1. The Effects of Brief Incarcerations on Jail Diversion Outcomes for People with Serious Mental Illness Presenter: Allison Gilbert Robertson, Ph.D., M.P.H. Duke University School of Medicine Department of Psychiatry & Behavioral Sciences allison.gilbert@duke.edu Academic and Health Policy Conference on Correctional Health Chicago, IL March 22, 2013

2. Sponsor and Collaborators Duke University Medical Center –Allison Gilbert Robertson, PhD, MPH (PI) –Marvin Swartz, MD (Co-PI) Connecticut Dept. of Mental Health and Addiction Services (DMHAS)/UConn SSW –Hsiu-Ju Lin, PhD –Linda Frisman, PhD University of South Florida –John Petrila, JD, LLM This work was funded by Public Health Law Research, a national program of the Robert Wood Johnson Foundation.

3. Jail diversion Court-based jail diversion programs: a growing policy response to problem of CJ involvement among adults with SMI –~560 diversion programs are currently operating in 47 states Various program models—MH court structure, others use alternative approaches Common criteria include: –SMI diagnosis –Many exclude felony or violent offenders –Indication that mental illness was a contributing factor in referral offense, determination of “suitability” –Willingness to comply with court-arranged treatment plan

4. Jail diversion: what we know now Generally, significant reductions in recidivism are evident –But improvements are modest Evidence lacking on which program components predict successful diversion –Access to treatment services... ? –A legal mechanism that uniquely engages participants and promotes their success... ?

5. CT’s jail diversion program CT one of two states with an innovative, statewide jail diversion program Community MH clinicians based in courts –Work with court personnel to identify and divert eligible adults SMI Reports that some judges opt to first put some individuals in jail for a few days to enhance motivation for entering treatment and avoiding a jail sentence - Enhance motivation- Ineffective, inappropriate - Good set up for Tx- Traumatizing –Detox –Stabilization Therapeutic jurisprudence Counter-therapeutic and -productive - or -

6. Research Questions Compared to immediate diversion, to what extent do brief jail stays before initiating diversion improve outcomes by... 1)further reducing use of crisis-driven health care (i.e., hospitalization and ED visits)? 2)further reducing recidivism (subsequent arrest and incarceration)?

7. Study Design Part 1: Observational study of effect of pre- diversion brief incarcerations Quasi-experimental study of administrative records from public behavioral health and CJ systems for adults with SMI who participated in a statewide jail diversion program in Connecticut during FYs 2006 & 2007 Part 2: Diversion observations and personnel interviews Observations of jail diversion proceedings in CT courts Informal interviews with key jail diversion and court personnel

8. Study Measures Dependent variables Psychotropic medication adherence –Medication possession ratio Targeted outpatient service use Hospitalizations for MH or substance abuse treatment ED visits Rearrest (Re)incarceration

9. Study Measures Dependent variables Psychotropic medication adherence –Medication possession ratio Targeted outpatient service use Hospitalizations for MH or substance abuse treatment ED visits Rearrest (Re)incarceration

10. Study Measures Dependent variables Psychotropic medication adherence –Medication possession ratio Targeted outpatient service use Hospitalizations for MH or substance abuse treatment ED visits Rearrest (Re)incarceration

11. Study Measures Independent variables Study group variable: “Jail first” - any v. no brief incarceration before diversion Clinical diagnoses & demographics Pre-diversion OP service use Pre-diversion psychotropic medication adherence Recent offending history

12. Analysis Propensity-score matching to identify a balanced comparison group Multivariable models to estimate effect of jail first on probability and level of recidivism and crisis- driven service use –Generalized Estimating Equations (GEE) for binary outcomes –Mixed-effects, mixed-distribution models for count variables with many zeros –Structural Equation Models for mediation analysis

13. Clinical and demographic characteristics after propensity matching

14. Pre-diversion service use and offending characteristics after propensity matching

15. Regression results

16. Individuals with jail first were more likely to have better improvements in medication adherence over time after diversion and more time with good adherence.

17. Regression results

18. No differences in probability or level of post-diversion incarceration or psych hospitalization between study groups.

19. Regression results People with good medication adherence were less likely to go to jail after diversion; and among those who did, those with good medication adherence were incarcerated for fewer days.

20. Regression results Among people with at least one DMHAS hospital day after diversion, those with good medication adherence were hospitalized for fewer days than those with poor adherence.

21. Interpretations Brief incarceration before diversion Treatment adherence Outcomes: -Reoffending -Hosp/ED + “Jail first” is significantly associated with improved Tx adherence. 1

22. Interpretations Brief incarceration before diversion Treatment adherence Outcomes: -Reoffending -Hosp/ED + “Jail first” is significantly associated with improved Tx adherence. NS Our main models suggested that Tx adherence reduces main outcomes, but formal mediation analysis found no significant effect. 1 2

23. Interpretations Brief incarceration before diversion Treatment adherence Outcomes: -Reoffending -Hosp/ED + “Jail first” is significantly associated with improved Tx adherence. NS Our main models suggested that Tx adherence reduces main outcomes, but formal mediation analysis found no significant effect. And this direct effect of study condition is not evident. NS 1 2 3

24. Summary and next steps Explore moderator analyses –Estimating effects of jail before diversion on specific sub-groups (e.g., dual Dx, felony index arrest) Future research –Examine role of Tx adherence more closely How/why jail first improve Tx adherence Why that doesn’t translate to improved health and public safety outcomes

25. Thank you!

26. Extra slides

27. CT site visit and interviews Semi-structured interviews with key players in jail diversion program –Judge, bail commissioners, public defender, PD social worker, court coordinator, jail diversion clinicians Key themes emerged –Where goal is to divert clients at arraignment, public safety comes first – “Frequent fliers” among most likely to get some pre- diversion jail time; many perceived to be willingly making bad choices –Need for detox, general stabilization in combination with lack of Tx slots also often means jail time first

28. Propensity Score Method Step 1: –Case control match with local greedy algorithm Is a local matching algorithm, i.e., making optimal matching decisions at each step without attempting to make the best overall global matching decision Once a match is made, the match is not reconsidered Study group cases are ordered and sequentially matched to the nearest unmatched control group cases If more than one unmatched control matches to a case, the control is random selected 92 cases matched Step 2: –Distance score within same quintile For 10 un-matched cases, distance scores were computed between treated cases unmatched control cases with the same quintile Unmatched control case with smallest absolute distance is selected All 102 matched, and all covariates were balanced between study and control groups

29. Latent Growth Curve Analysis Study group Baseline - CJ Slope- CJ Baseline - Rx Slope- Rx -0.205**0.031** -2.086 0.368 0.082 -1.075* 0.210