The relationships between behavioral health (mental health and substance use) disorders and physical health disorders should be examined through comprehensive screening, assessment, and treatment of individuals in prison and jail. (See Policy Statement 8, Development of Intake Procedure, for additional discussion of screening and assessment at admission to a correctinoal facility.) Substance use disorders are causally related to many blood-borne communicable diseases, such as HIV and hepatitis C, and mental illnesses are frequently associated with cognitive impairments that threaten medication and treatment compliance. Indeed, many prisoners will have not only dual diagnoses but also triple and quadruple diagnoses. This has implications for prevention and treatment strategies and poses the challenge to correctional health care providers of integrating a range of clinical interventions. Behavioral and physical health-related services should therefore be closely coordinated in the jail or prison setting. The more progress that can be achieved in this regard, the greater will be the effectiveness of in-house treatment interventions and the possibility of successful community transition for inmates with serious and complex health problems. (See Policy Statement 11, Mental Health Care, for a detailed discussion of appropriate treatment for individuals with co-occurring mental health and substance abuse disorders.)

Medication management of the multi-diagnosed individual presents unique complications. Drug interactions must be anticipated. Treating physicians should consider the impact of psychoactive somatic medications on individuals with behavioral health problems, and should avoid prescribing medications with potential for abuse or other negative results. These issues are best addressed when integrated record-keeping allows an accurate understanding of the complex needs of patients with two or more diagnoses. When an effective medication regimen has been established in a correctional institution, it is particularly important that it not be interrupted or changed upon the person's re-entry into the community. Challenges to coordinated medical, mental health, and substance abuse treatment are evident in the treatment of people who suffer from HIV disease, a condition that disproportionately affects people in prison and jail. Jurisdictions rarely provide aligned treatments for HIV, substance abuse, and mental illness, yet the complexity of the effects of these illnesses and their treatments can make such coordination critically important. ^[1]  

Individuals with multiple health issues have a wide range of service needs, and policymakers should consider implementing a range of service models that allow for individualized treatment solutions. The various models of service integration include consultation, collaboration, and integration. (See Policy Statement 11, Mental Health Care, for definitions of these terms established by the National Association of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Program Directors.) Further, there are several methods for realizing these models, some of which, like multi-disciplinary teams, cross-training, co-location, and dual licensure, may be applicable in a corrections context.

Research shows that treatment-or lack thereof-for one disorder affects an individual's treatment for a co-occurring disorder. For instance, when patients are treated for substance abuse disorders, the treatment improves the likelihood that they will benefit from adequate HIV treament, particularly if integrated systems of care are used. ^[2]   On the other hand, a failure to address a substance use disorder can negatively affect a person's physical health treatment; substance abuse has been shown to impede individuals' access to care for HIV/AIDS and their compliance with treatment recommendations. ^[3]  

The degree of disability increases when multiple disorders are present. This, in turn, can make it difficult for individuals with multiple diagnoses to succeed in vocational, social, and educational pursuits. Thorough and comprehensive programming for individuals with needs in multiple health systems requires attention to housing, income support and entitlements, and case management. Challenges to health can impede the ability of individuals to engage in many forms of institutional programming, and policymakers should seek to promote communication between service providers and to develop accommodations to allow individuals to participate as effectively as possible in all needed program areas.

Example: Risk Reduction Services, The Osborne Association (NY)

Osborne's Risk Reduction Services offers integrated treatment and support for people who are involved in the criminal justice system and are at risk for, or diagnosed with, a substance abuse disorder and HIV/AIDS or another infectious disease, such as Hepatitis C or tuberculosis. Each client is assigned both a case manager and a counselor, who provide clients assistance with getting tuberculosis or HIV tests, obtaining substance abuse treatment, finding housing, getting psychological and family counseling, receiving benefits and medical care, finding employment and training, and other issues. Although the Risk Reduction Services program is community-based, its model could be replicated in a correctional setting.