“Worse than when they came in”: dual diagnosis, prison health neglect and the structural violence of denied care

Purpose This paper critically aims to examine how the co-occurrence of mental health conditions and substance use, commonly referred to as dual diagnosis, is addressed within Australian custodial settings. Design/methodology/approach Grounded in an abolitionist framework, it explores how prisons routinely rely on solitary confinement to manage drug withdrawal and psychological distress, compounding harm for those with complex health needs, with a particular focus on women. Findings The structural exclusion of incarcerated people from Medicare and the Pharmaceutical Benefits Scheme plays a central role in limiting access to essential care, including mental health plans, chronic disease management and affordable medication. Without access to a specialist of their choice, and with significant barriers to services like the National Disability Insurance Scheme and aged care, people in prison are routinely denied care equivalent to what is available in the community. Women with dual diagnosis are particularly impacted – often exiting prison in worse physical and mental health than when they entered, placing them at heightened risk of re-incarceration. Originality/value This paper argues that prison environments reproduce and intensify the very conditions they claim to address, and calls for the dismantling of carceral responses to mental distress and drug use in favour of community-based approaches rooted in dignity, collective care and social justice.