Incomplete discussion of bipolar disorder and comorbid substance use disorder
Authors: Kyoung-Sae Na
Journal: The Lancet Global Health (2019)

Gergő Baranyi and colleagues' systematic review and meta-analysis,1Baranyi G Scholl C Fazel S Patel V Priebe S Mundt AP Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studies.Lancet Glob Health. 2019; 7: e461-e471Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar published in The Lancet Global Health, provided an interesting summary of the prevalence of mental illness (psychotic disorder, bipolar disorder, and major depression) and substance use disorder among prisoners in low-income and middle-income countries (LMICs). However, I have two concerns: the first regarding the authors' categorisation of psychotic illness, and the second regarding comorbid substance use disorder. First, I disagree that the category psychotic illness should include bipolar disorder. Except for severe manic or depressive episodes with psychotic features, no psychotic symptoms occur in bipolar disorder. Thus, the category of psychotic illness in the study inaccurately encompasses non-psychotic bipolar disorder. This classification contrasts with the selective inclusion of psychotic depression into psychotic illness, while the rest of the depressive disorders were separately categorised as major depression. In addition to the inappropriate nomenclature, this combination obscures the possible prominence of bipolar disorder in people who become involved with the criminal justice system. Because of the core symptoms of bipolar disorder, such as irritability, impulsivity, elated mood, and increased energy, the disorder has received much attention as a root cause of crimes.2Fovet T Geoffroy PA Vaiva G Adins C Thomas P Amad A Individuals with bipolar disorder and their relationship with the criminal justice system: a critical review.Psychiatr Serv. 2015; 66: 348-353Crossref PubMed Scopus (31) Google Scholar, 3Fazel S Lichtenstein P Grann M Goodwin GM Langstrom N Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review.Arch Gen Psychiatry. 2010; 67: 931-938Crossref PubMed Scopus (195) Google Scholar The prevalence of bipolar disorder among incarcerated individuals (2–7%)2Fovet T Geoffroy PA Vaiva G Adins C Thomas P Amad A Individuals with bipolar disorder and their relationship with the criminal justice system: a critical review.Psychiatr Serv. 2015; 66: 348-353Crossref PubMed Scopus (31) Google Scholar is far higher than that among the general population (about 1% for bipolar 1 disorder). If bipolar disorder is not adequately recognised by prison personnel, its core symptoms can be seen as defiant attitudes or personality traits, which in turn delays treatment. Second, I wonder why the authors did not examine the comorbidity of severe mental illnesses and substance use disorder. Substance use disorder is commonly accompanied by severe mental illnesses. For example, 50% or more of patients with schizophrenia and bipolar disorder have comorbid substance use disorder.4American Psychiatric AssociationDiagnostic and statistical manual of mental disorders.5th edn. American Psychiatric Publishing, Arlington, VA2013Crossref Google Scholar In addition, as shown in previous studies,3Fazel S Lichtenstein P Grann M Goodwin GM Langstrom N Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review.Arch Gen Psychiatry. 2010; 67: 931-938Crossref PubMed Scopus (195) Google Scholar, 5Fazel S Langstrom N Hjern A Grann M Lichtenstein P Schizophrenia, substance abuse, and violent crime.JAMA. 2009; 301: 2016-2023Crossref PubMed Scopus (468) Google Scholar the risk of violent crimes is heightened when severe mental illness is accompanied by substance use disorder. Thus, the prevalence of severe mental illness stratified by the co-occurrence of substance use disorder would have provided valuable information on the characteristic features of the mental conditions of prisoners in the LMICs. If quantitatively summarising the dual diagnosis from the individual studies was not possible because of insufficient data, there would be implications for interpreting the results of the research studies in LMICs. I declare no competing interests. Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studiesThe prevalence of major psychiatric disorders is high in prisoners in LMIC compared with general populations. As these findings are likely to reflect unmet needs, the development of scalable interventions should be a public health priority in resource-poor settings. Full-Text PDF Open AccessIncomplete discussion of bipolar disorder and comorbid substance use disorder – Authors' replyNa raises two issues. Regarding the first issue, we agree that bipolar disorders in prison populations merit further discussion. The inclusion of bipolar disorder as a psychotic illness is based on the increasingly accepted view that bipolar disorder and schizophrenia-spectrum disorders share phenomenological, biological, and genetic overlap.1 In addition, for a diagnosis of type 1 bipolar disorder, a manic episode is necessary, which is typically psychotic in nature. However, our decision not to separate out bipolar disorder from the other psychoses was based on the difficulty of establishing this distinction in prisoners. Full-Text PDF Open Access