摘要：Objectives. To better understand jail mental health services entry, we analyzed diagnosis timing relative to solitary confinement, nature of diagnosis, age, and race/ethnicity. Methods. We analyzed 2011 to 2013 medical records on 45 189 New York City jail first-time admissions. Results. Of this cohort, 21.2% were aged 21 years or younger, 46.0% were Hispanic, 40.6% were non-Hispanic Black, 8.8% were non-Hispanic White, and 3.9% experienced solitary confinement. Overall, 14.8% received a mental health diagnosis, which was associated with longer average jail stays (120 vs 48 days), higher rates of solitary confinement (13.1% vs 3.9%), and injury (25.4% vs 7.1%). Individuals aged 21 years or younger were less likely than older individuals to receive a mental health diagnosis (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.93; P < .05) and more likely to experience solitary confinement (OR = 4.99; 95% CI = 4.43, 5.61; P < .05). Blacks and Hispanics were less likely than Whites to enter the mental health service (OR = 0.57; 95% CI = 0.52, 0.63; and OR = 0.49; 95% CI = 0.44, 0.53; respectively; P < .05), but more likely to experience solitary confinement (OR = 2.52; 95% CI = 1.88, 3.83; and OR = 1.65; 95% CI = 1.23, 2.22; respectively; P < .05). Conclusions. More consideration is needed of race/ethnicity and age in understanding and addressing the punishment and treatment balance in jails. The care of persons with mental illness in the United States is inextricably linked to the criminal justice system. Approximately 12 million people pass through a jail or prison annually, with the majority cycling through local jails. 1 Approximately one third of these persons have an identified mental illness diagnosed before or during incarceration. Treatment and discharge planning for this population represent considerable challenges. In some small jails, a single mental health professional may only be available for several hours a week, whereas in larger jails more comprehensive services may be available. Research shows that significant health disparities exist for incarcerated persons of color, including the occurrence of infection, violence, and mortality. 2–5 The distribution of psychiatric morbidity and mortality by race in correctional settings is complex, with studies showing higher rates of major affective and depressive disorder diagnoses and suicide among White patients and higher rates of schizophrenia and nonschizophrenic psychotic disorder diagnoses among African American patients. 6–10 Similar disparities exist in the community settings where these patients originate and for most, to which they will return. 11 In the New York City jail system, the Bureau of Correctional Health Services of the New York City Department of Health and Mental Hygiene is responsible for all aspects of medical and mental health care and the New York City Department of Correction is responsible for security and custody management. The New York City jail system is the nation’s second largest, with 70 000 annual admissions and 11 000 persons incarcerated at any given time, with a median length of incarceration of 9 days. Unlike most jail settings, which use relatively cursory intake health screenings, every person who enters the New York City jail system undergoes a comprehensive 4- to 6-hour intake history taking, physical examination, and preventive medicine encounter. Approximately 25% of those admitted to the jails will be admitted into the mental health service, and approximately 4% of those admitted will ultimately be designated as seriously mentally ill (SMI). Although the proportion of SMI patients has remained stable in recent years, the percentage of admitted persons who become part of the mental health service has increased from approximately 12% in 2004 to 25% today. (Note: Entrance into the mental health service is based on ever receiving a mental health diagnosis during incarceration in the New York City jail system.) In addition, because persons with mental illness have longer lengths of stay than others, they now represent approximately 38% of persons in jail at any given time. Entry into the jail mental health service is typically described as resulting from a mental health referral that occurs during the intake history or physical examination during jail admission. Nonetheless, we also have patients enter into the mental health service later in their stay and our clinical experience is that these later admissions may be associated with environmental stressors of the jail itself. Recent Correctional Health Services quality improvement studies on the issue of self-harm have revealed that SMI patients, in addition to adolescents and those in solitary confinement, are significantly more likely to self-harm while in jail. 12 Solitary confinement refers to the isolation of persons from others for 22 to 24 hours per day in a locked cell, which is employed in the New York City jail system for punishment reasons. To better understand how persons with a mental health diagnosis initially come to the attention of the mental health service, we conducted an epidemiological analysis focused on timing of diagnosis during jail stay and, where relevant, relative to solitary confinement, nature of diagnosis, age, and race/ethnicity of patients. The overarching goal of this analysis is to improve the quality of care for patients by detecting characteristics of our health system and those of our patients that merit special attention.
