Medication Adherence and Substance Abuse Predict 18-Month Recidivism among Mental Health Jail Diversion Program Clients Elizabeth N. Burris 1, Evan M. Lowder 1, Candalyn B. Rade 1, Sarah L. Desmarais 1, & Richard A. Van Dorn 2 1 North Carolina State University, 2 RTI International Introduction The Present Study Methods Discussion Results Acknowledgments This project was funded by the Bristol Myers Squibb Foundation. We thank the 11 th Judicial District of Florida Criminal Mental Health Project for its cooperation and support. Prior studies have established an association between medication adherence and recidivism among adults with mental illnesses. For example, Young and colleagues (1999) found patients with schizophrenia who failed to adhere to medication were at increased risk for recidivism. In another study of adults with serious mental illnesses, monthly medication possession after hospitalization was associated with decreased rates of arrest (Van Dorn, Desmarais, Petrila, Hayes & Singh, 2013). Similarly, multiple studies have established an association between co-occurring substance use and recidivism among justice-involved adults with mental illnesses, including prison inmates (Baillargeon et al., 2010), jail inmates (Wilson et al., 2011), and probationers (Castillo & Alarid, 2011). However, there is relatively limited research on the relationship between substance use and medication adherence with recidivism among justice-involved adults with mental illness. Farabee and Shen (2004) found substance use was associated with increased recidivism rates in a population of parolees with serious mental illnesses who used cocaine and were prescribed antipsychotic medication. Additionally, there was a significant interaction between substance use and medication adherence on recidivism; however, medication adherence alone was not significantly associated with decreased recidivism (Farabee and Shen, 2004). To our knowledge, no study to date has examined the associations of substance use and medication adherence among mental health diversion clients with recidivism as the primary outcome. The present study explored associations between medication adherence, substance use, and recidivism at 6-,12-, and 18-month follow-up in a sample of mental health jail diversion clients. Specifically, we examined associations between: 1) medication adherence and recidivism; 2) substance use and recidivism; 3) medication adherence and substance use; 4) medication adherence and recidivism after controlling for substance use, and 5) substance use and recidivism after controlling for medication adherence. Study Context Data were collected as part of a larger study evaluating behavioral health services delivered to participants in mental health jail diversion programs in a metropolitan center of a southeastern state. Sample Participants were 95 mental health jail diversion clients (81.1% male). Half were Hispanic/Latino (54.7%) and 44.2% identified as African American. The sample included felony (47.4%) and misdemeanor (52.6%) diversion clients. Participants had an average of 6.69 (SD = 5.42) jail bookings in the past three years and (SD = 14.99) lifetime bookings. Primary diagnoses included schizophrenia (35.8%), psychosis NOS (25.3%), and bipolar disorder (20.0%). Measures Medication Adherence. Medication adherence was measured by the self-reported number of times in the three months prior to baseline participants had taken prescribed medication for behavioral health problems. Participants who never missed taking their medication or missed only one or two times were coded as adherent. All other responses were coded as non-adherent. Substance Use. Substance use was defined as whether participants had a current substance use diagnosis at baseline or were currently using at baseline as indicated by an Addiction Severity Index (ASI; McLellan et al., 1992) alcohol composite score of ≥0.17 or drug composite score of ≥0.16 (Rikoon et al. 2006). Recidivism. Self-reported and official recidivism records were used to measure any arrest, number of arrests, any jail, and days incarcerated at each follow-up period. Procedures Semi-structured interviews were conducted by trained research assistants at baseline 6-,12-, and 18-month follow-up. Participant demographics were collected at baseline; recidivism was collected at all follow-up periods. Findings revealed medication adherence and substance use predicted arrest and incarceration over the 18-month follow-up period in a sample of mental health jail diversion program clients. Consistent with research in other populations (Farabee & Shen, 2004; Wilson et al., 2011), findings suggest that substance use is associated with recidivism in a mental health jail diversion sample. Additionally, and inconsistent with prior research in other populations (Young et al.,1999; Van Dorn et al. 2013), medication adherence was not associated with recidivism in bivariate analyses; however, when controlling for substance use, baseline medication adherence predicted recidivism at follow-up. Conclusions are limited by the self-report nature of the data, low base rates, and sample homogeneity. Implications include the need for improved access to services to promote medication adherence and substance use treatment which may decrease substance use and increase medication adherence rates. Further research is needed to clarify the role of substance use and medication adherence in predicting recidivism among mental health jail diversion samples over longer follow-up periods and with additional covariates, including psychiatric symptom severity. Descriptive Statistics Overall, few participants were incarcerated or arrested (see Table 1).The majority of participants reported being medication adherent, and approximately half had co-occurring substance use. Table 1. Descriptive Statistics Substance Use Logistic regression analyses revealed substance use was significantly associated with any jail (OR = 1.77; p =.058) and days incarcerated (OR = 0.44; p =.032) at 18-month follow-up. Specifically, participants who were using substances at baseline were likely to spend more time in jail at 18-month follow-up, compared to participants who were not using substances at baseline. However, substance use at baseline was not significantly associated with recidivism across other follow-up periods. Medication Adherence Logistic regression analyses revealed medication adherence alone was not significantly associated with any arrests (ps ≥.119), number of arrests (ps ≥.179), any jail (ps ≥.111), or days incarcerated (ps ≥.217) across all follow-up periods. Substance Use, Medication Adherence, and Recidivism A series of logistic regression analyses were conducted with substance use and medication adherence as predictors of recidivism (see Table 2). Results showed that participants who were medication adherent at baseline, compared to those who were not, were more likely to be arrested or incarcerated during the 18-month follow-up period, while controlling for substance use. Additionally, when controlling for medication adherence, participants who were using substances at baseline, compared to those who were not, were more likely to be arrested or incarcerated during the 18-month follow-up period. Logistic regression models testing associations of medication adherence and substance use at baseline with recidivism were not significant for 6-month and 12-month follow-up. Table 2. Summary of Logistic Regression Results Notes. *p <.05 **p <.01 ***p <.001. OR = Odds Ratio; CI = confidence interval. Medication Adherence and Substance Use Chi-squared analyses revealed a marginally significant difference in the likelihood of substance use as a function of medication adherence (OR = 0.69; p =.060). Participants who were not medication adherent at baseline were more likely to report substance use at baseline, compared to participants who were medication adherent.