Defendants with intellectual disabilities and mentalhealth diagnoses: faring in a mental health

Compared with defendants without disabilities,defendants with intellectual disabilities (IDs) aremore likely to have low-socioeconomic backgroundsand limited educations, as well as to be unemployed,male and young (Hayes 1996). Furthermore,compared with defendants without IDs,persons with IDs also seem to be incarcerated atgreater rates (Hodgins 1992; Holland et al. 2002).These defendants with IDs may also have cooccurring mental health disorders.To date, weknow little about defendants with co-occurring disorders(IDs and psychiatric disorders), includingtheir prevalence, demographics and treatment options within the criminal justice system. By betterunderstanding these defendants, we can createbetter interventions to decrease their rates of recidivism.

Although rates vary across studies, as many as40% of individuals with IDs may also have mental illness (Dykens 2000). Similarly, within the criminaljustice system, persons with IDs have high rates of mental health needs (Birmingham et al. 1996;Winter et al. 1997; Simpson & Hogg 2001). In one retrospective study, Day (1988) noted that of the 20persons with IDs he studied in the criminal justice system, 30% had concomitant mental illness, 50%had a background of psychosocial deprivation, 85%had a history of serious childhood behaviouralproblems and 50% had a family history of offending.More recently, European studies have examined the co-occurrence of IDs and mental health diagnosesamong defendants across three settings –community, medium/low security prison and high security prison. In high security settings, for example, the prevalence of individuals with cooccurring disorders is strikingly high, with 39.3% of defendants having a personality disorder and IDs(Lindsay et al. 2006).

There may also be important differences between individuals with dual diagnoses and individuals withmental illness alone. For example, individuals withdual diagnoses (vs. individuals with psychiatric diagnoses but without IDs) are less likely to retainemployment and more likely to be subject to socialstigma (Reiss & Benson 1984). In addition, comparedwith individuals with psychiatric diagnosesbut without IDs, individuals with dual diagnoseshad more symptoms of turning-against-others andfewer symptoms of turning-against-themselves,more symptoms related to action rather thanthought, and more hallucinations without delusions(Glick & Zigler 1995).

Having a dual diagnosis may also add to difficultiesin attaining appropriate services. Lying betweentwo spheres of services, one for persons with IDsand the other for persons with mental illness, individualswith dual diagnoses are likely to fallbetween the cracks (Hayes 1996). It may also bedifficult for persons with IDs to receive an accuratediagnosis of co-occurring psychiatric disorders. The lack of appropriately trained diagnosticians andlimited time within the criminal justice system contributeto less sensitive and effective screening for mental illness (Birmingham et al. 1996). Further more,persons with IDs experience recidivism rates that are strikingly high. From 1962 to 1990, withfollow-up periods ranging from 1 to 20 years,reconviction rates for persons with IDs ranged from39% to 72% (Lindsay 2002). These exceedingly high reconviction rates suggest that, when they leavethe criminal justice system, persons with IDs donot have the services and supports they need tostay out of jail.

Begun in theUSAin the late 1990s, mentalhealth courts are specialty criminal courts developed to address the needs of persons with mental illness. Witnessing the inappropriate placement of persons with mental illness in the criminal justice system, Judges Mark A. Speiser and Ginger LernerWren developed the first mental health court in1997. Currently, theUSAhas more than 100 such courts – with over 7500 active defendants (Redlich2005) – and the mental health court system is expanding rapidly. The foremost attribute of mental health courts is their mission to serve persons with mental health diagnoses. Primary characteristics of mental health courts include: (1) uniformity in recognisingthe inappropriate placement of personswith mental illness in the criminal justice systemand the need for this population to receive effectivetreatment and (2) partnership between the criminaljustice system and community mental health providersto ensure these persons receive appropriatetreatment. Defendants who enter the regular criminaljustice system, for example, are generallyreferred to attorneys, assigned money for bond and,depending upon the charge, placed in jail until thecourt hears the case. In contrast, mental healthcourt defendants are usually placed in residential facilities with mental health supports along with a treatment plan. The primary difference between criminal justice and mental health courts concernsthis shift from punishment to treatment. For example, mental health courts may send defendants to outpatient or inpatient facilities to access treatment.Additionally, if a defendant violates parole oris issued another warrant, that defendant may be sent to jail. Jail, however, is the least preferred interventionused with mental health court defendants.

To date, few studies have evaluated the effectivenessof mental health courts; among those that have, findings are often mixed. Using propensityscores to compare defendants with mental illness inSan Francisco’s mental health court as opposed toregular criminal justice system, McNiel & Binder(2007) found that mental health court defendantswent for a longer period of time without incurringany new criminal charges or charges for violentcrimes. Similarly, Trupin & Richards (2003) also found that defendants in the mental health courthad fewer criminal charges and increased treatmentreferrals, with medium to large effect sizes. In contrast,mental health courts may have few effects onthe defendants’ mental health status. Using theBrief Psychiatric Rating Scale, Boothroyd et al.(2005) found no differences between the mentalhealth court and the regular court related to thedefendants’ clinical status, intervention received orinteraction between the intervention and type ofcourt.

In 2000,Davidson County,Tennesseebegan amental health court, the fifth (of 100) in thecountry, to serve individuals with mental healthproblems. Unlike the courts of the regular criminaljustice system, the emphasis ofDavidson CountyMental Health Courtis on treatment rather than punishment. Defendants in the court receive avariety of interventions to address their needs (e.g.psychotropic medications, behaviour analysis, arttherapy). Defendants are generally referred to thecourt by the public defender, private attorney, case manager or probation officer.

In this study, we utilised records fromDavidson County Mental Health Courtto assess the prevalenceof court defendants who have IDs, as well astheir treatments and outcomes. So far, no studies have examined who is in the mental health courtsystem or the effectiveness of the mental healthcourts for individuals with IDs and mental healthdisorders. This study compared defendants with IDs and mental health disorders with defendants with mental illness alone. By examining the courtrecords of defendants, this paper had two goals: (1)to examine the prevalence of defendants with dualdiagnoses in the mental health court and (2) to compare the two groups (individuals with dual diagnoses vs. individuals with mental illness alone)in relation to demographic variables, symptomatology,levels of support available, and interventions and subsequent outcomes.

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