Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study

This quasi-experimental non-equivalent comparison group study examines outcomes for participants in eight programs conducting criminal justice diversion for people with co-occurring serious mental illness and substance use disorders compared with jail detainees eligible for diversion, but who were processed through standard criminal justice methods without diversion. Nearly 2000 participants were interviewed at baseline, and 1500 at 3 month and 1300 at 12 month follow-up to baseline. In these interviews, outcome measures of re-arrest, mental health functioning, substance abuse, quality of life, and service utilization were obtained. Those diverted were more likely to have received mental health counseling, mental health medication, and mental health hospitalization than those not enrolled in a diversion program, but were equally likely to have received substance abuse counseling. Overall, the differences in proportions receiving services between the two groups were small, even when these differences were statistically significant. The effect associated with diversion differed somewhat across the individual sites. However, overall cross-site pooled analyses revealed no outcome differences between groups on measures of mental health symptoms, substance use, criminal justice recidivism, or quality of life. Although the immediate benefit of diversion as an access mechanism to community treatment is indicated in pooled cross-site results, such access was driven by more coercive (pre-booking and court) models and results suggest that effecting substantially greater access to services or services use did not occur. The findings also suggest that mental health, substance abuse, and criminal justice outcomes remain dependent on the treatment intervention received, perhaps moderated by type of diversion intervention, rather than on a generic and initial diversion event.     

An analysis of post-booking jail diversion programming for persons with co-occurring disorders

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.     

Correctional treatment for co-occurring disorders: results of a national survey

The significant expansion of correctional populations in the last decade, coupled with the gradual erosion of community treatment infrastructure and health insurance, have brought greater attention to the needs of offenders who have co-occurring mental health and substance use disorders. Individuals with co-occurring disorders frequently cycle through acute care facilities in the community and increasingly are placed in jails or prisons. Approximately 16% of inmates in correctional facilities have major mental health disorders (Bureau of Justice Statistics, 1999), and a large majority of these inmates have co-occurring substance use disorders. Few studies have examined the effectiveness of correctional treatment for co-occurring disorders, and there is little information available regarding clinical and programmatic approaches used with this population. The current study provides findings from a comprehensive national survey of co-occurring disorder treatment programs in correctional settings. A total of 20 co-occurring disorder treatment programs from 13 state correctional systems were identified and surveyed. Many of the programs featured modified therapeutic communities, but there was significant diversity in the duration of treatment and type of services provided. Several unique structural and clinical modifications to treatment have been developed in these settings. Implementation of co-occurring disorder treatment programs has led to enhanced collaboration with prison health services and community supervision and treatment agencies, and greater use of interdisciplinary staff to provide outreach and case management services. Research is now being conducted to examine outcomes in several of these correctional treatment programs.     

Characteristics of START Assessments Completed in Mental Health Jail Diversion Programs

Many different instruments have been developed to assist in the assessment of risk for violence and other criminal behavior. However, there is limited evidence regarding how these instruments work in the 'real world'. Even less is known about how these instruments might work for assessing risk in jail diversion populations, whether in research or practice. To address these knowledge gaps, the present study examined the characteristics of risk assessments completed by program staff (n?=?10) on 96 mental health jail diversion clients (72 men and 24 women) using the Short-Term Assessment of Risk and Treatability (START). The findings provide preliminary support for the reliability and validity of START assessments completed in jail diversion programs, the first evidence of the transportability of START outside psychiatric settings, and further evidence regarding the reliability and validity of START assessments completed in the field. They additionally support the consideration of an eighth, general offending risk domain in START assessments. Copyright ? 2012 John Wiley & Sons, Ltd.     

Co-occurring disorders among mentally ill jail detainees. Implications for public policy.

Studies have demonstrated that police often arrest the mentally ill when treatment alternatives would be preferable but are unavailable. Thus, jails may contain disproportionate numbers of severely mentally ill persons who have co-occurring disorders. Data on the co-occurrence of severe mental disorder, substance abuse, and antisocial personality disorders were gathered from 728 randomly selected male urban jail detainees. Using difference of proportions tests and loglinear analysis, the authors demonstrated that most subjects with a severe mental disorder (schizophrenia or a major affective disorder) also meet criteria for a substance abuse or antisocial personality disorder. These findings suggest several changes in public policy regarding health care delivery in correctional settings and for the general population.     

Contrasting jail diversion and in-jail services for mental illness and substance abuse: do they serve the same clients?

Baseline data from a study of jail diversion services and in-jail behavioral health services were used to examine the differences in clients served by these two models of responding to people with co-occurring mental health and substance abuse problems in the criminal justice system. Clients of the diversion service had more acute psychiatric symptoms and were more likely to have a diagnosis of psychosis NOS. Clients of the in-jail service were more likely to have been on probation or parole in the past and to have received substance abuse treatment. Different service models may attract and serve different populations of clients. Diversion services may cast a wider net that includes clients who may not have otherwise been involved in forensic services.     

Critical elements of the crisis intervention team model of jail diversion: An expert survey

The Crisis Intervention Team (CIT) model of jail diversion is a promising approach to addressing the over-involvement of people with mental illness with the criminal justice system. Despite its popularity and promising empirical support, the literature has yet to clarify CIT's critical elements. The aim of this study was to assess the degree to which experts agreement on the importance and perceived implementation of the critical elements of CIT. Study 1 used a literature review to cull potential elements. Three experts familiar with the CIT model reviewed these elements. Study 2 utilized an online survey of 55 CIT co-ordinators/officers and published experts to assess agreement regarding importance and degree the element is implemented. A preliminary list of 36 elements was identified with a high level of expert agreement on their importance regarding importance and implementation. This study developed a preliminary list of elements of the CIT's program. Further research should develop consensus, explore elements' association with outcomes, and differentiate elements from those common to all jail diversion programs. Copyright © 2010 John Wiley & Sons, Ltd.     

Pre-arrest diversion of people with mental illness: Literature review and international survey

Mental health diversion is a process where alternatives to criminal sanctions are made available to persons with mental illness (PMI) who have come into contact with the law. One form of mental health diversion is pre-arrest, in which the police use their discretion in laying charges. Concomitant with the growth of pre-arrest diversion programs is a growing body of research devoted to the phenomenon. The purpose of this paper is to review the existing literature of pre-arrest diversion, and to report the results of an international survey of pre-arrest diversion programs we conducted to identify evidence-based practices. On the basis of our review and survey, we note that successful pre-trial programs appear to integrate relevant mental health, substance abuse and criminal justice agencies by having regular meetings between key personnel from the various agencies. Often, a liaison person with a mandate to effect strong leadership plays a key role in the coordination of various agencies. Streamlining services through the creation of an emergency drop-off center with a no-refusal policy for police cases is seen as crucial. While there is some indication that mentally ill offenders benefit from their participation in this form of diversion, the evaluative literature has not yet achieved the "critical mass" necessary to create generalizable, evidence-based knowledge. The absence of generally agreed-upon outcomes could lead to the inequitable application of basic principles of diversion. We suggest that indicators, benchmarks, and outcomes must be agreed upon if a comprehensive understanding of pre-arrest programs is to emerge.     

The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.     

Community-based co-occurring disorder (COD) intermediate and advanced treatment for offenders

Against a backdrop of increasing concern about the adequacy of treatment for co-occurring substance use and mental disorders (typically known as "co-occurring disorders," or COD) in the criminal justice system, this article attempts to provide empirical evidence for a typology of levels of COD treatment for offenders in both prison and community settings. The paper investigates two levels of treatment programs for COD; "intermediate" programs, in which treatment programming has been designed primarily for offenders with a single disorder, and "advanced" programs, in which programming has been designed to provide integrated substance abuse treatment and mental health services. Findings from a national survey of program directors indicated that both intermediate and advanced COD treatment programs were similar in their general approach to substance abuse treatment, but differed considerably in their treatment of mental disorders, where the advanced programs employed significantly more evidence- and consensus-based practices. Results provide support for the distinction between intermediate- and advanced-level services for offenders with COD and support a typology that defines advanced programs as integrating a range of evidence- and consensus-based practices so as to modify treatment sufficiently to address both diseases.     

Working at the social-clinical-community-criminology interface: The GMU Inmate Study

This paper describes our attempt to import social-personality theory and research on moral emotions and moral cognitions to applied problems of crime, substance abuse, and HIV risk behavior. Thus far, in an inmate sample, we have evidence that criminogenic beliefs and proneness to guilt are each predictive of re-offense after release from jail. In addition, we have evidence that jail programs and services may reduce criminogenic beliefs and enhance adaptive feelings of guilt. As our sample size increases, our next step is to test the full mediational model, examining the degree to which programs and services impact post-release desistance via their effect on moral emotions and cognitions. In addition to highlighting some of the key findings from our longitudinal study of jail inmates over the period of incarceration and post-release, we describe the origins and development of this interdisciplinary project, highlighting the challenges and rewards of such endeavors.     

Mental Health Identification Practices of Jails: The Unmet Needs of the “Silent” Population

The overrepresentation of individuals with mental illness in the criminal/legal system is well documented. While professional associations urge diversion towards treatment, little is known about the practices these institutions use to identify this population. One understudied space in the criminal/legal continuum is jails. This exploratory study compares two types of mental health identification at jail booking to assess jail‐ and community‐based service outcomes by identification type (N = 2956): (a) staff observation and (b) a standardized screening instrument. Individuals identified through staff observation were significantly more likely to receive jail‐ and community‐based services, even though current symptomology and substance misuse were both significantly higher for individuals identified only by the screening instrument. These findings point to the importance of jails in providing stabilizing services during incarceration, but further, show the impact that identification practices have on individuals as they transition to the community. Community context showed varied rates of jail staff observations of mental illness, showing greater risks for individuals in rural communities. Implications include a need for system‐level changes by instituting evidence‐based identification practices in jails, and improving professional collaboration practices between mental health and criminal/legal practitioners as individuals enter and exit jails.     

Research Protections for Diverted Mentally Ill Individuals: Should they be Considered Prisoners?

The number of diversion programs for the mentally ill has increased dramatically over the past decade. These programs serve the valuable goal of reducing the growing population of incarcerated mentally ill persons by providing supervised community treatment. Research within these programs, critical for improving outcomes for these vulnerable individuals, is complicated by the fact that participants may have legal statuses which carry significant coercive leverage. In this way their ability to freely consent to research may be limited. In this paper, the authors describe the practice of diversion and review relevant research on coercion, informed consent and decisional capacity among the mentally ill and imprisoned. Current legal protections for prisoners are then discussed in the light of a recent proposal to broaden the legal definition of “prisoner” for research purposes to include community corrections populations, thus including diverted individuals. Copyright © 2011 John Wiley & Sons, Ltd.     

Gender differences in the development and adult outcome of co-occurring depression and delinquency in adolescence

Using a dual trajectory modeling approach, we examined co-occurring trajectories of depression and delinquency from age 11 to age 18 and their relation to adult outcome six years later in a community sample of 1423 (674 boys) adolescents. We also examined the effects of childhood externalizing, internalizing, and social problems on trajectory membership for depression and delinquency. The results showed that although more girls than boys were likely to follow high-level, co-occurring trajectories on depression and delinquency, the adult outcome of adolescents following high-level trajectories on both domains was poorer for boys than for girls. However, the combination of decreasing depression symptoms and increasing delinquency symptoms across adolescence was related with poorer adult outcomes for girls compared to boys. Finally, whereas boys' high-level co-occurring trajectory of depression and delinquency was predicted by childhood aggression, girls' equivalent trajectory was predicted by childhood depression and delinquency. The findings support the "gender paradox" effect (Loeber & Keenan, 1994) stating that in disorders with an unequal gender ratio, members of the gender with the lower prevalence rate tend to be more seriously affected in terms of comorbidity and poor outcome.     

COD services in community correctional settings: an examination of organizational factors that affect service delivery

Little is known about service delivery for those in the correctional system with co-occurring mental health and substance abuse disorders (COD). Using data from the National Criminal Justice Treatment Practices survey (NCJTP) on community corrections and jail agencies, this study found that correctional organizations that offer COD services differ from agencies that do not. Organizations that respond to the needs of COD offenders tend to be more "service friendly," rank higher on measures of various dimensions of organizational climate that embrace learning and goal achievement, and tend to adopt more innovations, particularly those classified as evidence-based practices. These survey findings indicate that correctional agencies who serve COD offenders are in a better position to be responsive to the changing service needs of the populations, and are more likely to be able to balance public safety and treatment goals. Future steps to develop support environments for COD assessment and treatment services are discussed in light of these findings.     

Dual diagnosis in an Australian forensic psychiatric hospital: prevalence and implications for services

Despite a growing awareness of the unique needs of psychiatric patients with co-occurring substance abuse and dependence disorders (i.e. dual diagnosis), there is a dearth of research investigating the prevalence of dual diagnosis in forensic psychiatric populations. Similarly, little work has been done to determine the implications of dual diagnosis for forensic psychiatric patients. Patients at the Thomas Embling Hospital in Victoria, Australia, were assessed to determine the prevalence of substance abuse disorders and mental illnesses within this population. Results reveal that the majority of patients (approximately 74%) have a lifetime substance abuse or dependence disorder. Information was collected concerning patients' criminal histories and the Level of Service Inventory, Revised, was completed for each patient who participated. Results suggest that patients with both major mental illnesses and substance abuse disorders have more extensive criminal histories and demonstrate a higher level of risks and needs when compared with patients with major mental illness alone. The implications for the development and delivery of effective forensic mental health services that address both co-occurring disorders are also discussed.     

Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

Benefits of recreational dance and behavior analysis for individuals with neurodevelopmental disorders: A literature review

Dance can be an entertaining experience that offers multiple benefits for those who participate. Unlike typically developing populations, studies examining benefits of recreational dance for individuals with neurodevelopmental disorders are limited. In this review, we conducted a literature search, where “dance” was cross‐listed with all neurodevelopmental disorders across five databases, yielding 19 articles. Twelve studies involved children and youth with neurodevelopmental disorders aged 3–19 years, two studies included both adolescents and adults aged 14–22 years, and five studies included adults aged 20–65 years. Given the effectiveness of applied behavior analysis in enhancing skill development, it is encouraging that eight studies explicitly identified behavioral components. Results suggest potential benefits of recreational dance across studies using self‐report and objective measures, but limited research with sound methodology exists. There is a need for controlled research with measurable outcomes to evaluate programs tailored to these populations to improve core challenges and secondary outcomes such as quality of life.     

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and “other” types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.     

The question of sanity restoration in jail

Severe mental illness, especially psychotic disorders that are worsening, acute or complicated, normally require intensive psychiatric care and treatment that is most appropriately provided in a mental hospital. For criminal defendants, transfer to a forensic security hospital has traditionally been the means of achieving hospital care for mentally disordered defendants who have been found incompetent to stand trial or not guilty by reason of insanity. In recent years, with the shortage of intermediate and long-term hospital beds in the United States, including forensic security hospital beds, jail-based competency restoration programs are being established, seemingly obviating hospital transfer. Potential advantages of and concerns about jail-based, as opposed to hospital-based, competency restoration programs are discussed in the literature. If defendants with severe mental illness traditionally treated in a forensic security hospital for competency restoration are now treated for competency restoration in jail, it is not inconceivable that insanity acquittees could one day be treated in jail for sanity restoration. With the premise that it is better to consider the potential consequences before this becomes a serious proposal and is implemented, this analysis examine the advantages and concerns that have been put forth for jail-based competence restoration programs as they may or may not apply to jail-based sanity restoration programs. Substantial commonality is recognized, but also some differences, as well as reason for skepticism of the purported virtues of either alternative to care and treatment in forensic security hospitals.