Gender and Racial/Ethnic Disparities in Mental Health, Substance Use Disorders, and Behavioral Health Treatment Utilization in US Parolees and Probationers

Abstract

Behavioral health (BH) refers to emotional well-being and actions that affect wellness, and includes mental health (MH) and substance use (SU) disorders. Although estimates vary, it is generally agreed that about 50% of all individuals held in jails and prisons suffer from a BH disorder. Justice-involved (JI) adults under supervision in the community (i.e. parolees, individuals exiting prison, and probationers, individuals that may be exiting jail, or under correctional supervision in the community for a specified amount of time instead of incarceration) often have untreated BH needs, particularly co-occurring MH and SU disorders. Untreated BH disorders are a barrier to community re-integration, and contribute to risk taking behaviors, SU relapse, and recidivism post-release. However, rehabilitative reentry efforts typically focus on SU treatment alone, resulting in unmet MH treatment needs. Research also indicates differential rates of BH disorders among justice-involved adults by self-reported gender and race/ethnicity, but national estimates are limited. Likewise, the post-release BH care experiences for these individuals are poorly delineated. The overall purpose of this dissertation was to develop a deeper understanding of the BH needs and community-based BH treatment utilization in justice-involved adults. Chapter one provides an overview of the research problem, background, and significance; identifies gaps in knowledge related to this dissertation study as identified by the literature; and provides a summary of the conceptual and theoretical frameworks that guided the aims of this dissertation. Chapter two provides the results of a systematic review of the extant literature on the unmet BH needs and barriers and facilitators to community-based BH treatment utilization among justice-involved adults. Chapters three and four present the results of a secondary analysis of data from the 2016 National Survey on Drug Use and Health (NSDUH). Chapter five summarizes and synthesizes dissertation results, and provides recommendations for future research and implications for nursing practice. Chapter three details the results of a cross-sectional, descriptive, and correlational study to describe and compare the past-year prevalence of depression, serious psychological distress, and/or SU disorders among JI adults compared to a group of adults not on parole or probation at any point during the past year, adjusting for individual characteristics informed by the social determinants of health (SDOH) framework. Chapter four describes the employment of a modified version of the Meleis’ Transitions Theory to highlight the increased vulnerability of JI adults with these BH needs during community reentry. This dissertation treated community reentry as a situational transition and the pattern of transition as multiple and simultaneous in JI adults, as they often face multiple challenges related to community reentry and integration. Specifically, this chapter focused on the describing the impact of self-reported gender, race/ethnicity, and their intersectionality (factors that influence the pattern of transition) on past-year BH needs and BH treatment utilization among JI adults with BH needs. Chapter four also details the individual-level and community/societal-level barriers to BH treatment utilization among JI adults with BH needs. Results from our systematic review of the literature support high rates of BH needs and psychosocial stressors among justice-involved adults. Sociodemographic and geographical location were critical influences on disparities in BH needs and BH treatment utilization, and justice-involvement was a significant facilitator of BH treatment utilization among justice-involved adults. Further, although rates of health insurance have increased among justice-involved adults, rates of BH treatment utilization have not significantly improved and considerable unmet need for BH treatment persists. Dissertation study results (chapters three and four) revealed that almost half (46%) of the justice-involve group were affected by a BH disorder, and self-reported gender, race/ethnicity, and their intersectionality, significantly impact the probability of being affected by a past-year BH need and BH treatment utilization. Justice-involvement was a significant predictor of being affected by a BH need, with higher prevalence rates among the JI group. Age (18-49 years), an annual income less than $20 thousand, not married, and reporting fair/poor health were SDOH that were found to significantly increase the risk factors for BH needs in the JI group in this dissertation study. Justice health is integral to public health, and efforts to address the national BH crisis must include and prioritize justice-involved individuals. Study results contribute to the limited literature on the impact of gender, race/ethnicity, and their intersectionality on BH and BH treatment utilization in justice-involved adults. Further, inability to access BH treatment utilization due to cost remains a persistent barrier to community-based BH treatment utilization among justice-involved adults. Dissertation findings provide further evidence of the disproportionately higher prevalence of BH needs among justice-involved adults compared to the non-justice-involved adults. It provides the first examination of co-occurring MH and SUDs in justice-involved adults in a nationally representative sample, and contributes to overcoming the paucity of literature differentiating substance misuse and dependency, which have significant implications for community-based BH treatment service planning and provision. Findings can inform a public health approach to identifying and treating BH disorders that is population-based, aid in the development of effective BH transitional and post-release reentry efforts, and contribute to improved BH equity and community integration in justice-involved adults.