Cross-Sectional Study of Homeless High Service Utilizers in Los Angeles County Jails: Race, Marginalization and Opportunities for Diversion.

Objective: To describe the demographic, legal, and clinical characteristics of a cross-section of incarcerated homeless individuals with the highest utilization of Los Angeles (LA) County public services in order to increase opportunities for focused jail diversion. Methods: The "5% list" (N=5,905 in February 2018), LA County's list of homeless individuals with the highest 5% utilization of public services, was cross-matched with the total jail population to obtain a sample of 333 homeless high-utilizing individuals. This sample was compared with the overall jail population (N=17,121) from publicly available aggregate data by Chi-square testing. Results: 84% of the high-utilizing sample were male, 38% Black, 37% Hispanic, 21% White. 67% were prescribed psychiatric medication. Compared with the overall jail population, the sample was significantly older, with a greater proportion of Black and White persons, and a lesser proportion of Hispanic individuals relative to the overall jail population. A significantly greater proportion of high-utilizing individuals faced misdemeanor charges. Conclusion: These data highlight the compounding effects of homelessness, race, and mental illness on carceral and social vulnerability. Findings suggest homeless high utilizers in jail with mental illness are likely to benefit from court-based diversion efforts aimed at housing and treatment.

Differential Incarceration by Race-Ethnicity and Mental Health Service Status in the Los Angeles County Jail System.

OBJECTIVE: This study analyzed race-ethnicity and arrest charge data from the Los Angeles (LA) County jail mental health (JMH) population to examine disparities by race and ethnicity. METHODS: Data from the LA County Sheriff's Department for all persons in the JMH population on February 14, 2019 (N=5,134), and for the overall LA County jail population (N=16,975) were compared with chi-square tests (p≤0.05 for binary measures and Bonferroni correction for multiple comparisons). RESULTS: The JMH sample had a significantly larger proportion of black (41% versus 30%) and white (19% versus 15%) persons and a smaller proportion of Hispanic persons (35% versus 52%), compared with the overall jail population (p<0.001). A significantly smaller proportion of the JMH sample was charged with a felony (80% versus 91%, p<0.001). CONCLUSIONS: Resources should be invested in prioritizing jail diversion of black individuals with mental illness and addressing the incarceration of persons with mental disorders charged with misdemeanors.

Decriminalization in action: lessons from the Los Angeles model.

Los Angeles County's Office of Diversion and Reentry (ODR) has removed over 3800 people from the largest jail system in the country. Across various diversion programs, ODR's fundamental goal is to provide permanent, lifetime care for each diverted person. This article describes ODR's various diversion programs, and elucidates the types of elaborate clinical and court-related interventions that are necessary to remove persons with serious mental disorders from jail custody. As Los Angeles continues to build the necessary community-based continuum of mental health care, ODR's model proves that thoughtfully removing persons with serious mental disorders from jail is possible and necessary for the health of both patients and community.

Mental Health and Immigrant Detainees in the United States: Competency and Self-Representation.

Most immigrant detainees held in U.S. Immigration and Customs Enforcement (ICE) facilities do not have legal representation, because immigration proceedings are a matter of civil, not criminal, law. In 2005, Mr. Franco, an immigrant from Mexico with an IQ between 35 and 55, was found incompetent to stand trial, but was not appointed an attorney for his immigration proceedings. This failure led to a class action lawsuit, known as the Franco litigation, and in April 2013, a federal judge ordered the U. S. government to provide legal representation for immigrant detainees in California, Arizona, and Washington who are incompetent to represent themselves due to a mental disorder or defect. This development has implications for forensic evaluators, because there is likely to be an increase in the number of competency examinations requested by courts for immigrant detainees. Furthermore, forensic evaluators must understand that an evaluation for competency of an immigrant detainee includes both the Dusky criteria and capacity for self-representation. In this article, we explore the legal context and ethics concerns related to the Franco litigation.

Disparities in justice and care: persons with severe mental illnesses in the U.S. immigration detention system.

As the total number of persons held within the U.S. immigration detention system has grown, the number of detained persons with severe mental illnesses has grown correspondingly. Reports issued by the government, legal and human rights advocates, and the media have brought to light a problematic and growing detention system with pervasive legal and mental health care disparities. Described are the structure and funding of the U.S. immigration detention system, the legal state of affairs for immigration detainees with mental illnesses, and what is known about the present system of mental health care within the U.S. immigration detention system. Attention is given to the paucity of legal protections for immigration detainees with severe mental illnesses, such as no right to appointed legal counsel and no requirement for mental competence before undergoing deportation proceedings. A case example and discussion of potential alternatives to detention highlight the need for wide-ranging reform.

Heroin overdose among young injection drug users in San Francisco.

OBJECTIVES: We sought to identify prevalence and predictors of heroin-related overdose among young injection drug users (IDU). METHODS: A total of 795 IDU under age of 30 years were interviewed in four neighbourhoods in San Francisco, California, USA. Participants were recruited as part of a broader study of HIV, hepatitis B and C among injecting drug users in San Francisco using street outreach and snowball techniques. Independent predictors of recent heroin overdose requiring intervention were determined using regression analysis. RESULTS: Of 795 injecting drug users under age of 30 years, 22% (174/795) of participants reported a heroin overdose in the last year. In stepwise multiple logistic regression, independent predictors of recent heroin overdose were lifetime incarceration exceeding 20 months (odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.52-5.88); heroin injection in the last 3 months (OR = 4.89, 95% CI = 2.03-11.74); cocaine injection in the last 3 months (OR = 1.67, 95% CI = 1.14-2.45); injection of heroin mixed with methamphetamine in the last 3 months (OR = 1.74, 95% CI = 1.15-2.65); ever tested for hepatitis B or C (OR = 1.66 per year, CI = 1.09-2.54) and ever having witnessed another person overdose (OR = 2.89, 95% CI = 1.76-4.73). CONCLUSIONS: Individuals with high levels of incarceration are at great risk of overdose, and prison or jail should be considered a primary intervention site. Further research on the role of cocaine and amphetamine in heroin-related overdose is indicated.

Witnessing heroin-related overdoses: the experiences of young injectors in San Francisco.

AIMS: Assessment of young injectors' exposure and response to others' heroin-related overdose. DESIGN: Cross-sectional survey. SETTING: San Francisco, CA, United States. PARTICIPANTS: Nine hundred and seventy-three street-recruited current injectors under 30 years old. MEASUREMENTS: Self-reported experiences of witnessing heroin-related overdoses from structured interviews. FINDINGS: Seven hundred and nine of 973 (73%) had ever witnessed at least one heroin-related overdose, and 491 of 973 (50%) had witnessed an overdose in the last 12 months. Fourteen per cent of those who had witnessed an overdose in the past year reported that the outcome of the overdose was death. Emergency services were called to 52% of most recent witnessed overdoses. Cardiopulmonary resuscitation (CPR) or expired air resuscitation (EAR or 'rescue breathing') was performed in 61% of cases. Inappropriate strategies such as injection with stimulants or application of ice were rare. In 67% of cases in which emergency services were not called the witness said this was because the victim regained consciousness. In the remaining 33%, 56% stated emergency services were not called due to fear of the police. CONCLUSIONS: Respondents were willing to act at overdoses at which they were present, but frequently did not do so in the most efficacious manner. Fear of police was identified as the most significant barrier to the ideal first response of calling emergency services.

Prevalence and correlates of HIV infection among young injection drug users in San Francisco.

OBJECTIVE: We assessed the prevalence of HIV infection and associated risk behaviors among street-recruited young injection drug users (IDUs) in San Francisco. METHODS: In a cross-sectional study, 304 young (age <30 years) IDUs with a history of injecting in the previous 30 days were interviewed and tested for antibodies to HIV. Analyses assessing independent associations with HIV infection were limited to males only, due to the low number of infections in women. RESULTS: The prevalence of HIV infection was 5.3% overall but was highly stratified by gender and sexual preference (15.6% among homosexual/bisexual men vs. heterosexual men) and recruitment neighborhood (18% in the Polk Street area). Of 16 HIV infections, 14 (88%) were in males. Factors independently associated with HIV infection in males included sexual preference (homosexual/bisexual vs. heterosexual: adjusted odds ratio [AOR], 7.5; 95% confidence interval [CI], 1.5-36.6), recruitment neighborhood (Polk Street neighborhood vs. other neighborhoods: AOR, 4.8; 95% CI, 1.4-16.7), and duration of residence in San Francisco (>or=1 year vs. <1 year: AOR, 11.8; 95% CI, 1.4-95.8). CONCLUSIONS: The prevalence of HIV infection was highest among male IDUs who have sex with men. The strong associations between HIV infection and sexual orientation and HIV infection and recruitment locale suggest that risk may be attributable largely to sexual risk. In addition to successful prevention efforts aimed at reducing needle-associated risk, current intervention models aimed at young IDUs should target high-risk neighborhoods and emphasize sexual risk reduction measures, in particular among men who have sex with men.