An opportunity through the local jail

In the United States, more people with substance use and mental health conditions are housed in correctional institutions than in hospitals and treatment centers. Although state prisons receive much of the notoriety when it comes to housing individuals with behavioral health needs, local jails have a disproportionate number of inmates with behavioral health conditions.

Federal regulations require that correctional facilities evaluate inmates to determine whether they have behavioral health conditions or needs. However, many facilities do not adhere to this mandate, especially in smaller correctional settings where resources and the availability of services are more limited.

In larger jails (commonly in metropolitan areas), rapid screening may be the only logical alternative, due to the number of individuals being processed on a given day. Also, the typical stay in a jail is only a few days, which precludes the possibility of providing more than simply referrals to community providers.

A recent study conducted in a rural detention center in western North Carolina has demonstrated that screening and identification of possible behavioral health conditions is not only feasible, but also practical. This opens up the possibility that treatment providers are missing a prime opportunity to engage individuals at a point where they might be receptive to treatment options.

Details and findings of study

A random sample of 225 adults (160 men and 65 women) booked into a local county jail within the previous four days were evaluated using the CAAPE-5 (Comprehensive Addictions and Psychological Evaluation), a structured diagnostic interview for substance use disorders and commonly co-occurring mental health conditions. Interviews typically required fewer than 30 minutes to complete. The assessment information then was compared to the past arrest and booking history of the inmates during the 12 months prior to the assessment.

Inmates ranged in age from 18 to 66, with a median age of 30. About 85% were white, while Native Americans were the largest minority group, accounting for just under 10%. In this North Carolina county, whites constitute about 95% of the population. Most of the inmates (52%) had never married; one-third had not graduated from high school; 49% were currently unemployed; and, as might be expected, personal incomes were low, with 47% reporting an annual income of less than $10,000.

Recidivism is a problem in most communities. Almost two-thirds (64%) of the inmates had been booked into the jail at least once in the 12 months prior to the diagnostic interview. In fact, 43% had been booked at least twice in that period. Multiple prior bookings represent one of the major contributing factors to crowding in detention centers. They also represent considerable societal costs for law enforcement, adjudication and incarceration, not to mention the impact of repeat offenses on victims.

These were the findings on prevalence of conditions and recidivism among the participants:

• 85.5% had at least one substance use disorder based on the current diagnostic criteria, and 67.5% had at least one severe substance use disorder.

• 38.2% had a severe methamphetamine diagnosis.

• 29.7% had a severe opioid diagnosis.

• 24.4% had a severe alcohol diagnosis.

• Almost 40% of the inmates had injected a drug in the past 12 months, and 32.9% reported regular injecting.

• 48.1% had indications of possible post-traumatic stress disorder (PTSD).

• 34.6% reported a major depressive disorder in the past two months.

• 60.9% of those with multiple serious substance use disorders had multiple bookings, vs. 35.3% for inmates without multiple diagnoses.

• 52.7% of repeat drug injectors had multiple prior bookings, vs. 38.4% for individuals who did not inject.

The clinical findings were startling. The most common severe substance use disorder (SUD) diagnoses involved stimulants, usually methamphetamine (40%); followed by opioids (30%); and alcohol (25%). This is a dramatic change from findings using the same type of structured interview a few years ago in a neighboring county, when alcohol was still the most prevalent dependence diagnosis. More notably, around 40% had injected some substance in the past 12 months, with almost a third reporting regular injection, which highlights significant public health risk for overdose and transmission of infectious diseases.

Among mental health conditions, PTSD was the most common. A similar proportion (47%) reported symptoms of panic attacks, and the same proportion appeared to meet diagnostic criteria for antisocial personality disorder.

Not only were SUDs and PTSD among the more prevalent conditions, they also were associated with multiple previous bookings. Of the 30% of inmates with two or more serious SUD diagnoses, 65% had been booked two or more times in the previous 12 months, compared to only 33% of those without two such diagnoses. Just over 50% of those with indications of probable PTSD had two or more prior bookings, as compared to 35% without PTSD indications.

Another key finding was that the UNCOPE, a six-item screen, was effective in identifying those with a severe substance use disorder. With a score of three or more positive items indicating a severe SUD, almost 92% of those with at least one such condition were accurately identified. However, the false positive rate was 32%, with many of these individuals being positive for a moderate condition rather than a severe SUD. When the UNCOPE threshold was increased to four or more positive items, 85% of severe cases were still identified, but the false positive rate dropped to 21%. Since five of the UNCOPE items map to five different DSM-5 diagnostic criteria, a score of three or more would indicate at least a mild SUD.

Implications

The first implication of the findings is that local jails are a potential source for individuals with substance use disorders who may be responsive to the opportunity for treatment. A potential impediment to treatment might be that many of these individuals would need to be enrolled in programs such as Medicaid to provide reimbursement. Another possibility would be to negotiate reimbursement with the county, because these individuals pose public health and safety risks that can result in expenditure of county funds related to health and criminal justice issues.

A second implication is that screening and assessment are practical for facilities of varying sizes. For larger facilities, the UNCOPE, an effective and free screen, is readily available to make referrals for assessment in the community, with most individuals with a serious SUD accurately identified. However, in smaller jails with a smaller volume of bookings, it may be practical to have a trained individual conduct a 30-minute diagnostic interview to obtain more definitive information on recently booked individuals. This is especially true once assessment is in place, because only a proportion of newly booked individuals will be new cases.

The caveat on screening and assessment is that they need to be done by someone who is not identified as an officer of the jail. Research has shown that a perceived neutral clinician gathers more accurate information than a correctional officer.

The bottom line is that the vast majority of individuals booked into local detention facilities are in need of behavioral health services. This may be a challenging population to treat and for whom to get reimbursement for treatment. However, it is a population that tends to be significantly underserved.

Norman G. Hoffmann, PhD, is a clinical psychologist and recognized expert in clinical assessment and the evaluation of behavioral health programs. He has developed assessment instruments used throughout the United States, Canada, Sweden, Norway and the United Kingdom. Alyssa Raggio has a master's degree in clinical psychology from Western Carolina University. Her research focuses on mental health and substance use disorders related to recidivism among rural jail populations. Albert M. Kopak. PhD, is a substance abuse researcher at Western Carolina University's Department of Criminology and Criminal Justice.