Jail, Mental Illness and Health: Finding the Safest, Healthiest Options

Feb 25, 2013, 5:57 PM

Allison Robertson, Duke University Allison Robertson, Duke University

At the recent Public Health Law Research Program annual meeting in New Orleans, Duke University assistant professor Allison Robertson, PhD, MPH, presented research on the value of diverting some offenders with serious mental illness to treatment instead of incarceration. NewPublicHealth spoke with Robertson about her research outcomes.

NewPublicHealth: Can you explain the current practice of jail diversion that prompted you to do your study?

Allison Robertson: The broad goal is to identify eligible adults with serious mental illness who are charged with criminal offenses, and offer them the opportunity to participate in community treatment as an alternative to proceeding along the prosecution pathway. If program participants adhere to the treatment plan and avoid new offenses, the original changes are often eventually dropped. Post-booking jail diversion programs are excellent opportunities to help adults with serious mental illness get off the criminal-justice pathway and instead be linked to needed mental health care in the community. 

In some cases, and for various reasons, diversion program participants spend a brief period of time in jail in the pre-trial phase before they are formally diverted to the community. Our study of an innovative, statewide jail diversion program in Connecticut aims to understand if brief incarcerations before being diverted to the community improved participants’ mental health and criminal justice outcomes. Anecdotal reports have indicated that some judges opt to have some participants spend a short time in jail before offering them the jail diversion opportunity as a way to enhance their motivation to accept the offer and fully engage in the program once diverted, with the idea that this could ultimately reduce their likelihood of reoffending and thereby avert convictions and potentially lengthy prison sentences.

NPH: What was the scope of your study?

Allison Robertson: We analyzed administrative records from public behavioral health and criminal justice agencies for 204 adults with serious mental illness (SMI) who participated in Connecticut's jail diversion program in fiscal years 2006 and 2007. We estimated the effect of brief, pre-diversion incarcerations (or “jail first”) on a set of  outcomes: community treatment adherence, use of crisis-driven health care (psychiatric hospitalization and emergency department visits), and reoffending (re-arrest and re-incarceration). 

NPH: What did you expect the findings might be?

Allison Robertson: If “jail first” works as intended, we would expect it to be associated with reductions in post-diversion crisis-driven health care use and reoffending.  Conversely, if "jail first" were detrimental to these adults with SMI (for example, if it were traumatizing or engendered distrust in the judicial system), it could be associated with worst post-diversion outcomes as compared to their counterparts who were diverted straight to the community with no jail time first.

NPH: And what were the preliminary findings?

Allison Robertson: Our analyses have demonstrated that the “jail first” condition was associated with improved community treatment adherence, including use of psychotropic medication and targeted outpatient treatment services. The improvements in treatment adherence, however, did not extend to our main outcomes of interest – crisis-driven health care use and reoffending. For those outcomes we found no significant differences between the group who had some jail before diversion and those who were diverted straight to the community. 

So, brief jail time before diversion did appear to improve community treatment adherence once diverted, which could be interpreted as a benefit. That could relate to enhanced motivation, but it could also be that the short time in jail before being diverted to the community allowed the participant an opportunity to stabilize – getting them back on needed psychotropic medications, detoxing from acute intoxication, or even just getting food and sleep – which could set them up for better treatment adherence once they made the transition back to the community. However, the observed improvement in treatment adherence for the "jail first" group was not sufficient to improve participants’ post-diversion use of crisis-driven health care or criminal justice outcomes.

NPH: What are the policy implications of this study?

Allison Robertson: Policymakers could use these results to begin considering ways in which to limit the frequency with which jail diversion participants spend some time in jail before being diverted to the community, and how those averted incarceration costs could be spent differently to support this vulnerable population’s often intensive needs for treatment and social support services.

Individuals with SMI face many complex needs, including housing and employment; and high quality, consistently available, integrated substance abuse treatment for the large majority justice-involved adults with SMI who also have substance use disorders.

This commentary originally appeared on the RWJF New Public Health blog.