Criminal or Patient

Criminal or Patient?

by Diana Nielsen

Dr. Joseph Calabrese, Professor of Psychiatry at Case Western Reserve University in Cleveland, Ohio, and Director of the Dual Diagnosis Center of Excellence Mood Disorders Program, presented a workshop at the DBSA (Depression and Bipolar Support Alliance) national conference on bipolar disorder accompanied by alcohol and drug abuse. He said that although we think treating depression is our greatest challenge in mental health, the greatest unmet need is treating people with dual diagnosis. I was particularly interested in this subject because of my work at a local soup kitchen and men’s shelter where we see many people with these problems.

One disorder seems to cause the other perhaps because of the use of stimulants and an underlying biological vulnerability. He stated that the Los Angeles County Jail holds more people with mental illnesses than any psychiatric hospital. Of all the mental illnesses, bipolar I disorder has the greatest risk, (eight times the risk in the general population) for co-occurring alcohol or drug use. Among prisoners with bipolar disorder I, 90% have substance use disorders.

There is a growing consensus that behavior during the manic phase of the illness leads to legal complications. The prevalence of being jailed, arrested or convicted of a crime for someone with bipolar disorder is 25% overall, mostly in young adult males. Most of these have circular periods of high and lows without many periods of stability. These people are rapid cyclers with an average of eight episodes in the last year. The biggest problem is that these men are generally not diagnosed. Dr. Calabrese said that 42% have never been treated, 33% are incorrectly treated for depression and 20% have never been diagnosed with a mood disorder. When these men use one substance, they usually use another. Statistics reveal 44% use alcohol, marijuana and cocaine, 21% alcohol and 19% alcohol and marijuana. He stressed that significant others can help when these individuals get impulsive.

Seventy-four percent of people with dual diagnosis are charged with legal offenses. Fewer are convicted. Of these, 70% are males. For the most part, these are not violent crimes, rather 29% for drugs, 17% for shoplifting, 17% for parole probation and violation, 15% for assault, and 13% for contempt of court. Many of these people are not criminals but people with mental illnesses who need treatment programs not prison sentences.

He made a distinction between substance use, substance abuse and substance dependence. If a person is “just” abusing, they can sometimes stabilize, but with a substance dependence, it is much more difficult. Usually the best treatment in those cases is a 12-step program. In a study where they treated people with lithium and depakote for six months, they found the following: depression relapse 17%, hypomania or mania 10%, responders 19% and poor adherence and drop outs 44%.

I am not a big fan of statistics, yet it was important to him to share these to show us the extent of the problem. He revealed that only half of the psychiatrists determine the right diagnosis, with 20% of primary care doctors and 20% of therapists. This is not good news. Because people with dual diagnosis will rapid cycle and show mixed states of depression and racing thoughts, there is a high rate of suicide and suicide attempts.

How can we treat these individuals? He recommends never, ever having an initial assessment without a family or a significant other present except in cases of abuse. The professional should look for cycling during periods of at least two to three months of abstinence. He suggests reviewing a life chart with the patient to determine the phase of illness. He says it is extremely important to try and understand the relationship between mood state and substance use. At the soup kitchen, we serve lunch to about 100 people a day. Some of these people are coming through on their way to better jobs and better living conditions. Others are with us for a long time. They may not be homeless, but hovering on the brink. Most of these people are men. Most of these people have struggled with addictions. What I learned is that many of these people probably have undiagnosed mental illnesses.

Occasionally a man will come up to me and tell me that he has been treated for bipolar disorder. Most of the time, he will not. Most of these men have been arrested. Many have served sentences in jails and prisons. Most of them do want to take prescribed medication. They would rather continue to drink or take drugs. This is a form of self medication. Here in Rochester it seems as if the preferred drugs are alcohol, marijuana and crack cocaine. This leads to a downward spiral. Crack cocaine is expensive and a person who is high may lie and steal to get more. Afterwards there is a huge letdown which is when someone may want to smoke marijuana to ease the pain. Then the next time he experiences stress, back to the same pattern. A person caught in this cycle does not feel good about himself. He would like to stop but doesn’t know how. Society has told men that they should be strong enough to handle it themselves. Friends and family have lost patience with them and given up on them. They do not feel worthy of love and more than anything would like to find someone who cares.

People in the audience wanted to know why nothing has been done about this. Dr. Calabrese said that up to now, there have been no large scale open trials of men in prison. Essentially no one has studied the mental health of men in prison. We as a society have not wanted to address this problem.

When I was in Albany advocating for mental health reform, I did not want to hear about alternatives to inhumane disciplinary segregation of state inmates with psychiatric disabilities because it was too cruel to think about. Severe psychiatric disabilities interfere with many inmates’ ability to conform to prison rules. Inmates confined in disciplinary lockdown spend 23 hours a day in a cell and are permitted to “exercise” for one hour in a small outdoor cage without equipment. These people face severe social isolation, extreme boredom and idleness. Sensory deprivation and social isolation are well known to have serious damaging effect on a person’s mental health leading to self-injury, suicide, delusions, manic activity and paranoia. This may lead to even more time in “the Box.” NYAPRS( the New York Association of Psychiatric Rehabilitation Services) urges the use of alternative therapeutic housing for prisoners with psychiatric disabilities, which will improve prison security and safety for staff and inmates. However, with prison psychologists assigned to hundreds of men, how are they going to diagnose these people?

Last fall I attended meetings of our county legislature when funding was being cut to social services. Our county executive told us that he had no money for our hotline and other preventive programs because he had to spend so much on county jails. I suggested that if he supported preventive programs and drug and alcohol treatment, he would not have to keep building jails and locking up people who are not violent. It is costing the taxpayer much more money to incarcerate these men than it would cost for good outpatient treatment. As usual, we would rather wait until there is a crisis rather than try to prevent one.