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

Which comes first?Which comes first?

Chicken or the egg?Chicken or the egg?

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

AlcoholAlcohol

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

MethamphetamineMethamphetamine

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

PCPPCP

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

EcstasyEcstasy

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

Marijuana/CannabisMarijuana/Cannabis

How Marijuana is usedHow Marijuana is used

SmokeSmoke Chew on seedsChew on seeds

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

Cocaine/CrackCocaine/Crack

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

QuestionsQuestions