Debra A. Pinals

NMDA receptor function and human cognition: the effects of ketamine in healthy volunteers.

A rapidly growing body of preclinical data has implicated the glutamatergic N-methyl-d-aspartate (NMDA) receptor in memory and other cognitive processes. There is comparatively less information about this receptor system in human cognition. We examined the effects of subanesthetic doses of ketamine, a noncompetitive NMDA receptor antagonist, on two forms of memory, free recall and recognition, as well as attention and behavior in a double-blind, placebo-controlled, 1-hour infusion in 15 healthy volunteers. Ketamine produced decrements in free recall, recognition memory, and attention. In addition, ketamine induced a brief psychosis in our healthy volunteers marked by thought disorder and withdrawal-retardation. Ketamine-induced memory impairments were not accounted for by changes in subjects attention and were not significantly related to psychosis ratings. These data suggest that the NMDA receptor plays a direct role in two types of explicit memory. The implications of these data for the pathophysiology of schizophremia are discussed.

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. RESULTS Two percent of patients committed a violent act involving a gun, 6% committed a violent act involving a stranger, and 1% committed a violent act involving both a gun and a stranger. CONCLUSIONS When public perceptions and policies regarding mental illness are shaped by highly publicized but infrequent instances of gun violence toward strangers, they are unlikely to help people with mental illnesses or to improve public safety.

Recidivism Among Released State Prison Inmates Who Received Mental Health Treatment While Incarcerated

This study assesses the likelihood of rearrest among a cohort of all adults (N = 1,438) released from the Massachusetts state prison system who received mental health services while they were incarcerated. All individuals were followed for 24 months. The analysis focused on four classes of variables: demographic characteristics, clinical history, criminal justice history, and postrelease supervision. These analyses showed that criminal history factors—a juvenile record and a history of multiple previous incarcerations—were significant risk factors, but that clinical factors, including a history of substance abuse, were not. Overall, the models developed here look much like the ones that would be observed in the general offender population. The implications of these findings for criminal justice and mental health policy are discussed.

Predictors of criminal justice involvement in severe mania

BACKGROUND Criminal justice problems among those with bipolar disorder lead to disruption in social functioning, treatment, and recovery. Understanding factors that contribute to arrest during episodes of illness can help inform approaches to risk management and improve clinical care. METHODS Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey conducted in two waves were used to identify factors that predicted inter-wave criminal justice involvement during bipolar I manic episodes. RESULTS Over 10% of respondents experienced legal involvement during their most severe manic episode. Risk was found in a range of historical, clinical, and contextual factors. Multivariate analyses suggest risk is particularly high for those who are unemployed, non-white, have past juvenile detention, have a prior arrest (while using substances or when manic), used an illicit drug in the past year, and whose mania is characterized by both social and occupational impairment. Legal problems were particularly elevated among those who lacked health insurance while experiencing both social and occupational impairment. LIMITATIONS Respondents did not include prisoners and hospital inpatients; criminal justice problems were only assessed with regard to the most severe manic episode. CONCLUSIONS The particular array of factors that elevate the risk of legal involvement during manic episodes offers guidance when identifying prevention strategies and evaluating patients in clinical and forensic settings. Reducing such involvement will require that these issues be dealt with in the broader context of mental health and other services, which in turn necessitates providing adequate access to healthcare.

States’ Standards for Training and Certifying Evaluators of Competency to Stand Trial

The standards used to select, train, certify, and retain forensic evaluators of Competency to Stand Trial (CST) vary widely across states. Despite the very important ramifications that CST evaluations have for the defendants who undergo them, little is currently known about how states ensure that evaluators provide the highest-quality work possible. A survey was sent to all 50 states and Washington, DC, to solicit information regarding evaluator selection and certification processes, payment of CST evaluators, and other related topics. Results were compared to previous studies completed in 1997 and 2006 to allow for a longitudinal analysis. Results indicate that although some progress has occurred since the publication of those studies, most states still do not have a formal process for selecting or certifying their CST evaluators. Also, professional qualifications for CST evaluations are loosening, and payment remains relatively low. These findings, as well as the importance of retaining high standards for the field of forensic mental health assessment, are discussed. Specific components of existing certification programs are also detailed.

Harmonizing databases? Developing a quasi-experimental design to evaluate a public mental health re-entry program

Our study is the first-ever initiative to merge administrative databases in Massachusetts to evaluate an important public mental health program. It examines post-incarceration outcomes of adults with serious mental illness (SMI) enrolled in the Massachusetts Department of Mental Health (DMH) Forensic Transition Team (FTT) program. The program began in 1998 with the goal of transitioning offenders with SMI released from state and local correctional facilities utilizing a core set of transition activities. In this study we evaluate the programs effectiveness using merged administrative data from various state agencies for the years 2007-2011, comparing FTT clients to released prisoners who, despite having serious mental health disorders, did not meet the criterion for DMH services. By systematically describing our original study design and the barriers we encountered, this report will inform future efforts to evaluate public programs using merged administrative databases and electronic health records.

Crime, violence, and behavioral health: collaborative community strategies for risk mitigation

Criminal conduct is not always violent, and violence does not always lead to criminal charges. Moreover, crime and violence have multifaceted etiologies. Most violence in society is not attributable to mental illness. Where there is a small relationship between violence and mental illness, the risk of violence increases for individuals with substance use histories. Underlying trauma can also play a role. Antisocial attitudes, behaviors, and peer groups further increase the risk that individuals, including those with mental illness, will find themselves at risk of criminal recidivism. Criminal histories among public mental health populations, and mental health and substance use disorders among criminal populations are each higher than general population comparisons. Care within behavioral health settings should therefore target decreased criminal recidivism and decreased violence as part of recovery for those individuals at risk, using trauma-informed approaches and peer supports. Interventions that show promise bring criminal justice and behavioral health systems together, and include police-based diversion, specialty courts, court-based alternatives to incarceration, and coordinated re-entry programs. This article reviews these options along with specific risk management strategies, such as using risk, needs, and responsivity factors as a means of improving overall outcomes for persons with mental illness, while minimizing their risk of further criminalization and victimization.

Fitness-for-Duty of Law Enforcement Officers

Law enforcement personnel are often at greater risk of exposure to critical incidents involving serious trauma and public safety events. Psychiatric sequelae of these events can include increased risk for trauma-related symptoms, substance use, and possibly suicide. Fitness-for-duty issues arise both for clinicians treating law enforcement officers and in disability-related assessments pertaining to an officer’s return to work. These include whether the officer is able to perform essential functions of the job, is able to function in a prior role, or in any role within the police department, whether the job would require access to and handling of firearms, and whether any ongoing symptoms could be accommodated with special arrangements in the workplace. In general, fitness-for-duty evaluations for law enforcement officers require expertise in forensic assessments given the complexity of issues and risks involved especially when the inquiry involves access to firearms. This discussion reviews case examples, the basic legal landscape that an officer may face in a fitness-to-work assessment, as well as clinical factors and recommendations related to fitness-for-duty evaluation assessments.

Substance Use and Mental Health Stigma in Veterans with Co-occurring Disorders.

ABSTRACT Objective: This pilot study examined whether substance use or mental illness was more stigmatizing among individuals with co-occurring mental health and substance abuse problems. Methods: This study included 48 individuals with co-occurring substance use and mental health problems enrolled in a Substance Abuse and Mental Health Services funded treatment program. Subjects received a baseline assessment that included addiction, mental health, and stigma measures. Results: The sample consisted primarily of White males with an average age of 38 years. Substance abuse was found to be more stigmatizing than mental illness, F(1, 47) = 14.213, p < .001, and stigma varied across four different levels of stigma (Aware, Agree, Apply, and Harm), F(2.099, 98.675) = 117.883, p < .001. The interaction between type and level of stigma was also significant, F(2.41, 113.284) = 20.250, p < .001, indicating that differences in reported stigma between types varied across levels of stigma. Post hoc tests found a significant difference between all levels of stigma except for the comparison between Apply and Harm. Reported stigma was significantly higher for substance abuse than mental illness at the Aware and Agree levels. In addition, pairwise comparisons found significant differences between all levels of stigma with the exception of the comparison between Apply and Harm, indicating a pattern whereby reported stigma generally decreased from the first level (Aware stage) to subsequent levels. Conclusions: These results have important implications for treatment, suggesting the need to incorporate anti-stigma interventions for individuals with co-occurring disorders with a greater focus on substance abuse.

Integrating a Co-occurring Disorders Intervention in Drug Courts: An Open Pilot Trial

Little research has focused on systematically integrating clinical treatment within existing drug court procedures. This could be particularly useful for clients with substance use disorders, who comprise those on court dockets and often have co-existing mental health issues. This article reports on the preliminary outcomes of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use wraparound intervention, within two Massachusetts drug courts. In this open pilot, clients completed intake and 6-month follow-up assessments. The participants were primarily Caucasian (86%), male (82%), had at least 2 prior arrests, and received outpatient treatment for mental health (54%), alcohol use (51%), or drug use (88%) prior to enrolling in MISSION-CJ. Six-month follow-up data suggested that participants showed statistically significant reductions in average number of nights spent in jail, alcohol use, and drug use, as well as an increase in full time employment.