Risk of Arrest Among Public Mental Health Services Recipients and the General Public William H. Fisher, Ph.D. Lotna Simon, M.S. Kristen Roy-Bujnowski, M.S. Albert Grudzinskas, Jr., J.D. Nancy Wolff, Ph.D. Emily Crockett Steven Banks, Ph.D. Objective: This study compared arrest rates on a broad range of offenses in a cohort of public mental health service recipients and in the general population. Methods: Administrative data from a state mental health agency were merged with data capturing arrests over a 9.5-year period in a cohort of persons with severe and persistent mental illness who used public mental health services and were aged 18-54 (N=10,742). The com hort’s arrest rates for eight offense categories were compared with those of the general population for persons in the same age group over the same period (N=3,318,269). The data for the cohort that received mental health services were weighted by age and gender to align the cohort’s de- mographie characteristics with those of the general population. Results The service use cohort members’ odds of experiencing at least one arrest in any charge category were significantly higher than those of the gener al population (odds ratio [OR]=1.62, 95% confidence interval=1.52-1.72);, ‘odds were higher across all charge categories, with ORs ranging from 1.84 for drug-related offenses to 5.96 for assaull and battery on a police officer: Aside from the crime of assault and battery on a police officer, the largest ORs were associated with misdemeanor crimes against persons and property and with crimes against public decency. ORs associated with, felony charges, while significant, tended to be slightly smaller in magni- tude. Conclusions: The offenses for which persons with serious mental ill. ness are at greatest risk of arrest are many of those targeted by current diversion programs. These findings suggest the need for additional re- search addressing the ways in which individual psychopathology and so- cioenvironmental factors affect risk of offending in this population. (Pry- chiatric Services 62:67-72, 2011) Criminal justice system is not a America’s correctional population— rare experience for people in just one segment of those involved the United States; it was recently re- with the criminal justice system—in- ported that an estimated 47 million dicate that at the end of 2008 over people in the United States have an seven million persons (3.2% of all anrest record (1). Data from the U.S. adults) were on probation, in jail or B yallaccounts, contact with the Bureau of Justice Statistics describing Allthe authors except for De Wolff are afiated with the Department of Peychiatry, Uni versity of Massachusetts Medical School, 55 Lake Ave. N., Worcester, MA O1655 (e-mail: Dill fisher @umassmed ed). Dr: Wolff with the Center for Behavioral Health Services and Criminal Justice Research, Rutgers University, New Brunswick, New Jersey. PSYCHIATRIC SERVICES + ps paychitryontine org. # January 2011 Vol. 62 No. 1 prison, or on parole (2). As is well known, however, the risk of such in- volvement is not evenly distributed throughout the population. Instead, the risk clusters in social groupings chose members share certain indi- vidual or social statuses and risk fac- tors. As evidenced by the characteris- ties of the correctional population, this risk is highly skewed by gender, age, and race, Other data from the US, Bureau of Justice Statistics for 2008 indicate that men are roughly ten times more likely than women to be incarcerated and that African Americans are six times more likely than whites to be confined in jail or prison (3) Persons with serious mental illness- es are also known to be at high risk of amest and incarceration. It has been estimated that each year in the Unit- ed States nearly one million bookings involve persons with mental illnesses (A). Two longitudinal studies, one ex- amining recipients of services from a state mental health ageney (5) and an- other focusing on Medicaid benefici- aries with psychiatric illnesses (6), ob- served that rates of arrest were be- tween 25% and 28% over a ten-year period. Pandiani and colleagues (7), using probabilistic population estima- tion techniques, observed rates of ar- rest among public mental health serv- ice recipients that were roughly 4.5 times higher than those observed in the general population, ‘The literature about persons with serious mental illness in correctional settings is consistent with this trend. oA recent study of jail inmates in Maryland and New York, using the Structured Clinical Interview for DSM-IV, found point prevalence rates of nearly 15% for males and 31% for females (8)—levels far in ex- cess of those observed in the general population, Substantial system cross- over is also observed from the per speetive of the mental health syst as evidenced by Theriot and Segals {9) report of high levels of previous criminal justice involvement among. new clientele at California commu nity mental health centers. System involvement in this population also appears to skew heavily toward the criminal justice system; Morrissey ‘and colleagues (4) recently estimat- ed that a person with a serious psy- chiatric illness has @ higher likeli hood of spending a night in jail than being admitted to an inpatient psy- chiatrie facility It is thus well established that per- sons with serious mental illnesses have high rates of eriminal justice im volvement, and there is evidence that these rates exceed those observed in the general population. Our study fo- cused on a question that is not ad- dressed in these studies—that is, whether the higher arrest rates ob- served among persons with mental ill nesses are for certain types of offens- es or for a broad array of offenses. ‘The answer to this question has im- portant ramifications for framing pol- icy and practice at the interface of the mental health and criminal justice systems. This is particularly true with respect to conceptualizing risk factors and perhaps shifting resources to- ward offense-specifie interventions that might help persons with mental illnesses avoid involvement or reine volvement with the criminal justice system. Background Research focusing on the criminal jus- tice involvement of persons with men- tal illnesses has been a consistent and increasingly common feature of the psychiatric, psychological, sociologi- cal, and services research literature since the early 1970s. A number of perspectives have emerged within this literature, each emphasizing different types of offending behavior A sub- stantial body of research has shown substance abuse (10), long-standing antisocial personality disorder (11), and paranoid delusions (12,13) to be risk factors, especially for engaging in violent behaviors, only some of which ever come to the attention of police. Research grounded in this perspec- tive does not typically address the lev- cl of risk that these factors pose for other offenses, such as crimes against property, ‘A second perspective implicates features ofthe social environments in which many individuals with serious mental illnesses reside, These include mown criminogenic risk factors, such as poverty, unemployment, lack of ac- cess to prosocial networks, pervasive substance abuse, and concentrations of persons who engage in various tisocial and illegal behaviors (14-18) This perspective argues that, to para- phrase Silver's (19) observation with respect to violent behavior, persons with mental illnesses offend for many of the same reasons that others do in similar social situations, suggesting that the offenses with which they are charged will be roughly the same ‘ones as those in the general popula- tion exposed to the same concentra- tion of risk factors. Further evidence for this point, again with respect to vie lence bat arguably generalizable to offending behavior in general, comes from the MacArthur Violence Risk Assessment Study, which found that the likelihood of persons with mental illnesses engaging in violence was similar to that of others in their n borhoods (20), Finally, the criminalization model (21) traces the source of criminal jus- tice involvement to system failures for persons with mental illnesses. That is, problematic operations of mental health services, the laws and policies Ariving these services, and the failure of mental health systems to promote continuity of treatment engagement among their clientele often result in decompensation and expressions of deviant behavior among persons with mental illness, and police are often forced to make arrests (21). This per- spective and the jail diversion mecha- nists that have been motivated by it tend to focus on low-level offenses, such as disturbing the peace and tres- passing, and to deemphasize involve- rent in criminal activity that is more serious (22), As this very brief overview sug- gests, different conceptual foci tend to lead researchers to emphasize cer- tain offending behaviors, such as vio- lence or low-level misdemeanors, to the exclusion of other kinds of offens- os. As a result, there have been few reports that have quantified the ex- ‘cess risk of criminal justice involve- ment across offense types. Our study represents an effort to provide such offense-specific data, comparing ar- rest rates on a range of key charges in a cohort of state mental health service recipients with those observed in their state's general population, Methods This study used data from a longitudi- nal study of arrest in a cohort of pub- lie mental health serviee recipients. The cohort included persons aged 18-54 who received inpatient, resi- dential, or case management serviees from the Massachusetts Department of Mental Health (DMH) during Massachusetts fiscal year 1992 (July 1, 1991, through June 30, 1992) (N=10,742). Their eligibility for re- cciving services was based on having received a diagnosis of a severe and persistent psychiatric disorder (most typically a psychotic or major affec- tive disorder) of significant duration that caused substantial functional im pairment and resulted in a history of multiple hospitalizations over a de- ned period. Diagnostic data for this cohort were incomplete, and those available were based on clinical assessments, not structured research diagnostic protocols. However, given the nature of the DMI service eligibility crite- ria, we are reasonably assured that the cohort in this study is representa- tive of public mental health agency clientele across the nation who were served over this period. Arrests for these individuals were tracked through December 2000, or for just under ten years. This period predates the widespread development of di- version programs in Massachusetts that could potentially have reduced the arrest rate among persons with serious mental illness PSYCHIATRIC SERVICES + ps peychistryontine org. # January 2011 Vol. 62 No. 1Data ‘The DMIT data inchided elements lowing matching with the arrest or ar- raignment data maintained by the Massachusetts Criminal Offender Record Information (CORI) system, the official registry of eriminal history data compiled by the Massachusetts Trial Court. These data include all charges and dates of arraignment for all arrests occurring in nonfederal Massachusetts courts. Arrest data spanning this period for the general population were also obtained from the CORI system. Published data from the 1990 U.S. census for Massa chusetts were used to construct de- nominators for general population ar- rest rates, This study was reviewed and ap- proved by the Committee for the Pro- tection of Human Subjects in Re search at the University of Massachu- setts Medieal School and by the DMI Central Office Research Review ‘Committee. Access to CORI data also required review of the study by the Massachusetts Trial Court's Criminal History Systems Board, which over- sees operation of the CORI system. Categorizing offenses In order to compare offense-specific rates of arrest for the DMIT cohort with those of the general population, it was first necessary to reduce more than 100 charges in these data to a workable number. To do so, an inter- disciplinary team, including a law professor who is also a former trial at- torney as well as a researcher with graduate training in criminal justice, identified a set of key legal categories and then grouped offenses within them. The same coding schemes were used for classifying DMH at general population offenses. The: categories included felony and misde- meanor crimes against persons and property erimes against public order, drug-related offenses, erimes against public decency, and assault and bat- tery on a police officer, A number of hard-to-categorize low-level offenses, as well as offenses with low prevae Tence rates in the service use echort for example, firearm charges, motor vehicle violations, and white collar crimes, such as embezzlement) were not included in the analysis. A full iste Summary and classification of charges lodged against cobort members a Bea 28 Felony crimes against persons: Murder, nonneglgent manslaughter, forcible rape; robbery inhaling armed robbery; or aggravated assault and battery sn a dangerous weapon, again a petton over 65, against a dabled person, orto colt a dee \ ; Misdemeanor crimes agaist persons: Domest violence (nt resulting ina Cargo of rerlour violent este), simple ssa, simple aru and bate, ‘Oreatening oF ninidatin, indent seal assault (Oat i tring tothe legal definition af foreble rape), or violation of restraining order, Asgult and battery on a police ficer Felony erines aga propery Burglary larceny ofan tems worth more than $500, welfare rau receiving soln proper tering (passing bad checks), Ureaking and entering arson, ot motor vec et Misdemeanor exes aginst propery Thel or shoplifting ofan tem worth less than $500 or mali destracion of prop eee ae eee a eee tee ee etn alse slr, perpetrating a bomb hoax erpssng or consuming alco in «publi place (alition of open contalne lav) Crimes against public docency Offenses related to sex fr hte (oiitng rorittion or beings sex worker) indecent exposure, or ewd and lascivious ator Drugtelited offenses: Poststion of «controlled substance; postesson with intent to ditsbute, dition or manufactur of, or walling in con- tolled substance; o congpray to violate the Controlled Substance Act ing of the offenses included in each ed by activities in the DMH cohort, category is provided in the box on this although they inevitably include per- page. (More detail on this process is sons with serious mental illness in the provided in a study by Fisher and col- population who are not members of Teagues (5].) this particular service use cohort. The DMIL cohort rate is the weighted Comparative approach number of cohort arrestees divided ‘Our comparison utilized a retrospec- by the total number of cohort mem- tive cohort design, in which the of- bers ( fense-specific rates of arrest (that is, the proportion of persons expe Statistical analysis ing at Ieast one arrest during the ob- Simple od ratios (ORs) were calcu servation period in the various charge lated to determine the degree and categories) for the DMH cohort were statistical significance of differences ‘compared with those from the gener- between the service use cohort and al population observed over the same the general population in the odds of period. The numerators of these rates are the number of persons experienc- any given OR, a 95% confidence in- ing at least one arrest for an offense interval (CI) not including 1.00 was as- ‘each category: For the general popu- sumed to be statistically significant at lation, the mumerator for a given p<.05. Calculations were cartied out charge category is the numberof per- with Stata, version 10.1 sons in the population with an arrest ina given charge category minus the Results number of DMI cohort members Sample characteristics with similar charges, That is, the de- ‘The genderand age breakdowns of the nominator for the general population DMI cohort and the Massachusetts (N=3,318,269) is based on the num- population are shown in Table I. As in- her of persons aged 18-54 counted in dicated in Table 1, the age and gender, the 1990 Federal Census for Massa- as well as ageawithin-gender distribu- 0,743) chusotts rninus the number of per- tions of the two groups were distinctly sons in the DMH cohort. The gener- different. The DMH cohort member- al population rates are thus unalfect- ship was slightly older and included a PSYCHIATRIC SERVICES + ps paychistryontine org. # January 2011 Vol. 62 No. 1 6Table Age and gender distribution of a cohort of persons who received services from the Massachusetts Department of Mental Health (DMI) and the Massachusetts population DMH cohort Massachusetts population Weighted N) (N= 10,719.7), Weighted % Within gender Within cohort Unweighted Unweighted N* (93,318,260) Within gender ‘Within population Unweighted N Variable (N=10,742) Male ‘Age 1S 456 2539 3.268, 4054 2.749 Total GATS Female ‘Age 24263 539 1.907 40-54 2.009 Total 4.269 11345 25090 1619.6 5,263.1 Last, 2589.1 17103 5.4565 70 42 505 302 426 256 1000 500 62 25 467 186 471 187 1000 398 350,230 ‘783.204 5005503, 1,634,027 358,150 797.195 528,187 1,684 242 21d 479 306 vag 213 a3 sid 1000 105 los. 20) 159 507, ‘Based onthe 1990 US. Census for Massichosets minus the mumber of perronr in the DMH cohort, Rounding of group percentages caused some tal to exceed 1005. In these cates the taal were reported a: 100% much higher percentage of males. ‘Weights based on these differences for h of the six age-by-gender group- ings were estimated and used to align the DME cohort’ age and g fender dis tribution with that of the general pop- ulation. Data on race-ethnicity that had sufficient detal in the various age and gender groups wore unavailable in the published census data for this peri- cod; thus race-ethnicity was not able to be incorporated in the weighting scheme. Both weighted and unweight- ced values for the DMI sample are shown in Table 1 Overall arrest rates Weighted DMIH cohort data were used to compare the odds of experi~ fencing at Teast ono arrest on any the listed charges in the service use cohort with those of the Massachu- setts population. Among the DMI cohort members, 3,662 (32.8%) were arresto: at least once during the ob- servation period, compared with 792 (23.2%) Massachusetts resi- dents (OR=1.62, 95% Cl=1.52-1.72 } indicating that the cohort members ‘were nearly two-thirds more likely to experience at least one arrest during the observation period nse-spe- cific arrest rates for each group, ORs, and 95% Cls are shown in Table 2. As indicated in Table 2, for every of- fense category, the DMH group's age and gonderadjusted arrest rate was significantly higher than that for the general population, and in some cases, dramatically so, ORs ranged from 1.84 for drug-related offenses to 5.96 for as- sault and battery on a police offices Discussion Soveral things should be kept in mind when considering the data presented Table? ‘Odds of experiencing an arrestin each charge category during the observation period for service recipients of the Massachusetts Department of Mental Health (DMH) and for the Massachusetts population* DEM cohort Unweighted N Weighted N. Weighted % Unweighted N Unweighted % Massachusetts population” Variable OR 95% CI (Crimes against persone Felony 1,783, 1.956 182 217,983 66 BIT 285-348 Misdemeanor vit Li9 los lor 933 33 422 370-482 Assault and battery on ‘4 police officer 369 404 38 29,047 6 596 4587.74 Crinies against property Felony 1,250 13 196,280 59. 2.92-2.72 Misdemeanor 1054 Wt 94,966 29 3.6924 82 Drugzrelated offenses 1253 17 45 1632.08 Crimes against public decency “47 47 10. 381-585 Crimes against pubhe order 514 165. 53 321-394 Te n nein Both cohorts were aged ISS years. Odds ratio with 95% confidence intervals not including 00 were aramed to be significant ot po. * Population rites exclude DMH cohort members. PSYCHIATRIC SERVICES + ps peychistryontine org. # January 2011 Vol. 62 No. 1here. First, arrests represent police officers’ perceptions and categoriza- tions of the behaviors they see, which they fit into a legal framework that can be managed by the eriminal justice system. Many charges are dropped before prosecution. The data present- ced here thus represent intial, street- level definitional processes. Whether the outcome of these processes is dif- ferent for persons with a severe men- tal illness is unclear But whatever their social meaning, arrests represent involvement with the criminal justice system, a phenomenon that in and of itself is of extreme importance to ‘mental health authorities secking to minimize rates of involvement. Several methodological limitations ‘warrant attention. First, we were un- able to adjust for racial and ethnie dif= ferences between the DMI cohort and the general population. It is well mown that persons from racial or the nie minority groups are at greatly cle- vated risk of arrest (3), and our inabile ity to adjust for this factor represents a serious shortcoming. Moreover, sim ple demographic adjustment, even when race-ethnicity is included, is clearly inadequate to answer the ques- tion of whether being a public mental health services recipient per se places persons at greater risk of arrest, As we noted earlier, such individuals en- counter a host of potentially crimino- genic socioenvironmental and socioe- conomic risk factors. In order to ade just for these factors one would need to adopt the strategy of the MacAr- thur Violence Risk Assessment Study (20), comparing cohort members with neighbors exposed to the same fac- tors. This was clearly beyond the scope of our project. ‘Also, our data did not capture ade- quately the differences between the DMH cohort and the general public with respect to time in which the per- son isat risk of arrest, Persons such as the cohorts members experience a range of incapacitating events, in- cluding arrest and psychiatric hospi talization, which may be less common in the general population. ‘Thus the time in which the person is at risk of arrest may be lower for persons with tmental illnesses than for population. ‘An additional concern is the age of the data—a problem plaguing many Tongitudinal studies, Since the time spanned by the observation period, numerous diversion mechanisms have been developed at the interface ofthe mental health and criminal jus- tice systems that, had they been in place in the 1990s, might have affect- ced the arrest rates of the service use cohort. For our purposes this can be seen as both a curse and a blessing by observing activity in the prediver- sion era we can assume that these rates are “uncontaminated” by the ef- fects of those services. Comparisons with a similar cohort identified in the carly 2000s would be interesting in this regard Finally, the general population ‘comparison group did not exclude all persons who are mental health servie- es recipients, There were undoubted- ly recipients who happened not to re- ceive services in the index year as well as persons who had not yet begun re- ceiving services. However, this num bers presumably small relative to the ‘entire Massachusetts population and unlikely to have significantly biased cour results, With those considerations in mind, wwe shift attention to the implications of the data presented here, These data show arrest to be a far more ‘common experience for persons in the DMIT cohort than it was for the general population, both overall and within all of the offense categories shown here, However, with the ex: ception of assault and battery on a po- lice officer, the largest ORs wore as- sociated with misdemeanor crimes against persons and property and against public order and public de- ccency, which typify the low-level mis- demeanors that are the focus of most diversion efforts, But the importance of the felony charges is not to be over- looked. An arrest and conviction for ‘one of the misdemeanor charges may hhave an impact on individuals’ hous- ing, employment, and other pros- pects but lack serious long-term con- sequences and few publie safety im- plications. Felony charges, on the other hand, may be associated with events that significantly affect other persons’ health or property, and ¢ victions on these charges can lead to long-term incarceration in settings PSYCHIATRIC SERVICES + ps paychistryontine org. # January 2011 Vol. 62 No. 1 where mental health services may be inadequate (23,24), These offenses are not generally the focus of diver- sion programs; nonetheless, under- standing the pathways to involvement in these events and the individual, en- Vironmental, and systemic factors as- sociated with them is critical given their societal importance Conclusions Administrative data such as those used in this study have the advantage of providing glimpses of large popula- tions and providing information on population and subpopulation of- fending rates and patterns. As such, they can inform policy and service delivery discussions, However, the lack of key variables—detailed diag- nostie profiles, information on chang ing social networks and environ- ments, routine activities, use of men- tal health services, continuity of treat- ment, and other factors—limits the extent to which important causal rela- tionships ean be explored. The signif- icance of this problem argues for the development of a research agenda that includes longitudinal studies fea~ turing comprehensive interview pro- tocols coupled with administrative data on treatment, employment, criminal justice involvement, and other factors that are routinely cap- tured over time, Understanding what differentiates persons with intensive justice involvement from those with litle or no such involvement is essen- tial ifthe excess risk of arrest faced by public mental health services reeipi- ents isto be reduced. Acknowledgments and disclosures ‘This study was supported by grant IROL [MH5515 from the National neste of Men= tal Heald and by the Center for Bchavioral Health and Criminal Justice Reseatch andthe Sidney R. Baer, Jr Foundation, The authors thank Jelly Swanson, PhD, fo help come rents on an earlier version of thie article Thit sworkiededicsted to oar beloved clleag, the Tate Dr Steven Banks, without whom none of these analyses could have been undertaken, “The authors report no competing interest References 1, Bach A: Ordinary Injustice: How Ame Holds Court New York, Metropol 2008) 2, Total Comrectional Population. Washing. ton, DE, Department of Justice, Office of nJustice Prograas,Bureuu of Justice Stats fier. Available a be oped} gow West JC, Sabol W]: Prison Inmates at Midyear 2008 Statistica Tables. 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ME: The criminaization of tnetally dsondered bebavior: possible ‘de effect of «new commitment law Hos pital and Community Peyhinty 23:101— 47, 1972 Swattz MS, Swinson JW, Hiday VA, tab Violence and severe mienta less: the ef fects of substance abuse and non-adher- ‘ence to mediation. American Journal of Pryehitry 155.226-251, 1998 Psychiatric Services Reviewers Can Earn CME Credits ‘The American Psychiatrie Association, in keeping with American Medical Asso- ciation (AMA) guidelines, offers AMA PRA Category 1 Gredit™ for review of ‘manuscripts submitted to Psychiatric Services. To earn CME credit, reviewers must enroll in the program by submitting a dis closure form. Reviewers who ate not enrolled will not be able to do so retroac= tively (that, after completion ofa review), To read more about the program and. to download the disclosure form (with instructions for submitting it), please go to \wwn.appi.org/SiteCollectionDocuments/Journals/PSY/PSCMEDisclosureF orm Reviewers pdf. 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