Caution!: Underdiagnosis of Substance Use Disorders in Forensic Populations Overlooks Criminogenic Treatment Need
Research suggests that co-occurring substance use disorder (SUD) is prevalent among adults with psychiatric illness. To help determine how widespread co-occurring disorders (CD) are internationally, we compared current clinical diagnoses recorded in the clinical record with clinical evidence gathered during forensic assessments in an inpatient forensic facility in Ontario, Canada. The majority of the sub-sample (61%) met criteria for CD, but only 19% were diagnosed as such. Underdiagnosing SUD has a potential impact on understanding substance use as a criminogenic treatment need in forensic mental health. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | International Journal of Forensic Mental Health | 2018, Vol. 2018, No. 17, 145-153
Co-Occurring Mental Illness and Substance Use Disorders in Canadian Forensic Inpatients: Underdiagnosis and Implications for Treatment Planning
N. Zoe Hilton, Department of Psychiatry, University of Toronto, Toronto, Canada; Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
Shari A. McKee, Department of Psychiatry, University of Toronto, Toronto, Canada; Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
Elke Ham, Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
Michelle Green, Correctional Services of Canada, Beaver Creek Institution, Gravehurst, Ontario, Canada
Lauren Wright, Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
Research suggests that co-occurring substance use disorder (SUD) is prevalent among adults with psychiatric illness. Studies with forensic patients in Australia indicate that co-occurring disorders (CD) are underdiagnosed. To help determine how widespread CD underdiagnosis is in forensic populations internationally, we compared current diagnoses recorded in the clinical record with clinical evidence gathered during forensic assessment meeting DSM-IV criteria for SUD, in a Canadian sample of 638 male forensic inpatients. Among 491 with a major mental illness diagnosis, most (61%) met criteria for CD but only 19% were diagnosed as such. CD was associated with longer hospitalization, and with greater evidence of criminal history, antisociality, and risk of violent recidivism, regardless of how CD was defined. Identifying CD based on documented evidence, though, allowed for slightly greater detection of group differences. Underdiagnosing SUD has a potential impact on understanding substance use as a criminogenic treatment need in forensic mental health.
Substance use, forensic inpatients, diagnosis, criminogenic needs
Summary of the Research
“The term co-occurring disorders (CD) is used to describe the presence of both a substance use disorder (SUD) and a psychiatric illness…Having both a mental disorder and SUD is associated with the poorest mental health status and greatest prevalence of unmet mental health needs in the Canadian population. Among psychiatric patients in Canada, the United States, and Australian, substance use increases hospitalization risk, readmission, and is associated with longer length of stay…The goal of the present study was to estimate presence of CD in a sample of forensic inpatients, and to identify the rate at which SUD is formally diagnosed” (p.145).
“In Canada’s forensic services, particularly those providing court-ordered psychiatric assessments, the presence of a major mental illness has important legal implications and may affect whether a person is fit to stand trial or is eligible for a plea of ‘not criminally responsible on account of mental disorder.’ Accurate assessment of other disorders, however, is also important in forensic practice because both recovery from mental illness and the reduction of criminal offending are important goals of intervention…In the present study, we aimed to replicate findings reported by Ogloff et al. (2004, 2015) in a Canadian sample of male forensic inpatients, based on an analysis of clinical documentation rather than conducting a clinical assessment of diagnoses ourselves for the purpose of the study” (p.146).
“We studied the presence of SUD and CD among forensic inpatients according to the current diagnosis recorded in the medical record following formal court-ordered assessment by forensic psychiatrists working with a multidisciplinary clinical team (‘current diagnosis’). Then, as a comparison, we used a standard coding form to quantify the clinical evidence gathered and documented on the medical record during this assessment in order to determine whether the DSM-IV criteria for SUD were met (‘documented evidence’). Previous research reporting that SUD is underdiagnosed among forensic patients…led us to expect that the proportion of patients with a current diagnosis of CD would be significantly lower than the proportion meeting the documented evidence criteria (Hypothesis 1)” (p.146).
“A second goal of this study was to examine the implications for forensic treatment planning, by testing the association of CD with hospital length of stay and with criminal history and recidivism risk…we expected that CD would be positively associated with length of stay in the forensic hospital (Hypothesis 2). Based on previous research indicating that forensic patients with CD had more serious and frequent offending histories than those with mental illness alone, we expected that CD would be positively associated with violent and nonviolent criminal histories, past antisociality, and a history-based measure of criminal recidivism risk (Hypothesis 3). We explored differences in Hypotheses 2 and 3 as a function of whether CD was identified by current diagnosis or documented evidence, to help elucidate the effect of under-diagnosis, if any, on understanding the profile of forensic patients with CD. The present sample was drawn from a longitudinal study of 638 men admitted to a secure forensic assessment program in the Province of Ontario, Canada, from January 2009 to December 2012” (p.146).
“A total of 491 patients had a current diagnosis of a major mental illness (i.e., psychotic or mood disorders) and the reported results were based on this sub-sample. Current diagnosis resulted in only 95 (19%) patients being identified as having both a major mental illness and a co-occurring SUD. Documented evidence resulted in an additional 205 patients being identified, for a total of 300 (61%) with CD by either definition. That is, two-thirds of patients with CD based on the DSM-IV criteria for SUD had not been diagnosed with SUD. The proportion of patients identified with CD was significantly lower using current diagnosis alone…than using documented evidence…consistent with Hypothesis 1” (p. 149).
“The mean length of stay was 152 days (SD = 261). Using either the current diagnosis or documented evidence, patients with CD stayed longer in the forensic hospital. The mean length of stay for patients without a current diagnosis of SUD was 130 days…compared with a current diagnosis of CD, M = 293…Controlling for year of admission, CD was associated with a longer length of stay…consistent with Hypothesis 2. Using documented evidence, the mean length of stay for patients without CD was 122 days…compared with patients with CD, M = 184…Controlling for year of admission, documented evidence of SUD was associated with a longer length of stay…Thus, the hypothesis that CD would be associated with longer stay was supported, whether using current diagnosis or documented evidence of CD” (p.149).
“Most patients in the total sample had prior criminal charges for nonviolent offenses (382, 60%) and half (322, 50%) had prior violent charges…First…we observed no significant differences in CLCH [Cormier-Lang Criminal History] scores between groups defined using the current diagnosis. Using documented evidence, there were differences in CLCH violent history between the CD group…and group without CD…but not for nonviolent criminal history…Second, we observed a significant overall effect of CD on criminality measures when using the current diagnosis…The CD group had higher APD [Antisocial Personality Disorder] total scores…than the no-CD group” (p.149).
Translating Research into Practice
“…Interventions targeting problematic substance use have been shown to reduce risk of reoffending in a CD population, and are associated with a general reduction in criminal behavior. Furthermore, planning for the provision of such treatment services would be aided by accurate estimates of SUD in a patient population. Once SUD is suspected, comprehensive screening and assessment of substance use is recommended, including the type of substances used, as each may have different criminogenic and treatment implications. The present study also supports calls for further development and evaluation of substance use treatment programs for forensic patients, particularly the need for integrated treatment for CD” (p.150).
“Formal diagnosis is often a needed first step to assessing appropriate clinical care, and the present study indicates that forensic assessment professionals are well positioned to make a formal diagnosis of CD, given that the necessary clinical evidence is often already gathered and documented during the assessment process. Therefore, we encourage forensic clinicians to assess substance use, and record diagnoses of SUD, regardless of the instant question before the court (e.g., criminal responsibility, competence to stand trial)…The presence of a SUD diagnosis would highlight the need for treatment and remind all practitioners involved with a patient to target this key criminogenic factor” (p.151).
Other Interesting Tidbits for Researchers and Clinicians
“…Discovering that missed diagnoses of SUD occur even when clinical information indicating the presence of diagnostic criteria is documented on the medical record suggests a systematic problem. That is, underdiagnosis is not entirely attributable to failure to collect adequate information. Instead, it could be related to the way forensic assessment is conducted, whereby practitioners focus on specific disorders in order to answer particular legal questions…The present study raises the possibility that this problem begins with sub-optimal assessment and diagnosis…It is hoped that these diagnoses will inform care planning, result in integrated treatment of mental illness and addiction problems, and lead to improved mental health outcomes and reduced recidivism” (p.152).
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Authored by Amanda Beltrani
Amanda Beltrani is a current doctoral student at Fairleigh Dickinson University. Her professional interests include forensic assessments, professional decision making, and cognitive biases.