Racial Disparities in Access to, and Utilization of, Jail- and Community-Based Mental Health Treatment

Background: Individuals with serious mental illness (SMI) and persons of color (PoC) occupy a space of dual disproportionality in the criminal justice system. Within jails, 1 in 4 persons are likely to have SMI(Bronson & Berzofsky, 2017) and Non-Hispanic blacks and American Indians are incarcerated in jails at higher rates than non-Hispanic whites (Zeng, 2018). Studies of appropriate, culturally conscious interventions to identify individuals in jails as having mental health (MH) issues, provide services, and links to community-based services is of crucial importance to smart decarceration efforts (Epperson & Pettus-Davis, 2015). This study asked: Does race impact access to jail-based and community-based MH services for individuals who screen positive for MH issues at jail booking?

Methods:In the spring of 2017, eight county jails assessed the prevalence of individuals with mental illness utilizing an objective screening instrument (Kessler-6; Kessler et al., 2010, 2011), which also included demographic (age, race, gender, housing stability), behavioral health history (co-occurring disorder, COD; prior treatment, community MH client), and criminal/legal history (prior jail stay, current charge, days in jail) information. These individuals were followed through each jail’s process of MH issue identification, referral to jail-based MH services, receipt of MH services, and receipt of MH diversion services. Medicaid encounter data was used to assess community-based MH treatment engagement (TxE) and continuity of care outcomes. Bivariate (chi-square and t-tests) and hierarchical logistic regression models were used to uncover differences by race for MH identification and provision of jail-based and community-based MH services.

Results: A total of 860 individuals with SMI were included in this study: one-third PoC (n=323, 37.6%) and two-thirds White (n=537, 62.4%). Bivariate analysis found that PoC were more likely to be identified with a MH issue (76.8%, White=69.8%,χ²(1)=4.877, p<.05) and receive jail-based services (56.7%, White= 43.9%, χ²(1)=13.038,p<.001) than White individuals; while White individuals were more likely to receive diversion services (10.8%, PoC=5.6%, χ²(1)=6.843, p<.01). For community-based MH TxE, bivariate analysis found differences by race, which benefitted White individuals: MH TxE (51.3%, PoC=29.4%, χ²(1)=12.022,p<.001), substance use (SU) TxE (50.0%, PoC=22.5%, χ²(1)=19.425, p<.001), SU continuity of care (11.7%, PoC=2.0%, χ²(1)=8.062,p<.01), and COD TxE (34.1%, PoC=12.1%, χ²(2)=20.159, p<.001). Five hierarchical regression models were performed to predict the MH outcomes, with race being the predictor variable of concern. After controlling for all other predictors, race was only significant at predicting SU TxE (χ²(1)=7.778,p<.01)and COD TxE (χ²(1)=7.968,p<.01). White individuals had 2.7 times greater odds of engaging in community-based SU treatment (AOR=2.662, p<.01, CI=1.325-5.32), compared to PoC. White individuals also had 3.0 times greater odds of receiving community-based COD services (AOR=2.965, p<.01, CI=1.362-6.452), compared to PoC.

Conclusions: Findings show racial disparities in access to and utilization of MH services, in both jail and community-based settings.Incarceration of individuals with SMI and PoC are overrepresented and underserved; thus, it is essential that jails effectively identify and deliver services to this population. Implications exist for social workers to influence policy and practice within jails and community MH, and strengthen linkages between both systems.