Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Delayed Access to Involuntary Mental Health Examinations.

Delayed access to involuntary mental health examination for people who receive care in emergency departments (EDs) was examined, and factors that influenced delayed access were explored. A retrospective review of records for the 12 months prior to data collection was conducted to address the study questions. The health services utilization model served as the conceptual framework for this study. Societal, system, and individual factors were considered in examining access to involuntary emergency mental health examination by adult ED patients. Records of 170 people who sought care in EDs and who required involuntary mental health examinations at two hospitals in Florida served as the sources for study data. The mean duration of delay was 14.9 h. The determinants that were significantly associated with longer delays were being male, increased age, and intoxication. The findings can inform the allocation of resources to increase opportunities for positive long-term outcomes following involuntary care.

What makes a peer a peer?

OBJECTIVE: The purpose of this study was to learn more about which characteristics are considered important for consumers to feel that a person is their peer. METHODS: Forty-one participants in a jail diversion program for veterans were asked to rate characteristics in terms of importance for acting in a peer support role. Differences by gender, combat exposure, trauma history, and mental health and substance abuse treatment were analyzed using t tests and Pearson correlations. RESULTS: Having served in the military had the highest average rating; trauma experience second. Participants with combat experience were significantly more likely than those without to indicate this as an important characteristic. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Increasingly behavioral health programs are recognizing the importance of peer involvement. This study offers guidance on who should be designated a "peer," suggesting that this should vary according to the population served and be based on the perceptions of the consumers.

Emergency commitment of people residing in assisted living facilities.

The objective of this study was to describe emergency commitment of people from assisted living facilities (ALFs) and to discuss relevant policy issues. This study used statewide, archival emergency commitment data from July 2000 through June 2008. During the 1 year from July 07 through June 08 there were 3,061 people with 4,163 emergency commitments from ALFs. Some individuals had more than one emergency commitment during the year, with 20% having between 2 and 9 emergency commitments from ALFs. Some of these individuals also had substantial numbers of emergency commitments in the 7 years from July 2000 through June 2007. Discussed are possible factors related to emergency commitment from ALFs and the need for additional research on these topics. This includes availability of mental health services for these populations, the role of client characteristics, and how licensing of ALFs relates to emergency commitment of ALF residents.

Suicide assessment and prevention during and after emergency commitment.

The purpose of this study was to address two primary issues within the context of emergency commitment: (a) the suicide-prevention measures implemented at receiving facilities where emergency commitments occur and (b) the perceptions of key stakeholders about access to community services post-discharge. One hundred seventy-eight respondents who worked in receiving facilities, where emergency commitments occur, responded to an online survey or were interviewed. Respondents indicated the use of suicide-prevention measures such as suicide assessment tools used at intake and discharge and strategies utilized to maintain client safety when the issue of suicidality had been determined at intake. Almost half of respondents (46.6%) described the availability of community mental health treatment at discharge from emergency commitment as being "less than adequate." Emerging themes about community service availability are discussed and include long waiting periods and funding issues.

Emergency commitment from nursing homes.

PURPOSE: The purpose of this study was to describe emergency commitment of residents from nursing homes and to discuss relevant policy issues. DESIGN AND METHODS: This study used statewide, archival emergency commitment data from July 2000 through June 2008. These data are created by entering data from paper emergency commitment initiation forms of law enforcement, mental health professionals, and judges submitted by facilities as required by Florida law. RESULTS: During the 1 year from July 2007 through June 2008 there were 898 residents of Florida nursing homes with a total of 1032 emergency commitments. Some individuals had more than one emergency commitment from a nursing home during the year, with 9% having between two and five emergency commitments. One-third of the emergency commitments were for residents younger than 65. Some of these individuals also had substantial numbers of emergency commitments in the 7 years from July 2000 through June 2007. IMPLICATIONS: There are facility, client, and regulatory factors that can be addressed to reduce the inappropriate usage of emergency commitments in nursing homes.

Factors affecting jail detention of defendants adjudicated incompetent to proceed.

The movement of defendants through the legal process who have been adjudicated incompetent to proceed is little studied, yet it is important. The purpose of this study was to provide empirical data regarding factors that affected the amount of time defendants adjudicated incompetent to proceed and ordered to undergo hospitalization remained in jail while awaiting transfer to a state hospital. Statewide data collected in Florida between July 2005 and June 2008 were used to determine the lengths of time incompetent defendants spent at certain stages in the legal process. The addition of forensic bed capacity following media attention and litigation resulted in a significant decrease in the amount of time defendants adjudicated incompetent to proceed waited in jail for transfer to a state hospital for treatment. The amount of time it took for completed commitment orders to be submitted to the state mental health authority by the Clerks of Court of each county accounted for a meaningful portion of days defendants spent in jail awaiting transfer to a state hospital, with considerable variation across counties with respect to waiting times. These findings reflect how various stakeholders can affect the amount of time defendants spend in jail while awaiting hospitalization. These issues are discussed in the context of controversy related to Florida's forensic mental health system, as well as issues related to the political process and funding of the state's mental health authority.

Who initiates emergency commitments?

Florida's Mental Health Act was amended in 2005 and 2006 to include licensed mental health counselors and licensed marriage and family therapists, respectively, to the list of professionals authorized to initiate emergency commitments. The present study evaluates the volume of involuntary emergency commitments by type of initiator for a 5 year period. The results indicate that allowing licensed mental health counselors and licensed marriage and family therapist to initiate emergency commitments has not been related to increased numbers of emergency commitments or a higher proportion of emergency commitments being initiated by mental health professionals. Potential policy and fiscal implications, as well as future directions for research, are discussed.

Florida's outpatient commitment law: a lesson in failed reform?

An involuntary outpatient commitment law became effective in Florida in January 2005. However, only 71 orders for outpatient commitment have been issued in three years, even though during that period 41,997 adults had two or more 72-hour involuntary emergency examinations under Florida's civil commitment law. This column describes the criteria for outpatient commitment in the Florida statute and discusses possible reasons for its low rate of use, including additional statutory criteria that make filing a petition for outpatient commitment difficult, lack of community treatment resources, and lack of enforcement mechanisms.

Short-term involuntary examination of older adults in Florida.

The elder population continues to grow rapidly in many countries. Florida's elder population is growing faster than most states', with over one-quarter of the Florida population projected to be aged 65 and over by 2025. Involuntary examination (i.e. emergency commitment) under a state's civil commitment law is one means by which older adults experience assessment for acute mental health care. In Florida, the civil commitment law permits the involuntary examination of an individual for up to 72 hours to determine whether the person meets standards for involuntary treatment. From calendar year 2001 through 2005, there were 531,091 involuntary examinations in Florida for 301,886 people of all ages. Thirteen percent were 60 years and older at the time of their examination. The purpose of this paper is to describe the characteristics of older adults subject to involuntary examination and the nature of their examinations. While these data permit a number of inferences, there is an expansive area of research and policy analysis that remains untapped and would permit better understanding of how older adults experience such examinations. These research and policy issues will also be discussed.

Rates of unemployment and incidence of police-initiated examinations for involuntary hospitalization in Florida.

OBJECTIVE: This study tested the hypothesis that contraction of regional economies affects the incidence of involuntary admissions to psychiatric emergency services by reducing community tolerance for persons perceived as threatening to others. METHODS: This hypothesis was tested with time-series analyses of the relationship between initial claims for unemployment in Florida between July 4, 1999, and June 28, 2003, and the weekly number of men and women presented by police to be examined for involuntary psychiatric hospitalization because of danger to others. The analyses controlled for admissions presented by mental health professionals because of danger to others and for admissions presented by police because of neglect or disability. RESULTS: When the analyses controlled for autocorrelation and other covariates, claims for unemployment insurance were significantly associated with the number of men presented by police for danger to others. During the study period, police presented 5,897 men for examination because of danger to others. Increased unemployment claims were associated with approximately 309 more men being presented for examination than expected from prior presentation rates and from the number presented by mental health professionals for danger to others and by police for neglect or disability. No such association was found for women. CONCLUSIONS: Consistent with theory, this study found that presentations for involuntary admission to psychiatric services increased after contractions in the labor market. Combining the methods of this study with econometric forecasting may allow providers to anticipate better the need for psychiatric services.

Short term involuntary psychiatric examination of children in Florida.

This study describes the use of emergency mental health services by children over a 4-year period. Analysis of a statewide database revealed 51,861 or 15% of all involuntary examinations were conducted on children. These youth were on average a little over 14 years of age and law enforcement officials initiated the majority of examinations. The majority of examinations were initiated due to the children demonstrating harmful behaviors to themselves or others. One-fifth of the children (21%) experienced more than one examination over the 4-year period. Areas of future research on this topic are discussed. The implications of the nature of examinations and patterns of repeated examinations are discussed.

Clinical outcomes of defendants in mental health court.

OBJECTIVE: Mental health courts successfully divert defendants into treatment. However, few studies have examined whether this increased access to services positively affects client outcomes. This study compared changes in symptoms in a sample of defendants in Broward County mental health court with such changes in a comparison sample of defendants in a regular court. METHODS: Participants included 116 defendants from mental health court and 101 defendants from a magistrate court who were assessed one, four, and eight months after an initial court appearance by using the Brief Psychiatric Rating Scale (BPRS). Both administrative and self-report data were used to identify defendants who received treatment after their initial court appearance. Participants were included in our analysis if they had at least one follow-up interview. RESULTS: A total of 97 defendants from mental health court and 77 from the regular court were included in our analysis. Analyses of covariance performed on changes in BPRS scores revealed no significant main effects by type of court, receipt of treatment, or the interaction between type of court and receipt of treatment. CONCLUSIONS: Although mental health courts have been found to increase defendants' access to mental health services, they have little control over the type and quality of services that defendants receive. The fact that reductions in symptoms were not observed among defendants who received treatment in either court setting more likely reflects the chronic nature of their disorders and concerns about the adequacy of our public mental health system, rather than a failure of the mental health court.

Rediversion in two postbooking jail diversion programs in Florida.

OBJECTIVE: Patterns of rediversion in two postbooking jail diversion programs in Florida were examined to better understand the extent to which diversion programs served repeating clients. Rediversion occurs when a former or current diversion program participant is booked into jail on a new charge and diverted once again through the same diversion program. METHODS: Data from 18 months of consecutive entries into the Hillsborough County jail diversion program (N = 336) and Broward County mental health court (N = 800) were examined. RESULTS: Similar rediversion patterns were observed for the two diversion programs. About one-fifth of those who were diverted during the 18-month study period were rediverted at least once. Nearly half of those who experienced rediversion did so within 90 days of their initial diversion. Although fewer than 6 percent were rediverted two or more times, these individuals accounted for a disproportionately large number of overall diversions and were rediverted more quickly than those with only one rediversion. CONCLUSIONS: The diversion programs examined here appear to be experiencing a level of repeating clients similar to that observed in other pathways for accessing mental health treatment.

Involuntary psychiatric examinations for danger to others in Florida after the attacks of September 11, 2001.

OBJECTIVE: Theories of perceived risk state that when people feel threatened, they will react more strongly than they would otherwise. This study tested the hypothesis that evaluations for involuntary psychiatric hospitalizations that were initiated by law enforcement personnel in Florida increased in the weeks after the attacks of September 11, 2001. METHODS: The authors applied interrupted time-series designs to determine whether there was a relationship between the number of involuntary psychiatric examinations initiated by law enforcement officials and the attacks of September 11, 2001. They examined the number of psychiatric evaluations of men and women who were considered to be mentally ill and harmful to others by law enforcement personnel in Florida during seven-day periods ("areal" weeks) that began with Tuesday, July 6, 1999, and ended with Monday, December 31, 2001 (because September 11, 2001, fell on a Tuesday). RESULTS: Over the 130 weeks of the study, law enforcement officials initiated examinations of an average of 25.96 men and 13.47 women per areal week. Law enforcement officials initiated examinations of approximately 14 more women than expected in the areal week that began with September 11, 2001. During the three areal weeks that began with September 18, 2001, a total of 34 more men than expected were presented for evaluation. These findings cannot be attributed to trends, seasonality, other cycles, or the tendency of the examination time series to remain elevated or depressed after high or low values in the series. CONCLUSIONS: Perceived general risk in a community may increase the likelihood that law enforcement personnel and the persons who summon them perceive persons with mental illness as imminently harmful. The public health response to any future terror attacks should include efforts to alert psychiatric service providers to the possibility of lower community tolerance for mental illness in the aftermath of an attack.

Evaluating the efficiency and community safety goals of the Broward County Mental Health Court.

Mental health courts have developed as one response to persons with mental illness who are involved with the criminal justice system. This study investigated the efficiency and safety goals of one such court in Broward County, FL. Mental health court (MHC) clients spent significantly fewer days in jail for the index arrest associated with study enrollment than a comparison group. MHC clients had similar survival time to re-arrest up to one year after study enrollment. MHC clients did not significantly differ from the comparison group in self-reported aggressive acts over an 8 month follow-up period, while they did self-report significantly fewer acts of violence than the comparison group at the 8 month follow-up. These findings suggest that some of the benefits associated with the MHC reported in prior studies were not achieved at the expense of efficiency and safety.

The reported prevalence of mandated community treatment in two Florida samples.

Questions on multiple modes of mandated community treatment (e.g. outpatient commitment, advance directive, representative payee, and special housing) were included in two studies of persons with mental illness, using a mail survey of Medicaid enrollees receiving SSI and interviews conducted as part of an evaluation of a specialty mental health court. Results indicate that the majority of individuals reported no experience with any forms of mandated community treatment. However, respondents from the two samples who had been subject to community mandates reported comparatively similar experiences. Additional studies of the prevalence of mandated community treatment are necessary to garner expanded information regarding the use of such mandates. In addition, future studies must assure that the language employed to query individuals regarding such mandates is clearly understood by respondents, as certain terms (e.g. "outpatient commitment") may mean different things to different respondents.