Greg A. Greenberg

Jail Incarceration, Homelessness, and Mental Health: A National Study

OBJECTIVE This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.

Mental Health Correlates of Past Homelessness in the National Comorbidity Study Replication

This study uses data from a nationally representative epidemiologic survey, the National Comorbidity Survey Replication, to investigate the association of mental health and substance use disorders, along with other factors, with past homelessness. Approximately 5% of the 5,251 adults reported having been homelessness. Multivariate analysis showed the strongest independent risk factors for past homelessness were past receipt of welfare payments (odds ratio [OR]=5.7), incarceration for 27 or more days (OR=3.9), exposure to personal violence (OR=2.7), lifetime substance use disorder (OR=2.4), and Black race (OR=2.1). Several non-substance use psychiatric disorders were also significantly, if less strongly (OR 1.4 to 1.6), associated with past homelessness. Past homelessness is associated with a broad array of sociodemographic, economic, and mental health problems. While the association of both substance use and psychiatric disorders with past homelessness was quite strong, non-substance use psychiatric disorders was not as strong an independent risk factor as substance abuse disorders.

Homelessness in the state and federal prison population

AIMS This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs). METHOD Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics. RESULTS Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4-6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income. CONCLUSIONS Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals.

Risk of Incarceration among Male Veterans and Nonveterans Are Veterans of the All Volunteer Force at Greater Risk

In this study, we used data from national surveys of U.S. veterans and nonveterans to investigate whether military service increased risk for incarceration compared to non-veteran peers. White veterans aged thirty-five to fifty-four (early years of the All Volunteer Force and the Vietnam era) were at higher risk for incarceration than white nonveterans. Black and Hispanic veterans of these eras were generally at lower risk of incarceration than age-and race-matched nonveterans. For all racial/ethnic groups, the risk of incarceration among veterans compared to nonveterans declined among those who served in the later years of the implementation of the All Volunteer Force. These findings may reflect the disadvantaged backgrounds of recruits during the early implementation of the All Volunteer Force, from 1973 to 1980, and the improved quality of personnel recruited after 1980. Among all males, the risk of incarceration was not elevated among Vietnam-era and World War II veterans.

Correlates of Past Homelessness in the National Epidemiological Survey on Alcohol and Related Conditions

This study sought to investigate correlates of past homelessness, especially mental illness and substance abuse, using data from the National epidemiological survey on alcohol and related conditions (NESARC), a large nationally representative survey conducted in 2001–2002. Multivariate analyses showed that the factors most strongly related to past homelessness were diagnoses of behavioral health conditions which showed consistently stronger association than sociodemographic characteristics, measures of economic well being, or general health indicators. The results presented here confirm in a nationally representative sample a number of single site studies that have also demonstrated the over representation of both mental illness and substance abuse disorders in homeless populations.

Mental Health and Other Risk Factors for Jail Incarceration Among Male Veterans

Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veterans show that having mental health problems in addition to such sociodemographic characteristics as being a member of a minority group, not being married, having less education, and being younger are risk factors for incarceration among veterans, as they are for the general population. As in previous studies veterans who served during the Vietnam Era and to an even greater extent, those who served in the early years of the All Volunteer Force were at greater risk of incarceration than veterans from the most recent period of the AVF, after controlling for age and other factors.

Continuity of care and clinical effectiveness: outcomes following residential treatment for severe substance abuse.

Background. Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, the relationship between COC and clinical outcomes has received little empirical evaluation. Research Design. This study used hierarchical linear modeling to examine the relationship between six indicators of COC and seven outcome measures addressing symptoms, substance abuse, and social functioning. Subjects. Patient interviews were conducted with 1576 veterans 3 months after their discharge from one of 22 residential work therapy programs for the treatment of severe substance abuse. Results. Few significant relationships were found between COC and outcome measures in analyses conducted at both the client and program level and fewer than half of these show better outcomes with greater COC. When a Bonferroni corrected P level of P <0.0012 was used, none of the relationships were statistically significant. Conclusion. Although there were significant relationships between outcomes and measures of services received during residential treatment, postdischarge COC does not seem to be related to improved outcomes, at least when examined following long term intensive residential treatment. Thus, our results are specific to the context of aftercare following long-term residential rehabilitation and indicate that the value of standard performance measures may vary by treatment context.

Continuity of care and clinical effectiveness: treatment of posttraumatic stress disorder in the Department of Veterans Affairs.

Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addictive disorders has often focused on the assessment of continuity of care (COC) as measured with administrative data. However, there has been little empirical evaluation of the relationship of measures of COC and treatment outcomes. This study used hierarchical linear modeling to examine the relationship between 6 indicators of COC and 6 outcome measures in a multisite monitoring effort for veterans with war-related posttraumatic stress disorder. There were few consistently significant associations between COC and outcome measures. Although measures of COC at the level of individual patients were associated with reductions in substance abuse symptoms, when COC measures were averaged to the site level and examined with hierarchical linear modeling models, thereby reducing the impact of intrasite selection bias, they were not associated with any desired outcomes. COC measures, at least in the sample used for this study, are not consistently associated with desirable client outcomes and may therefore be less than ideal performance measures in outcome evaluations following inpatient treatment, except to the extent that COC is considered to be an intrinsic indicator of higher quality regardless of its relationship to outcomes.

VHA mental health information system: applying health information technology to monitor and facilitate implementation of VHA Uniform Mental Health Services Handbook requirements.

Aim: To describe the design and deployment of health information technology to support implementation of mental health services policy requirements in the Veterans Health Administration (VHA). Methods: Using administrative and self-report survey data, we developed and fielded metrics regarding implementation of the requirements delineated in the VHA Uniform Mental Health Services Handbook. Finalized metrics were incorporated into 2 external facilitation-based quality improvement programs led by the VHA Mental Health Operations. To support these programs, tailored site-specific reports were generated. Results: Metric development required close collaboration between program evaluators, policy makers and clinical leadership, and consideration of policy language and intent. Electronic reports supporting different purposes required distinct formatting and presentation features, despite their having similar general goals and using the same metrics. Discussion: Health information technology can facilitate mental health policy implementation but must be integrated into a process of consensus building and close collaboration with policy makers, evaluators, and practitioners.

An Evaluation of an Initiative to Improve Coordination and Service Delivery of Homeless Services Networks

This study examines system changes associated with the implementation of the Collaborative Initiative to Help End Chronic Homelessness, an 11-site multi-agency intervention for chronically homeless adults. Data obtained from key informants on community-level interventions and interorganizational relationships were gathered from an average of 6.6 agencies at each site in four yearly waves. Hierarchical linear modeling was used to examine time trends and bivariate relationships between measures. There were significant increases over the full study period in the use of practices designed to encourage system integration, as well as in interorganizational measures of joint planning and coordination, and of trust and respect, although in later waves of the study these measures leveled off. There were also highly significant and positive cross-sectional associations between the use of practices designed to encourage system integration and direct measures of service system integration as well as between measures of change in these system characteristics.