Local access to mental healthcare and crime

Monica Deza, Catherine Maclean, Keisha Solomon 14 November 2020

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The correlation between mental illness and crime has been widely documented. In general, individuals with poor mental health are more likely to be involved with crime, either as an offender or as a victim, compared to other individuals. As a specific example, 50% of individuals incarcerated in US jails and prisons have been diagnosed with a mental illness (James and Glaze 2006), more than double the rate among the civilian adult population (Center for Behavioral Health Statistics and Quality 2020). Further, the number of individuals with mental illness housed in large US incarceration facilities (Cook County Jail, Los Angeles County Jail, and Riker’s Island) exceeds the number of patients in any psychiatric institution in the country (Frank and McGuire 2010).  

Recent violent attacks, particularly mass shootings, have been linked (at least anecdotally) to mental illness within the media, and, occasionally, by elected officials. These events have spurred public discussion among Americans of mental healthcare as a potential crime reduction tool alongside more standard policy approaches such as optimising policing strategies and expanding the size of the police workforce.

Indeed, there is an argument to be made that mental healthcare is not used to its full potential from the perspective of crime-control within the US. To date, US criminal justice policies that encompass mental healthcare are mainly restricted to involuntary treatment. For instance, the criminal justice system has made ample use of involuntary commitment laws, which afford discretion to judges to mandate that convicted offenders receive mental healthcare treatment or face (additional) time incarcerated (Swartz et al. 2017, Kisely et al. 2017). While involuntary mental healthcare treatment may prevent recidivism among offenders mandated to seek treatment as part of their sentence (McNiel and Binder 2007, Abracen et al. 2016), numerous modalities of voluntary mental healthcare are also effective in improving mental health among non-incarcerated populations (i.e. counselling and pharmacotherapies (American Psychiatric Association 2006)). Such voluntary treatment could plausibly decrease crime rates. These changes could occur in terms of reducing the propensity to commit a crime. For example, through an improved ability to de-escalate violent situations and by improving labour market outcomes (which can mitigate need to engage in financially motivated crime). Improved mental health through treatment could also lessen the likelihood of crime victimisation. For example, by reducing homelessness (which increases the opportunities for victimisation) which is much more prevalent among those with mental illness than among other individuals. 

However, despite its effectiveness, mental healthcare is possibly underused within the general (non-incarcerated) population in the US. The most recent government data suggest that more than 50% of US non-institutionalised adults meeting diagnostic criteria for a mental illness did not receive any mental healthcare in the past year (Center for Behavioral Health Statistics and Quality 2020). Further, there are well-established shortages of mental healthcare providers: the Kaiser Family Foundation (2020) documents that in 2018 just 26% of mental healthcare needs were met with the existing supply. There are of course myriad reasons for not seeking mental healthcare that are likely unrelated to the ability to access a provider. These include stigma, inability to pay, and a belief that treatment is not needed and/or not effective (Walker et al. 2015, Center for Behavioral Health Statistics and Quality 2020). However, difficulty locating a provider is a commonly stated barrier among individuals who meet diagnostic criteria for a mental illness but do not receive care (Center for Behavioral Health Statistics and Quality 2020). Hence, expanding the number of providers could spur greater treatment uptake, improved mental health, and, in turn, less crime.  

We attempt to shed new light on this question in our recent working paper (Deza et al. 2020). Specifically, we explore the effect of access to office-based mental healthcare on crime. That is, we focus on physicians (e.g. psychiatrists) and non-physicians (e.g. psychologists) who specialise in mental healthcare treatment delivered within a private office. While a patient seeking mental healthcare has a wide range of treatment options from which to choose, we view office-based care as important to study in terms of reducing crime. First, office-based providers play an increasingly important role in delivering mental healthcare: their services represented 24% of total mental healthcare expenditures in 1986, but this share grew to 44% by 2014 (Substance Abuse and Mental Health Services Administration 2016). Second, office-based care is potentially conducive to treatment adherence as this setting is likely more convenient and less stigmatised. This means it may be more acceptable to patients in comparison to other modalities of mental healthcare. For example, receiving mental healthcare treatment in a private healthcare provider’s office may be more tolerable to patients than care in a specialised facility (e.g. a 30-day residential treatment). Third, office-based care is relatively inexpensive compared to other treatment options. For example, a group counseling session with a physician costs $9.84 per patient, while a day in a psychiatric hospital costs $999 (McCollister et al. 2017). 

In our analysis, we rely on administrative government crime data from the Federal Bureau of Investigation's (FBI) Uniform Crime Reporting (UCR) programme to construct crime rates. This is used alongside data from the US Census Bureau's County Business Patterns (CBP) from 1999 to 2014. The Uniform Crime Reporting data provides counts of crime incidents known to police for the following offenses: murder, manslaughter, rape, aggravated assault, robbery, burglary, larceny, and motor vehicle theft. Our outcome variable is the number of crimes per 10,000 county residents. We obtain the number of establishments of physicians and non-physicians specialising in mental healthcare in each county to proxy local access to office-based care from the County Business Patterns data (that is, we assume that the county is the healthcare market in which a prospective patient seeks mental healthcare). In our study, an establishment is an office in which one or more physicians or non-physicians deliver mental healthcare. We apply econometric techniques (i.e. difference-in-differences and event-studies) to estimate the causal effect of expanding mental healthcare access on county-level crime rates.  These methods compare changes in crime rates between counties that opened an additional mental healthcare office to counties that did not, before and after the opening, holding all other factors constant. Under certain assumptions, which we test in our analysis, we are able to isolate the impact of expanded access to mental healthcare from other crime determinants.  

We have several findings that can be summarised as follows. Ten additional offices in a county reduces crime by 1.7 crimes per 10,000 residents (or 0.5%). We also test to see whether violent and non-violent crime rates respond to expanded access to office-based treatment within the county. We observe that both violent and non-violent crime rates decline following the opening of an office-based provider office. In particular, ten additional offices in a county leads to 0.9 fewer violent crimes per 10,000 residents (2%) and 0.8 fewer non-violent crimes per 10,000 residents (0.2%). Interestingly, these findings suggest that violent crime is more responsive to better local access to mental healthcare than non-violent crime. We decompose our overall count of the number of office-based mental healthcare providers in a county into the number of (i) physician and (ii) non-physician offices per county. Our findings appear to be driven by non-physician offices. We further establish that increases in offices leads to improved mental health (measured by suicide deaths using government death certificates and survey data specifically designed to measure mental illness). This finding supports our assumed causal chain that improved access care leads to better mental health and, in turn, less crime. Overall, our findings suggest that increasing access to office-based mental healthcare providers have positive (albeit somewhat small) spillover effects on crime rates. 

While the magnitude of our effect sizes is arguably modest, the costs of crime (in particular, violent crime) to society are extremely high. For example, the savings to society of averting just one murder is nearly eleven million dollars (McCollister et al. 2017). As a result, even minor reductions in the number of crimes may be valuable. Policymakers seeking to reduce crime may wish to consider enhanced investments in this modality of mental healthcare, for instance through subsidies or tax credits to mental healthcare providers opening in areas with high crime rates. At the same time, our study suggests that any cost-benefit calculations of mental healthcare should take into account these additional societal benefits (less crime). Finally, our findings do not suggest that standard criminal justice policies (e.g. optimising policing strategies) are not valuable for crime-control. Instead, we interpret our findings to imply that policymakers could consider a suite of policies (healthcare, criminal justice, and likely others) to reduce crime. Crime is a complex outcome and therefore a multi-faceted policy response is likely warranted. In summary, our study adds to an emerging line of economic research that suggests that treatment-based approaches to behavioural health (i.e. mental illnesses and substance use disorders) can reduce crime rates (Bondurant et al. 2018, Wen et al. 2017).

References

Abracen, J, A Gallo, J Looman and A Goodwill (2016), "Individual community-based treatment of offenders with mental illness: Relationship to recidivism", Journal of Interpersonal Violence 31(10): 1842-1858.

American Psychiatric Association (2006), American Psychiatric Association Practice guidelines for the treatment of psychiatric disorders: Compendium, American Psychiatric Publications.

Bondurant, S R, J M Lindo and I D Swensen (2018), "Substance abuse treatment centers and local crime", Journal of Urban Economics 104: 124-133.

Center for Behavioral Health Statistics and Quality (2020), "Results from the 2019 National Survey on Drug Use and Health: Detailed Tables", Substance Abuse and Mental Health Services Administration, Rockville, MD.

Deza, M, J C Maclean and K T Solomon (2020), "Local access to mental healthcare and crime", NBER Working Paper.

Frank, R G and T G McGuire (2010), "Mental health treatment and criminal justice outcomes", in Cook, P J, J Ludwig and J McCrary (eds) Controlling crime: Strategies and tradeoffs, University of Chicago Press.

James, D J and L E Glaze (2006), "Mental health problems of prison and jail inmates",  Bureau of Justice Statistics.

Kaiser Family Foundation (2020), "Mental Health Care Health Professional Shortage Areas (HPSAs)", Kaiser Family Foundation.

Kisely, S R, L A Campbell and R O'Reilly (2017), "Compulsory community and involuntary outpatient treatment for people with severe mental disorders", Cochrane database of systematic reviews 3.

McCollister, K, X Yang, B Sayed, M T French, J A Leff and B R Schackman (2017), "Monetary conversion factors for economic evaluations of substance use disorders", Journal of Substance Abuse Treatment (81): 25-34.

McNiel, D E and R L Binder (2007), "Effectiveness of a mental health court in reducing criminal recidivism and violence", American Journal of Psychiatry 164 (9): 1395-1403.

Substance Abuse and Mental Health Services Administration (2016), "Behavioral Health Spending and Use Accounts, 1986–2014", Substance Abuse and Mental Health Services Administration, Rockville, MD.

Swartz, M S, S Bhattacharya, A G Robertson and J W Swanson (2017), "Involuntary outpatient commitment and the elusive pursuit of violence prevention: A view from the United States", The Canadian Journal of Psychiatry 62 (2): 102-108.

Walker, E R, J R Cummings, J M Hockenberry and B G Druss (2015), "Insurance status, use of mental health services, and unmet need for mental health care in the United States", Psychiatric Services 66 (6): 578-584.

Wen, H, J M Hockenberry and J R Cummings (2017), "The effect of Medicaid expansion on crime reduction: Evidence from HIFA-waiver expansions", Journal of Public Economics (154/C): 67-94.

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Topics:  Health economics

Tags:  Mental health, crime, US, healthcare

Assistant Professor of Economics, City University of New York Hunter College and CUNY Graduate Center

Associate Professor of Economics, Temple University

Postdoctoral Fellow, Johns Hopkins School of Public Health

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