Predictors of Accessing Substance Abuse Services Among Individuals With Mental Disorders Released From Correctional Custody.

OBJECTIVE: In the context of an increasing correctional population and corresponding rates of mental illness and substance abuse among this population, this study focuses on describing the predictors of substance abuse service utilization for ex-inmates with dual disorders. Our aim is to assess the likelihood and characteristics of ex-inmates with mental disorders who access substance abuse treatment services within two years of correctional release. METHODS: Using merged administrative data on all ex-inmates with open mental health cases released from Massachusetts Department of Corrections and two County Houses of Corrections from 2007 to 2009 (N=2,280) and substance abuse treatment outcome data through 2011, we analyze the influence of demographics, behavioral and mental disorders, and criminal justice variables on entry into substance abuse treatment within 24 months post release. We also describe primary drug use and services utilized for all the ex-inmates who accessed substance abuse services (N=1,383). Regression techniques were used to analyze the probability of utilizing substance abuse treatment services by various demographic, behavioral, and criminal involvement characteristics. RESULTS: The prevalence of a history of substance use disorders is high in this population (69%; n = 1,285). Subsequently, at 24 months post release 61% (n = 1,383) of ex-inmates with open mental health cases utilized substance abuse treatment services. This group was disproportionately female, with a preincarceration history of substance abuse, an increased number of previous incarcerations, and more likely released under correctional supervision. CONCLUSIONS: Substance abuse is a chronic relapsing disorder and dual diagnosis is common among individuals with mental disorders involved with the criminal justice system. Their service needs and contacts across substance abuse, mental health, and criminal justice systems highlight individuals caught up in the institutional circuit. Study results point to the need for expanded and targeted dual diagnosis treatment approaches and relapse prevention for ex-inmates with mental disorders post correctional release.

Arrest types and co-occurring disorders in persons with schizophrenia or related psychoses.

This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.

Public policy and limits of diversion programs for reducing jail exposure of persons with serious mental illness.

OBJECTIVE: Diverting potential arrestees with serious mental illnesses from the criminal justice system to mental health services has become a mainstay of public policy. Federal funding for local diversion and mental health court programs mandates that recipients of funds focus on "nonviolent misdemeanants," allowing more serious offenders to proceed through the justice system. This study explored the potential effects of applying such exclusions to a group of arrestees with serious psychiatric illnesses. METHODS: Data on charges in a cohort of mental health service recipients (N=13,816) were analyzed. RESULTS: Episodes of felony arrest, including some involving violence toward others, outnumbered misdemeanors. Under federal funding policies, many such cases would be processed through the justice system. CONCLUSIONS: Expanding inclusion criteria is necessary if diversion is to significantly affect incarceration rates among persons with mental illnesses. Policy makers should heed the accumulating evidence in this area in determining priorities for funding.

Risk of arrest among public mental health services recipients and the general public.

OBJECTIVE: This study compared arrest rates on a broad range of offenses in a cohort of public mental health service recipients and in the general population. METHODS: Administrative data from a state mental health agency were merged with data capturing arrests over a 9.5-year period in a cohort of persons with severe and persistent mental illness who used public mental health services and were aged 18-54 (N=10,742). The cohort's arrest rates for eight offense categories were compared with those of the general population for persons in the same age group over the same period (N=3,318,269). The data for the cohort that received mental health services were weighted by age and gender to align the cohort's demographic characteristics with those of the general population. RESULTS: The service use cohort members' odds of experiencing at least one arrest in any charge category were significantly higher than those of the general population (odds ratio [OR]=1.62, 95% confidence interval=1.52-1.72); odds were higher across all charge categories, with ORs ranging from 1.84 for drug-related offenses to 5.96 for assault and battery on a police officer. Aside from the crime of assault and battery on a police officer, the largest ORs were associated with misdemeanor crimes against persons and property and with crimes against public decency. ORs associated with felony charges, while significant, tended to be slightly smaller in magnitude. CONCLUSIONS: The offenses for which persons with serious mental illness are at greatest risk of arrest are many of those targeted by current diversion programs. These findings suggest the need for additional research addressing the ways in which individual psychopathology and socioenvironmental factors affect risk of offending in this population.

Categorizing temporal patterns of arrest in a cohort of adults with serious mental illness.

Temporal patterns of arrest among mental health systems' clientele have not been well explored. This study uses "trajectory analysis," a methodology widely employed by criminologists exploring patterns of desistence in offending, to examine patterns of criminal justice involvement in a cohort of mental health service recipients. Data for this study are from a statewide cohort of individuals who received services from the Massachusetts Department of Mental Health in 1991 (N = 13,876) and whose arrests were followed for roughly 10 years. Zero-inflated Poisson trajectory analysis applied to cohort members having two or more arrests identified five trajectories with widely varying arrest patterns. Analysis of differences in the composition of the five trajectory-based groups revealed few between-group differences in members' demographic and service use characteristics, while certain offense types were disproportionately prevalent among particular trajectory-based groups. The implications of these findings for understanding criminal justice involvement in this population and the utility of the trajectory model for system planning are discussed.

Drug-related arrests in a cohort of public mental health service recipients.

OBJECTIVES: The excessive prevalence of comorbid substance abuse among persons with severe mental illness has been well established and identified as the source of numerous negative outcomes. An overlooked aspect of illicit drug use in this population is its illegality and the potentially dire criminal sanctions. This study examined the prevalence of drug arrests in a cohort of persons receiving services from a state mental health agency who were followed for roughly ten years. METHODS: Data on arrest spanning from 1991 to 2000 were obtained for all individuals receiving inpatient, case management, or residential services from July 1991 to June 1992 (N=13,816). Reports of prevalence were based on the number with at least one drug-related arrest in the observation period. RESULTS: Five percent of individuals in the cohort experienced at least one drug-related arrest (N=720). These included simple possession as well as manufacturing and distribution. The prevalence was much higher (15%) among persons aged 18 to 25 years than in other age groups. Roughly 95% of persons with a drug arrest also had an arrest for another type of offense. This pattern is similar to that observed among persons with a drug-related arrest in the general population. CONCLUSIONS: Convictions on drug charges can void access to Section Eight housing and other benefits and are associated with other patterns of offending that also carry significant criminal sanctions. State mental health agencies may wish to target interventions toward youthful clientele by focusing specifically on the risks associated with involvement with illicit drugs.

Consent form readability and educational levels of potential participants in mental health research.

OBJECTIVES: Poor readability of informed consent forms has been a persistent problem in clinical research. The low educational attainments of many patients with mental illness might suggest a still greater problem in mental health settings. To explore this potential disparity, this study sought to determine whether the informed consent forms used in research approved by the Massachusetts Department of Mental Health were written at a grade level that was higher than that achieved by potential study participants. METHODS: The readability (grade level necessary to read text) of informed consent forms for 154 studies was calculated with several standard formulas. Readability scores were stratified on the basis of the risk level of the study from which the consent form was taken. These data were then compared with data on the maximum attained grade level of potential participants aged 19 years or older. RESULTS: The overall mean readability scores for the informed consent forms, as determined by the four methods, ranged from grade levels 12 to 14.5. Furthermore, the mean readability scores increased with higher risk levels of the studies. Approximately 35% of potential participants had not graduated from high school, 37% had graduated from high school or obtained a GED, and 28% had some education beyond the 12th grade. CONCLUSIONS: These data demonstrate poor readability of informed consent forms used in research approved by the Massachusetts Department of Mental Health and highlight a mismatch between consent form readability and the educational level of potential study participants. The findings suggest that methods of reducing the complexity of forms, as part of improving the overall consent process, are much needed.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers.

OBJECTIVE: Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients. METHODS: The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined. RESULTS: About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types. CONCLUSIONS: The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Integrating the criminal justice system into mental health service delivery: the worcester diversion experience.

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.

Relationship between race and ethnicity and forensic clinical triage dispositions.

OBJECTIVE: Racial and ethnic disparities in the criminal justice system have been widely reported, as have racial and ethnic disparities in diagnoses and certain aspects of clinical management. This study examined the association between race and ethnicity and dispositions for pretrial defendants who were referred for forensic mental health evaluations. METHODS: Available data were reviewed for all defendants in Massachusetts who were referred to a Massachusetts court clinic from 1994 to 2001 for a screening evaluation of their competence to stand trial, their criminal responsibility, or both. Logistic regression models were developed to assess the relationship between defendants' race and ethnicity and the likelihood that they would be referred for inpatient evaluation and the likelihood that they would be evaluated within a strict-security facility. Race or ethnicity of the pretrial defendants was identified by clinicians. RESULTS: Blacks, but not Hispanics, were significantly more likely than whites to be referred for an inpatient evaluation after an outpatient forensic screening evaluation. Among male defendants, both Hispanics and blacks were more likely than whites to be referred for an inpatient evaluation in a strict-security facility, regardless of diagnoses and the level of severity of the criminal charges. CONCLUSIONS: Racial and ethnic disparities in disposition decisions exist within the forensic mental health system. These disparities, however, likely reflect numerous clinician and nonclinician variables.

Self-reported lifetime psychiatric hospitalization histories of jail detainees with mental disorders: comparison with a non-incarcerated national sample.

Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mentally ill jail inmates have reduced access to psychiatric inpatient treatment, without addressing the adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.