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Gun violence and mental illness is a major area of media attention, especially because highly publicized mass shootings seem to have become more commonly reported in the press. Gun access also is undergoing a highly politicized debate in the United States. It is important for mental health practitioners to understand the background and context of laws related to firearms access, and to understand data related to risk of suicide and violence toward others caused by gun violence among persons with mental illness. In addition, clinically driven risk assessments with specific inquiry related to firearms can be important for identifying individuals for whom firearm-focused clinical risk mitigation may be warranted.

Background Criminal justice problems among those with bipolar disorder lead to disruption in social functioning, treatment, and recovery. Understanding factors that contribute to arrest during episodes of illness can help inform approaches to risk management and improve clinical care. Methods Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey conducted in two waves were used to identify factors that predicted inter-wave criminal justice involvement during bipolar I manic episodes. Results Over 10% of respondents experienced legal involvement during their most severe manic episode. Risk was found in a range of historical, clinical, and contextual factors. Multivariate analyses suggest risk is particularly high for those who are unemployed, non-white, have past juvenile detention, have a prior arrest (while using substances or when manic), used an illicit drug in the past year, and whose mania is characterized by both social and occupational impairment. Legal problems were particularly elevated among those who lacked health insurance while experiencing both social and occupational impairment. Limitations Respondents did not include prisoners and hospital inpatients; criminal justice problems were only assessed with regard to the most severe manic episode. Conclusions The particular array of factors that elevate the risk of legal involvement during manic episodes offers guidance when identifying prevention strategies and evaluating patients in clinical and forensic settings. Reducing such involvement will require that these issues be dealt with in the broader context of mental health and other services, which in turn necessitates providing adequate access to healthcare.

Our study is the first-ever initiative to merge administrative databases in Massachusetts to evaluate an important public mental health program. It examines post-incarceration outcomes of adults with serious mental illness (SMI) enrolled in the Massachusetts Department of Mental Health (DMH) Forensic Transition Team (FTT) program. The program began in 1998 with the goal of transitioning offenders with SMI released from state and local correctional facilities utilizing a core set of transition activities. In this study we evaluate the program's effectiveness using merged administrative data from various state agencies for the years 2007–2011, comparing FTT clients to released prisoners who, despite having serious mental health disorders, did not meet the criterion for DMH services. By systematically describing our original study design and the barriers we encountered, this report will inform future efforts to evaluate public programs using merged administrative databases and electronic health records.

Before the Supreme Court’s 2008 decision in District of Columbia v. Heller, the American Psychiatric Association’s position on gun policy reflected the strong gun control perspective championed by the nation’s public health establishment. After Heller declared that an individual’s right to bear arms is constitutionally protected, the APA refocused its attention on the specific aspects of firearm policy that implicate the interests and rights of persons with mental illness. Psychiatrists are mindful of the need to curtail firearm access by persons with mental disorders that elevate the risk of suicide or violence to others, but they are also opposed to stigmatization, discrimination and unfair treatment of individuals based on mental illness. Although civil commitment is an acceptable basis for prohibiting access to firearms, other adjudications of conduct indicative of elevated risk should also be included. Every state should provide a fair and reasonable process for restoring firearm rights after a suitable waiting period based on individualized assessment of whether the person remains at elevated risk. However, restricting firearm rights of persons solely on the basis of a diagnosis of a mental disorder or voluntary treatment, whether inpatient or outpatient, discourages treatment and would be counterproductive.

Objective: The authors sought to determine if there were gender differences in neuroleptic response in male and female patients with schizophrenia who were matched for clinical and demographic variables and participated in a double-blind trial of traditional antipsychotic drugs. Methods: 24 males (m) and 20 females (f) with schizophrenia or schizoaffective disorder who did not differ in clinical characteristics (age of onset, course of illness, prior hospitalizations, premorbid functioning) participated in an extended drug-free period followed by a neuroleptic trial under double-blind, placebo-controlled conditions. Results: Males and females showed significant improvement in total, positive and negative BPRS symptoms during neuroleptic treatment. However, there were no significant differences in treatment response between sexes. No sex differences were found in baseline drug-free symptomatology, neuroleptic dose or dosage by weight. Conclusions: There were no significant sex differences in neuroleptic treatment response in male and female patients well-matched for clinical, treatment and demographic characteristics. Methodological issues which distinguish this study from prior studies reporting gender differences in neuroleptic response are examined.

s / Drug and Alcohol Dependence 146 (2015) e34–e117 e89 Brief guide to prevent overdose fatality for prescription opioid abusers: A harm reduction initiative Lauren E. Sandstrom1, Paul Coplan1, Howard Chilcoat1, Fred W. Brason2, Carl Leukefeld3, Louis A. Morris4 1 Purdue Pharma, Stamford, CT, United States 2 Project Lazarus, Moravian Falls, NC, United States 3 University of Kentucky, Lexington, KY, United States 4 Louis A Morris & Assoc., Dix Hills, NY, United States Aims: Pharmaceutical companies are required by FDA to distribute Medication Guides to patients with each pill bottle of extended-release opioids educating them on safe use. However, a large portion of overdoses occur among abusers without prescriptions. To fill this gap, a 1-page Guide was developed targeted to opioid abusers and friends/families, which provides information to reduce risk of fatal overdose. Methods:Adraft Guidewas developedwith input fromexperts. The draft addressed key risks and effective steps to intervene in 5 areas:What are the risks?What are the signs? How do I respond to an overdose in another person?What increases the risks? Help for drug treatment. Qualitative researchwas conducted usingmultiple diverse focus groups (FG) composed of 8–15daily non-medical opioid users. Phase I focused on version (concise versus detailed) and Phase II focused on participants’ understanding and acceptance of content. Results: Phase I testing determined a concise version was preferred over a detailed one (368 vs. 611words) but some items from the detailed version were considered valuable e.g., list of opioids. Phase II examined a single version of revised content in 2 diverse rural FG in KY and NC. Themes highlighted by both FG included the dangers of mixing drugs and alcohol and increasing doses to get high. The groups differed on preferred order of presentation of content. The recommendation to Call 911 was identified as risky in KY, but not in NC where Good Samaritan legislation was in place. FG participants highlighted key information in the Guide that was learned including

s / Drug and Alcohol Dependence 146 (2015) e34–e117 e101 A pilot specialty jail diversion program for justice-involved veterans with co-occurring disorders David Smelson1,2, D.A. Pinals3,2, Leon Sawh1,2,4, C. Fulwiler2, S. Singer2, K. O’Connor2, W. Fisher4, S. Hartwell5, Gerardo Gonzalez2 1 Department of Veterans Affairs, Bedford, MA, United States 2 University of Massachusetts Medical School, Worcester, MA, United States 3 Massachusetts Department of Mental Health, Boston, MA, United States 4 University of Massachusetts Lowell, Lowell, MA, United States 5 University of Massachusetts Boston, Boston, MA

s / Drug and Alcohol Dependence 146 (2015) e34–e117 e55 evaluated by randomly assigning parolees to 6monthly naltrexone injections or treatment as usual (TAU) without medication. Methods: All patients met DSM-IV criteria for opioid dependence. 308 parolees were randomized and 290 are now eligible for 6-month follow up. The naltrexone group received 6 monthly injections of 380mg and amonthly visit with a nurse. The parolees randomized to TAU received help in joining a community counseling program. Outcomes were measured by urine tests and self-report. Results: Retention rates in treatment at 27, 52, and 78 weeks were 64%, 58% and 54% for the TAU group and 66%, 54% and 52% for the naltrexone group. Urine tests were examined at 27, 52 and 78 weeks andwithpooleddata fromall 5 sites, therewere significantly fewer opioid positive urines in the naltrexone group (p< .0001 for the pooled analysis). The rate of positive opioids for TAU was 3.36 times higher than that for naltrexone. No significant differencewas found for other drugs. There were 2 opioid overdoses in the TAU group and none in the naltrexone group. There were 4 deaths from all causes in the TAU group and 2 deaths in the naltrexone group unrelated to medication. Conclusions: A monthly injection of depot naltrexone significantly reduced opioid relapse in parolees. Six-month retentionwas similar in the two groups. Serious adverse events including opioid overdose occurred less often in the group receiving naltrexone (18 naltrexone vs. 43 for TAU). In this interim analysis, depot naltrexone was found to be both safe and effective in reducing the rate of relapse to opioid use. Financial support: This research was supported by collaborative RO-1 grants to the 5 sites involved. The extended release naltrexone in the form of Vivitrol was supplied by Alkermes Inc. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.519 A needs comparison of justice-involved Iraq/Afghanistan veterans to other service eras Kathryn O’Connor1,2, Debra A. Pinals3,1, David Smelson1,2, Leon Sawh2,4,1, Carl Fulwiler1, Stephanie Singer1, William Fisher4, Stephanie Hartwell5, Gerardo Gonzalez1 1 University of Massachusetts Medical School, Worcester, MA, United States 2 US Department of Veterans Affairs, Bedford, MA, United States 3 Massachusetts Department of Mental Health, Boston, MA, United States 4 University of Massachusetts, Lowell, Lowell, MA, United States 5 University of Massachusetts, Boston, Boston, MA

The law concerning when a criminal defendant can be subjected to involuntary psychotropic medication prior to trial relies upon two distinct paradigms: a parens patriae-based treatment rationale and an institutional security rationale. These distinctions have created an unclear jurisprudence, which has left unanswered the basic questions: when can involuntary medication of the criminal defendant occur, and what procedure must be followed in order to undertake such medication? The existing jurisprudence was based upon two implicit premises concerning the practice of involuntary medication: it was very rare, and it was accompanied by numerous severe physiological and mental risks. Deinstitutionalization of the mentally ill, changes in treatment methodologies, and the development of new drugs, however, are rapidly undermining both these premises. These changes highlight the shortcomings in the law. Moreover, they demand that a jurisprudence be recognized which clearly reflects the range of constitutional interests implicated by involuntary medication of the criminal defendant prior to trial, particularly those interests implicated by his trial-related constitutional rights. We would reformulate the analysis to include an initial determination of the defendant's competence to make treatment decisions. We argue that the jurisprudence should then require that the government demonstrate both a compelling interest in psychotropically medicating the defendant, and that medication is medically appropriate and the most narrowly tailored, least intrusive means of achieving that interest, and that whenever such a showing is made appropriate safeguards be implemented to protect the defendant's trial-related rights. We also argue that establishing competence to stand trial, alone, may constitute such a compelling interest. Procedurally, we argue that this showing should be made before a trial judge (rather than hospital administrators or doctors), after a full hearing, at which the defendant is afforded the rights to notice, counsel, confrontation, and cross-examination, and that the government should satisfy its burden through clear and convincing proof.

Recent developments in psychopharmacology have lead to the introduction of several novel antipsychotic agents into clinical practice. As these agents become more commonly encountered, it is essential that forensic psychiatrists have a working knowledge of their efficacy as well as the advantages of their use. This article reviews current literature regarding the clinical efficacy and mechanisms of action of clozapine, risperidone, olanzapine, quetiapine, sertindole, and ziprasidone, with a discussion of their use in forensic psychiatry. Specifically, studies show certain advantages of the novel agents in the treatment of violent patients. Use of these medications may also reduce the risk of civil litigation. The novel antipsychotic agents offer the potential of improved patient care within forensic settings by both expediting judicial processing while providing long-term cost savings. Forensic patients represent an underserved population but must have equal access to new medications as they become available. Familiarity with these issues and the medications themselves will facilitate their use in forensic settings.