Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.     

Use of PASRR programs to assess serious mental illness and service access in nursing homes

OBJECTIVE: This study assessed the implementation of state Preadmission Screening and Resident Review (PASRR) programs with respect to identification of serious mental illness among nursing facility applicants and residents and access to mental health services. METHODS: A national survey was conducted with representatives from agencies that implement PASRR in all 50 states and the District of Columbia. Also, 44 states sent PASRR data for review. Four states were selected for an in-depth study; six nursing homes per state were selected and one staff member from each facility was interviewed (N=24). Medical records were reviewed for 30 to 40 residents from each facility who met criteria for potentially having a disabling serious mental illness (N=786). RESULTS: Medical records showed that 50 percent of patients at the time of admission and 68 percent of patients at the time of the record review had a psychiatric diagnosis, typically a diagnosis of depressive disorder. At the time of admission, fewer records identified individuals with a serious mental illness (9 to 20 percent) or a primary diagnosis of any psychiatric illness (5 to 12 percent). Many records indicated that in-depth, required PASRR screens were not performed. Ninety percent of the states reported that Medicaid covers only basic psychiatric consultation services, such as medication monitoring, in nursing facilities. Between 30 and 32 percent of national survey respondents also characterized access to facilities that provide mental health services as limited and of variable quality. Although all 24 nursing facilities reported providing psychiatric consultation services, access to other mental health services, such as psychosocial rehabilitation or individual counseling, varied considerably. CONCLUSIONS: Nursing facility compliance with administration and documentation of PASRR screens appears problematic. Nevertheless, there do not appear to be excessively high numbers of residents with serious mental illness, suggesting that state PASRR programs may contribute positively to the identification of people with serious mental illness. However, many nursing facility residents have some type of psychiatric illness, and PASRR legislation does not appear to have enhanced their ability to gain access to mental health services beyond standard psychiatric consultation and medication therapy.     

Admissions, length of stay, and medication use among women in an acute care state psychiatric facility

OBJECTIVE: Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility. METHODS: A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database. RESULTS: The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50. CONCLUSIONS: Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

One-year follow-up of persons discharged from a locked intermediate care facility

OBJECTIVES: This study examined outcomes during a one-year follow-up for persons who were discharged from a locked intermediate care facility in an urban area in California. The purpose of this study was to determine the extent to which persons with severe mental illness can be successfully transferred from an intermediate care facility to lower levels of care. METHODS: A total of 101 persons consecutively discharged were studied by record review and by obtaining information from facility staff members, therapists, case managers, and other community caretakers. RESULTS: During the follow-up period 56 percent of the patients who were discharged from the intermediate care facility were not able to demonstrate even minimal functioning in the community. These persons spent 90 or more days in locked or highly structured institutions that provided 24-hour care (including jail) or had five or more acute hospitalizations. However, 44 percent spent less than 90 days in these institutions and had fewer than five acute hospitalizations. Thirty-three percent were not known to have spent any time in an institution or hospital. CONCLUSIONS: The high rate of recidivism shown in this cohort suggests that the current emphasis on transferring patients from more structured, intermediate inpatient services to lower levels of care is not effective for a majority of patients. Furthermore, the poor clinical outcomes found in this cohort did not seem to be offset by any reduction in overall governmental costs because of the high use of acute and intermediate hospitalization and the costs of the criminal justice system.     

The prediction of mental health service use in residential care

The purpose of this study was to characterize the clinical and psychosocial factors of residents living in psychiatric nursing homes, assess residents' levels of mental health service utilization, and examine the factors that predict the utilization of mental health services. Data were collected from 200 randomly selected residents with schizophrenia living in four intermediate care facilities. Fewer than 60% of residents received mental health services beyond medication and nearly one-half of the residents were readmitted to the hospital in the course of a year. Family contact and involvement in activities were associated with mental health service utilization. Hospital readmission was predicted, not by substance use, but rather by not using substances. There is a growing need among service providers to better identify relevant factors that are important in treatment planning and service delivery. Attention to these issues may impact treatment provision and outcomes for persons with schizophrenia and their families.     

Use of VA aftercare following military discharge among patients with serious mental disorders

OBJECTIVE: This study examined the use of Department of Veterans Affairs (VA) aftercare services among patients with serious mental disorders who were discharged from the military after a first admission to a Department of Defense (DoD) hospital. METHODS: Administrative data from the DoD and VA health systems were linked to identify active-duty servicemen and -women who were hospitalized in a military hospital with a diagnosis of major depression, bipolar disorder, or schizophrenia between 1993 and 1996 and who were subsequently discharged from the military. Split population survival analysis was used to examine separately the correlates of contact with VA outpatient mental health services and, among those who had contact, the time to contact after military discharge. RESULTS: Fifty-two percent of 2,861 identified individuals had received outpatient care from VA mental health clinics by the end of September 1998. The rate of contact was lower than in virtually all studies of aftercare following hospital discharge. Women, older persons, and persons with schizophrenia or bipolar disorder were more likely to contact VA outpatient mental health services than men, younger persons, and those with major depression. Among those who made contact, older persons had a longer time to contact. CONCLUSIONS: Many people who leave the military because of serious mental illness do not receive aftercare from the VA. The reasons for such low rates of contact are not clear. Identifying patients who need aftercare but do not receive it and ensuring that they have access to needed services remains an important challenge for the DoD and the VA.     

Satisfaction of caregivers of patients with schizophrenia in Finland

OBJECTIVE: The aims of the study were to determine whether the caregivers of discharged patients with schizophrenia were satisfied with their situation in general and with psychiatric services in particular and to examine the factors associated with caregiver satisfaction. METHODS: The data were drawn from a national project designed to study the treatment and life situation of deinstitutionalized schizophrenia patients in Finland. The patients were discharged from psychiatric hospitals in 1986, and both the patients (N=775) and their caregivers (N=545) were interviewed after a three-year follow-up. RESULTS: One-fifth of the caregivers were dissatisfied with the situation in general, and one-third were dissatisfied with the psychiatric services the patient received. Caregivers were more likely to be dissatisfied with the situation if they lived with the patient and if the patient's functional state was poor or the patient's use of services, particularly medication and rehabilitation, was low. Caregivers were likely to be dissatisfied with the psychiatric services if the patient had severe psychotic symptoms and poor "maintenance of grip on life" or if the patient was given less psychiatric care and rehabilitation or used more social services. CONCLUSIONS: The satisfaction of caregivers of persons with mental illness appears to have two dimensions. First, caregivers need to be accepted and treated as active partners in the patients' care and rehabilitation. Second, the burden on the families of persons with mental illness can be alleviated with long-term rehabilitation and care to help patients gain as high a functional state as possible.     

Training persons with schizophrenia in illness self-management: a randomized controlled trial in Japan

Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1).The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.     

Use of health care services and costs of psychiatric disorders among National Health Insurance enrollees in Taiwan

The National Health Insurance (NHI) database in Taiwan was used to detect the use of health care services and the costs of psychiatric disorders among NHI enrollees. Data were analyzed for 126,146 enrollees. Four categories were used for enrollees: no psychiatric disorder, a minor psychiatric disorder, a major psychiatric disorder without catastrophic illness registration, and a major psychiatric disorder with catastrophic illness registration (which eliminates copayments). Compared with enrollees with a minor psychiatric disorder, those with a major psychiatric disorder, either with or without catastrophic illness registration, had higher use and costs of mental health care services. Compared with enrollees without a psychiatric disorder, those with a minor psychiatric disorder or a major psychiatric disorder without catastrophic illness registration had higher use and costs of non-mental health care services. Both the mental and general health care of persons with psychiatric disorders are important.     

Use of mental health services in Chile

OBJECTIVE:S: To address the growing burden of mental illness in Latin America, a better understanding of mental health service use and barriers to care is needed. Although many Latin American countries have nationalized health care systems that could potentially improve access to care, significant barriers to care remain. The authors report the results of a study examining mental health service utilization in the general population of Chile. METHODS: The data were drawn from the Chile Psychiatric Prevalence Study, a national household survey of 2,987 persons aged 15 years and older conducted in 1992-1999. As part of the survey, psychiatric diagnoses were obtained by using the Composite International Diagnostic Interview, and respondents were asked about their use of general and mental health care services in the past six months and about their experience of barriers to treatment. RESULTS: More than 44 percent of respondents reported use of any health care services in the past six months, and 20 percent reported use of mental health services. Of the respondents who met criteria for a psychiatric disorder, a large proportion (62 percent) did not receive mental health care. Increasing severity of the psychiatric disorder correlated with increasing frequency of overall help seeking, but only a small proportion of the respondents with a psychiatric disorder sought specialized mental health services. Regional disparities and inequities in access to care were found. In addition, indirect barriers to mental health care, such as stigma and misconceptions about the course of psychiatric disorders, were important deterrents to service utilization, particularly among persons with lower socioeconomic status. CONCLUSIONS: To reduce the burden of mental illness in Chile, additional efforts are needed to address both the direct and the indirect barriers to mental health care, including regional inequities in access to care.     

Use of general medical services among Medicaid patients with severe and persistent mental illness

OBJECTIVE: The aim of this study was to examine patterns of use of general medical services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. METHODS: A total of 669 persons with a severe and persistent mental illness were identified by using statewide clinical criteria. A three-year database of Medicaid claims was developed to examine service use. The main outcome measures were use of outpatient services for a general medical problem, use of dental and vision services, and use of screening tests for women. Service use was examined by primary psychiatric diagnosis (schizophrenic, affective, paranoid, and anxiety disorders), and analyses controlled for the presence of a chronic medical condition, age, race, and sex. RESULTS: This study found high levels of service use for outpatient services but very low levels for primary and preventive services. Although 78 percent of persons with a schizophrenic disorder had an office-based visit during the three-year period, all persons with an anxiety disorder had such a visit. Sixty-nine percent of persons with a schizophrenic disorder had at least one emergency department visit, whereas 83 percent of those with an anxiety disorder had such a visit. Dental and vision visits and the use of mammograms and pap tests followed the same pattern; persons with a schizophrenic disorder had fewer visits and had less overall use than the other diagnostic groups. The use patterns across the four groups were significantly different in outpatient service use, dental and vision service use, and screening tests for women. Compared with persons with a schizophrenic disorder, those with an anxiety disorder were more likely to have had an office-based visit and to have received vision services, those with a paranoid disorder were more likely to have used dental services or received a mammogram, and those with an affective disorder were more likely to have had a pap test. CONCLUSION: Although this group of Medicaid patients with severe and persistent mental illness had access to providers, they received an unacceptably low level of preventive care. Use of health services for general medical problems differed somewhat by primary psychiatric illness.     

One-year follow-up of a multiple-family-group intervention for Chinese families of patients with schizophrenia

OBJECTIVES: This study tested the effectiveness of a mutual support multiple-family-group intervention for schizophrenia in terms of improvements in patients' psychosocial functioning, use of mental health services, and rehospitalization compared with a psychoeducation intervention and standard care. METHODS: A controlled trial was conducted in a sample of 96 Chinese families who were caring for a relative with schizophrenia in Hong Kong. The families were randomly assigned to one of three groups: mutual support (N=32), psychoeducation (N=33), and standard care (N=31). The interventions were delivered at two psychiatric outpatient clinics over a six-month period. The mutual support and psychoeducation interventions consisted of 12 group sessions every two weeks, each lasting about two hours. The mutual support group was a peer-led group designed to provide information, emotional support, and coping skills for caregiving in stages. The psychoeducation group was a professional-led group designed to educate families about the biological basis of schizophrenia and treatment and to improve illness management and coping skills. The standard care group and the other two groups received routine psychiatric outpatient care during the intervention. Data analyses of multiple outcomes over one-year follow-up were conducted on an intention-to-treat basis. RESULTS: Multivariate analyses of variance showed that the mutual support intervention was associated with consistently greater improvements in patients' functioning and rehospitalization and stable use of mental health services over the follow-up period compared with the other two interventions. CONCLUSIONS: The study provides evidence that mutual support groups can be an effective family intervention for Chinese persons with mental illness in terms of improving patients' functioning and hospitalization without increasing their use of mental health services.     

Regular sources of medical care among persons with severe mental illness at risk of hepatitis C infection

OBJECTIVE: An estimated 19.6 percent of persons with severe mental illness are infected with the hepatitis C virus. Given the pressing need to identify and treat persons with severe mental illness who are at risk of hepatitis C infection and transmission, the authors sought to estimate the proportion of hepatitis C-positive and -negative persons with severe mental illness who have a regular source of medical care. METHOD:S: Data for this study were obtained from 777 adults with severe mental illness at four diverse geographic sites at which respondents with severe mental illness participated in a structured interview and laboratory testing for HIV infection, AIDS, hepatitis B infection, and hepatitis C infection. RESULTS: In bivariate analyses, 54.2 percent of hepatitis C-positive and 62.5 percent of hepatitis C-negative study participants with severe mental illness had a regular source of medical care. In multivariate analyses in which potential confounders were statistically controlled for, hepatitis C-positive persons with severe mental illness were less than half as likely as hepatitis C-negative persons to have a regular source of care. Being older, married, insured, or employed or having self-reported health problems increased the likelihood of receiving care. Being black or male or living in a community with high exposure to community violence lowered those odds. CONCLUSION: There is an urgent need to improve access to medical care for persons with severe mental illness, especially those who may be at high risk of or are already infected with the hepatitis C virus.     

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.     

Involvement in the child welfare system among mothers with serious mental illness

OBJECTIVE: This study sought to determine the association between maternal schizophrenia and major affective disorders (serious mental illness) and child custody arrangements in a sample of Medicaid-eligible mothers. METHODS: Medicaid eligibility and claims data were merged with data from the child welfare system in Philadelphia for 1995 to 2000. The sample comprised 4,827 female residents of Philadelphia between the ages of 15 and 45 as of 1996, who were initially eligible for Medicaid through Aid to Families With Dependent Children between 1995 and 1996 and who had at least one family member younger than 18 years at the beginning of the study period. Logistic regression was used to determine association between maternal mental illness and involvement in the child welfare system. RESULTS: Among the 4,827 mothers, 7.2 percent had a serious mental illness and 4.4 percent had other psychiatric diagnoses. More than 14 percent of mothers with serious mental illness received child welfare services, compared with 10.8 percent of those with other psychiatric diagnoses, and 4.2 percent of those without a diagnosis. After the analyses adjusted for a past inpatient episode, race or ethnicity, and age, mothers with serious mental illness were almost three times as likely to have had involvement in the child welfare system or to have children who had an out-of-home placement. CONCLUSIONS: The results suggest the urgent need for increased planning and coordination between the child welfare and mental health systems, including provision of parenting support as part of mental health treatment for mothers.     

Differences in HIV care between patients with and without severe mental illness

OBJECTIVE: This study explored how HIV care differs for infected persons with and without severe mental illness. METHODS: Data were obtained through interviews with and chart review of 295 patients with severe mental illness and HIV from public mental health agencies in Los Angeles County and New York City. Data were compared with data from 1,294 HIV patients without severe mental illness from a separate national probability sample. Measures were difficulty obtaining care, whether patients recommend their HIV care provider, hospital problem score, functional health status, and disability days. RESULTS: In Los Angeles, HIV patients with severe mental illness were more likely than those without severe mental illness to have difficulty obtaining care (p<.001); to not recommend their provider (10% versus 5%, p=.007); and to have problematic hospital care (p=.001), poor health status (p=.001), and more disability days (p<.001). In New York City, HIV patients with severe mental illness were more likely than patients without severe mental illness to have difficulty obtaining care (p=.002) and not recommend their provider (p=.02). The relationship between severe mental illness and health status in Los Angeles and access in New York City became insignificant after adjustment for sociodemographic factors, drug use, and CD4 cell count. Further adjustment for higher case management rates among HIV patients with severe mental illness reduced disparities only in the West. CONCLUSIONS: Patients with severe mental illness experienced more problems with HIV care than patients without severe mental illness, although high case management rates for patients with severe mental illness may have offset some problems.     

Association between interruptions in medicaid coverage and use of inpatient psychiatric services

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.     

Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.     

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail’s central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.