Outcomes and service use among homeless persons with serious mental illness and substance abuse

OBJECTIVE: This study compared baseline characteristics and clinical improvement after 12 months among homeless persons with a diagnosis of serious mental illness with and without a comorbid substance use disorder. METHODS: The study subjects were 5,432 homeless persons with mental illness who were participating in the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program. Analysis of covariance was used to compare clients who had dual diagnoses and those who did not and to identify any association between service use and clinical improvement. RESULTS: Follow-up data were available for 4,415 clients (81 percent). At baseline, clients with dual diagnoses were worse off than those without dual diagnoses on most clinical and social adjustment measures. Clients with dual diagnoses also had poorer outcomes at follow-up on 15 (62 percent) of 24 outcome measures. However, among clients with dual diagnoses, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than that of clients without dual diagnoses. On measures of alcohol problems, clients with dual diagnoses who had a high rate of participation in self-help groups had outcomes superior to those of other clients with dual diagnoses. Clients with dual diagnoses who received high levels of professional services also had superior outcomes in terms of social support and involvement in the criminal justice system. CONCLUSIONS: Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.     

Older criminals: a descriptive study of psychiatrically examined offenders in Sweden

OBJECTIVE: We retrospectively examined psychiatric diagnoses of older offenders referred by court for psychiatric assessment in Sweden, and compared them with younger offenders. METHOD: In Sweden, structured court-ordered forensic psychiatric evaluations are undertaken by a forensic psychiatric team. Data on age, sex, citizenship, psychiatric diagnoses, offences, and legal insanity declarations were obtained for the years 1988-2000 (n = 7297). RESULTS: There were 210 forensic psychiatric evaluations in those aged 60 and over. 7% had a diagnosis of dementia, 32% psychotic illness, 8% depressive or anxiety disorder, 15% substance abuse or dependence, and 20% personality disorder. Older offenders were significantly less likely to be diagnosed with schizophrenia or a personality disorder, and more likely to have dementia or an affective psychosis compared to younger ones. Logistic regression analyses suggested that of the studied factors, the ones most typical of older offenders were a diagnosis of dementia and being charged with a sexual offence. CONCLUSION: There appear to be important differences in psychiatric morbidity between older offenders and younger ones who come into contact with forensic psychiatric services. This research may assist in the planning of forensic and therapeutic services for the increasing number of older adults passing through the criminal justice system.     

Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD Only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.     

Rural and urban differences in patients with a dual diagnosis

OBJECTIVES: To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas. METHODS: Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life. RESULTS: Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness. CONCLUSIONS: Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

The availability of psychiatric programs in private substance abuse treatment centers, 1995 to 2001

OBJECTIVE: The high rate of co-occurrence of substance abuse and mental disorders renders the availability of psychiatric programs, or integrated service delivery, a vital quality-of-care issue for substance abuse clients. This article describes the availability of psychiatric programs and integrated care for clients with severe mental illness in the private substance abuse treatment sector and examines these patterns of service delivery by profit status and hospital status. METHOD:S: Survey data from the National Treatment Center Study, which is based on a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in service availability by profit status and hospital status. RESULTS: About 59 percent of private centers offered a psychiatric program, and this proportion did not significantly change over time. The proportion of centers that referred clients with severe mental illness to external providers increased significantly from 57 percent to 67 percent. For-profit centers and hospital-based centers were significantly more likely to offer psychiatric programs and were less likely to refer severe cases to other providers. CONCLUSION:S: Although the importance of integrated care for clients with dual diagnoses is widely accepted, data from the private substance abuse treatment sector suggest that this pattern of service delivery is becoming less available.     

Gender differences in homicide offenders' criminal career,substance abuse and mental health care. A nationwide register‐based study of Finnish homicide offenders 1995–2004

Background It is generally considered that women who kill are more likely to have a psychiatric disorder than their male counterparts, but as a relatively small group, women are much less often studied than men in this context. Aim To explore gender differences in the psychosocial history of homicide offenders. Method In this nationwide register‐based study, data were extracted from the forensic psychiatric examination and crime reports of all 91 women prosecuted for homicide in Finland between 1995 and 2004 and from those of the next adjacent man convicted of a separate homicide (n = 91). Results Both female and male homicide offenders had a troubled childhood, but more women had witnessed or experienced family violence; more women had failed to complete their primary education. Men, however, were more likely to have had an offending history. Although there were no differences between the men and women in the frequencies of psychiatric diagnoses or of substance abuse, the women had more often received prior mental health treatment. The women were also more likely to have had a history of suicidal behaviour. Conclusions Both female and male homicide offenders are a troubled group of people, with slightly different criminal careers. Many use mental health services and therefore prevention could be improved. The suggestion of a special sub‐group of women characterised by early educational and behavioural difficulties needs replication, as it may have implications for service development. Copyright © 2010 John Wiley & Sons, Ltd.     

Clinical utility and policy implications of a statewide mental health screening process for juvenile offenders

OBJECTIVES: This study examined the utility of screening adjudicated juvenile offenders for mental health symptoms at intake to the State of Washington Juvenile Rehabilitation Administration. The authors assessed the ability of a screening measure, the Massachusetts Youth Screening Inventory, second edition (MAYSI-2), to identify youths with mental health problems and co-occurring substance use problems. This study also examined the relationship of these symptoms to treatment utilization both before and after intake to the juvenile justice system. Ethnic and gender differences in the screening results were studied. METHODS: The MAYSI-2 was administered to 1,840 youths consecutively admitted to state custody. Cluster analysis was used to group the youths by mental health symptom status, and the relationship between symptoms and treatment utilization was tested in the groups identified in the cluster analysis. RESULTS: Youths who reported a high level of mental health symptoms, with or without co-occurring substance use problems, were more likely to have received previous mental health treatment than youths with a low level of mental health symptoms. Youths with a high level of mental health symptoms were more likely to receive extraordinary sentences and were thus less likely to be eligible for community transition programs than youths with a low level of mental health symptoms. Significant gender and ethnic differences in mental health symptom reporting on the screening inventory were found. Female offenders were significantly more likely than male offenders to report a high level of symptoms, and Hispanic youths were significantly less likely than youths in other ethnic groups to report a high level of symptoms. CONCLUSIONS: The MAYSI-2 has utility in identifying youths in the juvenile justice system who have mental health problems, and MAYSI-2 results are related to use of treatment services both before and after intake to the juvenile justice system. Ethnic and gender differences in MAYSI-2 reporting must be considered in interpreting mental health screening data.     

Gender differences in criminality: bipolar disorder with co-occurring substance abuse

Outpatient interviews to collect criminal history data were conducted with 55 women and 77 men who had the dual diagnosis of rapid-cycling bipolar disorder with co-morbid substance abuse disorders (DD-RCBD), to ascertain gender-related similarities and differences. Fifty-three percent of women and 79 percent of men reported that they had been charged with a crime, and nearly half of those charged had been incarcerated. Men with DD-RCBD were more likely to have committed a felony and had a trend of committing more misdemeanors. Although women with DD-RCBD were less likely to have a criminal history than their male counterparts, they were far more likely to have a criminal history than were women in the general population. Implications from this pilot study include the need for earlier identification of bipolar disorder and for the increased availability of psychiatric and substance abuse services within correctional facilities.     

Older offenders, substance abuse, and treatment.

OBJECTIVE: The adoption of more stringent truth-in-sentencing laws and the aging of the United States population in general has led to an increase in the proportion of prison inmates age 55 years and older. Recent judicial rulings require prisoners to receive adequate medical and mental health care. Care for substance abuse is often included to reduce recidivism. However, little systematic research has been conducted on the mental health and substance abuse treatment needs of older prisoners. METHODS: The authors examined age differences in substance abuse history provided by 10,952 offenders as part of their orientation and evaluation on entry into prison. Trained substance abuse counselors interviewed each offender and recorded data in an institutional database. RESULTS: Seventy-one percent of older inmates reported a substance abuse problem. When compared with younger inmates, older offenders were more likely to abuse alcohol only. Those older inmates with abuse problems had used substances for over 40 years, yet more than one-third had never received treatment. CONCLUSION: Like younger inmates, most older offenders would benefit from substance abuse treatment. The treatment may need to be tailored to age and lack of previous treatment experience and should be sensitive to this high-risk group's additional medical needs.     

Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.     

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register-based study

Background   Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID.
Method   We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996–2006).
Results   One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure.
Conclusions   The offenders with so-called triple diagnosis – substance abuse, mental illness and ID – form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.     

Criminal offending and distinguishing features of offenders among persons experiencing a first episode of psychosis

Aims: Persons with severe mental illness (SMI) are at increased risk of criminal offending, particularly violent offending, as compared with the general population. Most offenders with SMI acquire convictions prior to contact with mental health services. This study examined offending among 301 individuals experiencing their first episode of psychosis. Methods: Patients provided information on sociodemographic and clinical variables and completed a neurological soft sign examination and neuropsychological tests. Additional information was extracted from clinical files and official criminal records. Results: The results show that 33.9% of the men and 10.0% of the women had a record of criminal convictions, and 19.9% of the men and 4.6% of the women had been convicted of at least one violent crime. Proportionately more male and female patients than men and women in the general UK population had prior convictions for violent crimes. In a multivariate model including background and clinical variables, only one variable distinguished the male offenders. African‐Caribbean ethnicity was associated with a threefold increase in the odds of offending (odds ratio = 3.84, 95% confidence interval 1.03–14.37). Offenders, as compared with non‐offenders, obtained significantly lower premorbid and current intelligence quotient scores and similar scores on tests of neurological soft signs, working memory and executive functions. Conclusions: At contact with mental health services for a first episode of psychosis, significant numbers of patients have records of criminal convictions and thereby a high risk for future violent behaviour. These patients require specific interventions, in addition to medication, to reduce offending and aggressive behaviour.     

Abuse of carers by relatives with severe mental illness

BACKGROUND: Relatives often experience considerable problems looking after a family member with severe mental illness. The problems arising from verbal and physical abuse are not well researched or acknowledged. AIMS: To examine the frequency with which family carers experienced verbal and physical abuse from relatives who were being looked after by a community mental health service and to identify the correlates and consequences of that abuse. METHOD: Interviews with all the clients of a community mental health service in suburban Melbourne who had regular contact with a family carer together with interviews with the carers. RESULTS: One hundred and one clients and their family carers were interviewed. Supporting a previous study of patients on an acute admission ward, the experiences of verbal and physical abuse were positively correlated. Higher rates of abuse were associated with poor relationships between patients and their families and a history of poly-drug misuse and previous criminal offences on the part of the patient. Relatives experiencing higher levels of abuse were more likely to have. symptoms of emotional distress and were rated as experiencing more burden. CONCLUSIONS: Verbal and physical abuse are not infrequent problems facing family members caring for a relative with severe mental illness. Some of the risk factors for such abuse can be identified. Care plans for family carers could usefully target risk reduction strategies to minimise the occurrence of abuse.     

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Demographic,clinical and forensic characteristics of alleged offenders referred to West End Specialised Hospital,Kimberley, South Africa

The study investigated demographic, clinical and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders'' clinical records. The subjects were mainly young males, aged between 18 and 35 years, with low educational levels and high unemployment rate. The most common diagnoses were substance-related and addictive disorders, and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. In total, 55.5% of the offenders were found competent to stand trial, and 46.5% were declared criminally responsible. Offenders presenting with schizophrenia and intellectual disabilities were often declared incompetent to stand trial and were generally not responsible for alleged crimes. There was association between adjudicative competence and criminal responsibility. The results highlight effect of substances on mental illness and crime. Key words: clinical, competency, criminal responsibility, demographic, forensic, law, mental health, offenders     

Comorbid substance use disorder in women with bipolar disorder associated with criminal arrest

OBJECTIVES: Previous research has indicated that comorbid substance abuse in patients with bipolar disorder (BPD) is strongly linked to criminal arrest. This study was conducted to further evaluate possible gender differences in substance use and risk of criminality in BPD. METHODS: Subjects were selected from all inmates with a DSM-IV diagnosis of BPD type I at Los Angeles County correctional facility. As a comparison, a sample of Los Angeles County patients with BPD type I who had not been arrested during the course of their psychiatric treatment within LA County was identified. The county's Management Information System (MIS) was utilized to obtain primary and secondary diagnoses as well as demographic information. RESULTS: The odds of having a comorbid substance use diagnosis for arrested female patients was more than 38 times that for community female patients (odds ratio = 38.75). Women were more likely to have been arrested for violent and substance use charges; men were more likely to have been arrested for theft and miscellaneous charges. CONCLUSIONS: Substance abuse appears to be a significant risk factor for arrest in patients with BPD and is especially significant for women with BPD. Our study suggests that comorbid BPD and substance use in women may significantly increase the risk of criminal arrest.     

Risk of Future Offense Among Probationers with Co-occurring Substance Use and Mental Health Disorders

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.     

Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse

OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.