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An opportunity through the local jail

July 24, 2017
by Norman G. Hoffmann, PhD, Alyssa L. Raggio, MS, and Albert M. Kopak, PhD
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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.