Exploring Racial Disparities in The Brief Jail Mental Health Screen.

The authors analyzed validation data from the Brief Jail Mental Health Screen (BJMHS) to determine whether race predicted screening results and if such a prediction was driven by particular screen items. A total of 22,000 individuals entering five jails over two 8-month periods were screened. The authors constructed binary logistic regression models to assess the impact of race on screening positive and endorsing particular items. Blacks and Latinos had lower odds than Whites of screening positive. Blacks and Latinos had somewhat lower odds than Whites of endorsing two or more symptom items but had appreciably lower odds of endorsing items regarding prior mental health service utilization. Racial differences in BJMHS screening results likely reflect the reproduction of racial disparities rather than valid differences because results were driven by items reflecting known barriers in access to mental health services. Nonetheless, the instrument is likely to remain an improvement over typical jail screening procedures.

The Classification of Violence Risk.

(Reprinted with permission from Behav. Sci. Law 24: 721-730, 2006).

Revalidating the brief jail mental health screen to increase accuracy for women.

OBJECTIVE: Jails need a reliable tool to identify inmates who require further mental health assessment and treatment. This research attempted to revalidate the Brief Jail Mental Health Screen (BJMHS) as such a tool. This research added four items to the original eight-item screen (BJMHS-R), targeting depression and trauma to improve performance of the screen with women. METHODS: BJMHS-R data were collected in four jails from 10,258 detainees. A subset of 464 were administered the Structured Clinical Interview for DSM-IV (SCID) for cross-validation. RESULTS: The original BJMHS outperformed the revised screen. The original correctly classified 80% of males and 72% of females on the basis of SCID diagnoses, compared with classification rates of 72% and 66%, respectively, with the BJMHS-R. Overall, the BJMHS identified 16% of screened detainees as needing referral for further assessment, whereas the BJMHS-R identified 22%. CONCLUSIONS: The original eight-item BJMHS is a practical, efficient tool for intake screening by jail correction officers of male and female detainees.

Violence to Others, Violent Self-Victimization, and Violent Victimization by Others Among Persons With a Mental Illness.

OBJECTIVE: This research examined the frequency of and characteristics associated with three forms of violence among persons with mental illness-violence directed at others, self-directed violence, and violence directed at them by others. METHODS: Previously unreported data from a follow-up sample of 951 patients from the MacArthur Violence Risk Assessment Study were analyzed to characterize involvement in violence directed at others, self-directed violence, and violence directed at them by others. RESULTS: Most patients (58%) experienced at least one form of violence, 28% experienced at least two forms, and 7% experienced all three forms. Several diagnostic, social, and historical variables distinguished the groups. CONCLUSIONS: Given the substantial overlap among the three forms of violence, clinicians should routinely screen patients who report one form for the occurrence of the other two. Co-occurrence of several forms of violence may require a package of interventions with components geared to each.

Use of the criminal justice system to leverage mental health treatment: effects on treatment adherence and satisfaction.

In efforts to divert persons with mental illness from jails and prisons, the option of community mental health treatment in lieu of incarceration is sometimes offered. In addition, community treatment can be mandated, or "leveraged," as a condition of probation or parole. However, little is known about the characteristics and attitudes of persons who are and who are not leveraged into community mental health treatment via the criminal justice (CJ) system. In the present study, over 1,000 outpatients with mental disorders were queried about their experiences with CJ leverages, as well as their clinical and treatment histories. Persons who had experienced at least one form of CJ leverage were more likely to be younger and male and to have more hospitalizations than persons who had never experienced a CJ leverage. However, leverage experience was not associated with treatment compliance and satisfaction, or perceptions of coercion and mandate efficacy, particularly when demographic characteristics were considered.

Validation of the brief jail mental health screen.

OBJECTIVE: Jails have a substantial legal obligation to provide health and mental health care for inmates; yet screening procedures across American jails are highly variable. Currently, no valid, practical, standardized tool is available. The study reported here sought to validate a revision of the Referral Decision Scale (RDS)--the Brief Jail Mental Health Screen (BJMHS)--which provides an even briefer and more practical tool for use in jails. METHODS: Valid BJMHS data were collected in four jails (two in Maryland and two in New York) from 10,330 detainees. A total of 357 detainees were also administered the Structured Clinical Interview for DSM-IV (SCID) for standardized clinical cross-validation: 125 detainees (74 men and 51 women) who were classified as referrals for further mental health assessment on the basis of BJMHS and 232 detainees (137 men and 95 women) who were not classified as referrals. RESULTS: The BJMHS takes an average of 2.5 minutes to administer. It correctly classified 73.5 percent of males but only 61.6 percent of females on the basis of SCID diagnoses. Overall, the BJMHS identified 11.3 percent of screened detainees for further mental health assessment. CONCLUSIONS: The BJMHS is a practical, efficient tool that jail correction officers can give male detainees on intake screening. However, the screen has an unacceptably high false-negative rate for female detainees.

An actuarial model of violence risk assessment for persons with mental disorders.

OBJECTIVES: An actuarial model was developed in the MacArthur Violence Risk Assessment Study to predict violence in the community among patients who have recently been discharged from psychiatric facilities. This model, called the multiple iterative classification tree (ICT) model, showed considerable accuracy in predicting violence in the construction sample. The purpose of the study reported here was to determine the validity of the multiple ICT model in distinguishing between patients with high and low risk of violence in the community when applied to a new sample of individuals. METHODS: Software incorporating the multiple ICT model was administered with independent samples of acutely hospitalized civil patients. Patients who were classified as having a high or a low risk of violence were followed in the community for 20 weeks after discharge. Violence included any battery with physical injury, use of a weapon, threats made with a weapon in hand, and sexual assault. RESULTS: Expected rates of violence in the low- and high-risk groups were 1 percent and 64 percent, respectively. Observed rates of violence in the low- and high-risk groups were 9 percent and 35 percent, respectively, when a strict definition of violence was used, and 9 percent and 49 percent, respectively, when a slightly more inclusive definition of violence was used. These findings may reflect the "shrinkage" expected in moving from construction to validation samples. CONCLUSIONS: The multiple ICT model may be helpful to clinicians who are faced with making decisions about discharge planning for acutely hospitalized civil patients.

Use of leverage to improve adherence to psychiatric treatment in the community.

OBJECTIVES: A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage. METHODS: Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States. RESULTS: The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use. Use of money as leverage ranged from 7 to 19 percent of patients; outpatient commitment, 12 to 20 percent; criminal sanction, 15 to 30 percent; and housing, 23 to 40 percent. CONCLUSIONS: Debates on current policy emphasize only one form of leverage, outpatient commitment, which is much too narrow a focus. Attempts to leverage treatment adherence are ubiquitous in serving traditional public-sector patients. Research on the outcomes associated with the use of leverage is critical to understanding the effectiveness of the psychiatric treatment system.

Gun Violence and Victimization of Strangers by Persons With a Mental Illness: Data From the MacArthur Violence Risk Assessment Study.

OBJECTIVE: Highly publicized incidents in which people with apparent mental illnesses use guns to victimize strangers have important implications for public views of people with mental illnesses and the formation of mental health and gun policy. The study aimed to provide more data about this topic. METHODS: MacArthur Violence Risk Assessment Study data were analyzed to determine the prevalence of violence by 951 patients after discharge from a psychiatric hospital, including gun violence, violence toward strangers, and gun violence toward strangers. RESULTS: Two percent of patients committed a violent act involving a gun, 6% committed a violent act involving a stranger, and 1% committed a violent act involving both a gun and a stranger. CONCLUSIONS: When public perceptions and policies regarding mental illness are shaped by highly publicized but infrequent instances of gun violence toward strangers, they are unlikely to help people with mental illnesses or to improve public safety.

Perceived coercion and treatment adherence in an outpatient commitment program.

The authors investigated whether mental health inpatients' perceptions of coercion were associated with postdischarge treatment adherence. Patients eligible for New York's outpatient commitment program were interviewed and their perceptions of coercion measured during hospitalization and at one, five, and 11 months after discharge. Medication and clinical treatment adherence were measured at the three postdischarge interviews. Among the 117 participants who completed at least one follow-up interview, higher perceived coercion scores were correlated with greater self-reported adherence to clinical treatment at the one-month follow-up but not with participants' greater self-reported adherence at subsequent follow-ups or with providers' ratings of participants' adherence. Perceived coercion scores were positively correlated with participants' self-reported adherence to injected medications.

Perceived coercion at hospital admission and adherence to mental health treatment after discharge.

The authors investigated whether mental health inpatients' perceptions of coercion were associated with later treatment adherence. Psychiatric inpatients receiving acute care at three sites were interviewed during their hospitalization and up to five times after discharge. Patients' perceptions of coercion were measured at admission. Adherence to medication and clinical treatment was measured every ten weeks for one year after discharge. Among the 825 patients who had a perceived coercion score and ten-week follow-up data and who reported that outpatient treatment was prescribed, perceived coercion scores were not associated with treatment adherence. The authors concluded that perceived coercion neither increases nor decreases psychiatric inpatients' medication adherence or use of treatment services after discharge.

Criminal justice and behavioral health care costs of mental health court participants: a six-year study.

OBJECTIVE: This study examined whether there were differences in costs for mental health court (MHC) participants and a matched comparison group for three years after a target arrest. METHODS: Data from the MacArthur Mental Health Court Study, the first multisite study of MHCs, were used to compare behavioral health treatment and criminal justice costs for MHC participants and a matched group (using coarsened exact matching) of jail detainees who were not enrolled in an MHC but who received jail-based psychiatric services in the same cities. Cost data for three years before and after a target arrest were calculated separately for each year and for each participant at three sites of the multisite study-296 MHC participants and 386 matched jail detainees. High-cost MHC participants were identified. RESULTS: Total annual costs for MHC participants averaged $4,000 more for all three follow-up years. The additional costs resulted from treatment costs, which were not offset by criminal justice cost savings. The highest-cost MHC participants were those with diagnoses of co-occurring substance use disorders and those who had more arrest incarceration days before their target arrest. Separate analyses determined that the higher average costs were not the result of outlier cases. CONCLUSIONS: Participation in an MHC may not result in total cost savings in the three years after enrollment. To become more efficient and to serve participants with the greatest needs, MHCs need to more effectively define the target group for intervention.

The cost of assisted outpatient treatment: can it save states money?

OBJECTIVE: The authors assessed a state's net costs for assisted outpatient treatment, a controversial court-ordered program of community-based mental health services designed to improve outcomes for persons with serious mental illness and a history of repeated hospitalizations attributable to nonadherence with outpatient treatment. METHOD: A comprehensive cost analysis was conducted using 36 months of observational data for 634 assisted outpatient treatment participants and 255 voluntary recipients of intensive community-based treatment in New York City and in five counties elsewhere in New York State. Administrative, budgetary, and service claims data were used to calculate and summarize costs for program administration, legal and court services, mental health and other medical treatment, and criminal justice involvement. Adjusted effects of assisted outpatient treatment and voluntary intensive services on total service costs were examined using multivariate time-series regression analysis. RESULTS: In the New York City sample, net costs declined 43% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In the five-county sample, costs declined 49% in the first year and an additional 27% in the second year. Psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. Regression analyses revealed significant declines in costs associated with both assisted outpatient treatment and voluntary participation in intensive services, although the cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services. CONCLUSIONS: Assisted outpatient treatment requires a substantial investment of state resources but can reduce overall service costs for persons with serious mental illness. For those who do not qualify for assisted outpatient treatment, voluntary participation in intensive community-based services may also reduce overall service costs over time, depending on characteristics of the target population and local service system.

Effect of mental health courts on arrests and jail days: a multisite study.

CONTEXT: Mental health courts are growing in popularity as a form of jail diversion for justice system-involved people with serious mental illness. This is the first prospective multisite study on mental health courts with treatment and control groups. OBJECTIVES: To determine if participation in a mental health court is associated with more favorable criminal justice outcomes than processing through the regular criminal court system and to identify defendants for whom mental health courts produce the most favorable criminal justice outcomes. DESIGN: Longitudinal study. SETTING: Four mental health courts in San Francisco County, CA, Santa Clara County, CA, Hennepin County (Minneapolis), MN, and Marion County (Indianapolis), IN. PARTICIPANTS: A total 447 persons in the mental health court (MHC) and 600 treatment-as-usual (TAU) controls. INTERVENTION: Eighteen months of pre-entry and postentry data for 4 jurisdictions. All subjects were interviewed at baseline, and 70% were interviewed at 6 months. Objective outcome data were obtained on all subjects from Federal Bureau of Investigation arrest records, jails, prisons, and community treatment providers. MAIN OUTCOME MEASURES: Annualized rearrest rates, number of rearrests, and postentry incarceration days. RESULTS: The MHC and TAU samples are similar on the major outcome measures in the pre-entry 18-month period. In the 18 months following treatment, defined as entry into mental health court, the MHC group has a lower annualized rearrest rate, fewer post-18-month arrests, and fewer post-18-month incarceration days than the TAU group. The MHC graduates had lower rearrest rates than participants whose participation was terminated both during MHC supervision and after supervision ended. Factors associated with better outcomes among the MHC participants include lower pre-18-month arrests and incarceration days, treatment at baseline, not using illegal substances, and a diagnosis of bipolar disorder rather than schizophrenia or depression. CONCLUSIONS: Mental health courts meet the public safety objectives of lowering posttreatment arrest rates and days of incarceration. Both clinical and criminal justice factors are associated with better public safety outcomes for MHC participants.

The use of mental health court appearances in supervision.

A defining feature of mental health courts (MHCs) is the requirement that enrollees appear periodically for status review hearings before the MHC judge. Although the research base on these specialty courts is growing, MHC appearances have yet to be examined. In the present study, the authors followed more than 400 MHC clients from four courts. We examined the number of court appearances that were mandated versus attended, the number of bench warrants issued, and the proportion of court appearances that were made in-custody versus out-of-custody. Finally, we describe and report on the proportion of clients at each court who had graduated, had been terminated, or who were still in the court one year following enrollment.

Assisted outpatient treatment in New York: regional differences in New York's assisted outpatient treatment program.

OBJECTIVE: This study sought to describe the implementation of "Kendra's Law" in New York State and examine regional differences in the application of the program. METHODS: Between February 2007 and April 2008, interviews were conducted with 50 key informants across New York State. Key informants included assisted outpatient treatment (AOT) county coordinators, county directors of community services, judges, attorneys from the Mental Hygiene Legal Service (MHLS), psychiatrists, treatment providers, peer advocates, family members, and other referred individuals. Additional analyses were conducted using AOT program administrative and evaluation databases and client history data. RESULTS: From program inception in 1999 through 2007, a total of 8,752 initial AOT orders and 5,684 renewals were granted. Notable regional differences were found in the use of two distinct models of AOT: AOT First and Enhanced Voluntary Services First. Regional differences were also found in how the AOT program was implemented and administered. Other variations stemmed from the court proceedings themselves, the continuity and interest of the presiding judge, and the attitudes of the MHLS attorneys. CONCLUSIONS: Many regional adaptations of the AOT program were found. Many were the result of lack of guidance in implementing Kendra's Law. Policy makers may want to consider whether the law should change to allow for these differences or whether additional support from a central source is warranted to ensure more uniformity in the implementation of AOT and thus the fairness of its application across the state.

Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York.

OBJECTIVE: This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends. METHODS: Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods. RESULTS: For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. CONCLUSIONS: Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.

Assessing outcomes for consumers in New York's assisted outpatient treatment program.

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. METHODS: Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. RESULTS: On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. CONCLUSIONS: Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.

Reductions in arrest under assisted outpatient treatment in New York.

OBJECTIVE: Individuals with serious mental illness have a relatively high risk of criminal justice involvement. Assisted outpatient treatment (AOT) is a legal mechanism that mandates treatment for individuals with serious mental illness who are unlikely to live safely in the community without supervision and who are also unlikely to voluntarily participate in treatment. Under an alternative arrangement, some individuals for whom an AOT order is pursued sign a voluntary service agreement in lieu of a formal court order. This study examined whether AOT recipients have lower odds of arrest than persons with serious mental illness who have not yet initiated AOT or signed a voluntary service agreement. METHODS: Interview data from 2007 to 2008 from an evaluation of AOT in New York State were matched with arrest records from 1999 to 2008 for 181 individuals and analyzed using multivariable logistic regression. RESULTS: The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement. The odds of arrest among individuals currently under a voluntary service agreement (OR=.64) were not significantly different than for individuals who had not yet initiated either arrangement. The adjusted predicted probabilities of arrest in any given month were 3.7% for individuals who had not yet initiated AOT or a voluntary agreement, 1.9% for individuals currently on AOT, and 2.8% for individuals currently under a voluntary agreement. CONCLUSIONS: AOT may be an important part of treatment efforts to reduce criminal justice involvement among people with serious mental illness.

Perceived coercion to treatment and housing satisfaction in housing-first and supportive housing programs.

OBJECTIVES: This study of five housing programs across the United States examined whether the type of program-housing first or supportive housing-is related to an explicit requirement that residents adhere to mental health and substance abuse treatment, to residents' subjective perceptions that treatment adherence was being coerced, and to residents' housing satisfaction. METHODS: Interviews were conducted with 136 residents of housing programs at five sites. RESULTS: Results showed that compared with residents in supportive housing programs, those in housing-first programs were significantly less likely to report that mental health treatment adherence was an explicit requirement of obtaining housing and less likely to report that mental health and substance abuse treatment was a requirement of retaining housing. There was no difference between the programs in residents' satisfaction with their housing. CONCLUSIONS: Housing-first programs achieved a level of client satisfaction comparable to that of supportive housing programs while apparently staying consistent with their guiding "no coerced treatment" philosophy.