co-occurring substance disorders and mental illness among inmates tawnya j. meadows, ph.d. kelly...
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Co-Occurring Substance Co-Occurring Substance Disorders and Mental Illness Disorders and Mental Illness
among Inmatesamong Inmates
Tawnya J. Meadows, Ph.D.Tawnya J. Meadows, Ph.D.Kelly McKillip, B.A.Kelly McKillip, B.A.James R. Meadows, Ph.D.James R. Meadows, Ph.D.Beth Ehrisman, B.A.Beth Ehrisman, B.A.
PreviewPreview
Demographics/StatisticsDemographics/Statistics Mental IllnessMental Illness Substance AbuseSubstance Abuse QuestionsQuestions
DemographicsDemographics
Over 2 million individuals are Over 2 million individuals are incarcerated in jails and prisonsincarcerated in jails and prisons
4.5 million adult men and women 4.5 million adult men and women are on probation or paroleare on probation or parole
Mental Illness Mental Illness DemographicsDemographics
6.4% of males and 12.2% of females 6.4% of males and 12.2% of females entering jail have severe mental entering jail have severe mental disorder (schizophrenia, mania and disorder (schizophrenia, mania and major depressive disorder)major depressive disorder)
57% have active mental disorder 57% have active mental disorder without substance usewithout substance use
Each arrest significantly increases Each arrest significantly increases risk of MI (double)risk of MI (double)
Substance Use Substance Use DemographicsDemographics
29.1% of men and 53.3% of female detainees had a 29.1% of men and 53.3% of female detainees had a current substance use disordercurrent substance use disorder
Up to 83% were seriously involved with drugs or alcoholUp to 83% were seriously involved with drugs or alcohol 64% of jail inmates use drugs regularly with 47% use 64% of jail inmates use drugs regularly with 47% use
regularly the month before arrestregularly the month before arrest 82% of state and 85% of federal inmates are convicted of 82% of state and 85% of federal inmates are convicted of
substance-related crimes, under influence at time of substance-related crimes, under influence at time of arrest, committed crime to get drugs, regular use of arrest, committed crime to get drugs, regular use of alcohol or drugs alcohol or drugs
Women entering jail are at least 9 times as likely to have a Women entering jail are at least 9 times as likely to have a substance use disorder than the general populationsubstance use disorder than the general population
More women than men are in jail for drug chargesMore women than men are in jail for drug charges 46% of jail inmates have driven while high; 48% while 46% of jail inmates have driven while high; 48% while
drunkdrunk 17% have lost a job because of drugs; 11% because of 17% have lost a job because of drugs; 11% because of
alcoholalcohol Only 8% jail inmates receive any form of substance abuse Only 8% jail inmates receive any form of substance abuse
treatmenttreatment
Dual Diagnosis / Co-Dual Diagnosis / Co-OccurringOccurring
72% rate of co-occurring substance use 72% rate of co-occurring substance use disorder and severe mental disorderdisorder and severe mental disorder
Females more likely than males to have Females more likely than males to have dual diagnosisdual diagnosis
Those with mental illness (MI) are 2 times Those with mental illness (MI) are 2 times more likely to be arrested than those more likely to be arrested than those without MIwithout MI
No universal standards for dual diagnosisNo universal standards for dual diagnosis Dual diagnosis should be expectation, Dual diagnosis should be expectation,
rather than the exceptionrather than the exception
Demographics Demographics
Table 1 Demographics by Risk Classification
(n= 311)
Gender* Female Male % (n) % (n)
Race/Ethnicity Nonwhite White % (n) % (n)
High School (GED) NO YES % (n) % (n)
Dual Risk
40.7 (44) 31.5 (64) 32.7 (82) 42.2 (25) 39.6 (57) 30.5 (51)
Mental Disorder Risk Only
23.1 (25) 15.8 (32) 17.9 (45) 20.3 (12) 18.1 (26) 18.6 (31)
Substance Abuse Risk Only
13.0 (14) 19.2 (39) 16.3 (41) 20.3 (12) 14.6 (21) 19.2 (32)
No Risk
23.1 (25) 33.5 (68) 33.1 (83) 16.9 (10) 27.8 (40) 31.7 (53)
*p<.05
Co-Occurring DisordersCo-Occurring Disorders
Depressive DisordersDepressive Disorders SchizophreniaSchizophrenia Personality DisordersPersonality Disorders
Depressive DisordersDepressive Disorders
Major Depressive DisorderMajor Depressive Disorder Dysthymic DisorderDysthymic Disorder Depressive Disorder, NOSDepressive Disorder, NOS Bipolar DisorderBipolar Disorder Cyclothymic DisorderCyclothymic Disorder Bipolar Disorder, NOSBipolar Disorder, NOS Mood Disorder due to a General Medical Mood Disorder due to a General Medical
ConditionCondition Substance-Induced Mood DisorderSubstance-Induced Mood Disorder Mood Disorder, NOSMood Disorder, NOS
Schizophrenia CriteriaSchizophrenia Criteria
Types: Paranoid, Disorganized, Catatonic, Types: Paranoid, Disorganized, Catatonic, Residual, Undifferentiated Residual, Undifferentiated
Inappropriate affectInappropriate affect Poor insight regarding psychotic illnessPoor insight regarding psychotic illness Anhedonia (loss of interest or pleasure)Anhedonia (loss of interest or pleasure) May have disturbances in sleep patternMay have disturbances in sleep pattern May refuse food due to delusional beliefsMay refuse food due to delusional beliefs Abnormalities in psychomotor activity (pacing, Abnormalities in psychomotor activity (pacing,
rocking or apathetic immobility)rocking or apathetic immobility) Difficulty with concentration, attention, and Difficulty with concentration, attention, and
memorymemory
Schizophrenia StatisticsSchizophrenia Statistics
Adults= 0.5% to 1.5% of populationAdults= 0.5% to 1.5% of population Elevated risk reported among Elevated risk reported among
urban-born compared with rural-urban-born compared with rural-born individualsborn individuals
Declining incidence for later-born Declining incidence for later-born birth cohortsbirth cohorts
Personality Disorder Personality Disorder Types: Odd/EccentricTypes: Odd/Eccentric
ParanoidParanoid: pattern of distrust and : pattern of distrust and suspiciousness, such that others’ suspiciousness, such that others’ motives are interpreted as malevolentmotives are interpreted as malevolent
SchizoidSchizoid: pattern of detachment from : pattern of detachment from social relationships and restricted range social relationships and restricted range of emotional expressionof emotional expression
SchizotypalSchizotypal: pattern of acute discomfort : pattern of acute discomfort in close relationships, cognitive or in close relationships, cognitive or perceptual distortions and eccentricities perceptual distortions and eccentricities of behaviorof behavior
Personality Disorder Personality Disorder Types: Types: Dramatic/Emotional/ErraticDramatic/Emotional/Erratic
AntisocialAntisocial: pattern of disregard for, and : pattern of disregard for, and violation of, the rights of othersviolation of, the rights of others
BorderlineBorderline: pattern of instability in : pattern of instability in interpersonal relationships, self-image, interpersonal relationships, self-image, and affects and marked impulsivityand affects and marked impulsivity
HistrionicHistrionic: pattern of excessive : pattern of excessive emotionality and attention seekingemotionality and attention seeking
NarcissisticNarcissistic: pattern of grandiosity, : pattern of grandiosity, need for admiration, and lack of need for admiration, and lack of empathyempathy
Personality Disorder Personality Disorder Types: Anxious/FearfulTypes: Anxious/Fearful
AvoidantAvoidant: pattern of social inhibition, : pattern of social inhibition, feelings of inadequacy, and feelings of inadequacy, and hypersensitivity to negative evaluationhypersensitivity to negative evaluation
DependentDependent: pattern of submissive and : pattern of submissive and clinging behavior related to an clinging behavior related to an excessive need to be taken care ofexcessive need to be taken care of
Obsessive-CompulsiveObsessive-Compulsive: pattern of : pattern of preoccupation with orderliness, preoccupation with orderliness, perfectionism and controlperfectionism and control
Vulnerability to Drug and Vulnerability to Drug and Alcohol AbuseAlcohol Abuse
BiologicalBiological Personal characteristicsPersonal characteristics Family situationFamily situation Social and community factorsSocial and community factors
The more factors, increased The more factors, increased likelihoodlikelihood
How Alcohol is UsedHow Alcohol is Used
Drink in liquid formDrink in liquid form May be snortedMay be snorted
Effects of AlcoholEffects of Alcohol
Feeling of well-being and Feeling of well-being and stimulationstimulation
Psychiatric Effects of Psychiatric Effects of AlcoholAlcohol
Worsens depressive illnessWorsens depressive illness Increases suicide riskIncreases suicide risk Accentuates sleep problem-users Accentuates sleep problem-users
wake in middle of night as blood wake in middle of night as blood alcohol level fallsalcohol level falls
May cause personality changesMay cause personality changes Loss of recent memoryLoss of recent memory Dis-inhibiting effects may lead to Dis-inhibiting effects may lead to
serious violenceserious violence
More Psychiatric Effects More Psychiatric Effects of Alcoholof Alcohol
May induce psychosis similar to schizophrenia May induce psychosis similar to schizophrenia with ideas of persecution and “voices”with ideas of persecution and “voices”
Sudden withdrawal for someone who has Sudden withdrawal for someone who has developed addiction can produce alarming developed addiction can produce alarming symptomssymptoms Autonomic hyperactivity (sweating or pulse Autonomic hyperactivity (sweating or pulse
increases)increases) Hand tremorHand tremor Nausea or vomitingNausea or vomiting Grand mal seizuresGrand mal seizures Insomnia Insomnia AnxietyAnxiety
Other considerationsOther considerations
Antabuse (antagonist)Antabuse (antagonist) 125,000 alcohol-related deaths 125,000 alcohol-related deaths
each year in the USeach year in the US Many Asians lack an enzyme Many Asians lack an enzyme
needed to metabolize alcohol and needed to metabolize alcohol and have immediate aversive effectshave immediate aversive effects
Caffeine may exacerbate alcohol Caffeine may exacerbate alcohol effectseffects
How Meth is usedHow Meth is used
Injected or smoked- immediate and Injected or smoked- immediate and intense rush intense rush
Snorted or ingested orally- not as Snorted or ingested orally- not as intense and takes more time to intense and takes more time to effecteffect
Effects of MethEffects of Meth
Rapid heart rate, increased blood Rapid heart rate, increased blood pressure, damage to small blood vessels pressure, damage to small blood vessels in the brain. . . Strokein the brain. . . Stroke
Inflammation of heart liningInflammation of heart lining Overdoses may cause hyperthermia, Overdoses may cause hyperthermia,
convulsions, and deathconvulsions, and death Chronic users who inject- HIV, Hepatitis B Chronic users who inject- HIV, Hepatitis B
and C, collapsed veins, heart lining and C, collapsed veins, heart lining infectionsinfections
Psychiatric Effects of Psychiatric Effects of MethMeth
Violent behaviorViolent behavior ParanoiaParanoia AnxietyAnxiety ConfusionConfusion InsomniaInsomnia
** Effects may persist for months and ** Effects may persist for months and years after individual has stopped years after individual has stopped using the drugusing the drug
How PCP is usedHow PCP is used
Snort powder, swallow tablets or Snort powder, swallow tablets or smoke by applying it to a leafy smoke by applying it to a leafy substance, such as marijuana, mint, substance, such as marijuana, mint, parsley or oreganoparsley or oregano
Increasingly it is used by dipping Increasingly it is used by dipping marijuana or tobacco cigarettes into marijuana or tobacco cigarettes into liquid PCP and smokingliquid PCP and smoking
Effects of PCPEffects of PCP
Affects growth hormones and can Affects growth hormones and can impede learning processimpede learning process
Agitation, excitement, delirium, Agitation, excitement, delirium, hostility, and disorganization of hostility, and disorganization of perceptionsperceptions
May cause seizures, coma, and deathMay cause seizures, coma, and death Effects persist up to a year after Effects persist up to a year after
stopping usestopping use
Psychiatric Effects of PCPPsychiatric Effects of PCP
Psychological dependence, craving, and Psychological dependence, craving, and compulsive behaviorcompulsive behavior
Low doses- combativeness and catatoniaLow doses- combativeness and catatonia Long-term use can lead to memory loss, Long-term use can lead to memory loss,
difficulty with speech or thought, difficulty with speech or thought, schizophrenia, depression, and weight schizophrenia, depression, and weight lossloss
Effects may resemble symptoms Effects may resemble symptoms associated with schizophrenia, including associated with schizophrenia, including delusions and paranoiadelusions and paranoia
How Ecstasy is usedHow Ecstasy is used
Swallowed as a tabletSwallowed as a tablet Crush tablet and snortCrush tablet and snort
Effects of EcstasyEffects of Ecstasy
Feelings of euphoriaFeelings of euphoria Heightened perception of Heightened perception of
surroundingssurroundings
Psychiatric Effects of Psychiatric Effects of EcstasyEcstasy
Degree of anxiety, panic, confusion, Degree of anxiety, panic, confusion, and insomniaand insomnia
Rarely, users may experience a Rarely, users may experience a paranoid psychosis with paranoid psychosis with hallucinations like that found with hallucinations like that found with other amphetaminesother amphetamines
Some deaths reported, seizures, Some deaths reported, seizures, and prolonged comasand prolonged comas
Other considerations of Other considerations of EcstasyEcstasy
Most users experience no ill effects Most users experience no ill effects and deem it safeand deem it safe
Produced in illicit drug factories and Produced in illicit drug factories and labs, so composition varies and may labs, so composition varies and may contain toxic additives or more contain toxic additives or more potent varietiespotent varieties
Long-term effects unknown, but lab Long-term effects unknown, but lab animal experiments suggest it is animal experiments suggest it is highly toxic if taken over long periodshighly toxic if taken over long periods
Effects of MarijuanaEffects of Marijuana
Talkativeness, relaxation, Talkativeness, relaxation, cheerfulnesscheerfulness
Enhanced appreciation of sound and Enhanced appreciation of sound and colorcolor
Reduction in ability to do Reduction in ability to do complicated taskscomplicated tasks
Frequent chest coldsFrequent chest colds Increase heart rateIncrease heart rate
Psychiatric Effects of Psychiatric Effects of MarijuanaMarijuana
May affect short-term memoryMay affect short-term memory Difficulty in concentrationDifficulty in concentration Heavy use- psychosisHeavy use- psychosis AnxietyAnxiety Panic attacksPanic attacks SchizophreniaSchizophrenia Feels like loss of controlFeels like loss of control Worsens bipolar symptomsWorsens bipolar symptoms High doses- Hallucinations, Image High doses- Hallucinations, Image
distortion, loss of personal identitydistortion, loss of personal identity
Other considerations of Other considerations of MarijuanaMarijuana
1960 average joint contained 10 mg 1960 average joint contained 10 mg ThcThc
2005 average joint contains 150+ 2005 average joint contains 150+ mgmg
48% of all high school seniors have 48% of all high school seniors have used at least onceused at least once
37% of all US citizens 12 years and 37% of all US citizens 12 years and older have used marijuanaolder have used marijuana
How Cocaine is usedHow Cocaine is used
SnortedSnorted Smoked Smoked Injected intravenouslyInjected intravenously
Effects of CocaineEffects of Cocaine
Feelings of euphoria, exhilaration, Feelings of euphoria, exhilaration, and confidence and confidence
Accelerated heart rate Accelerated heart rate Increase in body temperature Increase in body temperature A burst of energy A burst of energy Dilated pupils Dilated pupils Loss of appetite Loss of appetite The urge to have sexThe urge to have sex
Psychiatric Effects of Psychiatric Effects of CocaineCocaine
Prolonged use can lead to severe Prolonged use can lead to severe anxiety and insomniaanxiety and insomnia
Cocaine psychosis may develop Cocaine psychosis may develop with ideas of persecution and with ideas of persecution and various hallucinatory experiencesvarious hallucinatory experiences
May cause anxiety or panic and May cause anxiety or panic and people suffering from anxiety states people suffering from anxiety states should be especially carefulshould be especially careful
Other considerations of Other considerations of CocaineCocaine
Rapid acting and cause dependence and Rapid acting and cause dependence and compulsive use in some userscompulsive use in some users
Unpleasant “rebound” symptoms occur Unpleasant “rebound” symptoms occur as drug wears offas drug wears off
Effects generally clear up once the use of Effects generally clear up once the use of cocaine stopscocaine stops
Nationwide, 38% of detainees test Nationwide, 38% of detainees test positivepositive
Clonidine may ease withdrawalClonidine may ease withdrawal Bromocriptine may reduce cravingBromocriptine may reduce craving Every 1 dollar spent on cocaine treatment Every 1 dollar spent on cocaine treatment
in prison saves $7.48 in societal benefitsin prison saves $7.48 in societal benefits
Prescription DrugsPrescription Drugs
Ritalin (stimulant)- Kibbles and bits, Ritalin (stimulant)- Kibbles and bits, Kiddy cocaine, pineapple, skippy, Kiddy cocaine, pineapple, skippy, smarties, Vitamin R, west coastsmarties, Vitamin R, west coast
Ritalin and Talwin (pain killer)- Ritalin and Talwin (pain killer)- crackers, ones and ones, rits and ts, crackers, ones and ones, rits and ts, set, ts and rits, ts and rsset, ts and rits, ts and rs
How Prescription Drugs How Prescription Drugs are Usedare Used
Ritalin- swallow, crush to snort, Ritalin- swallow, crush to snort, dissolve in water (not all) and injectdissolve in water (not all) and inject
Effects of Prescription Effects of Prescription DrugsDrugs
Ritalin- appetite suppression, Ritalin- appetite suppression, wakefulness, euphoria, increased wakefulness, euphoria, increased focus and attention, cardivascular focus and attention, cardivascular complications, if inject- risk blocking complications, if inject- risk blocking blood vessels, HIV, Hepatitis B and blood vessels, HIV, Hepatitis B and CC
Psychiatric Effects of Psychiatric Effects of Prescription DrugsPrescription Drugs
Ritalin- psychotic episodes, severe Ritalin- psychotic episodes, severe psychological addictionpsychological addiction
RelapseRelapse
StatisticsStatistics 29-42% of individuals drop out of treatment29-42% of individuals drop out of treatment Relapse rate 35-90%Relapse rate 35-90% 67% relapse within 4 months of residential 67% relapse within 4 months of residential
treatmenttreatment WhyWhy
False sense of control over addictionFalse sense of control over addiction Fail to change prompting behaviors or triggersFail to change prompting behaviors or triggers Deny existence of addictionDeny existence of addiction Lack of coping skills Lack of coping skills Self-efficacy problemsSelf-efficacy problems Positive effects of substance abusePositive effects of substance abuse
Relapse PreventionRelapse Prevention
Removal of stimuliRemoval of stimuli Accurately assess for co-occurring Accurately assess for co-occurring
disordersdisorders Treatment of co-occurring mental Treatment of co-occurring mental
illnessillness
Reciprocal RelapseReciprocal Relapse
One addiction precipitates relapse of One addiction precipitates relapse of another addictionanother addiction
Example:Example: May be sober, but continue to engage in May be sober, but continue to engage in
other addictive behaviorsother addictive behaviors
Addictions Intervention Addictions Intervention EducationEducation
Physiological effects of alcohol and other Physiological effects of alcohol and other drugs, interactions, and the effects on drugs, interactions, and the effects on behavior and drivingbehavior and driving
Possible psychological consequencesPossible psychological consequences Blood Alcohol Concentration importance, Blood Alcohol Concentration importance,
legalities, physical effectslegalities, physical effects Resources for treatment and supportResources for treatment and support Alternative activities to drug and alcohol Alternative activities to drug and alcohol
useuse Understanding costs of useUnderstanding costs of use
Coping Skills TrainingCoping Skills Training
Decision makingDecision making Relaxation techniquesRelaxation techniques Exercise!!!Exercise!!! Good nutritionGood nutrition Replacement behaviorsReplacement behaviors Setting goalsSetting goals Making plans to execute Making plans to execute
goalsgoals Establishing social Establishing social
networknetwork Legal social activitiesLegal social activities Problem solving Problem solving
techniquestechniques Awareness of community Awareness of community
resourcesresources
Job/career skills and Job/career skills and trainingtraining
Behavioral self-controlBehavioral self-control Avoiding high risk Avoiding high risk
situationssituations Social skills trainingSocial skills training STD/HIV trainingSTD/HIV training Pacing/teaching Pacing/teaching
moderation drinking skills moderation drinking skills and strategiesand strategies
Tapes of them Tapes of them high/inebriatedhigh/inebriated
Noncatastrophizing Noncatastrophizing thoughtsthoughts
Identification of stressIdentification of stress Assertiveness trainingAssertiveness training