The Classification of Violence Risk.

(Reprinted with permission from 24: 721-730, 2006).

Violence to Others, Violent Self-Victimization, and Violent Victimization by Others Among Persons With a Mental Illness.

Objective: This research examined the frequency of and characteristics associated with three forms of violence among persons with mental illness-violence directed at others, self-directed violence, and violence directed at them by others.

Methods: Previously unreported data from a follow-up sample of 951 patients from the MacArthur Violence Risk Assessment Study were analyzed to characterize involvement in violence directed at others, self-directed violence, and violence directed at them by others.

Results: Most patients (58%) experienced at least one form of violence, 28% experienced at least two forms, and 7% experienced all three forms.

Gun Violence and Victimization of Strangers by Persons With a Mental Illness: Data From the MacArthur Violence Risk Assessment Study.

Objective: Highly publicized incidents in which people with apparent mental illnesses use guns to victimize strangers have important implications for public views of people with mental illnesses and the formation of mental health and gun policy. The study aimed to provide more data about this topic.

Methods: MacArthur Violence Risk Assessment Study data were analyzed to determine the prevalence of violence by 951 patients after discharge from a psychiatric hospital, including gun violence, violence toward strangers, and gun violence toward strangers.

Criminal justice and behavioral health care costs of mental health court participants: a six-year study.

Objective: This study examined whether there were differences in costs for mental health court (MHC) participants and a matched comparison group for three years after a target arrest.

Methods: Data from the MacArthur Mental Health Court Study, the first multisite study of MHCs, were used to compare behavioral health treatment and criminal justice costs for MHC participants and a matched group (using coarsened exact matching) of jail detainees who were not enrolled in an MHC but who received jail-based psychiatric services in the same cities. Cost data for three years before and after a target arrest were calculated separately for each year and for each participant at three sites of the multisite study-296 MHC participants and 386 matched jail detainees.

The cost of assisted outpatient treatment: can it save states money?

Objective: The authors assessed a state's net costs for assisted outpatient treatment, a controversial court-ordered program of community-based mental health services designed to improve outcomes for persons with serious mental illness and a history of repeated hospitalizations attributable to nonadherence with outpatient treatment.

Method: A comprehensive cost analysis was conducted using 36 months of observational data for 634 assisted outpatient treatment participants and 255 voluntary recipients of intensive community-based treatment in New York City and in five counties elsewhere in New York State. Administrative, budgetary, and service claims data were used to calculate and summarize costs for program administration, legal and court services, mental health and other medical treatment, and criminal justice involvement.

Exploring Racial Disparities in The Brief Jail Mental Health Screen.

The authors analyzed validation data from the Brief Jail Mental Health Screen (BJMHS) to determine whether race predicted screening results and if such a prediction was driven by particular screen items. A total of 22,000 individuals entering five jails over two 8-month periods were screened. The authors constructed binary logistic regression models to assess the impact of race on screening positive and endorsing particular items.

Effect of mental health courts on arrests and jail days: a multisite study.

Context: Mental health courts are growing in popularity as a form of jail diversion for justice system-involved people with serious mental illness. This is the first prospective multisite study on mental health courts with treatment and control groups.

Objectives: To determine if participation in a mental health court is associated with more favorable criminal justice outcomes than processing through the regular criminal court system and to identify defendants for whom mental health courts produce the most favorable criminal justice outcomes.

Reductions in arrest under assisted outpatient treatment in New York.

Objective: Individuals with serious mental illness have a relatively high risk of criminal justice involvement. Assisted outpatient treatment (AOT) is a legal mechanism that mandates treatment for individuals with serious mental illness who are unlikely to live safely in the community without supervision and who are also unlikely to voluntarily participate in treatment. Under an alternative arrangement, some individuals for whom an AOT order is pursued sign a voluntary service agreement in lieu of a formal court order.

Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York.

Objective: This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends.

Methods: Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods.

Assessing outcomes for consumers in New York's assisted outpatient treatment program.

Objective: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals.

Methods: Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects.

Assisted outpatient treatment in New York: regional differences in New York's assisted outpatient treatment program.

Objective: This study sought to describe the implementation of "Kendra's Law" in New York State and examine regional differences in the application of the program.

Methods: Between February 2007 and April 2008, interviews were conducted with 50 key informants across New York State. Key informants included assisted outpatient treatment (AOT) county coordinators, county directors of community services, judges, attorneys from the Mental Hygiene Legal Service (MHLS), psychiatrists, treatment providers, peer advocates, family members, and other referred individuals.

The use of mental health court appearances in supervision.

A defining feature of mental health courts (MHCs) is the requirement that enrollees appear periodically for status review hearings before the MHC judge. Although the research base on these specialty courts is growing, MHC appearances have yet to be examined. In the present study, the authors followed more than 400 MHC clients from four courts.

Perceived coercion to treatment and housing satisfaction in housing-first and supportive housing programs.

Objectives: This study of five housing programs across the United States examined whether the type of program-housing first or supportive housing-is related to an explicit requirement that residents adhere to mental health and substance abuse treatment, to residents' subjective perceptions that treatment adherence was being coerced, and to residents' housing satisfaction.

Methods: Interviews were conducted with 136 residents of housing programs at five sites.

Results: Results showed that compared with residents in supportive housing programs, those in housing-first programs were significantly less likely to report that mental health treatment adherence was an explicit requirement of obtaining housing and less likely to report that mental health and substance abuse treatment was a requirement of retaining housing.

Prevalence of serious mental illness among jail inmates.

Objective: This study estimated current prevalence rates of serious mental illness among adult male and female inmates in five jails during two time periods (four jails in each period).

Methods: During two data collection phases (2002-2003 and 2005-2006), recently admitted inmates at two jails in Maryland and three jails in New York were selected to receive the Structured Clinical Interview for DSM-IV (SCID). Selection was based on systematic sampling of data from a brief screen for symptoms of mental illness that was used at admission for all inmates.

Racial disparities in involuntary outpatient commitment: are they real?

In this paper we explore racial disparities in outpatient civil commitment, using data from Kendra's Law in New York State. Overall, African Americans are more likely than whites to be involuntarily committed for outpatient psychiatric care in New York. However, candidates for outpatient commitment are largely drawn from a population in which blacks are overrepresented: psychiatric patients with multiple involuntary hospitalizations in public facilities.

Revalidating the brief jail mental health screen to increase accuracy for women.

Objective: Jails need a reliable tool to identify inmates who require further mental health assessment and treatment. This research attempted to revalidate the Brief Jail Mental Health Screen (BJMHS) as such a tool. This research added four items to the original eight-item screen (BJMHS-R), targeting depression and trauma to improve performance of the screen with women.

The classification of violence risk.

The Classification of Violence Risk (COVR) is an interactive software program designed to estimate the risk that a person hospitalized for mental disorder will be violent to others. The software leads the evaluator through a chart review and a brief interview with the patient. At the end of this interview, the software generates a report that contains a statistically valid estimate of the patient's violence risk-ranging from a 1% to a 76% likelihood of violence-including the confidence interval for that estimate, and a list of the risk factors that the program took into account to produce the estimate.

Use of the criminal justice system to leverage mental health treatment: effects on treatment adherence and satisfaction.

In efforts to divert persons with mental illness from jails and prisons, the option of community mental health treatment in lieu of incarceration is sometimes offered. In addition, community treatment can be mandated, or "leveraged," as a condition of probation or parole. However, little is known about the characteristics and attitudes of persons who are and who are not leveraged into community mental health treatment via the criminal justice (CJ) system.

The use of housing as leverage to increase adherence to psychiatric treatment in the community.

For people with mental disorder, access to subsidized housing may be used as "leverage" to obtain adherence to treatment. Interview data from 200 outpatients at each of five sites provided the first national description of the use of housing as leverage. Results indicated that housing is most likely to be used as leverage when it is "special" housing, available only to people with mental illness.

Validation of the brief jail mental health screen.

Objective: Jails have a substantial legal obligation to provide health and mental health care for inmates; yet screening procedures across American jails are highly variable. Currently, no valid, practical, standardized tool is available. The study reported here sought to validate a revision of the Referral Decision Scale (RDS)--the Brief Jail Mental Health Screen (BJMHS)--which provides an even briefer and more practical tool for use in jails.

An actuarial model of violence risk assessment for persons with mental disorders.

Objectives: An actuarial model was developed in the MacArthur Violence Risk Assessment Study to predict violence in the community among patients who have recently been discharged from psychiatric facilities. This model, called the multiple iterative classification tree (ICT) model, showed considerable accuracy in predicting violence in the construction sample. The purpose of the study reported here was to determine the validity of the multiple ICT model in distinguishing between patients with high and low risk of violence in the community when applied to a new sample of individuals.

Use of leverage to improve adherence to psychiatric treatment in the community.

Objectives: A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed.

Persistence and stability of delusions over time.

Traditional descriptions of delusions have emphasized the conviction with which they are held and their resistance to change. This study utilizes data from a large cohort of delusional subjects to assess the persistence and stability of delusional beliefs, and the predictors of change. Data were collected from 1,136 acutely hospitalized psychiatric patients, reinterviewed at 10-week intervals for 1 year.

Mental disorder, violence, and gender.

Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community.