We found that the prevalence of SMMI was higher among those on parole or probation compared to all other older adults (21% vs. 7%, p < 0.001). Among older adults with SMMI, a higher proportion of those on parole or probation received any mental health treatment over the past 12 months compared to those who were not on correctional supervision (81% vs. 61%, p < 0.001). This association remained after adjusting for differences in sociodemographics and health. Older adults with SMMI and correctional supervision also had disproportionately high prevalence of co-occurring substance use disorders and socioeconomic disadvantage, which signals the need for complex health and social services coordination.

These results demonstrate that a large proportion (approximately 40%) of older adults with SMMI in the general population did not receive any mental health treatment, which is consistent with prior literature (Barry et al., 2012; Byers, Arean, & Yaffe, 2012; Han et al., 2011). Those on parole or probation were more likely to receive mental health treatment despite possessing several characteristics that are frequently associated with barriers to treatment in community-dwelling older adults, including male gender, socioeconomic disadvantage, and co-occurring substance use disorders (Barry et al., 2012; Garido, Kane, Kaas, & Kane, 2011; Han et al., 2011). While this study’s results do not include the precise elements of parole and probation that facilitated linkage to outpatient mental health treatment, we propose three potential explanations: mental health treatment delivered in prisons and jails; outpatient mental health care coordination in parole and probation settings; and court-mandated mental health and substance use treatment.

Mental health treatment delivered within prisons and jails could reduce stigma and enhance motivation for treatment. This explanation, if true, would counteract the widely held perception by clinicians and patients that mental health treatment is unacceptable or unnecessary for older adults (Alexopoulos, 2005; Callahan, Nienaber, Hendrie, & Tierney, 1992; Mackenzie, Pagura, & Sareen, 2010; Stewart, Jameson, & Curtin, 2015). Prior studies have shown that identification and treatment of mental health problems among incarcerated older adults can enhance coping resources (Maschi, Viola, Morgen, & Koskinen, 2015), which may improve resilience to stress and capacity to engage in outpatient treatment upon release from incarceration and reintegration into the community.

It is also possible that parole and probation services provide structured support and coordinating services for clients with mental illness, in turn reducing systemic barriers to mental health treatment access that are common among older adults (Brenes, Danhauer, Lyles, Hogan, & Miller, 2015). In addition to reducing stigma and enhancing motivation for treatment, parole and probation officers may help older adults overcome practical barriers related to cost, coverage, distance from services, and not knowing where to go. Best practices to coordinate healthcare and social services for individuals with mental illness during the reentry period emphasize cross-systems linkages, structured needs assessments, identification and engagement with existing community resources, education about the population for community providers, and development of targeted, evidence-based, and culturally competent interventions (Osher & King, 2015). The role of community corrections is often overlooked in these services coordination models, but vulnerable older adults with mental illness and few resources are likely to rely on corrections officers for support that goes beyond supervision and monitoring.

The third possible explanation for our findings is that high rates of mental health treatment in the community corrections group might reflect mandated court treatment for individuals diagnosed with mental illness and/or substance use disorders as part of an alternative sentencing scheme. Mental health courts, diversion programs, and specialized parole and probation services have emerged as interventions to address the “criminalization of mental illness,” i.e., the growing number of individuals with mental illness in the criminal justice system (Skeem, Manchak, & Peterson, 2011). Recent literature has questioned whether these programs reduce criminal recidivism, but they are still valuable to reduce mental health symptoms (Skeem et al., 2011). Since older justice-involved adults have lower recidivism rates than their younger counterparts (Piquero, Jennings, Diamond, & Reingle, 2015), programs that focus on mental health treatment linkage may be particularly important in this population.

The first two proposed explanations would suggest that comprehensive models of care, which have been developed to enhance service engagement for older adults with mental illness in the general population (Unutzer et al., 2002), are also capable of improving treatment rates among those on community correctional supervision. Existing reentry service models lack consideration of the unique needs of older adults, including geriatric syndromes, cognitive and functional impairment, and social role transitions specific to older adults (Metzger, Ahalt, Kushel, Riker, & Williams, 2017). Further studies on how to integrate evidence-based geriatric mental health interventions into existing reentry service coordination models are needed to tailor our community corrections programs to the needs of this growing population. The third proposed explanation, if true, might suggest that mental health courts, diversion programs, and specialized parole and probation services are particularly effective at facilitating mental health treatment for older adults on parole and probation.

Several of our secondary results also warrant additional exploration in future studies. For instance, individuals aged 65 or older and those without health insurance fared poorly in both groups (approximately 50% with SMMI received no treatment), whereas black individuals received treatment at much higher rates in the parole or probation group compared to those without community correctional supervision (85% vs. 48% received treatment). Further research is needed to replicate these preliminary findings and to shed light on the mechanisms responsible for the observed patterns.

Although older adults with SMMI were more likely to receive mental health treatment if they were on correctional supervision, nearly one out of every five individuals in this population (19%) received no treatment. This finding is worrisome, especially since the definition of “untreated” mental illness used in this study is quite severe: it requires no visits with any outpatient mental health providers and no mental health prescriptions, which is tantamount to no outpatient treatment whatsoever. The consequences of untreated or partially treated mental illness in older adults include poor quality of life, suicide, disability, cognitive impairment, greater likelihood of cardiovascular disease and chronic comorbidities, and economic loss (World Health Organization, 2003), all of which could be devastating in this already vulnerable population. Additional research is needed to understand barriers to healthcare access in this population and establish whether the treatment being received is appropriate and adequate to support positive mental health and criminal justice outcomes.

This study has several limitations. A relatively small sample size obviated our ability to use survey weights, which limits our ability to make population-based assumptions about our findings. Still, this is the first study to characterize outpatient mental health treatment among older adults on parole or probation with mental illness. Moreover, it is possible that the most disadvantaged and vulnerable older adults on parole or probation did not participate in the NSDUH, since the prevalence of justice involvement in the NSDUH sample lags behind national estimates (Kaeble, Maruschak, & Bonczar, 2015), and the NSDUH sampling frame is not well suited to identify individuals experiencing homelessness or other severe deprivation that is common in justice-involved populations (Williams et al., 2010). Therefore, our results could be interpreted as establishing a lower limit for population prevalence of mental illness among older adults on parole or probation. Finally, the NSDUH measures of mental illness are based on symptom severity rather than diagnosis, which means that individuals who lacked insight or whose symptoms were well controlled through treatment might not be identified as having SMMI. This could underestimate both the prevalence of diagnosable mental illness and the fraction of individuals with mental illness who received treatment. However, these results are still meaningful because self-reported symptom severity is an important person-centered mental health measure.