Leading indicators of community-based violent events among adults with mental illness.

BACKGROUND: The public health, public safety and clinical implications of violent events among adults with mental illness are significant; however, the causes and consequences of violence and victimization among adults with mental illness are complex and not well understood, which limits the effectiveness of clinical interventions and risk management strategies. This study examined interrelationships between violence, victimization, psychiatric symptoms, substance use, homelessness and in-patient treatment over time. METHOD: Available data were integrated from four longitudinal studies of adults with mental illness. Assessments took place at baseline, and at 1, 3, 6, 9, 12, 15, 18, 24, 30 and 36 months, depending on the parent studies' protocol. Data were analysed with the autoregressive cross-lag model. RESULTS: Violence and victimization were leading indicators of each other and affective symptoms were a leading indicator of both. Drug and alcohol use were leading indicators of violence and victimization, respectively. All psychiatric symptom clusters - affective, positive, negative, disorganized cognitive processing - increased the likelihood of experiencing at least one subsequent symptom cluster. Sensitivity analyses identified few group-based differences in the magnitude of effects in this heterogeneous sample. CONCLUSIONS: Violent events demonstrated unique and shared indicators and consequences over time. Findings indicate mechanisms for reducing violent events, including trauma-informed therapy, targeting internalizing and externalizing affective symptoms with cognitive-behavioral and psychopharmacological interventions, and integrating substance use and psychiatric care. Finally, mental illness and violence and victimization research should move beyond demonstrating concomitant relationships and instead focus on lagged effects with improved spatio-temporal contiguity.

Comorbid posttraumatic stress disorder is associated with suicidality in male veterans with schizophrenia or schizoaffective disorder.

The purpose of this study was to determine if patients with schizophrenia or schizoaffective disorders and comorbid posttraumatic stress disorder (PTSD) are at higher risk for suicidality than patients without comorbid PTSD. Participants were 165 male veterans with primary diagnoses of schizophrenia or schizoaffective disorder. Those with comorbid PTSD reported higher rates of suicidal ideation and suicidal behaviors compared to those without comorbid PTSD. These findings suggest that patients with comorbid PTSD are at higher risk for suicidality. Enhanced screening and targeted interventions may be warranted to address comorbid PTSD and increased suicide risk in this population.

Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness.

This study examines potential improvement in treatment adherence during a study of involuntary outpatient commitment among individuals with severe mental illnesses. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment after hospital discharge. A nonrandomized group with a recent history of serious violence was also studied under outpatient commitment. Randomized control and outpatient commitment groups did not differ significantly in group comparisons of treatment adherence. However, analyses of all subjects, including nonrandomized violent subjects, showed that those who underwent sustained periods of outpatient commitment (6 months or more) were significantly more likely to remain adherent with medication and other treatment, compared with those who underwent only brief outpatient commitment or none. Administration of depot antipsychotics also significantly improved treatment adherence independently of the effect of sustained outpatient commitment. Sustained periods of outpatient commitment may significantly improve adherence with community-based mental health treatment for persons with severe mental illness and thus may help improve other clinical outcomes affected by adherence.

Mandated community treatment: beyond outpatient commitment.

Outpatient commitment, although often viewed as merely an extension of inpatient commitment, is only one of a growing array of legal tools used to mandate treatment adherence. The authors describe various forms of mandated community treatment. People with severe and chronic mental disorders often depend on goods and services provided by the social welfare system. Benefits disbursed by representative payees and the provision of subsidized housing have both been used as leverage to ensure treatment adherence. Many discharged patients are arrested for criminal offenses. Favorable disposition of their cases by a mental health court may be tied to participation in treatment. Under outpatient commitment statutes, judges can order committed patients to comply with prescribed treatment. Patients may attempt to maximize their control over treatment in the event of later deterioration by executing an advance directive. The ideological posturing that currently characterizes the field must be replaced by an evidence-based approach.

A randomized controlled trial of outpatient commitment in North Carolina.

OBJECTIVE: A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses. METHODS: A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records. RESULTS: In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders. CONCLUSIONS: Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.

Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.

OBJECTIVES: This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness. METHODS: Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina. RESULTS: The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively. CONCLUSIONS: Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.

Psychiatric advance directives: an alternative to coercive treatment?

Psychiatric Advance Directives (PADs) are a legal means by which persons with mental illness, while competent to make healthcare decisions, may specify their preferences for treatment and may designate a surrogate decision-maker to act on their behalf in the event of an incapacitating mental health crisis. PADs have been advocated as a strategy to increase autonomy and decrease coercion in the treatment of severe psychiatric illness, but there has been little research on the actual use and effects of PADs. This article develops a conceptual model for how PADs might work, both directly and indirectly. According to the model proposed here, PADs might provide an effective tool for managing psychiatric crises but might also help to improve participation in regular outpatient treatment. This article further examines arguments for and against PADs and looks optimistically toward their use as an alternative to more coercive approaches to mental health treatment such as outpatient commitment (OPC).

Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness.

BACKGROUND: Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment. AIMS: To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI. METHOD: One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected. RESULTS: A significantly lower incidence of violent behaviour occurred in subjects with > or = 6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse. CONCLUSIONS: OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.

Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals.

OBJECTIVE: The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses. METHOD: Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected. RESULTS: In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment. CONCLUSIONS: Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.

Criminal victimization of persons with severe mental illness.

OBJECTIVE: The types and amounts of crime experienced by persons with severe mental illness were examined to better understand criminal victimization in this population. METHODS: Subjects were 331 involuntarily admitted psychiatric inpatients who were ordered by the court to outpatient commitment after discharge. Extensive interviews provided information on subjects' experience with crime in the previous four months and their perceived vulnerability to victimization, as well as on their living conditions and substance use. Medical records provided clinical data. RESULTS: The rate of nonviolent criminal victimization (22.4 percent) was similar to that in the general population (21.1 percent). The rate of violent criminal victimization was two and a half times greater than in the general population--8.2 percent versus 3.1 percent. Being an urban resident, using alcohol or drugs, having a secondary diagnosis of a personality disorder, and experiencing transient living conditions before hospitalization were significantly associated with being the victim of a crime. In the multivariate analysis, substance use and transient living conditions were strong predictors of criminal victimization; no demographic or clinical variable was a significant predictor. (Given the relatively high crime rates, subjects' perceived vulnerability to victimization was unexpectedly low; only 16.3 percent expressed concerns about personal safety. Those with a higher level of education expressed greater feelings of vulnerability. CONCLUSIONS: The study found a substantial rate of violent criminal victimization among persons with severe and persistent mental illness. Results suggest that substance use and homelessness make criminal victimization more likely.

Male-female differences in the setting and construction of violence among people with severe mental illness.

Data from a sample of severely and persistently mentally ill involuntary patients indicated that differences in violence between males and females in the 4 months prior to hospital admission depended on the measure. In the bivariate analysis, males had a greater prevalence of violence on the two indicators which separated more serious violence from lesser and no violence; but there was no gender difference on the more inclusive measure which incorporated threats and fights not involving weapons or injuries. In multivariate analysis when other relevant predictors were controlled, gender was significant in predicting only the most inclusive indicator of violence and only in interaction with substance abuse problems.

Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals.

Increasing numbers of severely mentally ill individuals are being treated in nonhospital, community-based settings and public concern about potential violence by these individuals has increased, often as a result of tragic, albeit uncommon events. The present study examines potential predictors of serious violence among persons with severe mental illness (SMI), with a specific focus on the joint effect of substance abuse and medication noncompliance. Subjects in the study are involuntarily admitted inpatients with SMI awaiting a period of court-ordered outpatient treatment, termed "involuntary outpatient commitment". During enrollment in a longitudinal outcome study of the effectiveness of OPC, 331 subjects and, whenever feasible, family members or other informants were interviewed. In addition, complementary data were gathered by review of involuntary commitment records and hospital records. Data collection included sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse and violent behavior during the 4 months preceding hospitalization. Descriptive and multivariable logistic regression procedures were used to examine the association between serious violent acts and a number of personal, social, and clinical characteristics. The combination of medication noncompliance and substance abuse was a significant predictor of serious violent acts in the community. Individuals who had problems with both alcohol and illicit drug abuse appear to be at greatest risk for violence. These results suggest that reducing violence risk among persons with SMI requires an aggressive approach to improving medication adherence in the context of integrated mental health and substance abuse treatment.

Administrative update: utilization of services. I. Comparing use of public and private mental health services: the enduring barriers of race and age.

Data from the NIMH-Epidemiologic Catchment Area Project were used to predict differential use of private versus public outpatient mental health services, a salient concern in integrating public and private services in market-based health care reform efforts. Having a recent psychiatric disorder, being age 25-44, female, white, of higher educational level, and unmarried increase the odds of any mental health service use. However, odds of treatment in the public sector are increased for males, African Americans, those with low educational and income levels, and odds are markedly decreased for the elderly, suggesting significant barriers to care for these mentally ill subpopulations.

Epidemiology of recurrent major and minor depression with a seasonal pattern. The National Comorbidity Survey.

BACKGROUND: Previous estimates of the prevalence of seasonal affective disorder (SAD) in community samples have been in the range 2-10%, using methods not derived from DSM algorithms. We report the first community-based study to estimate major and minor depression with a seasonal pattern in a community-based sample using a diagnostic instrument derived from DSM-III-R. METHOD: A modified version of the Composite International Diagnostic Interview was administered to 8098 subjects in the 48 coterminous states of the USA (the National Comorbidity Survey) to assess the prevalence of major and minor depression with a seasonal pattern. RESULTS: The lifetime prevalence of major depression with a seasonal pattern was 0.4%, and the prevalence of major or minor depression with a seasonal pattern was 1.0%. Among respondents with major depression, male gender and older age were associated with a higher prevalence with a seasonal pattern. CONCLUSIONS: Prevalence estimates of major and minor depression with a seasonal pattern are much lower than those found in previous studies of SAD in the community, probably due to the approach to diagnosis used in the present study, which more accurately represents DSM-III-R criteria for major depression with a seasonal pattern. The distribution of the disorder is similar to that found in previous studies except for the higher prevalence among males.

Violence and severe mental illness: the effects of substance abuse and nonadherence to medication.

OBJECTIVE: Violent behavior among individuals with severe mental illness has become an important focus in community-based care. This study examines the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness. METHOD: Involuntarily admitted inpatients with severe mental illness who were awaiting a period of outpatient commitment were enrolled in a longitudinal outcome study. At baseline, 331 subjects underwent an extensive face-to-face interview. Complementary data were gathered by a review of hospital records and a telephone interview with a family member or other informant. These data included subjects' sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse, insight into illness, and violent behavior during the 4 months that preceded hospitalization. Associations between serious violent acts and a range of individual characteristics and problems were analyzed by using multivariable logistic regression. RESULTS: The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled. CONCLUSIONS: Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with severe mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment.

Interpreting the effectiveness of involuntary outpatient commitment: a conceptual model.

Many experimental trials of community mental health interventions fail to develop testable conceptual models of the specific mechanisms and pathways by which relevant outcomes may occur, thus falling short of usefully interpreting what happens inside the experimental "black box." This paper describes a conceptual model of involuntary outpatient commitment (OPC) for persons with severe and persistent mental disorders. The model represents an attempt to "unpack" the effects of OPC by incorporating several interacting variables at various stages. According to this model, court-mandated outpatient treatment may improve long-term outcomes both directly and indirectly in several ways: by stimulating case management efforts, mobilizing supportive resources, improving individual compliance with treatment in the community, reducing clients' psychiatric symptoms and dangerous behavior, improving clients' social functioning, and finally by reducing the chance of illness relapse and rehospitalization. A randomized clinical trial of OPC is underway in North Carolina that will test the direct and indirect effects suggested by this model, using longitudinal data from the multiple perspectives of mental health clients, family members, and case managers.

The ethical challenges of a randomized controlled trial of involuntary outpatient commitment.

Involuntary outpatient commitment (OPC) is a civil justice procedure intended to enhance compliance with community mental health treatment, to improve functioning, and to reduce recurrent dangerousness and hospital recidivism. The research literature on OPC indicates that it appears to improve outcomes in rates of rehospitalization and length of stay. However, all studies to date have serious methodological limitations because of selection bias; lack of specification of target populations; unclear operationalization of OPC; unmeasured variability in type, frequency, and intensity of treatment; as well as other confounding factors. To address limitations in these studies, the authors designed a randomized controlled trial (RCT) of OPC, combined with community-based case management, which is now under way in North Carolina. This article describes ethical dilemmas in designing and implementing an RCT of a legally coercive intervention in community-based settings. These ethical dilemmas challenge the experimental validity of an RCT but can be successfully addressed with careful planning and negotiation.