Criminal Legal Involvement Among U.S. Adults With Serious Psychological Distress and Differences by Race-Ethnicity
Abstract
Objective:
The authors examined associations between criminal legal involvement (CLI) and serious psychological distress and how these associations differed by racial-ethnic group.
Methods:
The authors conducted a retrospective analysis of multiple cross-sections of data from the National Survey on Drug Use and Health (2015–2019) and used multivariable linear probability regression models to assess lifetime CLI and past-year probation, parole, supervised release, or other conditional release in a nationally representative sample of noninstitutionalized U.S. adults, ages ≥18 years (N=214,505), with and without serious psychological distress.
Results:
Adults with serious psychological distress had higher rates of CLI than adults without such distress (difference of 4.1 percentage points, 95% CI=3.3–4.8, p<0.001). The rate of CLI increased as distress severity increased, from mild (3.2 percentage-point difference, 95% CI=2.6–3.8, p<0.001) to high (7.2 percentage-point difference, 95% CI=6.4–8.0, p<0.001). The risk for CLI among those with serious psychological distress was even greater for Black and Latinx adults than for White adults (1.8 percentage-point difference, 95% CI=0.1–3.5, p<0.05, and 3.2 percentage-point difference, 95% CI=1.3–5.2, p<0.01, respectively).
Conclusions:
Rates of CLI were higher for adults with serious psychological distress. Efforts are needed to equitably triage individuals with acute mental health needs to timely psychiatric care instead of carceral settings. Collaborative models of care that commingle resources from mental health and law enforcement organizations are needed to prevent unnecessary incarceration of individuals experiencing mental health crises and to increase access to community-based treatment.
HIGHLIGHTS
•
Adults with serious psychological distress had higher rates of criminal legal involvement (CLI) than adults without serious psychological distress.
•
Rates of CLI increased as severity of psychological distress increased.
•
Black and Latinx adults with serious psychological distress, who experience systemic and structural inequities, had higher rates of CLI compared with White adults with serious psychological distress.
The U.S. incarceration rate is more than five times the rate of other developed countries (1), and individuals with mental illness are disproportionately represented in the incarcerated population. In the United States, as many as 31% of incarcerated adults have a mental illness (2), compared with 19% of adults in the general population (3). According to the U.S. Department of Justice, the rate of serious psychological distress is more than five times higher among incarcerated people than among individuals in the general population (4, 5). Serious psychological distress refers to a high level of nonspecific symptoms of stress, such as anxiety and depression, and is used as a nonspecific proxy indicator of probable serious mental illness (6–8). People with serious psychological distress have decreased daily functioning, lower socioeconomic status, increased levels of comorbid conditions, and health care utilization rates similar to those with serious mental illness (9).
To our knowledge, no previous nationally representative study has evaluated the association between history of criminal legal involvement (CLI) and mental illness among individuals in the general adult population; most studies instead have reported on the prevalence of mental illness in the currently arrested or incarcerated adult population. Quantifying the association between mental illness and CLI is important because incarceration has been shown to result in long-term adverse outcomes among people with serious psychological distress. Individuals receive poorer quality of care while incarcerated, which leads to higher rates of admission to intensive crisis-oriented services after release (10). Additionally, young adults (ages 23–29 years) who have experienced incarceration have low rates of health insurance coverage—with a noninsurance rate of 57% among individuals who have been incarcerated compared with a noninsurance rate of 20% among those who have not been incarcerated—further reducing their access to affordable mental health treatment (11).
A disproportionate share of the incarcerated population comprises Black and Latinx adults. According to the Federal Bureau of Prisons (12), as of April 2021, 39% of inmates in federal correctional facilities were Black, although Black adults constitute only 13% of the U.S. population (13). Similarly, Latinx adults account for 30% of inmates (12) but constitute only 18% of the nation’s population (13). One study (14) showed that the incarceration rate of non‐Latinx Black men is seven times higher than that of non‐Latinx White men and that non‐Latinx Black women have an incarceration rate almost three times as high as that of non‐Latinx White women. Structural racism, differential policing, and unjust criminal punishment are salient contributors to the higher rates of incarceration among Black and Latinx adults (15). The term structural racism refers to the manner in which societal policies, institutional practices, and cultural norms reinforce and perpetuate racial-ethnic inequality.
Although rates of mental illness among individuals belonging to racial-ethnic minority groups are similar to or lower than the rate among White individuals (16), individuals from minority groups experience greater persistence and severity of illness (15, 17, 18). Despite this increased burden of disease, people from racial-ethnic minority groups are less likely to access mental health treatment than are White individuals (19, 20), and an unmet need for mental health services is associated with higher likelihood of interacting with the criminal legal system (21). One study assessing incarceration rates in California (22) reported higher rates of mental illness among Black and Latinx inmates, relative to White inmates. A study (21) with those who have been involved in the criminal legal system has shown that both being Black and having a nonpsychotic mental disorder is associated with higher likelihood of rearrest and longer jail time.
The objective of this study was to build on the existing literature by assessing the association between serious psychological distress and CLI and by using nationally representative survey data to examine differences in this association among racial-ethnic groups. Identifying the association between CLI and serious psychological distress and how this association differs among racial-ethnic minority groups in the United States fills a gap in evidence needed to build interventions to disrupt the link between inequitable mental health care and a criminal legal system that disproportionately targets people of color. We hypothesized that adults with serious psychological distress have higher rates of CLI than adults without such distress and that the risk for CLI among those with serious psychological distress is greater for Black and Latinx adults than for White adults.
Methods
Data
In this retrospective analysis, we used multiple cross-sections of data from the annual National Survey on Drug Use and Health (NSDUH) of the Substance Abuse and Mental Health Services Administration (23). We pooled 5 years of data (for the 2015–2019 period) to increase the precision of our estimates. The NSDUH is a nationally representative survey that collects information on illicit drug use, alcohol use, CLI, behavioral health treatment, and sociodemographic characteristics in the noninstitutionalized population. Additionally, the NSDUH uses validated diagnostic instruments, in accordance with DSM criteria, to identify behavioral health disorders. The analytic sample included adults ages ≥18 years (N=214,505). This study received approval from the institutional review board of Cambridge Health Alliance.
Dependent Variables
Our primary outcome, CLI, was a dichotomous variable, operationalized as an individual having experienced any of the following: a lifetime arrest or conviction of a crime or past-year probation, parole, supervised release, or other conditional release from prison.
Independent Variables
Our primary independent variable of interest was an indicator for serious psychological distress, as measured by Kessler-6 Psychological Distress Scale (K6) score. K6 scores ≥13 (indicating a high level of nonspecific symptoms of psychological stress associated with anxiety and depression) were assigned a value of 1, and K6 scores ≤12 were assigned a value of 0. The K6 scale has a sensitivity of 90% and a specificity of 89% for identifying presence of a mood or anxiety disorder, as defined by the DSM-IV, and can distinguish cases from noncases with consistency across sociodemographic subsamples (24). A cutoff point of ≤12 versus ≥13 is optimal as an indicator of clinically significant psychiatric disorder (8, 24). To assess any differential association between CLI and mental illness by race-ethnicity, we focused on the interaction between the serious psychological distress indicator variable and the race-ethnicity categorical variable. We recognized that racial-ethnic categories are socially constructed and serve as a proxy for the experience of racism. We examined disparities between racial-ethnic minority groups and the referent majority White group to generate evidence indicating unfair and unjust distributions of CLI, recognizing that racial-ethnic disparities are driven by racism and long-standing structural inequities. On the basis of self-reports, we categorized race-ethnicity as non-Latinx White (hereafter referred to as White), non-Latinx Black (hereafter referred to as Black), Latinx, and non-Latinx Asian (hereafter referred to as Asian).
In our secondary analysis, we assessed associations between CLI and levels of psychological distress grouped into no (K6 score=0), mild (K6 scores=1–5), moderate (K6 scores=6–10), or high distress (K6 scores≥11) (7, 24). This categorization allowed us to ascertain the relationship between CLI and more moderate levels of mental distress, which may also warrant preventive mental health intervention. We adjusted the regression models for covariates that potentially confounded the relationship between serious psychological distress and CLI. Covariates included age (18–25, 26–35, 36–49, 50–64, or ≥65 years), sex (female or male), race-ethnicity, marital status (married or single), education (less than high school, high school graduate, some college, or college graduate), federal poverty level (FPL) (<100%, 100%–124%, 125%–199%, 200%–399%, or ≥400%), insurance status (private, Medicaid, Medicare, other insurance, or uninsured), general medical health status (excellent, very good, good, fair, or poor), any substance use disorder (yes or no), and survey year (2015, 2016, 2017, 2018, or 2019).
Statistical Analysis
We used chi-square tests and t tests for dichotomous and continuous variables, respectively, to compare adults’ demographic characteristics and CLI by serious psychological distress status. Next, we estimated multivariable linear probability regression models to assess the association between serious psychological distress and CLI, conditional on the previously mentioned covariates. This linear regression modeling approach enabled direct interpretation of regression coefficients as percentage-point differences (e.g., Black adults vs. White adults) in CLI rates.
Next, to obtain a better understanding of the relationship between psychological distress severity and CLI, we reestimated our regression model with a categorical variable illustrating levels of psychological distress that ranged from no to high psychological distress. To assess differential effects of serious psychological distress and race-ethnicity, we reestimated the regression models with an interaction between the serious psychological distress indicator variable and the race-ethnicity categorical variable (with White as reference). In secondary analyses, we disaggregated our primary outcome into two dichotomous variables: any lifetime arrest or conviction of a crime (hereafter referred to as lifetime arrest or conviction) and any past-year probation, parole, supervised release, or other conditional release from prison (hereafter referred to as past-year community supervision) to assess the robustness of our primary findings. We used predictive margins methods (25) to assess within- and between-group differences. All rates and model estimates were weighted to be nationally representative and to account for sample design and survey nonresponse. We present magnitudes of differences with CIs that allowed for comparisons across all racial-ethnic groups. Results were considered statistically significant at p<0.05 (two-tailed). Analyses were conducted with Stata, version 16 (26).
Results
Table 1 shows the demographic characteristics and CLI for adults by serious psychological distress status. Adults with serious psychological distress had higher rates of CLI than adults without such distress (23.8% vs. 15.9%, p<0.001). Relative to adults without serious psychological distress, adults with serious psychological distress were more likely to be White (69.1% vs. 65.1%, p<0.001), younger (e.g., 18–25: 29.0% vs. 12.0%, p<0.001), female (61.9% vs. 50.5%, p<0.001), and unmarried (30.8% vs. 54.4%, p<0.001) and to have some college education (37.3% vs. 30.0%, p<0.001), lower income (e.g., <100% FPL: 24.8% vs. 14.5%, p<0.001), Medicaid insurance (20.7% vs. 10.3%, p<0.001), poor self-rated general medical health (6.4% vs. 2.2%, p<0.001), and substance use disorder (11.4% vs. 1.8%, p<0.001).
| Serious psychological distress (N=33,487) | No serious psychological distress (N=181,018) | |||
|---|---|---|---|---|
| Characteristic | N | % | N | % |
| Criminal legal involvement | 7,970 | 23.8*** | 28,836 | 15.9 |
| Race-ethnicity | ||||
| White | 23,140 | 69.1*** | 117,933 | 65.1 |
| Black | 3,684 | 11.0*** | 22,301 | 12.3 |
| Latinx | 5,291 | 15.8* | 29,977 | 16.6 |
| Asian | 1,373 | 4.1*** | 10,807 | 6.0 |
| Age in years | ||||
| 18–25 | 9,711 | 29.0*** | 21,704 | 12.0 |
| 26–35 | 7,568 | 22.6*** | 27,370 | 15.1 |
| 36–49 | 8,077 | 24.1 | 44,766 | 24.7 |
| 50–64 | 5,827 | 17.4*** | 47,590 | 26.3 |
| ≥65 | 2,311 | 6.9*** | 39,589 | 21.9 |
| Female sex | 20,728 | 61.9*** | 91,342 | 50.5 |
| Married status | 10,314 | 30.8*** | 98,474 | 54.4 |
| Education | ||||
| Less than high school | 4,457 | 13.3 | 22,881 | 12.6 |
| High school graduate | 8,496 | 25.4 | 44,838 | 24.8 |
| Some college | 12,491 | 37.3*** | 54,342 | 30.0 |
| College graduate | 8,037 | 24.0*** | 58,958 | 32.6 |
| Federal poverty level in % | ||||
| <100 | 8,305 | 24.8*** | 26,284 | 14.5 |
| 100–124 | 2,143 | 6.4*** | 8,616 | 4.8 |
| 125–199 | 5,793 | 17.3*** | 26,266 | 14.5 |
| 200–399 | 6,995 | 20.9*** | 39,969 | 22.1 |
| ≥400 | 10,247 | 30.6*** | 79,883 | 44.1 |
| Insurance | ||||
| Private | 16,911 | 50.5*** | 97,315 | 53.8 |
| Medicaid | 6,932 | 20.7*** | 18,717 | 10.3 |
| Medicare | 4,420 | 13.2*** | 43,643 | 24.1 |
| Other insurance | 837 | 2.5** | 3,874 | 2.1 |
| None | 4,387 | 13.1*** | 17,468 | 9.6 |
| Self-rated health | ||||
| Excellent | 4,052 | 12.1*** | 40,168 | 22.2 |
| Very good | 10,414 | 31.1*** | 65,818 | 36.4 |
| Good | 10,615 | 31.7*** | 52,405 | 29.0 |
| Fair | 6,262 | 18.7*** | 18,663 | 10.3 |
| Poor | 2,143 | 6.4*** | 3,964 | 2.2 |
| Presence of any substance use disorder | 3,818 | 11.4*** | 3,186 | 1.8 |
| Survey year | ||||
| 2015 | 6,111 | 18.2 | 35,950 | 19.9 |
| 2016 | 6,342 | 18.9 | 36,077 | 19.9 |
| 2017 | 6,667 | 19.9 | 36,294 | 20.0 |
| 2018 | 6,872 | 20.5 | 36,439 | 20.1 |
| 2019 | 7,498 | 22.4 | 36,240 | 20.0 |
a
Data source: National Survey on Drug Use and Health (2015–2019). Criminal legal involvement was defined as a lifetime arrest or conviction of a crime or past-year probation, parole, supervised release, or other conditional release from prison. Serious psychological distress was defined as Kessler-6 scale scores ≥13; possible scores range from 0 to 24, with higher scores indicating more severe distress. Chi-square tests were used to compare adult characteristics by serious psychological distress status.
*p<0.05, **p<0.01, ***p<0.001.
In an adjusted regression analysis, the rate of CLI was about 4 percentage points higher (Table 2; see the online supplement to this article for the full regression results) for adults with serious psychological distress compared with adults without serious psychological distress (p<0.001). In examining the association between different levels of psychological distress and CLI (Table 2; see the online supplement for the full regression results), rates of CLI exhibited a gradient that increased in percentage points with higher levels of psychological distress (mild [increase by 3.2 percentage points, p<0.001], moderate [increase by 5.6 percentage points, p<0.001], and high [increase by 7.2 percentage points, p<0.001]), relative to no psychological distress.
| Criminal legal involvementb | ||
|---|---|---|
| Characteristic | Difference (percentage points) | 95% CI |
| Presence of serious psychological distress (reference: absence of distress)c | 4.1 | 3.3–4.8 |
| Kessler-6 scale scores (reference: 0 [none]) | ||
| 1–5 (mild) | 3.2 | 2.6–3.8 |
| 6–10 (moderate) | 5.6 | 4.8–6.4 |
| 11–24 (high) | 7.2 | 6.4–8.0 |
a
Data source: National Survey on Drug Use and Health, 2015–2019. The regression model was adjusted for the following covariates: age, sex, race-ethnicity, marriage status, education, insurance status, general medical health status, substance use disorder, and year. All differences were statistically significant at p<0.001.
b
Criminal legal involvement: a lifetime arrest or conviction of a crime or past-year probation, parole, supervised release, or other conditional release from prison.
c
Serious psychological distress was indicated by Kessler-6 scale scores ≥13; possible scores range from 0 to 24, with higher scores indicating more severe distress.
When we estimated the associations between CLI and serious psychological distress by race-ethnicity (Figure 1; see the online supplement for the full regression results), we found that the increased risk for CLI among those with serious psychological distress was greater for Black and Latinx adults than for White adults (increases in risk by 1.8 percentage points, 95% CI=0.1–3.5, p<0.05, and 3.2 percentage points, 95% CI=1.3–5.2, p<0.01, respectively). Similar to the results from our primary analyses, our secondary analyses (see the online supplement ) also indicated that serious psychological distress was positively associated with both lifetime arrest or conviction and past-year community supervision.
FIGURE 1. Adjusted rates of criminal legal involvement, by serious psychological distress and race-ethnicitya
aData source: National Survey on Drug Use and Health, 2015–2019. The regression model was adjusted for age, sex, marriage status, education, insurance status, general medical health status, substance use disorder, and year. Criminal legal involvement was defined as an individual experiencing any of the following: a lifetime arrest or conviction of a crime or past-year probation, parole, supervised release, or other conditional release from prison. Serious psychological distress was defined as Kessler-6 scale scores ≥13.
bWithin difference was the difference (in percentage points) between serious psychological distress and no serious psychological distress within a racial-ethnic group.
cDifference in differences was the difference (in percentage points) between serious psychological distress and no serious psychological distress among Black, Latinx, or Asian adults, minus the difference between serious psychological distress and no serious psychological distress among White adults (reference).
*p<0.05, **p<0.01, ***p<0.001.
Discussion
As we had hypothesized, greater psychological distress was associated with greater CLI, with CLI increasing on a gradient with increased psychological distress. This result was expected, given previous studies reporting higher rates of mental illness among those in carceral settings compared with the general population (2, 4, 5). However, this study provides new data showing that in the general population, CLI was greater among those with serious psychological distress than among those without such distress. To our knowledge, this is the first study to use nationally representative household survey data to evaluate the risk for CLI among adults with serious psychological distress. These results represent a much-needed contribution to the literature, because most studies have focused on mental illness among incarcerated populations and not on the heightened risk for incarceration among people with serious psychological distress in the general population and how the association within this population varies by racial-ethnic group.
The persistence of racial discrimination within the behavioral health and criminal legal systems is exemplified by the fact that the increased risk for CLI among those with serious psychological distress was greater for Black and Latinx adults than for White adults. Institutional systemic racism and implicit biases have perpetuated the differential treatment for these populations in both mental health and criminal legal systems (15). Underlying these results are multiple health care factors, such as poor access to mental health treatment (27), lower rates of help seeking (17), and inadequacy of available treatment (20) for individuals from racial-ethnic minority groups. These factors then combine with criminal legal system factors such as racial differences in incarceration rates and lower likelihood of mental health treatment diversion among Black and Latinx adults.
Efforts to reduce CLI and recidivism or to improve mental health service access are often racialized and closely associated with socioeconomic status. For example, drug court programs have successfully decreased recidivism rates among their participants (28, 29). Drug courts, the most common form of civil problem-solving courts, were established in the United States in 1989 to reduce recidivism among reoffending individuals with substance use disorder by focusing on treatment and rehabilitation as an alternative to criminal prosecution and incarceration (30, 31). However, studies (32, 33) have shown that many U.S. drug courts are less effective for Black participants than for White participants. Negative social and environmental factors are likely sources for the racial disparities in drug court graduation rates (34). For example, participants of drug court programs are more likely to be of White race and to have no criminal history, with research (35) suggesting that drug court eligibility criteria and implicit biases of prosecuting attorneys and other legal staff may select against non-White participants. These factors are a result of institutional bias closely associated with poverty as well as indicators of CLI and mental health issues (35–37). Future research should assess the intersection of serious psychological distress, illicit drug use, and CLI to elucidate the mechanisms that contribute to racial disparities in CLI.
Additionally, although studies (16) have indicated no differences in psychological distress between racial-ethnic minority individuals and White individuals, when matched by socioeconomic status, only 9% of U.S. Black adults receive any mental health services, nearly half the rate of White adults (16.6%) (38). Studies (17, 39) also have shown that people of color are more likely to attribute symptoms of psychological distress to circumstances and life stressors rather than to psychological disorders, contributing to less help seeking and service utilization by this population. A history of segregation and discrimination toward people of color has perpetuated the disproportionate chronic poverty that has resulted in inequitable effects on mental health (15, 40).
The advantages of living in the United States as a White person are evidenced through more favorable sociodemographic outcomes, such as housing status, education levels, and socioeconomic status—variables that are negatively associated with CLI and represent systemic privilege. Conversely, the disadvantages of living in the United States as a Black or Latinx adult with mental illness are complex and intersect to create a greater risk for CLI. The compounded consequences for people who are members of multiple stigmatized social groups result in public perception and attitudes of discrimination that have implications for the effectiveness and accessibility of appropriate interventions (36, 41). Solutions to these systemic issues would require a multitiered approach tailored to the challenges of specific populations. Such solutions would need to extend beyond the initiation of mental health services to include initiatives directed toward improving other social determinants of health for underprivileged populations. Efforts for improved mental health services should concurrently prioritize support and equitable opportunity for housing, education, transportation, and employment determinants. These factors promote access, utilization, and sustainability of behavioral health services and mitigate the racially disproportionate disadvantages that amplify the impacts of serious psychological distress and CLI.
Our study had several limitations. First, the NSDUH data are cross-sectional and preclude causal inferences. Nonetheless, the findings of our study illustrate significant associations between serious psychological distress and CLI in a nationally representative sample of adults. Second, the NSDUH data are based on survey respondents’ self-reports and, as such, depend on participant recall and truthfulness. To increase survey response accuracy, answers to sensitive questions are collected by using computer-assisted self-interview methods, in which respondents listen to prerecorded questions through headphones and answer directly by entering responses into a NSDUH laptop to maintain privacy (23). Third, the NSDUH population is limited to noninstitutionalized U.S. civilians and excludes people who are unhoused, incarcerated, or participating in residential treatment. Consequently, our results may have been conservative, because the aforementioned groups are likelier to experience high levels of serious psychological distress and to have previous CLI. Fourth, we used a psychological distress measure that captures how often an individual felt distressed (e.g., hopeless, restless or fidgety, and feeling that everything was an effort) during the previous year but does not capture specific mental disorders. However, the K6 captures symptoms commonly associated with depression and anxiety and can reliably, with high sensitivity and specificity (7, 24), distinguish clinical cases from nonclinical cases consistently across sociodemographic subsamples. The K6 scale was validated, in accordance with DSM-IV criteria and before changes in the diagnostic criteria for the DSM-5 (8, 42), for determining serious mental illness or any mental illness. Fifth, the NSDUH does not capture the type of infraction that led to CLI, contact frequency with the criminal legal system, or living situation during community supervision.
Conclusions
Despite these limitations, the results of our study suggest that adults with serious psychological distress experience higher rates of CLI and that this association is even greater among Black and Latinx individuals. Illuminating disparities in incarceration rates can inform efforts at the state and federal levels to incentivize incarceration alternatives for people experiencing behavioral health issues. Importantly, our findings underscore the need for unlearning and dismantling the racial stereotyping and heuristics that inform the prosecution of racial-ethnic minority groups in the criminal legal system. The disproportionate CLI resulting from historic and systemic racism may be most successfully mitigated through efforts to improve interdisciplinary collaboration among stakeholders, not only of law enforcement and criminal legal court systems but also of behavioral health providers and even educational institutions.
The findings from this study highlight the disparate social determinants that can lead to higher rates of CLI, especially for racial-ethnic minority populations with serious psychological distress. Enlisting the attention and action of cross-sectoral stakeholders to ensure early identification of need, access to, and affordability of mental health services, as well as establishing equitable opportunities for education, employment, and housing, may serve as holistic incarceration prevention for this population. It is critical for individuals experiencing psychological distress to avoid unnecessary interaction with the criminal legal system and to have timely access to evidence-based treatment that improves their mental health status and enables them to stay in the community.
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History
Received: 28 January 2022
Revision received: 27 September 2022
Accepted: 19 October 2022
Published online: 10 January 2023
Published in print: July 01, 2023
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Competing Interests
Dr. Fung serves as a consultant for Headspace and owns equity in and receives financial support from Vertex Pharmaceuticals. The other authors report no financial relationships with commercial interests.
Funding Information
This work was supported by a grant from the National Institute on Minority Health and Health Disparities (R01-MD-010456).
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