Mental disorder prevalence at the gateway to the criminal justice system

Foreword | Many criminal justice practitioners have observed that offenders experience poor mental health. While international studies have found mental health to be poorer among prisoners than in the general population, less information is available either about offenders who are not imprisoned or alleged offenders detained by police. The mental health of offenders is of key policy interest from both health service and crime prevention perspectives.

This is the first Australian study to measure the prevalence of mental disorder among offenders nationally, using information provided by 690 police detainees who participated in the Australian Institute of Criminology’s Drug Use Monitoring in Australia (DUMA) program. Around half reported having been diagnosed with a mental disorder in the past.

The study was also the first to use the Corrections Mental Health Screen (CMHS), an instrument validated for gender-specific screening, on an Australian offender population. Results suggest that almost half of detainees may have a diagnosable mental disorder at the time of arrest, including 42 percent of women and 28 percent of men with no previous diagnosis. In the routine screening of police detainees as they enter the criminal justice system, the CMHS could be used to identify for the first time those who would benefit from psychological assessment and appropriate intervention.

Adam Tomison

Director

Introduction

It has been well recognised, both in Australia and internationally, that poor mental health is more prevalent among prisoners than the general population (AIHW 2010; Butler & Allnutt 2003; Fazel & Danesh 2002). Substance abuse disorders are particularly prevalent among prisoners, and the comorbidity of these with other mental disorders has been found to increase the likelihood of criminal recidivism (Smith & Trimboli 2010). Such evidence has led to renewed government focus on improving mental health services for people in prison, as well as after release, with the intention of reducing recidivism by treating substance dependence and other mental disorders (Australian Government 2009). Although mental disorder does not necessarily contribute to offending behaviour, evidence suggests that, particularly in combination with substance abuse, mental disorders do play a part in criminal behaviour for some offenders (Day & Howells 2008).

Prisoners’ vulnerability to poor mental health has been specifically targeted for intensive intervention in Australian Government mental health policy (Australian Government 2009). The challenges of providing appropriate treatment to prisoners with both substance abuse and other mental disorders are well documented (Day & Howells 2008). However, prisoners represent only a proportion of the people who commit criminal offences, as most convicted offenders do not receive a custodial sentence. For example, in New South Wales, from 2004 to 2008, around seven percent of those convicted in local courts and 70 percent of those convicted in higher courts were given a prison sentence (BOCSAR 2008a, 2008b). This highlights the importance of adopting a multi-pronged and comprehensive approach to the identification and treatment of mental disorder among people throughout the criminal justice system—not only those in prison.

Mental disorder among non-incarcerated offenders is increasingly recognised as an issue of concern at various points in the criminal justice system. For example, court liaison services aim to improve the efficiency with which mentally disordered offenders are diverted to health services or supported through criminal justice processes (Bradford & Smith 2009). Specialist problem-solving courts have recently been introduced in many jurisdictions, and such courts consider mental disorder (including drug dependence) as criminogenic and aim to reduce criminal recidivism by legally mandating treatment (Payne 2006). NSW Police have introduced specialist training for frontline officers to improve interactions with mentally disordered people (Herrington et al. 2009). For these and other initiatives to be accurately targeted, good quality prevalence and causal pathway information has been identified as vital (Australian Government 2009).

Ogloff, Davis, Rivers and Ross (2007) recently highlighted the importance of accurately identifying mental disorders among people at the entry point of the criminal justice system. Diagnosis at this point presents a therapeutic opportunity, particularly for people who have concurrent substance abuse and other mental disorders. The authors recommend routine screening of police detainees using a structured and standardised screening instrument, assessment for those who are identified by the screening as mentally disordered, regular reassessment at various stages in the criminal justice system and sharing of health information to ensure continuity of care throughout the criminal justice system (Ogloff et al. 2007). The authors point out that routine screening identifies mentally disordered offenders for treatment provision, can help prevent violent incidents in detention facilities, allows resources to be allocated to the most needy and has the potential to reduce the cycle of admissions to the criminal justice system for people with mental health problems (Ogloff et al. 2007).

Routine screening identifies people who may appear well but who in actual fact are experiencing symptoms and therefore require a comprehensive psychological assessment. Such an assessment can then inform whether a diagnosis is warranted and treatment required—and, if so, the most appropriate type. In this paper, people whose responses on the screening instrument pass the appropriate threshold are referred to as screening in or having unmet need—that is, need for a comprehensive psychological assessment and possibly treatment. In this study the term treatment is used broadly to refer to medical, psychological and social interventions that have been found to help improve mental health.

Recent Australian studies have attempted to estimate the prevalence of mental disorders among people entering the criminal justice system. Heffernan, Finn, Saunders and Byrne (2003) measured substance use and other mental disorders among people arrested and detained in a Brisbane police facility. They interviewed 288 detainees and found that almost 80 percent of men and 85 percent of women were substance dependent. Using the General Health Questionnaire (GHQ-28) to screen for likely mental disorders (excluding substance-related disorders) the researchers found that almost all women and most of the men were assessed as likely to be experiencing a mental disorder. However, the authors concede that, as the GHQ was designed for use in general (rather than offender) populations, its validity for correctly screening for mental disorders among detainees is questionable.

Baksheev, Thomas and Ogloff (2010) interviewed 150 detainees in police facilities in Melbourne and found that three-quarters met criteria for a mental disorder diagnosis. The authors concluded that, as it may not be feasible to conduct a full psychiatric assessment of every detainee entering the criminal justice system, there is an urgent need to develop effective screening tools that quickly and routinely assess all police detainees to identify those who require a comprehensive psychiatric assessment.

Using the same detainee sample, Baksheev, Ogloff and Thomas (2011) compared police processes and two screening tools to assess which was most effective in identifying those detainees with mental disorders. They found both the screening instruments to be more effective than police processes, which tended to miss identifying people who had mental disorders. However, this study did not analyse whether the screening instruments were equally effective for male and for female detainees.

In another study, based on police detainees participating in the Drug Use Monitoring in Australia (DUMA) program in New South Wales, Queensland, South Australia and Western Australia, Forsythe and Adams (2009) found high levels of psychological distress and other indicators of mental disorder among detainees. Further, they found more indicators of mental disorder among women than men. However, it was acknowledged that the mental health measures utilised in that study had shortcomings, so it is not clear how accurately the results reflect actual prevalence rates. (For more detail about these measurement issues see Forsythe in press; Forsythe & Adams 2009.)

It is apparent that Australian studies which have attempted to estimate the prevalence of mental disorder among people entering the criminal justice system (that is, detained by police) have yielded very limited information. Studies have generally been conducted in a single jurisdiction (limiting generalisability), have used different instruments to measure mental health (compromising comparability), have used instruments not validated for offender populations and/or have been limited to male offenders.

Aims of the current study

The aims of this study are to:

• describe the mental disorder diagnoses reported by detainees
• estimate the unmet need for comprehensive psychological assessment and/or treatment among detainees
• describe the illicit drug use and offending patterns of detainees with mental disorders.

There are several particularly valuable aspects of this study. The data are drawn from the Australian Institute of Criminology’s Drug Use Monitoring in Australia (DUMA) program. As DUMA data are collected from people shortly after they have been arrested by police, the program is in a unique position to assess the prevalence of mental disorder among people who are at the gateway to the criminal justice system. Second, as DUMA is an ongoing program, it will be possible to repeatedly collect mental health information and thus monitor the prevalence of mental disorder among people entering the criminal justice system. Third, the data are collected from police facilities in a variety of jurisdictions and thus generate national data. Finally, the large sample size allows for gender analysis—as women constitute a minority of offenders, most studies either do not include female participants or include too few to allow for gender-specific analysis. There is some evidence that women’s mental health, drug use and offending tend to follow different pathways to men’s (Johnson 2004; Loxley & Adams 2009; Simpson, Yahner & Dugan 2008), and their representation in the criminal justice system appears to be increasing (Holmes 2010). Therefore, it is vital to produce a solid evidence base according to which gender-appropriate service responses can be made.

Methodology

The DUMA program is an ongoing national drug use and drug market monitoring program which collects information on a quarterly basis from people who have been detained in police custody (Gaffney et al. 2010; Makkai 1999). DUMA data are collected via a face-to-face, interviewer-administered survey comprising a core set of routinely asked questions, as well as additional questions incorporated as addenda and asked periodically of subsets of detainees. This study is based on DUMA data drawn from addendum questions about mental health—as well as demographic, illicit drug use, offending and medication use data elicited by the core questions.

Data were collected during the first quarterly data collection of 2010 (January–March) from police facilities hosting DUMA sites in Queensland (Southport and Brisbane), New South Wales (Bankstown and Kings Cross) and Western Australia (East Perth). Data from the Northern Territory site in Darwin were initially intended to be included. However, it became apparent during the data collection process that the mental health questions were not adequately understood or were inappropriate for the traditional Aboriginal detainees, who constitute the majority of Darwin detainees. The data from Darwin were therefore excluded from the analysis due to concerns about validity. This highlights the difficulties inherent in attempting to measure mental health in a multicultural sample—in particular of traditional Indigenous people.

In total 1,038 police detainees were potentially available to participate in the DUMA research at the QLD, NSW and WA sites. Of the 778 detainees interviewed, 83 percent were men and 17 percent were women. The remaining 260 either could not be interviewed (because they were violent, posed a security or safety risk, were too intoxicated or unwell, did not speak adequate English or were released too quickly to facilitate participation) or chose not to participate.

It is likely that detainees with the most severe mental disorder symptoms are under-represented among DUMA participants because detainees who were unable to provide informed consent or were exhibiting violent or uncontrolled behaviour were likely to be over-represented in the group that could not be interviewed.

Of the 778 detainees who participated in this study, 690 answered at least one of the mental health addendum questions. (Addendum questions are asked at the end of the core survey, and sometimes interviews stop before completion if the detainee is due to be released from custody, is taken to court or chooses not to complete, or because safety concerns become apparent during the research process.) Most of the DUMA sites only process adults (aged 18 and over), although the NSW sites also process juveniles, who were included in the study.

How mental health was measured

Full diagnostic interviews would provide the most accurate measure of mental disorder prevalence. However, as detainees are available to the DUMA research for a very limited time, shorter measurement methods were required. (For a full discussion on the challenges inherent in measuring mental health for criminology research see Forsythe in press.)

The two measures chosen for this study were a self-report measure, whereby detainees were asked whether they had ever been diagnosed with a mental health problem, and a screening instrument designed specifically to screen detainees for mental disorders.

Figure 1: Percentage of detainees who screened in by gender and age group

Results

Diagnosed mental disorders

Detainees were asked whether they had ever been diagnosed with a mental health problem by a doctor, psychiatrist, psychologist or nurse. Of the 668 detainees who answered this question, 281 (41%) reported having been previously diagnosed. Of these, 272 were able to recall at least one diagnosis, 23 reported two diagnoses and five reported three diagnoses. Respondents were asked this question first in a free recall format; then they were shown a comprehensive list of diagnostic labels as a cue. Up to three diagnoses were recorded for each format of this question.

This dual format was used to ascertain which form of the question yielded the most useful information in order to inform future research. All the diagnoses reported by detainees were classified using the DSM-IV-TR as a guide (APA 2000). Twenty-nine people who said that they had never been diagnosed with a mental disorder in response to the free recall version of the question remembered having been diagnosed when cued with the list. Of the 281 people who reported having been diagnosed in response to the free recall version of the question, 140 reported at least one additional diagnosis when cued with the list—69 mentioned two additional diagnoses and 35 mentioned three. The additional disorders most frequently elicited by cuing were (in order of frequency): anxiety, ADHD and behavioural disorders, learning disorders, mood disorders and sleep disorders.

Table 1 shows the diagnostic categories of mental health problems reported by detainees; it includes responses to the free recall and cued recall questions. The percentages in Table 1 are based on all detainees who answered the mental health questions (rather than just those who reported having been diagnosed), so that they provide an estimate of the prevalence of diagnosed mental disorders among the detainee population. Overall, 55 percent of women and 43 percent of men reported a diagnosis in response to the free recall and/or cued recall questions. Of those detainees who reported a diagnosis, 1.8 diagnoses per man were reported and 2.0 per woman.

Mental disorder screen

The Corrections Mental Health Screen for Men (CMHS-M) and Corrections Mental Health Screen for Women (CMHS-F) are gender-specific, standardised and validated sets of questions that screen detainees for mental disorder (Ford et al. 2009). The Corrections Mental Health Screen (CMHS) does not provide a diagnosis; rather, it was developed for routine screening by non-clinical jail staff to facilitate identification of detainees who are likely to be experiencing a mental disorder so that they can be referred for comprehensive psychological assessment.

For this study five or more ‘yes’ responses for men and four or more ‘yes’ responses for women were the cut-offs for determining that detainees screened in (Ford et al. 2009). Determining whether a detainee screens in identifies people who are likely to have a diagnosable mental disorder (Ford et al. 2009). Overall, nearly half of detainees (49%) scored above the cut-offs and thus screened in. A higher percentage of women (64%) screened in compared with men (46%). Figure 1 shows the percentage of detainees who screened in by age group and gender.

Screening results and previous diagnosis

Table 2 shows that detainees who reported having already been diagnosed with a mental disorder were also most likely to screen in. There are several reasons for this. First, some of the CMHS questions ask about symptoms ever experienced, This means that, even if the person has been diagnosed and treated and is currently well, they may answer these questions in the affirmative. Second, some of the CMHS questions canvas current symptomology, which could be indicative of a person still experiencing the condition they were diagnosed with or perhaps an undiagnosed disorder. However, the most notable information yielded by the CMHS relates to those detainees who reported never having been diagnosed. Of these 29% screened in and are therefore likely to have a diagnosable mental disorder. This rate is much higher among women: 42% of women who reported that they had not been diagnosed screened in, compared with 28% of men.

Another indicator of mental disorder diagnosis is the number of people who are taking legally prescribed psychoactive medications such as antidepressants, antipsychotics and antianxiety medications. Of the detainees who screened in, 33 percent of men and 46 percent of women reported currently taking prescribed psychoactive medications.

Figure 2: Percentage of detainees who screened in by most serious offence (MSO) and gender

Note: At least one variable was missing for 9 participants

Link between mental disorders and illicit drug use

Detainees who had used illicit drugs in the previous month were more likely to have been diagnosed with a mental disorder as well as more likely to screen in for a mental disorder.

Previous diagnosis and illicit drug use

Of detainees who had used at least one illicit drug during the previous month, 51 percent reported having been diagnosed with a mental disorder compared to 37 percent of detainees who had not used illicit drugs. This difference was more pronounced among women: 66 percent of women who used drugs in the previous month reported having been diagnosed, compared with 40 percent of those who had not recently used illicit drugs. Forty-eight percent of men who had used illicit drugs in the previous month reported a diagnosis, compared to 36 percent of those who had not recently used drugs.

Screen results and illicit drug use

Seventy percent of women who had used drugs in the previous month screened in compared to 54 percent who had not, whereas 54 percent of men who had used illicit drugs in the previous month screened in compared with 36 percent who had not.

Link between mental disorders and most serious offence type

The highest proportion of male detainees with mental disorder were among those charged with property offences (56% screened in and 55% reported a diagnosis). The proportion of female detainees with mental disorder was high across offence categories, the highest being among women charged with drug offences (82% both screened in and reported a diagnosis). As the number of female detainees in each offence category was quite small, the results may not be generalisable to female detainees beyond this sample.

Figure 2 shows the percentage of detainees who screened in within each most serious offence type. The distribution of mental disorder diagnosis within each offence type was very similar to that for those who screened in. Only the latter are shown in Figure 2, for visual clarity.

Discussion

Diagnosed mental disorders

The most common mental disorders found to be experienced by the general population (during the previous 12 months) were anxiety (11% of men and 18% of women), mood (5% of men and 7% of women) and substance use disorders (7% men and 3% women) (ABS 2008). In contrast, among detainees mood disorders (for example, depression and bipolar) were the most often reported disorders and at very high rates: 28 percent of male and 44 percent of female detainees. Anxiety and substance use disorder diagnoses were reported by detainees in similar proportions to those found in the general population. It is surprising that the rate of substance use disorders reported by detainees was not higher, considering the high rates of illicit drug and alcohol use and dependence previously found among detainees (Loxley & Adams 2009) and prisoners (Butler & Allnutt 2003). This could possibly reflect low levels of diagnosis of substance use disorders among detainees, memory issues or perhaps the fact that detainees may not consider substance use a mental health problem. In future, use of a standardised measure of substance use disorders would provide more accurate data.

Caution must also be urged in comparing the prevalence rates of specific disorder categories found in this study with those found in other populations, as different measurement instruments are used. For example, Australian general population prevalence rates from the National Survey of Mental Health and Wellbeing (NSMHWB) were measured with a standardised diagnostic instrument that identified mental disorders (whether or not they had previously been diagnosed) (ABS 2008). In contrast, our study asked detainees whether they had ever been diagnosed. This question would be expected to identify only a proportion of those who had actually experienced symptoms—it has been shown that not all people who experience symptoms seek out health services. The NSMHWB found that only 28 percent of men and 41 percent of women who had a mental disorder during the previous 12 months had used a service (general practitioner, psychiatrist, psychologist or other health professional) for their mental health problem (ABS 2008). Therefore, detainees who self-report diagnosis probably reflect only a small proportion of the detainees who actually experienced symptoms.

Nevertheless, at the point of entry to the criminal justice system a previous diagnosis flags that a comprehensive psychological assessment is warranted. This is not to suggest that a mental disorder necessarily plays a causal role in criminal offending; rather, diagnosis at the entry point to the criminal justice system can provide a window of opportunity for assessment and/or treatment (Day & Howells 2008).

Overall, 43 percent of male detainees and 55 percent of female detainees reported having been previously diagnosed with a mental disorder. These findings, while not directly comparable with the community prevalence rates of 18 percent of men and 22 percent of women having had a mental disorder within the previous year (ABS 2008), suggest that mental disorder among detainees is likely to be much more prevalent than in the general population.

Two other diagnostic categories are specifically worth highlighting: psychotic disorders, and the attention deficit and behavioural disorders.

In the Australian general population the lifetime prevalence of psychotic disorders (including schizophrenia, schizophrenia spectrum and other psychoses) has recently been estimated at 3.5% for men and 2.2% for women (Short et al. 2010). Psychotic disorders are typically chronic and are associated with high rates of substance use disorder comorbidity, as well as substantial personal and social cost (Jablensky et al. 2000; Short et al. 2010). In this study five percent of male and four percent of female detainees reported a psychotic disorder diagnosis. This was lower than rates recently reported by prisoners—nine percent of prisoners of both genders self-reported a schizophrenia diagnosis, and eight percent of men and 13 percent of women reported manic depressive psychosis (Indig et al. 2010)—but it was still higher than that found in the general population. Psychotic disorders are frequently associated with comorbid substance use disorders and criminal offending, including violent offending (Wallace et al. 2004). The identification of detainees experiencing psychotic disorders presents an important treatment and crime prevention opportunity, particularly in light of recent evidence suggesting that the first episode of psychosis is a particularly vulnerable time for violent offending (Yee et al. 2010).

There is a paucity of data in relation to the prevalence rates of attention deficit hyperactivity disorder (ADHD) in the Australian population. However, international studies suggest that approximately three percent of adults may experience ADHD—a condition associated with, and usually pre-dating, other mental disorders and significant life impairment (Fayyad et al. 2007). Six percent of Australian children have been estimated to experience ADHD (Sawyer et al. 2000). In this study 11 percent of male and six percent of female detainees reported having been diagnosed with ADHD, but it is unknown whether they were diagnosed during childhood or adulthood and whether the symptoms remediated in adulthood or were still being experienced. ADHD is conceptualised as a condition which starts in childhood (APA 2000), so adults with symptoms would be a subset of those who experienced symptoms in childhood. The rates found in this study suggest that there may be an over-representation of people with ADHD among detainees. Australian prisoners have self-reported ADHD diagnosis in similar proportions to the detainees in our study—12 percent of men and three percent of women (Indig et al. 2010). Adult ADHD is predicted by, and associated with, comorbidity and significant impairment (Biederman et al. 2010). Thus, screening detainees presents an opportunity to identify detainees who may benefit from comprehensive assessment and treatment.

Screening results

In this study almost half (49%) of the detainees sampled were experiencing a diagnosable mental disorder according to the diagnostic criteria of a validated screening instrument. This may be an underestimate, as in some jurisdictions police officers take people who appear mentally unwell directly to mental health facilities, and such people would not have been available to participate in this study. Additionally, detainees whose behaviour was violent or uncontrolled were excluded from participating, and it is possible that these detainees may have included a higher representation of people experiencing mental disorders.

However, despite this prevalence estimate being a possible underestimate, it is still almost 2½ times the 12-month prevalence rate of mental disorder in the Australian general population (20%) (ABS 2008). It is more comparable to a NSW study that found 58 percent of prisoners to have had a one-month prevalence rate of at least one mental disorder (Butler & Allnutt 2003). Thus it appears that people detained by police, most of whom will not end up with a prison sentence, are experiencing mental disorders at rates more comparable with prisoners than the general community (Butler & Allnutt 2003; Johnson 2004; Kenny et al. 2008).

While most detainees who reported a previous diagnosis of mental disorder screened in, 28 percent of male detainees and 42 percent of female detainees who had never been diagnosed also screened in, indicating that they were likely to have a diagnosable mental disorder. This suggests that a significant proportion of detainees who have no previous mental illness history are likely to have an unmet health need at the point of entry to the criminal justice system.

Gender differences

This study also suggests that unmet need may be unequally distributed among detainees. A higher proportion of women screened in (63%) compared to men (44%). Almost all (84%) of the women who reported having been previously diagnosed with a mental disorder also screened in, but 42% of those who had never been diagnosed still screened in. While women in the general population also typically have higher prevalence rates of mental disorder compared with men, the overall rates and differences are much lower than those found among detainees in this study. For example, the 12-month prevalence rate of mental disorder among women in the general Australian population is 22 percent, compared with 18 percent among men (ABS 2008).

As illustrated in Figure 1, women tended to screen in across all age categories, whereas among men smaller proportions of the youngest (under 20 years old) and the oldest (50 years and over) detainees screened in. Overall, the prevalence of mental disorder among detainees across age categories appears to be more congruent with the high prevalence rates documented among prisoners (both adult and juvenile) than those found in the general population.

Comorbidity

Some detainees screened in as well as reporting a previous diagnosis of mental disorder. As mentioned earlier, this could reflect the fact that the CMHS screening tool measures current symptoms as well as symptoms experienced at any stage of the respondent’s life. However, as screening in on the CMHS has been found to predict current diagnosable mental disorder, when detainees also report a past diagnosis, that is likely to indicate comorbidity or a period of ongoing ill health. Also, detainees who self-reported a diagnosis typically reported more than one: men reported on average 1.9 diagnoses and women reported two—a pattern of responses that also suggests comorbidity.

The results of this study showed that detainees who had recently used illicit drugs were more likely to have been diagnosed with a mental disorder as well as more likely to screen in at the time of their arrest. This co-occurrence of illicit drug use and other mental disorders presents a significant issue for the criminal justice system. It has been found that prisoners who experience comorbid substance use and non-substance use disorders have higher recidivism rates than those who have either one or the other (Smith & Trimboli 2010). It has also been found that people experiencing both substance use and other mental disorders have more complex treatment needs, including the additional common co-occurrence of multiple disadvantage in the social, financial, and educational spheres (Treloar & Holt 2008).

Treloar and Holt (2008) observed what they refer to as complex vulnerabilities among drug treatment clients with a dual diagnosis: poor housing, restricted income, debt, criminal justice system involvement and unemployment. The authors found that these interconnecting problems make it very difficult to successfully complete drug treatment and are deleterious to mental health. Similarly, a recent study on the psychosocial needs of NSW court defendants found high levels of self-reported mental health disorders, including substance dependence (Jones & Crawford 2007). Both of these studies advocate a holistic and comprehensive approach to drug addiction and mental health treatment which incorporates welfare and social support (Jones & Crawford 2007; Treloar & Holt 2008).

Summary

This study found that a high proportion of people arrested by police had been previously diagnosed with mental disorders. At the point of entry to the criminal justice system, a psychiatric history is one indicator that a detainee may require a comprehensive psychological assessment. However, the study found that many detainees who had never been diagnosed with a mental disorder were identified by screening as likely to be experiencing a diagnosable mental disorder. This suggests that detainees’ mental health needs are not being adequately identified and treated in the community and that the point of entry to the criminal justice system may provide this opportunity. Assessment and treatment are likely to benefit the detainee, the criminal justice system— which is tasked with the responsibility of managing the detainee—and the community if the mental disorder has a causal role in that person’s offending. Routine screening of detainees at the time of police processing using a short screening instrument, such as the CMHS, could readily identify detainees who have unmet mental health needs.

Ogloff et al. (2007) recently found considerable differences in how police in different Australian jurisdictions identified mentally disordered detainees—no jurisdiction that routinely screens detainees uses a standardised instrument. Given the findings of our study, such routine screening, followed by comprehensive psychological assessment and appropriate integrated treatment, seems well warranted. The challenge is to develop treatments that improve psychosocial functioning and reduce criminal behaviour (Drake et al. 2006). Considering that in many cases prison experiences are known to be criminogenic—putting people who are socially and mentally disadvantaged on a path to repeated recidivism (Baldry 2009)—well-targeted and appropriately integrated intervention at the point of police contact may provide opportunities to help break this cycle.

Limitations

The authors acknowledge several limitations to the study. First, it may underestimate mental disorder among detainees, as detainees whose behaviour was violent or uncontrolled were not approached for participation. Second, while it can be assumed that the CMHS correctly identified detainees with mental disorders—its psychometric properties have been found to be very good for both men and women (Ford et al. 2009)—the instrument has yet to be validated in an Australian context. Third, information about specific diagnoses was based on self-report rather than actual diagnosis, making the data vulnerable to factors known to potentially influence self-report, including the sensitivity of the questions asked (Tourangeau & Yan 2007).

References

• ABS 2008. National Survey of Mental Health and Wellbeing: Summary of results, 2007. Canberra: Australian Bureau of Statistics
• AIHW 2010. The health of Australian prisoners 2009. Canberra: Australian Institute of Health and Welfare
• APA 2000. Diagnostic and statistical manual of mental disorders, 4th ed (text revision ed). Washington DC: American Psychiatric Association
• Australian Government 2009. National mental health policy 2008
• Baksheev GN, Ogloff J & Thomas SDM 2011. Identification of mental illness in police cells: A comparison of police processes, the Brief Jail Mental Health Screen and the Jail Screening Assessment Tool. Psychology, Crime & Law DOI:10.1080/1068316X.2010.510118  
• Baksheev GN, Ogloff JRP & Thomas SDM 2010.Psychiatric disorders and unmet need in Australian police cells. Australian and New Zealand Journal of Psychiatry (44): 1043–1051
• Baldry E 2009. Australian prisons: A booming industry. Debate (4): 31–34
• Biederman J, Petty CR, Clarke A, Lomedico A & Faraone S 2011. Predictors of persistent ADHD: An 11-year follow-up study. Journal of Psychiatric Research 45(2): 150–5
• BOCSAR 2008a. NSW higher courts: Percentage of convicted offenders sentenced to prison by principal offence type 2004–08
• BOCSAR 2008b. NSW local courts: Percentage of convicted offenders sentenced to prison by principal offence type 2004–08
• Bradford D & Smith N 2009. An evaluation of the NSW Court Liaison Services. Sydney: NSW Bureau of Crime Statistics and Research
• Butler T & Allnutt S 2003. Mental illness among New South Wales prisoners. Matraville: NSW Corrections Health Service
• Day A & Howells K 2008. Problems in responding to co-occurring mental health and drug-related problems: A criminal justice perspective, in S Allsop (ed), Drug use and mental health: Effective responses to co-occurring drug and mental health problems. Melbourne: IP Communications
• Drake RE, Morrissey JP & Mueser KT 2006. The challenge of treating forensic dual diagnosis clients: Comment on ‘Integrated treatment for jail recidivists with co-occurring psychiatric and substance use disorders’. Community Mental Health Journal 42(4): 427–432
• Fayyad J, De Graaf R, Kessler J, Alonso M, Angermeyer Ket al. 2007. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. British Journal of Psychiatry 190: 402–409
• Fazel S & Danesh J 2002. Serious mental disorder in 23 000 prisoners: A systematic review of 62 surveys. The Lancet 359: 545–550
• Ford JD, Trestman RL, Wiesbrock VH & Zhang W 2009. Validation of a brief screening instrument for identifying psychiatric disorders among newly incarcerated adults. Psychiatric Services 60(6): 842–846
• Ford JD, Trestman RL, Wiesbrock VH & Zhang W 2009. Validation of a brief screening instrument for identifying psychiatric disorders among newly incarcerated adults. Psychiatric Services 60(6)
• Forsythe, L in press. Measuring mental health in criminology research: Lessons learnt from the Drug Use Monitoring in Australia program
• Forsythe L & Adams K 2009. Mental health, abuse, drug use and crime: Does gender matter? Canberra: Australian Institute of Criminology
• Gaffney A, Jones W, Sweeney J & Payne J 2010. Drug use monitoring in Australia: 2008 annual report on drug use among police detainees. Canberra: Australian Institute of Criminology
• Heffernan EB, Finn J, Saunders JB & Byrne G 2003. Substance-use disorders and psychological distress amongst police arrestees. Medical Journal of Australia 179: 408–411
• Herrington V, Clifford K, Lawrence PF, Ryle S & Pope P 2009. The impact of the NSW Police Force Mental Health Intervention Team: Final evaluation report. Charles Sturt University Centre for Inland Health
• Holmes J 2010. Female offending: Has there been an increase? Sydney: NSW Bureau of Crime Statistics and Research
• Indig D, Topp L, Ross B, Mamoon H, Border B, Kumar S et al. 2010. 2009 NSW Inmate Health Survey: Key findings report. Sydney: Justice Health
• Jablensky A, McGrath J, Herrman H, Castle D, Gureje O et al. 2000. Psychotic disorders in urban areas: An overview of the study on low prevalence disorders. Australian and New Zealand Journal of Psychiatry 34: 221–236
• Johnson H 2004. Drugs and crime: A study of incarcerated female offenders. Canberra: Australian Institute of Criminology
• Jones C & Crawford S 2007. The psychosocial needs of NSW court defendents. Sydney: NSW Bureau of Crime Statistics and Research
• Kenny D, Nelson P, Schreiner I, Lennings C & Butler T 2008. Young offenders on community orders: Health, welfare and criminogenic needs. Sydney, Australia
• Loxley W & Adams K 2009. Women, drug use and crime: Findings from the Drug Use Monitoring in Australia program. Canberra: Australian Institute of Criminology
• Makkai T 1999. Drug Use Monitoring in Australia (DUMA): A brief description. Canberra: Australian Institute of Criminology
• Ogloff JRP, Davis MR, Rivers G & Ross S 2007. The identification of mental disorders in the criminal justice system. Canberra: Australian Institute of Criminology
• Payne J 2006. Specialist courts: Current issues and future prospects. Canberra: Australian Institute of Criminology
• Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW et al. 2000. Child and adolescent component of the National Survey of Mental Health and Well-Being. Canberra: Commonwealth Department of Health and Aged Care
• Short T, Thomas S, Luebbers S, Ogloff JRP & Mullen P 2010. Utlilization of public mental health services in a random community sample. Australian and New Zealand Journal of Psychiatry 44: 475–481
• Simpson S, Yahner J & Dugan L 2008. Understanding women’s pathways to jail: Analysisng the lives of incarcerated women. The Australian and New Zealand Journal of Criminology 41(1): 84–108
• Smith N & Trimboli L 2010. Co-morbid substance and non-substance mental health disorders and re-offending among NSW prisoners. Sydney: NSW Bureau of Crime Statistics and Research
• Tourangeau R & Yan T 2007. Sensitive questions in surveys. Psychological Bulletin 133(5): 859–883
• Treloar C & Holt M 2008. Complex vulnerabilities as barriers to treatment for illicit drug users with high prevalence mental health co-morbidities.Mental Health and Substance Use: Dual Diagnosis 1(1): 84–95
• Wallace C, Mullen P & Burgess P 2004. Criminal offending in schizophrenia over a 25-year period sparked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. American Journal of Psychiatry 161: 716–727
• Yee NYL, Large MM, Kemp R & Nielssen OB 2011. Severe non-lethal violence during psychotic illness. Australian and New Zealand Journal of Psychiatry: 45(6): 466–72

About the Authors

Lubica Forsythe is a psychologist in a community mental health setting and was previously NSW DUMA Site Manager

Antonette Gaffney was a research officer at the Australian Institute of Criminology