Mental health screening refers to the administration of a measure (typically self-report or interview) to offenders entering a criminal justice agency for the purposes of identifying those offenders who have a mental illness. Screening is necessary to ensure that appropriate interventions can be administered or referrals to community resources can be made. This topic is relevant to the field of criminal psychology because it reflects an intersection between clinical psychology (assessment of mental illness) and the criminal justice system (offender population). This article focuses on mental health screening among adult offenders and describes (a) the purposes of mental health screening in various correctional settings, (b) characteristics of effective screening tools, (c) examples of promising screening tools, and (d) considerations for agencies administering these tools.
Purposes of Mental Health Screening
Screening is a first step toward identifying mental illness among offenders. There are a number of specific mental health screening tools, and these vary in the specific types of mental illness they are designed to detect. Some tools focus narrowly on the detection of serious mental illness (i.e., major depression, bipolar disorder, schizophrenia), whereas others seek to detect a broader range of mental illnesses such as post-traumatic stress disorder or personality disorders. Although some mental health screens detect suicide risk or substance abuse problems, not all do—separate screening tools exist for these conditions. Importantly, mental health screening tools do not yield psychiatric diagnoses; rather, they indicate which individuals are in need of further assessment by a mental health professional to determine whether a mental illness is present.
Screening has numerous purposes across different types of correctional agencies. In custodial facilities such as jails and prisons, inmates’ mental illness are typically entitled to mental health treatment. Providing such treatment can additionally reduce the likelihood of disciplinary problems and custodial concerns. Furthermore, some jails operate in jurisdictions that have programs such as mental health courts or other types of diversion programs, and some prisons have units designated for inmates with mental health problems. Screening can be used to identify inmates for all of these purposes.
In community corrections (i.e., probation and parole), mental health treatment is often not provided directly by the corrections agency, but referrals may be made to treatment providers in the community when needed. Such treatment is an important component to effective community supervision because correctional interventions can more effectively address recidivism risk when symptoms of mental illness are effectively managed. Screening is a systematic way to identify offenders who need such treatment. In addition, some community corrections agencies have specialized caseloads for offenders with mental illness; screening is a mechanism to identify offenders who are eligible for these specialized placements.
Characteristics of High-Quality Screening Tools
There are both practical and psychometric features of mental health screening tools that should be evaluated when determining a tool’s utility. Practical features include the format of administration and scoring procedures. Measures may be administered via paper and pencil, by interview, or by computer. Computerized measures are typically self-scoring, although these have been researched relatively less than the other formats. Paper-and-pencil forms may have simple scoring guidelines or may require professional judgment or specialized training to score. Interviews often require some degree of clinical training for staff to administer and score; as such, these may be appropriate only in settings where there is mental health staff. Paper-and-pencil tools may be more appropriate for community corrections settings, given that there may not be staff with mental health training, and these measures’ self-report nature is less demanding on staff time. In all correctional settings, the amount of time needed for an individual to be screened should be taken into account— screens with more items will take longer to administer.
Although there are many mental health screening tools available for use with the general population, screening tools used in correctional settings should be validated specifically for use in those settings to ensure that they adequately detect mental illness among criminal justice populations. This is important because the prevalence of mental illness is higher in correctional settings than in the general population, and there may be different response biases in correctional settings such as reluctance to report symptoms.
Effective screening tools should have strong psychometric properties, and ideally, there should be evidence of the tool’s utility from multiple samples and facilities. In addition to standard psychometric properties such as test–retest reliability, research on screening measures typically reports statistics such as sensitivity and specificity. These statistics refer to the proportion of correct classifications made by a screening tool, generally in terms of the level of agreement between the screening tool and a diagnostic clinical interview. Screening tools generally have one or more cutoff scores to indicate which individuals screen in as needing further assessment, whereas clinical interviews assess for the presence of a psychiatric diagnosis. The sensitivity of a screening tool refers to the proportion of individuals who have a diagnosable mental illness who screen in on the tool or true positives. A screening tool with high sensitivity will correctly flag a higher proportion of offenders who have mental illness compared to a tool with low sensitivity. Specificity refers to the proportion of individuals who do not have a mental disorder who do not screen in on the screening tool or true negatives.
It is difficult to achieve both high sensitivity and high specificity in the same screening tool; typically, an increase in one comes at the expense of the other. Every screening tool generates some amount of incorrect classifications (i.e., an offender with mental illness classified as non-disordered on a tool, or vice versa), but tools differ in the extent to which they are likely to generate false positives versus false negatives. Administrators making decisions regarding which tool to use must consider the relative consequences of different types of incorrect classifications when examining the psychometric properties of candidate tools. In agencies with extremely limited resources, there may be more emphasis placed on specificity, whereas agencies needing to ensure that all individuals in need of treatment receive it should look for measures with high sensitivity.
Because measures may perform differently with different subpopulations, psychometric properties of screening tools should be examined separately among inmates with various demographic characteristics. For example, women in correctional settings generally have higher rates of mental illness in general compared to men and have high rates of post-traumatic stress disorder in particular. Some screening tools have different versions for men and women or different scoring criteria by gender to account for this. In addition, there is evidence that some screening tools are less sensitive to mental illness among female offenders or offenders from certain ethnic minority groups. As such, administrators should consider evidence of a tool’s utility in populations similar to their agency’s.
Promising Mental Health Screening Tools for Adult Offenders
At least 20 mental health screening tools have been developed for use with adult offenders, but only a few of these have multiple studies reporting their psychometric properties. The vast majority of this research comes from institutional rather than community corrections settings. Next, some of the well-studied tools are briefly described.
Perhaps the most widely researched mental health screening tool for adult offenders is the Brief Jail Mental Health Screen (BJMHS). The BJMHS is based on the Referral Decision Scale and consists of 8 items that are answered in a yes-or-no format. Administration is done via interview and takes fewer than 5 min. The BJMHS has been examined in multiple studies across several U.S. jails, and this research indicates that it has relatively high sensitivity for serious mental illness (60–75%), although lower rates of accuracy were found for female offenders and ethnic minority offenders. In addition, one study found that the original BJMHS had high sensitivity when used as a self-report form in a probation setting.
The Jail Screening Assessment Tool consists of a semi-structured interview and file review and involves the use of clinical judgment to score. The Jail Screening Assessment Tool is designed to detect a wide range of mental health and behavioral concerns, including mental illness, suicide risk, and violence risk. It has been examined among samples of male and female Canadian jail inmates, with sensitivity estimates ranging from 38% to 84% and specificity ranges from 67% to 71%, although estimates vary by setting and which disorders the measure is used to detect.
The Correctional Mental Health Screen (CMHS) has separate versions for men and women. The 12-item CMHS-M (male version) and the 8-item CMHS-F (female version) are composed of interview questions with a yes-or-no format; these items were derived from other mental health assessment tools that were found to be the most strongly related to mental illness in the tool’s development study. The CMHS-M has demonstrated sensitivity of 70–74% for detecting any mental disorder, but higher sensitivity can be achieved by lowering the tool’s cutoff score. Similarly, the CMHS-F has sensitivity around 65%, which can be increased with a lower cutoff score, although a higher rate of false positives are generated with lower cutoff scores. The CMHS development study examined the tools’ utility with Caucasian and African American jail inmates and found that it had similar sensitivity with both ethnic groups.
Considerations for the Use of Mental Health Screening Tools
Despite the availability and utility of mental health screening tools, surveys of practices indicate that many jails use unstructured or unvalidated tools to screen for mental illness—the extent to which these tools identify offenders who have a mental disorder may be low or unknown. Research suggests that the majority of offenders with mental illness go undetected, so use of validated screening tools is important. This idea has caught the attention of governmental agencies such as the National Institute of Justice, which has issued recommendations for agencies calling for systematic screening as part of a comprehensive mental health assessment and treatment procedure.
Agencies seeking to implement mental health screening should attend to guidelines such as those published by National Institute of Justice for best practices for use of these measures. For example, staff conducting screening should receive training on proper procedures for administration and scoring of the tool. If the screen is conducted via interview, training on rapport building with offenders is helpful. In addition, staff should be trained on proper interpretation of the results (including the fact that screening in on a tool does not necessarily indicate a diagnosis is present). Policies should be implemented to guide decisions based on screening results. As with any mental health assessment procedure, screening should be done in accordance with ethical guidelines, particularly in regard to privacy and confidentiality.
No screening tool is perfect—it is only a sample of information about an individual at a point in time. There are factors that can affect scores on screening measures. For example, the level of privacy where the screen is conducted and the ability of the professional conducting the screening can affect an offender’s willingness to disclose symptoms or a history of treatment. In addition, administrators or staff may be concerned with malingering—inmates exaggerating or fabricating symptoms for the purposes of getting psychotropic medications or preferential placements. Although some inmates do try to feign symptoms of mental illness for secondary gain, staff must be cautious when responding to suspected malingering because the inmate may truly have a mental illness and thus would go untreated. Staff should also be made aware of the fact that some inmates, due to symptoms of mental illness or cognitive impairments, may have difficulty articulating the symptoms they are experiencing, which may be misinterpreted as malingering. On the other hand, inmates may be reluctant to disclose symptoms or hide their symptoms in an effort to avoid stigmatization by staff or other inmates.
In addition, different tools perform differently among different subgroups of offenders for a number of reasons. For example, members of ethnic groups may be less willing to disclose symptoms or experience mental health symptoms as physical problems; as such, staff should be trained in issues related to cultural diversity. Moreover, staff screening female offenders should be trained in working with individuals who have a history of trauma, which is highly prevalent among women in the criminal justice system. Female offenders may be reluctant to share mental health concerns with male staff if they have a history of male abusers.
Research on mental health screening tools for adult offenders is ongoing. Some specific areas in need of attention include further refinement of measures to improve utility with women and ethnic minority offenders and development of translated tools for use with offenders with limited English proficiency. In addition, researchers have begun to use technology to improve screening, such as using computerized versions of diagnostic interviews or computerized scoring for screens that generates offender classification schemes. As research on these novel measures continues, agencies may be able to identify a higher proportion of offenders with mental illness.
References:
- Ford, J., Trestman, R. L., Osher, F., Scott, J. E., Steadman, H. J., & Robbins, P. C. (2007). Mental health screens for corrections. Washington, DC: National Institute of Justice.
- Lurigio, A., & Swartz, J. A. (2006). Mental illness in correctional populations: The use of standardized screening tools for further evaluation or treatment. Federal Probation, 70, 29–35.
- Martin, M. S., Colman, I., Simpson, A. I., & McKenzie, K. (2013). Mental health screening tools in correctional institutions: A systematic review. BioMed Central Psychiatry, 13, 275–285. Retrieved from http://www.biomedcentral.com/1471-244X/13/275
- Peters, R. H., Bartoi, M. G., & Sherman, P. B. (2008). Screening and assessment of co-occurring disorders in the justice system. Delmar, NY: CMHS National GAINS Center.
- Taxman, F. S., Cropsey, K. L., Young, D. W., & Wexler, H. (2007). Screening, assessment, and referral practices in adult correctional settings: A national prospective. Criminal Justice and Behavior, 34, 1216–1234. doi:10.1177/009385480730443