Comorbid Bipolar Disorder, Substance Abuse Raises Risk of Criminal Justice System Involvement

People with bipolar disorder are not only more likely to become involved with the criminal justice system but also have more problems once inside jails or prisons, finds a new research review.

Thomas Fovet, M.D., of the Department of Psychiatry at the Centre Hospitalier Rȳgional Universitaire de Lille at France’s Universitȳ de Lille and colleagues identified 35 articles in the medical literature that explored the overlap between bipolar disorder and criminal justice involvement.

“This study gives a particular insight into patients with bipolar disorder who are involved with the criminal justice system, and the findings are pretty consistent with other research,” commented Marvin Swartz, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine. Swartz was not involved with Fovet’s study.

Estimated rates of bipolar disorder among people in jails and prisons range from 2 percent to 7 percent, much higher than the 1 percent in the general population, said Fovet. The nature of bipolar illness—especially in the manic phase—can be disruptive and become a risk for conflicts with guards or other prisoners. That behavior can lead to punitive extension of sentences or reincarcerations. More worrisome is the increased risk among patients with bipolar illness for suicide, already the leading cause of death in prisons.

Compared with the general population, patients with bipolar disorder are more likely to commit violent criminal acts in the first place, the researchers reported online in January in Psychiatric Services. For example, one especially rigorous, 30-year study (by the University of Oxford’s Seena Fazel, M.D., and colleagues) compared 3,743 patients in Sweden with 4,049 of their unaffected siblings and found that 8.8 percent of those with bipolar disorder committed violent crimes, compared with 3.1 percent of their siblings. The comparison with siblings helps adjust for many sociodemographic factors, said Fovet.

However, much of the difference was attributable to individuals with bipolar disorder who had a comorbid substance use disorder. Since 25 percent to 60 percent of patients in the articles reviewed had a substance use disorder, the authors suggested that patients with bipolar disorder should be “screened for addictive disorders to identify their risk for committing criminal acts.”

Moreover, bipolar disorder patients with comorbid substance use disorders also “have an increased risk of suicide, are less adherent to treatment, and are hospitalized more frequently than patients with bipolar disorder who do not have a comorbid substance use disorder.”

The role of substance abuse together with serious mental illness is complex, Swartz said. “There is a disinhibiting effect, but those patients are also less likely to be taking their prescribed psychotropic medications,” he said. “Nonadherent patients may have more psychotic symptoms.”

People with bipolar illness or other mental disorders who are using illicit substances are often connected to social networks that are involved in crime and reinforce antisocial behavior, added Swartz. “Many also have criminogenic personality traits like aggression, impulsivity, or antisocial thinking,” he said. “If you neglect that fact, you are missing one important aspect of treatment—namely, how to stay out of trouble.”

However, two-thirds of the people with serious mental illness in the criminal justice system are not in jaul but are under some form of community supervision—parole or probation, he said. Helping those people stay well in the community could be accomplished by supporting their medication adherence, helping them avoid substance use, and using counseling approaches to reduce their criminogenic behavior.

More dual-diagnosis treatment programs that focus on how to stay out of trouble would be valuable. “These individuals don’t have just one problem; they have multiple problems: mental illness, criminal justice involvement, addictive disorders, criminogenic factors in their peer networks,” said Swartz. “That underscores how complex a problem we face in treating this population.” ■