Race and Incarceration in an Aging Cohort of Vietnam Veterans in Treatment for Post-Traumatic Stress Disorder (PTSD)

Transcription

1 Psychiatr Q (2014) 85:79 89 DOI /s ORIGINAL PAPER Race and Incarceration in an Aging Cohort of Vietnam Veterans in Treatment for Post-Traumatic Stress Disorder (PTSD) Kendell L. Coker Robert Rosenheck Published online: 28 September 2013 Ó Springer Science+Business Media New York 2013 Abstract Cross sectional studies have addressed the incarceration of Vietnam veterans with post-traumatic stress disorder (PTSD), but no studies have examined changes in incarceration as they age. This study examines patterns of incarceration among Vietnam veterans treated in specialized veterans affairs (VA) intensive PTSD programs over time. Data was drawn from admission data from the initial episode of treatment of Caucasian and African American Vietnam veterans entering VA specialized intensive PTSD programs between 1993 and 2011 (N = 31,707). Bivariate correlations and logistic regression were used to examine associations among race and incarceration over time and the potentially confounding influence of demographic and clinical covariates on this relationship. Rates of reported incarceration declined from 63 to 43 %. Over time, African American veterans were 34 % more likely than Caucasian veterans to have a lifetime history of incarceration while interaction analysis showed steeper declines for Caucasians than African Americans. Rates of incarceration among these Vietnam veterans declined as they aged. Furthermore, African American veterans were substantially more likely than Caucasian veterans to have been incarcerated and showed less decline as the cohort aged. While reduced, needs for clinical PTSD services remain among aging combat veterans. Keywords Veterans Incarceration Race PTSD K. L. Coker (&) Forensic Drug Diversion Program (ForDD), Yale University School of Medicine, 1 Long Wharf, Suite 7, New Haven, CT 06511, USA kendell.coker@yale.edu R. Rosenheck VA New England Mental Illness, Research, Education and Clinical Center, 151D, West Haven, CT, USA R. Rosenheck The Child Study Center, Yale Medical School, VA Connecticut Health Care System, New Haven, CT, USA

2 80 Psychiatr Q (2014) 85:79 89 Introduction As of 2007, approximately 12 % of the 2,200,000 Americans incarcerated in jails and prisons were veterans and thousands of veterans are released from jail or prison each year [20]. Many of these veterans have a history of psychiatric or addiction problems. Among incarcerated veterans, those with post-traumatic stress disorder (PTSD) have been found in one study to have significantly more serious legal problems, psychiatric symptoms, worse general health, and more extensive substance use histories than those without PTSD [24]. Longitudinal cohort studies are thus needed to track changing risks and needs of aging veterans. In addition to psychiatric risk factors for incarceration, large discrepancies have been noted in incarceration rates between Caucasian and African American veterans [8, 30]. African American veterans are less likely to be incarcerated than African American nonveterans which may be attributed to the educational and employment opportunities which become available to African Americans as a result of their military experience [10]. On the other hand, Caucasian veterans have higher rates of incarceration than Caucasian nonveterans [10]. Nonetheless, studies have also shown that African American veterans are 2 3 times more likely to be incarcerated than Caucasian veterans [10]. While some studies have demonstrated a direct link between PTSD and incarceration among veterans [12, 33] their service needs related to PTSD may not be readily apparent for many years [11]. Also, veterans who suffer with PTSD often wait years or even decades before deciding to seek mental health treatment [11, 25]. Furthermore among veterans, African Americans are not only at higher risk for incarceration than Caucasians, but also more likely to report delayed onset of PTSD symptoms than Caucasians [16]. While much has been learned cross-sectionally about veteran incarceration, what remains unstudied is the longer term course of the relationship between PTSD and risk of incarceration among combat veterans as they age and whether there are changes in race-related risks of incarceration. Research on incarceration risk among aging cohorts of veterans with PTSD would allow planners to anticipate changing rates and correlates of incarceration as the current group of Middle East veterans ages. Although cross-sectional studies show less incarceration among older veterans [10] incarceration of younger veterans of recent Middle East combat is a growing concern [26]. One recent study revealed that in comparison to incarcerated veterans from other wars, incarcerated veterans of recent Middle East conflicts, while less likely to be incarcerated overall than veterans of other generations, were three times more likely to be diagnosed with combat-related PTSD by veterans affairs (VA) clinicians in a prison outreach program [26]. One way to investigate the long-term course of PTSD and its relationship to incarceration among veterans is to examine data from veterans with PTSD from prior wars such as those in the Vietnam veteran cohort as they age [12, 16]. From 1992 to 2011, VA s Northeast Program Evaluation Center (NEPEC) conducted a nationwide outcomes monitoring program which documented characteristics of veterans admitted into specialized intensive treatment programs for PTSD including inpatient, residential, and day treatment programs [7]. This unique dataset includes information on self-reported history of past incarceration and thus allows for the examination of changing rates of incarceration among a cohort of Vietnam veterans over an 18-year period whose PTSD was severe enough to require hospitalization. This dataset also allows for the exploration of the relationship between race and changes in clinical correlates of incarceration that may account for changes in incarceration risk over time. The current study aims to explore whether incarceration patterns change by cohort year and if there is an association between time and race.

3 Psychiatr Q (2014) 85: Method Participants Data were drawn from administrative evaluation data gathered by VA s NEPEC on all veterans who sought treatment from VA specialized intensive PTSD programs between 1993 and The cohort for the analysis was limited to first time admission assessments of African American and Caucasian Vietnam Veterans (N = 31,707). Measures Measures available from the intensive PTSD program sample addressed traumatic exposure, clinical status, and sociodemographic characteristics such as race (African American or Caucasian), marital status, employment history and status at time of admission, and lifetime reported history of incarceration. Two dichotomous variables inquired into a veteran s exposure to traumatic events: participating in atrocities, and witnessing atrocities with no participation in the atrocities. Variables which assessed clinical status included clinical diagnoses of PTSD and other Axis I and/or Axis II diagnoses, in addition to VA service connected disability for PTSD, VA service connection for a psychiatric disorder other than PTSD, VA service connection for a medical disorder, drug and alcohol use, current medical concerns, and a recent history of violent behavior. Clinical status at admission was measured by the Short Form of the Mississippi Scale for PTSD [5] (range = 15 55) and the NEPEC PTSD Scale [6]. The NEPEC PTSD Scale [6] is a 4-item scale developed for program monitoring in order to assess combat PTSD symptoms such as intrusive thoughts, flashbacks and nightmares, avoiding reminders of the war, numbness and emotional distancing from others, sleep disturbances, irritability, and hyperarousal. Alcohol and drug use were assessed using short versions of the composite indices from the Addiction Severity Index (ASI) [19]. Violent behavior was assessed by averaging 4 items from the National Vietnam Veterans Readjustment Study [14] (range = 0 4). Analyses Data analysis was conducted in three steps and as mentioned previously, was limited to only unique, first time admissions. First logistic regression was used to examine the relationship between race and year of admission to lifetime incarceration. A further analysis added a term representing the interaction of admission year and race to determine if the percentage of new admissions reporting a history of incarceration differed by race according to year. Next a correlation table was examined to identify the bi-variate associations between sociodemographic and clinical status variables with admission year, race, and incarceration to determine which characteristics changed over the years and which variables were associated with race and a reported history of past incarceration. Variables associated with all three factors may account for changing risk of incarceration and for changing relative risks for incarceration among veterans and therefore need to be included as covariates in multivariate analyses. Finally, stepwise logistic regression was used to determine the extent to which changes in clinical presentation over the years may account for the longitudinal

4 82 Psychiatr Q (2014) 85:79 89 pattern changes in the relationship between race and incarceration. In order to control for the inflated family wise error due to the large sample size and number of analyses, a more stringent alpha level of was adopted to test for statistical significance. Results General Characteristics of the Sample The sample consisted of 31,707 veterans (73 % Caucasian and 27 % African American) (Table 1) with declining numbers of admissions from a total of 3,975 in the first two years of the study to only 1,231 in the last two years. The average age was 53.3 years (SD = 5.8), which changed from an average of 47.6 years (SD = 4.8) in 1993 to 62.7 years (SD = 5.9) in Altogether 17,078 (53.9 %) of the sample reported past incarceration at the time of admission. Most veterans reported being either married (39 %) or separated/divorced (44 %). Substance abuse disorders were also quite common among this sample with 41 % having an alcohol abuse/dependency diagnosis and 30 % having a drug abuse/dependency diagnosis. Veteran Incarceration Rates The percentage of veterans in the specialized intensive PTSD program with a history of incarcerated steadily declined between 1993 and 2011 (Fig. 1). More specifically, whereas Table 1 Means and percentages of demographic and baseline variables Variable N % M SD Age 31, Race Caucasian 22, African American 8, Marital status Never married 4, Married 12, Separated/divorced 13, Widowed Years of education Observed or participated in atrocities 20, Psychiatric hospitalization (lifetime) 31, Prescribed psych medication (past 30 days) 26, Violence (lifetime) 9, Currently employed 8, Alcohol abuse/dependency 12, Drug abuse/dependency 9, Personality disorder 2,843 9 Service connected for PTSD 16, Service connected for psychiatric (other than PTSD) 1,262 4

5 Psychiatr Q (2014) 85: Fig. 1 Percentage of veterans incarerated over time. Note: The figure shows the percentage of veterans reporting a history of incarceration each year. The graph shows a reduction in the number of veterans in the study over time. The green bar represents African American veterans, the purple bar represents Caucasian veterans, and the red bar represents the percentage of total veterans (African Americans and Caucasians) reporting a history of incarceration. Although the rates of incarceration generally decline, the reduction is less for African American veterans as many as 63 % of the 1993 first-time admission cohort reported a history of incarceration, only 43 % of the 2011 first time admission cohort reported a history of incarceration. In 1993 the percentage of Caucasian veterans reporting a lifetime history of incarceration was 61 % compared to 68 % of African Americans. By 2011 only 33 % of Caucasians reported a lifetime history of incarceration (a decline of 28 %) as contrasted with 59 % of African Americans (a decline of only 9 %). In order to determine whether the incarceration trends were the result of changes in patterns of reporting, data from a subgroup of 7,520 veterans who had a subsequent episode of intensive PTSD treatment averaging 3.1 years (SD = 2.8 years) after their first admission was analyzed. The results revealed no significant change from one admission to the other in the proportion of veterans who reported a history of incarceration (57.1 % vs %; v 2 = 1.4, p = 0.237). Thus, the aforementioned changes in incarceration rates are not likely to be a reporting artifact. Racial and Clinical Correlates of Incarceration Logistic regression showed that year of admission and race was both significantly and independently associated with lifetime history of incarceration. Over the entire time period, the likelihood of this population of veterans having a prior history of incarceration declined steadily by 6 % per year (odds ratio = 0.937; 95 % confidence interval (95 % CI) = ; wald v 2 = , p \ ). Also over the entire time period, Caucasian veterans were 34 % less likely than African American veterans to have a history of incarceration (odds ratio = 0.663; 95 % CI = ; wald v 2 = 250.3, p \ ). The addition of the interaction term between admission year and race revealed that in comparison to African Americans, each year the likelihood of

6 84 Psychiatr Q (2014) 85:79 89 incarceration for Caucasians declined by 4 % (odds ratio = 0.96; 95 % CI = ; wald v 2 = 49.9, p \ ). Bi-variate correlation analysis identified several baseline characteristics that changed over time and were significantly associated with both race and incarceration (Table 2). Marital status, combat related PTSD, prior psychiatric hospitalization, and education level all significantly changed over time and were associated with race and history of incarceration. However, neither participation in atrocities (r = 0.007, p \ 0.262) nor being prescribed psychiatric medication in the past 30 days (r = 0.009, p \ 0.082) were significantly correlated with race. Stepwise logistic regression of incarceration including baseline variables significantly related to race and incarceration on bivariate analysis (identified in Table 3) showed several significant covariate effects. The 12 variables that were significant in the stepwise model were admission year, race, recent employment, marital status (including separation/ divorce), combat-related PTSD, history of violence, psychiatric hospitalization, psychiatric outpatient treatment, recent drug use, participation in atrocities, and level of education (Table 3). With these covariates in the model, the likelihood of incarceration independent of other factors declined by only 1 % per year (odds ratio = 0.987; 95 % CI = ; wald v 2 = 17.89, p \ ) and Caucasian veterans were 18 % less likely than African American veterans to have a lifetime history of incarceration (odds ratio = 0.816; 95 % CI = ; wald v 2 = 41.49, p \ ). Thus, the model controlling for potentially explanatory baseline covariates reduced the likelihood of incarceration each year from 6 to 1 % and the racial disparity in lifetime risk of incarceration reduced from 34 to 18 %. When the interaction term of race and admission year was added to the covariates that were significant in the stepwise logistic regression, there was no change in the strength of the interaction which continued to show a 4 % greater decline in risk of incarceration for Table 2 Baseline characteristics bivariate correlations with admission year, race, and history of incarceration Variable Admission year Race Ever incarcerated 1. Admission year -0.03* -0.14* 2. Race (Caucasian = 1; African American = 0) -0.11* 3. Ever incarcerated 4. Currently employed 0.18* 0.21* -0.29* 5. Married 0.12* 0.10* -0.23* 6. Separated/divorce -0.12* -0.06* 0.20* 7. Violence (lifetime) -0.20* -0.06* 0.14* 8. Drug abuse/dependency -0.15* -0.12* 0.15* 9. Medical problems Combat-related PTSD diagnosis -0.16* 0.03* 0.09* 11. Observed or participated in atrocities -0.28* * 12. Psych hospitalization (lifetime) -0.12* -0.03* 0.24* 13. Outpatient psych treatment (lifetime) * 0.06* 14. Prescribed psychotropic medication (past 30 days) 0.11* * 15. Years of education 0.06* 0.05* -0.11* Note Correlations marked with an asterisk (*) were significant at p \

7 Psychiatr Q (2014) 85: Table 3 Logistic stepwise regression model predicting any history of incarceration Variable a Odds ratio Wald v 2 p Admission year \ Race (Caucasian = 1; African American = 0) \ Currently employed \ Married \ Separated/divorce \ Combat-related PTSD \ Violence (lifetime) \ Drug abuse/dependency Medical problems Observed or participated in atrocities \ Psych hospitalization (lifetime) \ Outpatient psych treatment (lifetime) Prescribed psychotropic medication (past 30 days) Years of education \ a N = (31,707) Caucasian veterans than for African American veterans (odds ratio = 0.96; 95 % CI = ; wald v 2 = 41.0, p \ ). The Wald v 2 instead of the odds ratios from the logistic regression was used to determine the strength of the covariates because the measures used are on different scales. The covariates with the most influential effects were recent employment (wald v 2 = , p \ ) and lifetime history of psychiatric hospitalization (wald v 2 = , p \ ). Additional covariates which reduced the main effects were observed or participated in atrocities (wald v 2 = , p \ ), years of education (wald v 2 = , p \ ), being married (wald v 2 = , p \ ), and history of violence (wald v 2 = , p \ ). Discussion This study examined trends in reported history of incarceration of an aging cohort of Vietnam veterans admitted for the first time to specialized VA intensive PTSD programs over an 18-year period with special attention to changes in the relationship between incarceration and race. The veterans in this study had PTSD severe enough to warrant inpatient, residential or day hospital treatment. As the cohort aged, the numbers admitted to these treatment programs declined. Similarly, the data revealed that over time these Vietnam veterans were less likely to have a history of prior incarceration. This is consistent with prior studies which show that the likelihood of psychiatric hospitalization declines with age [15] as does the risk of arrest and imprisonment [1, 17]. Nonetheless, on average even in 2011, over 40 % of the veterans hospitalized for PTSD in this study reported a history of incarceration [9]. The covariates with the strongest effects were recent employment status and a history of psychiatric hospitalizations. Studies have shown that among hospitalized veterans, it was not uncommon for them to report a history of incarceration [4]. This is concerning because

8 86 Psychiatr Q (2014) 85:79 89 incarceration can exacerbate mental illness and have long term effects on the individual. Employment has also been found in other studies to be a significant protective factor against incarceration [9, 31]. The social support and financial stability that individuals gain from employment shift the risks and rewards related to criminal behavior thereby reducing the likelihood of incarceration [22]. As this cohort of veterans with severe PTSD aged, their likelihood of incarceration declined yet, strong racial patterns persisted. The current study was all unique, first time admissions and none of the participants were duplicate or multiple admissions. Nonetheless, the patterns of reported history of incarceration from these multiple cohorts over time was not an artifact of reporting differences because follow up analysis on an additional sample, as mentioned in the results, revealed their incarceration reporting patterns were consistent among veterans with multiple admissions several years apart. Rates of incarceration remained greater for African American veterans than Caucasian veterans throughout the period of the study. By 2011, 33 % of Caucasian veterans admitted for the first time to these specialized intensive PTSD programs reported a lifetime history of incarceration (a decline of 28 % from 1993) in comparison with 59 % of African American veterans (a decline of only 9 %). Overall, African American veterans were 34 % more likely than Caucasian veterans to have a lifetime history of incarceration. Even after accounting for many potential confounding covariates, African American veterans were still 18 % more likely than Caucasian veterans to have a reported history of incarceration over the nearly 20 years of this study. Thus, although covariates such as history of psychiatric hospitalizations, employment, being married, and education had a significant association with the likelihood of incarceration rates as shown in other studies, these have a greater protective effect for Caucasian veterans than for African American veterans [9, 22, 32]. This does not necessarily mean that changes in these covariates are the cause of the racial differences and declines in incarceration rates. But rather that these covariates could potentially have a strong influential effect. Other studies have also shown that over the life course, African American men are significantly more likely to be incarcerated than Caucasian men [31]. Since this racial disparity in incarceration continues to exist despite controlling for these many other factors, it cannot be fully explained by them. Some of the factors which may account for the African American veterans having higher rates of incarceration than Caucasian veterans despite controlling for multiple covariates may be due to marginalization and differential treatment of African Americans by police and the courts [2, 23]. Although African Americans do not commit offenses at higher rates than other races, studies have shown that police officers carry out their duties differently with minorities than with Caucasians and disproportionately arrest and detain African Americans who fit generalized descriptions of suspects [3, 29]. Studies also clearly demonstrate that African Americans are incarcerated at higher rates than Caucasians for the same offenses [29]. A U.S. Sentencing Commission report found that African Americans are even offered sentencing plea bargains less often than Caucasians [18]. Because African Americans are disproportionately represented at arrest, and prosecutorial discretion to bring charges is often exercised to the detriment of minorities, [29] they may have longer or more serious prior criminal records which further perpetuate their disadvantage in the legal system [3]. Thus, much of the racial disparities in incarceration rates appear to be a reflection of differential criminal justice system behavior at several major decision points and these seem to affect African American veterans of military service as they do other African Americans. Regardless of the racial disparities, it becomes apparent that many veterans re-integrating into the community after a period of incarceration are likely to benefit from support

9 Psychiatr Q (2014) 85: services and mental health, and especially substance abuse treatment [21]. Fortunately, the VA has been aware of this problem and actively engaged in nationwide efforts to meet the needs of veterans being released from prisons [13]. Nonetheless, there remains much to learn about finding the best ways to address the needs of veterans with severe PTSD in order to attenuate their risks of incarceration. This study had several potential limitations. The data presented in this paper is based on self-reporting experiences of incarceration which have not been independently validated. Also, while this study informs the literature about veterans with severe PTSD requiring specialized intensive treatment, there are many more veterans with a history of incarceration and PTSD who are treated exclusively as outpatients. The generalizability of these data to that larger group of veterans is unknown. This paper is based on the assumption that veterans hospitalized due to suffering from severe PTSD are generally representative of the larger population of aging Vietnam veterans with severe trauma who served during wartime. This assumption is, in part, based on the fact that this study consisted of a large sample size and each case is an independent first episode of hospitalization from the aging cohort. Also, no data was available on the charges for which these veterans were incarcerated or the exact dates of their incarceration. It may be possible that the decline in incarceration rates may be due to some veterans serving longer prison sentences. However, research shows that less than one percent of Vietnam aged veterans were incarcerated in 2000 and the decline in these rates among the aging veteran population has been fairly consistent over the past decade [8, 27, 28]. This lends evidence to support the position that the decline in incarceration rates shown in this paper may not necessarily function as an artifact of veterans not seeking treatment because some of them are serving longer prison sentences nor an artifact of any changes in veterans tendency or willingness to report incarceration history as they age. Conclusions Despite the limitations, this large study adds to the existing literature on incarceration and PTSD among veterans. This study revealed that strong racial disparities in incarceration persist among aging Vietnam veterans entering intensive treatment for PTSD over a period of nearly 20 years even after accounting for multiple potential confounding variables. Hopefully studies such as this will allow empirically based anticipation of the needs of veterans returning from recent conflicts as they get older and the role that race plays in their risk of incarceration over time in light of the racial disparities which continue to exist in the criminal justice system. References 1. Aday RH, Krabill JJ: Older and geriatric offenders: critical issues for the 21st century. In: Gideon L (Ed): Special Needs of Offenders in Correctional Institutions. Thousand Oaks, CA, Sage, Alexander M: The New Jim Crow. New York, The New Press, Banks C: Criminal Justice Ethics: Theory and Practice. Thousand Oaks, CA, Sage, Copeland LA, Miller AL, Welsh DE, McCarthy JF, Zeber JE, Kilbourne AM: Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder. American Journal of Public Health 99: , 2009

10 88 Psychiatr Q (2014) 85: Fontana A, Rosenheck RA: A short form of the Mississippi scale for measuring change in combatrelated PTSD. Journal of Traumatic Stress 7: , Fontana A, Rosenheck RA: Outcome monitoring of VA Specialized Intensive PTSD Programs: Fiscal Year 1996 Report. Northeast Program Evaluation Center, West Haven (CT), Fontana A, Rosenheck RA: Treatment-seeking veterans of Iraq and Afghanistan Comparison with veterans of previous wars. Journal of Nervous and Mental Disease 196: , Greenberg GA, Rosenheck RA: Incarceration among male veterans: relative risk of imprisonment and differences between veteran and nonveteran inmates. International Journal of Offender Therapy and Comparative Criminology 56: , Greenberg GA, Rosenheck RA: Mental health and other risk factors for jail incarceration among male veterans. Psychiatric Quarterly 80:41 53, Greenberg GA, Rosenheck RA, Desai R: Risk of incarceration among male veterans and non-veterans: are veterans of the All Volunteer Force at greater risk? Armed Forces & Society 33: , Hermes ED, Rosenheck RA, Desai R, Fontana AF: Recent trends in the treatment of post-traumatic stress disorder and other mental disorders. Psychiatric Services 63: , Institute for Veteran Policy: Veterans and criminal justice: a review of the literature. Swords to Plowshares. Retrieved from Criminal-Justic-Literature-Review.pdf, Kopera-Frye K, Harrison MT, Iribarne J, Dampsey E, Adams M, Grabreck T, McMullen T, Peak K, McCown WG, Harrison WO: Veterans aging in place behind bars: A structured living program that works. Psychological Services 10:79 86, Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS: Trauma and the Vietnam War generation: report of findings from the national Vietnam veterans readjustment study. New York, Brunner/Mazel, Lay B, Rössler W: Psychiatric hospitalisation across the lifespan. Neuropsychiatrie 25:67 74, Lindman C, Engdahl B, Frazier P: A longitudinal and retrospective study of PTSD among older prisoners of war. American Journal of Psychiatry 158: , Long LM: A study of arrests of older offenders: trends and patterns. Journal of Crime and Justice 15: , Mauer M: Race to Incarcerate. New York, The New Press, McClellan AT, Luborsky L, Cacciola J, Griffith J, Evans F, Barr HL, O Brien CP: New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Disease 173: , McGuire J: Closing a front door to homelessness among veterans. Journal of Primary Prevention 28: , McGuire J, Rosenheck RA, Kasprow WJ: Health status, service use, and costs among veterans receiving outreach services in jail or community settings. Psychiatric Services 54: , Pettit B, Lyons CJ: Incarceration, employment, and wages over the life course. Law & Society Review 43: , Pettit B, Western B: Mass imprisonment and the life course: race and class inequality in U.S. incarceration. American Sociological Review 69: , Saxon AJ, Davis TM, Sloan KL, McKnight KM, McFall ME, Kivlahan DR: Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans. Psychiatric Services 52: , Sayer NA, Clothier B, Spoont M, Nelson DB: Use of mental health treatment among veterans filing claims for post-traumatic stress disorder. Journal of Traumatic Stress 20:15 25, Tsai J, Rosenheck RA, Kasprow W, McGuire JW: Risk and characteristics of incarcerated veterans in a national sample: Comparison between veterans who served in Iraq and Afghanistan and other veterans. Psychiatric Services 64:36 43, U.S. Dept. of Justice, Bureau of Justice Statistics: Survey of inmates in local jails, Conducted by U.S. Dept. of Commerce, Bureau of the Census. ICPSR04359-v2. Ann Arbor, MI, Inter-university Consortium for Political and Social Research [producer and distributor] gov/bjs/otdc.html Accessed 10 Nov U.S. Dept. of Justice, Bureau of Justice Statistics: Survey of inmates in state and federal correctional facilities, Conducted by U.S. Dept. of Commerce, Bureau of the Census. ICPSR04572-v1. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [producer and distributor] Accessed 5 April Weich R, Angulo C: Racial disparities in the American criminal justice system. In Piche DM, Taylor WL, Reed RA (Eds): Rights at Risk: Equality in an Age of Terrorism. Citizen s Commission on Civil Rights: Washington, D.C., 2002

11 Psychiatr Q (2014) 85: Western B: Punishment and Inequality in America. New York, Russell Sage Foundation, Western B, Kleykamp M, Rosenfeld J: Crime, punishment, and American inequality. In Neckerman KM (Ed): Social Inequality. New York, Russell Sage Foundation, Williams BA, McGuire J, Lindsay RG, Baillargeon J, Cenzer IS, Lee SJ, Kushel M: Coming home: health status and homelessness risk of older pre-release prisoners. Journal of General Internal Medicine 25: , Wortzel HS, Blatchford P, Conner L, Adler LE, Binswanger IA: Risk of death for veterans on release from prison. Journal of the American Academy of Psychiatry & the Law 40: , 2012 Author Biographies Kendell L. Coker, PhD, JD is a Postdoctoral Fellow at Yale University in the Division of Substance Abuse. He works at the Forensic Drug Diversion Program (ForDD) and his research interests include violence, substance use, and racial disparities in juvenile justice and in the adult criminal justice system. Robert Rosenheck, MD is a Senior Investigator at the VA New England Mental Illness Research and Education Center and Professor of Psychiatry and Public Health at Yale University Medical School s Child Study Center where he is also Director of the Division of Mental Health Services and Outcomes Research in the Department of Psychiatry. His research interests include homelessness, veterans, Post-Traumatic Stress Disorder, and cost-effectiveness analysis.