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Health, social and criminal justice factors associated with dual diagnosis among incarcerated adults in Brazil and Australia: a cross-national comparison



To estimate the prevalence of dual diagnosis and identify health, social and criminal justice factors associated with dual diagnosis among incarcerated adults in Australia and Brazil.


We compared data from cross-sectional surveys of incarcerated adults (aged ≥ 18 years) in Australia and Brazil. Using data from linked emergency department, hospital, and in-prison medical records in the Australian sample, and from the Composite International Diagnostic Interview (CIDI) in the Brazilian sample, participants were categorised as having: (1) no mental disorder; (2) substance use disorder only; (3) mental illness only; or (4) dual diagnosis. A multivariate multinomial logistic regression model was fitted to identify factors associated with dual diagnosis in each country.


Approximately one quarter of participants in both Australia (22%) and Brazil (25%) met the diagnostic criteria for dual diagnosis. In both countries, dual diagnosis was associated with being female [relative risk (RR) = 2.25 (95% CI 1.47–3.43) Australia; RR = 2.59 (95% CI 1.79–3.74) Brazil], having a history of prior incarceration [RR = 2.99 (95% CI 1.99–4.48) Australia; RR = 2.27 (95% CI 1.57–3.29) Brazil], and having comorbid physical health problems [RR = 1.54 (95% CI 1.08–2.19) Australia; RR = 2.53 (95% CI 1.75–3.65) Brazil].


Despite differences in health, social, and criminal justice systems between Australia and Brazil, the prevalence of and factors associated with dual diagnosis in incarcerated adults appear to be similar in the two countries. A number of generalisable principles can be inferred and should be considered in health and criminal justice policy making.

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  1. 1.

    DoH. A Guide for the Management of Dual Diagnosis for Prisons. Best Practice Guidance 11165; National Offender Management Service, Ministry of Justice. Department of Health, UK. 2009.

  2. 2.

    Fazel S, Seewald K (2012) Severe mental illness in 33588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry 200(5):364–373

    PubMed  Article  Google Scholar 

  3. 3.

    Latt N, Jurd S, Tennant C, Lewis J, Macken L, Joseph A et al (2011) Alcohol and substance use by patients with psychosis presenting to an emergency department: changing patterns. Aust Psychiatry 19(4):354–359

    Article  Google Scholar 

  4. 4.

    Jiménez-Castro L, Raventós-Vorst H, Escamilla M (2011) Substance use disorder and schizophrenia: prevalence and sociodemographic characteristics in the Latin American population. Actas Españolas de Psiquiatría 39(2):123–130

    PubMed  PubMed Central  Google Scholar 

  5. 5.

    Carrà G, Crocamo C, Borrelli P, Popa I, Ornaghi A, Montomoli C et al (2015) Correlates of dependence and treatment for substance use among people with comorbid severe mental and substance use disorders: findings from the “psychiatric and addictive dual disorder in Italy (PADDI)” study. Compr Psychiatry 58:152–159

    PubMed  Article  Google Scholar 

  6. 6.

    Hapangama A, Kuruppuarachchi K, Pathmeswaran A (2013) Substance use disorders among mentally ill patients in a general hospital in Sri Lanka: prevalence and correlates. Ceylon Med J 58(3):111–115

    CAS  PubMed  Article  Google Scholar 

  7. 7.

    Wilson AB, Draine J, Hadley T, Metraux S, Evans A (2011) Examining the impact of mental illness and substance use on recidivism in a county jail. Int J Law Psychiatry 34(4):264–268

    PubMed  Article  Google Scholar 

  8. 8.

    Baillargeon J, Penn JV, Knight K, Harzke AJ, Baillargeon G, Becker EA (2010) Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders. Adm Policy Mental Health Mental Health Serv Res 37(4):367–374

    Article  Google Scholar 

  9. 9.

    Nowotny KM, Belknap J, Lynch S, DeHart D (2014) Risk profile and treatment needs of women in jail with co-occurring serious mental illness and substance use disorders. Women Health 54(8):781–795

    PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Hawthorne WB, Folsom DP, Sommerfeld DH, Lanouette NM, Lewis M, Aarons GA et al (2012) Incarceration among adults who are in the public mental health system: rates, risk factors, and short-term outcomes. Psychiatr Serv 63(1):26–32

    PubMed  Article  Google Scholar 

  11. 11.

    Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ (2009) Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry 166(1):103–109

    PubMed  Article  Google Scholar 

  12. 12.

    Fazel S, Bains P, Doll H (2006) Substance abuse and dependence in prisoners: a systematic review. Addiction 101(2):181–191

    PubMed  Article  Google Scholar 

  13. 13.

    Tavares GP, Scheffer M, de Almeida RMM (2012) Drogas, Violência e Aspectos Emocionais em Apenados. Psicologia: Reflexão e Crítica 25(1):89–95

    Google Scholar 

  14. 14.

    Kinner SA, Young JT (2018) Understanding and improving the health of people who experience incarceration: an overview and synthesis. Epidemiol Rev 40(1):4–11

    PubMed  PubMed Central  Article  Google Scholar 

  15. 15.

    Walmsley R (2018) World prison population list, 12th edn. Home Office, London

    Google Scholar 

  16. 16.

    Kalichman AO, Ayres JRdCM (2016) Integralidade e tecnologias de atenção à saúde: uma narrativa sobre contribuições conceituais à construção do princípio da integralidade no SUS. Cadernos de Saúde Pública. 32:e00183415

    PubMed  Article  Google Scholar 

  17. 17.

    OECD. (2015) OECD Reviews of health care quality: Australia 2015. Organisation for economic co-operation and development.

  18. 18.

    Xiong Lai H, Huang QR (2009) Comorbidity of mental disorders and alcohol-and drug-use disorders: analysis of New South Wales inpatient data. Drug Alcohol Rev 28(3):235–242

    Article  Google Scholar 

  19. 19.

    Laranjeira R, Madruga C, Pinsky I, Caetano R, Mitsuhiro S, Castello G (2014) II levantamento nacional de álcool e drogas (LENAD)-2012. Instituto Nacional de Ciência e Tecnologia para Políticas Públicas de Álcool e Outras Drogas (INPAD), UNIFESP, São Paulo

    Google Scholar 

  20. 20.

    Ministério da Saúde (MS), Brazil. Portaria Interministerial nº 1.777, de 9 de setembro de 2003. Diário Oficial da União 2004; 10 set

  21. 21.

    Roberts BM, Maybery D (2014) Dual diagnosis discourse in Victoria Australia: the responsiveness of mental health services. J Dual Diagn 10(3):139–144

    PubMed  Article  Google Scholar 

  22. 22.

    DHHS (2015) Victoria's 10-year mental health plan. Department of Health and Human Services, Victorian Government. Accessed 3 July 2019

  23. 23.

    Kinner SA, Lennox N, Williams GM, Carroll M, Quinn B, Boyle FM et al (2013) Randomised controlled trial of a service brokerage intervention for ex-prisoners in Australia. Contemp Clin Trials 36(1):198–206

    PubMed  Article  Google Scholar 

  24. 24.

    Australian Bureau of Statistics (2016) Prisoners in Australia 2016. 4517.0. Australian Government.

  25. 25.

    Andreoli SB, dos Santos MM, Quintana MI, Ribeiro WS, Blay SL, Taborda JGV et al (2014) Prevalence of mental disorders among prisoners in the state of Sao Paulo, Brazil. PLoS ONE One 9(2):e88836

    Article  Google Scholar 

  26. 26.

    Quintana MI, Gastal FL, Jorge MR, Miranda CT, Andreoli SB (2007) Validity and limitations of the Brazilian version of the composite international diagnostic interview (CIDI 21). Braz J Psychiatry. 29(1):18–22

    PubMed  Article  Google Scholar 

  27. 27.

    NCCH (2004) International statistical classification of diseases and related health problems, 10th revision, Australian modification (ICD-10-AM). National Centre for Classification in Health. Sydney: National Centre for Classification in Health, Faculty of Health Sciences, University of Sydney, Australia.

  28. 28.

    OUP (1998) International classification of primary care, 2nd ed (ICPC-2), Oxford University Press, Oxford.

  29. 29.

    Peters RH, Wexler HK, Lurigio AJ (2015) Co-occurring substance use and mental disorders in the criminal justice system: a new frontier of clinical practice and research. Psychiatr Rehabil J 38(1):1–6

    PubMed  Article  Google Scholar 

  30. 30.

    Stata (2017) Stata Release 15.0. Stata Corporation, Texas

    Google Scholar 

  31. 31.

    Padwa H, Larkins S, Crevecoeur-MacPhail DA, Grella CE (2013) Dual diagnosis capability in mental health and substance use disorder treatment programs. J Dual Diagn 9(2):179–186

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Ponizovsky AM, Rosca P, Haklai Z, Goldberger N (2015) Trends in dual diagnosis of severe mental illness and substance use disorders, 1996–2010. Israel Drug Alcohol Depend 148:203–208

    PubMed  Article  Google Scholar 

  33. 33.

    D Indig (2016) Comorbid substance use disorders and mental health disorders among New Zealand prisoners Wellington. NZ New Zealand Department of Corrections

  34. 34.

    Fazel S, Danesh J (2002) Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. Lancet 359(9306):545–550

    PubMed  Article  Google Scholar 

  35. 35.

    Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R (2016) Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry 3(9):871–881

    PubMed  PubMed Central  Article  Google Scholar 

  36. 36.

    Caravaca Sánchez F, Wolff N (2016) Self-report rates of physical and sexual violence among Spanish inmates by mental illness and gender. J Forensic Psychiatry Psychol 27(3):443–458

    Article  Google Scholar 

  37. 37.

    AIHW (2015) The health of Australia's prisoners 2015. Australian Institute of Health and Welfare. Cat. no. PHE 207. Canberra: AIHW

  38. 38.

    McCallum S, Mikocka-Walus A, Turnbull D, Andrews JM (2015) Continuity of care in dual diagnosis treatment: definitions, applications, and implications. J Dual Diagn 11(3–4):217–232

    PubMed  Article  Google Scholar 

  39. 39.

    Bizzarri J, Rucci P, Vallotta A, Girelli M, Scandolari A, Zerbetto E et al (2005) Dual diagnosis and quality of life in patients in treatment for opioid dependence. Subst Use Misuse 40(12):1765–1776

    PubMed  Article  Google Scholar 

  40. 40.

    Benaiges I, Prat G, Adan A (2012) Health-related quality of life in patients with dual diagnosis: clinical correlates. Health Q Life Outcomes 10(1):106

    Article  Google Scholar 

  41. 41.

    Moyes HCA, Heath JJ, Dean LV (2016) What can be done to improve outcomes for prisoners with a dual diagnosis? Adv Dual Diagn 9(1):14–25

    Article  Google Scholar 

  42. 42.

    Kinner SA, Wang EA (2014) The case for improving the health of ex-prisoners. Am J Public Health 104(8):1352–1355

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Young JT, Heffernan E, Borschmann R, Ogloff JR, Spittal MJ, Kouyoumdjian FG et al (2018) Dual diagnosis of mental illness and substance use disorder and injury in adults recently released from prison: a prospective cohort study. Lancet Public Health 3(5):e237–e248

    PubMed  Article  Google Scholar 

  44. 44.

    Barrowclough C, Haddock G, Wykes T, Beardmore R, Conrod P, Craig T et al (2010) Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial. BMJ 341:c6325

    PubMed  PubMed Central  Article  Google Scholar 

  45. 45.

    Baier A, Fritsch R, Ignatyev Y, Priebe S, Mundt AP (2016) The course of major depression during imprisonment: a 1 year cohort study. J Affect Disord 189:207–213

    PubMed  Article  Google Scholar 

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The Brazilian study was funded by Brazil's Ministry of Health and Ministry of Science and Technology, via grant no. 554553/2005 (AI type) under the CNPq 07/2005 funding cycle, and by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES, whose grant no. 88881.131763/2016-01 provided a PhD scholarship for Maira Mendes. The Australian study was funded by National Health and Medical Research Council (NHMRC) Strategic Award APP409966 and Project Grant APP1002463. Rohan Borschmann is supported by NHMRC Early Career Fellowship APP1104644. Stuart Kinner is supported by NHMRC Senior Research Fellowship APP1078168.

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Correspondence to Rohan Borschmann.

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Borschmann, R., dos Santos, M.M., Young, J.T. et al. Health, social and criminal justice factors associated with dual diagnosis among incarcerated adults in Brazil and Australia: a cross-national comparison. Soc Psychiatry Psychiatr Epidemiol 55, 1355–1362 (2020).

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  • Mental disorder
  • Dual diagnosis
  • Substance use
  • Prison
  • Incarceration