The National Institute of Mental Health defines serious mental illness (SMI) as “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.”1 Compared with the general population, adults who are incarcerated are more likely to have SMI, and individuals with SMI who are incarcerated often go untreated or inadequately treated.2,3 The estimated prevalence of SMI among individuals incarcerated in jail settings is 20% and among individuals incarcerated in prison settings is 15%.4 Early identification of SMI is important because it allows for early intervention. Early intervention reduces the risk of harm to the individual who is incarcerated and others around them, and it decreases the risk of disruption of daily operations.4-7

Individuals who are incarcerated who have SMI are more likely to self-harm; to be victims of exploitation, violence, and physical assault; and to be perpetrators of exploitation, violence, and physical assault among other individuals who are incarcerated as well as medical and security staff.5,8,9 Suicide is more common among individuals who are incarcerated compared with the general population. It is the leading cause of death in jails and the fifth leading cause in prisons.9 The number of suicide deaths in jails continues to increase, and more than half of all suicides in jail settings are among individuals with SMI.4,5 Identification of SMI is a necessary antecedent to early intervention and is essential for better correctional health outcomes.

Current standard practice for SMI screening varies significantly across correctional settings. Many settings use standard medical questionnaires, which help to obtain a brief medical history but often miss any history of SMI.7 The jail in which this project was conducted used an internally developed and nonvalidated 22-item standard medical questionnaire (SMQ) on intake that had two questions related to mental health: “Are you suicidal or homicidal?” and “Do you have any current mental health problems?”11 Without specific questions related to current SMI symptoms, treatment, and history, identification of possible SMI is unlikely. Conversely, the Brief Jail Mental Health Screen (BJMHS) is a valid and reliable tool that has been shown to identify individuals with possible SMI in correctional settings.7,10 The BJMHS can be used to screen for SMI in both men and women in any correctional setting, and it does not require a trained health professional to administer the assessment. Therefore, the investigators sought to evaluate the BJMHS tool in the current setting to gauge its ability to identify possible SMI, thereby potentially facilitating early mental health intervention for individuals who are incarcerated.

Background

“Correctional setting” is a broad term that includes a “jail, prison, or other detention facility used to house people who have been arrested, detained, held, or convicted by a criminal justice agency or a court.”12 The US Bureau of Justice Statistics defines jails as “locally operated short-term facilities that hold inmates awaiting trial or sentencing or both” as well as “inmates sentenced to a term of less than 1 year, typically misdemeanants.”13 Conversely, prisons are “longer-term facilities run by the state or the federal government that typically hold felons and persons with sentences of more than 1 year.”13 The Federal Bureau of Prisons classifies its institutions into one of five security levels (minimum, low, medium, high, and administrative), and individuals incarcerated under the agency's purview are themselves classified by the level of security and supervision they require as well as their needs (for example, those relating to substance use disorder, physical or mental health, and educational training).14

Correctional settings are required to provide mental health screening, referral, evaluation, and, if needed, treatment; however, only 83% of jails report providing some form of mental health screening.15-17 Among jails that perform screening, a wide variation in screening procedures exists, ranging from use of one or two questions about diagnosis or treatment to performance of a detailed mental status exam.7,17 Indeed, it was found that 63% of individuals who are incarcerated who have acute mental health symptoms were not identified during routine screening and, as a result, did not receive treatment.7 Many adults with SMI try to hide their illness from staff and other individuals who are incarcerated, and some lack awareness of their needs due to substance use issues or an inability to communicate symptoms; therefore, the approach in place within some systems that depends on and expects SMI to be obvious is unreliable and ineffective.18 Valid and reliable SMI screening tools exist but are underutilized.

Literature review

A literature review was conducted to identify barriers to SMI screening in the correctional setting as well as the most effective screening tools for adults who are incarcerated. The data were then used to guide selection of an appropriate tool for use in the described setting. Ten articles published between 2005 and 2021 met inclusion criteria and were reviewed.6,7,10,17-22,25 These included prospective and retrospective studies, cohort studies, cross-sectional studies, and a systematic review; all had a common goal of identifying which screening tools were more effective in early detection of possible SMI.

These articles generally were in agreement that screening tools need to be brief and easily administered because of the limited amount of time correctional facility staff are able to spend with each individual.17-20 Screening tools also need to be sensitive to mental health disorders and have predictive utility for both men and women with low false-negative and false-positive rates.7,20

In a systematic review of use of mental health screening tools in correctional institutions, 22 different screening tools were evaluated on various psychometric properties and performance across demographic groupings such as race and gender.21 Five tools were identified as the most promising. Of the five tools, the review's authors recommended consideration of contextual factors, including setting and population details, when deciding which to use. Based on the setting and population under study, the pool of five tools was narrowed to three that would be most appropriate for this project. For the purposes of this article, a brief summary of each of the three is provided below; more in-depth reviews are published elsewhere.7,11,21-28

The Correctional Mental Health Screen (CMHS) is one of two screening tools developed by the National Institute of Justice to use for mental health screening in adults who are incarcerated.6,7,22 The CMHS has two versions, one for women (CMHS-W) and one for men (CMHS-M). The women's version has 8 yes/no questions, whereas the men's version has 12 yes/no questions. Of these questions, six, which pertain to psychiatric symptoms and history of mental illness, are the same across both versions; the remaining questions differ. Each screen can be administered by a trained correctional officer or staff member and takes less than 5 minutes to complete. A referral for further evaluation should be initiated when “yes” is answered to six or more questions for men or five or more questions for women.

BJMHS is the second of the two screening tools developed by the National Institute of Justice to be used for mental health screening in adults who are incarcerated.7,10 The BJMHS has eight yes/no questions; six questions are related to current symptoms of mental health disorders, and two questions ask about history of hospitalization or medication for mental or emotional problems. A “yes” to two or more of the six questions about current symptoms or a “yes” to either of the history questions warrants referral for further evaluation. This screen takes fewer than 3 minutes to complete and can be done by intake staff, correctional officers, or nursing staff, with minimal training required to administer.

The third tool is the Jail Screening Assessment Tool (JSAT).25 It is a semistructured interview that is designed to identify mental health needs and high-risk indicators such as suicide risk, self-harm, and potential for violence. It takes about 20 minutes to complete and must be conducted by a nurse or qualified mental health professional.

The three tools were compared during the literature review. The BJMHS tool correctly identified SMI or no SMI in 73.5% of men , and the CMHS–M correctly identified 75.5% of men with a previously undiagnosed mental illness.7 The BJMHS was able to correctly classify 62% of women who met the criteria for mood or psychotic disorders, compared to a sensitivity of 65% with the CMHS-W and 75% with the JSAT.17, 21, 22 With a sensitivity of 84%, the JSAT had a higher sensitivity among men compared with both the BJMHS tool and the CMHS-M.21 However, comparison of the BJMHS with the JSAT showed no significant difference in ability to identify SMI among individuals who are incarcerated (P = .109).19

The BJMHS was selected for this study because of its ease, feasibility, and applicability across settings as well as its functionality for men and women. It is appropriate to use in jail or prison settings, takes fewer than 3 minutes to complete, effectively screens for SMI in both men and women who are adults, and it does not have to be administered by a mental health professional.

Purpose

The purpose of this study was to evaluate the use of the BJMHS tool to identify possible SMI in a jail setting to facilitate early mental health intervention for individuals who are incarcerated who screened positive for SMI based on the BJMHS tool. The specific aims were to 1) describe implementation of the evidence-based BJMHS tool in a jail setting and 2) evaluate SMI screening rates, identification of possible SMI, and referral to mental health services with the use of the BJMHS tool.

Methods Context

The study setting was a county jail that houses state inmates classified as level I, II, or III; parole violators; controlled intake inmates; community level I inmates; and federal inmates from various locations. The facility is secured and not open to the public. At baseline, this setting utilized a standard procedure entailing screening of every individual with the internally developed SMQ on intake; if the individual answered “yes” to being suicidal/homicidal or to having had a previous mental health diagnosis, then the facility would follow standard policies and procedures for these individuals, including assessment by a psychiatric nurse within 24 hours of screening and prior to being moved to a general population housing cell.

Intervention

This project used a cross-sectional study design to evaluate the use of the BJMHS tool over a 30-day period. A convenience sample of incarcerated individuals who were arrested between November 6, 2021, and December 6, 2021, and booked in the county jail that served as the study site were recruited. Inclusion criteria included male or female sex; age older than 18 years; being arrested and booked into the detention center during the prescribed 30-day period; being an English speaker; being of any racial or ethnic background; and classification status of county, state, or federal incarceration. Exclusion criteria consisted of reported SMI, previous mental health diagnosis prior to arrest, history of traumatic brain injury, developmental disability, substance use, and/or display of signs of impaired capacity during initial screening at booking.

Using the jail management software, every 24 to 48 hours the principal investigator (PI) reviewed records of incarcerated individuals who had been taken into custody during that time to identify all those who met inclusion criteria based on SMQ data and information from the arresting citation over the course of the 30-day period. The PI provided a list of eligible individuals to the security officer, who then approached each individual with the opportunity to hear about the study. If the individual agreed, they were taken to the medical department and placed by the security officer in medical holding, where the PI met with them and provided a copy of the survey cover letter before reading it aloud to them. If the individual agreed to participate in the survey, then informed consent was obtained and the individual was handed a duplicate laminated copy of the BJMHS tool. The PI read aloud the eight-question survey, which took fewer than 3 minutes to complete, placing checkmarks in the “yes” or “no” checkboxes on the paper copy to record how the individual answered each question. The paper copy was always visible to the individual so that they could observe the answers recorded by the PI and verify their accuracy. The BJMHS screening was conducted by the PI in a medical exam room to provide privacy for screening within the first 24 to 48 hours of the individual's arrest. If the screen was positive, the incarcerated individual was referred to the psychiatric nurse for further evaluation and intervention.

Next, the PI reviewed the participating individuals' medical records for the mental health survey completed by the psychiatric nurse to evaluate whether those who screened positive for possible SMI were offered a mental health intervention. An intervention was defined as an interview with the psychiatric nurse, an outside referral to a mental health provider to evaluate for SMI, and/or forwarding of the individual's medical record to the medical staff advanced practice registered nurse (APRN).

Finally, a postgroup comparison of the SMQ with the BJMHS over a 30-day period (from December 7, 2021, to January 7, 2022) was completed using the same cross-sectional design. This evaluation occurred after the study group data collection period due to timing of institutional review board (IRB) approval. Data regarding the number of individuals arrested during this time and, of those individuals, the number who would have been eligible to participate in the study and undergo screening with the BJMHS were collected using the jail management software. The PI then compared the postgroup's SMQ results to the study group's BJMHS responses to evaluate differences in screening for possible SMI between the facility's standard screening practice using the SMQ and the study's screening practice using the BJMHS. The PI reviewed the SMQ of any individual who was incarcerated who answered “yes” to either of the two mental health questions (“Are you suicidal?” and “Do you have any mental health problems?”). Based on the SMQ, the PI screened to see if the individual would have been included in the study based on inclusion criteria and, if so, whether they were offered a mental health intervention.

Data analysis

Descriptive analyses were used to describe demographic data and study variables. Data analysis was conducted using IBM SPSS version 25.

Ethical considerations

This study design was approved by the University of Kentucky IRB with enhanced scrutiny considering the participation of this vulnerable population.

Results

A total of 181 individuals were arrested and incarcerated between November 6, 2021, and December 6, 2021. Of these individuals, 100 met inclusion criteria and were invited to participate in the study, with 89 ultimately volunteering to participate. The participants were predominantly White (66.3%) and male (77.9%) with an average age of 35.6 years and range of 19 to 66 years (Table 1). Among the 89 participants, 25 screened positive for possible SMI using the BJMHS (Table 2), and all 25 who screened positive were referred for mental health services (Table 3). Of the 25 participants referred for mental health services, three refused to be interviewed by the nurse following the BJMHS screen and seven were released before the nurse could meet with them. As a result of this attrition, 15 individuals who screened positive were ultimately evaluated by the APRN: Of them, 4 (26.7%) did not require psychotropic medication but were offered alternative therapy measures such as counseling, breathing exercises, journaling, and other coping strategies; 3 (20.0%) did not have a reported history of SMI but, after assessment, were started on psychotropic medication; and 8 (53.3%) had a previous mental health diagnosis and were prescribed medication.

Table 1. - Demographic summary of study participants Study group (n = 181) Poststudy group (n = 143) Gender, n (%)    Man 141 (77.9%) 106 (74.1%)    Woman 40 (22.1%) 37 (25.9%) Race, n (%)    Black 37 (20.4%) 19 (13.3%)    Hispanic 17 (9.4%) 14 (9.8%)    White 120 (66.3%) 103 (72.0%)    Unknown 7 (3.9%) 7 (4.9%) Age in years, mean (range) 35.6 (19-66) 37.3 (18-65)
Table 2. - Eligibility, participation, and screening outcomes by group Study group Poststudy group Eligible 100 97 Declined 11 NA Underwent mental health screening 89a 97b Positive screen, n (%) 25 (28.1%) 3 (3.1%) Negative screen, n (%) 64 (71.9%) 94 (96.9%)

aIndividuals were screened using the Brief Jail Mental Health Screen (BJMHS).

bIndividuals were screened using the standard medical questionnaire (SMQ).

Abbreviation: NA, not applicable.

Table 3. - Interventions upon positive screen with BJMHS among study group participants Intervention n (%) Previously diagnosed: Prescribed medication(s) 8 (53.3%) Not previously diagnosed: Prescribed medication(s) 3 (20.0%) Alternative therapy 4 (26.7%)

Note: The number of individuals in the study group who received interventions was 15; 10 of the 25 individuals who originally screened positive were lost to follow-up before intervention could occur due to release (n = 7) or declining to meet with nurse (n = 3).

During the postcomparison month (December 7, 2021, to January 7, 2022), 143 individuals were arrested, and 97 would have been eligible for participation in the study and potentially screened using the BJMHS (Table 2). The two groups were comparable across demographics, with the second sample being predominantly White (72%) and male (74%) with an average age of 37.3 years; no statistically significant differences in age, gender, or race were noted between the two groups. Using the SMQ, only three (3%) of these incarcerated individuals in the comparison group met criteria for referral to mental health services. Comparison of the two groups showed a higher percentage of positive mental health screens using the BJMHS tool (28%) than with the SMQ (3%; Table 2).

Discussion

In this study, a significantly higher number of individuals who were incarcerated screened positive for possible SMI with the BJMHS than with the standard intake screening process using the SMQ. All individuals who screened positive for possible SMI and who were not lost to follow-up (for example, due to release or care refusal) received a behavioral health evaluation and evidence-based treatment as needed. Early identification and intervention for individuals who are incarcerated who have SMI reduces the risk of harm to the individual and to others around them and decreases the risk of disruption of daily operations.4-7,29 Individuals who are incarcerated comprise a vulnerable population with unique challenges, including access to mental health services, both inside and outside of correctional settings. They often try to hide their illness or symptoms from staff and other individuals who are incarcerated for a variety of reasons, including stigma and fear of consequences, mistreatment, and exploitation.18 Therefore, relying on obvious signs or answers from a nonspecific generic mental health screen to identify possible SMI is insufficient and can lead to dangerous, potentially fatal outcomes.

Although correctional settings are required to provide mental health screening and treatment as needed, an evidence-based, standardized approach to providing such care does not currently exist. Many facilities use a standard general medical questionnaire that includes vague, nonspecific mental health questions that are not supported by evidence to identify possible SMI, and as a result, SMI often goes undetected and untreated or undertreated.3 The BJMHS has demonstrated good reliability and validity to detect SMI in both men and women, and it can be used in any correctional setting and administered by any trained staff member in fewer than 3 minutes. Among the other psychometrically sound assessments for screening for possible SMI in a prison population, the BJMHS is the most versatile and most appropriate for widespread implementation across correctional facilities. As such, the main recommendation from this study is to implement use of the BJMHS across all correctional facilities or at least any facility that does not currently use a validated assessment to screen for possible SMI.

Future studies could compare the BJMHS to the other cited tools in appropriate populations with appropriate resources as a measure of concurrent validity. For example, comparison of the JSAT administered by a psychologist with the BJMHS administered in the same setting by intake staff would provide further insight into the strength of the BJMHS, as would its comparison with the CMHS-M among men. All three tools are effective, but the BJMHS is superior in terms of its applicability to both men and women as well as its ease of administration.

Practice recommendations

Early identification of and intervention in SMI is critical, as it improves the well-being and safety of everyone in a correctional setting.29 Considering the generalizability and effectiveness of the BJMHS, the authors recommend using this tool to assess for SMI in all correctional facilities that are not already using an assessment tool that has demonstrated validity and reliability for identifying possible SMI among individuals who are incarcerated. Since the conclusion of this study and the dissemination of its results to stakeholders, system leadership has replaced use of other screening tools with the BJMHS in more than 250 facilities in the US.

The PI recommended an implementation strategy for the study site facility which could be applied to other sites. The first recommended step is to provide a required training session for booking officers or the equivalent, as they are responsible for screening all incarcerated individuals at intake. This training session could be accomplished in 1 hour or less, which includes time for training and questions. This training should focus on SMI and the importance of SMI screening, identification, and early intervention in the correctional setting. Studies have demonstrated that providing such training for correctional officers can have a direct impact on the safety of both individuals who are incarcerated and officers.29 Additionally within the training session, the BJMHS and its administration should be described as well as any specific process or protocol for the setting in question; time for practice, discussion, and questions should be allowed. This implementation strategy, or some variation of it, should work in most settings.

The eight questions in the BJMHS should be placed directly into the facility's comprehensive SMQ, replacing or adding to the standard mental health questions. Integration into the existing jail management software is ideal, and hard stops would help to ensure completion. Electronic completion of the intake questionnaire would also allow for immediate electronic referral or at least some mechanism (flag, alert, or other notification) for the nurse to review. The booking officer could take the individual to the nurse immediately following the intake evaluation to allow the nurse to complete a more detailed assessment and initiate action for identification and early intervention as indicated.

Limitations

Study limitations include the early time of day for data collection, the length of the consent process, and the strict inclusion criteria. The study had to be conducted during a time that did not impact daily operations; as a result, individuals were usually screened between 7:00 a.m. and 9:00 a.m., which may have influenced the decision to participate. Although the BJMHS takes fewer than 3 minutes to complete, the consent process required anywhere from 5 to 10 minutes before the BJMHS questions could be asked; this also may have influenced willingness to continue with participation. Finally, the strict inclusion criteria may have overly restricted eligibility; during the study period, 181 individuals were arrested but only 100 were eligible to participate. Most of the participants from this single study site who met inclusion criteria and agreed to participate were White (66%) males (80%), which constrains the demographic reach of the findings. These potential limitations should be considered in future studies and, when possible, addressed in study design.

Conclusion

Although mental health screening in correctional facilities is a requirement, only 83% of facilities complete it, and wide variation exists in how the screening occurs. Many settings use screening tools that are not sensitive, valid, or reliable in identifying possible SMI, which leads to unidentified SMI among the correctional facility population. Early identification of and intervention in SMI is critical; failing to identify possible SMI and to deliver the necessary interventions upon identification poses a significant safety concern for the individual who is incarcerated, other individuals incarcerated in the facility, and facility staff. All correctional facilities need to use a valid and reliable screening tool that has a low false-negative rate and low false-positive rate for screening for possible SMI; the BJMHS is such a tool that is quick and easy to administer and can be used in any correctional setting for men and women. The BJMHS was significantly better at screening for possible cases of SMI needing additional evaluation than standard practice using the SMQ. Ultimately, identification of SMI leads to better care for the individual who is incarcerated and increased safety in the facility.

The single jail setting at which this study was conducted is part of a larger system of more than 250 correctional facilities throughout the Midwestern US that also used the same or a similar unvalidated, internally developed SMQ screening protocol. Findings from this study were shared with system leadership, which then decided to replace the SMQ with the BJMHS in all their facilities. As a result, the BJMHS is now being used in at least 250 correctional facilities in the US. The authors recommend that other facilities consider its use to improve care and outcomes for individuals who are incarcerated and to increase compliance with the requirement for correctional settings to provide mental health screening, evaluation, and, if needed, referral and treatment.15,16 Detention or incarceration may present the first opportunity for some individuals to ever receive evaluation for SMI and subsequent therapy as needed, or it may provide an opportunity for individuals with known SMI to resume or start needed medication. Improving universal screening for SMI with the use of evidence-based and validated measures could have far-reaching benefit for individuals who are incarcerated and the communities in which they dwell, both during the time spent in correctional settings and beyond.

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