental illness was assessed using the Hamilton scales for anxiety and depression. The DUSOI was used to evaluate the severity of physical illness. The MOS SF-36 was used to assess health related quality of life. RESULTS: The estimated prevalence of ICD-10 psychiatric disorders and subthreshold disorders was 12.4 percent and 18 percent respectively. The most common psychiatric disorders were generalized anxiety, major depression, and neurasthenia. The severity of physical illness did not vary across diagnostic status categories. Significant impairment, both in physical and mental functioning was seen in patients suffering from ICD-10 full-fledged and subthreshold disorders. Severity of impairment increased from sub-threshold cases to full-fledged cases, and among the latter according to the severity of depressive and anxious symptoms, assessed using Hamilton scales. The most frequent psychiatric disorders were associated with significant worsening in health related quality of life, with relevant differences between psychiatric diagnoses regarding the domains affected. Impairment associated with mental disorders was greater than that associated with physical illness. CONCLUSIONS: The results of the present study confirm that ICD-10 psychiatric disorders are common in general practice and are associated with relevant impairment in physical and mental functional status. Psychiatric morbidity is not related to severity of physical illness rated by general practitioner.     

Race-ethnicity and the prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and Axis I and II disorders: United States, 2001 to 2002

The objective of this study was to compare the current prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and mood, anxiety, and personality disorders among whites, blacks, Native Americans, Asians, and Hispanics in a large representative sample of the US population. Striking mental health disparities were observed in the prevalences of psychiatric disorders, especially among Native Americans. Disparities in psychiatric comorbidity differed from those associated with prevalence. Most significantly, the association between alcohol disorders and personality disorders was significantly greater among Asians relative to whites, blacks, and Native Americans, despite lower prevalences of these disorders among Asians. Taken together, the results of this study highlight the need of future studies that help unravel the risk factors underlying the disparities in both prevalence and comorbidity of psychiatric disorders observed among race-ethnic groups in the United States.     

The prevalence of personality disorders,psychotic disorders and affective disorders amongst the patients seen by a community mental health team in London

BACKGROUND: There is a lack of information regarding the prevalence and co-occurrence of personality disorders, psychotic disorders and affective disorders amongst patients seen by community mental health teams. This study aims to describe the population of patients served by a community mental health team in South London in terms of demographic and clinical characteristics. METHOD: Computerised hospital records and keyworkers' caseloads were used to identify 193 patients. The Standardised Assessment of Personality was used to assess personality disorders and the Operationalised Criteria Checklist was used to assess psychotic and affective disorders. RESULTS: Fifty-two per cent of patients met the criteria for one or more personality disorders, 67 % of patients had a psychotic illness and 23 % had a diagnosis of a depressive disorder. Community psychiatric nurses (CPNs) mainly saw patients with psychotic illnesses. The non-psychotic patients seen by CPNs had extremely high rates of personality disorder. Patients seen by psychiatrists and psychologists had significantly lower rates of personality disorder. CONCLUSIONS: The prevalence of personality disorder is high amongst patients seen by community mental health teams. Possible explanations for this are presented and implications for community care are discussed.     

Epidemiology of psychiatric disorders in very young children in a Romanian pediatric setting

A growing literature demonstrates that early clinical intervention can reduce risks of adverse psychosocial outcomes. A first step necessary for developing early intervention services is to know the prevalence of clinical disorders, especially in systems that are rebuilding, such as Romania, where the mental health system was dismantled under Ceausescu. No epidemiologic studies have examined prevalence of psychiatric disorders in young children in Romania. The objective of this study was to determine the prevalence of psychiatric disorders in Romanian children 18–60 months in pediatric settings. Parents of 1,003 children 18–60 months in pediatric waiting rooms of two pediatric hospitals completed background information, the Child Behavior Checklist (CBCL). A subgroup over-sampled for high mental health problems were invited to participate in the Preschool Age Psychiatric Assessment. Rates of mental health problems were similar to the US norms on the CBCL. The weighted prevalence of psychiatric disorders in these children was 8.8%, with 5.4% with emotional disorders and 1.4% with behavioral disorders. Comorbidity occurred in nearly one-fourth of the children with a psychiatric disorder and children who met diagnostic criteria had more functional impairment than those without. Of children who met criteria for a psychiatric disorder, 10% of parents were concerned about their child’s emotional or behavioral health. This study provides prevalence rates of psychiatric disorders in young Romanian children, clinical characteristic of the children and families that can guide developing system of care. Cultural differences in parental report of emotional and behavioral problems warrant further examination.     

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

Objectives The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan. Methods A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders. Results Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders. Conclusions Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.     

Psychiatric disorders among poor victims following a major disaster: Armero, Colombia

We evaluated 102 adult victims of low socioeconomic status living in tent camps 8 months following the Armero disaster in Colombia to ascertain the level of psychiatric morbidity. Ninety-one percent of the subjects identified by the screening instrument as being emotionally distressed met DSM-III criteria for a psychiatric disorder. The most frequent diagnoses were posttraumatic stress disorder and major depression. These findings indicate that a simple screening instrument can be reliably used for the detection of significant emotional problems among disaster victims. They also show that these victims are not merely distressed; rather, they present clear and treatable psychiatric disorders that center on anxiety and depression. Interventions for their adequate management need to be designed, implemented, and evaluated. In a developing country, however, the high prevalence of mental disorders among disaster victims far exceeds the specialized mental health resources. The general health sector, particularly the primary level of care, must participate actively in the delivery of mental health services to meet this need, particularly for a socioeconomically disadvantaged population. The narrow range of psychiatric disorders detected among the disaster victims makes it possible to circumscribe the training of the primary care worker in disaster mental health to these priority conditions.     

Mental Health Referrals Reduce Recidivism in First-Time Juvenile Offenders,But How Do We Determine Who is Referred?

While psychiatric disorders are common among juvenile delinquents, many mental health problems go undetected, increasing the likelihood for persistent difficulties. This is the first known study to examine mental health referral rates and recidivism in the juvenile justice system. In addition to the study, we review juvenile justice mental health screening to improve detection and treatment. Juvenile criminal records in conjunction with behavioral health screenings were analyzed to determine differences in referrals and recidivism among first time offenders. Recidivism rates were significantly lower (p = 0.04) and time to recidivism was significantly longer (p = 0.03) for those referred specifically for mental health services than for those without any referrals, even after adjusting for offense severity. While black youths had a significantly higher recidivism rate (p = 0.02) and a shorter time to recidivism (p = 0.009) than white youths, there was no significant difference between races when referred specifically for mental health services. Among the groups studied, black youths had the most profound positive effect from mental health referrals (p < 0.0001). This study indicates the importance of detecting mental health problems among juvenile delinquents, especially for black offenders. The apparent protective effect of mental health interventions necessitates screening that better identifies underlying psychosocial factors rather than strict reliance upon diagnostic criteria and self-report. Broader or even universal mental health referrals for juvenile offenders could reduce future legal system involvement and costs to society. We review potential reasons that mental health problems go undetected and provide recommendations.     

Psychiatric disorders among the Mapuche in Chile

BACKGROUND: The Mapuche are the largest indigenous group in Chile; yet almost all data on the mental health of indigenous populations are from North America. AIM: The study examines the differential DSM-III-R prevalence rates of psychiatric disorders and service utilization among indigenous and non-indigenous community residence. METHODS: The Composite International Diagnostic Interview (CIDI) was administered to a stratified random sample of 75 Mapuche and 434 non-Mapuche residents of the province of Cautín. Lifetime prevalence and 12-month prevalence rates were estimated. RESULTS: Approximately 28.4% of the Mapuche population had a lifetime, and 15.7% a 12-month, prevalent psychiatric disorder compared to 38.0% and 25.7%, respectively, of the non-Mapuche. Few significant differences were noted between the two groups; however, generalized anxiety disorder, simple phobia, and drug dependence were less prevalent among the Mapuche. Service utilization among the Mapuche with mental illness was low. CONCLUSIONS: This is a preliminary study based on a small sample size. Further research on the mental health of indigenous populations of South America is needed.     

Treatment of offenders with mental disorders: focusing on prison psychiatry

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.     

Changes in child and adolescent inpatient psychiatric admission diagnoses between 1995 and 2000

This study examined changes in the prevalence of psychiatric diagnoses at admission among children and adolescents treated for mental health problems in psychiatric inpatient settings between 1995 and 2000. Using a large, nationwide database (MarketScan) of private health insurance claims, our sample consisted of 5,346 children under the age of 18 who received psychiatric inpatient services, out of a total of 1,723,681 covered children. Odds ratios were used to measure changes in the prevalence of specific mental health disorders between 1995 and 2000. The study identified several significant changes, most notably, that the proportion of hospitalized children treated for bipolar or eating disorder doubled between 1995 and 2000. Significant decreases were observed for adjustment, anxiety, oppositional, and substance abuse disorders. This study lends support to recent concerns that the prevalence of bipolar disorder among the youth is increasing. Further research is needed to identify the underlying reasons for these observed changes.     

Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care

OBJECTIVE: Prevalence rates of mental health problems in primary care vary according to population and the type of measure used. This study examined the prevalence of a full range of mental health problems, including sub-threshold diagnoses, and the socio-demographic risk factors for psychiatric disorders among a population with low out-of-pocket expenditures for medical care. METHOD: Four validated mental health assessment instruments, including the CIDI-SF, were administered to a sample of 976 users of primary care in Israel between the ages of 25-75 in eight clinics throughout the country. Prevalence estimates were obtained for seven psychiatric diagnoses, two "other mental health disorders" (somatization and disordered eating) and five sub-threshold conditions. RESULTS: The most common types of morbidity were depression and disordered eating (20.6% and 15.0%, respectively), followed by somatization (11.8%) and general anxiety (11.2%). Among respondents, 31.1% had at least one psychiatric diagnosis, 24.3% had 'other mental disorders' and 15.5% had sub-threshold conditions. Panic attack, disordered eating and somatization, as well as a global measure of any psychiatric diagnosis were significantly more prevalent among women than men. Psychiatric diagnoses were also more common among those in the age group 45-64, with less education and insufficient income, the never married and separated/divorced and those not working. No significant differences were found between recent immigrants, veteran immigrants and Israeli-born, between Arab and Jewish Israelis or between secular or religious sectors of the population. CONCLUSIONS: This study establishes the prevalence of the most common disorders in primary care including PTSD, somatization and disordered eating behaviors. The additional of other mental disorders suggests that a more accurate picture of mental disorders in primary care requires an expanded assessment procedure.     

A 3-year panel study of mental disorders among adolescents in Taiwan

OBJECTIVE: This study investigated the prevalence and changing trends of mental disorders and the effects of gender and urbanization among adolescents in Taiwan. METHOD: A random sample of seventh-grade students (N=1,070) was recruited from one urban and one rural junior high school in which 1,051 (98.2%) and 1,035 (96.7%) were reassessed in the second and third years, respectively. A two-stage case identification was conducted by mental health professionals with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version, supplemented by information from the Child Behavior Checklist. RESULTS: The weighted 3-month prevalence rates across the 3 consecutive years for overall psychiatric disorders were 20.3%, 22.7%, and 14.8%, respectively. The most prevalent psychiatric condition was attention deficit hyperactivity disorder (ADHD) in the first 2 years and substance use disorders in the third. During the 3 years, the rates for ADHD, specific phobia, and social phobia decreased, and the rates for major depression and substance use disorders, conversely, increased. Although conduct disorder, ADHD, and substance use disorders were more prevalent among boys, the rates for major depression, social phobia, specific phobia, and adjustment disorder were higher among girls. Rural adolescents had higher rates of conduct disorder, oppositional defiant disorder, and substance use disorders than their urban counterparts. CONCLUSIONS: Our findings are similar to those of previous studies among adolescents in prevalence rates, changing trends of most mental disorders, and gender effects. The differential changing trends in various diagnostic groups may imply the importance of specific measures for prevention during adolescence.     

Japan needs more forensic psychiatrists

In recent years increased consideration has been given to the human rights of Japanese psychiatric patients and there have been significant improvements in the care afforded to them. It is argued that mentally disordered offenders have not yet benefited to the same extent as general psychiatric patients and further improvements could be achieved. This paper describes the forensic mental health system in Japan and institutions which provide services for mentally disordered offenders. At present there are no hospital units specifically designed to care for mentally ill offenders and most are detained within general psychiatric facilities. There is no equivalent to Part III of the English Mental Health Act 1983 enabling courts and prisons to transfer people to hospital, so that offender patients are detained by the use of civil sections as defined in the Japanese ‘Mental Health Law’ of 1987 (translated by the Mental Health Division of the Health Service Bureau of the Ministry of Health and Welfare of Japan,1988). Some mentally abnormal offenders are incarcerated in prison or medical prisons where they can be treated against their will and where they do not have effective access to an independent appeal system. It is the author’s view that the development of forensic psychiatry would be an important stimulus to improving the care given to mentally disordered offenders both within institutions and in the community.