Beyond the Bridge: Evaluating a Novel Mental Health Program in the New York City Jail System

摘要

Objectives. We evaluated Beyond the Bridge, a novel mental health program in the New York City jail system designed to provide residentially based cognitive behavioral therapy in jail mental observation units. Methods. We used propensity score matching and a dose–response analysis. Outcome measures included reduction in violent incidents and fights, reduction in uses of force by corrections officers, reduction in time spent on suicide watch and incidents of self-injurious behavior, and increased length of community survival. Results. There were significant reductions in all outcomes when we compared program participants (n?=?218) with an earlier cohort of patients residing on the mental observation unit before programming began (n?=?413). However, when we compared program participants with a cohort of other patients residing on the units at the same time but who chose not to participate (n?=?267), only time spent on suicide watch unit (rate ratio [RR]?=?0.72; 95% confidence interval [CI]?=?0.59, 0.89) and recidivism (RR?=?0.70; 95% CI?=?0.59,0.83) were significantly reduced. Conclusions. This evaluation and the model we piloted may provide useful information for other settings contemplating similar interventions. The concentration of persons with serious mental illness in jails and prisons is a growing problem for managers of these systems as well as patients who come to be incarcerated. As the proportion of jail and prison inmates with mental illness increases, so too does friction between these patients and the rigid correctional setting in which they are housed. 1 Approximately one third of persons admitted into the New York City jail system become recipients of mental health services while in jail, with one quarter of these patients diagnosed with mental illnesses meeting criteria for serious mental illness. Consequently, between 700 and 1000 of the approximately 12?000 inmates in the New York City jail system have serious mental illness at a given time. Most patients with a serious mental illness designation are housed in dedicated mental observation units (MOUs) that are staffed with specially trained security and mental health professionals. Patients who exhibit psychosis or other symptoms that cannot be effectively managed in these units are transferred to a nearby hospital forensic ward for a higher level of care. In the New York City jail system, the city’s Department of Health and Mental Hygiene’s Bureau of Correctional Health Services is responsible for all aspects of health care for the incarcerated. Security and general custody management in the jail system are the responsibility of the New York City Department of Correction. In 2010, the Bureau of Correctional Health Services designed and implemented a new approach to improve mental health services for patients in the jail’s dedicated mental health units. The broad goals of this program, named Beyond the Bridge, were to bring comprehensive mental health services into the units where these patients reside. Specifically, the program included group therapy, as well as individual encounters with social workers, psychologists, psychiatrists, and discharge planners. The rationale for this new approach was to reengage patients by using an inpatient psychiatric center treatment model while incentivizing patients’ participation and to improve outcomes, including reductions in mental illness symptoms, violence while in jail, and recidivism. The Beyond the Bridge program represents a significant shift in therapeutic treatment of the most acutely mentally ill patients within the New York City jail system. Overall, the goal of this program was to improve outcomes by bringing clinical and therapeutic interventions into housing areas where interactions with clinical personnel would be ongoing, instead of relying on sporadic contact with patients in medical clinics. Most of the patients in the MOUs were identified as having a serious mental illness, and they faced significant challenges in accessing mental health services outside of their housing areas because of lack of acuity, need for security escorts, and lack of continuity of mental health providers. A significant challenge in treating mental illness in jail is the congregate setting in which the treatment occurs. For mentally ill inmates, jail can be a significantly disorienting experience, particularly for those living in dormitories of up to 50 people, all of whom may at certain times be experiencing troubling symptoms, and many of whom have other complicating medical conditions such as epilepsy, drug addiction, or diabetes and may be less compliant with prescribed medication regimens than the population at large. Jail—with little to do every day, and with its many attendant rules and regulations that govern when and where one sleeps, whom one talks with and when, what one wears, and when and what one eats—is an especially challenging place for those who are severely mentally ill. In these condition