PSYCHIATRIC SERVICES f ps.psychiatryonline.org f June 2009 Vol.60 No.6 7 6 1 A ccording to the Bureau of Jus- tice Statistics, during the 12 months ending at midyear 2007, there were 13 million admis- sions to local jails in the United States (1). At midyear 2007, local jails held 673,697 adult males and 100,047 adult females 4figures that represent increases of 24.0% and 42.1%, re- spectively, since midyear 2000. The majority of these jail inmates were pretrial detainees (1).
Prisoners have a constitutional right to adequate health care, includ- ing mental health treatment (2 34), and the growth of local correctional populations has strained the limited capacity of jails to respond to the health needs of inmates (5). The situ- ation is particularly challenging in the case of inmates with serious mental illnesses, who require specialized treatment and services (6). There has been consistent evidence that per- sons with mental illnesses are over- represented in jails, and determining the extent of these higher rates is a first step to improved jail manage- ment and the development of alterna- tives to incarceration.
Prevalence estimates of mental ill- nesses in U.S. jails have varied widely depending on methodology and set- ting. Using survey methodology, ... more. less.
a 1999 report from the Bureau of Jus- tice Statistics (BJS) estimated that 16.3% of jail inmates reported either a cmental condition d or an overnight stay in a mental hospital during their lifetime (7).<br><br> In 2006 BJS reported that 64% of jail inmates had a recent cmental health problem d (8). The 2006 findings were based on personal interviews conducted in the 2002 Survey of Inmates in Local Jails, and the rate of 64% included all inmates who reported one or more symptoms of any mental illness. Data on func- tional impairment and duration of ill- ness were not collected, and inmates were not excluded if their symptoms were a result of general medical con- ditions, bereavement, or substance use (8).<br><br> Although the methods used in this study are not consistent with other efforts to establish the preva- lence of mental illnesses in jails, the findings are often, and mistakenly, cited as evidence of an escalating problem. More recently, Trestman and colleagues (9) evaluated a cohort of inmates who were not identified at intake as having a mental illness and found that over two-thirds met crite- ria for a lifetime psychiatric disorder, including anxiety disorders and anti- social personality disorder. Prevalence of Serious Mental Illness Among Jail Inmates H e n r y J .<br><br> S t e a d m a n , P h . D . F r e d C .<br><br> O s h e r , M . D . P a m e l a C l a r k R o b b i n s , B .<br><br> A . B r i a n C a s e , B . A .<br><br> S t e v e n S a m u e l s , P h . D . Dr.<br><br> Steadman, Ms. Robbins, Mr. Case, and Dr.<br><br> Samuels are affiliated with Policy Research Associates, Inc., 345 Delaware Ave., Delmar, NY 12054 (e-mail: firstname.lastname@example.org). Dr. Osher is with the Council of State Governments Justice Center, Bethesda, Maryland.<br><br> Objective: This study estimated current prevalence rates of serious mental illness among adult male and female inmates in five jails during two time periods (four jails in each period). Methods: During two data collection phases (2002 32003 and 2005 32006), recently admitted in- mates at two jails in Maryland and three jails in New York were select- ed to receive the Structured Clinical Interview for DSM-IV (SCID). Se- lection was based on systematic sampling of data from a brief screen for symptoms of mental illness that was used at admission for all inmates.<br><br> The SCID was administered to a total of 822 inmates 4358 during phase I and 464 during phase II. To determine the current (past-month) prevalence of serious mental illness (defined as major depressive disor- der; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; schizophrenia spectrum disorder; schizoaf- fectivedisorder; schizophreniform disorder; brief psychotic disorder; delusional disorder; and psychotic disorder not otherwise specified), in- terview data were weighted against strata constructed from the screen- ing samples for male and female inmates by jail and study phase. Results: Across jails and study phases the rate of current serious mental illness for male inmates was 14.5% (asymmetric 95% confidence interval [CI]=11.0% 318.9%) and for female inmates it was 31.0% (asymmetric CI=21.7% 342.1%).<br><br> Conclusions: The estimates in this study have pro- found implications in terms of resource allocation for treatment in jails and in community-based settings for individuals with mental illness who are involved in the justice system. Psychiatric Services 60:761 3765, 2009) REPRINTED WITH PERMISSION The most rigorous data on the prevalence of mental disorders among both male and female jail in- mates were collected by Teplin, Abram, and McClelland (10 314) in the 1980s and 1990s in Cook County (Chicago), Illinois. The data were col- lected for the purpose of measuring severe mental disorders, which are not comparable to broader estimates of serious mental illness.<br><br> These re- searchers used the National Institute of Mental Health Diagnostic Inter- view Schedule with stratified random samples of inmates awaiting trial in the Cook County Department of Cor- rections and estimated rates of cur- rent (two-week) severe mental disor- ders to be 6.4% for male inmates (12) and 12.2% for female inmates (11). The study reported here sought to estimate current prevalence rates of serious mental illness at two jails in Maryland and three jails in New York during two time periods. These in- mates would constitute the group that meets constitutional requirements for jail mental health services and for whom aggressive discharge planning would be a priority (15).<br><br> Data from a screen for mental illness were collect- ed for all inmates who were booked into the jails during the data collection phases, and a portion of those screened were selected through systematic sam- pling for administration of the Struc- tured Clinical Interview for DSM-IV (SCID). Prevalence rates were esti- mated through a weighting procedure whereby the data were organized into strata by gender, phase, and jail. The original purpose of gathering the data used in this study was to validate and refine a mental health screen for cor- rectional officers to administer to jail inmates at intake (16,17).<br><br> Methods From large samples of recently admit- ted jail inmates who were screened with the Brief Jail Mental Health Screen (BJMHS), subgroups were se- lected and the SCID was administered to them. Results for the subsamples were weighted back to the larger screened samples in order to estimate current prevalence rates of serious mental illness. Because the original purpose of data collection was to vali- date the BJMHS, systematic sampling methods were used to select individu- als for the SCID subsamples in order to obtain an adequate sample of in- mates who screened positive and a suf- ficient number of female inmates to enable a separate gender analysis.<br><br> Data collection The BJMHS was developed as a jail in- take screen to determine whether an inmate should be referred for further mental health evaluation. The BJMHS was validated during two phases of data collection. During phase I (May 2002 through January 2003) the origi- nal eight-item screen was validated at two county jails in Maryland (Mont- gomery County and Prince George 9s County) and two county jails in New York (Albany County and Rensselaer County).<br><br> For phase II (November 2005 through June 2006) a revised 12- item version of the screen was tested at the same jails in Maryland and at the Rensselaer County jail, but the Mon- roe County jail in New York was sub- stituted as the fourth site. During both phases, the screen was administered to inmates during intake, except for Monroe County in phase II, where screens were administered within 24 hours of intake after the initial court appearance (17). SCID The SCID is a semistructured clinical interview designed to assess the pres- ence of selected DSM-IV axis I diag- noses (18).<br><br> The instrument is adminis- tered by a trained clinical interviewer or mental health professional and uses a modular format with skip patterns within diagnostic sections. When crite- ria for a given diagnosis are met, the diagnosis is scored in terms of its life- time prevalence and its presence in the past month. For the phase I and phase II data collections, a subset of modules were administered.<br><br> For this study, serious mental illness was defined as the presence of one or more of the following diagnoses in the past month: major depressive disor- der; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; schizophrenia spectrum disorder; schizoaffective dis- order; schizophreniform disorder; brief psychotic disorder; delusional disorder; and psychotic disorder not otherwise specified. There were no measures of functional impairment. As soon as inmates were classified into those who screened positive and those who screened negative, clinical research interviewers who were blind to the inmates 9 sampling group status approached the inmates on their list of potential participants.<br><br> Participation in both phases was voluntary. Informed consent forms approved by the institu- tional review board of Policy Research Associates, Inc., were required and ob- tained for all SCID subsample partici- pants. Participants were informed that the decision to participate would not affect their stay in the jail, and a brief quiz was administered to assess com- petency to consent.<br><br> All SCID inter- views occurred within 72 hours of an inmate 9s admission to the jail but typi- cally not within the first eight hours. In both phases the overall refusal rate of inmates approached for the SCID interview was 31% (16,17). In phase I women were more likely than men (p<.05) to refuse when ap- proached for an interview, and in phase II the refusal rate was particu- larly high in the Prince George 9s County jail 4126 of 228 inmates (55%) who were approached refused to participate.<br><br> The refusal rate was likely due to the fact that compensa- tion was not offered to SCID sample participants at this jail and to the con- straints imposed by the jail on sched- uling and conducting interviews. However, because the results of all analyses are presented by gender and by jail and because no significant dif- ferences were found between those who refused and those who consented in Prince George 9s County, there are no biases on these two factors. Interviewer training Nine clinical research interviewers were trained for phase I, and 16 were trained for phase II.<br><br> Many of the phase I interviewers also participated in phase II. During each phase, inter- viewers participated in a two-day on- site training in administration of the SCID by a certified SCID instructor. Interviewers practiced with acquain- tances and volunteer psychiatric pa- tients.<br><br> Interrater reliability ( ± =.964) was ensured by having each interview- er complete two reliability tapes, PSYCHIATRIC SERVICES f ps.psychiatryonline.org f June 2009 Vol.60 No.6 7 6 2 REPRINTED WITH PERMISSION which were scored. Interviewers were also observed while conducting inter- views in the jails. Data analysis All data management and analyses were conducted in SPSS (version 12) or Stata (release 10).<br><br> Weighted preva- lence estimates and confidence inter- vals were computed with the survey procedures in Stata (release 10). Weighting Persons who were screened by the BJMHS (a cpopulation d) were grouped into strata defined by study phase, jail, gender, and BJMHS result (positive or negative). Those who also were administered the SCID (the csample d) were classified into the same strata.<br><br> Each person in the SCID subsample received a selection weight W=(N/n), where N was the number of population members in the person 9s population stratum and n was the number in the person 9s SCID sample stratum. If a certain number 4repre- sented by ca d 4of those who also were administered the SCID are classified as having serious mental illness, then the estimated prevalence in the stra- tum is p=a/n and the estimated num- ber of population members with seri- ous mental illness in the stratum is A=(N/n)a=Np.These stratum num- bers were added to form the numera- tors and were divided by the known population totals to get estimated prevalence rates. Confidence intervals for specific rates for jail, phase, and gender were based on the assumption that within strata individuals were se- lected for the SCID by systematic sampling.<br><br> This was at best an approxi- mation. The pooled gender-specific rates compute confidence intervals by treating jails as sampled clusters. The intervals were computed on the logit scale and transformed to the probabil- ity scale (19) and were asymmetric.<br><br> Screening samples Phase I. Screening data were collected from 11,438 male and female jail in- mates admitted to one of four county jails from May 2002 through January 2003. Valid data were obtained for 11,168 inmates.<br><br> The percentage with positive scores on the eight-item BJMHS ranged from an overall high of 14% (N=399) in Prince George 9s County to an overall low of 9% (N=287) in Albany County. Phase II. Between November 2005 and June 2006 a total of 10,562 in- mates admitted to one of the four county jails were screened with the 12-item BJMHS.<br><br> Valid data were ob- tained for 10,240 inmates. The per- centage of screened inmates classi- fied as positive on the basis of scoring for the eight-item BJMHS ranged from 24% (N=296) in Monroe Coun- ty to 9% (N=880) in Montgomery County. The high positive rate in Monroe County is due to the large PSYCHIATRIC SERVICES f ps.psychiatryonline.org f June 2009 Vol.60 No.6 7 6 3 T a b l e 1 Inmates at four jails who screened positive or negative on the Brief Mental Health Jail Screen (BJMHS) and rates of serious mental illness among those selected for assessment with the Structured Clinical Interview for DSM-IV (SCID), by gender and study phase BJMHSSCID-diagnosed serious mental illness PositiveNegativeBJMHS Selected for SCIDSelected for SCIDPositiveNegative Gender, phase, TotalTotal and county jailNN%NN%N%N% Male inmates Phase I Montgomery2751873,092311739516 Prince George 9s3231442,26835264339 Rensselaer871517987303747517 Albany20127132,4844121867717 Phase II Montgomery2711663,34542174425 Prince George 9s6891012,88644255025 Rensselaer656954327535027 Monroe1031717723446635614 All2,014123616,328294259483211 Female inmates Phase I Montgomery1131412326247750521 Prince George 9s7645256125250433 Rensselaer3592615626178891039 Albany86242840334811461544 Phase II Montgomery1002121442751710481115 Prince George 9s191158375308640517 Rensselaer501326711825646422 Monroe193371919349251643510 All844137162,2222681266485922 REPRINTED WITH PERMISSION proportion of female inmates and the consistently higher number of posi- tive scores for women.<br><br> SCID samples The SCID was administered to a total of 822 inmates 4358 during phase I and 464 during phase II. In both phas- es, women and inmates who screened positive were approached in larger numbers for an interview. Across the four jails, a total of 147 (41%) women were interviewed in phase I, and 258 (56%) women were interviewed in phase II.<br><br> Of the inmates in the SCID subsample, 125 (35%) at phase I and 135 (29%) at phase II had screened positive on the basis of the eight-item BJMHS. Among both men and women, consistently higher rates of se- rious mental illness were observed for those who screened positive, which was expected given the predictive ac- curacy of the BJMHS (16,17). Results Prevalence of mental illness Table 1 shows the results of screening at the four jails by phase and by gen- der as well as the SCID results for the subsamples.<br><br> Table 2 presents the weighted prevalence and asymmetric 95% confidence intervals (CIs) of current serious mental illness in the jails by gender and phase. The weighted es- timates adjust for oversampling in the SCID subsample of women and of inmates who screened positive and provide accurate estimates of the prevalence of serious mental ill- ness. Data from all four jails were used for analysis in each phase.<br><br> The same analysis using just the three jails that participated in both phases yielded results that were not signifi- cantly different. Male inmates. Prevalence of serious mental illness among male inmates in phase I ranged from 12.8% in Prince George 9s County to 20.8% in Albany County, with an overall rate of 17.5%.<br><br> In phase II prevalence of serious men- tal illness for men ranged from 7.7% in Montgomery County to 16.3% in Monroe County, with an overall rate of 11.1%. Analysis of pooled data from the two phases yielded an estimated 14.5% prevalence rate of serious men- tal illness among male jail inmates. The addition of posttraumatic stress disorder (PTSD) as a serious mental illness increased the estimate to 17.1% (asymmetric CI=3.2% 321.8%).<br><br> Female inmates. Estimated rates of serious mental illness among female inmates in phase I ranged from 28.3% in Montgomery County to 47.7% in Rensselaer County, with an overall rate of 38.3%. Phase II results for women were slightly lower, with prevalence rates ranging from 20.7% in Montgomery County to 32.1% in Rensselaer County and an overall rate of 24.4%.<br><br> Analysis of pooled data from the two phases yielded a prevalence rate of 31% among female jail inmates. As with the male inmates, the addition of PTSD as a serious mental illness raised the prevalence rate among fe- male inmates only modestly to 34.3% (asymmetric CI=24.4% 345.7%). Discussion The final, weighted prevalence rates of current serious mental illness for re- cently booked jail inmates were 14.5% for men and 31.0% for women across the jails and study phases.<br><br> When these estimates are applied to the 13 million annual jail admissions in 2007, assum- ing that the proportion of female ad- missions was 12.9%, there were about two million (2,161,705) annual book- ings of persons with serious mental ill- nesses into jails. If a primary SCID di- agnosis of PTSD was included as a se- rious mental illness, the weighted esti- mates increased to 17.1% for men and 34.3% for women. The estimated prevalence rates among female inmates found in this study were double those for male in- mates.<br><br> This gender difference is par- ticularly important given the rising number and proportion of female in- mates in U.S. jails (1). The estimated prevalence among female inmates is higher whether or not current PTSD is included as a serious mental illness.<br><br> These prevalence estimates pro- vide evidence for what jail staff al- ready know to be true: the volume of inmates entering jails with serious mental illnesses is substantial. One possible explanation for the high esti- mates is limited access to community behavioral health services (20). We believe that rates for male and fe- male inmates could be applied to a particular jail to yield a reasonable estimate for planning purposes.<br><br> Us- ing these estimates, jail administra- tors can likely anticipate that the prevalence of serious mental illness will be between 11.0% and 18.9% among men and between21.7% and 42.1% among women, with a 14.5% average among men and a 31.0% av- erage among women. Several limitations of this study are noteworthy. Because no measure of functional impairment was used, it is unclear whether these individuals met federal and state definitions of serious or severe mental illness (21).<br><br> In addi- tion, the definition of serious mental illness did not include some axis I dis- orders that can be very severe, such as anxiety disorder. Similarly, some axis II PSYCHIATRIC SERVICES f ps.psychiatryonline.org f June 2009 Vol.60 No.6 7 6 4 T a b l e 2 Weighted prevalence rates of serious mental illness among inmates at four jails, by gender and study phase a Gender, phase, and county jail%95% CI Male inmates Phase I Montgomery18.08.8 333.4 Prince George 9s12.86.1 325.2 Rensselaer19.19.4 335.0 Albany20.810.3 337.5 Total17.512.5 324.0 Phase II Montgomery7.73.5 316.0 Prince George 9s13.36.3 326.0 Rensselaer12.05.6 323.7 Monroe16.37.9 330.9 Total11.16.1 319.5 Both phases (pooled data)14.511.0 318.9 Female inmates Phase I Montgomery28.314.7 347.5 Prince George 9s37.120.5 357.5 Rensselaer47.728.5 367.6 Albany44.425.9 364.6 Total38.325.4 353.1 Phase II Montgomery20.710.3 337.4 Prince George 9s24.512.5 342.6 Rensselaer32.117.1 352.0 Monroe26.713.8 345.5 Total24.419.4 330.1 Both phases (pooled data)31.021.7 342.1 a Rates are based on the number of inmates given a diagnosis of a serious mental illness on assessment with the Structured Clinical Inter- view for DSM-IV The percentages are weight- ed to reflect the total population at each jail. Confidence intervals are asymmetric.<br><br> REPRINTED WITH PERMISSION disorders, such as borderline personal- ity disorder, can also be severe, and none were included. On the other hand, only a small proportion of the overall SCID subsample who were deemed to have a serious mental ill- ness received a primary diagnosis of depressive disorder not otherwise specified (four inmates, or 1.9%) Although some variation was noted across the jails and study phases, the estimates were consistent. The reason for the variation is unclear because the same screening and diagnostic inter- view, and in many cases the same in- terviewers, were employed during both phases.<br><br> We examined other fac- tors, such as differences or changes in racial composition, as possible reasons for the differences among jails or phas- es, but none were found. Conclusions There is broad consensus that jails are not the optimal settings to provide acute psychiatric treatment. In line with the recommendations of the Criminal Justice/Mental Health Con- sensus Project report (22) and the President 9s New Freedom Commis- sion on Mental Health (23), many communities have instituted mecha- nisms to divert individuals with serious mental illnesses from the front door of the jail to community-based services or have established linkages to services by way of transition planning at the back door.<br><br> Since a 1992 survey esti- mated that only 52 jail diversion pro- grams operated in the United States (24), there has been a rapid expansion of specialized law enforcement 3based responses (25), problem-solving men- tal health courts (26), and specialized probation models (27) aimed at reduc- ing the prevalence of individuals with mental illnesses in jail settings. Such expansion has been supported by an array of state and federal grant pro- grams, including the Criminal Justice, Mental Health and Substance Abuse Reinvestment Act in Florida; the Mental Health Courts Program and the Justice and Mental Health Collab- oration Program of the Bureau of Jus- tice Assistance; and the Targeted Ca- pacity Expansion for Jail Diversion Programs and the Jail Diversion and Trauma Recovery 3Priority to Veterans initiatives of the Substance Abuse and Mental Health Services Administra- tion. Nonetheless, the substantial presence of individuals with serious mental illnesses in our country 9s jails, as estimated in this study, calls for a clearer explication of the contributing factors and discussion of appropriate responses.<br><br> Acknowledgments and disclosures This research was partly supported by a contract from the Council of State Governments. The original data were collected under grants 2001- IJ-CX-0030 and 2005-IJ-CX-0004 from the Of- fice of Justice Programs, National Institute of Justice, U.S. Department of Justice.<br><br> The points of view in this article are those of the authors and do not necessarily represent the official positions or policies of the U.S. Department of Justice. The authors report no competing interests.<br><br> References 1.Sabol WJ, Minton TD: Jail Inmates at Mid- year 2007. Washington, DC, Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2008 2.Cohen F, Dvoskin J: Inmates with mental dis- orders: a guide to law and practice. 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