The Rich Nonprofits Get Richer: Centering Psychiatric Grant Funding at the Margins.

Community psychiatrists serve multiple institutional roles, and at times these roles may include the review of grant proposals from nonprofit organizations. In this column, the authors argue that privilege and social capital can easily become concentrated among a small group of centralized model organizations and influence the grant review process. Established and wealthy nonprofits can co-opt the growing interest in health equity by leveraging their existing resources, thereby excluding emerging organizations within communities in need. By applying a structural lens to this problem, funding entities can identify approaches that more effectively promote equity throughout the grant life cycle.

Adult criminal outcomes of juvenile justice involvement.

BACKGROUND: The juvenile justice system in the USA adjudicates over seven hundred thousand youth in the USA annually with significant behavioral offenses. This study aimed to test the effect of juvenile justice involvement on adult criminal outcomes. METHODS: Analyses were based on a prospective, population-based study of 1420 children followed up to eight times during childhood (ages 9-16; 6674 observations) about juvenile justice involvement in the late 1990 and early 2000s. Participants were followed up years later to assess adult criminality, using self-report and official records. A propensity score (i.e. inverse probability) weighting approach was used that approximated an experimental design by balancing potentially confounding characteristics between children with v. without juvenile justice involvement. RESULTS: Between-groups differences on variables that elicit a juvenile justice referral (e.g. violence, property offenses, status offenses, and substance misuse) were attenuated after applying propensity-based inverse probability weights. Participants with a history of juvenile justice involvement were more likely to have later official and violent felony charges, and to self-report police contact and spending time in jail (ORs from 2.5 to 3.3). Residential juvenile justice involvement was associated with the highest risk of both, later official criminal records and self-reported criminality (ORs from 5.1 to 14.5). Sensitivity analyses suggest that our findings are likely robust to potential unobserved confounders. CONCLUSIONS: Juvenile justice involvement was associated with increased risk of adult criminality, with residential services associated with highest risk. Juvenile justice involvement may catalyze rather than deter from adult offending.

Gun violence among young adults with a juvenile crime record in North Carolina: Implications for firearm restrictions based on age and risk.

Youth who acquire a juvenile crime record may be at increased risk of perpetrating gun violence as adults. North Carolina and 22 other states permit young adults who were adjudicated by a juvenile court - even for some felony-equivalent offenses - to legally access firearms. Effectiveness of gun restrictions for adults with juvenile crime histories has not been systematically studied. This article reports findings from a longitudinal study of arrests and convictions for gun-involved and other offenses in 51,059 young adults in North Carolina, comparing those with gun-disqualifying and not-disqualifying juvenile records. The annualized rate of arrest for gun-involved crime in those with a felony-level juvenile record was 9 times higher than the rate of reported comparable offenses in the same age group in the North Carolina general population (3349 vs. 376 per 100,000). Among those with a felony-equivalent juvenile delinquency adjudication who became legally eligible to possess firearms at age 18, 61.8% were later arrested for any criminal offense, 14.3% for a firearm-involved offense. Crimes with guns were most likely to occur among young adults who had committed more serious (felony or equivalent) offenses before age 18; had been adjudicated at younger ages; acquired a felony conviction as a youth; and spent time in prison. The prevalence of arrests for crimes involving guns among young adults in North Carolina with a gun-disqualifying felony record acquired before age 18 suggests that the federal gun prohibitor conferred by a felony record is not highly effective as currently implemented in this population. From a risk-based perspective, these restrictions appear to be justified; better implementation and enforcement may improve their effectiveness. Gun crime prevention policies and interventions should focus on these populations and on limiting illegal access to firearms.

Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type.

Although it is widely accepted that patients do better when evidence-based health care practices are used, there is less acknowledgment of the positive outcomes associated with evidence-based policy making. To address the need for high-quality evidence to inform mental health policies, Psychiatric Services has recently launched a new article format: the Policy Review. This review type defines a specific policy-relevant issue affecting behavioral health systems, describes current knowledge and limitations, and discusses policy implications. Reviews can focus on mental health policies or examine how other health or social policies affect people with mental illness or substance use disorders. This brief overview of the need for a policy review article type describes differences between evidence-based policy making and practices and looks at research approaches focused on evidence-based policy making, as well as legislative and other efforts to support it. Broad guidelines for potential submissions are also provided.

Appropriateness of psychiatric advance directives facilitated by peer support specialists and clinicians on Assertive Community Treatment teams.

BACKGROUND: Psychiatric advance directives (PADs) are used to document a person's treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs. AIMS: This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency. METHODS: Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content. RESULTS: Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency. CONCLUSIONS: Results should alleviate some clinicians' apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Childhood Gun Access, Adult Suicidality, and Crime.

OBJECTIVES: To test the associations of childhood domestic gun access with adult criminality and suicidality. METHODS: Analyses were based on a 20+ year prospective, community-representative study of 1420 children, who were assessed up to 8 times during childhood (ages 9-16; 6674 observations) about access to guns in their home. Participants were then followed-up 4 additional times in adulthood (ages 19, 21, 25, and 30; 4556 observations of 1336 participants) about criminality and suicidality. RESULTS: During childhood, the 3-month prevalence of having a gun in the home was 55.1% (95% confidence interval [CI]: 52.1%-58.7%). Of the children in homes with guns, 63.3% (95% CI: 59.7%-66.9%) had access to a gun, and 25.0% (95% CI: 21.2%-28.8%) owned a gun themselves. Having gun access as a child was associated with higher levels of adult criminality (odds ratios = 1.1-3.5) and suicidality (odds ratios = 2.9-4.4), even after adjusting for childhood correlates of gun access. Risk of adult criminality and suicidality among those with childhood gun access was greatest in male individuals, those living in urban areas, and children with a history of behavior problems. Even in these groups, however, most children did not display adult criminality or suicidality. CONCLUSIONS: Childhood gun access is prospectively associated with later adult criminality and suicidality in specific groups of children.

North Carolina Specialty Courts, Treatment Access, and the Substance Use Crisis: A Promising but Underfunded Model.

Treatment courts aim to reduce criminal recidivism by addressing the behavioral health care needs of persons with psychiatric or substance use disorders that contribute to their offending. Stable funding and access to behavioral health providers are crucial elements of success for the treatment court model. What happens when courts lose state funding and must rely on local initiatives and resources? In this study, a survey of North Carolina treatment court professionals identified resource gaps and unmet needs. The authors argue that continuing state investment could make treatment courts more viable and effective. Medicaid expansion is a potential new resource for these problem-solving courts.

Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists.

BACKGROUND: A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams. AIMS: We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference. METHODS: Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1-2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis. RESULTS: There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment. CONCLUSIONS: PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Implementing Psychiatric Advance Directives: The Transmitter and Receiver Problem and the Neglected Right to Be Deemed Incapable.

Psychiatric advance directives (PADs) can help adults with serious mental illnesses preserve their autonomy and avoid involuntary interventions during an incapacitating mental health crisis. A PAD is a legal document prepared while mentally competent and states the person's treatment preferences to be implemented during a future crisis, ideally with the advocacy of an authorized proxy decision maker. PADs have been available in the United States for more than three decades but have yet to be robustly implemented in practice. This Open Forum describes PADs metaphorically as a device for remote communication among the person with mental illness, a proxy decision maker, and health care providers. Barriers to PAD usage occur on both "transmitter" and "receiver" sides and must be addressed to advance PAD implementation.

Gun-Related and Other Violent Crime After Involuntary Commitment and Short-Term Emergency Holds.

This article presents a survival analysis of long-term risk of firearm-related and other violent crime in a large sample of adults with serious mental illness in Florida, comparing those who received a gun-disqualifying civil commitment after a short-term hold, those who were evaluated for commitment but were released or hospitalized voluntarily, and a third group with no holds or commitments. Among 77,048 adults with a diagnosis of schizophrenia-spectrum disorder, bipolar disorder, or major depression, 42.7 percent were detained for psychiatric examination under Florida's Baker Act; of that detained group, 8.4 percent were involuntarily committed while the remainder were released within 72 hours or agreed to voluntary admission. Over a follow-up period averaging six to seven years, 7.5 percent of the sample were arrested for a violent offense not involving a gun, and 0.9 percent were arrested for a violent crime involving a gun. A short-term hold with or without commitment was associated with a significantly higher risk of future arrest for violent crime, although the study population had other violence risk factors unrelated to mental illness. Risk of gun-involved crime, specifically, was significantly higher in individuals following a short-term hold only, but not in those who were involuntarily committed and became ineligible to purchase or possess guns. Policy implications are discussed.