Incomplete discussion of bipolar disorder and comorbid substance use disorder – Authors' reply
Authors: Adrian P Mundt, Gergő Baranyi, Seena Fazel
Journal: The Lancet Global Health (2019)

Na 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.1Keshavan MS Morris DW Sweeney JA et al.A dimensional approach to the psychosis spectrum between bipolar disorder and schizophrenia: the Schizo-Bipolar Scale.Schizophr Res. 2011; 133: 250-254Crossref PubMed Scopus (141) Google Scholar 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. Many prisoners have histories of drug misuse and also personality disorders in which mood instability (and in particular slightly elevated mood or hypomania, common in the rarer form of bipolar 2 disorder) is common and diagnoses require repeat examination and informant histories. Thus, most structured interviews administered in prevalence studies do not perform well to detect bipolar disorder. Second, Na raises the important issue of comorbidities. We looked again at the 23 studies reported in our review,2Baranyi 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 and found that six reported on comorbidities between substance use disorders and severe mental illness (table). These comorbidities are common, and prison health should take these into account by joining up psychiatric and substance misuse services.TablePrevalence of comorbid substance use disorders among prisoner populations with severe mental illness in low-income and middle-income countriesAlcohol use disorders in people with affective disorder or major depressionDrug use disorders in people with affective disorder or major depressionSubstance use disorders in people with major depressionSubstance use disorders in people with psychosisCurrent or 1-year prevalence, %Andreoli et al (2014)3Andreoli SB Dos Santos MM Quintana MI et al.Prevalence of mental disorders among prisoners in the state of Sao Paulo, Brazil.PLoS One. 2014; 9: e88836Crossref PubMed Scopus (51) Google Scholar18·7% (men), 60·0% (women)2·7% (men), 60·0% (women)....Joshi et al (2014)4Joshi P Kukreja S Desousa A Shah N Shrivastava A Psychopathology and other contributing stressful factors in female offenders: an exploratory study.Indian J Forensic Med Toxicol. 2014; 8: 149-155Crossref Scopus (3) Google Scholar22·2%11·1%33·3%..Mundt et al (2013)5Mundt AP Alvarado R Fritsch R et al.Prevalence rates of mental disorders in Chilean prisons.PLoS One. 2013; 8: e69109Crossref PubMed Scopus (45) Google Scholar....22·8%..Naidoo and Mkize (2012)6Naidoo S Mkize DL Prevalence of mental disorders in a prison population in Durban, South Africa.Afr J Psychiatry (Johannesbg). 2012; 15: 30-35Crossref PubMed Scopus (63) Google Scholar....30·3%55·5%Zamzam and Hatta (2000)7Zamzam R Hatta SM Specific psychiatric disorders among convicted female offenders in a Malaysian prison.Malaysian J Psychiatry. 2000; 8: 34-42Google Scholar....61·9%..Lifetime prevalence, %Andreoli et al (2014)3Andreoli SB Dos Santos MM Quintana MI et al.Prevalence of mental disorders among prisoners in the state of Sao Paulo, Brazil.PLoS One. 2014; 9: e88836Crossref PubMed Scopus (51) Google Scholar40·7% (men), 68·3% (women)52·3% (men), 68·3% (women)....Assadi et al (2006)8Assadi SM Noroozian M Pakravannejad M et al.Psychiatric morbidity among sentenced prisoners: prevalence study in Iran.Br J Psychiatry. 2006; 188: 159-164Crossref PubMed Scopus (81) Google Scholar....82·5%95·0% Open table in a new tab We declare no competing interests. APM receives funding from CONICYT (grant FONDECYT Regular 1190613). SF receives funding from the Wellcome Trust (grant number 202836/Z/16/Z). GB receives funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant (agreement number 676060 [LONGPOP]) This publication reflects only the author's view and the Research Executive Agency is not responsible for any use that may be made of the information it contains. 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 disorderGergő Baranyi and colleagues' systematic review and meta-analysis,1 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. Full-Text PDF Open Access