Effectiveness of a mental health court in reducing criminal recidivism and violence

Living Dead: Trans Cooperations with Mad Necropolitics and the Mad Trans Coalitions that Might Replace Them

Trans subjectivities continue to be included in major compendia of mental illness, despite recent moves to depathologize "cross-gender identification." Regardless, the inclusion of "gender dysphoria" is often framed as a formal mechanism to support access to gender affirming care as transgender subjectivities are re-conceptualized as part of sex/gender diversity and away from madness. The latter permits trans individuals to evade sanist oppressions. However, moves to disassociate from mad individuals also often serve to condone sanism. For instance, a contemporary policy landscape often sees transgender advocates arguing for the "medical necessity" of gender affirming care for gender dysphoria as a "recognized medical condition," thereby skirting the inclusion of gender dysphoria as a psychiatric condition and implying that gender dysphoria carries a special ontological status that separates it from madness (reified as "mental illness"). More though, this framework endorses material violences toward mad individuals that are often advanced via the workings of the state to consign marginalized constituents to death by withholding the means of life, i.e., necropolitics. In the following, I argue that trans disassociations from madness often endorses or assents to mad necropolitics. Drawing from Mbembe's (Necropolitics. Duke University Press, Durham, 2019) framework, I suggest that medicalizing trans narratives, despite being used to object to anti-trans laws in contemporary context, ideologically support mad "death worlds" organized through the U.S.A. welfare state and prison industrial complex. However, I also suggest alternative strategies, i.e., intersectional collaboration, that may uplift mad and/or trans communities.

Testing the Impact of a Law Enforcement-Operated Co-responder Program for Youths: A Quasi-Experimental Approach

OBJECTIVE

The authors examined whether use of a co-responder program reduced the likelihood of an involuntary commitment examination as the disposition of a police encounter with youths experiencing a mental health crisis and 1 year after the initial incident.

METHODS

Using a quasi-experimental design, the authors compared 206 incidents that involved the co-response program with 327 incidents that did not involve the program. Propensity score matching was used to balance groups on demographic and incident characteristics. The dependent variables included the disposition of the incident (deescalation or involuntary commitment examination), whether the youths experienced a later involuntary commitment examination within 1 year of the initial intervention, and time to the subsequent examination. Propensity score-weighted binary logistic regression and time-to-event analysis were used.

RESULTS

The co-responder program was associated with a significantly lower likelihood of police officer-initiated involuntary commitment examinations and a lower likelihood of an involuntary commitment examination within 1 year. Eighty percent of the incidents that resulted in a co-response involving a police officer and a mental health professional were deescalated, allowing the youth to remain in the community with a safety plan, whereas 17% of incidents with a police-only response ended with crisis deescalation.

CONCLUSIONS

These findings provide further support for the implementation of co-responder options that are available to police officers during encounters with children and adolescents experiencing a mental health crisis.

Treating Trauma in Criminal Justice-Involved with SMI: "Trauma Is a Huge Part of It"

Individuals with serious mental illness are both disproportionately represented in the criminal justice system and more likely to experience correlates with offending (e.g., trauma, substance abuse, and homelessness). Moreover, research using the Adverse Childhood Experiences has found strong correlation between childhood trauma and later negative outcomes, including criminal justice involvement. Despite this, research has yet to examine how trauma can influence treatment decisions for criminal justice-involved individuals with SMI. Using a qualitative approach and in-depth semi-structured interviews with 61 community mental health service providers, the current study addresses this gap in the literature. Findings confirm the high prevalence of trauma in this population as well as suggests a number of key findings for this population including (1) how trauma affects treatment decisions, (2) the existing barriers related to the treatment of trauma, and (3) what service providers need to effectively treat trauma. Implications for policy and practice are extensive.

Mental health service utilisation and reoffending in offenders with a diagnosis of psychosis receiving non-custodial sentences: A 14-year follow-up study

OBJECTIVE

While psychosis is considered a risk factor for offending, little is reported about mental health service utilisation in offenders with psychosis and its relationship with reoffending. We examined the association between contact with mental health services and reoffending in those diagnosed with psychosis.

METHODS

We linked health and offending records in New South Wales (Australia) and identified all individuals with a diagnosis of psychosis and a subsequent offence resulting in a non-custodial sentence between 2001 and 2012. We examined the incidence and risk factors for reoffending, and time to reoffending between 2001 and 2015 using Cox regression and Kaplan-Meier survival methods. We specifically examined the association between clinical contact with community mental health services following the index offence and reoffending.

RESULTS

Of the 7393 offenders with psychosis, 70% had clinical contact and 49% reoffended. There was a linear relationship between an increased number of clinical contacts and reduced risk of reoffending: those with no clinical contact had more than a fivefold risk of reoffending compared to those with the highest number of contacts (adjusted hazard ratio = 5.78, 95% confidence interval = [5.04, 6.62]). Offenders with substance-related psychosis and those convicted of non-violent offences had fewer clinical contacts and higher rates of reoffending when compared with controls (adjusted hazard ratio = 1.29, 95% confidence interval = [1.13, 1.47] and adjusted hazard ratio = 1.26, 95% confidence interval = [1.18, 1.35], respectively).

CONCLUSION

This study supports an association between more frequent mental health service use and reduced risk of reoffending. Efforts to enhance mental health service utilisation in those with psychosis who are at a higher risk of reoffending should be promoted.

Knowledge of evidence-based practices for PTSD among mental health court judges

Mental health courts offer access to community-based care for defendants with psychiatric disorders, including posttraumatic stress disorder (PTSD). However, limited information is available on how judges make treatment decisions about evidence-based practices. In this qualitative study, we interviewed mental health court judges to evaluate: (1) perspectives toward the role of PTSD in criminal behavior; (2) knowledge about evidence-based practice for PTSD; (3) treatment decisions for defendants with PTSD; and (4) treatment decisions for defendants at risk for suicide, a common comorbidity with PTSD. We hypothesized that mental health court judges would report low familiarity with evidence-based practices for PTSD despite wide recognition of the impact of trauma on criminal behavior. Methods: Mental health court judges (N = 11, 60% women, 60% between 50-59 years) were recruited from 7 states in the US and completed a demographics questionnaire and semi-structured qualitative interview that was transcribed and double-coded. Results: Judges in mental health court unanimously agreed that PTSD is highly prevalent among their defendants, but that they had not having received formal education about evidence-based practices for PTSD. They reported relying on their team members to provide recommendations for treatment planning and viewed their role as the enforcer of the treatment teams' suggestions. Finally, judges also reported that suicide prevention is an important consideration and that there is a need for universal suicide risk assessments. Conclusions: These findings have implications for continuing education among judges in mental health court, and we recommend mandated training to increase awareness of evidence-based practices for PTSD and suicide prevention.

Specialty Probation Officers as Street-Level Bureaucrats: Exploring How Discretion Is Perceived and Employed on a Mental Health Caseload

This study explores the perceptions of specialty mental health caseload probation officers and their use of discretion in day-to-day supervision of individuals with mental illness in one large jurisdiction in the United States. Scholars have examined overall effectiveness of specialty probation programs, probation officers' roles as street-level bureaucrats, and the impact of the mental health caseload probation officer and probationer relationship on successful completion. Less attention, however, has been placed on examining how the officers supervising these specialty caseloads perceive their roles as mental health probation officers and how they use discretion in their caseload management. The current study examines the narratives of 24 specialty mental health caseload probation officers and supervisors to understand how discretion is used on a problem-solving caseload and how discretionary decision-making may impact probationer outcomes.

The Role of Mental Health Courts in Mitigating Family Violence

Mental health courts are one potential means to mitigate violence against family members by people with mental illness. This study identified the rate at which cases of family violence come before a mental health court and the success of defendants charged with assaulting family members. In a sample of 1,456 defendants eligible to participate in a mental health court, descriptive statistics were used to report rates of admission of defendants charged with assaulting family members and their characteristics; a static group design was used to compare post-program rearrests among defendants who assaulted family members who successfully completed the program, who did not complete the program, and who did not participate despite being eligible; and logistic regression was used to determine the effect of participation on rearrest when controlling for demographic and clinical factors. The study found that family violence occurred in 24.7% of admitted cases. Most eligible defendants who assaulted family members (75.8%) participated in the court program, and among those who did, 72.2% successfully completed the program. Defendants who assaulted family members and had a positive program termination had a much lower rate of rearrest post-program completion compared with those who did not complete the program or did not participate despite being eligible, a finding that held when controlling for other factors. This study suggests that mental health courts can be an effective option for mitigating family violence committed by people with mental illness.

Could Expanding and Investing in First-Episode Psychosis Services Prevent Aggressive Behaviour and Violent Crime?

OBJECTIVE

Some persons developing, or presenting, schizophrenia engage in aggressive behaviour (AB) and/or criminal offending. Most of these individuals display AB prior to a first episode of psychosis (FEP). In fact, approximately one-third of FEP patients have a history of AB, some additionally display other antisocial behaviours (A+AB). The large majority of these individuals have presented conduct problems since childhood, benefit from clozapine, have extensive treatment needs, and are unlikely to comply with treatment. A smaller sub-group begin to engage in AB as illness onsets. A+AB persists, often for many years in spite of treatment-as-usual, until a victim is seriously harmed. This article proposes providing multi-component treatment programs at FEP in order to prevent aggressive and antisocial behaviours of persons with schizophrenia.

METHOD

Non-systematic reviews of epidemiological studies of AB among persons with schizophrenia, of the defining characteristics of sub-types of persons with schizophrenia who engage in AB and their responses to treatment, and of FEP service outcomes.

RESULTS

Studies have shown that mental health services that simultaneously target schizophrenia and aggressive behaviour are most effective both in reducing psychotic symptoms and aggressive behaviour. Evidence, although not abundant, suggests that a multi-component treatment program that would include the components recommended to treat schizophrenia and cognitive-behavioural interventions to reduce A+AB, and the other factors promoting A+AB such as substance misuse, victimisation, and poor recognition of emotions in the faces of others has the potential to effectively treat schizophrenia and reduce A+AB. Patients with a recent onset of AB would require few components of treatment, while those with prior conduct disorder would require all. Such a program of treatment would be long and intense.

CONCLUSIONS

Trials are needed to test the effectiveness of multi-component treatment programs targeting schizophrenia and A+AB at FEP. Studies are also necessary to determine whether providing such programs in hospitals and/or prisons, with long-term community after-care, and in some cases with court orders to participate in treatment, would enhance effectiveness. Whether investing at FEP would be cost-effective requires investigation.

Individual factors associated with recidivism among mental health court program clients

There is growing evidence that diversion to a mental health court program (MHC) can reduce recidivism rates and improve the quality of life of clients. However, there is less known about MHC client characteristics and factors associated with recidivism. Yet, this information would be useful to increase the effectiveness of these programs. Cross-sectional quantitative data were collected on MHC clients in three consecutive years. Of the 155 program clients that were successfully interviewed, only 154 were included in the analysis due to one non-consent to collect further data from their case manager. The purpose of this secondary analysis was to examine "What individual factors are associated with recidivism among MHC program clients?" This analysis specifically explored the association of sex, age, low functional ability, homelessness, court site, and criminal history. From the multiple logistic regression results, the increased risk of recidivism was found to be significantly associated with younger clients and a prior criminal history. The results of this study suggest programs tailored to young adults and repeat offenders may be areas that MHCs could potentially focus on to increase their effectiveness.

Association Between Early Contact With Mental Health Services After an Offense and Reoffending in Individuals Diagnosed With Psychosis

IMPORTANCE

Psychosis is a known risk factor for offending behavior, but little is known about the association between clinical contact with mental health services after an offense and reoffending.

OBJECTIVE

To examine the association between early contact with mental health services and reoffending after an index offense in individuals with psychosis.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, individuals diagnosed with psychosis before their index offense from July 1, 2001, to December 31, 2012, and who received a noncustodial sentence were identified by linking health and offending databases in New South Wales, Australia. The incidence of and risk factors for reoffending and time to reoffending within 2 years from the index offense were examined using Cox proportional hazards regression and Kaplan-Meier survival estimates. Specifically, the association between contact with mental health services within 30 days after an offense and reoffending was examined. Data were analyzed from July 1, 2019, to March 5, 2020.

EXPOSURES

Hospital admission, emergency department presentation, and contact with community mental health services associated with psychosis.

MAIN OUTCOMES AND MEASURES

Reoffending within 2 years of the index offense was compared in individuals with and without clinical contact with mental health services within 30 days after an offense, with adjustment for potential confounders.

RESULTS

Of the 7030 offenders with psychosis (4933 male [70.2%]; median age at the index offense, 34 [interquartile range, 26-42] years), 2605 (37.1%) had clinical contact with mental health services within 30 days after the index offense. The risk of reoffending was significantly lower in those with vs without clinical contact (adjusted hazard ratio [AHR], 0.83; 95% CI, 0.76-0.91). The risk of reoffending was 30% less in male offenders with 5 or more clinical contacts compared with male offenders with no clinical contact (AHR, 0.71; 95% CI, 0.59-0.84). Reoffending in both male and female offenders was associated with younger age (eg, AHR for male offenders aged <18 years, 3.31 [95% CI, 2.39-4.59]; AHR for female offenders aged <18 years, 2.60 [95% CI, 1.69-3.99]) and offending history (eg, AHR for male offenders with ≥4 prior offenses, 2.28 [95% CI, 1.98-2.64]; AHR for female offenders with ≥4 prior offenses, 2.22 [95% CI, 1.67-2.96]).

CONCLUSIONS AND RELEVANCE

In this cohort, early and frequent clinical contact with mental health services after an offense in individuals with psychosis was associated with reduced risk of reoffending in this group. More support may be needed for early treatment of those with serious mental illness who are at risk of reoffending.

Deciding to participate in mental health court: Exploring participant perspectives

As the number of mental health courts (MHC) expands across the United States, so does the body of research demonstrating its effectiveness in reducing criminal recidivism. While there has been considerable research conducted on MHC operations, less is known about how individuals decide to participate in MHCs. Data from in-depth interviews with 26 MHC participants from two MHCs in the United States were analyzed using grounded dimensional and thematic analyses. Results suggest that individuals participated in MHC to avoid incarceration and obtain treatment. Participants understood the court to function in four distinct ways: 1) to help through service provision, 2) to structure a judicial agreement allowing MHCs to make treatment decisions in exchange for community living, 3) to protect people from risks within the criminal justice system, and 4) to reward participants for treatment adherence. Findings can be used to guide the need for policy and practice for those referring to MHCs.

Judicial perspectives on mental health courts: The role of psychiatric disorder and violence risk

OBJECTIVE

The extent to which psychiatric diagnosis, treatment compliance, and violence risk influenced judges perceived benefits of Mental Health Court ("MHC") for defendants with psychiatric disorders was examined.

METHOD

81 judges completed one vignette in which psychiatric diagnosis (Schizophrenia, Major Depressive Disorder, Posttraumatic Stress Disorder), treatment compliance (yes/no), and violence risk (high/low) were randomized. The online survey was distributed via email and following the vignette, judges answered a question about the appropriateness of MHC.

RESULTS

Judges assessed defendants with severe psychiatric disorders (Schizophrenia and Major Depressive Disorder) - compared to defendants with PTSD - as more likely to benefit from MHCs. If deemed at low treatment compliance and/or high violence risk, judges were unlikely to appraise MHCs as beneficial, regardless of psychiatric diagnosis.

IMPLICATIONS

Judges appear to consider relevant factors when determining whether MHC will benefit defendants with psychiatric disorders; however, future research should include more variables (e.g., addictions, history of violence) to examine the combined influence on judges' perception of MHC suitability.

Does in-prison physical and mental health impact recidivism?

Incarceration is definitively linked to poor health, and upon release from prison, many individuals experience difficulty in maintaining good health. Given the complexity of the reentry process, one's health status, both in and out of prison, likely influences additional aspects of reentry, such as abstaining from crime or adhering to parole terms. The purpose of this study is to determine whether in-prison physical and mental health, as well as changes to an individual's health upon release from prison, are related to the likelihood of recidivating. We employ the Serious and Violent Reentry Initiative (SVORI) data, a multi-state sample of formerly incarcerated males who are followed from prison to release into the community and interviewed about a number of post-prison release issues, including health. We use hierarchical logistic and multinomial regressions, where survey waves are nested within people, to assess if in-prison physical and mental health and post-release changes to health are associated with recidivism in two ways: general re-incarceration and re-incarceration due to either a technical violation of parole or a new conviction. With right-censoring due to recidivism or “failure,” our final sample size is 2180 person-periods (i.e., waves) nested within 871 respondents. We find that better physical health, both in-prison and changes in health post-release, is related to a higher likelihood of recidivating. Better mental health, both in-prison and changes to mental health post-release, is related to a decrease in the likelihood of recidivating. Individuals with poor mental health in-prison who make significant improvements after release see the largest reduction in their odds of recidivating. Finally, the combination of better mental health in-prison and increases in mental health post-release is associated with reductions in the likelihood of re-offending for both technical violations and new convictions. In sum, in-prison health continues to influence individuals after prison and is associated with their odds of recidivating, thus contributing to the churning of individuals through the prison system.

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We examine the relationship between in-prison and change in post-release health and recidivism.

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Better physical health in-prison and post-release is related to higher recidivism likelihood.

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Better mental health in-prison and post-release is related to lower recidivism likelihood.

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This mental health benefit applies to both technical violations and new convictions.

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A person's health in prison may be related to prison system churning.

The Effectiveness of Mental Health Courts in Reducing Recidivism and Police Contact: A Systematic Review

Mental health courts were created to help criminal defendants who have a mental illness that significantly contributes to their criminal offense. The purpose of this systematic literature review is to assess the current evidence to address the question, "How effective are mental health courts in reducing recidivism and police contact?" Systematic literature searches of eight electronic databases were performed. A total of 2590 unique citations were identified. Of these, 20 studies were included in the final analysis. The results of this systematic review suggest there is some evidence to show that mental health courts help to reduce recidivism rates, but the effect on police contact is less clear. Results also suggest case managers or access to vocational and housing services may be important components of effective mental health courts.

The impact of mental health court: A Sacramento case study

Mental health courts (MHCs) use a collaborative justice approach to provide a therapeutic alternative to the traditional justice process for defendants with mental illnesses directly relevant to their alleged criminal offenses. MHCs have proliferated in recent years, in light of early research reports documenting their successes. The aim of this paper is to provide further evaluation of the effects of MHCs by evaluating the impact of the Sacramento County MHC in California. We analyzed quantitative data and conducted interviews with stakeholders and MHC participants to understand how the MHC influenced individual participants' recidivism rates, mental health, and quality of life. Results from the quantitative data analysis indicate that defendants had a lower rate of recidivism after the MHC program than before it. Moreover, graduates were less likely to be rearrested and rehospitalized than non-graduates. Qualitative analyses revealed several core themes regarding participants' views on facilitators and barriers related to the MHC's success. These findings provide further insights into the effectiveness of MHCs.

The Queensland mental health court: a unique model

There is a longstanding but sometimes controversial belief that a person is not criminally responsible for a crime if they were suffering from a mental illness at the time of the offence. The Queensland Mental Health Court (QMHC) system, in which assisting clinicians have a central role, is underwritten by this belief. This paper describes the QMHC system.

A Three Stage Model for Mental Health Treatment Court: A Qualitative Analysis of Graduates' Perspectives

Mental Health Treatment Courts (MHTC) address the overrepresentation of individuals with mental health disorders in the criminal justice system and strive to minimize the "revolving door" cycle of arrest/incarceration/release/re-arrest. A qualitative research group interview design was conducted with program graduates resulting in a three stage model. Participant's motivation was initially to avoid jail, but over time participants begin to make intentional choices leading to mental health recovery. Participants also described the importance of their relationship with the staff and the judge as well as the need for trust, understanding, and respect throughout the program. Recommendations for future research and program development are discussed.

Violent criminal behavior in the context of bipolar disorder: Systematic review and meta-analysis

BACKGROUND

Despite the potential importance of understanding violent criminal behavior (VCB) in individuals suffering from bipolar disorder (BD), previous findings are conflicting. The aims of the present study are to clarify the association of VCB and BD in comparison to general population and other psychiatric conditions.

METHODS

A systematic review of literature from January 1st, 1980 through January 16th, 2017 from 3 electronic databases (MEDLINE/PubMed, EMBASE and PsycInfo), following the PRISMA and the MOOSE statements. Original peer-reviewed studies reporting data on VCB in BD were included. A random-effects meta-analysis was performed. Potential sources of heterogeneity were examined through subgroup and meta-regression analyses. The protocol was registered in PROSPERO, CRD42017054070.

RESULTS

Twelve studies providing data from 58,475 BD participants. The prevalence of VCB in BD was 7.1% (95%CI = 3.0‒16.5%; k = 4). The association of BD and VCB compared to general population was not significant (OR = 2.784; 95% CI, 0.687‒11.287, P = .152). The association was significant only in cross-sectional studies, in studies in which VCB was assessed through self-reported measures, and in studies conducted in the USA. BD was more likely to be associated with VCB when BD patients were compared to controls with depressive disorders, whilst it was found to be less associated with VCB when BD was compared to psychotic disorders.

LIMITATIONS

1. the methodological heterogeneity across the included studies. 2. causal inferences were precluded by the inclusion of cross-sectional studies.

CONCLUSIONS

These findings might provide a more balance portrait of the association between BD and VCB to clinicians, law enforcement and general public.

Life After: Examining the Relationship Between Sociobehavioral Factors and Mental Health Among African American Ex-Offenders

Mental health problems are 3 times higher among prisoners than the general population. After release, reentry barriers and other factors can exacerbate mental problems. This study of 250 African American ex-offenders examines the relationship between sociobehavioral factors and mental health. Independent variables included self-reported health, alcohol use, employment, and history of mental problems before prison. Covariates included the number of immediate family with mental problems and the number of serious conflicts with family members or friends. Analyses revealed that men who had serious conflicts, used alcohol more often, reported less than excellent health, and not employed were more likely to report being troubled by mental problems. Family mental health history was not statistically significant. The current study adds to the literature by identifying selected factors associated with the mental health of African American male, ex-offenders. Findings from this study can inform interventions to address mental health issues and reduce recidivism.

Characteristics and Outcomes of People With Intellectual and Developmental Disabilities Participating in a Mental Health Court

This study compares characteristics and outcomes of 70 defendants with and 1,122 without intellectual and developmental disabilities (IDD) participating in a mental health court. Demographic and clinical characteristics differed, but criminal justice or program characteristics did not. Age, race, marital status, living situation, court location, health insurance status, and likelihood of mental illness or substance abuse diagnosis differed between the two groups. When controlling for other factors, a diagnosis of IDD did not affect the odds of negative termination from the court but did reduce the odds of rearrest within 1 year of leaving the court. Some mental health courts exclude people with IDD; the study concludes inclusion is appropriate.

Gender and mental health: An examination of procedural justice in a specialized court context

The procedural justice framework has been applied in the criminal justice contexts of policing, corrections, and courts. According to this perspective, fair treatment, respectful dialogue and being given a proper voice will contribute to citizens' positive views of authority figures. While this literature has grown immensely, several questions remain unanswered. Do males and females perceive similar levels of procedural justice? Does mental health status influence perceptions of fair treatment? Whether procedural justice is a general perspective that can be applied across social groupings has important implications for correctional treatment in that programs that truly "work" for all are more cost-effective. Toward that end, the current study investigates the relationships among procedural justice perceptions, gender, and mental health status in specialized drug courts, a context that has received little empirical attention. We do so using secondary data originally collected between 2003 and 2009 for Rossman, Roman, Zweig, Rempel and Lindquist's Multisite Adult Drug Court Evaluation (MADCE). Results from a full-sample analysis reveal that women report higher levels of procedural justice; that drug court participation significantly influences procedural justice perceptions; and that depressive symptomology is a significant predictor of procedural justice perceptions. In male- and female-specific subsamples, drug court participation exerts similar effects for males and females, as does depressive symptomology. Implications for theory, research, and practice are discussed.

Mental health courts and forensic assertive community treatment teams as correctional diversion programs

Problem-solving courts (PSCs) developed as a means of mandating treatment and judicial supervision of certain types of court participants. PSCs have rapidly expanded in number and type over several decades. Mental health courts (MHCs) are a type of PSC that arose in response to the growing number of persons with mental illness within the criminal justice system. Their primary role is to divert individuals with mental illness from incarceration into psychiatric treatment and to reduce recidivism while improving psychosocial functioning of participants. Although different in history, philosophy, and program structure, forensic assertive community treatment (FACT) programs serve a similar goal of reducing recidivism and improving functioning in persons with mental illness who are involved with the criminal justice system. FACTs may be used as a standalone diversion option or be linked with a MHC as a form of intensive treatment and monitoring. Suggestions for future research and evaluation of these programs are offered.

Biobehavioral Approaches to Aggression Implicate Perceived Threat and Insufficient Sleep: Clinical Relevance and Policy Implications

Besides reducing the burden of aggression and violence on society, the biobehavioral study of aggression can inform our understanding of emotional problems and maladaptive behaviors more broadly, since aggression can often co-occur with psychological disorders (e.g., depression). This article reviews the neuroscience/psychophysiology literature to explain brain processes in aggression that can be targeted to reduce its scourge on society. In particular, the review implicates brain circuitry that is often triggered by feelings of threat, which in turn disrupt higher order cognitive processes and may prompt aggression. One potentially modifiable factor less frequently considered in the study of aggression is sleep insufficiency or problems. The neurophysiological impact of sleep insufficiency can parallel the brain-related risk factors of aggression. Policy recommendations span individual mental health innovations, community-based interventions, and public health campaigns promoting healthy lifestyles to reduce aggression and violence.

The many wounds of war: The association of service-related and clinical characteristics with problems with the law in Iraq and Afghanistan veterans

Previous research has demonstrated that veterans with posttraumatic stress disorder (PTSD) are at higher risk for aggression, hostility, and anger, potentially leading to problems with the law or disciplinary action while in the military. There have been calls for increased consideration of the unique aspects of the judicial system in legal matters with veterans involved. The bulk of the research so far has considered the link between PTSD, traumatic brain injury (TBI), and combat exposure, but little is known about the potential role of chronic pain and Military Sexual Trauma (MST) in a veteran's experience of anger, aggression, and discipline while in the military and legal concerns. The present study used retrospective cross-sectional health screening data in a sample of 1250 Iraq and Afghanistan veterans to examine the associations of demographic, service-related, and clinical characteristics with self-reported legal problems. A total of 440 veterans (34.6%) endorsed having experienced some type of problems with the law. Independent logistic regression analyses demonstrated that those who screened positive for PTSD, MST, TBI, and clinical levels of pain were more likely to report legal problems; only the associations with positive PTSD (p=0.001) and MST (p=0.007) screens remained significant in multivariate regression analyses. The findings underscore the need for a thorough psychological evaluation when veterans are involved in the legal system with a special emphasis on factors prevalent to Iraq and Afghanistan veterans.

The effectiveness of specialized legal counsel and case management services for indigent offenders with mental illness

BACKGROUND

In recent years, jurisdictions have recognized the strain placed on limited existing resources by criminal offenders with mental illness who frequently cycle through local jail facilities. In response, many locales have developed and implemented specialized programs to more effectively and efficiently manage these offenders, particularly the process of assigning defense attorneys to these often indigent defendants.

METHODS

The current study examined the impact of an Indigent Defense Counsel (IDC) program designed to provide specially trained defense attorneys, and enhanced case management services to 257 indigent jail inmates with a qualifying, major mental health diagnosis (e.g., major depression). These offenders were compared to 117 similar offenders who did not receive these services, on both their length of stay in the jail, and their likelihood of recidivism after release to the community.

RESULTS

Survival analyses revealed that program participants spent about 17 fewer days in jail; however, recidivism rates between groups, measured as return to the same county jail or as statewide re-arrest, did not differ.

CONCLUSIONS

These results suggest that defendants with mental illness can potentially be managed effectively in the community, with little added risk to public safety and at potential savings in jail bed days/costs. Implications for the processing of indigent criminal defendants with mental illness are presented.

The prevalence and geographic distribution of complex co-occurring disorders: a population study

AIMS

A subset of people with co-occurring substance use and mental disorders require coordinated support from health, social welfare and justice agencies to achieve diversion from homelessness, criminal recidivism and further health and social harms. Integrated models of care are typically concentrated in large urban centres. The present study aimed to empirically measure the prevalence and distribution of complex co-occurring disorders (CCD) in a large geographic region that includes urban as well as rural and remote settings.

METHODS

Linked data were examined in a population of roughly 3.7 million adults. Inclusion criteria for the CCD subpopulation were: physician diagnosed substance use and mental disorders; psychiatric hospitalisation; shelter assistance; and criminal convictions. Prevalence per 100 000 was calculated in 91 small areas representing urban, rural and remote settings.

RESULTS

2202 individuals met our inclusion criteria for CCD. Participants had high rates of hospitalisation (8.2 admissions), criminal convictions (8.6 sentences) and social assistance payments (over $36 000 CDN) in the past 5 years. There was wide variability in the geographic distribution of people with CCD, with high prevalence rates in rural and remote settings.

CONCLUSIONS

People with CCD are not restricted to areas with large populations or to urban settings. The highest per capita rates of CCD were observed in relatively remote locations, where mental health and substance use services are typically in limited supply. Empirically supported interventions must be adapted to meet the needs of people living outside of urban settings with high rates of CCD.

Psychiatric symptoms and mental health court engagement

People with mental illnesses are overrepresented in the criminal justice system. Many interventions have been implemented to treat the underlying causes of criminal justice involvement and prevent people with mental illnesses from recidivating. Mental health courts (MHC) are one of these programs. This analysis examines the relationship between psychiatric symptoms and MHC engagement. Eighty MHC participants from two Midwestern MHCs were interviewed. Symptom severity was assessed at baseline using the Brief Psychiatric Rating Scale. MHC engagement was estimated by treatment adherence, substance use, days spent in jail, probation violations, and MHC retention during a six month follow-up period. Using nonparametric statistical tests and logistic regression, results indicate symptoms of depression, anxiety, and guilt are more severe at baseline for those people who are incarcerated during the follow-up period. Symptoms of anxiety are more severe for people who are terminated or went missing during the follow-up period. Further research is needed to determine the directionality and causality of these relationships. MHCs professionals should be aware of the relationship between symptom severity and MHC engagement and attempt to connect participants with treatment and services as early as possible and individualize treatment plans based on current symptoms and need.

No Soldier Left Behind: The Veterans Court Solution

This paper concerns one of the newer iterations of problem-solving courts: veterans treatment courts. We trace the history of problem solving court implementation and explore the functioning of an established veterans court. The focus of this exploratory, qualitative study is the courthouse workgroup and their interactions both within the veterans court and with more traditional criminal courts and criminal justice agencies. We summarize the literature on problem solving courts and the experience, insights and suggestions of the members of the court we examined.

A theoretical evaluation of a youth mental health court program model

Mental health courts are a promising new approach to addressing the overrepresentation of mental health needs among offender populations, yet little is known about how they facilitate change, particularly for youth. The current study reports on a process evaluation of a youth mental health court in Toronto, Canada. Drawing upon observations of the court and interviews with key informants, we developed a program model of the court and explored its implementation within the context of empirical evidence for treating justice-involved youth. Findings revealed that the proposed mechanism of change, which focuses on reducing recidivism through the treatment of mental health needs, should also consider factors directly related to offending behavior. Findings further highlight several strengths of the program, including the program's supportive environment and ability to engage and link youth and families with treatment. Areas for continued growth include the need for comprehensive protections of legal rights.

Exploring the relationship between criminogenic risk assessment and mental health court program completion

The two primary goals of mental health courts are to engage individuals with severe mental illness in the criminal justice system with clinical mental health services and to prevent future involvement with the criminal justice system. An important factor in helping to achieve both goals is to identify participants' level of clinical needs and criminogenic risk/needs. This study seeks to better understand how criminogenic risk affects outcomes in a mental health court. Specifically, we explore if high criminogenic risk is associated with failure to complete mental health court. Our subjects are participants of a municipal mental health court (MHC) who completed the Level of Services Inventory-Revised (LSI-R) upon entry to the program (N=146). We used binary logistic regression to determine the association between termination from the program with the total LSI-R. Our findings suggest that, net of prior criminal history, time in the program and clinical services received, high criminogenic risk/need is associated with failure to complete mental health court. In addition to providing clinical services, our findings suggest the need for MHCs to include criminogenic risk assessment to identify criminogenic risk. For participants to succeed in MHCs, both their clinical and criminogenic needs should be addressed.

New Frontiers for Conditional Release: Applying Lessons Learned from Other Offenders with Mental Illness

There is relatively little research in the literature on insanity acquittees as compared with the large number of studies focused on the supervision and treatment of probationers and parolees with mental illness. Ideally, the latter literature could be successfully applied to insanity acquittees discharged from an inpatient hospital on "conditional release." This article describes the challenges faced by persons on conditional release as well as the gaps in extant conditional release literature. Then, five evidence-based models for the supervision and/or treatment of probationers and parolees with mental illness are applied to a theoretical conditionally released population (mental health courts, forensic assertive community treatment teams, the risk-need-responsivity model, informed supervision practices, and HOPE probation). Benefits and limitations are noted, and recommendations for such crossover are given. Copyright © 2016 John Wiley & Sons, Ltd.

A Specialized Treatment Court for Veterans with Trauma Exposure: Implications for the Field

This study examines the efficacy of providing a Veterans Treatment Court specialized docket to trauma-affected veterans. Eighty-Six veterans enrolled in a jail diversion and trauma recovery Veterans Treatment Court program. Veteran participants were interviewed at baseline, 6- and 12-months to determine if the program led to improvements in jail recidivism, psychiatric symptoms, quality of life, and recovery. The results suggest that veteran's involved in the Veterans Treatment Court programs experienced significant improvement in PTSD, depression, substance abuse, overall functioning, emotional wellbeing, relationships with others, recovery status, social connectedness, family functioning, and sleep.

When prison is "easier": probationers' perceptions of health and wellbeing

PURPOSE

There are currently over 300,000 offenders in England and Wales and the majority, around 240,000, are in the community on probation. However, there is a paucity of research on their health and healthcare needs. The purpose of this paper is to explore issues around health and access to health services for those on probation. In particular the paper explores what people on probation consider to be the key health issues currently affecting them, and to identify barriers to accessing healthcare in the community.

DESIGN/METHODOLOGY/APPROACH

The authors ran six focus groups with a total of 41 participants; two were with staff and the others with men and women on probation. In each focus group, the researchers used semi-structured guide and the discussions were recorded electronically and then transcribed. The paper adopted a thematic analytical framework and used NVivo 7 to facilitate analysis.

FINDINGS

Both probationers and professionals largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation which was not generally recognised by professionals. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health and alcohol services.

RESEARCH LIMITATIONS/IMPLICATIONS

This was a small study conducted in one part of England and therefore it is not clear that the findings are generalisable. However, it raises important issues about the mental health needs of probationers and the lack of appropriate services for them. Effective services may have positive impact on re-offending and further research is needed to evaluate models of care.

PRACTICAL IMPLICATIONS

The challenge remains for local health service commissioners and providers and the probation service to work together to provide appropriate and accessible services for all those on probation.

ORIGINALITY/VALUE

Nearly one-quarter of a million people are on probation at any one time in the UK but the existing evidence on their health is patchy and dated. Little is known about effective health interventions or the extent to which their health needs are met. This study shows that probationers see the stress of being on probation as their most important health concern. Both probationers and staff recognise that mental health and substance use are persistent problems and that these important health needs in these areas are not being met by existing services.

What Happens to Mental Health Court Noncompleters?

Mental health court (MHC) research consistently finds that defendants who successfully complete and graduate from the court are less likely to recidivate than those who do not. However, research has not assessed what happens to these noncompleters once they are sent back to traditional court. Using follow-up data on six years of noncompleters from pre-adjudication MHC, we examine what happens to these defendants in traditional court. Findings suggest that 63.7% of defendants' charges were dismissed, 21.0% received probation, and 15.3% were sentenced to incarceration. We examine the time to disposition and differences in defendant characteristics and disposition outcome as well as the relationship between disposition and subsequent recidivism. Results suggest that more severe punishments in traditional court are associated with recidivism. Logistic regression analysis shows that defendants whose charges were dismissed in traditional court were less likely to recidivate than those who were sentenced to probation or incarceration. Our findings highlight the need for future MHC evaluations to consider traditional court outcomes and support trends towards post-adjudication courts.

Cost analysis of long-term outcomes of an urban mental health court

Multiple studies have demonstrated decreased recidivism and increased treatment engagement for individuals with serious mental illness involved in Mental Health Courts (MHC). However, the limited availability of social and fiscal resources requires an analysis of the relationship between a program's effectiveness and its costs. Outcome costs associated with a sample of 105 participants discharged for more than 1 year - and grouped by completion status - were compared to an eligible sample not enrolled (n=45). Transactional costs analysis (TCA) was used to calculate outcomes associated with treatment, arrest, and confinement in the 12-month post-MHC. Total outcome costs for the Successful Group ($16,964) significantly differed from the Unsuccessful ($32,258) and Compare Groups ($39,870). Costs associated with the higher number of arrests for those in the Compare Group created the largest differences. Total cost savings between Successful and Compare (M=$22,906) equated to $916,240 and savings between Unsuccessful and Compare (M=$7612) were $494,708. The total combined cost savings for participants in the 12-month post-MHC period was $1,411,020. While it is important to understand that MHCs and the individuals that they serve vary and these results are for a felony-level court, policy makers and researchers can use these results to guide their decision-making.

Comorbid mental illness and criminalness implications for housing and treatment

The relationship between mental illness, violence, and criminal behavior is complex, and involves a multifaceted interaction of biological, psychological, and social processes. In this article, we review the emerging research that examines the neurobiological and psychological factors that distinguish between persons with mental illness who do and who do not engage in crime and violence. Additionally, a novel model for understanding the interaction between mental illness and criminalness is proposed. (As defined by Morgan and colleagues, criminalness is defined as behavior that breaks laws and social conventions and/or violates the rights and wellbeing of others.) Stemming from this model and outlined research, we argue that management and treatment approaches should target the co-occurring domains of mental illness and criminalness to improve criminal and psychiatric outcomes. Specifically, we discuss and propose effective housing (management) and biopsychosocial intervention strategies for improving outcomes.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.

Rethinking responsibility in offenders with acquired paedophilia: punishment or treatment?

This article reviews the current neurobiological literature on the aetiology of developmental and acquired paedophilia and examines what the consequences could be in terms of responsibility and treatment for the latter. Addressing the question of responsibility and punishment of offenders with acquired paedophilia from a neurobiological perspective is controversial. Consequently it is essential to avoid hasty conclusions based strictly on neurobiological abnormality justifications. This study establishes a distinction between developmental and acquired paedophilia. The article investigates whether offenders who fulfil the diagnosis of acquired paedophilia should be held fully responsible, particularly in cases where the offender's conduct appears to result from volitionally controlled behaviour that is seemingly incompatible with a neurological cause. Moreover, the article explores how responsibility can be compromised when offenders with acquired paedophilia have (partially) preserved moral knowledge despite their sexual disorder. The article then examines the option of offering mandatory treatment as an alternative to imprisonment for offenders with acquired paedophilia. Furthermore, the article addresses the ethical issues related to offering any form of quasi-coercive treatment as a condition of release. This study concludes that decisions to fully or partially excuse an individual who fulfil the diagnosis of acquired paedophilia should take all relevant information into account, both neurobiological and other environmental evidence, and should proceed on a careful case by case analysis before sentencing or offering treatment.

Criminal justice system contact and mortality among offenders with mental illness in British Columbia: an assessment of mediation

BACKGROUND

Persons with mental illness are over-represented in prison populations around the world. They are more vulnerable to arrest and more likely to experience repeated encounters with the criminal justice system. Whether criminal justice involvement, in and of itself, is associated with higher mortality, particularly among offenders with mental illness, is unknown.

METHODS

The authors conducted a mediation analysis of mortality rates in a cohort of 79,088 offenders from British Columbia using administrative records spanning 2001-2010, where the mediating variable was the individual-level rate of criminal sentencing.

RESULTS

During 339,506 person-years of follow-up, there were 1841 deaths. The diagnosis of mental illness had no direct association with higher mortality after adjustment for confounders (HR=0.98, 95% CI 0.86 to 1.06). However, mental illness had an indirect association with mortality that was mediated through more frequent criminal justice involvement (HR=1.02, 95% CI 1.01 to 1.04).

CONCLUSIONS

These findings support the hypothesis that offenders with mental illness experience higher mortality that is mediated by higher rates of criminal justice contact. The results of our study indicate that criminal justice diversion programmes are further warranted because they may contribute to the prevention of mortality among offenders with mental illness.

Predictors of incarceration among urban adults with co-occurring severe mental illness and a substance use disorder

OBJECTIVE

People with severe mental illness and a co-occurring substance use disorder (co-occurring disorders) who live in urban areas experience high rates of incarceration. This study examined sociodemographic, clinical, economic, and community integration factors as predictors of incarceration among people with co-occurring disorders.

METHODS

This secondary analysis used data from a randomized controlled trial of assertive community treatment versus standard case management. In the parent study, researchers interviewed 198 people with co-occurring disorders from two urban mental health centers in Connecticut at baseline and every six months for three years. Researchers tracked incarceration, clinical engagement and status, employment, living situation, social relationships, and substance use. The study reported here used bivariate analyses and logistic regression analyses to compare individuals who were incarcerated during the study period with those who were not.

RESULTS

The overall incarceration rate was 38% during the study period. In multivariate analyses, prior incarceration predicted incarceration during the study period (odds ratio [OR]=3.26). Two factors were associated with a reduced likelihood of incarceration: friendships with individuals who did not use substances (OR=.19) and substance use treatment engagement (OR=.60).

CONCLUSIONS

Positive social relationships and engagement in substance use treatment are promising service and policy targets to prevent incarceration in this high-risk population.

Why do mental health courts work? A confluence of treatment, support & adroit judicial supervision

The article contributes to the understanding of 'what works' in mental health courts (MHCs). There are now almost 400 MHCs in the US and more worldwide. A substantial body of evidence demonstrates that MHCs can succeed in reducing recidivism among offenders who suffer mental disorders. This article argues that MHCs succeed when they have achieved the right confluence of essential elements, including providing evidence-based treatment and psychosocial supports and using adroit judge-craft. After a brief review of some of the studies demonstrating MHC success, this article discusses the research into the necessary foundations of rehabilitation programs. It is argued that, although treatment and psychosocial services should be supplied within an evidence-based framework, neither of the two leading conceptual models - Risk-Needs-Responsivity and the Good Lives Model - are empirically proven with offenders who suffer from mental disorders. Despite the absence of proof, the Good Lives Model is argued to be appropriate for MHCs because it is normatively consonant with therapeutic jurisprudence. The MHC judge is another essential element. The judicial role is assayed to elucidate how it functions to promote the rehabilitation of offenders with mental disorders. It is argued that the role of the MHC judge during supervisory status hearings is to establish a therapeutic alliance and practice motivational psychology with each MHC participant.

Long-term recidivism of mental health court defendants

The first MHC was established in 1997 and now, over 15years later, there are over 300 mental health courts in the United States. In a relatively short time these courts have become an established criminal justice intervention for persons with a mental illness. However, few studies have looked at the long-term outcomes of MHCs on criminal recidivism. Of the studies evaluating the impact of MHCs on criminal recidivism, most follow defendants after entry into the court during their participation, and only a few have followed defendants after court exit for periods of one or two years. This study follows MHC defendants for a minimum of five years to examine recidivism post-exit with particular attention to MHC completion's effect. Findings show that 53.9% of all MHC defendants were rearrested in the follow-up and averaged 15months to rearrest. Defendants who completed MHC were significantly less likely to be rearrested (39.6% vs. 74.8%), and went longer before recidivating (17.15months vs. 12.27months) than those who did not complete. This study suggests that MHCs can reduce criminal recidivism among offenders with mental illness and that this effect is sustained for several years after defendants are no longer under the court's supervision.

Mental health diversion courts: a two year recidivism study of a South Australian mental health court program

The need to develop specialized judicial processes to deal with offenders with mental illnesses is now widely recognized and has led to the introduction of mental health court diversion programs around the world. At present, however, there is only limited evidence from which to assess the impact of these initiatives. This paper describes the South Australian model of diversion, with specific reference to the relationship between identified participant characteristics, program compliance rates, and re-offending outcomes. The results of a two-year recidivism study suggest that involvement with the program has a positive impact on recidivism, but that this is independent from the individual's level of success in the program. Lower risk offenders were more likely to achieve successful outcomes than those in the higher risk categories. The implications of these results, as well the factors that might inform the ongoing development of mental health court programs, are discussed.

The impact of judge-defendant communication on mental health court outcomes

Previous research has shown that mental health courts have been successful in reducing the rates of recidivism among mentally ill offenders. However, none of these studies, to date, have examined exactly what aspects of the courts reduce these rates of recidivism and what makes them successful. The current study utilized a sample of 291 mentally ill criminal offenders participating in a mental health court to examine whether those participants who were addressed by and communicated with the judge had a reduction in recidivism rates and the severity of new charges in comparison to those who did not. The hypotheses regarding greater judge-defendant communication and recidivism were not supported. This suggests that communication in and of itself is not sufficient to reduce recidivism. Future research of a qualitative nature is essential to identify if the frequency, tone, and valence of the communication results in improved outcomes. In addition, these results may indicate a necessity for more stringent training and guidelines for the maintenance of Mental Health Courts. Results of the current study suggested differences between genders, such that females were spoken to by the judge more frequently than were men.