It is an alarming statistic that more people with serious mental illness are housed in America’s jails than in the nation’s hospitals (Torrey, E. F., Kennard, A. D., Eslinger, D., et al. 2010. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Arlington/Alexandria, VA: National Sheriffs Association and Treatment Advocacy Center). Millions of people with serious mental illness cycle repeatedly through local jails, emergency rooms, shelters, and other public health systems. These individuals are often arrested for non-violent misdemeanors (White House Fact Sheet, Data Driven Justice Initiative, June 30. 2016: https://www.whitehouse.gov/the-press-office/2016/06/30/fact-sheet-launching-data-driven-justice-initiative-disrupting-cycle). It has been estimated that 64% of people in local jails suffer from mental illness, 68% with substance abuse disorder, and 44% with chronic health problems (White House Fact Sheet, Data Driven Justice Initiative, June 30. 2016: https://www.whitehouse.gov/the-press-office/2016/06/30/fact-sheet-launching-data-driven-justice-initiative-disrupting-cycle). Research that has used county and statewide criminal justice data as well as health and social services data has found that the odds of being arrested increase in those who are homeless, those who have had an involuntary psychiatric evaluation (indicating serious mental illness), and those who do not receive outpatient mental health treatment (Constantine, R, Andel, R., Petrila, J., et al. 2010. Characteristics and Experiences of Adults with a Serious Mental Illness Who Were Involved in the Criminal Justice System. Psychiatric Services, 61(5), 451-457). The implications of this state of affairs is quite serious. Even a short stay in a jail may impact someone’s psychological status, employment, family stability, and health (Haney, C., U.S. Department of Health & Human Services. https://aspe.hhs.gov/basic-report/psychological-impact-incarceration-implications-post-prison-adjustment).
Many of these vulnerable individuals are released from prison and re-enter the community in critical need of appropriate treatment to prevent their relapse and recidivism. However, these individuals often do not receive the required care, given that they are faced with an overwhelmed, underfunded, and uncoordinated health system. Lack of timely access to appropriate treatment is essential for this vulnerable population and its absence underpins persistent recidivism. Based on our recent research evidence, we know that receipt of healthcare services within the first 3 months after release from jail significantly reduces the risk of future re-arrest (Falconer E, El-Hay T, Alevras D, et al. Health & Justice, in press). In particular, those who receive case management –including assessment, coordination of services, referral and follow-up services – after they are arrested, have a 50% reduction in the likelihood of being arrested again (Falconer E, El-Hay T, Alevras D, et al. Health & Justice, in press). Also, receiving medical services – including psychiatric assessment, therapy and medication management – can significantly reduce recidivism in this vulnerable population (Falconer E, El-Hay T, Alevras D, et al. Health & Justice, in press).
Not only is it important to ensure that these vulnerable individuals with mental illness and related comorbidities (including substance abuse) receive timely intervention after they are arrested, it is also critical to find ways to identify those who are most at risk and to proactively divert them into appropriate care. Initiatives to identify those individuals with mental illness and divert these people out of the criminal justice system have been successful at reducing incarceration and the burden on the criminal justice system. Miami-Dade County has implemented a jail diversion program that includes a pre-booking brief mental health assessment by a crisis intervention policing team, and diversion to appropriate crisis stabilization services and community-based treatment, as well as post-booking mental health assessment, whereby within 24-48 hours after arrest, misdemeanor defendants with mental illness are diverted to community mental health treatment and timely case management. Between 2010 and 2015 “Miami-Dade police have responded to nearly 50,000 calls for service for people in mental-health crises, but have made only 109 arrests, diverting more than 10,000 people to services or safely stabilizing situations without arrest,” (White House Fact Sheet, Data Driven Justice Initiative, June 30. 2016: https://www.whitehouse.gov/the-press-office/2016/06/30/fact-sheet-launching-data-driven-justice-initiative-disrupting-cycle).
Initiatives such as jail diversion and appropriate coordination of services have the potential to improve the lives of vulnerable, chronically-ill individuals with behavioral health issues, and they also will help to save system costs. Between 2010 and 2015 “the jail population (in Miami-Dade County) fell from over 7,000 to just over 4,700, and the county was able to close an entire jail facility, saving of nearly $12 million a year” (White House Fact Sheet, Data Driven Justice Initiative, June 30. 2016: https://www.whitehouse.gov/the-press-office/2016/06/30/fact-sheet-launching-data-driven-justice-initiative-disrupting-cycle). Research has also shown that overall system costs are lower for adults with serious mental illness who are not arrested; for those on Medicaid in Florida and involved with Florida Department of Children and Families and Florida Department of Law Enforcement, for example, it costs less to administer appropriate mental health treatment than to deal with the cost burden if these individuals were arrested (Van Dorn RA, Desmarais SL, Petrila J, et al. 2013, Psychiatric Services, 64(9), 856-862). In other words, total system costs are less if adults with mental illness are given appropriate mental health treatment services than if they are arrested and required to navigate the criminal justice system.
The need to address the health of vulnerable patient populations who are cycling through the criminal justice system is critical. These high-risk individuals are often homeless, have a chronic mental illness, and are more likely to end up and stay longer in jail than would be the case if they were provided required mental health and social services. At a systems level, this challenge needs to be addressed through a coordinated effort between governmental agencies and criminal justice, and social and behavioral services. At the level of care services delivery, there needs to be an increased awareness of the urgent need to identify these high-risk individuals in a more timely and proactive manner, and to then divert these individuals into appropriate, immediate medical and behavioral health care management.