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The disproportionately high percentage of adults with serious mental illnesses in correctional facilities is well documented. For decades, mental health officials, family members, and people with mental illnesses have implored local, state, and federal government officials to invest in community-based mental health services as a way to address this phenomenon. This chapter explores why it is that so many adults with mental illness are arrested and incarcerated, what is different about this problem today than years ago, how much recent progress has been realized, and what challenges must be addressed in the years ahead to make fundamental change. The chapter ends with a description of promising national initiatives that build on the accomplishments to date with the express purpose of reducing the number of adults with serious mental illnesses under correctional supervision.

Across the United States, a disproportionate number of individuals with behavioural health disorders (mental, substance-use, or co-occurring disorders) are under correctional supervision. This creates challenges for corrections systems that must juggle the multiple responsibilities of confinement, rehabilitation, treatment, and supervision. Correctional administrators and behavioural health administrators who work with the same populations have different goals that may lead to conflicting priorities and decisions: correctional administrators’ primary goal is to ensure public safety, whereas behavioural health administrators’ primary goals are treatment and recovery. While some efforts have been made to collaborate and coordinate between the two groups, little consensus exists between the two communities on how to serve their shared population. This chapter presents a shared framework for both groups for reducing recidivism and the prevalence of behavioural health disorders among individuals under correctional control or supervision, while also optimizing the best use of their limited resources.

The authors analyzed validation data from the Brief Jail Mental Health Screen (BJMHS) to determine whether race predicted screening results and if such a prediction was driven by particular screen items. A total of 22,000 individuals entering five jails over two 8-month periods were screened. The authors constructed binary logistic regression models to assess the impact of race on screening positive and endorsing particular items. Blacks and Latinos had lower odds than Whites of screening positive. Blacks and Latinos had somewhat lower odds than Whites of endorsing two or more symptom items but had appreciably lower odds of endorsing items regarding prior mental health service utilization. Racial differences in BJMHS screening results likely reflect the reproduction of racial disparities rather than valid differences because results were driven by items reflecting known barriers in access to mental health services. Nonetheless, the instrument is likely to remain an improvement over typical jail screening procedures.

There is an overrepresentation of persons with co-occurring disorders (COD) involved in the criminal justice system. The provision of integrated services to persons with COD has been identified as an evidence-based practice (EBP), and data suggests that positive public safety and health outcomes for justice involved persons with COD are associated with integrated program models as well. Sadly, in real world settings the vast majority of persons with COD, including those with histories of justice involvement, do not have access to integrated care. This paper will review the research associated with integrated treatment, highlight efforts to adapt integrated treatment for justice involved persons with COD, and describe efforts along a justice continuum to identify and link these persons to integrated treatment.

By the end of 2003, 3.2% of the U.S. adult population or 6.9 million adults were incarcerated, on probation or on parole. While non-whites constitute approximately 25% of the general U.S. population, they represent the majority of the prison (62%) and jail population (57%), a 33% increase since 1980. Approximately 15% of this prison and jail population has active symptoms of serious mental illness with two-thirds likely to have a co-occurring substance use disorder diagnosis. Meanwhile, the lack of adequate mental health and substance abuse treatment within all levels of the criminal justice system continues to exist. This is further exaggerated by the dearth of evidence showing appropriate cultural awareness and competence in delivery of these much needed services to a majority non-white population. This article will review the existing racial disparities present in the criminal justice system, the lack of appropriate psychiatric services, and the effect of cultural dissonance in service provision when services do exist. Policy implications and recommendations are included in the conclusion with a call for action to all agencies directly and indirectly affected by this multifaceted problem.

(2005). The Substance Abuse and Mental Health Services Administration's Co-Occurring Center for Excellence (COCE) Journal of Dual Diagnosis: Vol. 1, No. 2, pp. 107-112.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.

OBJECTIVES: The authors sought to better understand the relationship of substance abuse to higher rates of transmission of hepatitis C among persons with severe mental illness. METHODS: The authors assessed 668 persons with severe mental illness for HIV, hepatitis B, and hepatitis C infection through venipuncture. Demographic characteristics, substance abuse, and risk behaviors for blood-borne infections were assessed through interviews and collection of clinical data. RESULTS: Eighty-two percent of the assessed persons were not infected, and 18 percent had hepatitis C. Among those with hepatitis C infection, 546 (82 percent) tested negative for all viruses. Of the 122 (18 percent) who had hepatitis C, 53 (8 percent) had only hepatitis C, 56 (8 percent) had both hepatitis C and hepatitis B, three (1 percent) had hepatitis C and HIV, and ten (2 percent) had all three infections. More than 20 percent of the sample reported lifetime intravenous drug use, and 14 percent reported lifetime needle sharing. Fifty...

This article outlines the history and rationale of a multisite study of blood-borne infections among persons with severe mental illness reported in this special section of Psychiatric Services. The general problem of blood-borne diseases in the United States is reviewed, particularly as it affects people with severe mental illness and those with comorbid substance use disorders. The epidemiology and natural history of three of the most important infections are reviewed: the human immunodeficiency virus (HIV), the hepatitis B virus, and the hepatitis C virus. Current knowledge about blood-borne diseases among people with severe mental illness as well as information on current treatment advances for hepatitis C are summarized. A heuristic model, based on the pragmatic, empirical, and conceptual issues that influenced the final study design, is presented. The specific rationale of the five-site collaborative design is discussed, as well as the sampling frames, measures, and procedures used at the participating sites. Alternative strategies for analyzing data deriving from multisite studies that use nonrandomized designs are described and compared. Finally, each of the articles in this special section is briefly outlined, with reference to the overall hypotheses of the studies.

OBJECTIVE: An estimated 19.6 percent of persons with severe mental illness are infected with the hepatitis C virus. Given the pressing need to identify and treat persons with severe mental illness who are at risk of hepatitis C infection and transmission, the authors sought to estimate the proportion of hepatitis C-positive and -negative persons with severe mental illness who have a regular source of medical care. METHODS: Data for this study were obtained from 777 adults with severe mental illness at four diverse geographic sites at which respondents with severe mental illness participated in a structured interview and laboratory testing for HIV infection, AIDS, hepatitis B infection, and hepatitis C infection. RESULTS: In bivariate analyses, 54.2 percent of hepatitis C-positive and 62.5 percent of hepatitis C-negative study participants with severe mental illness had a regular source of medical care. In multivariate analyses in which potential confounders were statistically controlled for, hepatitis C-p...

OBJECTIVES: The authors assessed gender differences in hepatitis C infection and associated risk behaviors among persons with severe mental illness. METHODS: The sample consisted of 777 patients (251 women and 526 men) from four sites. RESULTS: Across sites, the rate of hepatitis C infection among men was nearly twice that among women. Clear differences were noted in hepatitis C risk behaviors. Men had higher rates of lifetime drug-related risk behaviors: needle use (23.1 percent compared with 12.5 percent), needle sharing (17.6 percent compared with 7.7 percent), and crack cocaine use (45.2 percent compared with 30.8 percent). Women had significantly higher rates of lifetime sexual risk behaviors: unprotected sex in exchange for drugs (17.8 percent compared with 11.2 percent), unprotected sex in exchange for money or gifts (30.6 percent compared with 17 percent), unprotected vaginal sex (94 percent compared with 89.7 percent), and anal sex (33.7 percent compared with 22.6 percent). Gender appeared to mod...

OBJECTIVE: Previous reports have indicated that persons with severe mental illness have an elevated risk of contracting HIV, hepatitis B, and hepatitis C compared with the general population. This study extends earlier findings by examining the factors that are most predictive of serologic status among persons with severe mental illness. METHODS: A total of 969 persons with severe mental illness from five sites in four states were approached to take part in an assessment involving testing for blood-borne infections and a one-time standardized interview containing questions about sociodemographic characteristics, substance use, risk behaviors for sexually transmitted diseases, history of sexually transmitted diseases, and health care. RESULTS: The greater the number of risk behaviors, the greater was the likelihood of infection, both for persons in more rural locations (New Hampshire and North Carolina), where the prevalence of infection was lower, and those in urban locations (Hartford, Connecticut; Bridg...

Almost all jail inmates with mental illness will leave correctional settings and return to the community. Inadequate transition planning puts jail inmates who entered the jail in a state of crisis back on the streets in the middle of the same crisis. The outcomes of inadequate transition planning include the compromise of public safety, an increased incidence of psychiatric symptoms, hospitalization, relapse to substance abuse, suicide, homelessness, and rearrest. Although there are no outcomes studies to guide evidence-based transition-planning practices, there is enough guidance from the multisite studies of the organization of jail mental health programs to create a best practice model. This article presents one such model.

We compared the patterns of substance use among patients with severe mental illness (SMI) served by three community treatment teams, substance users with non-severe mental illness (NSMI), and substance abusers without mental illness (no mental illness: NMI). There were highly significant differences in substance use patterns among the groups: among patients with SMI, the order of drug preference was alcohol, cocaine, cannabis, and then heroin; in the NMI group, it was cocaine, alcohol, heroin, and then cannabis; while in the NSMI group, it was alcohol, cocaine, heroin, and then cannabis. The data suggest that the choice of drugs by individuals with SMI may be determined by factors related to their illness, in addition to the price and availability of the particular drug.

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.

The problem of violence against individuals with severe mental illness (SMI) has received relatively, little notice, despite several studies suggesting an exceptionally high prevalence of victimization in this population. This paper describes the results of an investigation of the prevalence and correlates of past year physical and sexual assault among a large sample of women and men with SMI drawn from inpatient and outpatient settings across 4 states. Results confirmed preliminary findings of a high prevalence of victimization in this population (with sexual abuse more prevalent for women and physical abuse more prevalent for men), and indicated the existence of a range of correlates of recent victimization, including demographic factors and living circumstances, history of childhood abuse, and psychiatric illness severity and substance abuse. The research and clinical implications of these findings are discussed.

We examined the prevalence and correlates of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) risk behaviors in a large sample of severely mentally ill (SMI) patients. Risk levels were correlated with demographic factors, diagnosis, symptom severity, trauma history, post-traumatic stress disorder (PTSD), substance use disorder (SUD), and sexual orientation. SMI clients from urban and rural settings (N = 275) were assessed regarding HIV/AIDS risk behaviors, and hypothesized risk factors. Patients exhibited substantial levels of risky behavior, particularly sexual risk. Correlates of increased risk included SUD, trauma, male homosexual orientation, younger age, and symptom severity. Structural equation modeling identified SUD and sexual orientation as the primary determinants of both drug and sexual risk behavior. We conclude that specific illness related variables appear to have less impact on risk behavior among people with SMI than previously hypothesized. Substance abuse prevention and treatment may be the most effective means of reducing HIV risk in this population.

OBJECTIVES: This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness. METHODS: Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina. RESULTS: The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively. CONCLUSIONS: Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.

M has embarked on its own version of mental health system reform using the section 1115 Medicaid waiver to change its historic approach to providing, purchasing, and managing care. The article by Dr. Oliver (page 735) outlines the conceptual approach selected. The Maryland General Assembly voted for this plan with broad support from the mental health advocacy community. As the director of an urban comprehensive mental health service system, I offer a provider’s perspective on Maryland’s mental health plan and its implementation and raise questions relevant for future reform efforts. Well into the first year of the new system, the Mental Hygiene Administration has not clarified many details of the plan, and the leaders of the administrative service organization openly acknowledge that they were not adequately prepared for the transition. The reform’s ultimate impact remains the subject of intense speculation.

Homelessness is a far too common outcome for persons with dual diagnoses. This chapter discusses existing housing barriers and suggests housing, treatment, and support services responsive to population need.

Persons with mental illnesses are vastly overrepresented in the criminal justice system—from arrest to reentry from jails and prisons. Researchers have documented serious mental illnesses in 14.5% of male jail inmates and 31% of female jail inmates (Steadman et al. 2009); rates in excess of 3–6 times those found in the general population (Kessler et al. 1996). Generalized to the findings that over 13 million jail admissions were reported in 2009 (Minton 2010), this implies that over two million bookings of a person with a serious mental illness occur annually. The presence of so many people with mental illnesses in criminal justice settings represent an enormous burden on federal and state corrections and behavioral health systems of care, our communities, families, and those with mental illnesses. There are multiple factors that contribute to this phenomenon, but none that can justify the tragic circumstance of imprisoning someone when effective treatment options are possible alternatives.

Objective: This study estimated current prevalence rates of serious mental illness among adult male and female inmates in five jails during two time periods (four jails in each period). Methods: During two data collection phases (2002–2003 and 2005–2006), recently admitted inmates at two jails in Maryland and three jails in New York were selected to receive the Structured Clinical Interview for DSM-IV (SCID). Selection was based on systematic sampling of data from a brief screen for symptoms of mental illness that was used at admission for all inmates. The SCID was administered to a total of 822 inmates—358 during phase I and 464 during phase II. To determine the current (past-month) prevalence of serious mental illness (defined as major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder; delusional disorder; and psychotic disorder not otherwise specified), interview data were weighted against strata constructed from the screening samples for male and female inmates by jail and study phase. Results: Across jails and study phases the rate of current serious mental illness for male inmates was 14.5% (asymmetric 95% confidence interval [CI]=11.0%–18.9%) and for female inmates it was 31.0% (asymmetric CI=21.7%–42.1%). Conclusions: The estimates in this study have profound implications in terms of resource allocation for treatment in jails and in community-based settings for individuals with mental illness who are involved in the justice system. Psychiatric Services 60:761–765, 2009)

Comorbid alcohol use disorders are common in schizophrenia. Although a variety of explanatory hypotheses involving self-medication have been proposed, few data available regarding schizophrenic patients' subjective experiences while using alcohol. We report interview data from 75 DSM-III-R schizophrenic outpatients regarding their subjective responses to alcohol. Over half of our sample reported that alcohol improved social anxiety, tension, dysphoria, apathy, anhedonia, and sleep difficulties. Other nonpsychotic experiences were frequently improved as well. In contrast, no more than 15% of subjects reported that alcohol relieved any specific psychotic symptom; similar proportions of subjects reported that alcohol aggravated psychotic symptoms. Reporting that alcohol had a positive effect on nonpsychotic experiences was associated with having lifetime alcohol use disorders. Reporting that alcohol relieved psychotic symptoms was associated both with having lifetime alcohol use disorders and with the number of psychotic symptoms reported. We discuss the implications of these findings for understanding alcohol abuse and dependence among schizophrenics.

New Hampshire's specialized dual diagnosis services include continuous treatment teams and substance abuse treatment groups within each mental health center. These services are embedded in an extensive system of care for the dually diagnosed.

This paper reviews recent research on the physical and mental health status of homeless single adults and briefly summarizes definitional, sampling, and measurement problems. It presents findings from research examining the physical health status of homeless adults; the data suggest that homelessness places people at greater risk for specific health problems and also complicates treatment. The authors then review findings on the mental health status of homeless adults from several methodologically rigorous studies that carefully define and measure mental illness among the homeless population. The final section discusses what is known about the short‐ and long‐term service needs of the physically and mentally disabled homeless population. The studies reviewed suggest that individuals with chronic physical or severe mental illnesses are more vulnerable than others to homelessness. Homelessness exacerbates physical and/or mental conditions and complicates their treatment. Despite myths to the contra...

No studies have reported HIV risk behavior in rural populations with severe mental illness. A total of 84 rural patients with severe mental illness in New Hampshire and 158 urban patients in Baltimore were interviewed about their HIV risk behavior in the past six months using the Risk Assessment Battery, a 38-item structured clinical interview. Rates of sexual and drug risk behavior among rural patients were significantly lower than among urban patients. Regression analyses showed that urban setting, younger age, never having been married, and a bisexual or gay orientation significantly predicted higher HIV risk scores. The differences in risk behaviors may reflect urban-rural differences in drug availability and sexual practices.

Alcohol use disorders are common comorbid conditions in schizophrenia, and their presence is associated with poor adjustment and poor treatment response. Standard alcohol assessment instruments have not been validated for use with schizophrenic patients, and several authors have questioned the validity of these patients' self-reports. A reliable and valid screening procedure for assessing alcohol use is needed. The present study used the following three methods to evaluate a rural sample of 75 outpatients with DSM-III-R schizophrenia or schizoaffective disorder: (1) clinical records; (2) research interviews using standard alcohol assessment instruments; and (3) case managers' ratings. In addition, consensus diagnoses, determined by combining information from all three methods with intensive case reviews, were used to determine the sensitivity and specificity of the other approaches. As expected, clinical evaluations frequently missed alcohol problems. Research interviews and case managers' ratings differentiated between alcoholic and nonalcoholic schizophrenic patients and were highly correlated. Case managers' ratings, which incorporated longitudinal observations of behavior and collateral reports as well as interview data, were more sensitive measures of current alcohol use disorders than research interviews. Subjects frequently manifested alcohol-related problems that interfered with community adjustment without the full dependence syndrome, suggesting that schizophrenic patients may be particularly vulnerable to negative effects of alcohol.

Objective: Jails need a reliable tool to identify inmates who require further mental health assessment and treatment. This research attempted to revalidate the Brief Jail Mental Health Screen (BJMHS) as such a tool. This research added four items to the original eight-item screen (BJMHS-R), targeting depression and trauma to improve performance of the screen with women. Methods: BJMHS-R data were collected in four jails from 10,258 detainees. A subset of 464 were administered the Structured Clinical Interview for DSM-IV (SCID) for cross-validation. Results: The original BJMHS outperformed the revised screen. The original correctly classified 80% of males and 72% of females on the basis of SCID diagnoses, compared with classification rates of 72% and 66%, respectively, with the BJMHS-R. Overall, the BJMHS identified 16% of screened detainees as needing referral for further assessment, whereas the BJMHS-R identified 22%. Conclusions: The original eight-item BJMHS is a practical, efficient tool for intake screening by jail correction officers of male and female detainees. (Psychiatric Services 58: 1598–1601, 2007) T he most recent data from the Federal Bureau of Investigation indicate that approximately 14 million people were arrested in 2005 (1). The best clinical estimates suggest that about 1.1 million of these detainees met criteria for having mental illness in the year before incarceration (2,3). The importance of gender considerations in responding to the needs of these 1.1 million individuals is illustrated by data showing that rates of current serious mental illness are about two times higher for female detainees than for male detainees (12% versus 6.4%), largely because of higher rates of depression among female detainees (4). To respond to the vast needs of detainees with serious mental illness, the American Psychiatric Association’s Guidelines for Psychiatric Services in Jails and Prisons (5) recommends that all detainees should be screened immediately upon booking and that the initial screening should be done by correction officers. This recommendation is extremely challenging to implement because of the high volume of jail bookings and limited medical and mental health staff members. Practically, this means that there must be some type of standard screening tool that can be administered quickly during the usual booking process for which minimal training is required. Although the screening tool must be sensitive enough to detect those with a serious mental illness, the rate of detainees identified for referral for subsequent, fuller mental health assessment must not be so high as to overwhelm a resourcepoor organization. The need for such a tool has been recognized for some time, but a workable, valid instrument has been elusive. Relying on data from the Diagnostic Interview Schedule from 728 jail detainees with and without mental illness, Teplin and Swartz (6) created the Referral Decision Scale (RDS). A number of follow-up studies of

The overrepresentation of persons with mental illnesses in the criminal justice system is well documented. As more communities attempt to offer appropriate evidence-based practices in diversion and reentry programs, a major issue that has become apparent is that adaptations to the standard practices are often required because of the legal predicaments faced by clients. The associated question is how extensive can adaptations be before fidelity to the proven practice is compromised. To better understand these pressing issues, the National GAINS Center for Evidence-Based Programs in the Justice System held a series of six meetings focused on evidence-based practices (assertive community treatment, housing, trauma interventions, supported employment, illness self-management and recovery, and integrated treatment) and their applicability for persons involved in the criminal justice system. This Open Forum integrates the results of those meetings and proposes future steps to establish relevant evidence-based practices that can influence both behavioral health and public safety outcomes for persons involved with the criminal justice system.

Jails have a substantial legal obligation to provide health and mental health care for inmates; yet screening procedures across American jails are highly variable. Currently, no valid, practical, standardized tool is available. The study reported here sought to validate a revision of the Referral Decision Scale (RDS)--the Brief Jail Mental Health Screen (BJMHS)--which provides an even briefer and more practical tool for use in jails.Valid BJMHS data were collected in four jails (two in Maryland and two in New York) from 10,330 detainees. A total of 357 detainees were also administered the Structured Clinical Interview for DSM-IV (SCID) for standardized clinical cross-validation: 125 detainees (74 men and 51 women) who were classified as referrals for further mental health assessment on the basis of BJMHS and 232 detainees (137 men and 95 women) who were not classified as referrals.The BJMHS takes an average of 2.5 minutes to administer. It correctly classified 73.5 percent of males but only 61.6 percent of females on the basis of SCID diagnoses. Overall, the BJMHS identified 11.3 percent of screened detainees for further mental health assessment.The BJMHS is a practical, efficient tool that jail correction officers can give male detainees on intake screening. However, the screen has an unacceptably high false-negative rate for female detainees.

We compared the patterns of substance use among patients with severe mental illness (SMI) served by three community treatment teams, substance users with non-severe mental illness (NSMI), and substance abusers without mental illness (no mental illness: NMI). There were highly significant differences in substance use patterns among the groups: among patients with SMI, the order of drug preference was alcohol, cocaine, cannabis, and then heroin; in the NMI group, it was cocaine, alcohol, heroin, and then cannabis; while in the NSMI group, it was alcohol, cocaine, heroin, and then cannabis. The data suggest that the choice of drugs by individuals with SMI may be determined by factors related to their illness, in addition to the price and availability of the particular drug.

An estimated 19.6 percent of persons with severe mental illness are infected with the hepatitis C virus. Given the pressing need to identify and treat persons with severe mental illness who are at risk of hepatitis C infection and transmission, the authors sought to estimate the proportion of hepatitis C-positive and -negative persons with severe mental illness who have a regular source of medical care.S: Data for this study were obtained from 777 adults with severe mental illness at four diverse geographic sites at which respondents with severe mental illness participated in a structured interview and laboratory testing for HIV infection, AIDS, hepatitis B infection, and hepatitis C infection.In bivariate analyses, 54.2 percent of hepatitis C-positive and 62.5 percent of hepatitis C-negative study participants with severe mental illness had a regular source of medical care. In multivariate analyses in which potential confounders were statistically controlled for, hepatitis C-positive persons with severe mental illness were less than half as likely as hepatitis C-negative persons to have a regular source of care. Being older, married, insured, or employed or having self-reported health problems increased the likelihood of receiving care. Being black or male or living in a community with high exposure to community violence lowered those odds.There is an urgent need to improve access to medical care for persons with severe mental illness, especially those who may be at high risk of or are already infected with the hepatitis C virus.

This article outlines the history and rationale of a multisite study of blood-borne infections among persons with severe mental illness reported in this special section of Psychiatric Services. The general problem of blood-borne diseases in the United States is reviewed, particularly as it affects people with severe mental illness and those with comorbid substance use disorders. The epidemiology and natural history of three of the most important infections are reviewed: the human immunodeficiency virus (HIV), the hepatitis B virus, and the hepatitis C virus. Current knowledge about blood-borne diseases among people with severe mental illness as well as information on current treatment advances for hepatitis C are summarized. A heuristic model, based on the pragmatic, empirical, and conceptual issues that influenced the final study design, is presented. The specific rationale of the five-site collaborative design is discussed, as well as the sampling frames, measures, and procedures used at the participating sites. Alternative strategies for analyzing data deriving from multisite studies that use nonrandomized designs are described and compared. Finally, each of the articles in this special section is briefly outlined, with reference to the overall hypotheses of the studies.

The authors sought to better understand the relationship of substance abuse to higher rates of transmission of hepatitis C among persons with severe mental illness.S: The authors assessed 668 persons with severe mental illness for HIV, hepatitis B, and hepatitis C infection through venipuncture. Demographic characteristics, substance abuse, and risk behaviors for blood-borne infections were assessed through interviews and collection of clinical data.Eighty-two percent of the assessed persons were not infected, and 18 percent had hepatitis C. Among those with hepatitis C infection, 546 (82 percent) tested negative for all viruses. Of the 122 (18 percent) who had hepatitis C, 53 (8 percent) had only hepatitis C, 56 (8 percent) had both hepatitis C and hepatitis B, three (1 percent) had hepatitis C and HIV, and ten (2 percent) had all three infections. More than 20 percent of the sample reported lifetime intravenous drug use, and 14 percent reported lifetime needle sharing. Fifty-seven percent had sniffed of snorted cocaine, and 39 percent had smoked crack. A stepwise regression model was used to identify interaction effects of these behaviors and risk of hepatitis C infection among persons with severe mental illness. Use of needles and of crack cocaine were associated with a large increase in the likelihood of hepatitis C infection.S: The high rates of co-occurring substance use disorders among persons with severe mental illness, coupled with the role of substance abuse as the primary vector for hepatitis C transmission, warrants special consideration.

The authors assessed gender differences in hepatitis C infection and associated risk behaviors among persons with severe mental illness.S: The sample consisted of 777 patients (251 women and 526 men) from four sites.Across sites, the rate of hepatitis C infection among men was nearly twice that among women. Clear differences were noted in hepatitis C risk behaviors. Men had higher rates of lifetime drug-related risk behaviors: needle use (23.1 percent compared with 12.5 percent), needle sharing (17.6 percent compared with 7.7 percent), and crack cocaine use (45.2 percent compared with 30.8 percent). Women had significantly higher rates of lifetime sexual risk behaviors: unprotected sex in exchange for drugs (17.8 percent compared with 11.2 percent), unprotected sex in exchange for money or gifts (30.6 percent compared with 17 percent), unprotected vaginal sex (94 percent compared with 89.7 percent), and anal sex (33.7 percent compared with 22.6 percent). Gender appeared to modify some sex risks. Unprotected sex in exchange for drugs increased the risk of hepatitis C seropositivity for both men and women. In the multivariate model, gender was not significantly associated with hepatitis C seropositivity after adjustment for other risk factors.S: Gender differences in the lifetime rates of drug risks explain the higher rates of hepatitis C infection among men with severe mental illness.

Previous reports have indicated that persons with severe mental illness have an elevated risk of contracting HIV, hepatitis B, and hepatitis C compared with the general population. This study extends earlier findings by examining the factors that are most predictive of serologic status among persons with severe mental illness.S: A total of 969 persons with severe mental illness from five sites in four states were approached to take part in an assessment involving testing for blood-borne infections and a one-time standardized interview containing questions about sociodemographic characteristics, substance use, risk behaviors for sexually transmitted diseases, history of sexually transmitted diseases, and health care.The greater the number of risk behaviors, the greater was the likelihood of infection, both for persons in more rural locations (New Hampshire and North Carolina), where the prevalence of infection was lower, and those in urban locations (Hartford, Connecticut; Bridgeport, Connecticut; and Baltimore, Maryland), where the prevalence was higher. Although no evidence was found that certain behaviors increase a person's risk of one blood-borne infection while other behaviors increase the risk of a different infection, it is conceivable that more powerful research designs would reveal some significant differences among the risks.S: Clinicians should be attentive to these risk factors so as to encourage appropriate testing, counseling, and treatment.

The objective of this work was to assess the reliability and validity of the Medical Outcomes Study Short-Form 12-Item Health Survey (SF-12) in a large sample of people with severe mental illness (SMI).We examined the internal factor structure of the SF-12, compared component scores for this sample with normative levels, examined test-retest reliability, and examined convergent and divergent validity by comparing SF-12 scores to other indexes of physical and mental health.The SF-12 distinguished this sample of people with SMI from the general population, was stable over a 1-week interval, consisted of 2 fairly distinct factors, and was related to physical and mental health indexes in expected ways.The SF-12 appears to be a psychometrically sound instrument for measuring health-related quality of life for people with SMI.

Implementation of the Clinton Administration's proposed Health Security Act could significantly increase the number of seriously mentally ill persons enrolled in health maintenance organizations (HMOs). Studies of the mental health status and outcomes of seriously mentally ill persons treated in HMOs show conflicting findings and provide little guidance about the likely effect of the Health Security Act on this population. However, implementation of the Health Security Act would be likely to influence the treatment of seriously mentally ill persons by altering the activities of state and local governments in the financing and delivery of care, facilitating the integration of public and private services, and encouraging development of additional service capacity. To clarify HMOs' likely role in providing services to seriously mentally ill persons under health care reform, more research is needed on the current service capacity of HMOs, on treatment approaches and outcomes in different HMO models, on whether seriously mentally ill persons would be likely to choose HMOs from among health plan options, and on whether higher-income HMO enrollees would seek care outside HMO provider networks.

High familial expressed emotion, which may be a specific form of social overstimulation, has been linked to schizophrenic relapse and rehospitalization. Research on expressed emotion has led to a new generation of demonstrably effective family treatments for schizophrenia that rely heavily on psychoeducational techniques. Although most schizophrenic patients do not live with families, the family psychoeducational model has not been applied in nonfamilial living settings. The authors report two examples in which the family psychoeducational model was successfully used in group living situations and discuss the implications of expressed emotion and family psychoeducation for schizophrenic patients who live in nonfamilial settings.

The authors examined patterns of alcohol use among 115 DSM-III schizophrenics discharged from the state hospital and participating in an urban aftercare program. According to ratings by mobile outreach clinicians, 45% of the patients used alcohol, and 22% were clearly abusing alcohol. Alcohol use was associated with younger age, male sex, street drug use, medication noncompliance, lack of psychosocial supports, increased symptomatology, chronic medical problems, and a higher rate of rehospitalization. Even minimal drinking, not considered alcohol abuse by clinicians, predicted rehospitalization during 1-year prospective follow-up.

The treatment of individuals with coexisting psychoactive substance abuse and severe psychiatric disorders requires an integration of principles from the mental health and chemical dependency fields. The authors outline a conceptual model for treating dually diagnosed patients that consists of four treatment phases--engagement, persuasion, active (or primary) treatment, and relapse prevention. The components of these phases include case management, group therapy, psychopharmacology, toxicologic screening, detoxification, family involvement, and participation in self-help groups. Due to the high morbidity and mortality associated with dual diagnoses, the authors encourage the development, implementation, and scientific evaluation of integrated treatment models targeted toward this population.

This is in essence the oldest of biological problems—the classic struggle between the Lamarckians and the Darwinians on the nature of adaptation in evolution. It is a theme that has been played on in an infinity of variations over the last 100 years, and I can only hope that in the present treatment there are scattered elements of novelty, either in regard to example or approach, which will make up for the inevitable inclusion of much that is trite and familiar.