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

Objective: The study evaluated an intervention to help veterans with psychiatric disabilities, who face a unique set of challenges concerning money management.Methods: A randomized clinical trial was conducted of a brief (one to three hours) psychoeducational, recovery-oriented money management intervention called $teps for Achieving Financial Empowerment ($AFE).Results: Analyses revealed no main effects on outcomes of random assignment to $AFE (N=67) or a control condition consisting of usual care (N=77). Veterans who reported using $AFE skills showed significantly lower impulsive buying, more responsible spending, higher rates of engaging in vocational activities, and greater number of work hours compared with veterans in the control condition.Conclusions: Findings have clinical implications for case management services involving informal money management assistance. Offering veterans with psychiatric disabilities a one-time money management intervention is unlikely to lead to substantial changes. Results imply that efforts to improve psychosocial outcomes among veterans must not only teach but also increase use of money management skills. [ABSTRACT FROM AUTHOR]

Objective: Adults with serious mental illness have a relatively high risk of criminal justice involvement. Some risk factors for justice involvement are known, but the specific interaction of these risk factors has not been examined. This study explored the interaction of gender, substance use disorder, and psychiatric diagnosis among patients with schizophrenia or bipolar disorder to identify subgroups at higher risk of justice involvement. Methods^ Administrative service records of 25,133 adults with schizophrenia or bipolar disorder who were clients of Connecticut's public behavioral health system during 2005-2007 were merged with state records of criminal convictions, incarceration, and other measures of justice involvement. The main effects and the effects of interactions of gender, substance use disorder, and psychiatric diagnosis on risk of justice involvement ("offending") were estimated by using multivariable logistic regression. Results: Men with bipolar disorder and co-occurring substance use disorder had the highest absolute risk of offending in every category of justice involvement. For both men and women, bipolar disorder was associated with an increased risk of offending versus schizophrenia, but the increase was significandy greater for women. Substance use disorder also increased risk of offending more among women than men, especially among those widi schizophrenia. Conclusions: Men and women with bipolar disorder and substance use disorders have much higher risk of justice involvement than diose with schizophrenia, especially those without a substance use disorder. Research is needed to validate these effects in other populations and specify risk factors for justice involvement among adults with mental illness. [ABSTRACT FROM AUTHOR]

After nearly three decades of studies evaluating the legal practice of involuntary outpatient commitment, there is yet little consensus about its effectiveness and only limited implementation. Debate continues over how best to assist adults with serious mental illnesses who are unable or unwilling to participate in prescribed community treatment and as a result experience repeated involuntary hospitalizations or involvement with the criminal justice system. The authors comment on the Oxford Community Treatment Order Evaluation Trial (OCTET), a recently conducted randomized trial of outpatient commitment, and discuss the limitations of the study's design for resolving the persistent question of whether compulsory treatment is more effective than purely voluntary treatment for this difficult-to-reach target population. The authors conclude that the search for a definitive and generalizable randomized trial of outpatient commitment may be a quixotic quest; the field should, rather, welcome the results of well-conducted, large-scale, quasi-experimental and naturalistic studies with rigorous multivariable statistical controls. [ABSTRACT FROM AUTHOR]

The article focuses on the placing a patient on either an involuntary psychiatric hold or a form of guardianship or surrogate decision making is one of the most solemn duties of a mental health professional. Topics discussed include preempt a person's autonomy is a responsibility that clinicians must approach with great care; and the study examines the differences in state statutes that define default surrogate decision making for mental health treatment.

Objective: This study sought to describe the implementation of "Kendra's Law" in New York State and examine regional differences in the application of the program. Methods: Between February 2007 and April 2008, interviews were conducted with 50 key informants across New York State. Key informants included assisted outpatient treatment (AOT) county coordinators, county directors of community services, judges, attorneys from the Mental Hygiene Legal Service (MHLS), psychiatrists, treatment providers, peer advocates, family members, and other referred individuals. Additional analyses were conducted using AOT program administrative and evaluation databases and client history data. Results: From program inception in 1999 through 2007, a total of 8,752 initial AOT orders and 5,684 renewals were granted. Notable regional differences were found in the use of two distinct models of AOT: AOT First and Enhanced Voluntary Services First. Regional differences were also found in how the AOT program was implemented and administered. Other variations stemmed from the court proceedings themselves, the continuity and interest of the presiding judge, and the attitudes of the MHLS attorneys. Conclusions: Many regional adaptations of the AOT program were found. Many were the result of lack of guidance in implementing Kendra's Law. Policy makers may want to consider whether the law should change to allow for these differences or whether additional support from a central source is warranted to ensure more uniformity in the implementation of AOT and thus the fairness of its application across the state. [ABSTRACT FROM AUTHOR]

Psychiatric advance directives (PADs) are legal documents that allow individuals to express their wishes for future psychiatric care and to authorize a legally appointed proxy to make decisions on their behalf during incapacitating crises. PADs are viewed as an alternative to the coercive interventions that sometimes accompany mental health crises for people with mental illness. Insofar as coercive interventions can abridge clients' autonomy and self-determination--values supported by the NASW Code of Ethics--social workers have a vested interest in finding ways to reduce coercion and increase autonomy and self-determination in their practice. However, PADs are also viewed as having the potential to positively affect a variety of other clinical outcomes, including, but not limited to, treatment engagement, treatment satisfaction, and working alliance. This article reviews the clinical and legal history of PADs and empirical evidence for their implementation and effectiveness. Despite what should be an inherent interest in PADs and the fact that laws authorizing PADs have proliferated in the past decade, there is little theoretical or empirical research on PADS in the social work literature. [ABSTRACT FROM AUTHOR]

Objective: Demographic, behavioral, and diagnostic information should routinely be collected from clients with severe mental illness, and data gathering should employ the most efficient techniques available. Surveys are increasingly conducted via Web-based computer-assisted interviewing (CAI), but this technique is not well validated for patients with severe mental illness. A randomized clinical trial of 245 clients was carried out to compare face-to face and computer-assisted interviewing (233 clients completed two surveys). Methods: Self-report data were collected on demographic characteristics, substance abuse, risk behaviors for blood- borne diseases, trauma history, and posttraumatic stress disorder. Each client was assessed twice and randomly assigned to one of the four possible combinations of interviewer and computer (computer and computer, N=53; computer and interviewer, N=56; interviewer and computer, N=59; and interviewer and interviewer, N=65). The two formats were compared on feasibility, client preference, cost, reliability, convergent validity, and criterion validity. Results: This study demonstrated the feasibility of CAI across a variety of inpatient and outpatient settings. All participants who began the CAI process completed the interview and responded to over 95% of the survey items. Participants liked using the computers as well as they liked face-to-face interviews, and they completed the CAI as quickly. CAI produced data as reliable and valid as face-to-face interviews produced and was less expensive, and results were available more quickly. The two formats were similar in criterion validity. Conclusions: CAI appears to be a viable technology for gathering clinical data from the population with severe mental illness and for transforming such information into a useful, quickly accessible form to aid in clinical decision making. [ABSTRACT FROM AUTHOR]

The authors provide an overview of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sponsored by the National Institute of Mental Health. CATIE was designed to compare a proxy first-generation antipsychotic, perphenazine, to several newer drugs. In phase 1 of the trial, consenting patients were randomly assigned to receive olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone for up to 18 months on a double-blind basis. Patients with tardive dyskinesia were excluded from being randomly assigned to perphenazine and were assigned to one of the four second-generation antipsychotics in phase 1A. Clozapine was included in phase 2 of the study. Overall, olanzapine bad the longest time to discontinuation in phase 1, but it was associated with significant weight and metabolic concerns. Perphenazine was not significantly different in overall effectiveness, compared with quetiapine, risperidone, and ziprasidone. Also, perphenazine was found to be the most cost-effective drug. Clozapine was confirmed as the most effective drug for individuals with a poor symptom response to previous antipsychotic drug trials, although clozapine was also associated with troublesome adverse effects. There were no differences in neurocognitive or psychosocial functioning in response to medications. Subsequent randomizations suggest that a poor response to an initial medication may mean that a different medication will be more effective or better tolerated. Although the CATIE results are controversial, they are broadly consistent with most previous antipsychotic drug trials and meta-analyses; however, the results may not generalize well to patients at high risk of tardive dyskinesia. Patient characteristics and clinical circumstances affected drug effectiveness; these patient factors are important in making treatment choices. [ABSTRACT FROM AUTHOR]

Objective: Although the Social Security Administration frequently assigns family members to serve as representative payees for relatives with psychiatric disabilities, few studies have examined characteristics associated with these payee arrangements or the perceptions of the individuals involved in them. Methods: One hundred participants (50 dyads of consumers with psychiatric disabilities and their representative payees from their family) were interviewed for data on perceived benefits and problems of the payeeship, knowledge of payee guidelines, the consumer-payee relationship, arithmetic and money management skills, and payeeship characteristics. Results: Most consumers and payees believed that payeeship led to greater living stability; however, 36% of consumers and 50% of payees reported disagreement and conflict. Some consumers thought payeeship reduced their autonomy, although payees were less aware of this. Consumers and payees showed gaps in knowledge of payeeship, with only 28% correctly recognizing that payeeship did not last indefinitely. Both groups showed deficiencies in money management skills and basic arithmetic abilities; in these domains, there were no significant differences between payees and consumers. Risk of conflict was elevated when consumers had better money management skills and when payees had not completed high school. Conclusions: Although payeeship was beneficial, the data revealed potential problems in skills and knowledge about representative payeeship among consumers and payees. Efforts by policy makers and clinicians to increase collaboration between payees and consumers and to improve accurate knowledge of payeeship could help address its downsides. [ABSTRACT FROM AUTHOR]

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self-determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty-eight open-ended, semi-structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self-determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PAD to clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients. [ABSTRACT FROM AUTHOR]

Objective: Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives. Method: A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded. Results: Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed. Conclusions: The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings. [ABSTRACT FROM AUTHOR]

Background: Research has uncovered many characteristics related to violence committed by people with mental illness. However, relatively few studies have focused on understanding the connection between violence and dynamic, malleable variables such as a patient's level of treatment engagement.Aims: To explore the link between community violence and patients'beliefs about psychiatric treatment benefit.Method: A sample of 1011 adults receiving out-patient treatment for a psychiatric disorder in the public mental health systems of five US states were interviewed.Results: Bivariate analyses revealed community violence was inversely related to treatment adherence, perceived treatment need and perceived treatment effectiveness. Multivariate analyses showed these three variables were associated with reduced odds of violent and other aggressive acts.Conclusions: The results suggest clinical consideration of patients' perceptions of treatment benefit can help enhance violence risk assessment in psychiatric practice settings. [ABSTRACT FROM AUTHOR]

The article presents information on a study which examines the attitudes of mental health providers toward psychiatric advance directives. The study findings suggest that psychiatric advance directives include documenting advance instructions and designating health care agents. The study shows that clinicians' legal defensiveness is potentially important determinant of treatment decision making.

Limited research has examined patients' preferences for psychiatric advance directives (PADs). This study examines the preferences and interest in PADs among patients with severe mental illness. Participants in a randomized controlled trial of PAD facilitation versus usual care were interviewed about their preferences and interest in PADs. Preferences scores were estimated and compared among patients wishing to complete types of PADs. The large majority of participants indicating an interest in a PAD that included a healthcare power of attorney gave greatest importance to enabling surrogate decision making and continuity of care during crises, a minority who expressed interest in a stand-alone advance instruction for mental health treatment or no PAD at all gave highest priority to avoiding unwanted treatment. Persons with severe mental illness have diverse interests in PADs. Most patients give high priority to improving surrogate decision making and continuity of care with PADs. [ABSTRACT FROM AUTHOR]

The article examines the correlation of outpatient commitment and a number of related civil court mechanisms used to improve adherence to mental health treatment in the community in the U.S. Examination suggests that a history of civil court-ordered outpatient treatment was most common among persons with mental illness who came into contact with multiple mental health, social welfare and criminal justice agencies.

Although representative payeeship is prevalent among people with mental illness and shows promise to positively influence clinically relevant outcomes, research also suggests this legal mechanism could be implemented in ways that are problematic. The current study examined whether family representative payeeship was associated with elevated risk of family violence perpetrated by persons with severe mental illness (SMI). Data were collected every 4 months for 1 year in structured interviews with N = 245 persons with SMI who received disability benefits. Multivariate analyses showed that substance abuse, history of violence, frequency of family contact, and family representative payeeship were associated with elevated odds of family violence. Analyses also showed family contact and family representative payeeship had a cumulative effect on increasing the predicted probability of family violence (controlling for covariates such as violence history and substance abuse). The data shed light on the potential for family representative payeeship to be associated with increased risk of interpersonal conflict and violence in SMI. [ABSTRACT FROM AUTHOR]

Focuses on the benefits of psychiatric advance directives in holding promise of improving care during mental health crisis. Preferences regarding future mental health treatment in the event of a loss of capacity to make healthcare decisions; Variation of generic advance directives in their treatment of mental health decision-making; Details on the potential conflict between community standards of care and preferences stated in a PAD.

This study took preliminary steps to explore the relationship between involuntary outpatient commitment (OPC) and the risk of homelessness among individuals with severe mental disorders. Involuntarily hospitalized patients were randomly assigned to be released or maintained under OPC following hospital discharge. Multivariate analyses demonstrated that involuntary OPC was associated with a significant decrease in the risk of homelessness during the first 4 months following hospital discharge for participants with severe functional impairment at baseline. OPC did not appear to affect risk of homelessness among participants with mild-to-moderate functional impairment. Co-occurring substance abuse, treatment nonadherence, and outpatient services intensity were found to be strongly associated with episodes of homelessness. This study suggests that involuntary OPC may provide a short-term reduction in the risk of homelessness among a subgroup of treatment-reluctant individuals with severe mental disorders combined with severe functional impairment. [ABSTRACT FROM AUTHOR]

Objectives. This study examined the prevalence and correlates of violent behavior by individuals with severe mental illness. Methods. Participants (N = 802) were adults with psychotic or major mood disorders receiving inpatient or outpatient services in public mental health systems in 4 states. Results. The 1-year prevalence of serious assaultive behavior was 13%. Three variables--past violent victimization, violence in the surrounding environment, and substance abuse--showed a cumulative association with risk of violent behavior. Conclusions. Violence among individuals with severe mental illness is related to multiple variables with compounded effects over the life span. Interventions to reduce the risk of violence need to be targeted to specific subgroups with different clusters of problems related to violent behavior. (Am J Public Health. 2002;92:1523-1531) [ABSTRACT FROM AUTHOR]

Background: Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment.Aims: To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI.Method: One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected.Results: A significantly lower incidence of violent behaviour occurred in subjects with > or = 6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse.Conclusions: OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse. [ABSTRACT FROM AUTHOR]

The impact of criminal justice involvement and clinical characteristics on the cost of public treatment services for adults with serious mental illnesses is unknown. The authors examined differential effects of justice involvement on behavioral health treatment costs by primary psychiatric diagnosis (schizophrenia or bipolar disorder) and also by substance use diagnosis among 25,133 adult clients of Connecticut's public behavioral health system in fiscal years 2006 and 2007. Justice-involved adults with schizophrenia had the highest costs, strongly driven by forensic hospitalizations. Addressing the cross-system burdens of forensic hospitalizations may be a sensible starting point in the effort to reduce costs in both the public behavioral health and justice systems. [ABSTRACT FROM AUTHOR]

Objective: Clinicians have raised concerns that psychiatric advance directives may be used to refuse all treatment. However, people writing psychiatric advance directives can explicitly state their reasoning underlying treatment decisions. This study examined whether patients' reasons for re- fusing treatment influenced clinician decision making about implementing psychiatric advance directives. Methods: A total of 597 mental health professionals completed a questionnaire that presented two scenarios: one in which the patient wrote a psychiatric advance directive refusing all medication because of paranoid delusions and one in which the patient wrote a psychiatric advance directive refusing all medication because of concerns about side effects. Results: Twenty-two percent of clinicians reported that they would respect the former psychiatric advance directive, whereas 72% reported that they would respect the latter. After multivariate regression was used, the reason for treatment refusal remained the single significant predictor of clinicians' decision to honor a patient's psychiatric advance directive. Conclusions: Results show reasons for treatment refusal in psychiatric advance directives are likely to affect clinicians' decisions to implement the directives. [ABSTRACT FROM AUTHOR]

Involuntary psychiatric treatment is sometimes necessary and beneficial, but may also exert negative effects. The impact of involuntary commitment on subsequent mental health treatment experience is poorly understood. We examined whether history of involuntary commitment was associated with current perceptions of coercion in a sample of voluntarily hospitalized veterans (N = 205). In adjusted analyses, perceived coercion during the voluntary admission was significantly associated with prior history of involuntary commitment (Rate Ratio = 1.60, p = .05). Perceived coercion was also higher among participants who were married/cohabiting (Rate Ratio = 1.83, p = .01) and among those with greater functional impairment (Rate Ratio = 0.97, p = .04). Although frequently unavoidable, the current results underscore the potential negative effects of coercive practices such as involuntary commitment, and support the importance of policies that aim to minimize coercive treatment experiences among psychiatric patients. [ABSTRACT FROM AUTHOR]

Abstract: Objective: There were two aims: first, to examine the relationship between prior sexual abuse and three types of adult risky sexual behaviors [(1) ever traded sex for drugs or money, (2) had unprotected sex in the past 6 months, and (3) frequency of unprotected sex in the past 6 months] among persons with severe mental illness (SMI), and second, to examine the potential mediating effects of adult rape, substance use, and PTSD. Method: Using a pooled sample of individuals with SMI (N =609), logistic and negative binomial regression analyses were used to investigate the impact of prior sexual abuse on these adult risky sexual behaviors. Results: Childhood sexual abuse was associated with having ever traded sex for money and having engaged in unprotected sex in the past 6 months. However, childhood sexual abuse was inversely associated with the number of times males had unprotected sex in the past 6 months. Results differed between males and females and the impact of potential mediators also varied by gender and type of outcome studied. Conclusion: These findings suggest a complex link between childhood sexual abuse and adult risky sexual behaviors in persons with SMI. Clinical assessments of child abuse sequelae should include a variety of indicators and parameters of adult risky sexual behavior, as persons with SMI are at an increased risk of engaging in high-risk sexual behaviors and tend to have a higher exposure to childhood sexual abuse than does the general population. [Copyright &y& Elsevier]

Objectives: Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes. Methods: A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina. Results: Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness. Conclusions: In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HI V/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed. [ABSTRACT FROM AUTHOR]