OBJECTIVE: While criminal justice involvement among persons with severe mental illness is a much discussed topic, there are few large scale studies that systematically describe the patterns and prevalence of arrest in this population. This study examines rates, patterns, offenses and sociodemographic correlates of arrest in a large cohort of mental health service recipients. METHOD: The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health in 1991-1992 were examined over roughly a 10-year period. Bivariate relationships between sociodemographic factors and arrest were also examined. RESULTS: Roughly 28% of the cohort experienced at least one arrest. The most common charges were “crimes against public order” (trespassing, disorderly conduct, etc.) followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5% of the cohort) accounted for roughly 17% of arrests. The proportion of males arrested was double that of females. Persons 18-25 had a 50% chance of at least one arrest. This rate declined with age, but did so unevenly across offense types. CONCLUSIONS: The likelihood of arrest appears substantial among persons with severe mental illness, but the bulk of offending appears concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services seeking to reduce both initial and repeat offending among persons with serious mental illness.

The problems posed by persons with mental illness involved with the criminal justice system are vexing ones that have received attention at the local, state and national levels. The conceptual model currently guiding research and social action around these problems is shaped by the "criminalization" perspective and the associated belief that reconnecting individuals with mental health services will by itself reduce risk for arrest. This paper argues that such efforts are necessary but possibly not sufficient to achieve that reduction. Arguing for the need to develop a services research framework that identifies a broader range of risk factors for arrest, we describe three potentially useful criminological frameworks-the "life course," "local life circumstances" and "routine activities" perspectives. Their utility as platforms for research in a population of persons with mental illness is discussed and suggestions are provided with regard to how services research guided by these perspectives might inform the development of community-based services aimed at reducing risk of arrest.

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.

Arrest rates among the population of youth who have been served in child mental health systems are known to be high during adolescence and young adulthood, but individual longitudinal patterns have not been examined. The present study used developmental trajectory modeling, a contemporary method used widely in criminology, to examine clusters of individual criminal justice involvement patterns at ages 8 through 25, from database records of 13 individuals in public adolescent mental health services. Three groups of particular concern emerged: one with increasingly high offense rates and two with moderate to high violent offense rates that did not desist. Offense patterns in these groups indicate that early intervention should occur before age 15. Some risk factors were identified. Peak offending for most groups occurred between ages 18 and 20. Implications of these findings for mental health services during the transition to adulthood are offered. Studies that have followed youth with serious emotional disturbance (SED) from child.

OBJECTIVE: The inability to blind research participants to their experimental conditions is the Achilles' heel of mental health services research. When one experimental condition receives more disappointed participants, or more satisfied participants, research findings can be biased in spite of random assignment. The authors explored the potential for research participants' preference for one experimental program over another to compromise the generalizability and validity of randomized controlled service evaluations as well as cross-study comparisons. METHOD: Three Cox regression analyses measured the impact of applicants' service assignment preference on research project enrollment, engagement in assigned services, and a service-related outcome, competitive employment. RESULTS: A stated service preference, referral by an agency with a low level of continuity in outpatient care, and willingness to switch from current services were significant positive predictors of research enrollment. Match to service assignment preference was a significant positive predictor of service engagement, and mismatch to assignment preference was a significant negative predictor of both service engagement and employment outcome. CONCLUSIONS: Referral source type and service assignment preference should be routinely measured and statistically controlled for in all studies of mental health service effectiveness to provide a sound empirical base for evidence-based practice.

OBJECTIVE: Racial and ethnic disparities in the criminal justice system have been widely reported, as have racial and ethnic disparities in diagnoses and certain aspects of clinical management. This study examined the association between race and ethnicity and dispositions for pre-trial defendants who were referred for forensic mental health evaluations. METHODS: Available data were reviewed for all defendants in Massachusetts who were referred to a Massachusetts court clinic from 1994 to 2001 for a screening evaluation of their competence to stand trial, their criminal responsibility, or both. Logistic regression models were developed to assess the relationship between defendants' race and ethnicity and the likelihood that they would be referred for inpatient evaluation and the likelihood that they would be evaluated within a strict-security facility. Race or ethnicity of the pretrial defendants was identified by clinicians. RESULTS: Blacks, but not Hispanics, were significantly more likely than whites to be referred for an inpatient evaluation after an outpatient forensic screening evaluation. Among male defendants, both Hispanics and blacks were more likely than whites to be referred for an inpatient evaluation in a strict-security facility, regardless of diagnoses and the level of severity of the criminal charges. CONCLUSIONS: Racial and ethnic disparities in disposition decisions exist within the forensic mental health system. These disparities, however, likely reflect numerous clinician and nonclinician variables.

The original 'plan' for deinstitutionalization of America's population of persons with severe and persistent mental illness saw community mental health services as providing many of the functions of large mental hospitals in community settings. While substantial effort and resources have been committed to this enterprise, many persons with mental illness encounter significant problems in adjusting to life in the community. Prominent among these problems is the disproportionate involvement in the criminal justice system of persons with psychiatric disorders. This problem, popularly described as the 'criminalization' of mental illness, often threatens the clinical stability and safety of persons with mental disorders, and at the same taxes heavily the resources of the criminal justice system. This paper reviews data exploring the relationship between levels and availability of community-based services and the likelihood that persons with mental illness will become involved with the criminal justice system. Finding no relationship, we conjecture that community mental health services are effective with only certain individuals, and move toward a taxonomy of offenders with mental illness. This classification scheme takes into account the relationship between psychiatric disorder, lifestyle and pre-morbid criminal involvement, and is designed to inform system actors with regard to the targeting of these resources.

This paper examines the effects of Medicaid managed mental health care in Massachusetts on the likelihood of admission to the inpatient forensic mental health service maintained by the state's Department of Mental Health (DMH). A cohort of individuals receiving services from DMH before and the after the introduction of managed care was used to assess the effect of Medicaid beneficiary status on the likelihood of forensic hospitalization before and after managed care. The overall rate of forensic hospitalization declined in this cohort across the two time periods. However, for Medicaid beneficiaries, whose care had become managed, this decline occurred at a slower rate. This statistical finding warrants further exploration, but should be considered by policy makers in the design of future mental health system interventions.

Lack of access to hospitalization is often cited as risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. New admissions to two jails in Massachusetts (N=996) were screened for serious mental illness using the Diagnostic Interview Schedule. Self-report data were obtained regarding hospitalization history. Rates of hospitalization in this group were compared with those of a comparable subset of respondents in the National Comorbidity Survey (NCS). Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the NCS group. Lifetime psychiatric use among the NCS subsample experiencing recent "trouble with the law" had an elevated lifetime hospitalization rate similar to the Massachusetts jail sample. These findings draw into question the notion that persons with mental illness in the criminal justice system have had reduced access to psychiatric inpatient treatment.

Persons with mental illness in the criminal justice system are a vexing problem in many countries. The chapters presented in this volume explore issues central to this problem, including the role of mental illness in criminal justice involvement, the effectiveness of psychopharmacologic and traditional community mental health treatment modalities, and the conceptualization and potential efficacy and effectiveness of new community based approaches for serving offenders with mental illness. Included in this multi-disciplinary work are chapters by Jeffrey Draine; William Fisher; Stephanie Hartwell; John Pandiani, Steven Banks, and Shiela Pomeroy; Rani Desai and Dena Plemmons; Phyllis Solomon; and Nancy Wolff.