Investigating the impact of the legal system on treatment outcome of persons with severe mental illness and the risk and protective factors mediating the relationship between violence and mental disorder.

Effectively Implementing Psychiatric Advance Directives (Jeff Swanson PI, Marvin Swartz Co-PI, Eric Elbogen, Richard Van Dorn, H. Ryan Wagner). Psychiatric advance directives (PADs) allow competent persons to declare their preferences and instructions for future mental health treatment, or appoint a surrogate decisionmaker through Health Care Power of Attorney, in advance of an incapacitating psychiatric crisis. Although sixteen states have passed legislation in the last decade establishing authority for PADs, little attention has been given to emerging policy questions about these legal instruments. This study examines the effectiveness of a facilitation process designed to implement PADs. The study also examines the content of PADs and their potential effects on working alliance, crisis management, information sharing, and other treatment processes. The project is funded by NIMH and the John D. and Catherine T. MacArthur Foundation. (2002-2006).

Psychiatric Advance Directives for Improved Mental Health Care in the Veterans Affairs Health System. (Mimi Butterfield-PI, Jeff Swanson, Marvin Swartz, Eric Elbogen).
This study examines the effectiveness of Facilitated Psychiatric Advance Directives (F-PAD) in a sample of hospitalized veterans with severe mental illness or post-traumatic stress disorder. The project is funded by a grant from the Veterans Health Administration, Office of Research & Development, to the Durham Veterans Affairs Medical Center. The facilitation intervention and study design parallels that of the ongoing NIMH-funded study, Effectively Implementing Psychiatric Advance Directives. (2003-2007).

Violent behavior and atypical antipsychotic medication effectiveness in schizophrenia (Jeff Swanson) This project uses data from the NIMH CATIE trials to accomplish the following objectives: (1) Examine the effectiveness of atypical antipsychotic medications in reducing risk of violent behavior in persons with schizophrenia; (2) Identify mechanisms of treatment effectiveness in reducing violence, i.e., estimate the relative impact of direct vs. indirect causal pathways by which the newer atypical antipsychotic medications may reduce violence risk in persons with schizophrenia; (3) Develop specific causal models of violent behavior in persons with schizophrenia, estimating the relative effects of clinical, demographic, and social-environmental risk factors; (4) Identify specific patterns of violent behavior in persons with schizophrenia in terms of frequency, severity, relationship to targets, associated clinical factors, and social factors; (5) Develop an empirically-based typology for classifying violent behavior into clinically useful categories; (6) Examine the relative effectiveness of atypical antipsychotic medications, psychosocial treatment, and combined interventions in reducing risk of different types/patterns of violence.

Evaluating Assisted Outpatient Treatment in New York State
Mandating adherence to community mental health treatment through a civil court order is among the most divisive contemporary issues in mental health policy; polar disagreement has emerged among stakeholders on matters ranging from the effectiveness of outpatient commitment to its probity on legal and ethical grounds.  Because of this debate, policy-makers require much more information about the potential benefits and/or detrimental effects of assisted outpatient treatment. This study is a legislatively-mandated external evaluation of New York State’s implementation of court-mandated outpatient psychiatric treatment under Mental Hygiene Law 9.60, “Assisted Outpatient Treatment” (AOT), also known as “Kendra’s Law.”  The purpose of the study is to examine the process and outcomes of AOT programs in New York State, by addressing specific research questions. This project is funded by the NYS Office of Mental Health. (2006-2009).

Costs of Criminal Justice Involvement among Persons with Severe Mental Illness in Connecticut
Growing research demonstrates that a substantial proportion of people with severe mental illnesses come into contact with the criminal justice system at some point in the course of their illness.  Annually, approximately 1.1 million persons with severe mental illness enter US jails (National GAINS Center, 2006).  Many of these individuals continue on to prison and then parole, or to probation, and some cycle repeatedly through the criminal justice system.  The largest urban jails encounter more persons with severe mental illness than any hospital nationwide, and are aptly referred to as de facto mental health institutions. The overrepresentation of persons with severe mental illness in criminal justice settings, and the associated challenges that follow (e.g., providing access to treatment, handling behavioral health problems for incarcerated individuals, reducing repeated cycling through the system), constitutes a large and costly public health problem. Comprehensive and specific information is lacking about the costs of both mental health and criminal justice services provided to justice-involved persons with severe mental illness. This study will provide such information by gathering and jointly analyzing data from public mental health, correctional, and health services entitlement programs in Connecticut. This project is funded by Eli Lilly & Co. (2007-2009).