Association of Employment and Mental Health Service Use Among Individuals with Criminal Histories

Background and Significance:Given that the lack of health insurance is a main barrier to healthcare access, employment linked to the subsequent acquisition of health insurance, is considered one of the most important factors associated with mental health service utilization. However, previous studies have shown mixed outcomes regarding the relationship between employment and mental health service use. In particular, little is known about the association of employment and mental health service use among people with criminal histories who may lack employment opportunities. Thus, the present study examines the extent to which employment status was associated with mental health service use and identified the factors associated with mental health service use among people with criminal histories.

Methods: We analyzed data from the National Comorbidity Survey Replication (NCS-R). As a nationally representative survey, the NCS-R estimates the prevalence of mental disorders and rates of mental health service utilization by community residents in the U.S. The sample of the present study included 1,525 individuals with criminal histories (ages 18 years and older). To measure mental health service utilization, three types of mental health service providers were classified into specialty mental health care providers, general health care providers, and other care providers, such as social workers, counselors, and religious or spiritual advisors. Chi-square tests were conducted to compare the sample characteristics between the employed and unemployed. Guided by Andersen’s behavioral model of health service use, logistic regression analyses were conducted to examine mental health service utilization among individuals with criminal histories, while controlling for predisposing, enabling, and need factors.

Results: The results of chi-square tests indicated that the unemployed were more likely to use mental health service than the employed (18.1% vs. 12.0%, p < .05). In particular, the unemployed were more likely to use mental health service from general health care providers when compared to their employed counterparts (13.9% vs. 6.0%, p < .001). The results of logistic regression models also confirmed that being employed was negatively associated with mental health service use, after controlling for predisposing, enabling, and need factors. As predisposing factors, being younger, non-married, and having higher education were likely to increase the likelihood of using mental health service. All need factors, which included psychiatric disorders and the number of comorbid health conditions, also increased the likelihood of receiving mental health service. Interestingly, none of the enabling factors were found to be associated with mental health service use among people with criminal histories (p> .5).

Conclusion and Implications: Findings of the study suggest that employment status is negatively associated with mental health service use among people with criminal histories. This result may reflect a higher level of psychiatric disorders among the unemployed. To better understand the need and service utilization pattern among people with criminal histories, further studies should account for causal relationships among employment, service need, and service utilization by employing a longitudinal design.