Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis

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Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.