The interaction of serious mental disorder and race on time to reincarceration.

Individuals with a serious mental disorder (SMD) are disproportionately incarcerated in state prisons, and research has shown that individuals with SMD are more likely to recidivate upon release. Persons of color are also disproportionately incarcerated and at risk for repeat incarcerations. However, minimal research has yet to examine whether the relationship between SMD and recidivism is conditioned on race. This study used proportional hazards Cox regression modeling to investigate the effect of SMD on criminal recidivism over an 8-year period among 22,376 former prisoners in North Carolina. The interaction between race and SMD is explored to test for cross-racial variation in time-to-reincarceration. A significant interaction effect of non-Black minority by SMD was found. Non-Black minority former prisoners with SMD returned to prison significantly quicker than non-Black minorities without SMD. No interaction effect was found for either Black or White former prisoners. Hazard to return to prison was also significantly increased for former prisoners that were younger in age, male, Black, not employed at arrest, and indicated for substance abuse. Those factors contributing to the effect of SMD on criminal recidivism within non-Black minority former prisoners is unclear. Additional research is needed on the interactive effects of racial group and SMD on postprison experiences. (PsycINFO Database Record

Comparing behavioral health models for reducing risky drinking among older male veterans.

BACKGROUND: Screening older veterans in Veterans Affairs Medical Center (VAMC) primary care clinics for risky drinking facilitates early identification and referral to treatment. OBJECTIVE: This study compared two behavioral health models, integrated care (a standardized brief alcohol intervention co-located in primary care clinics) and enhanced referral care (referral to specialty mental health or substance abuse clinics), for reducing risky drinking among older male VAMC primary care patients. VAMC variation was also examined. METHOD: A secondary analysis of longitudinal data from the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study, a multisite randomized controlled trial, was conducted with a sample of older male veterans (n = 438) who screened positive for risky drinking and were randomly assigned to integrated or enhanced referral care at five VAMCs. RESULTS: Generalized estimating equations revealed no differences in either behavioral health model for reducing risky drinking at a 6-month follow-up (AOR: 1.46; 95% CI: 0.42-5.07). Older veterans seen at a VAMC providing geriatric primary care and geriatric evaluation and management teams had lower odds of risky drinking (AOR: 0.24; 95% CI: 0.07-0.81) than those seen at a VAMC without geriatric primary care services. CONCLUSIONS: Both integrated and enhanced referral care reduced risky drinking among older male veterans. However, VAMCs providing integrated behavioral health and geriatric specialty care may be more effective in reducing risky drinking than those without these services. Integrating behavioral health into geriatric primary care may be an effective public health approach for reducing risky drinking among older veterans.

Enhancing Social Support Postincarceration: Results From a Pilot Randomized Controlled Trial.

OBJECTIVE: Over 50% of released prisoners are reincarcerated within 3 years. Social support from loved ones postincarceration significantly reduces the likelihood of reincarceration. Increasingly, intervention developers aim to implement interventions that will enhance the stability of support available. This study responds to gaps in knowledge. METHOD: The current efficacy study reports findings from a randomized controlled trial (n = 57) of a social support intervention. A priori power analysis indicated moderate effect sizes could be detected. Participants were men, average age was 25 years, and over 90% were African American. Preliminary effects on social support, cognitions, substance use, and rearrest were assessed. Recruitment and consent occurred in prison; the intervention and 4 follow-ups occurred postrelease. RESULTS: Findings converge with research indicating declines in social support (b = -.70, p < .05) and perceived quality of support (b = .05, p < .01) over time. Age showed inverse relationships with support (b = -1.77, p < .05). There were no statistically significant group effects for social support, cognitions, substance use (with the exception of marijuana), or recidivism. Clinical implications are discussed. CONCLUSION: This study advances research on intervention dosage, potency, and measurement considerations.

Violent Death Rates and Risk for Released Prisoners in North Carolina.

Released prisoners face high risk of early mortality. The risk of violent death, specifically homicide and suicide, are addressed in this study. Data on inmates released from the North Carolina Division of Adult Corrections (N = 476) matched to the Violent Death Reporting System are analyzed to estimate rates and demographic and criminal justice-related predictors. Violent death rates for persons released from prison were more than 7 times higher than for the general adult population. Results from multinomial logistic regression indicate decreased homicide risk for every year of age, whereas male gender and minority race increased risk. For suicide, minority race, release without supervision, and substance abuse treatment in prison decreased fatality risk. By contrast, a history of mental illness increased suicide risk. Implications for practice and research are discussed.

Faculty perceptions of accommodations, strategies, and psychiatric advance directives for university students with mental illnesses.

OBJECTIVE: Universities across the country struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of serious mental illness. This mixed-method study provides information on faculty knowledge of mental health problems in students, their use of available accommodations and strategies, and their willingness to accept psychiatric advance directives (PADs) as helpful interventions for managing student crises. METHOD: Participants were 168 faculty members at a large, public, Southern university. A web-based survey was used to collect quantitative self-report data as well as qualitative data in the form of open-ended questions. Quantitative data are presented with descriptive statistics. Qualitative data were analyzed using thematic analysis. RESULTS: The majority of faculty surveyed have an overall supportive stance and are willing to provide accommodations to students with a mental illness. The most common advantage faculty see in a PAD is support of student autonomy and choice, and the primary concern voiced about PADs is that students with mental illness will have poor judgment regarding the contents of the PADs they create. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: PADs may be effective recovery tools to help university students with mental illnesses manage crises and attain stability and academic success. For PADs to be effective, university faculty and administration will need to understand mental illnesses, the strategies students need to manage mental health crises, and how PADs can play a role in supporting students.

Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners' perspectives before and after community reentry.

BACKGROUND: Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison. METHODS: We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher's Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures. RESULTS: Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care. CONCLUSION: These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

"Let momma take 'em": portrayals of women supporting male former prisoners.

Women provide support for many vulnerable groups, work that is frequently discounted with gendered stereotypes. One growing vulnerable group is former prisoners who often return to women family members. We completed a qualitative study with 25 former prisoners and criminal justice staff to examine their conceptualizations of the demands placed on women supporters of former prisoners. Results indicate a significant burden of support experienced by women, discounted by prisoners and criminal justice staff through a dynamic of gendered idealization and stigmatization. Implications include the importance of exposing this dynamic and providing supports to decrease the burden of care that women experience.

University students' views on the utility of psychiatric advance directives.

OBJECTIVE: Rates of serious mental illnesses (SMIs) among university students are increasing, and universities are struggling with how to respond to students who show SMI symptoms. Psychiatric advance directives (PADs) allow individuals, when well, to document their wishes for treatment during a psychiatric crisis. This project explored the feasibility of using PADs in university settings by examining students' views towards PADs. PARTICIPANTS: Forty university students with SMIs were recruited for this study from 1 large university. METHODS: A mixed-methods design was used, with both quantitative survey instruments and qualitative interviews with students. RESULTS: Respondents were positive about PAD utility for students. Respondents saw PADs as beneficial because PADs gave students control over their treatment. However, students also considered PADs potentially problematic because PAD use raised a risk of breaching student privacy and stigmatizing students with SMIs. CONCLUSIONS: Although a promising intervention for students with SMI, this approach requires further research.

Jail administrators' perceptions of the use of psychiatric advance directives in jails.

OBJECTIVE: Individuals with serious mental illnesses are at high risk of incarceration. Jails are often unable to obtain information needed to provide appropriate care. Psychiatric advance directives may be useful tools to communicate treatment information to jails. This study explored their use as a novel intervention for individuals with mental illnesses in jails. METHODS: Eighty jail administrators in North Carolina were surveyed to determine their support for psychiatric advance directives in jails. Relationships between respondents' job type (jail administrator or medical administrator) or jail census and support for the directives were examined by using chi square tests. Open-ended responses were analyzed using qualitative methods. RESULTS: Seventy-three percent of respondents indicated they supported psychiatric advance directives. Respondents from jails at or below a median census of 120 were significantly more likely to support psychiatric advance directives than those from larger jails. CONCLUSIONS: Psychiatric advance directives' informational function may prove valuable in jail settings. Additional research assessing directives as interventions for individuals with mental illnesses at risk of incarceration is needed.

Front line workers' attitudes towards psychiatric advance directives.

Studies have begun to explore provider attitudes' toward psychiatric advance directives (PADs) and how those attitudes are related to provider characteristics. The study gathered attitudinal data from a sample of 193 social workers serving mentally ill adults. Social workers with pro-healthcare power of attorney (HCPA) attitudes were likely to have prior experience with an HCPA and to believe that involuntary treatment violates the NASW Code of Ethics. Social workers are more favorable of HCPAs than advance instructions. The findings suggest that clinical experiences with PADs may positively impact social worker's perceptions of the law.

Psychiatric advance directives: a tool for consumer empowerment and recovery.

Individuals with psychiatric disabilities identify choice and self-direction as central elements of recovery. During times of psychiatric crisis people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic. Psychiatric advance directives (PADs) are legal documents created to address this loss of autonomy and choice during crises by allowing individuals to communicate in the present wishes for care during a future crisis. This paper examines the ways in which PADs support and can be a tool for recovery and discusses future recovery-oriented directions for PAD research and intervention.

Understanding the personal and clinical utility of psychiatric advance directives: a qualitative perspective.

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self-determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty-eight open-ended, semi-structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self-determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PAD to clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients.

Clinicians' attitudes regarding barriers to the implementation of psychiatric advance directives.

OBJECTIVE: Psychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals. METHODS: A total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs. RESULTS: Across the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers' desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers. CONCLUSION: Psychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals' work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.

An exploration of case management courses in university curricula.

Case management is an essential service for adults with severe mental illnesses. Case managers, however, often come to their positions with little formal case management education. This preliminary study examined the catalogues of one hundred public universities, looking for case management content. Less than 200 courses with case management content were found, few of these specific to mental illness. These results suggest a need for additional research on the academic training needs of case managers.

Approaching Complex Cases With a Crisis Intervention Model and Teamwork: A Commentary.

This article is a response to the case of SA presented by O'Daniel and Wells. In this response I support the approach used with the patient, and discuss and expand on the applicability of a crisis intervention model to genetic counseling. In addition, I explore the issue of autonomy and informed decision making for patients who are in crisis. I also discuss the surface contradiction between the mandate for nondirectiveness and the need to provide direction during crisis intervention are discussed and reframe the issue as one of process versus content directiveness. I argue that during times of crisis, genetic counselors may need to direct process in order for patients to be able to make autonomous decisions.