Predictors of Unmet Need for Medical Care Among Justice-Involved Persons With Mental Illness

Mental illness is a leading cause of disability, surpassing other chronic diseases, such as cancer (1). Persons with mental illness typically have more health problems and shorter life expectancies than the general population (1), and they also often have worse access to health care (2). Rates of mental illness, especially serious mental illness, are estimated to be two to five times higher in the criminal justice population than in the general population (3,4). Persons with mental illness who are involved in the criminal justice system are particularly vulnerable to poor access to mental health care. A U.S. survey of corrections inmates with mental health conditions reported that only 26%−39% were taking psychiatric medications at arrest (5). Experts have called for a significant increase in mental health services for persons with severe mental illness in the criminal justice system (6,7). Court support and diversion programs are one way of identifying and addressing unmet need among offenders with mental illness.

This study examined the extent and correlates of unmet need for care from primary care physicians and psychiatrists among accused individuals in mental health court support programs in a large urban center in Canada.

Methods

Toronto, Ontario, Canada, is home to a large multisite mental health court support program established to help accused persons with mental illness access treatment. Court officials refer individuals suspected of having mental illness to program staff (mental health professionals employed by community mental health agencies), who screen for mental illness, complete an intake assessment, consult with current providers to determine current level of support, and then link clients to needed treatment services. Staff record information in a program database, which served as the data source for the study. Entry of information into the database was guided by a user manual to promote consistency. Ethics approval was obtained from the Community Research Ethics Office, a provincial organization that monitors community-based research.

The sample was drawn from 1,416 admissions to five court support programs between January 1 and December 31, 2009. Of these, 244 were considered ineligible because they were repeat admissions, younger than 18 years, or had a primary diagnosis of head injury, intellectual disability, or dementia. Of the 1,172 eligible clients, 178 had missing data, leaving a final sample of 994 persons.

A client’s unmet need for care by a primary care physician and by a psychiatrist (dependent variables) was determined during his or her intake assessment by a mental health court support worker and was based on clinical judgment and feedback from current providers.

Potential correlates of unmet need were grouped as predisposing (age, gender, marital status, and language), clinical (diagnosis and presenting issues), and enabling or impeding (housing type, living arrangement, income source, charge severity, and use of case management services) (8). Diagnosis was provided by a licensed physician or psychologist or self-reported by the client and verified with a current or past service provider. Diagnoses were categorized as schizophrenia or other psychotic disorder, nonpsychotic disorder, or unknown (if a physician- or psychologist-provided diagnosis was not available). Presenting issues included symptoms of serious mental illness, such as delusions or hallucinations; threat to self or others; and substance abuse problems (alcohol or drug). These were coded as present or absent. Charge severity was categorized as Class 1 (public nuisances or minor property offenses), Class 2 (serious property offenses or minor assaults), and Class 3 (serious violence or bodily harm offenses).

Frequencies were calculated for predisposing, clinical, and enabling variables and for unmet need for care by a primary care physician or a psychiatrist. Logistic regression models were developed to predict each unmet need outcome.

Results

As shown in Table 1, 77% of the 994 study participants presented with symptoms of serious mental illness, 49% received public disability benefits, 18% received welfare assistance or had no income, and 13% were homeless. Class 2 charges were most common (45%). Most (78%) did not have a case manager. Staff reported unmet need for care from a primary care physician for 124 clients (12%) and unmet need for care from a psychiatrist for 337 clients (34%). Significant predictors of unmet need for both types of physician care were unknown diagnosis, receipt of welfare assistance or no income, no fixed address or residence in a hostel or shelter, and not having a case manager (Table 1). Additional significant predictors of unmet need for care from a psychiatrist were presence of symptoms of serious mental illness and current hospitalization.

Compared with the study sample, people excluded because of missing data (N=178) were younger (mean age of 33 years) and were more likely to have unmet need for care from a primary care physician (19%) and from a psychiatrist (38%).

Discussion

This study examined unmet need among adults admitted to mental health court support programs in Toronto. Program participants likely had more supports than many justice-involved adults with mental illness because about half were receiving disability support, which requires physician review, and more than a fifth were connected with case managers. This may help explain the relatively low rate of unmet need for care from a primary care physician. Similar rates of unmet need for primary care have been reported in Canadian community surveys of the general population (11%) (9) and of Canadians with major depression in Atlantic provinces (10.5%) (10).

A larger proportion of the sample had unmet need for care from a psychiatrist (34%) than from a primary care physician (12%). The unmet need for care from psychiatrists was similar to that reported in an Ontario survey of correctional clients with mental disorders in 1993 (32.2%) (11). In contrast, a general population study in Ontario reported a much lower rate of unmet need for mental health care (4.5%) (12).

Unmet need for care from psychiatrists is a concern because medication management has been identified by community practitioners as a key support for helping offenders with mental illness live successfully in the community (7). Challenges in psychiatrist capacity and training to support this client group have been identified. These clients may have characteristics such as impulsivity and disorganization, and psychiatrists may feel that they lack sufficient resources to provide the structure and extensive support required by these clients (7,9). Psychiatrists also may be deterred by stigma, perception of risk, or concerns that clients will resist treatment. In Ontario, psychiatrist reimbursement uses fee codes for time-based patient interactions, a disincentive to seeing patients with a higher-than-usual risk of missing appointments.

In this study, structural factors—income source and homelessness—were associated with elevated risk of unmet need. Community stability is particularly important for individuals with a propensity for legal involvement. In addition, practitioners have noted the challenge of providing treatment when basic needs are not met (7). Because of universal medical care coverage in Ontario, lack of insurance is not a barrier to physician-provided care, as it is in some other systems (13). However, proof of coverage or identification is still required to receive services and may be a barrier for some individuals, particularly if they are homeless (14).

Having a case manager was also associated with reduced risk of unmet need. Case management can be an important support for offenders with mental illness because case managers assume responsibility for the client’s overall care, assisting with solving practical problems and facilitating access to general medical providers (7). However, only 22% of this sample had case managers.

This study had several limitations. First, the program database lacked some desired information (for example, data on race-ethnicity and education). Second, unmet service need was determined by program staff, not by standardized measures. However, workers’ clinical judgment has been supported as a reliable measure of service need (15). Third, analyses were cross-sectional, preventing inferences about causality. In addition, generalizability may be limited because the sample included individuals who accepted referrals to the program and who had complete data for variables under study.

Conclusions

In a large sample of persons in mental health court support programs in a health care system with universal insurance, one-eighth had unmet need for care from a primary care physician and one-third had unmet need for care from a psychiatrist. Policies and practices that improve access warrant more attention (12,15).