Analysis Underscores Financial Burden Of Mental Illness On Criminal Justice And Health Care Systems

Main Category: Mental Health
Also Included In: Psychology / Psychiatry
Article Date: 12 Nov 2009 - 11:00 PST

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Results from a large, retrospective analysis of inmates with a serious mental illness (SMI) underscores the financial burden of mental illness on the criminal justice and health and human services (HHS) systems, and may provide useful information to policy makers. The results of the analysis, which evaluated patterns of arrest, utilization of services, and corresponding expenditures among nearly 3,800 inmates in a large urban county of Florida, were presented this week at the 137th American Public Health Association (APHA) Annual Meeting & Exposition.

The estimated number of adults with a SMI incarcerated each year is approaching one million.1 Few jails have adequate funding to provide appropriate mental health care for these inmates. As a result, many may receive inadequate treatment and cause management and financial problems while incarcerated. Improved understanding of these individuals, and their diverse histories, problems and needs, may help in developing effective policies and programs.

Analyses from the retrospective data assessed these issues and sought to better understand trends among inmates with a SMI.

"The large size of the studied population allows us to identify trends, which along with other information, could be used to impact public sector expenditures associated with individuals with a SMI who have contact with the criminal justice system." said Robert Constantine, PhD, Associate Professor of Mental Health Law and Policy, University of South Florida, who moderated the session at APHA. "Specifically, this valuable knowledge can be used to create more targeted mental health programming."

At the APHA meeting, researchers presented an overview and selected findings from the Florida data set. The analysis evaluated criminal justice and HHS histories, as well as associated costs to state and local systems, of 3,769 individuals with a SMI.

Key Results and Conclusions

All analyses used data from the County criminal justice system to identify individuals in local jails during fiscal year 2003 - 2004. Participants were followed for one year prior and two years following that timeframe. A variety of state (Medicaid, mental health authority) and local (County health, social service) data sets were used to identify which of these individuals had a SMI.

One analysis looked at patterns of utilization and costs for individuals in this population. Cluster analysis was used along with utilization data to identify groups with similar patterns within and across behavioral health and criminal justice systems. Per capita and aggregate service costs for each group were also determined.

While aggregated costs for criminal justice and HHS were comparable in subjects with a SMI, individual patterns differed significantly. Of note, only 6 percent of those subjects studied with a SMI incurred almost half of the total behavioral health care costs of all subjects with a SMI, including almost two-thirds of inpatient and emergency costs, while also incurring above-average criminal justice costs. Characteristics most strongly and independently associated with this high-intensity service pattern were being older, being male, having been diagnosed with psychotic, bipolar, or substance abuse disorder, and having a history of homelessness. The analysis concluded that distinguishing subpopulations with substantially different profiles of involvement in criminal justice and HHS systems may help in identifying differential strategies for intervention.

Another analysis using the same data set looked at arrest patterns in subgroups of individuals with a SMI, and evaluated differences in the characteristics of these individuals. Latent class growth and multinomial logistic regression analyses were used. Three sub-groups were identified: 1) a group with little or no recidivism beyond the index year, 2) a group with a consistent arrest pattern of about one-half arrest per year, and 3) a group averaging just over four arrests per year. Compared to participants with low/no recidivism, those with some and high recidivism were more likely to be relatively young, men, homeless, and with fewer outpatient and more ER/inpatient mental health contacts. Participants with the highest recidivism were also more likely to have a psychotic, as opposed to Bipolar 1 disorder, and be substance abusers, whereas those with some recidivism were least likely to have undergone an involuntary psychiatric examination. The analysis concluded that identification of sub-populations with different risks of arrests over time provides useful information to policy makers regarding the differential targeting of resources designed to reduce the risk of arrest and increase treatment access.

Ortho-McNeil Janssen Scientific Affairs, LLC provided funding to the University of South Florida/Florida Mental Health Institute (FMHI) for the research study.

About Serious Mental Illness (SMI)

Serious Mental Illness encompasses individuals with schizophrenia, schizoaffective disorder, other psychotic disorders, bipolar 1 disorder, and major depressive or other bipolar and mood disorders. Within the study population, 22 percent of the inmates had psychotic disorders, inclusive of schizophrenia, 29 percent had bipolar 1 disorder, and 31 percent had major depression. These disorders can lead to substantial interference with life activities, basic daily living skills, and functioning in social, family, and vocational/education contexts.

1 Morrissey JP, Cuddeback GS, Cuellar AE, et.al. The role of Medicaid enrollment and outpatient service use in jail recidivism among persons with serious mental illness. Psychiatric Services 58: 794-801, 2007

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Janssen