Measures

Consenting inmates complete computerized mental health screening between 3 and 14 days after admission to an intake prison. Three items capture self-reported diagnosis, psychotropic medication, and hospitalization in the month prior to incarceration: endorsement of any of these 3 items is considered a recent mental health history. Two standardized measures are also included to capture self-harm risk and potential mental illness. The Depression Hopelessness Suicide Screening Form (DHS)³³ is a 39-item questionnaire. Increased self-harm risk is indicated by endorsement of 1 of 5 items capturing a recent (i.e., past 2 years) or multiple prior suicide attempts, history of self-harm, or current thoughts of or a plan to self-harm.³⁴ A total score, as well as depression and hopelessness subscale scores, is calculated based on the number of endorsed items. A total score of 8 or higher, 7 or higher on the depression subscale (17 items), or 2 or higher on the hopelessness scale (10 items) is considered elevated distress warranting further assessment.³⁵ The Brief Symptom Inventory (BSI)³⁶ is a 53-item self-report measure. Nine subscale scores (depression, anxiety, phobia, psychoticism, interpersonal sensitivity, paranoia, hostility, somatization, and obsessive-compulsive) and a global severity index are calculated as the average item response. A respondent scoring above a T-score of 63 (using general adult population norms) on the Global Severity Index or on 2 of the 9 subscales is considered a possible case.³⁶ Screening also measures intellectual functioning,³⁷ attention-deficit hyperactivity disorder,³⁸ and self-reported lifetime mental health needs; these do not factor into the scoring model but are used to inform recommendations for correctional programming and/or to help interpret ambiguous screening results.

During the study period, inmates were classified as either flagged, unclassified (requiring clinical judgment based on a minimum of a file review in addition to reviewing test results), or screened out using an iterative classification tree.³⁹ However, as part of a recent consultation with front-line screening staff (manuscript in preparation), many staff reported finding the prior model difficult to understand and reliance on certain information (namely, recent mental health histories and self-harm risk) to override recommendations of the model. Our prior work³² developed a simpler model that arrived at similar decisions for most (82%) offenders. This model classified inmates into mutually exclusive groups of those who reported (1) a recent history, (2) increased self-harm risk (on the DHS), (3) elevated distress on both the BSI and DHS, and (4) none of the prior needs (i.e., screened negative). This model is being implemented in Canadian prisons. Furthermore, since it can help estimate the yield of screening versus continuity of care for known cases and is more generalizable to other settings, we apply it in the current study. Supplementary analyses showed similar findings to the primary analyses in terms of the pattern of findings (see the online supplement).

Clinical contacts in regular prisons were documented by staff in the Mental Health Tracking System (a system used for corporate reporting that has since been replaced by an electronic medical record). Because treatment end dates were not systematically recorded, an inmate was considered to be receiving treatment if they had at least 1 contact with a mental health professional for counseling, medication review, or crisis intervention within the past 30 days. Second, each of the 5 regions has a regional treatment center that provides 24-hour inpatient mental health care for acute and serious mental illness. We extracted admission and discharge dates for treatment center admissions from the prison’s electronic case management system’s transfer log; the entire duration of a treatment center admission was counted as time in treatment. To account for unequal follow-up times, we adopted the definition from past work that inmates who spent 10% or more of their time in treatment received treatment that is equivalent to most prior definitions of minimally adequate treatment or guidelines.³²