Dr James Freeman, Prof Jane Maxwell & Prof Jeremy Davey ICADTS Oslo August 2010

1. Psychiatric and Substance Abuse Comorbidity among a Large Sample of Texas Offenders Dr James Freeman, Prof Jane Maxwell & Prof Jeremy Davey ICADTS Oslo August 2010 CRICOS No. 00213J

2. Summary • Overview of problem • Aim of study: examine the extent of psychiatric problems among a large sample of DUI offenders entering treatment • Results: It’s fairly high! • Implications • Warning: This is a straight forward presentation

3. Acknowledgements • Texas Department of State Health Services for the use of their data • Motor Accident Insurance Commission (MAIC)

4. Current Context • Research has generally demonstrated a strong link between substance abuse and comorbid psychiatric disorders (Grant et al., 2004), in particular, among those with alcohol abuse problems (Kessler et al., 2005). • Comorbid issues often predict poor treatment outcomes as such individuals usually require a greater frequency of hospitalisations and are less compliant with treatment.

5. Current Context • The negative symptoms associated with psychiatric disorders can often be amplified through alcohol abuse and dependence, and this comorbid group is believed to be at an increased risk of relapse (Petrakis et al., 2002). • Within the (DUI) population, it is generally accepted that alcohol and drugdependence and severe alcohol abuse problems remain core issues that are likely to be found within impaired driving cohorts • Such issues are also predictive of relapse

6. Current Context • Research has also begun to demonstrate the complex nature of the DUI problem, as offenders are increasingly likely to also present with drug problems in addition to alcohol, and that females are also susceptible to such poly substance use problems • Given the strong link between substance abuse and comorbid psychiatric disorders, as well as that DUI offenders often present with elevated levels of substance abuse problems, it appears warranted to examine the extent of such comorbid psychiatric issues among DUI offenders.

7. Psychiatric Disorders • Preliminary research into this issue has started to provide some very interesting results. • The elevated presence of bipolar disorder among a sample of repeat offenders N = 729 Albanese et al. (2010) • DUI offenders (N = 2714) entering treatment also reported the elevated presence of a range of psychiatric disorders, including Major Depressive Episode, Panic Disorder, PTSD (McCutcheon et al. 2009) • Psychiatric symptoms associated with early drink driving experiences (Marczynski & Wieczorek, 2010)

8. Psychiatric Disorders • Another concern is that preliminary research shows that DUI offenders who are presenting for treatment with comorbidity issues are not disclosing the severity of their symptoms to justice officials at sentencing and also not receiving appropriate treatment (Albanese et al., 2010). • Despite this delay, it is well recognised that accurate identification of psychiatric disorders naturally improves treatment outcomes.

9. AIM OF THE STUDY • The prevalence of psychiatric comorbidity issues in a sample of DUI offenders in treatment; • Whether recidivist offenders present with more complex psychiatric and substance abuse needs; and • The levels of complexity of psychiatric and substance abuse comorbidity issues among females as compared to male DUI clients.

10. SAMPLE • This is a secondary analysis of an administrative dataset containing records on all individuals admitted to treatment programs funded by the Texas Department of State Health Services (DSHS) between 2005 and 2008. These programs are non-profit community-based programs that may offer residential and outpatient services; they do not offer inpatient hospitalization.

11. SAMPLE • Records of 36,372 clients who had a DUI offence in the past 12 months were selected to be compared to all the remaining 308,714 clients who were admitted to the same treatment programs but had no past-year DUI status.

12. SAMPLE DUI’s • Age M = 33 • Male 71.8% Female 28.2% • Employed Past Year 6.3% • Homeless 4.6% • Placed on Medication at Admission 21.9% • Past Month Emergency Room Visit 24.4%

13. PROCEDURE • Assessment and data collection were completed by intake counsellors in 79 public treatment programs across the state. Only programs who had personnel trained to diagnose clients using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000) could report the mental health diagnoses of their clients.

14. ANALYSIS • The specific diagnoses were collapsed into four major diagnostic groups (depression, bipolar, anxiety and schizophrenia-related disorders) for reasons of parsimony to facilitate analysis • For example, the depression diagnostic category included a range of Major Depressive Disorders such as Single Episodes as well as Recurrent, with and without psychotic features, ranging from mild to severe.

15. For those interested in the Statistics Freeman, J., Maxwell, J., & Davey, J. (in press). Unraveling the Complexity of Driving While Intoxicated: a Study into the Prevalence of Psychiatric and Substance Abuse Comorbidity. Accident Analysis and Prevention.

16. SUBSTANCE PROBLEM • Primary Alcohol Problem 65.9% • Primary Cannabis Problem 12.5% • Primary Cocaine Problem 8.6% • Primary Methamphetamine Problem4.7% • No Secondary Drug Problem 52.6%

17. QUESTION 1 • 85% had no diagnosis or condition on the DSM-IV Axis I or II • 15% received a DSM-IV diagnosis • Depression was the most common psychiatric problem experienced by all the clients

18. QUESTION 1 DUI Non-DUI • Depression 8.6% Depression 11.8% • Bipolar 4.2% Bipolar 6.1% • Anxiety 1.7% Anxiety 1.7% • Schizophrenia 1.0% Schizophrenia 2.5% • DUI’s Program Completion 59.7% • Non-DUI’s Program Completion 69.1%

19. SYMPTOMS Depression - Sustained depressed mood, significant weight loss, insomnia or hypersomnia, fatigue, diminished ability to think or concentrate as well as suicide ideation Anxiety - Uncontrollable worry that is extremely upsetting and stressful, anxiety significantly affects social and vocational functioning, is ongoing Bipolar - Extreme mood instability, self-destructive habits, suicide ideation, etc Schizophrenia • Formal thought disorder, perceptual disturbances (visual, auditory), • Tremendous vocational and social impact

20. QUESTION 1 • Of particular concern is that a Bipolar Disorder diagnosis was also associated with an: • increased likelihood of not completing treatment; and • Primary problems with opiates.

21. SYMPTOMS OF BIPOLAR • Extreme mood instability • Manic Episodes & Depressed Episodes • Clinically significant distress or impairment in vocational, social and personal functioning • Use substances to manage mood instability

22. QUESTION 2 • First vs Repeat offenders • Repeat offenders were more impaired than those with only one DUI arrest in regards to the Addiction Severity Index (ASI) • Were more likely to have a history of injection drug use and to have used daily • First offenders more likely to have cannabis problems while recidivist offenders had alcohol problems

23. QUESTION 3 FEMALES MALES Depression 13.7% Depression 6.3% Bipolar 7.8% Bipolar 2.8% Anxiety 2.7% Anxiety 1.2% Schizophrenia 0.9% Schizophrenia 1.0%

24. QUESTION 3 • Female DUIs were more likely than males to have problems with methamphetamine, cocaine, and opiates • Females were also more likely to be placed on medication at treatment commencement.

25. OVERVIEW • DUI clients were most likely to have a primary problem with alcohol. • However, an increasing proportion of DUI offenders entering treatment had a primary drug-related problem e.g., cannabis • DUI population is at risk of presenting with a psychiatric disorder, in particular, a mood disorder • In regards to co-morbid psychiatric conditions, it is noteworthy that Depression was the most common psychiatric condition recorded by DUI clients, although Bipolar and Anxiety-based disorders were substantial • Females were more likely to be diagnosed with a mental health problem, have substance abuse problems and be medicated.

26. DISCUSSION • We need to screen, identify and treat the clinically significant impairment of such disorders • Such individuals are at an increased risk of non-program completion, which increases risk of recidivism • Need to recognise that females are just at risk (or more) of substance or psychiatric impairment

27. DISCUSSION Need to ensure the use of effective and widely-used mental health and substance abuse screening methods for individuals who are first arrested for a DUI offence, rather than delay such processes until those at risk re-offend and/or possibly experience a deterioration in their condition; Under diagnosis of mental health issues remains a concern 8 year lag between symptom onset and diagnosis Under diagnosis has clear implications for relapse Shorter periods of untreated illness have better outcomes In regards to DUI treatment, we need to ensure we look beyond just alcohol-related issues to identify and treat other factors

28. TREATMENT • While there is scant research that has focused on the impact that such mood disorders have on the driving task, treating the negative symptoms associated with mental health problems can only improve an individual’s driving capacity.

29. Questions? Mark your Diaries! International Council on Alcohol, Drugs and Traffic Safety Conference (T2013) August 2013, Brisbane Convention and Exhibition Centre