The four dimensions: a model for the social aetiology of psychosis

Recently, there has been increasing focus on prevention of mental illness, early intervention and the promotion of mental health. The social determinants of health and public health approaches are considered key. Early intervention has focused on psychotic disorders but prevention has not. This may in part reflect the fact that public health planners do not have a clear model for how social determinants influence the risk of developing a psychotic illness. Drawing on biological, genetic and epidemiologic evidence regarding the relationship between social risk factors and psychosis, this paper outlines a conceptual framework for understanding how individual and ecological factors contribute and interact to modulate the risk of developing psychotic illness. The framework asserts that there are four dimensions: individual factors; ecological factors; the interaction between individual and ecological factors; and time. It may help those considering interventions to understand the multilevel and multifactorial effects of social factors on the aetiology of psychotic illness, to develop targeted strategies for the prevention of psychotic illness and serve as a template for the assessment of initiatives.     

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

OBJECTIVE: In response to the large-scale involvement of people with mental disorders in the criminal justice system, many communities have created specialized mental health courts in recent years. However, little research has been done to evaluate the criminal justice outcomes of such courts. This study evaluated whether a mental health court can reduce the risk of recidivism and violence by people with mental disorders who have been arrested. METHOD: A retrospective observational design was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. A matching strategy based on propensity scores was used to adjust analyses for nonrandom selection into mental health court. RESULTS: Propensity-weighted Cox regression analysis, controlling for other potential confounding variables (demographic characteristics, clinical variables, and criminal history), showed that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with maintenance of reductions in recidivism and violence after graduates were no longer under supervision of the mental health court. CONCLUSIONS: The results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.     

Risk of Reincarceration Among Prisoners with Co-occurring Severe Mental Illness and Substance Use Disorders

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.     

Predictors of mental health service utilization by people using resources for homeless people in Canada

OBJECTIVE: This study used Pescosolido's network episode model to examine mental health service utilization among impoverished people accessing resources for the homeless in Canada's universal health care setting. METHODS: The sample consisted of 439 people who met DSM-IV criteria for affective or psychotic disorders who were assessed as part of a larger study of resources for homeless or impoverished people in Montreal and Quebec City. Interviews were organized into the framework of four network episode model concepts: sociodemographic characteristics, illness characteristics, illness history, and social network. These blocks of variables were then analyzed in terms of their accuracy in predicting mental health service utilization. RESULTS: Eighty-four percent of the sample were male, the mean+/-SD age was 41+/-12 years, and 36% were homeless at the time of the interview, but nearly half (48%) of the population had been homeless previously. The research shows that each network episode model concept except illness history significantly predicted utilization of mental health services. Female gender, youth, never being homeless (sociodemographic characteristics), presence of antisocial personality disorders within the preceding year, past or current alcohol-related disorders (illness characteristics), hospitalization before the preceding year (illness history), and a larger social support network were related to utilization of mental health services. CONCLUSIONS: In the absence of economic barriers to health care, there are other significant barriers to the use of mental health services for people who live in poverty. A better understanding of these factors will help in meeting the service needs of impoverished mentally ill people.     

Service responses for youth onset mental disorders

PURPOSE OF REVIEW: Many psychiatric disorders have their highest first-onset rates in adolescence and young adulthood. We summarize recent work indicating where interventions are most needed and effective. We also review the literature that examines the scope for reorienting mental health services to meet the needs of adolescents and young adults. RECENT FINDINGS: The continuities between youth onset and later life disorders, as well as later social adjustment, have become clearer. Emotional disorders that persist or recur during the teens have the greatest effect on future mental health. To date, service systems, even in the developed world, cater poorly for youth with mental disorders. Intervention studies demonstrate the short-term benefits of intensive multidisciplinary intervention for early psychosis. There are few data concerning the benefit of early intervention for other disorders. Long-term benefits for early intervention for any condition are unknown. Youth streams of psychiatric care have developed for early-onset psychotic disorders. SUMMARY: An increasing understanding of the high prevalence and longer-term effects of youth onset mental disorders has not yet been adequately matched by intervention research or the evaluation of different models of mental health service delivery.     

A Mother's Love? Postpartum Disorders,the DSM-5 and Criminal Responsibility – A South African Medicolegal Perspective

The interface between criminal law and the field of psychiatry has manifested predominantly with reference to the defence of pathological criminal incapacity, more commonly referred to as the insanity defence. The threshold requirement for establishing the defence of pathological criminal incapacity entails that the accused at the time of the commission of the offence should have suffered from a ‘mental illness’ or ‘mental defect’. Once it is established that the accused suffered from a mental illness or mental defect at the time of the commission of the offence, an assessment is conducted to determine whether the illness or defect rendered the accused either incapable of appreciating the wrongfulness of the act or of acting in accordance with such appreciation. The problem that inevitably arises during the assessment of the defence relates to the fact that the terms ‘mental illness’ and ‘mental defect’ are not defined. Mental health practitioners mainly rely on the DSM for answers, yet the DSM cautions that the disorders contained may not be wholly relevant for legal purposes. Postpartum disorders are generally classified as postpartum depression and the more serious manifestation, postpartum psychosis. Postpartum disorders were not provided for in the DSM-IV (1994) or the DSM-IV-TR (2000) as distinct mental disorders. The DSM-5 came into operation in 2013, and yet again these disorders fall outside the scope of the DSM-5. Research indicates that the mental health professional plays a vital and pivotal role in explaining these disorders and the various complexities associated with them. The focus of this article is to illustrate the phenomena of postpartum depression and postpartum psychosis against the backdrop of the defence of pathological criminal incapacity within the context of South African criminal law. The vital and essential role of the mental health expert within this context is explored.     

Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months

OBJECTIVE: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. METHODS: A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. RESULTS: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. CONCLUSIONS: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost.     

Screening offenders with histories of mental illness and violence for supportive housing

This article describes a community mental health agency's process of screening supportive housing applicants with histories of violent felonies and serious mental illness. The agency adopted its corporate intranet as a tool so that geographically dispersed senior staff could participate in information gathering in order to ensure expert input in admissions decisions. This broad-based participation was designed to maintain community safety, while making the agency's residential resources available to people with mental illness and criminal histories. Considering the high recidivism rate of ex-offenders with mental illness and lack of clearly established best practices to serve them in the community, the authors believe that it is timely for housing providers to reevaluate how to better serve these individuals.     

Social selection and mental health service utilization among mentally ill parolees: A research agenda

The purpose of this article is to describe a conceptual and methodological approach to research on mental health service utilization by parolees with mental illness. This approach can be used by researchers and policy makers to understand and improve the interface between criminal justice and mental health organizations. We justify the need for research on this population; discuss the conceptual framework which draws on social selection and organizational theory; describe methodological problems; and discuss implications of the research.     

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): Interventions and Transitions

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): Interventions and Transitions, builds upon the framework presented in the first publication of BRIDGE. BRIDGE 2 moves beyond increasing the understanding of the relationship between body image and eating disorders and encourages a movement into action. First, it suggests the appropriate point of intervention for both parents and teachers. Second, the continuum of health care from promotion to prevention, to early intervention, and to basic and specialized treatment services is positioned on the BRIDGE framework. This added dimension offers a new level of understanding specific to eating disorders by utilizing concepts from mental health promotion and mental illness prevention literature.     

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): interventions and transitions

BRIDGE 2 (Building the Relationship Between Body Image and Disordered Eating Graph and Explanation): Interventions and Transitions, builds upon the framework presented in the first publication of BRIDGE. BRIDGE 2 moves beyond increasing the understanding of the relationship between body image and eating disorders and encourages a movement into action. First, it suggests the appropriate point of intervention for both parents and teachers. Second, the continuum of health care from promotion to prevention, to early intervention, and to basic and specialized treatment services is positioned on the BRIDGE framework. This added dimension offers a new level of understanding specific to eating disorders by utilizing concepts from mental health promotion and mental illness prevention literature.     

Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness

The Sequential Intercept Model provides a conceptual framework for communities to use when considering the interface between the criminal justice and mental health systems as they address concerns about criminalization of people with mental illness. The model envisions a series of points of interception at which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system. Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point. The interception points are law enforcement and emergency services; initial detention and initial hearings; jail, courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons, and forensic hospitalization; and community corrections and community support. The model provides an organizing tool for a discussion of diversion and linkage alternatives and for systematically addressing criminalization. Using the model, a community can develop targeted strategies that evolve over time to increase diversion of people with mental illness from the criminal justice system and to link them with community treatment.     

Service Engagement in First-Episode Psychosis: Current Issues and Future Directions

It has been reported that up to 50% of patients receiving mental health services disengage from treatment, with adolescents and young adults being particularly at high risk. Even in the context of specialized services in youth mental health, such as early intervention programs for psychosis, disengagement rates remain high. There is a need for extensive and innovative efforts to address the issue of service disengagement in first-episode psychosis (FEP). A multi-dimensional understanding of the phenomenon of engagement can help to inform the development of strategies to address this important clinical issue. In our paper, we propose a conceptual framework for understanding service engagement, provide an overview of the issues pertaining to service engagement in FEP, and suggest future directions for research and practice.     

Preventing depression after stroke

Mental health prevention research is an emerging and intriguing field. Preventing mental disorders is attractive as successful prevention, as it could potentially avert both emotional suffering and illness related morbidity and mortality. Several studies have looked at preventing post-stroke depression, a common complication of stroke. In this review article, we will first provide a conceptual overview of mental health prevention research. Then, we will discuss recent research supporting the prevention of depression after stroke and the likely positive effect successful prevention may have on non-psychiatric outcomes.     

Crime victims and criminal offenders among adults with serious mental illness

OBJECTIVE: This study compared crime victimization rates with rates of criminal offending among adults with serious mental illness. METHODS: Statistical estimation determined caseload overlap between anonymous extracts from public mental health and criminal justice databases for 13 rural Vermont counties. Participants included 2,610 adults who received community-based services during the study year (July 2005 through June 2006). RESULTS: Among the 2,610 adults 6.6% were identified by police as criminal offenders and 7.1% were identified as crime victims. Compared with the general population, however, their elevated risk of being identified as a victim (2.4) was lower than their elevated risk of being identified as an offender (2.6). These categories are not mutually exclusive. CONCLUSIONS: To better understand involvement in the criminal justice system among adults with serious mental illness, research should consider rates of criminal offending and victimization and compare these with rates for the general population.     

Examining the Impact of Mental Illness and Substance Use on Time till Re-incarceration in a County Jail

This paper examines the role that substance use and serious mental illness play in criminal justice recidivism by examining the time to return to jail for a cohort of people admitted to jail in 2003 (N = 16,434). These analyses found that people with serious mental illness alone experienced the longest time in the community before returning to jail and were found to have a risk of re-incarceration that did not differ significantly from individuals with no psychiatric or substance use diagnoses. People with co-occurring disorders had a risk of re-incarceration that was over 40 % higher than that of individuals with no diagnosis.     

Reincarceration Risk Among Men with Mental Illnesses Leaving Prison: A Risk Environment Analysis

Reentry interventions for persons with mental illness leaving prison have consisted primarily of linkage to mental health services and have produced mixed results on psychiatric and criminal recidivism. These interventions primarily focus on intra-individual risk factors. However, social and environmental factors may also increase risk of reincarceration by constraining choices and pro-social opportunities for community reintegration upon release from prison. In order to add to the knowledge base on understanding reincarceration risk for men with mental illnesses leaving prison, we examined interpersonal and environmental factors that exposed men to heightened risk for reincarceration. As part of a larger study examining the effectiveness of Critical Time Intervention for men with mental illness leaving prison, in-depth interviews were conducted with 28 men within 6 months of release from prison. Policies and practices at local and state levels, community conditions, and interpersonal obligation and conflict were identified as increasing risk for reincarceration.     

Clinical and legal characteristics of inmates with bipolar disorder

Individuals with bipolar disorder are at an increased risk of criminal arrest compared with those in the population at large. The combination of manic symptoms and substance abuse seem to be the primary illness factors for this increased risk, and the public mental health system has faced challenges in treating these patients successfully in community settings. To decrease the risk for arrest in bipolar patients, clinicians can screen and refer patients for substance use disorders, stabilize mania in hospital settings, and take measures to improve outpatient adherence in the postmanic hospitalization period. Psychiatric advance directives, new developments in civil commitment law, and mental health courts are legal mechanisms that may be critical in preventing the criminalization of those with bipolar disorder.     

Targeting Criminal Recidivism in Mentally Ill Offenders: Structured Clinical Approaches

Decreasing criminal recidivism in justice-involved individuals with mental illness, is among the most consistently desired outcomes by programs, policy makers and funding agencies. Evidencebased practices with track records of effectiveness in treating mental illness and co-occurring substance abuse, while important clinically, do not necessarily address criminal recidivism. Addressing recidivism, therefore, may require a more targeted criminal justice focus. In this paper, we describe recent challenges to decriminalization approaches and review factors associated with recurrent criminal behavior. In particular, we focus on structured clinical interventions which were created or adapted to target the thoughts and behaviors associated with criminal justice contact.