September 2008: This Month's Highlights

The lead article in this month's issue draws attention to a juvenile population about which little is known: youths who are transferred from the juvenile justice system to adult criminal court. Historically, juvenile court judges made transfer decisions on a case-by-case basis. However, 29 states have now passed laws making transfer mandatory solely on the basis of the type of offense, criminal history, and age of the youth. Another 15 states also bypass juvenile court judges and allow prosecutors to make transfer decisions. In a study of 1,715 youths who were arrested and detained in Chicago, Jason J. Washburn, Ph.D., and colleagues compared two groups—1,440 youths who were processed in juvenile court and 275 who were transferred to adult criminal court. They found similarly high rates of psychiatric and substance use disorders in both groups. Males, Hispanics, and African Americans were significantly more likely to be transferred. After transfer, youths with a psychiatric or substance use disorder were twice as likely to receive a prison sentence. The authors note that the sociodemographic factors they found to be associated with transfer are the same factors found by others to be associated with a lower likelihood of receiving psychiatric services ( page 965 ). In the Taking Issue commentary, Bonnie T. Zima, M.D., M.P.H., notes that "tough on crime" legislation has undermined the parens patriae legal premise for the juvenile justice system and commends Washburn and colleagues for outlining research and policy agendas to improve mental health care for youths in the justice system ( page 955 ).

Analyses of data for nearly 27,000 persons with co-occurring psychiatric and substance use disorders who were discharged from inpatient treatment at Veterans Affairs facilities found that nearly a quarter (23.4%) were rehospitalized for additional care within 90 days. Mark A. Ilgen, Ph.D., and colleagues also found that receipt of substance abuse treatment in the 30 days after discharge significantly reduced the odds of rehospitalization at both 90 days and 12 months. The authors note that although guidelines for treatment of co-occurring disorders highlight the need for both psychiatric and substance-related treatment, only one-fifth of the sample received such treatment after discharge ( page 982 ). Effective implementation of integrated dual disorders treatment is the focus of a study reported this month by Mary F. Brunette, M.D., and colleagues. The authors analyzed qualitative data to identify factors that helped and hindered implementation of this evidence-based practice at 11 community mental health centers that demonstrated varying degrees of fidelity to the model. The presence of a committed midlevel administrative leader was instrumental to success, as were regular use of the expert consultant and skilled clinical supervision of team members ( page 989 ).

Two studies in this issue focus on samples of homeless women and a third examines consumers' housing preferences. Rani A. Desai, Ph.D., and colleagues report positive clinical outcomes for more than 350 homeless female veterans who participated in Seeking Safety, a six-month cognitive-behavioral intervention that addresses issues of safe behaviors, life skills, and relapse prevention ( page 996 ). Data from a sample of 738 homeless women indicated that those who had symptoms of mental illness had higher rates of use of three types of services—behavioral, medical, and human. Tammy W. Tam, Ph.D., and colleagues discuss the evidently stronger service linkage for this subgroup of homeless women, whose symptoms appeared to trigger referrals to an array of supports ( page 1004 ). A Montreal research group led by Myra Piat, Ph.D., examined consumers' housing preferences by surveying seven random samples of 48 consumers each; consumers were living in seven types of housing, from hospital settings to private rooming homes. More than a third reported that they were already living in their preferred housing, but most consumers' current housing ranked second to their preference for living in their own apartment ( page 1011 ).

• Investigators at a state psychiatric hospital found three distinct patterns of seclusion and restraint among patients with stays of at least 60 days ( page 1027 ).

• Analyses of Medicare data for nearly 42,000 elderly persons hospitalized with a primary psychiatric diagnosis other than dementia or an organic disorder indicated that 22% were rehospitalized for psychiatric reasons within six months ( page 1038 ).

• The Open Forum examines the ethical basis for decisions about the design of psychiatric hospitals—architectural paternalism ( page 1060 ).