Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD Only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.     

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study.

OBJECTIVE: The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs. METHODS: Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years. RESULTS: Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction. CONCLUSIONS: Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success.     

Risk of Reincarceration Among Prisoners with Co-occurring Severe Mental Illness and Substance Use Disorders

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.     

Homelessness in the state and federal prison population

AIMS: This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs). METHOD: Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics. RESULTS: Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4-6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income. CONCLUSIONS: Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals.     

Three-year recovery outcomes for long-term patients with co-occurring schizophrenic and substance use disorders

Little is known about the expected treatment outcomes of patients with co-occurring schizophrenic and substance use disorders. This paper reports 3-year outcomes for 152 patients with schizophrenia or schizoaffective disorder and substance use disorders, all of whom received integrated dual disorders treatments in the New Hampshire Dual Diagnosis Study. Outcomes are defined as positive coping behaviors identified by consumers as indicators of recovery. Participants improved steadily in terms of controlling symptoms of schizophrenia, actively attaining remissions from substance abuse, increasing competitive employment, increasing social contacts with non-substance abusers, and improving life satisfaction. Though successful in reducing hospitalization and homelessness, they did not increase time in independent living situations. Outcomes were only weakly interrelated, suggesting that recovery is a multidimensional concept. Neither psychotic diagnosis (schizophrenia vs. schizoaffective disorder) nor substance abuse diagnosis (alcohol vs. other drug disorder vs. both) was related to outcomes. However, these patients with co-occurring schizophrenic and substance use disorders did significantly less well than patients with co-occurring bipolar and substance use disorders in terms of hospitalization, independent living, and quality of life. Overall, the findings provide a hopeful long-term perspective for dual diagnosis patients.     

A clinical and demographic comparison between a forensic and a general sample of female patients with schizophrenia

Diagnoses of psychiatric diseases do not include criminal behavior. In schizophrenia, a non-negligible subgroup is incarcerated for capital and other crimes. Most studies that compared offender and non-offender patients with schizophrenia have only focused on male patients. With this study, we compared demographic and disease-related characteristics between 35 female incarcerated forensic patients (fSZ) and 35 female inpatients with schizophrenia (SZ). Basic clinical documentation and basic forensic clinical documentation revealed significant clinical and demographic differences between the two groups. Compared to SZ, fSZ were more severely clinically impaired, showing higher rates of comorbid alcohol and substance disorder, more suicide attempts, had more previous hospitalizations, and were younger at disease onset. Regarding demographic variables, fSZ showed a higher rate of unemployment and homelessness and had to rely more often on housing and legal guardianships compared to SZ. These results suggest that female forensic patients with schizophrenia are more severely affected by clinical and non-clinical variables requiring an adapted intervention program. These results may also indicate two developmental trajectories for criminal and non-criminal schizophrenia in females.     

Comparison of four groups of substance-abusing in-patients with different psychiatric comorbidity.

OBJECTIVE: Comparisons of different groups of dual patients are rare, yet potential differences could have therapeutic implications. In this study, four groups of psychiatric in-patients with substance use disorder were compared to each other: patients with no psychiatric comorbidity, patients with comorbid schizophrenia and patients with affective and personality disorder. METHOD: Apart from sociodemographic, therapy-related variables and a detailed survey of their substance use, all subjects were assessed with BPRS and SCL-90-R. RESULTS: No differences were found in the patients' demography, psychosocial adjustment and substance consumption career. Significant differences were found in regard to some therapy variables reflecting adherence to treatment and global outcome and to the level of psychopathology. CONCLUSION: Both substance use and comorbid psychiatric disorder have a variable impact on distinct areas of patients' general condition and functioning. The group with comorbid affective disorder appeared to be the most difficult to treat and the therapeutic approach to this disorder deserves reconsideration.     

Risk of incarceration between cohorts of veterans with and without mental illness discharged from inpatient units

OBJECTIVE: This study examined the risk of incarceration among cohorts of veterans treated in the Department of Veterans Affairs (VA) Connecticut Healthcare System. Incarceration rates of persons with and without mental illness were compared and adjusted for various clinical and service utilization variables. Data were compared before and after the closure of over 80% of the Connecticut VA psychiatric inpatient beds in 1996. METHODS: Data from five annual cohorts of patients (1993-1997) treated in an inpatient unit in the VA Connecticut Healthcare System (N=36,385) were merged with state Department of Correction data. Logistic regression models were used to identify risk factors for incarceration. RESULTS: Bivariate analysis showed that incarceration rates were higher for VA patients with psychiatric disorders and with substance use disorders than for those without such diagnoses, but there were no significant increases in likelihood of incarceration over these years of extensive closures. In multiple logistic regression analysis only diagnoses of substance use disorders and major depression were independently associated with an increased likelihood of incarceration, whereas schizophrenia, personality disorders, and co-occurring psychiatric and substance use disorders were not independently associated with increased likelihood in multivariate analysis. CONCLUSIONS: Alcohol and drug problems appeared to account for much of the risk of incarceration among hospitalized veterans during the study period. Unlike in previous studies, schizophrenia and related psychotic disorders were not independently associated with an increased risk of incarceration.     

Prediction of homelessness within three months of discharge among inpatients with schizophrenia.

OBJECTIVE: The authors' goal was to identify factors that place inpatients with schizophrenia at risk of becoming homeless after hospital discharge. METHODS: Patients with schizophrenia or schizoaffective disorder (N=263) were assessed at discharge from general hospitals in New York City and reassessed three months later to evaluate whether they had become homeless. Sociodemographic and clinical characteristics associated with homelessness were identified using likelihood ratio chi square analysis and logistic regression. RESULTS: Twenty patients (7.6 percent) reported an episode of homelessness during the follow-up period. Patients who had a drug use disorder at hospital discharge were significantly more likely to report becoming homeless than those without a drug use disorder. Patients with a total score above 40 on the Brief Psychiatric Rating Scale (BPRS) at hospital discharge were more likely to report becoming homeless than patients with lower scores, as were those with Global Assessment Scores less than 43. Twelve of 30 patients with a drug use disorder, a BPRS score above 40, and a GAS score less than 43 at hospital discharge reported becoming homeless. CONCLUSIONS: The combination of a drug use disorder, persistent psychiatric symptoms, and impaired global functioning at the time of hospital discharge poses a substantial short-term risk of homelessness among patients with schizophrenia. Patients who fit this profile may be candidates for community-based programs that are specifically aimed at preventing homelessness among patients with severe mental illness.     

Behavioral interventions for dual-diagnosis patients.

Dual diagnosis patients come to treatment with a variety of deficits,talents, and motivations. A biopsychosocial treatment plan involves multiple interventions, including medications, medical treatment, psychotherapy, family therapy, housing, and vocational rehabilitation. Treatment must be individualized and integrated, and this requires collaboration among a variety of health caregivers. There is empirical evidence that dual-diagnosis patients can be helped to stabilize, to remain in the community,and even to enter the workforce. Behavioral interventions are key ingredients to integrated and comprehensive treatment planning. There is no single model for dual disorders that explains why substance use and psychiatric illness co-occur so frequently. Mueser et al described four theoretical models accounting for the increased rates of comorbidity between psychiatric disorders and substance use disorders. They suggested that there could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other. There is evidence for each, although some are more compelling than others, and none is so compelling that it stands alone. Although family studies and genetic research could explain the common factor, no common gene has appeared. Antisocial personality disorder has been associated with very high rates of substance use disorders and mental illness; however, its prevalence is too low to explain most of the co-occurring phenomena. Common neurobiology, specifically the dopamine-releasing neurons in the mesolimbic system, also may be involved in mental illness, but this is not compelling at the moment. The Self-medication model is very appealing to mental health professionals, as an explanation for the secondary substance abuse model. Mueser et al suggest that three lines of evidence would be present to support this explanation: (1) patients would report beneficial effects of substance use on their symptoms; (2) epidemiology would report that a specific substance would be used by specific psychiatric disorders, and (3) psychiatric patients with severe symptoms would be more likely to abuse substances than those with mild symptoms. Unfortunately the research data do not support these. The primary substance abuse causing secondary psychiatric disorder model could be explained by neuronal kindling from substance-induced disorders. Patients who develop the psychiatric disorder after the substance use disorder do have a course of illness similar to those with a psychiatric disorder, but without substance use disorder. The bidirectional model is consistent with the tendency of disturbed teenagers to socialize with youth using alcohol and drugs; however, this model has not been tested rigorously in research studies. With such a disparate set of models, behavior interventions are conceptualized best as a multi-component program, a treatment plan that generates a problem list and devises an intervention to respond to each member of the list. This requires a talented, multi-disciplinary team or network that can assess carefully and package the interventions creatively, and dose the treatment components empathically to fit the patient's tolerance, motivation, and abilities.     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Chronically mentally ill patients with and without substance use disorders: a pilot study

The study was designed to assess characteristics of chronic mentally ill patients with and without a substance use disorder. Study patients (n=48) had either psychiatric illness alone (they received conventional psychiatric rehabilitation) or dual diagnoses (they received mental illness and substance abuse services). All patients were administered the Brief Symptom Inventory (BSI), the Client Satisfaction Questionnaire, the Perceived Social Support Scales, and the Composite International Diagnostic Interview. Higher proportions of dually diagnosed patients had schizophrenia, had higher scores on the BSI, and were less satisfied with treatment.     

Risk factors for HIV,hepatitis B,and hepatitis C among persons with severe mental illness

OBJECTIVE: Previous reports have indicated that persons with severe mental illness have an elevated risk of contracting HIV, hepatitis B, and hepatitis C compared with the general population. This study extends earlier findings by examining the factors that are most predictive of serologic status among persons with severe mental illness. METHOD:S: A total of 969 persons with severe mental illness from five sites in four states were approached to take part in an assessment involving testing for blood-borne infections and a one-time standardized interview containing questions about sociodemographic characteristics, substance use, risk behaviors for sexually transmitted diseases, history of sexually transmitted diseases, and health care. RESULTS: The greater the number of risk behaviors, the greater was the likelihood of infection, both for persons in more rural locations (New Hampshire and North Carolina), where the prevalence of infection was lower, and those in urban locations (Hartford, Connecticut; Bridgeport, Connecticut; and Baltimore, Maryland), where the prevalence was higher. Although no evidence was found that certain behaviors increase a person's risk of one blood-borne infection while other behaviors increase the risk of a different infection, it is conceivable that more powerful research designs would reveal some significant differences among the risks. CONCLUSION:S: Clinicians should be attentive to these risk factors so as to encourage appropriate testing, counseling, and treatment.     

Gambling disorders among homeless persons with substance use disorders seeking treatment at a community center

OBJECTIVES: Epidemiological research suggests that homelessness is a risk factor for elevated levels of psychiatric comorbidity and other health risks. This study examined the prevalence of disordered gambling and its association with treatment of psychiatric and substance use disorders among a cohort of homeless people seeking treatment at a community services program. METHODS: Between 1998 and 2000, intake workers evaluated the level of gambling disorder among 171 consecutive homeless persons with substance use disorders who sought treatment at the Moving Ahead Program in Boston. Program staff administered the DSM-IV subscale of the Massachusetts Gambling Screen at intake. RESULTS: The prevalence rates of level 2 and level 3 gambling disorders were 12.8 percent and 5.5 percent, respectively. These rates are higher than that of the general adult population but comparable to those of other patients with substance use disorders and psychiatric diagnoses. Program participants with level 3 gambling disorders had been homeless more often and at a younger age and had had less substance abuse treatment and more psychiatric treatment than participants with level 1 or level 2 gambling disorders. Participants with level 2 gambling disorders had been homeless more often and for a longer duration than participants without gambling disorders. CONCLUSIONS: These findings should encourage clinicians working with homeless people to screen for gambling-related problems and disorders.     

Criminal conviction, impulsivity, and course of illness in bipolar disorder

Swann AC, Lijffijt M, Lane SD, Kjome KL, Steinberg JL, Moeller FG. Criminal conviction, impulsivity, and course of illness in bipolar disorder.
Bipolar Disord 2011: 13: 173–181. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objective: Criminal behavior in bipolar disorder may be related to substance use disorders, personality disorders, or other comorbidities potentially related to impulsivity. We investigated relationships among impulsivity, antisocial personality disorder (ASPD) or borderline personality disorder symptoms, substance use disorder, course of illness, and history of criminal behavior in bipolar disorder. Methods: A total of 112 subjects with bipolar disorder were recruited from the community. Diagnosis was by Structured Clinical Interview for DSM‐IV (SCID‐I and SCID‐II); psychiatric symptom assessment by the Change version of the Schedule for Affective Disorders and Schizophrenia (SADS‐C); severity of Axis II symptoms by ASPD and borderline personality disorder SCID‐II symptoms; and impulsivity by questionnaire and response inhibition measures. Results: A total of 29 subjects self‐reported histories of criminal conviction. Compared to other subjects, those with convictions had more ASPD symptoms, less education, more substance use disorder, more suicide attempt history, and a more recurrent course with propensity toward mania. They had increased impulsivity as reflected by impaired response inhibition, but did not differ in questionnaire‐measured impulsivity. On logit analysis, impaired response inhibition and ASPD symptoms, but not substance use disorder, were significantly associated with criminal history. Subjects convicted for violent crimes were not more impulsive than those convicted for nonviolent crimes. Conclusions: In this community sample, a self‐reported history of criminal behavior is related to ASPD symptoms, a recurrent and predominately manic course of illness, and impaired response inhibition in bipolar disorder, independent of current clinical state.     

Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Violent victimization of persons with co-occurring psychiatric and substance use disorders

OBJECTIVE: This study examined the frequency with which persons in the community with psychiatric disorders, substance use disorders, and both types of disorders are victims of violence. METHODS: The relationship between diagnosis, gender, and victimization over a one-year period was examined in two cross-sectional data sets, one drawn from a study of adaptation to community life of persons with severe mental illness in Connecticut (N=109) and the other drawn from assessments made by caseworkers in a Connecticut outreach project for persons with psychiatric and substance use disorders (N=197). Analysis of variance was used to evaluate the frequency of victimization across diagnostic categories in each data set. RESULTS: People with co-occurring psychiatric and substance use disorders had significantly more episodes of victimization than those with either a psychiatric or a substance use disorder only. Gender was not associated with victimization. Qualitative data from focus groups indicated that social isolation and cognitive deficits leading to poor judgment about whom to trust may leave people with serious mental illness vulnerable to drug dealers. CONCLUSIONS: Social environmental mechanisms, such as exploitation by drug dealers, may play an important role in maintaining victimization among persons with co-occurring disorders.