Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.     

Current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake in Connecticut's jails

This study presents estimates of current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake into all five of Connecticut's adult jails (four male facilities and one female facility). Diagnoses were assessed with the Structured Clinical Interview for DSM-IV (SCID), Clinician-Administered PTSD Scale, and the Global Assessment of Functioning (GAF) and are reported by gender and race/ethnicity. The results showed that more than two of three inmates met the criteria for at least one lifetime psychiatric disorder, almost half for an anxiety disorder, and more than one-third for an affective disorder. Overall, estimates of psychiatric morbidity in the women were higher than those in the men, with the exception of antisocial personality disorder (ASPD). Of particular note, borderline personality disorder was diagnosed in 23.2 percent of women and 12.9 percent of men. An allegation of a violent offense was not associated with the presence of mental illness or with a specific diagnosis. Lifetime history of any mental illness was associated with significantly reduced scores (range, 12-15 points reduction) on the Global Assessment of Functioning. The study showed that current and lifetime psychiatric morbidity are elevated among newly incarcerated adults who do not exhibit obvious signs of severe mental illness and are associated with functional impairment. While such disorders do not necessarily require treatment, unrecognized mental illness may place offenders at greater risk while incarcerated than offenders without mental illness. This study reinforces the need for appropriate screening and referral for treatment at intake into jail.     

Assessing gaps between policy and practice in Medicaid disenrollment of jail detainees with severe mental illness

OBJECTIVE: This prospective cohort study in two large metropolitan jail systems examined whether Medicaid disenrollment policies for persons detained in jail were enforced. The extent to which persons with severe mental illness lost their Medicaid benefits while detained was determined. METHODS: Mailed questionnaires to state Medicaid directors in 2000 yielded a 95 percent response rate. Directors responded to questions about procedures that are followed when enrollees become inmates in public institutions. In addition, community mental health service records, jail detention records, and Medicaid enrollment records were linked in King County (Seattle) and in Pinellas County (Clearwater and St. Petersburg), Florida, to identify persons with severe mental illness who were incarcerated at any time during a two-year period (1996-1998 in King County and 1998-2000 in Pinellas County). The samples consisted of 1,816 persons representing 4,482 detentions in King County and 1,210 persons representing 2,878 detentions in Pinellas County. Detentions were used as the unit of analysis to determine how often Medicaid disenrollment occurred during jail incarceration. RESULTS: The stated policy in many states, including Florida and Washington, is to terminate Medicaid benefits upon incarceration, but termination occurred for only 3 percent of the detainees enrolled in Medicaid in each county. In both counties, in 97 percent of the detentions, persons who had Medicaid at entry also had it upon release. In both counties, the 3 percent who lost Medicaid while jailed had longer jail stays (three to five months compared with 16 to 30 days). CONCLUSIONS: Stated policies do not align with actual Medicaid disenrollment of persons with severe mental illness who become incarcerated. In most instances, short jail stays allowed detainees with severe mental illness to retain their Medicaid benefits.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

RISK FACTORS FOR POST‐INJURY MENTAL HEALTH PROBLEMS

Serious nonfatal physical injuries and burns are common occurrences that can have substantial implications for personal, social, and occupational functioning. Such injuries are frequently associated with significant mental health issues, and compromised quality of life and well‐being. The purpose of this review is to summarize the current literature on physical, psychological, and social risk factors for mental health issues post‐injury and to contextualize findings using Engel's biopsychosocial framework. We distinguish between pre‐injury, injury‐related, and post‐injury risk factors for mental health problems. Female sex, history of mental health problems or trauma, type of injury, and level of pain are among the strong risk factors for mental health problems post‐injury. We highlight inconsistent findings in the literature, identify directions for future research, and explore the implications of the risk factors identified for treatment and prevention.     

Lifetime risk and correlates of incarceration in a nationally representative sample of U.S. adults with non-substance-related mental illness

Purpose

High rates of psychiatric disorders in correctional facilities have fueled widespread concern about the “criminalization of mental illness.” While the link between incarceration, substance abuse, and antisocial-personality disorder is well established, the relationship between non-substance-related psychiatric disorders and incarceration has not been thoroughly investigated. This study examines the association of mental illness, excluding substance use disorders, with risk for incarceration in US adults.

Methods

Nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) were used to compare the proportions of respondents with lifetime incarceration among those with no lifetime history of DSM-5 disorders, or with lifetime history of mental illness, substance use disorders, dual diagnosis, and antisocial personality/conduct disorder. Logistic regression analysis was used to examine the independent association of incarceration with mental illness alone, both in comparison to and net of associations with sociodemographic and behavioral characteristics.

Results

Among adults with mental illness alone, 6.7% reported past incarceration, compared to 4.8% with no history of DSM-5 disorders, and 20–40% in other DSM-5 diagnostic groups. Sociodemographic and behavioral risk factors were more strongly associated with incarceration (c-statistics = 0.74 and 0.77, respectively), than mental illness (c-statistic = 0.56). Schizophrenia or other psychoses and borderline personality disorder were independently associated with incarceration, but with effect sizes no greater than eight other sociodemographic or behavioral risk factors.

Conclusion

A weak association of mental illness alone with incarceration was found, despite high level of public attention to “criminalization of mental illness.”

     

Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse

OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.     

Assessing and responding to suicidal jail inmates

Assessing and responding to suicidal risk among inmates is discussed based on a comprehensive literature review and personal experience. Sections detailing jail conditions, suicide risk factors, reasons for self-harm, and practical responses are included. Intoxication, isolation, and the initial 24 hours of incarceration stand out as significant risk factors within the jail. Determination of risk and considerations in decision-making are emphasized from a practical standpoint, while the inmate's safety and mental health, as well as accountability, are deemed priorities.     

The Nexus of Trauma,Victimization, and Mental Health Disorders Among Incarcerated Adults in Spain

Victimization and exposure to trauma, commonly linked to co-occurring mental health disorders, are prevalent among prison populations. The purpose of this study is to shed light on the prevalence of various kinds of victimization and trauma exposure at distinct life stages (childhood, adulthood and during prison) among incarcerated persons in Spain. The research team surveyed a random sample of 453 male and female inmates, serving time in two Spanish prisons, to gather information on experiences of physical and sexual victimization in both childhood and adulthood along with the presence or absence of in-prison treatment for a mental health disorder(s). More than 80% of participants reported experiencing some kind of traumatic/shocking life event – and this was significantly higher for those receiving in-prison mental health treatment than their non-treated counterparts (96.3 versus 83.3%, respectively). Logistic regression analyses revealed that inmates who were receiving in-prison treatment for a mental health disorder reported significantly higher rates of both physical and sexual victimization in prison, prior to prison, and during childhood. The results of this study strongly suggest the importance of comprehensive and accurate identification of inmates’ traumatic, victimization, and mental health histories that necessitate treatment during incarceration. We discuss the implications of our study for correctional practice, policy and future research in order to reduce victimization in the Spanish Prison System.     

Homelessness in the state and federal prison population

AIMS: This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs). METHOD: Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics. RESULTS: Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4-6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income. CONCLUSIONS: Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals.     

Characteristics of suicide attempts in a large urban jail system with an established suicide prevention program

OBJECTIVE: The King County Department of Adult and Juvenile Detention in Washington State, like many jail systems across the nation, implemented a suicide prevention program in response to high suicide rates. A review committee was formed to prospectively study the patterns of suicide attempts that occurred in the system after the program was implemented and to make recommendations for improvements. METHODS: All first suicide attempts per jail booking over a 33-month period in two of the department's jails were studied. For each attempt, characteristics of the individual and of the attempt were abstracted by trained staff. RESULTS: A total of 132 first suicide attempts were made by 124 individual inmates during the study period. The prevalence of mental illness among inmates who attempted suicide was 77 percent, compared with 15 percent in the general jail population. Seventy-five percent of the inmates who attempted suicide had received a mental health evaluation from jail personnel before the attempt. Suicide attempts that were made in observation units for suicidal inmates (42 percent of all attempts), particularly those made in group observation units, necessitated fewer visits to an emergency department than those that occurred in general areas of the jail. CONCLUSIONS: On the basis of these findings, the jails implemented interventions such as more suicide screening and treatment for inmates who have active substance abuse, greater consensus building in decisions about housing, and structural changes such as greater use of group-housing units and the use of barriers to prevent the inmates from jumping from balconies.     

Gender- and violence-related prevalence of mental disorders in prisoners

Objectives To clarify the prevalence of mental diseases including personality disorders in a sample of German prisoners regarding delinquency and gender specificity. Method Crime history, present state and lifetime mental disorders, as well as personality disorders, were assessed amongst 415 inmates and compared regarding gender and type of delinquency. Results Female offenders more often committed homicide while male offenders more frequently committed assault and robbery. Men had a higher prevalence of alcohol abuse and dissocial PD while women more often showed depression, anxiety disorders and Borderline PD. Violent offences were related to a higher prevalence of alcohol abuse and dissocial PD, as well as higher comorbidities of mental disorders. Conclusion Results emphasize the complexity of the needs and requirements of imprisoned offenders. Our findings reveal an urgent need for psychiatric–psychotherapeutic services to provide suitable care to inmates in order to contribute to a more favorable legal prognosis.     

Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of Operation Desert Storm

OBJECTIVE: The present report is part of a follow-along investigation focusing on the evolution of trauma-related symptoms in veterans of Operation Desert Storm. The goal of the current report was to examine three hypotheses on the relationship between severity of war-related trauma, symptoms of posttraumatic stress disorder (PTSD), and symptoms of borderline personality disorder with a mixed retrospective/prospective design. METHOD: Ninety-four National Guard reservists completed self-administered measures of combat-related trauma, PTSD symptoms, and borderline personality disorder features after their Gulf War duty. RESULTS: Consistent with study hypotheses, prewar features of borderline personality disorder predicted variability in postwar PTSD symptoms beyond that predicted by combat exposure, combat exposure predicted variability in postwar features of borderline personality disorder, and PTSD severity assessed shortly after combat exposure accounted for additional variability in subsequent features of borderline personality disorder. CONCLUSIONS: Taken together, the present findings suggest that trauma, symptoms of PTSD, and features of borderline personality disorder are related to one another in a complex fashion that may exceed simple linear models. Clinical and research implications for the relationships among trauma, PTSD, and borderline personality disorder are discussed.     

Availability of behavioral health treatment for women in prison

OBJECTIVES: This study examined whether women with behavioral health needs are more likely to receive treatment for these problems in prison or in the community and to what extent prison disrupts or establishes involvement in treatment for these women. METHODS: Data were collected in August 2004 as part of a population survey of female inmates in the only state correctional facility for women in New Jersey. RESULTS: A total of 908 women were surveyed. Fifty-six percent of the women surveyed reported needing behavioral health treatment before incarceration, but only 62 percent of this group reported receiving such treatment in the community. The rate at which treatment matched need within this population before incarceration varied by type of treatment needed: it was the highest (58 percent) for women who needed treatment for mental health problems, lower (52 percent) for those who needed substance abuse treatment, and lowest (44 percent) for those who needed treatment for comorbid mental health and substance abuse problems. In comparison, the rate of match between need for and receipt of treatment in prison was higher for all three types of behavioral health treatment (78 percent, 57 percent, and 65 percent, respectively). Additionally, the findings suggest that prison did not disrupt the type of behavioral health treatment that inmates had previously received in the community. CONCLUSIONS: At least in New Jersey, prison appears to improve access to behavioral health treatment among female inmates. Although this conclusion is consistent with the rehabilitation goals of incarceration, it also suggests that some women may have been able to avoid prison if treatment had been provided in the community, especially for substance-related problems.     

Integrated Treatment for Jail Recidivists with Co-occurring Psychiatric and Substance Use Disorders

Jail recidivists with serious mental illness and substance use disorders were treated in an in-custody setting and then randomly assigned to either a high fidelity Integrated Dual Disorders Treatment program (103 participants) or to service as usual (79 participants). Outcomes were tracked an average of 18 months from program entry at the termination of the initial incarceration. A reduction in jail days from baseline to study period was significant for both groups. The pre to post reduction for arrests and total convictions was significant in the experimental group but not the control group. However, during the study period, differences between experimental and control groups in arrests, convictions and jail days were not statistically significant. Experimental participants had lower study period psychiatric inpatient and crisis utilization and greater outpatient utilization than did control group participants. The groups did not differ with regard to total institutional days. Experimental group attrition was relatively high.Daniel Chandler is an Independent Research Consultant in Trinidad, CA, USA.Gary Spicer, MBA is affiliated with Alameda County Behavioral Health Care Services, 2000 Embarcadero Cover, Suite 400, Oakland, CA.     

Criminal conviction, impulsivity, and course of illness in bipolar disorder

Swann AC, Lijffijt M, Lane SD, Kjome KL, Steinberg JL, Moeller FG. Criminal conviction, impulsivity, and course of illness in bipolar disorder.
Bipolar Disord 2011: 13: 173–181. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objective: Criminal behavior in bipolar disorder may be related to substance use disorders, personality disorders, or other comorbidities potentially related to impulsivity. We investigated relationships among impulsivity, antisocial personality disorder (ASPD) or borderline personality disorder symptoms, substance use disorder, course of illness, and history of criminal behavior in bipolar disorder. Methods: A total of 112 subjects with bipolar disorder were recruited from the community. Diagnosis was by Structured Clinical Interview for DSM‐IV (SCID‐I and SCID‐II); psychiatric symptom assessment by the Change version of the Schedule for Affective Disorders and Schizophrenia (SADS‐C); severity of Axis II symptoms by ASPD and borderline personality disorder SCID‐II symptoms; and impulsivity by questionnaire and response inhibition measures. Results: A total of 29 subjects self‐reported histories of criminal conviction. Compared to other subjects, those with convictions had more ASPD symptoms, less education, more substance use disorder, more suicide attempt history, and a more recurrent course with propensity toward mania. They had increased impulsivity as reflected by impaired response inhibition, but did not differ in questionnaire‐measured impulsivity. On logit analysis, impaired response inhibition and ASPD symptoms, but not substance use disorder, were significantly associated with criminal history. Subjects convicted for violent crimes were not more impulsive than those convicted for nonviolent crimes. Conclusions: In this community sample, a self‐reported history of criminal behavior is related to ASPD symptoms, a recurrent and predominately manic course of illness, and impaired response inhibition in bipolar disorder, independent of current clinical state.     

Criminal history as a prognostic indicator in the treatment of homeless people with severe mental illness

OBJECTIVE: This study examined the clinical problems and treatment outcomes of homeless people with severe mental illness and a history of incarceration. METHODS: Between May 1994 and June 1998, a total of 5,774 people entered assertive community treatment case management services in the Access to Community Care and Effective Services and Supports (ACCESS) demonstration program at 18 sites in nine states. This study used data from reassessments at 12 months after program entry. Analysis of variance was used to compare baseline status and 12-month outcomes for clients with a lifetime incarceration history of less than six months, of six months or more, and no incarceration history. The outcomes assessed were housing status, employment status, psychiatric problems, alcohol problems, drug problems, and criminal justice involvement. RESULTS: Two-thirds of the ACCESS clients had a history of incarceration, with about one-third having less than six months of incarceration and about one-third having six months or more of incarceration. Clients with a long-term incarceration history had higher psychiatric symptom scores, higher drug use and alcohol use scores, and higher levels of dual diagnosis than those with a short-term incarceration history or those with no history of incarceration. The same order of differences was found on measures of childhood abuse, family-of-origin stability, and childhood conduct disorder. Clients with an incarceration history of six months or more reported higher levels of long-term homelessness than the group without an incarceration history. The group with an incarceration history of less than six months showed less improvement at the 12-month follow-up evaluation than the group with no incarceration history on only one outcome measure, psychiatric problems. The group with an incarceration history of six months or more had poorer outcomes than the group with no incarceration history on only two of six outcomes, psychiatric problems and number of days in jail. CONCLUSIONS: This study found that among homeless clients with severe mental illness, clients with a history of incarceration have more serious problems and show somewhat less improvement in some community adjustment domains.     

Attention deficit/hyperactivity disorder in female offenders: prevalence,psychiatric comorbidity and psychosocial implications

Attention deficit-/hyperactivity disorder (ADHD) is associated with social maladaptation and delinquency in later life. This study was conducted to determine the prevalence of ADHD and comorbid conditions in female prison inmates. One hundred and ten adult female prison inmates of a German prison for women were investigated. SCID-I and -II interviews and standardized German instruments for the assessment of ADHD in adults (HASE) were used. The lifetime prevalence of ADHD was 24.5 and 10% for persisting ADHD according to DSM-IV criteria. A decline of the prevalence of persisting ADHD with age from 17.9% (age <25 years) to 10% (age 26–45 years) and 0% (age >45 years) was observed. Female prisoners with ADHD were younger at their first conviction as compared with females without ADHD and they showed longer incarceration periods in relation to age. The prevalence of other axis I disorders was high in both the ADHD and the non-ADHD female population, but significantly higher in ADHD females. Mean number of axis I diagnoses was 3.6 in females with ADHD and 2.3 in females without ADHD. No differences were found between females with and without ADHD regarding the prevalence of psychotic, affective, anxiety, somatization and posttraumatic disorders. Substance use disorders and in particular the use of stimulants were more frequent in females with ADHD as well as borderline personality disorder and eating disorders. The results suggest a high prevalence of ADHD in female prisoners that exceeds the prevalence estimates from epidemiological studies in general female populations. Moreover, it appears that ADHD is particularly frequent in adolescent and young adult female offenders and increases the risk for further psychiatric morbidity. The results indicate the need of adequate psychiatric support of female prison inmates including therapeutic programs for ADHD.     

The Impact of a State Hospital Closure on Local Jails: The Kansas Experience

In 1990, Kansas's Mental Health Reform legislation began transferring fiscal support for the delivery of mental health services away from state institutions and into the local community, culminating in the closure of one state hospital facility in 1997. Kansas jails were studied to determine the resulting impact of that hospital closure on the State's jail systems, including whether an increase in incarceration rates of persons with severe and persistent mental illnesses followed the closure of the hospital. Though a relationship between the hospital closure and incarceration rates cannot be substantiated, the results do provide a rare birds-eye view of the extent of and problems associated with the incarceration of persons with mental illness in a predominantly rural state.