Offenders with mental health problems and problematic substance use : treatment interventions and crime relapse

Sammanfattning: Background: The relationships between problematic substance use, mental health problems and criminal behavior have been firmly established in research. Offenders with mental health problems and concurrent problematic substance use have high risk of reoffending and may display low rates of treatment retention. The overall aim of this thesis was to explore treatment needs, treatment participation and crime relapse among Swedish offenders with mental health problems and problematic substance use. Methods: The studies composing this thesis were part of the larger ongoing prospective follow-up project: Mental Disorder, Substance Abuse and Crime (MSAC) (n = 207) including offenders with mental health problems and problematic substance use in Stockholm County. Data from the baseline assessment and follow-up assessments of the MSAC-project were analyzed, as well as data gathered from Swedish registers and semi structured in-depth interviews. The participants were followed for approximately three years. Both quantitative and qualitative methodological approaches were used. Results: The following main findings emerged: (1) Participation in planned substance abuse outpatient visits was associated with a significantly reduced risk of criminal recidivism in the study population. (2) Higher scores of the Antisocial Psychopathy Checklist-Revised (PCL-R) facet and membership of a subgroup described as “Triply troubled with medical problems” were associated with an increased risk of criminal recidivism. (3) The Affective PCL-R facet was negatively related with participation in planned outpatient substance abuse visits and dry housing residence. (4) Among participants with various degrees of psychopathic personality traits, there were more similarities than differences in perceptions of substance abuse treatment. However, participants with a low degree of such traits stated that control requirements in treatment were rather manageable; whereas those with a high degree of psychopathic personality traits expressed that those requirements were difficult to fulfill. (5) All participants of the four previously defined subgroups/clusters of the study population showed improvements with regard to problem severity over the course of time, but the improvements were cluster-specific rather than sample specific. Cluster membership could also predict treatment participation and quality of life. (6) The Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT) showed reliability and concurrent validity in screening for substance dependence of alcohol and illicit drugs, as well as problem severity with regard to alcohol, drugs and illegal areas. Conclusions: Among offenders with mental health problems and problematic substance use, participation in planned outpatient substance abuse interventions should be considered important from a clinical risk management perspective, and be encouraged. Some personality traits as well as subgroup membership (based on specific problem profiles) could be considered in order to individualize treatment planning and improve outcomes. In order to identify problematic substance use, the AUDIT and the DUDIT questionnaires could be used.