Using the Theory of Planned Behavior to Understand How Crisis Intervention Team (CIT) Training Facilitates Police Officers' Mental Health Referrals.

The Theory of Planned Behavior posits that behaviors are predicted by one's intention to perform them; intention is driven by attitude toward the behavior, subjective norm, and perceived behavioral control. We used this theory to predict Crisis Intervention Team (CIT)-trained and non-CIT officers' intention to facilitate referral of persons with suspected mental illnesses to mental health services. CIT-trained (n = 251) and non-CIT (n = 335) officers from six law enforcement agencies participated. CIT-trained officers had significantly greater scores on all constructs. Theory constructs fit the data well, and fit did not differ meaningfully between the two groups. Direct and indirect predictors together accounted for 28% and 21%, respectively, of variance in behavioral intention. Attitude was the strongest predictor. Intentions to facilitate mental health referrals may be driven by the same factors among CIT-trained and non-CIT officers, but CIT officers, even at a median of 22 months after training, have significantly higher scores on those factors.

Police officers' volunteering for (rather than being assigned to) Crisis Intervention Team (CIT) training: Evidence for a beneficial self-selection effect.

Officers' volunteering for Crisis Intervention Team (CIT) training-rather than being assigned-is assumed to be an important, beneficial self-selection bias. This bias remains poorly characterized, though CIT officers are more likely to be female and to have had exposure to the mental health field. We determined whether or not self-selection is beneficial with regard to knowledge, attitudes, and skills, as well as level of force used (i.e., no or low force versus any form of physical force) and disposition of subjects, in actual encounters. We compared CIT-trained officers who had volunteered with those who had been assigned using data from two prior, linked studies that compared CIT-trained and non-CIT officers on knowledge, attitudes, and skills (251 CIT-trained officers; 68% had volunteered), as well as behaviors (517 actual encounters provided by 91 CIT-trained officers; 70% had volunteered). Of 28 scores on knowledge, attitudes, and skills compared, six were statistically significantly different (p < .01) and another eight were marginally significant (.01 < p < .05). Furthermore, although CIT officers who had volunteered were more likely to report use of some form of physical force as we had defined it (which included the use of handcuffs), when they did so they were more likely to refer to treatment services and less likely to make an arrest. These effects were apparent even when taking into account effects of gender, having had exposure to the mental health field, empathy, and other covariates. In conclusion, we found evidence for benefits of self-selection/volunteering that should be further characterized, as it appears to be associated with better outcomes with regard to key attitudes, skills, and behaviors.

Modeling the effects of Crisis Intervention Team (CIT) training for police officers: How knowledge, attitudes, and self-efficacy drive de-escalation skills and referral decisions.

OBJECTIVE: Prior research on Crisis Intervention Team (CIT) training for police officers has demonstrated improvements in knowledge, attitudes, self-efficacy, and stigma, but how these factors work together to influence behavioral outcomes like de-escalation skills and referral decisions remains unstudied. METHOD: 251 CIT-trained and 335 non-CIT officers completed in-depth surveys measuring these six constructs. We used structural equation modeling to test fit of the data to our hypothesized model and made indicated changes to improve fit. RESULTS: An alternate 8-path model (with three paths originally hypothesized being removed) fit reasonably well, and allowing path coefficients to differ for CIT and non-CIT groups resulted in models with similar fit statistics. CONCLUSION: CIT training enhances knowledge and attitudes, both of which have beneficial effects on stigma. Though an important outcome itself, lower stigma does not have an effect on de-escalation skills and referral decisions, though self-efficacy clearly does.

Characteristics of patients referred to psychiatric emergency services by crisis intervention team police officers.

The Crisis Intervention Team (CIT) program trains police officers in crisis intervention skills and local psychiatric resources. Because the safety and appropriateness of any new intervention is a crucial consideration, it is necessary to ensure that CIT training does not result in excessive or inappropriate referrals to psychiatric emergency services (PES). Yet, aside from one prior report by Strauss et al. (2005) in Louisville, Kentucky, little is known about the comparability of patients referred to PES by CIT-trained officers in relation to other modes of referral. The research questions driving this retrospective chart review of patients referred to PES were: (1) What types of patients do CIT-trained officers refer to PES?, and (2) Do meaningful differences exist between patients referred by family members, non-CIT officers, and CIT-trained officers? Select sociodemographic and clinical variables were abstracted from the medical records of 300 patients during an eight-month period and compared by mode of referral. Differences across the three groups were found regarding: race, whether or not the patient was held on the locked observation unit, severe agitation, recent substance abuse, global functioning, and unkempt or bizarre appearance. However, there were virtually no differences between patients referred by CIT-trained and non-CIT officers. Thus, while there were some expected differences between patients referred by law enforcement and those referred by family members, CIT-trained officers appear to refer individuals appropriately to PES, as evidenced by such patients differing little from those referred by traditional, non-CIT police officers. Trained officers do not have a narrower view of people in need of emergency services (i.e., bringing in more severely ill individuals), and they do not have a broader view (i.e., bringing in those not in need of emergency services). Although CIT training does not appear to affect the type of individuals referred to PES, future research should examine the effect of CIT training on the frequency of referrals or proportion of subjects encountered that are referred, which may be expected to differ between CIT-trained and non-CIT officers.

Targeting PPARalpha in Alzheimer's Disease.

BACKGROUND: The molecular mechanisms underlying Alzheimer's disease (AD) are yet to be fully elucidated. The so-called "amyloid cascade hypothesis" has long been the prevailing paradigm for causation of disease, and is today being revisited in relation to other pathogenic pathways, such as oxidative stress, neuroinflammation and energy dysmetabolism. The peroxisome proliferator-activated receptors (PPARs) are expressed in the central nervous system (CNS) and regulate many physiological processes, such as energy metabolism, neurotransmission, redox homeostasis, autophagy and cell cycle. Among the three isotypes (α, ß/δ, γ), PPARγ role is the most extensively studied, while information on α and ß/δ are still scanty. However, recent in vitro and in vivo evidence point to PPARα as a promising therapeutic target in AD. CONCLUSION: This review provides an update on this topic, focussing on the effects of natural or synthetic agonists in modulating pathogenetic mechanisms at AD onset and during its progression. Ligandactivated PPARα inihibits amyloidogenic pathway, Tau hyperphosphorylation and neuroinflammation. Concomitantly, the receptor elicits an enzymatic antioxidant response to oxidative stress, ameliorates glucose and lipid dysmetabolism, and stimulates autophagy.

Cocaine use disorders and suicidal ideation.

The goal of this study was to determine the contribution of substance abuse to the expression of suicidal ideation in a sample of patients referred for evaluation of chemical dependency in a large urban Psychiatric Emergency Service (PES). Records from 777 consecutive patients referred to the chemical dependency service of the PES were analyzed. Of this sample, 43.7% of the patients with only a cocaine use disorder expressed suicidal ideation compared to 38% of those with both cocaine and alcohol use disorders, 24.3% with only an alcohol use disorder and 17% with other drug use disorders (chi(2)=24.768; df=3; P<0.0001). More than half of the patients (55.26%) with a substance-induced mood or psychotic disorder expressed suicidal ideation (chi(2)=23.174, df=1, P<0.0001), and the majority (85%) of these patients had a cocaine use disorder (chi(2)=12.309, df=1, P<0.0005). In this sample of patients served by an urban PES, cocaine use is associated with suicidal ideation, more so than other substances of abuse.

Reduction of episodes of seclusion and restraint in a psychiatric emergency service.

The authors developed a comprehensive plan focusing on the early identification and management of problematic behaviors in an effort to reduce seclusion and restraint in a psychiatric emergency service and to increase adherence to hospital standards for its use. Hospital data for nine months before and nine months after the implementation of the plan were retrospectively reviewed. Two key factors that were believed to increase the likelihood of episodes of seclusion and restraint were ineffectual management of problematic behavior and inadequate monitoring. The plan, when instituted, was associated with a 39 percent reduction of instances of seclusion and restraint. Compliance with hospital standards increased to 100 percent.

The relationship of restrictions on state hospitalization and suicides among emergency psychiatric patients.

OBJECTIVE: This study explored the relationship between mandated decreases in transfers to a state hospital from a large urban psychiatric emergency facility and the occurrence of suicide in the catchment area served. METHODS: During 1996, new admission criteria that emphasized psychiatric diagnosis and potential benefit from hospitalization and that restricted the admission of recidivistic patients and of those with a primary diagnosis of a substance use disorder were phased in. Data on the number of patients seen in a psychiatric emergency service and the number transferred to the state hospital were obtained for the period 1994-1998. Data on all completed suicides in the county served by the hospital were also obtained. RESULTS: During 1994 and 1995, a total of 9,308 patients were transferred to the state hospital. In 1997 and 1998, a total of 4,072 patients were transferred. The number of patients seen in the emergency service remained constant throughout the study period. No change was noted in the absolute number or the rate of suicide in the county after the new admission criteria were implemented. A total of 164 suicides were recorded in 1994-1995 (12 per 100,000 population per year), compared with 152 in 1997-1998 (ten per 100,000 population per year). CONCLUSIONS: Transfers to the state hospital were reduced by 56 percent, with no change in the suicide rate. This finding suggests that the availability of inpatient psychiatric hospitalization may not have a direct effect on the suicide rate.

Suicide prevention: a vital national public health issue.

Suicide continues to be a major public health problem in the United States, with 30,000 deaths per year. The suicide rate, which hovers around 10-12/100,000, has remained virtually unchanged over the past three decades. In 1999 the Surgeon General proposed a national plan to serve as a roadmap toward developing a comprehensive national suicide prevention strategy. The key features of this plan were encapsulated in the acronym AIM, Awareness, Intervention and Methodology, to define the relevant components of a national strategy. This refers to increasing public awareness of the problem of mental illness and suicide, providing increased access to treatment and prevention resources and developing improved research methodologies. Despite the overall numbers, suicide is a low base-rate event, which makes studying intervention and prevention strategies very difficult, as very large subject samples are required for meaningful outcome assessments. Suicide prevention and prevention research have received substantially fewer public resources than many other medical conditions, and apparent public health risks such as bioterrorism. It is for this reason that a comprehensive, national public health based suicide prevention program is required.

The police-based crisis intervention team (CIT) model: I. Effects on officers' knowledge, attitudes, and skills.

OBJECTIVE: Individuals with serious mental illnesses are very likely to interact with police officers. The crisis intervention team (CIT) model is being widely implemented by police departments across the United States to improve officers' responses. However, little research exists on officer-level outcomes. The authors compared officers with or without CIT training on six key constructs related to the CIT model: knowledge about mental illnesses, attitudes about serious mental illnesses and treatments, self-efficacy for deescalating crisis situations and making referrals to mental health services, stigmatizing attitudes, deescalation skills, and referral decisions. METHODS: The sample included 586 officers, 251 of whom had received the 40-hour CIT training (median of 22 months before the study), from six police departments in Georgia. In-depth, in-person assessments of officers' knowledge, attitudes, and skills were administered. Many measures were linked to two vignettes, in written and video formats, depicting typical police encounters with individuals with psychosis or with suicidality. RESULTS: CIT-trained officers had consistently better scores on knowledge, diverse attitudes about mental illnesses and their treatments, self-efficacy for interacting with someone with psychosis or suicidality, social distance stigma, deescalation skills, and referral decisions. Effect sizes for some measures, including deescalation skills and referral decisions pertaining to psychosis, were substantial (d=.71 and .57, respectively, p<.001). CONCLUSIONS: CIT training of police officers resulted in sizable and persisting improvements in diverse aspects of knowledge, attitudes, and skills. Research should now address potential outcomes at the system level and for individuals with whom officers interact.

The police-based crisis intervention team (CIT) model: II. Effects on level of force and resolution, referral, and arrest.

OBJECTIVE: The crisis intervention team (CIT) model is a widely implemented police-based program to improve officers' responses to individuals with behavioral disorders. The authors examined levels of force used by officers with or without CIT training and disposition decisions in a large sample of encounters with individuals whom they suspected of having a serious mental illness, a drug or an alcohol problem, or a developmental disability. METHODS: A total of 180 officers (91 with CIT training and 89 without) in six departments reported on 1,063 encounters, including level of force and disposition (resolution at the scene, referral or transport to services, or arrest). RESULTS: CIT training status was generally not predictive of level of force, although CIT-trained officers were significantly more likely to report verbal engagement or negotiation as the highest level of force used (odds ratio [OR]=2.00, p=.016). For CIT-trained officers, referral or transport was a more likely outcome (OR=1.70, p=.026) and arrest was less likely (OR=.47, p=.007) than for officers without CIT training; these findings were most pronounced when physical force was necessary. Analyses of disposition differences by officers' perceptions of subjects' primary problem (for example, mental illness only versus a drug or an alcohol problem) found some effects of CIT training status. CONCLUSIONS: CIT training appears to increase the likelihood of referral or transport to mental health services and decrease the likelihood of arrest during encounters with individuals thought to have a behavioral disorder. Research should address subject- and system-level outcomes that complement this early evidence of successful prebooking jail diversion.