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Community psychiatrists serve multiple institutional roles, and at times these roles may include the review of grant proposals from nonprofit organizations. In this column, the authors argue that privilege and social capital can easily become concentrated among a small group of centralized model organizations and influence the grant review process. Established and wealthy nonprofits can co-opt the growing interest in health equity by leveraging their existing resources, thereby excluding emerging organizations within communities in need. By applying a structural lens to this problem, funding entities can identify approaches that more effectively promote equity throughout the grant life cycle.

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.

The response to the global COVID-19 pandemic has important ramifications for mental health systems and the patients they serve. This article describes significant changes in mental health policy prompted by the COVID-19 crisis across five major areas: legislation, regulation, financing, accountability, and workforce development. Special considerations for mental health policy are discussed, including social determinants of health, innovative technologies, and research and evaluation. These extraordinary advances provide an unprecedented opportunity to evaluate the effects of mental health policies that may be adopted in the post-COVID-19 era in the United States.

Youth who acquire a juvenile crime record may be at increased risk of perpetrating gun violence as adults. North Carolina and 22 other states permit young adults who were adjudicated by a juvenile court - even for some felony-equivalent offenses - to legally access firearms. Effectiveness of gun restrictions for adults with juvenile crime histories has not been systematically studied. This article reports findings from a longitudinal study of arrests and convictions for gun-involved and other offenses in 51,059 young adults in North Carolina, comparing those with gun-disqualifying and not-disqualifying juvenile records. The annualized rate of arrest for gun-involved crime in those with a felony-level juvenile record was 9 times higher than the rate of reported comparable offenses in the same age group in the North Carolina general population (3349 vs. 376 per 100,000). Among those with a felony-equivalent juvenile delinquency adjudication who became legally eligible to possess firearms at age 18, 61.8% were later arrested for any criminal offense, 14.3% for a firearm-involved offense. Crimes with guns were most likely to occur among young adults who had committed more serious (felony or equivalent) offenses before age 18; had been adjudicated at younger ages; acquired a felony conviction as a youth; and spent time in prison. The prevalence of arrests for crimes involving guns among young adults in North Carolina with a gun-disqualifying felony record acquired before age 18 suggests that the federal gun prohibitor conferred by a felony record is not highly effective as currently implemented in this population. From a risk-based perspective, these restrictions appear to be justified; better implementation and enforcement may improve their effectiveness. Gun crime prevention policies and interventions should focus on these populations and on limiting illegal access to firearms.

A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams.We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference.Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment.PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

OBJECTIVES: To test the associations of childhood domestic gun access with adult criminality and suicidality. METHODS: Analyses were based on a 20+ year prospective, community-representative study of 1420 children, who were assessed up to 8 times during childhood (ages 9–16; 6674 observations) about access to guns in their home. Participants were then followed-up 4 additional times in adulthood (ages 19, 21, 25, and 30; 4556 observations of 1336 participants) about criminality and suicidality. RESULTS: During childhood, the 3-month prevalence of having a gun in the home was 55.1% (95% confidence interval [CI]: 52.1%–58.7%). Of the children in homes with guns, 63.3% (95% CI: 59.7%–66.9%) had access to a gun, and 25.0% (95% CI: 21.2%–28.8%) owned a gun themselves. Having gun access as a child was associated with higher levels of adult criminality (odds ratios = 1.1–3.5) and suicidality (odds ratios = 2.9–4.4), even after adjusting for childhood correlates of gun access. Risk of adult criminality and suicidality among those with childhood gun access was greatest in male individuals, those living in urban areas, and children with a history of behavior problems. Even in these groups, however, most children did not display adult criminality or suicidality. CONCLUSIONS: Childhood gun access is prospectively associated with later adult criminality and suicidality in specific groups of children.

Psychiatric advance directives (PADs) are used to document a person's treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs.This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency.Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content.Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency.Results should alleviate some clinicians' apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Treatment courts aim to reduce criminal recidivism by addressing the behavioral health care needs of persons with psychiatric or substance use disorders that contribute to their offending. Stable funding and access to behavioral health providers are crucial elements of success for the treatment court model. What happens when courts lose state funding and must rely on local initiatives and resources? In this study, a survey of North Carolina treatment court professionals identified resource gaps and unmet needs. The authors argue that continuing state investment could make treatment courts more viable and effective. Medicaid expansion is a potential new resource for these problem-solving courts.

Psychiatric advance directives (PADs) can help adults with serious mental illnesses preserve their autonomy and avoid involuntary interventions during an incapacitating mental health crisis. A PAD is a legal document prepared while mentally competent and states the person's treatment preferences to be implemented during a future crisis, ideally with the advocacy of an authorized proxy decision maker. PADs have been available in the United States for more than three decades but have yet to be robustly implemented in practice. This Open Forum describes PADs metaphorically as a device for remote communication among the person with mental illness, a proxy decision maker, and health care providers. Barriers to PAD usage occur on both "transmitter" and "receiver" sides and must be addressed to advance PAD implementation.

This article presents a survival analysis of long-term risk of firearm-related and other violent crime in a large sample of adults with serious mental illness in Florida, comparing those who received a gun-disqualifying civil commitment after a short-term hold, those who were evaluated for commitment but were released or hospitalized voluntarily, and a third group with no holds or commitments. Among 77,048 adults with a diagnosis of schizophrenia-spectrum disorder, bipolar disorder, or major depression, 42.7 percent were detained for psychiatric examination under Florida's Baker Act; of that detained group, 8.4 percent were involuntarily committed while the remainder were released within 72 hours or agreed to voluntary admission. Over a follow-up period averaging six to seven years, 7.5 percent of the sample were arrested for a violent offense not involving a gun, and 0.9 percent were arrested for a violent crime involving a gun. A short-term hold with or without commitment was associated with a significantly higher risk of future arrest for violent crime, although the study population had other violence risk factors unrelated to mental illness. Risk of gun-involved crime, specifically, was significantly higher in individuals following a short-term hold only, but not in those who were involuntarily committed and became ineligible to purchase or possess guns. Policy implications are discussed.

Objective To determine if a single baseline adherence assessment (Brief Adherence Rating Scale [BARS]) could identify patients who are likely to respond to long-acting injectable (LAI) antipsychotic treatment. Method The current secondary analysis included a sub-sample of adult outpatients (N = 176) with schizophrenia or schizoaffective disorder who participated in the “A Comparison of Long-Acting Injectable Medications for Schizophrenia (ACLAIMS)” trial and had a baseline BARS assessment and a baseline and month 3 Positive and Negative Syndrome Scale (PANSS) rating. The main outcome was LAI treatment response, defined as a ≥ 20% decrease (baseline to month 3) on the PANSS total score. Receiver Operating Characteristic (ROC) and Area Under the Curve (AUC) analysis was conducted to determine the optimal cutpoint of baseline BARS adherence in discriminating LAI treatment response at month 3. A logistic mixed model estimated the odds of response to LAI treatment at month 3 from the optimal baseline BARS cutpoint. Results The ROC analysis determined that the single baseline BARS rating (cutoff ≤66%), indicating low adherence, best discriminated patients likely to respond to LAI treatment (AUC = 0.603, SE = 0.046, 95% binomial exact CI = 0.527 to 0.676, p = 0.025), with 38% sensitivity and 85% specificity. The logistic mixed model analysis revealed that patients with ≤66% BARS adherence had 3.464 times the predicted odds (95% CI = 1.604 to 7.480, p = 0.001) of responding to LAI treatment than those who were >66% BARS adherent. Conclusion A single baseline BARS assessment discriminated response to LAI treatment suggesting it is a reasonable tool to identify candidates for LAI antipsychotic treatment.

Adults suffering from a serious mental illness (SMI) and a substance use disorder are at especially high risk for poor clinical outcomes and also arrest and incarceration. Pharmacotherapies for treating opioid dependence could be a particularly important mode of treatment for opioid-dependent adults with SMI to lower their risk for overdose, high-cost hospitalizations, repeated emergency department visits, and incarceration, given relapse rates are very high following detoxification in the absence of one of the three FDA-approved pharmacotherapies. This study estimates the effects of methadone, buprenorphine, and oral naltrexone on clinical and justice-related outcomes in a sample of justice-involved adults with SMI, opioid dependence, and criminal justice involvement. Administrative data were merged from several public agencies in Connecticut for 8736 adults 18years of age or older with schizophrenia spectrum disorder, bipolar disorder, or major depression; co-occurring moderate to severe opioid dependence; and who also had at least one night in jail during 2002-2009. Longitudinal multivariable regression models estimated the effect of opioid-dependence pharmacotherapy as compared to outpatient substance abuse treatment without opioid-dependence pharmacotherapy on inpatient substance abuse or mental health treatment, emergency department visits, criminal convictions, and incarcerations, analyzing instances of each outcome 12months before and after an index treatment episode. Several baseline differences between the study groups (opioid-dependence pharmacotherapy group versus outpatient treatment without opioid-dependence pharmacotherapy) were adjusted for in the regression models. All three opioid-dependence pharmacotherapies were associated with reductions in inpatient substance abuse treatment, and among the oral naltrexone subgroup, also reductions in inpatient mental health treatment, as well as improved adherence to SMI medications. Overall, the opioid-dependence pharmacotherapy group had higher rates of arrest and incarceration in the follow-up period than the comparison group; but those using oral naltrexone had lower rates of arrest (including felonies). The analysis of observational administrative data provides useful population-level estimates but also has important limitations that preclude conclusive causal inferences. Large reductions in crisis-driven service utilization associated with opioid-dependence pharmacotherapy in this study suggest that evidence-based medications for treating opioid dependence can be used successfully in adults with SMI and should be considered more systematically during assessments of treatment needs for this population.

With insufficient access to treatment and a tradition of criminalizing addiction, people with substance use disorders — including opioid dependence — are more likely to be incarcerated than they are to receive the treatment they need. Drug treatment courts aim to address this problem, engaging their participants in substance use treatment in lieu of incarceration. Drug courts offer an especially important window of opportunity to connect opioid-dependent participants to extended-release naltrexone (XR-NTX), at a time when they are under highly-structured court supervision and required to detoxify from opioids to participate. Given the high cost of XR-NTX and high rates of uninsurance in the drug court population, new rigorous cost-effectiveness evidence is needed to demonstrate the extent to which XR-NTX improves program outcomes, including by reducing recidivism. With that new evidence, drug courts and the counties in which they are situated can make informed and difficult policy decisions about funding XR-NTX for some of their highest-risk community members.

Background The increase in cannabis potency may have treatment implications for cannabis use disorder (CUD). Given the reported increase in prevalence of cannabis use among adults, there is a need to understand substance use treatment needs for CUD. Methods We examined demographics and behavioral health indicators of adults aged ≥18 years that met criteria for past-year CUD (n = 10,943) in the 2005–2013 National Surveys on Drug Use and Health. We determined prevalence and correlates of past-year treatment use for alcohol/drug, any drug, and cannabis use related problems, to inform treatment efforts for CUD. Results The majority of adults with past-year CUD were young adults aged 18–25 or men, had low income, and did not attend college. Two-thirds of adults with CUD met criteria for cannabis dependence, which was comparatively common among younger adults, women, low-income or publicly insured adults, and college-educated adults. Nicotine dependence (40.92%) and alcohol (44.07%) or other drug use disorder (19.70%) were prevalent among adults with CUD. Overall, less than 13% of adults with CUD had received alcohol/drug use treatment the past year; only 7.8% received cannabis-specific treatment. There was no significant yearly variation in treatment use prevalence over 9 years. In particular, Asian-Americans, women, and college-educated adults underutilized cannabis-specific treatment. Conclusions This large sample of adults with CUD reveals pervasive underutilization of cannabis-related treatment, especially in women, married adults, and those with college education, despite a high proportion of comorbid behavioral health problems.

This chapter addresses a complex and persistent challenge for mental health services delivery: What to do about adult members of our communities who suffer from debilitating psychiatric illnesses such as schizophrenia but fail to receive consistent and effective treatment. Many are gravely disabled and/or pose a danger to themselves or others, but are often unable or unwilling to adhere to recommended treatment until they deteriorate to the point of requiring involuntary hospitalization or are arrested for a minor crime. Involuntary outpatient commitment—often termed ‘assisted outpatient treatment’—was developed as one potential remedy to address this population of ‘revolving door’ patients. In this civil court procedure, a judge orders a person with mental illness to comply with recommended treatment. We discuss involuntary outpatient commitment in the broader context of mandated community treatment, review the controversies about its effectiveness, the ethics of its use and discuss some potential alternative approaches. Mandated community treatment, if properly targeted and implemented with sufficient resources, can offer a less-restrictive alternative to hospitalization or arrest with the goal of ensuring that beneficial treatment is consistently maintained, rather than delaying intervention until confinement is required.

How are gun violence and mental health problems connected (or not connected)? How effective are current laws designed to prevent firearm-related violence and suicide in the United States? What other feasible measures could be taken to meaningfully reduce the number of firearm injuries and deaths, without stigmatizing people with mental illnesses or unduly curtailing the rights of law-abiding gun owners? This chapter addresses such questions broadly from a public health perspective, examining key federal and state regulatory approaches to preventing intentional firearm-related injury—particularly as these approaches intersect with mental health policy. We describe the nature and scope of the problem and the unique challenge that it poses in the American context, where mass shootings continue to shape popular views of mental illness and public safety goals collide with individual gun rights concerns. We summarize empirical evidence for the effectiveness and shortcomings of mental-health-based gun restrictions at the point of sale. We describe a new generation of risk-based, non-criminalizing, time-limited, preemptive gun-removal laws as an important piece in the policy puzzle of gun violence and suicide prevention in the United States. Expert consensus recommendations on selected policies to reduce gun violence and suicide are discussed.

BackgroundThe United States is experiencing an opioid overdose epidemic. Treatment use data from diverse racial/ethnic groups with opioid use disorder (OUD) are needed to inform treatment expansion efforts.MethodsWe examined demographic characteristics and behavioral health of persons aged ≥12 years that met criteria for past-year OUD (n=6,125) in the 2005–2013 National Surveys on Drug Use and Health (N=503,101). We determined the prevalence and correlates of past-year use of alcohol/drug use treatment and opioid-specific treatment to inform efforts for improving OUD treatment.ResultsAmong persons with OUD, 81.93% had prescription (Rx) OUD only, 9.75% had heroin use disorder (HUD) only, and 8.32% had Rx OUD+HUD. Persons with Rx OUD+HUD tended to be white, adults aged 18–49, males, or uninsured. The majority (80.09%) of persons with OUD had another substance use disorder (SUD), and major depressive episode (MDE) was common (28.74%). Of persons with OUD, 26.19% used any alcohol or drug use treatment, and 19.44% used opioid-specific treatment. Adolescents, the uninsured, blacks, native-Hawaiians/Pacific-Islanders/Asian-Americans, persons with Rx OUD only, and persons without MDE or SUD particularly underutilized opioid-specific treatment. Among alcohol/drug use treatment users, self-help group and outpatient rehabilitation treatment were commonly used services.ConclusionsMost people with OUD report no use of OUD treatment. Multifaceted interventions, including efforts to access insurance coverage, are required to change attitudes and knowledge towards addiction treatment in order to develop a supportive culture and infrastructure to enable treatment-seeking. Outreach efforts could target adolescents, minority groups, and the uninsured to improve access to treatment.

Raw data were used from five studies of adults with mental illnesses (N=4,480) in an attempt to identify a psychiatric symptoms factor structure, as measured by the Positive and Negative Syndrome Scale or the Brief Psychiatric Rating Scale, that was generalizable across participant characteristics. First, the fit of four extant models was tested via confirmatory factor analysis (CFA), then exploratory factor analyses (EFA) were conducted with a 50% random sample, followed by a CFA with the remaining 50% to confirm the EFA factor structure. Measurement invariance of the factor structure was also examined across diagnosis, sex, race, age, and hospitalization status. The extant models were not generalizable to these data. However, a 4-factor (Affective, Positive, Negative, Disorganized Cognitive Processing) model was identified that retained all items and showed invariance across participant characteristics. It is possible to obtain a psychiatric symptoms factor structure that is generalizable across patient characteristics, which has clinical and research implications. Specifically, future research examining the impact of various interventions on psychiatric symptoms among adults with mental illnesses should confirm, and assuming good model-data fit, use the 4-factor model identified in this study.

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.

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.

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.

Men and women with co-occurring substance use disorders and mental illness are at relatively high risk for becoming involved in the criminal justice system. Programs, such as post-booking jail diversion, aim to connect these individuals to community-based treatment services in lieu of pursuing criminal prosecution. Gender appears to have an important influence on risk factors and pathways through the criminal justice system, which in turn may influence how interventions like jail diversion work to engage men and women in treatment services and reduce recidivism. Different circumstances, levels of engagement, and outcomes by gender may be related to both person-level characteristics and external factors such as availability of gender-specific services and resources. This mixed-methods study identified specific ways in which men and women use services and reoffend after being diverted, and complemented those findings with in-depth insights from program clinicians about how program experiences and resources differ in important ways by gender. We matched and merged administrative records from 2007 to 2009 for 16,233 adults from several state agencies in Connecticut, and included data on demographic characteristics, clinical diagnoses, outpatient and inpatient behavioral health treatment utilization, arrest, and incarceration. Using propensity analysis, the 1693 men and women who participated in the statewide jail diversion program were matched to respective comparison groups of nondiverted men and women. We used longitudinal multivariable regression analyses to estimate the effects of jail diversion participation on treatment utilization, arrest, and incarceration, separately for men and women. We conducted three focus groups with jail diversion clinicians from around the state (n = 21) to gain in-depth insight from them about how circumstances, program experiences, and resources differ by gender in important ways; these subjective clinician insights complement the quantitative analyses of diversion outcomes for men and women. For both men and women, diversion was associated with reductions in risk for incarceration and increases in utilization of outpatient treatment services. For men only, diversion was associated with higher utilization of inpatient mental health care. No differences in treatment or criminal justice outcomes were observed in models that compared men and women directly. Major themes from the focus groups included: the existence of too few inpatient and residential resources for women with co-occurring disorders; different challenges to treatment engagement that men and women face; and a need for more effective, gender-specific services for all program participants. Results from this mixed-methods study offer information on gender-specific program outcomes and surrounding circumstances that can help programs to better understand and address unique risks and needs for men and women with co-occurring substance use and mental health disorders who are involved in the criminal justice system.

Assisted outpatient treatment (AOT) is an outpatient court-ordered treatment for people with severe mental illness (SMI) whose care needs are often unmet in the community due, in part, to treatment non-adherence. AOT is controversial, and the goal of this review is to provide an update on recent research, the status of AOT in the United States, and future directions for research and implementation. Several recent studies have demonstrated that it is not just a lack of access to appropriately intensive care that prevents some individuals with SMI from engaging in and benefiting from treatment and that AOT can improve engagement and patient outcomes over and above the provision of care. The future of AOT in the United States is still somewhat uncertain and will largely depend on the effectiveness and sustainability of the SAMHSA AOT grant programs. Future research efforts should investigate the conditions under which and for whom AOT can be most effective, to help avoid poor outcomes for this vulnerable population.

Adults with serious mental illness and comorbid alcohol dependence are at high risk for both high utilization of crisis-driven health care services and criminal justice involvement. Evidence-based medication-assisted treatment (MAT) for alcohol dependence may reduce both crisis service utilization and criminal recidivism. The authors estimated the effect of MAT on behavioral health treatment utilization and criminal justice outcomes for this population.Relevant administrative data were merged from several public agencies in Connecticut for 5,743 adults ≥18 years old who had schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder comorbid with moderate to severe alcohol dependence and who were incarcerated for at least one night during the study window (2002-2009). Longitudinal multivariable regression models were used to estimate the effect of MAT compared with other outpatient substance abuse treatments on inpatient mental health and substance abuse hospitalizations, emergency department visits, criminal convictions, and incarcerations.MAT was associated with significant improvements in clinical outcomes in the 12 months following initiation compared with non-MAT comparison treatment, including greater reductions in mental health hospitalization and emergency department visits and greater improvements in psychotropic medication adherence. No benefits of MAT were found for most criminal justice outcomes, except for significant reductions in felony convictions among adults with bipolar disorder.MAT is underused for treating alcohol dependence, especially among adults with serious mental illness. These results suggest that MAT can have important benefits for clinical outcomes in this population. More research is needed to improve its use in this patient population as well as to address barriers to its availability.

This study examined psychiatry resident burnout in emergency departments and its association with residents' posttraining plans to care for Medicaid patients and others publicly insured.Between November and December 2013, psychiatry residents in North Carolina were recruited for a cross-sectional, Internet-based survey concerning emergency department experiences, attitudes about their roles, feelings of burnout, and posttraining intentions to treat Medicaid patients. The completion rate was 51% (N=91).In bivariate analyses (N=82 with an emergency psychiatry rotation), burnout was positively associated with frequent exhaustion (p.001) and perceived suboptimal supervision by the attending physician (p.01). Compared with other residents, residents planning to accept Medicaid after training had significantly lower burnout scores (p.05). Experiencing assault in the emergency department indicated decreased likelihood of treating publicly insured patients after training (Medicaid, odds ratio=.09, p.05).Adverse experiences with patient care in the emergency department during psychiatry residency appear to be linked to professional burnout and threaten to shape long-term plans regarding care for publicly insured patients.

Due to changes in cannabis policies, concerns about cannabis use (CU) in adolescents have increased. The population of nonwhite groups is growing quickly in the United States. We examined perceived CU norms and their association with CU and CU disorder (CUD) for White, Black, Hispanic, Native-American, Asian-American, Native Hawaiian/Pacific Islander (NH/PI), and mixed-race adolescents. Data were from adolescents (12e17 years) in the 2004e2012 National Surveys on Drug Use and Health (N ¼ 163,837). Substance use and CUD were assessed by computer-assisted, self-interviewing methods. Blacks, Hispanics, Native-Americans, and mixed-race adolescents had greater odds of past-year CU and CUD than Whites. Among past-year cannabis users (CUs), Hispanics and Native-Americans had greater odds of having a CUD than Whites. Asian-Americans had the highest prevalence of perceived parental or close friends' CU disapproval. Native-Americans and mixed-race adolescents had lower odds than Whites of perceiving CU disapproval from parents or close friends. In adjusted analyses, adolescent's disapproval of CU, as well as perceived disapproval by parents or close friends, were associated with a decreased odds of CU in each racial/ethnic group, except for NHs/PIs. Adolescent's disapproval of CU was associated with a decreased odds of CUD among CUs for Whites (personal, parental, and close friends' disapproval), Hispanics (personal, parental, and close friends' disapproval), and mixed-race adolescents (personal, close friends' disapproval). Racial/ethnic differences in adolescent CU prevalence were somewhat consistent with adolescents' reports of CU norm patterns. Longitudinal research on CU health effects should oversample nonwhite adolescents to assure an adequate sample for analysis and reporting. © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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. Copyright © 2015 John Wiley & Sons, Ltd. Language: en

OBJECTIVE: To investigate subgroup responses to long-acting injectable (LAI) haloperidol decanoate (HD) and paliperidone palmitate (PP) in a randomized controlled trial that found no difference between the treatments on the primary outcome of efficacy failure. METHOD: A Comparison of Long-Acting Injectable Medications for Schizophrenia (ACLAIMS) enrolled 311 participants from March 2011 to July 2013 meeting DSM-VI-TR criteria for diagnoses of schizophrenia or schizoaffective disorder at risk of relapse due to medication non-adherence or substance abuse. Participants were randomly assigned to double-blinded treatment with HD or PP and followed for up to 2 years. A committee blinded to treatment assignment adjudicated efficacy failure based on meeting at least one of these criteria: psychiatric hospitalization, crisis stabilization, increased outpatient visits, could not discontinue oral antipsychotic, discontinued assigned LAI due to inadequate therapeutic benefit, or prolonged need for adjunctive oral antipsychotic medication. Survival analyses examined modification of treatment effects on efficacy failure by age, gender, race, substance abuse, baseline symptom severity, and baseline adherence. Mixed effect linear models and analysis of covariance examined this modification on safety outcomes. RESULTS: An interaction between age and treatment (p=0.009) revealed younger participants assigned HD had longer time to efficacy failure than those assigned PP. Interactions were not significant between treatment group and gender, race, substance use disorder, baseline symptom severity, or baseline adherence. An interaction of treatment and age on akathisia (p=0.047) found an advantage for PP that was larger among younger persons. An advantage for HD on serum prolactin levels was larger among younger women (p=0.033). CONCLUSION: Among younger persons, HD was associated with lower rates of efficacy failure than PP. Age effects on adverse effects were mixed. Age-related heterogeneity of antipsychotic treatment effects warrants further investigation and consideration in clinical practice. CLINICAL TRIALS REGISTRATION: A Comparison of Long-acting Injectable Medications for Schizophrenia (ACLAIMS) https://clinicaltrials.gov/ct2/show/NCT01136772?term=ACLAIMS&rank=1, NCT01136772

The primary aim is to examine concordant/discordant results of drug use assessments in adults with schizophrenia.Latent class analysis and multinomial logistic regression were used to examine concordance/discordance between drug use measures and identify characteristics differentiating participants across classes.Four classes - non-users, users, probable users, and RIA discordant - fit best. Age, sex, race/ethnicity, and psychiatric symptoms differed significantly across classes.Findings showed that discordance between results occurs at non-trivial rates and is, in part, attributable to individual characteristics. Results suggest the need for strategies to limit discordance and improve detection of drug use in adults with schizophrenia.

During the last 30 years, new ways of legally mandating psychiatric treatment for patients living in the community have emerged. Changes to law and practice have occurred in various jurisdictions and cultures. The simultaneous introduction in a range of settings of new approaches to mandating community treatment suggests that there may be shared causes for these changes. This chapter reviews the experience of mandated community treatment in the United States, Australia, and the United Kingdom. For each of these countries, we examine the measures and prevalence of their use, the evidence for their effectiveness, and the most likely explanation of any differences between the results in their jurisdiction and experience elsewhere.

Outpatient commitment is the legal practice of using civil court orders to mandate mental health treatment in the community for certain adults with serious and chronic mental illnesses. In this chapter, we examine the historical context in which the practice of outpatient commitment emerged in the United States. We discuss the controversial nature of outpatient commitment, examining the assumptions and perspectives of those on either side of ongoing arguments about whether the practice is legitimate, fair, and effective. In the final section of the chapter, we discuss whether, and under what conditions, outpatient commitment may be ethical. We discuss a useful conceptual framework for disentangling the various types of considerations involved in determining whether public policies are ethical. The framework identifies four principles relevant to ethical decision making in the context of outpatient commitment: (1) respect for autonomy, (2) non-maleficence, (3) beneficence, and (4) justice.

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.

There are concerns over nonmedical use of prescription stimulants among youths, but little is known about the extent of use among young Asian-Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals—the fastest growing segments of the U.S. population. We examined prevalences and correlates of nonmedical stimulant use (NMSU) and disorder (StiUD) for these underrecognized groups. Whites were included as a comparison. Data were from young individuals aged 12–34 years in the 2005–2012 National Surveys on Drug Use and Health. We used logistic regression to estimate odds of past-year NMSU status. Significant yearly increases in lifetime NMSU prevalence were noted in Whites only. NHs/PIs (lifetime 7.33%, past-year 2.72%) and mixed-race individuals (10.20%, 2.82%) did not differ from Whites in NMSU prevalence (11.68%, 3.15%). Asian-Americans (lifetime 3.83%, past-year 0.90%) had lower prevalences than Whites. In each racial/ethnic group, “Methamphetamine/Desoxyn/Methedrine or Ritalin” was more commonly used than other stimulant groups; “got them from a friend/relative for free” and “bought them from a friends/relative” were among the most common sources. Females had greater odds than males of NMSU (among White, NH/PI, mixed-race individuals) and StiUD (among mixed-race individuals). Young adults (aged 18–25) had elevated odds of NMSU (White, NH/PI); adolescents had elevated odds of StiUD (White, mixed-race). Other substance use (especially marijuana, other prescription drugs) increased odds of NMSU and StiUD. NHs/PIs and mixed-race individuals were as likely as Whites to misuse stimulants. Research is needed to delineate health consequences of NMSU and inform prevention efforts for these understudied, rapidly-growing populations.

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.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.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 significantly greater for women. Substance use disorder also increased risk of offending more among women than men, especially among those with schizophrenia.Men and women with bipolar disorder and substance use disorders have much higher risk of justice involvement than those 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.

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.

A program of court-mandated assisted outpatient treatment in New York appears to reduce the costs allocated for mental health services. The reduction in costs reflected fewer repeated episodes of expensive inpatient psychiatric treatment as patients instead received outpatient care and appropriate medications.

The racial/ethnic composition of the United States is shifting rapidly, with non-Hispanic Asian-Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals the fastest growing segments of the population. We determined new drug use estimates for these rising groups. Prevalences among Whites were included as a comparison.Data were from the 2005-2011 National Surveys on Drug Use and Health. Substance use among respondents aged ≥ 12 years was assessed by computer-assisted self-interviewing methods. Respondents' self-reported race/ethnicity, age, gender, household income, government assistance, county type, residential stability, major depressive episode, history of being arrested, tobacco use, and alcohol use were examined as correlates. We stratified the analysis by race/ethnicity and used logistic regression to estimate odds of drug use.Prevalence of past-year marijuana use among Whites increased from 10.7% in 2005 to 11.6-11.8% in 2009-2011 (P0.05). There were no significant yearly changes in drug use prevalences among Asian-Americans, NHs/PIs, and mixed-race people; but use of any drug, especially marijuana, was prevalent among NHs/PIs and mixed-race people (21.2% and 23.3%, respectively, in 2011). Compared with Asian-Americans, NHs/PIs had higher odds of marijuana use, and mixed-race individuals had higher odds of using marijuana, cocaine, hallucinogens, stimulants, sedatives, and tranquilizers. Compared with Whites, mixed-race individuals had greater odds of any drug use, mainly marijuana, and NHs/PIs resembled Whites in odds of any drug use.Findings reveal alarmingly prevalent drug use among NHs/PIs and mixed-race people. Research on drug use is needed in these rising populations to inform prevention and treatment efforts.

Non-Hispanic Asian Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals are the fastest growing segments of the US population. We examined prevalences and correlates of tobacco use among these understudied groups. Prevalences among whites were included as a comparison.Data were drawn from the 2002-2010 National Surveys on Drug Use and Health. Respondents aged ≥12 years were assessed for current (past-month) use of cigarettes, cigars, smokeless tobacco (chewing tobacco, snuff), and pipe tobacco. Respondents' race/ethnicity, age, sex, household income, government assistance, urbanicity of residence, residential stability, self-rated health, alcohol use, and drug use were examined as correlates.Between 2002 and 2010, there was a decline in the prevalence of cigarette smoking among whites (26.9% in 2002; 24.3% in 2010) and Asian Americans (18.0% in 2002; 11.1% in 2010). Prevalence of pipe tobacco use among mixed-race individuals increased from 0.2% in 2002 to 1.6% in 2010; there was little change in the prevalence of cigar and smokeless tobacco use in these racial/ethnic groups. Adjusted analyses showed that, compared with Asian Americans, mixed-race individuals had greater odds of using four tobacco products, and NHs/PIs had greater odds of using cigarettes, cigars, and smokeless tobacco. Regardless of race/ethnicity, male sex was a correlate of use of cigars, smokeless tobacco, and pipe tobacco; alcohol and drug use increased the odds of cigarette and cigar smoking.These new findings show prevalent tobacco use among NHs/PIs and mixed-race individuals, and highlight the importance of including these populations in future research and reporting.

Medication outcome literature in schizophrenia across racial-ethnic groups is sparse, with inconsistent findings. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study provided an opportunity for exploratory analyses of racial-ethnic outcomes. The study objective was to examine race-ethnicity outcomes for CATIE's main outcome (study discontinuation) and secondary outcomes.CATIE participants included whites (non-Hispanic) (N=722), African Americans (N=506), and Hispanics (N=170). Survival analyses and mixed-effects regression modeling were conducted, with adjustment for baseline sociodemographic differences and baseline scores of the secondary outcomes.Racial-ethnic groups had unique patterns of outcomes. Hispanics were much more likely to discontinue for lack of efficacy from perphenazine (64% versus 42% non-Hispanic whites and 24% African Americans) and ziprasidone (71% versus 40% non-Hispanic whites and 24% African Americans); Hispanics' quality of life also declined on these medications. Non-Hispanic whites were more likely to discontinue for lack of efficacy in general (averaging olanzapine, quetiapine, and risperidone discontinuation rates). African Americans were less likely to continue after the first phase (32% continuing versus 40% for non-Hispanic whites and 41% Hispanics). Discontinuations were driven by research burden, personal issues, and unspecified loss to follow-up. Non-Hispanic whites had higher depression scores during the follow-up period. African Americans had fewer side effects.CATIE results did not show disparities favoring non-Hispanic whites. CATIE may have provided state-of-the-art treatment and thus reduced disparate treatments observed in community clinics. African Americans discontinued even after consideration of socioeconomic differences. Why perphenazine and ziprasidone may be less effective with Hispanics should be explored.