Substance abuse disorders (SUDs) and other psychiatric disorders are common among prison populations. A dual diagnosis (DD) refers to a co-existing SUD and any Axis I disorder, such as depression, schizophrenia, or social phobia. A new study has not only confirmed DD among prisoners in France, but has also found that it is a major risk factor for suicide.

Results will be published in the January issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

“We knew from our earlier work that psychiatric disorders were prevalent among French prisoners,” explained Michael Lukasiewicz, a practicing physician at the Hôpital Universitaire Paul Brousse, France and first author of the study. “Clinicians and prison authorities had reported that SUDs were also very prevalent. DD is frequently found among psychiatric populations outside of prison, and the appropriate screening and treatment of each disorder – both independently and simultaneously – is imperative as the prognosis of these patients is often worse than for individuals with just one disorder. However, DD is still under-recognized in France, and even among the general population there are few specific intervention options.”

“There are few randomized representative studies of the comprehensive prevalence of serious mental illnesses in prison,” added co-author Michel Reynaud, a professor in the department of psychiatry and addiction at the Hôpital Universitaire Paul Brousse. “This national study is really among the few exceptions that seriously address this question with the appropriate methodological design and tools.”

Researchers interviewed and evaluated 998 prisoners in 23 prisons: 100 women and 100 men from France’s overseas regions, and 798 men from metropolitan France. DD prisoners were compared with three other groups of prisoners: those with no diagnosis, SUD alone, or with other isolated psychiatric disorders. Researchers also examined the influence of DD on risk of suicide in prison.

“We showed that not only was DD highly prevalent in prison – one prisoner in four were diagnosed – but their prognosis was also more serious, especially in term of suicidality,” said Lukasiewicz. “Mood and anxiety disorders were the most frequent disorders found in the DD group, at 74 percent and 80 percent, but psychotic disorders also accounted for almost a third of DD. We found that SUD alone was less frequent, approximately one in ten patients.” Lukasiewicz is also a member of the research group, Paris Sud Innovation Group in Adolescent Mental Health, of the Institut national de la santé et de la recherche médicale.

“These results really question the relevance of the relationship between our prison and health-care systems,” said Reynaud. “Like other countries, I think we have a problem defining the linkages between crimes and criminal behaviour linked to SUDs or psychiatric disorders, and how to punish and treat them.”

“The first aim of this study was to sensitize health and prison authorities about this issue,” noted Lukasiewicz. “Officials need to correctly screen prisoners with trained personnel and then provide effective, integrated treatment for their disorders. Prisoner treatment should not differ from what is given to DD patients in the general population. Of course, in France, treatment of DD often resembles a ‘ping pong’ game between psychiatrists and addiction specialists, each respectively waiting for their counterpart to treat their ‘specific problem.’ One could say these patients are victims of a ‘double penalty.’”

“In addition, I would like to point out that, due to the complex nature of DD and the usual division between psychiatric and addiction care, DD is often under-diagnosed or worse, the victim of this division” added Reynaud. “The patient is often left untreated as the psychiatrist and addiction specialist don’t want to offer the ‘first treatment,’ instead waiting for an illusory stabilization of one of the diagnoses. For example, ‘you have to be abstinent before I treat your bipolar disorder.’ This is especially the case in prison where there is a lack of resources.”

Lukasiewicz said that the prognosis for DD among prisoners only becomes worse if left untreated. “Even though the research is limited, studies have shown that prisoners with DD have more severe SUD, more psychiatric disorders, more criminal history, and are more likely to be re-incarcerated,” he said. “Worryingly, they also had a higher risk of contracting HIV. We should ask ourselves if prison is the appropriate place for people suffering from such a severe disorder.”

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Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper, “Dual Diagnosis: Prevalence, Risk Factors and Relationship With Suicide Risk in a Nationwide Sample of French Prisoners,” were: L. Blecha of the Institut national de la santé et de la recherche médicale (INSERM), Paris and the Centre de Recherche et de Traitment des Addictions at the Hôpital Paul Brousse AP-HP, Villejuif; B. Falissard of the Université Paris-Sud, Université Paris-V, the Département de santé publique at the Hôpital Paul Brousse AP-HP, and INSERM; X. Neveu of INSERM; A. Benyamina of the Université Paris-Sud, Université Paris-V, INSERM, and the Centre de Recherche et de Traitment des Addictions at the Hôpital Paul Brousse AP-HP, Villejuif; and I. Gasquet of the Département de santé publique at the Hôpital Paul Brousse AP-HP, and INSERM. The study was funded by the French Ministry of Health and the Department of Justice.

Contact: Michael Lukasiewicz, M.D.
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01.45.59.69.78 (France)
Hôpital Universitaire Paul Brousse

Add’l contact: Michel Reynaud, Ph.D.
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01.45.59.30.88 (France)
Hôpital Universitaire Paul Brousse

Michael Lukasiewicz, M.D.
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33-014-559-6978

Alcoholism: Clinical & Experimental Research