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.

Estimation of Latent Variable Scores with Multiple Group Item Response Models: Implications for Integrative Data Analysis.

Integrative data analysis (IDA) involves obtaining multiple datasets, scaling the data to a common metric, and jointly analyzing the data. The first step in IDA is to scale the multisample item-level data to a common metric, which is often done with multiple group item response models (MGM). With invariance constraints tested and imposed, the estimated latent variable scores from the MGM serve as an observed variable in subsequent analyses. This approach was used with empirical multiple group data and different latent variable estimates were obtained for individuals with the same response pattern from different studies. A Monte Carlo simulation study was then conducted to compare the accuracy of latent variable estimates from the MGM, a single-group item response model, and an MGM where group differences are ignored. Results suggest that these alternative approaches led to consistent and equally accurate latent variable estimates. Implications for IDA are discussed.

Results of the Brief Jail Mental Health Screen Across Repeated Jail Bookings.

OBJECTIVE: The Brief Jail Mental Health Screen (BJMHS) is widely used at intake in county jails to identify detainees who may have serious mental illness and who should be referred for further mental health evaluation. The BJMHS may be administered multiple times across repeated jail bookings; however, the extent to which results may change over time is unclear. To that end, the authors examined the odds of screening positive on the BJMHS across repeated jail bookings. METHODS: Data were drawn from the administrative and medical records of a large, urban county jail that used the BJMHS at jail booking. The study sample comprised BJMHS results for the 12,531 jail detainees who were booked at least twice during the 3.5-year period (N=41,965 bookings). Multilevel logistic modeling was used to examine changes over time overall and within the four decision rules (current psychiatric medication, prior hospitalization, two or more current symptoms, and referral for any other reason). RESULTS: Results show that the odds of a positive screen overall increased with each jail booking, as did the odds of referral for any other reason. In contrast, the odds of screening positive for two or more current symptoms and prior hospitalization decreased. There was no change in the odds of screening positive for current psychiatric medication across bookings. CONCLUSIONS: Findings show that BJMHS results changed across bookings. Further research is needed to determine whether changes reflect true changes in mental health status, issues with fidelity, the repeated nature of the screening process, or other factors.

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.

Trends in mental health outcomes and combat exposure among US marines returning from Iraq, Afghanistan or other deployments, 2004-13.

BACKGROUND: As of 2015, more than 2.7 million US military Veterans have served in support of the Global War on Terror. The negative sequelae associated with deployment stressors and related traumas are well-documented. Although data on mental health issues are routinely collected from service members returning from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. METHODS: Population-based data of US Marines returning from deployment between 2004 and 2013 were analyzed, using the Post-Deployment Health Assessment. RESULTS: Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02%; suicidal ideation ranged from 0 to 1.44%. Marines screening positive for PTSD ranged from 3.00 to 12.41%; combat exposure ranged from 15.58 to 55.12%. Depression was indicated for between 12.54 and 30.04% of Marines returning from Afghanistan, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18%; combat exposure ranged between 42.92 and 75%. CONCLUSION: Our results support the heterogeneity of experiences and mental health sequelae of service members returning from deployments. Outcomes for Afghanistan and Iraq Veterans fluctuate with changes in OPTEMPO across theaters over time.

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).

Predictors of Posttraumatic Stress Disorder, Anxiety Disorders, Depressive Disorders, and Any Mental Health Condition Among U.S. Soldiers and Marines, 2001-2011.

Understanding mental health disorder diagnosis and treatment seeking among active-duty military personnel is a topic with both clinical and policy implications. It has been well documented in military populations that individual-level military experience, including deployment history and combat exposure, influences mental health outcomes, but the impact of unit-level factors is less well understood. In the current study, we used administrative longitudinal data to examine a comprehensive set of unit- and individual-level predictors of posttraumatic stress disorder (PTSD), non-PTSD anxiety disorders, depressive disorders, and overall mental health diagnoses among Army and Marines Corps personnel. Using Cox survival models for time-dependent variables, we analyzed time from military accession (between January 1, 2001 and December 31, 2011) until first mental health diagnosis for 773,359 soldiers and 332,093 Marines. Prior diagnosis of a substance abuse disorder during one's military career, hazard ratios (HRs) = 1.68-3.10, and cumulative time spent deployed, HRs = 1.11-2.04, were the most predictive risk factors for all outcomes. Male sex, HRs = 0.35-0.57, and officer rank, HRs = 0.13-0.23, were the most protective factors. Unit-level rate of high deployment stress was a small but significant predictor of all outcomes after controlling for individual-level deployment history and other predictors, HRs = 1.01-1.05. Findings suggest both unit- and individual-level risk and protective factors of mental health diagnoses associated with treatment seeking. Clinical, including mental health assessment and management, and policy implications related to the military environment and the individual as it relates to mental health disorders are discussed.

Barriers and facilitators to implementing an evidence-based woman-focused intervention in South African health services.

BACKGROUND: Since the beginning of the HIV epidemic, numerous behavior change, risk-reduction, and biomedical interventions have been developed and tested. While some of these interventions have shown to be efficacious in randomized trials, it often takes almost two decades for an intervention to be translated into practice. Meanwhile, South Africa continues to have among the highest prevalence of HIV globally, with women of childbearing age bearing the burden of the epidemic. Given the urgency of the HIV epidemic among vulnerable women in South Africa, it is imperative that evidence-based interventions be implemented rapidly into practice. This study presents a first step toward examining the acceptability and feasibility of implementing the Women's Health CoOp (WHC) in clinics and substance abuse rehab settings in Cape Town, South Africa. METHODS: We conducted focus group discussions with women who use substances and with service providers, we also conducted in-depth interviews with health service planners. Our goal was to examine implementation and clinical outcomes associated with delivery of the WHC across clinics and substance abuse rehab programs. RESULTS: All participants agreed on the need for the WHC. Perceived facilitators to implementing the WHC included the recognizable need for programs to empower women and to build the capacity of staff to address issues of substance use, sexual risk, and intimate partner violence. Participants also identified potential barriers to women engaging with this program, including the stigma women experience when seeking services and the lack of person-centered care at healthcare facilities. CONCLUSIONS: In a country with the largest number of women of childbearing age living with HIV, an evidence-based woman-focused intervention that comprehensively addresses women's risk for suboptimal antiretroviral adherence may be essential for reducing HIV incidence. However, potential barriers to implementing the WHC successfully must be addressed before the program can be fully integrated into the services delivered by healthcare facilities. TRIAL REGISTRATION: Clinical trials NCT02733003 . Date of Registration: January 21, 2016, registered retroactively after participant enrollment.

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.

Preventing and De-escalating Aggressive Behavior Among Adult Psychiatric Patients: A Systematic Review of the Evidence.

OBJECTIVE: The project goal was to compare the effectiveness of strategies to prevent and de-escalate aggressive behaviors among psychiatric patients in acute care settings, including interventions for reducing use of seclusion and restraint. METHODS: Relevant databases were systematically reviewed for comparative studies of violence prevention and de-escalation strategies involving adult psychiatric patients in acute care settings. Studies (trials and cohort studies) were required to report on aggression or seclusion or restraint outcomes. Both risk of bias, an indicator of quality of individual studies, and strength of evidence (SOE) for each outcome were independently assessed by two study personnel. RESULTS: Seventeen primary studies met inclusion criteria. Evidence was limited for benefits and harms; information about characteristics that might modify the interventions' effectiveness, such as race or ethnicity, was especially limited. All but one study had a medium or high risk of bias and thus presented worrisome limitations. For prevention, risk assessment reduced both aggression and use of seclusion and restraint (low SOE), and multimodal interventions reduced the use of seclusion and restraint (low SOE). SOE for all other interventions, whether aimed at preventing or de-escalating aggression, and for modifying characteristics was insufficient. CONCLUSIONS: Available evidence about strategies for preventing and de-escalating aggressive behavior among psychiatric patients is very limited. Two preventive strategies, risk assessment and multimodal interventions consistent with the Six Core Strategies principles, may effectively lower aggressive behavior and use of seclusion and restraint, but more research is needed on how best to prevent and de-escalate aggressive behavior in acute care settings.

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.

Visualization of Categorical Longitudinal and Times Series Data.

Plotting growth curves is a powerful graphical approach used in exploratory data analysis for continuous longitudinal data. However, plotted growth curves for multiple participants rapidly become uninterpretable with categorical data. Categorical data define specific states (e.g., being single, married, divorced), and these states do not necessarily need to represent any hierarchical order. Thus, a trajectory becomes a sequence of states rather than a continuum. We introduce a horizontal line plot that uses shade or color to differentiate between states on a categorical longitudinal variable for multiple participants. With appropriate sorting, stacking the horizontal lines that represent each participant can reveal important patterns such as the shape of, or heterogeneity in, the trajectories. We illustrate the plotting techniques for large sample sizes, observed groups, the exploration of unobserved latent classes, large numbers of time points such as are found with intensive longitudinal designs or multivariate time series data, individually varying times observation, unique numbers of observations, and missing data. We used the R package longCatEDA to create the illustrations. Illustrative data include both simulated data and alcohol consumption data in adult schizophrenics from the Clinical Antipsychotic Trials of Intervention Effectiveness.

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.

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.

Getting less of what you want: reductions in statistical power and increased bias when categorizing medication adherence data.

Medication adherence is thought to be the principal clinical predictor of positive clinical outcomes, not only for serious mental illnesses such as schizophrenia, bipolar disorder, or depression, but also for physical conditions such as diabetes. Consequently, research on medication often looks not only at medication condition (e.g., placebo, standard medication, investigative medication), but also at adherence in taking those medications within each medication condition. The percentage (or proportion) scale is one of the more frequently employed and easily interpretable measures. Patients can be 0 % adherent, 100 % adherent, or somewhere in between. For simplicity, many reported adherence analyses dichotomize or trichotomize the adherence predictor when estimating its effect on outcomes of interest. However, the methodological literature shows that the practice of categorizing continuously distributed predictors reduces statistical power at best and, at worst, can severely bias parameter estimates. This can result in inflated Type I errors (false positive acceptance of null adherence effects) or Type II errors (false negative rejection of true adherence effects). We extend the methodological literature on categorization to the construct of adherence. The measurement scale of adherence leads to a diverse family of potential distributions including uniform, n-shaped, u-shaped (i.e., bimodal), positively skewed, and negatively skewed. Using a simulation study, we generated negative, null, and positive "true" effects of adherence on simulated continuous and binary outcomes. We then estimated the adherence effect with and without categorizing the adherence variable. We show how parameter estimates and standard errors can be severely biased when categorizing adherence. The categorization of adherence is shown to cause null effects to become positive or negative depending on the distribution of the simulated adherence variable, inflating Type I errors. When the adherence effect was significantly different from zero, categorization can render the effect null, inflating Type II errors. We recommend that adherence be measured continuously and analyzed without categorization when using it as a predictor in regression models.

Mental health correlates of drug treatment among women who use methamphetamine.

BACKGROUND AND OBJECTIVES: Women comprise over one-third of people who use methamphetamine in the United States and have a higher prevalence of negative mental health consequences of methamphetamine use than men. Yet, few studies have investigated the mental health correlates of drug treatment among this population. We examined the relationship between mental disorders, mental health treatment, and drug treatment among women who use methamphetamine. METHODS: We used respondent-driven sampling to recruit women who use methamphetamine (N = 322) for a survey about mental disorders, mental health treatment, drug use and treatment, and sociodemographic factors. Bivariate and multivariable logistic regression analyses were conducted. RESULTS: Bivariate analyses indicated that race/ethnicity, mental health treatment, and presence and number of mental disorders were associated with drug treatment. Multivariable analyses revealed that women who reported mental health treatment during a 6-month period had almost twice the odds of also reporting drug treatment than other women (AOR = 1.90; 95% CI = 1.11, 3.25), after controlling for mental disorders and race/ethnicity. CONCLUSION: Among women who use methamphetamine, participation in one service system (mental health treatment) is a key factor in increasing the odds of participation in another service system (drug treatment). Further research should establish the temporal association between mental health and drug treatment. SCIENTIFIC SIGNIFICANCE: The present study demonstrates the association between mental health treatment and drug treatment, above and beyond presence or number of mental disorders, and provides direction for drug treatment providers seeking to improve treatment entry and participation among women who use methamphetamine.

Treatment adherence in schizophrenia: a patient-level meta-analysis of combined CATIE and EUFEST studies.

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) obtained a sample of 1493 chronic schizophrenia patients. The European First Episode Schizophrenia Trial (EUFEST) studied a sample of 498 patients. We have combined these two samples to study the predictors and correlates of adherence to treatment. Here we report on adherence to pharmacological treatment at the six and twelve month assessments of these trials with a combined subsample of 1154 schizophrenia patients. Individual patients׳ data were used for analyses. We used logistic regression to examine the effects of substance use, akathisia, parkinsonism, dyskinesia, hostility, and insight on pharmacological adherence. The results showed that reduced adherence to pharmacological treatment was associated with substance use (p=0.0003), higher levels of hostility (p=0.0002), and impaired insight (p<0.0001). Furthermore, poor adherence to study medication was associated with earlier discontinuation in the combined data. The clinical implications of the results point to the importance of routine assessments and interventions to address patients׳ insight and comorbid substance use and the establishment of therapeutic alliance.