The associations of poor psychiatric well-being among incarcerated men with injecting drug use histories in Victoria, Australia
Cossar et al. Health and Justice
The associations of poor psychiatric well-being among incarcerated men with injecting drug use histories in Victoria, Australia
Reece Cossar 0 1
Mark Stoové 0 2
Stuart A. Kinner 2 3 4 5 6
Paul Dietze 0 2
Campbell Aitken 0 2
Michael Curtis 0
Amy Kirwan 0
James R. P. Ogloff 1
0 Behaviours and Health Risks, Burnet Institute , Melbourne , Australia
1 Centre for Forensic Behavioural Science, Swinburne University of Technology & Forensicare , Melbourne , Australia
2 School of Public Health and Preventive Medicine, Monash University , Melbourne , Australia
3 Mater Research Institute-UQ, University of Queensland , Mount Gravatt , Australia
4 Griffith Criminology Institute, Griffith University , Brisbane , Australia
5 Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne , Melbourne , Australia
6 Centre for Adolescent Health, Murdoch Children's Research Institute , Melbourne , Australia
Background: Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome. Methods and Results: Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being. Conclusions: Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.
Injecting drug use; Dual diagnosis; GHQ-12; Prisoner health
Over the past decade, the Victorian incarceration rate
has increased from 100 per 100,000 adults in 2006 to
138 per 100,000 adults in 2016
(Australian Bureau of
. People with a history of injecting drug
use are over-represented in the Australian prison
population. An estimated half of Australian prisons report a
lifetime history of injecting drug use and approximately
one in four reports at least one injection episode in the
month prior to incarceration
(Australian Institute of
Health and Welfare, 2015; Reekie et al., 2014)
who inject drugs (PWID) face a heightened risk of
bloodborne viral infections
(Snow et al., 2014; Vescio et al.,
(Artenie et al., 2015)
, overdose following
(Winter et al., 2015)
, and reduced personal
(Scott et al., 2017)
People experience disproportionate levels of psychiatric
and psychological problems in prison relative to people in
(Fazel & Baillargeon, 2010; Markowitz,
2011; Sirdifield et al., 2009)
. Australian research findings
suggest that 44% of prison entrants have a mental health
(Australian Institute of Health and Welfare,
2015; Schilders & Ogloff, 2016)
. Many present with
multiple diagnoses (Sirdifield et al., 2009), including
(Chang et al., 2015; Davis et al., 2007;
Munetz et al., 2001)
, major mood disorders
(Brink et al.,
, anxiety disorders
(Butler et al., 2011)
posttraumatic stress disorder
(Ogloff et al., 2017)
(Fazel & Danesh, 2002)
(Durand et al., 2017; O’Rourke et al., 2016)
and cognitive impairment
(Dias et al., 2013; McCausland
et al., 2013)
. Limited access to prison mental healthcare
services in some correctional settings mean the needs
of many people detained in prison with psychiatric or
psychological problems may not be adequately met
(Senior et al., 2013)
. Upon reception into a Victorian
correctional setting all prison entrants undertake a
mental health screen, typically conducted by
(Every-Palmer et al., 2014)
who may be
inadequately trained. In addition, specialist mental health
staff may provide voluntary assessment and treatment for
people detained in prison throughout Victorian
correctional settings. People detained in prison requiring court
ordered or involuntary assessment and treatment are
transferred to the Victorian secure forensic hospital under
Mental Health Act 2014
Dual diagnosis – a term used to describe the
cooccurrence of substance dependence with one or more
psychiatric disorders – compounds the independent
impact of drug dependence and mental health problems
and is widely documented in prison studies
Wallach, 2000; Ogloff et al., 2004; Ogloff et al., 2015)
The health profile of people in prison with dual diagnosis
demands a multidisciplinary medical, psychological, and
social needs approach to address extensive criminal histories
(Kinner, 2006; Ogloff et al., 2015)
, poor quality of life
(Warden et al., 2016), reduced treatment engagement
(Horsfall et al., 2009)
, and high reoffending risk
et al., 2004; Youssef et al., 2016)
. Although there are
numerous studies of people in prison with injecting drug
histories, comparatively few investigate co-occurring
psychiatric well-being and substance use in detail. In
the context of a rapidly increasing global prison
population, characterising people in prison with histories of
injecting drug usewith current poor psychiatric well-being
could help identify unmet needs for targeted screening,
improved integration of prison and community service
models of care, and post-release continuation of care.
In this study we identify associations of psychiatric
well-being in a cohort of incarcerated men with histories
of injecting drug use, four to 6 weeks prior to release
from prison. Whereas previous studies have typically
examined substance use problems in people in prison with
a mental health condition, our focus is on the mental
health of people who inject drugs. People in prison require
varying degrees of support to facilitate a successful release,
and inadequate pre-release planning has been shown to
be a barrier to successful reintegration from prison to
(Butzin et al., 2005)
. Identifying high-risk,
vulnerable subpopulations oof people detained in prison
prior to release could inform evidence-based policy to
target transitional support services for those most at-risk
of reoffending and substance use relapse.
Study design, sample and setting
Data for this paper come from baseline interviews (N = 400)
from the Prison and Transition Health study, which is a
prospective cohort study of incarcerated men who reported
regular injecting drug use prior to their current sentence.
Interviews with eligible participants occur at three, 12, and
24 month time points post release from prison. Participants
were recruited from one maximum, one medium, and one
minimum-security correctional facility in the Australian
state of Victoria to ensure a representative sample of people
with regular histories of injecting drug use. Interviews
occurred between the September 17, 2014 and May 24,
2016. Eligible participants (≥18 years of age, injecting at
least monthly in the 6 months prior to their current
sentence, expected release in the succeeding 4 weeks, and
able to provide informed, written consent) completed a
researcher-administered structured questionnaire that
canvassed a range of issues (detailed below), typically
taking 45–60 min. People on remand (pre-trial detention)
were excluded from the study.
The study was approved by the Alfred Hospital Human
Research Ethics Committee (79/12) and the Victorian
Department of Justice Human Research Ethics Committee
Psychiatric well-being was assessed using the
12itemGeneral Health Questionnaire (GHQ-12), a
wellvalidated screening instrument for identifying current poor
psychiatric well-being. Participants rate themselves
according to the degree to which they have experienced each of
12 symptoms over the past few weeks, using a four-point
Likert scale. The standard method of scoring is that
symptomatic responses are scored ‘1’ and non-symptomatic
responses are scored ‘0’
(Goldberg, 1992; Goldberg et al.,
, resulting in overall scores ranging from zero to 12.
Mean derived cut-off thresholds are considered the most
appropriate method of identifying current poor psychiatric
well-being (Goldberg et al., 1998).
Based on a review of literature, a range of potential
correlates of psychiatric well-being was selected from the
sociodemographic, health, criminological, alcohol and
other drug use, and adverse childhood experiences
Sociodemographic Age (≤ 30/31–40/≥ 41), number of
years of education completed (≤ 9/≥ 10 years completed),
accommodation status (stable (owner occupied, private
rental, or public housing)/unstable (parent/sibling/other
family’s home, boarding house, crisis accommodation,
staying with friend, squat, homeless), and Aboriginal and/
or Torres Strait Islander identification (no/yes).
Health Attempted suicide ever (no/yes), number of
selfreported medical (respiratory, circulatory, musculoskeletal,
neurological, hearing, vision or metabolic) conditions
(none/one/≥ two), self-reported hepatitis C status (negative
or don’t know/positive), and self-reported acquired brain
Criminological Prison security level (maximum/medium/
minimum), youth detention ever (no/yes), number of
previous adult incarcerations (0–3/≥4), and Level of
Service Inventory – Revised: Screening Version
& Bonta, 1998 - continuous)
; an eight-item quantitative
screening tool used to determine level of service and
supervision required to help focus treatment plans and
predict future reoffending risk
(Ferguson et al., 2009)
score of three or more suggests further follow-up with the
individual is required.
Alcohol and other drug use Age first injected (≤16/17–
20/≥21), poly-drug injecting drug use in the month
before their current sentence (no/yes), illicit substances
used by any route of administration (heroin only/crystal
methamphetamines only/heroin and crystal
methamphetamines) in the week before their current sentence,
and high risk alcohol consumption (at least two times per
week and at least five or more drinks per usual drinking
episode) in the year before their current sentence (no/yes).
Adverse childhood experiences Removed from family
home as a child ever (no/yes) and expelled from school
Descriptive statistics were generated for each variable
with respect to psychiatric well-being according to the
GHQ-12. Potential correlates were examined using
modified Poisson regression with robust standard errors,
using odds ratios (OR/adjusted OR (aOR)) and 95%
confidence intervals (95%CI). Bivariate analyses were
conducted to examine associations between each potential
correlate and psychiatric well-being. A multivariable model
was constructed in which all potential correlates were
included to determine the individual effects of each
potential correlate after adjustment for others, with a complete
case approach used. Statistical significance set at p < 0.05.
All analyses were conducted with Stata 14 for Windows
Characteristics of the sample according to level of
psychiatric well-being are shown in Table 1. Eighty-three
participants were excluded due to incomplete data. In
our sample a total GHQ-12 score of three or more
(MGHQ-12 = 3.13, SD = 3.24) was indicative of current
poor psychiatric well-being. Of the 317 men (Mage = 36.1,
SD = 8.47) included for full case analysis, 139 (44%) were
classified as experiencing current poor psychiatric
wellbeing. The sample were mostly born in Australia (89%),
lived in a metropolitan area before their current sentence
(56%), identified as heterosexual (98%), and expected
straight (under no supervision) release (70%).
Methamphetamine (53%) was the drug type first injected by most,
followed by heroin (37%). Nine (3%) of the men were
homeless or had no fixed address prior to their current
sentence. There was a high prevalence of self-reported
depression (64%), anxiety (52%), schizophrenia (15%),
anti-social personality disorder (9%), and bi-polar disorder
(16%). Two thirds of the sample (64%)
selfreportedhepatitis C infection and only one participant
reported no prior adult incarceration.
Yes 99 (71) 114 (64) 1.21 (0.94–1.57)
Note: P values: * = p < .05; ** = p < .001; a OR = Odds ratio; b aOR = Adjusted odds ratio; cAt least one use, by any route of administration, in the week before
their current sentence; dThe 12 months before their current sentence; e The week before their current sentence
Associations with current poor psychiatric well-being
In bivariate analyses, history of suicide attempt, number
of self-reported medical conditions, use of crystal
methamphetamine (by any route of administration) in the
week prior to their current sentence, and being removed
from the home as a child were statistically significantly
associated with current poor psychiatric well-being.
Compared to participants released from a maximum
security prison, participants recruited from the minimum
security prison were less likely to have current poor
In the multivariate model, history of suicide attempt
(aOR = 1.36, 95%CI 1.03–1.78), reporting two or more
medical conditions (aOR = 1.87, 95%CI 1.30–2.67) and
use of crystal methamphetamine in the week prior to their
current sentence (aOR = 1.52, 95%CI 1.05–2.22) remained
statistically significantly associated with current poor
psychiatric well-being (Table 1). Post-model testing
was conducted to determine overall fit. All variables in
the multivariable model showed VIF < 2, suggesting no
In a sample of incarcerated men who reported regular
injecting drug use prior to their current sentence, 44%
were classified as experiencing current current poor
psychiatric well-being as measured by the GHQ-12,
indicating potential unmet need during periods of
incarceration for people detained in prison regarding
mental health service delivery. We found that history of
suicide attempt, having two or more self-reported medical
conditions, and use of crystal methamphetamine in the
week prior to their current sentence were independently
associated with an increased likelihood of current poor
Findings from several studies indiate that suicide rates
among people in prison and those released from prison
are higher than among the general community
et al., 2015; Haglund et al., 2014; Meltzer et al., 2003;
Spittal et al., 2014)
. In addition to standard history and
examination by medical professionals, our findings support
the inclusion of screening for past suicidial behaviours
during reception in-take procedures. Referrals of individuals
meeting criteria of past suicidal behaviours with histories of
injecting drug use during this time could provide
opportunities for additional assessment by
advancedtrainedmental health professionals with specialist clinical
expertise (Brunette et al., 2008), particularly pertaining
to dual diagnosis. In correctional facilities in England
and Wales analogous systems have been implemented
(Hopkin et al., 2017)
. Local adaptions to screening
processes in-prison have shown to statistically significantly
improve measures of depression, anxiety and
psychological distress for people detained in prison at high-risk
(Evans et al., 2017)
and be relatively
(Brown, Cullen, Kooyman, & Forrester, 2015)
Two or more physical health conditions remained
associated with current poor psychiatric well-being. Chronic
pain and disease are well known to impact on psychiatric
(Burke et al., 2015)
, particularly for those with
severe mental illness
(Miller et al., 2006)
. Our findings
highlight the need for coordination of treatment services
in correctional and community settings, where the
prevalence and co-occurrence of both conditions is high. The
integration of physical health assessment, physical activity
(Richardson et al., 2005)
, and targeted healthy
(Smith et al., 2007)
based psychiatric care services have shown to be
successful models for increasing coordination of service delivery
by health professionals and reducing the health burden for
individuals. The introduction of similar health service
delivery models in prison for people with dual diagnosis
may foster the transition to community and encourage
the continuation of care once released. In Victorian
correctional settings, treatment programs for mental
health conditions and substance dependence are delivered
separately. The forthcoming results of a randomised trial
(Van Dorn et al., 2017)
combining two evidence-based
treatments (i.e., motivational interviewing and integrated
group therapy) for substance dependence and mental
health disorders aimed at increasing treatment
engagement from prison to community is likely to provide
insight into the feasibility of such a model for people with
dual diagnosis detained in prison.
Participants who reported using crystal
methamphetamine only (by any route of administration) in the week
prior to their current sentence were more likely to have
current poor psychiatric well-being than men who had
used heroin only or crystal methamphetamine and heroin.
The use of crystal methamphetamine has been shown
to be associated with many physical and psychiatric
problems, particularly psychosis
(Degenhardt, & Topp,
2003; Degenhardt et al., 2008; Marshall, & Werb, 2010)
In addition, for those with pre-existing mental health
disorders, the impact of dependent substance use may
. Prison program and health
services often focus resources towards people detained
in prison with a complex array of health and
psychosocial issues that may predispose them to recurring
morbidity and reoffending. Our findings suggest that
prioritising people detained in prison for mental health
screening and follow-up services on the basis of types
of drugs used or the types of drugs related to their
offending behaviours may provide opportunities to
appropriate target health service referrals in prison and in
pre-release planning. This prioritisation is particularly
pertinent in the context of contemporary changes in the
drug use and harms among PWID. Methamphetamine
has now overtaken heroin as the most commonly injected
drug in Australia
(Stafford, & Breen, 2017)
increases in the purity of methamphetamine have been
(Scott et al., 2015)
and increases have been
observed in methamphetamine-related arrests and
presentations of amphetamine use disorders and amphetamine
psychosis at mental health services in some Australian
(Degenhardt et al., 2017)
. In this context it
may be beneficial to consider the development of dual
service models of care that address both mental health
and methamphetamine dependence simultaneously rather
than have mental health and addiction specialists working
with people detained in prison in relative isolation
(Cumming et al., 2016)
. Just models may become more
feasible in the future with promising
methamphetaminereplacement pharmacotherapies being trialled
. Our findings should be considered in relation to
study limitations. Self-report survey methodologies are
prone to recall and social desirability biases. However,
these methods among PWID have previously shown
reliability relating to the collection of sensitive information
(Darke, 1998; Ross et al., 1995)
, and have provided
(Cutcher et al., 2014)
. The GHQ-12
has shown some variability across population groups in
detecting current psychiatric symptoms
(Goldberg et al.,
1998; Willmott et al., 2004)
. However, is used widely as a
screening tool for mental health referral (Hewitt et al.,
2011). The findings from this study should therefore be
seen in the context of identifying potential unmet need
and for informing care and referral pathways, rather than
the definitive identification and diagnosis of psychiatric
morbidity. The authors have presented baseline (i.e,
crosssectional) data from this larger prospective cohort meaning
we were unable to make causal inferences. Extensive future
prospective and retrospective data linakge to health,
criminogenic and social service data in this study will
provide opportunities to investigate the temporal
relationships between a range of exposures and mental health
disorders among participants. This will also provide an
opportunity to examine relationships of dual diagnosis
with ongoing health, crime and reoffending risk to inform
general and targeted service need.
We observed a high prevalence of current poor psychiatric
well-being and potential service need in a sample of
incarcerated men who injected drugs regularly prior to their
current sentence. Comprehensively addressing the
healthrelated needs for this vulnerable population will require a
multidisciplinary approach. Enhancing opportunities to
screen and triage people detained in prison for mental
health and other potential co-occurring health issues at
appropriate points in their engagement with the criminal
justice system will provide opportunities to better address
their individual health needs and reoffending risk.
All the participants involved in the Prison and Transition Health Study for
their time and knowledge and the Burnet Institute fieldwork team for their
tireless efforts with study follow-up.
The research was funded by a National Health and Medical Research Council
Grant (APP1029915). RC is supported by the Australian Government Research
Training Program Scholarship. MS is supported by NHMRC Career
Development Fellowship APP1090445. SK is supported by NHMRC Senior
Research Fellowship APP1078168.
Availability of data and materials
There is potential for data availability with ethics approval from each ethics body.
RC led the concept of the paper, including writing, editing, statistical
analysis, and author coordination. MC provided assistance with statistical
analysis including data cleaning. AK, CA, and PD provided editorial feedback.
SK provided editorial feedback and guidance for paper development. MS
and JO are primary supervisors for RC’s Doctor of Psychology and thus
provided guidance, editorial support throughout the duration of planning
and writing. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Alfred Hospital Human Research Ethics
Committee (79/12) and the Victorian Department of Justice Human Research
Ethics Committee (CF/14/10169). Participants were required to provide
informed, written consent prior to study inclusion.
Consent for publication
The authors’ consent to publication.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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