Content area
Full Text
Introduction
People with serious and enduring mental health problems have higher rates of co-morbid problematic substance misuse compared with the general population (Regier et al., 1990; Department of Health, 2002). Studies of forensic patients in the UK show that rates of substance misuse are higher still within this population (Scott et al., 2004; Derry, 2008; De Burca et al., 2013). Rates of problematic substance misuse amongst patients admitted to forensic units are typically between 50 and 90 per cent (Oddie and Davies, 2009). Ongoing misuse of substances following admission has also been shown to be a common problem within forensic units (Whyte and Harrison, 2004; Durand et al., 2006).
There are several reasons why addressing these problems should be a priority for secure services. Mental disorder with co-morbid substance misuse is associated with poorer outcomes on many measures, including prognosis following discharge from forensic units. For example, forensic patients who misuse substances have been found to be at higher risk of violent recidivism (Maden et al., 2004; Howard et al., 2013; Pickard and Fazel, 2013) and reconviction following discharge (Scott et al., 2004; Pickard and Fazel, 2013). Substance misuse is strongly associated with violence, including amongst forensic and non-forensic psychiatric populations (e.g. Scott et al., 1998; Soyka, 2000; Pickard and Fazel, 2013), and it has been shown that the higher rates of violence seen in patients with schizophrenia and other psychoses may largely be the result of higher rates of substance misuse among these groups (Fazel et al., 2009), highlighting the need to address substance misuse problems as a component of risk management in such patients.
Despite this, there is limited empirical research determining the effectiveness of treatments for substance misuse in forensic settings (Weldon and Ritchie, 2010) and until 2013 there was no specific guidance in this area. Arguably, there has been little consensus agreement on the most appropriate way to address the issue. Consequently, in the past, interventions to address substance misuse in forensic settings have been shown to vary both in design and sophistication (Whyte and Harrison, 2004).
However, literature regarding the treatment of co-morbid substance misuse in patients with severe mental illness (“dual diagnosis”) in other settings is somewhat more clear, and...