OBJECTIVES: We describe behavioral health diagnoses and community release patterns among adult male and female inmates in New Jersey prisons and assess their implications for correctional health care and community reentry. METHODS: We used clinical and classification data on a census of "special needs" inmates (those with behavioral health disorders) in New Jersey (n=3189) and a census of all special needs inmates released to New Jersey communities over a 12-month period (n=974). RESULTS: Virtually all adult inmates with special needs had at least 1 Axis I mental disorder, and 68% of these had at least 1 additional Axis I mental disorder, a personality disorder, or addiction problem (67% of all male and 75% of all female special needs inmates). Of those special needs inmates released, 25% returned to the most disadvantaged counties in New Jersey (27% of all male and 18% of all female special needs inmates). CONCLUSIONS: Two types of clustering were found: gender-specific clustering of disorders among inmates and spatial clustering of ex-offenders in impoverished communities. These findings suggest a need for gendered treatment strategies within correctional settings and need for successful reentry strategies.

OBJECTIVE: This article discusses examples of structural stigma that results from state governments' enactment of laws that diminish the opportunities of people with mental illness. METHODS: To examine current trends in structural stigma, the authors identified and coded all relevant bills introduced in 2002 in the 50 states. Bills were categorized in terms of their effect on liberties, protection from discrimination, and privacy. The terms used to describe the targets of bills were examined: persons with "mental illness" or persons who are "incompetent" or "disabled" because of mental illness. RESULTS: About one-quarter of the state bills reviewed for this survey related to protection from discrimination. Within that category, half the bills reduced protections for the targeted individuals, such as restriction of firearms for people with current or past mental illness and reduced parental rights among persons with a history of mental illness. Half the bills seemed to expand protections, such as those that required mental health funding at the same levels provided for other medical conditions and those that disallowed use of mental health status in child custody cases. Legislation frequently confuses "incompetence" with "mental illness." CONCLUSIONS: Examples of structural stigma uncovered by surveys such as this one can inform advocates for persons with mental illness as to where an individual state stands in relation to the number of bills that affect persons with mental illness and whether these bills expand or contract the liberties of this stigmatized group.

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.

Criminal justice, mental health, and social service professionals face a myriad of role expectations in working with prisoners with mental illness to facilitate community re-entry. These expectations include those related to law enforcement, social welfare, and administrative efficiency. The challenge for front line workers and the multiple systems that employ them is to integrate all these expectations effectively on behalf of the individual as well as the community. Current models of re-entry for individuals leaving prison with mental illness focus on the management and interaction of service systems. This paper presents a model of prisoner re-entry that incorporates a larger social context, illustrating dynamics related to both individuals with mental illness leaving prison and their interaction with the community setting. This model was generated through an interdisciplinary team effort. It was refined through a focus group process that included advocates, community members and other informants from mental health and criminal justice systems in five states. The model is designed to generate new questions for research that address both individual and community level issues.

In the face of the Massachusetts Governor's attempts to close one of the state's four remaining state hospitals, Massachusetts legislators overrode the Governor's veto of funding for the hospital, but required the state's Mental Health Authority to author a study of the implications of further loss of public sector inpatient beds. The Center for Mental Health Services Research of the University of Massachusetts Medical School conducted its own study concluding that maintaining a longer-term inpatient capacity in the public sector in central Massachusetts was both necessary and accrued a significant number of benefits. This article can serve as a model for the reasoned position that a state hospital in 21st century psychiatry can be looked at as a multiservice center that fulfills a key role in a public sector, integrated system of treatment, care, training and research.

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.

BACKGROUND: Little is known about the nature of community police interactions with older adults. This is a major gap in our knowledge as police are potential "first responders" to a variety of emergent criminal, legal, social, and medical problems faced by this population, yet previous studies have focused primarily on domestic elder abuse. SPECIFIC AIMS: To estimate the prevalence of police department contact in an observational cohort of community dwelling older people and to determine the role of the older person in such contact. Secondary aims were to determine the distribution of crime types experienced by cohort members and to identify factors at cohort inception that were associated with police contact. SUBJECTS: Members of the New Haven EPESE cohort (Established Population for Epidemiologic Studies in the Elderly) who were alive in 1985 (n = 2,321), an observational cohort of community-dwelling older adults who had regular standardized evaluations of medical, functional, and psychosocial health. TYPE OF STUDY: Observational Cohort. METHODS: Police records in same catchment area of the cohort were searched to determine if cohort members had any interaction with police over the follow-up period 1985-1995; those cohort members who had such interactions had detailed abstraction of police records to determine the nature of the event(s) which were then linked to cohort records so that health and criminal justice records could be analyzed concordantly. RESULTS: The sampling adjusted prevalence of police contact was 29% over an eleven year follow-up period with 684 members of the 2,321 subject cohort experiencing a total of 1,651 separate contacts. The most common context in which cohort members interacted with police was solely as a victim of an alleged crime (57.5 of subjects, sampling adjusted, 62.1% of contacts), but subjects also had substantial interactions with police as complainants, witnesses, and perpetrators of crime. Violent crimes accounted for 21% of the contacts in which subjects were victims. Three factors at cohort inception were independently associated with being victimized over the follow-up period in multivariable analysis: being ADL dependent (OR .42, 95% CI .22-.80), being African American (OR 1.48, 95% CI 1.01-2.18), and being a younger cohort member (OR for age .94 per year, 95% CI .91-1.02). Gender was not significantly associated with victimization. CONCLUSIONS: Older adults have substantial interaction with community police in a variety of contexts, but primarily as victims of crime. ADL impairment and older age actually conferred a decreased risk of victimization in this study, defying the stereotype of victimized elders as the frail "oldest old." However, the extremely high prevalence of police interaction with older adults suggests that health and criminal justice policy makers need to consider this population in law enforcement manpower planning and training.

Neutralization theory, though a popular framework for understanding deviant behavior, remains badly underdeveloped. Few attempts have been made to connect it to narrative and sociocognitive research in psychology and related fields. From this wider perspective, one reason neutralization theory has received only mixed empirical support is that it has been understood as a theory of criminal etiology. This makes little sense (how can one neutralize something before they have done it?) and makes the theory difficult to test. Neutralization should instead be seen as playing a role in persistence in or desistance from criminal behavior. The theory's central premises need to be substantially complicated. The notions that all excuses or justifications are "bad" and that reform involves "accepting complete responsibility" for one's actions are not tenable.

Nearly 60% of convicted sex offenders serve a term of felony probation or parole. Using data for 917 convicted male sex offenders on probation in 17 states, this study examines the efficacy of community supervision for this population. Offenders 'social demographics and baseline criminality were studied in conjunction with formal and informal social controls to determine their collective deterrent impact. The overall recidivism rate was 16%. However, only 4.5% of offenders committed a new sex crime during probation. Regression analyses indicate that factors readily available to court personnel can accurately predict non-sexual recidivism among sex offenders on probation. However, accurately predicting additional sexual violence proved a more dubious task. The only significant predictor of chronic sex offending was the imposition of a jail term as a condition of probation. Results indicate that under the right set of conditions, probation is the most appropriate criminal sanction for some types of sex offenders.

The federal "Second Chance Act of 2005" calls for expanding reentry services for people leaving prison, yet existing policies restrict access to needed services for those with criminal records. We examined the interaction between individual-level characteristics and policy-level restrictions related to criminal conviction, and the likely effects on access to resources upon reentry, using a sample of prisoners with Axis I mental disorders (n=3073). We identified multiple challenges related to convictions, including restricted access to housing, public assistance, and other resources. Invisible punishments embedded within existing policies were inconsistent with the call for second chances. Without modification of federal and state policies, the ability of reentry services to foster behavioral health and community reintegration is limited.

OBJECTIVE: We examined the association between mental disorder and violent victimization in a general population sample. METHODS: We performed a multivariate analysis of violent victimization in a 12-month period on a total birth cohort with follow-up data that assessed, during their 21st year, males and females born in Dunedin, New Zealand, in the early 1970s. RESULTS: Compared with people with no mental disorder, (1) people with anxiety disorders experienced more sexual assaults, (2) people with schizophreniform disorders experienced more threatened and completed physical assaults, (3) people with alcohol dependence disorders experienced more completed physical assaults, and (4) people with marijuana dependence disorders experienced more attempted physical assaults. These results held after control for psychiatric comorbidity, demographic characteristics, and the study participants' own violent behavior. CONCLUSION: Mentally disordered young adults tend to experience more violent victimization in the community than those without a mental disorder.

Research on the relationship between metal disorder and violence has focused largely on the effects of clinical characteristics, such as treatment adherence and psychotic symptoms, with little attention given to the potentially important role of stressful life events and impaired social support. Yet, stressful life events and impaired social support have been found to be significantly associated with the onset and course of mental disorder and with the occurrence of violence. This raises the question: Do stressful life events and impaired social support contribute to the association between mental disorder and violence? The current study addresses this question using general population data from the Durham site of the National institute of Mental Health's Epidemiological Catchment Area Surveys (n=3,437). Results indicate then when stressful life events and impaired social support were controlled, the association between mental disorder and violence was substantially reduced. Implications for future research on the relationship between mental disorder and violence are discussed.

In this Foreword, the co-guest editors of this symposium on mental health courts introduce the topic by defining the concept, describing the reasons for its inception, and noting the controversies it has provoked. It then summarizes the articles in the symposium. Finally, the editors, who disagree about the value, effectiveness, and consequences of this new model, air their differences in a dialogue designed to delineate the issues and educate the reader.

OBJECTIVE: Youth processed in the juvenile justice system are at great risk for early violent death. Groups at greatest risk, i.e., racial/ethnic minorities, male youth, and urban youth, are overrepresented in the juvenile justice system. We compared mortality rates for delinquent youth with those for the general population, controlling for differences in gender, race/ethnicity, and age. METHODS: This prospective longitudinal study examined mortality rates among 1829 youth (1172 male and 657 female) enrolled in the Northwestern Juvenile Project, a study of health needs and outcomes of delinquent youth. Participants, 10 to 18 years of age, were sampled randomly from intake at the Cook County Juvenile Temporary Detention Center in Chicago, Illinois, between 1995 and 1998. The sample was stratified according to gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10-13 or >= 14 years), and legal status (processed as a juvenile or as an adult), to obtain enough participants for examination of key subgroups. The sample included 1005 African American (54.9%), 296 non-Hispanic white (16.2%), 524 Hispanic (28.17%), and 4 other-race/ethnicity (0.2%) subjects. The mean age at enrollment was 14.9 years (median age: 15 years). The refusal rate was 4.2%. As of March 31, 2004, we had monitored participants for 0.5 to 8.4 years (mean: 7.1 years; median: 7.2 years; interquartile range: 6.5-7.8 years); the aggregate exposure for all participants was 12 944 person-years. Data on deaths and causes of death were obtained from family reports or records and were then verified by the local medical examiner or the National Death Index. For comparisons of mortality rates for delinquents and the general population, all data were weighted according to the racial/ethnic, gender, and age characteristics of the detention center; these weighted standardized populations were used to calculate reported percentages and mortality ratios. We calculated mortality ratios by comparing our sample's mortality rates with those for the general population of Cook County, controlling for differences in gender, race/ethnicity, and age. RESULTS: Sixty-five youth died during the follow-up period. All deaths were from external causes. As determined by using the weighted percentages to estimate causes of death, 95.5% of deaths were homicides or legal interventions (90.1% homicides and 5.4% legal interventions), 1.1% of all deaths were suicides, 1.3% were from motor vehicle accidents, 0.5% were from other accidents, and 1.6% were from other external causes. Among homicides, 93.0% were from gunshot wounds. The overall mortality rate was >4 times the general-population rate. The mortality rate among female youth was nearly 8 times the general-population rate. African American male youth had the highest mortality rate (887 deaths per 100 000 person-years). CONCLUSIONS: Early violent death among delinquent and general-population youth affects racial/ethnic minorities disproportionately and should be addressed as are other health disparities. Future studies should identify the most promising modifiable risk factors and preventive interventions, explore the causes of death among delinquent female youth, and examine whether minority youth express suicidal intent by putting themselves at risk for homicide.

CONTEXT: Since deinstitutionalization, most persons with severe mental illness (SMI) now live in the community, where they are at great risk for crime victimization. OBJECTIVES: To determine the prevalence and incidence of crime victimization among persons with SMI by sex, race/ethnicity, and age, and to compare rates with general population data (the National Crime Victimization Survey), controlling for income and demographic differences between the samples. DESIGN: Epidemiologic study of persons in treatment. Independent master's-level clinical research interviewers administered the National Crime Victimization Survey to randomly selected patients sampled from 16 randomly selected mental health agencies. SETTING: Sixteen agencies providing outpatient, day, and residential treatment to persons with SMI in Chicago, IL. PARTICIPANTS: Randomly selected, stratified sample of 936 patients aged 18 or older (483 men, 453 women) who were African American (n=329), non-Hispanic white (n=321), Hispanic (n=270), or other race/ethnicity (n = 22). The comparison group comprised 32449 participants in the National Crime Victimization Survey. MAIN OUTCOME MEASURE: National Crime Victimization Survey, developed by the Bureau of justice Statistics. RESULTS: More than one quarter of persons with SMI had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population rates even after controlling for demographic differences between the 2 samples (P <.001). The annual incidence of violent crime in the SMI sample (168.2 incidents per 1000 persons) is more than 4 times higher than the general population rates (39.9 incidents per 1000 persons) (P <.001). Depending on the type of violent crime (rape/sexual assault, robbery, assault, and their subcategories), prevalence was 6 to 23 times greater among persons with SMI than among the general population. CONCLUSIONS: Crime victimization is a major public health problem among persons with SMI who are treated in the community. We recommend directions for future research, propose modifications in public policy, and suggest how the mental health system can respond to reduce victimization and its consequences.

The use of legal coercion to compel individuals to participate in mental health treatment is expanding despite a lack of empirical support for many of its forms. Policies supporting mandated treatment are made by legislators and judges, often based on perceptions of public concern. Using data from the MacArthur Mental Health Module contained in the 1996 General Social Survey (N = 1,444), the authors examined the impact of political ideology, attributions about the cause of mental illness, and perceptions of dangerousness in determining public support for legally mandated mental health treatment. Perceived dangerousness and attributions about the cause of the mental disorder were significant predictors of support for legally mandated treatment. Conservative political ideology was related to attributing the vignette problem to bad character, indirectly affecting support for legal coercion.

Responding effectively and efficiently to the needs of persons with mental illness returning to the community from prison requires identifying their differences in need and placement difficulties upon return and targeting reintegration investments to reflect these differences. This paper has three parts. The first part profiles the male special needs population in New Jersey prisons. These profiles describe behavioral health and criminal justice characteristics of 2715 male inmates with mental health problems, and are used to identify the scope and nature of the public's investment opportunity. The next part describes the costs associated with possible "investments." The special needs population is classified by need and placement difficulty, and then matched to reentry and community-based treatment programs. Costs are estimated for reentry planning and community-based treatment for the first year post-release. The third part recommends an investment strategy and a set of operational changes that might minimize the loss and maximize the return on the public's investment dollar in mental health.

Correctional facilities are under increasing pressure to respond to the treatment needs of mentally disordered offenders during their incarceration and to arrange for treatment post release through reentry planning. This paper constructs cost estimates for three different reentry investments using data on the population (n = 2715) of male mentally disordered inmates in New Jersey prisons. Different assumptions are used on the distribution of treatment needs and criminal characteristics within the population, ranging from equal treatment needs and placement difficulties to different treatment needs and difficulties accessing community-based resources as a consequence of their past criminal behaviors. The costs of these investments range from approximately $700,000 to $934,000 per year for roughly 500 released inmates. Reentry planning, as a social investment, protects the outcomes produced by correctional health care during incarceration and protects the public from future crime associated with untreated mental illness.

How will we know if mental health courts are effective? The answers provided by future evaluation research will reflect the extent to which the social and procedural complexity of mental health courts drives the research design and plan. This article identifies the research challenges associated with studying the effectiveness of an intervention that is nonstandardized by nature and highly dependent on macro and local influences within the environment as well as personal preferences and relationship dynamics within the intervention itself. Explored are the research challenges related to isolating the independent effects associated with mental health courts. The article concludes with recommendations for how best to evaluate mental health courts to inform best practice and policy.

Many evaluations of public health education campaigns attempt to draw conclusions regarding the effect of messages on audiences' attitudes, beliefs, and behaviors based on observational data. To make causal inferences in these instances, it is necessary to adjust estimated campaign effects for possible selection bias due to systematic differences between respondents exposed to the campaign and those that were not. In particular, it is necessary to adjust for the impact of confounding variables that are likely to be determinants of both campaign exposure and outcomes. In comparison to other available methods for adjusting for selection bias such as multiple regression and instrumental variable methods, propensity scores offer a particularly simple way of adjusting estimates of campaign exposure effects for selection bias. This paper discusses the logic of this approach and illustrates its application to the evaluation of the National Youth Anti-Drug Media Campaign.

In this study, I examined direct and indirect influences of sensation seeking, a personality trait, on adolescent drug use. I hypothesized that some or even most of the contribution of sensation seeking to drug use by adolescents is mediated through association with deviant peers and communication with peers that is favorable toward drug use. I examined the role of additional risk or protective factors in facilitating or impeding association with deviant peers, pro-drug communication, and marijuana use as well. The results of analyzing nationally representative cross-sectional data from the evaluation of the National Youth Anti-Drug Media Campaign support the study's hypotheses and suggest that different factors may protect high sensation-seeking adolescents from using drugs or engaging in activities (e.g., association with deviant peers) that may increase their risk for drug use. I discuss the theoretical, methodological, and practical implications of these findings to the design of health communication interventions.