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. Author manuscript; available in PMC: 2025 Nov 14.
Published in final edited form as: J Correct Health Care. 2025 Oct 24;31(6):383–390. doi: 10.1177/10783458251388607

Association Between Loneliness and Mental Health Treatment Utilization in a Prison-based Substance Use Treatment Population

S Michaela Barratt 1, Evan Batty 2, Megan E Marziali 4, Carrie B Oser 3, Amanda M Bunting 1
PMCID: PMC12614331  NIHMSID: NIHMS2110237  PMID: 41136220

Abstract

This study examines mental health service use among 395 incarcerated individuals with opioid use disorder in 14 prison-based substance use programs, as part of the GATE Study. It explores how mental health symptoms and loneliness relate to service utilization using two multivariate logistic regression models for pre-incarceration and during incarceration. Utilization rose from 19% before incarceration to 38% during incarceration. While 78% met criteria for depression and 58% for anxiety, neither predicted service use. In contrast, loneliness was significantly associated with greater utilization during incarceration (aOR: 1.14, p = .026). These findings highlight loneliness as a key driver of mental health service use in incarcerated populations, consistent with general population trends. Further research should explore the role of social networks in shaping service utilization in correctional settings.

Keywords: Co-occurring disorders, mental health, opioid, service utilization

Introduction

People with co-occurring substance use and mental health disorders are disproportionately represented in the criminal legal system (CLS). According to data from the 2017–2019 National Survey on Drug Use and Health, individuals with both a substance use disorder and mental health disorders were six times more likely to be arrested annually than those with mental illness alone and twelve times more likely to be arrested than those with neither disorder (NSDUH, 2020). Specifically, within this population, individuals with opioid use disorder and mental health disorders (i.e., co-occurring disorders) are at risk for severe health consequences. For the purposes of this paper, co-occurring disorders refer to individuals with concurrent opioid use and mental health disorders. In comparison to those who solely have an opioid use or mental health disorders alone, individuals with co-occurring disorders have, higher morbidity and mortality rates, have worse treatment outcomes, and are at higher risk for suicidal behavior (Pettit Brums & Kraguljack, 2023; Novak et al., 2019; Jones et al., 2019; Ali & Dubenitz, 2021). Despite the life-threatening effects of co-occurring disorders, an alarmingly low number of individuals receive treatment for either disorder. In the general population, only 10% of individuals with co-occurring disorders receive treatment for both disorders (NSDUH 2020), and just 7% of CLS-impacted individuals with co-occurring disorders receive both substance use and mental health treatment during incarceration (Hunt et al., 2015). Access and encouragement to engage in both substance use, and mental health treatment is a critical public health priority. Therefore, it is essential to understand the factors that influence individuals to seek and engage in available treatment both before and during CLS involvement.

In the community, several barriers significantly impact individuals’ ability to engage in treatment for co-occurring disorders. There is a lack of specialized treatment options for co-occurring disorders, and even when services are available, access is limited due to lack of transportation and the affordability of services (Harwerth et al., 2023; Novak et al., 2019). In the absence of structural barriers, treatment is often underutilized due to stigma related to substance use and mental illness which can discourage individuals from seeking help or adhering to treatment plans (Stringer et al., 2018, Priester et al., 2016; Zwick et al., 2020). Additionally, a lack of trust in institutions due to past negative experiences results in individuals being less willing to engage with treatment providers (Priester et al., 2016). These barriers can be amplified in certain communities, such as rural locations and among minoritized populations (Oser et al., 2016; Pullen & Oser, 2014).

During incarceration, there is an opportunity to provide treatment to individuals with co-occurring disorders while common community barriers, such as transportation and affordability, are removed. However, the CLS has its own set of barriers that may discourage individuals from utilizing substance use or mental health treatment while incarcerated. Treatment within the CLS can be limited and restrictive due to factors such as staff capacity, biases, and poor implementation of treatment protocols (Grella et al., 2020). Mental health treatment in jails and prisons often lack comprehensiveness, individualized care, adequate staff training, and reliable screening methods (Kolodziejczak & Sinclair, 2018). Moreover, stigma serves as a significant barrier for incarcerated individuals seeking treatment for substance use and mental health disorders. Many people who are incarcerated are reluctant to engage in treatment due to fears of discrimination and mistreatment by staff and inmates (Cheetham et al., 2022; Canada et al., 2022).

While addressing structural and institutional barriers is an essential first step to increasing service utilization in both the community and the CLS, studies indicate that interpersonal factors, such as a strong social support system, are key facilitators for individuals seeking and engaging in mental health and substance use treatment. Treatment combined with peer support has shown positive effects on hope, service engagement, long-term recovery, and relapse prevention among CLS-involved populations (Shalaby and Agyapong, 2020; Stack et al., 2022; Scannell, 2021). In criminal-legal settings, certain programs offered within prisons may foster a sense of belonging and community to mitigate feelings of loneliness. For example, therapeutic communities are a popular modality of prison-based treatment (DeLeon and Unterrainer, 2020) that may also help mitigate feelings of isolation and loneliness. Research on loneliness in the general population indicates that feelings of loneliness lead to increased health care use (Burns et al., 2020; Sirois and Owens, 2023). Despite evidence that individuals with a substance use disorder are seven times more likely to report feelings of loneliness compared to the general population, and five times more likely to view their loneliness as a concern, there is limited research on how loneliness potentially impacts service utilization amongst a CLS-impacted population (Ingram et al., 2020). Additionally, other factors at the individual level such as gender, ethnicity, race, and socioeconomic status have been shown to affect service utilization in both the community and during incarceration (Manuel et al., 2018; Baird et al., 2022).

The purpose of this study was to investigate mental health service utilization before and during incarceration among people with opioid use disorder (OUD) in a prison-based substance use program. We examined self-reported symptoms of anxiety and depression, perceptions of loneliness, and mental health service utilization before and during incarceration among men and women with OUD enrolled in a prison-based substance use disorder treatment program. We were specifically interested in understanding if these individual level factors differentially affected individuals’ decision to engage in mental health care both in the community and in prison.

Methods

Data from the current study were collected from the Geographic Variation in Addiction Treatment Experiences (GATE) (Oser et al., 2023). This study was conducted by the University of Kentucky’s Center on Drug and Alcohol Research to identify multi-level factors that influence initiation of medications for opioid use disorder in prison and the continuity of care after release from prison. This longitudinal study collected survey data from June 2021 to January 2024 in prison at four points: baseline (part 1 during incarceration and part 2 immediately post-release), 6 months post-release, and 12 months post-release. The current analysis is a cross-sectional analysis, using survey data from only the baseline data collection. The GATE study was reviewed and approved by the University of Kentucky’s Institutional Review Board.

The GATE study enrolled 395 people from fourteen prisons that offer medications for OUD (MOUD) within one southern state. People were eligible for inclusion in the study if they: (1) were over the age of 18, (2) had a history of OUD based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,(American Psychiatric Association, 2013) (3) were enrolled in a prison-based substance use program, (4) within 60 days of being released from prison, and (5) released within the state of Kentucky.

A Department of Correction liaison provided a monthly list of people currently incarcerated, in a prison-based substance use program, and were within 60 days of either being paroled or serving out their sentence. Participants who met eligibility criteria were provided with a recruitment letter to attend an information session. The letter stated that information session attendance, the screening process, and GATE study participation were voluntary. At the information session, individuals were screened for eligibility and provided written informed consent prior to enrollment in the study. The prison-based substance use program is offered to any individual who meets the clinical criteria for a substance use disorder, and all eligibility criteria for treatment (e.g., less than 36 months remaining before their release or meeting with the parole board, no recent disciplinary violations, etc.). Any person who is incarcerated can request an application to apply for treatment. The six-month long program utilizes a modified prison-based therapeutic community (De Leon, 2000) approach, in which a shared responsibility and mutual support among participants are emphasized in a structured, participatory environment. The prison-based substance use treatment program also uses the evidence-based New Directions curriculum from the Hazelden Betty Ford Foundation, which is designed for people involved in the criminal legal system. All prison-based substance use treatment programs are independently licensed through the state (KY DOC, 2025). Good Time Credit is provided for individuals who complete the prison-based substance use treatment program.

Survey data were collected at baseline by qualified and trained study staff. Data was collected in person, over the phone, or via zoom. Research Electronic Data Capture (REDCap, 2019) surveys were used for questions regarding individual sociodemographic, criminal history, psychiatric comorbidities, and treatment motivation and utilization. Participants received $5 USD for screening (regardless of eligibility status) and $60 USD for participating in baseline survey part 1 and part 2.

Measures

Dependent Variable

Two dependent variables are of interest. Participants self-reported lifetime mental health service utilization prior to incarceration and mental health service utilization during the most recent six months of incarceration (utilization=1, no utilization=0). The question specified the timeframe and was adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Mental Health Care Surveys. Specifically, the question asked, “did you receive mental health care.” (CAHPS, 2021)

Indicator Variables

Loneliness was assessed using the Three-Item Loneliness Scale and was measured by summing responses across all items, where participants indicated the frequency (1=hardly ever, 2=some of the time, 3=often) of loneliness (Hughes et al., 2004). The timeframes used when administering the loneliness scale included asking participants about the six-month period prior to incarceration (α = 0.76) and the last six months during incarceration (α = 0.77).

Items from the Depressive Symptom and Anxiety/Fear Symptom subscales were scored according to the GAIN manual (GAIN Coordinating Center, 2011) to determine if participants met criteria consistent with Major Depressive Disorder and/or Generalized Anxiety (1=yes, 0=no).

Participants completed a modified version of the Traumatic Life Events questionnaire (Kubany et al., 2000). The modified scale included 17 distinct traumatic event items, where participants indicated whether the event occurred never (=0), once (=1), twice (=2), three times (=3), four times (=4), five times (=5), or more than five times (=6) (α = 0.87). Responses were averaged to create a score indicating the frequency of experienced traumas.

Participants reported the total number of times they were admitted to a substance use treatment program (continuous). The question was adapted from the Global Appraisal of Individual Needs- I survey (Dennis, 2016) and asked, “how many times in your life have you been admitted to treatment or counseling (including the prescription of medication for a substance use disorder) for your use of alcohol or any other drugs?”

Demographic Variables

Participants provided self-reported: age in years, race (non-Hispanic White=1, non-white=0), gender identity (cisgender male=1, non-cisgender male=0), having insurance during the six month period prior to incarceration (had insurance =1, did not have insurance =0), and education (high school diploma/GED or higher=1, less than high school/GED=0). County of conviction was classified as a binary variable using each county’s Rural-Urban Continuum Code (RUCC) (USDA, 2013). RUCC values 1–3 were coded as 0 for non=rural, and values 4–9 were recoded as 1 for rural.

Analytic Plan

Descriptive statistics were calculated for all variables of interest. Two multivariable logistic regression models assessed the relationship between the indicator variables outlined above and mental health service utilization prior to and during incarceration, respectively, adjusting for demographic variables. In the model that assessed mental health service utilization during incarceration, we adjusted for mental health services utilized prior to incarceration. We assessed multicollinearity using Pearson’s r; no variable exceeded a score of 0.52, which is well below the commonly accepted threshold of 0.8 for multicollinearity diagnostics (Vatcheva et al., 2016). Missing data, which was less than 7%, were excluded from analyses. All analyses were conducted using Stata 18 (StataCorp, 2023).

Results

An overview of the study population is provided in Table 1. Prior to incarceration, 18.9% of participants had utilized mental health services, compared to 37.9% during incarceration. Feelings of loneliness were similar prior to (x̄= 6.1, R:3–9) and during incarceration (x̄= 5.8, R:3–9). The majority of the sample met the criteria for major depressive disorder (77.7%) or generalized anxiety disorder (57.7%). Participants varied in their lifetime experiences of traumatic events (x̄=1.7, R:0–5.2). On average, participants were admitted to a substance use treatment program 2.5 times in their lifetime (R:0–30). The sample included 53.9% of individuals from a rural county. Participants were on average, 39.2 years old, white (81.5%), cisgender male (74.9%), with health insurance prior to incarceration (67.1%), and had a high school diploma, GED, or higher education (84.5%).

Table 1.

Descriptive Statistics

Variable N Mean (SD) or %(n) Range
Mental Health Service Utilization
 Prior to Incarceration 387 18.9% (73) 0–100
 During Incarceration 388 37.9% (147) 0–100
Loneliness
 Prior to Incarceration 391 6.1 (2.1) 3–9
 During Incarceration 391 5.8 (2.2) 3–9
Criteria Consistent with Major Depressive Disorder 395 77.7% (307) 0–100
Criteria Consistent with Generalized Anxiety 395 57.7% (228) 0–100
Lifetime Traumatic Events Scale (higher scores=greater frequency of trauma) 393 1.7 (1.0) 0–5.18
Lifetime Substance Use Treatment Admittance 395 2.5 (3.3) 0–30
Had Rural County of Conviction 393 53.9% (212) 0–100
Age 395 39.2 (8.9) 21–66
Race (non-Hispanic white) 394 81.5% (321) 0–100
Gender (men) 394 74.9% (295) 0–100
Had Health Insurance 386 67.1% (259) 0–100
Education (HS diploma/GED or Higher) 394 84.5% (333) 0–100
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Model 1 of Table 2 reports adjusted odds ratios (aOR) for correlates of mental health service utilization prior to incarceration. People meeting the criteria for generalized anxiety disorder (aOR: 2.22, p=.044) were more likely to access mental health services prior to incarceration, compared to not accessing services. Similarly, people who were admitted to a substance use treatment program (aOR: 1.11, p=.005) were more likely to access mental health services prior to incarceration, compared to not accessing treatment. Loneliness prior to incarceration, major depressive disorder, traumatic history, and demographic variables were not associated with mental health service utilization prior to incarceration.

Table 2.

Multivariate logistic regression analyses of variables correlated with mental health service utilization prior to and during incarceration

Model 1: Prior to incarceration N=374 Model 2: During incarceration N=372
Variable AOR [95% CI] p-value AOR [95% CI] p-value
Loneliness Prior to Incarceration 1.04 [0.90, 1.21] 0.579 -- --
Loneliness During Incarceration -- -- 1.14 [1.02, 1.28] 0.026
Criteria Consistent with Major Depressive Disorder 0.91 [0.36, 2.28] 0.836 1.24 [0.60, 2.57] 0.567
Criteria Consistent with Generalized Anxiety 2.22 [1.02, 4.81] 0.044 1.86 [0.99, 3.50] 0.052
Lifetime Traumatic Events Scale (higher scores=greater frequency of trauma) 1.00 [0.74, 1.33] 0.976 1.10 [0.85, 1.42] 0.453
Lifetime Substance Use Treatment Admittance 1.11 [1.03, 1.19] 0.005 0.94 [0.87, 1.01] 0.111
Had Rural County of Conviction 1.10 [0.63, 1.93] 0.741 1.03 [0.62, 1.69] 0.920
Age 1.01 [0.98, 1.04] 0.495 1.02 [0.99, 1.05] 0.131
Race (non-Hispanic white) 0.60 [0.30, 1.20] 0.151 0.60 [0.32, 1.15] 0.125
Gender (men) 0.70 [0.38, 1.27] 0.241 0.38 [0.21, 0.66] 0.001
Had Health Insurance 1.80 [0.93, 3.46] 0.081 1.01 [0.59, 1.72] 0.978
Education (HS diploma/GED or Higher) 0.71 [0.35, 1.42] 0.334 1.53 [0.77, 3.03] 0.222
Mental Health Services Utilized Prior to Incarceration -- -- 7.22 [3.74, 13.95] 0.000
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Note: Bolded values p≤.05

AOR: Adjusted Odds Ratio

CI: Confidence Interval

The relationship between mental health service utilization during incarceration is presented in Model 2 of Table 2. During incarceration, increased feelings of loneliness were associated with mental health service utilization (aOR: 1.14, p=.026), compared to not accessing treatment. Additionally, women (aORmales: 0.38, p=.001) and those who had accessed treatment prior to their incarceration (aOR: 7.22, p=.000) were more likely to access mental health treatment services during incarceration. Other variables were not significant (Table 2).

Discussion

The current study aimed to explore factors that facilitate mental health service engagement within an incarcerated population participating in prison-based substance use programs. We found that people involved in the CLS had strikingly low rates of mental health service utilization. We found that participants were more likely to utilize treatment during incarceration. People who had used services before incarceration were more likely to report symptoms consistent with the criteria for generalized anxiety and have a history of substance use treatment. In contrast, people who accessed services during incarceration were more likely to have used mental health services prior to incarceration, identify as female, and report feelings of loneliness.

Our study provides novel insights into the relationship between loneliness and mental health service utilization. We found that individuals who reported higher levels of loneliness during incarceration were more likely to use mental health services while incarcerated. These findings align with existing evidence that loneliness predicts service utilization in both the general population and specific clinical groups (Sirosis & Owens, 2023). For instance, loneliness has been linked to increased primary care visits, emergency department visits (Chamberlain et al., 2022; Mullen, 2019), and health and social care service utilization among elderly populations (Wang et al., 2019). Interestingly, although our population’s feelings of loneliness during incarceration were similar to those reported prior to incarceration, the association between loneliness and service utilization was not found prior to incarceration.

A possible reason for increased service use could be due to the absence of usual coping mechanisms that individuals may have adopted prior to incarceration. Increased social involvement, personal development, religious beliefs, and increased activity - are well known coping strategies that individuals experiencing loneliness may utilize (Rokach and Brock, 1998). Without these coping behaviors it may be difficult for individuals to manage feelings of loneliness in a carceral environment that removes them from family, places them in a different highly controlled setting, and possibly exposes them to imposed social isolation such as solitary confinement. It is possible that individuals in our study may have gravitated towards treatment as an alternative coping mechanism. This finding mirrors general population studies where increased loneliness is related to increased service utilization, thought to be a source of connection for individuals with limited social network (Wang, 2019). In our population, individuals were a part of a prison-based substance use program that integrated community building and peer support by housing individuals separately from the general prison population. Within this program, cognitive therapy and behavioral intervention classes were provided by trained Department of Correction staff, and participatory communities were implemented in which peers held each other accountable for their behaviors. Additionally, individual and group activities focus on the aforementioned and emphasize goal setting to include substance use treatment, family, and/or employment goals. Research suggests that incorporating peer support into treatment can enhance the likelihood of incarcerated individuals seeking mental health services (Shalaby and Agyapong, 2020). These individuals have reported better social support, self-efficacy, family relationships, and overall quality of life following their release (Stack et al., 2020). Another possible explanation for greater service utilization could be competing demands within the general community that serve as barriers to accessing mental health treatment. For example, childcare, employment, or simply the demands to fulfill daily needs could greatly inhibit an individual’s ability to access treatment in the community (Priester et al., 2016).

Prior to incarceration, individuals who reported symptoms of generalized anxiety were more likely to access mental health treatment. Across all healthcare settings, anxiety disorders are associated with increased healthcare utilization (Horenstein and Heimberg, 2020). Our findings, along with others in the literature, suggest that this pattern also applies to individuals with co-occurring disorders. Specifically, the relationship between anxiety and opioid use disorder is well-established as cyclical, where anxiety symptoms often exacerbate substance use, and substance use can worsen anxiety (McHugh et al., 2021). These exacerbated symptoms could potentially lead to a higher perceived need for service utilization within this population. Additionally, people with a lifetime history of SUD treatment were more likely to seek mental health treatment prior to incarceration. This finding is concurrent with literature that suggests that healthcare utilization increases once engaged with the system and accessibility is improved and common barriers are removed (Hostetter et al., 2020). Engagement in substance use treatment can therefore promote utilization of mental health services, and vice versa.

During incarceration, individuals were more likely to utilize services if they identified as female, and/or had access to mental health services prior to incarceration. Research consistently shows that women are more likely to seek mental health services than men (Wang et al., 2005). This trend is also observed among incarcerated women with co-occurring disorders; one study found that currently incarcerated females were more likely to participate in available mental health programs compared to their male counterparts (Koons-Witt & Crittenden, 2018). This association was not observed prior to incarceration, which may be due to limited access to services and common barriers in the broader community. Individuals who used mental health services before incarceration were more likely to continue during incarceration, emphasizing the importance of continuity of care, especially for those with co-occurring disorders who face high recidivism (deAndrade et al. 2018).

Limitations

Our study uniquely contributes to the literature by examining the link between loneliness and service utilization among CLS-impacted individuals with co-occurring mental health and opioid use disorders. Despite this, several limitations must be acknowledged. Racial homogeneity, the location of incarceration, and the focus on opioid use disorder and mental health may reduce the generalizability of our findings to other racial and ethnic groups, other states, and other substance use populations. Moreover, the measures of anxiety and depression used in this study are based on self-reported data rather than clinical diagnoses. The Three-Item Loneliness Scale (Hughes et al., 2004), although commonly used, may not fully encompass the complexity of loneliness in this population. Moreover, recall bias may have influenced participants’ self-reports of loneliness prior to incarceration. Participants may have misclassified their past feelings of loneliness if they were experiencing loneliness at the time of completing the scale. Individuals in this study were recruited based on their involvement in a prison-based substance use program. While this program is easily accessible for individuals incarcerated in Kentucky prisons with over 6,072 treatment slots in 2025 (KY DOC, 2025), there may be unique characteristics that are not generalizable to an overall population of persons with OUD. Finally, while we controlled several factors, other confounding variables such as stigma (Cheetham et al., 2022; Canada et al., 2022), solitary confinement, and other potential barriers (Cloud et al., 2023; Henry, 2022) which are prevalent in the carceral settings, were not considered in the analysis. Future studies should examine how these variables influence the relationship between mental health symptoms, loneliness, and access to mental health services for people with co-occurring disorders.

Conclusion

This study provides valuable insights into the factors influencing mental health service utilization in a population with co-occurring disorders both prior to and during incarceration. Mental health service utilization doubled during incarceration, with gender-based differences and prior service utilization emerging as key factors. Most significantly, our study presents novel findings regarding the role of loneliness in service utilization, highlighting differences between community-based and incarceration-based services. Loneliness was associated with service utilization during incarceration, but this association was not found prior to incarceration. Additionally, although people are getting their mental health treatment needs met, 62% of our population did not receive treatment. Future research should explore in greater detail how loneliness impacts this population to better understand factors that influence service engagement in the broader community and in carceral systems.

Funding:

This work was supported by NIDA R01-DA48876 (PI: Oser), R36DA061635 (PI: Marziali), K01DA053435 (PI: Bunting).

Footnotes

Disclaimer: The contents of this publication are solely the responsibility of the authors and do not represent the official views of NIDA or the Kentucky Department of Corrections.

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