Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems.

OBJECTIVES: Length of stay (LOS) and boarding for pediatric psychiatric patients presenting in the emergency department (ED) have been understudied, despite evidence that children with psychiatric disorders experience longer LOS relative to those without. This investigation examined correlates of LOS and boarding among youth with psychiatric disorders presenting to the ED in a large, statewide database. METHODS: Using the 2010 to 2013 Florida ED discharge database, generalized linear mixed models were used to examine for associations between LOS and patient and hospital characteristics among pediatric patients (<18 years) who presented with a primary psychiatric diagnosis (N = 44,328). RESULTS: Patients had an overall mean ± SD ED LOS of 5.96 ± 8.64 hours. Depending on the definition used (ie, 12 or 6 hours), between 23% and 58% of transferred patients were boarded. Patient characteristics associated with a longer LOS included female sex, being 15 to 17 years old, Hispanic ethnicity, having Medicaid or VA/TriCare insurance, having impulse control problems, having mood or psychotic disorders, and exhibiting self-harm behaviors. Patient transfer, large hospital size, and rural designation were associated with longer LOS. Teaching hospital status and profit status were not significantly associated with LOS. CONCLUSIONS: These data suggest that LOS for pediatric psychiatry patients in the ED varies significantly by psychiatric presentation, patient disposition, and hospital factors. Such findings have implications for quality of care, patient safety, and health outcomes.

The Role of Dental Providers in Preventing HPV-Related Diseases: A Systems Perspective.

Successfully educating dental providers and patients about the link between human papillomavirus (HPV) and oropharyngeal cancer requires coordinated efforts to increase HPV-related prevention practices. The aim of this study was to identify, using a systems perspective, the multi-level determinants related to how dental providers can promote HPV prevention in dental practices. Data for this qualitative study were collected in 2015-16 from focus groups with dentists (four focus groups, n=33), focus groups with dental hygienists (four focus groups, n=48), and in-depth interviews with dental opinion leaders (n=13). Results were triangulated and mapped along micro, meso, and macro system levels. At the micro level, participants identified patient characteristics and low self-efficacy as influential determinants when discussing HPV prevention. At the meso level, relationships among dentists, dental hygienists, and the physical practice environment were factors affecting dental providers' HPV prevention efforts. At the macro level, professional organizations impacted how dental providers interacted with their patients on this topic. These results suggest that improving HPV prevention among dental providers requires a multi-level approach that considers the distinctive context of dental settings, dental training, and perceptions of professional roles. The findings suggested that the macro- and meso-level determinants may be challenging to modify due to the distinctive culture and practice models of dentistry. Nevertheless, the association between HPV and oral cancer requires an expansion of prevention strategies used in dental practices. Improving dental providers' self-efficacy to communicate HPV prevention through continuing education and integration of skill-guided training in dental and dental hygiene curricula could facilitate this process.

Are dental providers the next line of HPV-related prevention? Providers' perceived role and needs.

The rise in HPV-related oropharyngeal cancer incidence necessitates novel prevention efforts including multiple provider types. Although dental providers screen for HPV-related oropharyngeal cancers, little is known about their needs to advance "primordial prevention," or interventions at the earliest possible stage, to prevent HPV-related cancers. This study assessed dentists' and dental hygienists' perceived roles and needs regarding HPV-related primordial prevention. We conducted a mixed-method study with data from focus groups with dentists (n= 33) and dental hygienists (n= 48) and surveys from both provider types (n= 203) among providers from a diverse set of practice settings and geographic communities. Data were analyzed using qualitative thematic analysis and chi square tests. Participants affirmed dental professionals' roles in preventing HPV-related cancers and identified needs to overcome barriers to fulfilling prevention objectives. Barriers included: (1) practice environment and patient characteristics, and (2) the sensitive topic of HPV. Further, participants identified needs to improve HPV-related cancer prevention. Findings from this study suggest that dental providers may become the next line of prevention for HPV-related cancers. Dental providers' professional associations have provided guidance on HPV and oropharyngeal cancers, but our study reveals dental providers' needs for following professional organizations' guidance to advance prevention efforts and reduce HPV-related cancer incidence.

Correlates of Length of Stay and Boarding in Florida Emergency Departments for Patients With Psychiatric Diagnoses.

OBJECTIVE: Length of stay (LOS) and boarding in the emergency department (ED) for psychiatric patients have been the subject of concern, given the problems with crowding and excessive wait times in EDs. This investigation examined correlates of LOS and boarding in Florida EDs for patients presenting with psychiatric complaints from 2010 to 2013. METHODS: Utilizing the Florida ED discharge database, the authors examined the association of LOS and boarding with hospital and encounter factors for adult patients presenting with a primary psychiatric diagnosis (N=597,541). RESULTS: The mean LOS was 7.77 hours. Anxiety disorders were the most frequent psychiatric complaint and were associated with the lowest mean LOS compared with other diagnoses (p<.05). Patient encounters resulting in a presentation of intentional self-harm and suicidality or schizophrenia were associated with significantly longer stays compared with other psychiatric diagnoses. Commercial insurance was associated with the shortest average LOS. African Americans, Hispanics, and patients age 45 and older were associated with a longer average LOS. Smaller hospital size, for-profit ownership, and rural designation were associated with a shorter average LOS. Teaching status was not associated with LOS. Furthermore, 73% of encounters resulting in transfers qualified as episodes of boarding (a stay of more than six or more hours in the ED). CONCLUSIONS: Extended LOS was endemic for psychiatric patients in Florida EDs.

Gun Violence, Mental Illness, And Laws That Prohibit Gun Possession: Evidence From Two Florida Counties.

Gun violence kills about ninety people every day in the United States, a toll measured in wasted and ruined lives and with an annual economic price tag exceeding $200 billion. Some policy makers suggest that reforming mental health care systems and improving point-of-purchase background checks to keep guns from mentally disturbed people will address the problem. Epidemiological research shows that serious mental illness contributes little to the risk of interpersonal violence but is a strong factor in suicide, which accounts for most firearm fatalities. Meanwhile, the effectiveness of gun restrictions focused on mental illness remains poorly understood. This article examines gun-related suicide and violent crime in people with serious mental illnesses, and whether legal restrictions on firearm sales to people with a history of mental health adjudication are effective in preventing gun violence. Among the study population in two large Florida counties, we found that 62 percent of violent gun crime arrests and 28 percent of gun suicides involved individuals not legally permitted to have a gun at the time. Suggested policy reforms include enacting risk-based gun removal laws and prohibiting guns from people involuntarily detained in short-term psychiatric hospitalizations.

State Laws on Emergency Holds for Mental Health Stabilization.

OBJECTIVE: Psychiatric emergency hold laws permit involuntary admission to a health care facility of a person with an acute mental illness under certain circumstances. This study documented critical variation in state laws, identified important questions for evaluation research, and created a data set of laws to facilitate the public health law research of emergency hold laws' impact on mental health outcomes. METHODS: The research team built a 50-state, open-source data set of laws currently governing emergency holds. A protocol and codebook were developed so that the study may be replicated and extended longitudinally, allowing future research to accurately capture changes to current laws. RESULTS: Although every state and the District of Columbia have emergency hold laws, state law varies on the duration of emergency holds, who can initiate an emergency hold, the extent of judicial oversight, and the rights of patients during the hold. The core criterion justifying an involuntary hold is mental illness that results in danger to self or others, but many states have added further specifications. Only 22 states require some form of judicial review of the emergency hold process, and only nine require a judge to certify the commitment before a person is hospitalized. Five states do not guarantee assessment by a qualified mental health professional during the emergency hold. CONCLUSIONS: The article highlights variability in state law for emergency holds of persons with acute mental illness. How this variability affects the individual, the treatment system, and law enforcement behavior is unknown. Research is needed to guide policy making and implementation on these issues.

Mental health and reoffending outcomes of jail diversion participants with a brief incarceration after arraignment.

OBJECTIVE: Jail diversion programs strive to divert offenders with mental illness from prosecution and into mental health treatment. Participants sometimes spend a short time in jail after arraignment, either because treatment resources are not immediately available or because judges want to increase their motivation for treatment. This study explored the effects of short jail stays before jail diversion ("jail first") on participants' postdiversion service use and reoffending. METHODS: The data were merged administrative records from public behavioral health and criminal justice systems in Connecticut for 712 adults with serious mental illness who participated in the jail diversion program during fiscal years 2005-2007. The effects on treatment receipt, crisis-driven service use, and reoffending during the six months postdiversion among jail first participants (N=102) versus a propensity-matched sample of participants who were diverted immediately (N=102) were estimated. RESULTS: Jail first participants had greater improvements in receipt of psychotropic medication during the follow-up compared with their counterparts who were diverted immediately. However, compared with participants who were immediately diverted, they did not have greater reductions in crisis-driven service use or reoffending and the time to reincarceration was shorter. CONCLUSIONS: Short stays in jail before diversion did not appear to be associated with improved mental health and reoffending outcomes, even though they appeared to improve receipt of psychotropic medication. Further research is needed to better understand the relationships between jail first, receipt of psychotropic medication, and broader health and offending outcomes, with a focus on identifying missing links that address criminogenic risks and participants' more intensive social service needs.

Law & Psychiatry: Has the ADA Been Reborn as a Tool of Broad Community Change for People With Mental Disabilities?

Twenty-five years after enactment of the Americans with Disabilities Act (ADA), the U.S. Justice Department has begun to aggressively use the law to compel states to reform community care of individuals with mental disabilities. In this month's Law & Psychiatry column, the author highlights settlement agreements between Justice and the states of New York and Rhode Island that will produce sweeping changes in housing and employment for thousands of individuals with mental disabilities. Is the ADA's original promise finally being realized? The Americans with Disabilities Act (ADA) was enacted with the hope that it would result in the end of segregation based on disability. That promise has been only partially met. However, two recent settlement agreements between the U.S. Department of Justice and the states of New York and Rhode Island promise sweeping change in housing and employment for thousands of individuals with mental disabilities. This column describes the agreements, which adopt best practices as the foundation for community change and which suggest that the ADA may be reaching its full promise.

Novel shifts in memory research and their impact on the legal process: introduction to the special issue on memory formation and suggestibility in the legal process.

The functioning and frailties of memory are frequently at the centerpiece of much expert testimony about the reliability of eyewitness accounts. Although we have much knowledge about how false memories and suggestibility can affect testimonies, the contributions in this special issue show that when using a sound theoretical framework, novel directions in this field can surface. The papers in this issue can broadly be divided into contributions that are related to: (1) the exact determinants of false memory and suggestibility; (2) new paradigms in legal psychology; (3) positive consequences of memory illusions; and (4) developmental false memory research. Collectively, these contributions have the potential to provide novel shifts in memory research and push this field beyond its current boundaries.

Effects of outpatient treatment on risk of arrest of adults with serious mental illness and associated costs.

OBJECTIVE: This study examined whether possession of psychotropic medication and receipt of outpatient services reduce the likelihood of posthospitalization arrest among adults with serious mental illness. A secondary aim was to compare service system costs for individuals who were involved with the justice system and those who were not. METHODS: Claims data for prescriptions and treatments were used to describe patterns and costs of outpatient services between 2005 and 2012 for 4,056 adult Florida Medicaid enrollees with schizophrenia or bipolar disorder after discharge from an index hospitalization. Multivariable time-series analysis tested the effects of medication and outpatient services on arrest (any, felony, or misdemeanor) in subsequent 30-day periods. RESULTS: A total of 1,263 participants (31%) were arrested at least once during follow-up. Monthly medication possession and receipt of outpatient services reduced the likelihood of any arrests (misdemeanor or felony) and of misdemeanor arrests. Possession of medications for 90 days after hospital discharge also reduced the likelihood of arrest. Prior justice involvement, minority racial-ethnic status, and male sex increased the risk of arrest, whereas older age decreased it. Criminal justice and behavioral health system costs were significantly higher for the justice-involved group than for the group with no justice involvement. CONCLUSIONS: Routine outpatient treatment, including medication and outpatient services, may reduce the likelihood of arrest among adults with serious mental illness. Medication possession over a 90-day period after hospitalization appears to confer additional protection. Overall, costs were lower for those who were not arrested, even when they used more outpatient services.

Measuring and interpreting the predictive validity of violence risk assessments: an overview of the special issue.

Mental health professionals are routinely called upon to assess and testify concerning the violence risk of their patients. Expert opinion on risk assessment continues to influence decisions resulting in the long-term denial of civil liberty or even death in the case of capital proceedings. Today, many clinicians use structured risk assessment tools to assist in these tasks. Although few would claim that violence can be predicted without error, all but the most skeptical would concede that our knowledge and ability to assess violence risk far exceeds that of three decades ago. This said, whether current practices are empirically, ethically, or legally valid remains a question of great importance given the consequences that may follow erroneous assessments. And while 30 years ago there was a broad (albeit often overstated) consensus that expert opinion on this topic was inherently suspect, today the field appears to operate on a broad (albeit often overstated) consensus that practices have improved to a sufficient extent to warrant the sizeable impact that violence risk assessments often have on individual liberty, levels of service, and resource allocation.

Characteristics of START assessments completed in mental health jail diversion programs.

Many different instruments have been developed to assist in the assessment of risk for violence and other criminal behavior. However, there is limited evidence regarding how these instruments work in the 'real world'. Even less is known about how these instruments might work for assessing risk in jail diversion populations, whether in research or practice. To address these knowledge gaps, the present study examined the characteristics of risk assessments completed by program staff (n=10) on 96 mental health jail diversion clients (72 men and 24 women) using the Short-Term Assessment of Risk and Treatability (START). The findings provide preliminary support for the reliability and validity of START assessments completed in jail diversion programs, the first evidence of the transportability of START outside psychiatric settings, and further evidence regarding the reliability and validity of START assessments completed in the field. They additionally support the consideration of an eighth, general offending risk domain in START assessments.

"Hired guns," "charlatans," and their "voodoo psychobabble": case law references to various forms of perceived bias among mental health expert witnesses.

Although in principle the legal system expects and professional ethics demand that expert witnesses be unbiased and objective in their forensic evaluations, anecdotal evidence suggests that accusations of financial bias, partisanship, and other forms of nonobjectivity are common. This descriptive survey of published legal cases expands on an earlier case law review (Mossman, 1999) attempting to encapsulate and summarize key issues concerning perceptions or allegations of bias in mental health expert witness testimony. Using a series of search terms reflecting various potential forms of accusatory bias, a total of 160 published civil and criminal court cases were identified in which 185 individuals (e.g., attorneys, trial and appellate judges, other witnesses) made one or more references to clinicians' alleged lack of neutrality. Allegations most typically involved describing the expert as having an opinion that was "for sale," or as a partisan or advocate for one side, although aspersions also were made concerning "junk science" testimony and comparing mental health experts to mystics and sorcerers. Our results indicate that diverse forms of bias that go beyond financial motives are alleged against mental health experts by various players in the legal system. Means are discussed by which experts can attempt to reduce the impact of such allegations.

Association of involuntary psychiatric examination with probability of arrest of people with serious mental illness.

OBJECTIVE: This study examined the association between the occurrence of an involuntary psychiatric examination under Florida civil commitment law and the probability of arrest during the next quarter. METHODS: County criminal justice records and several statewide and local health and social service data sets were used to identify inmates with a serious mental illness who spent at least one day in the Pinellas County jail between July 1, 2003, and June 30, 2004. These same data sets were combined with statewide arrest and prison records to identify the criminal justice and health and social services histories of these individuals from July 1, 2002, to June 10, 2006, with the four-year period divided into 16 periods of 90 days. The main analysis used individual fixed-effects models to examine the relationship between involuntary examinations and subsequent probability of arrest. RESULTS: There were 3,728 inmates with serious mental illness in the sample, with 40% (N = 1,485) having at least one involuntary examination during the four-year period. Individuals who experienced an involuntary examination during the four years were arrested in 34% (N = 1,038) of the quarters after an examination and in 27% (N = 3,786) of the quarters not preceded by an involuntary examination. Individual fixed-effects models found a significant positive relationship between the receipt of an involuntary examination in one period and the likelihood of arrests, felony arrests, and misdemeanor arrests in the next period. CONCLUSIONS: Involuntary psychiatric examinations were associated with increased risk of arrest. Thus an involuntary examination was a significant signal that individuals with serious mental illness were at risk for criminal behavior and arrest.

Medicaid enrollment rates among individuals arrested in the state of Florida before and at the time of arrest.

OBJECTIVE: This study examined Medicaid enrollment for all individuals arrested in Florida in fiscal year (FY) 2006. METHODS: Florida Department of Law Enforcement arrest data were used to identify all individuals arrested in Florida in FY 2006. Arrest data were matched against Medicaid claims data to determine how many individuals had been enrolled in Medicaid in the 365 days before arrest, had used Medicaid-reimbursed behavioral health services during this period, and were enrolled in Medicaid at the time of arrest. RESULTS: In FY 2006, a total of 689,046 individuals were arrested in Florida. A total of 65,097 (9.5%) of those were enrolled in Medicaid before arrest, and 37,662 (5.5%) were still enrolled at the time of arrest. CONCLUSIONS: Because of the importance of Medicaid enrollment for service access after release from jail, the loss of enrollment among a large number of individuals has important policy implications.

Competence to proceed in SVP commitment hearings: Irrelevant or fundamental due process right?

Sexually Violent Predator (SVP) civil commitment, intended to incapacitate offenders and protect the public, has been implemented in 21 jurisdictions. While respondents in traditional civil commitment proceedings need not be competent to proceed, SVP commitment may present a greater deprivation of liberty and therefore greater procedural protections may be merited. Statutes and case law regarding competence in this context address two issues: competence to challenge unproven sexual offense allegations and competence to participate in the SVP commitment process. Of the 14 states that have addressed the issue, one concluded that respondents must be competent to challenge unproven allegations and one concluded that all SVP respondents must be competent to participate in the commitment process. Differences between SVP and traditional civil commitment, the rationale underlying the competence requirement, and decisions regarding competence in SVP commitment are reviewed to inform debate regarding whether SVP respondents must be competent to proceed with the commitment process.

Characteristics and experiences of adults with a serious mental illness who were involved in the criminal justice system.

OBJECTIVE: This study identified characteristics and experiences of arrestees and jail inmates with a serious mental illness that were associated with misdemeanor and felony arrests and additional days in jail. METHODS: County and statewide criminal justice records and health and social service archival data sets were used to identify inmates with serious mental illness who were in the Pinellas County, Florida, jail between July 1, 2003, and June 30, 2004, and their health and social service contacts from July 1, 2002, to June 10, 2006. Criminal justice and mental health services were recorded longitudinally across 16 quarters, or 90-day periods. Generalized estimating equations for count data were used to describe the associations between individual characteristics and experiences and the risks of misdemeanor and felony arrests and additional days in jail. RESULTS: A total of 3,769 jail inmates (10.1% of all jail inmates) were diagnosed as having a serious mental illness. Participants experienced a mean+/-SD of .90+/-.60 arrest for every three quarters and 10.9+/-23.6 days in jail per quarter that they resided in the county. Being male, being homeless, not having outpatient mental health treatment, and having an involuntary psychiatric evaluation in the previous quarter were independently associated with significantly increased odds of misdemeanor arrests and additional days in jail. On the other hand, being black, being younger than 21 years, having a nonpsychotic diagnosis, and a co-occurring substance use disorder diagnosis were all independently associated with significantly increased odds of felony arrests, and with the exception of having a nonpsychotic diagnosis, they were also significantly associated with additional days in jail. CONCLUSIONS: Findings suggest that there are subgroups of individuals with a serious mental illness in the criminal justice system that may require different policy and programmatic responses.

Public expenditures related to the criminal justice system and to services for arrestees with a serious mental illness.

OBJECTIVE: The study identified expenditures related to criminal justice, health, mental health, and social welfare services over a four-year period for arrestees with serious mental illnesses in a large Florida county and characteristics of subgroups. METHODS: Multiple data sets were used to identify 3,769 persons arrested in a one-year period who had serious mental illnesses. Multiple regression with all variables mutually adjusted was used to explore associations with a log of aggregate criminal justice, health, mental health, and social welfare expenditures. RESULTS: Aggregate expenditures were $94,957,465, with a median per person of $15,134. Individuals with the highest expenditures were at least 40 years old with a psychotic disorder, an involuntary psychiatric examination, and more arrests and mental health contacts. Medicaid enrollees had higher expenditures than nonenrollees overall but lower criminal justice expenditures. CONCLUSIONS: Identifying characteristics of subgroups with higher expenditures may assist policy makers and providers in designing appropriate criminal justice and treatment responses.

Congress restores the Americans With Disabilities Act to its original intent.

The Americans With Disabilities Act (ADA) was created to prohibit discrimination based on disability. Although many individuals filed claims alleging discrimination in the workplace based on disability, the federal courts, led by the U.S. Supreme Court, adopted an increasingly constricted interpretation of key provisions of the ADA. As a result, many individuals with serious impairments were found by the courts to not be disabled. In 2008 Congress overturned these court decisions by enacting the ADA Amendments Act. These amendments overrule several decisions by the United States Supreme Court that narrowed the applicability of the ADA, and they restore the ADA to its original intent.