Meeting the Needs of Justice-Involved People With Serious Mental Illness: In Reply

IN REPLY: As admirers of their work, we thank Drs. Lamberti and Weisman for their comments on our article. We agree that the evolution of forensic assertive community treatment (FACT) they describe is exactly the type of community-based, multi-pronged, comprehensive service approach needed to address the high rates of justice involvement among people with serious mental illness. We also agree that the FACT service delivery model as described by the Substance Abuse and Mental Health Services Administration (SAMHSA) is one example of how our proposed vision can be put into action

Meeting the Needs of Justice-Involved People With Serious Mental Illness Within Community Behavioral Health Systems

The overrepresentation of people with serious mental illness in the criminal justice system is a complex problem. A long-standing explanation for this phenomenon, the criminalization hypothesis, posits that policy changes that shifted the care of people with serious mental illness from psychiatric hospitals to an underfunded community treatment setting resulted in their overrepresentation within the criminal justice system. This framework has driven the development of interventions to connect people with serious mental illness to needed mental health and substance use treatment, a critical component for people in need. However, the criminalization hypothesis is a limited explanation of the overrepresentation of people with serious mental illness in the criminal justice system because it downplays the social and economic forces that have contributed to justice system involvement in general and minimizes the complex clinical, criminogenic, substance use, and social services needs of people with serious mental illness. A new approach is needed that focuses on addressing the multiple factors that contribute to justice involvement for this population. Although the authors' proposed approach may be viewed as aspirational, they suggest that an integrated community-based behavioral health system-i.e., intercept 0-serve as the focal point for coordinating and integrating services for justice-involved people with serious mental illness

Diversity in case management modalities: the Summit model

Though ubiquitous in community mental health agencies, case management suffers from a lack of consensus regarding its definition, essential components, and appropriate application. Meaningful comparisons of various case management models await such a consensus. Global assessments of case management must be replaced by empirical studies of specific interventions with respect to the needs of specific populations. The authors describe a highly differentiated and prescriptive system of case management involving the application of more than one model of service delivery. Such a diversified and targeted system offers an opportunity to study the technology of case management in a more meaningful manner

How to examine patients using the Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) examination has been widely recommended for periodic screening for tardive dyskinesia and follow-up of patients diagnosed with the disorder. However, few guidelines exist about how to use the examination in clinical practice. The authors discuss for whom, when, and how the AIMS examination can be used in a multidisciplinary setting; amplify the original instructions for the examination; and propose conventions to clarify scoring. Noting that the AIMS examination is not specific for tardive dyskinesia, they discuss a clinical approach to the patient who is found to have abnormal movements. The AIMS examination is best conducted within the context of an ongoing treatment program, the authors say, and should be part of the informed consent process necessary with patients treated with neuroleptic drugs

CMHC practices related to tardive dyskinesia screening and informed consent for neuroleptic drugs

OBJECTIVE: The authors conducted a national survey of community mental health centers to determine their policies and practices about screening patients for tardive dyskinesia and obtaining informed consent for use of neuroleptic drugs. METHODS: Clinical directors of 235 centers in the United States, selected by geographic region and population, were surveyed through a nine-item questionnaire. RESULTS: Although nearly all the 160 respondents reported that they screened patients for tardive dyskinesia, only about two-fifths had formal screening policies, and about two-fifths had screening programs. The Abnormal Involuntary Movement Scale examination was used by almost two-thirds of respondents who screened patients, and about one-fifth relied on unstructured observation. Slightly more than half of respondents specified a frequency for screening examinations, at a modal interval of six months. Seventy percent used nonpsychiatric clinicians for screening. Almost three-quarters of the respondents had informed consent policies for use of neuroleptics. Urban centers tended to be more aware than rural centers of the American Psychiatric Association\u27s tardive dyskinesia screening guidelines. They also used fewer nonmedical practitioners for screening and were more likely to obtain informed consent for neuroleptics. CONCLUSIONS: Despite the existence of APA guidelines and state policies and regulations about tardive dyskinesia screening, a national effort to educate clinicians about prevention of tardive dyskinesia is still needed

Who should perform the AIMS examination

Psychiatrists and nonphysician mental health professionals working in community mental health centers have difficulty establishing the scope of their expertise, defining the limits of their roles, delegating responsibility, and sharing professional liability. The clinical, political, and administrative aspects of these tensions are examined in the context of arguments for and against physicians\u27 delegating to nonphysician mental health professionals the task of screening CMHC patients for tardive dyskinesia using the Abnormal Involuntary Movement Scale. In 43 percent of mental health centers in Massachusetts surveyed by the authors, nonphysicians perform tardive dyskinesia screening. The authors suggest that the benefits of involving nonphysicians in tardive dyskinesia screening in the CMHC setting outweight the disadvantages