Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• Comparative effectiveness of correctional programs, facilities, and interventions for people involved with the criminal justice system with serious mental illness.
• Please see the attached presentation by Dr. Curley Bonds entitled “The Color of Justice: Planning for Successful Re-Entry,” and the presentation by Dr. Cassandra Newkirk entitled “Re-entry & Mental Health Issues.” (In November 2009 Dr. Bonds was the Chief Medical Director of the Los Angeles County Jail System, one of the largest jail systems in the country that provides mental health services to prisoners.)

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of evidence-based correctional practices for patients with SMI (such as those targeting risk factors for crime, like antisocial attitudes, with cognitive-behavioral techniques) with psychiatric treatment alone for their ability to promote community re-entry.

Note, this bullet is also relevant for outcomes that are more specific to mental health, such as confinement in a psychiatric forensic unit, acts of aggression, and harm to others or self including suicide and homicide

• Compare the effectiveness of correctional programs vs. psychiatric treatment alone on outcomes such as community reentry among criminal offenders with mental illness.
• For adults with SMI who are involved with the criminal justice system, compare the effectiveness of organized interventions that can prevent re-arrest and re-incarceration.
• Compare the effectiveness of various approaches to training the law enforcement workforce to identify and appropriately disposition people with SMIrecognize that an individual may have a serious mental illness and assist them in reaching an appropriate location where further evaluation can occur.
• For adults with psychotic disorders who are involved with the criminal justice system, compare the effectiveness of supported employment and traditional job counseling on job placement, job retention, and criminal recidivism. It would also be useful to examine other outcomes that are more directly related to psychiatric illness and not look only at typical measures used in the criminal justice system such as recidivism.
• Compare the effectiveness of crisis intervention teams, mental health courts, and mental health probation or parole on community adjustment, reductions in criminal recidivism, and costs.
• Compare the use of electronic monitoring in lieu of incarceration as a possible intervention in non-violent offenders that would allow ongoing psychiatric treatment in the community.
• Compare the effectiveness

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Adults with Serious Mental Illness (SMI) who are in the criminal justice system

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• Those incarcerated with a serious mental health illness
• In analyzing data, it would be important to look at differences between violent and non-violent offenders, substance use comorbidity (including substance related offenses), and the presence/absence of clear-cut antisocial features (not simply arrests and behaviors relating to drug-seeking in those with substance use disorder).
• Another subgroup of individuals in whom further information would be helpful are those who have committed sexual offenses. Policy decisions are being made in many states relating to the continued confinement of such individuals after release from correctional facilities. For those who do return to the community, there are profound difficulties in community re-entry and in finding work and housing. Individuals with serious mental illness may be convicted of sexually related offenses based on disorganized behavior that they exhibit while psychotic (e.g., indecent exposure), which is likely to have very different long-term implications for community risk than sexually violent individuals with co-occurring serious mental illness.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Community reentry/adjustment
• Avoidance of arrest recidivism
• Decreased costs
• Job placement and retention
• Psychiatric and general medical health benefits or outcomes

Describe any health-related risks, side effects, or harms that you are concerned about.

• Adequate medical treatment for those with SMI, as well as rehabilitation for the crime that they might have committed.
• A primary risk would be harm to the individual and/or others from early release into a non-secure setting for purposes of treatment in a community rather than institutional setting.
• Re-arrest and re-incarceration
• In addition to measures of arrest and incarceration recidivism, other outcome measures could include differences in rates of psychiatric hospitalization (including forensic admission), evidence of potentially harmful behavior to self or others, functioning and quality of life, specific symptoms/syndromes that may be associated with incarceration (e.g., PTSD due to victimization while incarcerated, worsened psychosis due to solitary confinement and sensory deprivation)
• Outcomes that are specific to mental health, such as confinement in a psychiatric forensic unit, acts of aggression, and harm to others or self including suicide and homicide

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Functional limitations and disability
• Obesity
• Substance abuse

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Development and comparison of correctional programs, facilities, and interventions for people with serious mental illness who are involved with the criminal justice system may result in promotion of community reentry/adjustment, prevention of arrest recidivism, job placement and retention, and reduced costs. Such programs may also result in improved short and long term mental health outcomes, reduced rates of harm to self and others, reduced development of syndromes such as PTSD related to incarceration and enhancements in functioning.

Certain settings have been underrepresented in SMI research, including prisons, jails, and the criminal justice system, where the prevalence of mental health disorders is quite high. In addition, development and comparison of these interventions may result in revisions to the training of the law enforcement workforce to recognize that an individual may have a serious mental illness and assist them in reaching an appropriate location where further evaluation can occur.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

• Unfair treatment of the mentally ill population.
• Some of our prior practice guidelines have included sections that discuss the modifications in treatment that may needed when working with patients in jail and prison settings. Having specific comparative effectiveness data would help in future guideline development efforts.
• In my work with patients who have serious mental illness, I often see individuals who have had experiences in the criminal justice system or who are brought for assessment of suicidal ideation prior to being taken to jail. There is a lack of information about the specific interventions that would be most effective in addressing psychiatric needs while staying within the constraints of correctional settings.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Please see the attached presentation by Dr. Curley Bonds entitled “The Color of Justice: Planning for Successful Re-Entry,” and the presentation by Dr. Cassandra Newkirk entitled “Re-entry & Mental Health Issues.” (In November 2009 Dr. Bonds was the Chief Medical Director of the Los Angeles County Jail System, one of the largest jail systems in the country that provides mental health services to prisoners.)

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to care of individuals with serious mental illness who are in correctional settings.

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Health services disparities for people in the criminal justice system have been identified. The population of people with serious mental illness in the criminal justice system has been characterized as underserved.

• Individuals with serious mental illness are particularly vulnerable when residing in correctional settings. They are often subjected to victimization and may be placed in solitary confinement with profound sensory deprivations for behaviors relating to their psychiatric disorder, each of which can further worsen their psychiatric condition.
• Not all medications for psychiatric illnesses can be used in correctional settings due to concerns about misuse. This may also lead to inequities in care compared with treatment in the community.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to care of individuals with serious mental illness who are in correctional settings.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

1- The Practice Guidelines project of the American Psychiatric Association was asked for the name of someone to participate; my name was submitted; 2- We were asked to participate by the Oregon Health and Science University on behalf of the Agency for Healthcare Research and Quality’s (AHRQ) Effective Health Care (EHC) Program.