Prevalence Rates for Behavioral Health Conditions: A Tale of Four Jails

In exploring prevalence rates among those recently booked into local jails, we have come to one universal conclusion: When you know the prevalence rates in one location, you know the prevalence rates in one location.

Numerous studies and monitoring systems, such as the large multi-site Arrestee Drug Abuse Monitoring (ADAM) project involving metropolitan area jails, have consistently found vast differences in the prevalence of alcohol and drug use among recent arrestees throughout the United States. At a conference a few years ago, the lead investigator on the ADAM project, Dana Hunt, PhD, presented data showing results of urinalyses for methamphetamine and cocaine among arrestees from California to New York. The positive test rates for methamphetamine were 51%, 16%, 1% and 0% for Sacramento, Denver, Chicago and New York City, respectively. In contrast, the urine specimens testing positive for cocaine were 7%, 20%, 24% and 32% for the same respective cities.

While such differences may not surprise those familiar with the literature, what may be equally important is that prevalence rates for a variety of substance use disorders and mental health conditions can vary substantially at a more local level. Even adjacent counties can experience significant differences in the prevalence of substance use disorders.

Like leaders of many large metropolitan area jails, the sheriff of Haywood County, N.C., was responsible for the largest behavioral health facility in the area by virtue of the conditions reported by inmates. The problem at the time was that he did not have the resources or personnel available to document prevalence rates accurately. A psychology graduate student at Western Carolina University had an interest in correctional populations, so she was recruited to conduct Comprehensive Addiction And Psychological Evaluation-5 (CAAPE-5) interviews. The typical interview took 25 to 30 minutes and documented DSM-5 compatible criteria for substance use disorders and common co-occurring mental health conditions. The sheriff has used the findings to educate local leaders and to promote a variety of initiatives to address the needs of inmates.

Subsequently, we have found other sheriffs in both North Carolina and Florida interested in documenting the prevalence of behavioral health conditions in their jurisdictions. Most recently, a sheriff in Florida used prevalence rates from his jail in submitting a funding request for a behavioral health program in his county.

Among the unsurprising findings of high prevalence of substance use disorders was the realization that prevalence rates of some conditions varied considerably while others were relatively constant, even between states. For example, the prevalence of a moderate to severe alcohol use disorder as defined by the DSM-5 saw a slight variation among four counties, ranging from a low of 31% to a high of 36%. Findings for indications of possible post-traumatic stress disorder (PTSD) ranged from 45% to 52%. These are a few of the conditions that were observed consistently across local populations.

On the other hand, the prevalence of a moderate to severe cocaine use disorder ranged from 4% to 25% between two adjacent counties. The prevalence of a stimulant use disorder within those two counties was 60% vs. 45%, respectively. Between two adjacent counties, the prevalence rates for two substances were very different.

Previous work examining prevalence rates over a period of eight years found that in general, mental health conditions remained relatively stable but substance use disorders varied significantly. The greatest variation in prevalence rates among counties was found with substance use disorders, while the differences in rates of mental health conditions tended to be smaller. That said, mental health conditions such as depression and antisocial personality disorder did show statistically significant variation among the counties.

The bottom line is that in order to know prevalence rates of behavioral health conditions within a geographic area or criminal justice jurisdiction, periodic monitoring with a tool that captures diagnostic data is essential. With newly available online interview tools, such monitoring can be done efficiently at reasonable cost. Collaboration with local universities or agencies with analytic capabilities can assist local officials in developing empirical foundations to help guide policies and planning.

Norman G. Hoffmann, PhD, is an affiliate professor of psychology at Western Carolina University and founder of Evince Diagnostics LLC, which provides online assessments for behavioral health. Albert M. Kopak, PhD, is an associate professor in the Department of Criminology and Criminal Justice at Western Carolina University.