Predicting Psychiatric Service Use Prior to Arrest Among Incarcerated Persons with Serious Mental Illness (SMI)

Background and Purpose Among persons who are incarcerated, rates of mental illness are disproportionately high. Persons with mental illness are in fact more likely to be imprisoned than hospitalized. An increased understanding of the barriers and facilitators of this population’s use of mental health services is needed to improve access to mental health care and prevent incarceration.  The purpose of this study was to identify factors that predict psychiatric hospitalization and outpatient mental health service use prior to arrest among persons with serious mental illnesses (SMI) who are incarcerated.

Methods Study data were obtained from interviews conducted in 2007 with 459 adult detainees (305 men and 154 women) receiving residential psychiatric treatment in a large Midwest urban jail. Study eligibility criteria included: 18 years of age or older, the ability to comprehend the interview in English, and the absence of cognitive impairment or active hallucinations and delusions. The recruitment rate was 67.5%.  The primary instrument was selected sections of a computerized version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI). Binary logistic regression was used to assess factors associated with (1) any outpatient mental health service use or (2) hospitalization for a psychiatric disorder in the year prior to arrest. Independent variables included: gender, age, race, educational level, insurance status, primary care physician intervention related to psychiatric symptoms on a routine visit, DSM-IV-TR past-year psychiatric disorders in the year prior to arrest, perceived stigma and self-stigma related to mental illness, self-rated health and mental health statuses, and the K-6 scale score (0-24) indicative of severe psychological distress.

Results Being male (OR=1.65); having insurance (OR=2.95); the provision of medical advice regarding psychiatric symptoms (OR=3.31); and meeting DSM-IV criteria for non-affective psychotic disorder (OR=2.60), hypomania (OR=3.44) and/or bipolar disorder (OR=2.62) were associated with significantly higher odds of participating in outpatient mental health services during the year before arrest. The provision of medical advice regarding psychiatric symptoms (OR= 2.80) and meeting criteria for non-affective psychotic disorder (OR=2.64) and/or hypomania (OR=2.41) were associated with significantly higher odds of hospitalization for a psychiatric disorder in the year prior to arrest.

Conclusions and Implications Findings suggest that doctors are influential in the treatment decisions made by persons with an SMI.  Detainees with SMI who, during the course of a routine visit for medical care, also received brief counseling or advice from their medical doctor related to their psychiatric problems were about three times more likely to receive outpatient services and to be hospitalized for a psychiatric illness. This demonstrates the importance of addressing behavioral health in conjunction with providing medical care. The study also underscored the importance of insurance in promoting access to outpatient mental health care, suggesting that ACA provisions for expanded coverage could provide greater access to psychiatric as well as medical care. Although participants in this study who received psychiatric care were nevertheless incarcerated, the possibility remains that closer coordination between medical and psychiatric care through case management services provided by social workers could reduce incarceration rates for persons with SMI.