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To appropriately evaluate people in their communities requires careful consideration of a panoply of contextual parameters. These are composed of a welcoming and safe ambience; physical plant characteristics; the clinical setting (e.g., inpatient, outpatient, emergency room, homeless shelter or under a bridge, correctional setting); whether the assessment is routine, urgent, emergent, or investigatory; the nature of the evaluation’s expected product; and the cultural attributes of people, their communities, and the evaluator. Consideration of all these contextual issues will expand the evaluator’s capacity to establish a therapeutic alliance, and to engage the patient in the assessment, and possibly treatment. Awareness of and responses to these contextual concerns will improve both the evaluative process and the evaluation product.

Previous research on housing loss among severely mentally ill persons who have been placed in housing after being homeless has been largely atheoretical and has yielded inconsistent results. We develop a theory of housing loss based on identifying fundamental causes—problems in motives, means and social situation—and test these influences in a longitudinal, randomized comparison of housing alternatives. As hypothesized, individuals were more likely to lose housing if they had a history of alcohol or drug abuse, desired strongly to live independently contrary to clinician recommendations, or were African Americans placed in independent housing. Deficits in daily functioning did not explain these influences, but contributed to risk of housing loss. Our results demonstrate the importance of substance abuse, the value of distinguishing support preferences from support needs, and the necessity of explaining effects of race within a social context and thus should help to improve comparative research.

Nonadherence for first-episode schizophrenia is a major unsolved challenge. The long-acting injectable route is an appealing strategy, but there are concerns about acceptability. We report on acceptance and initial adherence outcomes with risperidone long-acting injection (RLAI) in first-episode schizophrenia patients.We conducted a prospective randomized controlled trial in which we enrolled patients defined by appropriate Structured Clinical Interview for DSM-IV diagnosis andor = 16 weeks of lifetime antipsychotic exposure. Participants were randomly assigned (2:1 ratio) to a recommendation of changing to RLAI versus continuing on oral therapy (ORAL). Nonadherence behavior was defined as a medication gapor = 14 days. Adherence attitudes were determined by the Rating of Medication Influences (ROMI) scale. A priori analysis defined treatment groups as intent-to-treat (ITT) and as-actually-treated (AAT) for the first 12 weeks after initial randomization. Participants were enrolled from December 2004 to March 2007.Of 46 eligible patients, 37 were randomly assigned, 11 to ORAL and 26 to RLAI. Nineteen of 26 patients (73%) accepted the RLAI recommendation. There were no differences in adherence behavior at 12 weeks based on initial randomization (Kaplan-Meier survival for ITT: 76% [95% CI, 35%-90%] adherent for RLAI vs 72% [95% CI, 55%-89%] for ORAL; log-rank P = .78), but patients accepting RLAI were significantly more likely to be adherent than patients staying on ORAL (AAT: 89% [95% CI, 64%-97%] adherent for RLAI vs 59% [95% CI, 32%-78%] for ORAL; log-rank P = .035). There were no ROMI attitude differences between either treatment group comparison at 12 weeks.Most first-episode patients taking oral antipsychotics will accept a recommendation of RLAI therapy. On the basis of initial randomization status, an RLAI recommendation did not affect adherence behavior at 12 weeks. However, acceptance of RLAI was associated with significantly better adherence. Regardless of whether RLAI is recommended or accepted, there is no adverse impact on subsequent medication attitudes at 12 weeks. These results support the feasibility and acceptability of introducing RLAI as a treatment option for first-episode schizophrenia patients.clinicaltrials.gov Identifier: NCT00220714.

Objective: To test the influence of neurocognitive functioning on community functioning among formerly homeless persons with serious mental illness and to determine whether that influence varies with social context, independent of individual characteristics. Methods: In metropolitan Boston, 112 persons in Department of Mental Health shelters were administered a neuropsychological test battery and other measures and then randomly assigned to empowerment-oriented group homes or independent apartments, as part of a longitudinal study of the effects of housing on multiple outcomes. Subjects’ case managers completed Rosen's 5-dimensional Life Skills Inventory at 3, 6, 12, and 18 months and subjects reported on their social contacts at baseline, 6, 12, and 18 months. Subject characteristics are controlled in the analysis. Results: Three dimensions of neurocognitive functioning—executive function, verbal declarative memory, and vigilance—each predicted community functioning. Better executive function predicted improved self-care and less turbulent behavior among persons living alone, better memory predicted more positive social contacts for those living in a group home, and higher levels of vigilance predicted improved communication in both housing types. Conclusion: Neurocognition predicts community functioning among homeless persons with severe mental illness, but in a way that varies with the social context in which community functioning occurs.

The authors tested the hypotheses that neuropsychological functioning would improve after homeless persons with severe and persistent mental illness were provided with housing and that executive functioning would improve more among those placed in group homes than among those placed in independent apartments. A total of 114 persons with serious and persistent mental illness who were stable residents of homeless shelters completed neuropsychological testing and were randomly assigned to group homes or independent apartments; 91 participants (52 assigned to group homes and 39 assigned to independent apartments) were retested after 18 months. Overall neuropsychological functioning improved significantly across the full study sample. Executive performance, measured by the Wisconsin Card Sorting Test, decreased significantly among persons assigned to independent apartments and increased, but not significantly, among those assigned to group homes. The findings suggest that providing housing for persons who have severe and persistent mental illness improves cognitive functioning but that independent living may diminish executive functioning.

The study examined the influence of group or individual housing placement and consumer characteristics on the number of days subsequently homeless among formerly homeless mentally ill persons.A total of 303 homeless shelter residents with severe mental illness were screened for dangerousness, 118 were randomly assigned to either independent apartment or staffed group living sites, and 110 were followed for 18 months. Study participants' sociodemographic characteristics, diagnosis, and residential preferences and the residential recommendations made by clinicians were measured at baseline.Overall, 76 percent of the study participants were housed at the end of the 18-month follow-up period, although 27 percent had experienced at least one episode of homelessness during the period. The number of days homeless was greater for individuals assigned to independent apartments than for those placed in staffed group homes, but only for members of minority groups. Substance abuse was the strongest individual-level predictor of days homeless. Individuals whom clinicians identified as needing group living experienced more days homeless, irrespective of the type of housing they received. Consumers who stated a strong preference for independent living had more days homeless than those who were amenable to staffed group homes.Although consumers more frequently prefer independent living, placement in staffed group housing resulted in somewhat fewer days homeless for some groups of consumers. Further experience of homelessness by formerly homeless mentally ill individuals may be reduced by providing effective substance abuse treatment and by paying special attention to consumers identified by clinicians to be at particular risk for housing loss.

The novel antipsychotic medications clozapine and olanzapine provide well-documented clinical improvement for some patients with psychosis. We interviewed 15 patients with chronic psychosis who demonstrated significant improvement on these new medications and offer a conceptual framework to organize their narratives. In our conceptual model, our patients' descriptions are divided into three broad areas: sense of self, sense of connection, and sense of purpose. We also highlight the opportunities for psychotherapy with this population.

The disconfirmation model is used to specify hypotheses about the effect of housing type and housing preferences, of clinical status, social characteristics and personality on satisfaction with housing and with life. These hypotheses are tested with data collected from homeless mentally ill shelter users who were randomly assigned to either group or individual housing. As hypothesized, subjects were more satisfied with their residential accommodations after moving into permanent housing and liked independent housing more than group living. Housing satisfaction did not vary as a consequence of the discrepancy between type of housing preferred and obtained. Life satisfaction was related to personality measures but was not affected by the move into housing or by the type of housing obtained. These findings highlight the limits of applicability of the disconfirmation model, the need to treat satisfaction as multidimensional, and the importance of personality in explaining more general aspects of satisfaction.

OBJECTIVE Most homeless persons who have received services for serious mental illness want to live on their own, but mental health professionals usually recommend group housing. This study examined the relationship between the types of residential arrangements preferred by homeless mentally ill persons and their demographic and clinical characteristics and perceptions of their health and functional status. METHODS The study sample consisted of 118 homeless mentally ill persons living in publicly funded shelters in Boston who were enrolled in a research demonstration project that would provide them with housing. Before random assignment to housing, study participants were interviewed about their interest in moving, in staff support, and in living with others. Their clinical status and functional strengths and impairments were assessed using a variety of objective and subjective measures. RESULTS Study participants reported a marked preference for independent living but expressed substantial interest in staff support. The desire for independent living was associated with a perceived ability to manage independent living, but was also associated with current substance abuse. Most indicators of clinical status and functional ability were not associated with housing preferences. CONCLUSIONS Self-perceived functional ability may not be an influence on housing preferences, except when that ability is perceived as making independent living more difficult. Symptoms of mental illness did not appear to interfere with study participants' rational decision making about where to live. However, the study finding that substance abusers expressed a desire for independent living suggests the need for caution in adhering to homeless mentally ill persons' housing preferences, given the problems posed by substance abuse for their ability to maintain stable community housing.

There is little data about the role of psychiatrists within CMHCs. To gain perspective on this issue, job descriptions for medical directors and staff psychiatrists were collected from 214 CMHCs. The data demonstrated that most CMHCs want fully trained psychiatrists involved in a variety of activities in addition to prescribing medication. Policy development was specifically included as part of the medical director's job for 69% of the CMHC's, and 50% mentioned training as part of the staff psychiatrist's job. Although job descriptions may not accurately reflect the actual roles of the psychiatrist in all cases, these data suggest that CMHCs support a multifaceted role for their psychiatrists.

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.

Despite the AIDS epidemic's impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.

Clinicians who work with homeless people are likely to encounter a very broad spectrum of mental disorders and residential patterns. As with any other patient population, the particulars of clinical interventions must be guided by the specific constellations of biological, psychological, and social needs. However, for individuals who not only suffer from serious psychiatric disorders, but are also homeless, effective approaches may require significant modifications of traditional techniques and changes in the prioritization, timing, and framing of specific interventions. In this article we will focus on people who are severely and persistently mentally ill and who have been sleeping for months or years in shelters or in public spaces such as parks, streets, and bus terminals.

There is a subpopulation of the seriously mentally ill who remain acute care recidivists, rarely becoming engaged in follow-up treatment. It has been argued that these individuals are system, rather than treatment resisters. The perceptions they have of their problems are often in conflict with staff evaluations, or with what the system has to offer. In the present study, patients who dropped out of residential care against staff's advice were compared to patients who remained in treatment. The results suggest that the greater the difference between the perceptions a patient and therapist have concerning the patient's problem, the greater the likelihood of the patient dropping out of treatment.

Social and cultural issues may have a profound impact on different populations' responses to the AIDS epidemic. To maximize their own effectiveness, clinicians need to be aware of special needs and concerns.

In the early 1990s the National Institute of Mental Health sponsored projects in four cities that served a total of 896 homeless mentally ill adults. Each project tested the effectiveness of different housing, support, and rehabilitative services in reducing homelessness. Most homeless individuals resided in community housing after the intervention. The proportion in community housing varied between sites. A 47.5 percent increase in community housing was found for those in active treatment conditions. At final follow-up, 78 percent of participants in community housing were stably housed. The findings indicate that effective strategies are available for serving homeless individuals with severe mental illness.

Objective To test the effect of living in group housing rather than independent apartments on executive functioning, verbal memory and sustained attention among formerly homeless persons with serious mental illness and to determine whether substance abuse modifies this effect. Method In metropolitan Boston, 112 persons in Department of Mental Health shelters were randomly assigned to group homes (“Evolving Consumer Households”, with project facilitator, group meetings, resident decision-making) or independent apartments. All were case managed. A neuropsychological test battery was administered at baseline, at 18 months (Time 2), with an 81% follow-up rate, and at 48 months (Time 3), with a 59% follow-up rate. Hierarchical Linear Modeling was applied to executive functioning—assessed with the Wisconsin Card Sorting Test (Perseverations)—Logical Memory story recall, and an auditory Continuous Performance Test (CPT) for sustained attention. Subject characteristics were controlled. Results When moved to group homes, subjects without a lifetime substance abuse history improved on Perseverations, while those who moved to independent apartments deteriorated on Perseverations. Across the two housing conditions, subjects showed no change in Perseverations, but improved on Logical Memory story recall and the CPT. Conclusions Type of housing placement can influence cognitive functioning; notably, socially isolating housing is associated with weakened executive functioning. Substance abuse significantly diminishes environmental effects. These are important factors to consider in housing placement and subsequent treatment.

Prior research indicates that homeless consumers of mental health services have a marked preference for independent living, while clinicians tend to recommend staffed, group housing. In order to understand this divergence and identify its consequences for mental health policy, we test influences on housing preferences suggested by rational choice and social structural perspectives. We use a randomized field trial of independent and group housing to identify the consequences for subsequent housing loss and consumer functioning of consumer- and clinician-determined housing placements. We find that consumer preference at baseline for independent living indicates greater vulnerability to housing loss, but the bases of preferences change after consumers gained experience with stable housing. We interpret the results as indicating the contingent rationality of preferences and the susceptibility of preferences to change with experience.

Housing recommendations made by two clinicians for 86 homeless mentally ill consumers were compared with the consumers' own housing preferences. Clinicians recommended independent living much less often than did the consumers. The two groups varied less on specific housing features such as eagerness for consumers to leave the shelter and consumers' need for part-time staff help. Only one of the clinicians took into account some aspects of social background and health status in formulating housing recommendations. The authors conclude that housing providers should encourage clinicians to work together with consumers to identify appropriate placements.

Quality of care is widely assumed to be related to patient outcomes, but little is known about care in relation to outcomes in county general hospital psychiatric emergency services. It was hypothesized that conformity to professional standards (technical quality) and engagement of the patient (artful care) in psychiatric emergency services evaluations would contribute to improved patient functioning (Global Assessment Scale score) and appropriate disposition. A total of 583 cases in seven facilities were analyzed. Conformity to technical standards of care was associated with retention even after constraints, biases, and admission criteria had been taken into account. Conversely, artful care was associated with lower probability of retention and improved functioning.

Treatment Alternatives for Dually Diagnosed (TADD) was developed to address the need for criminal justice diversion of seriously mentally ill substance-using felons and persistent misdemeanants. The population served by the TADD program and key elements of the program are described, including identification, screening and assessment, specialized court processing and judicial oversight, case management monitoring, joint case conferencing between community and monitoring staff, enforcement, and key stakeholder collaboration. One hundred and thirteen clients diverted by the TADD program were followed for six months. A description is provided of these clients, the community services accessed, as well as the monitoring of clients drug use. During six months of program involvement 87% remained connected to the diversion team, 80% remained in community treatment and the majority took advantage of the rich service environment created through TADD's case management linkage services. The majority of these clients tested drug-free during this six-month period.

Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Although placement in community housing is a frequent intervention with populations of seriously mentally ill homeless individuals, there has been little formal investigation of the criteria used by clinicians in screening individuals for such placement. In this paper, we describe screening a population of 303 homeless people with severe mental illness for placement in independent apartments. We assess subjects' level of risk along multiple dimensions and determine the contribution of each risk dimension to the final safety decision. In addition, we evaluate the validity of the risk measures with other measures of clinical condition. Two-thirds of the sample were judged as safe for independent living. Assaultiveness was the most frequent risk identified, followed by self-destructiveness, substance abuse, and medication non-compliance. The final safety decision was associated most strongly with assaultiveness, self-destructiveness, and medication non-compliance. We conclude that it is possible to assess risk with measures that are available from shelter and medical records, and call for more research on the role of medication non-compliance in safety decisions and for longitudinal research to validate risk assessments.

Objective The study examined patterns of mental health service use among 112 formerly homeless mentally ill adults to determine whether clients in a staffed group living situation would need fewer types of services or lesser amounts of some services than those living independently in single apartments. Methods Clients in the Boston McKinney demonstration project were randomly assigned to two housing types: individual apartments or a group living situation designed to teach residents to manage the house and their own affairs with minimal staff presence. The types and amounts of services these clients used during an 18-month period were documented and compared. Results Service use by all clients was heavy, especially use of inpatient psychiatric services. It did not differ by housing type. The large majority of clients in both housing types were able to remain housed and avoid homelessness. Clients who did not stay in assigned housing for the duration of the study had higher levels of inpatient service use, including detoxification and substance abuse treatment. Conclusions When homeless mentally ill adults are provided permanent housing and accessible mental health treatment and specialized social services, they are likely to avoid unstable housing patterns, which are associated with higher use of inpatient services.

Objectives: The study examined the usefulness of a three-perspective model for determining the quality of evaluations in psychiatric emergency services. The model was used to evaluate the hypothesis that the provision of high- quality care in emergency services is primarily influenced by service objectives related to patients' clinical characteristics rather than by institutional constraints, such as workload or physical facilities, or by social biases, such as clinicians' attitudes toward patients or perceptions of community expectations. Methods: The evaluations of 683 persons assessed in nine California public facilities were independently observed. Multivariate techniques were used to test the relative importance of patients' clinical characteristics, possible sources of social bias among clinicians, and institutional constraints in influencing three quality-of- care dimensions: technical quality, the art of patient care, and optimum investment of time. Results: The findings generally confirmed the hypothesis that patients' clinical characteristics have more influence on the quality of care provided than institutional constraints or social biases. However, one institutional constraint increased workload demands-led to reduced technical quality and to less than optimal use of time. Further, social biases reflected in the clinician's like for and preconceptions about the patient also influenced the quality of their evaluations. Conclusions: The model is a useful tool for examining quality of care in the psychiatric emergency service. Increasing workload pressures negatively affect quality of care.

With the increasing incidence of HIV infection, the role of mental health practitioners will extend far beyond the care of those directly affected by the epidemic.

(2001) Br J Gen Pract 51, 730. Kai J, Crosland A . . . Perspectives of people with enduring mental ill health from a community-based qualitative study. . Sep; . : . –6 . [OpenUrl][1][Abstract/FREE Full Text][2] QUESTION: How do people with enduring mental health problems experience health care? Community based qualitative study. 4 general practices serving a disadvantaged locality of 5 wards in {Newcastle upon Tyne}*, UK. 32 people (56% men, mean duration of mental illness of 21 y) who were identified by their general practitioner as disabled by enduring mental ill health (≥2 y impaired social behaviour and inability to keep a job, maintain self care, complete domestic chores, or participate in recreational activities). Exclusion criteria were age

A subgroup of chronic mentally ill persons who have had little or no state hospitalization and who are difficult to engage in existing systems of community care is emerging in major urban areas. Observations made at a large municipal general hospital indicate the patients are typically young, more likely to be male, and highly transient. They have frequent interactions with emergency psychiatric and crisis units, coupled with intermittent involuntary short-term stays in local inpatient units. They have few skills and virtually no natural support systems. Under stress they show disorders in reality testing, exhibit anger and depression, and are prone to impulsive aggressive and self-destructive behaviors. They are typically unwilling to voluntarily accept continuing care. There is a lack of fit between this group's characteristic style of interaction and existing community-based programs. The costs of this lack of fit, both in staff morale and inappropriate use of expensive services, make the exploration of approaches to these "new chronic patients" a matter of immediate importance.

cussed. A program designed to meet the needs of this population is described, and further programmatic and policy considerations to respond to the problem of homelessness are advocated. Homeless individuals suffer from multiple needs in many spheres. In addition to a lack of adequate shelter, they frequently have difficulty obtaining adequate food and clothing. Also, homeless people face the problems that caused or contributed to their homelessness, and from other prob lems that result from being homeless. This article describes an effort to under stand and respond to the medical and psychiatric needs of the homeless. San Fran cisco began organizing a service delivery system for its homeless people in October 1982 when a group of agencies that serve this population met to coordinate services. Mayor Diane Feinstein appointed a task force to advise her on issues involving the home less, and out of the task force grew a work ing group of service providers, known as the Shelter Providers Coalition. The Shelter Pro viders Coalition has a broad membership, in cluding representatives from agencies as diverse as the Social Security Administration, the Veterans Administration Hospital, veterans' and welfare rights groups, the mayor's office, all city shelters, San Francisco General Hospital (SFGH), San Francisco Community Mental Health Services, and the San Francisco Department of Public Health.

Case reports show how system breakdowns impede continuity of care for young adult chronic patients and how these fragmentation prototypes can affect individual patients.

Decisions facing the psychiatric emergency room clinician cannot be addressed without examining the history, context, and meaning of our work.

Patients who overutilize acute care services are responding to systemic as well as to individual difficulties. Designing a service system for these patients requires us to rethink our approach to care delivery on many dimensions.

• Critics of the dangerousness standard for civil commitment contend that there is no professional standard for the evaluation of dangerousness. We used Three Ratings of Involuntary Admissibility, a reliable index of behavioral indicators of danger to self, danger to others, and grave disability, and found that when combined into weighted patterns these indicators predicted disposition decisions of 70 clinicians in five psychiatric emergency rooms over 251 cases. A concurrent measure of perceived dangerousness, Clinician's Global Ratings of patients on these criteria, yielded similar results. We conclude that clinicians in California psychiatric emergency rooms apply a shared concept of dangerousness that can be described in behavioral terms.

In 251 evaluations observed in five California public psychiatric emergency rooms, patients who were retained, whether new to the system or having histories of hospitalization, rated higher on measures of danger to self, danger to others, and grave disability than patients who were released. They were also more severely symptomatic and more often given major diagnoses. The combination of dangerousness and mental disorder predicted disposition for 93% of new patients and 88% of recidivist patients. Impulsivity was the most influential aspect of mental disorder. © 1988, American Medical Association. All rights reserved.