Share of Adult Suicides After Recent Jail Release

Importance

Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown.

Objective

To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts.

Design, Setting, and Participants

This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024.

Main Outcomes and Measures

The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated.

Results

Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays.

Conclusions and Relevance

This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Assessing Rural-Urban Differences in Screening for Mental Health Needs Among Individuals in County Jails

Rural jails are increasingly contributing to the overall jail population and little is known about how they differ from non-rural jails. This study compares demographic, behavioral health and criminal/legal histories of 3,797 individuals who booked into three rural jails and seven non-rural jails. In addition, the study assessed how jails identify mental illness, which was compared to an objective screening instrument (Kessler-6). Individuals in rural jails were more likely to be white, female, have a history of mental health services, misuse substances, and to recidivate. After controlling for these differences, they had 1.5 times greater odds of having a mental illness but lower odds of being identified by the jails. Individuals in rural jails have more behavioral health needs and other criminogenic risk factor and their needs are less likely to be identified by jail staff, which may result in poor connection to diversion or treatment opportunities.

Assessing County-Level Behavioral Health and Justice Systems with the Sequential Intercept Model Practices, Leadership, and Expertise Scorecard

The Sequential Intercept Model has helped conceptualize interventions for people with serious mental illness in the criminal/legal system. This paper operationalizes the Sequential Intercept Model into a 35-item scorecard of behavioral health and legal practices. Using interviews, survey, and observational methods, the scorecard assesses an exploratory sample of 19 counties over 27 independent data collections. A series of ordinary least squares regression models assessed the predictor scores on four jail outcomes: prevalence of serious mental illness, length of stay, connections to treatment, and recidivism. Increases in pre-booking scores showed significant decreases in jail prevalence of serious mental illness at the p < 0.05 level, and post-booking scores and overall scores showed significant positive associations with connections to treatment at the p < 0.05 level, though these were non-significant after correcting for multiple comparisons. Preliminary findings suggest a combination of practices across the Sequential Intercept Model could have synergistic impacts on key jail diversion outcomes.

County jails' responses to COVID-19: Practices, procedures, and provisions of behavioral health services

Michigan was one of the first states to feel the effects of the coronavirus disease 2019 (COVID-19) pandemic. This exploratory, mixed-methods study describes 20 county jails' responses to the pandemic across Michigan and presents a case study of one rural jail to examine changes in booking trends and behavioral health needs and services. Qualitatively, jails decreased their population at the outset of the pandemic via early releases, reconsideration of bond, and reductions in arrests. Quantitatively, the greatest prevalence of serious mental illness was found during the spring (initial shutdown period), which had the lowest weekly booking rates. Significant differences were found when comparing charge severity and charge type between study periods. Bookings occurring during the spring were significantly related to felony charges and drug/alcohol charges while individuals were less frequently booked because of violations. Past year recidivism significantly decreased from the winter to summer phase. Policy should mandate that jails screen for behavioral health problems and provide access to behavioral health services, while also expanding diversion opportunities during and after a pandemic. Innovations in continuity of care are critical for both behavioral and public health needs given the high risk for suicide, overdose, and viral spread after release from jail. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factors of Recidivism among Individuals with Co-occurring Conditions in Rural Mental Health Jail Interventions

Estimates indicate that nearly half of rural jail detainees meet the criteria for co-occurring disorders (COD). It is critical to examine factors of recidivism among detainees with COD in rural communities. This exploratory study aimed to examine factors of recidivism among adults in rural jails. Administrative data sources were utilized to assess postyear recidivism among 191 individuals with COD who participated in a jail-based intervention. Results indicated that a greater number of previous jail bookings and not receiving continuity of care were the strongest associations of overall recidivism, and a greater number of previous jail bookings was associated with of multiple recidivism events. The protective effect of receiving continuity of care was diminished in reducing recidivism 4- to 12-months following jail release. Re-entry services should consider developing or further expand specialized psychiatric care parole and connections to evidence-based integrated dual diagnosis treatment with a focus on programs with adaptability for rurality.

Transition Planning from Jail; Treatment Engagement, Continuity of Care, and Rearrest

Mental illness is experienced at a higher rate among incarcerated individuals than the general population. This study is one of the first assessing the association of a jail-based mental health (MH) transition planning program with continuity of care (CoC) (defined as no gap in treatment upon reentry), behavioral health treatment engagement, and rearrest. A one group pre-posttest design merged three data sources: program, community-based MH treatment, and jail data. Participants included 161 people from a Midwest metropolitan county jail. The utilization of MH treatment significantly increased after the program, particularly stabilizing services (i.e. case management). Individuals who engaged most in the program had greater odds of treatment engagement and increased odds of CoC. Time to first rearrest was delayed for those who received CoC. By providing transition planning services, jails and community-based services may increase treatment engagement and CoC, and reduce the risk and frequency of rearrest.

Incarcerated Women's Experiences of Staff-Perpetrated Rape: Racial Disparities and Justice Gaps in Institutional Responses

Within correctional settings, incarcerated women have disproportionately high rates of experiencing staff-perpetrated sexual victimization. In addition, only a small proportion of incarcerated women formally report their victimization experiences to correctional staff and even fewer reports are fully investigated by internal investigators and found to be substantiated. Given the multiple steps in this process, incarcerated women face several possible justice gaps in receiving preventive and intervention-focused responses from correctional staff. Racial differences among incarcerated women's experiences of these steps have not been explored. This study used a structural intersectional framework to examine racial differences in these areas: incarcerated women's experiences of staff-perpetrated rape, reporting decisions, and correctional staff's investigation decisions. With a sample of 180 incarcerated women, this study included analysis of archival data (i.e., settlement claim forms and internal investigation files) from a class action lawsuit involving incarcerated women who had experienced staff sexual misconduct. Black women represented over half of the incarcerated women who experienced staff-perpetrated rape. There were no statistical differences between Black and White women with regard to the characteristics of their victimization experiences, and they had similar rates of reporting their victimization to institutional staff. However, significant differences were found between women with regard to prison staff's responses to their reports; Black women were less likely to have their reports investigated by staff and were more likely to have their investigated reports found to be unsubstantiated. A detailed analysis of 100 specific incidents showed similar findings. Thus, while justice gaps existed for all women, gaps in institutional responses were exacerbated for Black women. Centering incarcerated Black women's experiences is pivotal for guiding efforts to transform correctional settings, to prevent and address staff-perpetrated sexual victimization, and to build safety for incarcerated women.

Law Enforcement and Suicide Calls for Service: A Mixed-Methods Study of Suicide Attempts and Deaths

INTRODUCTION

Suicide is a major public health issue, however, little is known about the characteristics/circumstances of suicide events. Data from law enforcement (LE) call reports are an important source of information related to suicide. Hence, this study explores suicide events captured in LE call reports.

METHOD

This mixed-methods study used data from call reports collected in a metropolitan county in 2017 in a Midwestern state wherein LE responded to suicide incidents (N=213). Descriptive and bivariate analyses of quantitative data were used to assess differences between incident type (i.e. attempts vs. deaths). Themes of suicide emerged from the qualitative data.

RESULTS

Findings revealed that suicide decedents tended to be male, older, and had at least one intrapersonal issue as a precipitating factor. The qualitative sections illuminated three themes across suicide attempts: self-harm as an autonomy seeking strategy; challenging claims of suicidality; and promising to not self-harm.

CONCLUSIONS

Suicide incidents that rise to the level of crisis requiring a LE response is understudied in both the suicide and LE literature. Increasing the sophistication of call report documentation procedures would allow for communities to deepen their understanding of how suicide manifests and could create pathways to non-institutionalized care.

"He Acted as If He Owned Me": An Exploratory Case Study Analysis of Correctional Staff Sexual Misconduct Against Women on Parole

While the Prison Rape Elimination Act focuses on sexual victimization in correctional settings, staff-perpetrated sexual misconduct against women under community-based correctional supervision has received little attention. This study explored women's experiences of sexual victimization by correctional staff while on parole and used a case study approach to examine sexual victimization incidents experienced by ten women. Women described how staff's misuse of power permeated the abuse tactics. Officers used their status to gain access to women, applied individualized tactics with promises and threats, and controlled when the abuse ended. Practices and policies are needed to build safety for women under community-based correctional supervision.

Comparing Women's and Men's Sexual Offending Using a Statewide Incarcerated Sample: A Two-Study Design

This study identifies the characteristics that distinguish between women's and men's sexual offending. We compare women and men currently incarcerated for a sex offense in one state using two data sources: administrative data on sex offenders in the state prison (N = 9,235) and subsample surveys (n = 129). Bivariate and logistic regressions were used in these analyses. Women account for a small proportion (1.1%, N = 98) of incarcerated sex offenders. In the population, women and men were convicted of similar types of sex offenses. The subsample was demographically similar to the population. In the subsample, women were more likely than men to have a child victim, be the parent/guardian of the victim, have a co-offender, and repeatedly perpetrate against the same victim. Findings suggest that women convicted and sentenced for a sex offense differ from their male counterparts, with predictive factors being dependent upon the age of their victim(s). Sex offender treatment interventions developed for men are poorly suited to and may have limited efficacy for women.

Mental Health Identification Practices of Jails: The Unmet Needs of the "Silent" Population: Special Issue: Criminal Justice and Community Psychology: Our Values and Our Work

The overrepresentation of individuals with mental illness in the criminal/legal system is well documented. While professional associations urge diversion towards treatment, little is known about the practices these institutions use to identify this population. One understudied space in the criminal/legal continuum is jails. This exploratory study compares two types of mental health identification at jail booking to assess jail- and community-based service outcomes by identification type (N = 2956): (a) staff observation and (b) a standardized screening instrument. Individuals identified through staff observation were significantly more likely to receive jail- and community-based services, even though current symptomology and substance misuse were both significantly higher for individuals identified only by the screening instrument. These findings point to the importance of jails in providing stabilizing services during incarceration, but further, show the impact that identification practices have on individuals as they transition to the community. Community context showed varied rates of jail staff observations of mental illness, showing greater risks for individuals in rural communities. Implications include a need for system-level changes by instituting evidence-based identification practices in jails, and improving professional collaboration practices between mental health and criminal/legal practitioners as individuals enter and exit jails.

Racial Disparities in Access to and Utilization of Jail- and Community-Based Mental Health Treatment in 8 US Midwestern Jails in 2017

Objectives. To examine the dual disproportionality that individuals with serious mental illness and people of color (PoC) occupy in the criminal-legal system.Methods. This study follows a cohort of 623 individuals who screened positive for mental health issues at booking in 8 Midwestern jails in 2017. We followed individuals through the jails' practices of jail-based mental health treatment, and we used Medicaid billing data to assess community-based behavioral health treatment engagement in the postyear period after jail release. The aim was to examine if an individual's race/ethnicity was associated with their access to jail- and community-based mental health treatment.Results. We did not find any racial disparities in jail-based treatment, although 3 community-based outcomes significantly differed. Compared with PoC, White people had 1.9 times greater odds of receiving community-based mental health and substance use treatment and 4.5 times greater odds of receiving co-occurring disorder treatment.Conclusions. Barriers that individuals released from jail face adversely affect PoC, resulting in reduced access to treatment. Critical race theory can expose the assumptions and functions of systems of care and the possible reproduction of implicit bias in potential solutions.

Identification, Referral, and Services for Individuals With Serious Mental Illness Across Multiple Jails

Identification of serious mental illness (SMI) among those entering jail is the first step in diversion or appropriate services in jail. Although best practices guidelines for identifying SMI exist, many jails do not employ these standards. Researchers describe identification of SMI in the "practice as usual" and compare/contrast the results with a validated screening instrument for 2,961 individuals across eight jails. Overall, 20% scored positive on the screening instrument, and staff identification yielded an additional 16%. While the instrument was consistent in identifying the proportion of persons with SMI across each county (16% to 22%), the proportion identified by jail staff varied greatly (3% to 33%). Moreover, referral to-and receipt of-subsequent services for the staff-identified individuals varied greatly, leading to recommendations for improved processes.

Evaluating the implementation of a prisoner re-entry initiative for individuals with opioid use and mental health disorders: Application of the consolidated framework for implementation research in a cross-system initiative

Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justice-involved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation. The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures. This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.

Enhancing knowledge of adolescent mental health among law enforcement: Implementing youth-focused crisis intervention team training

This study explores the feasibility, acceptability, fidelity, and outcomes of a youth version of the Crisis Intervention Team training (CIT-Y). This intervention is designed to keep youth with a mental health problem out of the criminal/legal system by equipping police officers with developmentally appropriate information and techniques. Whereas much is known about the adult-focused CIT training, little is known about the youth-focused training. This preliminary investigation uses multiple methods (training observations, officer interviews, and pre/post-tests) to assesses the implementation of CIT-Y in two Midwest counties. Multiple 8-hour training sessions were offered in both counties with 127 officers participating and completing the pre/post measure. The findings of this study confirmed that CIT-Y training was feasible in these counties and acceptable to the officers who participated. Outcomes from the pre/post-tests show that 86% of officers positively changed their knowledge and attitudes regarding youth with mental health problems. Interviews revealed a positive impact on officers' reported behaviors. While this preliminary investigation of CIT-Y showed positive outcomes, recommendations for enhancing the curriculum and subsequent research are discussed.

The relation of borderline personality disorder to aggression, victimization, and institutional misconduct among prisoners

OBJECTIVE

Borderline personality disorder (BPD) is highly prevalent among incarcerated populations; however, research has yet to examine whether prisoners diagnosed with BPD experience greater interpersonal dysfunction and institutional misconduct while incarcerated.

PROCEDURE

This study drew from a sample of 184 male and female prisoners diagnosed with major depressive disorder (MDD) in a randomized trial of depression treatment. The presence of a BPD diagnosis (n = 69) was analyzed as a predictor of disciplinary incidents/infractions (i.e., fights, arguments with staff, disciplinary infractions, isolation), time spent in isolation, and types of aggression and victimization experiences during incarceration.

RESULTS

There was a trend suggesting prisoners with BPD were about twice as likely as those without BPD to report disciplinary incidents/infractions (OR = 1.76 [0.93, 3.32], p = 0.075). Having a BPD diagnosis was unrelated to time in isolation and overall aggression and victimization. However, prisoners with BPD were more likely than those without BPD to perpetrate and be victimized by psychological aggression. Due to high rates of antisocial personality disorder (ASPD) in the sample as a whole (72%), additional analyses compared outcomes across prisoners with no BPD or ASPD diagnosis, BPD diagnosis only, ASPD diagnosis only, and comorbid BPD and ASPD. Prisoners with comorbid BPD and ASPD were no more likely than prisoners with ASPD only to report disciplinary incidents/infractions, but were significantly more likely than those with ASPD only to report perpetrating and being victimized by psychological aggression.

CONCLUSIONS

Among prisoners with MDD, those with a BPD diagnosis have increased risk of psychological aggression and disciplinary infractions during incarceration.

Factors Related to Co-Offending and Coerced Offending Among Female Sex Offenders: The Role of Childhood and Adult Trauma Histories

Research suggests two important domains of women's sexual offending: co-offending, in which additional perpetrators are present with the woman during the crime, and coerced offending, in which the woman feels pressured by someone else to commit the crime. This exploratory analysis examines these 2 domains using self-report data from 60 incarcerated female sex offenders (FSOs) in a Midwestern state. In addition to indicating whether a co-offender was present and whether they felt pressure to commit the sex offense for which they were incarcerated, participants provided demographic information about themselves, the victim, and the offense, as well as about their own trauma, substance abuse, and mental illness histories. Results indicate that childhood and adult trauma histories are related to both co-offending and coerced offending among FSOs. Implications for theory, policy and practice, and future research are discussed.

Countywide implementation of crisis intervention teams: Multiple methods, measures and sustained outcomes

The crisis intervention team (CIT) is a tool that can be used to foster pre-booking diversion of individuals with mental illness from the criminal justice system and into community treatment services. Although CIT is often implemented solely as the training of law enforcement officers, the model stipulates that CIT is a vehicle for collaboration with community stakeholders who share a similar philosophy, as well as expanded mental health services offering a 24 hour-seven days per week drop-off option for law enforcement officers. This case study presents the countywide implementation of CIT and expands previous findings on the prevalence of officer interaction with persons with mental health issues and CIT training outcomes, including changes in officer perception of individuals with mental health issues. Furthermore, analysis of the disposition of calls for officer assistance coded as mental health or suicide found significant increases in officer drop-offs to the mental health crisis center post-CIT training. Interrupted time series analysis determined that this change has been sustained over time, perhaps owing to the unique communication between county law enforcement and mental health staff. Implications for policy and practice are discussed.

Examining Perpetration of Physical Violence by Women: The Influence of Childhood Adversity, Victimization, Mental Illness, Substance Abuse, and Anger

Research on women's perpetration of physical violence has focused primarily on partners, often neglecting perpetration against nonpartners. This study proposes a conceptual model with direct and indirect relationships between childhood adversity and different targets of violence (partners and nonpartners), mediated by victimization experiences (by partner and nonpartners), mental illness, substance abuse, and anger. Using survey data from a random sample of incarcerated women (N = 574), structural equation modeling resulted in significant, albeit different, indirect paths from childhood adversity, through victimization, to perpetration of violence against partners (β = .20) and nonpartners (β = .19). The results indicate that prevention of women's violence requires attention to specific forms of victimization, anger expression, and targets of her aggression.

Cost analysis of long-term outcomes of an urban mental health court

Multiple studies have demonstrated decreased recidivism and increased treatment engagement for individuals with serious mental illness involved in Mental Health Courts (MHC). However, the limited availability of social and fiscal resources requires an analysis of the relationship between a program's effectiveness and its costs. Outcome costs associated with a sample of 105 participants discharged for more than 1 year - and grouped by completion status - were compared to an eligible sample not enrolled (n=45). Transactional costs analysis (TCA) was used to calculate outcomes associated with treatment, arrest, and confinement in the 12-month post-MHC. Total outcome costs for the Successful Group ($16,964) significantly differed from the Unsuccessful ($32,258) and Compare Groups ($39,870). Costs associated with the higher number of arrests for those in the Compare Group created the largest differences. Total cost savings between Successful and Compare (M=$22,906) equated to $916,240 and savings between Unsuccessful and Compare (M=$7612) were $494,708. The total combined cost savings for participants in the 12-month post-MHC period was $1,411,020. While it is important to understand that MHCs and the individuals that they serve vary and these results are for a felony-level court, policy makers and researchers can use these results to guide their decision-making.

Post-Separation Abuse of Women and their Children: Boundary-setting and Family Court Utilization among Victimized Mothers

Continued abuse of themselves and their children is a concern for many mothers leaving intimate partner violence (IPV) perpetrating husbands. This research examines women's responses to abuse committed by ex-husbands with whom they had undergone custody disputes. In-depth, qualitative interviews were conducted with 19 mothers who had divorced IPV-perpetrating husbands between one and three years prior. Participants were located through publicly available family court divorce records and interviews were examined using analytic induction. Women's strategies to protect themselves and their children from abuse involved setting boundaries to govern their interactions with ex-husbands. Mothers often turned to family court for assistance in setting boundaries to keep children safe, but found that family court did not respond in ways they believed protected their children. Conversely, when women turned to the justice system for restraining orders or called the police for help against IPV, they generally found the justice system responsive.

Analysis of success and survival in the health industry

Modern management theory accepts that people work for many reasons and to fulfill many goals. People want to survive and succeed and, given the opportunity and the skills, they will. Health professionals seek some of the higher goals. They want to serve their fellow man without being a servant. They want to succeed by providing relief to the suffering; such success must, by necessity, be exceptionally sweet. When human lives are at stake, the word "important" is truly defined. To a health professional, advancement can be an organizational promotion or it can be a professional achievement. In either case, how he/she succeeds will depend on what he/she does. He/she must perform well against a yardstick that grows constantly due to the advances in medical science. He/she must also realize constantly that what he/she performs on is a human being, and must be treated as such. He/she must keep technically able without losing his/her ability to deal in human relations. This study has shown that the health professional accepts the importance of these concepts.