Psychiatric Disorders and Crime in the US Population: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Wave III

Abstract

Objective:

Current knowledge regarding the intersection of psychiatric disorders and crime in the U.S. is limited to psychiatric, forensic, and youth samples. This study presents nationally representative data on the relationship of DSM-5 psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized U.S. adults.

Methods:

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012–2013; n=36,309). Logistic regressions were used to examine the association of specific disorders (e.g., mood, anxiety, eating, posttraumatic stress, substance), comorbid substance and mental health disorders, and multimorbidity with lifetime criminal behavior, incarceration experience, and past 12 month general, alcohol-related, and drug-related legal problems.

Results:

28.5% of participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current general legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems. The presence of any disorder was associated with 4 to 5 times increased risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime (OR=6.8, 95% CI=6.1–7.6), incarceration (OR=4.7; 95% CI=4.1–5.3), and current legal problems (OR=3.3; 95% CI=2.6–4.2). Multimorbidity and comorbid substance and mental health disorders were associated with additional risk. Controlling for antisocial personality disorder did not change the findings.

Conclusion:

Community adults with substance use disorders, comorbid substance and mental health disorders, and increasing multimorbidity are most at risk of crime and justice involvement, highlighting the importance of community-based addiction treatment.

INTRODUCTION

The issue of mental illness and crime often attracts national attention and brings to question whether people with psychiatric disorders are more likely to engage in criminal behavior. Ample research supports the association of psychiatric disorders with crime and justice system involvement^1,2, however, the majority of this research is drawn from forensic populations^3–7, psychiatric populations^8,9, youth^10,11, or people with serious mental illness (e.g., schizophrenia)^12,13. While population-based studies have examined the association of psychiatric disorders with antisocial personality^14,15 and violence^16,17, there have been few studies focused more broadly on crime and justice system involvement in the general population¹⁸. Research on the current intersection of psychiatric disorders and crime among non-institutionalized U.S. adults is needed to inform treatment efforts within community mental health and criminal justice systems, and guide U.S. policy.

Among forensic and psychiatric samples, people with substance use disorders (SUDs),^19,20 psychotic disorders (e.g., schizophrenia)^13,21, and mood disorders^4,8,9,22,23 demonstrate higher rates of criminal behavior and justice system involvement compared to people without these disorders. More recently, trauma-related disorders have been identified as a risk factor for crime¹ with studies among veterans²⁴ and offenders^7,25 showing that a posttraumatic stress disorder (PTSD) diagnosis increases risk for incarceration and arrests. Studies among youth suggest an added risk of multiple psychiatric disorders (i.e., multimorbidity) on crime¹¹, and comorbid substance and mental health disorders are associated with greater risk of crime outcomes among forensic^4,5 and psychiatric^26–28 populations.

Research on the association of psychiatric disorders and crime in community-based samples is limited. Studies in Sweden and New Zealand have shown that people with major psychiatric disorders (e.g., schizophrenia/psychosis, affective disorders) have increased risk of justice system involvement^18,29; however, there have been no studies to our knowledge examining these relationships in the U.S. Moreover, less is known about the association of a variety of psychiatric disorders (e.g., anxiety, eating) with crime outcomes, despite the shared emotional/behavioral dysregulation observed across disorders^1,30.

The present study drew from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III), the only nationally representative sample including Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) data as well as crime and justice system involvement among adults. This report examines the relationship between specific psychiatric disorders and criminal behavior (engaging in crime) and justice involvement (incarceration, current general, alcohol-, and drug-related legal problems). We examined each disorder category (i.e., mood, anxiety, eating, posttraumatic stress, schizophrenia/psychosis, substance), disorders within each category, and multimorbidity (number of disorders) as predictors. We also distinguish between mental health [mood, anxiety, eating, trauma, schizophrenia/psychosis] and SUDs to examine aspects of comorbidity (i.e., SUD only, mental health disorder only, comorbid substance and mental health disorder). To our knowledge, this is the first study to examine the association of psychiatric disorders, comorbidity, and multimorbidity with crime and justice system involvement among the general U.S. population.

METHOD

Study Design and Participants

Data were drawn from the NESARC-III, a survey conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) from April 2012 to June 2013³¹. The original dataset is available from NIAAA (https://www.niaaa.nih.gov/research/nesarc-iii). The sample consisted of 36,309 non-institutionalized U.S. adult men and women whose addresses were randomly selected from the 2010 census via probability sampling of counties in 50 states. Subjects provided written informed consent after receiving a description of the study. Trained NIAAA interviewers conducted an in-person computer-assisted interview (Alcohol Use Disorder and Associated Disabilities Interview Schedule-5; AUDADIS-5), a reliable and valid measure of DSM-5 criteria³². The response rate was 72% for households, 84% for individuals, and 60.1% overall, which is comparable to other national surveys^33,34. Data were weighted to adjust for nonresponse and were nationally representative with regard to age, sex, and race/ethnicity. Original data collection and secondary analysis of data were approved by the institutional review board.

Measures

DSM-5 Diagnoses.

Lifetime and current (past 12-month) presence vs. absence of DSM-5 diagnoses available in the NESARC-III were categorized as follows: mood disorder (major depression, persistent depression, bipolar I), anxiety disorder (generalized anxiety, social anxiety, specific phobia, panic, agoraphobia), eating disorder (anorexia nervosa, bulimia, binge eating), PTSD, schizophrenia/psychosis, and substance use disorder (SUD; includes alcohol use disorder [AUD] and drug use disorder [DUD; marijuana, cocaine, opiates, heroin, sedatives, stimulants, hallucinogens, inhalants/solvents, club drugs, other drugs]). AUDADIS-5 scoring was used for all disorders except for schizophrenia/psychosis which, in the NESARC-III, was queried by asking: “Did a doctor or other health professional tell you that you had schizophrenia or a psychotic illness or episode in the last 12 months,” “Did this happen before 12 months ago?”

Multimorbidity and Comorbidity.

Multimorbidity was assessed by counting lifetime and current diagnoses. We created two four-level variables (i.e., lifetime, current): 0 disorders, 1 disorder, 2 disorders, and 3 or more disorders. Two four-level variables were created for lifetime and current comorbid disorders: 0 disorders, SUDs only, mental health disorders only, and comorbid substance and mental health disorders. All levels of these variables were compared to the reference category of 0 disorders.

Outcomes.

We assessed two primary lifetime crime outcomes (n = 36,309). The lifetime presence vs. absence of criminal behavior was assessed using questions that pertained to illegal behavior from the NESARC-III antisocial personality module. If participants endorsed (since age 15) ever using an alias, scamming someone, engaging in reckless behavior that could hurt someone (e.g., driving while intoxicated), destroying property, setting fires, stealing, shoplifting, mugging, breaking into a house/car, forging checks, making money illegally, using a credit card without permission, forcing someone to have sex, starting fights, physically hurting someone/family on purpose, hitting and causing a serious injury, threatening/harassing, using weapons in a fight, hurting animals on purpose, or “something you could have been arrested for regardless of whether caught or not,” they were coded as having endorsed adult criminal behavior. The presence vs. absence of lifetime incarceration was assessed with the question, “Since you were 18, were you ever in jail, prison, or a correctional facility?” In addition to these two outcomes, among people who reported having been incarcerated (n = 4,130), the number of days incarcerated was assessed by asking: “About how long altogether were you in jail or a correctional facility since you were 18?” Responses were recorded in number of days.

We assessed three current crime outcomes: general, alcohol-related, and drug-related legal problems. General legal problems were assessed by asking, “Did you have serious trouble with the police or law [in the past 12 months]?” If participants endorsed ever having used alcohol, they were asked, “Did you ever get arrested, held at a police station, or have other legal problems because of drinking? Did this happen in the last 12 months? Participants who never drank were not asked this question, resulting in a sample of 31,189. If participants endorsed ever having used illegal drugs, they were asked, “In the last 12 months, did you more than once get arrested, held at a police station or have any other legal problems because of your medicine or drug use?” Participants who never used drugs in the past 12 months were not asked this question, resulting in a sample of 5,107. Of note, alcohol- and drug-related legal problems variables are not considered mutually exclusive from other variables, but are more focused on substance-related legal involvement. All items had possible response of yes, no, or unknown; unknown responses were recoded as missing.

Covariates.

Analyses were adjusted for sociodemographic characteristics used in prior analyses of the NESARC (i.e., gender, age, race/ethnicity, educational attainment, marital status, personal income, urbanicity, and region^35,36,14,37) and all other categories of psychiatric disorders (other than the disorder evaluated as the predictor).

Statistical Analysis

Data were analyzed using PROC SURVEYLOGISTIC in SAS, version 9.4 (Cary, NC). This procedure allows for incorporating the stratification, clustering (i.e., primary sampling unit (PSU)), and unequal weighting of the sampling design. Chi square analyses compared sample descriptives across crime outcomes. Logistic regressions examined associations between lifetime psychiatric disorders, lifetime comorbid substance and mental health disorders, and lifetime multimorbidity with lifetime criminal behavior and incarceration; and current psychiatric disorders, current comorbid substance and mental health disorders, and current multimorbidity with current general, alcohol-related, and drug-related legal problems, controlling for sociodemographics and psychiatric comorbidity (Tables 3 and 4). Adjusted odds ratios (AOR) are presented. Supplemental analyses present unadjusted odds ratios (Supplementary Tables 1 and 5) and analyses controlling for antisocial personality disorder (ASPD; i.e., due to the potential influence of ASPD on crime outcomes) in addition to sociodemographics and psychiatric disorders (Supplementary Tables 4 and 8). We also explored the effect of gender on outcomes by examining whether associations across our primary analysis differed by gender, and present results stratified by gender in Supplementary Tables 2, 3, 6, and 7. An analysis of variance (ANOVA) comparing mean lifetime days incarcerated by the presence vs. absence of psychiatric disorders was examined, controlling for sociodemographic characteristics. All tests were two-tailed and the significance level was p<.001³⁷.

Table 3.

Association of Lifetime Psychiatric Disorders with Lifetime Crime Outcomes Adjusted for Sociodemographic Characteristics and Other Disorders (n = 36,309)

	Lifetime Crime			Lifetime Incarceration
Lifetime Diagnosis	%a	AORd	[95% CI]	%a	AOR	[95% CI]
No Diagnosis	14.11	Ref	----	5.14	Ref	----
Any Diagnosis	43.50	4.34*	[4.06–4.62]	18.01	4.11*	[3.71–4.56]
Any Mood Disorder	43.65	1.61*	[1.50–1.73]	16.08	1.21	[1.08–1.35]
Major Depression	40.85	1.41*	[1.32–1.52]	14.35	1.10	[0.98–1.23]
Persistent Depressive Disorder	50.07	1.60*	[1.39–1.85]	18.52	1.11	[0.92–1.34]
Bipolar I	69.12	2.20*	[1.72–2.81]	31.46	1.48	[1.13–1.94]
Any Anxiety Disorder	44.31	1.46*	[1.36–1.57]	16.90	1.29*	[1.15–1.45]
Generalized Anxiety	49.65	1.47*	[1.32–1.64]	18.72	1.23	[1.07–1.42]
Social Anxiety	52.24	1.63*	[1.41–1.88]	21.96	1.35	[1.11–1.65]
Specific Phobia	42.18	1.37*	[1.20–1.56]	15.54	1.17	[0.99–1.39]
Panic	48.50	1.21	[1.05–1.40]	19.61	1.20	[0.97–1.48]
Agoraphobia	53.86	1.39	[1.15–1.67]	23.07	1.30	[0.96–1.78]
Eating Disordersb	50.41	1.39	[1.05–1.83]	14.42	1.16	[0.81–1.66]
Posttraumatic Stress	57.27	2.09*	[1.82–2.39]	22.77	1.50*	[1.27–1.77]
Schizophrenia/Psychosis	46.45	1.44	[1.13–1.83]	24.22	1.42	[1.05–1.92]
Any Substance Use Disorder	55.52	4.30*	[3.99–4.64]	24.59	4.17*	[3.76–4.63]
Alcohol Use Disorder	54.91	3.77*	[3.49–4.07]	24.03	3.54*	[3.19–3.93]
Any Drug Use Disorder	75.80	6.81*	[6.12–7.58]	38.07	4.65*	[4.08–5.30]
# of Diagnosesc
1	31.67	2.62*	[2.43–2.83]	12.91	2.72*	[2.39–3.09]
2	45.65	4.90*	[4.47–5.37]	18.75	4.44*	[3.89–5.05]
3+	62.97	10.60*	[9.61–11.70]	26.55	7.55*	[6.67–8.54]
Comorbid Substance Use and Mental Healthc
SUD Only	47.44	4.36*	[3.97–4.79]	22.95	4.63*	[4.07–5.27]
Mental Health Only	24.29	2.11*	[1.94–2.29]	7.50	1.82*	[1.56–2.12]
Both	63.58	9.51*	[8.75–10.34]	26.23	6.72*	[5.94–7.59]

Note.

^*p0<.001.

^aUnweighted percentages.

^bCombined prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder.

^cThese models only controlled for sociodemographic characteristics. Reference category for these analyses is “no diagnoses” (n = 18,548).

^dOdds ratios are adjusted for gender, age, race/ethnicity, educational attainment, marital status, personal income, urbanicity, and region in addition to other psychiatric disorders. Abbreviations: AOR=Adjusted Odds Ratio.

Table 4.

Lifetime Days Incarcerated by Lifetime Psychiatric Diagnoses Adjusted for Sociodemographic Characteristics and Other Disorders (n = 4,076)

Lifetime Diagnosis	N	M	SE	Fb	p
Any Diagnosis	3144	124.09	23.45	4.94	0.028
No Diagnosis	932	62.91	28.51
Any Mood Disorder Diagnosis	1363	193.46	59.36	0.69	0.407
No Mood Disorder	2713	167.58	52.92
Major Depression	1045	190.19	64.09	0.10	0.753
No Major Depression	3031	179.18	53.25
Persistent Depressive Disorder	367	171.38	72.96	0.08	0.774
No Persistent Depressive Disorder	3709	185.70	54.29
Bipolar I	233	238.86	71.64	1.40	0.239
No Bipolar I	3843	168.32	56.12
Any Anxiety Disorder	1001	169.13	53.18	0.55	0.462
No Anxiety Disorder	3075	191.91	59.06
Generalized Anxiety	499	156.90	60.98	0.59	0.443
No Generalized Anxiety	3577	190.58	56.36
Social Anxiety	273	138.64	66.88	1.41	0.237
No Social Anxiety	3803	191.91	54.51
Specific Phobia	350	169.17	67.59	0.07	0.789
No Specific Phobia	3726	183.54	55.69
Panic	352	179.61	65.35	0.00	0.968
No Panic	3724	181.84	56.68
Agoraphobia	158	192.56	93.29	0.02	0.886
No Agoraphobia	3918	179.94	55.60
Eating Disordersa	88	173.69	74.58	0.03	0.856
No Eating Disorders	3988	187.36	55.58
Posttraumatic Stress	524	207.04	65.70	1.47	0.228
No Posttraumatic Stress	3552	154.00	49.82
Schizophrenia/Psychosis	213	260.96	88.77	3.51	0.064
No Schizophrenia/Psychosis	3863	100.09	40.64
Any Substance Use Disorder	2645	227.81	54.15	16.93	<0.001
No Substance Use Disorder	1431	133.23	56.33
Alcohol Use Disorder	2365	219.24	56.01	4.43	0.038
No Alcohol Use Disorder	1711	164.24	54.82
Any Drug Use Disorder	1332	284.54	52.00	17.09	<0.001
No Drug Use Disorder	2744	134.51	58.72

Note.

^aCombined prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder.

^bAnalysis of covariance models are adjusted for gender, age, race/ethnicity, educational attainment, marital status, personal income, urbanicity, region, and other psychiatric diagnoses

RESULTS

Unweighted prevalence estimates of sociodemographic characteristics by lifetime crime outcomes are reported in Table 1, and by current crime outcomes in Table 2. Regarding lifetime crime, 28.5% of U.S. adults reported engaging in criminal behavior (since age 15) and 11.4% reported a history of incarceration as an adult. Adults who were male, younger, Native American, unmarried/separated, or had ASPD were more likely to report criminal behavior and incarceration. Adults in higher income brackets and who were more educated reported similar rates of criminal behavior to those in lower income brackets, but were less likely to be incarcerated. Regarding current crime, 1.8% of U.S. adults reported general legal problems; out of people who drank alcohol, 0.8% reported past-year alcohol-related legal problems, and out of people who used drugs, 2.7% reported past-year drug-related legal problems. Adults who were male, younger, unmarried, had lower education and income, or had ASPD were more likely to report current legal problems.

Table 1.

Lifetime Crime Outcomes by Sociodemographic Characteristics (n = 36,309)

	Lifetime Crime	p	Lifetime Incarceration	p
	%a		%a
Total	28.5		11.4
Gender
Women	21.57	<.001	5.96	<.001
Men	37.40		18.49
Age (years)
18–29	31.90	<.001	9.52	<.001
30–44	31.11		13.66
45–64	29.40		13.35
65+	17.16		6.20
Race-ethnicity
White	31.46	<.001	11.12	<.001
Black	29.52		14.72
Native American	46.94		25.30
Asian/Pac. Islander	13.89		2.73
Hispanic	21.62		9.91
Education
< High School	25.11	<.001	16.44	<.001
High School	28.91		14.09
Some college	29.17		8.89
Marital Status
Married/cohabitating	25.69	<.001	9.11	<.001
Widowed/ Separated/Divorced	29.46		13.86
Never Married	32.21		13.04
Income
$0–19,999	28.14	.203	13.28	<.001
$20,000–$34,999	28.17		11.25
$35,000–$69,999	29.38		9.57
$70,000 or more	28.84		7.09
Urbanicity
Rural	29.25	.147	11.69	.497
Urban	28.33		11.38
Region
Northeast	27.57	.001	7.46	<.001
Midwest	29.25		12.19
South	27.62		12.02
West	29.75		12.14
Antisocial PD
No	25.44	<.001	9.89	<.001
Yes	94.37		44.79

Note.

^aUnweighted percentages.

Table 2.

Current Crime Outcomes by Sociodemographic Characteristics (n = 36,309)

	Current Legal Problemsa (n = 36,309)	p	Current Alcohol-related Legal Problems (n = 35,772)	p	Current Drug-related Legal Problems (n = 36,121)	p
	%b		%b		%b
Total	1.8		0.8		2.7
Gender
Women	1.14	<.001	0.33	<.001	1.79	<.001
Men	2.66		1.33		3.44
Age (years)
18–29	3.67	<.001	1.51	<.001	3.49	.018
30–44	1.97		0.81		2.43
45–64	1.14		0.60		2.21
65+	0.33		0.04		0.76
Race-ethnicity
White	1.50	<.001	0.65	<.001	2.27	.155
Black	2.43		0.80		3.61
Native American	3.52		1.36		2.50
Asian/Pac. Islander	0.67		0.22		1.57
Hispanic	2.13		1.22		2.83
Education
< High School	3.32	<.001	1.36	<.001	4.40	<.001
High School	2.11		1.06		3.35
Some college	1.27		0.53		1.91
Marital Status
Married/cohabitating	1.04	<.001	0.34	<.001	1.89	.001
Widowed/ Separated/Divorced	1.63		0.77		1.92
Never Married	3.24		1.54		3.61
Income
$0–19,999	2.62	<.001	1.08	<.001	3.54	<.001
$20,000–$34,999	1.61		0.66		2.63
$35,000–$69,999	0.79		0.50		0.81
$70,000 or more	0.62		0.37		.00
Urbanicity
Rural	1.60	.188	0.51	.015	1.33	.020
Urban	1.85		0.83		2.89
Region
Northeast	1.35	.001	0.50	.071	1.18	.034
Midwest	2.21		0.85		3.32
South	1.66		0.76		2.91
West	1.97		0.92		2.72
Antisocial PD
No	1.51	<.001	0.65	<.001	2.26	<.001
Yes	8.25		3.49		5.57

Note.

^aRefers to the past 12 months.

^bUnweighted percentages.

About half (48.9%) of adults reported lifetime psychiatric disorders and 33.4% reported current psychiatric disorders. For lifetime disorders, 24.1% had 1 disorder, 11.4% had 2, and 13.4% had 3 or more. For current disorders, 19.9% had 1 disorder, 17.2% had 2, and 6.4% had 3 or more. Among people with 3 or more lifetime disorders, the most prevalent disorders were AUD (71.0%), major depression (65.7%), and DUD (46.6%). Among people with 3 or more current disorders, the most prevalent disorders were major depression (59.6%), AUD (48.1%) and generalized anxiety (43.9%). In their lifetime, 15.0% of adults had a SUD only, 18.8% had a mental health disorder only, and 15.07% had a comorbid substance and mental health disorder. In the past year, 9.9% of adults had SUDs only, 17.4% had a mental health disorder only, and 6.1% had comorbid substance and mental health disorders.

Lifetime psychiatric disorders were associated with increased risk for lifetime criminal behavior (see Table 3). Drug use disorders (DUDs) were associated with the greatest absolute risk of any disorder (75.8% of those with DUDs reported criminal behavior), followed by AUD. Among other disorders, the odds of criminal behavior were greatest for PTSD, social anxiety disorder, and bipolar I. Multimorbidity and comorbidity were associated with increased risk; 47% of those with SUDs only reported criminal behavior, compared to 24% of those with mental health disorders only and 64% of those with comorbid substance and mental health disorders.

Lifetime psychiatric disorders were associated with increased risk for incarceration (see Table 3). DUD was associated with the greatest absolute risk of incarceration, followed by AUD. Among other disorders, PTSD, followed by any anxiety disorder, was associated with the greatest risk of incarceration. Risk of incarceration over the lifetime increased as more lifetime disorders were present. Adults with comorbid substance and mental health disorders had the greatest risk of incarceration (26%) compared to those with SUDs only (23%) and mental health disorders only (8%). Analyses comparing the length of time incarcerated by the presence vs. absence of psychiatric disorders show that adults with SUDs and in particular DUDs were incarcerated more days in their lifetime compared to adults without these disorders (see Table 4).

Any current psychiatric disorder was associated with increased risk of current legal problems (see Table 5). The presence of a SUD was associated with the greatest absolute risk of current legal problems, and within this category, AUDs and DUDs were associated with equal risk. Among other disorders, mood disorders were associated with the greatest risk of current legal problems, followed by major depressive disorder. Risk of current legal problems increased with multimorbidity and comorbidity; 5% of adults with SUDs only and 2% of adults with mental health disorders only reported current legal problems, compared to 8% of adults with comorbid substance and mental health disorders.

Table 5.

Association of Current Psychiatric Disorders with Current Crime Outcomes Adjusted for Sociodemographic Characteristics and Other Disorders (n = 36,309)

	Currenta Legal Problems			Current Alcohol-related Legal Problems			Current Drug-related Legal Problems
Current Diagnosis	%b	AORe	[95% CI]	%b	AOR	[95% CI]	%b	AOR	[95% CI]
No Diagnosis	0.78	Ref	----	0.13	Ref	----	0.83	Ref	----
Any Diagnosis	3.85	3.94*	[3.24–4.79]	2.26	12.22*	[6.40–23.34]	3.59	3.73	[1.84–7.57]
Any Mood Disorder	4.04	1.78*	[1.40–2.27]	1.55	0.98	[0.63–1.54]	3.75	1.51	[0.94–2.41]
Major Depression	3.76	1.68*	[1.31–2.16]	1.21	0.82	[0.46–1.48]	3.64	1.40	[0.80–2.48]
Persistent Depressive Disorder	4.39	1.54	[1.08–2.21]	2.07	1.35	[0.68–2.67]	3.21	1.40	[0.59–3.37]
Bipolar I	5.58	1.50	[0.87–2.60]	2.93	1.30	[0.58–2.92]	4.13	1.18	[0.55–2.55]
Any Anxiety Disorder	3.30	1.37	[1.02–1.85]	1.09	0.66	[0.44–0.97]	3.14	0.91	[0.53–1.58]
Generalized Anxiety	4.30	1.79	[1.27–2.54]	1.13	0.75	[0.39–1.44]	3.11	0.96	[0.51–1.82]
Social Anxiety	3.78	0.96	[0.62–1.49]	1.27	0.60	[0.27–1.36]	4.98	1.60	[0.82–3.12]
Specific Phobia	2.51	1.07	[0.74–1.57]	0.94	0.43	[0.24–0.78]	2.49	0.75	[0.36–1.58]
Panic	4.71	1.08	[0.72–1.60]	1.54	1.00	[0.52–1.94]	4.55	1.28	[0.58–2.80]
Agoraphobia	4.01	0.90	[0.52–1.58]	1.77	0.97	[0.40–2.34]	5.52	2.09	[0.84–5.21]
Eating Disordersc	1.55	0.41	[.16–1.08]	1.01	1.03	[0.29–3.69]	2.06	0.92	[0.20–4.17]
Posttraumatic Stress	4.89	1.29	[0.92–1.82]	1.86	1.05	[0.64–1.72]	5.05	1.82	[1.12–2.96]
Schizophrenia/Psychosis	8.31	2.18	[1.14–4.19]	2.80	1.22	[0.43–3.48]	4.17	1.12	[0.33–3.75]
Any Substance Use Disorder	6.06	3.53*	[2.83–4.40]	3.89	22.92*	[12.07–43.53]	4.22	2.88	[1.62–5.11]
Alcohol Use Disorder	5.96	3.22*	[2.58–4.02]	4.17	18.55*	[10.27–33.51]	3.60	0.99	[0.68–1.45]
Any Drug Use Disorder	10.36	3.27*	[2.57–4.17]	5.71	5.04*	[3.34–7.62]	5.99	3.14*	[1.98–4.99]
# of Diagnosesd
1	2.73	2.77*	[2.20–3.49]	1.94	10.79*	[5.60–20.77]	2.39	2.68	[1.21–5.92]
2	4.32	4.84*	[3.63–6.46]	2.13	12.55*	[5.74–27.44]	3.65	3.35	[1.55–7.26]
3+	6.80	6.71*	[5.14–8.76]	3.38	16.74*	[8.48–33.05]	5.29	5.70*	[2.64–12.32]
Comorbid Substance Use and Mental Healthd
SUD Only	5.04	4.16*	[3.20–5.39]	4.16	20.80*	[10.62–40.74]	3.80	3.62	[1.74–7.52]
Mental Health Only	1.82	2.32*	[1.76–3.06]	0.07	0.20	[0.05–0.77]	1.24	2.03	[0.70–5.84]
Both	7.73	7.03*	[5.46–9.04]	3.45	14.77*	[7.16–30.45]	4.73	4.74*	[2.15–10.45]

Note.

^*p<.001.

^aCurrent refers to the past 12 months.

^bUnweighted percentages.

^cCombined prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder.

^dThese models only controlled for sociodemographic characteristics. Reference category for these analyses is “no diagnoses” (n = 18,548).

^eOdds ratios are adjusted for gender, age, race/ethnicity, educational attainment, marital status, personal income, urbanicity, and region in addition to other psychiatric disorders. Abbreviations: AOR=Adjusted Odds Ratio.

Any current psychiatric disorder was associated with increased risk of alcohol-related legal problems; however, among specific disorders, only SUDs were associated with increased risk. Within the category of SUDs, adults with AUDs experienced the greatest risk of alcohol-related legal problems. Unlike other crime outcomes, more adults with SUDs only (4.2%) reported alcohol-related legal problems compared to adults with comorbid substance and mental health disorders (3.5%). The only disorder associated with risk of current drug-related legal problems was DUD. Similar to other crime outcomes, the risk of current drug-related legal problems increased as more current disorders were present. Additionally, 5% of adults with comorbid substance and mental health disorders reported current drug-related legal problems, compared to 4% of adults with SUDs only and 1% of adults with mental health disorders only.

Primary analyses stratified by gender are shown in Supplementary Tables 2, 3, 6, and 7; interaction analyses showed that within the comorbid substance and mental health variable (i.e., no disorders, SUDs only, mental health disorders only, comorbid substance and mental health disorders), men with SUDs only had lower risk of criminal behavior compared to women (OR = 0.69, 95% CI = 0.58–0.81, p < .001). Additionally, men with SUDs (OR = 0.70, 95% CI = 0.59–0.82, p < .001), AUDs (OR = 0.76, 95% CI = 0.66–0.89, p < .001), DUDs (OR = 0.71, 95% CI = 0.58–0.87, p < .001), and comorbid substance and mental health disorders (OR = 0.55; 95% CI = 0.45–0.69, p < .001) had lower risk of incarceration than women. There were no significant gender differences in other crime outcomes. As is shown in Supplementary Tables 4 and 8, including ASPD as a covariate slightly decreased effect sizes but did not change the pattern of findings.

DISCUSSION

This study evaluated the risk of crime outcomes (i.e., criminal behavior, incarceration, general and substance-related legal problems) associated with specific psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity in the most recent representative U.S. sample.

A considerable portion of the U.S. population reported engaging in criminal behavior (28.5%) and having been incarcerated (11.4%) as an adult. Given that NESARC-III data captures any incarceration, including brief jail detention, this rate is greater than prior research predicting 6.6% of the U.S. population will go to state or federal prison in their lifetime³⁸. The U.S. has the highest rate of incarceration in the world, with 1% of its total population currently incarcerated³⁹. The presence of any psychiatric disorder (controlling for sociodemographics and ASPD) was associated with 4 to 5 times the likelihood of crime outcomes. Multimorbidity, as well as comorbid substance and mental health disorders, were associated with higher risk of crime, consistent with research showing poor health and social outcomes associated with increasing multimorbidity^40,41. Importantly, these findings do not suggest that all people with psychiatric disorders commit crime. The majority of adults with a psychiatric disorder (57%) denied engaging in criminal behavior; however, this contrasts with 86% of adults without psychiatric disorders who denied criminal behavior.

Adults most at risk of current substance- and non-substance related crime had multiple psychiatric disorders, SUDs (particularly DUDs), or comorbid substance and mental health disorders, which is consistent with international studies examining psychiatric disorders and violent crime²⁹. Over a third of adults with DUDs reported having been incarcerated. These findings parallel research showing that veterans and offenders with substance use/comorbid substance and mental health disorders have the highest risk for future crime^19,42–44. There are numerous pathways from substance use to crime, including possession of drugs, engagement in crime to financially support addiction, risky behavior while intoxicated, and being in environments wherein crime is common⁴⁵. Community-based treatment of SUDs is necessary to reduce crime and justice-system involvement. Unfortunately, among U.S. adults in need of substance use treatment, only 11% receive treatment⁴⁶. Once people with SUDs become involved in the justice system, they are unlikely to receive evidence-based treatment⁴⁷ and have heightened rates of recidivism⁴³.

Though smaller in magnitude compared to SUDs, several other mental health disorders had significant associations with crime outcomes. Bipolar I and PTSD were associated with the strongest risk of lifetime crime and, in the case of PTSD, incarceration. The link between bipolar I and crime is well-documented⁴⁸, and may reflect engagement in reckless behavior during mania²². Indeed, mania symptoms are commonly diagnosed (up to 50%) among inmates⁴⁹. In addition, research has uncovered a heightened prevalence of risky, impulsive (including antisocial) behavior among people with PTSD⁵⁰. Theories suggest that hypervigilance paired with aggression, or suspiciousness and subsequent distancing from prosocial individuals and communities among people with PTSD may be an explanatory mechanism²⁵, though these theories have yet to be tested empirically. Alternatively, psychiatric disorders share common risk factors that may increase the propensity for illicit behaviors, such as emotion dysregulation⁵¹. As noted by Skeem and colleagues³, there are many factors associated with psychiatric disorders that contribute to crime in addition to uncontrolled symptoms, such as low socioeconomic status. Though controlling for such factors helps account for their contribution to crime risk, the association between mental illness and crime is complex and prospective data is needed to draw conclusions about mechanisms explaining this relationship.

Supplemental analysis of gender differences highlighted that women with SUDs and comorbid substance and mental health disorders had greater risk of incarceration than men, which is consistent with a national study of psychiatric disorders and crime in Sweden¹⁸. Research has suggested that the well-documented “gender-gap” in crime (i.e., men report more crime and violence than women) is smaller among those with psychiatric disorders, especially bipolar, psychosis, or phobias⁵². It may be that women with SUDs have more severe/impairing psychiatric symptoms that prompt arrest compared to men. More research is needed to clarify the mechanisms explaining such gender differences.

Though this study presents current data on the intersection of psychiatric disorders and crime in a nationally representative sample, there are limitations. Crime outcomes are self-reported and there may be an unknown amount of underreporting or biased recall, though self-reported crime is adequately correlated with official records^53–55. We were limited to the available questions in the NESARC-III; there were no questions assessing types of justice involvement (e.g., charges, convictions), or severity of crime (e.g., misdemeanor vs. felony). Questions about drug-related and alcohol-related legal problems differed slightly; participants were scored affirmatively for alcohol-related legal problems if they endorsed any legal issues, whereas only those with more than one legal issue were scored affirmatively on drug-related legal problems. Though we analyzed lifetime diagnoses with lifetime outcomes, and current diagnoses with current outcomes, the time of diagnosis may not have overlapped with when the crime was committed. Temporal precedence could not be established using NESARC-III. Finally, NESARC-III did not contain a comprehensive list of DSM-5 diagnoses, and schizophrenia/psychosis may have been under-represented, as it was assessed via self-report (which could explain our lack of findings for this diagnosis).

In conclusion, in a nationally representative sample, criminal behavior and incarceration are prevalent and SUDs, comorbid substance and mental health disorders, and multimorbidity are most strongly associated with criminal behavior and justice system involvement. Our findings about disorders associated with crime risk parallels research on disorders that increase risk for recidivism among forensic populations²³. Thus, high-risk individuals (i.e., SUDs, PTSD, comorbid disorders) who are likely to become involved in the justice system are also more likely to stay in this system. With regard to clinical implications, improved access to community-based treatment, including diversion from the justice system to mental health or substance use treatment, may reduce crime and incarceration^56,57. At-risk individuals, including those with SUDs, PTSD, bipolar I, or comorbidity, should be screened for criminal behavior in community-based systems to identify and target behaviors that lead to arrest. Psychiatric symptoms and other criminogenic factors should be treated to prevent continued criminal justice involvement.

Clinical Points.

• There are currently no national estimates of the relationship between DSM-5 psychiatric disorders and crime outcomes among U.S. adults.

• People with substance use disorders, PTSD, bipolar, or comorbid substance and mental health disorders should be screened for criminal behavior to identify and target issues that lead to justice system involvement.

• Increased access to community-based substance use and mental health treatment may reduce crime and incarceration in the U.S.