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Objective: Involuntary outpatient commitment (OPC)-also referred to as 'assisted outpatient treatment' or 'community treatment orders'-are civil court orders whereby persons with serious mental illness and repeated hospitalisations are ordered to adhere to community-based treatment. Increasingly, in the United States, OPC is promoted to policy makers as a means to prevent violence committed by persons with mental illness. This article reviews the background and context for promotion of OPC for violence prevention and the empirical evidence for the use of OPC for this goal., Method: Relevant publications were identified for review in PubMed, Ovid Medline, PsycINFO, personal communications, and relevant Internet searches of advocacy and policy-related publications., Results: Most research on OPC has focussed on outcomes such as community functioning and hospital recidivism and not on interpersonal violence. As a result, research on violence towards others has been limited but suggests that low-level acts of interpersonal violence such as minor, noninjurious altercations without weapon use and arrests can be reduced by OPC, but there is no evidence that OPC can reduce major acts of violence resulting in injury or weapon use. The impact of OPC on major violence, including mass shootings, is difficult to assess because of their low base rates., Conclusions: Effective implementation of OPC, when combined with intensive community services and applied for an adequate duration to take effect, can improve treatment adherence and related outcomes, but its promise as an effective means to reduce serious acts of violence is unknown., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Prior research suggests considerable overlap of violence perpetration and victimization among adults with mental illnesses. However, there has been no examination of how the likelihood of being a victim and/or perpetrator of violence may change over time, nor consideration of clinically-relevant factors affecting these transitions. In a pooled sample of adults with mental illnesses (N=3,473) we employed latent transition analysis to: (a) determine prevalence of four violence and victimization classifications (i.e., non-victim/non-perpetrator, victim only, perpetrator only, and victim-perpetrator) over a 6-month period; (b) calculate the likelihood that adults with mental illnesses will remain in or transition between these classifications over time; and (c) assess the effects of recent substance use, psychiatric symptoms, and suicidal behaviors on transitions over time. At each time point, the majority of participants identified as non-victim/non-perpetrators, followed by victim-perpetrators, victims only, and perpetrators only. Analyses also revealed many individuals transitioned between classifications over time. These distinct pathways towards, and away from, violent outcomes were, in part, a function of recent violence and/or victimization, as well as substance use, psychiatric symptoms, and suicidal behaviors. Findings inform the identification of adults with mental illnesses at risk of violence and victimization and highlight points of intervention., Competing Interests: None, (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study examined the role of static indicators and proximal, clinically relevant indicators in the prediction of short-term community violence in a large, heterogeneous sample of adults with mental illnesses., Methods: Data were pooled from five studies of adults with mental illnesses (N=4,484). Follow-up data were available for 2,579 participants. A hierarchical linear regression assessed the incremental validity of a series of variable clusters in the prediction of violence risk at six months: static characteristics (age, sex, race-ethnicity, and primary diagnosis), substance use (alcohol use and drug use at baseline), clinical functioning (psychiatric symptoms at baseline and recent hospitalization), recent violence, and recent victimization., Results: Results demonstrated improved prediction with each step of the model, indicating that proximal indicators contributed to the prediction of short-term community violence above and beyond static characteristics. When all variables were entered, current alcohol use, recent violence, and recent victimization were positive predictors of subsequent violence, even after the analysis controlled for participant characteristics., Conclusions: This study provides empirical evidence for three proximal, clinically relevant indicators in the assessment and management of short-term violence risk among adults with mental illnesses: current alcohol use, recent violence, and recent victimization. Consideration of these indicators in clinical practice may assist in the identification of adults with mental illnesses who are at heightened risk of short-term community violence.

Gun violence kills about ninety people every day in the United States, a toll measured in wasted and ruined lives and with an annual economic price tag exceeding $200 billion. Some policy makers suggest that reforming mental health care systems and improving point-of-purchase background checks to keep guns from mentally disturbed people will address the problem. Epidemiological research shows that serious mental illness contributes little to the risk of interpersonal violence but is a strong factor in suicide, which accounts for most firearm fatalities. Meanwhile, the effectiveness of gun restrictions focused on mental illness remains poorly understood. This article examines gun-related suicide and violent crime in people with serious mental illnesses, and whether legal restrictions on firearm sales to people with a history of mental health adjudication are effective in preventing gun violence. Among the study population in two large Florida counties, we found that 62 percent of violent gun crime arrests and 28 percent of gun suicides involved individuals not legally permitted to have a gun at the time. Suggested policy reforms include enacting risk-based gun removal laws and prohibiting guns from people involuntarily detained in short-term psychiatric hospitalizations., (Project HOPE—The People-to-People Health Foundation, Inc.)

Analyses from the National Comorbidity Study Replication provide the first nationally representative estimates of the co-occurrence of impulsive angry behavior and possessing or carrying a gun among adults with and without certain mental disorders and demographic characteristics. The study found that a large number of individuals in the United States self-report patterns of impulsive angry behavior and also possess firearms at home (8.9%) or carry guns outside the home (1.5%). These data document associations of numerous common mental disorders and combinations of angry behavior with gun access. Because only a small proportion of persons with this risky combination have ever been involuntarily hospitalized for a mental health problem, most will not be subject to existing mental health-related legal restrictions on firearms resulting from a history of involuntary commitment. Excluding a large proportion of the general population from gun possession is also not likely to be feasible. Behavioral risk-based approaches to firearms restriction, such as expanding the definition of gun-prohibited persons to include those with violent misdemeanor convictions and multiple DUI convictions, could be a more effective public health policy to prevent gun violence in the population., Competing Interests: None of the other authors has any potential conflicts to report., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objectives: In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes., Methods: Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants., Results: Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization., Conclusions: Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.

Background: Violence is an uncommon but significant problem associated with schizophrenia., Aims: To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence., Method: Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication., Results: Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence., Conclusions: Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

Violence in schizophrenia patients may result from many factors besides the symptoms of schizophrenia. This study examined the relationship between childhood antisocial behavior and adult violence using data from the NIMH CATIE study. The prevalence of violence was higher among patients with a history of childhood conduct problems than among those without this history (28.2% vs. 14.6%; P < 0.001). In the conduct-problems group, violence was associated with current substance use at levels below diagnostic criteria. Positive psychotic symptoms were linked to violence only in the group without conduct problems. Findings suggest that violence among adults with schizophrenia may follow at least two distinct pathways-one associated with premorbid conditions, including antisocial conduct, and another associated with the acute psychopathology of schizophrenia.

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.

Objective: This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment., Method: Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics., Results: Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage., Conclusions: A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

Context: Violent behavior is uncommon, yet problematic, among schizophrenia patients. The complex effects of clinical, interpersonal, and social-environmental risk factors for violence in this population are poorly understood., Objective: To examine the prevalence and correlates of violence among schizophrenia patients living in the community by developing multivariable statistical models to assess the net effects of psychotic symptoms and other risk factors for minor and serious violence., Design: A total of 1410 schizophrenia patients were clinically assessed and interviewed about violent behavior in the past 6 months. Data comprise baseline assessments of patients enrolled in the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness., Setting and Patients: Adult patients diagnosed as having schizophrenia were enrolled from 56 sites in the United States, including academic medical centers and community providers., Main Outcome Measures: Violence was classified at 2 severity levels: minor violence, corresponding to simple assault without injury or weapon use; and serious violence, corresponding to assault resulting in injury or involving use of a lethal weapon, threat with a lethal weapon in hand, or sexual assault. A composite measure of any violence was also analyzed., Results: The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. "Positive" psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while "negative" psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization., Conclusions: Particular clusters of symptoms may increase or decrease violence risk in schizophrenia patients. Violence risk assessment and management in community-based treatment should focus on combinations of clinical and nonclinical risk factors.

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.

Objective: This study prospectively examined the effectiveness of treatment with olanzapine versus risperidone in reducing violent behavior among patients with schizophrenia under "usual care" conditions in the community., Method: Participants were 124 adults with DSM-IV-diagnosed schizophrenia-spectrum disorders receiving services in public-sector mental health systems in North Carolina. After enrollment (1997-1999), subjects were followed for 3 years in an observational study with interviews at 6-month intervals to assess treatment, clinical outcomes, and violent behavior. Rates of violence were compared over time between periods of first switch to olanzapine or risperidone and periods following at least 1 year of treatment with each of these medications., Results: The study found that remaining on olanzapine for 1 year or more significantly lowered violence risk compared to first switch period, but no significant change in violence risk was found for subjects remaining on risperidone for 1 year or more. These results were obtained using multivariable time-series analysis controlling for salient demographic and clinical covariates., Conclusion: This study found that, in the complex "real world" settings where persons with schizophrenia reside, long-term treatment with olanzapine confers some advantage over risperidone in reducing violence risk. This advantage appears to be at least in part an indirect effect, via improvement in adherence with treatment. Specifically, adherence with prescribed medication was found to mediate the association between olanzapine treatment and reduced violent behavior.

This study prospectively compared the effectiveness of atypical antipsychotic medications to that of conventional neuroleptics in reducing violent behavior among patients with schizophrenia under "usual care" conditions in the community. Participants (n = 229) were adults with schizophrenia spectrum disorders receiving inpatient or outpatient services in public sector mental health systems in North Carolina. Subjects were followed for 2 years in an observational study using multiple methods of data collection at 6-month intervals to assess treatment, sociodemographic characteristics, clinical features, and violence outcomes. Treatment with atypical antipsychotic medications (clozapine, risperidone, or olanzapine) was found to significantly reduce the risk of violent behavior, whereas treatment with conventional neuroleptics did not have this same beneficial effect. A cumulative effect on reduced violence was attributable to consistent compliance with atypical antipsychotic medications over a 2-year period. Concurrent reductions in psychotic symptoms, substance abuse, and adverse medication side effects were found to mediate the association between adherence with atypicals and lower violence risk. Treatment with atypical antipsychotic medications should be considered as an important component of violence risk management for schizophrenia patients at risk for violent behavior.

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.

Objective: The authors' goal was to evaluate the effectiveness of outpatient commitment in reducing victimization among people with severe mental illness., Method: One hundred eighty-four involuntarily hospitalized patients were randomly assigned to be released (N=99) or to continue under outpatient commitment (N=85) after hospital discharge. An additional group of patients with a recent history of serious violent behavior (N=39) was nonrandomly assigned to at least a brief period of outpatient commitment following hospital disharge. All three groups were followed for 1 year, and case management services plus additional outpatient treatment were provided to all subjects. Outcome data were based on interviews with the patients and informants as well as service records., Results: Subjects who were ordered to outpatient commitment were less likely to be criminally victimized than those who were released without outpatient commitment. Multivariate analysis indicated that each additional day of outpatient commitment reduced the risk of criminal victimization and that outpatient commitment had its effect through improved medication adherence, reduced substance use or abuse, and fewer violent incidents., Conclusions: Protection from criminal victimization appears to be a positive, unintended consequence of outpatient commitment.

One clinical strategy for managing risk of arrest and violence among people with severe mental illness (SMI) involves targeting potentially treatable factors related to these risks. The current study examines the association between individuals’ perceived need for psychiatric treatment and their risk of arrest and violence among people with SMI. Adults meeting criteria for psychotic and affective disorders receiving public mental health services in four states are interviewed (N = 907), with 26% reporting being arrested or violent in the past year. Participants in this group are more likely to deny needing psychiatric treatment. Multivariate analyses confirm this pattern for participants both arrested and violent, controlling for clinical and demographic covariates. As a result, clinical interventions that address a patient’s perceived need for psychiatric treatment, such as compliance therapy and motivational interviewing, appear to hold promise as risk management strategies for clinicians providing services for individuals with SMI. [ABSTRACT FROM PUBLISHER]

This study compared four stakeholder groups regarding the presence of stigmatizing attitudes toward a hypothetical person diagnosed with schizophrenia. Participants included consumers with schizophrenia (n 104), family members of those with schizophrenia or other severe mental illness (n = 83), mental health clinicians (n = 85), and members of the general public (n = 59); all participants resided in North Carolina. The purpose of the analyses was to investigate whether mental health stakeholder groups differed from the general public and from each other in terms of key attitudes associated with stigmatization of persons with schizophrenia, that is, perceived likelihood of violent behavior, the desire for social distance, and the causes of the illness. Analysis of variance results with follow-up Scheffé tests indicated no statistically significant differences between the mental health stakeholder groups and members of the general public in the likelihood of violence or the desire for social distance. However, there was more variation between both the mental health stakeholder groups and the general public and within the mental health stakeholder groups in the perceptions of the causes of the mental illness. Throughout the analyses, the consumers tended to have the most negative views of the illness. Implications for future stigma research and education are discussed. [ABSTRACT FROM AUTHOR]

Recent evidence suggests that involuntary outpatient commitment (OPC), when appropriately applied, can improve adherence with psychiatric treatment, decrease hospital recidivism and arrests, and lower the risk of violent behavior in persons with severe mental illness. Presumably these are benefits that improve quality of life (QOL); however, insofar as OPC involves legal coercion, the undesirable aspects of OPC could also exert a negative effect on quality of life, thus offsetting clinical benefits. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment in the community after hospital discharge, and were followed for one year. Quality of life was measured at baseline and 12 months follow-up. Treatment characteristics and clinical outcomes were also measured. Subjects who underwent longer periods of outpatient commitment had significantly greater quality of life as measured at the end of the 1 year study. Multivariable analysis showed that the effect of OPC on QOL was mediated by greater treatment adherence and lower symptom scores. However, perceived coercion moderated the effect of OPC on QOL. Involuntary outpatient commitment, when sustained over time, indirectly exerts a positive effect on subjective quality of life for persons with SMI, at least in part by improving treatment adherence and lowering symptomatology. Copyright © 2003 John Wiley & Sons, Ltd. [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]