Arrest Rates Among Young Adult Psychiatric Patients Treated in Inpatient and Outpatient Settings William R. Holcomb, Ph.D., M.P.A. Paul R. Ahr, Ph.D., M.P.A. Within a statewide random sampie of 61 1 young adult patients who received public inpatient, outpatient, and community residential care, 38 percent were f ound to have been arrested at least once in their adult lifetimes. Thirty-five percent bad been arrested for felonies and 18.9 percent for violent crimes. Analyses byfive major diagnostic groups showed that patients with a primary diagnosis of drug or alcohol abuse bad the greatest overall frequency of arrests and also the greatest frequency of arrests for burglary, offenses against public order such as peace disturbance or loitering, and probation and parole violations. No significant differences between diagnostic groups were found for arrests for violent crimes. Characteristics that predicted which patients would be arrested in the year after receiving mental health services were a greater number oflifetimefelony arrests, Dr. Holcomb is coordinator of treatment services at the Mid- Missouri Mental Health Center, 3 Hospital Drive, Columbia, Missouri 65201. Dr. Ahr is president of Altenahr Group, Ltd., in St. Louis; formerly he was director of the Missouri Department of Mental Health. The woik was partly supported by National Institute of Mental Health grant MH38876. younger age, being black or a member of another minority group, and more years since first receiving public mental health care. The prevalence of criminal behavior among psychiatric patients is a major concern to mental health and criminal justice professionals and the community. Arrest rates have been found to be higher for those who have a history of mental health care than for the general population (1). It has been argued that the inadequacy of community resources for psychiatric patients together with the decrease of psychiatric beds is contributing to diversion of the mentally ill to the criminal justice system (2-4). Another major issue is the treatment of people who are mentally ill but who find themselves incarcerated in jails and prisons (5,6). Several shortcomings have been identified in previous efforts to determine the prevalence of criminal behavior among the mentally ill. Many studies looking at arrest records of the mentally ill have examined patients released from state hospitals and therefore may not be representative of people who have major psychiatric illnesses but have not been in state hospimis (7). Published studies have examined selected populations from New York (8,9) and California (10) that probably differ from other states populations on such key variables as degree of urbanization or public support of the mental health and criminal justice systems. Little research has been conducted on the frequency of arrests among random samples of patients treated in both inpatient and outpatient settings in a large geographic region. Even though the literature on young adult chronic patients has indicated a high frequency of arrests for this group (1 1), few data exist to verify the reported tendency toward criminal behavior. This paper reports an investigation of arrest histories of a random sample of all young adult psychiatnc patients who received public mental health services in the state of Missouri in calendar year 1982. As part of a larger study, all stateoperated institutions and not-forprofit community mental health centers (CMHCs) receiving state funds were sampled. The purposes of the study reported here were to determine the prevalence of criminal behavior among a statewide sample of young adult patients with major psychiatric diagnoses who were treated in both outpatient and inpatient settings and to identify factors contributing to a- rests. Method The Missouri State Dep#{225}rtthent of Mental Health maintaills a statewide computerized management information system that records all patient admissions to inpatient, outpatient, and community residential care. As part of a largescale study of young adult patients in the state, the system was used to select a random sample of 611 subjects from all patients receiving public psychiatric services during calendar year 1982 (a pool of 32,000 patients) who had one of five major diagnoses and who were 52 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry
between the ages of 18 and 35 years (N 7,800). The diagnostic criteria were based on the literature on young adult chronic patients, which indicates that generally patients in this population have a primary diagnosis ofdrug or alcohol abuse, schizophrenia or other psychosis, major affective disorder, personality disorder, or organic brain syndrome (12). The age criterion is the one most commonly used to define young adult chronic patients. Further data for the sample were gathered through a review of medical records of all 611 subjects. Sample characteristics. The average age of the 61 1 subjects was 27 years. Sixty-eight percent were white, and 32 percent were black or members of other minorities. Seventy percent were male. Eighty-one percent were unemployed at the time of admission in 1982, and only 15.2 percent were married. During the study year, 5 1 percent were psychiatric inpatients at their last contact with the public mental health system, 47 percent were outpatients, and 1.7 percent were admitted to community residential facilities. On the average, subjects had 3.27 prior psychiatric inpatient admissions. Thirty-four percent were receiving care from one of 1 2 private, not-for-profit CMHCs, and 66 percent from one of eight state-operated facilities. Variables examined. A complete history of all arrests of each patient was obtained from the Missouri Highway Patrol Department, which maintains a computerized record ofall arrests both within the state and from all other states. Monahan and Steadman (7) have argued that arrests rather than convictions should be used to estimate the true prevalence of criminal behavior. Even though arrests as an index of true criminal behavior may be questioned, it has been found that arrested persons are, as a group, responsible for the majority of the crimes committed (7) and also that the large majority of those arrested for crimes did, in fact, commit the crimes for which they were arrested (1 3). Arrests were divided into 1 3 categories based upon the type of offense allegedly committed: murder and first-degree assault (assault with intent to kill); second- and third-degree assault, kidnapping, and all weapons charges; violent sex offenses (for example, rape, sodomy, and sexual abuse); nonviolent sex offenses (such as sexual misconduct, indecent exposure, and prostitution); offenses against family (for example, criminal nonsupport and contributing to the delinquency of a child); robbery; burglary, fraud, and theft; offenses against public order (such as peace disturbance, littering, and loitering); offenses against administration of justice (such as false reports and resisting arrest); drug- and alcohol-related offenses (for instance, possession of a controlled substance and driving while intoxicated); probation and parole violations; traffic violations; and other offenses. For further analyses, the first three categories (including murder and first-degree assault, secondand third-degree assault, and violent sex offenses) were combined with robbery into a violent-crime group; all other arrests were grouped as nonviolent offenses. In addition, each arrest was rated as being either a misdemeanor or a felony arrest. A key variable in relating mental illness to criminal behavior is the subject s level of functioning. Ratings of functioning were obtained from the direct-care clinician (whether outpatient therapist, physician, or case manager) who was most familiar with the patient; the clinicians were identified through a review of medical records of all facilities. The clinician was asked to rate the patient s functioning at his last contact with the service system using the axis V level-offunctioning scale of DSM-I1I. If the patient was in the clinician s current caseload, the clinician was asked to rate the current level of functioning. Clinicians also were asked to rate the patient s future need for treatment after discharge on a scale of 1, little or none, to 7, will need a great deal of help. One hundred sixty-seven of the forms (27 percent) were returned uncompleted because the directcare clinician could not recall the patient well enough; for example, some subjects were seen only briefly in an emergency room. Sixty-two forms (1 1 percent) were returned because the clinician was no longer employed at the facility, and 55 forms (9 percent) were not returned. Thus ratings were obtamed for 327 patients, or 53 percent of the total sample. Analysis. The relationship between numerous demographic and mental illness variables (such as DSM-lII diagnosis) and frequency of adult arrests was explored with chi square analysis and correlation coefficients. Logistic multiple regression was used to compare patients with and without histories of arrest. Multiple regression was also used to predict who would commit crimes within one year after receiving public mental health services. Results Thirty-eight percent of the sample were arrested at least once in their adult lifetimes, with 21 percent arrested on felony charges, 3.5 percent on misdemeanor charges, and 14 percent on both. When crimes were grouped into violent crimes against persons and nonviolent crimes, the data showed that 19 percent of the sample committed only nonviolent crimes, 4.4 percent committed only violent crimes, and 14.5 percent committed both violent and nonviolent crimes. Overall, the 61 1 patients were charged with a total of 1,412 crimes in their adult lifetimes, or 989 felony arrests and 423 misdemeanor arrests. Table 1 shows the frequency of arrests in the 1 3 categories of offenses. In terms of arrests for felonies and misdemeanors, noteworthy differences were found by diagnosis (2=26.13, df=12, p=.0l), as Hospital and Community Psychiatry January 1988 Vol. 39 No. 1 53
Table I Types of charges on which 61 1 young adult patients were arrested N of per- N of sons with arrests N of % of multiple Type of charge (N= 1,412) persons persons arrests Murder and first-degree assault 78 44 7.0 18 Other assault, kidnapping, weapons charges 66 44 7.0 12 Violent sex offenses 26 19 3.0 4 Nonviolent sex offenses 30 1 1 2.0 4 Offenses against family 5 5.8 0 Robbery 87 42 7.0 18 Burglary, fraud, theft 642 169 28.0 111 Offenses against public order 49 29 5.0 8 Offenses against administration ofjustice 175 49 8.0 14 Drug- and alcohol-related offenses 184 86 14.0 40 Probation and parole violations 28 22 4.0 3 Traffic violations 39 24 4.0 11 Other 3 2.3 2 Table 2 shows. Overall, patients with primary diagnoses of alcohol and drug abuse were more likely to be arrested for crimes than patients in the other four diagnostic groups in this study; 47 percent of alcohol and drug abuse patients were arrested, compared with 32 percent of patients with all other diagnoses combined (x2 14.3, df=1, p=.oo1). Arrest rates for the other groups were 46 percent for patients with organic brain syndrome, 40 percent for those with personality disorder, 32 percent for patients with major affective disorder, and 28 percent for patients with schizophrenia or other psychosis. It is notable that overall arrest rates for alcohol and drug abuse patients and patients with organic brain syndrome were almost identical. As for arrests for felony crimes (shown by the categories of febonies only and felonies and misdemeanors in Table 2), alcohol and drug abuse patients were almost twice as likely as patients with schizophrenia or other psychosis to be arrested on felony charges, with totals of 42. 1 percent compared with 25.4 percent (x2 13.5, df= 1, p=.oo1). Alcohol and drug abuse patients also were considerably more likely to be arrested on felony charges than patients with major affective disorders (24.8, df=1, p=.ol). Table 3 presents data for arrests for violent and nonviolent crimes by primary diagnosis. Twenty-two percent of alcohol and drug abusers and 23. 1 percent of patients with organic brain syndrome were arrested for violent crimes against persons, compared with 15.6 percent of schizophrenic patients, 13.3 percent of patients with major affective disorders, and 20.4 percent of patients with personality disorders. However, none of these comparisons reached statistical significance. To better describe the patterns of arrests for criminal activity of young mental patients, different categories of arrests were exammed by diagnoses. There were no significant statistical differences among the five diagnostic groups in frequency of arrests for any of the types of violent crimes (such as murder, assault, and sexual violence), for nonviolent sex crimes, or for offenses against family or offenses against the administration of justice. On the other hand, diagnostic groups did differ significantby on frequency of arrests for the category of burglary, fraud, or theft; patients with alcohol or drug abuse diagnoses were more likely than other groups to be arrested for these crimes (2=7.3, df= 1, p=.oo7), and patients with schizophrenia or other psychosis were less likely (212.8, dfl, p=.0003). Contrary to expectations, patients with schizophrenia or other psychosis were also less likely to be arrested for offenses against public order, such as peace disturbance, littering, or loitering (24.15, df=1, p=.o4). However, alcohol and drug abusers were more likely than all other diagnostic groups combined to be arrested for these offenses (2816 df=1, p=.oo4). As expected, alcohol and drug abusers were more likely than all Table 2 Arrests for felonies and misdemeanors among 6 1 1 young adult patients, by diagnosis Alcohol, Schizo- Major affec- Personality Organic brain drug abuse phrenia tive disorder disorder syndrome (N=254) (N=193) (N=75) (N=59) (N=26) Category N % N % N % N % N % Felonies and misdemeanors 47 18.5 18 9.3 5 6.7 8 13.6 7 26.9 Feloniesonly 60 23.6 31 16.1 16 21.3 14 23.7 4 15.4 Misdemeanors only 12 4.7 3 1.6 3 4.0 2 3.4 1 3.8 Nocrime 135 53.2 141 73.1 51 68.0 35 59.3 14 53.9 54 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry
Table 3 Arrests for violent and nonviolent crimes among 61 1 young adult patients,by diagnosis Alcohol, Schizo- Major altec- Personality Organic brain drug abuse phrenia tive disorder disorder syndrome (N=254) (N=193) (N=75) (N=59) (N=26) Category N % N % N % N % N % Violent and nonviolent 46 18.1 20 10.4 9 12.0 8 13.6 5 19.2 Violentonly 11 4.3 10 5.2 1 1.3 4 6.8 1 3.9 Nonviolent only 62 24.4 22 11.4 14 18.7 12 20.3 6 23.1 Nocrime 135 53.15 141 73.1 51 68.0 35 59.3 14 53.9 other diagnostic groups combined to be arrested for drug- and alcohol-related offenses such as possession of controlled substances and driving while intoxicated (2816 df=1, p=.0004). Interestingly, patients with a primary diagnosis of organic brain syndrome also were arrested for significantly more alcohol- and drugrelated offenses in comparison with all other diagnostic groups (29.58, df=1, p=.oo2). Groups significantly less likely to be arrested for these offenses were patients with schizophrenia (213.4, df= 1, p=.0004) and major altective disorders (27.1, dfl, p=.oofl. Finally, alcohol and drug abuse patients were much more likely than all other subjects combined to be arrested for probation and parole violations (x2 10.54, df 1, p=.oo1). Again, patients with schizophrenia or other psychosis were significantly less likely to be arrested for these offenses (29 df=1, p=.025). The relationships of various demographic and mental health variables to the 1 3 specific arrest categories were examined with correlation coefficients. In general, very few significant correlations emerged. Noticeably, arrest categories were not significantly correlated with race, sex, educational level, whether the subject was employed, early family history variables, and a history of mental illness in the immediate family. In addition, few significant correlations were found between service utilization variables (such as number of inpatient admissions and inpatient days in the year after the study year) and criminal activity. However, low level of functioning, as indicated by clinicians ratings on axis V, was related to a- rests for first-degree assault (r.28, p=.0o2), burglary (r.27, p=.o03), and felony crimes in general (r.29, p=.o0l), and it was marginally related to arrests for offenses against public order (r.19, p.o4), offenses against the administration of justice (r.19, p.o 4), and violent crimes in general (r.17, p.o5). The greater the need for future treatment, as rated by clinicians on the 7-point scale, the more likely the patients were to be arrested for assault (r=.24, p=.oo9). To explore differences between patients who had a history of arrest and patients who had none, a stepwise logistic multiple regression analysis was used (14). This procedure employs a maximum-likelihood approach to best fit the multiple regression model to a single dichotomous dependent variable (whether patients had been arrested). The 19 independent variables Table 4 Summary of multiple regression analysis describing young adult patients with and without histories of arrests Variable Beta p Age when psychiatric problems began 0.04.001 Alcohol or drug abuse diagnosis (yes 1, no=0) -0.59.02 Years since first receiving public mental health care -0.23.0008 Involuntary commitment on last admission (yes 1, noo) - 1.09.002 From a more urban county -0.01.003 Nonschizophrenic diagnosis (yes 1, noo) 0.69.024 Intercept 1.10 R=.27 used were degree of urbanization of the patient s home county according to the 1980 census, age, race, sex, employment status, number of inpatient admissions in the last five years, number of inpatient admissions in the last two years, number of inpatient admissions in 1983 (the year after the study year), number of inpatient days in 1983, age when psychiatric problems began, yeas since first receiving public mental health care, the five diagnoses, whether the patient was involuntarily committed on the last inpatient admission, whether the patient was an inpatient or outpatient at time of sample selection, and whether the patient was treated at a state facility or private CMHC receiving state funds. The analysis identified six variables that, when combined, best described patients with and without histories of arrests (see Table 4). Compared with patients with no history of arrests, patients who had an arrest history tended to have first experienced psychiatric problems later in life even though they Hospital and Community Psychiatry January 1988 Vol. 39 No. 1 55
Table 5 Summary of multiple regression analysis predicting young adult patients who would and would not be arrested within one year after receiving psychiatric services Variable Beta p Number of lifetime felony arrests -.32.000 Age.14.000 Race (white 1, black or other minority=0) -.98.006 Years since first receiving public mental health care.31.025 Intercept -.86 R=.51 had longer histories ofpublic mental health care. They were more likely to have a diagnosis of alcohol or drug abuse and less likely to have a diagnosis of schizophrenia OE other psychosis. In addition, they tended to have been involuntarily committed on their last inpatient admission and were more likely to come from a more urban county. However, this model was abbe to account for only 7 percent of the variance. Another analysis was aimed at identifying patients who are at risk for later criminal behavior. State highway patrol information was used to identify patients who were arrested within one year after their last admission to Missouri public mental health services in 1982. Fifty-two patients (8. 5 percent of the sample) were identified. A total of 164 arrests were recorded for the group. The most frequent charge was stealing (26 arrests), followed by second-degree burglary (24 a- rests), first-degree burglary (16), forgery (eight), and carrying a concealed weapon (eight). Seventyfour arrests were for minor offenses such as trespassing or failure to appear to answer a summons. There were three arrests for second-degree assault, two for assault with intent to kill, two for manslaughter, and one for capital murder. The logistic multiple regression procedure was used to distinguish those who committed crimes after treatment from those who did not. The same independent variables as in the regression analysis were used, with the addition of total number of felony arrests and total number of arrests committed in the subject s adult lifetime. The regression analysis revealed four variables that, when combined, accounted for more than 25 percent of the variance (see Table 5). The variables that were most predictive of arrests after treatment were higher number of lifetime felony arrests, younger age, race (being black or member of another minority), and a greater number of years since first receiving public mental health care. Discussion Thirty-eight percent of this random sample of young adult psychiatric patients had an adult history of criminal arrests, with 35 percent having felony arrests. This rate is considerably below the 5 1 percent arrest rate found earlier for state hospital patients in New York (8,9) and the 5 3 percent for state hospital patients in California (10). The bower rate for the Missouri subjects may be due to the nature of the sample; 47 percent were outpatients when the sample was selected, and 34 percent were seen at private, not-for-profit CMHCs rather than state hospitals. However, because this sample was limited to young adults (ages 18 to 35 years), it probably underestimates the lifetime prevalence of arrests in comparison with samples from New York and California in which a broader age range of patients was studied. When criminal arrests were analyzed by diagnosis, it was found that patients with schizophrenia or other psychosis were less likely than other diagnostic groups to have been arrested for burglaries, offenses against public order, alcohol- and drug-related offenses, or probation and parole violations. On the other hand, patients with a primary diagnosis of alcohol or drug abuse were more likely to have been arrested for offenses in these categories as well as having a larger number of arrests in general. Patients with a primary diagnosis of organic brain syndrome were just as likely to be arrested for alcohol- and drug-related offenses as were patients with a primary diagnosis of alcohol or drug abuse. Six variables were found to be significant in distinguishing young adult patients with and without histories of criminal arrests. Those who were arrested tended to have shorter histories of psychiatric problems but longer histories of care in the public mental health system. A possible explanation for this finding is the recent trend for the public inpatient mental health sector to treat people with criminal histories (7), a trend that may apply to public outpatient services as well. The fact that patients with criminal arrests tend to have shorter psychiatric histories suggests that patients who have more chronic disorders, with onset in childhood or bate adolescence, are not as likely to commit crimes. This view is further substantiated by the study finding that patients with schizophrenia or other psychotic diagnoses tend not to have histories of criminal arrests. This same finding contradicts a popular belief that as a group, young chronic psychiatric patients are likely to be arrested. On the other hand, the diagnosis of alcohol or drug abuse is positively related to a history of criminal a- rests. Alcohol or drug abuse may be a significant catalyst for criminal behavior among young people receiving public mental health services. The finding that patients admitted on an involuntary basis tend to have histories of criminal arrests is not surprising since staff may take arrest histories into consideration when evaluating patients for involuntay admission. Also, according to Missouri law, patients who are brought into the mental health system through involuntary civil commitment must have been judged to be dangerous to self or others by a 56 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry
mental health official. The same characteristics of patients that lead mental health officials to judge a person to be dangerous could also be important decision factors in whether an arrest is made (3). Four significant variables were identified as predictors of future criminal behavior. Clearly the vanable that accounts for the most variance in arrests after treatment is number of previous felony a- rests. Future criminal behavior also was associated with being younger and black or a member of another minority. The finding that young black patients have a greater tendency than young white patients to commit crimes in the year after treatment may indicate a need to look critically at the efficacy of public treatment services for the young black male. The finding that those who tend to commit crimes after treatment have longer histories of public mental health care may be due to the fact that such care is often the last recourse for the high-risk and most volatile young patients. This variable, however, accounted for less than 1 percent of the variance. The results of the study suggest that because past research on arrest records of psychiatric patients has been based on samples of former state hospital patients, the prevalence ofarest records among psychiatric patients has been exaggerated. However, in this study the arrest rate for young psychiatnc patients with severe diagnoses a year after admission to public mental health services, 8.5 percent, is still 1 7 times greater than the a- rest rate for the same-age general population in Missouri,.05 percent (15). Approximately half of all the patients treated by public mental health services in Missouri are between 1 8 and 3 5 years of age. This study underscores the significant percentage of these young people who also become involved in criminal activities. The results argue strongly that public mental health and criminal justice administrators must put a high priority on programs to address the needs of this young adult patient group. The numbers of these young people are too large, and the economic and human-potential costs to the cornmunity are too high, not to do so. The Missouri study sampled patients treated in public mental health services but of necessity excluded those treated in Veterans Administration facilities, private for-profit hospitals, and general hospital psychiatric units as well as people who are mentally ill but have not received psychiatric services. Future epiderniobogical studies of mental illness and criminal arrests should make an effort to include these individuals. References 1. Teplin LA: Criminalizing mental disorder. American Psychologist 39:794-803, 1984 2. BonovitzJC, BonovitzJS: Diversion of the mentally ill into the criminal justice system: the police intervention perspective. American Journal of Psychiatry 138:973-976, 1981 3. Teplin LA: The criminalization of the mentally ill. Psychological Bulletin 94:54-67, 1983 4. Weiner BA: Interfaces between the mental health and criminal justice system: the legal perspective, in Mental Health and Criminal Justice. Edited by Teplin LA. Beverly Hills, Calif, Sage, 1984 5. Lamb HR. Grant RW: The mentally ill in an urban county jail. Archives of General Psychiatry 39:17-22, 1982 6. Hartstone E, Steadman HJ, Robbins PC, et al: Identifying and treating the mentally disordered prison inmate, in Mental Health and Criminal Justice. Edited by Teplin LA. Beverly Hills, Calif, Sage, 1984 7. Monahan J, Steadman HJ: Crime and mental disorder: an epidemiological approach, in Crime and Justice: An Annual Review of Research 4:145-189, 1983 8. Steadman HJ, CocozzaJJ, Meick ME: Explaining the increased arrest rate among mental patients: the changing clientele of state hospitals. American Journal of Psychiatry 135:816-820, 1978 9. Steadman HJ, Vanderwyst D, Ribner 5: Comparing arrest rates of mental patients and criminal offenders. American Journal of Psychiatry 135:1218-1220, 1978 10. Sosowsky L: Crime and violence among mental patients reconsidered in view of the new legal relationships between the state and the mentally ill. American Journal of Psychiatry 135:33-42, 1978 1 1. Pepper B, Ryglewicz H: The young adult chronic patient: a new focus, in The Chronic Mental Patient: Five Years Later. Edited by Talbott JA. Orlando, Fla, Grune & Stratton, 1984 12. Pepper B, Ryglewicz H: Treating the young adult chronic patient: an update. New Directions for Mental Health Services, no 21:5-15, 1984 1 3. Heumann M: Plea Bargaining: The Experience of Prosecutors, Judges, and Defense Attorneys. Chicago, University of Chicago Press, 1978 14. Harrell FE: The logist procedure, in SUGI Supplemental Library User s Guide. Edited byjoyner SP. Cary, NC, SAS Institute, 1983, pp 18 1-222 1 5. Flanagan TJ, van Alstyne DJ, Gottfredson MR (eds): Sourcebook of Criminal Justice Statistics, 1981. Washington, DC, Bureau of Justice Statistics, US Department ofjustice, 1982 Information for H&CP Contributors Hospital and Community Psychiatry reviews material for publication with the understanding that it has not been previously published and is not being reviewed for publication elsewhere. Submit manuscripts (five copies) to the editor, John A. Talbott, M.D., H&CP, American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005. (Phone inquiries, 202-682-6070.) Manuscripts are sent for blind review to at least three independent peer reviewers; the final decision is the editor s. Regular articles should not exceed 3,000 words excluding references and tables. Include a one-paragraph abstract (100 to 150 words). All material, including tables, should be prepared in a typeface that can be read by an electronic scanner; a list of these typefaces appeared in the September issue. Authors identifications must be typed on a separate title page that can be removed when the manuscript is sent for blind review. For additional information, see the September issue or contact the editorial office. Hospital and Community Psychiatry January 1988 VoL 39 No. 1 57