"Good luck, social distance": rapid decarceration and community care for serious mental illness and substance use disorder during the COVID-19 pandemic.

The COVID-19 pandemic inspired calls for rapid decarceration of prisons and jails to slow the spread of disease in a high-risk congregate setting. Due to the rarity of intentionally-decarcerative policies, little is known about the effects of rapid decarceration on individuals with serious mental illness (SMI) substance use disorder (SUD), a population who receive many services via the criminal legal system (CLS). We conducted interviews with 13 key informants involved in CLS in San Francisco, CA to better understand the implication of the decarcerative policies put into practice in early 2020. Participants described a tension between the desire to have fewer people incarcerated and the challenges of accessing services and support - especially during the lockdown period of the pandemic - outside of the CLS given the number of services that are only accessible to those who have been arrested, incarcerated, or sentenced. These findings emphasize the need for investing in community social services rather than further expanding the CLS to achieve the goal of supporting individuals with SMI and SUD shrinking the US system of mass incarceration.

Nowhere Else to Go-Solitary Confinement as Mental Health Care.

This Viewpoint examines the clinical, ethical, and legal concerns of the use of solitary confinement to manage acute psychiatric distress among incarcerated people.

Mental Health and Legal Implications of Access to the Outdoors during Incarceration.

The prevalence of mental disorders and substance use disorders among incarcerated populations has called attention to the availability of mental health services in U.S. jails and prisons. Yet, structural factors, such as access to outdoor recreation, can also shape mental health in correctional environments, and U.S. jails and prisons often restrict incarcerated people from going outside. This article examines correctional policies on outdoor access, including mental health implications and related litigation. Research supports the widely held view that outdoor access can be an important determinant of mental health; nevertheless, U.S. courts have come to varying conclusions about the rights of incarcerated people to such access, leading to a patchwork of legal precedents and institutional practices with some striking inequities. For example, in California, pretrial detainees who have not been convicted of any crimes may be denied outdoor access for years, whereas convicted individuals on death row typically have access to weekly outdoor time. By examining mental health literature and case law, the authors suggest general principles for the provision of outdoor access to incarcerated individuals, as well as call for additional research on the adverse effects of the common practice of restricting such access.

Understanding the association between frequent emergency department use and jail incarceration: A cross-sectional analysis.

BACKGROUND: Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration. METHODS: We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters. RESULTS: The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest. CONCLUSIONS: Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.

Gentrification and Displacement in the San Francisco Bay Area: A Comparison of Measurement Approaches.

Gentrification may play an important role in influencing health outcomes, but few studies have examined these associations. One major barrier to producing empirical evidence to establish this link is that there is little consensus on how to measure gentrification. To address this barrier, we compared three gentrification classification methodologies in relation to their ability to identify neighborhood gentrification in nine San Francisco Bay Area counties: the Freeman method, the Landis method, and the Urban Displacement Project (UDP) Regional Early Warning System. In the 1580 census tracts, 43% of the population had a bachelor's degree or higher. The average median household income was $79,671 in 2013. A comparison of gentrification methodologies revealed that the Landis and Freeman methodologies characterized the vast majority of census tracts as stable, and only 5.2% and 6.1% of tracts as gentrifying. UDP characterized 46.7% of tracts at risk, undergoing, or experiencing advanced stages of gentrification and displacement. There was substantial variation in the geographic location of tracts identified as gentrifying across methods. Given the variation in characterizations of gentrification across measures, studies evaluating associations between gentrification and health should consider using multiple measures of gentrification to examine the robustness of the study findings across measures.

Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine.

Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.

Gentrification and binge drinking in California neighborhoods: It matters how long you've lived there.

BACKGROUND: Neighborhood context plays a role in binge drinking, a behavior with major health and economic costs. Gentrification, the influx of capital and residents of higher socioeconomic status into historically-disinvested neighborhoods, is a growing trend with the potential to place urban communities under social and financial pressure. Hypothesizing that these pressures and other community changes resulting from gentrification could be tied to excessive alcohol consumption, we examined the relationship between gentrification and binge drinking in California neighborhoods. METHODS: California census tracts were categorized as non-gentrifiable, stable (gentrifiable), or gentrifying from 2006 to 2015. Outcomes and covariates were obtained from the California Health Interview Survey using combined 2013-2015 data (n = 60,196). Survey-weighted logistic regression tested for associations between gentrification and any binge drinking in the prior 12 months. Additional models tested interactions between gentrification and other variables of interest, including housing tenure, federal poverty level, race/ethnicity, sex, and duration of neighborhood residence. RESULTS: A third of respondents reported past-year binge drinking. Controlling for demographic covariates, gentrification was not associated with binge drinking in the population overall (AOR = 1.13, 95% CI = 0.95-1.34), but was associated with binge drinking among those living in the neighborhood <5 years (AOR = 1.49, 95% CI 1.15-1.93). No association was seen among those living in their neighborhood ≥5 years. CONCLUSIONS: For those newer to their neighborhood, gentrification is associated with binge drinking. Further understanding the relationship between gentrification and high-risk alcohol use is important for policy and public health interventions mitigating the impact of this process.

Competencies for Global Mental Health: Developing Training Objectives for a Post-Graduate Fellowship for Psychiatrists.

BACKGROUND: Despite an increase in psychiatry trainees' interest in global mental health (GMH), there is a lack of relevant training competencies developed using educational frameworks that incorporate viewpoints from high- and low-income countries. Objective: The aim of this study was to determine competencies for a two-year post-graduate GMH fellowship for psychiatrists utilizing Kern's six-step process as a theoretical framework for curriculum development. Methods: We conducted a targeted needs assessment via key informant interviews with a purposive sample of stakeholders (n = 19), including psychiatry trainees, generalist clinicians, medical directors, psychiatrists, researchers, and GMH educators from high- and low-resource settings in the United States and abroad. We analyzed data using a template method of thematic analysis. Findings: We tabulated learning objectives across 20 domains. Broadly, clinical objectives focused on providing supervision for short-term, evidence-based psychotherapies and on identifying red flags and avoiding harmful medication use among vulnerable populations such as children and the elderly. Non-clinical objectives focused on social determinants of health, education, and clinical supervision as part of capacity-building for non-specialists, engagement in a systems-wide project to improve care, and ethical and equitable partnerships that involve reciprocal and bidirectional education. Several competencies were also relevant for global health work in general. Conclusions: A theory-informed framework for curriculum development and a diverse set of key informants can provide educational objectives that meet the priorities of the trainees and the clinical sites in both low- and high-income settings. Limitations of this study include a small sample size and a focus on clinical needs of specific sites, both of which may affect generalizability. Given the focus on training specialists (psychiatrists), the low-resource sites highlighted the importance of educating and supervising their permanent, generalist clinicians, rather than providing direct, independent patient care.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study.

INTRODUCTION: The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours. METHODS: In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects. RESULTS: Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X (2)=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there. CONCLUSIONS: Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators.

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Hospitality Invites Sociability, Which Builds Cohesion: a Model for the Role of Main Streets in Population Mental Health.

The aim of this study was to investigate the contribution of main streets to community social cohesion, a factor important to health. Prior work suggests that casual contact in public space, which we call "sociability," facilitates more sustained social bonds in the community. We appropriate the term "hospitality" to describe a main street's propensity to support a density of such social interactions. Hospitality is a result of the integrity and complex contents of the main street and surrounding area. We examine this using a typology we term "box-circle-line" to represent the streetscape (the box), the local neighborhood (the circle), and the relationship to the regional network of streets (the line). Through field visits to 50 main streets in New Jersey and elsewhere, and a systematic qualitative investigation of main streets in a densely interconnected urban region (Essex County, New Jersey), we observed significant variation in main street hospitality, which generally correlated closely with sociability. Physical elements such as street wall, neighborhood elements such as connectivity, inter-community elements such as access and perceived welcome, and socio-political elements such as investment and racial discrimination were identified as relevant to main street hospitality. We describe the box-circle-line as a theoretical model for main street hospitality that links these various factors and provides a viable framework for further research into main street hospitality, particularly with regard to geographic health disparities.

Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour.

BACKGROUND: In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV. METHODS: A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI. RESULTS: Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005). CONCLUSIONS: Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine.

BACKGROUND: People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined. METHODS: A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL). RESULTS: On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants. CONCLUSIONS: These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.

High rates of police detention among recently released HIV-infected prisoners in Ukraine: implications for health outcomes.

BACKGROUND: Ukraine's HIV epidemic, primarily affecting people who inject drugs (PWID), is expanding and transitioning despite free opioid substitution therapy (OST) and antiretroviral therapy (ART), two effective ways to reduce HIV transmission. Police detention of PWID not resulting in a formal charge or imprisonment is common, but its prevalence and impact on health are not known. METHOD: HIV-infected individuals (N=97) released from prison within one year were recruited and surveyed in two HIV-endemic Ukrainian cities about post-release police detention experiences. Data on the frequency of police detention, related adverse events, and impact on OST and ART continuity were collected, and correlates of detention were examined using logistic regression. RESULTS: Detention responses were available for 94 (96.9%) participants, of which 55 (58.5%) reported police detentions (mean=9.4 per person-year). For those detained while prescribed OST (N=28) and ART (N=27), medication interruption was common (67.9% and 70.4%, respectively); 23 of 27 participants prescribed OST (85.2%) were detained en route to/from OST treatment. Significant independent correlates of detention without charges included post-release ART prescription (AOR 4.98, p=0.021), current high-risk injection practices (AOR 5.03, p=0.011), male gender (AOR 10.88, p=0.010), and lower lifetime months of imprisonment (AOR 0.99, p=0.031). CONCLUSIONS: HIV-infected individuals recently released from prison in Ukraine experience frequent police detentions, resulting in withdrawal symptoms, confiscation of syringes, and interruptions of essential medications, including ART and OST. Structural changes are urgently needed to reduce police detentions in order to control HIV transmission and improve both individual and public health.