• Mental health treatment in prison reduces violence among released prisoners

    The mental health treatment of prisoners is an important issue in the United States, where there are more mentally ill people in prison than in hospital.

    The United States has the highest rate of adult incarceration among the developed countries, with 2.2 million currently in jails and prisons. Those with mental disorders have been increasingly incarcerated during the past three decades, probably as a result of the deinstitutionalization of the state mental health system. Correctional institutions have become the de facto state hospitals, and there are more seriously and persistently mentally ill in prisons than in all state hospitals in the United States.

    The quality of mental health care in US prisons is inconsistent, with many prisoners failing to receive treatment. It is likely that mental health care is even worse following release from prison. In Estelle v. Gamble, the Supreme Court ruled that

    deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’…proscribed by the Eighth Amendment.

    Ironically — but really, tragically — U.S. prisoners have a right to medical care while they are incarcerated. Which they lose when they are released.

    In JAMA Psychiatry, Zheng Chang and his colleagues report on the treatment of mentally ill prisoners in Sweden. They show that good mental health care in prison and afterwards appears to reduce violence by prisoners after release.

    OBJECTIVE. To investigate the associations between major classes of psychotropic medications and violent reoffending.

    DESIGN, SETTING, AND PARTICIPANTS. This cohort study included all released prisoners in Sweden from July 1, 2005, to December 31, 2010, through linkage of population-based registers. Rates of violent reoffending during medicated periods were compared with rates during nonmedicated periods using within-individual analyses. Follow-up ended December 31, 2013.

    EXPOSURES. Periods with or without dispensed prescription of psychotropic medications (antipsychotics, antidepressants, psychostimulants, drugs used in addictive disorders, and antiepileptic drugs) after prison release…

    MAIN OUTCOMES AND MEASURES. Violent crime after release from prison.

    Sweden has national data sets on medications and crime. The authors linked these data and identified prisoners who had received mental health treatment. They compared post-release periods when prisoners were being treated to periods in which the same prisoners were not being treated. The statistic used in this comparison is the hazard ratio,

    HR = (Rate of Offending While Treated) / (Rate of Offending While Not-Treated).

    So HR = 0.50 means that a released prisoner committed half as many acts of violence while he was taking psychiatric medication compared to periods when he was not taking medication.

    RESULTS. The cohort included 22,275 released prisoners… During follow-up (median, 4.6 years…), 4031 individuals (18.1%) had 5653 violent reoffenses. The within-individual hazard ratio (HR) associated with dispensed antipsychotics was 0.58 (95% CI, 0.39-0.88), based on 100 events in 1596 person-years during medicated periods and 1044 events in 11,026 person-years during nonmedicated periods, equating to a risk difference of 39.7 (95% CI, 11.3-57.7) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed psychostimulants was 0.62 (95% CI, 0.40-0.98), based on 94 events in 1648 person-years during medicated periods and 513 events in 4553 person-years during nonmedicated periods, equating to a risk difference of 42.8 (95% CI, 2.2-67.6) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed drugs for addictive disorders was 0.48 (95% CI, 0.23-0.97), based on 46 events in 1168 person-years during medicated periods and 1103 events in 15 725 person-years during nonmedicated periods, equating to a risk difference of 36.4 (95% CI, 2.1-54.0) fewer violent reoffenses per 1000 person-years. In contrast, antidepressants and antiepileptics were not significantly associated with violent reoffending rates… The most common prison-based program was psychological treatments for substance abuse, associated with an HR of 0.75 (95% CI, 0.63-0.89), which equated to a risk difference of 23.2 (95% CI, 10.3-34.1) fewer violent reoffenses per 1000 person-years.

    The key finding is that for some medications and therapies, prisoners were substantially less violent when they were in treatment. Substance abuse treatment in prison also reduced post-release violence.

    This is not an experimental study. The strength of the design is that the authors estimated the effect of treatment by comparing periods when a released prisoner was treated to periods when the same prisoner was not treated. Therefore, unmeasured differences between prisoners cannot bias the estimated treatment effect.  However, this design does not control unmeasured differences within prisoners. Suppose, for example, a released prisoner loses his job. The stress of being unemployed causes him to both stop taking his medications and start getting into fights. This would look like a treatment effect in this study. The authors suggest that this is unlikely, because that type of confounding would make all psychiatric medications look beneficial. They argue that the effect of treatment is seen only for medications that would be expected to reduce violence.

    There are two big takehome messages here.

    First, effective mental health treatment can reduce violence. Many mentally ill people are imprisoned. They should get treatment there and following their release. This would both help them reintegrate into society, it would benefit their families, and it would help protect other citizens.

    Second, we see once again how useful it is to have national data sets of the quality achieved by the Scandinavians. There are important questions about public policy and public safety that can only be answered when you can link lifetime medical and social service data for an entire population.

    @Bill_Gardner

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