Likelihood of Treatment Post-Incarceration for Individuals with Co-Occurring Disorders

Background: Over one million individuals with a severe mental illness (SMI) are jailed each year. The presence of co-occurring substance use disorders (COD) increases risk for incarceration. Integrated models of care, in which both disorders are treated by the same provider, have proven to be the best practice standard. Although integrated care is gradually being adopted by community mental health (CMH) and substance abuse treatment systems, jails are often not part of the discussions. Because individuals with COD are likely to cycle in and out of jail, often with brief periods of incarceration, inclusion of the jail in the integrated treatment process is necessary to ensure a continuum of care between settings. The purpose of this longitudinal study is to determine: 1) What proportion of incarceration episodes for individuals with COD result in transition to CMH services, and 2) What factors predict service engagement post-incarceration?

Method: Individuals meeting diagnostic criteria for COD within the CMH database in 2003 were selected (N=1440). Prospective data on service attainment (e.g. type, dates, etc.) was obtained over the next 48 months. Data from the county jail for the same time was matched and extracted, including treatment within the jail's mental health care unit. We found 63% (n=920) of the sample interfaced with the jail, however due to incomplete matching criteria, the remaining analysis focused on 677 verified individuals. Some individuals had multiple incarceration episodes during the study period therefore a logistic regression was fit to the data using a generalized estimating equation (GEE), clustered on individuals, to analyze the correlated data.

Results: There were 1,774 episodes of incarceration (unit of analysis), with an average of 2.6 (SD 2.2; Range 1-14) episodes per person. Mean number of days in jail was 37.2 (SD 50.5) with nearly half (46.3%) of episodes lasting 14 days or less. In one third (32%) of incarceration episodes the next mental health service the individual received post release was back in the jail; in 22% there was no evidence of subsequent treatment within the community or jail; and in 44% of episodes of incarceration there was the expected result of treatment engagement within the community. Any COD diagnosis involving substance dependency (versus abuse), a mental health diagnosis of bi-polar or major depressive disorder, and gender predicted lack of engagement in community care.

Conclusion/Implications: Multiple episodes of incarceration for individuals with COD were more likely to result in either no follow-up treatment or the next treatment within jail rather than the expected transition to community treatment. A diagnosis of more severe substance use predicted less engagement in treatment, irrespective of mental health diagnosis, illuminating the difficulty of providing integrated services for CMH providers since they are the primary system of care for those with SMI. Incarcerations may disrupt community supports, treatment and medication regime. Alternately, jail may be a catalyst for treatment engagement. Whichever the scenario, policy and practice initiatives that support and strengthen collaboration between these systems will decrease costly incarcerations and increase opportunities for treatment in a less restrictive environment.