Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis.

OBJECTIVE: In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program. METHODS: A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost. RESULTS: The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT. CONCLUSIONS: The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

Promoting Mental Health and Criminal Justice Collaboration Through System-Level Partnerships.

Recent high-profile deaths of unarmed individuals in police custody have raised concerns about the role of police officers in responding to people who are experiencing mental health crises. Of further concern, people with serious mental illness are highly over-represented throughout the entire criminal justice system including within jail, prison and community corrections populations. It is widely accepted that promoting mental health and criminal justice collaboration is a key to addressing these concerns. Promoting effective collaboration is challenging, however, due to fundamental differences in cultures and methods that exist between mental health and criminal justice service providers. To promote effective collaboration between service providers, a conceptual framework was recently published that divides the collaborative process into separate steps and outlines respective responsibilities at each step. Yet optimal collaboration between mental health and criminal justice service providers requires the support of their respective supervisors and agency heads. This paper extends previous work at the service provider level by applying the conceptual framework to promote effective collaboration at the systems level (i.e., between agencies). Barriers to inter-agency collaboration are discussed, and strategies for facilitating collaboration at each step of the collaborative process are presented.

Essential Elements of Forensic Assertive Community Treatment.

LEARNING OBJECTIVE: After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs. ABSTRACT: Forensic assertive community treatment (FACT) has emerged internationally as an intervention strategy for people with serious mental disorders who are involved with the criminal justice system. Studies to date have shown marked variability, however, in FACT program design and operation. Based upon a literature review and relevant experience, the authors present their perspective on the essential elements of FACT. Given that FACT is an adaptation of the evidence-based assertive community treatment (ACT) model, it is recommended that FACT programs maintain a high-fidelity ACT component. FACT programs should also have both mental health and criminal justice admission criteria because service recipients are involved in both service systems. For optimal effectiveness, FACT team clinicians must partner with criminal justice agencies that provide community-based supervision to their patients. Prospective FACT enrollees should receive a clear explanation of the program, including how their respective mental health and criminal justice service providers will work collaboratively with them to prevent incarceration. FACT programs should also use risk/need assessment to inform treatment planning, evidence-based mental health and community correctional practices to promote both wellness and public safety, and shared training to promote effective collaboration. Additional elements to consider include housing, medical care, and transitional services. These elements are presented and discussed, including a rationale and evidence to support each component. The article concludes with introduction of a FACT fidelity scale, the Rochester Forensic Assertive Community Treatment Scale (R-FACTS). By operationalizing essential FACT elements, the R-FACTS is designed to support FACT program development, implementation, and dissemination in a more consistent and measurable manner.

Psychosis, Mania and Criminal Recidivism: Associations and Implications for Prevention.

People with mental illness are overrepresented throughout the criminal justice system, including jail, prison, probation, and parole populations. Yet much disagreement remains about why this problem exists and how best to address it. This article specifically examines empirical evidence regarding the question of whether psychosis and mania are associated with criminal recidivism, and whether this association is predictive or causal in nature. Review of the current literature suggests that psychotic and manic symptoms are associated with increased likelihood of arrest and incarceration. In addition, current evidence shows that pharmacotherapy can reduce criminal recidivism among justice-involved adults with psychosis or mania. However, the extent to which the association between psychosis, mania, and criminal justice system involvement is causal remains uncertain. Also, the literature suggests that most crimes committed by people with schizophrenia spectrum disorders or bipolar I disorder may be driven by factors other than their psychotic or manic symptoms. These established "criminogenic needs" are more common among people with severe mental disorders than in the general population. For optimal prevention, those who serve justice-involved adults with psychosis or mania in community settings should consider addressing the full range of factors that potentially drive their criminal justice system involvement.

A Randomized Controlled Trial of the Rochester Forensic Assertive Community Treatment Model.

OBJECTIVE: Forensic assertive community treatment (FACT) is an adaptation of the assertive community treatment model and is designed to serve justice-involved adults with serious mental illness. This study compared the effectiveness of a standardized FACT model and enhanced treatment as usual in reducing jail and hospital use and in promoting engagement in outpatient mental health services. METHODS: Seventy adults with psychotic disorders who were arrested for misdemeanor crimes and who were eligible for conditional discharge were recruited from the Monroe County, New York, court system. Participants were randomly assigned to receive either FACT (N=35) or enhanced treatment as usual (N=35) for one year. Criminal justice and mental health service utilization outcomes were measured by using state and county databases. RESULTS: Forty-nine participants (70%) completed the full one-year intervention period. Nineteen (27%) were removed early by judicial order, one was removed by county health authorities, and one died of a medical illness. Intent-to-treat analysis for all 70 participants showed that those receiving the FACT intervention had fewer mean±SD convictions (.4±.7 versus .9±1.3, p=.023), fewer mean days in jail (21.5±25.9 versus 43.5±59.2, p=.025), fewer mean days in the hospital (4.4±15.1 versus 23.8±64.2, p=.025), and more mean days in outpatient mental health treatment (305.5±92.1 versus 169.4±139.6, p<.001) compared with participants who received treatment as usual. CONCLUSIONS: The Rochester FACT model was associated with fewer convictions for new crimes, less time in jail and hospitals, and more time in outpatient treatment among justice-involved adults with psychotic disorders compared with treatment as usual.

Patient experiences of autonomy and coercion while receiving legal leverage in forensic assertive community treatment.

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.

The role of probation in forensic assertive community treatment.

OBJECTIVE: Forensic assertive community treatment (FACT) is an adaptation of the assertive community treatment model designed to prevent criminal recidivism through criminal justice collaborations. A national survey was conducted to examine FACT collaborations with probation departments. METHODS: Members of the National Association of County Behavioral Health and Developmental Disability Directors were surveyed to identify FACT programs. Programs reporting collaborations with probation departments were contacted to provide details. RESULTS: Fifty-six percent of FACT programs (15 of 27) reported collaborating with probation departments. Probation officers were assigned an average of 29±16 hours weekly, and 80% of programs (12 of 15) reported a favorable impact of collaboration on risk of patient rearrest. Only two programs reported using standard tools to formally assess recidivism risk. The most common barrier to collaboration was differences in philosophy between FACT team clinicians and probation officers. CONCLUSIONS: FACT collaborations involving probation departments are common and are viewed by most program leaders as helpful in reducing criminal recidivism.

Quetiapine in the successful treatment of schizophrenia with comorbid alcohol and drug dependence: a case report.

BACKGROUND: Excluding nicotine and caffeine dependence, almost 50% of individuals with schizophrenia also meet the criteria for substance abuse or dependence. Comorbid drug abuse presents complications to the effective treatment of these patients because they have increased psychotic symptoms and poorer treatment compliance. CASE REPORT: This report describes thecase of a young man with schizophrenia and comorbid alcohol and cocaine abuse who was successfully treated with quetiapine. The patient was previously treated with olanzapine and developed priapism, which required emergency medical treatment. CONCLUSIONS: The possible utility of atypical antipsychotics in the treatment of patients with schizophrenia and comorbid substance abuse needs to be confirmed in clinical trials.

Persons with severe mental disorders in the criminal justice system: challenges and opportunities.

Persons with schizophrenia and other severe mental disorders are at risk for falling through the cracks between the criminal justice and mental health systems. This article is based on a panel discussion between representatives from both systems that recently convened at a regional conference to discuss integration of services. The purpose of the panel discussion was to identify challenges and opportunities related to integrating mental health and criminal justice services at each phase of the criminal justice process. A synopsis of the discussion is presented, along with new models of service delivery designed to prevent the inappropriate arrest and incarceration of persons with severe mental disorders.

Violence prevention and safety training for case management services.

Violence inflicted by individuals with mental illness towards healthcare workers has received significant media attention. Though such incidents are relatively infrequent, they inspire reactive responses and contribute to further stigmatization of the mentally ill. Prevention of violence is an important challenge for those who train and supervise mental health workers. Project Link is an outpatient treatment program designed to reduce jail and hospital recidivism among severely mentally ill adults with histories of criminal justice system involvement. Utilizing a Safety and Violence Education (SAVE) curriculum, Project Link has successfully transitioned high-risk mentally ill individuals from the criminal justice system into the community since 1995. The SAVE curriculum uses a preventative strategy to train case managers to identify warning signs of impending violence, and to safely engage patients in community settings. This paper will present an overview of the SAVE curriculum and its development, as well as results from a preliminary evaluation of trainee satisfaction.