Patterns and Predictors of Reincarceration among Prisoners with Serious Mental Illness: A Cohort Study: Modèles et prédicteurs de réincarcération chez les prisonniers souffrant de maladie mentale grave : Une étude de cohorte

Mental Healthcare Practices from Entry to Release across Southeastern Jails

Background

Individuals with mental illnesses are disproportionately incarcerated in jails, which have become de facto mental health institutions across the US. Yet there is limited research describing mental healthcare practices from entry to release among multiple jails and states.

Methods

We conducted 34 semi-structured interviews with jail healthcare personnel across five Southeastern states.

Results

We report results on challenges and practices related to mental health staffing, screening, additional evaluations and services, and discharge planning in jails. Initial mental health screenings were often restricted to the detection of suicidality and history of treatment and medications as opposed to current mental health symptoms. Use of validated mental health screening forms was uncommon. We found delays in care between the initial health screening and being evaluated by a mental health professional. Most jails reported primary responsibilities for mental health care as preventing suicides and managing psychiatric medications. Jails reported mental health care as challenging to manage, with high volumes of individuals with mental health needs, yet limited resources, especially regarding staffing. Discharge planning was limited despite reports of poor continuity of mental healthcare.

Conclusions

Jails have a constitutional duty and opportunity to provide adequate healthcare to individuals with mental illnesses, yet practices are insufficient and resources are limited across jails. Based on our findings, we recommend 1) greater adoption and revisions of jail health standards 2) system improvement that expands identification of mental illnesses and quicker, less variable follow-up mental health evaluations, 3) improved linkages and supports for community resources that prevent incarceration of this population.

Risk of homelessness after prison release and recidivism in Denmark: a nationwide, register-based cohort study

BACKGROUND

Transitional periods between and across services have been linked to homelessness. We aimed to investigate the association of previous history of homelessness and psychiatric disorders with risk of homelessness after release from prison. Additionally, we examined the association between homelessness after release and risk of recidivism.

METHODS

We did a nationwide, register-based cohort study of people aged 15 years or older who were released from prison for the first time in Denmark between Jan 1, 2001, and Dec 31, 2021. We obtained data using the Danish Civil Registration System with data linked across other registries (the Danish Central Criminal Register, the Danish Homeless Register, the Danish National Patient Register, and the Danish Psychiatric Central Research Register) on release date, homeless shelter contacts, psychiatric disorders, and new convictions. Outcomes were homelessness after release from prison, defined as first homeless shelter contact following release from first imprisonment, and recidivism within 2 years of release, defined as the first police-recorded criminal conviction after prison release. We calculated incidence rates per 1000 person-years, incidence rate ratios (IRRs) using Poisson regression analysis, and probability of homelessness and recidivism after release. Sex, age, calendar year, country of origin, highest educational level, relationship status, and length of index imprisonment were included as confounders.

FINDINGS

The study cohort included 37 382 individuals (34 792 males [93·1%] and 2590 females [6·9%]) aged 15-41 years, who were released from prison between Jan 1, 2001, and Dec 31, 2021, contributing 202 197 person-years at risk. Mean follow-up duration was 5·4 person-years (SD 5·6). Overall, 1843 (4·9%) of 37 382 individuals became homeless. 1 year after release from prison, 788 (2·1%) of 37 382 individuals had at least one homeless shelter contact, and among 1761 individuals with previous history of homelessness before index imprisonment, 357 (20·7%) became homeless. The incidence of homelessness after release was 102·5 cases per 1000 person-years for individuals with previous history of homelessness and 6·7 cases per 1000 person-years in individuals without (IRR 16·4, 95% CI 14·8-18·2; adjusted for sex, age, and calendar year). Individuals who additionally had a mental illness had a higher risk of homelessness (IRR 22·6, 19·7-25·9) compared with those without either previous homelessness or mental illness, and a substantially higher risk was observed for those with previous homelessness and drug use disorder (25·0, 21·6-28·9) compared with those without. Within 2 years of release from prison, the probability of recidivism was 73·2% (95% CI 72·8-73·7). The risk of recidivism was higher among people experiencing homelessness after release from prison than those who did not experience homelessness after release (IRR 1·5, 95% CI 1·3-1·7), adjusted for sex, age, and calendar year.

INTERPRETATION

Criminal justice services should review approaches to reduce risk of homelessness, and consider improving liaison with mental health and substance misuse services to prevent adverse outcomes on release from prison. Clinical guidelines applied to criminal justice settings should address the health of individuals who experience homelessness.

FUNDING

Lundbeck Foundation.

Recidivism among prisoners with severe mental disorders

Introduction

Mental disorders are common among prison inmates, with a high rate of recidivism found among those with severe mental disorders. In Japan, the number of inmates with mental disorders has been increasing with the increasing rate of recidivism. Prisoners need an uninterrupted connection to post-release support to prevent them from being incarcerated again. This study identified inmates diagnosed with mental disorders whose recidivism had recently increased to investigate recidivism among inmates with severe mental disorders and the risk factors for reincarceration.

Methods

This study included 148 prisoners released from the Medical Correction Center in East Japan. Clinical diagnoses were coded using the World Health Organization's International Classification of Diseases, Tenth Revision. Risk factors focusing on the central eight items were categorized, and recidivism within 3 years of release was investigated.

Result

Overall, the recidivism rate was 29.7%, with the risk of recidivism increasing by 170% in inmates with multiple incarcerations. A diagnosis of intellectual disability increased the risk of recidivism by 176%. Patients with schizophrenia were consistently less likely to recidivate than patients with other disorders.

Conclusion

Intellectual disability was identified as a risk factor for recidivism, as was multiple incarcerations. These prisoners may not be connected to medical and social services and thus may not be receiving appropriate assistance. Patients with schizophrenia might be more likely to be connected to medical care and receive support after release. Further research should be conducted using these findings to prevent recidivism among inmates with mental disorders.

Change in Severity of Mental Disorder of Remand Prisoners: An Observational Group-Based Trajectory Study

BACKGROUND

Mental disorder is common among prisoners; however, little is known about how illness severity changes during incarceration, and especially to what extent there are different trajectories of change.

AIMS

Our aims were to investigate trajectories of illness severity among male and female inmates with serious mental disorders, and to investigate whether clinical or demographic variables are associated with different trajectories.

METHODS

We carried out a retrospective cohort study of newly remanded inmates who had three or more serial measures of illness severity as measured by psychiatrists using the Clinical Global Impression-Corrections (CGI-C), and used group-based trajectory modelling to identify trajectories. We investigated whether clinical and demographic variables were associated with different groups.

RESULTS

We found an overall reduction in the severity of illness (mean change in CGI-C score -0.74, SD 1.5), with women showing greater improvement than men. We identified three distinct trajectories among men and three among women, all showing improvement in illness severity. Approximately 15% of the entire cohort had full resolution of symptoms, whereas the remainder showed partial improvement. Women, younger inmates, and those with substance use disorders were more likely to have full resolution of symptoms.

CONCLUSIONS

Although most prisoners showed improvement, and a small proportion had full resolution of symptoms, a significant number continued to have moderately severe symptoms. There is a need for comprehensive treatment within the detention centre, but also a need for transfer to hospital for those with severe symptoms as improvement within the correctional setting tends to be modest.

Association of Mental Health Services Access and Reincarceration Among Adults Released From Prison in British Columbia, Canada

IMPORTANCE

Diagnosis of mental disorder is prevalent among people who have been incarcerated. Nevertheless, community mental health services are often limited following release from prison, and reincarceration rates are high. The prevalence of mental disorders is growing among people who are incarcerated in British Columbia (BC), Canada, increasing the urgency of timely and accessible mental health services after release.

OBJECTIVE

To examine the association of mental health services access and timeliness of services access with reincarceration risk among people released from prison.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, mental disorder diagnoses were derived from International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in administrative health records. Data on prison release and reincarceration were retrieved from corrections records. Population-based health and corrections data were retrieved from the BC Provincial Overdose Cohort, which contains a 20% general population random sample of 1 089 677 BC residents. This study examined releases from provincial prisons between January 1, 2015, and December 31, 2018, among people in the 20% random sample who had a mental disorder diagnosis in the year before their release. Analyses were performed from January to June 2022.

EXPOSURES

Mental health services access (primary care, emergency department visits, or hospitalization) and sociodemographic, health, and incarceration characteristics.

MAIN OUTCOMES AND MEASURES

A multistate modeling approach was taken. Cox proportional hazards models were stratified by transition, from release to reincarceration, with and without mental health services access. A state arrival extended model examined the influence of timeliness of mental health services access on subsequent hazard of reincarceration.

RESULTS

A total of 4171 releases among 1664 people (3565 releases among male individuals [84.6%]; 2948 releases [70.7%] among people <40 years old; 2939 releases [70.5%] among people with concurrent substance use disorder diagnosis) were identified. The total study follow-up time was 2834.53 person-years, with a mean (SD) of 0.68 (0.93) years and median (IQR) of 0.25 (0.07-0.84) years per release. Mental health services access was associated with a reduction in the hazard of reincarceration (hazard ratio, 0.61; 95% CI, 0.39-0.94). For each additional month between release and mental health services access, the hazard of reincarceration was increased by 4% (hazard ratio, 1.04; 95% CI, 1.01-1.07).

CONCLUSIONS AND RELEVANCE

In this cohort study of people with mental disorder diagnoses released from prison in BC, mental health services access was associated with reduced reincarceration risk. These findings suggest that these services may have the greatest impact on reducing reincarceration risk when they are available in a timely manner in the days and weeks immediately following release.

"People say you're going home, but I don't have a home": Housing After Prison

Recidivism in Australia is high, especially in the Australian Capital Territory (ACT). While high-quality stable housing has been shown to reduce recidivism, people released from prison face many barriers in obtaining housing. This paper reports on a qualitative study exploring the housing experiences of 11 people released from prison in the ACT. Participants felt the importance of housing for reintegration and avoiding recidivism, but reported many challenges, including issues relating to lack of pre-release planning, income and employment, drug use, difficulties and delays with accessing social housing, and complying with parole or bail conditions. We recommend increased investment in services to assist people in prison with organizing housing before release. Furthermore, as housing is a foundational need for reintegration and drug use is high among the prison population in the ACT, Housing First initiatives may be the most appropriate model for providing accommodation and reducing recidivism.

A comparison of men and women referred to provincial correctional mental health services in Ontario, Canada

BACKGROUND

Women comprise around 15% of admissions to provincial correctional institutions in Canada. Women in custody are known to have a high prevalence of mental health concerns, but little is known about how those referred to mental health services compare with referred men at a similar stage of imprisonment.

AIMS

Our aim was to describe and compare clinical, social and demographic characteristics of a complete cohort of custodially remanded men and women who were referred to mental health services while under custodial remand in two correctional institutions.

METHODS

We carried out retrospective analysis of data obtained from 4040 men and 1734 provincially detained women referred to mental health services in two correctional centres holding mainly pre-trial prisoners and serving a large mixed urban-rural catchment area in Toronto, Canada over a nearly five-year period. Men and women were first screened using the Brief Jail Mental Health Screen. Those who screened positive were assessed using the Jail Screening Assessment Tool the Brief Psychopathology Rating Scale-Expanded (BPRS-E) and the Clinical Global Impression-Corrections (CGI-C).

RESULTS

There were many similarities between men and women, but also some important differences. Women were more socioeconomically disadvantaged than men. More women than men reported having children, yet fewer reported having any form of employment or social supports, although men were more likely to report unstable housing. In addition, women were significantly more likely to have mood and anxiety problems and to be self-harming, but did not differ from men in current psychotic symptoms. We also found differences in patterns of substance use, with a higher proportion of women using heroin and methamphetamines but fewer women having accessed addiction services.

CONCLUSIONS

Our findings have implications for clinicians and service planners. They underscore the value of systematic screening for identifying need. More specifically, they suggest need for increased availability of addiction services for women as well as ensuring support for those women who have dependent-age children. Improvement in supports for entry into employment is particularly needed for women, while men are particularly likely to need access to stable housing.

Health Care Costs of Individuals With Chronic Psychotic Disorders Who Experience Incarceration in Ontario

OBJECTIVE

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.

METHODS

The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.

RESULTS

Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p<0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p<0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).

CONCLUSIONS

Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

Continuity of mental health care during the transition from prison to the community following brief periods of imprisonment

PURPOSE

The prison-to-community transition period is one of high risk and need, particularly for those with mental illness. Some individuals cycle in and out of prison for short periods with little opportunity for mental health stabilization or service planning either in prison or the community. This study describes the socio-demographic, clinical and criminal justice characteristics of individuals with mental illness and frequent, brief periods of imprisonment, examines continuity of mental health care between prison and the community for this group, and reports on their post-release mental health and criminal justice outcomes.

DESIGN/METHODOLOGY/APPROACH

This study examined a sample of 275 men who had recently entered prison in New South Wales (NSW), Australia, who had been charged with relatively minor offenses and had been identified on reception screening as having significant mental health needs. Baseline demographic and mental health information was collected via interview and file review and contacts with the prison mental health service were recorded for the period of incarceration. Follow-up interviews were conducted 3 months post-release to determine level of health service contact and mental health symptoms. Information on criminal justice contact during the 3 month period was also collected.

FINDINGS

The majority (85.5%) of the sample had contact with a mental health professional during their period of incarceration. Mental health discharge planning was, however, lacking, with only one in 20 receiving a referral to a community mental health team (CMHT) and one in eight being referred for any kind of mental health follow-up on release. Of those followed up 3 months post-release (n = 113), 14.2% had had contact with a CMHT. Of those released for at least 3 months (n = 255), one in three had received new charges in this period and one in five had been reincarcerated.

CONCLUSION

Continuity of mental health care for those exiting prison is poor, particularly for those with mental health needs experiencing brief periods of imprisonment, and rates of CMHT contact are low in the immediate post-release period. These findings suggest a need for early identification of individuals in this group for timely commencement of intervention and release planning, and opportunities for diversion from prison should be utilized where possible.

Nutritional supplementation in the treatment of violent and aggressive behavior: A systematic review

Aggression in correctional and psychiatric settings is relatively common and has a negative effect on physical and mental health both among inmates/clients and staff, as well as organizational-level functioning. The aim of the present study was to critically review the evidence on the effectiveness of nutritional supplements in reducing aggression and violence to contribute to a better understanding of options available for managing aggressive behaviors in adults. The EMBASE, MEDLINE, PsycINFO, Cochrane Library, and PubMed databases were searched for effectiveness studies published in English anytime up until March 2020. Study quality was assessed using the Mixed Methods Appraisal Tool. Altogether, 14 studies met inclusion criteria; 2 investigated micronutrients, 10 examined macronutrients, while further 2 examined a combination of micro and macronutrients. Out of the 14 studies, 5 reported a beneficial effect of nutritional supplementation (omega-3 fatty acids, vitamins/minerals, S-adenosyl-l-methionine, or tryptophan). Five studies did not report a significant beneficial effect of nutritional supplementation (omega-3 fatty acids, folic acid, tryptophan, broad range supplement containing vitamins and fatty acids, and fatty acids in augmentation with valproic acid), while four studies reported mixed effects (on l-tryptophan, broad-range micronutrient formula, folic acid, and omega-3 fatty acids). The results overall indicated that research in this area is in its infancy: very few studies examined the same composition of nutritional supplementation and when they did so the results were contradictory. The methodological shortcoming of existing studies and directions for future research are discussed to facilitate high-quality research in this evolving area of nutritional psychiatry.

A Systematic Review of Reviews of Correctional Mental Health Services Using the STAIR Framework

BACKGROUND

Rising demand for correctional mental health services (CMHS) in recent decades has been a global phenomenon. Despite increasing research, there are major gaps in understanding the best models for CMHS and how to measure their effectiveness, particularly studies that consider the overall care pathways and effectiveness of service responses. The STAIR (Screening, Triage, Assessment, Intervention, and Re-integration) model is an evidence-based framework that defines and measures CMHS as a clinical pathway with a series of measurable, and linked functions.

METHOD

We conducted a systematic review of the reviews of CMHS elements employing PRISMA guidelines, organized according to STAIR pillars. We assessed the quality of included studies using the AMSTAR-2 criteria. Narrative reviews were read and results synthesized.

RESULTS

We included 26 review articles of which 12 were systematic, metaanalyses, and 14 narrative reviews. Two systematic reviews and seven narrative reviews addressed screening and triage with strong evidence to support specific screening and triage systems. There was no evidence for standardised assessment approaches. Eight systematic reviews and seven narrative reviews addressed interventions providing some evidence to support specific psychosocial interventions. Three systematic reviews and six narrative reviews addressed reintegration themes finding relatively weak evidence to support reintegration methods, with interventions often being jurisdictionally specific and lacking generalizability.

CONCLUSIONS

The STAIR framework is a useful way to organize the extant literature. More research is needed on interventions, assessment systems, care pathway evaluations, and reintegration models.