The Jail Screening Assessment Tool (JSAT) is a set of questions designed to determine mental health needs of newly admitted inmates and identify those prisoners who need mental health treatment or pose a risk to themselves or others. By identifying those individuals in need of mental health treatment upon intake, the JSAT can aid with efficiently determining appropriate placement and effective treatment locales and programs for entering inmates. First developed in Canada in 1991, this tool has been adopted successfully in correctional settings in such additional countries as the United States and Australia. This article first provides an overview of mental disorders and mental health screenings in correctional settings; then, the entry focuses on the JSAT: its key characteristics and research evidence.
Mental Disorders in Correctional Settings
The overrepresentation of individuals with mental disorders in correctional settings is an international public health problem. There are approximately 10 million prisoners worldwide and as many as one in seven inmates with psychosis or major depression. Moreover, up to three-quarters of inmates have primary or comorbid (in conjunction with other medical issues) substance use disorders. A systematic review of studies published between 1966 and 2010 (33,588 prisoners, 81 publications, 109 samples) across 24 countries concluded that the rates of psychosis (men = 3.6%; women = 3.9%) and major depression (men = 10.2%; women = 14.1%) have not changed substantially across the 40-year period, with the exception that the rate of depression has increased in U.S. prisons.
Many correctional facilities are ill-equipped to serve people with mental disorders. Inadequate care contributes to increased risk of institutional incidents that might put the safety of inmates and staff at risk of harm (e.g., inmates with mental disorders are at higher risk to violate rules, engage in self-harmful behavior, and are more vulnerable to physical and sexual abuse while incarcerated) and is known to lead to elevated staff stress, sick days, and turnover. In the absence of appropriate care and discharge planning, the transition back to the community is a particularly risky period for suicide, return to substance use with an increased possibility of overdose, recidivism, and other challenges common to marginalized populations (e.g., homelessness). Furthermore, most inmates are released to the community (50% within 3 years), and some estimates note that up to 50% return to correctional facilities within 3 years of release. Recidivism rates for offenders with mental disorders exceed those of individuals from the general prison population. Thus, addressing mental health needs may not only help ease the transition of prisoners to the community but also help reduce reoffending and associated economic burdens.
Substantial advances have been achieved in responding to the recognized need to advance standards of care in the provision of mental health services in jails and prisons. In North America, these developments have been spearheaded by the work of organizations such as the American Psychiatric Association, the Treatment Advocacy Center, National Commission on Correctional Health Care, and the Federal-Provincial- Territorial Heads of Corrections Working Group on Mental Health and Mental Health Commission of Canada. These standards consistently recommend a continuum of care, of which mental health screening is considered a key element.
Mental Health Screening in Jails
Jails are generally the gateway into the criminal justice system. Although the distinctions are sometimes fuzzy, jails typically house individuals who have been arrested and are remanded to be held while awaiting a plea agreement, trial, or sentencing; jails also house individuals serving short sentences, whereas inmates who are convicted, generally sentenced to more than 1 year, are detained in prisons (also known as penitentiaries). Jails often are the initial point of contact with mental health providers for many mentally disordered inmates. A considerable number of people arriving at a jail are actively or recently intoxicated, arrive with injuries from fights or assaults, and/or are mentally ill with no other place for law enforcement to deliver them. This makes the intake process challenging for the jail’s staff and its medical personnel. Jails thus provide an important public health opportunity for implementing innovative and comprehensive systems of care. Systematic screening for mental health needs in jails is the essential first step.
Mental health screening in jails can accomplish several core objectives: (a) redirect severely mentally ill individuals out of the criminal justice system and into more appropriate settings and diversion programs; (b) ensure that other less acutely ill individuals receive the care and services they require while they are housed in correctional settings; (c) prevent violence and other disruptive incidents which, in turn, would reduce stress and injuries for inmates and staff; and (d) support release planning with the goal of improved quality of life for the individuals, reduced recidivism, and substantial public health benefits, including reduced economic burdens.
Mental health screening should occur as early upon admission to a correctional facility as possible, typically within the first 24 hr. Ideally, the mental health screening process includes a brief review of any available file information, consideration of any collateral information (e.g., from correctional staff who interacted with the inmate during admission or transport), and a face-to-face interview with the inmate. Where relevant and possible, mental health records should be accessed and the inmate’s general practitioner should be consulted. Interviews should take place in a reasonably private interview room where the interviewer is also provided with safety measures.
Key Characteristics of the JSAT
A trained interviewer can complete a JSAT interview in approximately 15–20 min for male inmates and 25–30 min for female inmates (women tend to contextualize their circumstances and articulate the trajectory that brought them to their current circumstances) and those with more complex needs (e.g., a combination of current psychiatric symptoms and substance abuse withdrawal or risk of harm to self/others). The JSAT is not a standardized psychological test and thus can be administered by non-licensed professionals provided they have the requisite expertise in mental health. Typically, sites have employed graduate students in clinical psychology, psychological interns or psychiatric nurses, forensic case workers, or social workers to complete the screening interviews.
Intake interviewers/screeners do not wear uniforms and clearly communicate that although there are limitations (e.g., threats of suicide or violence), the information they collect is kept confidential and not shared with correctional officers. Assurances about confidentiality and advising the inmate that the purpose of the interview and the collection of the information is to help make their admission and stay at the institution as smooth and safe as possible can help develop rapport and facilitate open and honest conversations.
The JSAT manual provides a semi-structured interview (e.g., Do you have a history of aggression/violence?) and additional prompts (e.g., Have you ever been told you have an anger management problem? Do you sometimes kick or hit things when you get frustrated or angry?). The information is collated on a double-sided, legal-sized, copyright-protected form (note, there are no fees to implement the form beyond the initial purchase of the manual) or can be integrated into the inmates’ electronic health records, which can be useful for tracking population profiles and supporting quality research and evaluation initiatives.
The JSAT screening interview and summary form prompt screeners to collect data in the following categories:
- identifying information and demographics (e.g., age, language, ethnicity/cultural identity)
- social background (e.g., marital status, relationship stability, living situation, social support, financial support, family support, children, and education)
- previous and current legal status (e.g., prior incarcerations, current charges, current legal status)
- violence issues (e.g., past violent offenses, prior institutional charges, current anger level)
- substance use (e.g., tobacco, alcohol, drug(s), methods of use, treatment, including methadone/suboxone)
- recent or past mental health treatment (e.g., prior psychiatric hospitalization, current medication needs)
- current mental health status (supported by a modified version of the Brief Psychiatric Rating Scale)
- suicide/self-harm issues (e.g., prior attempts, including those while in custody, method/ lethality, current ideation, current plans)
In addition to these domains, the screening procedure also includes completion of a revised version (4.0) of the Brief Psychiatric Rating Scale. This section consists of 14 items coded (i.e., assessed and recorded) on the basis of the patient’s self-report (and behavior) during the interview (e.g., anxiety, depression, bizarre behavior, self-neglect) and 10 items coded on the basis of the individual’s behavior and speech during the interview (e.g., grandiosity, uncooperativeness, motor hyperactivity). Based on early feedback, the JSAT authors revised the 7-point rating scale on the Brief Psychiatric Rating Scale to a 3-point scale (present, possible, absent) to support inter-rater reliability (i.e., the extent to which discrete interviewers come to consistent decisions) and to increase the efficiency of the interviews (i.e., reduce the per-inmate time required to complete the JSAT).
The screeners use this information to evaluate risk of adverse events common to correctional settings (e.g., suicide, self-harm, violence, and victimization), make management recommendations (e.g., mental health referrals, placement in a mental health unit, protective custody), or refer the inmate for a more comprehensive mental health assessment (typically with a mental health coordinator initially, or psychology, psychiatry). This requires clear communication and documentation protocols so that urgent safety and security needs are shared with correctional staff in a timely manner, recommendations for placement within the jail or other specific accommodations are considered by the appropriate personnel, and referrals for mental health follow-up are made efficiently (e.g., referral for medications). These decisions are made using structured professional judgment, a guided clinical approach to decision-making without fixed and explicit rules but which is based in part on the standardized information gathered from the JSAT interview.
Given that the JSAT is a screen for mental health and management needs, the preference is to err on the side of caution to ensure that individuals with mental health needs and/or individuals who might present a risk of harm to self or others, or victimization, are not overlooked. It can be difficult to evaluate risk and to discern serious mental health concerns from situational distress and/or substance use withdrawal in a brief interview, so the manual recommends that screeners be overly inclusive when uncertain (i.e., overrefer rather than underrefer). Optimally a brief check-in can be done the following day with inmates who were referred for mental health services. The objective is to touch base with inmates who may have settled well after the initial stress of admission; often inmates will drop off the referral list as a result.
Research Evidence
The JSAT has been evaluated in four studies in British Columbia, Canada, and one in Melbourne, Australia. An early study with male inmates revealed a high rate of agreement between intake interviewers’ assessments and independent evaluations with the Structured Clinical Interview for DSM (SCID). The JSAT exhibited a sensitivity or true positive rate of 84%, meaning that 84% of individuals identified as having mental health needs did, in fact, have a mental disorder. Conversely, 67% of individuals who did not have a mental disorder were correctly identified as such, also called the specificity or true negative rate.
When testing the JSAT in a sample of women admitted to a Canadian federal institution against comprehensive assessments completed using the SCID for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis-I Disorders— Non-Patient Edition, intake interviews had a sensitivity (i.e., true positive rate) of 70.6% and a specificity (i.e., true negative rate) of 75.0%. The false-positive rate was 29.4%, meaning that 29.4% of the individuals who had been assessed as having mental health needs with the JSAT were not diagnosed with a mental disorder when assessed with the more comprehensive SCID. The false-negative rate was 25.0%, meaning that one fourth of the individuals who were assessed as not having a mental disorder did, according to the SCID assessments. The positive predictive power was 64.3% (i.e., the proportion of positive test results that were actually from people who had a mental disorder according to the SCID) and the negative predictive power was 80.0% (the proportion of people with negative test results who actually did not have a mental disorder according to the SCID). Finally, as would be expected (given the low base rate of severe disorders such as schizophrenia), very few of the women were identified as severely mentally ill, with just 1% of female inmates identified as being in need of transfer to a secure mental health facility.
A third Canadian study, sampling 106 inmates in British Columbia screened randomly and in a counterbalanced fashion, demonstrated that the Brief Jail Mental Health Screen had better sensitivity, while the JSAT had better specificity across most definitions of mental disorder. Findings from an Australian study with 150 detainees in police cells demonstrated that the JSAT performance was similar to the Brief Jail Mental Health Screen in identifying seriously mentally ill individuals but superior in terms of identifying Axis-I disorders (i.e., all psychological diagnostic categories except mental retardation and personality disorder; however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published in 2013, did away with the Axes) with the exception of substance use disorders. The JSAT identified all inmates with a diagnosis of schizophrenia, bipolar disorder, depressive disorder, and almost all of those with an anxiety disorder (92.3%).
The evidence to date suggests that the JSAT is an efficient, valid, and reliable means of screening for mental disorder and making placement and treatment recommendations in correctional populations. Additional research is needed, however, to further examine clinical utility, particularly with respect to unique subgroups (e.g., women, ethnic minorities, and across cultures).
References:
- Baksheev, G. N., Ogloff, J. R. P., & Thomas, S. (2012). Identification of mental illness in police cells: A comparison of police processes, the Brief Jail Mental Health Screen and the Jail Screening Assessment Tool. Psychology, Crime, & Law, 18, 529–542.
- Martin, M. S., Colman, I., Simpson, A. I. F., & McKenzie, K. (2013). Mental health screening tools in correctional institutions: A systematic review. BMC Psychiatry, 13, 275. doi:10.1186/1471-244X-13-275
- Nicholls, T. L., Lee, Z., Corrado, R. R., & Ogloff, J. R. P. (2004). Women inmates’ mental health needs: Evidence of the validity of the jail screening assessment tool (JSAT). International Journal of Forensic Mental Health, 3, 167–184. Retrieved from http://dx.doi.org/10.1080/14999013.2004.10471205
- Nicholls, T. L., Roesch, R., Olley, M. C., Ogloff, J. R. P., & Hemphill, J. F. (2005). Jail screening assessment tool (JSAT): Guidelines for mental health screening in jails. Burnaby, Canada: Simon Fraser University.