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Abstract

Research shows criminal justice system involved individuals are more likely to have behavioral health needs. This study analyzes nationally representative data on non-incarcerated individuals with mental disorders. It examines whether having past year criminal justice system involvement was associated with perceiving an unmet need for mental health treatment and the reasons for that unmet need. Results show criminal justice system involved individuals were more likely to report perceived unmet need for mental health treatment (OR = 1.20, p <.001). Among those not receiving mental health treatment, criminal justice system involvement yielded a higher relative risk of identifying affordability as the primary reason for having unmet mental health treatment need (RRR = 1.92, p <.001). Among those receiving mental health treatment, having criminal justice system involvement yielded a higher relative risk of identifying stigma as the primary reason for having unmet need (RRR = 1.99, p <.001).

Key words

Criminal justice, mental health, unmet need

Rates of mental illness and substance use disorders are disproportionately higher among the criminal justice system involved population.1 Mental health conditions have been found to be two to five times higher in the criminal justice system involved population than in the general population,2 and approximately 25% of adults with serious mental illness have criminal justice system involvement.3 Previous research has found that more than 30 percent of individuals with any mental illness perceive an unmet need for mental health treatment even when they have received treatment.4 A study that examined unmet need for treatment of major depression in the general population in the U.S. found that concerns about cost were the major reason for perceived unmet need (46%), regardless of whether or not they had sought treatment.5 However, little is known about perceived unmet mental health care need and the reasons for unmet need among the criminal justice system involved population. This is an important [End Page 214] omission from the literature given the high prevalence of mental illness and the low rate of mental health treatment among this population.6

There have been initiatives to help incarcerated individuals get Medicaid coverage for mental health services upon their release;7,8 however, access to insurance coverage may not be sufficient to meet the needs of the criminal justice system involved population with mental health needs. Inadequate funding and fragmented service delivery may make it difficult for the criminal justice system involved population to navigate the health care system to obtain necessary care.6 However, the literature has documented mixed evidence on the association between criminal justice system involvement and utilization of mental health services, with some studies suggesting an increase in treatment utilization and others showing a barrier to treatment when individuals are involved in the justice system.9,10

While there is an emerging literature on strategies to help criminal justice system involved individuals with mental illness receive mental health treatment,11,12 the extent to which individuals in that population perceive an unmet need and the reasons for their unmet need have not been examined before. The current study expands on previous research efforts through the use of nationwide data to investigate the extent to which criminal justice system involvement among adults (age 18 and over) with any mental illness (AMI) is associated with those individuals having a perceived unmet need for mental health treatment, as well as the reasons for the unmet need.

Data

This study uses data from the 2008–2014 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the non-institutionalized population in the United States conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA). The NSDUH collects detailed information on the use of alcohol and illicit drugs, mental and substance use disorders, and utilization of a variety of behavioral health treatments.13

The NSDUH asks respondents questions about past year psychological symptoms in order to determine if they had AMI in the past year. Any mental illness among adults aged 18 and older is defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) during the year prior to the survey interview.14 The mental health-related questions in the NSDUH are detailed enough to determine AMI by DSM standard (see CBHSQ, 2015 for more information).15 Given that the focus of the current study is on the association of criminal justice system involvement with unmet mental health need and the reasons for that unmet need, the sample is restricted to individuals aged 18 and older with AMI (unadjusted pooled N = 64,000). All estimates are weighted to account for NSDUH's complex survey design and to make the estimates nationally representative (weighted pooled N ≈ 42 million). Comprehensive information on the NSDUH data collection methods and survey design can be found elsewhere.13

Measures

The NSDUH asked all respondents, regardless of mental health status or treatment received, whether during the past 12 months was there a time when they needed mental health treatment or counseling but did not get it. Perceived unmet mental health need was measured based on this question, with a positive response being [End Page 215] coded as 1 and 0 otherwise. Among those who reported needing treatment but not getting it, NSDUH further asked respondents to identify the reasons for not getting treatment from a list of 14 possible answers. For this analysis, these 14 possible answers were grouped into the following six hierarchical, mutually exclusive categories to construct a categorical dependent variable used in the analysis: affordability, treatment access, stigma, treatment not a priority, fear, and other reason. "Affordability" is defined as not receiving treatment because 1) the individual could not afford the cost, 2) his or her insurance did not cover the treatment, or 3) his or her insurance was not enough to cover the cost of treatment. "Treatment access" included not receiving treatment because 1) the individual did not have any transportation, 2) the person did not know where to go for treatment, or 3) the treatment location was too far away. "Stigma" is defined as not receiving treatment because 1) the individual was concerned that his or her neighbors would have a negative opinion, 2) the individual did not want others to know, 3) the individual thought it would have a negative effect on his or her job, or 4) the individual had concerns about confidentiality. "Treatment not a priority" included not receiving treatment because 1) the individual thought he or she could handle the problem without treatment, 2) he or she or did not have time for treatment, or 3) he or she or did not think treatment would help. "Fear" is defined as not receiving treatment because the individual feared he or she would be involuntarily committed for treatment or forced to take medications. Finally, "other reason" is defined as some other reason for not receiving treatment.

The primary independent variable of interest in the empirical model is whether the individual had criminal justice system involvement in the past 12 months. Individuals were defined as having prior-year involvement with the criminal justice system if they reported being either arrested, booked, or on probation or parole in the prior 12 months. The study population does not include currently incarcerated individuals because they are not surveyed by NSDUH. In addition, the NSDUH did not explicitly ask respondents questions about prior jail/prison custody.

The empirical model includes an indicator for health insurance status, which is constructed as a categorical variable with four mutually exclusive categories: private insurance, Medicaid (including those with dual eligibility also enrolled in Medicare), uninsured, and other insurance (such as veteran's benefits and TRICARE). Variables in the analysis also include respondents' demographic characteristics, such as age, gender, race, level of education, employment status, federal poverty level (FPL), marital status, residence in a metropolitan statistical area, geographic region (Midwest, South, West, Northeast), and self-rated physical health status. The Andersen behavioral model16 of health care utilization was used to guide the selection of covariates, and these covariates have also been used in prior studies related to unmet mental health need and the criminal justice system involved population.1,4,17

Methods

To estimate the association of criminal justice system involvement with unmet mental health need, three separate multivariable logistic regression models were estimated to [End Page 216] calculate odds ratios of (i) perceiving an unmet mental health need regardless of whether or not the individual had received any mental health treatment in the past 12 months; (ii) perceiving an unmet mental health need given that the individual had received any mental health treatment in the past 12 months; and (iii) perceiving an unmet mental health need given that the individual had not received any mental health treatment in the past 12 months. Mental health treatment is defined as whether in the past 12 months the respondent had received any inpatient mental health treatment (i.e., staying overnight in a hospital), any outpatient mental health treatment (i.e., treatment at an outpatient mental health clinic/center, or in the office of a private therapist, psychologist, psychiatrist, social worker, counselor, or in a doctor's office, or in an outpatient medical clinic, or in a partial day hospital, or in day treatment program), or was prescribed any psychotropic medication.

Three separate multinomial logistic regressions are also used in the study to estimate the association of criminal justice system involvement with reasons for unmet mental health need stratified by the individual's utilization of mental health treatment services. The three separate regressions are reasons for unmet need regardless of whether the individual received any treatment, reasons for unmet need given that the individual received treatment, and reasons for unmet need given that the individual did not receive any treatment. Multinomial logistic regression models are used because the dependent variable that measures the reasons for unmet need is a categorical variable of more than two unordered, mutually exclusive outcomes. As noted previously, the six categories for perceiving an unmet mental health need are (i) affordability, (ii) treatment access, (iii) stigma, (iv) treatment not a priority, (v) fear, and (vi) other reasons. Treatment not a priority was the reference group for the calculations of the relative risk ratios (RRRs) since this would allow us to estimate the impact of the reasons for not getting treatment that are more likely to be affected by policy. Reasons such as affordability, treatment access, stigma, and fear can be addressed by policy initiatives, whereas it is very unlikely for policy to influence an individual's priorities. For each independent variable, the analysis produces three sets of five RRRs, which show how the relative risk of reporting a particular reason for unmet mental health need changes relative to treatment not a priority as a reason for unmet need as the independent variable of interest (e.g., criminal justice system involvement) changes. We report only the RRRs for criminal justice system involvement (which estimate the association of having criminal justice system involvement relative to no involvement with reasons for unmet mental health need) in modeling five logit models simultaneously: (i) comparing affordability with treatment not a priority as a reason for unmet mental health need, (ii) comparing treatment access with treatment not a priority for unmet mental health need, (iii) comparing stigma as a reason for unmet mental health need with treatment not a priority, (iv) comparing fear with treatment not a priority for unmet mental health need, and (v) comparing other reason with treatment not a priority for unmet mental health need. In other words, the multinomial logistic regression models will produce fifteen RRRs that will indicate how involvement with the criminal justice system affects the reasons for unmet mental health need stratified by individual's receipt of any mental health treatment. [End Page 217]

Results

Descriptive statistics on the study sample and the variables used in the analysis are provided in Table 1. In the overall pooled sample, 7% of respondents reported involvement with the criminal justice system, which translates to a nationally representative weighted estimate of approximately 3 million individuals. Individuals with criminal justice system involvement are younger on average compared to those without any criminal justice system involvement (mean age 36 versus 44) with a greater proportion being males (60% versus 36%). Only 8% of criminal justice involved respondents have a college degree, compared with 28% of non-criminal justice involved respondents. Criminal justice involved individuals are also more likely to have incomes below 138% of the federal poverty level (50% versus 30%) and to be uninsured (38% versus 20%) compared with those without any criminal justice system involvement.

There were significant differences in perceived unmet need for mental health treatment by criminal justice system involvement status (Table 2). More than a quarter (28%) of the individuals with criminal justice system involvement reported perceiving an unmet need for mental health treatment in the past 12 months, regardless of whether or not they had received any mental health treatment. Among those with no criminal justice system involvement, the rate of perceived unmet mental health treatment need was 20% (p <.001). The difference in perceived unmet need between those with criminal justice system involvement and those without is much larger when looking at those who reported receiving any mental health treatment in the past 12 months (40% versus 28%; p <.001). For those who reported not receiving any mental health treatment, perceived unmet need was 19% among those with a criminal justice system involvement and 15% among those with no criminal justice system involvement (p <.001).

For those both with and without criminal justice system involvement overall, affordability was the primary reason for unmet mental health treatment need, followed by treatment not a priority for the non-criminal justice-involved population and stigma for the criminal justice system involved population. A similar pattern in reasons for unmet mental health treatment need is observed for the sample who received mental health treatment. However, when looking at those with no mental health treatment, affordability remains the primary reason for unmet mental health treatment need among the criminal justice system involved population, but treatment not a priority becomes the most common reason for unmet mental health treatment need for the non-criminal justice system involved population.

Table 3 presents estimates from the three logistic regression models that account for an extensive set of control variables. Estimates indicate that compared with individuals with no criminal justice system involvement, criminal justice system involved individuals have higher odds of perceiving an unmet mental health treatment need, regardless of whether they have received any mental health treatment (OR = 1.20; p <.001). Criminal justice system involvement is also associated with higher odds of perceiving an unmet mental health treatment need when the individual reports receiving any mental health treatment in the past 12 months (OR = 1.22; p <.001) and also when the individual reports not receiving any mental health treatment (OR = 1.18; p <.05). Other correlates that had a significant impact on perceiving an unmet need [End Page 218]

Table 1. DESCRIPTIVE STATISTICS FOR 2008–2014 NSDUH RESPONDENTS 18 AND OLDER WITH ANY MENTAL ILLNESS (WEIGHTED PERCENTAGE, STANDARD ERROR)
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Table 1.

DESCRIPTIVE STATISTICS FOR 2008–2014 NSDUH RESPONDENTS 18 AND OLDER WITH ANY MENTAL ILLNESS (WEIGHTED PERCENTAGE, STANDARD ERROR)

[End Page 219] for treatment included the respondent's age, gender, and health insurance status. Older individuals have lower odds of perceiving an unmet need for mental health treatment. Females have higher odds than males of perceiving an unmet mental health treatment need. Compared with uninsured individuals, those with private insurance, Medicaid, and other insurance had lower odds of perceiving an unmet need for mental health treatment. (Other insurance is not significant in the analysis of individuals who did not receive treatment.)

Table 4 presents the estimates for the multinomial regression models that control for the same set of variables as the logistic regression models. For the purpose of brevity and since the control variables exhibit similar results, only the RRR for the criminal justice system involvement variable is presented, but the results from the fully specified models are available from the authors upon request. Having criminal justice system involvement yields a higher relative risk of identifying affordability (RRR = 1.52; p <.001), stigma (RRR = 1.68; p <.001), and fear (RRR = 1.48; p <.01) as reasons for perceiving an unmet mental health treatment need, compared with not having criminal justice system involvement and identifying treatment not a priority as the reason for unmet mental health need. For those who reported receiving any mental health treatment, criminal justice system involvement was associated with identifying stigma as a reason for perceiving an unmet need for mental health treatment (RRR = 1.99; p <.001). None of the other reasons had a statistically significant association. However, for those who reported not receiving any mental health treatment, only affordability had a statistically significant association (RRR = 1.92; p <.001). [End Page 220]

Table 2. UNMET MENTAL HEALTH NEED AND REASONS FOR UNMET NEED AMONG THOSE 18 AND OLDER WITH ANY MENTAL ILLNESS BY CRIMINAL JUSTICE SYSTEM INVOLVEMENT STATUS
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Table 2.

UNMET MENTAL HEALTH NEED AND REASONS FOR UNMET NEED AMONG THOSE 18 AND OLDER WITH ANY MENTAL ILLNESS BY CRIMINAL JUSTICE SYSTEM INVOLVEMENT STATUS

Discussion

Using data from the 2008–2014 NSDUH, this study explored the relationship between criminal justice system involvement and unmet need for mental health treatment among individuals with AMI. In addition, the study also examined the association between criminal justice system involvement and the reasons for unmet mental health need. Unmet mental health need and reasons for unmet mental health need were also examined [End Page 221]

Table 3. LOGISTIC REGRESSION ESTIMATES OF CRIMINAL JUSTICE SYSTEM INVOLVEMENT &amp; UNMET MENTAL HEALTH TREATMENT NEED (ODDS RATIO, CONFIDENCE INTERVAL) Notes: *** p &lt; .001; ** p &lt; .01; * p &lt; .05
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Table 3.

LOGISTIC REGRESSION ESTIMATES OF CRIMINAL JUSTICE SYSTEM INVOLVEMENT & UNMET MENTAL HEALTH TREATMENT NEED (ODDS RATIO, CONFIDENCE INTERVAL)

Notes: *** p < .001; ** p < .01; * p < .05

[End Page 223] for those receiving any mental health treatment in the past 12 months and for those who did not receive any mental health treatment in the past 12 months. The analysis finds that criminal justice system involvement is associated with perceived unmet mental health need in the study population overall, as well as among those who have received mental health treatment and also among those not receiving any treatment. For those who did not receive treatment, criminal justice system involvement was associated with a higher relative risk of reporting affordability as the primary reason for perceiving an unmet need for treatment. Criminal justice system involvement was associated with a higher relative risk of identifying stigma as the primary reason for perceiving an unmet need for treatment among those who received mental health treatment.

Table 4. MULTINOMIAL LOGISTIC REGRESSION ESTIMATES OF CRIMINAL JUSTICE SYSTEM INVOLVEMENT AND REASON FOR UNMET MENTAL HEALTH NEED (RELATIVE RISK RATIOS, CONFIDENCE INTERVAL) Notes: *** p &lt; .001; ** p &lt; .01; * p &lt; .05; Reference Category: Treatment Not A Priority
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Table 4.

MULTINOMIAL LOGISTIC REGRESSION ESTIMATES OF CRIMINAL JUSTICE SYSTEM INVOLVEMENT AND REASON FOR UNMET MENTAL HEALTH NEED (RELATIVE RISK RATIOS, CONFIDENCE INTERVAL)

Notes: *** p < .001; ** p < .01; * p < .05; Reference Category: Treatment Not A Priority

The finding that 40% of those with criminal justice system involvement who received treatment in the past 12 months perceived an unmet need for mental health treatment is concerning and worthy of further examination. It may reflect dissatisfaction with the adequacy, responsiveness, and/or quality of services some patients are receiving. It is also possible that it reflects a greater understanding among individuals concerning what their needs are and a desire to receive more services.

Saloner et al.1 reported evidence of a notable increase in health insurance among the criminal justice system involved population with a substance use disorder in 2014, and notes that this increase in insurance rate indicates that some aspects of recent health care reforms might benefit not just the general population but also the criminal justice system involved population with a substance use disorder. Although Saloner et al.1 [End Page 224] did not study individuals with mental illness, their study potentially has important implications for this analysis. The finding that individuals with criminal justice system involvement who did not receive mental health treatment are more likely to report affordability (e.g., lack of health insurance coverage or insurance not covering the cost of treatment) as the reason for their unmet mental health need implies that increased insurance coverage among this population might help mitigate the affordability barrier. Individuals with criminal justice system involvement living in the community can face many barriers, including barriers to housing, employment, and financial aid. Criminal justice-involved individuals who seek treatment for mental illness may become concerned that additional treatment seeking will cause further stigmatization and associated barriers. The finding that among those who reported receiving mental health treatment, having criminal justice involvement yielded a higher relative risk of identifying stigma as the primary reason for having an unmet mental health treatment need suggests that this group is likely to benefit from greater outreach, awareness, and early intervention efforts.

In the current study, data limitations in the NSDUH precluded further analyses of responses regarding unmet need. Individuals who report receiving mental health treatment but also having unmet need for treatment are not asked follow-up questions regarding the type, duration, or setting of their treatment, or regarding their satisfaction with the provider or treatment they received. Further, individuals who indicated that they had an unmet need could be referring to a single episode or to a long-standing problem. Additionally, the NSDUH does not distinguish between whether the perceived unmet need or the treatment occurred first. In addition, the data do not permit analysis of the type and severity of the criminal offense, when mental health treatment occurred relative to the individual's involvement in the criminal justice system, and whether the treatment was court-mandated. The study does not reflect the experiences of individuals who were incarcerated at the time of the survey because these individuals are not included in the NSDUH survey population.

A recent case study of three states—Arizona, Connecticut, and Massachusetts—examined a number of initiatives not only to connect the justice system involved population to health care coverage but also to provide further assistance, such as appointment scheduling, services referral, identification of providers who demonstrate cultural competence in interacting with criminal justice system involved individuals, and provision of medication. These approaches have increased coverage and access to care for individuals with criminal justice system involvement and have resulted in savings to states.18

The findings of the current study highlight an important issue for researchers and policymakers—the extent to which adults who have had involvement in the criminal justice system subsequently receive mental health treatment, whether they feel that such treatment adequately meets their needs, and the reasons they report experiencing an unmet need for mental health treatment. Understanding the experience of adults who are involved in the criminal justice system and who have mental health conditions for which they seek treatment may have important implications for improving and developing innovative interventions to prevent recidivism19 and improve the individual's quality of life. [End Page 225]

Mir M. Ali, Judith Teich, and Ryan Mutter

MIR M. ALI, JUDITH TEICH, and RYAN MUTTER are all affiliated with the Center for Behavioral Health Statistics and Quality in the Substance Abuse and Mental Health Services Administration, an agency of the U.S. Department of Health and Human Services.

Mir M. Ali, PhD, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20852; Email: mir.ali@samhsa.hhs.gov, Phone: 240-276-1336, Fax: 240-276-1260.

Acknowledgment

The views expressed here are those of the authors and do not necessarily reflect the views of the Substance Abuse and Mental Health Services Administration.

References

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7. Wenzlow AT, Ireys HT, Mann B, et al. Effects of a discharge planning program on Medicaid coverage of state prisoners with serious mental illness. Psychiatr Serv. 2011 Jan;62(1):73–8 https://doi.org/10.1176/ps.62.1.pss6201_0073 PMid: 21209303
8. Bandara SN, Huskamp HA, Riedel LE, et al. Leveraging the Affordable Care Act to enroll justice-involved populations in Medicaid: state and local efforts. Health Aff (Millwood). 2015 Dec;34(12):2044–51. https://doi.org/10.1377/hlthaff.2015.0668 PMid: 26643624
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13. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings. Rockville, MD: U.S. Department of Health and Human Services, 2014 Available at: https://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf
14. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed.) Arlington, VA: American Psychiatric Association, 2000. Available at: https://dsm.psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890420249.dsm-iv-tr
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Additional Information

ISSN
1548-6869
Print ISSN
1049-2089
Pages
214-227
Launched on MUSE
2018-02-27
Open Access
No
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