Lifetime Suicide-Related Behavior, Violent Victimization, and Behavioral Health Outcomes: Results From a Vulnerable Population Needs Assessment.

This study is concerned with two risk factors that have been independently associated with poor behavioral health: (a) lifetime suicide-related behavior (SRB) and (b) interpersonal violence victimization experiences. The purpose of this article was to assess whether the combination of SRB (ideation, attempt) and violent victimization exacerbates behavioral health symptom risk. This pattern is examined across three vulnerable population samples: community-based adults, college students, and bondage and sadomasochism (BDSM) community members. Data from a community health and sexuality survey (n = 2,175) were collected as a health needs assessment in partnership with the National Coalition for Sexual Freedom; latent class analysis (LCA) was then employed to identify intersectionality. This paper builds on prior findings yielding two distinct violence-related classes: (a) SRB only and (b) violent victimization + SRB. Controlling for demographic covariates, analyses revealed a consistent pattern in which the violent victimization + SRB subgroup displayed significantly worse behavioral health outcomes, including symptoms of depression, anxiety, general distress, and posttraumatic stress. Membership in any of the three available samples did not moderate the latent class-behavioral health associations, suggesting the additive impact of lifetime victimization + SRB is equitable across samples. Results are consistent with social-ecological framing of shared suicide-interpersonal violence falling under the same category of public health concerns sharing risk factors and health outcomes.

Methodological limitations in the measurement and statistical modeling of violence among adults with mental illness.

OBJECTIVES: Methodological limitations of extant research hinder the development of effective violence risk screening, assessment, and management strategies for adults with mental illness. This study quantifies the effects of three common limitations: (a) insensitive measurement of violence that results in violence classification with high levels of information bias, (b) use of cross-sectional data, and (c) use of data lacking spatiotemporal contiguity. METHODS: We utilize secondary data (N = 3,000 participants; N = 10,017 observations) and parametric and nonparametric bootstrap simulation methodologies. RESULTS: Not utilizing self-reported violence data increases information bias. Furthermore, cross-sectional data that exclude self-reported violence produce biased associations between substance use and psychiatric symptoms and violence. Associations between baseline variables and subsequent violence attenuate over longer time lags and, when paired with high levels of violence information bias, result in fewer significant effects than should be present. Moreover, the true direction of the simulated relationship of some significant effects is reversed. CONCLUSIONS: Our findings suggest that the validity of conclusions from some extant research on violence among adults with mental illness should be questioned. Efforts are needed to improve both the measurement of violence, through inclusion of self-report, and the statistical modeling of violence, using lagged rather than nonlagged models with improved spatiotemporal contiguity.

Reliability and Validity of START and LSI-R Assessments in Mental Health Jail Diversion Clients.

Risk assessment instruments are increasingly used in mental health jail diversion programs. This study examined the reliability and validity of Short-Term Assessment of Risk and Treatability (START) and Level of Service Inventory-Revised (LSI-R) assessments overall and by client race. Research assistants completed START and LSI-R assessments for 95 diversion clients. Arrests and jail days were collected via official records and self-report 3, 6, 9, 12, and 18 months after baseline. Assessments demonstrated good interrater reliability and convergent validity. START strength total scores and LSI-R risk estimates were the strongest predictors of recidivism. Total scores and risk estimates did not differ as a function of client race, but there were some differences in accuracy of START vulnerability and LSI-R total scores and risk estimates in predicting jail days (but not arrests), over shorter follow-ups. No such differences were found for START strength total scores across any follow-up period or recidivism measure.

Performance and clinical utility of a short violence risk screening tool in U.S. adults with mental illness.

Risk assessment instruments are typically long, costly, and resource-intensive. Thus, a short, easily administered preliminary screening tool can increase the efficiency of the subsequent violence risk assessment process. A preliminary tool can identify those at low risk of violence so that they can be screened out of the process of further violence risk assessment. Recently, Singh, Grann, Lichtenstein, Långström, and Fazel (2012) used data drawn from national registries to develop a short screening tool for a sample of Swedish adults diagnosed with schizophrenia. The screening tool included 5 items: male sex, previous criminal conviction, under 32 years of age, alcohol abuse, and drug abuse. The current study examines the predictive validity and clinical utility of the screening tool developed by Singh et al. (2012) in predicting community-based violence over 6-month and 12-month durations in U.S. adults with schizophrenia (n = 3,471) and the generalizability of those findings to the assessment of violence risk in adults with other primary diagnoses. Results demonstrated that the screening tool performed reasonably well at screening out individuals who did not commit violence during follow-up; however, the screening tool did not perform as well at identifying individuals who did commit violence during follow-up. Although those who screened positive were about twice as likely to engage in violence in the 6-month follow-up period, by the 12-month follow-up there was little difference in likelihood of engaging in violence between participants who were screened in and those who were screened out. Overall, findings of the present study do not provide compelling support for the clinical utility of the screening tool in its current form. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Jail-to-community treatment continuum for adults with co-occurring substance use and mental disorders: study protocol for a pilot randomized controlled trial.

BACKGROUND: Adults with co-occurring mental and substance use disorders (CODs) are overrepresented in jails. In-custody barriers to treatment, including a lack of evidence-based treatment options and the often short periods of incarceration, and limited communication between jails and community-based treatment agencies that can hinder immediate enrollment into community care once released have contributed to a cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among this vulnerable and high-risk population. This paper describes a study that will develop research and communication protocols and adapt two evidence-based treatments, dual-diagnosis motivational interviewing (DDMI) and integrated group therapy (IGT), for delivery to adults with CODs across a jail-to-community treatment continuum. METHODS/DESIGN: Adaptations to DDMI and IGT were guided by the Risk-Need-Responsivity model and the National Institute of Corrections' implementation competencies; the development of the implementation framework and communication protocols were guided by the Evidence-Based Interagency Implementation Model for community corrections and the Inter-organizational Relationship model, respectively. Implementation and evaluation of the protocols and adapted interventions will occur via an open trial and a pilot randomized trial. The clinical intervention consists of two in-jail DDMI sessions and 12 in-community IGT sessions. Twelve adults with CODs and four clinicians will participate in the open trial to evaluate the acceptability and feasibility of, and fidelity to, the interventions and research and communication protocols. The pilot controlled trial will be conducted with 60 inmates who will be randomized to either DDMI-IGT or treatment as usual. A baseline assessment will be conducted in jail, and four community-based assessments will be conducted during a 6-month follow-up period. Implementation, clinical, public health, and treatment preference outcomes will be evaluated. DISCUSSION: Findings have the potential to improve both jail- and community-based treatment services for adults with CODs as well as inform methods for conducting rigorous pilot implementation and evaluation research in correctional settings and as inmates re-enter the community. Findings will contribute to a growing area of work focused on interrupting the cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among adults with CODs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02214667 . Registered on 10 August 2014.

The intersection of interpersonal and self-directed violence among general adult, college student and sexually diverse samples.

BACKGROUND: Suicide and interpersonal violence (i.e. victimization and perpetration) represent pressing public health problems, and yet remain mostly addressed as separate topics. AIMS: To identify the (1) frequency and overlap of suicide and interpersonal violence and (2) characteristics differentiating subgroups of violence-related experiences. METHODS: A health survey was completed by 2,175 respondents comprised of three groups: college students ( n = 702), adult members of a sexuality special interest organization ( n = 816) and a community adult sample ( n = 657). Latent class analysis was used to identify subgroups characterized by violence experiences; logistic regression was used to identify respondent characteristics differentiating subgroups. RESULTS: Overall rates of violence perpetration were low; perpetration, victimization and self-directed violence all varied by sample. Adults with alternative sexual interests reported high rates of victimization and self-directed violence. Analyses indicated two subgroups: (1) victimization + self-directed violence and (2) self-directed violence only. The victimization + self-directed violence subgroup was characterized by older, White, female and sexual orientation minority persons. The self-directed violence subgroup was characterized by younger, non-White, male and straight counterparts engaging with more sexual partners and more frequent drug use. CONCLUSION: Findings support the Centers for Disease Control and Prevention (CDC) definition of suicide as self-directed violence. Suicide intervention and prevention should further account for the role of violent victimization by focusing on the joint conceptualization of self-directed and interpersonal violence. Additional prevention implications are discussed.

Effects of sample size and distributional assumptions on competing models of the factor structure of the PANSS and BPRS.

Factor analytic work on the Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) has yielded varied and conflicting results. The current study explored potential causes of these discrepancies. Prior research has been limited by small sample sizes and an incorrect assumption that the items are normally distributed when in practice responses are highly skewed ordinal variables. Using simulation methodology, we examined the effects of sample size, (in)correctly specifying item distributions, collapsing rarely endorsed response categories, and four factor analytic models. The first is the model of Van Dorn et al., developed using a large integrated data set, specified the item distributions as multinomial, and used cross-validation. The remaining models were developed specifying item distributions as normal: the commonly used pentagonal model of White et al.; the model of Van der Gaag et al. developed using extensive cross-validation methods; and the model of Shafer developed through meta-analysis. Our simulation results indicated that incorrectly assuming normality led to biases in model fit and factor structure, especially for small sample size. Collapsing rarely used response options had negligible effects.

A longitudinal analysis of the overlap between violence and victimization among adults with mental illnesses.

Prior research suggests considerable overlap of violence perpetration and victimization among adults with mental illnesses. However, there has been no examination of how the likelihood of being a victim and/or perpetrator of violence may change over time, nor consideration of clinically-relevant factors affecting these transitions. In a pooled sample of adults with mental illnesses (N=3,473) we employed latent transition analysis to: (a) determine prevalence of four violence and victimization classifications (i.e., non-victim/non-perpetrator, victim only, perpetrator only, and victim-perpetrator) over a 6-month period; (b) calculate the likelihood that adults with mental illnesses will remain in or transition between these classifications over time; and (c) assess the effects of recent substance use, psychiatric symptoms, and suicidal behaviors on transitions over time. At each time point, the majority of participants identified as non-victim/non-perpetrators, followed by victim-perpetrators, victims only, and perpetrators only. Analyses also revealed many individuals transitioned between classifications over time. These distinct pathways towards, and away from, violent outcomes were, in part, a function of recent violence and/or victimization, as well as substance use, psychiatric symptoms, and suicidal behaviors. Findings inform the identification of adults with mental illnesses at risk of violence and victimization and highlight points of intervention.

The latent structure of psychiatric symptoms across mental disorders as measured with the PANSS and BPRS-18.

Raw data were used from five studies of adults with mental illnesses (N=4,480) in an attempt to identify a psychiatric symptoms factor structure, as measured by the Positive and Negative Syndrome Scale or the Brief Psychiatric Rating Scale, that was generalizable across participant characteristics. First, the fit of four extant models was tested via confirmatory factor analysis (CFA), then exploratory factor analyses (EFA) were conducted with a 50% random sample, followed by a CFA with the remaining 50% to confirm the EFA factor structure. Measurement invariance of the factor structure was also examined across diagnosis, sex, race, age, and hospitalization status. The extant models were not generalizable to these data. However, a 4-factor (Affective, Positive, Negative, Disorganized Cognitive Processing) model was identified that retained all items and showed invariance across participant characteristics. It is possible to obtain a psychiatric symptoms factor structure that is generalizable across patient characteristics, which has clinical and research implications. Specifically, future research examining the impact of various interventions on psychiatric symptoms among adults with mental illnesses should confirm, and assuming good model-data fit, use the 4-factor model identified in this study.

Performance of recidivism risk assessment instruments in U.S. correctional settings.

With the population of adults under correctional supervision in the United States at an all-time high, psychologists and other professionals working in U.S. correctional agencies face mounting pressures to identify offenders at greater risk of recidivism and to guide treatment and supervision recommendations. Risk assessment instruments are increasingly being used to assist with these tasks; however, relatively little is known regarding the performance of these tools in U.S. correctional settings. In this review, we synthesize the findings of studies examining the predictive validity of assessments completed using instruments designed to predict general recidivism risk, including committing a new crime and violating conditions of probation or parole, among adult offenders in the United States. We searched for studies conducted in the United States and published between January 1970 and December 2012 in peer-reviewed journals, government reports, master's theses, and doctoral dissertations using PsycINFO, the U.S. National Criminal Justice Reference Service Abstracts, and Google. We identified 53 studies (72 samples) conducted in U.S. correctional settings examining the predictive validity of 19 risk assessment instruments. The instruments varied widely in the number, type, and content of their items. For most instruments, predictive validity had been examined in 1 or 2 studies conducted in the United States that were published during the reference period. Only 2 studies reported on interrater reliability. No instrument emerged as producing the "most" reliable and valid risk assessments. Findings suggest the need for continued evaluation of the performance of instruments used to predict recidivism risk in U.S. correctional agencies. (PsycINFO Database Record

Proximal Risk Factors for Short-Term Community Violence Among Adults With Mental Illnesses.

OBJECTIVE: This study examined the role of static indicators and proximal, clinically relevant indicators in the prediction of short-term community violence in a large, heterogeneous sample of adults with mental illnesses. METHODS: Data were pooled from five studies of adults with mental illnesses (N=4,484). Follow-up data were available for 2,579 participants. A hierarchical linear regression assessed the incremental validity of a series of variable clusters in the prediction of violence risk at six months: static characteristics (age, sex, race-ethnicity, and primary diagnosis), substance use (alcohol use and drug use at baseline), clinical functioning (psychiatric symptoms at baseline and recent hospitalization), recent violence, and recent victimization. RESULTS: Results demonstrated improved prediction with each step of the model, indicating that proximal indicators contributed to the prediction of short-term community violence above and beyond static characteristics. When all variables were entered, current alcohol use, recent violence, and recent victimization were positive predictors of subsequent violence, even after the analysis controlled for participant characteristics. CONCLUSIONS: This study provides empirical evidence for three proximal, clinically relevant indicators in the assessment and management of short-term violence risk among adults with mental illnesses: current alcohol use, recent violence, and recent victimization. Consideration of these indicators in clinical practice may assist in the identification of adults with mental illnesses who are at heightened risk of short-term community violence.

Latent class analysis of discordance between results of drug use assessments in the CATIE data.

OBJECTIVE: The primary aim is to examine concordant/discordant results of drug use assessments in adults with schizophrenia. METHODS: Latent class analysis and multinomial logistic regression were used to examine concordance/discordance between drug use measures and identify characteristics differentiating participants across classes. RESULTS: Four classes - non-users, users, probable users, and RIA discordant - fit best. Age, sex, race/ethnicity, and psychiatric symptoms differed significantly across classes. CONCLUSIONS: Findings showed that discordance between results occurs at non-trivial rates and is, in part, attributable to individual characteristics. Results suggest the need for strategies to limit discordance and improve detection of drug use in adults with schizophrenia.

A typology of community violence perpetration and victimization among adults with mental illnesses.

The primary objective of this article was to evaluate the overlap between community violence perpetration and victimization in a large, heterogeneous sample of adults with mental illnesses (N = 4,474). We also explored participant characteristics differentiating four categories of perpetration and victimization: non-victim/non-perpetrators, victims only, perpetrators only, and victim-perpetrators. Results indicated that adults with mental illnesses were unlikely to report violent outcomes but, when they did, were more likely to report perpetration and victimization, rather than perpetration alone. In addition, bivariate and multivariable analyses showed that sex, age, race/ethnicity, and primary diagnosis differed across categories. Victim-perpetrators, for example, were more likely to be young, Black, and have a primary diagnosis of bipolar disorder, major depressive disorder, substance use disorder, or "other." Altogether, our findings provide evidence for a victim-perpetrator overlap in this population and suggest that preventive measures targeting violence and victimization may be more effective than those with separate strategies for each.

Community violence perpetration and victimization among adults with mental illnesses.

OBJECTIVES: In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes. METHODS: Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants. RESULTS: Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization. CONCLUSIONS: Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.

Drug and alcohol trajectories among adults with schizophrenia: data from the CATIE study.

OBJECTIVE: The primary aim is to describe drug and alcohol trajectories in adults with schizophrenia. METHOD: Growth mixture models were used to examine disordered and non-disordered use and abstinence in the Clinical Antipsychotic Trials of Intervention Effectiveness study. RESULTS: Five classes - always abstinent; fluctuating use, abuse, and occasional abstinence; occasional (ab)use; stopped (ab)use; abusing - fit best. Overlap exists between always abstinent drug and alcohol classes; less overlap exists across other classes. CONCLUSION: There is heterogeneity in drug and alcohol use among adults with schizophrenia. The lack of overlap between classes, save always abstinent, suggests modeling drug and alcohol use separately.