Showing papers in "Psychiatric Services in 2006"

Transformational and Transactional Leadership: Association With Attitudes Toward Evidence-Based Practice

Abstract: Objective: Leadership in organizations is important in shaping workers’ perceptions, responses to organizational change, and acceptance of innovations, such as evidence-based practices. Transformational leadership inspires and motivates followers, whereas transactional leadership is based more on reinforcement and exchanges. Studies have shown that in youth and family service organizations, mental health providers’ attitudes toward adopting an evidence-based practice are associated with organizational context and individual provider differences. The purpose of this study was to expand these findings by examining the association between leadership and mental health providers’ attitudes toward adopting evidence-based practice. Methods: Participants were 303 public-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, adolescents, and their families. Data were gathered on providers’ characteristics, attitudes toward evidence-based practices, and perceptions of their supervisors’ leadership behaviors. Zero-order correlations and multilevel regression analyses were conducted that controlled for effects of service providers’ characteristics. Results: Both transformational and transactional leadership were positively associated with providers’ having more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers’ perception of difference between the providers’ current practice and evidence-based practice. Conclusions: Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices. (Psychiatric Services 57:1162–1169, 2006)

Shared decision making and medication management in the recovery process.

Abstract: Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence. The authors argue that compliance is an inadequate construct because it fails to capture the dynamic complexity of autonomous clients who must navigate decisional conflicts in learning to manage disorders over the course of years or decades. Compliance is rooted in medical paternalism and is at odds with principles of personcentered care and evidencebased medicine. Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts. It requires a partnership between two experts: the client and the practitioner. Shared decision making provides a model for them to assess a treatment’s advantages and disadvantages within the context of recovering a life after a diagnosis of a major mental disorder. (Psychiatric Services 57: 1636–1639, 2006) A lthough the exact definitions of compliance and noncompliance remain a topic of debate, Weiden and Rao (1) suggested that the most common definition of the word is “a deviation or cessation of a medication regimen that is less than what was recommended by the doctor.” Compliance interventions are often designed to increase clients’ behavioral conformity to a practitioner’s view of optimal treatment. Shared decision making diverges radically from compliance because it assumes that two experts—the client and the practitioner—must share their respective information and determine collaboratively the optimal treatment. Contemporary evidence-based approaches to the management of long-term medical illnesses are based on the process of shared decision making. Similarly high standards should be adopted in psychiatry. In this Open Forum, we present a rationale for adoption of the shared decision-making approach in psychiatry from both the client and practitioner points of

The top ten concerns about recovery encountered in mental health system transformation.

Abstract: The notion of "recovery" has recently taken center stage in guiding mental health policy and practice. However, it is not yet clear what the term means and what is to be entailed in transforming the nation's mental health system to promote it. The authors discuss the various meanings of recovery as applied to mental illness and list the top ten concerns encountered in efforts to articulate and implement recovery-oriented care. These concerns include the following: recovery is old news, recovery-oriented care adds to the burden of already stretched providers, recovery involves cure, recovery happens to very few people, recovery represents an irresponsible fad, recovery happens only after and as a result of active treatment, recovery-oriented care is implemented only through the addition of new resources, recovery-oriented care is neither reimbursable nor evidence based, recovery-oriented care devalues the role of professional intervention, and recovery-oriented care increases providers' exposure to risk and liability. These concerns are addressed through discussion of the two over-arching challenges that they pose, namely the issues of resources and risk.

On Your Own Without a Net: The Transition to Adulthood for Vulnerable Populations

Abstract: In the decade after high school, young people continue to rely on their families in many ways - sometimes for financial support, sometimes for help with child-care, and sometimes for continued shelter. But what about those young people who confront special difficulties during this period, many of whom can count on little help from their families? "On Your Own Without a Net" documents the special challenges facing seven vulnerable populations during the transition to adulthood: former foster care youth, youth formerly involved in the juvenile justice system, youth in the criminal justice system, runaway and homeless youth, former special education students, young people in the mental health system, and youth with physical disabilities. During adolescence, government programs have been a major part of their lives, yet eligibility for most programs typically ends between the ages of eighteen and twenty-one. This critical volume shows the unfortunate repercussions of this termination of support and points out the issues that must be addressed to improve these young people's chances of becoming successful adults.

Mortality and medical comorbidity among patients with serious mental illness.

Abstract: OBJECTIVES This study examined mortality and medical comorbidity among patients with serious mental illness in Ohio. METHODS Data for 20,018 patients admitted to an Ohio public mental health hospital between 1998 and 2002 were matched against state death records, and 608 deaths were identified. Leading causes of death and medical comorbidities, years of potential life lost (YPLL), and standardized mortality ratios were calculated for this population. RESULTS Heart disease (126 persons, or 21 percent) and suicides (108 persons, or 18 percent) were the leading causes of death. The mean+/-SD number of YPLL was 32.0+/-12.6 years. The highest cause-specific mean YPLL was for suicides (41.7+/-10.3 years). Deaths from unnatural causes had higher mean YPLL than deaths from any other causes. Cause-specific mean YPLL were higher for women than for men, except for homicides, pneumonia and influenza, and heart disease. The aggregated standardized mortality ratio from all causes of death was 3.2, corresponding to 417 excess deaths (p<.001). Obesity (144 persons, or 24 percent) and hypertension (136 persons, or 22 percent) were the most prevalent medical comorbidities. CONCLUSIONS This study demonstrated excess mortality among patients in Ohio with serious mental illness. Results highlight the need to integrate delivery of currently fragmented mental and physical health services and to target interventions that improve quality-of-life outcomes for this population.

Collaborative Care for Bipolar Disorder: Part II. Impact on Clinical Outcome, Function, and Costs

Abstract: Methods: The intervention was designed to improve outcome by enhancing patient self-management skills with group psychoeducation; providing clinician decision support with simplified practice guidelines; and improving access to care, continuity ofcare, and information flowvianurse carecoordinators.Inaneffectiveness design veterans with bipolardisorder at11 Veterans Affairs hospitals were randomly assigned to three years of care in the intervention or continued usual care. Blinded clinical and functional measures were obtained every eight weeks. Intention-to-treat analysis (N5306) with mixed-effects models addressed the hypothesis that improvements would accrue over three years, consistent with social learning theory. Results: The intervention significantly reduced weeks in affective episode, primarily mania. Broad-based improvements were demonstrated in social role function, mental quality of life, and treatment satisfaction. Reductions in mean manic and depressive symptoms were not significant. The intervention was cost-neutral while achieving a net reduction of 6.2 weeks in affective episode. Conclusions: Collaborative chronic care models can improve some long-term clinical outcomes for bipolar disorder. Functional and quality-of-life benefits also were demonstrated, with most benefits accruing in years 2 and 3.

Transforming Mental Health Care at the Interface With General Medicine: Report for the Presidents Commission

Abstract: This paper is based on a report commissioned by the Subcommittee on Mental Health Interface With General Medicine of the Presidents New Freedom Commission on Mental Health. Although mental and medical conditions are highly interconnected, medical and mental health care systems are separated in many ways that inhibit effective care. Treatable mental or medical illnesses are often not detected or diagnosed properly, and effective services are often not provided. Improved mental health care at the interface of general medicine and mental health requires educated consumers and providers; effective detection, diagnosis, and monitoring of common mental disorders; valid performance criteria for care at the interface of general medicine and mental health; care management protocols that match treatment intensity to clinical outcomes; effective specialty mental health support for general medical providers; and financing mechanisms for evidence-based models of care. Successful models exist for improving the collaboration between medical and mental health providers. Recommendations are presented for achieving high-quality care for common mental disorders at the interface of general medicine and mental health and for overcoming barriers and facilitating use of evidence-based quality improvement models.

Employment Barriers for Persons With Psychiatric Disabilities: Update of a Report for the President's Commission

Abstract: A major public policy problem is the extremely low labor force participation of people with severe mental illness coupled with their overrepresentation on the public disability rolls. This situation is especially troubling given the existence of evidence-based practices designed to return them to the labor force. This article reviews research from the fields of disability, economics, health care, and labor studies to describe the nature of barriers to paid work and economic security for people with disabling mental disorders. These barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, labor force discrimination, failure of protective legislation, work disincentives caused by state and federal policies, poverty-level income, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. The article concludes with a discussion of current policy initiatives in health care, mental health, and disability. Recommendations for a comprehensive system of services and supports to address multiple barriers are presented. These include access to affordable health care, including mental health treatment and prescription drug coverage; integrated clinical and vocational services; safe and stable housing that is not threatened by changes in earned income; remedial and post-secondary education and vocational training; benefits counseling and financial literacy education; economic security through asset development; legal aid for dealing with employment discrimination; peer support and self-help to enhance vocational self-image and encourage labor force attachment; and active involvement of U.S. business and employer communities.

Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness.

Abstract: The Sequential Intercept Model provides a conceptual framework for communities to use when considering the interface between the criminal justice and mental health systems as they address concerns about criminalization of people with mental illness. The model envisions a series of points of interception at which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system. Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point. The interception points are law enforcement and emergency services; initial detention and initial hearings; jail, courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons, and forensic hospitalization; and community corrections and community support. The model provides an organizing tool for a discussion of diversion and linkage alternatives and for systematically addressing criminalization. Using the model, a community can develop targeted strategies that evolve over time to increase diversion of people with mental illness from the criminal justice system and to link them with community treatment.

Evaluation Methodology Basics: The Nuts and Bolts of Sound Evaluation

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Trends in the Use of Psychotropic Medications Among Adolescents, 1994 to 2001

Abstract: OBJECTIVES: Few psychotropic medications are approved for use among children younger than 18 years. Yet previous studies have shown an increase in the use of psychotropic medications among school-a...

Crisis intervention team training for police officers responding to mental disturbance calls.

Abstract: Objectives: In recognition of the fact that police are often the first responders for individuals who are experiencing a mental illness crisis, police departments nationally are incorporating specialized training for officers in collaboration with local mental health systems. This study examined police dispatch data before and after implementation of a crisis intervention team (CIT) program to assess the effect of the training on officers’ disposition of calls. Methods: The authors analyzed police dispatch logs for two years before and four years after implementation of the CIT program in Akron, Ohio, to determine monthly average rates of mental disturbance calls compared with the overall rate of calls to the police, disposition of mental disturbance calls by time and training, and the effects of techniques on voluntariness of disposition. Results: Since the training program was implemented, there has been an increase in the number and proportion of calls involving possible mental illness, an increased rate of transport by CIT-trained officers of persons experiencing mental illness crises to emergency treatment facilities, an increase in transport on a voluntary status, and no significant changes in the rate of arrests by time or training. Conclusions: The results of this study suggest that a CIT partnership between the police department, the mental health system, consumers of services, and their family members can help in efforts to assist persons who are experiencing a mental illness crisis to gain access to the treatment system, where such individuals most often are best served. (Psychiatric Services 57:232–237, 2006)

Brief reports: crisis intervention team training: changes in knowledge, attitudes, and stigma related to schizophrenia.

Abstract: Objective: Crisis intervention team (CIT) training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses. This study determined changes in knowledge, attitudes, and social distance related to schizophrenia among police officers after CIT training. Methods: A survey was administered to 159 officers immediately before and after a 40-hour CIT training program in Georgia. Pre- and posttest data were gathered from surveys taken between December 2004 and July 2005. Results: After the training, officers reported improved attitudes regarding aggressiveness among individuals with schizophrenia, became more supportive of treatment programs for schizophrenia, evidenced greater knowledge about schizophrenia, and reported less social distance toward individuals with schizophrenia. Conclusions: This study supports the hypothesis that an educational program for law enforcement officers may reduce stigmatizing attitudes toward persons with schizophrenia. (Psychiatric Services 57:1199–1202, 2006)

Effects of Attributing Serious Mental Illnesses to Genetic Causes on Orientations to Treatment

Abstract: OBJECTIVE: Professional services for persons with serious mental illnesses are underutilized. The genetics revolution has the potential to increase professional help seeking by increasing biomedical interpretations of mental illness among the public. The objective of this study was to assess whether genetic attributions for serious mental illnesses are associated with more positive orientations to professional treatment among members of the general public. METHODS: Data from two nationally representative surveys were analyzed. First, associations between perceptions of genetic causes of both schizophrenia and depression and treatment recommendations and perceived treatment effectiveness were assessed in a vignette study that was part of the 1996 General Social Survey (GSS). Second, the effect of various descriptions of the role of genetic factors in schizophrenia and depression on perceived treatment effectiveness was assessed in a vignette experiment conducted in 2002-2003. RESULTS: Perception of genetic...

Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization.

Abstract: OBJECTIVE This is the first cross-national population-based investigation exploring the prevalence and functional implications of comorbid general medical disorders in bipolar disorder. METHODS Data were extracted from the Canadian Community Health Survey (N = 36,984). Analyses were conducted to ascertain the prevalence and prognostic implications of predetermined comorbid general medical disorders among persons who screened positive for a lifetime manic episode (indicative of a diagnosis of bipolar disorder). Within the subpopulation of people who screened positive for a manic episode, the effect of medical comorbidity on employment, functional role, psychiatric care, and medication use was examined. RESULTS When the data were weighted to be representative of the household population of the ten provinces in 2002, an estimated 2.4 percent of respondents screened positive for a lifetime manic episode. Rates of chronic fatigue syndrome, migraine, asthma, chronic bronchitis, multiple chemical sensitivities, hypertension, and gastric ulcer were significantly higher in the bipolar disorder group (all p < .05). Chronic medical disorders were associated with a more severe course of bipolar disorder, increased household and work maladjustment, receipt of disability payments, reduced employment, and more frequent medical service utilization. CONCLUSIONS Comorbid medical disorders in bipolar disorder are associated with several indices of harmful dysfunction, decrements in functional outcomes, and increased utilization of medical services.

Racial differences in stigmatizing attitudes toward people with mental illness.

Abstract: Objective: Stigma is a significant impediment to the successful treatment of individuals with mental illness, especially among racial minority groups. Although limited, the literature suggests that African Americans are more likely than Caucasians to believe that people with mental illnesses are dangerous. The authors reexamined this issue and assessed whether racial differences also extend to beliefs about how people with mental illness should be treated if violent. Methods: A nationally representative probability sample of 1,241 respondents participated in a telephone survey. The analysis focused on the 81 African-American and 590 Caucasian respondents who participated in a vignette experiment about a person with schizophrenia or major depressive disorder. The authors analyzed respondents’ perceptions that the person would be violent, as well as their attitudes about blame and punishment. Results: African Americans were more likely than Caucasians to believe that individuals with schizophrenia or major depression would do something violent to other people. At the same time they were less likely to believe these individuals should be blamed and punished for violent behavior. These racial differences were not attributable to sociodemographic factors. Conclusions: The study found racial differences in stigmatizing attitudes toward individuals with mental illness; however, African Americans’ negative perception did not necessarily result in endorsement of harsher treatment of mentally ill persons. This study highlights the complexity of the stigma process and emphasizes the need to consider racial differences in developing interventions targeted to improve public attitudes. (Psychiatric Services 57:857–862, 2006)

Toward Evidence-Based Practice for Probationers and Parolees Mandated to Mental Health Treatment

Abstract: OBJECTIVES: Many individuals with serious mental illness are on probation or parole. These individuals are twice as likely as those without mental illness to fail on supervision—that is, to have their community term revoked for a technical violation or a new offense. This article reviews a small but growing body of research on this problem and on practices designed to respond to it. METHODS: Eight publication databases were searched for articles in English published between January 1975 and April 2005 that focused on adult probationers or parolees with mental illness. Unpublished evaluations were also included. RESULTS: Three studies suggest that the link between mental illness and supervision failure is indirect and complex. A national survey of probation described five key features of specialty agencies, where offenders with mental illness are assigned to officers with relatively small caseloads. Two studies suggest that stakeholders perceive specialty caseloads as more effective than traditional caselo...

Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001.

Abstract: OBJECTIVE: The authors surveyed a sample of Project Liberty crisis counseling recipients approximately 1.5 years after the terrorist attacks on September 11, 2001, to determine the proportion of respondents who screened positive for complicated grief, a recently identified condition marked by symptoms of continuing separation distress and accompanying bereavement-related traumatic distress. METHODS: A total of 149 service recipients drawn from eight high-volume providers responded to a telephone survey that included questions to screen for complicated grief. RESULTS: Approximately half of the recipients knew someone who had been killed in the attacks. Of those recipients, 44 percent screened positive for complicated grief. Individuals who lost a family member were more likely than those who lost an acquaintance to screen positive for complicated grief. Positive screens were associated with functional impairment independent of the presence of symptoms consistent with full or subthreshold major depression or posttraumatic stress disorder (PTSD). Thirty-two percent of those who screened positive for complicated grief did not meet even subthreshold criteria for major depression or PTSD. CONCLUSIONS: Results affirmed the importance of complicated grief as a unique condition and indicated the need to attend to the psychological consequences of bereavement in disaster-related mental health services. Language: en

Self-stigma, empowerment, and perceived legitimacy of discrimination among women with mental illness.

Abstract: OBJECTIVE: The study sought to better understand why some people with mental illness self-stigmatize and develop low self-esteem while others remain indifferent to stigma or respond with a sense of empowerment. The authors hypothesized that a high level of perceived discrimination, little sense of identification with the group of people with mental illness, and a high level of perceived legitimacy of discrimination lead to self-stigma. METHODS: Sixty women with borderline personality disorder and 30 women with social phobia, who were recruited at three centers in Germany and Switzerland, completed stigma-related questionnaires. RESULTS: After depression and index diagnosis were controlled for, a low level of perceived discrimination and of the legitimacy of discrimination predicted high self-esteem and high empowerment. Identification with the group of people with mental illness did not predict self-esteem or empowerment. CONCLUSIONS: Perceived legitimacy of discrimination may be a crucial determinant of ...

Comparison of ACT and Standard Case Management for Delivering Integrated Treatment for Co-occurring Disorders

Abstract: OBJECTIVE: Clients with co-occurring severe mental and substance use disorders are at high risk of institutionalization and other adverse outcomes. Although integrated mental health and substance abuse treatment is becoming a standard clinical approach for such clients, the optimal method for delivering integrated treatment remains unclear. METHOD: This study compared integrated treatment delivered within two different models of community-based case management (assertive community treatment and standard clinical case management). A total of 198 clients in two urban sites who had co-occurring disorders and were homeless or unstably housed were randomly assigned to one of two treatment conditions and were followed for three years. RESULTS: Participants in both treatment conditions improved over time in multiple outcome domains, and few differences were found between the two models. Decreases in substance use were greater than would be expected given time alone. At the site that had higher rates of instituti...

The treatment relationship in peer-based and regular case management for clients with severe mental illness.

Abstract: Objective This study compared the quality of treatment relationships and engagement in peer-based and regular case management. It also assessed the value of positive relationship qualities in predicting motivation for and use of community-based services for persons with severe mental illness. Methods One hundred thirty-seven adults with severe mental illness participated in a 2x2 prospective longitudinal randomized clinical trial with two levels of case management intervention (peer and regular) and two interviews (six and 12 months). Self-report questionnaires assessed treatment relationships, motivation, and service use, and providers rated participants' initial engagement and monthly attendance in treatment. Results Participants perceived higher positive regard, understanding, and acceptance from peer providers rather than from regular providers at six months only, with initially unengaged clients showing more contacts with case managers in the peer condition and decreasing contacts in the regular condition. Six-month positive regard and understanding positively predicted 12-month treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings. Conclusions Early in treatment, peer providers may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients and a facility for increasing treatment participation among the most disengaged, leading to greater motivation for further treatment and use of peer-based community services. Findings strongly suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system.

Impact of permanent supportive housing on the use of acute care health services by homeless adults

Abstract: Objectives: This analysis examined the impact of permanent supportive housing on the use of acute care public health services by homeless people with mental illness, substance use disorder, and other disabilities. Methods: The sample consisted of 236 single adults who entered supportive housing at two San Francisco sites, Canon Kip Community House and the Lyric Hotel, between October 10, 1994, and June 30, 1998. Eighty percent had a diagnosis of dual psychiatric and substance use disorders. Administrative data from the city’s public health system were used to construct a retrospective, longitudinal history of service use. Analyses compared service use during the two years before entry into supportive housing with service use during the two years after entry. Results: Eighty-one percent of residents remained in permanent supportive housing for at least one year. Housing placement significantly reduced the percentage of residents with an emergency department visit (53 to 37 percent), the average number of visits per person (1.94 to .86), and the total number of emergency department visits (56 percent decrease, from 457 to 202) for the sample as a whole. For hospitalizations, permanent supportive housing placement significantly reduced the likelihood of being hospitalized (19 to 11 percent) and the mean number of admissions per person (.34 to .19 admissions per resident). Conclusions: Providing permanent supportive housing to homeless people with psychiatric and substance use disorders reduced their use of costly hospital emergency department and inpatient services, which are publicly provided. (Psychiatric Services 57:XXXXXXX, 2006)

Brief Reports: Unequal Treatment: Mental Health Care for Sexual and Gender Minority Groups in a Rural State

Abstract: Objective: This qualitative study examined the social dynamics of communities and clinic settings that impede the delivery of culturally relevant services to lesbian, gay, bisexual, and transgender (LGBT) people living in rural areas. Methods: Ethnographic interviews were conducted with 20 providers in rural areas to document their perceptions of LGBT mental health care. Results: A majority of rural providers claimed that there is no difference between working with LGBT clients and non-LGBT clients. This neutral therapeutic posture may be insufficient when working with rural LGBT clients. Despite providers’ claims of acceptance, lack of education about LGBT mental health issues, and homophobia influenced services for rural LGBT people. LGBT clients had been denied services, discouraged from broaching sexuality and gender issues by providers, and secluded within residential treatment settings. Conclusions: The challenges of ensuring access to quality care for this population are magnified by provider discourses of “therapeutic neutrality.” (Psychiatric Services 57:867– 870, 2006)

Collaborative Care for Bipolar Disorder: Part I. Intervention and Implementation in a Randomized Effectiveness Trial

Abstract: Outcome for bipolar disorder remains suboptimal despite the availability of efficacious treatments. To improve treatment effectiveness in clinical practice, a Veterans Affairs study team created a care model conceptually similar to the lithium clinics of the 1970s but augmented by principles of more recent collaborative care models for chronic medical illnesses. This intervention consists of improving patients' self-management skills through psychoeducation; supporting providers' decision making through simplified practice guidelines; and enhancing access to care, continuity of care, and information flow through the use of a nurse care coordinator. In this article, which is part I of a two-part report, the authors summarize the conceptual background and development of the intervention, describe the design of a three-year, 11-site randomized effectiveness trial, and report data describing its successful implementation. Trial design emphasized aspects of effectiveness to support generalizability of the findings and eventual dissemination of the intervention. Part II (see companion article, this issue) reports clinical, functional, and overall cost outcomes of the trial.

Impact of consumer-operated services on empowerment and recovery of people with psychiatric disabilities

Abstract: Objective: Although the professional literature is replete with descriptions of consumer-operated services, empirical examination of these services has been relatively limited. In this study, the cross-sectional relationship between participation in consumeroperated services and measures of recovery and empowerment is examined. Methods: A total of 1,824 people with psychiatric disability indicated whether they had participated in a peer support program (the proxy of consumer-operated services) during the past four months. They also were administered two five-factor measures of recovery and of empowerment. Results: Participation in peer support was associated with nine of ten factors generated by the recovery and empowerment instruments. These associations remained significant when commensurate demographic variables were controlled for. Conclusions: Participation in peer support showed a significant association with multiple outcome and recovery subscales, but the magnitude of the effect was small. The associative nature of the data precludes stating that peer support caused the observed improvement. (Psychiatric Services 57: 1493–1496, 2006)

Patient functioning and family burden in a controlled, real-world trial of family psychoeducation for schizophrenia.

Abstract: Objective: This study explored the effectiveness of a psychoeducational family intervention for schizophrenia on patients’ personal and social functioning as well as on relatives’ burden and perceived support. Methods: Thirty-four mental health professionals from 17 public mental health centers in Italy selected 71 families of consumers with schizophrenia. Forty-two families were randomly assigned to a group that received the intervention for six months, and 29 families were assigned to a waiting list for six months. At baseline and six months later, validated tools were used to assess patients’ clinical status, personal and social functioning, and social network as well as relatives’ burden, social resources, and perception of professional support. Results: In the intervention group the number of patients with poor or very poor global personal and social functioning decreased significantly, from 17 (47 percent) at baseline to nine (25 percent) at follow-up. A significant improvement was found for the intervention group in patients’ social relationships, interests in obtaining a job, maintenance of social interests, and management of social conflicts. Twenty-seven patients (74 percent) reported that their social relationships had improved during the sixmonth period. For both the intervention and control groups, family burden significantly improved. Relatives’ social contacts and perception of professional support significantly increased only in the intervention group. Conclusions: The results suggest that a psychoeducational family intervention may have a significant impact on functional outcomes of schizophrenia when provided to patients and caregivers in real-world settings. (Psychiatric Services 57:1784–1791, 2006) Special Section: A Memorial Tribute

Effects of Serious Mental Illness and Substance Abuse on Criminal Offenses

Abstract: Objective Some believe serious mental illness has been "criminalized." Effects of serious mental illness and substance abuse on criminal offenses were studied for 113 postbooking jail diversion participants and their nondiverted counterparts. Methods Raters read participants' and police report descriptions of criminal offenses and participants' explanations for them. Using 5-point scales, raters independently estimated whether an offense resulted directly or indirectly from serious mental illness or substance abuse. Results Serious mental illness and substance abuse had little effect on offenses. However, substance abuse led to a sizable minority of offenses and was more likely than mental illness to cause an offense. Conclusions Unless factors unique to serious mental illness can be specifically associated with behavior leading to incarceration, the criminalization hypothesis should be reconsidered in favor of more powerful risk factors for crime that are widespread in social settings of persons with serious mental illness.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers.

Abstract: Objective: Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients. Methods: The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined. Results: About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types. Conclusions: The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness. (Psychiatric