Individuals with serious mental illness (SMI)—which may include schizophrenia, severe bipolar disorder, and major depressive disorder—and those with severe substance use disorders (SUDs) face greater challenges accessing care and other supportive services needed to thrive. As a result, those with SMI and severe SUDs experience higher rates of incarceration, homelessness, hospitalization, unemployment, and early death than the general population, as well as significant associated economic costs. For example, while individuals with SMI make up 4% of the general population, they represent 25% of the homeless population and on average die 10 to 25 years earlier due to greater difficulty managing other chronic conditions and from suicide. Individuals with severe SUDs face similar challenges: More than 700,000 people have died from an opioid overdose since 1999, at a rate that has been growing steadily each year, costing the United States hundreds of billions of dollars.
However, comprehensive care and support tailored to the unique needs of these individuals help reduce re-hospitalization and recidivism (i.e., re-arrest, re-conviction or return to prison), and increase long-term employment. For example, a study of one such program in New York found that participants’ involvement in education or employment increased from 40% to 80% and hospitalization rates decreased from 70% to 10%. For those people with SMI and SUDs involved in the criminal justice system, alternatives to incarceration and reentry programs often serve as an opportunity to access care when all other attempts have failed. Mental health programs in jails and prisons have been found to reduce recidivism rates by an average of 21%.
Addressing the needs of those with the most serious disorders not only helps save and improve lives, but also significantly reduces the associated economic costs. For funders choosing to implement this strategy, we outline the following four opportunities for action.
Alternatives to Incarceration
Individuals experiencing a mental health crisis are more likely to interact with the police than they are to engage with the healthcare system. Several approaches can reduce involvement with the criminal justice system or direct people to treatment at the earliest possible stage. Crisis intervention team (CIT) programs are a community partnership between law enforcement, Emergency Medical Services professionals and mental health advocates to provide training to those who are often the first responders to a mental health crisis. Other approaches include community-based resources that keep people from engaging with law enforcement, as well as alternative to incarceration (ATI) policies and programs, which provide prosecutors and police with alternatives when interacting with individuals who have mental health disorders or SUDs.
An estimated 83% of incarcerated people with a mental health disorder do not have access to the needed treatment while in jail. Successful reentry begins by providing care during incarceration. It also includes supports that prevent people from returning to prison or jail. Individuals who participated in educational and vocational resources during and after incarceration were shown to be 43% less likely to recidivate. Funders can also support efforts to remove policy barriers that make it more difficult for those with a criminal record to obtain employment, housing, and education.
People with SMI and SUDs often need specialized care at an increased level of intensity and consistency. For those with SMI, this may include coordinated specialty care for first episode psychosis (CSC-FEP), a recovery-oriented program that connects young people experiencing their first episode of psychosis to treatment that focuses on improving mental health and achieving personal goals related to work, school, and social and family relationships. For those with severe SUDs, this may include medication assisted treatment (MAT) or harm reduction programs. MAT is a combination of psychosocial and pharmacological treatment. It is the current best practice to treat opioid use disorder, particularly when offered with other supportive services. Harm reduction programs provide targeted overdose education, naloxone distribution, and needle exchange programs alongside access to care and social services, such as housing.
Comprehensive Support Services
Almost half of homeless adults in shelters have a serious mental health disorder or SUD. Those with serious mental health disorders face unemployment rates up to 45%. Housing and employment provide physical and financial stability that is critical to maintaining participation in treatment programs and supportive relationships. Housing First, a model in which supportive housing is provided without the precondition of sobriety, leads to discontinued substance use, greater participation in job training programs, and fewer days of hospitalization. Supportive employment programs provide financial benefits as well as increased pride, self-esteem, and coping strategies. The clubhouse model is a community mental health approach that provides access to general medical and psychiatric care, wellness activities, social relationships, education and vocational training, employment programs, and connections to housing. Its members are more likely to demonstrate greater independence, report having close friendships, and be employed in longer-tenure jobs.