Behavioral Health Services Following Release From Jail: A Widening Racial Disparity Gap

Despite growing public awareness and bipartisan political support for policy change, the United States continues to incarcerate more people than any other country. Incarceration, whether short or long term, can have devastating health, mental health, social, and financial consequences for individuals, families, and entire communities. In 2018, 10.7 million people entered jail.¹ Although this was a roughly 11% decline compared with the previous 10-year trend, we continue to house an average of nearly 740 000 people in jails every day. Black and Native people continue to be grossly overrepresented in jails at 592 and 401, respectively, per 100 000 people compared with White people, who are incarcerated at a rate of 187 per 100 000.¹

HEALTH AND MENTAL HEALTH IN JAILS

Jails concentrate people with highly infectious and chronic diseases and untreated mental illness and substance use problems, which contributes to the health inequities in the communities to which they return.² We see this today more than ever, with jails being vectors for spreading COVID-19.³ People spend an average of 25 days in jail¹; these short stays can disrupt established mental health care and bring infectious disease home to people’s families and neighbors.

Across studies, the rates of people with serious mental illness (SMI; i.e., bipolar, schizophrenia spectrum, major depression, delusional, and psychotic disorders) are higher in jails than the community.^4,5 Fifty-three percent of females in jail met criteria for posttraumatic stress disorder in their lifetime,⁶ and more than half of people in jail used substances at the time of arrest. The overrepresentation of people with SMI in jails affects rural communities and the largest jail systems in the United States.

Jails were not designed as clinical treatment facilities. Many jails face monetary, staffing, and space-related challenges that further prohibit their ability to manage the complex clinical needs of people. Even short jail stays can affect family caregiving, employment, and financial stability. For people with SMI and other behavioral health needs, the best place to receive care is the community. Unfortunately, as Hedden et al. (p. 277) highlight in this issue of AJPH, Black people with SMI were less likely to utilize needed services in the 14 months following jail stays. White counterparts had 1.9 times greater odds of using community-based services and 4.5 times greater odds of using cooccurring disorder treatments. The postincarceration period is when people are most likely to self-harm, overdose, and have unstable housing and food insecurity. This is a critical period for connection to support services and treatments.

DATA INTEGRATION FOR SYSTEMS CHANGE

Without integrated data systems, it is near impossible for communities to identify the racial disparities that Hedden et al. found in their work across eight Midwestern counties. This work is essential for better understanding the intervention points at which to engage people in treatment and in support services to deter reincarceration and to address mental health, substance use, and cooccurring disorders. Despite the need for data-driven policy, many communities struggle with data system integration. By integrating criminal–legal data with health systems, emergency dispatch, and homeless data, for example, communities can identify the gaps in their systems of care.

Hedden et al. bridge jail and Medicaid data to explore racial disparity in jail- and community-based treatment. By merging these data, they identified that no racial disparities existed in identifying people with SMI in the jails or receiving jail-based treatment, but they did find that more White people were referred to diversion programs and engaged in community-based treatment following their jail stay.

Accessible and integrated data are needed to identify and monitor disparities, health inequity, and opportunities for innovations in system-spanning intervention. Hedden et al. provide an example of how integrated data can produce critical place-based findings that are needed to inform and drive policy change at the local and state levels. The National Association of Counties’ Data-Driven Justice Initiative is one campaign that provides resources to help counties build integrated data systems. This initiative details case studies on communities such as Polk County, Iowa, and Prince George County, Maryland, which have successfully integrated health, social services, and corrections data, creating a roadmap for other counties to carry out this work. With integrated data systems, communities are able to move from awareness to action.

SYSTEM- AND PERSON-LEVEL BARRIERS

Hedden et al. produced new information on racial disparities in service utilization during the postincarceration period, but the next step in this work is arguably the most critical. We need to increase our understanding of the systemic factors as well as the individual-level barriers that get in the way of people of color accessing and utilizing needed treatment and services. Hedden et al. suggest several solutions, including the application of critical race theory to policy and practice in the criminal–legal and behavioral health fields, authentic leadership that mirrors affected populations, and culturally responsive interventions to address systemic and individual barriers. It is well established that Black and low-income communities receive, on average, poorer quality mental health services, have fewer options for care, and distrust the mental health system. This distrust stems from historical trauma and abuse in research (e.g., the Tuskegee studies), systems of care that are not culturally responsive, and diagnostic tools and treatments that are Euro- and androcentric. Barriers such as cost, childcare, transportation, available appointments outside work hours, and location of services further widen the gap in service use.

Racism is pervasive. It invades the very systems of care that are designed to help people recover and thrive. Policy reform and the development and testing of interventions that work for people of color with SMI who enter or are at risk for entering the criminal–legal system are essential in closing the gap between need and service utilization in this critical postincarceration period. Funding is needed for community-based participatory research that builds capacity for the voices of affected communities to collaborate in intervention and policy development.

Additionally, frameworks and practices developed by Black, Latinx, and Native scholars and practitioners (e.g., critical race theory, intersectionality,⁷ interventions designed through the Center for American Indian Health) should be integrated into systems of care so that community-based services work for all people. Health-promotion efforts, no matter how good the policy or service, will be ineffective as long as they are embedded in systems that retraumatize, oppress, and further marginalize people. The efforts to reform our criminal–legal system must persist and expand to reduce the number of people who are incarcerated. As a next step, leaders in behavioral health and medical systems must identify policy and practice that need reform by applying critical race theory to address structural racism and prioritize culturally responsive systems of care, as suggested by Hedden et al., that embed trauma-informed policies and procedures, reduce barriers to service use, and prioritize the training and retention of diverse workforces.