Kiersten L. Johnson

Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

OBJECTIVES In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes. METHODS Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants. RESULTS Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization. CONCLUSIONS Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.

A Typology of Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

The primary objective of this article was to evaluate the overlap between community violence perpetration and victimization in a large, heterogeneous sample of adults with mental illnesses (N = 4,474). We also explored participant characteristics differentiating four categories of perpetration and victimization: non-victim/non-perpetrators, victims only, perpetrators only, and victim–perpetrators. Results indicated that adults with mental illnesses were unlikely to report violent outcomes but, when they did, were more likely to report perpetration and victimization, rather than perpetration alone. In addition, bivariate and multivariable analyses showed that sex, age, race/ethnicity, and primary diagnosis differed across categories. Victim–perpetrators, for example, were more likely to be young, Black, and have a primary diagnosis of bipolar disorder, major depressive disorder, substance use disorder, or “other.” Altogether, our findings provide evidence for a victim–perpetrator overlap in this population and suggest that preventive measures targeting violence and victimization may be more effective than those with separate strategies for each.

The latent structure of psychiatric symptoms across mental disorders as measured with the PANSS and BPRS-18

Raw data were used from five studies of adults with mental illnesses (N=4,480) in an attempt to identify a psychiatric symptoms factor structure, as measured by the Positive and Negative Syndrome Scale or the Brief Psychiatric Rating Scale, that was generalizable across participant characteristics. First, the fit of four extant models was tested via confirmatory factor analysis (CFA), then exploratory factor analyses (EFA) were conducted with a 50% random sample, followed by a CFA with the remaining 50% to confirm the EFA factor structure. Measurement invariance of the factor structure was also examined across diagnosis, sex, race, age, and hospitalization status. The extant models were not generalizable to these data. However, a 4-factor (Affective, Positive, Negative, Disorganized Cognitive Processing) model was identified that retained all items and showed invariance across participant characteristics. It is possible to obtain a psychiatric symptoms factor structure that is generalizable across patient characteristics, which has clinical and research implications. Specifically, future research examining the impact of various interventions on psychiatric symptoms among adults with mental illnesses should confirm, and assuming good model-data fit, use the 4-factor model identified in this study.

Proximal Risk Factors for Short-Term Community Violence Among Adults With Mental Illnesses

OBJECTIVE This study examined the role of static indicators and proximal, clinically relevant indicators in the prediction of short-term community violence in a large, heterogeneous sample of adults with mental illnesses. METHODS Data were pooled from five studies of adults with mental illnesses (N=4,484). Follow-up data were available for 2,579 participants. A hierarchical linear regression assessed the incremental validity of a series of variable clusters in the prediction of violence risk at six months: static characteristics (age, sex, race-ethnicity, and primary diagnosis), substance use (alcohol use and drug use at baseline), clinical functioning (psychiatric symptoms at baseline and recent hospitalization), recent violence, and recent victimization. RESULTS Results demonstrated improved prediction with each step of the model, indicating that proximal indicators contributed to the prediction of short-term community violence above and beyond static characteristics. When all variables were entered, current alcohol use, recent violence, and recent victimization were positive predictors of subsequent violence, even after the analysis controlled for participant characteristics. CONCLUSIONS This study provides empirical evidence for three proximal, clinically relevant indicators in the assessment and management of short-term violence risk among adults with mental illnesses: current alcohol use, recent violence, and recent victimization. Consideration of these indicators in clinical practice may assist in the identification of adults with mental illnesses who are at heightened risk of short-term community violence.

Drug and alcohol trajectories among adults with schizophrenia: Data from the CATIE study

OBJECTIVE The primary aim is to describe drug and alcohol trajectories in adults with schizophrenia. METHOD Growth mixture models were used to examine disordered and non-disordered use and abstinence in the Clinical Antipsychotic Trials of Intervention Effectiveness study. RESULTS Five classes - always abstinent; fluctuating use, abuse, and occasional abstinence; occasional (ab)use; stopped (ab)use; abusing - fit best. Overlap exists between always abstinent drug and alcohol classes; less overlap exists across other classes. CONCLUSION There is heterogeneity in drug and alcohol use among adults with schizophrenia. The lack of overlap between classes, save always abstinent, suggests modeling drug and alcohol use separately.

A longitudinal analysis of the overlap between violence and victimization among adults with mental illnesses

Prior research suggests considerable overlap of violence perpetration and victimization among adults with mental illnesses. However, there has been no examination of how the likelihood of being a victim and/or perpetrator of violence may change over time, nor consideration of clinically-relevant factors affecting these transitions. In a pooled sample of adults with mental illnesses (N=3,473) we employed latent transition analysis to: (a) determine prevalence of four violence and victimization classifications (i.e., non-victim/non-perpetrator, victim only, perpetrator only, and victim-perpetrator) over a 6-month period; (b) calculate the likelihood that adults with mental illnesses will remain in or transition between these classifications over time; and (c) assess the effects of recent substance use, psychiatric symptoms, and suicidal behaviors on transitions over time. At each time point, the majority of participants identified as non-victim/non-perpetrators, followed by victim-perpetrators, victims only, and perpetrators only. Analyses also revealed many individuals transitioned between classifications over time. These distinct pathways towards, and away from, violent outcomes were, in part, a function of recent violence and/or victimization, as well as substance use, psychiatric symptoms, and suicidal behaviors. Findings inform the identification of adults with mental illnesses at risk of violence and victimization and highlight points of intervention.

The intersection of interpersonal and self-directed violence among general adult, college student and sexually diverse samples

Background: Suicide and interpersonal violence (i.e. victimization and perpetration) represent pressing public health problems, and yet remain mostly addressed as separate topics. Aims: To identify the (1) frequency and overlap of suicide and interpersonal violence and (2) characteristics differentiating subgroups of violence-related experiences. Methods: A health survey was completed by 2,175 respondents comprised of three groups: college students (n = 702), adult members of a sexuality special interest organization (n = 816) and a community adult sample (n = 657). Latent class analysis was used to identify subgroups characterized by violence experiences; logistic regression was used to identify respondent characteristics differentiating subgroups. Results: Overall rates of violence perpetration were low; perpetration, victimization and self-directed violence all varied by sample. Adults with alternative sexual interests reported high rates of victimization and self-directed violence. Analyses indicated two subgroups: (1) victimization + self-directed violence and (2) self-directed violence only. The victimization + self-directed violence subgroup was characterized by older, White, female and sexual orientation minority persons. The self-directed violence subgroup was characterized by younger, non-White, male and straight counterparts engaging with more sexual partners and more frequent drug use. Conclusion: Findings support the Centers for Disease Control and Prevention (CDC) definition of suicide as self-directed violence. Suicide intervention and prevention should further account for the role of violent victimization by focusing on the joint conceptualization of self-directed and interpersonal violence. Additional prevention implications are discussed.

Reliability and Validity of START and LSI-R Assessments in Mental Health Jail Diversion Clients:

Risk assessment instruments are increasingly used in mental health jail diversion programs. This study examined the reliability and validity of Short-Term Assessment of Risk and Treatability (START) and Level of Service Inventory–Revised (LSI-R) assessments overall and by client race. Research assistants completed START and LSI-R assessments for 95 diversion clients. Arrests and jail days were collected via official records and self-report 3, 6, 9, 12, and 18 months after baseline. Assessments demonstrated good interrater reliability and convergent validity. START strength total scores and LSI-R risk estimates were the strongest predictors of recidivism. Total scores and risk estimates did not differ as a function of client race, but there were some differences in accuracy of START vulnerability and LSI-R total scores and risk estimates in predicting jail days (but not arrests), over shorter follow-ups. No such differences were found for START strength total scores across any follow-up period or recidivism measure.

Latent class analysis of discordance between results of drug use assessments in the CATIE data

OBJECTIVE The primary aim is to examine concordant/discordant results of drug use assessments in adults with schizophrenia. METHODS Latent class analysis and multinomial logistic regression were used to examine concordance/discordance between drug use measures and identify characteristics differentiating participants across classes. RESULTS Four classes - non-users, users, probable users, and RIA discordant - fit best. Age, sex, race/ethnicity, and psychiatric symptoms differed significantly across classes. CONCLUSIONS Findings showed that discordance between results occurs at non-trivial rates and is, in part, attributable to individual characteristics. Results suggest the need for strategies to limit discordance and improve detection of drug use in adults with schizophrenia.

Jail-to-community treatment continuum for adults with co-occurring substance use and mental disorders: Study protocol for a pilot randomized controlled trial

BackgroundAdults with co-occurring mental and substance use disorders (CODs) are overrepresented in jails. In-custody barriers to treatment, including a lack of evidence-based treatment options and the often short periods of incarceration, and limited communication between jails and community-based treatment agencies that can hinder immediate enrollment into community care once released have contributed to a cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among this vulnerable and high-risk population. This paper describes a study that will develop research and communication protocols and adapt two evidence-based treatments, dual-diagnosis motivational interviewing (DDMI) and integrated group therapy (IGT), for delivery to adults with CODs across a jail-to-community treatment continuum.Methods/designAdaptations to DDMI and IGT were guided by the Risk-Need-Responsivity model and the National Institute of Corrections’ implementation competencies; the development of the implementation framework and communication protocols were guided by the Evidence-Based Interagency Implementation Model for community corrections and the Inter-organizational Relationship model, respectively. Implementation and evaluation of the protocols and adapted interventions will occur via an open trial and a pilot randomized trial. The clinical intervention consists of two in-jail DDMI sessions and 12 in-community IGT sessions. Twelve adults with CODs and four clinicians will participate in the open trial to evaluate the acceptability and feasibility of, and fidelity to, the interventions and research and communication protocols. The pilot controlled trial will be conducted with 60 inmates who will be randomized to either DDMI-IGT or treatment as usual. A baseline assessment will be conducted in jail, and four community-based assessments will be conducted during a 6-month follow-up period. Implementation, clinical, public health, and treatment preference outcomes will be evaluated.DiscussionFindings have the potential to improve both jail- and community-based treatment services for adults with CODs as well as inform methods for conducting rigorous pilot implementation and evaluation research in correctional settings and as inmates re-enter the community. Findings will contribute to a growing area of work focused on interrupting the cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among adults with CODs.Trial registrationClinicalTrials.gov, NCT02214667. Registered on 10 August 2014.