Interrupting the Mental Illness-Incarceration-Recidivism Cycle

Access to Psychiatric and Education Services During Incarceration in the United States

OBJECTIVE

Individuals with psychiatric disorders are incarcerated at disproportionately high rates and often have low educational attainment. Access to psychiatric and education services within prisons has been described as inadequate, but recent data are lacking. The authors sought to assess the association of psychiatric disorders with both educational attainment before incarceration and access to psychiatric and education services during incarceration.

METHODS

Data were from the 2016 Survey of Prison Inmates, a national survey of adults incarcerated in U.S. state and federal prisons (N=24,848). Multinomial regression was used to identify associations of educational attainment before incarceration with psychiatric disorders and sociodemographic factors. Multivariable logistic regression models were used to assess associations of psychiatric disorders with access to psychiatric and education services during incarceration and with sociodemographic factors.

RESULTS

Before incarceration, 57.3% of survey respondents had less than a high school diploma. Across four education and psychiatric services, only 8.4%-44.8% of respondents reported participating in these services during incarceration, despite 57.3% reporting a psychiatric or learning disorder. Psychiatric disorders were associated with lower educational attainment before incarceration and lower access to education services during incarceration. Psychiatric disorders were associated with higher odds of access to psychiatric services during incarceration. Men had lower educational attainment before incarceration and lower odds of accessing psychiatric and education services during incarceration.

CONCLUSIONS

Incarcerated people had a high need for psychiatric and education services. Individuals with psychiatric disorders had lower odds of participating in education services during incarceration, highlighting the need for policies and services that increase participation.

Treating Trauma in Criminal Justice-Involved with SMI: "Trauma Is a Huge Part of It"

Individuals with serious mental illness are both disproportionately represented in the criminal justice system and more likely to experience correlates with offending (e.g., trauma, substance abuse, and homelessness). Moreover, research using the Adverse Childhood Experiences has found strong correlation between childhood trauma and later negative outcomes, including criminal justice involvement. Despite this, research has yet to examine how trauma can influence treatment decisions for criminal justice-involved individuals with SMI. Using a qualitative approach and in-depth semi-structured interviews with 61 community mental health service providers, the current study addresses this gap in the literature. Findings confirm the high prevalence of trauma in this population as well as suggests a number of key findings for this population including (1) how trauma affects treatment decisions, (2) the existing barriers related to the treatment of trauma, and (3) what service providers need to effectively treat trauma. Implications for policy and practice are extensive.

Costs attributable to criminal justice involvement in injuries: a systematic review

CONTEXT

Costs related to criminal justice are an important component of the economic burden of injuries; such costs could include police involvement, judicial and corrections costs, among others. If the literature has sufficient information on the criminal justice costs related to injury, it could be added to existing estimates of the economic burden of injury.

OBJECTIVE

To examine research on injury-related criminal justice costs, and what extent cost information is available by type of injury.

DATA SOURCES

Medline, PsycINFO, Sociological Abstracts ProQuest, EconLit and National Criminal Justice Reference Service were searched from 1998 to 2021.

DATA EXTRACTION

Preferred Reporting Items for Systematic reviews and Meta-Analyses was followed for data reporting.

RESULTS

Overall, 29 studies reported criminal justice costs and the costs of crime vary considerably.

CONCLUSIONS

This study illustrates possible touchpoints for cost inputs and outputs in the criminal justice pathway, providing a useful conceptualisation for better estimating criminal justice costs of injury in the future. However, better understanding of all criminal justice costs for injury-related crimes may provide justification for prevention efforts and potentially for groups who are disproportionately affected. Future research may focus on criminal justice cost estimates from injuries by demographics to better understand the impact these costs have on particular populations.

Understanding the association between frequent emergency department use and jail incarceration: A cross-sectional analysis

BACKGROUND

Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration.

METHODS

We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters.

RESULTS

The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest.

CONCLUSIONS

Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.

Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial

AIMS

Housing First (HF), a recovery-oriented approach, was proven effective in stabilising housing situations of homeless individuals with severe mental disorders, yet had limited effectiveness on recovery outcomes on a short-term basis compared to standard treatment. The objective was to assess the effects of the HF model among homeless people with high support needs for mental and physical health services on recovery, housing stability, quality of life, health care use, mental symptoms and addiction issues on 4 years of data from the Un Chez Soi d'Abord trial.

METHODS

A multicentre randomised controlled trial was conducted from August 2011 to April 2018 with intent-to-treat analysis in four French cities: Lille, Marseille, Paris and Toulouse. Participants were homeless or precariously-housed patients with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia. Two groups were compared: the HF group (n = 353) had immediate access to independent housing and support from the assertive community treatment team; the Treatment-As-Usual (TAU) group (n = 350) had access to existing support and services. Main outcomes were personal recovery (Recovery Assessment Scale (RAS) scale), housing stability, quality of life (S-QoL), global physical and mental status (Medical Outcomes Study 36-item Short Form Health Survey (SF-36)), inpatient days, mental symptoms (Modified Colorado Symptom Index (MCSI)) and addictions (Mini International Neuropsychiatric Interview (MINI) and Alcohol Use Disorders Identification Test (AUDIT)). Mixed models using longitudinal and cluster designs were performed and adjusted to first age on the street, gender and mental disorder diagnosis. Models were tested for time × group and site × time interactions.

RESULTS

The 703 participants [123 (18%) female] had a mean age of 39 years (95% CI 38.0-39.5 years). Both groups improved RAS index from baseline to 48 months, with no statistically significant changes found between the HF and TAU groups over time. HF patients exhibited better autonomy (adjusted β = 2.6, 95% CI 1.2-4.1) and sentimental life (2.3, 95% CI 0.5-4.1), higher housing stability (28.6, 95% CI 25.1-32.1), lower inpatient days (-3.14, 95% CI -5.2 to -1.1) and improved SF-36 mental composite score (-0.8, 95% CI -1.6 to -0.1) over the 4-year follow-up. HF participants experienced higher alcohol consumption between baseline and 48 months. No significant differences were observed for self-reported mental symptoms or substance dependence.

CONCLUSION

Data at 4 years were consistent with 2-year follow-up data: similar improvement in personal recovery outcomes but higher housing stability, autonomy and lower use of hospital services in the HF group compared to the TAU group, with the exception of an ongoing alcohol issue. These sustained benefits support HF as a valuable intervention for the homeless patients with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01570712.

Effectiveness of psychological interventions in prison to reduce recidivism: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Repeat offending, also known as criminal recidivism, in people released from prison has remained high over many decades. To address this, psychological treatments have been increasingly used in criminal justice settings; however, there is little evidence about their effectiveness. We aimed to evaluate the effectiveness of interventions in prison to reduce recidivism after release.

METHODS

For this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, Embase, Global Health, MEDLINE, PsycINFO, and Google Scholar for articles published from database inception to Feb 17, 2021, without any language restrictions. We searched for randomised controlled trials (RCTs) that evaluated the effect of psychological interventions, delivered to adolescents and adults during incarceration, on recidivism outcomes after release. We excluded studies of solely pharmacological interventions and of participants in secure psychiatric hospitals or special residential units, or attending therapies mainly delivered outside of the prison setting. We extracted summary estimates from eligible RCTs. Data were extracted and appraised according to a prespecified protocol, with effect sizes converted to odds ratios. We used a standardised form to extract the effects of interventions on recidivism and estimated risk of bias for each RCT. Planned sensitivity analyses were done by removing studies with fewer than 50 participants. Our primary outcome was recidivism. Data from individual RCTs were combined in a random-effects meta-analysis as pooled odds ratios (ORs) and we explored sources of heterogeneity by comparing effect sizes by study size, control group, and intervention type. The protocol was pre-registered with PROSPERO, CRD42020167228.

FINDINGS

Of 6345 articles retrieved, 29 RCTs (9443 participants, 1104 [11·7%] females, 8111 [85·9%] males, and 228 [2·4%] unknown) met the inclusion criteria for the primary outcome. Mean ages were 31·4 years (SD 4·9, range 24·5-41·5) for adult participants and 17·5 years (SD 1·9; range 14·6-20·2) for adolescent participants. Race or ethnicity data were not sufficiently reported to be aggregated. If including all 29 RCTs, psychological interventions were associated with reduced reoffending outcomes (OR 0·72, 95% CI 0·56-0·92). However, after excluding smaller studies (<50 participants in the intervention group), there was no significant reduction in recidivism (OR 0.87, 95% CI 0·68-1·11). Based on two studies, therapeutic communities were associated with decreased rates of recidivism (OR 0·64, 95% CI 0·46-0·91). These risk estimates did not significantly differ by type of control group and other study characteristics.

INTERPRETATION

Widely implemented psychological interventions for people in prison to reduce offending after release need improvement. Publication bias and small-study effects appear to have overestimated the reported modest effects of such interventions, which were no longer present when only larger studies were included in analyses. Findings suggest that therapeutic communities and interventions that ensure continuity of care in community settings should be prioritised for future research. Developing new treatments should focus on addressing modifiable risk factors for reoffending.

FUNDING

Wellcome Trust, Fonds de recherche du Québec - Santé.

Recent release from prison - A novel risk factor for intimate partner homicide

BACKGROUND

The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims.

METHODS

A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson χ2 and Wilcoxon rank sum tests were used for comparison.

RESULTS

There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006).

CONCLUSION

Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system.

Community Mental Health Practice in the United States: Past, Present and Future

Similar to trends in Europe, approaches to mental illness in colonial America and recorded in early United States history were commonly characterized by incarceration and the removal of individuals from communities. In the mid-20th century, a major shift began in which treatment was offered in the community with the aim of encouraging individuals to rejoin their communities. In this paper, we will provide a brief history of community mental health services in the United States, and the forces which have influenced its development. We will explore the early antecedents of community-based approaches to care, and then detail certain factors that led to legislative, peer and clinical efforts to create Community Mental Health Centers. We will then provide an overview of current community mental health practices and evolving challenges through to the present day, including the development of services which remain focused on recovery as the ultimate goal.

Arrest and emergency medical services events among participants from one of the first mental health courts

OBJECTIVE

This study looked at, in addition to subsequent arrest, emergency medical services (EMS) events as an outcome of participation in mental health court (MHC).

METHODS

We linked information from participants of a MHC in Marion County, Indiana with jail booking and EMS services data. To understand programmatic impact, we looked at differences in jail bookings and EMS events within one year prior to and one year after MHC participation. We ran paired t-tests to understand whether correlations were significant. We also considered differences in outcomes between those who successfully completed MHC versus those who did not.

RESULTS

MHC participation was significantly associated with a reduction in jail bookings and EMS events in the 12 months after program participation compared to the 12 months before. When comparing MHC participant groups, a significant reduction in jail bookings is found consistently whereas a significant reduction in EMS events was found in only some participant groups: the entire MHC group and the misdemeanor-level court (PAIR) participants when they successfully completed the program.

CONCLUSIONS

EMS utilization should be an outcome of consideration in evaluating the success and cost savings of MHCs. Where MHCs do not result in significantly reduced EMS events, communities should consider what individual-level and community-level factors contribute to this and adjust accordingly.

Polysubstance use among frequent marijuana users: an examination of John Henryism Active Coping, psychiatric symptoms, and family social support among African American incarcerated men

Incarcerated African American men who use marijuana are vulnerable to polysubstance use, which is associated with greater risk for negative health and psychosocial outcomes than marijuana use alone. It is imperative to understand risk and protective factors for polysubstance use among this vulnerable population to inform the development of culturally tailored substance use interventions. The current study examined the association between John Henryism Active Coping (JHAC), family social support, psychiatric symptoms, and polysubstance use among African American incarcerated men who frequently use marijuana. Results indicated that higher John Henryism Active Coping (JHAC) is associated with decreased likelihood of engaging in polysubstance use, while psychiatric symptoms are associated with increased likelihood of polysubstance use. Incorporating elements of JHAC into concurrent mental health and substance use treatment may reduce risk for overdose and reincarceration among African American incarcerated men upon release into the community.

Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States

This article investigates the gap in access to and quality of mental health care in the United States. This work first discusses how minority populations are most affected by the treatment gap. It summarizes recent literature on the topic for better understanding the needs of psychiatrically underserved and disenfranchised populations and the causes of mental health disparities. It reviews some of the barriers to behavioral health care, including lack of insurance coverage, lack of community-based interventions, unequal access to evidence-based practices, stigma, mental health workforce shortages, and geographical maldistribution of providers. Second, it reviews opportunities to address these disparities. The article provides examples of effective interventions that researchers worldwide have already implemented to address the gap of mental health services within the collaborative care model and global mental health initiatives. Telepsychiatry and improvements in training of the mental health workforce are also listed as useful implementations to overcome the treatment gap for patients seeking mental health care.

Interactions between Police and Persons Who Experience Homelessness and Mental Illness in Toronto, Canada: Findings from a Prospective Study

OBJECTIVE

We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions.

METHOD

We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status.

RESULTS

This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73).

CONCLUSIONS

For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

Peer support on the “inside and outside”: building lives and reducing recidivism for people with mental illness returning from jail

Purpose

The purpose of this paper is to gain understanding about the effectiveness of a forensic peer support program’s impact on reducing criminal recidivism. People with histories of mental illness returning to the community following incarceration face tremendous challenges in jails and prisons and in successful reentry to community. Transitioning from jails and prisons is fraught with additional challenges such as reconnecting or connecting with mental health and substance abuse treatment, finding adequate housing, finding employment, reuniting with family and friends, etc. Unfortunately, recidivism remains high, principally because of these challenges. Many state and local authorities have supported the development of the forensic peer specialist.

Design/methodology/approach

Kaplan–Meier survival analyses were conducted to examine time to re-incarceration.

Findings

The population served was determined to be a particularly high risk of re-incarceration population, when released from prison. All had a mental illness diagnosis, with 80 percent diagnosed with at least one serious mental illness, and more than 50 percent had three or more anterior incarcerations. Utilizing Kaplan–Meyer survival analysis, the chance of re-incarceration for participants after one year was of 21.7 percent. Surprisingly, in the first year after release from prison, participants did much better than those in the general US prison population when in terms of re-incarceration rates (21.7 percent vs 43.4 percent).

Originality/value

While preliminary findings of this approach, this study reaffirms the idea that forensic peer support programs are beneficial in reducing recidivism rates for people diagnosed with a mental illness coming out of prison, offering individuals supports to maintain their lives in the community.

History of Incarceration Among Women with HIV: Impact on Prognosis and Mortality

Objectives: To identify factors associated with incarceration among women and examine the relationship between incarceration and human immunodeficiency virus (HIV)-related outcomes. Materials and Methods: We analyzed longitudinal data from 3324 women (2372 with HIV and 952 uninfected) from 2007 to 2016 in the Women's Interagency HIV Study, a U.S. cohort of women with and without HIV. Lifetime history of incarceration before first study visit was used as the outcome and then as a predictor for HIV outcomes and mortality. Using multivariable models, we assessed associations between socio-demographic, behavioral, and clinical characteristics and incarceration, and between incarceration and HIV outcomes, including mortality. Results: Overall, 1256 (38%) of women reported ever being incarcerated. Women who had a history of drug use had a 44% greater prevalence of incarceration compared with those who did not use drugs. Sexual minority women and women who experienced physical and sexual abuse had a 47% and 28%, respectively, greater prevalence of incarceration than heterosexual women and those not abused. For the 862 women with HIV and a history of incarceration, having an incarceration history was independently associated with less viral suppression (adjusted prevalence ratios = 0.95; confidence intervals [CI]:0.90-1.00 p = 0.04) and higher likelihood of death (adjusted hazard ratios = 1.39; CI:1.04-1.86 p = 0.03). Conclusions: Incarceration is common in this cohort and may put women with HIV at increased odds of worse HIV outcomes and mortality than those without a history of incarceration. Addressing the intersecting epidemics of HIV, substance use, and incarceration by providing needed treatment and resources and avoiding criminalization may improve health outcomes in vulnerable women with HIV.