Changes in Jail Inmates’ Substance Use, Substance Dependence, and Mental Illness from Pre- to Post-Incarceration June Tangney and Jeffrey Stuewig George Mason University

Today’s Topics Are there changes in substance use and dependence from pre- to post-incarceration? What is the prevalence of substance use and dependence? For the year prior to incarceration For the first year post-release How do symptoms of mental illness change over the period of incarceration? Do inmates deteriorate or improve ? What inmate characteristics predict changes in mental illness?

The GMU Jail Study Funded by NIDA (2002-present) Conducted in partnership with: Fairfax County Sheriff’s Office OAR, Fairfax

Participants Upon Incarceration (n=553) – 69% male –44% African American, 36% Caucasian, 9% Mexican American/Hispanic, 11% Other/Mixed One year post-release (n=324)* – 71% male –48% African American, 35% Caucasian, 6% Mexican American/Hispanic, 11% Other/Mixed

Retention 508 participants completed the full baseline assessment and were followed longitudinally. Due dates for phases are staggered because of rolling enrollment (June 2002-May 2007) and because sentences – and hence release dates -- of inmate participants vary considerably. 75% of eligible participants were assessed at 1 year post- release There were very few differences between eligible individuals who were re-interviewed vs. those who were not on 34 baseline variables. Non-respondents tended to be younger and Hispanic.

Substance Use and Dependency: TCU Correctional: Residential Treatment Form, Initial Assessment (TCU-CRTF; Simpson and Knight 1998) Frequency of alcohol, marijuana, cocaine, and opiate use during prior year (0 = “never” to 8 = “more than once a day”). Dependency symptoms in the prior year (0 = “never” to 4 = “7 or more times”). How often did you find that your usual number of drinks had much less effect on you or that you had to drink more in order to get the effect you wanted? Alpha =

Does substance use and dependence change from the year pre-incarceration to the first year post-release?

How often did participants use substances in the past 12 months? p<.01 0=never, 1= < once a month, 2= 1 a month, 3=1 to 3 times a month, 4= 1 to 2 times a week, 5=3 to 4 times a week, 6= 5 to 6 times a week, 7=daily, 8= > once a day

Mean scores on dependency symptoms p<.01

Percentage of individuals classified as substance dependent p<.01 Percentage of Participants

Summary High levels of substance use and dependence – For the year prior to initial incarceration – Also for the first year post-release Frequency of use and symptoms of dependence were lower at one year post-release compared to pre-incarceration levels

Mental Illness in Jail Jail inmates suffer from mental illness at rates far higher than in the community. Recent estimates based on DSM criteria are as high as 70%. Most studies have only examined a few diagnostic categories such as Substance Dependence, Antisocial Personality, Depression and Psychosis. (Teplin, 1994; James & Glaze, 2006; Veysey & Bichler-Robertson, 2002)

Key Questions: Assessing a wider range of symptoms.... Do symptoms of mental illness increase or decrease over the period of incarceration? What factors predict who does and who does not deteriorate or improve while incarcerated? (10 key factors: gender, age, race, education, income, stability of living situation (year prior), previous incarceration experience, length of incarceration, history of mental health treatment, and symptoms of substance dependence.) Changes in Symptoms over Incarceration?

Participants BaselinePre-release N Male70% African American 45% Caucasian36%37% Hispanic9% Other10%9% Age (SD)32 (10)33 (10) No difference between those interviewed at Time 2 and those not interviewed on gender, race, age, or symptoms of mental illness

Retention 508 participants completed the full baseline assessment and were followed longitudinally. Only those who remained incarcerated 6+ weeks following baseline were eligible for reassessment. 77% of eligible participants were assessed at pre-release No differences beyond chance between eligible individuals who were re-interviewed vs. those who were not on 34 baseline variables. Average length of incarceration = about 7 months

Personality Assessment Inventory (PAI; Morey, 1991) 344 item self-report measure of psychopathology and personality traits. Respondents indicated whether each item was “False,” “Sometimes True,” “Mainly True,” and “Very True.” Clinical scales: Somatization, Anxiety, OCD, Phobias, Traumatic Stress, Depression, Mania, Paranoia, Schizophrenia, Borderline Features, Antisocial Features, Alcohol Problems and Drug Problems

Clinical Scale Mean (SD) α Somatic52.77 (10.94).88 Anxiety55.33 (11.27).89 Obsessive-Compulsive53.71 (10.76).56 Phobias49.05 (10.63).56 Traumatic Stress63.42 (15.19).86 Depression58.03 (12.88).89 Mania58.62 (11.78).83 Paranoia59.73 (11.47).83 Schizophrenia55.43 (13.12).85 Borderline Features63.22 (12.80).89 Antisocial Features64.34 (12.01).85 Alcohol Problems59.88 (17.31).92 Drug Problems71.40 (20.46).91 N= Note: scales were transformed to T-scores based on norms from the census sample (M=50, SD=10) (Morey, 1991) * p <.05; ** p <.01 Level of Symptoms Upon Incarceration 76% reported clinically significant symptoms (a T- score >70) on a least one PAI clinical scale. Most prevalent were: Drug Problems (47%) Traumatic Stress (34%) Antisocial Features (31%) Borderline Features (31%) Alcohol Problems (26%). Even when excluding antisocial, drug, and alcohol problems, 57% still reported clinically significant symptoms.

Clinical Scale Mean (SD) α Somatic52.77 (10.94).88 Anxiety55.33 (11.27).89 Obsessive-Compulsive53.71 (10.76).56 Phobias49.05 (10.63).56 Traumatic Stress63.42 (15.19).86 Depression58.03 (12.88).89 Mania58.62 (11.78).83 Paranoia59.73 (11.47).83 Schizophrenia55.43 (13.12).85 Borderline Features63.22 (12.80).89 Antisocial Features64.34 (12.01).85 Alcohol Problems59.88 (17.31).92 Drug Problems71.40 (20.46).91 N= Note: scales were transformed to T-scores based on norms from the census sample (M=50, SD=10) (Morey, 1991) * p <.05; ** p <.01 Level of Symptoms Upon Incarceration 76% reported clinically significant symptoms (a T- score >70) on a least one PAI clinical scale. Most prevalent were: Drug Problems (47%) Traumatic Stress (34%) Antisocial Features (31%) Borderline Features (31%) Alcohol Problems (26%). Even when excluding antisocial, drug, and alcohol problems, 57% still reported clinically significant symptoms.

BaselinePre-Release rDifferencet-value Somatic53.16 (11.24)50.93 (9.94) (7.35)-4.59** Anxiety56.13 (11.93)53.67 (10.60) (8.14)-4.56** Obsessive-Compulsive53.64 (10.93)52.14 ( 9.64) (9.11)-2.50* Phobias49.37 (10.91)49.78 (10.57) (8.48) 0.74 Traumatic Stress63.43 (15.68)60.05 (15.36) (9.62)-5.31** Depression58.59 (13.13)55.05 (12.01) (8.45)-6.34** Mania58.59 (12.23)56.69 (11.19) (8.37)-3.43** Paranoia59.64 (11.64)57.31 (11.05) (8.10)-4.35** Schizophrenia56.03 (14.20)53.33 (12.88) (9.99)-4.08** Borderline Features63.60 (12.78)60.75 (12.78) (8.39)-5.15** Antisocial Features65.39 (11.74)64.26 (11.54) (7.12)-2.40* Alcohol Problems61.17 (17.43)62.41 (17.37) (9.86) 1.92 Drug Problems72.30 (20.44)73.00 (19.61) (10.10) 1.03 Change in Symptoms Over the Course of Incarceration Note: scales were transformed to T-scores based on norms from the census sample (M=50, SD=10) (Morey, 1991) * p <.05; ** p <.01

Who Improved the Most? In general symptoms of mental illness decreased (modestly) over time. More Improvement: – for women than men – for those with prior jail experience as opposed to first- time offenders – for inmates with a history of prior mental health treatment as opposed to those without – for inmates with higher substance dependence symptoms as opposed to those reporting lower or no dependence on drugs or alcohol

Who Improved the Most? Changes in symptoms were not a function of: – Race – Age – Education – Income – Stability of living situation prior to incarceration – Length of incarceration

Conclusions Although symptoms of mental illness decreased during jail incarceration, they were still very high – 73% of participants reported clinically significant symptoms on a least one PAI clinical scale at pre-release – Even when excluding antisocial, drug, and alcohol problems, 48% still reported clinically significant symptoms Effects are most pronounced for women, repeat offenders, and those with substance abuse problems. (Why?)

Is Mass Incarceration a Good Idea? No Decreases in substance use and dependence likely tied to probation and parole Decreases in symptoms of mental illness were modest – Reflects changes over the period of incarceration – NOT what happens once an inmates steps back into the community facing myriad barriers and challenges

Limitations Findings reflect symptoms of mental illness, not formal diagnoses. Cannot distinguish if the decrease in symptoms over time was due to a large spike of symptoms due to initial incarceration or whether these symptoms were present before incarceration. Based on data from felony offenders at a single jail.

Future Directions Examine predictors of changes in substance use and dependence (e.g., P&P, SA Tx, employment) Investigate how symptoms of mental illness change from pre-release to 1 year post-release

MANY THANKS... To the many graduate and undergraduate students who have worked in the Human Emotions Research Lab: Tania Abi-Najm, Leah Adams, Nicole Adock, Gayathri Adikesavan, Kauser Ahmed, Cecilia Anon, Molly Appel, Jalmeen Arora, Chris Arra, Zara Arshad, Brian Athey, Judy Back, Deb Hill-Barlow, Sheri Bailey, Ruth Barrientos, Rebecca Beam, Kim Becker, Mary Bolton, Angie Boone, Eleni Boosalis, Elly Bordeaux, Julie Borenstein, Laura Bowling, Thea Bowling, Lorenzo Bozzelli, Adam Brode, Phyllis Brodie, Tracey Brown, Lorenzo and Mina Bozzelli, Crystal Brothers, Heather Buller, Dalo Burje, Rachel Burroughs, Hannah Bustamante, Daniela Butler, Phyllis Byrne, Rhonda Campagna, Lisa Cannaday, Solange Caovan, Kyle Carlson, Eliana Castano, Meredith Cato, Tina Chan, Ericka Cho, David Choi, Lauren Christensen, Margaret Claustro, Luis Clavijo, Sarah Clements, Emily Clime, Erin Clyne, Eddie Codel, Bill Connell, Lisa Conner, Joe Constantin, Kenny Corson, Susan Cottrell, Michelle Covert, Brit Creelman, Helena Crick, John Crum, Sheila Cunningham, Ingrid Czintos, Chrissy Dale, Devra Dang, Zermarie Deacon, Ronda Dearing, Deanna DeGidio, Steve Devers, Bronwyn Devlin, Rosangela Di Manto, Ashley Dobbins, Robin Dold, Karisa Dominguez, Bertille Donohoe, Andy Drake, Amy Drapalski, Rebecca Duckworth, Robert Dumville, Kristen Durbin, Leigh Earley, Keesha Edwards, Kate Egbert, Rebekka Eilers, Drew Emery, Pam Estilong, Daniela Ettlinger, Barbara Evans, Samantha Fede, Kate Federline, Diana Fitek, Michelle Flanagan, Naheed Flanagan, Carey Fletcher, Laura Flicker, Jen Floor, Bridget Fonseca, Kerry Ford, Peter Forkner, Megan Formeck, Faye Fortunato, Marcelle Fozard, Karen Friedman, Juan Funes, Dee Dee Atkinson-Furr, Emi Furukawa, John Gavlas, Casey Gilchrist, Lynn Glikbarg, Lauren Gonzales, Melissa Gonzalez, Monica Gonzalo, Gerica Goodman, Kimberely Goodman, Jennifer Gosselin, Richard Gramzow, Theresa Grant, Beth Gunzelman, Logaina Hafez, Angela Hall, Sarah Hall, Alice Hansburger, Barbara Harding, Bill Harman, Sharie Harman, Angie Harris, Laura Harty, Mark Hastings, Kim Havenner, Marna Hayes, Ashley Heald, Courtney Heffernan, Caron Heigel, Nancy Heleno, Charlie Hendricks, Jolene Hering, Sheena-Dave’ Heslop, Dustin Higgins, Rachel Hite, Junellyn Hood, Kelly Hughes, Leslie Hughes, Mark Hyer, Miguel Iglesias, Nikki James, Rebecca Jackson, Tricia Jacobsen, Christina James, Margaret Jefferies, Ashley Jennings, Charlotte Joelsson, Heather Johnson, Karen Johnson, Mark Johnson, Caydie Jones, Heather Jones, Sarah Jones, Sara Julian, Sahair Kaboli-Monfared, Kristina Kallini, Ramineh Kangarloo, Marc Kaplan, Lesley Kato, Stephanie Kendall, Amy Kiernan, Nicole Kierein, Agnes Kim, Elysha Kim, Leslie Kirk, Sarah Klein, Linda Knauss, Greg Kramer, Stephanie Kowal, Chris Krause, Shilpa Krishnan, Maria Lacayo, Allan Langley, Patrick Lechleitner, Sylvia Lederman, Norman Lee, Elizabeth Leon, Jennifer Lerch, Pete Lielbriedis, Julie List, Claudia Lopez, Conrad Loprete, Charmaine Lowe, Michaela Lynch, Devon Madison, Jessica Magrath, Harry Malik, Elizabeth Malouf, Terri Markel, Andrea Martinez, Debra Mashek, Donna Marschall, Luis Mateus, Narges Maududi, James Maxfield, Lauren McGill, Heather McGraw, Megan McKenny, Mary McKnight, Amy McLaughlin, Patrick Meyer, Natalie Migliorini, Kimberly Minnema, Katie Mitchell, Sean Mitchell, Tim Mohr, Joanne Moller, Kelly Moore, Julie Morig, Corkie Morrill, Noha Mostafa, Kristen Mudrezow, Amy Muntz, Sara Mutnick, Melody Myers, Yvette Nageotte, Yasi Nejat, Nhu Nguyen, Thuy Nguyen, Vienna Nightingale, Jean No, Kyle Novak, Amanda Nuber, Beverly Nyokabi, Windi Oehms, Lia Ojeda, Judy Okawa, Dulce Orozco Martinez, Gabriel Ortiz, Jose Osorio, Erica Otter, Troy Pafenberg, Helen Pak, Gita Parlier, Caite Partamian, Elizabeth Patchen, Akhil Pathania, Jeff Pattison, Ray Payton, Chad Peddie, Phillip Pegg, Julie Pelch, Will Pennell, Geoffrey Pennoyer, Enrique Peralta, Marc Perez, Jill Perkins, Erica Perry, Amy Peterson, Dave Petersen, Greg Petrecca, Heather Phillips, Giorgia Picci, Kayla Pope, Steve Potter, Michelle Price, Erin Quigley, Adam Rabinowitz, Sara Rahai, Paula Raikkonen, Samira Ramezan, Michael Raumer, Candi Reinsmith, Megan Remener, Justin Reznick, Claudia Reyes, Katie Rich, Nakiia Robeson, Diana Rodriguez, Fernando Rodriquez, Monique Romeo, Charles Rong, Lori Roop, Karen Rosenberg, Tricia Roy, Melissa Rudy, Karey Rush, Candice Russell, Gary Russell, Provie Rydstrom, Paul Saenz, Leila Safavian, Dolly Saini, Jackie Sakati, Veronica Sanchez, Jennifer Sanftner, Lauren Saunders, Karen Schaefer, Ann Scharff, Heather Sevier, Danielle Sewell, Vicki Shaffer, Ann Shannon, Gordon Shaw, Kay Shows, Farhad Siahpoush, Jenn Sims, Deb Sinek, Chris Smart, Alison Smith, Deena Smith, Erika Smith, Steve Smith, Caryn Smonskey, Alisa Sneiderman, Jonathan Sollinger, Larry Spahr, Sabrina Speights, Brad Starring, Gary Stone, Stephanie Storck, Jeff Stuewig, Bianchi Suarez, Jenn Sullivan, Lauren Tangney, Tina Tehrani, Angela Termini, Dave Testa, Gia Thi, Rebecca Thompson, Chris Tiller, Andrea Thorson, Tammy Tower, Mike Tragakis, Berrin Tutuncuoplu, Tony Tzoumas, Kim Udell, Lisa Unrine, Jocelyn Valenzuela, Jacqueline Valdes, Suchi Vatsa, Jennifer Vaught, Marilyn Vivanco, Ivan Voronin, Svenja Wacker, Patti Wagner, Tammy Walker, Katherine Wallace, Rebecca Warden, Abigail Wear, Julie Weismoore, Kristine Welch, Dane Westermeyer, Simone Whyte, Dina Wieczynski, Rebecca Wilbur, Layla Wilder, Kelsey Wilkerson, Lauren Williams, Tara Williams, Brittany Wilson, Edward Witt, Sabura Woods, Susan Wyman, Autumn Yang, Tim Yerington, Siyon Yi, Kerstin Youman, Doris Yuspeh, Parin Zaveri, Nancy Zenich, Kate Zinsser, Patty Zorbas, and Tev Zukor

Decrease in SymptomsMaleAgeWhiteEducationIncome Unstable Living Situation Somatic -.19*.20* Anxiety -.14* Obsessive-Compulsive * Phobias Traumatic Stress * Depression -.14* Mania Paranoia * Schizophrenia Borderline Features Antisocial Features * Alcohol Problems Drug Problems -.14* Total Score -.17* What is related to decreases in symptoms * p <.05; ** p <.01

Decrease in Symptoms Prior IncarcerationTime Incarcerated Prior MH TX Substance Dependence Somatic.09.13*.21*.19* Anxiety.15* * Obsessive-Compulsive Phobias Traumatic Stress Depression *.21* Mania Paranoia Schizophrenia.14*.08.15*.14* Borderline Features * Antisocial Features * Alcohol Problems Drug Problems.14* * Total Score.14*.06.16*.23* What is related to decreases in symptoms * p <.05; ** p <.01