What are Behavioral Health Disorders? When we use the term, we are referring to: Mental disorders (or mental illnesses) + substance use disorders = behavioral health disorders However, the term “behavioral health” is not universally agreed upon in the field Historical context Differences between mental health and substance use treatment communities/systems Council of State Governments Justice Center

What are Mental Disorders? A syndrome characterized by clinically significant disturbances in a person’s thinking, emotional state, and/or behavior that disrupt his/her ability to work or carry out other daily activities, and engage in satisfying personal relationships The diagnosis of a mental disorder should have clinical utility: it should help determine prognosis, plan treatment, and potential outcomes. Individuals whose symptoms do not meet full criteria for a disorder may still need treatment or care. Council of State Governments Justice Center

The Key Dimensions of Mental Disorders Anxiety Feelings of fear or dread, rapid heart rate, shortness of breath, lightheadedness Disturbances in perception and thinking Hallucinations, delusions Disturbances of cognition Difficulty organizing, processing, and recalling information Disturbances of mood Emotional highs or lows as prominent feature Council of State Governments Justice Center

When Do Symptoms Cross a Threshold to Become a Disorder? Mental illness and mental health exists on a continuum that is based on the: Nature and severity of symptoms Duration of symptoms Extent to which symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Council of State Governments Justice Center

How Are Disorders Determined and Described? Meets explicit criteria as described in the DSM-5 Recognizable pattern of symptoms (Syndrome) Multiple sources of information Council of State Governments Justice Center

How Are Mental Disorders Diagnosed? The Diagnostic and Statistical Manual Fifth Edition (DSM- 5) of the American Psychiatric Association provides a common language and typology for mental disorders in both children and adults. APA published first classification of mental disorders in 1844 as forerunner of DSM Four iterations post WW II with DSM-IV-TR published in 2000 The DSM-5 was released by the American Psychiatric Association in May 2013 DSM 5 builds on its predecessors Key differences between the DSM-IV-TR and DSM-V highlighted on next slide Council of State Governments Justice Center

What Are Substance Use Disorders? Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. National Institute on Drug Abuse: Drug Facts- Treatment Approaches for Drug Addiction: http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction The annual total estimated societal cost of substance abuse in the United States is $510.8 billion Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014 Executive Summary and Introduction. HHS Publication No. (SMA) 11-4629 Summary. Rockville, MD: Substance Abuse and Mental Health Services Administration,2011. Council of State Governments Justice Center

Not all Mental Illnesses are Alike: Mental Illness in the General Population Diagnosable mental disorders 16% Serious mental disorders 5% Severe mental disorders 2.5% Key Points: Council of State Governments Justice Center

In a Given Year… 16% Meet criteria for mental illness 22% of the United States adult population will be diagnosed with a behavioral disorder 16% Meet criteria for mental illness 9% Meet criteria for substance use disorders 16% of individuals will meet the criteria for mental illness 9% will meet the criteria for substance use disorders Council of State Governments Justice Center

What Are Co-Occurring Disorders? The term refers to co-occurring substance use (abuse or dependence) and mental health disorders. Clients said to have co-occurring disorders when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder. COCE, 2007 Council of State Governments Justice Center

PARALLELS: MENTAL ILLNESSES AND ADDICTIONS (Minkoff, 1996) MAJOR MENTAL ILLNESS A biological illness. Hereditary (in part). Chronicity Incurability Leads to lack of control of behavior and emotions Affects the whole family Symptoms can be controlled with proper treatment Progression of the disease without treatment Disease of denial Facing the disease can to lead to depression and despair.  Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes Feelings of guilt and failure Feelings of shame and stigma Physical, mental, and spiritual disease ALCOHOLISM/ADDICTION   A biological illness. Hereditary (in part). Chronicity Incurability Leads to lack of control of behavior and emotions Affects the whole family Symptoms can be controlled with proper treatment Progression of the disease without treatment Disease of denial Facing the disease can to lead to depression and despair.  Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes Feelings of guilt and failure Feelings of shame and stigma Physical, mental, and spiritual disease Council of State Governments Justice Center

What is the Relationship between Mental Illnesses and Substance Use Disorders? Acute and chronic substance use can produce psychiatric symptoms Substance withdrawal can cause psychiatric symptoms Substance use can mask psychiatric symptoms Psychiatric disorders can mimic symptoms associated with substance use Acute and chronic substance use can exacerbate psychiatric disorders Acute and chronic psychiatric disorders can exacerbate the recovery process from addictive disorders Council of State Governments Justice Center

Consequences of Co-occurring Disorders Increased vulnerability to relapse and rehospitalization More psychotic symptoms Inability to manage finances Housing instability and homelessness Noncompliance with medications and treatment Increased vulnerability to HIV infection and hepatitis Increased contact with the criminal justice system Council of State Governments Justice Center

Substance Abuse & Addiction in Criminal Justice Percent of Population Nationwide more than 4 in 10 state prison inmates are dually diagnosed with substance abuse and mental health disorders. 8 % Source: Compton et al., Am J Psychiatry, 2010. CSG Justice Center

SMI and Co-Occurring Substance Use Disorders (CODs) 4/13/2017 SMI and Co-Occurring Substance Use Disorders (CODs) Prevalence of SMI and CODs in Jail Populations General Population Jail Population 83% 28% 17% There is a real overrepresentation of individuals with SMI in our correctional systems- not just anecdotal This is happening at both the jail and the prison level- affects misdemeanor and felony-level offenses Even more pronounced overrepresentation among women Research indicates that the prevalence rates of co-occurring disorders among male and female detainees with SMI are the same upon intake (72%) Consumers, families, providers are frustrated by systemic barriers Associated morbidity and mortality is stunning Costs of ineffective care are enormous Effective interventions have been demonstrated In addition: Only 30% of U.S. prisoners with SMI taking medications at time of arrest “However, a much smaller proportion of inmates with a mental health diagnosis were taking psychiatric medication at the time of their arrest: 25.5% (SE=7.5%) of federal, 29.6% (SE=1.9%) of state, and 38.4% (SE=1.6%) of local jail inmates.” Far more likely to have previous incarcerations compared with inmates without SMI Source:The Health and Health Care of US Prisoners: A Nationwide Survey Andrew P. Wilper, MD, MPH, Steffie Woolhandler, MD, MPH, J. Wesley Boyd, MD, PhD, Karen E. Lasser, MD, MPH, Danny McCormick, MD, MPH, David H. Bor, MD, and David U. Himmelstein, MD. April 2009, Vol 99, No. 4 | American Journal of Public Health Serious Mental Illness Serious Mental Illness COD No Serious Mental Illness No Serious Mental Illness No COD Sources: Kessler RC, Chiu WT, Demler O, Walters EE. “Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication” (NCS-R). Archives of General Psychiatry, 2005 Jun; 62 (6): 617-27; Henry Steadman, Fred C. Osher, Pamela C. Robbins, Brian Case, and Steven Samuels, “Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services, 60 (2009): 761-65; Abram, K. M., Teplin, L. A. (1991). “Co-occurring disorders among mentally ill jail detainees,” American Psychologist, 46 (10), 1036–1045. Council of State Governments Justice Center

What Are Co-Occurring Disorders? (contd.) Among the jail population: 83% 28% 17% Henry Steadman, Fred C. Osher, Pamela C. Robbins, Briand Case, and Steven Samules, “Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services, 60 (2009): 761-65. Abram, K. M., Teplin, L. A. (1991). Co-occurring disorders among mentally ill jail detainees. American Psychologist, 46(10), 1036–1045. Co-Occurring Substance Use Disorder Serious Mental Illness No Co-Occurring Substance Use Disorder No Serious Mental Illness Council of State Governments Justice Center

4/13/2017 The Problem: Overrepresentation of Persons with Behavioral Disorders. Why? Arrested at disproportionately higher rates Co-occurrence of substance use disorders Homelessness Stay longer in jail and prison Limited access to health care Low utilization of EBPs High recidivism rates More criminogenic risk factors With individuals who are homeless, there is the perception that criminal justice involvement may be seen as a path to health care. However, jail involvement starts a cascade of events that cause new problems for the individual. Stay longer in jails and prison – with the same charges and sentences. Criminogenic risk—we will explain a few slides from now. Council of State Governments Justice Center

What Accounts for the Problem? High Recidivism Rates on Reentry 4/13/2017 What Accounts for the Problem? High Recidivism Rates on Reentry Screened 2,934 probationers for mental illness: 13% identified as mentally ill Followed for average of two years People with mental illnesses have more trouble meeting conditions of release See also: Eno Louden & Skeem, 2009; Porporino & Motiuk, 1995 No more likely to be arrested … … but 1.38 times more likely to be revoked Source: Vidal, Manchak, et al. (2009); see also: Eno Louden & Skeem (2009); Porporino & Motiuk (1995) Council of State Governments Justice Center

What Accounts for the Problem? Those with Mental Illnesses Have More “Central 8” Dynamic Risk Factors 4/13/2017 ** Risk here refers to criminogenic risk, which is a very specific type of risk discussed in following slides. It is not the risk of violence or aggressive behavior. We know that specific thoughts, behaviors, and attitudes puts an individual at risk for criminal justice involvement.  It turns out that persons with mental illnesses that have contact with the C-J system have more of these risk factors than persons without mental illnesses as illustrated in this study by Skeem, et. al. Pictured here: results of 2008 study of parolees. Those with mental illnesses scored higher on criminogenic risk factors than those without mental illnesses. (The LS/CMI is the Level of Service/Case Management Inventory, one of several types of tools used to assess individuals’ criminogenic risk) There is overlap between the dynamic risk factors and criteria for antisocial personality disorder. Specialized assessment for antisocial patterns would attend to the criteria outlined in DSM IV-TR as follows: Early and diverse antisocial behavior (Item A plus at least one of B, C, or D) Severe problems of adjustment in childhood, as indicated by school and social welfare records, or arrested and charged under age 16 Official record of assault/violence Escape history from a correctional facility, unlawfully-at-large Charge laid, probation breached, or parole suspended during prior community supervision Criminal attitude (At least one of A, B, or C) Supportive of crime (1.7.36) Unfavorable toward convention (1.7.37) Poor, toward supervision/treatment (1.7.39) Pattern of generalized trouble (At least four of letters A. through H.) Financial problems (Yes if rated as "0" or "1") 3 or more address changes last year Never employed for a full year (1.2.11) Less than a regular grade 10 or equivalent (1.2.12) Suspended or expelled at least once (1.2.14) Nonrewarding, parental (1.3.19) Could make better use of time (1.4.23) Few anticriminal friends (1.5.27) ….and these predict recidivism more strongly than mental illness Source: Skeem, Nicholson, & Kregg (2008) Council of State Governments Justice Center 19

The Behavioral Health – Criminal Justice Problem in Summary 4/13/2017 The Behavioral Health – Criminal Justice Problem in Summary We arrest them more often . . . We stress them while they’re incarcerated . . . We keep them incarcerated longer . . . They don’t get access to adequate mental health care . . . They are more likely to “fail” community supervision. Council of State Governments Justice Center