Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Surveys of the general population and of criminal justice populations have established that substance use disorders commonly occur among those with serious mental illnesses (SMI) and vice versa. Although precise estimates are not available, it has also been shown that those with co-occurring psychiatric and substance use disorders (CODs) are at increased risk for a variety of medical conditions such as tuberculosis and hepatitis C and for sexually transmitted diseases (STDs) such as gonorrhea and HIV/AIDS. This study sought to examine the relative rates of CODs and medical disorders in a sample comprised of adult male and female detainees in a jail-based, residential psychiatric treatment program.

Methods: Lengthy, structured interviews with 32 randomly selected male (N=16) and female (N=16) detainees in residential psychiatric treatment at a large urban jail were conducted using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI). We assessed lifetime and past-year substance use and psychiatric disorders based on DSM-IV criteria as well as lifetime medical conditions. We also reviewed the medical records of a separate group of 120 randomly selected male (N=60) and female (N=60) detainees who had received residential psychiatric treatment at the jail and were discharged. Medical records were coded for psychiatric and substance use diagnoses as well as for medical conditions as indicated by treating physicians.

Findings: The most prevalent psychiatric disorders for the men (based on our interview data) were: psychotic disorder (44%), post-traumatic stress disorder (PTSD; 38%), and major depressive episode (31%). The most prevalent psychiatric disorders for the women (based on our interview data) were: PTSD (69%), major depressive episode (50%), dysthymia (44%), and psychotic disorder (44%). Despite the high rates of PTSD for men and (especially) for women, this disorder was never diagnosed on the treatment units per the medical records review. Co-occurring substance use disorders were also common among both men (56%) and women (69%). Medical conditions reflecting stress or trauma such as lower back pain, severe headaches and high blood pressure were common as was asthma. Many participants (> 50%) reported being in chronic pain of one type or another including arthritic pain. The rate of HIV infection for the interviewed sample (2/32) and for the chart abstraction sample (6/120) was near 6% and is multiple times higher than for the general population.

Implications: The considerable overlap among psychiatric, substance use and medical conditions requires more study to learn about the longitudinal inter-relationships among these conditions and how individuals seeking treatment interface with the criminal justice and treatment systems and how these systems interact with each other. Among criminal justice populations in psychiatric treatment (and likely drug treatment) the rates of co-occurring PTSD are very high, especially among women and appear to go undiagnosed and, as a result, untreated. The high rates of reported chronic pain suggest that substance use in this population may be due, in part, to an attempt to manage physical pain and hence treatment for pain may help reduce the use of alcohol and other drugs among those with CODs.