Firstly read these 2 articles I have attached below which are by Anestis and Carbonell (2014) and Snedker (2015) on mental health courts. Familiarize yourself with how the authors organized their work. In today’s discussion, I would like you to think about the content of the articles. What aspect about the arguments put forward by Anestis and Carbonell (2014) and/or Snedker (2015) peaked your curiosity? What grabbed you? What did you find yourself agreeing with? Disagreeing with? Wanting to know more about? Did a question or puzzle emerge for you about the arguments? These issues might be about the content, conclusions, or the methodology.
Stopping the Revolving Door: Effectiveness of Mental Health Court in Reducing Recidivism by Mentally Ill Offenders
Joye C. Anestis, Ph.D.
Joyce L. Carbonell, Ph.D.
Objectives: This study compared recidivism outcomes among criminal
offenders with mental illness who were assigned to a mental health court
(MHC) or a traditional criminal court. It also explored potential differences in outcomes between subgroups of offenders, including felony and
misdemeanor offenders and violent and nonviolent offenders. Methods:
Data were obtained from court databases. Offenders in the MHC (N=198) and the traditional criminal court (N=198) were matched by
propensity scores and followed for 12 months after the index offense.
Data for the 12 months preceding the index offense were obtained for MHC participants. Intent-to-treat analyses were conducted, using both
between-group and within-subjects designs. Results: After control for covariates, logistic and Cox regressions indicated that MHC assignment
predicted a lower overall rate of recidivism and longer time to rearrest for a new charge compared with assignment to traditional court. The
groups did not significantly differ on the severity of the offense associated with rearrest. The findings largely held for felony, misdemeanor, violent,
and nonviolent offenders, with the exception of analyses involving time to rearrest for violent offenders. Within-subjects analyses suggested that
after MHC participation, there were improvements in occurrence of rearrest and time to rearrest but a tendency for rearrest to be associated
with more severe offenses. Within the MHC group, recidivism outcomes did not significantly differ by class of offense. Conclusions: The results
suggest that an MHC can be effective in reducing recidivism among offenders with mental illness and also indicate that persons who commit
more severe offenses may be appropriate candidates for MHC. (Psychiatric Services 65:1105–1112, 2014; doi: 10.1176/appi.ps.201300305)
T he prevalence of mental illness is higher among persons who have committed criminal offenses than in the general population
(1,2). Offenders with mental illness reoffend at higher rates and more quickly after incarceration than offenders without mental illness (1,3–6).
Mental health courts (MHCs) were developed to stem this trend, aiming to reduce the number and limit
incarceration time of mentally ill offenders in the criminal justice system (7–9).
Although no standardized model exists, many MHCs share several characteristics (8,10–13). MHCs are criminal courts with a specialized court
docket for mentally ill offenders, who typically voluntarily consent to enrollment. MHCs require participants to have a mental illness that likely con-
Dr. Anestis is with the Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi (e-mail: [email protected]). Dr. Carbonell is with the
Department of Psychology, Florida State University, Tallahassee.
PSYCHIATRIC SERVICES
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9 tributed to one or more crimes, and
some restrict enrollment to misdemeanor or nonviolent offenses (11,14). MHCs rely on a collaborative team of individuals, such as judges and social workers, to facilitate relationships between offenders and community support and to provide additional supervision.
Several studies have reported a trend for MHC participation to have an impact on recidivism outcomes. A recent
meta-analysis reported a significant, moderate mean effect size for decreased rates of recidivism among participants
in MHCs (15). MHC participants tend to reoffend less frequently (16–23),
commit less severe crimes at rearrest (20), and take longer to reoffend (20,23,24). Although MHC researchers generally report positive findings,
the methodology they employ varies greatly, and the quality of the study has an impact on the significance of the results. Meta-analytic data indicate that
results for quasi-experimental studies were moderate and significant, whereas the pooled effect for studies comparing the effect of the program on a single
group of individuals was nonsignificant (15). Even with quasi-experimental design, studies of MHCs typically utilize nonequivalent matched control groups
(for example, Herinckx and colleagues [18]). Although random assignment would be ideal—examples include studies by Cosden and colleagues
(16,25)—many stakeholders resist withholding services from control participants. Only two studies have employed statistical methods designed to control
for the problems inherent in nonrandom assignment (21,26).
1105
In addition to these concerns, previous studies failed to adequately address potential differences in effectiveness of MHC among classes of offenders. Many
MHCs exclude or limit felony and violent offenders (10). Felony defendants, however, tend to have better recidivism outcomes than misdemeanants in the general population (27), among mentally ill offenders (5,6), and in drug courts (28). Felony-only (29) and combined misdemeanorfelony MHCs (16,20,22,25,26) have reported favorable recidivism outcomes, and two studies have reported no significant relationship between offense type and either odds of recidivism or number of jail days after exiting an
MHC (22,24). No similar empirical examination has compared recidivism outcomes of violent and nonviolent offenders, although studies of drug courts offered preliminary support for inclusion of violent offenders in diversion programs (30). Generally speaking, the conclusions that can be drawn from research on recidivism among
MHC participants have been limited by a lack of analyses by subgroup of offense type, given that the “dose” of MHC may differ on the basis of the
type of index crime. (For example, the number of status hearings could differ as a function of severity of index offense [31]).
This study of an MHC in the southeastern United States attempted to expand upon previous findings in three main ways: by employing propensity score matching to control for nonrandom assignment, utilizing a control group of mentally ill offenders in traditional criminal court in the same jurisdiction, and exploring potential differences between felony and misdemeanor participants and violent and nonviolent participants. Outcomes were examined with both between-groups and within-subjects designs. We predicted that at 12-month follow-up, MHC defendants would have significantly lower rates of recidivism; ifarrested again, would be charged with a less severe crime; and would haveincreased time to rearrest. We also predicted similar findings for subgroups of felony, misdemeanor, violent, and nonviolent offenders. In
addition, we predicted MHC defendants would exhibit significantly lower
1106
rates of recidivism, subsequent arrests
for less severe crimes, and increased
time to rearrest during the 12 months
after enrollment than during the 12
months before enrollment. Finally,
we predicted recidivism outcomes
for MHC defendants charged with
a felony would be superior to those
of MHC defendants charged with
a misdemeanor, and violent MHC
defendants would have superior recidivism outcomes than nonviolent
MHC defendants.
Methods
Participants
Inclusion criteria for both the MHC
group and the traditional-court control
group were presence of a new charge
in the years 2008–2010, index offense
or reoffense other than a technical
violation, and complete data for all
demographic, diagnostic, and clinical
variables used to generate propensity
scores. Of the 824 MHC participants,
450 met inclusion criteria for this
study. Included and excluded MHC
participants significantly differed by gender (males, N=329, 73%, and N=243,
65%, respectively; x2=7.75, df=1,
p,.05). Of the 522 mentally ill offenders assigned to traditional criminal
court, 227 were included in this study.
Included and excluded traditionalcourt offenders significantly differed
by diagnosis of a bipolar disorder
(N=9, 4%, and N=47, 16%, respectively; x2=21.47, df=1, p,.001). [A
detailed description of the study setting and group assignment procedures
is available online as a data supplement
to this article.]
Florida State University’s Institutional Review Board approved the
study, and the court also consented to
data collection. This study was part of
a larger data collection evaluating the
MHC. Because data were retrieved
from public records, informed consent
was not required.
Measures
Access to the Jail Information System
(JIS) and the Management Information System (MIS) was granted by the
MHC’s Board of County Commissioners. The JIS contains data for MHC
and traditional court collected by the
MIS. This database contains demographic, criminal, and diagnostic inPSYCHIATRIC SERVICES
formation for every defendant in the
county of the MHC. These databases
contain only information about arrests
made in Florida. All data used in the
analyses were retrieved from JIS and
MIS or created by using data from
those systems.
Index offense variables. The index
offense for the MHC group was the
arrest resulting in a new charge that
qualified the individual for participation in MHC. For the control group,
the index offense was the first new
charge that occurred during the same
time period (2008–2010). The following index offense variables were used:
severity of offense, categorization as
misdemeanor or felony (0 or 1), and
categorization as nonviolent or violent
(0 or 1). Severity of offense was determined by a scale from 1 to 13, with 1
indicating noncriminal violations; 2,
second-degree misdemeanors; 3, firstdegree misdemeanors, and 4–13, felony offenses. Classification of felony
offenses was based on the felony
sentencing guidelines of the State of
Florida (32). If an index arrest involved two or more charges, the most
severe charge was used for analyses.
Following McNiel and Binder (26),
a violent offense was defined as harm
or threat to a person; all others offenses were considered nonviolent.
Independent variable. A dichotomous variable indicated assignment
to traditional criminal court or MHC
(0 or 1).
Dependent variables. Data were
collected for the following outcome
variables during the 12 months after
the index offense: any arrest resulting
in a new charge (rearrest), sum of
rearrests, number of months between
index offense and rearrest, and severity of charge at first rearrest. In cases
of two or more charges at rearrest, the
most severe was used for analyses.
Rearrest severity was coded by using
the scale described above.
Pre-MHC variables. Data for the
12 months before the index offense
were obtained for MHC participants.
The following variables were used: total
number of arrests, type and severity
of offense closest in time to the index
offense, classification of offense closest
in time to index offense as misdemeanor or felony and as nonviolent
or violent, and number of months
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9
between the offense closest in time
to the index offense and the index
offense. Classification of severity and
type of offense was defined and coded
by using the procedures described
above.
Control variables. Along with index
offense variables, the following covariates were used in the between-group
analyses: diagnosis of mental illness,
homelessness, and demographic information. Age at index offense was calculated by using date of birth and date
of index offense. Two individuals were
identified as Asian/Pacific Islander and
were combined with African-American
individuals to create a dichotomous
race variable (white or nonwhite).
Data analysis
An intent-to-treat approach was utilized for all analyses.
Between-group analyses. Analyses
were conducted to compare recidivism
between MHC and control group
participants for the full sample and for
each offense subgroup. Univariate
comparisons were conducted for continuous (t tests) and categorical (chi
square tests) recidivism variables. Multivariate techniques allowing for the
consideration of the covariates’ impact
on the relationships of interest were
employed. Logistic regression analyses
tested the hypotheses that court membership predicted rearrest in the 12
months after the index offense. Cox
proportional hazards models tested
the effect of court assignment on time
to rearrest. Proportional hazards models assess group differences in survival time and consider time to failure
(rearrest) in estimating the coefficients
while controlling for the effects of
covariates. In this study, individuals
who had not reoffended by the end of
the 12-month period were censored at
month 12. For ease of interpretation,
odds ratios [ORs] less than 1.00 were
converted to ORs greater than 1.00. If
univariate comparisons indicated that
severity of rearrest was associated with
group assignment, we were prepared
to conduct multiple regression analyses to determine the impact of MHC
enrollment on rearrest severity.
Within-subjects analyses. Changes
in outcomes in the MHC sample
before and after enrollment in MHC
were explored by using paired t tests.
PSYCHIATRIC SERVICES
In addition, the bivariate and multivariate analyses described above were
repeated to compare results for the
MHC sample before and after participation. In these analyses, classification
of index offense as felony or misdemeanor or as violent or nonviolent
served as the independent variables.
Results
Propensity score matching
Propensity score matching was utilized to control for nonrandom assignment, resulting in a data set of 396
offenders (N=198 in each group)
(33,34). [Detailed information on this
procedure as well as overall data
issues is available in the data supplement.] No significant differences were
found between the two groups for the
32 variables assessed (Table 1). After
the matching procedure was completed,
tests of the proportionality of hazards
assumption and multicollinearity were
conducted, and the values were within
acceptable levels (35).
Between-group analyses
Full sample. The MHC group had superior recidivism outcomes relative to
the control group on nearly all observed
outcome variables (Table 2). The MHC
group had a significantly lower occurrence of rearrest (x2 =20.89, df=1,
p,.001, f=–.23), took longer to reoffend
(t=–4.66, df=394, p,.001, d=–.47),
and accrued a significantly lower number
of rearrests (t=4.70, df=393, p,.001,
d=.47). Severity of the rearrest offense
did not significantly differ between the
groups; therefore, multivariate analyses involving rearrest severity were not
conducted.
To assess the extent to which
assignment to MHC predicted rearrest and time to rearrest, logistic and
Cox regressions were conducted (Tables
3 and 4, Figure 1). The addition of
court membership in the second step
of the logistic regression contributed
significantly to the model (Dx2=19.47,
df=1, p,.001), and the overall model
was significant (x2=43.71, df=14,
p,.001). Assignment to the traditional criminal court compared with
assignment to MHC significantly increased the odds of rearrest by 251%
(b=–1.25, p,.001, exp[b]=3.51) (Table 3). Likewise, addition of court
assignment significantly contributed
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9
to the Cox proportional hazards model
(Dx2=18.75, df=1, p,.001), and the
overall model was significant (x2=38.38,
df=14, p,.001) (Table 4). MHC participation compared with assignment
to traditional criminal court predicted
a longer time to rearrest for the full
sample (b=–1.08, p,.001, exp[b]=
2.94). In addition, being male predicted a shorter time to rearrest for
the full sample (b=.70, p=.021, exp
[b]=2.01).
Subgroup analyses. The results of
subgroup analyses are reported in
Tables 2–4 and in Figure 1. For each
subgroup, assignment to MHC versus
traditional criminal court significantly
decreased the odds of rearrest (Table
3). MHC assignment was also significantly related to longer time to rearrest
of participants charged with felony,
misdemeanor, and nonviolent offenses.
In addition, being male predicted a
shorter time to rearrest for participants
charged with misdemeanor (b=1.28,
p=.005, exp[b]=3.61) and nonviolent
(b=.73, p=.026, exp[b]=2.07) offenses.
For violent offenders, the overall Cox
regression model was nonsignificant,
and the prediction of time to rearrest
by MHC participation failed to reach
statistical significance. All subgroup analyses involving severity of rearrest offense failed to reach significance.
Within-subjects analyses
Within-subjects analyses were conducted by using the full sample of
MHC participants (N=450). [A table
presenting the results of the analyses
is available in the online data supplement.] The total number of arrests
resulting in a new charge in the 12
months preceding the index offense
was significantly higher than the total
number of rearrests in the 12 months
after the index offense (t=8.77, df=358,
p,.001, d=.62). In addition, the number of months between the index
arrest and the closest previous arrest
was significantly less than the number of months between the index offense and the first rearrest (t=7.47,
df=130, p,.001, d=1.02). Contrary
to expectation, severity of the offense
associated with rearrest was significantly higher than the severity of the
offense associated with the arrest prior
to the index offense (t=–2.16, df=110,
p=.033, d=.25).
1107
Table 1
Characteristics of criminal offenders with mental illness assigned to mental
health court (MHC group) or traditional criminal court (control group)a
Total
(N=396)
Characteristic
Age at index offense
(M6SD)
Severity of index offense
(M6SD)b
Gender
Male
Female
Race
White
Nonwhite
Diagnoses
Substance use disorder
Intellectual disability
Depressive disorder
Bipolar disorder
Psychotic disorder
Anxiety disorder
Cognitive disorder
Personality disorder
Homeless
Category of index offense
Theft
Robbery or burglary
Drug offense
Assault or battery
Murder
Weapons
Driving
Fraud
Kidnapping
Obstruction
Sex offense
Child abuse or neglect
Miscellaneous
Classification of index
offense
Misdemeanor
Felony
Nonviolent
Violent
a
b
N
MHC group
(N=198)
%
N
Control group
(N=198)
% N
%
35.93611.74
36.42612.47
35.45611.21
5.0863.13
5.1063.12
5.0663.15
284
112
72 137
28 61
69 147
31 51
74
26
193
203
49 95
51 103
48 98
52 100
50
51
31
9
28
18
56
11
1
3
1
8
2
7
5
14
3
,1
1
,1
20
5
17
10
30
8
1
2
1
10
3
9
5
15
4
1
1
1
11
4
11
8
26
3
0
1
0
6
2
6
4
13
2
0
2
0
62
44
39
67
5
5
57
17
2
28
13
3
54
16
11
10
17
1
1
14
4
1
7
3
1
14
35
24
19
32
2
2
31
10
1
10
6
2
24
18
12
10
16
1
1
16
5
1
5
3
1
12
27
20
20
35
3
3
26
7
1
18
7
1
30
14
10
10
18
2
2
13
4
1
9
4
1
15
50 106
50 92
77 144
23 54
54
47
73
27
205
191
297
99
52 99
48 99
75 153
25 45
The two groups were matched by propensity scores to control for nonrandom assignment of
participants.
Severity of offense was determined by a scale from 1 to 13, with 1 indicating noncriminal
violations; 2, second-degree misdemeanors; 3, first-degree misdemeanors, and 4–13, felony
offenses. Classification of felony offenses was based on the felony sentencing guidelines of the
State of Florida (32).
Hypotheses predicting greater success for felony offenders relative to
misdemeanor offenders and for violent offenders relative to nonviolent
offenders within the MHC were largely
not supported by the results (data not
shown). MHC defendants charged with
a misdemeanor had a significantly higher
occurrence of rearrest, relative to those
charged with a felony (x2=4.87, df=1,
p=.027, f = –.104); however, defendants
1108
charged with misdemeanors and felonies did not differ on odds of rearrest
or time to rearrest. Defendants charged
with violent and nonviolent offenses did not differ on any recidivism
outcomes.
Discussion
This study adds to increasing evidence
supporting the effectiveness of MHC
in reducing recidivism among offenders
PSYCHIATRIC SERVICES
with mental illness. Consistent with
previous findings (16,20,22,23,25,26),
MHC participants demonstrated better recidivism outcomes than a control
group of offenders assigned to traditional criminal court as well as improvements in the occurrence of rearrest and
time to rearrest before and after their
participation. The results build upon
previous findings in three important
ways: employing propensity score
matching to control for nonrandom
assignment, utilizing a control group
of mentally ill offenders in traditional
criminal court in the same jurisdiction, and exploring differences
between felony and misdemeanor participants and violent and nonviolent
participants.
The inclusion of subgroup analyses
is a significant contribution to the literature (31). Between-group findings
remained unchanged across subgroups,
with the exception of a nonsignificant
finding for the prediction of time to
rearrest by violent offense. Furthermore, within the MHC sample, misdemeanor offenders had higher rearrest
prevalence than felony offenders but
did not significantly differ on time to
rearrest or severity of rearrest offense.
Violent and nonviolent offenders did
not significantly differ on any recidivism outcome. This demonstration of
benefit across subgroups of offenders
offers preliminary evidence that classification of offense is an inefficient
variable for excluding individuals from
MHC.
Given the nature of the MHC studied (as described in the online data
supplement), these data, in conjunction with existing literature, suggest
that the mere act of keeping mentally
ill offenders out of jail may be one
primary mechanism by which MHCs
affect offending outcomes. The criminology literature has established that,
at best, incarceration does not reduce
recidivism and, at worst, is iatrogenic
(36,37). It is not unreasonable, therefore, to posit that placing vulnerable
mentally ill offenders in a jail or prison, resulting in poor treatment access
and exposure to a potentially dangerous
environment, may be acutely harmful. As this study and others show,
programs to keep mentally ill offenders in the community seem to
have a positive impact on recidivism.
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9
Table 2
Rearrest outcomes during the 12 months after the index offense among offenders assigned to mental health court
(MHC) or traditional criminal court (control)a
Severity of
rearrest offenseb
Occurrence of rearrest
Index offense
Full sample
MHC
Control
Felony
MHC
Control
Misdemeanor
MHC
Control
Violent
MHC
Control
Nonviolent
MHC
Control
a
b
c
N
%
20
56
10
28
7
27
72
29
13
29
13
27
2
12
4
22
18
44
12
31
p
f
,.001
–.23
,.001
.012
.011
,.001
–.29
M
SD
4.65
5.67
2.82
2.87
6.14
6.11
2.67
2.78
3.85
5.25
2.64
2.95
3.00
7.08
.00
3.29
4.83
5.28
2.92
2.66
p
d
ns
—
ns
–.18
ns
–.25
ns
–.23
N of rearrestsc
ns
—
—
—
—
M
SD
.12
.42
.37
.86
.07
.43
.26
.88
.16
.41
.45
.85
.04
.37
.21
.90
.14
.44
.40
.85
Time to rearrest (months)
p
d
,.001
.47
,.001
,.001
.019
,.001
M
SD
11.27
9.63
2.49
4.30
11.71
9.58
1.36
4.35
10.84
9.67
3.21
4.28
11.60
10.04
1.89
3.87
11.18
9.47
2.64
4.46
.28
.37
p
d
,.001
–.47
,.001
–.32
,.001
–.31
.015
–.50
,.001
–.47
.54
.47
The MHC and control group each consisted of 198 offenders with a mental illness. Means were compared by t tests. Proportions were compared by chi
square tests.
Severity of offense was determined by a scale from 1 to 13, with 1 indicating noncriminal violations; 2, second-degree misdemeanors; 3, first-degree
misdemeanors, and 4–13, felony offenses. Classification of felony offenses was based on the felony sentencing guidelines of the State of Florida (32).
Nontransformed means are reported, but transformed means were used for t tests.
The increased attention and supervision paid to the MHC participants
through regular status hearings also
bear consideration as an explanation
for the effects of MHC participation,
but they are likely an associated mechanism rather than a primary mechanism
of change. Perhaps the attention and
supervision increase accountability
and decrease criminal behavior among
mentally ill offenders. Frequency of
judicial status hearings varies greatly
between MHCs. For example, Redlich
and colleagues (38) reported a small,
inverse relationship between court appearances and MHC completion, such
that having fewer hearings was related
to completion. This relationship, however, became nonsignificant after the
study controlled for other predictor
variables (38). Notably, whereas many
authors have asserted that participantjudge interaction style results in positive MHC outcomes (39–45), others
have pointed to the importance of the
entire MHC team’s knowing the defendant and treating him or her with
empathy and respect (44). Given the
limited judge-defendant interaction in
the MHC studied (45), future studies
should consider not only frequency
of hearings but also team-defendant
PSYCHIATRIC SERVICES
interactions as well. More globally,
future studies should dismantle the
components of MHC and experimentally test their importance in order to
fully understand the mechanisms of
change in MHCs.
Contrary to prediction, comparisons of severity of the rearrest offense
between the MHC and the control
groups failed to reach significance,
and severity of rearrest offense was
significantly higher after participation
in the MHC. Although examination of
this outcome is considered important by many, findings in the literature regarding rearrest severity are
limited and equivocal (20,46). Utilization of a Florida statute as the
basis for severity ranking, a system
developed by the legislature, could
have influenced the findings of this
study.
Although this study had a number
of strengths, it should be considered
in light of the limitations. Generalizability of findings is concerning for a
Table 3
Odds of rearrest in the 12 months after the index offense predicted by
participation in mental health or traditional criminal court, by index offensea
Index offense
–2LLb
x2
df
Change
in x 2
b
SE
Wald
Exp(b) c
Full sample
Felony
Misdemeanor
Violent
Nonviolent
340.12
150.90
181.75
63.87
275.05
43.71***
26.03*
24.77**
16.20
26.43**
14
12
14
11
14
19.47***
17.56***
4.41*
5.63*
13.07***
–1.25
–1.83
–.81
–1.89
–1.12
.30
.48
.40
.91
.32
17.51***
14.28***
4.20*
4.27*
12.11**
3.51
6.21
2.25
6.59
3.08
a
The data represent step 2 of five logistic regressions. All covariates were entered in step 1, and
court membership was entered in step 2. Only data for the independent variable are displayed.
The change in chi square indicates the change from step 1 to step 2 (df=1).
b
–2LL, –2 log likelihood
c
To aid in interpretation, negative odds ratios (,1.00) were converted to positive odds ratios
(.1.00).
*p,.05, **p,.01, ***p,.001
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9
1109
Table 4
Length of time to rearrest in the 12 months after the index offense predicted
by participation in mental health or traditional criminal court, by index
offensea
Index offense
–2LLb
x2
df
Change
in x 2
b
SE
Wald
Exp(b)c
Full sample
Felony
Misdemeanor
Violent
Nonviolent
849.86
324.46
415.00
111.46
664.76
38.38**
23.96*
20.50*
15.26
24.02*
14
12
14
11
14
18.75**
17.35**
4.13*
4.78*
13.09**
–1.08
–1.62
–.67
–1.55
–.98
.27
.44
.34
.82
.29
16.49**
13.72**
3.60*
3.60
11.86**
2.94
5.05
1.95
4.72
2.67
a
The data represent step 2 of five logistic regressions. All covariates were entered in step 1, and
court membership was entered in step 2. Only data for the independent variable are displayed.
The change in chi square indicates the change from step 1 to step 2 (df=1).
b
–2LL, 2 log likelihood
c
To aid in interpretation, negative odds ratios (,1.00) were converted to positive odds ratios
(.1.00).
*p,.05, **p,.001
variety of reasons, including findings
of lower rearrest rates than reported
by other studies and the use of data
from only one jurisdiction. Aggregate
observations of multiple courts are
necessary to determine the overall
effect of MHC independent of the
idiosyncrasies of individual courts
(21). Although we believe that the
use of a control group in the same
jurisdiction strengthened the study,
we were unable to determine the reasons
that members of the control group did
not qualify for MHC.
Another limitation was the lack of
random assignment. Although propensity score matching was utilized
to reduce risk of selection bias, it remains possible that factors we were
unable to control for influenced court
assignment. Likewise, data on jail time
during the follow-up period were
unavailable, and the absence of this
information could have had an impact
on the results; however, individuals in
the control group would be more likely
to spend time in jail, causing an overestimation of the control group’s success and an underestimation of the
effect of MHC. Finally, one judge
presided over each branch of the MHC
(felony and misdemeanor); thus, no
comparisons could be made across the
court’s two judges, given that their cases
did not overlap.
Conclusions
These findings add to the evidence
that MHC produces favorable recidivism outcomes. The results also indicate that felony and violent offenders
Figure 1
Cumulative proportion not reoffending
Time to rearrest among criminal offenders with mental illness assigned to a mental health court (MHC) or a traditional
criminal court (control), by type of offensea
Total sample
Felony
Misdemeanor
1.0
.9
.8
.7
.6
.5
0
2
4
6
8
Months
10
12
0
2
4
6
8
Months
10
12
Cumulative proportion not reoffending
Violent
a
0
2
4
6
8
Months
10
12
Nonviolent
1.0
MHC
Control
.9
.8
.7
.6
.5
0
2
4
6
8
Months
10
12
0
2
4
6
8
Months
10
12
The cumulative survival function represents the proportion of offenders who survived (were not rearrested) in each group by the length of time (in
months) from index offense. Survival functions were calculated by using the Kaplan-Meier estimator. For both groups, the follow-up period was 12
months following index offense.
1110
PSYCHIATRIC SERVICES
‘ ps.psychiatryonline.org ‘ September 2014 Vol. 65 No. 9
can benefit from inclusion in MHCs.
Despite lacking some “essential” characteristics of MHC, the MHC studied
engendered significant improvements.
Such findings highlight a need for
more studies investigating the necessity of common MHC characteristics.
Future research would benefit from
a focus on the mechanisms of change
in MHC and on identifying characteristics of individuals who respond best
to participation in MHC.
Acknowledgments and disclosures
This study was in part supported by a State of
Florida Substance Abuse and Reinvestment
Grant (2009–2011). Dr. Anestis completed this
research in partial fulfillment of the degree of
Doctor of Philosophy at Florida State University and thanks her dissertation committee for
their feedback and guidance regarding the
manuscript: Chris Schatschneider, Ph.D., Mark
Licht, Ph.D., Edward Bernat, Ph.D., and William
Bales, Ph.D. She also thanks Amanda Gallagher,
M.S., Emily Gottfried, M.S., Haley Gummelt,
M.S., and the undergraduate lab members
who aided in data collection; Scott Vrieze, Ph.D.,
and Sylia Wilson, Ph.D., for statistical advice; and
Michael Anestis, Ph.D., for his feedback.
The authors report no competing interests.
References
1. Mental Health Problems of Prison and Jail
Inmates. Washington, DC, US Department
of Justice, Bureau of Justice Statistics, 2006.
Available at www.bjs.gov/content/pub/pdf/
mhppji.pdf
2. Kessler RC, Chiu WT, Demler O, et al:
Prevalence, severity, and comorbidity of
12-month DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of
General Psychiatry 62:617–627, 2005
3. Baillargeon J, Binswanger IA, Penn JV,
et al: Psychiatric disorders and repeat
incarcerations: the revolving prison door.
American Journal of Psychiatry 166:103–
109, 2009
4. Cloyes KG, Wong B, Latimer S, et al:
Time to prison return for offenders with
serious mental illness released from prison:
a survival analysis. Criminal Justice and
Behavior 37:175–187, 2010
5. Lovell D, Gagliardi GJ, Peterson PD: Recidivism and use of services among persons
with mental illness after release from
prison. Psychiatric Services 53:1290–1296,
2002
6. O’Keefe ML, Schnell MJ: Offenders with
mental illness in the correctional system.
Journal of Offender Rehabilitation 45:81–
104, 2007
7. Casey P, Rottman DB: