Although previous studies have examined the prevalence of co-occurring mental and substance use disorders among patients in community-based treatment, this study extends prior research by examining the prevalence of specific categories and combinations of mental disorders and the clinical profiles associated with these various diagnostic groups among offenders in corrections-based treatment. Over two-thirds of the sample met criteria for at least one mental disorder, approximately one-third for mood disorders, one-quarter for anxiety disorders, and 45% with either borderline or antisocial personality disorder. Furthermore, lifetime mood or anxiety disorders and borderline personality disorder were strongly associated in this sample, whereas antisocial personality disorder did not increase one’s likelihood of having either a mood or anxiety disorder. This finding replicates that of the Verheul et al. (2000a)
study that was conducted with a community-based treatment sample, which similarly found a strong relationship between borderline personality disorder, but not antisocial personality disorder, and having a mood or anxiety disorder.
Several findings emerged with regard to the association of gender with diagnostic group and psychosocial functioning. A majority of the total sample (65%) was male, but there was a greater proportion of females than males among the group with only an Axis I disorder (57 versus 43%, respectively). This finding is not surprising, given the substantially higher prevalence of mood disorders among women, both in the general population (Kessler et al., 1996
) and in samples from correctional settings (Fazel & Danesh, 2002
; Jordan, Schlenger, Fairbank, & Caddell, 1996
; Pelissier & O’Neil, 2000
). However, women reported more problems related to physical health and to fights and arguments, and were more likely to have problems across multiple domains, after controlling for diagnosis. The greater likelihood of problems related to fights and arguments among women is unexpected and suggests that substance-abusing women offenders may be more likely to engage in, or to perceive, problems related to interpersonal conflict, as compared with their male counterparts. They also appeared to have more impaired functioning overall, which is consistent with the findings reported by Zlotnick, Clark, and Friedmann (2008)
in this issue.
Individuals with only an Axis II disorder generally had a profile indicative of an earlier initiation of both substance use and criminal behavior. This was evident in their lower ages at first arrest and at the initiation of alcohol, tobacco, and drug use; greater number of juvenile arrests; and lower age at initiation of drug treatment. As would be expected, this profile of those with Axis II disorders suggests a longer and more extensive history of criminal behavior, drug use, and associated problems. This profile is consistent with the dominant diagnosis within this group of antisocial personality disorder, which is characterized by a “pervasive pattern of disregard for and violation of the rights of others,” as displayed in rule-breaking, deceitfulness, impulsivity, aggressiveness, disregard for safety of self or others, irresponsibility, and lack of remorse (American Psychiatric Association, 1994
). The study findings further demonstrated the strong association of having an Axis II disorder with problems in pre-treatment psychosocial functioning across several domains, whether it was combined with an Axis I disorder or not.
There was a marked differentiation in the association of diagnostic group with several types of criminal activity reported prior to incarceration. Those with only an Axis I disorder had the lowest rates of several drug-related crimes, including public intoxication, drunk driving, possession of illegal drugs, and possession of drug paraphernalia, whereas those with only an Axis II disorder were predominant in most of these activities. In contrast, the group with both Axis I and Axis II disorders were more likely to report engaging in several types of property and violent crime, including forgery/fraud, prostitution/pimping, robbery, assault, kidnapping, and homicide. This group also had the highest rate of probation/parole violations. Thus, there was a potentiating effect of having both types of mental disorder on their profile of criminal behavior severity.
Similarly, there appeared to be more substance abuse severity among those with both Axis I and Axis II disorders. This group had the highest rates of individuals reporting use of hallucinogens and crack, whereas a greater proportion of those with only an Axis II disorder reported use of marijuana. Those with both types of disorder also had the highest proportion scoring above the TCUDS clinical cut-off and reporting that they had a history of drug overdose. This group also reported the highest number of symptoms of health and psychological problems, including suicidality and prior inpatient mental health treatment. The profile of those with both types of disorder, as suggested by these data, is that they have greater symptom severity regarding both their substance use and psychological status, more involvement in violent crime and less success in the community following parole (as seen in higher rates of parole violations). This profile is consistent with having symptoms related to both internalizing and externalizing disorders. Hence, treatment programming for this group may necessitate different clinical approaches to address this complex array of problems, such as longer duration and/or more intensive treatment. Multiple clinical approaches may be required for this group, including medication (for mood and anxiety symptoms) and cognitive behavioral therapies (for criminal thinking and behavior). The sequencing and integration of such approaches, within correctional settings, is an area for future investigation.
Interestingly, those with both types of disorder were also most likely to report having attended 12-step meetings in the past. It is not clear whether this high rate of 12-step participation was a result of being court-ordered into these programs or from self-initiation. Nearly all of the sample had tried to stop their drug use (for at least 3 months) at some point and there were no differences among groups in duration of prior periods of abstinence.
In addition, there was no significant difference among the groups with regard to their rating of the importance of receiving substance abuse treatment, with over 60% stating that their level of need was considerable or significant. It may be that this high level of treatment receptivity reflects the respondents’ interpretation of a socially desirable response, particularly since the assessments were administered within a treatment setting. Other studies have shown relatively high levels of problem recognition among inmates in substance abuse treatment (Pelissier & Jones, 2006
). This finding suggests that interventions can build upon offenders’ existing problem recognition at admission to prison-based treatment, even among those with co-occurring disorders, in order to enhance their engagement in treatment (Hiller, Knight, Leukefeld, & Simpson, 2002
As seen in the multivariate models, having an Axis II disorder, either alone or in combination with an Axis I disorder, was strongly associated with problems in pre-treatment psychosocial functioning across multiple domains. After controlling for demographics, individuals in these two diagnostic groups were approximately two to three times more likely than those without either an Axis I or Axis II disorder to experience serious problems in psychosocial functioning prior to their incarceration. The strongest association was between having problems in emotional health and having both an Axis I and Axis II disorder; however, individuals with only an Axis II disorder also reported greater problems in this area than those without any disorder.
The study is observational in nature, and hence the relationships between diagnostic groups and psychosocial functioning are correlational. Therefore, we cannot discern a causal ordering to the association between problems in functioning and the diagnostic profiles. Another consideration is that there is some overlap in diagnostic criteria for Antisocial Personality Disorder and psychosocial outcome domains, particularly regarding problems related to “fights and arguments,” as well as overlap between Axis I disorders and problems regarding “emotional health.” Yet the study findings suggest that problems in psychosocial functioning cut across both diagnostic groups and may have an additive effect on symptom severity for those with both types of disorder. Lastly, since study participants were sampled from prison-based substance abuse treatment programs, the study findings do not necessarily generalize to the general population of offenders (including those with substance use disorders who are not referred to or do not volunteer for treatment), and may be specific to those in who participated in treatment in these study sites.
In sum, the study findings provide clinically significant information on the diagnostic heterogeneity among this sample of offenders in corrections-based substance abuse treatment. Especially noteworthy was the high degree of association between Axis I (mood and anxiety) disorders and borderline personality disorder, despite the relatively small number of individuals with borderline personality disorder in this sample. Individuals with an Axis II disorder, either alone or combined with an Axis I disorder, emerged as having more severe problems in psychosocial functioning across a broad range of domains and those with both types of disorder had the highest level of symptom severity. This finding may stem from the additive effect associated with having both internalizing and externalizing disorders (Dennis et al., 2006
The criminal justice system—either in long-term prison facilities, jail, re-entry programs, or detention centers—is often unequipped to address the treatment needs presented by offenders with CODs (Center for Substance Abuse Treatment, 2005
; Chandler, Peters, Field, & Juliano-Bult, 2004
). Initial attempts to improve treatment for this group have focused on the integration of substance abuse and mental health services (Chandler & Spicer, 2006
; Drake, Morrissey, & Mueser, 2006
; Osher, Stedman, & Barr, 2003
). The findings from this paper suggest that more than service integration is required to address the treatment needs of offenders who present with complex diagnostic profiles, as examined in this study. Further, the high level of criminal justice contact among these individuals, and the difficulty in managing and treating their complex problems, requires a better level of understanding of their diverse treatment needs (Hills, 2000
). A goal for future clinical research should be to develop and test the efficacy of treatment approaches that specifically address the psychosocial and clinical profiles associated with these diagnostic profiles among offenders, in conjunction with health service strategies that can ensure the delivery of effective treatment to this population, within both correctional settings and community settings.