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Open Access

Adverse Impacts of Mental Health Needs Assessment on Jail Outcomes

Evidence from Transition Age Youth and Adults

View ORCID ProfileScott Cunningham, View ORCID ProfileJonathan A. Seward, View ORCID ProfileKaren Clay and View ORCID ProfileVivian S. Vigliotti
Journal of Human Resources, April 2024, 59 (S) S282-S316; DOI: https://doi.org/10.3368/jhr.1222-12713R2
Scott Cunningham
Scott Cunningham is the Ben H. Williams Professor of Economics at Baylor University .
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  • For correspondence: scunning{at}gmail.com
Jonathan A. Seward
Jonathan A. Seward is a Postdoctoral Research Associate in the Economics Department at Baylor University and holds a joint appointment as Adjunct Staff in the Economics, Sociology, and Statistics Department at RAND Corporation.
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Karen Clay
Karen Clay is a Professor of Economics and Public Policy at Carnegie Mellon University’s Heinz College of Information Systems and Public Policy and an NBER Fellow.
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Vivian S. Vigliotti
Vivian S. Vigliotti is a Health Outcomes Researcher II, Team Lead at Yale New Haven Health System.
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  • Figure 1
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    Figure 1

    Distribution of Clinician Leniency and First Stage

Tables

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    Table 1

    Summary Statistics 2016–2019

    Transition AgeAdults (over 25)
    MisdemeanorFelonyMisdemeanorFelony
    N = 11,147N = 9,227N = 30,643N = 27,515
    Panel A: Inmate Characteristics
    Age at booking21.6221.5139.0838.62
    (2.47)(2.52)(10.46)(9.93)
    Male0.700.810.730.78
    (0.46)(0.39)(0.44)(0.41)
    White0.730.670.730.71
    (0.44)(0.47)(0.44)(0.46)
    Black0.260.320.250.29
    (0.44)(0.47)(0.43)(0.45)
    Asian0.01110.00860.01180.0079
    (0.1049)(0.0921)(0.1079)(0.0885)
    Race other0.00070.00080.00070.0006
    (0.0268)(0.0275)(0.0255)(0.0241)
    Hispanic0.350.360.240.28
    (0.48)(0.48)(0.43)(0.45)
    Number of priors3.044.446.074.53
    (5.56)(6.11)(11.20)(6.85)
    Mental health needs rating
     None/mild9,2897,81722,68021,979
    (83%)(85%)(74%)(80%)
     Moderate/severe1,8581,4107,9635,536
    (17%)(15%)(26%)(20%)
    Panel B: Outcomes
    LOS8.1458.5611.1158.84
    (19.93)(99.26)(25.66)(91.05)
    Suicide attempt (SA)0.00570.00610.00640.0069
    (0.0756)(0.0777)(0.0799)(0.0826)
    SA/(LOS + 1)0.00100.00020.00120.0003
    (0.0194)(0.0055)(0.0194)(0.0071)
    Recid. within 1 year0.370.390.430.35
    (0.48)(0.49)(0.49)(0.48)
    Recid. within 18 months0.420.440.460.40
    (0.49)(0.50)(0.50)(0.49)
    Recid. within 2 years0.440.470.480.42
    (0.50)(0.50)(0.50)(0.49)
    • Notes: Mean (SD); N (%).

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    Table 2

    Mental Health Classification Descriptive Regressions (IV Sample)

    Transition AgeAdults
    VariablesMisdemeanorFelonyMisdemeanorFelony
    (1)(2)(3)(4)
    Age at booking0.00060.0043***0.0025***0.0027***
    (0.0012)(0.0015)(0.0003)(0.0003)
    Male−0.0557***−0.0783***−0.0660***−0.0669***
    (0.0076)(0.0103)(0.0067)(0.0064)
    Black0.0120−0.0186**0.00870.0151**
    (0.0109)(0.0083)(0.0071)(0.0063)
    Asian0.03570.0355−0.0354*0.0223
    (0.0352)(0.0446)(0.0203)(0.0279)
    Race other0.08040.3560**−0.0145−0.1989***
    (0.1381)(0.1652)(0.0762)(0.0285)
    Hispanic−0.0433***−0.0549***−0.0754***−0.0645***
    (0.0062)(0.0078)(0.0055)(0.0060)
    Number of prior charges0.0124***0.00070.0108***0.0064***
    (0.0009)(0.0005)(0.0004)(0.0004)
    Month–year fixed effectsYesYesYesYes
    Observations11,1479,22730,64327,515
    Outcome mean0.16670.15280.25990.2012
    • Notes: Each column represents a linear probability model with the binary outcome of interest being the mental health classification of moderate/severe as opposed to none/mild. Clustered (month–year) standard errors are in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 3

    Mental Health Classification Descriptive Regressions (3Q2018–4Q2019)

    Transition AgeAdults
    MisdemeanorFelonyMisdemeanorFelony
    Age at booking0.00120.0044***0.0021***0.0025***
    (0.0020)(0.0014)(0.0003)(0.0004)
    Male0.0040−0.0127−0.0182**−0.0158**
    (0.0073)(0.0096)(0.0064)(0.0061)
    Black0.0332**−0.01000.01240.0328***
    (0.0117)(0.0099)(0.0077)(0.0080)
    Asian0.03750.00750.04230.0144
    (0.0379)(0.0470)(0.0269)(0.0285)
    Race other−0.0510*0.1213−0.1117**−0.1742**
    (0.0285)(0.3345)(0.0425)(0.0614)
    Hispanic−0.0095−0.0230**−0.0351***−0.0275***
    (0.0108)(0.0090)(0.0062)(0.0084)
    Number of prior charges0.0095***0.00080.0080***0.0039***
    (0.0011)(0.0006)(0.0004)(0.0005)
    Suicide risk: Mild0.0673***0.0452***0.1363***0.1206***
    (0.0120)(0.0131)(0.0109)(0.0139)
    Suicide risk: Moderate/severe0.3382***0.4090***0.3847***0.4048***
    (0.0341)(0.0282)(0.0232)(0.0258)
    Prior psych. hospitalization0.0600**0.01720.1278***0.0838***
    (0.0246)(0.0240)(0.0150)(0.0128)
    Prior psych. medications0.02040.0087−0.0296***−0.0033
    (0.0152)(0.0140)(0.0066)(0.0084)
    Self-report drug/alcohol use0.02670.0138−0.0433***−0.0077
    (0.0339)(0.0131)(0.0130)(0.0125)
    Month–year fixed effectsYesYesYesYes
    Observations3,9693,57711,80611,275
    Outcome mean0.11140.08650.20270.1396
    • Notes: Each column represents a linear probability model with the binary outcome of interest being the mental health classification of moderate/severe as opposed to none/mild. Clustered (month–year) standard errors are in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 4

    First-Stage Regressions for Initial Assessment of Moderate/Severe (Misdemeanors)

    Transition AgeAdults
    (1)(2)(3)(4)
    Z: Clinician’s leave-out mean mental health score0.783***0.758***0.981***0.861***
    (0.033)(0.028)(0.030)(0.030)
    Kleibergen–Paap F5757151,048808
    Time fixed effectsYesYesYesYes
    Baseline controlsNoYesNoYes
    Observations11,14711,14730,64230,642
    • Notes: We report the first-stage results of a linear probability model stratified by age group. The binary outcome of interest is the initial assessment of an inmate’s mental health needs being either none/low or moderate/severe. The propensity to assign the most severe score is estimated using data from other cases assigned to the clinician following the procedure described in the text. Columns 1 and 2 limit the sample to transition age youth, whereas Columns 3 and 4 limit the sample to adults. Columns 1 and 3 show the results by controlling only for month–year fixed effects, whereas Columns 2 and 4 also include the inmate baseline controls as shown in Table 1. Each column gives the corresponding clinician and inmate robust two-way clustered standard errors in parentheses. Robust (Kleibergen–Paap) first-stage F-statistic is reported. Note this is equivalent to the effective F-statistic of Montiel Olea and Pflueger (2013) in this case of a single instrument. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 5

    First-Stage Regressions for Initial Assessment of Moderate/Severe (Felonies)

    Transition AgeAdults
    (1)(2)(3)(4)
    Z: Clinician’s leave-out mean mental health score0.881***0.860***0.977***0.940***
    (0.043)(0.045)(0.046)(0.048)
    Kleibergen–Paap F428370455389
    Time fixed effectsYesYesYesYes
    Baseline controlsNoYesNoYes
    Observations9,2269,22627,51527,515
    • Notes: We report the first stage results of a linear probability model stratified by age group. The binary outcome of interest is the initial assessment of an inmate’s mental health needs being either none/low or moderate/severe. The propensity to assign the most severe score is estimated using data from other cases assigned to the clinician following the procedure described in the text. Columns 1 and 2 limit the sample to transition age youth, whereas Columns 3 and 4 limit the sample to adults. Columns 1 and 3 show the results by controlling only for month–year fixed effects, whereas Columns 2 and 4 also include the inmate baseline controls as shown in Table 1. Each column gives the corresponding clinician and inmate robust two-way clustered standard errors in parentheses. Robust (Kleibergen–Paap) first-stage F-statistic is reported. Note this is equivalent to the effective F-statistic of Olea and Pflueger (2013) in this case of a single instrument. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 6

    Test of Randomization for Moderate/Severe (Misdemeanors)

    Transition AgeAdults
    Moderate/Severe (Misdemeanors)Z: Moderate/Severe (Misdemeanors)Moderate/Severe (Misdemeanors)Z: Moderate/Severe (Misdemeanors)
    (1)(2)(3)(4)
    Asian0.0360.004−0.035−0.001
    (0.041)(0.017)(0.037)(0.007)
    Black0.012−0.0020.009−0.003**
    (0.014)(0.002)(0.010)(0.001)
    Race other0.080−0.043**−0.015−0.020
    (0.110)(0.019)(0.097)(0.018)
    Hispanic−0.043***−0.004−0.075***−0.004
    (0.011)(0.004)(0.011)(0.003)
    Male−0.056***−0.012**−0.066***−0.011**
    (0.014)(0.006)(0.011)(0.005)
    Age at booking0.0010.0000.003***0.001***
    (0.001)(0.000)(0.000)(0.000)
    Number of priors0.012***0.0000.011***0.001***
    (0.002)(0.000)(0.001)(0.000)
    Time fixed effectsYesYesYesYes
    F-test112334
    Observations11,14711,14730,64230,642
    • Notes: These linear probability models control for the baseline characteristics used in the instrumental variables analyses. The binary dependent variable in Columns 1 and 3 is being assigned a moderate to severe mental illness score at initial assessment. The dependent variable in Columns 2 and 4 is the propensity to assign a high or low score to inmates. Time fixed effects include month–year fixed effects. Clinician and inmate two-way clustered standard errors shown in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 7

    Test of Randomization for Moderate/Severe (Felonies)

    Transition AgeAdults
    Moderate/Severe (Misdemeanors)Z: Moderate/Severe (Misdemeanors)Moderate/Severe (Misdemeanors)Z: Moderate/Severe (Misdemeanors)
    (1)(2)(3)(4)
    Asian0.036−0.0010.022−0.005
    (0.048)(0.013)(0.035)(0.005)
    Black−0.019−0.0040.0150.001
    (0.013)(0.003)(0.010)(0.002)
    Race other0.356**0.023−0.199***0.010
    (0.158)(0.026)(0.037)(0.022)
    Hispanic−0.055***−0.003−0.064***−0.005
    (0.014)(0.003)(0.010)(0.004)
    Male−0.078***−0.015**−0.067***−0.010*
    (0.017)(0.007)(0.009)(0.006)
    Age at booking0.004***0.001***0.003***0.001***
    (0.002)(0.000)(0.000)(0.000)
    Number of priors0.001−0.001***0.006***0.000
    (0.001)(0.000)(0.001)(0.000)
    Time fixed effectsYesYesYesYes
    F-test43254
    Observations9,2269,22627,51527,515
    • Notes: These linear probability models control for the baseline characteristics used in the instrumental variables analyses. The binary dependent variable in Columns 1 and 3 is being assigned a moderate to severe mental illness score at initial assessment. The dependent variable in Columns 2 and 4 is the propensity to assign a high or low score to inmates. Time fixed effects include month–year fixed effects. Clinician and inmate two-way clustered standard errors shown in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 8

    Balance of Instrument and Inmate Characteristics for Moderate/Severe (Misdemeanors)

    Bottom TercileMiddle TercileTop TercileMiddle vs. Bottom p-ValueTop vs. Bottom p-Value
    Panel A: Transition Age
    Z: Clinician’s leave-out mean mental health score−0.097−0.0150.119(0.000)(0.000)
    Inmate characteristics
     Asian0.0130.0090.012(0.257)(0.772)
     Black0.2530.2710.257(0.261)(0.837)
     Race other0.0010.0010.000(0.689)(0.143)
     Hispanic0.3550.3490.353(0.651)(0.955)
     Male0.7200.6970.690(0.438)(0.285)
     Age at booking21.56921.65621.647(0.182)(0.193)
     Number of priors2.7543.2453.179(0.279)(0.115)
    Panel B: Adults
    Z: Clinician’s leave-out mean mental health score−0.097−0.0090.126(0.000)(0.000)
    Inmate characteristics
     Asian0.0110.0120.012(0.151)(0.417)
     Black0.2510.2620.247(0.105)(0.464)
     Race other0.0010.0010.000(0.412)(0.081)
     Hispanic0.2460.2480.240(0.967)(0.636)
     Male0.7430.7230.726(0.379)(0.401)
     Age at booking38.39239.08239.718(0.053)(0.005)
     Number of priors4.9206.1987.018(0.012)(0.007)
    • Notes: Data are from a large county correctional complex. Time fixed effects include month–year fixed effects. Clinician and inmate two-way clustered standard errors shown in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 9

    Balance of Instrument and Inmate Characteristics for Moderate/Severe (Felonies)

    Bottom TercileMiddle TercileTop TercileMiddle vs. Bottom p-ValueTop vs. Bottom p-Value
    Panel A: Transition Age
    Z: Clinician’s leave-out mean mental health score−0.102−0.0320.108(0.001)(0.000)
    Inmate characteristics
     Asian0.0080.0090.009(0.991)(0.907)
     Black0.3340.3220.317(0.306)(0.056)
     Race other0.0010.0010.001(0.895)(0.453)
     Hispanic0.3540.3700.358(0.275)(0.873)
     Male0.8330.8040.783(0.148)(0.119)
     Age at booking21.42421.51221.615(0.348)(0.000)
     Number of priors4.7644.5303.990(0.108)(0.003)
    Panel B: Adults
    Z: Clinician’s leave-out mean mental health score−0.101−0.0280.111(0.001)(0.000)
    Inmate characteristics
     Asian0.0090.0070.007(0.288)(0.266)
     Black0.2790.2850.294(0.479)(0.151)
     Race other0.0010.0000.001(0.235)(0.985)
     Hispanic0.2840.2810.268(0.539)(0.422)
     Male0.7970.7750.774(0.064)(0.332)
     Age at booking38.22138.51039.125(0.226)(0.002)
     Number of priors4.3794.6224.575(0.865)(0.572)
    • Notes: Data are from a large county correctional complex. Time fixed effects include month–year fixed effects. Clinician and inmate two-way clustered standard errors shown in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 10

    Average Monotonicity Tests (Misdemeanors)

    MaleFemaleBlackWhiteHispanic
    (1)(2)(3)(4)(5)
    Panel A: Transition Age
    Z: Clinician’s leave-out mean mental health score0.738***0.796***0.824***0.729***0.632***
    (0.045)(0.083)(0.062)(0.040)(0.045)
    Observations7,8413,3062,8978,1183,930
    Time fixed effectsYesYesYesYesYes
    ControlsYesYesYesYesYes
    Panel B: Adults
    Z: Clinician’s leave-out mean mental health score0.846***0.901***0.941***0.841***0.734***
    (0.035)(0.057)(0.049)(0.045)(0.059)
    Observations22,3808,2627,76222,4987,502
    Time fixed effectsYesYesYesYesYes
    ControlsYesYesYesYesYes
    • Notes: This table presents a test for satisfying average monotonicity as proposed in Frandsen, Lefgren, and Leslie (2020), where they show that average monotonicity can suffice in lieu of strict monotonicity if the average treatment propensities move in the same direction as their potential treatment decisions. In the context of our paper, we can relax strict monotonicity for any given clinician if the individual monotonically complies with enough other judges. Thus, the coefficients should all be significant and the same direction to support average monotonicity.

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    Table 11

    Average Monotonicity Tests (Felonies)

    MaleFemaleBlackWhiteHispanic
    (1)(2)(3)(4)(5)
    Panel A: Transition Age
    Z: Clinician’s leave-out mean mental health score0.797***1.078***0.884***0.848***0.672***
    (0.040)(0.129)(0.107)(0.045)(0.054)
    Observations7,4491,7762,9956,1453,328
    Time fixed effectsYesYesYesYesYes
    ControlsYesYesYesYesYes
    Panel B: Adults
    Z: Clinician’s leave-out mean mental health score0.931***0.977***0.913***0.956***0.752***
    (0.039)(0.106)(0.088)(0.047)(0.052)
    Observations21,5086,0057,87319,4097,642
    Time fixed effectsYesYesYesYesYes
    ControlsYesYesYesYesYes
    • Notes: This table presents a test for satisfying average monotonicity as proposed in Frandsen, Lefgren, and Leslie (2020), where they show that average monotonicity can suffice in lieu of strict monotonicity if the average treatment propensities move in the same direction as their potential treatment decisions. In the context of our paper, we can relax strict monotonicity for any given clinician if the individual monotonically complies with enough other judges. Thus, the coefficients should all be significant and the same direction to support average monotonicity.

    • View popup
    Table 12

    Effects of Initial Assessment of Moderate/Severe (Misdemeanors)

    Transition AgeAdults
    OLS2SLSIVLASSOOLS2SLSIVLASSO
    (1)(2)(3)(4)(5)(6)
    LOS5.649***6.082**7.650***6.510***−0.1281.339
    (0.473)(2.928)(2.256)(0.323)(2.068)(1.900)
    [0.641, 11.524][−3.978, 3.722]
    Suicide attempt (SA)0.019***0.046***0.040***0.012***0.021***0.018**
    (0.006)(0.011)(0.013)(0.002)(0.006)(0.007)
    [0.025, 0.067][0.011, 0.032]
    SA/(LOS + 1)0.0030.007***0.007***0.002***0.004***0.004***
    (0.002)(0.002)(0.002)(0.000)(0.001)(0.001)
    [0.003, 0.012][0.001, 0.007]
    Recid. within 1 year0.053***0.0490.0540.162***0.245***0.249***
    (0.008)(0.056)(0.066)(0.02)(0.065)(0.071)
    [−0.055, 0.154][0.124, 0.366]
    Recid. within 18 months0.064***−0.004−0.0190.149***0.216***0.195***
    (0.011)(0.069)(0.061)(0.02)(0.063)(0.075)
    [−0.131, 0.123][0.099, 0.332]
    Recid. within 2 years0.074***0.031−0.0390.140***0.245***0.157
    −0.01−0.072−0.044−0.017−0.069−0.099
    [−0.102, 0.164][0.132, 0.385]
    Time fixed effectsYesYesYesYesYesYes
    Baseline controlsYesYesYesYesYesYes
    • Notes: This table reports the ordinary least squares (OLS), two-stage least squares (2SLS), and the instrumental variables LASSO (IVLASSO) estimates of the impact of being assigned a moderate/severe mental health needs rating. The dependent variable is listed in each row. The recidivism within one year sample is truncated to one year prior to the last date our data set. Similarly, the recidivism within 18 months and two years samples are truncated to 18 months and two years prior to the last date. The 2SLS and IVLASSO specifications instrument for assignation of a high mental health needs score using a clinician leniency measure that is estimated using data from other cases assigned to a clinician as described in the text. We include month–year fixed effects and baseline controls for all specifications. The clinician and inmate robust two-way clustered standard errors are shown in parentheses. For the 2SLS estimates, confidence intervals based on the inversion of the Anderson–Rubin test are shown in brackets. *p < 0.10, **p < 0.05, ***p < 0.01.

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    Table 13

    Effects of Initial Assessment of Moderate/Severe (Felonies)

    Transition AgeAdults
    OLS2SLSIVLASSOOLS2SLSIVLASSO
    (1)(2)(3)(4)(5)(6)
    LOS23.165***47.372***54.055*23.112***24.658**22.628*
    (2.548)(14.415)(27.763)(1.178)(11.104)(12.974)
    [20.597, 74.147][3.988, 45.328]
    Suicide attempt (SA)0.017***0.038**0.0150.017***0.030***0.018*
    (0.002)(0.017)(0.011)(0.002)(0.008)(0.009)
    [0.007, 0.070][0.016, 0.046]
    SA/(LOS + 1)0.001***0.00100.001***0.002***0.001***
    (0.000)(0.001)(0.001)(0.000)(0.001)(0.000)
    [−0.001, 0.003][0.001, 0.003]
    Recid. within 1 year0.054***0.0550.0280.039***0.060.051
    (0.008)(0.053)(0.062)(0.006)(0.047)(0.050)
    [−0.043, 0.152][−0.019, 0.157]
    Recid. within 18 months0.041**−0.0380.0240.029***−0.0080
    (0.019)(0.053)(0.052)(0.006)(0.043)(0.055)
    [−0.147, 0.061][−0.079, 0.079]
    Recid. within 2 years0.054***0.0360.0250.017**−0.054−0.062
    (0.015)(0.081)(0.062)(0.007)(0.051)(0.057)
    [−0.113, 0.184][−0.139, 0.050]
    Time fixed effectsYesYesYesYesYesYes
    Baseline controlsYesYesYesYesYesYes
    • Notes: This table reports the ordinary least squares (OLS), two-stage least squares (2SLS), and the instrumental variables LASSO (IVLASSO) estimates of the impact of being assigned a moderate/severe mental health needs rating. The dependent variable is listed in each row. The recidivism within one year sample is truncated to one year prior to the last date our data set. Similarly, the recidivism within 18 months and two years samples are truncated to 18 months and two years prior to the last date. The 2SLS and IVLASSO specifications instrument for assignation of a high mental health needs score using a clinician leniency measure that is estimated using data from other cases assigned to a clinician as described in the text. We include month–year fixed effects and baseline controls for all specifications. The clinician and inmate robust two-way clustered standard errors are shown in parentheses. For the 2SLS estimates, confidence intervals based on the inversion of the Anderson–Rubin test are shown in brackets. *p < 0.10, **p < 0.05, ***p < 0.01.

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    • 1222-12713R2_repmat.zip
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Journal of Human Resources: 59 (S)
Journal of Human Resources
Vol. 59, Issue S
1 Apr 2024
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Adverse Impacts of Mental Health Needs Assessment on Jail Outcomes
Scott Cunningham, Jonathan A. Seward, Karen Clay, Vivian S. Vigliotti
Journal of Human Resources Apr 2024, 59 (S) S282-S316; DOI: 10.3368/jhr.1222-12713R2

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Adverse Impacts of Mental Health Needs Assessment on Jail Outcomes
Scott Cunningham, Jonathan A. Seward, Karen Clay, Vivian S. Vigliotti
Journal of Human Resources Apr 2024, 59 (S) S282-S316; DOI: 10.3368/jhr.1222-12713R2
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