Psychology: Drugs, Society & Human Behavior
Psychology: Drugs, Society & Human Behavior
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Journalarticalassignment.docx
1) What is a co-occuring disorder (COD)? What are some of the challenges facing people diagnosed with COD? Psychology: Drugs, Society & Human Behavior
2) How effective are jails, prisons and other justice settings in treating substance abuse disorders?
3) Describe the procedures the researchers used in conducting their study?
4) Describe the racial disparities that the researchers discovered in conducting their study.
5) Describe how prior substance abuse treatment impacted future treatment for offenders.
Behavioral Health Treatment History Among Persons in the Justice System: Findings From the Arrestee Drug Abuse Monitoring II Program
Elizabeth Hunt and Roger H. Peters University of South Florida
Janine Kremling California State University–San Bernardino
Objective: Despite the high prevalence of substance use disorders, mental disorders, and co-occurring disorders among persons in the justice system, there is a fairly low rate of treatment utilization among this population. This study explored rates of lifetime behavioral health treatment utilization and factors associated with involvement in treatment. Methods: The study examined data from the Arrestee Drug Abuse Monitoring II program from 2007 to 2010, including over 18,000 arrestees in 10 U.S. metropolitan jails. Logistic regression and �2 analyses were used to explore the relationship between self-reported lifetime treatment history and sociodemographic characteristics, self-reported substance use, and severity of substance use. Results: Over half of arrestees reported no history of behavioral health treatment (62%), and Caucasians were significantly more likely to have received treatment than African Americans and Hispanics. Rates of treatment for substance use disorders or for both substance use and mental disorders were lowest among arrestees reporting marijuana and alcohol use and highest for heroin users. Meth- amphetamine users were the most likely to have received prior mental health treatment. Severity of alcohol and drug use was the highest among arrestees who had received both substance abuse and mental health treatment. Conclusions and Implications for Practice: Considering the high rates of mental and substance use disorders in this population, the overall lack of behavioral health service utilization among offenders is concerning and points to the need to engage offenders in mental health and substance abuse treatment and to expand these services in jails, prisons, diversionary programs, and community correc- tions settings. Psychology: Drugs, Society & Human Behavior
Keywords: treatment history, mental health, substance abuse, offenders, criminal justice
The U.S. criminal justice system has expanded to include over 2 million individuals incarcerated in jails and prisons and approx- imately 5 million who are under community supervision (Glaze & Herberman, 2013). Rates of behavioral health disorders are signif- icantly higher among justice-involved individuals than in the gen- eral population (Kessler, Chiu, Demler, & Walters, 2005; Lurigio, 2011). For example, it is estimated that 70 –74% of adult offenders have substance use disorders and over half have mental health problems (Feucht & Gfroerer, 2011; James & Glaze, 2006; Stead- man, Osher, Robbins, Case, & Samuels, 2009). Furthermore, be- tween 60% and 70% of offenders have co-occurring mental health and substance use problems (Belenko, Lang & O’Connor, 2003; James & Glaze, 2006), including approximately 12–15% of males. Psychology: Drugs, Society & Human Behavior
and 24 –34% of females who have severe co-occurring disorders (CODs) (Steadman et al., 2009, 2013).
Persons who have CODs present significant challenges within the criminal justice system and have higher rates of arrest (Balya- kina et al., 2014) and greater substance use severity (Lurigio, 2011) than the general population. Many persons with CODs cycle rapidly through different parts of the criminal justice and social service systems and are frequently unemployed and/or homeless, lack vocational skills and financial and social supports, and face difficulties in engaging in community treatment (Osher, Steadman, & Barr, 2003; Peters, Kremling, Bekman, & Caudy, 2012; Weis- man, Lamberti, & Price, 2004). Psychology: Drugs, Society & Human Behavior
Despite the high rate of mental disorders, substance use disor- ders, and CODs among offenders, relatively few jails, prisons, or other justice settings provide adequate services to address these issues (Lurigio, 2011; National GAINS Center for People with Co-Occurring Disorders in the Justice System, 2004; Peters et al., 2012). As a result, the rates of treatment utilization are relatively low across justice settings (Weisman et al., 2004). For example, one study found that 18% of offenders with substance use prob- lems had received prior treatment for mental health problems (Belenko et al., 2003). Similar patterns of service utilization are evident among nonoffender samples of substance users in the community, in which only 18% sought any type of behavioral health treatment during the previous year (Green-Hennessy, 2002). Among those receiving care, approximately half received sub- stance abuse treatment (46%), approximately one third received
Elizabeth Hunt, Department of Psychology, University of South Florida; Roger H. Peters, Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute, University of South Florida; Janine Kremling, Department of Criminal Justice, California State University–San Bernardino.
The data utilized in this study were made available by the National Archive of Criminal Justice Data, operated by the Interuniversity Consor- tium for Political and Social Research at the University of Michigan.
Correspondence concerning this article should be addressed to Roger H. Peters, Department of Mental Health Law and Policy, University of South Florida, MHC 2733, 13301 N. Bruce B. Downs Boulevard, Tampa, FL 33592. E-mail: rhp@usf.edu
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Psychiatric Rehabilitation Journal © 2015 American Psychological Association 2015, Vol. 38, No. 1, 7–15 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000132
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http://dx.doi.org/10.1037/prj0000132
mental health treatment, and 20% received both mental health and substance abuse treatment (Green-Hennessy, 2002).
Patterns of service utilization vary according to sociodemo- graphic factors. For instance, offenders between the ages of 20 and 40 years are most likely to receive prior treatment (Farrell et al., 2006), whereas a nonoffender sample showed that persons of middle age are more likely to have used mental health services and younger adults were more likely to have used substance abuse services (Keyes et al., 2008). In addition, several studies suggest that Caucasian offenders are more likely than African Americans to have received prior treatment and that Caucasians generally have higher rates of substance use and mental health symptoms than African Americans (Farrell et al., 2006; Nowotny, 2015; Youman, Drapalski, Stuewig, Bagley, & Tangney, 2010). In one study, 14% of Caucasians had a past psychiatric hospitalization and 21% had received outpatient mental health treatment, in com- parison to 7% and 8% of African Americans, respectively (You- man et al., 2010). Similar trends have been noted among the general population, with a higher proportion of Caucasians (32%) receiving prior behavioral health treatment as compared with Af- rican Americans (28%) and Hispanics (30%; Wells, Klap, Koike, & Sherbourne, 2001). Some findings suggest that Caucasians tend to have greater utilization of behavioral health services and more frequent treatment for mental disorders, whereas African Ameri- cans are more likely to have received substance abuse treatment (Anglin, Hser, & Grella, 1997; Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008; Keyes et al., 2008). However, a recent study comparing utilization of substance abuse services in prison among Caucasians, African Americans, and Latinos found that Latinos were the least likely to receive services (Nowotny, 2015). It is interesting to note that there were no differences between Cauca- sians and African Americans. In general, the literature appears to be mixed regarding racial and ethnic differences in treatment utilization.
Education and marital status are also associated with history of prior treatment, but the effects appear to vary by the type of treatment. For example, individuals with higher education (e.g., high school diploma) are more likely to have received prior treat- ment (Anglin et al., 1997), especially mental health treatment (Green-Hennessy, 2002; Katz, Kessler, Frank, Leaf, & Lin, 1997). Those who are widowed, separated, divorced, or never married are also more likely to have received prior behavioral health treatment (Anglin et al., 1997; Compton, Thomas, Stinson, & Grant, 2007; Keyes et al., 2008), although one study (Keyes et al., 2008) found that this group was more likely to have received mental health services whereas those who were never married were more likely to have received substance abuse services.
The severity and type of substance use also appear to be related to the history of involvement in behavioral health treatment. Find- ings from offender and nonoffender samples indicate that persons with more severe substance use problems (e.g., dependence) have higher rates of prior behavioral health treatment (Anglin et al., 1997; Compton et al., 2007; Farrell et al., 2006; Warner & Leu- kefeld, 2001). Among offenders, those using opioids are more likely to have received prior treatment compared with those using marijuana or stimulants (Farrell et al., 2006). Likewise, the sever- ity of mental health problems, alone or in combination with sub- stance use problems, also increases the likelihood of prior treat- ment use (Compton et al., 2007; Farrell et al., 2006). Across both
offender and nonoffender samples, individuals who have a history of frequent arrests are more likely to have received behavioral health treatment, particularly substance abuse treatment (Green- Hennessy, 2002; Mateyoke-Scrivner, Webster, Staton, & Leuke- feld, 2004).
In general, there appears to be a lack of behavioral health service utilization among offenders (Weisman et al., 2004). Sociodemo- graphic characteristics may increase or decrease the likelihood of prior service utilization, as well as the type of services used. However, there is a lack of contemporary research exploring behavioral treatment utilization among offenders, factors related to seeking treatment, and barriers to treatment access and engage- ment. This information may help to identify disparities in access to treatment and strategies to more effectively enroll and retain offenders in behavioral health services. The current study exam- ined rates of utilization of mental health treatment, substance abuse treatment, and of both treatments among new arrestees housed in metropolitan jails. The relationship between prior treatment and several background and demographic variables was examined, including age, race/ethnicity, marital status, education, criminal justice involvement, type of substances used, and severity of alcohol and drug use. Specifically, the predictive utility of these background and demographic variables was explored as well as differences among these variables across types of prior treatment. Psychology: Drugs, Society & Human Behavior
Method
Participants and Program Description
The sample included 18,421 male arrestees who participated in the Arrestee Drug Abuse Monitoring II (ADAM II) program from 2007 to 2010. The ADAM II study is the successor to the Drug Use Forecasting (DUF) program and the subsequent ADAM program, which were designed to collect and analyze substance use data from arrestees in metropolitan jails in the United States. The DUF program started in 1987 with 12 jail sites, it was extended to 24 sites from 1997 to 2000, and then it expanded from 24 to 35 sites under the renamed ADAM program. The ADAM program was discontinued in 2003 because of budget constraints, but it was reinstated as ADAM II in 2007. As a result of budgetary consid- erations, only 10 of the original ADAM jail sites were active during 2007–2010 (ADAM II), including those located in the following cities: Atlanta, Charlotte, Chicago, Denver, Indianapo- lis, Minneapolis, New York, Portland, Sacramento, and Washing- ton, DC. The ADAM II program is operated by the Office of National Drug Control Policy (ONDCP). Psychology: Drugs, Society & Human Behavior
The ADAM and ADAM II programs differed from the original DUF program in that they provided probability-based sampling for all males who were arrested and booked at the jail sites, thus providing a representative sample from each site that was based on age, race/ethnicity, and offense type. Data collected for the pro- grams consisted of self-report data and urine specimens. The DUF and the ADAM programs have served as important vehicles to examine new and emerging trends in offender drug use throughout the United States. These databases have proven valuable to crim- inal justice professionals, researchers, and policy-makers, and they provide local and national data on drug use prevalence and trends (National Institute of Justice, 1998). Psychology: Drugs, Society & Human Behavior
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8 HUNT, PETERS, AND KREMLING
ADAM II participants were drawn from a larger sample of 32,139 arrestees. Participants were excluded from the current study if they did not receive an interview. Only facesheet infor- mation was available (N � 13,511) for participants who were not interviewed, and it was only available in aggregate form. Facesheet information included basic demographic information and the charges for which arrestees were booked. An additional 207 arrestees were excluded from the study who completed only a partial interview. Arrestees screened for the ADAM II program were not interviewed for several reasons, such as refusal to par- ticipate (23%), transfer to another location or jail facility (24%), and release from jail immediately after arrest (29%). Other reasons for not being able to interview included involvement in other jail activities (e.g., work assignments), which made them unavailable for an interview, and instability due to mental or other health problems.
ADAM II participants included 4,434 of 8,296 cases (52%) in 2007 for whom an interview was completed; 4,592 of 7,717 cases (60%) in 2008, 4,746 of 7,794 cases (61%) in 2009, and 4,749 or 8,332 cases (57%) in 2010. Given the lack of information available for arrestees for whom only facesheet information or partial inter- views was available, it was not possible to examine differences between these groups and the 18,421 study participants.
Procedures
The current study examined ADAM program data from 2007 to 2010. Arrestees were contacted by trained interviewers and re- cruited to participate in the voluntary ADAM program within 24 h of booking in the jail. Interviews were conducted 24 h/day, 7 days/week to ensure that results were not biased because of use of different interviewers. Structured interview protocols were used to inquire about arrestees’ substance use history and criminal in- volvement and to gather other psychosocial and background in- formation. Participants were also asked to provide a urine sample for drug testing at the end of the interview. If a participant was not available for an interview, then only a facesheet with basic demo- graphic characteristics and the “index” (most recent) arrest charges was completed. Participant responses were kept anonymous and, through arrangements with local prosecutors, any information ob- tained could not be used in legal proceedings.
Measures
The current study examined several variables from the 2007– 2010 ADAM database, which are described in the following sec- tion. Drug test results were not reviewed for the study because these were not available for alcohol use, provide only a short-term indicator of substance use (i.e., 72 h for most drugs), and do not provide relevant information about the history or severity of sub- stance use.
Treatment history. The ADAM database includes informa- tion describing self-reported history of lifetime treatment for men- tal and substance use disorders. Substance abuse treatment in- cluded inpatient and outpatient treatment episodes, whereas mental health treatment included only inpatient treatment.
Age. The sample included only adult arrestees because indi- viduals 18 years and younger were ineligible for participation in the ADAM program.
Race/ethnicity. The following categories of race/ethnicity were identified in the ADAM database: African American, Asian, Caucasian, Hispanic/Latino, and Native American.
Marital status. Marital status consisted of the following cat- egories: “single, never married,” “divorced, legally separated, wid- owed,” and “married.”
Education. The following categories were explored related to educational history: “high school/GED,” “some college/2-year de- gree,” “4-year college degree or higher,” and “vocational/trade school/no degree.”
Self-reported drug and alcohol use. The ADAM database includes information regarding several different periods of self- reported alcohol and drug use, including the past week, past month, and past year of use. The current study examined self- reported substance use in the past year. This broader period was selected to align with the goals of the study to examine the historical relationship between arrestees’ substance use and treat- ment history. Alcohol and 11 other types of drugs were assessed in the self-report interview, although for purposes of the analyses, we examined only drugs that were reportedly used in the past year by more than 4% of the sample, including alcohol, cocaine, mari- juana, methamphetamine, and opiates/opioids.
Severity of substance use. Severity of substance use was measured using the UNCOPE brief screening assessment (Hoff- mann, Hunt, Rhodes, & Riley, 2003), which is an acronym for the six dependence-related criteria for Diagnostic and Statistical Man- ual of Mental Disorders (4th edition; DSM–IV) diagnoses of drug or alcohol dependence (Using, Neglected, Cut down, Objected, Preoccupied, and Emotional discomfort) that was constructed in a previous study of the ADAM program. The UNCOPE measure has been found to have good sensitivity and specificity in evaluating substance use severity among offenders and across gender and race/ethnicity groups (Hoffmann et al., 2003). On the basis of the UNCOPE framework, the following variables were selected from the ADAM database as indicators of substance use severity: (a) “In the past 12 months, have you spent more time using drugs than you intended?”; (b) “Have you neglected some of your usual respon- sibilities because of using drugs?”; (c) “Have you wanted to cut down on your drug use?”, (d) In the past 12 months, has anyone objected to your use of drugs?”; (e) “Have you frequently found yourself thinking about using drugs?”; and (f) “Have you used drugs to relieve feelings such as sadness, anger, or boredom?”. The companion variables that use the term “alcohol” instead of “drug” were examined to assess the severity of alcohol use. The sum of the scores (0 – 6) for the UNCOPE variables was used to indicate substance use severity.
Prior arrests. The ADAM database included the frequency of prior arrests and the type of offense associated with the arrest leading to the most recent incarceration (index arrest/offense). Because of many outliers within this variable skewing the data (e.g., reported prior arrests exceeding 1,000), a cutoff of 1,000 was used to provide a more representative measure of prior arrests.
Index offense. Consistent with criminal justice research (Har- ris, Smallbone, Dennison, & Knight, 2009; Miethe, Olson, & Mitchell, 2006), index offenses for study participants were cate- gorized into four types: “Person” (e.g., assault, murder, domestic violence), “Property” (e.g., arson, burglary, theft), “Drug” (e.g., possession charges, driving under the influence), and “Other” (e.g., trespassing, gambling, violation of probation, traffic violations).
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9BEHAVIORAL HEALTH TREATMENT AMONG OFFENDERS
Data Analysis
A logistic regression including all predictor variables of history of treatment was conducted. To further examine the relationships emerging in the initial logistic regression, �2 and additional logis- tic regression analyses were conducted to examine differences in treatment history across demographic variables (i.e., age, race/ ethnicity, marital status, level of education), self-reported drug and alcohol use (type of substance used, severity of use), prior arrest history, and type of index offense.
Results
Sample Characteristics
As described in Tables 1 and 2, approximately 38% of arrestees reported receiving any type of previous behavioral health treat- ment, including 27% who had received substance abuse treatment (either outpatient or inpatient), 4% who had received mental health treatment (inpatient only), and 7% who had received both sub- stance abuse and mental health treatment. Only 16% had received any type of treatment during the past year. The mean age of the sample was 33.8 years, and most participants were African Amer- ican (51.7%). Forty-two percent of the sample had a high school diploma or GED, and 67% were single. The mean number of prior arrests was 12.6, with a median of 5. The type of index offense for the sample was most frequently categorized as “other” (35%), followed by “drug-related” (22.6%), “person” (22.2%), and “prop- erty offenses” (16.4%). Marijuana (50.7%) and alcohol (51.8%)
were the most commonly used substances. The mean level of severity related to drug use (3.1) and alcohol use (2.9) was quite high, as reflected by the UNCOPE ratings (ratings range from 0 to 6), which, according to previous research, indicates a level of severity that is commensurate with a DSM–IV “dependence” dis- order (Hoffmann et al., 2003).
Predictors of Lifetime Treatment History
Across the series of logistic regressions,1 several variables emerged as significant predictors of receiving lifetime behavioral health treatment (see Table 3). Arrestees who were older, Cauca- sian, had frequent prior arrests, reported cocaine or heroin use, and had more severe drug and alcohol problems were more likely to have received any type of treatment, both mental health and substance abuse treatment, or substance abuse treatment only, whereas those with a 4-year educational degree were less likely to have received any type of treatment. Recipients of mental health treatment more frequently reported having no educational degree and were more likely to have an index offense categorized as “person” and to have greater severity of alcohol use problems.
Lifetime Treatment History and Demographic/Background Characteristics
Across different types of treatment, arrestees were most likely to report involvement in previous substance abuse treatment in com- parison to mental health treatment and treatment for both sub- stance abuse and mental health problems. Contrary to expecta- tions, arrestees more frequently reported a history of both substance abuse and mental health treatment in comparison to mental health treatment alone. However, most arrestees reported receiving no treatment.
The relationship between the predictor variables and behav- ioral health treatment history was further examined through individual �2 analyses and logistic regression. Significant dif- ferences emerged across type of treatment history and race/ethnic- ity, age, education, marital status, and arrest history. Caucasians were more likely to have received prior treatment (�2 � 482.71, p � .001), with the most pronounced differences emerging for substance abuse treatment and for both substance abuse and mental health treatment (see Table 4). Furthermore, 71% of Hispanics and 64% and African Americans reported no previous treatment, com- pared with only 49% of Caucasians. A similar trend emerged for
1 The logistic regression analyses statistically control for the contribu- tion of other predictor variables in each of the models, thus providing the unique predictive utility of the variables included.
Table 1 Sample Characteristics
Variable n (%)
Treatment No treatment 11,329 (61.6) Substance abuse treatment 4,972 (27.0) Mental health treatment 805 (4.4)
Substance abuse/mental health treatment 1,299 (7.1) Race
Caucasian 4,464 (26.5) African American 8,705 (51.7) Hispanic 3,677 (21.8)
Education High School/GED 7,694 (41.8) Some college/2-year degree 3,548 (19.3) 4-year degree or higher 929 (5.1) No degree/vocational 6,219 (33.8)
Marital status Single, never married 12,574 (68.6) Divorced/separated/widowed 2,616 (14.3) Married 3,132 (17.1)
Offense type Person 4,096 (23.1) Drug 4,154 (23.5) Property 3,012 (17.0) Other 6,446 (36.4)
Drug type Marijuana 9,318 (50.7) Cocaine 3,952 (21.5) Heroin 1,143 (6.2) Methamphetamine 1,357 (7.4) Alcohol 9,535 (51.8)
Table 2 Sample Characteristics
Variable M (SD)
Age, years 33.8 (11.7) Prior arrests 12.6 (28.6) Severity of use
Drug use 3.1 (2.1) Alcohol use 2.9 (2.1)
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10 HUNT, PETERS, AND KREMLING
severity of drug and alcohol use across race/ethnicity groups. Caucasians had significantly higher drug use severity ratings (M � 3.31) compared with African Americans (M � 3.14) and Hispanics (M � 2.82; F(2) � 33.09, p � .001). Alcohol use severity ratings were also higher among Caucasians (M � 3.01) compared with African Americans (M � 2.96) and Hispanics (M � 2.64; F(2) � 21.33, p � .001).
A linear relationship emerged between age and behavioral health treatment history. Using no treatment as the reference category, the general trend indicated that as age increases, arrest- ees were more likely to report receiving treatment, with the highest odds ratio obtained for arrestees who received both substance abuse and mental health treatment (B(SE) � 0.050(0.002), Exp(B) � 1.05, p � .001), followed by substance abuse treatment (B(SE) � 0.038(0.003), Exp(B) � 1.04, p � .001) and mental health treatment (B(SE) � 0.0.17(0.003), Exp(B) � 1.02, p � .001).
Findings indicated that arrestees with no degree or with a vocational degree were more likely to have received treatment in comparison to those with a 4-year degree or higher (�2 � 37.52, p � .001). There was also a trend for arrestees who were widowed, separated, divorced, or unmarried to have higher rates of treatment than others (�2 � 223.23, p � .001). A linear relationship was
found between prior arrests and history of behavioral health treat- ment. Using no treatment as a reference category, persons with frequent prior arrests were more likely to report receiving treat- ment, with the strongest relationship for those receiving both substance abuse and mental health treatment (B(SE) � 0.03(0.001), Exp(B) � 1.03, p � .001), followed by substance abuse treatment, and mental health treatment. A trend was also noted for persons with drug-related offenses to have higher rates of substance abuse treatment and for those with “person” offenses to have higher rates of mental health treatment (�2 � 119.61, p � .001).
Lifetime Treatment History, Type of Substance, and Substance Use Severity
As described in Table 5, arrestees who reported marijuana and alcohol use generally had the lowest rates of prior treatment, and the highest rates of treatment were generally reported by heroin users. Furthermore, heroin users had higher drug use severity ratings (M � 4.75) than arrestees reporting other types of drug use (range of Ms � 2.98 –4.05). However, cocaine users had the highest alcohol use severity ratings (M � 3.53) compared with other types of drugs reported (range of Ms � 2.93–3.43). Finally,
Table 3 Logistic Regression Predicting Lifetime Treatment
Variable
Any treatment Substance abuse treatment Mental health treatment Substance abuse/mental health
B (SE) df Exp(B) p B (SE) df Exp(B) p B (SE) df Exp(B) p B (SE) df Exp(B) p
Age .03 (.00) 1 1.03 �.001 .02 (.00) 1 1.02 �.001 �.02 (.01) 1 0.99 .051 .03 (.01) 1 1.03 �.001 Caucasian .48 (.07) 1 1.62 �.001 .25 (.07) 1 1.28 .001 .12 (.15) 1 1.13 .427 .56 (.11) 1 1.75 �.001 Hispanic �.12 (.08) 1 0.89 .135 �.12 (.08) 1 0.89 .152 �.20 (.19) 1 0.82 .271 .03 (.14) 1 1.03 .847 2-year degree �.05 (.08) 1 0.96 .562 �.11 (.08) 1 0.89 .142 .13 (.18) 1 1.14 .460 .09 (.12) 1 1.10 .445 4-year degree �.50 (.17) 1 0.61 .003 �.33 (.17) 1 0.72 .052 �.98 (.59) 1 0.38 .099 �.38 (.29) 1 0.68 .192 No degree .11 (.07) 1 1.11 .112 �.04 (.07) 1 0.97 .597 .32 (.15) 1 1.38 .028 .19 (.11) 1 1.21 .075 Divorced .10 (.09) 1 1.10 .299 �.05 (.09) 1 0.95 .566 �.01 (.22) 1 0.99 .973 .25 (.12) 1 1.29 .044 Married �.09 (.09) 1 0.91 .305 �.07 (.09) 1 0.93 .434 .22 (.19) 1 1.25 .238 �.21 (.15) 1 0.81 .159 Prior arrests .01 (.00) 1 1.01 �.001 .00 (.00) 1 1.00 .009 .00 (.00) 1 1.00 .139 .00 (.00) 1 1.00 �.001 Person offense .09 (.08) 1 1.09 .262 �.02 (.08) 1 0.98 .819 .43 (.17) 1 1.54 .009 .03 (.13) 1 1.04 .784 Drug offense .08 (.08) 1 1.09 .271 .16 (.08) 1 1.17 .041 .09 (.18) 1 1.09 .613 �.25 (.12) 1 0.78 .045 Property offense �.12 (.09) 1 0.89 .182 �.04 (.09) 1 0.96 .673 .07 (.20) 1 1.08 .283 �.23 (.13) 1 0.80 .087 Marijuana �.09 (.09) 1 0.92 .318 �.16 (.09) 1 0.85 .060 .24 (.22) 1 1.27 .283 .07 (.12) 1 1.07 .584 Cocaine .33 (.07) 1 1.39 �.001 .24 (.07) 1 1.27 �.001 �.18 (.15) 1 0.84 .252 .37 (.10) 1 1.44 �.001 Heroin .72 (.11) 1 2.06 �.001 .42 (.10) 1 1.52 �.001 �.12 (.24) 1 0.89 .642 .38 (.13) 1 1.46 .003 Methamphetamine .04 (.10) 1 1.04 .701 �.07 (.10) 1 0.93 .438 .10 (.20) 1 1.11 .613 .23 (.13) 1 1.26 .082 Alcohol �.15 (.52) 1 0.86 .769 �.02 (.52) 1 0.98 .976 �.37 (1.04) 1 0.69 .719 �.03 (.79) 1 0.97 .973 Drug severity .12 (.02) 1 1.13 �.001 .06 (.02) 1 1.06 �.001 .03 (.04) 1 1.03 .424 .17 (.03) 1 1.18 �.001 Alcohol severity .17 (.02) 1 1.19 �.001 .11 (.02) 1 1.12 �.001 .10 (.04) 1 1.11 .003 .12 (.84) 1 1.12 �.001
Table 4 Race/Ethnicity and Lifetime Treatment History
Variable
Caucasian African American Hispanic �2 value
n (%) n (%) n (%) n (%)
Treatment 482.71���
Substance abuse treatment 1,532 (34.3) 2,235 (25.7) 787 (21.4) Mental health treatment 240 (5.4) 369 (4.2) 115 (3.1) Substance abuse/mental health treatment 495 (11.1) 517 (5.9) 168 (4.6) No treatment 2,196 (49.2) 5,575 (64.1) 2,604 (70.9)
��� p � .001.
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11BEHAVIORAL HEALTH TREATMENT AMONG OFFENDERS
there was a significant relationship between the severity of sub- stance use problems and prior behavioral health treatment (see Table 3). With “no history of treatment” as the reference category, logistic regression indicated that the severity of alcohol and drug use problems was elevated among arrestees who reported a history of treatment. This relationship was strongest for arrestees who had received both substance abuse and mental health treatment (sever- ity of drug problems [B(SE) � 0.40(0.02), Exp(B) � 1.49, p � .001]; severity of alcohol problems [B(SE) � 0.38(0.02), Exp(B) � 1.4, p � .001]), followed by substance abuse treatment and mental health treatment. As described in Table 6, there were significant differences for both the UNCOPE alcohol and drug use severity ratings across different types of treatment, with the most severe problems (scores ranged from 0 to 6, with higher scores reflecting more severe problems) reported by arrestees who had received both substance abuse and mental health treatment, fol- lowed by those who had received substance abuse treatment, mental health treatment, and no treatment.
Discussion
With a growing proportion of incarcerated offenders who have mental health and substance use disorders, jails and prisons now serve as “public health outposts” (Steadman, 2005), particularly for offenders who have severe behavioral health disorders such as co-occurring mental and substance use disorders. Of the 60 – 80% of offenders who have substance use disorders and the 15–34% who have severe mental disorders, it is likely that many could be diverted from correctional settings if comprehensive treatment and supervision services were available in the community (La Vigne et al., 2014).
Rates of Prior Treatment Among Arrestees
The current study examined the history of behavioral health treatment services among a large sample of arrestees in U.S.
metropolitan jails between 2007 and 2010. Despite significant needs for both mental health and substance abuse treatment among this population, relatively few arrestees had received either mental health or substance abuse treatment during their lifetime (38%) or during the past year (16%). For example, only 34% had received substance abuse treatment and only 11% had received mental health treatment during their lifetime. In the year before their arrest, only 14% were enrolled in any type of substance abuse treatment and 4% received mental health services. Findings point to a missed opportunity to provide behavioral health services for offenders in both community and institutional settings and to prevent subsequent arrest and incarceration. Findings also suggest that offender treatment services have not expanded to meet the growing needs of justice-involved individuals who have severe substance use and mental disorders.
Behavioral Health Care Disparities Among Ethnic/ Racial Minority Arrestees
The study examined predictors of lifetime and past year treat- ment involvement, and it found very similar patterns. Caucasians are significantly more likely than African Americans and Hispan- ics to have received any type of behavioral health services. This disparity was most pronounced for substance abuse treatment and occurred among arrestees who had received both substance abuse and mental health treatment. Racial/ethnic disparities in treatment history were apparent even after controlling for the severity of substance use. These health-care disparities are disturbing, but they mirror trends observed within nonoffender populations in the community (Smedley, Stith, & Nelson, 2009). It is unclear if these findings are explained in part by unequal access to health insur- ance, geographic barriers to services, or exclusion from treatment services in community and institutional settings. Given the rela- tively small (1–3%) differences in the prevalence rates of alcohol, drug, mood, and anxiety disorders among African Americans, Caucasians, and Hispanics (Smith et al., 2006) and the large
Table 5 Type of Substance Use and Lifetime Treatment History
Variable
Marijuana Cocaine Heroin Methamphetamine Alcohol
n (%) n (%) n (%) n (%) n (%)
Treatment Substance abuse treatment 2,768 (29.7) 1,733 (43.9) 601 (52.6) 541 (39.9) 2,982 (31.3) Mental health treatment 457 (4.9) 164 (4.1) 42 (3.7) 79 (5.8) 373 (3.9) Substance abuse/mental health treatment 734 (7.9) 576 (14.6) 213 (18.6) 194 (14.3) 856 (9.0) No treatment 5,359 (57.5) 1,479 (37.4) 287 (25.1) 543 (40.0) 5,321 (55.8)
�2 value 130.39��� 1,410.87��� 790.28��� 315.76��� 352.71���
��� p � .001.
Table 6 Severity of Drug and Alcohol Use Across Types of Lifetime Treatment Received
Variable
No treatment Mental health
treatment Substance abuse
treatment Substance abuse/mental
health treatment
F(df)M (SD) M (SD) M (SD) M (SD)
Drug use severity 2.6 (1.9) 3.1 (2.0) 3.7 (2.1) 4.2 (1.9) 318.9 (3)���
Alcohol use severity 2.3 (2.0) 3.2 (2.0) 3.5 (2.1) 3.9 (2.0) 290.7 (3)���
��� p � .001.
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12 HUNT, PETERS, AND KREMLING
disparities detected in the current study related to involvement in prior substance use and mental health services, there is a clear challenge to enhance access to behavioral health care among African Americans and Hispanics who are involved in the criminal justice system and to actively engage and sustain their involvement in treatment services.
Other Predictors of Behavioral Health Treatment Among Arrestees
Arrestees in metropolitan jails who used heroin and cocaine were more likely to have received substance abuse treatment and both substance abuse and mental health services. Alcohol use severity was associated with more frequent involvement in all types of treatment whereas drug use severity was associated with involvement in substance abuse treatment and both substance abuse and mental health treatment. The highest levels of alcohol and drug use severity were observed among arrestees who had received both substance abuse and mental health services, fol- lowed by those receiving substance abuse services and those receiving mental health services. These findings are consistent with the literature indicating more pronounced substance use dis- orders among persons who have CODs (Peters, Rojas, & Bartoi, in press). Previous treatment involvement is not currently reviewed during screenings conducted in many criminal justice settings. However, findings indicate the importance of examining prior treatment experiences among offenders, which may serve as a proxy for identifying those with the highest need for behavioral health services.
Study Limitations
The study findings should be considered in light of several limitations. The ADAM II study involved only male arrestees in metropolitan jails, and findings may not be generalizable to women. Women differ from men with regard to the prevalence and type of mental disorders (Eaton et al., 2012; Steadman et al., 2009). Gender differences may have important implications for treatment and supervision in the justice system.
The ADAM II study included a very large sample of arrestees in 10 metropolitan U.S. jails selected in part by their geographic diversity. However, these sites may not be fully representative of jails throughout the country, such as jails based in rural areas. Another concern is that the ADAM II database does not provide information to verify self-reported mental health and substance abuse treatment. Results from studies examining ADAM II arrest- ees (Peters, Kremling, & Hunt, 2014) and other offender popula- tions (Rosay, Najaka, & Herz, 2007) indicate that self-reported behavioral health disorders may be underreported, and it is likely that arrestees may have also underreported their involvement in behavioral health treatment. Another concern is that no informa- tion was available to describe arrestees for whom only facesheet information was available, although comparisons between study participants and those who provided only an interview yielded similar demographic profiles.
The current study examined four of the most common drugs of abuse (cocaine, marijuana, methamphetamine, opiates) and alco- hol, but low response rates prevented evaluation of barbiturates, amphetamine, benzodiazepines, phencyclidine (PCP), and metha-
done. Limited information was provided about the presence or severity of mental and substance use disorders because the data- base did not include information regarding mental health symp- toms.
ADAM II participants who were actively using drugs and who were under correctional supervision (e.g., probation or parole) at the time of their arrest may have been disinclined to participate in the study. Arrestees with severe mental health disorders may also be underrepresented in the study because they may have been deemed unfit for an interview by the jail-booking personnel and may have been less likely to complete the interview because of an inability to maintain concentration for a long period of time.
Conclusions and Directions for Future Research
Findings from the ADAM II study highlight the significant gap between the behavioral health needs of offenders and the treatment services received. Only a small proportion of the over 18,000 arrestees in the current sample received either mental health or substance abuse treatment services in the past year, and fewer than 40% received behavioral health services in their lifetime. This disparity between treatment needs and available treatment services is consistent with the literature reviewing behavioral health-care services that are offered in correctional settings (Belenko & Peugh, 2005). Findings signal the need to reexamine how we address offenders who have behavioral health disorders and to expand evidence-based treatment and supervision approaches that are de- signed to reduce criminal recidivism (Osher, D’Amora, Plotkin, Jarrett, & Eggleston, 2012).
The disparities in behavioral health treatment services received among arrestees from ethnic/racial minorities is also troubling and points to a broader need to identify and engage ethnic/racial minorities in health-care services in the community. Additional efforts are clearly needed to identify racial/ethnic minorities in the community who are at risk for criminal justice involvement and to provide incentives and appropriate interventions to enter and re- main in behavioral health services. Several important predictors of arrestees’ treatment involvement were identified (e.g., age, race/ ethnicity, type of substances used, frequency of prior arrests) that may help to inform screening and assessment approaches in crim- inal justice settings. Further research is needed to examine patterns of behavioral health treatment services received by female offend- ers and how to more effectively engage offenders in behavioral health services. Psychology: Drugs, Society & Human Behavior
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Received November 6, 2014 Revision received January 27, 2015
Accepted February 1, 2015 �
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15BEHAVIORAL HEALTH TREATMENT AMONG OFFENDERS
http://dx.doi.org/10.1081/ADA-100103709
http://dx.doi.org/10.1081/ADA-100103709
http://dx.doi.org/10.1023/B:PSAQ.0000007562.37428.52
http://dx.doi.org/10.1023/B:PSAQ.0000007562.37428.52
http://dx.doi.org/10.1176/appi.ajp.158.12.2027
http://dx.doi.org/10.1176/appi.ajp.158.12.2027
http://dx.doi.org/10.1037/a0017864
- Behavioral Health Treatment History Among Persons in the Justice System: Findings From the Arres …
- Method
- Participants and Program Description
- Procedures
- Measures
- Treatment history
- Age
- Race/ethnicity
- Marital status
- Education
- Self-reported drug and alcohol use
- Severity of substance use
- Prior arrests
- Index offense
- Data Analysis
- Results
- Sample Characteristics
- Predictors of Lifetime Treatment History
- Lifetime Treatment History and Demographic/Background Characteristics
- Lifetime Treatment History, Type of Substance, and Substance Use Severity
- Discussion
- Rates of Prior Treatment Among Arrestees
- Behavioral Health Care Disparities Among Ethnic/Racial Minority Arrestees
- Other Predictors of Behavioral Health Treatment Among Arrestees
- Study Limitations
- Conclusions and Directions for Future Research
- References
- Method