Mental Health Policy - Mental Illness and the Criminal Justice System

Mental Health Policy II
The Criminal Justice System
10/28/2015
Jane Addams College of Social Work
1

“On any given day, at least 284,000 schizophrenic and manic
depressive individuals are incarcerated, and 547,800 are on probation.
We have unfortunately come to accept incarceration and homelessness
as part of life for the most vulnerable population among us.”
“We are literally drowning in patients, running around trying to put our
fingers in the bursting dikes, while hundreds of men continue to
deteriorate psychiatrically before our eyes into serious psychoses…”
“The emergence of prisons and jails as the largest institutions in the
United States housing the mentally ill reflects the de facto
criminalization of mental illness.”
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The Criminal Justice Process
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Overview: Key Issues/Questions
• Why are so many people with a mental illness incarcerated or under
criminal justice supervision (e.g., probation or parole)?
• What is the adequacy of health care (including mental health and
substance abuse treatment) within jails and prisons?
• Does incarceration worsen mental illness?
• How is release into the community handled and what problems are
associated with release post-incarceration?
• Has the ACA improved access to care for CJS (criminal justice
system populations)?
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Overview: Key Legislation/Policies/Events
• Nixon’s War on Drugs (1970) – Carried out Nixon’s promise of
being tough on crime but disproportionately focused on and harmed
racial minorities (arguably also part of the “southern” political
strategy).
• Estelle v. Gamble (1976) – Established that under the eighth
amendment, failure to provide adequate health care to prisoners
violates the amendments prohibition against “cruel and unusual
punishment.” Requires jails and prisons to provide adequate health
care.
• Sentencing Reform Act (1984) and the Anti-Drug Abuse Acts
(1986, 1988) - established two tiers of mandatory prison terms for
first-time drug traffickers: a five-year and a ten-year minimum
sentence. Under the statute, these prison terms are triggered
exclusively by the quantity and type of drug involved in the offense
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• Mentally Ill Offender Treatment and Crime Reduction Act (2004)
– authorized the Justice and Mental Health Collaboration Program
to help states and local governments improve responses to people
with mental disorders. Funding reauthorized in 2008 through 2013.
Funding (~ 50 mill for JMHCP) provides for:
• Specialized law enforcement-based programs and training for law
enforcement officials on safely resolving encounters with people experiencing
a mental health crisis
• Mental health courts
• Mental health and substance use treatment for incarcerated individuals
• Community reentry services
• Cross-training of criminal justice and mental health personnel
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• Justice and Mental Health Collaboration Act (2015) – Would
reauthorize and improve on MIOTCRA:
• Continues support for mental health courts and crisis intervention teams
• Emphasizes evidence based practices that have been proven effective
through empirical evidence;
• Authorizes investments in veterans treatment courts, which serve arrested
veterans who suffer from PTSD, substance addiction, and other mental health
conditions;
• Supports the development of curricula for police academies and orientations;
• Increases focus on corrections-based programs, like transitional services that
reduce recidivism rates and screening practices that identify inmate with
mental health conditions.
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The “Experiment in Mass Incarceration”
At year end 2011, about
1 in every 34 adult
residents in the U.S.
was under some form of
correctional supervision,
down from 1 in 31 in
2007.
10/28/2015 Jane Addams College of Social Work Mental Health Policy II 8

At yearend 2013,
Illinois had a total
of 48,653 adults in
prison (45,000
men and 3,000
women).
These figures are
slightly down
from 2012.
About 31,000 are
released each year.

As the demographic figures suggest, there is “disproportionality”,
“disparity” in who is supervised and who is not.

Incarceration in prisons
is only one part of the
criminal justice system
that accounts for the
large number of
Americans under
supervision of one type
or another.

The Mentally Ill in the CJS
• Prisons and jails can have many adverse consequences on
inmates and especially those with a serious mental illness
• There is risk for infectious diseases such as HIV and tuberculosis
though the HIV infection rate in incarcerate settings is lower than in
the gp (see Dora et al.)
• Isolation and the generally punitive environment can lead to
deterioration and exacerbate mental illness symptoms
• Homelessness on release and sudden access to drugs (among
other factors) can lead to high mortality rates in the 2 weeks post-
release into the community

• The growing (?) number of mentally ill persons who are
incarcerated in the United States is an unintended consequence of
two distinct public policies adopted over the last thirty years:
• First, elected officials failed to provide adequate funding,
support, and direction for the community mental health systems
that were supposed to replace the mental health hospitals shut
down as part of the “deinstitutionalization” effort that began in
the 1960s.
• Second, elected officials embraced a punitive anti-crime effort,
including a national “war on drugs” that dramatically expanded
the number of persons brought into the criminal justice system,
the number of prison sentences given even for nonviolent
crimes (particularly drug and property offenses), and the length
of those sentences.

• There are no good national estimates of the prevalence/rates of
SMI among criminal justice populations in the United States. The
BJS published a study saying that the rate was 16% based on 2
questions:
• Do you have a psychiatric problem?
• Were you hospitalized in the past-year for psychiatric
treatment?
• More recently, they used an even more liberal criterion and
concluded that the rate of MI was over 50% among jail and prison
inmates:
Source: Bureau of Justice Statistics [BJS]. (2006). Mental health problems of jail and
prison inmates (U.S. DOJ Publication No. NCJ 213600). Washington, DC: U.S.
Government Printing Office.

• At midyear 2005 more than half of all prison and jail inmates had a
mental health problem, including 705,600 inmates in State prisons,
70,200 in Federal prisons, and 479,900 in local jails. These
estimates represented 56% of State prisoners, 45% of Federal
prisoners, and 64% of jail inmates. The findings in this report were
based on data from personal interviews with State and Federal
prisoners in 2004 and local jail inmates in 2002.
• Mental health problems were defined by two measures: a recent
history or symptoms of a mental health problem. They must have
occurred in the 12 months prior to the interview. A recent history of
mental health problems included a clinical diagnosis or treatment
by a mental health professional. Symptoms of a mental disorder
were based on criteria specified in the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV).

Source: BJS, September 200610/28/2015 Jane Addams College of Social Work Mental Health Policy II 16

These estimates are almost certainly too high. There are some
smaller-scale studies to provide guidance. It turns out that the 16%
number is probably closer to the mark.
If we restrict the definition of mental illness to serious mental illnesses
(schizophrenia, bipolar disorder, major depression) and moderate to
severe functional impairment (GAF > 50), then studies have
consistently found a past-year prevalence rate of 15% to 20% among
different criminal justice populations (arrestees, probationers,
detainees, prisoners).
This comports with estimates based on our own studies….

General Population Samples Criminal Justice – Matched Samples
Note. Data obtained from the 2002 National Survey on Drug Use and Health (NSDUH), the 2001 National Health
Interview Survey (NHIS), and Arrestee Drug Abuse Monitoring (ADAM) data collected in Chicago in 2003. The
NSDUH general population sample was comprised of all adult participants who did not report an arrest in the
past year (N = 34,271) while the NHIS general population sample was comprised of all adult participants (N =
33,326). The NSDUH criminal justice sample was comprised of all participants reporting a past-year arrest (N =
1, 684) while the NHIS “’criminal justice” sample (N = 277) was comprised solely of male respondents
demographically matched to the ADAM sample (N = 263), which was also comprised solely of adult male
arrestees.

• Transinstitutionalization (criminalization) is attributable to
4 factors:
• Deinstitutionalization
• Tougher (harder to commit) civil commitment laws
• Lack of community support services
• Role of the police
• To these add another three factors:
• Rise in drug use among all segments of society (1970s)
• War on drugs as a punitive policy combined with…
• High rates of drug use among those with psychiatric disorders
Contributing Factors - Transinstitutionalization

• Transinstitutionalization first attributable to Penrose
(1939)
• A relatively stable number of individuals are confined in any
industrial society (hospitals, prisons, jails)
• Inverse relationship between size of the population in mental
hospital settings and penal institutions in 18 European countries
• But wait a minute…
• Consider the rates of prison growth in the US compared with the
rate of decline in the mental hospital population
• Mental hospitals – declined from 559,000 in 1955 to 55,000 in 2000
with much of the decline in the 1960s and 1970s
• Over that same time, relatively constant prison population
• Prison and jail populations exploded 1970 – 2000 and continue to
increase

• Between 1974 and 2001 the number of current or former inmates
increased by 3.8 million men and women.
• This included an additional 1.1 million adults in prison (up from
216,000 inmates in 1974) and almost 2.7 million more former
inmates (up from 1,603,000 former prisoners in 1974).
• Almost two-thirds of the increase in the number of those who had
ever been incarcerated resulted from an increase in first
incarceration rates. One-third of the increase was attributed to
growth in the U.S. resident population and increases in life
expectancy.

Contributing Factors
• So some other factors besides deinstitutionalization have to be at
work?
• The institutional population in the United States has NOT been
stable and the proportion of the population in prisons and jails has
grown dramatically over the past 30 years while the decline in
mental hospital beds has slowed….
• This means that the decline in state hospital admissions can not
account for the increase in the prison and jail populations even
allowing for an increase in the general population between the
1950s and 2000s.

Contributing Factors – Community Health Care
• Lack of Access to Community Care
• Underfunded CMHC resulted in lack of access to services,
especially for those with serious and persistent mental illnesses
No place else to go! Streets or jails and prisons….

Contributing Factors – Community Health Care
• There appears to be little in the way of a ‘‘dose response’’
relationship between a locale’s level of mental health services and
the criminal justice involvement of its mental health system’s
clientele.
• Nor do any of these data directly support the notion that the
deinstitutionalization process has led to increased involvement of
person with mental illness in the criminal justice system. To make
such a case, one would have to show that the prevalence of mental
illness in the correctional system is significantly higher today than in
1970.

• The police, who
• Lack training in recognizing mental illness and distinguishing it
from criminal conduct and belligerence.
• Charged with protecting community safety.
• Parens patriae authority which dictates protection for citizens
with disabilities who cannot care for themselves, such as those
with mental illnesses. The state as a “parent”…
Contributing Factors – Police

But!
• Studies of policing lend no support to the premise that officers
systematically use arrest as a means of managing the behavior of
persons with mental illness. For example, Engel and Silver (2001),
analyzing data from two large scale, multi-site studies of police
behavior, found that police were in fact not more likely to arrest
mentally disordered suspects.
• Several studies conducted at both the system and person levels
have failed to detect significant crossovers between the mental
health and criminal justice systems that could be attributed either
to changes in mental health law or to the general reduction in state
hospital census.

• The data (I have seen) also do not support the contention that people
with SMI are arrested and brought to jail for “nuisance crimes” (e.g.,
disturbing the peace)…
• Consider these arrest history data we collected from detainees at the
Cook County Jail in psychiatric treatment in 2004…

Male (N = 15) Female (N = 15)
Illegal Drug Use 54% 39%
Drug Sales 15% 8%
Forgery/Fraud 15% 17%
Prostitution 15% 31%
Burglary/ Auto Theft 46% 23%
Theft 58% 39%
Robbery 15% 8%
Violent Offense
(assault/battery/homicide) 44% 69%
Mean # Prior Arrests (SD) 20.5 (21.1) 8.9 (13.9)
Note. Figures indicate at least one self-reported arrest in the charge category.10/28/2015 Jane Addams College of Social Work Mental Health Policy II 28

Contributing Factors – Homelessness
Homelessness
• One quarter of the homeless living on the streets have an
SMI and have no or inadequate access to appropriate
housing
• Within mental health, adequate housing has not been
considered a part of treatment
• Federal government support for affordable housing has
decreased over past two decades…

The role of drugs:
• Since the 1970s, increase in drug use beginning with heroin
epidemic and then followed by cocaine and crack-cocaine eras
in the 1980s through 1990s
• Country adopted punitive policies in the 1980s (Bill Bennett as
drug czar) – determinate and longer sentencing for drug
violations – “War on Drugs”
• Self-medication and vulnerability to drug use among the SPMI
and high rates of drug use
Contributing Factors – War on Drugs

The role of drugs:
• Drug use brings SPMI into contact with police because they are:
• Using illegal drugs
• Committing crimes to get money for drugs
• Destabilized by drug use (exacerbated symptoms,
increased propensity towards violence)
• Inept criminals (impulsive, poor, obvious)
• Recent study by S&L found that drug use explained all or most
of the increased risk for arrest for property and drug offenses
and a good proportion of the increased risk of arrest for violent
offenses
• Similar findings in other countries (Australia, Finland)

Note. The unweighted N for all models = 35,955 and excludes 415 cases with missing data for past-year arrest. All
standard errors are based on data weighted for sampling probabilities and controlling for design effects due to
stratification and clustering. All models include the following covariates: gender, age group, race/ethnicity, marital
status, education level, employment status, and population density. The additional drug use covariates include:
alcohol use/dependence, marijuana use/dependence, and use/dependence on other illegal drugs.

Does Mental Illness Cause Crime Per se?
• Increased mental health services often do not translate into reduced
recidivism, even for “state of the art” services.
Caslyn et al., 2005; Clark, Ricketts, & McHugo, 1999; Skeem & Eno Louden, 2006; Steadman &
Naples, 2005
• Untreated mental illness is a criminogenic need for only a small proportion
offenders with serious mental illness. Junginger et al. (2006), Peterson et al. (2009)
• Strongest criminogenic needs are shared by those with- and without-
mental illness. Bonta et al., (1998); Skeem et al. (2009)

• Some people with serious mental illness may “engage in
offending and other forms of deviant behavior not because
they have a mental disorder, but because they are poor. Their
poverty situates them socially and geographically, and places
them at risk of engaging in many of the same behaviors
displayed by persons without mental illness who are similarly
situated”
• Fisher et al. (2006), p. 553

Contributing Factors (Fisher & Wolf)
Offenders with mental illness have significantly
more “central 8” risk factors for crime
….and these predict recidivism more strongly than risk factors unique to
mental illness (e.g., diagnosis, symptoms, treatment compliance)

“Central eight” for criminal behavior
(Andrews, 2006)
Risk Factor Need
History of criminal behavior Build alternative behaviors
Antisocial personality pattern*** Problem solving skills, anger
management
Antisocial cognition* Develop less risky thinking
Antisocial peers Reduce association with
criminal others
Family and/or marital discord** Reduce conflict, build positive
relationships
Poor school and/or work performance* Enhance performance, rewards
Few leisure or recreation activities Enhance outside involvement
Substance abuse Reduce use

Direct Relationship
(One-Dimensional Model)
(Untreated)
Mental Illness
Criminal Behavior
Fully Mediated Relationship
(Criminological & Social Psychological Models)
Mental
Illness
Third
Variable

General
Risk
Factors
Criminal
Behavior
Moderated Mediation Effect of Mental Illness on Criminal Behavior
Moderator
(age of onset for criminal behavior?)
Evidence-
based
corrections
Evidence-based
psychiatric
services
(late?) (early?)

Evidence-based Corrections Targets Recidivism
40
• Focus resources on high RISK cases
• Target criminogenic NEEDS like anger, substance abuse, antisocial
attitudes, and criminogenic peers (Andrews et al., 1990)
• RESPONSIVITY - use cognitive behavioral techniques like relapse
prevention (Pearson, Lipton, Cleland, & Yee, 2002)
• Consider packaged programs like “Reasoning and Rehabilitation”
(Young and Ross, 2007)
• Ensure implementation (Gendreau, Goggin, & Smith, 2001)

Treatment Options – What Works?

Treatment Options – What Works?
• http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/to
olkits/about.asp
• Integrated dual diagnosis treatment (IDDT)
• Supported employment
• http://consensusproject.org/updates/features/GAINS-EBP-
factsheets
• Supported housing
• Trauma interventions

Combining Clinical and Risk Assessment
• Identify offenders with mental
illnesses, using a validated tool like
the K-6 or BJMHS
• http://www.hcp.med.harvard.edu/nc
s/k6_scales.php
• http://gainscenter.samhsa.gov/HTML
/resources/MHscreen.asp
• Or MAYSI, for youth
http://www.maysiware.com/MAYSI2
Research.htm
• Assess risk of recidivism, using a
validated tool like the LS/CMI
(includes youth version)
Example:
Good
supervision +
ACT
Example:
RNR
supervision +
ACT
Good
supervision +
good
treatment
Example:
RNR
supervision +
good
treatment
Screen and assess
Target criminogenic risk & clinical
needs with EBPs

The Risks-Needs-Responsivity Model
• First proposed in 1990 by Andrews, Bonta, and Hoge, the risk-need-
responsivity model has become one of the most influential models
guiding treatment interventions in corrections (Ogloff & Davis, 2004).
• Although the number of principles have greatly increased since the
1990 paper (presently numbering 15 principles; Andrews & Bonta,
2010a, Andrews & Bonta, 2010b), the three core principles that were
initially outlined continue to dominate. These three principles can be
summarized as follows:

The Risks-Needs-Responsivity Model
Risk principle: Match the level of services to the risk level of the offender.
Provide intensive services to higher risk clients and minimal services to lower
risk clients.
Need principle: In treatment, set criminogenic needs as the target of
intervention. Criminogenic needs are the dynamic risk factors associated
with criminal behaviour (e.g., procriminal attitudes, substance abuse,
criminal associates). Non-criminogenic needs (e.g., vague complaints of
emotional distress, self-esteem without consideration of procriminal
attitudes) are relevant only in that they may act as obstacles to changes in
criminogenic needs.
Responsivity principle: Match the style and mode of intervention to the
ability and learning style of the offender. Social learning and cognitive-
behavioral styles of influence (e.g., role playing, prosocial modeling, cognitive
restructuring) generally work best with offenders.

Mandated Treatment and the Courts – Drug Courts
• Opened in 1989 in Dade County, Florida
• Majority are pre-sentence (called diversion), with charges
dropped if all conditions are met/treatment completed.
• Can be post-sentence also but less common.
• Characterized by:
• Integration of treatment with supervision/case processing
• Access to a continuum of treatment services
• Abstinence monitored through frequent testing
• Graduated sanctions
• Close supervision by judge (therapeutic jurisprudence)
Civil Commitment Laws and other forms of leverage

As of June 2014, the estimated number of drug courts operating in the U.S. is over 3400. More than
half target adults, including DWI (driving while intoxicated) offenders and a growing number of
Veterans; others address juvenile, child welfare, and different case types

In the state of Illinois, there are (at least) 39 adult and juvenile drug courts in
operation including the following:
* Champaign County Adult * Coles County Adult
* Cook County Adult (4 programs) *Dekalb County Adult
* Cook County Juvenile
* Dewitt County Adult * DuPage County Adult
* Effingham County Adult * Grundy County Adult
* Jersey County Adult * Kane County Adult
* Kankakee County Adult * Macon County Adult
* Madison County Assessment and Treatment Alternative Court
* Peoria County Adult * Peoria County Juvenile
* Pike County Adult * Rock Island County Adult
* Saline County * Will County Adult
* Will County Juvenile * Winnebago County Adult

The Illinois statutes that encourage the formation of drug courts (730 ILCS 166
and 705 ILCS 410) incorporate “ten key components” of drug courts developed by
the Drug Court Standards Committee of the National Association of Drug Court
Professionals. These ten key components are as follows:
1. Drug courts integrate drug treatment services with justice system case
processing.
2. Use a non-adversarial approach, prosecution and defense counsel promote
public safety while protecting participants’ due process rights.
3. Eligible participants are identified early and promptly placed in the drug court
program.
4. Drug courts provide access to a continuum of drug treatment and
rehabilitation services.

5. Abstinence is monitored by frequent drug testing.
6. A coordinated strategy governs drug court responses to participants’
compliance.
7. Ongoing judicial interaction with each drug court participant is essential.
8. Monitoring and evaluation measure the achievement of program goals and
gauge effectiveness.
9. Continuing interdisciplinary education promotes effective drug court planning,
implementation, and operations.
10. Forging partnerships among drug courts, public agencies, and community-
based organizations generates local support and enhances drug court
effectiveness.

Mandated Treatment and the Courts – Mental Health Courts
• First mental health court opened in 1997 in Broward County,
Florida modeled after drug courts and involve close monitoring
by judge. (There were earlier courts established in Indiana in
the 1980s and early 1990s but these did not survive).
• Came about as a result of the popularity of drug courts.
• There are an estimated 414 mental health courts in operation
nationally.

Mandated Treatment and the Courts – Mental Health Courts
 MHCs have 4 defining characteristics (but no established set of
guidelines as with drug courts):
 Court docket for people with mental illness
 Team of criminal justice and mental health specialists to
recommend treatment and supervision
 Assurance treatment is available
 Court monitoring with possible sanctions for noncompliance,
such as reinstituting charges and sentences (incarceration).

Illinois Mental Health Court Treatment Act
Purpose of the Act
Create specialized mental health courts with the
necessary flexibility to meet the problems of criminal
defendants with mental illnesses and co‐occurring
mental illness and substance abuse problems
Effective June 1, 2008

Conclusions of the General Assembly
• Large percentage of criminal defendants have diagnosable mental
illness
• Mental illness has a dramatic effect on criminal justice system
• Mental illness and substance abuse co‐occur in substantial
percentage of criminal defendants
• Need a program that will reduce recidivism among this population
• Provide appropriate treatment for this population
• Reduce the incidence of crimes committed as a result of mental
illness or co‐occurring

Statistics
• In 2004, Winnebago County determined that 16% of inmates had a
severe mental illness.
• Commonly cited figures about jail detainees with mental illness are
in the range of 10 to 15% with some estimates much higher.
• In 2009, the Council of State Governments released a study of
more than 20,000 adults entering 5 local jails and found serious
mental illnesses in 14.5 % of men and 31% of women, or 16.9%.
These rates are 3 to 6 times those found in the general population.

Currently 21 Mental Health Courts in Illinois. By county:
• Champaign
• Cook (7)
• Dupage
• Kane
• Lake
• Lee
• Macon
• Madison
• McHenry
• McLean
• Peoria
• Rock Island
• St. Claire
• Will
• Winnebago

Eligibility under Mental Health Court Treatment Act:
Admitted with the agreement of the prosecutor and defendant and
with approval of the court
Exclusions:
• Crime is a crime of violence
• Defendant does not demonstrate a willingness to participate in a
treatment program
• Defendant has been convicted of a crime of violence in the past 10
years excluding incarceration
• Defendant previously completed or has been discharged from a
mental health court with in the last 3 years

Exclusionary Crimes of Violence Include:
• First degree murder
• Second degree murder
• Predatory criminal sexual assault of a child
• Aggravated criminal sexual assault or Criminal sexual assault
• Armed Robbery
• Aggravated Arson or Arson
• Aggravated Kidnapping or Kidnapping
• Stalking or aggravated stalking
• Any offense involving the discharge of a firearm

Eligibility Requirement Concerns
Defendant previously completed or has been discharged from a
mental health court within the last 3 years
Is this section necessary?
If Mental Health Courts are effective why do we want to
preclude someone from the Court
Lack of medication compliance is not a criminal act

Mental Health and Drug Courts – Research Findings
MacArthur Study” Steadman, Redlich, Callahan, Robbins, & Vesselinov
(2013): 4 sites, pre/post design, comparison group (jail/treatment as usual)
– felonies and misdemeanors
Findings:
• Post-entry annualized (time at risk to reoffend) re-arrest rate
significantly lower for MHC sample.
• Post-entry incarceration days significantly lower for MHC sample.
• More intensive treatment episodes and therapeutic treatment episodes
than similar defendants. In other words, among MHC participants, there
is a shift from crisis treatment to intensive treatment.
• MHC participants access community treatment more quickly following
discharge from jail than similar defendants.

Other Findings:
• Re-arrest rates lower for MHC participants who:
• Graduate from the program
• Had lower pre-arrest and incarceration rates
• Had treatment at baseline interview/admission to MHC
• Re-incarceration rates lower for MHC participants who:
• All of the above plus
• Did not use illegal substances in past 30 days
• Had a diagnosis of bi-polar disorder, rather than depression or
schizophrenia

• One year project (2007) to collect self-report, medical records and arrest
data from CCDOC detainees in RTU.
• Sampling with certainty monthly admissions to RTU stratified by gender
• Two-step recruitment process (overall recruitment rate of 67.5% of
eligible cases; main reason not accessed before transfer or discharge)
• Administered WHO-CIDI via laptop computers
• Medical record abstraction (not completed – too many missing charts)
• Arrest data from ISP via CJIA
A Study of Co-occurring Health and Psychiatric Conditions at
CCDOC

Reception and
Classification
(~ 300 per day)
Cermak Health Services
General Population
Admissions/Acute Care
(48 hrs., 2 dorms, 40 beds)
( ~ 600 in “outpatient”
medication
management)
Medication Clinic
Women
(Division 3 - 120 beds)
Men
(Division 8 - 300 beds)
Residential Treatment Units
RTU/RU
Intensive Care
65

Key research questions:
• Epidemiology of psychiatric, substance use, and medical disorders.
• Access to medical and behavioral healthcare services when not
incarcerated and what have been the primary barriers to service
access?
• Determine what community-based medical and behavioral healthcare
services are most needed upon release from the jail?
• Determine how community-based medical and behavioral healthcare
services should best be coordinated post-release.
• What are the criminal careers of those in psychiatric treatment within
the jail and do the number and severity of crimes committed vary by
the type of psychiatric disorder and/or the presence of substance use
and medical disorders?
66

Epidemiology of psychiatric, substance use, and medical
disorders
• Substance use disorders including alcohol and drug abuse and
dependence (81.8%);
• Nicotine dependence (64.5%);
• Conduct disorder (56.5%);
• Anti-social Personality Disorder (ASP) (47.2%);
• PTSD (44%);
• Major affective disorder (61%; major depressive episode most common
– 50%)
67

Epidemiology of psychiatric, substance use, and medical
disorders
• Women more likely to have:
• Major depressive episode or disorder
• PTSD
• Men more likely to have
• Non-affective psychosis
• Gambling disorder
• Alcohol abuse
• About 20% did not meet DSM-IV criteria for any diagnosis!
68

Treatment access and use
• A majority of participants have had prior psychiatric care and around
60% to 70% have been hospitalized in the community.
• Only 54 percent reported having a regular doctor and only 40
percent reported having a regular place to go for routine medical
services.
• Only 35 percent saw a dentist or obstetrician (among women) in the
year preceding their arrest.
• More participants visited a medical facility for emergency or urgent
care (52.5%) than for a scheduled surgery or routine care (17.6%).
69

• Contact with treatment professionals was uneven in a number of
ways:
• By disorder (PTSD, ADHD relatively undertreated)
• By professional contact (psychiatrists most common, other
health care professionals relatively less common).
• Few have private health insurance and less than half (45%) have
any kind of government insurance such as Medicaid/Medicare.
Given psychiatric disability, many more should be on Medicaid.
• However, lack of insurance was not the main reason most people
reported delaying getting treatment. Most said they wanted to handle
their problems on their own. Or that they were not bothered much by
their problem.
70

Lack of insight appears to be a general and important issue that affects
service use:
• 33% rate their overall mental health as ‘very good’ to
‘excellent’.
• 59% rate their overall physical health as ‘good’ to ‘excellent’.
71

Mental Health Policy - Mental Illness and the Criminal Justice System

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