Economic evaluations of mental health interventions in criminal justice

Background

Mental health interventions targeting crime perpetrators are available. An overview of the current scenario of their economic benefits will help policy decisions.

Aim

To provide an update on economic evidence for mental health interventions in criminal justice, and to identify challenges and responses in using economic evidence to inform policy.

Method

Narrative review with an analysis frame that organises evidence around four points on the criminal justice system pathway: (a) point of contact; (b) post-arrest; (c) incarceration/punishment and (d) post-incarceration.

Results

There is a paucity of high-quality economic evidence, especially from cost-benefit analyses. However, there is some evidence of cost-effectiveness in support of interventions at the point of incarceration, such as cognitive behavioural therapy, multisystemic therapy for juvenile delinquents, therapeutic communities, electronic monitoring and telepsychiatry in forensic psychiatry settings. There is also evidence that post-incarceration interventions such as assertive community treatment can be cost-effective.

Conclusion

There remain large evidence gaps. There are also challenges in turning economic evidence on mental health interventions in criminal justice into policy changes and improved practice, such as hidden costs, silo budgeting and delayed pay-off. Research incorporating multi-sectoral costs and benefits recommended by health economics and health technology assessment groups should be prioritised to support difficult resource allocation decisions faced by policy makers.     

Chronic mental illness and the criminal justice system

A total of 260 family members responded to a survey seeking information about their mentally ill relatives' contacts with the criminal justice system. Reports by family members indicated that the mentally ill relatives were mainly men in their early thirties with a diagnosis of schizophrenia or bipolar disorder; they had had an average of four admissions to a state mental hospital. The majority had been arrested, but only a fifth had been convicted of a crime. Substance abuse and noncompliance with psychiatric medications were significant predictors of arrest. Family members overwhelmingly attributed the arrests to psychiatric crises, and in about half the cases a failed attempt at commitment had preceded the arrest. However, only a minority of the mentally ill relatives were taken to a hospital at the time of the arrest. The findings highlight the need for closer collaboration between mental health specialists and law enforcement personnel.     

Update on the disposition of military insanity acquittees

There has been little study of the use of the insanity defense within the military judicial system, and aggregated data concerning such cases are not readily available when needed. Useful information is not consolidated in a central location, hindering potential research and the development of systemic improvements. One key area that would benefit from closer analysis is the process of the disposition of insanity acquittees. The Manual for Courts-Martial (2000 ed. Washington, DC: U.S. Government Printing Office) provides limited guidance in procedures to disposition, outlining the process in rather broad terms. The result is often a time-consuming and resource-draining process that can create significant burdens for both the military legal and health care systems. The need to address challenges within the system is discussed, and the creation of a centralized databank as a step toward improving this system is recommended.     

Administrative issues in the follow-up treatment of insanity acquittees

This paper discusses issues in the community-based management of forensic patients. Community acceptance and safety demand a careful system of follow-up treatment for insanity acquittees. Many studies have examined the recidivism of this population, but few have dealt with administrative strategies to manage their care as outpatients. In this paper, we discuss our experiences in developing systems for follow-up care of insanity acquittees in the state of Maryland. Central to this work is the balancing of clinical, judicial and community concerns. The decision for outpatient care or movement of the patient to a non-forensic (regional) hospital is a significant turning point in the forensic patient's care. One of the major challenges faced by forensic mental health services is to develop consistency of practice throughout a state. A centralized system is easier to manage, but costly. A system embedded in community mental health centers is less duplicative, but requires major and ongoing educational support. A private practice model is flexible, but administratively challenging. The authors believe Maryland possesses well-developed approaches for the evaluation, treatment and conditional release of insanity acquittees. The state continues to study and redesign its systems toward increased effectiveness and efficiency.     

Involvement in the criminal justice system among recipients of mental health services after September 11

OBJECTIVE: This study examined the relative risk of arrest among recipients of mental health services in Washington, D.C., during the 23 months before and the 13 months after the terrorist attacks of September 11, 2001, with the purpose of identifying any change in involvement with the criminal justice system after the attacks. METHODS: Analysis of anonymous data sets provided by the local mental health and police departments provided measures of risk of arrest, relative to that of the general population, for the approximately 5,000 people receiving mental health services each month. Interrupted time-series analysis was used to measure change in relative risk during the 36-month study period. RESULTS: Significant increases were noted in relative risk of arrest after September 11, 2001, among male, nonwhite young-adult recipients of mental health services. Significant change was evident for eight of the 12 age, gender, and racial groups used in this analysis. CONCLUSIONS: Disaster planning and response should include attention to involvement with the criminal justice system among recipients of mental health services. Future research should focus on the nature of the relationship between terrorism and arrest among service recipients.     

Goals to guide the interactions of the mental health and justice systems

Interactions occur routinely between the mental health and justice systems, yet they are hindered by misunderstandings and misconceptions regarding their proper course. In addition, a number of outside forces shape these interactions and complicate efforts to improve them. In order to more clearly delineate and facilitate these interactions, 50 professionals concerned with these interactions were assembled as part of a symposium on the interactions of the justice and mental health systems. One of the primary tasks was to identify goals to direct these interactions. This article describes and categorizes the goals that were generated.     

The conditional release of insanity acquittees: three decades of decision-making

The problem with the practical application of decision-making regarding release of mentally ill defenders lies in the inherently ambiguous definitions of mental illness and dangerousness, both of which are necessary for the continued commitment of insanity acquittees. In this study, we examined how clinicians make release decisions in a forensic facility, with particular attention paid to how such decision-making may have changed over time. Records were reviewed to determine documented criteria indicating readiness for release. The results indicated that compliance and treatment response were the primary reasons that the patients were judged ready for release. In addition, increasing attention to the use of substances as a risk factor was evident in the records, with substantially more documentation found in the most recent decade. Our data suggest that clinicians view three concerns to be of primary import when making release decisions: responsiveness to and compliance with the treatment, substance use, and risk of violence.     

New York State's system of managing insanity acquittees in the community

New York State's Insanity Defense Reform Act of 1980 outlined specific procedures for conditional release to the community of persons found not guilty of a criminal offense by reason of insanity. To assess how well the procedures were working, the authors examined data on all clients placed on conditional release in the state between 1980 and 1987. The majority of the 331 clients so identified had been found to be dangerously mentally ill and were subsequently released to the community after extensive periods of involuntary inpatient treatment. The most common condition for community release was participation in a treatment program. While in the community, 22 percent of the clients were arrested, and 5 percent had their conditional releases revoked and were recommitted. The authors compare the New York program with similar programs elsewhere. They believe the key features of a successful program include centralized responsibility, a uniform system of treatment and supervision, and a network of community services.     

Childhood risk factors for criminal justice involvement in a sample of homeless people with serious mental illness

It has been suggested that criminal justice involvement among the homeless, particularly those with mental illness, is largely situational. The objective of this study was to assess, in a sample of homeless seriously mentally ill people, the prevalence of childhood conduct disorder behaviors as a risk factor for adult criminal activity as well as the extent and types of adult criminal justice contact. Data were taken from the national ACCESS program, which conducted extensive baseline interviews with 7,222 homeless seriously mentally ill adults. The interview assessed demographics, childhood risk factors for criminal activity such as conduct disorder behaviors, foster care, and parental abuse, as well as current illness severity and recent criminal justice contact. The 2-month arrest rate in this sample was much higher than national rates (11% compared with 1% annually in the general population). Although most arrests were for minor crimes (10.8%), there were also substantial rates of arrest for major (2.7%) and substance-related charges (2.0%). The prevalence of a history of conduct disorder behavior was also substantial (55% in male subjects, 40% in female subjects), and conduct disorder was a strong predictor of recent criminal justice involvement, even after controlling for other predictors of arrest (odds ratio = 1.76 for major crimes, 1.49 for minor crimes, and 1.98 for substance-related crimes). Recent literature has criticized a trend to criminalize homeless mentally ill persons for attempting to get needed food, shelter, or medical attention. However, these data indicate that at least some proportion of arrests in this population are of people who have been exhibiting antisocial behavior since early adolescence, and that early antisocial behavior is a strong predictor of all types of recent arrests in this population.     

The effect of length of hospitalization on re-arrest among insanity plea acquittees

State psychiatric hospitals are increasingly populated by forensic patients. In New York State, the growth in the forensic population is largely attributable to increased lengths of stay of patients deemed not guilty by reason of insanity (NGRI). This research was conducted to determine whether longer periods of hospitalization are associated with better outcomes in the community, as measured by re-arrest for any offense and re-arrest for violence. The sample included 386 NGRI patients released into the community in New York State. A Cox regression proportional hazards model was used to assess the unique effects of length of hospitalization on re-arrest. The results showed that the length of treatment had little effect on either measure of re-arrest. Re-arrest was largely explained by demographics and prior criminal histories.     

The effects of the justice system on mental health

Anyone involved in legal proceedings will warn you that a long-drawn-out legal battle will drain your mental health. This study aimed to assess the psychological effects of being processed by the justice system. The sample consisted of 360 subjects, residents in Spain. Were administered a questionnaire on the experience of contact with the justice system, a temporal perspective inventory, locus of control, psychological reactance, coping strategies, health self-efficacy, and psychosomatic symptomology. Results revealed significant differences between plaintiffs and defendants, although it was also confirmed that both parties showed greater pessimism about the future. So, the former were more pessimistic about the future, used poor strategies for protecting their health, and had less empathy. In contrast, coincidentally in some variables, defendants had a more negative outlook on life, and in general more psychosomatic symptomology. The health of the group with the longest exposure to legal proceedings was the most deteriorated.Key words: defendants, family law, justice system, legal psychology, litigation, mental health, plaintiffs     

Use of the criminal justice system to leverage mental health treatment: effects on treatment adherence and satisfaction

In efforts to divert persons with mental illness from jails and prisons, the option of community mental health treatment in lieu of incarceration is sometimes offered. In addition, community treatment can be mandated, or "leveraged," as a condition of probation or parole. However, little is known about the characteristics and attitudes of persons who are and who are not leveraged into community mental health treatment via the criminal justice (CJ) system. In the present study, over 1,000 outpatients with mental disorders were queried about their experiences with CJ leverages, as well as their clinical and treatment histories. Persons who had experienced at least one form of CJ leverage were more likely to be younger and male and to have more hospitalizations than persons who had never experienced a CJ leverage. However, leverage experience was not associated with treatment compliance and satisfaction, or perceptions of coercion and mandate efficacy, particularly when demographic characteristics were considered.