Allison G. Robertson

Costs of criminal justice involvement among persons with serious mental illness in connecticut.

OBJECTIVE This study sought to describe patterns and costs of criminal justice involvement among adults with serious mental illness who received services across public agencies within a single state. Costs were examined from the perspective of state agencies providing mental health, substance abuse, and criminal justice services. METHODS Administrative records for 25,133 adults who were served by the Connecticut Department of Mental Health and Addiction Services (DMHAS) during fiscal years 2006 and 2007 and who had a diagnosis of schizophrenia or bipolar disorder were matched with records of the state Medicaid program, Judicial Branch, Department of Correction, and Department of Public Safety. Unit costs for service events were combined with utilization data to calculate costs per person. RESULTS About one in four individuals was involved with the justice system during the two-year period. The justice-involved group incurred costs approximately double those of the group with no involvement-

Involuntary outpatient commitment and the elusive pursuit of violence prevention: a view from the United States

48,980 compared with

Economic Grand Rounds: Treatment Participation and Medication Adherence: Effects on Criminal Justice Costs of Persons With Mental Illness

24,728 per person. Costs were shared by several state agencies and Medicaid. DMHAS bore the largest proportion of state service costs, covering 49% of total costs for persons with justice involvement and 69% of costs for those without involvement. CONCLUSIONS Criminal justice involvement is a complex and costly problem that affects a substantial proportion of adults with serious mental illness who receive services across state agencies. Applying per-person cost estimates in other states could help mental health and criminal justice systems to better plan, coordinate, and deliver cost-effective services to individuals with serious mental illness who become involved with the criminal justice system.

Influence of Criminal Justice Involvement and Psychiatric Diagnoses on Treatment Costs Among Adults With Serious Mental Illness

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.

Extended-release naltrexone and drug treatment courts: Policy and evidence for implementing an evidence-based treatment.

Little empirical research has directly examined the extent to which early and consistent participation in outpatient services and adherence to prescribed psychotropic medications after a psychiatric hospitalization can help people with serious mental illnesses avoid arrest and incarceration and what impact this might have on state and local costs. The authors examined effects of medication adherence in the first 90 days after a psychiatric hospitalization among 1,367 adults with schizophrenia or bipolar disorder served by the public behavioral health systems of Miami-Dade County and Pinellas County in Florida. Better adherence was associated with lower subsequent criminal justice costs and greater use of treatment services. A modest investment in promoting treatment participation and medication adherence may reduce criminal justice involvement and costs for persons with serious mental illness.

Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious 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 Connecticuts 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.

Building on the Evidence: Guiding Policy and Research on Police Encounters with Persons with Mental Illnesses

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.

Medication-Assisted Treatment for Alcohol-Dependent Adults With Serious Mental Illness and Criminal Justice Involvement: Effects on Treatment Utilization and Outcomes

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.

Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams

Police–citizen encounters that end badly—with someone getting injured or killed—have lately captured media attention in the United States. These events have focused public attention on the troubled relationship between law enforcement and urban communities plagued by violent crime, entrenched poverty, and a legacy of racial discrimination. Within that larger social context are complex situations that police officers often face when called to intervene with people who appear to be mentally ill and who might pose a risk of harm to themselves or the public. In these encounters, police act not only as public safety officers but also as informal social workers, emergency health-care workers, and providers of access to treatment services (Wood, Swanson, Burris, and Gilbert, 2011). The question of when to use force in such cases, as well as how best to avoid or minimize its use without compromising officer safety, is an ongoing challenge for law enforcement training, practice, policy, and community relations. The U.S. Supreme Court’s recent decision in City and County of San Francisco v. Sheehan (2015) highlighted complex legal issues related to these matters as well. The court held that officers who forcibly entered the room of a woman with a mental disability and shot her are entitled to qualified immunity from a lawsuit seeking redress for the woman’s injuries.The court left undetermined the broader question of whether police officers who arrest or detain and transport a person with a mental illness are subject to ADA Title II requirements to provide reasonable accommodation of persons with disabilities. In this policy essay, I discuss several underlying issues that are raised by Morabito and Socia’s (2015, this issue) study on the question of potentially increased risk of injury when police officers encounter persons in the community who seem to suffer from acute psychiatric symptoms or substance intoxication. Within the broad range of police encounters, special attention is needed to understand and inform encounters with persons with mental illnesses—a challenging interface during which police and persons in mental-health crisis may both feel vulnerable, raising the risk that the exchange could involve use of force or injury. Officers’ presumptions about the dangerousness of persons in mental-health crisis are likely to have a strong influence on their response, including the extent to which they use force during those encounters. There have been longstanding concerns that persons with mental illnesses face prejudicial treatment by police largely for being misunderstood and stigmatized, and that they are disproportionately vulnerable to police use of force and injury for those reasons. Little definitive evidence exists, however, to support or discount this hypothesis.

Mental Health Courts: Does Treatment Make a Difference?

OBJECTIVE 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. METHOD 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. RESULTS 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. CONCLUSIONS 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.