The Role of Criminal History in Mental Health Service Use Among People with Severe Mental Illness

Background and Significance: Research has consistently found people with severe mental illness (SMI) are overrepresented in the criminal justice system. The provision of adequate mental health services is often considered the primary method for preventing and reducing criminal behaviors of people with SMI. However, little is known about the different types of mental health services that people with SMI who have been justice-involved access. Is a criminal history predictive of more or less mental health service usage among people with SMI? Does the particular type (i.e., specialty, general medical or other) of service used differ among those who do and do not have a criminal history? This study examines the extent to which the presence of criminal history is associated with the use of various mental health services and related service use predictors among people with SMI.

Methods: Data were obtained from the National Comorbidity Survey Replication (NCS-R). The NCS-R is a nationally representative face-to-face survey that estimates the prevalence of mental disorders and rates of mental health service utilization by English-speaking community residents (ages 18 years and older) in the U.S. The sample consisted of 1,588 adults with SMI, including major depressive disorder (n = 1,398) and bipolar disorder (n =190). Chi-square tests were conducted to compare respondents characteristics based upon the presence/absence of a criminal history. Guided by Andersen’s behavioral health service utilization model, logistic regression analyses were conducted to examine various mental health services usage among people with SMI while controlling for predisposing, enabling, and need factors.

Results: About 30% of respondents reported they had a criminal record. Bivariate analyses indicated that people with a criminal history were more likely to use specialty mental health services when compared to those without a criminal history. The logistic regression models indicated that after controlling for other covariates, the presence of a criminal record increased the probabilities of using specialty mental health service (OR=1.42, p<0.05). Among those with a criminal history, African Americans and those married were less likely to use mental health services than their white and the non-married counterparts (OR=0.33, p<0.05; OR=0.41, p<0.001, respectively). The need factor remained as a significant predictor of mental health service use in all models; those with bipolar disorder were more likely to use mental health services when compared to those with major depressive disorder (p<0.001).

Conclusion and Implications: Findings suggest that, as in substance abuse treatment, the criminal justice system may serve as a significant referral source to specialty mental health treatment services. Recognizing the predisposing, enabling, and need factors associated with mental health service use among individuals with SMI who are justice-involved can help service providers identify sources of support that can facilitate involvement in needed services. This, in turn, can contribute to reductions in criminal involvement among this population.