Richard A. Van Dorn

Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies.

Background Previous reviews on risk and protective factors for violence in psychosis have produced contrasting findings. There is therefore a need to clarify the direction and strength of association of risk and protective factors for violent outcomes in individuals with psychosis. Method We conducted a systematic review and meta-analysis using 6 electronic databases (CINAHL, EBSCO, EMBASE, Global Health, PsycINFO, PUBMED) and Google Scholar. Studies were identified that reported factors associated with violence in adults diagnosed, using DSM or ICD criteria, with schizophrenia and other psychoses. We considered non-English language studies and dissertations. Risk and protective factors were meta-analysed if reported in three or more primary studies. Meta-regression examined sources of heterogeneity. A novel meta-epidemiological approach was used to group similar risk factors into one of 10 domains. Sub-group analyses were then used to investigate whether risk domains differed for studies reporting severe violence (rather than aggression or hostility) and studies based in inpatient (rather than outpatient) settings. Findings There were 110 eligible studies reporting on 45,533 individuals, 8,439 (18.5%) of whom were violent. A total of 39,995 (87.8%) were diagnosed with schizophrenia, 209 (0.4%) were diagnosed with bipolar disorder, and 5,329 (11.8%) were diagnosed with other psychoses. Dynamic (or modifiable) risk factors included hostile behaviour, recent drug misuse, non-adherence with psychological therapies (p values<0.001), higher poor impulse control scores, recent substance misuse, recent alcohol misuse (p values<0.01), and non-adherence with medication (p value <0.05). We also examined a number of static factors, the strongest of which were criminal history factors. When restricting outcomes to severe violence, these associations did not change materially. In studies investigating inpatient violence, associations differed in strength but not direction. Conclusion Certain dynamic risk factors are strongly associated with increased violence risk in individuals with psychosis and their role in risk assessment and management warrants further examination.

Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia

BACKGROUND Violence is an uncommon but significant problem associated with schizophrenia. AIMS To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence. METHOD Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication. RESULTS Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence. CONCLUSIONS Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: Perceived likelihood of violence and desire for social distance

Abstract This study compared four stakeholder groups regarding the presence of stigmatizing attitudes toward a hypothetical person diagnosed with schizophrenia. Participants included consumers with schizophrenia (n = 104), family members of those with schizophrenia or other severe mental illness (n = 83), mental health clinicians (n = 85), and members of the general public (n = 59); all participants resided in North Carolina. The purpose of the analyses was to investigate whether mental health stakeholder groups differed from the general public and from each other in terms of key attitudes associated with stigmatization of persons with schizophrenia, that is, perceived likelihood of violent behavior, the desire for social distance, and the causes of the illness. Analysis of variance results with follow-up Scheffé tests indicated no statistically significant differences between the mental health stakeholder groups and members of the general public in the likelihood of violence or the desire for social distance. However, there was more variation between both the mental health stakeholder groups and the general public and within the mental health stakeholder groups in the perceptions of the causes of the mental illness. Throughout the analyses, the consumers tended to have the most negative views of the illness. Implications for future stigma research and education are discussed.

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

OBJECTIVE This study examined whether New York States 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 States 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. RESULTS On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. CONCLUSIONS Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.

Psychiatric advance directives and reduction of coercive crisis interventions

Background: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. Aims: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. Method: The study prospectively compared a sample of PAD completers (n = 147) to non-completers (n = 92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. Results: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR = 0.50; 95% CI = 0.26–0.96; p < 0.05). Conclusions: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.

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. RESULTS For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. CONCLUSIONS Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.

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.

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. This study examined whether AOT recipients have lower odds of arrest than persons with serious mental illness who have not yet initiated AOT or signed a voluntary service agreement. METHODS Interview data from 2007 to 2008 from an evaluation of AOT in New York State were matched with arrest records from 1999 to 2008 for 181 individuals and analyzed using multivariable logistic regression. RESULTS The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement. The odds of arrest among individuals currently under a voluntary service agreement (OR=.64) were not significantly different than for individuals who had not yet initiated either arrangement. The adjusted predicted probabilities of arrest in any given month were 3.7% for individuals who had not yet initiated AOT or a voluntary agreement, 1.9% for individuals currently on AOT, and 2.8% for individuals currently under a voluntary agreement. CONCLUSIONS AOT may be an important part of treatment efforts to reduce criminal justice involvement among people with serious mental illness.

Clinicians’ Attitudes Regarding Barriers to the Implementation of Psychiatric Advance Directives

ObjectivePsychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals.MethodsA total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs.ResultsAcross the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers’ desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers.ConclusionPsychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals’ work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.