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BACKGROUND: Individuals with severe mental illnesses experience high rates of chronic health conditions; however, the extent to which risk of chronic physical health problems varies by race and gender among these individuals is understudied. AIMS: This study examines variations in health problems by race and gender among individuals with severe mental illnesses. METHOD: Administrative data, which included blood pressure, body mass index (BMI), and glycated hemoglobin (HbA1c) values, were obtained from 603 individuals with serious mental illnesses who received integrated health and behavioral health services from a large mental health agency in the Midwest. Bivariate and multivariate statistical models were used to examine variation in physical health problems by race and gender. RESULTS: Compared with men, women with severe mental illnesses were more likely to have BMI levels indicating obesity or morbid obesity ( p < .001). Compared with White participants, Black participants were less likely to have high HbA1c levels ( p < .001) but were more likely to have high blood pressure ( p < .001). Among race and gender groups, Black women were more likely to have high BMI ( p < .05), Black men were more likely to have high blood pressure ( p < .001), and White men were more likely to have high HbA1c levels ( p < .01) when holding constant all other variables. CONCLUSIONS: There is evidence that types and severity of physical health problems among individuals with severe mental illnesses varies by race and gender. Replication of these results and more research is needed to ensure that health-related education and integrated health and behavioral health interventions meet the needs of individuals with serious mental illnesses.

Objective Justice-involved people with mental illnesses, in general, experience poor criminal justice outcomes (i.e., high rates of recidivism and probation revocations) and are at increased risk of homelessness, unemployment, stigma, trauma, and poor physical health. Low social support is repeatedly associated with worse mental health outcomes in the general population but little is known about social support among probationers with serious mental illnesses. Method To address these gaps in the literature, we used an observational cross-sectional study design and data from a large, randomized controlled trial of specialty mental health probation to examine self-reported social support and its relationships with mental health functioning and other outcomes for individuals with serious mental illnesses on supervised probation. Results Probationers who self-reported lower levels of social support also reported greater mental health symptomatology and reported lower quality relationships with their probation officers. Conclusions and implications for practice Low social support among probationers with mental illnesses has important implications for mental health and criminal justice practice and policy. Coordinating services between the criminal justice and mental health systems to offer opportunities for social support and meaningful community engagement for those with mental illnesses who are on probation could improve a number of mental health and criminal justice outcomes for this population. Peer support and supported employment services, for example, in addition to outpatient mental health services, could be two strategies that could address social isolation and help individuals living with mental illnesses optimize their recovery and rehabilitation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

This paper presents the results of a qualitative study designed to explore and identify the resources that probation officers need to implement specialized mental health probation caseloads, a promising practice that enhances mental health treatment engagement and reduces recidivism among people with mental illnesses. Our research team conducted a directed content analysis guided by the Practical, Robust Implementation and Sustainability Model (PRISM) to analyze qualitative interviews with 16 specialty mental health probation officers and their supervising chiefs. Results indicated five components and resources related to multiple PRISM constructs: (1) meaningfully reduced caseload sizes (intervention design), (2) officers’ ability to build rapport and individualize probation (organizational staff characteristics), (3) specialized training that is offered regularly (implementation and sustainability infrastructure), (4) regular case staffing and consultation (implementation and sustainability infrastructure), and (5) communication and collaboration with community-based providers (external environment). Agencies implementing specialized mental health probation approaches should pay particular attention to selecting officers and chiefs and establishing the infrastructure to implement and sustain specialty mental health probation.

Although the research on specialty mental health probation (SMHP) is promising, there have been no randomized controlled trials (RCT) of the prototypical model advanced in the research literature and little focus on SMHP implementation. This study assesses the adoption of SMHP in two counties and examines its impact on mental health and criminal justice outcomes. Researchers conducted a RCT within a hybrid implementation-effectiveness study to examine intervention adoption as well as mental health treatment engagement and criminal justice outcomes for 100 individuals with serious mental illnesses on probation in one rural and one urban county in a southeastern state. Randomization produced equivalent treatment (n = 47) and control (n = 53) groups with no statistically significant differences between groups on demographic or background characteristics. Compared to standard probation officers, SMHP officers addressed the mental health needs of individuals with serious mental illness (i.e., adoption) at higher rates (p 0.001). Compared to individuals on standard caseloads, individuals on SMHP had a higher rate of mental health engagement (e.g., mental health assessment, attending treatment appointment; p 0.050); however, more individuals on SMHP caseloads had a new crime violation during follow-up compared with individuals on standard caseloads (p 0.01). In conclusions, results suggest successful adoption of the intervention and increased mental health engagement among those on SMHP caseloads. Results are consistent with the mixed findings on the impact of SMHP on improving criminal justice outcomes.

Nationally representative data on mental health disorder prevalence are critical to set informed mental health priorities and policies. Data indicating mental health diagnoses within our nation's veteran population treated at the Veterans Health Administration (VHA) are available, but have yet to be examined for changing trends to inform both VHA and community care. We use VHA national program evaluation data from a time of increasing military enrollment (2007) to troop draw down (2013) to examine changes over time in the number of diagnoses in veterans receiving VHA services. The number of veterans in all diagnostic categories increased during our study period with the smallest increase in psychotic disorders (8%) and the largest in posttraumatic stress disorder (71%). Trends in behavioral health diagnoses among veterans have important implications for policy and clinician competencies within VHA and community providers as veteran mental health care needs change.

Adults released from incarceration are at high risk of death from drug-related causes, pointing to the importance of connecting individuals to healthcare services after release from prison. Though Medicaid plays an important role in financing behavioral health treatments for vulnerable groups, many states terminate individuals' Medicaid coverage during incarceration. A significant risk factor for substance use disorders (SUD) among incarcerated individuals is serious mental illness (SMI). In January 2006, Washington State began a program of expedited Medicaid enrollment for individuals with mental illnesses being discharged from state prisons, jails, and psychiatric hospitals. Prior literature has shown this program to be effective in increasing Medicaid enrollment and use of mental health services for people with SMI. The current paper examined the effect of referral to expedited Medicaid on use of SUD treatment for people with SMI released from prison. Our sample consisted of 3086 individuals with a diagnosis of SMI who were released from prison from January 1, 2006 to December 31, 2007. Of the sample we identified, 871 individuals received referrals for expedited Medicaid and 2215 did not. To control for selection bias on observed characteristics for referral, we used inverse probability weights (IPW) to balance the referred and not-referred groups on more than 50 baseline covariates. We used doubly-robust IPW models to estimate the effect of referral to expedited Medicaid on use of SUD treatments following prison release. Approximately 12% of our sample used any SUD treatment by 3 months after release, with this percentage rising to 28% at 12 months. When controlling for baseline differences, referral to expedited Medicaid enrollment was associated on average with a 6.7 (SE 2.9, p .05) percentage point increase in the predicted probability of using any SUD treatment in the 3 months following release as compared to those not referred to the program. This effect size represents a 61% increase in the probability of using any treatment by 3 months. The result was similar for the 6-month follow-up period and persisted at the 12-month follow-up though the magnitude of the effect decreased somewhat. Overall, our results suggest that expedited Medicaid enrollment for people with SMI released from prison can increase use of SUD services.

OBJECTIVE: To increase the rate of cardiometabolic monitoring for patients receiving antipsychotic drugs in an academic outpatient psychiatric clinic serving people with serious mental illness. METHODS: Using a prospective quasi-experimental interrupted time-series design with data from the electronic health record (EHR), metabolic monitoring rates were determined before, during, and after implementation of prespecified quality improvement (QI) measures between August 2016-July 2017. QI measures included a combination of provider/patient/staff education, systematic barrier reduction, and an EHR-based reminder system. RESULTS: After one year of QI implementation, the rate of metabolic monitoring increased from 33% to 49% (p

Although a growing body of literature has demonstrated that justice-involved people with mental illnesses have criminogenic risk factors at similar or elevated rates as compared to justice-involved people without mental illnesses, more information about how criminogenic risks vary by intensity of mental health symptoms is needed. This information is particularly important for probation agencies who supervise the vast majority of justice-involved individuals with mental illnesses and who are increasingly implementing specialty mental health supervision approaches. To this end, this study examines the relationship between criminogenic risk and intensity of self-reported symptoms of mental illnesses among 201,905 individuals on probation from a large southeastern state. Self-report measures of symptoms of mental illnesses were categorized as low, moderate or high and criminogenic risks were compared among the following three groups: (1) those with no or low self-reported symptoms of mental illness; (2) those reporting moderate levels of symptoms; and (3) those reporting high or elevated levels of symptoms. Our findings suggest that the strength of relationships between symptoms of mental illnesses and criminogenic risks varies by type of criminogenic risk. Also, elevated symptoms of mental illness are associated with higher levels of criminogenic risks. More research about interventions that address mental illnesses and criminogenic risks is needed to inform practice and policy.

BACKGROUND The large and growing number of individuals with severe mental illnesses who are on probation presents challenges to both mental health and criminal justice authorities. The clinical and mental health service needs of probationers with severe mental illnesses have however, been insufficiently researched, particularly with respect to trauma and the need for trauma-informed services. AIMS To explore the lifetime prevalence of post-traumatic stress disorder (PTSD) among people on probation who also have other serious mental illnesses and their demographic characteristics. METHODS Individuals on probation in six counties in one southeastern state who had been diagnosed with severe mental illnesses were assessed for PTSD; they were also asked whether they had experienced any of 14 traumatic events of interest over their lifetimes. RESULTS Of 207 participants, about half had clinically diagnosable PTSD. Nearly two-thirds had experienced more than five traumatic events during their lifetimes: 86% experienced at least one non-interpersonal traumatic event, such as a car accident, and 90% experienced at least one interpersonal traumatic event, such as a physical assault. The latter was the single most frequently reported traumatic event (80%, n = 160). PTSD was, on average, associated with a higher number of prior traumatic experiences overall. CONCLUSIONS In one state in the USA, rates of trauma experiences and PTSD among probationers with other mental illnesses are high. Relative to prisoners, little is known about the mental health needs among probationers, so replication in a larger sample across jurisdictions would be useful. Findings are likely to have implications for form of service delivery as well as treatment needs.

Assertive community treatment (ACT) is an evidence-based practice for individuals living with severe mental illnesses. Originally conceptualized as a lifetime service, there is a need for standardized measures to help ACT teams identify clients who are potentially ready for a transition to less intensive services. Here, to address this gap in the literature, the psychometric properties of the Assertive Community Treatment Transition Readiness Scale (ATR) were examined. Data on the ATR were collected from ACT staff from across the country who had experience transitioning ACT clients to less intensive services. Results from an exploratory factor analysis suggested a one-factor solution and that items on the ATR demonstrated excellent internal consistency reliability as well as predictive criterion validity and known-groups validity. The ATR is an easy-to-use, 18-item measure that has the potential, in combination with clinical judgment and practice wisdom, to be a useful tool for identifying ACT clients who could transition to a less intensive level of care.

The inclusion of indirect spillover costs and benefits that occur in non-healthcare sectors of society is necessary to make optimal societal decisions when assessing the cost effectiveness of healthcare interventions. Education costs and benefits are relevant in the disease area of mental and behavioral disorders, but their inclusion in economic evaluations is largely neglected due to lack of methodological knowledge.This study aims to explore, using a scoping review, the identification, measurement, and valuation methods used to assess the impact of mental and behavioural disorders on education costs and benefits.A scoping review was conducted to identify articles that were set in the education sector and assessed education costs and benefits. An adapted 5-step approach was used: (i) initating a scoping review; (ii) identifying component studies; (iii) data extraction; (iv) reporting results; (v) discussion and interpretation of findings. Results were summarized in a narrative synthesis per identification, measurement, and valuation method.177 component articles were identified in the scoping review that reported 61 mutually exclusive education costs and benefits. The nomenclature used to describe the costs and benefits was poorly defined, heterogeneous in nature and largely context dependent. This was also reflected in the diverse number of measurement and valuation methods found in the component articles.This is the first study, which offers a classification of education costs and benefits and costing methods reported by studies set in the education sector. In conclusion, mental and behavioral disorders have a notable impact on a variety of different education costs and benefits.The classification provided in the current study gives an indication of the wide-spread impact of mental and behavioral disorders on the education sector. Hence, the inclusion of relevant education costs and benefits in economic evaluations for mental and behavioral disorders is necessary to make optimal societal decisions.By exploring a new area of research from a sector-specific perspective, the current study adds to the existing intersectoral cost and benefit literature base. Future research should focus on standardizing costing methods in pharmacoeconomic guidelines and assessing the relative importance of individual education costs and benefits in economic evaluations for specific interventions and diseases.

This study examined long-term outcomes (at 36 months) from Washington State's policy of expediting Medicaid enrollment for prison releasees with severe mental illness and compares them with previously reported short-term outcomes (at 12 months).Linked administrative data on prison releasees (2006-2007) were analyzed by using a quasi-experimental design comparing those referred to expedited Medicaid (N=895) with a control group of those not referred (N=2,189). Aggregate outcomes were analyzed with inverse probability of treatment-weighted logit models.Expedited Medicaid had a sustained effect on both increased months of enrollment (p.01) and increased use of community mental health and general medical services (p.01) 36 months after prison release. However, expedited Medicaid did not reduce criminal recidivism, consistent with 12-month findings, Conclusions: Outcome results at 12 months were sustained at 36 months-namely, expedited Medicaid for released prisoners with severe mental illness improved enrollment and service use with no effects on criminal recidivism.

An emerging focus of Assertive Community Treatment (ACT) teams is the transition of clients to less intensive services, which creates space for individuals in need of ACT and is consistent with a recovery orientation of treatment. However, there is limited research on team transition rates, post-ACT services, and strategies to overcome transition barriers. In addition, few studies have examined differences in these factors among urban and rural ACT teams. To address these knowledge gaps, we interviewed eight ACT teams in urban and rural areas of eastern Ontario regarding their transition rates, processes of transitioning ACT clients to less intensive services, transition barriers, and solutions to overcoming these barriers. On average, teams transitioned about 6% of their clients over our 3-year study period. Urban and rural teams described both similar and distinct clinical and systemic barriers, such as client reluctance to transition and finding psychiatric follow-up outside of ACT. Implications for ACT practice and policy are discussed.

Background Adults with co-occurring mental and substance use disorders (CODs) are overrepresented in jails. In-custody barriers to treatment, including a lack of evidence-based treatment options and the often short periods of incarceration, and limited communication between jails and community-based treatment agencies that can hinder immediate enrollment into community care once released have contributed to a cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among this vulnerable and high-risk population. This paper describes a study that will develop research and communication protocols and adapt two evidence-based treatments, dual-diagnosis motivational interviewing (DDMI) and integrated group therapy (IGT), for delivery to adults with CODs across a jail-to-community treatment continuum. Methods/design Adaptations to DDMI and IGT were guided by the Risk-Need-Responsivity model and the National Institute of Corrections’ implementation competencies; the development of the implementation framework and communication protocols were guided by the Evidence-Based Interagency Implementation Model for community corrections and the Inter-organizational Relationship model, respectively. Implementation and evaluation of the protocols and adapted interventions will occur via an open trial and a pilot randomized trial. The clinical intervention consists of two in-jail DDMI sessions and 12 in-community IGT sessions. Twelve adults with CODs and four clinicians will participate in the open trial to evaluate the acceptability and feasibility of, and fidelity to, the interventions and research and communication protocols. The pilot controlled trial will be conducted with 60 inmates who will be randomized to either DDMI-IGT or treatment as usual. A baseline assessment will be conducted in jail, and four community-based assessments will be conducted during a 6-month follow-up period. Implementation, clinical, public health, and treatment preference outcomes will be evaluated. Discussion Findings have the potential to improve both jail- and community-based treatment services for adults with CODs as well as inform methods for conducting rigorous pilot implementation and evaluation research in correctional settings and as inmates re-enter the community. Findings will contribute to a growing area of work focused on interrupting the cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among adults with CODs. Trial registration ClinicalTrials.gov, NCT02214667. Registered on 10 August 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2088-z) contains supplementary material, which is available to authorized users.

Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements.In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks.We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models.We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association.These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period.Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time.Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes.Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.

Little is known about the job satisfaction of licensed clinical social workers (LCSWs) participating in the National Health Service Corps (NHSC) federal Loan Repayment Program (LRP). Employee satisfaction in organizations is important for organizational well-being and to decrease turnover. A satisfied NHSC LCSW workforce is also important given the array of services it provides, especially in rural and underserved areas. This study examined the work satisfaction of 386 LCSWs participating in the NHSC LRP in 21 states. Rural upbringing, being older than 40 years, and a higher salary were significantly associated with overall work and practice satisfaction. In addition, satisfaction with administration, staff and the practices’ linkages to other health providers, the mission of the practice, and connection with patients were strongly associated with overall work and practice satisfaction. To our knowledge, this is the first study to examine the work and practice satisfaction of LCSWs participating in the NHSC LRP, and our findings have the potential to inform the NHSC’s strategies in managing and retaining LCSWs.

Individuals who have committed sex offenses (ISOs) with severe mental illnesses are a complex population to serve and more research is needed to guide practice and policy, especially around community supervision, enrollment in Medicaid, housing, employment, criminal justice contacts, and reincarceration after prison reentry. To further the literature in this area, we used logistic regression to model recidivism and admissions to violator or prison facilities among 127 ISOs with severe mental illnesses and 2,935 people with severe mental illnesses who were incarcerated in prison for other crimes. Compared to prison releasees with severe mental illnesses who committed crimes other than sex offenses, prison releasees with severe mental illnesses who committed sex offenses were admitted to violator facilities at higher rates, when controlling for substance use, Medicaid enrollment, homelessness, and unemployment. Implications for practice, policy and research are discussed.

Objective To examine whether the receipt of timely mental health services is associated with changes in criminal justice interactions. Data sources We used linked administrative data from Medicaid, mental health, and criminal justice settings in Washington State for persons with severe mental illness released from prison (n = 3086). Study design We estimate local and average treatment effects to examine measures of criminal justice use in the year following release as a function of timely mental health services. Data extraction methods Measures of timely service and criminal justice use within 12 months postrelease were created from administrative data. Principal findings Individuals receiving timely mental health services are more likely to experience prison re-incarceration overall and specifically for technical violations 12 months postrelease. The effect of service receipt on incarceration for new charges was negative but not significant. Conclusions The finding that mental health services receipt is associated with increased risk of re-incarceration due to technical violations speaks to the complexity of the relationship between mental health and criminal justice services for justice-involved persons with severe mental illness. Further research should examine strategies at the interface of criminal justice and mental health that can improve mental health and criminal justice outcomes for this vulnerable population.

We sought to explore clinical factors associated with successful transition from Assertive Community Treatment to less intensive clinical services. Mixed-method observational follow up study of veterans discharged from three VA-affiliated ACT teams to less intensive clinical services. Of the 240 veterans in ACT, 9% (n = 21) were discharged during the study period. Among the 11 of 21 discharged veterans who enrolled in the follow up study, reason for discharge, designated by the veteran's primary clinician at the time of discharge, predicted outcomes (p = 0.02) at 9 months, with "disengagement" as a reason for discharge predicting poorer outcomes. Six of 11 veterans experienced poor outcomes at 9 months, including incarceration and substance use relapse. ACT clinicians rarely discharge clients. Many clients may experience negative clinical events following ACT discharge, and clients may be difficult to follow post-discharge. Client disengagement from ACT may indicate higher likelihood of poor outcomes following discharge to less intensive clinical services.

TOPIC Although individuals with medical problems (e.g., diabetes, hypertension) can monitor their symptoms using objective measures (e.g., blood glucose, blood pressure), objective measures are not typically used by individuals with psychotic disorders to monitor symptoms of mental illness. PURPOSE To examine the benefits and limitations of the use of video self-observation for treatment of individuals with psychotic disorders. SOURCES USED The authors reviewed studies examining video self-observation among individuals with severe mental illnesses. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Individuals with psychotic disorders who viewed videos of themselves while symptomatic reported some benefit to this approach, with 1 study showing sustained improvement in understanding of mental illness. Still, some individuals reported negative feelings about the process, and also attributed symptoms to stress or drug abuse rather than their psychotic disorder. The authors found no studies examining the potential for video self-observation as a strategy to improve clinical decision-making in the context of mental health care. Implications of this approach for mental health recovery and clinical practice are discussed. (PsycINFO Database Record

Low executive function (EF) and depression are each determinants of health. This study examined the synergy between deficits in EF (impaired cognitive flexibility;75th percentile on the Wisconsin Card Sorting Test perseverative error score) and depressive symptoms (modified Centers for Epidemiologic Studies-Depression) and preincarceration well-being among incarcerated African American men ( N = 189). In adjusted analyses, having impaired EF and depression was strongly associated with pre-incarceration food insecurity (odds ratio [ OR] = 3.81, 95% confidence interval [CI] = [1.35, 10.77]), homelessness ( OR = 3.00, 95% CI [1.02, 8.80]), concern about bills ( OR = 3.76, 95% CI [1.42, 9.95]), low significant other support ( OR = 4.63, 95% CI [1.62, 13.24]), low friend support ( OR = 3.47, 95% CI [1.30, 9.26]), relationship difficulties ( OR = 2.86, 95% CI [1.05, 7.80]), and binge drinking ( OR = 3.62, 95% CI [1.22, 10.80]). Prison-based programs to treat depression and improve problem-solving may improve postrelease success.

OBJECTIVE With nearly 11 million people in the United States arrested in 2015, the need to identify antecedent risk factors driving criminal justice involvement (CJI) and possible mitigating factors is crucial. This study examines the relation between childhood trauma and CJI in adolescence and adulthood and assesses how this relation is moderated by mentoring during young adulthood. METHODS The analysis included 3 waves of data-adolescents, young adults, and adults-collected from 1995 to 2008 from 12,288 adolescents who participated in the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of adolescents in grades 7 to 12. Logistic regression was used to examine how having a close mentor in adolescence moderated the relation between criminal justice involvement and 9 childhood traumatic events: (1) neglect, (2) emotional abuse, (3) physical abuse, (4) sexual abuse, (5) parental incarceration, (6) parental binge drinking, (7) witnessed violence, (8) threatened with violence, and (9) experienced violence. RESULTS Cumulative exposure to childhood trauma was associated with CJI in adolescence (adjusted odds ratios [AORs] ranging from 2.24 to 25.98) and adulthood (AOR range, 1.82-6.69), and parental incarceration was consistently one of the, if not the, most strongly associated with each form of CJI; the strength of these associations was weakened for those who reported a close mentor compared to those who did not. CONCLUSIONS This study advances the literature regarding trauma and CJI, highlighting the role of social support and mentorship as protective factors for youth who experience childhood trauma. Interventions aimed at protecting vulnerable children from the harms of trauma should be the next priority.

Women with severe mental illnesses face high rates of violence victimization, yet little is understood about the unique needs and challenges these women present to the domestic violence and behavioral health agencies that serve them. To help address this knowledge gap, focus groups were conducted with 28 staff members from local behavioral health and domestic violence service agencies. Results from this exploratory study suggest that women with severe mental illnesses who experience intimate partner violence face additional challenges that exacerbate behavioral health and domestic violence issues and put these women at greater risk for continued victimization. DV and behavioral health agency staff experience individual-, provider-, and system-level barriers to serving this high-risk, high-need population. Recommendations and implications for domestic violence and behavioral health providers are discussed.

A previous study of a recovery-oriented assertive community treatment initiative (PACT) in Washington State found reductions in state psychiatric hospital use and related costs for PACT participants, especially in the first six months after enrollment and for consumers who were high users of the state psychiatric hospital before ACT enrollment. This study examined whether these outcomes varied by team fidelity to recovery-oriented ACT practices.Generalized estimating equations (GEE) were used to examine the relationship between scores on the Tool for Measurement of Assertive Community Treatment (TMACT), a recently developed tool for assessing fidelity to recovery-oriented ACT, and the use of state hospitals, local hospitals, emergency departments, local crisis stabilization units, and arrests for 631 PACT consumers. These relationships were also examined for PACT consumers with any state hospital use (N=450) and those considered high users of the state hospital (≥ 96 days in two years before PACT enrollment).TMACT scores were associated (p.01) with a decrease in the amount of use but not the probability of using state psychiatric hospitals, local hospital psychiatric inpatient units, and local crisis stabilization units. The marginal effects of higher TMACT scores on the probability and use of emergency departments or arrests were not statistically significant.This study provides preliminary evidence for the predictive validity of the TMACT. Future research should examine the subscale structure of the TMACT as well as the association between TMACT fidelity and consumer well-being, quality of life, and other important person-centered outcomes.

There are more than 2,500 Crisis Intervention Teams (CIT) in operation across the country. Results of research on the effectiveness and impact of CIT are mixed. One aspect of CIT training that has yet to be examined is the expert-derived suggestion that 40 consecutive hours of training is an essential element of CIT for law enforcement officers. That is, CIT training is delivered in one 40-hour week, but it is unclear whether the training could be delivered in segments and still achieve its desired outcomes. Segmented training could make CIT more accessible to smaller, particularly rural, law enforcement agencies. Can segmented CIT achieve outcomes similar to those of traditional CIT training? We compared the knowledge and attitudes of 47 police officers who received traditional CIT training and 32 officers who received segmented CIT training. Our findings suggest that segmented CIT training and traditional CIT training produce comparable results regarding officers' knowledge of mental illness and attitudes toward persons with mental illness, providing preliminary support for this adaptation to the delivery of CIT training.

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail's central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.

Despite the high prevalence of substance use disorders (SUDs) in the U.S., many with a SUD go untreated and/or report lengthy delays to help-seeking initiation. From a public health standpoint, because SUDs often emerge in early adulthood, information on help-seeking behaviors among young adults is important. Using data from young adults ages 18-23 years with a history of a SUD (n = 672) in Miami-Dade County, Florida, this study estimates the prevalence of lifetime help-seeking initiation and examines factors related to help seeking and delays to help-seeking initiation. The majority (68%) of young adults with a history of a SUD reported never having sought help, and those who reported help seeking experienced relatively lengthy delays (1-7 years) to help-seeking initiation. These findings underscore the need for both timely substance abuse treatment and for accelerated research on successful outreach strategies for young adults with SUDs.

PURPOSE: Forensic assertive community treatment (FACT) is a recent adaptation of the assertive community treatment (ACT) model; however, more information is needed about how FACT and ACT consumers differ and how FACT should be modified to accommodate these differences. METHOD: Linked, multisystem administrative data from King County, Washington, were used to compare the demographic, clinical, and criminal justice characteristics of ACT- and FACT-eligible consumers. RESULTS: FACT consumers were more likely to be male, persons of color, and had more complex clinical profiles. Also, some FACT consumers were incarcerated for sex offenses, and more than half had violent offenses. CONCLUSIONS: Traditionally, ACT teams avoid serving consumers with personality disorders, violent consumers, and sex offenders; however, given increased use of mandated outpatient treatment and mental health courts, FACT teams may have less discretion to choose whom they serve. The addition of clinical interventions and other modifications may be particularly important for FACT teams.

BACKGROUND: Assertive community treatment (ACT) is characterized as a service delivery platform and represents an ideal setting in which mental health and physical health care can be integrated. OBJECTIVE: Little is known about the extent to which ACT integrates physical health care with mental health care or the challenges ACT teams experience. To address this gap, focus groups were conducted with five ACT teams in a Midwestern US state to explore how ACT teams address the physical health care needs of persons with severe mental illness. DESIGN: A qualitative study design was used. RESULTS: Three major themes emerged: ACT teams recognize serious and chronic physical health problems, ACT teams take on a variety of roles to address physical health problems, and there are challenges to integrating primary and mental health care within an ACT setting. CONCLUSIONS: ACT needs to be adapted to incorporate promising practices designed to better integrate physical health care and mental health care.

Persons with severe mental illness have higher rates of chronic general medical illness compared with the general population. Similarly, compared with the general population, incarcerated persons have higher rates of chronic medical illness; however, there is little information about the synergy between severe mental illness and incarceration and the general medical problems of consumers. To address this gap in the literature this study addressed the following question: are consumers with a history of incarceration at greater risk of general medical problems compared with consumers without such a history?Administrative data were used to compare the medical problems of 3,690 persons with severe mental illness with a history of incarceration and 2,042 persons with severe mental illness with no such history.Consumers with a history of incarceration were more likely than those with no such history to have infectious, blood, and skin diseases and a history of injury. Furthermore, when analyses controlled for gender, race, age, and substance use disorders, consumers with an incarceration history were 40% more likely to have any general medical problem and 30% more likely to have multiple medical problems.The findings presented here call for better communication among local public health and mental health providers and jails and better integration of primary care and behavioral health care among community mental health providers. Also, research should be accelerated on evidence-based interventions designed to divert persons with severe mental illness from the criminal justice system and facilitate community reentry for persons with severe mental illness who are released from jails and prisons.

Objective: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. Methods: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). Results: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county’s mental health users and .06 percent of its adult population. Conclusions: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations. (Psychiatric Services 57:1803–1806, 2006)

Objective: This prospective cohort study in two large metropolitan jail systems examined whether Medicaid disenrollment policies for persons detained in jail were enforced. The extent to which persons with severe mental illness lost their Medicaid benefits while detained was determined. Methods: Mailed questionnaires to state Medicaid directors in 2000 yielded a 95 percent response rate. Directors responded to questions about procedures that are followed when enrollees become inmates in public institutions. In addition, community mental health service records, jail detention records, and Medicaid enrollment records were linked in King County (Seattle) and in Pinellas County (Clearwater and St. Petersburg), Florida, to identify persons with severe mental illness who were incarcerated at any time during a two-year period (1996–1998 in King County and 1998–2000 in Pinellas County). The samples consisted of 1,816 persons representing 4,482 detentions in King County and 1,210 persons representing 2,878 detentions in Pinellas County. Detentions were used as the unit of analysis to determine how often Medicaid disenrollment occurred during jail incarceration. Results: The stated policy in many states, including Florida and Washington, is to terminate Medicaid benefits upon incarceration, but termination occurred for only 3 percent of the detainees enrolled in Medicaid in each county. In both counties, in 97 percent of the detentions, persons who had Medicaid at entry also had it upon release. In both counties, the 3 percent who lost Medicaid while jailed had longer jail stays (three to five months compared with 16 to 30 days). Conclusions: Stated policies do not align with actual Medicaid disenrollment of persons with severe mental illness who become incarcerated. In most instances, short jail stays allowed detainees with severe mental illness to retain their Medicaid benefits. (Psychiatric Services 57:803–808, 2006)

Objectives To identify trends in compounding pharmacies with a focus on women's health and, more specifically, the types and combinations of medications used in the treatment of vulvodynia. Methods This survey study was conducted with 653 nonchain pharmacies that compound medications. Each pharmacy was asked to complete a 19-item online survey assessing general practice and common compounding indications, focusing on women's health. Results Of the 653 pharmacies contacted, 200 (31%) responded to our survey. Women's health issues ranked third (19%) among the common indications for compounding, preceded by otolaryngology (30%) and dermatology (28%). Of the medications compounded for women's health, the most common indication was bioidentical hormone therapy (73%) followed closely by vaginal dryness (70%) and low libido (65%). Vulvodynia, or vulvar pain, was the fourth most common indication for compounding medication for women's health issues (29%). Vulvovaginal infections were reported as an indication for compounding medications by 16% of respondents. Conclusions Vulvovaginal symptoms are a common indication for compounding medications in women's health. Further research in understanding the rationale for using compounded medications, even when standard treatments are available for some of these symptoms (eg, vaginal dryness, vulvovaginal infections), is warranted.

Results of a previous survey of 46 young adults with cancer led to the development of a professionally led support group to address their unique concerns. The intervention combined group therapy techniques with Psychoeducational strategies in six weekly sessions on the topics of anxiety about health and physical well-being, worry about fertility and raising children, problems in relationships, financial concerns, and body image. Pretest and posttests demonstrated significant improvement in the 14 participants' scores on a measure of psychological well-being but no changes in coping mechanisms or overall quality of life. Practice recommendations include expanding the group to eight sessions and providing less structure. Arguments in favor of time-limited group interventions for cancer patients are presented.

ObjectiveMore research is needed about forensic assertive community treatment (FACT) and challenges that offenders with severe mental illness present to jail diversion and prison reentry teams. Jail diversion and prison reentry populations may require different interventions and strategies to engage and serve them.MethodsThis study used data from a mental health agency in a large urban area in Ohio to compare the demographic and clinical characteristics of 212 consumers served by jail diversion FACT teams and 192 consumers served by prison reentry FACT teams.ResultsFindings suggest that jail diversion and prison reentry consumers have different demographic and clinical profiles, which may present unique challenges to FACT teams.ConclusionsPopulation- and gender-specific strategies and interventions could be warranted to better serve FACT consumers. This study furthers the literature about the needs of justice-involved consumers and offers important information for providers of FACT for jail diversion and ...

BACKGROUND:A number of states have implemented Assertive Community Treatment (ACT) teams statewide. The extent to which team-based care in ACT programs substitutes or complements primary care and other types of health services is relatively unknown outside of clinical trials. OBJECTIVE: To analyze whether investments in ACT yield savings in primary care and other outpatient health services. DESIGN: Patterns of medical and mental health service use and costs were examined using Medicaid claims files from 2000 to 2002 in North Carolina. Two-part models and negative binomial models compared individuals on ACT ( n = 1,065 distinct individuals) with two control groups of Medicaid enrollees with severe mental illness not receiving ACT services ( n = 1,426 and n = 41,717 distinct individuals). RESULTS: We found no evidence that ACT affected utilization of other outpatient health services or primary care; however, ACT was associated with a decrease in other outpatient health expenditures (excluding ACT) through a reduction in the intensity with which these services were used. Consistent with prior literature, ACT also decreased the likelihood of emergency room visits and inpatient psychiatric stays. CONCLUSIONS: Given the increasing emphasis and efforts toward integrating physical health and behavioral health care, it is likely that ACT will continue to be challenged to meet the physical health needs of its consumers. To improve primary care receipt, this may mean a departure from traditional staffing patterns (e.g., the addition of a primary care doctor and nurse) and expansion of the direct services ACT provides to incorporate physical health treatments.

There is an on-going concern that reductions in psychiatric inpatient bed capacity beyond a critical threshold will further exacerbate the incarceration of persons with mental illness. However, research to date to assess the proposed relationship between inpatient bed capacity and jail use has been limited in several ways. In addition, mechanisms through which changes in psychiatric bed capacity may affect jail use by persons with mental illness remain unexamined empirically.The aim of this study is to test whether changes in inpatient psychiatric resources, measured by per-capita psychiatric beds, inversely affect the likelihood of jail use by persons with severe mental illness. We also examine mechanisms that link psychiatric bed supply and jail detention.We analyze unique individual-level panel data on 41,236 adults in King County, Washington who were users of jails, the public mental health system, or the Medicaid program from 1993 to 1998. Using administrative records, we identify persons ever diagnosed with severe mental illness during the study period. Our analyses build upon a system of simultaneous equations that captures mechanisms from changes in psychiatric bed supply to jail detention. We estimate a reduced-form model and calculate the total effect of a shift in psychiatric bed supply on the likelihood of jail use by persons with severe mental illness. We also estimate a semi-reduced-form equation to examine whether changes in mental health and substance use mediate the relationship between bed supply and jail detention. We estimate linear probability models with person-level fixed effects to control for individual heterogeneity. Standard errors are adjusted for intra-cluster correlations. When an equation includes an endogenous variable, we calculate generalized method of moments estimators with instrumental variables.A decrease in the supply of psychiatric hospital beds is significantly associated with a greater probability of jail detention for minor charges among persons diagnosed with severe mental illness. Substance use appears to mediate this relationship.A reduction of inpatient psychiatric beds, ceteris paribus, is associated with an increase in jail detention among persons with severe mental illness via substance use problems. Further research should examine whether the magnitude of this relationship is greater for persons who have severe mental illness but are unable to obtain necessary treatment.This study further confirms an identified relationship between the supply of inpatient psychiatric beds, substance use and jail detention among persons with severe mental illness. These important relationships should be incorporated in the policy planning process, especially at the time of psychiatric inpatient bed reductions.

When first conceptualized, it was thought that individuals with severe mental illness who needed assertive community treatment (ACT) would need ACT for life. Today, ACT-for-life is contrary to recovery-based principles, and teams routinely transition consumers to less intensive services. However, there is little qualitative information about the experiences of consumers who transition from ACT. To address this gap in our knowledge, we conducted semi-structured interviews with 11 consumers who had transitioned from ACT to case management services. Consumers expressed feelings of loss and frustration about transitioning from ACT to case management services. Findings underscore the importance of facilitating open dialogue about transitions with consumers, managing consumers’ expectations of post-transition services, and facilitating consumer independence prior to transition. ACT teams should be deliberate about preparing consumers for transitions from ACT. More research is needed about facilitating successful transitions from ACT. [ Journal of Psychosocial Nursing and Mental Health Services, 51 (8), 39–45.]

Objective The evidence for forensic assertive community treatment (FACT) is promising; however, a number of gaps in our knowledge about FACT remain. For example, only one study in the extant literature includes the perspectives of FACT consumers and more information about what consumers like and/or dislike about FACT is needed. Methods To address this gap in our knowledge, semi-structured interviews were conducted with 14 FACT consumers from four FACT teams in Ohio. Interviews were audio recorded and transcribed and open coding analysis techniques were used to identify themes. Results Findings suggest most consumers have no complaints or dislikes about FACT and found housing assistance, access to mental health services, and access to medication and psychiatrists particularly helpful. Conclusions and implications for practice FACT consumers have profound needs and teams must be prepared to provide a wide array of intensive services, especially in early stages of intervention. Collaborations with local Housing First or other initiatives may be particularly important to facilitate consumer engagement and build therapeutic rapport. This study contributes to the growing literature on FACT; however, more research is needed about how FACT needs to be adapted to serve justice-involved consumers, the critical ingredients of FACT, and FACT's impact on psychiatric functioning and other outcomes.

Edited byMona M. Shattell, PhD, RN University of North Carolina at Greensboro, School of Nursing, Greensboro, North Carolina, USAPersons with severe mental illness have high rates of physical healt...

Objective: Emergency medical services transport and emergency department misuse among persons with behavioral health conditions is a concern. Administrative data were used to examine medical transports and hospital admissions among persons with behavioral health conditions. Methods: Data on 70,126 medical transports to emergency departments in three southeastern counties were analyzed. Results: Compared with general medical transports, fewer behavioral health transports resulted in a hospital admission. Among behavioral health transports, persons with schizophrenia were 2.62 times more likely than those with substance use disorders to be admitted, and persons with mood disorders were 4.36 times more likely than those with substance use disorders to be admitted. Also, among behavioral health transports, rural transports were less likely than more urban transports to result in a hospital admission. Conclusions: More training of emergency medical services personnel and more behavioral health crisis resources, especially targeting rural areas and substance use disorders, are needed. (Psychiatric Services 61:412–415, 2010)

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.

Despite the growing interest in forensic assertive community treatment (FACT), there is no standardized definition of FACT eligibility and no guidelines for how many FACT teams communities may need. In this brief report a definition for FACT eligibility is proposed—severe and persistent mental illness and three jail detentions in a one-year period— and modeled by using 5.5 years of administrative data (July 1, 1993, through December 31, 1998) from a large, urban county in the western United States. Findings suggest that large, urban communities should develop enough FACT teams to serve approximately 44% of their populations of persons with severe mental illness, or roughly .05% of their adult populations. Developing standardized eligibility criteria for FACT is an important first step toward developing its evidence base.

This study sought to determine whether having Medicaid benefits and receiving behavioral health services are associated with a reduction in recidivism for jail detainees with severe mental illness.A quasi-experimental design with linked administrative data was used. All persons released over a two-year period from jails in King County, Washington (N=5,189), and Pinellas County, Florida (N=2,419), who had severe mental illness were followed for 12 months after jail release. Those who were receiving Medicaid benefits at release and those who were not were compared on three indicators: how many subsequent arrests occurred, how soon the arrest occurred, and how serious the associated offense was. The data were analyzed with negative binomial, Cox proportional hazards models and logistic regression with adjustments for dependent observations.In both counties, having Medicaid at release was associated with a 16% reduction in the average number of subsequent detentions (p.001 and p.01, respectively). After the analysis controlled for demographic and clinical variables, more days on Medicaid were associated with a reduced number of subsequent detentions in King County (p.001) and more days in the community before subsequent arrest in both counties (p.01 and p.05, respectively). No association was found between Medicaid status and the seriousness of the subsequent offense in either county.Although Medicaid benefits and behavioral health services were associated with fewer rearrests and more time in the community, the observed differences were relatively small. Further research is needed to determine how greater reductions in jail recidivism can be achieved for this target population.

This paper presents an overview of Assertive Community Treatment (ACT) as an evidence-based practice in mental health care. We then consider current evidence for FACT (ACT for forensic populations) and FICM (intensive case management for forensic populations) and the ways these models have been extended and adapted to serve mentally ill persons in a variety of criminal justice settings. The available evidence about the effectiveness of these models towards preventing recidivism among criminally-justice involved persons with mental illness is weak. We conclude with several suggestions for how the clinical model of FACT needs to be expanded to incorporate interventions aimed at reducing criminal behavior and recidivism.

Researchers have raised concerns about the adequacy of the training and services for foster families in general and kinship families in particular. This study examines the training and services received by kinship and nonkinship family foster caregivers. The article compares kinship and nonkinship caregivers in terms of an array of training and services. The authors examine the demographic characteristics of these two groups and the problems of the foster children placed with them to better understand their needs. Consistent with previous research, levels of training and services received were inadequate for both groups. Contrary to previous research, few differences between kinship and nonkinship caregivers were found in training or services, in demographic characteristics, or in foster children's problems.