‹
SHARE

Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children

Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children

April 3, 2020

1 Introduction

Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The four drugs prescribed to children with the highest Medicaid cost are all psychoactive medications (1, 2). Stimulants alone account for 20.6% of all pediatric drug expenditures. At the same time, psychoactive medications have extensive and expensive side effects and frequently have minimal monitoring. For example, although metabolic monitoring through laboratory assessments is recommended for all children and adolescents taking antipsychotics, less than one-fifth of children receive such monitoring (1). Studies of prescribing practices and their costs, both economically and medically, have raised concerns among clinicians, patient advocates, and agencies with accountability for insuring children and adolescents that psychoactive medications are often used inappropriately.

We briefly review prescribing for three classes of psychoactive drugs—stimulants, antidepressants, and antipsychotics—and then discuss current system approaches to improving appropriateness of prescribing.

Here, we briefly review prescribing for three classes of psychoactive drugs—stimulants, antidepressants, and antipsychotics—and then discuss current system approaches to improving appropriateness of prescribing. System approaches include monitoring guideline concordance or lack thereof, and new but untested pharmaceutical policies and implementation of prescribing strategies to improve appropriateness. Inappropriate prescribing is difficult to define except on a case-by-case basis. Therefore, we refer to the broader category of potentially inappropriate prescribing as “questionable prescribing practices.” Both refer to the prescription of drugs in patterns that appear incongruous with clinically accepted, evidence-based guidelines. (For convenience, we sometimes use the word “children” to refer to children and adolescents.)

2 Stimulant Prescribing

One of the most challenging areas of psychotropic prescribing involves children and adolescents diagnosed as having attention-deficit hyperactivity disorder (ADHD). Although the American Academy of Pediatrics (AAP) continues to update clinical guidelines for the treatment of ADHD (3), there remains debate among providers about the accuracy of diagnosis, because many disruptive or impulsive behaviors attributed to ADHD can overlap with normative behavior among young children or may be a manifestation of trauma history or other psychosocial challenges.

Nevertheless, overall diagnosis rates for ADHD are increasing, and prescribing has followed in tow. By 2011, one in nine parents of youths ages 4–17 reported a history of ADHD diagnosis among their children, up more than 40% from the prior decade (4). ADHD stimulant use has similarly risen, reaching one in 15 of all youths, up 25% during the same period (4). One in three ADHD diagnoses occurs among preschool children, and diagnoses have climbed among younger children since the AAP issued new guidelines in 2011 (4, 5). At the same time, diagnosis and treatment have not been consistent across all groups of children. In particular, children in Medicaid and African-American and Latino children lag behind white children in diagnosis rates and access to many kinds of behavioral treatments (6). Meanwhile, as diagnoses have climbed for older youths, so have concerns about overdiagnosis and increasing trends in illegal diversion of medication from youths with prescribed stimulants to their fellow high school and college students (7).

The result has been a highly variable treatment environment in which many children may be at risk of overdiagnosis and treatment; however, we are also mindful that many children continue to be undertreated. In fact, half of the estimated 7.7 million U.S. children with a treatable mental disorder do not obtain necessary treatment (8). Multiple challenges exist in connecting children to services, including substantial differences in access to treatment for vulnerable groups. Insurance coverage, race-ethnicity, income, gender, and geography all affect children and families’ access to mental health services (9), and reactions to overtreatment, as evidenced here, should be anchored in this acknowledgment.

The response among the pediatric community to questionable prescribing, both over- and undertreatment, has led to calls to standardize care and to an emphasis on the value of shared decision making between providers and caregivers. The AAP guidelines seek to clarify the treatment environment for children and adolescents with ADHD (3). These guidelines endorse behavior therapy as the primary line of therapy for preschool children, and medications and behavior therapy are endorsed, with clinical equipoise, for school-age children. The guidelines emphasize medication treatment as a primary indication for older children.

Recent research has lent support to the criminogenic risk perspective by finding that criminogenic risk factors mediate the risk of recidivism among people with serious mental illness. A growing body of research suggests that justice-involved individuals with serious mental illness may manifest the same criminogenic risk factors as those in the criminal justice system without serious mental illness but at greater rates (14, 25–27). Taken together, research on co-occurring substance use and the criminogenic risk perspective illustrate another layer of complexity in the treatment needs of justice-involved people with serious mental illness. However, criminogenic needs are not a focus of treatment in most existing mental health services, which is a situation that must be corrected.

3 Antipsychotic Prescribing

The story is different for antipsychotics. The largest part of antipsychotic pediatric use is off-label use for nonpsychotic disorders, primarily for ADHD and other externalizing symptoms (10–12). In a large study by the Mental Health Research Network, a consortium of 13 healthcare delivery systems across the United States, 66% of boys ages 6–11 who were prescribed an antipsychotic medication did not have a psychotic disorder or other indication approved by the U.S. Food and Drug Administration (FDA). In the American Psychiatric Association’s Choosing Wisely recommendations, the fifth recommendation is, “Don’t routinely prescribe an antipsychotic medication to treat behavioral and emotional symptoms of childhood mental disorders in the absence of approved or evidence supported indications” (13).

Another concerning trend is that antipsychotics are disproportionately given to children in foster care, most commonly for disruptive behaviors (14). Giving antipsychotics to foster care children not only increases risks of side effects but also exposes the developing brain to medications for which there have been no long-term studies of outcomes. Antipsychotics are also associated with increased risk of death among children (15).

The sequential intercept model proposes five points of contact in the criminal justice system at which a person with mental illness can be “intercepted.” These points include the following:

INTERCEPT 1
interactions with law enforcement and the crisis response system

INTERCEPT 2
initial detention and initial hearings

INTERCEPT 3
jail and courts after initial hearings

INTERCEPT 4
reentry from jail, prison, or a forensic hospital

INTERCEPT 5
community corrections and community support

Originally in this model, the community mental health system was described as the “ultimate intercept,” where people with serious mental illness at risk of justice involvement or who may have other conditions putting them at risk of such involvement, such as trauma, social disadvantages, or substance dependence, could be identified and an integrated treatment or intervention plan could be enacted or coordinated with the appropriate service system (55). Thus the ultimate intercept refers to a treatment and service system that is responsive to the diverse, and at times intricately intertwined, needs of people with severe and persistent mental illnesses — ideally, before they ever become involved in the criminal justice system.

Recently Policy Research Associates, which operates the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) GAINS Center, introduced “intercept 0” within the sequential intercept model and defined it as encompassing “the early intervention points for people with mental and substance use disorders before they are placed under arrest by law enforcement” (58). Whereas intercept 1 represents a collaborative effort between law enforcement and the behavioral health community to avoid arrest when possible, the concept of intercept 0 recognizes the need for a full crisis response continuum and expands the partnership to broader mental health and law enforcement collaborations (58, 59). The discussion around intercept 0 has effectively mobilized advocacy to expand crisis services, as evidenced by the inclusion in the fiscal year 2020 SAMHSA budget passed by the U.S. House of Representatives of a 5% set-aside in block grant funds to the states to enhance crisis services (60).

Although we fully endorse intercept 0, we believe that it is best conceptualized as a renaming, and perhaps reframing, of what was called the ultimate intercept in the original description of the model. Although crisis services are an important piece of a comprehensive mental health system, they are only one element of the ultimate intercept as originally conceptualized, which also identified the need for evidence-based interventions, including community support services, medications, and vocational and housing services (55). The vision that we are presenting here is for an integrated behavioral health system to serve as the ultimate intercept, as originally envisioned, which we now call intercept 0, to include accessible, effective, and criminologically informed services for people with serious mental illness to help them avoid entering the justice system altogether (55, 57, 61).

4 The Behavioral Health System as Intercept 0

For the integrated community behavioral health system to operate as an
effective intercept 0, the system must both widen and deepen its array of services.
To do so, it will need to master integration at multiple levels. Mental health,
substance use, primary medical, criminogenic, and social needs all must be
addressed in a coordinated and timely manner to achieve the desired goals of improved health, prevention of institutionalization (hospitalization and incarceration), and overall recovery.

Incorporating multiple layers of integration into the operation of any one system is challenging, but this type of integration is an essential effort aimed at reducing the overrepresentation of people with serious mental illness in the justice system, and we believe it can be done. Because of its focus on prevention, early intervention, and recovery, the community behavioral health system is well poised to lead coordinated efforts to address the multiple needs of people with serious mental illness who are in the justice system. An integrated behavioral health system can focus on the provision of trauma-informed care to reduce the risk of traumatization as people with serious mental illness become involved (or reinvolved) with the justice system. Prevention efforts around substance use and efforts to intervene earlier in the course of serious mental illness have proven to be effective models of lessening the trajectory and harmful impact of illness (62).

Furthermore, integrated approaches have worked in the past. Historically, community mental health services, substance use services, and overall health care were provided in largely separate systems. To better address the needs of individuals with serious mental illness, there have been considerable efforts to integrate mental health treatment with treatment for co-occurring substance use disorders through integrated dual-diagnosis treatment (63). More recently, there have been major efforts to further integrate behavioral health care with overall primary health care (64, 65), including the current eight-state initiative establishing certified community behavioral
health clinics (66).

There is an increasing awareness of the need to address criminogenic needs of people with serious mental illness to prevent justice involvement. Interventions based in cognitive-behavioral therapy that engage a social learning approach to target specific criminogenic needs (e.g., antisocial behavior or attitudes) have been effective in reducing criminal offending (30), and evidence is emerging that these approaches can be effective for justice-involved people with serious mental illness (67). Osher and colleagues (51) developed a shared framework to integrate approaches to address multiple needs that builds on efforts to classify and treat mental illness and substance use disorders (e.g., the four-quadrant model) by adding the dimension of criminogenic risk. In this framework, individuals may be assessed on the basis of high or low levels of criminogenic need and clinical mental health or substance use treatment needs, and if a broader array of clinical services is available, appropriate service engagement can be arranged to meet these individual needs. There is also recent acknowledgment of the importance of earlier intervention in the trajectory of justice involvement by recognizing both individual factors and social conditions that contribute to criminality and justice involvement (33, 68).

For the integrated community behavioral health system to operate as an effective intercept 0, the system must both widen and deepen its array of services.

The community behavioral health system is also well positioned to address the structural risk factors that drive justice involvement of people with serious mental illness (e.g., poverty, homelessness, and unemployment), either directly or through the coordination of services. There is evidence that suggests that addressing these social determinants of health within the purview of the community behavioral health system can lead to successful outcomes. For instance, supported employment and Housing First initiatives have been shown to effectively increase treatment engagement among people with serious mental illness and also help them gain independent housing or competitive employment and reduce criminal reoffending (69–71).

Our vision is also consistent with current directions and priorities at the federal level. In 2017, the Interdepartmental Serious Mental Illness Coordinating Committee, a partnership among U.S. federal agencies to enhance coordination to improve service access and delivery of care for people with serious mental illness, developed priorities for increasing community partner engagement to address social determinants of health, improve service coordination, and create effective jail diversion opportunities (72).
.

5 Implications for Policy and Practice

Strange as it may seem, having the behavioral health system take the lead in addressing the overrepresentation problem is a significant change in many communities. Justice system leaders assert that they have been placed in the position of taking on the responsibility of justice-involved people with serious mental illness (73). Many of the newer solutions to the problems confronting this population have been led by sheriffs, judges, and other criminal justice system leaders (74).

Although mental and substance use disorders and criminogenic needs all need to be addressed, efforts to make the behavioral health system the focal point for the provision of this care will likely encounter resistance. The community behavioral health system may not want to take on this challenge, the criminal justice system may not want to give up control, and social service agencies may not be prepared for the degree of collaboration needed. Within community mental health systems, justice-involved individuals with serious mental illness are perceived to be qualitatively different from other individuals with serious mental illness. As with earlier resistance to integrate care for co-occurring substance use disorders with care for mental illness, community behavioral health system stakeholders should recognize that justice involvement in the population served is common and not a rare exception. Studies have reported a range from 25% to as high as 71% of people with serious mental illness in community samples who have a history of justice involvement (75–78). Community behavioral health agencies and social service agencies will need to make a commitment to integrating approaches and coordinating efforts to reduce the siloed organization of services. They must also be prepared to accept that justice-involved individuals should not be additionally stigmatized but should be welcomed as an appropriate, and substantial, population to be served (79). Research is needed to improve models of care that can deliver treatments as seamlessly as possible to meet the multiple needs of clients.

Funders of justice and mental health collaborative initiatives may need to rethink funding structures and priorities and ensure that treatment interventions and supports enhance an integrated behavioral health system rather than take place in the justice system. In most parts of the United States, the stark reality is that the publicly funded service system is not adequately supported to take on its daunting tasks. Current efforts to integrate mental health and substance use services within overall health care may run counter to our call for developing specialized service delivery approaches to meet complex medical and social needs of individuals with serious mental illness and justice involvement. We need innovative approaches to funding the behavioral health system that expand service capacity—initiatives such as the certified community behavioral health clinics currently being piloted. These resources may expand further under the proposed Excellence in Community Mental Health and Addiction Treatment Expansion Act.

We also need innovation and adaptability among state and mental health authority leadership. Arizona, for example, has essentially merged its state Medicaid and behavioral health agencies into a single entity and has worked with managed care plans to develop specialized programs for persons with serious mental illness.

We also need innovation and adaptability among state and mental health authority leadership. Arizona, for example, has essentially merged its state Medicaid and behavioral health agencies into a single entity and has worked with managed care plans to develop specialized programs for persons with serious mental illness (80, 81). Ohio may serve as another example of state leadership that has recognized the need for such vision. The state recently created RecoveryOhio, a plan to improve prevention, treatment, and recovery support efforts. Initially focused on the opioid epidemic, RecoveryOhio quickly expanded to include a broader focus on the mental health and substance use system and now emphasizes the need to address the problem of people with serious mental illness in the justice system. Directors of key state agencies work together with the RecoveryOhio director, who reports directly to the governor. Other states may find a model such as this conducive to effecting change to address a problem that they all face.

National initiatives have emerged to improve system responses to justice-involved people with serious mental illness. The Justice Reinvestment Initiatives supported by the Bureau of Justice Assistance, with technical assistance from the Council of State Governments, and the Safety and Justice Challenge, supported by the MacArthur Foundation, are significant efforts to address unnecessary incarceration. The National Partnership for Pre-Trial Justice, supported by Arnold Ventures, has multiple national partners considering best practices in pretrial detention. And the National Stepping Up Initiative provides a framework for local community stakeholders to collaborate across systems to address the problem.

Ultimately, critics and scholars of the problem of the overrepresentation of people with serious mental illness in the criminal justice system need to change the narrative. Instead of blaming overrepresentation on a failed mental health system or lack of inpatient beds, the complexity of the problem and the need for complex solutions must be acknowledged. In many ways, the community behavioral health system is doing the best it can with the resources it has. New initiatives such as the ones described here require increases in funding for community mental health and substance use services; the competency of these systems in integrating treatment of mental illness, co-occurring substance use, general medical conditions, and criminogenic factors must be enhanced, and new integrated treatments need to be developed and studied. In addition, social determinants of health, such as stable housing, employment, and education, need to be integrated, or addressed in coordination, with treatment. Larger social policies that have driven mass incarceration also need to be acknowledged as disproportionately affecting people with serious mental illness but with a recognition that the behavioral health system cannot fix these issues on its own.

Although an array of stakeholders across the behavioral health, justice, and social services systems can become strong advocates for policy change, they (we) must be joined by the public and policy makers alike. We know that broad advocacy works. Recent successes in states that have expanded Medicaid and the passage of the parity laws show that social policy can improve access to critically needed mental health services. The advocacy we need now could include a push for policy reforms and restructured financing models to increase access to integrated behavioral health services.

6 Conclusion

The overrepresentation of people with serious mental illness in the justice system is a complex issue that requires systematic change and collaborative problem solving. We believe that an integrated community-based behavioral health system (i.e., intercept 0) is ideally situated to address the complex needs of this population and prevent criminal justice involvement. If adequately supported, this system could provide accessible, effective, and criminologically informed services to address the clinical, criminogenic, and social support services needs of people with serious mental illness who are involved in the justice system. The goal is to identify people who would be best served in community settings and expand the continuum of services available within the behavioral health system to meet people where they live, work, and receive services. The role of the justice system will move toward collaboration and away from the need to build a parallel treatment system to address the treatment needs of justice-involved people with serious mental illness. We believe that this approach can improve individual and systems outcomes by preventing justice involvement, reducing service redundancy, and improving health and quality of life of people who are living in the community. All of society needs to take on the larger social issues that disproportionately affect people with serious mental illness.

Article Available in Psychiatric Services

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900417

Contents

Table of Contents

Authors 1. Introduction 2. Stimulant Prescribing 3. Antipsychotic Prescribing 4. The Behavioral Health System as Intercept 0 5. Implications for Policy and Practice 6. Conclusion Article Available in Psychiatric Services

References

  1. Steadman HJ, Osher FC, Robbins PC, et al.: Prevalence of serious mental illness among jail inmates. Psychiatr Serv 60:761–765, 2009.
  2. Frank RG, Goldman HH, Hogan M: Medicaid and mental health: be careful what you ask for. Health Aff 22:101–113, 2003.
  3. Mechanic D: Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Aff 31:376–382, 2012.
  4. Bonfine N, Ritter C, Munetz MR: Police officer perceptions of the impact of Crisis Intervention Team (CIT) programs. Int J Law Psychiatry 37:341–350, 2014.
  5. Lurigio AJ, Epperson MW, Canada KE, et al.: Specialized probation programs for people with mental illness: a review of practices and research. J Crim Justice 35:317–326, 2012.
  6. Skeem JL, Emke-Francis P, Louden JE: Probation, mental health, and mandated treatment: a national survey. Crim Justice Behav 33:158–184, 2006.
  7. The Stepping Up Initiative: The Counties. New York, Council of State Governments Justice Center, 2019. Available here https://stepuptogether.org/what-you-can-do
  8. Abramson MF: The criminalization of mentally disordered behavior: possible side-effect of a new mental health law. Hosp Community Psychiatry 23:101–105, 1972.
  9. Teplin LA: The criminalization of the mentally ill: speculation in search of data. Psychol Bull 94:54–67, 1983.
  10. Epperson M, Wolff N, Morgan R, et al.: The Next Generation of Behavioral Health and Criminal Justice Interventions: Improving Outcomes by Improving Interventions. Rutgers, NJ, Center for Behavioral Health Services and Criminal Justice Research, 2011. Available here https://pdfs.semanticscholar.org/33f4/1f0d950a8050fa27cba0e7ce4351d9c2e0b3.pdf
  11. Epperson MW, Wolff N, Morgan RD, et al.: Envisioning the next generation of behavioral health and criminal justice interventions. Int J Law Psychiatry 37:427–438, 2014.
  12. Morrissey J, Meyer P, Cuddeback G: Extending Assertive Community Treatment to criminal justice settings: origins, current evidence, and future directions. Community Ment Health J 43:527–544, 2007.
  13. Osher FC, Steadman HJ: Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatr Serv 58:1472–1478, 2007.
  14. Skeem JL, Manchak S, Peterson JK: Correctional policy for offenders with mental illness: creating a new paradigm for recidivism reduction. Law Hum Behav 35:110–126, 2011.
  15. Steadman HJ, Naples M: Assessing the effectiveness of jail diversion programs for persons with serious mental illness and co-occurring substance use disorders. Behav Sci Law 23:163–170, 2005.
  16. Abram KM, Teplin LA: Co-occurring disorders among mentally ill jail detainees: implications for public policy. Am Psychol 46:1036–1045, 1991.
  17. Baillargeon J, Binswanger IA, Penn JV, et al.: Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry 166:103–109, 2009.
  18. Hartwell SW: Comparison of offenders with mental illness only and offenders with dual diagnoses. Psychiatr Serv 55:145–150, 2004.
  19. Messina N, Burdon W, Hagopian G, et al.: One year return to custody rates among co-disordered offenders. Behav Sci Law 22:503–518, 2004.
  20. Wilson AB, Draine J, Hadley T, et al.: Examining the impact of mental illness and substance use on recidivism in a county jail. Int J Law Psychiatry 34:264–268, 2011.
  21. Wilson AB, Draine J, Barrenger S, et al.: Examining the impact of mental illness and substance use on time till re-incarceration in a county jail. Adm Policy Ment Health Ment Health Serv Res 41:293–301, 2014.
  22. Chandler DW, Spicer G: Integrated treatment for jail recidivists with co-occurring psychiatric and substance use disorders. Community Ment Health J 42:405–425, 2006.
  23. Drake RE, Morrissey JP, Mueser KT: The challenge of treating forensic dual diagnosis clients: comment on “integrated treatment for jail recidivists with co-occurring psychiatric and substance use disorders.” Community Ment Health J 42:427–432, 2006.
  24. Junginger J, Claypoole K, Laygo R, et al.: Effects of serious mental illness and substance abuse on criminal offenses. Psychiatr Serv 57:879–882, 2006.
  25. Peterson J, Skeem JL, Hart E, et al.: Analyzing offense patterns as a function of mental illness to test the criminalization hypothesis. Psychiatr Serv 61:1217–1222, 2010.
  26. Bonta J, Law M, Hanson K: The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychol Bull 123:123–142, 1998.
  27. Bonta J, Blais J, Wilson HA: A theoretically informed meta-analysis of the risk for general and violent recidivism for mentally disordered offenders. Aggress Violent Behav 19:278–287, 2014.
  28. Fisher WH, Silver E, Wolff N: Beyond criminalization: toward a criminologically informed framework for mental health policy and services research. Adm Policy Ment Health Ment Health Serv Res 33:544–557, 2006.
  29. Skeem JL, Steadman HJ, Manchak SM: Applicability of the risk-need-responsivity model to persons with mental illness involved in the criminal justice system. Psychiatr Serv 66:916–922, 2015.
  30. Andrews DA, Bonta J: The Psychology of Criminal Conduct, 5th ed. New Providence, NJ, Anderson, 2010.
  31. Draine J, Salzer MS, Culhane DP, et al.: Role of social disadvantage in crime, joblessness, and homelessness among persons with serious mental illness. Psychiatr Serv 53:565–573, 2002.
  32. Hiday VA: Mental illness and the criminal justice system; in A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems. Edited by Horwitz AV, Scheid TL. New York, Cambridge University Press, 1999.
  33. Barkan SE, Rocque M: Socioeconomic status and racism as fundamental causes of street criminality. Crit Criminol 26:211–231, 2018.
  34. Robert SA: Socioeconomic position and health: the independent contribution of community socioeconomic context. Annu Rev Sociol 25:489–516, 1999.
  35. Sampson RJ, Groves WB: Community structure and crime: testing social disorganization theory. Am J Sociol 94:774–802, 1989.
  36. Sampson RJ, Raudenbush SW, Earls F: Neighborhoods and violent crime: a multilevel study of collective efficacy. Science 277:918–924, 1997.
  37. Ross CE, Mirowsky J: Neighborhood disadvantage, disorder, and health. J Health Soc Behav 42:258–276, 2001.
  38. Roth A: Insane: America’s Criminal Treatment of Mental Illness. New York, Basic Books, 2018.
  39. Economic Perspectives on Incarceration and the Criminal Justice System. Washington, DC, Executive Office of the President of the United States, 2016. Available here https://obamawhitehouse.archives.gov/sites/whitehouse.gov/files/documents/CEA%2BCriminal%2BJustice%2BReport.pdf
  40. Primm AB, Osher FC, Gomez MB: Race and ethnicity, mental health services and cultural competence in the criminal justice system: are we ready to change? Community Ment Health J 41:557–569, 2005.
  41. Alexander M: The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York, New Press, 2012.
  42. Heitzeg NA: Whiteness, criminality and the double standards of deviance/social control. Contemp Justice Rev 18:197–214, 2015.
  43. McCallum KE, MacLean N, Neil Gowensmith W: The impact of defendant ethnicity on the psycholegal opinions of forensic mental health evaluators. Int J Law Psychiatry 39:6–12, 2015.
  44. Thompson M: Race, gender and the social construction of mental illness in the criminal justice system. Sociol Perspect 53:99–125, 2010.
  45. Thompson M, Newell S, Carlson MJ: Race and access to mental health and substance abuse treatment in the criminal justice system. J Offender Rehabil 55:69–94, 2015.
  46. Lamb HR, Weinberger LE: Decarceration of U.S. jails and prisons: where will persons with serious mental illness go? J Am Acad Psychiatry Law 42:489–494, 2014.
  47. Frank RG, Glied SA: Better but Not Well: Mental Health Policy in the United States Since 1950. Baltimore, Johns Hopkins Press, 2006.
  48. Lurigio AJ: People with serious mental illness in the criminal justice system: causes, consequences and correctives. Prison J 91:66S–86S, 2011.
  49. Prins SJ: Does transinstitutionalization explain the overrepresentation of people with serious mental illnesses in the criminal justice system? Community Ment Health J 47:716–722, 2011.
  50. Ditton PM: Mental Health and Treatment of Inmates and Probationers. Bureau of Justice Statistics: Special Report. Washington, DC, U.S. Department of Justice, Office of Justice Programs, 1999. Available here https://www.prisonlegalnews.org/media/publications/bojs_mental_health_and_treatment_of_inmates_and_probationers_1999.pdf
  51. Osher F, D’Amora DA, Plotkin M, et al.: Adults with Behavioral Health Needs Under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery. New York, Council of State Governments Justice Center, 2012. Available here https://www.bja.gov/Publications/CSG_Behavioral_Framework.pdf
  52. Blitz CL, Wolff N, Shi J: Physical victimization in prison: the role of mental illness. Int J Law Psychiatry 31:385–393, 2008.
  53. The New Conceptual Framework for Co-Occurring Mental Health and Substance Use Disorders. Washington, DC, National Association of State Mental Health Program Directors and National Association of State Alcohol/Drug Abuse Directors, 1998.
  54. Wolff N, Frueh BC, Huening J, et al.: Practice informs the next generation of behavioral health and criminal justice interventions. Int J Law Psychiatry 36:1–10, 2013.
  55. Munetz MR, Griffin PA: Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness. Psychiatr Serv 57:544–549, 2006.
  56. Munetz MR, Griffin PA, Kemp K: Jail diversion: using the Sequential Intercept Model; in Modern Community Mental Health: An Interdisciplinary Approach. Edited by Yeager KR, Cutler DL, Svendsen D, et al. New York, Oxford University Press, 2013.
  57. Griffin PA, Munetz MR, Bonfine N, et al.: Development of the Sequential Intercept Model: the search for a conceptual model; in The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. Edited by Griffin PA, Heilbrun K, Mulvey EP, et al. New York, Oxford University Press, 2015.
  58. Abreu D, Parker TW, Noether CD, et al.: Revising the paradigm for jail diversion for people with mental and substance use disorders: Intercept 0. Behav Sci Law 35:380–395, 2017.
  59. Police–Mental Health Collaborations: A Framework for Implementing Effective Law Enforcement Responses for People Who Have Mental Health Needs. New York, Council of State Governments, 2019. Available here https://csgjusticecenter.org/wp-content/uploads/2019/04/Police-Mental-Health-Collaborations-Framework.pdf
  60. Labor, Health and Human Services, Education, Defense, State, Foreign Operations and Energy and Water Development Appropriations Act, 2020, HR 2740, 116th Congress of the United States, 2019.
  61. Compton MT, Pope LG, Watson AC: A call to embrace our role at “Intercept 0.” Psychiatr Serv 70:975, 2019.
  62. Kane JM, Schooler NR, Marcy P, et al.: The RAISE early treatment program for first-episode psychosis: background, rationale, and study design. J Clin Psychiatry 76:240–246, 2015.
  63. Drake RE, Mercer-McFadden C, Mueser KT, et al.: Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophr Bull 24:589–608, 1998.
  64. Druss BG, Rohrbaugh RM, Levinson CM, et al.: Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry 58:861–868, 2001.
  65. Mauer BJ: Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. Rockville, MD, National Council for Community Behavioral Healthcare, 2006. Available here https://www.integration.samhsa.gov/resource/four-quadrant-model
  66. Protecting Access to Medicare Act of 2014, HR 4302. 113th U.S. Congress.
  67. Wilson AB, Farkas K, Bonfine N, et al.: Interventions that target criminogenic needs for justice-involved persons with serious mental illnesses: a targeted service delivery approach. Int J Offender Ther Comp Criminol 62:4677–4693, 2018.
  68. Pope LG, Hopper K, Davis C, et al.: First-Episode Incarceration: Creating a Recovery-Informed Framework for Integrated Mental Health and Criminal Justice Responses. New York, Vera Institute of Justice, 2016. Available here https://www.vera.org/publications/first-episode-incarceration-creating-a-recovery-informed-framework-for-integrated-mental-health-and-criminal-justice-responses
  69. Bond GR: Supported employment: evidence for an evidence-based practice. Psychiatr Rehabil J 27:345–359, 2004.
  70. Tsemberis S, Gulcur L, Nakae M: Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 94:651–656, 2004.
  71. Somers JM, Rezansoff SN, Moniruzzaman A, et al.: Housing First reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial. PLoS One 8:e72946, 2013.
  72. The Way Forward: Federal Action for a System that Works for All People Living with SMI and SED and Their Families and Caregivers. Rockville, MD, Substance Abuse and Mental Health Services Administration, Interdepartmental Serious Mental Illness Coordinating Committee, 2017. Available here https://store.samhsa.gov/system/files/pep17-ismicc-rtc.pdf
  73. Criminalization of Mental Illness. Chicago, Cook County Sheriff’s Office, 2017. Available here https://www.cookcountysheriff.org/criminilization-of-mental-illness
  74. Wilson AB, Draine J: Collaborations between criminal justice and mental health systems for prisoner reentry. Psychiatr Serv 57:875–878, 2006.
  75. Swanson JW, Frisman LK, Robertson AG, et al.: Costs of criminal justice involvement among persons with serious mental illness in Connecticut. Psychiatr Serv 64:630–637, 2013.
  76. Fisher WH, Roy-Bujnowski KM, Grudzinskas AJJ Jr, et al.: Patterns and prevalence of arrest in a statewide cohort of mental health care consumers. Psychiatr Serv 57:1623–1628, 2006.
  77. White MC, Chafetz L, Collins-Bride G, et al.: History of arrest, incarceration and victimization in community-based severely mentally ill. J Community Health 31:123–135, 2006.
  78. Theriot MT, Segal SP: Involvement with the criminal justice system among new clients at outpatient mental health agencies. Psychiatr Serv 56:179–185, 2005.
  79. Bandara SN, Daumit GL, Kennedy-Hendricks A, et al.: Mental health providers’ attitudes about criminal justice-involved clients with serious mental illness. Psychiatr Serv 69:472–475, 2018.
  80. Soper MH: Integrating Behavioral Health into Medicaid Managed Care: Design and Implementation Lessons from State Innovators. Hamilton, NJ, Center for Health Care Strategies, 2016.
  81. Bachrach D, Boozang PM, Davis HE: How Arizona Medicaid Accelerated the Integration of Physical and Behavioral Health Services. New York, Commonwealth Fund, 2017. Available here https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2017_may_bachrach_arizona_medicaid_integrated_behavioral_hlt_ib.pdf

Related Articles

Investing in School Mental Health: Strategies to Wisely Spend Federal and State Funding

Judicial Threats to Olmstead and the Americans with Disabilities Act

Redesigning Federal Health Insurance Policies to Promote Children’s Mental Health

Enhancing the Capacity of the Mental Health and Addiction Workforce: A Framework

Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children

How to use this paper to “Think Bigger” and “Do Good”

1 Send the paper to your local, state, and federal policy- and decision-makers

2 Share the paper with mental health and substance use advocates and providers

3 Endorse the paper on social media outlets

4 Link to the paper on your organization’s website or blog

5 Use the paper in group or classroom presentations

As strictly nonpartisan organizations, we do not grant permission for reprints, links, citations, or other uses of our data, analysis, or papers in any way that implies the Scattergood Foundation, Peg’s Foundation, Peter & Elizabeth Tower Foundation, or Patrick P. Lee Foundation endorse a candidate, party, product, or business.