The impact of criminal
justice involvement and clinical characteristics on the cost of public
treatment services for adults with serious mental illnesses is unknown. The
authors examined differential effects of justice involvement on behavioral
health treatment costs by primary psychiatric diagnosis (schizophrenia or
bipolar disorder) and also by substance use diagnosis among 25,133 adult
clients of Connecticut’s public behavioral health system in fiscal years 2006
and 2007. Justice-involved adults with schizophrenia had the highest costs,
strongly driven by forensic hospitalizations. Addressing the cross-system
burdens of forensic hospitalizations may be a sensible starting point in the
effort to reduce costs in both the public behavioral health and justice systems…
Approximately 27% of the sample was justice involved at some
time during the two-year study period. Among those with justice involvement,
37% had schizophrenia and 63% had bipolar disorder. The mean ± SD age of those
with justice involvement was 35.7±10.5, 65% were male, and 65% had a diagnosed
co-occurring substance use disorder. Among the 73% without justice involvement,
53% had schizophrenia, 47% had bipolar disorder, the mean age was 43.5±13.8,
46% were male, and only 28% had a co-occurring substance use disorder.
In the model that controlled only for gender, age, and
race-ethnicity, treatment costs were nearly 27% higher for those with justice
involvement compared with those who had no justice involvement ($31,166 versus
$24,602) (Figure 1, model 1). Having a co-occurring
substance use disorder increased treatment costs by nearly 50% among those with
no justice involvement, but a co-occurring substance use disorder had virtually
no effect among those who were justice involved (model 2).
Most notably, primary psychiatric diagnosis had the largest
influence on treatment costs, particularly among those who were justice
involved (model 3). Total predicted treatment costs for justice-involved adults
with schizophrenia ($61,824) were nearly 70% higher than the costs for adults
with schizophrenia and no justice involvement ($36,408). Costs for
justice-involved adults with schizophrenia were nearly five times higher than
costs for justice-involved adults with bipolar disorder ($61,824 versus
$12,864). Among those without justice involvement, costs among adults with
schizophrenia were 3.3 times higher than among their counterparts with bipolar
disorder ($36,408 versus $11,039).
A key driver of higher costs among justice-involved
adults with schizophrenia was the disproportionately high cost of forensic
hospitalizations, which are justice-connected in context but which are provided
and paid for by DMHAS. Forensic hospitalizations accounted for nearly half of
that group’s total treatment costs and contributed to their costs being 70%
higher than costs for adults with schizophrenia who had no justice involvement.
Among the justice-involved adults, forensic hospitalization was far more common
for those with schizophrenia than for those with bipolar disorder. Ten percent
of the justice-involved adults with schizophrenia had at least one forensic
hospitalization, with a cumulative mean of 265±269 hospital days during the
two-year period, whereas only 1% of the justice-involved adults with bipolar
disorder had a forensic hospitalization, with a cumulative mean of just 151±210
days (data not shown). Forensic hospital costs for the justice-involved adults
with schizophrenia were 18 times higher than for those with bipolar disorder
($30,528 versus $1,694). [Results of regression analyses described in this
section are available in an online data supplement to
this column.]
Below: Predicted treatment costs over two years of 25,133 adults with serious mental illness, by criminal justice involvement (CJI), substance use disorder (SUD) diagnosis, and primary psychiatric diagnosis
Full article at: http://goo.gl/4x1f6Y
By:
Dr. Robertson, Dr. Swanson, Dr. Easter, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina (Email: ude.ekud@treblig.nosilla). Dr. Lin and Dr. Frisman are with the School of Social Work, University of Connecticut, West Hartford. Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
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