which allows different interviewers
Brief Reports
Substance Abuse and Psychiatric
Disordersin Prison Inmates
John A. Chiles, M.D.
Elizabeth Von Cleve, Ph.D.
Ron P. Jemelka, Ph.D.
Eric W. Trupin, Ph.D.
The numberofmentally ill offenders
in prison has risen dramatically oven
the past decade. Reasons for this in
crease include a drop in the number
of long-term psychiatric beds, de
creasing community support, and
rigid criteria for civil commitment
(1). In addition, certain character
istics that are prevalent among men
tally ill individuals increase the like
lihood of incarceration. These char
actenistics include use ofillicit drugs,
failure to continue in treatment, and
violent behavior (2). Substance
abuse among the offender popula
tion has beenwell documented (3,4).
The nature and extent of substance
abuse among the subpopulation of
mentally ill offenders have not been
as thoroughly explored and are the
subject of this report.
Methods
Subjects. Interviewers solicited vol
unteens for the study from among
inmates at the Washington State
Corrections Reception Center, the
initial site of incarceration for more
than 95 percent of male prisoners
Dr. Chiles is associate professor,
Dr. Von Cleve is clinical instruc
tor, Dr. Jemelka is assistant pro
fessor, and Dr. Trupin isprofessor
in the department of psychiatry
and behavioral sciences at the
University ofWashington School
of Medicine in Seattle. Address
correspondence to Dr. Chiles at
Harborview Medical Center, ZA
15, 325 Ninth Avenue, Seattle,
Washington 98104.
1132
entering the Washington State pni
son system. A total of 109 male of
fenders were interviewed. The study
was conducted in accordance with
the institution's policy stipulating
that inmates must give informed
consentto participate in any research
activity.
To determine if the sample was
representative of the Washington
State inmate population, the group
who were interviewed were corn
pared with a larger sample of 1,409
consecutive admissions to the necep
iion center. No significant diffenenc
es between the groups in age, eth
nicity, marital status, offense, on IQ
were found. In addition, no differ
ences between groups were found in
scores on the Minnesota Multiphasic
Personality Inventory, the Buss
Durkee Hostility Inventory, the Sui
cide Probability Scale, the Veterans
AlcoholScneeningTest,onthe Mon
roe Dyscontrol Scale. Individuals
who show extremely violent on psy
chotic behavior are sent directly to a
prison psychiatric ward. Thus in
mates with severe psychiatric distur
bance are probably undenrepresent
ed in the sample discussed in this
paper.
Measures. Responses to ques
iions on the Diagnostic Interview
Schedule (DIS) (5) were used to de
tenmine lifetime prevalence of the
following DSM-IH-R axis I or axis II
diagnoses: depression, dysthymia,
alcohol abuse on dependence, drug
abuse on dependence, schizophre
nia, schizophreniform disorder,
mania, and antisocial personality dis
order. To assess intenraten reliability,
pairs of interviewers drawn from a
group of five interviewed 24 in
mates. The diagnoses made in each
joint interview were analyzed using
an extension of kappa (kappa v) (6),
October 1990 Vol. 41 No. 10
to make a diagnosis for each subject
aslong as the number of interviewers
pen subject remains the same. A high
level of internater reliability was
found: .71 for dysthymia; .86 for al
cohol abuse on dependence; .91 for
depression; and 1.0 for drug abuse
and dependence, mania, schizophre
nia, schizophreniform disorder, and
antisocial personality.
Results
Psychiatric diagnoses.Ninety-six
of 109 offenders in this study (88
percent) received at least one psychi
atric diagnosis. The prevalence of
each diagnosis in the sample, shown
in Table 1, was compared with life
time prevalence rates for the general
population available from recent
literature (7,8). Although statistical
comparison between the data sets
was not possible, the prevalence of
each diagnosis was higher in the of
fender group than in the general
population. Compared with the gen
enal population, offenders were five
to 30 times more likely to be given
one of the psychiatric diagnoses
listed in Table 1. These results sup
port the hypothesis that rates of the
psychiatric illnesses studied are high
en in an offender population than in
the community (1).
Substance abuse andmental ill
ness. The prevalence ofchemical de
pendency in inmates with a psychiat
tic diagnosis is reported in Table 1.
Symptoms of alcohol or drug abuse
on dependence were reported by 92
percent of the inmates with antiso
cial personality disorder and by 82
percent of the inmates with depres
sion. All offenders with a diagnosis
of schizophrenia, schizophrenifonm
disorder, dysthyrnia, on mania were
given a diagnosis of drug or alcohol
abuse on dependence.
Inmates' responses to questions
from the DIS sections on use of al
cohol and drugs were analyzed to
identify specific substance abuse
problems. The responses of mentally
ill offenders with substance abuse di
agnoses were compared with ne
sponses of offenders without such
diagnoses. To reduce the likelihood
ofa type I error, the probability level
was set at .001.
Hospital and Community Psychiatry
Table 1
Lifetime prevalence of selected psychiatric
aAlcoholAlcoholAll
sample ofmale prison inmates (N = 109)diagnoses
abusersDiagnosis inmates'
%N%Schizophrenia N %
5 5
100Schizophreniformdisorder
100Antisocial 2 2
person
alitydisorder
92Depression 47 44
82Dysthymia 33 30
100Mania 16 15
04100Alcohol 4 4
abuseor
dependence
—¿Drug 72 66
abuseordependence
66 61
1Percents sum to more than 100 because some inmates had more than one diagnosis.
A significant difference between
the groups was found on nine of the
36 items in the DIS section on al
cohol use. Compared with offenders
who did not have a diagnosis of al
cohol abuse on dependence, of
fenders with this diagnosis were
more likely to see themselves as cx
cessive drinkers (x2 = 18.28, df= 1,
p = .0000),to report drinking large
amounts in one day (x2 = 26.25,
df= 1, p = .0000), to report drinking
excessively at least once a week
(X2=13.2, df=1, p=.0003),
have their drinking objected to by
family members (x2 = 19.09, df= 1,
p = .0000), to have health care pro
fessionals tell them they drink too
much(@2= 15.45,df= l,p=.000l),
to go on binges that last for days
(x2=12.78,df=1,p=.0004),and
to suffer blackouts (x2 = 14.21,
df= 1, p= .0002). Offenders with a
diagnosis ofalcohol abuse or depen
dence were more likely to have been
arrested for drinking (x2 = 14.27,
df= 1, p = .0002) and to have gotten
into physical fights while drinking
(x2=30.93,df=1,p=.0000).
Both
mentally ill offenders with a diag
nosis of alcohol abuse on depen
dence and those without that diag
nosis hadproblemswith alcohol atan
early age. About half of each group
reported that they had problems
with drinking before age ten.
When offenders with a diagnosis
of drug abuse on dependence were
andalcohol and drugabuse in
Alcohol drug
abusersDrug abusersand abusersor
N %N %N
4 803 602 405
1 502 1001 502
38 8135 7430 6443
2 1 6422 6716 4827
13 8114 8811 6916
1253750
—¿ —¿50 69— —¿â€”
50 76— —¿â€” —¿â€”
compared with those who did not
have this diagnosis, a significant dif
fenence was found on only one of the
23 items in the DIS section on drug
use. Ninety-seven percent of the of
fenders with drug abuse diagnoses
butonly 4 percent of other offenders
answered yes to the question, Do
drugs interfere with your life a lot?
(x2=49.52,df=1,p=.0000).
Subjects were asked to identify
the three drugs that they had used
most frequently or that had caused
to them the most difficulty in their
lives. Fifteen offenders (14 percent)
indicated that they did not use drugs
or that they used them very infre
quently. A total of 94 inmates (86
percent) reported some regular drug
use, and 66 (6 1 percent of the sam
pie) were given a diagnosis of drug
abuse or dependence. Marijuana,
cocaine, and amphetamines were the
three drugs used most extensively
both by offenders with a diagnosis of
drug abuse or dependence and by
those who did not have this diag
nosis. An offender who used cocaine
or heroin was significantly more like
ly than users ofothendrugs to receive
a diagnosis of drug abuse or depen
dence.
Conclusions
Of the 96 mentally ill offenders in
the sample, 64 had a diagnosis other
than a substance abuse disorder, and
of these offenders, 54 (84 percent)
also had a diagnosis ofalcohol abuse
or dependence or drug abuse on de
pendence.
Previous studies have found that
drugs and alcohol are available in
drug prison, and substance abusers have
reported frequent use of alcohol on
drugs while incarcerated. In one
study, drug abusers reported being
in a chemically altered state of mind
during about 25 percent of their in
carcenation (9). Intoxicants are not
only prime contraband in prisons but
are the product of a significant cot
tage industry. In the Washington
prison system, fruits and vegetables
are often combined with yeast and
sugar and fermented in toilet bowls
to produce “¿pruno,― an alcoholic
—¿
mainstay. It is almost impossible for
a chemically addicted mentally ill
person to maintain sobriety in an en
vironment where drugs and alcohol
areavailable
andused.
The finding that substance abuse
and dependency are part ofthe lives
of most mentally ill offenders has
important implications for the devel
opmcnt of policies about compul
sory substance abuse treatment of
incarcerated offenders and for the
design oftreatmcnt plans for mental
ly ill prison inmates. Connectional of
ficers need training in the areas of
substance abuse, mental illness, and
dual diagnosis. Further attention to
substance abuse as a contributor to
incarceration of the mentally ill is
needed. In addition, substance abuse
should be addressed in community
based mental health programs that
provide services to former prison in
mates who are mentally ill.
References
1. Jemelka R,Trupin E, ChilesJ: The men
tally ill in prisons: a review. Hospital and
Community Psychiatry 40:481—491,
1989
2. SheetsJL, PrevostJA, ReihmanJ: Young
adult chronic patients: three hypothe
sized subgroups. Hospital and Commu
nityPsychiatry 33:194—203,1982
3. Collins JJ: Preliminary Findings: Drug
Use Among Arrestees in Three Urban
Areas. Research Triangle Park, NC,
Center for Social Research and Policy
Analysis, 1988
4. Wish ED, Brody E, Cuadrado M: Urine
testing of arrestees: findings from Man
hartan. Presented at a conference on
drugs and crime, sponsored by National

Hospital and Community Psychiatry October 1990 Vol. 41 No. 10 1133

 Institute of Justice, Washington, DC,
June 5, 1986
5. Robins LN, HelzerJE, RatcliffT, et a!:
Validity of the Diagnostic Interview
Schedule, version II: DSM-III diagno
ses. Psychological Medicine 12:855—
870,1982
6. FleissJL:Measuringnormalscaleagree
ment among many raters. Psychological
Bulletin16:378—382,1971
7. MyersJ, Weissman M, Tischler M, et a!:
Six-month prevalence ofpsychiazric dis
Barriers to Community
of Patients With Dual Diagnoses
Robert H. Howland, M.D.
There is a growing awareness of a
subpopulation of mental health pa
tients with coexistent substance
abuse and psychiatric disorders. Al
though various surveys have found
that this comonbidity may be quite
high in some populations (1,2), the
literature addressing clinical aspects
of the dual diagnosis patient—from
phenomenology to treatment—is
not extensive. What little literature
there is suggests that patients with
dual diagnoses are more problematic
to work with, frequently use emer
gency services, are difficult to
evaluate and often misdiagnosed, are
less responsive to treatment, fre
quently resist available services, and
are at higher risk for suicide and vio
lence (3—5). These characteristics
thus define a heterogeneous group
of patients with special needs who
pose particular problems for a sen
vice delivery system.
Historically, an artificial division
has stood between the provision of
Dr. Howland is clinical research
fellow in the department of psy
chiatry at theWestern Psychiatric
Institute andClinic ofthe Univer
sity of Pittsburgh School of Mod
icine. Address correspondence to
him at the clinic, 381 1 O'Hara
Street, Pittsburgh, Pennsylvania
15213.
1134
orders in three communities. Archives of
General Psychiatry 41:959—967,1984
8. Robins L, HelzerJ, Weissman M, et a!:
Lifetime prevalence of specific psychiat
nc disorders in three sites. Archives of
General Psychiatry 4 1:949—958,1984
9. SobellLC,SobellMB, MaistoSA,et a!:
Alcoholanddrugusebya!coholand drug
abusers when incarcerated: clinica! and
research implications. Addictive Behav
iors8:88—92,
1983
Treatment
services for mental health treatment
and those for substance abuse treat
ment. Given the extent of problems
faced by dual diagnosis patients and
their relatively poor fit in either the
mental health on the substance abuse
systems alone, specialized services
would seem appropriate. However,
few community programs exist to
provide such specialized services,
and those that do probably could not
adequately serve the large number of
patientswho might benefit. An alter
native would be to coordinate exist
ing services from each system, a
practice that is unfortunately the ex
ception rather the rule (6). This
paper describes some of the barriers
to the adequate provision of clinical
services for dual diagnosis patients
and recommends ways of ovencorn
ing these barriers.
Barriers to treatment
When describing the characteristics
of a service delivery system, it must
be recognized that although impor
tant general principles may apply,
not all systems or programs are alike.
Barriers to treatment of patients with
dual diagnoses have been described
elsewhere (6,7); the description used
in this paper is based on the general
organization of mental health sen
vices in Pennsylvania.
In most areas, the community
mental health system provides in
patient and outpatient services as
October 1990 Vol. 41 No. 10
well as a variety of residential pro
grams. Because of restrictive licens
ing and reimbursement regulations,
many ofthese services (especially in
patient and residential programs) are
not available to dual diagnosis pa
tients unless their psychiatric illness
is clearly predominant. Even so,
acute intoxication on a known history
of chronic severe substance abuse
may result in dismissal from on
refusal of treatment.
Psychiatric services are provided
primarily by staff therapists with
minimal formal training on expeni
ence in the treatment of substance
abuse (7,8). Similarly, the psychia
trists providing supervision and con
sultation may not have an extensive
background in substance abuse. Sub
stance abuse services are provided
by a drug and alcohol agency that is
independent of community mental
health in its funding and legislative
mandate. A variety of programs,
from education to treatment, are
maintained and staffed primarily by
persons who have been certified in
substance abuse counseling but who
have little training in mental health.
Although psychiatric consultation
may be available, treatment usually
is offered by referral to the mental
health system.
Programs that might serve dual
diagnosis patients are not typical in
these systems, nor is coordination of
services that might benefit these pa
tients. Referrals are made blindly be
tween the agencies; because of issues
surrounding patient confidentiality,
no clinical information is shared on
follow-up contact made to ensure
that services are provided. Likewise,
if patients are seen jointly by each
agency, it is unusual for clinical infor
mation to be shared or for contact
between the treating clinicians to
occur. There are generally no
provisions for joint training, educa
iion, or treatment programs that
could help inexperienced clinical
staffin working with these patients.
Barriers to treatment also stem
from philosophical differences be
tween the two systems. Because no
systematic effort to identify patients
as dually diagnosed exists, where and
whattype oftneatrnent these patients
receive may depend on the pencep
Hospital and Community Psychiatry