Using the Theory of Planned Behavior to Understand How Crisis Intervention Team (CIT) Training Facilitates Police Officers' Mental Health Referrals.

The Theory of Planned Behavior posits that behaviors are predicted by one's intention to perform them; intention is driven by attitude toward the behavior, subjective norm, and perceived behavioral control. We used this theory to predict Crisis Intervention Team (CIT)-trained and non-CIT officers' intention to facilitate referral of persons with suspected mental illnesses to mental health services. CIT-trained (n = 251) and non-CIT (n = 335) officers from six law enforcement agencies participated. CIT-trained officers had significantly greater scores on all constructs. Theory constructs fit the data well, and fit did not differ meaningfully between the two groups. Direct and indirect predictors together accounted for 28% and 21%, respectively, of variance in behavioral intention. Attitude was the strongest predictor. Intentions to facilitate mental health referrals may be driven by the same factors among CIT-trained and non-CIT officers, but CIT officers, even at a median of 22 months after training, have significantly higher scores on those factors.

Improving Adherence to Cardiovascular Therapies: An Economic Evaluation of a Randomized Pragmatic Trial.

OBJECTIVE: Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]). METHODS: Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. RESULTS: Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls. CONCLUSIONS: We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker's willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.

Prevalence and predictors of complementary and alternative medicine use in African-Americans with acquired immune deficiency syndrome.

BACKGROUND: The use of complementary and alternative medicine (CAM) among Human Immunodeficiency Virus (HIV)-positive individuals is becoming increasingly widespread. Unfortunately, some CAM therapies may jeopardize the efficacy of conventional HIV medication, making it critical to understand CAM use among this population. OBJECTIVE: To investigate the prevalence and predictors of CAM use in a theory-driven, multidimensional manner. METHODS: African-American individuals who had received a diagnosis of acquired immune deficiency syndrome (AIDS) were recruited. The computer-administered survey asked questions about participants' CAM use and various psychosocial and socio-demographic characteristics. Participants' most recent CD4+ cell counts and HIV RNA levels were abstracted from medical records. Linear regression analyses, adjusted for potential confounders, were conducted to assess the independent contribution of various factors in explaining frequency of CAM use. RESULTS: One hundred and eighty two subjects participated in the survey. Results indicate that most (94%) participants used at least one type of CAM therapy. The majority of participants (79.7%) used CAM therapies as a complement (rather than an alternative) to their HIV medications though half had not discussed these therapies with their healthcare providers. Female sex, high yearly income, high health literacy and high HIV RNA levels were associated with a greater frequency of CAM use, while stronger emotional well-being was associated with a lower frequency of CAM use. CONCLUSIONS: The implications of these findings are discussed and suggestions for future research are provided.

Modeling the effects of Crisis Intervention Team (CIT) training for police officers: How knowledge, attitudes, and self-efficacy drive de-escalation skills and referral decisions.

OBJECTIVE: Prior research on Crisis Intervention Team (CIT) training for police officers has demonstrated improvements in knowledge, attitudes, self-efficacy, and stigma, but how these factors work together to influence behavioral outcomes like de-escalation skills and referral decisions remains unstudied. METHOD: 251 CIT-trained and 335 non-CIT officers completed in-depth surveys measuring these six constructs. We used structural equation modeling to test fit of the data to our hypothesized model and made indicated changes to improve fit. RESULTS: An alternate 8-path model (with three paths originally hypothesized being removed) fit reasonably well, and allowing path coefficients to differ for CIT and non-CIT groups resulted in models with similar fit statistics. CONCLUSION: CIT training enhances knowledge and attitudes, both of which have beneficial effects on stigma. Though an important outcome itself, lower stigma does not have an effect on de-escalation skills and referral decisions, though self-efficacy clearly does.

Development, item analysis, and initial reliability and validity of a multiple-choice knowledge of mental illnesses test for lay samples.

The public's level of mental health literacy remains low, despite growing access to information regarding mental illnesses. Because few measures exist to assess the level of knowledge of mental illnesses in lay samples, the Multiple-Choice Knowledge of Mental Illnesses Test (MC-KOMIT) was developed, initially for use in a study involving police officers, some of whom received 40 h of training focused on recognizing mental illnesses, using verbal de-escalation techniques, and making mental health referrals when appropriate. This report details the initial development of the 100 questions in the item bank and the eventual selection of the final 33 items that were retained. For these 33 items, internal consistency was demonstrated, and test-retest reliability was examined among officers not in the mental health-related training who completed the test on Monday morning and again on Friday afternoon. Construct validity was examined by three hypothesis tests: the MC-KOMIT was sensitive to change related to the educational intervention, scores were significantly correlated with years of educational attainment, and officers reporting past or current treatment for a mental health problem scored higher than those without such a history. This initial report suggests that the MC-KOMIT may be useful in quantifying knowledge of mental illnesses in police officers and other diverse lay samples.

Development and initial reliability and validity of four self-report measures used in research on interactions between police officers and individuals with mental illnesses.

There currently exists a dearth of reliable and valid instruments to examine key police officer variables of importance in the growing research on their interactions with individuals with mental illnesses. This study tested reliability and validity of four newly designed measures of the constructs of self-efficacy (Self-Efficacy Scale; SES), referral decisions and de-escalation skills (Behavioral Outcomes Scale; BOS), attitudes toward psychiatric treatment (Opinions about Psychiatric Treatment; OPT), and social distance (Adapted Social Distance Scale; ASDS) in a sample of law enforcement officers. Self-administered, anonymous surveys, which included the measures of interest, were completed by 177 officers-68 of whom were undergoing Crisis Intervention Team (CIT) training and 109 of whom were not-at the beginning and end of week-long trainings. Analyses examined the internal consistency reliability, test-retest reliability, and construct validity of the instruments. The four measures of interest were found to be reliable and valid. Specifically, internal consistency coefficients and test-retest reliability correlations were generally acceptable, all four demonstrated sensitivity to change, and validity correlations were significant and in the expected direction. Findings demonstrated the ability to measure key constructs related to attitudes and intended behaviors in law enforcement officers utilizing psychometrically sound instruments. Further testing and the development of additional reliable and valid instruments focused on attitudinal and behavioral domains among officers who have frequent interactions with individuals with mental illnesses would be of great value.

The influence of neighborhood characteristics on police officers' encounters with persons suspected to have a serious mental illness.

OBJECTIVE: Police officers' decisions and behaviors are impacted by the neighborhood context in which police encounters occur. For example, officers may use greater force and be more likely to make arrests in disadvantaged neighborhoods. We examined whether neighborhood characteristics influence police encounters with individuals suspected to have a serious mental illness, addictive disorder, or developmental disability. METHOD: We obtained data on 916 encounters from 166 officers in six jurisdictions in Georgia, USA and abstracted geographical data pertaining to the location of these encounters from United States Decennial Census data. Encounters were nested within 163 census tracts. Officer-reported data covered general encounter characteristics, the officer's perception of the subject's condition, subject demographics, use of force, and disposition of the encounter (e.g., arrest v. referral or transport to treatment services). Geographical data included 17 variables representing population and housing characteristics of the census tracts, from which three indices pertaining to neighborhood income, stability, and immigration status were derived using factor-analytic techniques. We then examined associations of these indices with various encounter-related variables using multi-level analysis. RESULTS: Encounters taking place in higher-income and higher-stability census tracts were more likely to be dispatch-initiated and take place in a private home compared to those in lower-income and lower-stability neighborhoods. In higher-income neighborhoods, encounters were more likely to involve a subject suspected to have a mental illness (as opposed to an addictive disorder or developmental disability) and less likely to involve a subject suspected to have alcohol problems. The officer's level of force used was not associated with neighborhood factors. Regarding disposition, although the likelihood of arrest was unrelated to neighborhood characteristics, encounters taking place in higher-immigrant neighborhoods were more likely to result in referral or transport to services than those in lower-immigrant neighborhoods. CONCLUSION: Neighborhood characteristics are important to consider in research on police interactions with individuals with serious mental illnesses, addictive disorders, or developmental disabilities. Such research could inform departmental training policies and procedures based on the needs of the jurisdictions served.

The police-based crisis intervention team (CIT) model: I. Effects on officers' knowledge, attitudes, and skills.

OBJECTIVE: Individuals with serious mental illnesses are very likely to interact with police officers. The crisis intervention team (CIT) model is being widely implemented by police departments across the United States to improve officers' responses. However, little research exists on officer-level outcomes. The authors compared officers with or without CIT training on six key constructs related to the CIT model: knowledge about mental illnesses, attitudes about serious mental illnesses and treatments, self-efficacy for deescalating crisis situations and making referrals to mental health services, stigmatizing attitudes, deescalation skills, and referral decisions. METHODS: The sample included 586 officers, 251 of whom had received the 40-hour CIT training (median of 22 months before the study), from six police departments in Georgia. In-depth, in-person assessments of officers' knowledge, attitudes, and skills were administered. Many measures were linked to two vignettes, in written and video formats, depicting typical police encounters with individuals with psychosis or with suicidality. RESULTS: CIT-trained officers had consistently better scores on knowledge, diverse attitudes about mental illnesses and their treatments, self-efficacy for interacting with someone with psychosis or suicidality, social distance stigma, deescalation skills, and referral decisions. Effect sizes for some measures, including deescalation skills and referral decisions pertaining to psychosis, were substantial (d=.71 and .57, respectively, p<.001). CONCLUSIONS: CIT training of police officers resulted in sizable and persisting improvements in diverse aspects of knowledge, attitudes, and skills. Research should now address potential outcomes at the system level and for individuals with whom officers interact.

The police-based crisis intervention team (CIT) model: II. Effects on level of force and resolution, referral, and arrest.

OBJECTIVE: The crisis intervention team (CIT) model is a widely implemented police-based program to improve officers' responses to individuals with behavioral disorders. The authors examined levels of force used by officers with or without CIT training and disposition decisions in a large sample of encounters with individuals whom they suspected of having a serious mental illness, a drug or an alcohol problem, or a developmental disability. METHODS: A total of 180 officers (91 with CIT training and 89 without) in six departments reported on 1,063 encounters, including level of force and disposition (resolution at the scene, referral or transport to services, or arrest). RESULTS: CIT training status was generally not predictive of level of force, although CIT-trained officers were significantly more likely to report verbal engagement or negotiation as the highest level of force used (odds ratio [OR]=2.00, p=.016). For CIT-trained officers, referral or transport was a more likely outcome (OR=1.70, p=.026) and arrest was less likely (OR=.47, p=.007) than for officers without CIT training; these findings were most pronounced when physical force was necessary. Analyses of disposition differences by officers' perceptions of subjects' primary problem (for example, mental illness only versus a drug or an alcohol problem) found some effects of CIT training status. CONCLUSIONS: CIT training appears to increase the likelihood of referral or transport to mental health services and decrease the likelihood of arrest during encounters with individuals thought to have a behavioral disorder. Research should address subject- and system-level outcomes that complement this early evidence of successful prebooking jail diversion.

Do empathy and psychological mindedness affect police officers' decision to enter crisis intervention team training?

OBJECTIVE: Police officers' voluntary choice to participate in specialized, week-long crisis intervention team (CIT) training is generally assumed to be a critical factor in success as a CIT officer. However, issues about self-selection have not been empirically examined. The investigators hypothesized that officers entering CIT training, especially those electing to take it, would have a higher likelihood of exposure to and experience with mental health issues and mental health professionals and greater empathy and psychological mindedness. METHODS: A total of 177 officers-including 109 non-CIT-trained officers, 24 officers assigned to CIT training, and 44 officers who volunteered for CIT training-were assessed before and after their week-long classes (non-CIT officers were enrolled in other courses). Basic sociodemographic characteristics were assessed, and four psychometrically sound measures of empathy and psychological mindedness were administered. Associations between officer status and sociodemographic variables, past exposure to and experience with mental illness issues, and empathy and psychological mindedness were examined. RESULTS: The three groups did not differ on three of four exposure and experience variables; however, self-selected CIT officers were more likely to have prior exposure to mental health issues and professionals. No differences were found between the three groups on measures of empathy or psychological mindedness. One measure of empathy increased significantly after the weeklong CIT training. CONCLUSIONS: Findings did not support the hypothesis that officers self-selecting into CIT training would have greater baseline empathy and psychological mindedness. Although there may be other justifiable reasons to argue for the importance of volunteering, these two traits did not appear to be greater among officers self-selecting into CIT.

Opening doors to recovery: a novel community navigation service for people with serious mental illnesses.

This column describes Opening Doors to Recovery in Southeast Georgia, a partnership between public agencies, a private corporation, a not-for-profit organization, and an academic institution. Teams of community navigation specialists that include a licensed mental health professional, a family member of an individual with a serious mental illness, and a peer with lived experience in recovery seek to enhance participants' community integration, support them in developing a meaningful day, ensure access to adequate treatment, and facilitate stable housing, improved relationships, and desired vocational, volunteer, or educational activities.

Development and evaluation of a complementary and alternative medicine use survey in African-Americans with acquired immune deficiency syndrome.

OBJECTIVES: The purpose of the current study was to develop and evaluate the psychometric properties of a culturally- and stage-of-disease-appropriate measure of complementary and alternative medicine (CAM) use among a population of African-American individuals with acquired immune deficiency syndrome (AIDS) using a mixed-method design. DESIGN: Data were collected in two phases. In phase 1, qualitative data were used to refine an existing CAM measure for the specific study population in the present study. In phase 2, this refined instrument was implemented in a larger sample. The resulting numeric data were analyzed to evaluate the psychometric properties of the revised CAM instrument. SETTING: Data were collected from patients who were receiving care from the infectious disease clinic of a large, public, urban hospital in the Southeastern United States. SUBJECTS: Patients were eligible to participate if they (1) were receiving their care from the clinic, (2) had an AIDS diagnosis, (3) were identified as African-American, (4) were > or =21 years of age, (5) spoke English, and (6) were not cognitively impaired. MEASURES: Focus groups in phase 1 were conducted with a semistructured focus group guide. Participants also completed a basic sociodemographic survey. Phase 2 participants used programmed laptops to answer questions about their CAM use and several sociodemographic questions. RESULTS: Information from the focus groups prompted some substantive revisions in the already-existing CAM survey. The revised instrument had satisfactory face validity and adequate test-retest reliability (r = 0.79). Furthermore, the instrument factored in a manner that was interpretable and consistent with prior findings. CONCLUSIONS: In order for human immunodeficiency virus health care providers to provide the best care to their patients, they need to be informed about the types and frequency of CAM use among their patients. This can be accomplished by methodologically developing CAM instruments, rigorously implementing and assessing these instruments, and then disseminating the findings to researchers and practitioners.

System- and Policy-Level Challenges to Full Implementation of the Crisis Intervention Team (CIT) Model.

The Crisis Intervention Team (CIT) model of collaboration between law enforcement and mental health is widely recognized as being "more than just training" for police officers; the core elements of CIT include a number of other components. However, several system- and policy-level obstacles can make successful implementation of CIT difficult in many communities. Three such challenges are addressed in this article: insufficient training and policies for dispatchers, poor availability of psychiatric emergency receiving facilities, and complexities related to implementation of CIT in rural settings. Collaboratively addressing these and other challenges will undoubtedly advance the goals of CIT.