To identity inmates with mental illness, BOP screens inmates prior to designation to a facility by reviewing an inmate’s pre-sentence report and assigning preliminary medical and mental health screening levels. Once an inmate is designated to a BOP institution, the institution staff assesses inmates to provide an accurate mental health diagnosis and determination of the severity of any mental illness as well as determining their suicide risk. BOP also identifies the mental health needs of each inmate and matches the inmate to an institution with the appropriate resources. Institution mental health care levels range from 1 to 4, with 1 being institutions that care for the healthiest inmates and 4 being institutions that care for inmates with the most acute needs. Inmate mental health care levels are also rated in this manner from level 1 to level 4. After an inmate arrives at a BOP institution, during the admission and orientation process, every inmate receives information on mental health services available at that site. Table 1 identifies inmate mental health care levels and the percentage of all inmates by designated level. Throughout an inmate’s incarceration, BOP psychologists, psychiatrists, and qualified mid-level practitioners (i.e., a physician assistant or nurse practitioner who is licensed in the field of medicine and possess specialized training in mental health care) can determine a new mental health care level following a review of records and a face-to-face clinical interview. BOP’s Psychology Services Branch, which the Reentry Services Division oversees, provides most mental health services to inmates in BOP- operated institutions, including providing individualized psychological care and residential and non-residential treatment programs (Figure 1 shows BOP’s organization for providing mental health services). BOP’s Health Services Division manages psychiatry and pharmacy services. Most mental health treatment is provided in what BOP calls its mainline, or regular, institutions. Acutely ill inmates in need of psychiatric hospitalization, such as inmates suffering from schizophrenia or bipolar disorder, may receive these services at one of BOP’s five medical referral centers, which provide inpatient psychiatric services as part of their mission. At BOP institutions, psychologists are available for formal counseling and treatment on an individual or group basis. In addition, staff in an inmate’s housing unit is available for informal counseling. Psychiatric services available at the institution are enhanced by contract services from the community. Prior to the passage of the 21st Century Cures Act, and at the beginning of our work, BOP defined serious mental illness in accordance with the agency’s program statement—which states that classification of an inmate as seriously mentally ill requires consideration of diagnoses; the severity and duration of symptoms; the degree of functional impairment associated with the illness; and treatment history and current treatment needs. In accordance with BOP’s program statement, BOP used this guidance along with other variables to develop six criteria to identify the population of inmates with serious mental illness who were incarcerated in fiscal years 2016 and 2017—the most recent fiscal years for which data on these criteria are available. The additional criteria to identify the population of inmates with serious mental illness are as follows: 1. Inmate was evaluated by BOP and assigned a mental health care level 3: An inmate requires enhanced outpatient mental health care such as weekly psychosocial intervention or residential mental health care. 2. Inmate was evaluated by BOP and assigned a mental health care level 4: An inmate requires acute care in a psychiatric hospital; the inmate is gravely disabled and cannot function in a general population environment. 3. Inmate was assigned a mental health study level 4: This indicated that the inmate was subject to a court ordered forensic study that required an inpatient setting. 4. Inmate was diagnosed to have one or more of 74 Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses, both active and in remission, that BOP considers a serious mental illness. 5. Inmate was evaluated by BOP and identified as having a chronic suicide risk, due to the inmate having a history of two or more suicide attempts. 6. Inmate was evaluated by BOP and assigned a psychology alert status. This designation was applied to inmates who were evaluated as having substantial mental health concerns and requiring extra care when changing housing or transferring institutions. On August 15, 2017, in a memorandum for the Comptroller General of the United States from the Acting Director of BOP, BOP defined “serious mental illness” for purposes of section 14016 of the 21st Century Cures Act as follows: Individuals with a serious mental illness are persons: Who currently or at any time during the past year, Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the most current edition of the Diagnostic and Statistical Manual of Mental Disorders, That has resulted in functional impairment which substantially interferes with or limits one or more major life activities. The memorandum also stated that BOP may further operationalize this definition by identifying specific mental disorders which are to be classified as serious mental illness and providing examples of functional impairment specific to BOP’s settings and/or populations. BOP officials indicated that BOP’s program statement and the six criteria to identify the population of inmates with serious mental illness who were incarcerated in fiscal years 2016 and 2017 would coincide with the definition for “serious mental illness” provided in the memorandum for the Comptroller General of the United States for purposes of the 21st Century Cures Act and identify an identical set of BOP inmates with “serious mental illness” for fiscal years 2016 and 2017. The periods during incarceration in federal and state prisons and reentry into the community are considered to be key periods to implement interventions to reduce recidivism among individuals with serious mental illness, according to public health and correctional stakeholders. The Bureau of Justice Statistics has found that for all offenders, regardless of their mental health status, the highest rate of recidivism occurs during the first year after release from prison. Further, researchers have found that offenders with serious mental illness return to prison sooner than those without serious mental illness. Multiple factors may contribute to the cycle of repeated incarceration among individuals with serious mental illness. SAMHSA reports that individuals with mental illness face additional challenges upon reentering the community, including those associated with finding treatment providers, stable housing, and employment. Federal agencies have established interagency groups and other mechanisms to share information on how to address the challenges related to recidivism among offenders with serious mental illness. Examples of these information sharing mechanisms are described in appendix III. While the periods of incarceration and reentry are the focus of this review, there are other points in the criminal justice system where there are opportunities to intervene to prevent individuals with serious mental illness from becoming further involved with the system, such as during the initial law enforcement response or during court proceedings. Further, SAMHSA has identified connecting those in need of treatment to community mental health services before a behavioral health crisis begins as a way to prevent individuals with mental illness from becoming involved in the criminal justice system. About two-thirds of BOP inmates with a serious mental illness were incarcerated for four types of offenses—drug offenses (23 percent), sex offenses (18 percent), weapons and explosives offenses (17 percent), and robbery (8 percent)—as of May 27, 2017. As shown in figure 2, some differences in offenses exist between inmates with and without serious mental illness in BOP custody. Specifically, our analysis found that BOP inmates with serious mental illness were incarcerated for sex offenses, robbery, and homicide or aggravated assault at about twice the percentage of inmates without serious mental illness, and were incarcerated for drug and immigration offenses at about half or less the rate of inmates without serious mental illness. Additionally, we found some differences between BOP inmates with and without serious mental illness in the length and severity of sentences. Although a similar percentage of inmates with and without serious mental illness have life sentences (2.8 percent and 2.5 percent, respectively), a lower percentage of inmates with serious mental illness had sentences of 10 years or less (43.5 percent and 49.2 percent, respectively). About .06 percent (5 inmates) of inmates with serious mental illness and about .03 percent (52 inmates) of inmates without serious mental illness received a death sentence. See appendix I for additional information on the characteristics of BOP inmates with and without serious mental illness. Based on our analysis of available data provided by selected states’ departments of corrections, the most common crimes committed by inmates with serious mental illness varied from state to state. The difference in types of crimes reported by states and BOP may be due to different priorities, laws, and enforcement priorities across the state and federal criminal justice systems, among other things. The federal and state governments also define serious mental illness differently, and they track different categories of crime in their respective data systems. The percentages and types of crimes committed by incarcerated inmates are shown in figures 3 through 5 below for three selected states’ departments of corrections. The New York State Department of Corrections and Community Supervision (DOCCS) cared for 2,513 inmates with serious mental illness out of a total of 51,436 inmates as of December 31, 2016. Figure 3 shows the categories of offenses committed by inmates defined by DOCCS as having serious mental illness. Three out of four inmates with serious mental illness under the care of DOCCS were incarcerated for violent crimes. According to DOCCS program descriptions, diagnostic criteria for serious mental illness are: (1) an inmate is determined by the New York State Office of Mental Health to have specified mental health diagnoses; (2) an inmate is actively suicidal or has made a recent, serious suicide attempt; or (3) an inmate is diagnosed with serious mental illness, organic brain syndrome, or a severe personality disorder that is manifested in significant functional impairment such as acts of self-harm or other behaviors that have a serious adverse effect on life or on mental or physical health. The Virginia Department of Corrections cared for 527 inmates with serious mental illness out of a total of 30,052 inmates as of September 29, 2017. Figure 4 shows the crimes committed by inmates that Virginia defined as having serious mental illness. About one quarter of the inmates with serious mental illness in Virginia committed rape, sexual assault, and other assault crimes. Virginia policy defines an inmate with serious mental illness as an offender diagnosed with a psychotic disorder, bipolar disorder, major depressive disorder, PTSD or anxiety disorder, or any diagnosed mental disorder (excluding substance use disorders) currently associated with serious impairment in psychological, cognitive, or behavioral functioning that substantially interferes with the person’s ability to meet the ordinary demands of living and requires an individualized treatment plan by a qualified mental health professional(s). The Washington Department of Corrections cared for 1,881 inmates with serious mental illness out of a total of 17,234 inmates as of June 30, 2017. Figure 5 shows the crimes committed by Washington inmates that Washington defined as having serious mental illness. About half of the inmates with serious mental illness in Washington committed assault or sex crimes. The Washington Department of Corrections defines serious mental illness as a substantial disorder of thought or mood which significantly impairs judgment, behavior, or capacity to recognize reality or cope with the ordinary demands of life within the prison environment and is manifested by substantial pain or disability. The Washington Department of Corrections’ definition does not include inmates who are substance abusers or substance dependent—including alcoholics and narcotics addicts—or persons convicted of any sex offense, who are not otherwise diagnosed as seriously mentally ill. According to BOP officials, the agency does not track costs specifically associated with inmates with serious mental illness due to resource restrictions and the administrative burden such tracking would require. BOP officials stated that BOP, unlike a hospital, is not structured to bill individual interactions; and noted that, generally, the correctional industry does not account for costs by tracking individual costs. BOP officials said that requiring BOP staff to gather individual cost data manually would be an extremely time consuming and burdensome process. In addition, BOP does not maintain the mental health care cost data necessary to calculate the individual inmate costs related to specific program areas (i.e., psychology and psychiatric services). BOP tracks the costs associated with incarcerating its overall inmate population and with providing mental health care services to inmates system-wide and separately by institution. For fiscal year 2016, BOP’s institution-level data show that total incarceration costs vary by BOP institution (ranging from $15 million to over $247 million), for a number of reasons, including varying amounts of medical and mental health care available at each institution. Table 2 identifies BOP’s costs for mental health care services provided to all inmates (including inmates with serious mental illness) for fiscal year 2016, the last year for which BOP had complete data during our audit work. The costs below are the most readily available BOP-wide costs directly related to mental health care. BOP’s Psychology Services staff provides most inmate mental health services in BOP-operated institutions, including the provision of individualized psychological care. Psychotropic medication may be used to treat mental illness, although in some instances, BOP uses psychotropic medication to treat individuals with other kinds of health conditions. Residential Reentry Centers, also known as halfway houses, provide assistance to inmates nearing release, including some inmates with serious mental illness. BOP includes psychiatric treatment and services under medical care costs, but BOP does not track psychiatric costs separately. In July 2013, we reported that BOP also does not track its contractors’ costs of providing mental health services to the 13 percent of BOP inmates housed in privately managed facilities. The performance-based, fixed- price contracts that govern the operation of BOP’s privately managed facilities give flexibility to the contractors to decide how to provide mental health services. BOP tracks and maintains information on the number and types of inmate interactions with Psychology Services personnel. These interactions include clinical and non-clinical interactions between Psychology Services staff and inmates that may be crisis-oriented or routine, such as individual and group therapy. Based on our analysis of these data, in fiscal year 2016, BOP inmates with serious mental illness were more likely than other inmates to use 18 of the 20 services or programs tracked by Psychology Services. On average, we found that an inmate with serious mental illness had 9.6 clinical interventions compared to 0.24 clinical interventions for inmates without serious mental illness during fiscal year 2016. As a result, an average BOP inmate with serious mental illness was 40 times more likely to receive a clinical intervention than an average inmate without serious mental illness. BOP data do not capture the time and resources associated with any of the Psychology Services interactions; thus we cannot assign a cost value to differences between populations in receipt of these services. Appendix IV shows the extent to which BOP’s inmate population received specific types of psychology services in fiscal year 2016. The selected state departments of corrections provided us with estimates for different types of mental health care costs, but did not identify mental health care costs specifically for inmates with serious mental illness. Additionally, the states did not provide us with the total cost to incarcerate inmates with serious mental illness. For example, officials from one state said staff did not calculate costs separately for inmates with mental illness compared to inmates without mental illness as they did not believe an accurate comparison could be made. Officials from another state said that they did not track costs of incarceration or mental health services per inmate based on whether or not an inmate has mental illness, while officials from another state said they were not able to track costs for mental health services for inmates at the individual level. The selected state departments of corrections also used different methods to determine the costs of the mental health services they provided to their inmate population. For example: Two state departments of corrections provided us with the average per-inmate costs of incarceration for a mental health treatment unit or treatment center where some inmates with serious mental illness are treated, but these per-inmate costs also included incarceration costs for inmates without serious mental illness who were housed in these facilities. Another state department of corrections provided total psychotropic medication costs for all inmates and mental health care costs per offender. Mental health care costs per offender were averaged across all offenders, not exclusively those with serious mental illness. Two other states provided total costs for one budget item related to mental illness: total mental health program spending in one state, and psychiatric care expenditures in the other state. These costs were for all inmates, not exclusively for inmates with serious mental illness. Another state department of corrections provided an estimate for average mental health care costs per inmate with mental illness, but this estimate included all inmates diagnosed as having a mental illness, not exclusively those inmates diagnosed with serious mental illness. In 2012, the Council of State Governments Justice Center developed the Criminogenic Risk and Behavioral Health Needs Framework in collaboration with DOJ’s National Institute of Corrections and Bureau of Justice Assistance, SAMHSA, and experts from correctional, mental health, and substance abuse associations. The framework is an approach to reduce recidivism and promote recovery among adults under correctional supervision with mental illness, substance use disorders, or both. It calls for correctional agencies to assess individuals’ criminogenic risk (the risk of committing future crimes), substance abuse and mental health needs. The agencies are to use the results of the assessment to target supervision and treatment resources based on these risks and needs. Additionally, the framework states that individuals with the highest criminogenic risks should be prioritized for treatment to achieve the greatest effect on public safety outcomes. Mental health and substance abuse treatment There are a number of different approaches that can be tailored and combined to address an individual’s mental health and substance abuse treatment needs. Examples include: Psychopharmacology. Approach that aims to address dysfunctional thoughts, moods, or behavior through time-limited counseling. To help implement the principles set forth in the framework, SAMHSA developed additional guidance in collaboration with the Council of State Governments Justice Center, the Bureau of Justice Assistance and experts from correctional, mental health, and substance abuse associations. This guidance is for mental health, correctional, and community stakeholders, and uses the Assess, Plan, Identify, Coordinate model to provide procedural guidelines to reduce recidivism and promote recovery at different points during incarceration and reentry. Table 3 below describes selected guidelines and examples of strategies that were identified by BOP and the six selected states that correspond to each element of the model. A residential treatment program for individuals with both substance use and mental disorders that uses a peer community to address substance abuse, psychiatric symptoms, cognitive impairments, and other common impairments. who are in recovery and have previously been involved in the criminal justice system provide support to others who are also involved in the criminal justice system. Forensic intensive case management. A case manager coordinates services in the community to help clients sustain recovery and prevent further involvement with the criminal justice system. Forensic Assertive Community Treatment (FACT). Treatment is coordinated by a multidisciplinary team, which may include psychiatrists, nurses, peer specialists, and probation officers. FACT teams have high staff-to-client ratios and are available around-the-clock to address clients’ case management and treatment needs. Examples of Bureau of Prisons (BOP) and Selected State Strategies booking/intake process as feasible and throughout the criminal justice continuum to detect substance use disorders, mental disorders, co-occurring substance use and mental disorders, and criminogenic risk. Follow up with comprehensive assessment to guide program placement and service delivery. Assessment should include clinical needs, social support needs (e.g., housing, education, employment, and transportation), and risk factors. All six selected states and BOP have developed mental health assessments during the intake process. BOP officials stated that the agency is in the process of enhancing the predictive validity of its criminogenic risk assessment and expects to complete this project in 2018. One of the six selected states uses a multidisciplinary treatment team composed of a clinician, psychiatrist, and correctional counselor, to assess the treatment and programming needs of inmates with serious mental illness. In addition to mental health treatment, the multidisciplinary team assesses if the inmate is ready for and would benefit from institutional services such as academic and vocational education programs, work, or substance abuse counseling. These assessments occur at least annually, but may occur whenever an inmate’s treatment needs have changed. To identify strategies to reduce recidivism among offenders with mental illness during incarceration and reentry, we searched for studies that analyzed the relationship between programs and recidivism among offenders with mental illness. Our search identified about 200 publications. We used a systematic process to conduct the review, which appendix II describes in more detail. We ultimately identified 14 studies that (1) assessed correctional institution or reentry programs for offenders with mental illness implemented in the United States, (2) contained quantitative analyses of the effect of a program on recidivism, and (3) used sufficiently sound methodologies for conducting such analyses. The studies examined different kinds of recidivism outcomes (e.g., re- arrest, re-incarceration, reconviction) and one study often examined more than one recidivism outcome. We categorize the findings for each study as follows: Statistically significant reduction in recidivism: the study reported that one or more outcome measures indicated a statistically significant reduction in recidivism among program participants; the study may also have one or more recidivism outcome measures that were not statistically significant. Statistically significant increase in recidivism: the study reported that one or more outcome measures indicated a statistically significant increase in recidivism among program participants; the study may also have one or more recidivism outcome measures that were not statistically significant. No statistically significant effect on recidivism: the study reported only outcomes indicating no statistically significant effect on recidivism among program participants. The statistical significance finding categories are based on the effect of the program as a whole and do not indicate if or how all individual elements of the programs impacted recidivism. For additional information on recidivism findings, see appendices V and VI. See appendix VII for a bibliography of the studies. The results of the literature review provide insights into factors that can affect recidivism among individuals with mental illness; however, the following considerations should be taken into account: (1) the type of mental illness of program participants varied within and across programs making it difficult to generalize results to individuals with all types of mental illness; (2) the studies may not provide a full description of the programs; (3) not all participants may have used available program services; (4) studies assessed the programs as a whole and did not determine to what extent different elements of the programs impacted recidivism; and (5) some studies used designs which cannot control for all unobserved factors that could affect the recidivism results. Nine of the 14 studies we reviewed found statistically significant reductions in recidivism. The studies that found statistically significant reductions generally involved programs that offered multiple support services, as shown in figure 6. Providing mental health and substance abuse treatment (8 of 9 studies), case management (5 of 9 studies), release planning (5 of 9 studies), housing (6 of 9 studies) and employment assistance (4 of 9 studies) were the most common services across the programs where studies we reviewed found statistically significant reductions in recidivism. In addition, more than half of the programs that resulted in statistically significant reductions in recidivism were coordinated with multidisciplinary stakeholders, such as mental health providers, correctional officials, substance use specialists, social workers, and peer support specialists (7 of 9 studies), and community corrections agencies, such as probation or parole offices (6 of 9 studies). However, other studies found that programs that offered multiple support services did not reduce recidivism, suggesting that other factors may also affect recidivism. Such factors may include the extent to which participants used services, as well as other unique programmatic factors, such as addressing criminogenic risk or criminal thinking. We further discuss examples of programs that did and did not reduce recidivism below. For example, study 9 examined Washington’s Dangerously Mentally Ill Program, in which a multidisciplinary committee determines which offenders meet the program criteria of having a mental illness and are at high risk of being dangerous to themselves or others six months prior to their release from prison. Members of the committee include representatives from the Department of Social and Health Services, Department of Corrections, law enforcement, and community mental health and substance abuse treatment agencies. Offenders designated for participation are immediately assigned a community mental health treatment provider and receive special transition planning prior to their release from prison. After release, and for up to five years, a variety of services are available to participants based on assessed needs. Services may include mental health and substance abuse treatment, housing and medical assistance, training, and other support services. Researchers found that program participants were about 42 percent less likely to be reconvicted of a new felony than similar offenders in the comparison group four years after release (recidivism rates were 28 percent and 48 percent, respectively). Two other studies (numbers 3 and 6) evaluated Colorado’s Modified Therapeutic Community, a residential program that was provided both as a 12-month prison program and 6-month reentry program after release from prison for offenders with co-occurring mental illness and substance use disorders. Participants may have participated in only the prison program, only the reentry program, or both. Both programs use a cognitive-behavioral curriculum designed to help participants recognize and respond to the interrelationship of substance abuse, mental illness, and criminality and to use strategies for symptom management. The reentry program was coordinated with the community corrections agency, which provided the residential facility and monitored medication and compliance with parole terms for both participants and the comparison group. The reentry program also assisted with housing placement and employment. Researchers found that both the prison program and the reentry program resulted in statistically significant reductions in recidivism among participants. Specifically, the studies found that at 12 months post- release, prison program participants had a 9 percent reincarceration rate versus a 33 percent rate for the comparison group that did not participate in either program; and reentry program participants had a 19 percent reincarceration rate versus 38 percent for the comparison group. Further, researchers found that those who participated in both the prison and reentry program experienced the greatest reductions in recidivism, with a reincarceration rate of 5 percent versus a rate of 33 percent for the comparison group that did not participate in either program 12 months after release from prison. Studies that did not find a reduction in recidivism also provide insights on factors that may affect recidivism. For example, study 10 examined a Washington program to help enroll inmates with severe mental illness in Medicaid prior to their release from prison and found that jail and prison stays were higher among program participants than non-participants. The researchers hypothesized that receiving mental health treatment may have led to more interaction with authorities, putting participants at a greater risk of being caught violating the terms of their parole than non- participants. There was some evidence to support this: they found that most of the difference in prison days between participants and non- participants was the result of noncompliance with conditions of parole (technical violations) rather than the commission of new crimes. Further, the researchers conclude that Medicaid benefits alone are not enough to reduce arrests or keep people with severe mental illness out of jail or prison. In addition, study 11 examined Minnesota’s release planning services for inmates with serious and persistent mental illness, which provided some of the same types of services as the programs that did reduce recidivism. For example, while incarcerated, inmates were provided pre-release planning to address vocational, housing, chemical dependency, psychiatric, disability, medical, medication, and transportation needs. However, this program did not result in any significant reduction in recidivism. The researchers conclude that including programming to target criminogenic risks and providing a continuum of care from the institution to the community, instead of only providing services in the institution, may make the program more effective at reducing recidivism. We provided a draft of this report to DOJ and HHS for review and comment. DOJ and HHS did not provide official written comments or technical comments. We are sending copies of this report to the Assistant Attorney General for Administration, Department of Justice, the Secretary of Health and Human Services, selected congressional committees, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-8777 or maurerd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix VIII. The population of Federal Bureau of Prisons (BOP) inmates with and without serious mental illness varies in several characteristics, see table 4. To address all three objectives, we reviewed documents, interviewed officials, and analyzed data obtained from the Federal Bureau of Prisons (BOP) and selected states’ departments of corrections. For objective 3, we also reviewed documents and interviewed officials from the Department of Justice’s (DOJ) Office of Justice Programs and the Department of Health and Human Services’ (HHS) Substance Abuse and Mental Health Services Administrations (SAMHSA) and the National Institute of Mental Health. We selected six state departments of corrections (California, New York, Ohio, Texas, Virginia, and Washington) based upon variation in the rate of incarcerated adults per capita to obtain a mix of states with high, medium, and low rates, specialist recommendations on data quality and quality of programs for inmates with serious mental illness, and variation in geography. We contacted officials from SAMHSA and the National Institute of Mental Health and representatives from correctional accreditation organizations, as well as subject matter specialists from Pew Charitable Trusts and the Treatment Advocacy Center that we identified through previous work and asked for their recommendations of states that, in their view, had reliable data sources on the number of incarcerated individuals with serious mental illness and the costs of providing mental health services, as well as noteworthy programming for inmates with serious mental illness. The results from these six states are not generalizable, but provide insights. For purposes of this review, we based our work on the definition(s) of serious mental illness that are provided by each of the selected federal agencies and selected states’ departments of corrections. We analyzed policies and guidance at BOP and the departments of corrections in selected states to determine how, if at all, the agencies define serious mental illness and the processes used to identify incarcerated inmates with serious mental illness. To determine the population of inmates with serious mental illness for the purposes of our work, BOP operationalized its definition of serious mental illness using six criteria, covering the required degree of mental health care, mental illness diagnoses, and suicide risk. BOP defined “serious mental illness” in accordance with the agency’s program statement, BOP Program Statement 5310.16, Treatment and Care of Inmates with Mental Illness, May 1, 2014. On August 15, 2017, in a memorandum for the Comptroller General of the United States from the Acting Director of BOP, BOP defined “serious mental illness” for purposes of section 14016 of the 21st Century Cures Act. BOP officials indicated that BOP’s program statement and the six criteria to identify the population of inmates with serious mental illness who were incarcerated in fiscal years 2016 and 2017 would coincide with the definition for “serious mental illness” provided in the memorandum for the Comptroller General of the United States for purposes of the 21st Century Cures Act and identify an identical set of BOP inmates with “serious mental illness” for fiscal years 2016 and 2017. BOP applied these criteria to inmate information in its SENTRY, Bureau Electronic Medical Record (BEMR), and Psychology Data System (PDS) data systems to identify inmates with serious mental illness. To assess the reliability of the these data, we performed electronic data testing for obvious errors in accuracy and completeness, and interviewed agency officials knowledgeable about these systems to determine the processes in place to ensure the integrity of the data. We determined that the data were sufficiently reliable for identifying the population of BOP inmates with serious mental illness, for the purposes of this report. To determine what types of crimes were committed by inmates with serious mental illness who were incarcerated by the federal and selected state governments we analyzed available data from BOP and the departments of corrections in selected states on the most serious types of crimes for which inmates with serious mental illness were incarcerated during fiscal year 2017. BOP officials track and maintain information on the types of crimes for which inmates have been incarcerated via SENTRY. We interviewed officials from BOP’s Office of Research and Evaluation, Reentry Services Division, and Correctional Programs Division to discuss the number and types of crimes committed by BOP inmates with serious mental illness. To assess the reliability of BOP’s criminal offense data, tracked in BOP’s SENTRY system, we performed electronic data testing for obvious errors in accuracy and completeness, and interviewed agency officials from BOP’s Office of Research and Evaluation knowledgeable about BOP’s inmate tracking system to determine the processes in place to ensure the integrity of the data. We determined that the data were sufficiently reliable for the purposes of this report. We also interviewed and received written responses from officials from the selected state departments of corrections to determine the challenges they faced in recording, tracking, and maintaining data on inmates with serious mental illness, but we did not independently assess the internal controls associated with the selected states’ data systems. We provided state level data as illustrative examples of the crimes committed by inmates with serious mental illness in selected states. To identify what is known about the costs to the federal and selected state governments to incarcerate and provide mental health services to incarcerated individuals with serious mental illness, we interviewed and received written responses from officials from BOP’s Reentry Services Division, Correctional Programs Division, Administration Division, Program Review Division, and Health Services Division, and the departments of corrections in selected states to discuss and obtain documentation on the processes and systems used to track the costs to incarcerate and provide mental health services to inmates with serious mental illness, and obtain their perspectives on the challenges faced, if any, in tracking such costs. We analyzed BOP obligation data from fiscal year 2016 for the following budget categories: Psychology Services, psychotropic medications, and Residential Reentry Center mental health care costs. We included these obligation categories as indicators of BOP mental health care costs because our prior work identified that these services were used by inmates with mental illness. To assess the reliability of BOP’s obligations data, we performed electronic testing for obvious errors in accuracy and completeness, and interviewed agency officials knowledgeable about BOP’s budget to determine the processes in place to ensure the integrity of the data. We determined that the data were sufficiently reliable for the purposes of this report. In response to our inquiries, the selected states provided various data on costs to incarcerate and provide mental health care to inmates under their supervision. We did not independently assess the internal controls associated with the selected states’ data systems. We provided state level data as illustrative examples of the manner in which state correctional agencies tracked costs of incarceration and mental health care services for inmates under their supervision. Additionally, we obtained and analyzed BOP data from PDS on the extent to which inmates interacted with Psychology Services personnel and programs during fiscal year 2016, to calculate the average psychology services interactions (by category) per inmate during fiscal year 2016. To assess the reliability of BOP’s psychology services utilization services data, we performed electronic testing for obvious errors in accuracy and completeness, and interviewed agency officials knowledgeable about BOP’s psychology services to determine the processes in place to ensure the integrity of the data. We determined that the data were sufficiently reliable for the purposes of this report. To determine what strategies for reducing recidivism among individuals with serious mental illness have been identified by the federal and selected state governments and in literature, we obtained and analyzed documents and interviewed officials from BOP and the selected states’ corrections departments, as well as from DOJ and HHS organizations that support research, training, and programs related to mental health and recidivism. These DOJ organizations included the National Institute of Corrections, within BOP, and the Bureau of Justice Assistance and National Institute of Justice, within the Office of Justice Programs. The Department of Health and Human Services (HHS) organizations included SAMHSA and the National Institute of Mental Health. We also interviewed subject matter experts from the Council of State Governments Justice Center, Pew Charitable Trusts, and the Treatment Advocacy Center, which we selected to obtain perspectives from researchers and mental health and criminal justice organizations. Further, we conducted a literature review of studies that have sound methodologies and use primary data collection or secondary analysis to assess the impact of programs or interventions during incarceration or reentry on recidivism among adult offenders with mental illness. To identify relevant studies, we took the following steps: 1. A GAO research librarian conducted searches of various research databases and platforms including ProQuest, MEDLINE, PsycINFO, Social SciSearch, and Scopus, among others, to identify scholarly and peer reviewed publications; government reports; and publications by trade associations, nonprofits and think tanks from 2008 through 2017, a period chosen to identify a comprehensive set of relevant and timely research. 2. We identified and reviewed selected additional studies that were cited within literature reviews, meta analyses and studies referenced on information-sharing websites, including the Council of State Governments’ “What Works in Reentry” website, National Institute of Justice’s “Crime Solutions” website, and SAMHSA’s Registry of Evidence Based Practices and Programs, and other secondary sources published from 2000 through 2017. We chose this time period to ensure we identified key older, reliable studies we may have missed by virtue of our database search timeframe. We identified these secondary resources during the course of our audit through the previously discussed database search, interviews with agency officials and representatives from research, criminal justice, and mental health organizations, and by reviewing websites of relevant agencies. The literature search produced about 200 publications. To select studies that were relevant to our research objective two reviewers independently assessed the abstracts for each publication using the following criteria: 1. Program studied was implemented in the U.S. 2. Study described in the publication includes original data analysis to assess the impact of a program for adults with mental illness on recidivism. For those that met the above two criteria we obtained and reviewed the full text of the publication, using the same criteria. We also further categorized the studies that met the two criteria above into the following categories: 1) studies that evaluated programs implemented during the period of incarceration or reentry, 2) studies that evaluated programs meant to divert individuals with serious mental illness from jail or prison (e.g., mental health courts) and 3) other, for those interventions that did not fall into either of these categories. As our review focused on strategies to reduce recidivism during incarceration and reentry, we excluded the studies on diversion programs (the second category). We evaluated the 31 studies that fell into the incarceration and reentry and the other categories using a data collection instrument. The data collection instrument captured information on the elements of the program, the recidivism effects, and the study’s methodology. The data collection instrument was initially filled out by one individual and then verified for accuracy by another individual; any differences in the individuals’ assessments were discussed and reconciled. To determine if the findings of the 31 studies should be included in our review of the literature, the study reviewers conferred regarding each study and assessed if: 1) the study was sufficiently relevant to the objective; and 2) the study’s methodology was sufficiently rigorous. With regard to the study’s relevance, we included studies that evaluated: a program for individuals with mental illness incarcerated in prison or jail or provided directly upon release from prison or jail; or a program for individuals with mental illness that is not provided in a prison, jail, or directly upon release from prison or jail (e.g., in a psychiatric hospital or in the community after a psychiatric hospitalization), but is hypothesized to impact criminal justice involvement and could potentially be applied in a correctional setting. With regard to methodological rigor, two GAO methodologists used generally accepted social science standards to assess the design and analytic strategy of each study to ensure analyses were sufficiently sound to support the results and conclusions. Specifically, the methodologists examined such factors as how the effects of the programs were isolated (i.e., use of comparison groups and statistical controls); the appropriateness of treatment and comparison group selection, if used; and the statistical analyses used. As a result of this process, we found 18 studies within the scope of our review that used sufficiently sound methodologies. Some studies used a randomized controlled trial methodology or quasi-experimental research designs, and some studies used non-experimental designs to compare recidivism outcomes for a single population before and after the intervention. These studies used various recidivism measures, and some used more than one measure. For each of the 18 studies, we reviewed the study’s findings related to recidivism, and categorized the findings based on statistical significance as follows: Statistically significant reduction in recidivism: the study reported that one or more outcome measures indicated a statistically significant reduction in recidivism among program participants; the study may also have one or more recidivism outcome measures that were not statistically significant. Statistically significant increase in recidivism: the study reported that one or more outcome measures indicated a statistically significant increase in recidivism among program participants; the study may also have one or more recidivism outcome measures that were not statistically significant. No statistically significant effect on recidivism: the study reported only outcomes indicating no statistically significant effect on recidivism among program participants. For a list of the 18 studies, see appendix VII. We conducted this performance audit from February 2017 through February 2018, in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Federal agencies have established interagency groups and other mechanisms, such as web-based resources, to share information related to correctional mental health and reducing recidivism among individuals with serious mental illness, among other things. Examples of these information sharing mechanisms are described in table 5 below. Our literature review also identified four studies that met the criteria of (1) containing quantitative analyses of the effect of a program for individuals with mental illness on recidivism, and (2) using sufficiently sound methodologies for conducting such analyses; but were in non-correctional settings, such as in a psychiatric hospital or in the community after a psychiatric hospitalization. While the findings from these studies may not be generalizable to a correctional setting, they may offer insights on effective strategies for reducing recidivism, as many of the program participants had a history of involvement with the criminal justice system. As shown in figure 7, half (2 of 4) of the studies found statistically significant reductions in recidivism. The non-correctional programs that were found to reduce recidivism included some of the same elements as the correctional programs that reduced recidivism, including mental health treatment (2 of 2 studies), substance abuse treatment (1 of 2 studies), case management (2 of 2 studies), release planning (1 of 2 studies), employment assistance (2 of 2 studies), housing assistance (1 of 2 studies), and multidisciplinary coordination among mental health providers, substance use specialists, social workers, and/or peer support specialists, for example (1 of 2 studies). However, similar to the literature on correctional programs, there were also studies that found that programs that offered multiple support services did not reduce recidivism, suggesting other factors may affect recidivism; such factors may include the extent to which participants used services, as previously noted, as well as other unique programmatic factors. We further discuss examples of programs that did and did not reduce recidivism below. For example, study 15 evaluated New York’s Assisted Outpatient Treatment, a court-ordered treatment program for individuals with mental illness and a history of multiple hospitalizations or violence toward self or others. Individuals entering the program are assigned a case manager and prioritized for enhanced services that include housing and vocational services. Researchers found that the comparison group who never received Assisted Outpatient Treatment had nearly double the odds (odds ratio of 1.91) of being arrested than program participants during and shortly after the period of assignment to the program. The programs that were found not to reduce recidivism also provide some insights into factors that affect recidivism. For example, study 18 evaluated a Pennsylvania-based modified outpatient therapeutic community treatment program for individuals with co-occurring substance use disorder and emotional distress or mental illness and found that it had no significant effect on recidivism. Researchers attributed this finding to the program’s emphasis on substance use rather than on addressing criminogenic risks. The 14 studies we identified through our literature review that (1) assessed correctional institution or reentry programs for offenders with mental illness implemented in the United States (2) contained quantitative analyses of the effect of a program on recidivism, and (3) used sufficiently sound methodologies for conducting such analyses, used a number of different recidivism outcome measures, and some assessed more than one recidivism outcome measure. Tables 7, 8, and 9 below show the recidivism results for studies that measured reincarceration rates, reconviction rates, and number of days in jail or prison, which were reported by multiple studies. These do not represent all recidivism findings; some studies used other recidivism measures such as the number of arrests or convictions, odds ratio or hazard ratio of reincarceration, and self-reported criminal activity. This bibliography contains citations for the 18 studies we reviewed regarding programs for individuals with mental illness that may affect recidivism. (See appendix II for more information about how we identified these studies.) Following the citation we include the study numbers that we used to reference the study earlier in this report. Burke, C. and S. Keaton. San Diego County’s Connections Program Board of Corrections Final Report. San Diego, CA: SANDAG, June 2004. (Study 1) Chandler, D.W. and G. Spicer. “Integrated Treatment for Jail Recidivists with Co-occuring Psychiatric and Substance Use Disorders.” Community Mental Health Journal, vol. 42, no. 4 (2006):405-425. (Study 2) Compton, M.T., M.E. Kelley, A. Pope, K. Smith, B. Broussard, T.A. Reed, J.A. DiPolito, B.G. Druss, C. Li, and N.L. Haynes. “Opening Doors to Recovery: Recidivism and Recovery Among Persons With Serious Mental Illnesses and Repeated Hospitalizations.” Psychiatric Services, vol. 62, no. 2 (2016): 169-175. (Study 17) Cusack, K.J., J.P. Morrissey, G.S. Cuddleback, A. Prins, and D.M. Williams. “Criminal Justice Involvement, Behavioral Health Service Use, and Costs of Forensic Assertive Community Treatment: A Randomized Trial.” Community Mental Health Journal, vol. 46 (2010): 356-363. (Study 4) Duwe, G. “Does Release Planning for Serious and Persistent Mental Illness Offenders Reduce Recidivism? Results From an Outcome Evaluation.” Journal of Offender Rehabilitation, vol. 54, no. 1 (2015): 19- 36. (Study 11) Link, B.G., M.W. Epperson, B.E. Perron, D.M. Castille, and L.H. Yang. “Arrest Outcomes Associated with Outpatient Commitment in New York State.” Psychiatric Services, vol. 62, no. 5 (2011): 504-508. (Study 15) Mayfield, J. The Dangerous Mentally Ill Offender Program: Four-Year Felony Recidivism and Cost Effectiveness. Olympia, WA: Washington State Institute for Public Policy, February 2009. (Study 9) Morrissey, J.P., G.S. Cuddeback, A.E. Cuellar, and H.J. Steadman. “The Role of Medicaid Enrollment and Outpatient Service Use in Jail Recidivism Among Persons with Severe Mental Illness.” Psychiatric Services, vol. 58, no. 6 (2007):794-801. (Study 5) Morrissey, J.P., M.E. Domino, and G.S. Cuddeback. “Expedited Medicaid Enrollment, Mental Health Service Use, and Criminal Recidivism Among Released Prisoners With Severe Mental Illness.” Psychiatric Services, vol. 67, no. 8 (2016): 842-849. (Study 10) Sacks, J.Y., K. McKendrick, and Z. Hamilton. “A Randomized Clinical Trial of a Therapeutic Community Treatment for Female Inmates: Outcomes at 6 and 12 Months After Prison Release.” Journal of Addictive Diseases, vol. 31, no. 3 (2012): 258-269. (Study 7) Sacks, S., M. Chaple, J.Y. Sacks, K. McKendrick, C.M. Cleland. “Randomized Trial of a Reentry Modified Therapeutic Community for Offenders with Co-Occuring Disorders: Crime Outcomes.” Journal of Substance Abuse Treatment, vol. 42 (2012): 247-259. (Study 3) Sacks, S, K. McKendrick, J.Y. Sacks, S. Banks, M. Harle. “Enhanced Outpatient Treatment for Co-Occurring Disorders: Main Outcomes.” Journal of Substance Abuse Treatment, vol. 34 (2008): 48-60. (Study 18) Sacks, S., J.Y. Sacks, K. McKendrick, S. Banks, and J. Stommel. “Modified TC for MICA Offenders: Crime Outcomes.” Behavioral Sciences and the Law, vol. 22 (2004): 477-501. (Study 6) Taylor, N. An Analysis of the Effectiveness of Santa Clara County’s Mentally Ill Offender Crime Reduction Program. Anne Arbor, MI: ProQuest Information and Learning Company, May 2005. (Study 14) Theurer, G. and D. Lovell. “Recidivism of Offenders with Mental Illness Released from Prison to an Intensive Community Treatment Program.” Journal of Offender Rehabilitation, vol. 47, no. 4 (2008): 385-406. (Study 8) Van Stelle, K.R., and D.P. Moberg. “Outcome Data for MICA Clients After Participation in an Institutional Therapeutic Community.” Journal of Offender Rehabilitation, vol. 39 no.1 (2004): 37-62. (Study 12) Yates, K.F., M. Kunz, A. Khan, J. Volavka, and S. Rabinowitz. “Psychiatric Patients with Histories of Aggression and Crime Five Years after Discharge from a Cognitive-Behavioral Program.” The Journal of Forensic Psychiatry and Psychology, vol. 21, no. 2 (2010):167-188. (Study 16) Zlotnick, C., J. Johnson, and L.M. Najavits. “Randomized Controlled Pilot Study of Cognitive-Behavioral Therapy in a Sample of Incarcerated Women with Substance Use Disorder and PTSD.” Behavior Therapy, vol. 40 (2009): 325-336. (Study 13) In addition to the contact above, Tom Jessor (Assistant Director); Frederick Lyles, Jr. (Analyst-in-Charge); Pedro Almoguera; David Blanding, Jr.; Billy Commons, III; Thomas C. Corless; Dominick Dale; Michele Fejfar; Eric Hauswirth; Valerie Kasindi; Heather May; Leia J. Dickerson; Sam Portnow; and Cynthia Saunders all made key contributions to this report.

Summary: In 2016, SAMHSA estimated that about 10.4 million adults in the United States suffered from a serious mental illness, which generally includes conditions such as schizophrenia and bipolar disorder. As of May 27, 2017, BOP was responsible for overseeing 187,910 inmates and 7,831 of these inmates were considered to have a serious mental illness. Research has shown that inmates with serious mental illness are more likely to recidivate than those without. The 21st Century Cures Act directed GAO to report on the prevalence of crimes committed by persons with serious mental illness and the costs to treat these offenders—including identifying strategies for reducing recidivism among these individuals. This report discusses (1) what is known about crimes committed by inmates with serious mental illness incarcerated by the federal and selected state governments; (2) what is known about the costs to the federal and selected state governments to incarcerate and provide mental health care services to those individuals; and (3) what strategies have the federal and selected state governments and studies identified for reducing recidivism among individuals with serious mental illness. GAO selected six states that varied in their adult incarceration rates and provided geographic diversity. At BOP and the six states' departments of corrections, GAO analyzed criminal offense and incarceration and mental health care cost data and interviewed officials about strategies for reducing recidivism for inmates with serious mental illness. The results from these six states are not generalizable, but provide insights. GAO also reviewed studies that analyzed the relationship between various programs and recidivism among offenders with mental illness. About two-thirds of inmates with a serious mental illness in the Department of Justice's (DOJ) Federal Bureau of Prisons (BOP) were incarcerated for four types of offenses—drug (23 percent), sex offenses (18 percent), weapons and explosives (17 percent), and robbery (8 percent)—as of May 27, 2017. GAO's analysis found that BOP inmates with serious mental illness were incarcerated for sex offenses, robbery, and homicide/aggravated assault at about twice the rate of inmates without serious mental illness, and were incarcerated for drug and immigration offenses at about half or less the rate of inmates without serious mental illness. GAO also analyzed available data on three selected states' inmate populations and the most common crimes committed by inmates with serious mental illness varied from state to state due to different law enforcement priorities, definitions of serious mental illness and methods of tracking categories of crime in their respective data systems. BOP does not track costs related to incarcerating or providing mental health care services to inmates with serious mental illness, but BOP and selected states generally track these costs for all inmates. BOP does not track costs for inmates with serious mental illness in part because it does not track costs for individual inmates due to resource restrictions and the administrative burden such tracking would require. BOP does track costs associated with mental health care services system-wide and by institution. System-wide, for fiscal year 2016, BOP spent about $72 million on psychology services, $5.6 million on psychotropic drugs and $4.1 million on mental health care in residential reentry centers. The six state departments of corrections each used different methods and provided GAO with estimates for different types of mental health care costs. For example, two states provided average per-inmate costs of incarceration for mental health treatment units where some inmates with serious mental illness are treated; however, these included costs for inmates without serious mental illness housed in those units. DOJ, Department of Health and Human Service's Substance Abuse and Mental Health Services Administration (SAMHSA), and criminal justice and mental health experts have developed a framework to reduce recidivism among adults with mental illness. The framework calls for correctional agencies to assess individuals' recidivism risk and substance abuse and mental health needs and target treatment to those with the highest risk of reoffending. To help implement this framework, SAMHSA, in collaboration with DOJ and other experts, developed guidance for mental health, correctional, and community stakeholders on (1) assessing risk and clinical needs, (2) planning treatment in custody and upon reentry based on risks and needs, (3) identifying post-release services, and (4) coordinating with community-based providers to avoid gaps in care. BOP and the six states also identified strategies for reducing recidivism consistent with this guidance, such as memoranda of understanding between correctional and mental health agencies to coordinate care. Further, GAO's literature review found that programs that reduced recidivism among offenders with mental illness generally offered multiple support services, such as mental health and substance abuse treatment, case management, and housing assistance.