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Official websites use. Share sensitive information only on official, secure websites. Correspondence: Nora van Buitenen. Email: N. The relationship between psychopathology and criminal offending has been the subject of many studies. Co-occurring substance use seems to increase the risk of offending in those with mental illness. To present data on the prevalence of mental disorders and demographics of prisoners with mental illness, and investigate associations between diagnoses and substance use from a network perspective. Data used in this study are part of a cohort study within the four penitentiary psychiatric centres in The Netherlands. It includes data of incarcerated male patients. Prevalence rates of mental disorders and demographic variables were compared between individuals with and without problematic substance use. A network of diagnoses, including three categories of substance use, was constructed with regression coefficients. Most patients showed prior problematic substance use Three major findings of the network are discussed in detail: the role of antisocial personality disorder, impulsivity and psychotic disorders in combination with problematic substance use. Problematic substance use is highly prevalent among prisoners with mental illness, and should always be taken into account in research on this topic. Treatment should target substance use to reduce the risk of recidivism. Further differentiation in categories of substances is needed for the development of risk profiles. Keywords: Forensic psychiatry, criminal offending, substance use, network analysis, prisoners with mental illness. During the past several decades, the relationship between substance use and risk of violent criminal offending has been the subject of many studies. The risk of offending increases for individuals misusing substances, 1 making it a widely accepted risk factor for criminal behavior. Individuals who were diagnosed with a serious mental illness seem to be more prone to co-occurring problematic substance use than those who were not. Although there are meaningful associations between problematic substance use, serious mental illness and criminal offending, the direction of these associations remains unclear, and it seems plausible that they are not unilateral. Furthermore, the associations might differ across drug types and diagnoses. Additionally, associations could be obscured by polysubstance use and psychiatric comorbidity in offenders with mental illness. The current study aims to provide a detailed, overarching view of the relationships between mental illnesses and problematic substance use in a population of prisoners. This technique will allow us to visually explore the associations between mental disorders and problematic substance, as well as differentiate between categories of substance use. Three major categories are included in the model: alcohol use, the use of cannabis and the use of hard drugs. The results of this study will contribute to our understanding of the associations between problematic substance use and mental disorders in offender populations. The present study uses data collected in the penitentiary psychiatric centres PPCs in The Netherlands. PPCs are facilities within the Dutch penitentiary system, housing detainees incapable of functioning within a regular prison regime because of their mental state. The database contains diagnostic information, demographics and patient characteristics, and criminal records. The data are primarily used for policy making. For scientific research, the data are available in an anonymised version. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of , as revised in Secondary use of the previously gathered, anonymised data was authorised by the Dutch Ministry of Justice and Security. The committee had no ethical objections and positively advised on the research plan on 16 January In cases of multiple admissions, data gathered during the most recent admission were included. A sample of individuals was identified. Finally, because of insufficient reliable sources of information, the history of substance use problematic or not could not be determined for patients, resulting in a sample of patients. Upon admission to the PPC, both a psychiatrist and a psychologist conduct an independent primary interview with the patient. The final DSM diagnosis is the result of a consensus diagnosis between these two professionals. For the network analysis, the numerous DSM diagnoses had to be categorised into broader categories. Several demographic measures were examined, including age at admission, criminal history, level of education and country of birth following the definition of ethnic groups as presented by the Dutch Central Bureau of Statistics. A substantial part of the sample could have been incarcerated before admission to the PPC, forcing a possible SUD into remission, which would then be missed upon admission. Furthermore, SUDs are at risk of being underdiagnosed in cases of florid psychosis, a mental state that applies to many patients upon admission to the PPC. Scoring was based on all criminal files available to the researchers, often including extensive psychological reports. If insufficient reliable sources of information were available to assess a lifetime presence of problematic substance use, the item was scored as missing; for example, when individuals spent prolonged periods of time abroad or had recently migrated to The Netherlands. The item was scored on a five-point Likert scale 0—4. A score of either 3 frequent problems such as various instances of financial or housing issues, verbal aggression or disorderly conduct as a result of substance use or 4 expressions of physical violence as a result of substance use was defined as problematic substance use. The item is scored separately for the use of alcohol, cannabis and hard drugs. For a description of specific substances that comprise the hard drugs category, see Supplementary Appendix 2. The historical subscale, to which H10 belongs, has good internal consistency, with a Cronbach's alpha of 0. Furthermore, item H10 has shown to have a high intraclass correlation of 0. Comparisons of comorbid mental disorders between individuals with and without problematic substance use were performed by using either chi-squared tests or t -tests. For significantly associated variables, effect sizes were calculated with Cramer's V -statistic and Cohen's d -statistic, respectively. Furthermore, a Bonferroni correction was applied in all analyses. Network analyses were conducted in R version 4. Based on logistic regressions, the best-fitting function was selected by using the extended Bayesian information criterion, which has proven to estimate the most relevant features of a network successfully. To ensure sparsity of the network and cope with the problem of multicollinearity and multiple testing, all regression coefficients were penalised with the Enhanced Least Absolute Shrinkage and Selection Operator Regression Model eLasso , resulting in more conservative network structures. The hyperparameter was set to 0. Only positive estimates were included in the model to clearly describe associations between diagnoses and substance use, as comorbidity is indicated by positive edges. In the visualisation of the network, the Fruchterman—Reingold algorithm was used, which places strongly connected nodes close to each other. In total, Most patients Prevalence rates of mental disorders are displayed in Table 1. All other significant results in Table 1 indicate that individuals without substance use problems were more often diagnosed with the disorders listed in the table than those with substance use problems. Information on demographic variables is shown in Table 2. On average, individuals with problematic substance use mean The proportion of individuals completing a primary education was smaller for those without problematic substance use. The proportion of individuals born in Morocco was larger for those with problematic substance use. Most notable is that the proportion of individuals detained for violent property offences was larger for those with problematic substance use. It should be noted that effect sizes are small to medium. The final network model Fig. Thicker edges represent stronger correlations. Node names and sample sizes are listed in the legend. Note: Yellow nodes indicate categories of problematic substance use; purple nodes indicate categories of mental disorders. The thickness of the green edges represents the strength of the positive correlation, with thicker lines representing stronger correlations. The node that represents the problematic use of hard drugs has the most associations of the included categories of substances. This indicates that the associations are unidirectional. The problematic use of cannabis is also associated with ASPD. Furthermore, it is associated with the node that represents schizophrenia spectrum disorders. Problematic use of alcohol is associated with ASPD. The three categories of substances do not share a direct association; they are indirectly associated through the node that represents ASPD. This study presents data on the prevalence of mental disorders and demographic variables in a large sample of prisoners with mental illness, comparing individuals with and without problematic substance use. Those with problematic use were more often detained for violent property offences and showed higher proportions of recidivism. These findings underline the very relevant role of substance misuse in the development of patterns of offending behaviour by individuals with mental illness. Crimes that are known to have a high rate of recidivism, such as burglary and robbery, 33 are more prevalent among individuals with problematic substance use, and offenders of such crimes are even more likely to reoffend if they have a history of drug misuse. Individuals with mental illness who exhibit criminal behaviour are likely to be committed to closed facilities, forcing them into abstinence. In doing so, the interactions between the psychiatric disorder and the comorbid SUD s are reduced during treatment in these facilities. However, without appropriate treatment also targeting the problematic use of substances, they are likely to relapse upon release. This relapse could result in a drastic increase in psychiatric symptoms and an immediate increased risk of criminal behavior. Few treatment programmes have been developed specifically to target substance use in offenders with mental illness, and although these programmes seem promising, they need further evaluation. The main focus of this study was to provide an overarching view of the associations between psychiatric diagnoses and three major categories of problematic substance use in a large sample of offenders with mental illness. Analyses revealed many interesting connections, but three findings seem to stand out: the role of ASPD, the role of impulsivity and the role of psychotic disorders in combination with problematic use of cannabis. One finding seems to be of particular interest when investigating combinations of mental disorders with problematic substance use that could increase the risk of offending behaviour: ASPD is connected to all three categories of substances, and plays a central role in the network presented in the current study. Research has shown that ASPD is a potent predictor of criminal offending. Another interesting finding in the current study is that none of the substance categories were directly connected within the network model, but connected to each other through ASPD even when using the most conservative methods of analysis. This indicates that ASPD plays a central role in explaining the high prevalence of polysubstance use in offenders with mental illness. The problematic use of hard drugs is another key feature of the network presented in this study, as it is associated with the highest number of mental disorders compared with alcohol and soft drug use. Although the main body of empirical studies yields mixed results, 8 it has been proposed that individuals with ADHD are prone to self-medicating their symptoms by using stimulants, because of the calming effect that stimulants have on them. More precise differentiation, using more specific categories of substance use, is needed to further explore this association and its relation to criminal offending. There is little doubt about the existence of an association between psychotic disorders and substance use, 7 , 46 and substance use has a mediating effect on the risk of violent crime by individuals with a schizophrenia spectrum disorder. A pathway for this association has been proposed: the use of cannabis might induce or magnify positive symptoms, which increases the risk for offending. As mentioned, most studies investigating the associations between mental disorders, comorbid substance use and criminal offending focus on the effects within a single disorder, and research on this topic is often complicated by polysubstance use. This study presents data on a large sample of prisoners with mental illness, includes a wide range of mental disorders and three major categories of problematic substance use. Modelling these variables within a single model with a network approach offers two main advantages. First, possible obscuring effects of polysubstance use are discounted. Second, possible effects of other comorbid mental disorders are accounted for. The current study provides a representation of the complex psychopathology within this population, which is sensitive to the effects of high rates of polysubstance use and comorbidity. This study entails a secondary analysis of a large body of data gathered in clinical practice. Although diagnoses were carefully made, no standardised diagnostic process for research purposes was used to establish the diagnoses. This discrepancy in temporality of these measures could be viewed as a limitation. Problematic substance use is often a persistent, long-lasting problem in this population, and use of the lifetime presence of problematic substance use provides, in our view, a more accurate representation of problematic substance use. It should be noted that item H10 does not define whether a crime was committed under the influence of a substance. The current study does not aim to make claims about the state of mind a crime was committed in. Finally, the data did not allow for further specification of the substances, which would have contributed substantially, especially given the significant effect of problematic hard drug use. The results yielded by this study again underline the high prevalence of problematic substance use in offenders with mental illness. This combination of psychopathology poses a challenge for forensic healthcare professionals. Therefore, the development of treatment programmes for offenders with mental illness with co-occurring problematic substance use is of much importance. Adequate treatment for these offenders could reduce the risk of recidivism. Furthermore, this study investigated combinations of mental disorders and problematic use of substances that could increase the risk of criminal offending. Several directions for future research follow from this. The combination of ASPD and problematic substance use and its effects on criminal offending should be further investigated, not only focusing on assessing the cumulative risk of combining these factors, but also aiming to shed light on underlying mechanisms. Such research may become possible if and when the alternative diagnostic model for personality disorders, as proposed in part III of the DSM-5, becomes the new standard. Finally, other lines of research should revolve around the need for further differentiation based on more specific categories of problematic substance use, to develop more specific risk profiles. Further specifications of the role of impulsivity in the use of hard drugs, and the association between cannabis use and psychotic disorders, could contribute to adequately assessing the risk of future criminal offending by offenders with mental illness, and could aid in the detection of individuals at risk for future offending. The authors received permission from the Dutch Ministry of Justice and Security to access the data used in this study. However, they are unable to share the data as they are not the data custodians. Permission to conduct scientific research within a specific division of the Dutch Custodial Institutions Agency must be requested from the director of the relevant sector. Both edited and critically reviewed the manuscript, and contributed to the preparation of the manuscript. This research received no specific grant from any funding agency, commercial or not-for-profit sectors. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. BJPsych Open. Find articles by Nora van Buitenen. Find articles by Jesse Meijers. Find articles by Chantal J W van den Berg. Find articles by Joke M Harte. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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