Pamela Clark Robbins

A classification tree approach to the development of actuarial violence risk assessment tools

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.

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. DESIGN Longitudinal study. SETTING Four mental health courts in San Francisco County, CA, Santa Clara County, CA, Hennepin County (Minneapolis), MN, and Marion County (Indianapolis), IN. PARTICIPANTS A total 447 persons in the mental health court (MHC) and 600 treatment-as-usual (TAU) controls. INTERVENTION Eighteen months of pre-entry and postentry data for 4 jurisdictions. All subjects were interviewed at baseline, and 70% were interviewed at 6 months. Objective outcome data were obtained on all subjects from Federal Bureau of Investigation arrest records, jails, prisons, and community treatment providers. MAIN OUTCOME MEASURES Annualized rearrest rates, number of rearrests, and postentry incarceration days. RESULTS The MHC and TAU samples are similar on the major outcome measures in the pre-entry 18-month period. In the 18 months following treatment, defined as entry into mental health court, the MHC group has a lower annualized rearrest rate, fewer post-18-month arrests, and fewer post-18-month incarceration days than the TAU group. The MHC graduates had lower rearrest rates than participants whose participation was terminated both during MHC supervision and after supervision ended. Factors associated with better outcomes among the MHC participants include lower pre-18-month arrests and incarceration days, treatment at baseline, not using illegal substances, and a diagnosis of bipolar disorder rather than schizophrenia or depression. CONCLUSIONS Mental health courts meet the public safety objectives of lowering posttreatment arrest rates and days of incarceration. Both clinical and criminal justice factors are associated with better public safety outcomes for MHC participants.

A Multiple-Models Approach to Violence Risk Assessment Among People with Mental Disorder

Actuarial models for violencerisk assessment have proliferatedin recent years. In this article, we describe an approach that integrates the predictions of many actuarial risk-assessment models, each of which may capture a different but important facet of the interactive relationship between the measured risk factors and violence. Using this multiple-models approach, we ultimately combined the results of five prediction models generated by the iterative classification tree (ICT) methodology developed in the MacArthur Violence Risk Assessment Study. This combination of models produced results not only superior to those of any of its constituent models, but superior to any other actuarial violence risk-assessment procedure reported in the literature to date.

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. We examined the number of court appearances that were mandated versus attended, the number of bench warrants issued, and the proportion of court appearances that were made in-custody versus out-of-custody. Finally, we describe and report on the proportion of clients at each court who had graduated, had been terminated, or who were still in the court one year following enrollment.

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. Most frequently, respondents state that the requirement that they participate in treatment is imposed by their landlord, rather than by a clinician. The use of housing as leverage strongly increases respondents’ perceptions of coercion. Despite this, however, participants who experience housing as leverage are no less satisfied than other participants with the treatment that they receive, and are much more likely than other participants to believe that using housing as leverage is effective in helping people stay well.

Identifying Subtypes of Civil Psychiatric Patients at High Risk for Violence

Advances in risk assessment have improved the ability to identify psychiatric patients at high risk for violence. Identifying these patients is necessary for developing treatment to address their needs. However, if violence is caused by risk factors that vary across patients, relatively homogeneous subgroups of high-risk patients must be identified and studied to develop effective risk management programs for each. This study was designed to identify and describe valid subtypes of patients reliably identified as at high risk by the multiple Iterative Classification Tree (ICT) risk assessment approach. After existing typologies of violent individuals were integrated to develop hypothesized subtypes of high-risk patients, data on 165 patients identified as at high risk by the multiple ICT were used to determine whether clinically meaningful subtypes could be identified and externally validated. Three groups (alpha, beta, and delta) largely consistent with the hypothesized subtypes and their correlates were identified. The implications of these findings for research and treatment development efforts are discussed.

The Cost of Assisted Outpatient Treatment: Can It Save States Money?

OBJECTIVE The authors assessed a states 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. Adjusted effects of assisted outpatient treatment and voluntary intensive services on total service costs were examined using multivariate time-series regression analysis. RESULTS In the New York City sample, net costs declined 43% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In the five-county sample, costs declined 49% in the first year and an additional 27% in the second year. Psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. Regression analyses revealed significant declines in costs associated with both assisted outpatient treatment and voluntary participation in intensive services, although the cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services. CONCLUSIONS Assisted outpatient treatment requires a substantial investment of state resources but can reduce overall service costs for persons with serious mental illness. For those who do not qualify for assisted outpatient treatment, voluntary participation in intensive community-based services may also reduce overall service costs over time, depending on characteristics of the target population and local service system.

Racial disparities in involuntary outpatient commitment: are they real?

In this paper we explore racial disparities in outpatient civil commitment, using data from Kendras 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. Whether this overrepresentation under court-ordered outpatient treatment is unfair depends on ones view: is it access to treatment and a less restrictive alternative to hospitalization, or a coercive deprivation of personal liberty?

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.

Is Diversion Swift? Comparing Mental Health Court and Traditional Criminal Justice Processing

Formal diversion programs are increasingly popular options for offenders with mental illness. Diversion is recommended, and often assumed, to be swift in that eligible persons should be quickly identified and enrolled. In this study, the authors examine the length from initial arrest to enrollment into mental health court and compare it to time from arrest to disposition for offenders with and without mental illness traditionally processed. The authors, using medians as the metric and limiting the period to 1 year, found time to mental health court was 70 days, whereas traditional processing for offenders with and without known mental illness was 37 and 76 days, respectively. The authors also found detention status during this period to have a large effect on processing time.