Vaccine breakthrough infections with SARS-CoV-2: Why older adults need booster vaccinations.

Objectives: COVID-19 vaccinations are highly efficacious in preventing severe illness that can lead to hospitalizations and death, but incidents of vaccine breakthrough (VBT) infections persist. We examined VBT infections within a congregate setting to help guide public health practices. Study design: This is a retrospective cohort study of VBT infections identified via polymerase chain reaction (PCR) testing between 2/1/2021-11/1/2021. Methods: A VBT infection was defined as the detection of SARS-CoV-2 collected from a person ≥14 days after all recommended doses of a COVID-19 vaccine. VBT infections were examined in five California psychiatric inpatient hospitals with a workforce of more than 10,000 hospital staff and approximately 5500 patients. Results: 415 VBT infections out of 14,101 fully vaccinated individuals within our system (2.9%) were identified. Days since final vaccine date ranged from 16 to 291 days. Kruskal-Wallis nonparametric test revealed a statistically significant difference in age between individuals with VBT infections versus all other vaccinated individuals [U = 6.47, p = .01]. A chi-square test of independence revealed no significant sex differences between individuals with VBT infections (58.8% male and 41.2% female) versus all other vaccinated individuals (59.6% male and 40.4% female; X2 (3, N = 14101) = 5.059, p = .167). Out of 415 VBT cases, 65.1% received the Moderna vaccine, 33.2% received Pfizer, and 1.7% received J&J; and 38.1% were asymptomatic at time of VBT infection, 24.1% were symptomatic, while 37.8% were missing symptom data. Conclusions: Vaccination campaigns, including boosters and continued surveillance, are important complimentary strategies for reducing the proliferation of COVID-19 VBT cases and severity of symptoms associated with COVID-19.

Large-Scale Implementation of a Daily Rapid Antigen Testing Program in California for Detecting SARS-CoV-2.

Objectives. To evaluate a daily antigen testing program for health care personnel. Methods. We examined antigen testing results between December 13, 2020, and April 30, 2021, from 5 forensic psychiatric inpatient hospitals throughout California. Results. Among 471 023 antigen tests administered, 449 positives (0.0036% false positives) were detected. Conclusions. Antigen tests had low false-positive rates, high positive predictive value, and high levels of acceptability, important characteristics when considering their application in the community. Public Health Implications. Daily antigen testing was feasible and should be considered to reduce COVID-19 transmission. (Am J Public Health. 2022;112(3):467-471. https://doi.org/10.2105/AJPH.2021.306588).

Gender and Malingering in Defendants Deemed Incompetent to Stand Trial.

The relationships between gender and malingering have received little attention in the literature. Our study examined data from 1,748 patients committed as incompetent to stand trial between 2008 and 2017, of whom 397 were women. Scores on a structured assessment of feigned psychiatric symptoms were only slightly higher for men than for women. Yet evaluators believed that over 23 percent of men but less than 15 percent of women were malingering. Our data suggest that these gender differences in rates of malingering may be attributable to symptom constellations and extent of criminal arrest history.

The Cal-DSH diversion guidelines.

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

A social history of serious mental illness.

Despite medical, technological, and humanitarian advances, the criminalization of those with serious mental illness continues. This is not an isolated phenomenon. The benefits of treatment reform and innovation are difficult to maintain or sometimes outright harmful. Across time and geography, the care of those with serious mental illness tends towards maltreatment, be it criminalization or other forms of harm. We present a social history of serious mental illness, along with the idea that the treatment of serious mental illness is a Sisyphean task-perpetually pushing a boulder up a hill, only for it to roll down and start again. The history is provided as a basis for deeper reflection of treatment, and treatment reform, of those with serious mental illnesses.

Length of stay for inpatient incompetent to stand trial patients: importance of clinical and demographic variables.

OBJECTIVE: We investigated clinical and demographic variables to better understand their relationship to hospital length of stay for patients involuntarily committed to California state psychiatric hospitals under the state's incompetent to stand trial (IST) statutes. Additionally, we determined the most important variables in the model that influenced patient length of stay. METHODS: We retrospectively studied all patients admitted as IST to California state psychiatric hospitals during the period January 1, 2010 through June 30, 2018 (N = 20 041). Primary diagnosis, total number of violent acts while hospitalized, age at admission, treating hospital, level of functioning at admission, ethnicity, sex, and having had a previous state hospital admission were evaluated using a parametric survival model. RESULTS: The analysis showed that the most important variables related to length of stay were (1) diagnosis, (2) number of violent acts while hospitalized, and (3) age of admission. Specifically, longer length of stay was associated with (1) having a diagnosis of schizophrenia or neurocognitive disorder, (2) one or more violent acts, and (3) older age at admission. The other variables studied were also statistically significant, but not as influential in the model. CONCLUSIONS: We found significant relations between length of stay and the variables studied, with the most important variables being (1) diagnosis, (2) number of physically violent acts, and (3) age at admission. These findings emphasize the need for treatments to target cognitive issues in the seriously mentally ill as well as treatment of violence and early identification of violence risk factors.

Economics of decriminalizing mental illness: when doing the right thing costs less.

The United States' criminal justice system has seen exponential growth in costs related to the incarceration of persons with mental illness. Jails, prisons, and state hospitals' resources are insufficient to adequately treat the sheer number of individuals cycling through their system. Reversing the cycle of criminalization of mental illness is a complicated process, but mental health diversion programs across the nation are uniquely positioned to do just that. Not only are these programs providing humane treatment to individuals within the community and breaking the cycle of recidivism, the potential fiscal savings are over 1 billion dollars.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States.

OBJECTIVE: Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level. METHODS: The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted. RESULTS: A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth. CONCLUSIONS: Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

An overview of jail-based competency restoration.

Forensic populations in the United States are increasing, driven largely by a rise in individuals determined to be Incompetent to Stand Trial (IST). Across most states, including California, the number of mentally ill inmates awaiting competency restoration has increased dramatically in recent years. Traditionally, competency restoration has taken place in state hospitals, but incompetent inmates often experience a significant wait for state hospital beds because of the rising demand for beds in such facilities. The resulting waitlists, which range from days to months, have led to states being held in contempt of court for violating limits placed on how long incompetent defendants can be held in jail. Therefore, alternatives to state hospitalization for IST patients have been developed, including jail-based competency (JBCT) restoration programs. JBCT programs provide restoration services in county jails, rather than in psychiatric hospitals. The following article will review the nature of JBCT programs and will emphasize the structure and evolution of such programs within California.

A longitudinal description of incompetent to stand trial admissions to a state hospital.

OBJECTIVE: Evidence is clear that the nation is experiencing an increasing number of incompetent to stand trial (IST) admissions to state hospitals. As a result, defendants in need of treatment can wait in jail for weeks for admission for restoration. This study was conducted to better understand this growing population and to inform hospital administration about the characteristics of IST admissions. METHODS: The study was conducted at the Department of State Hospitals (DSH) facility in Napa (DSH-Napa), a 1200-bed primarily forensic inpatient psychiatric facility located in northern California. The records of patients found IST and admitted to DSH-Napa for restoration of competence between the dates of 1/1/2009 and 12/31/2016 were eligible for inclusion in the study. RESULTS: There were a total of 3158 unduplicated IST admissions available during the specified time period. Our data indicate that the number of admissions with more than 15 prior arrests increased significantly, from 17.7% in 2009 to 46.4% in 2016. In contrast, the percent of patients reporting prior inpatient psychiatric hospitalization evidenced a consistent decrease over time from over 76% in 2009 to less than 50% in 2016. CONCLUSION: Our data add to the body of literature on the potential causes of the nationwide increase in competency referrals. The literature is clear that jails and prisons are now the primary provider of the nation's mental health care. Our data suggest that another system has assumed this role: state hospitals and other providers charged with restoring individuals to competence.

Prevalence of physical violence in a forensic psychiatric hospital system during 2011-2013: Patient assaults, staff assaults, and repeatedly violent patients.

UNLABELLED: Introduction We examined physical violence in a large, multihospital state psychiatric system during 2011-2013, and associated demographic and clinical characteristics of violent patients to better understand issues of patient and staff safety. METHOD: Acts of physical violence committed by patients against other patients (n=10,958) or against staff (n=8429) during 2011-2013 were collected and analyzed for all hospitalized patients during the same time period to derive prevalence rates and associated odds ratios. RESULTS: Overall, 31.4% of patients committed at least 1 violent assault during their hospitalization. Differential risk factor patterns were noted across patient and staff assault. Younger age was associated with a higher prevalence of both patient and staff assault, as was nonforensic legal status. Females had a higher prevalence of staff assault than patient assault. Ethnic groups varied on rates of patient assault, but had no significant differences for staff assault. Schizoaffective disorder was associated with higher prevalence and odds of patient (OR 1.244, 95% CI 1.131 to 1.370) and staff (OR 1.346, 95% CI 1.202 to 1.507) assault when compared to patients diagnosed with schizophrenia. Most personality disorder diagnoses also had a higher prevalence and odds of physical violence. One percent of patients accounted for 28.7% of all assaults. Additionally, violent patients had a significantly longer length of hospitalization. Discussion Implications of these findings to enhance patient safety and inform future violence reduction efforts, including the need for new treatments in conjunction with the use of violence risk assessments, are discussed.

A new standard of care for forensic mental health treatment: prioritizing forensic intervention.

Many forensic psychiatric settings serve unique populations who have, in addition to traditional psychiatric symptoms, diverse legal and criminogenic needs. A lack of clear treatment standards that address all aspects of forensic care can lead to inefficient or inappropriate interventions and contribute to institutional violence.

Forensic focused treatment planning: a new standard for forensic mental health systems.

Almost no literature addresses treatment planning for the forensic psychiatric patient. In the absence of such guidance, recovery-oriented multifocal treatment planning has been imported into forensic mental health systems from community psychiatric settings, despite the fact that conditions of admission and discharge are vastly different for forensic psychiatry inpatients. We propose that instead of focusing on recovery, forensic treatment planning should prioritize forensic outcomes, such as restoration of trial competence or mitigation of violence risk, as the first steps in a continuum of care that eventually leads to the patient's ability to resolve forensic issues and return to the community for recovery-oriented care. Here we offer a model for treatment planning in the forensic setting.

The new mission of forensic mental health systems: managing violence as a medical syndrome in an environment that balances treatment and safety.

The association between violence and mental illness is well-studied, yet remains highly controversial. Currently, there appears to be a trend of increasing violence in state hospital settings, including both civilly and forensically committed populations. In fact, physical aggression is the primary reason for admission to many state hospitals. Given that violence is now often both a reason for admission and a barrier to discharge, there is a case to be made for psychiatric violence to be re-conceptualized dimensionally, as a primary syndrome, not as the byproduct of one. Furthermore, treatment settings need to be enhanced to address the new types of violence exhibited in inpatient environments, and this modification needs to be geared toward balancing safety with treatment.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guideline.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

"Meta-guidelines" for the management of patients with schizophrenia.

Guidelines for treating various conditions can be helpful in setting practice standards, but the presence of several sets of guidelines from different countries, experts, and settings, written at different times, can also create confusion. Here we provide a "guideline of guidelines" for the treatment of schizophrenia, or "meta-guidelines, which not only reconcile the various existing standards but also update them to include the use of several newer agents, most of which were marketed following the publication of existing standards.