Research That Matters (January 17 - 20, 2008)

Problem: It has been estimated that half of individuals with serious mental illness (SMI) also have a substance use disorder (SUD). Two decades of research have determined that the best practice standard for individuals with SMI and SUD is an integrated approach in which mental health and substance abuse treatment are combined through one provider (Drake, Essock, Shaner, et.al., 2001; SAMHSA, 2002). However, not only do significant gaps remain between the need for such integrated services and their availability, but administrative aspects often obstruct rather than encourage change. One obstruction may be that jails are not considered as part of integrated care - particularly activities such as outreach and service continuity.

Method: In 2003, individuals meeting diagnostic criteria for both a SMI and SUD were selected from a large urban metropolitan county's community mental health (CMH) database. Less than 5% of the county's clients were so identified (n=1474). These individuals were followed for the next three years through the countywide mental health and jail service records. Merging data files into case wise records allowed us to assess treatment and jail interface using descriptive and inferential statistics. Our research questions include: 1) how many of the clients identified as having a COD interfaced with the county jail, 2) what are the characteristics of those that interfaced with the jail versus those that did not; 3) what were the patterns of incarceration; and, 4) what were the patterns of service delivery before, during and after incarceration.

Results: Two thirds (n=972) of the individuals had at least one stay in the county jail over the three years with a mean of 2.6 and a range of 1 – 14 episodes of incarceration. For 400 clients their ONLY mental health service was in the county jail. Those incarcerated were more likely to have diagnoses of alcohol/drug dependency and bipolar disorder than those who were not jailed. Of those confined, nearly 20% had drug related charges and another 20% were misdemeanor or ordinance violations. Men were more likely than women to be jailed for assaultive offenses (20.2% v. 13.9%). Average days in jail were 36.3 (sd 50.4) with nearly half (47.4%) staying 14 days or less. Most (n=920) received mental health services within the jail, but 52 individuals were not identified as having a SMI and received no services. We found that only 4.6% of the clients were released with mental health service linkage and that 14.5% were released to substance abuse programs.

Conclusions/Implications: These results suggest that a large proportion of those with SMI and a co-occurring SUD are spending time confined within criminal justice institutions – certainly the most restrictive environment. There appears little collaboration between the jail and mental health or substance abuse treatment systems and an absence of the recommended integrated model that stipulate a continuum of care and outreach. Social workers need to evaluate local circumstances and use the results to educate and advocate for policy and practice changes that incorporate the jail into outreach and discharge planning.