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Articles   |    
Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study
Craig Beach, M.D., M.Sc.; Lindsay-Rose Dykema, M.D., M.P.H.; Paul S. Appelbaum, M.D.; Louann Deng, M.D.; Emily Leckman-Westin, Ph.D.; Jennifer I. Manuel, Ph.D.; Larkin McReynolds, Ph.D.; Molly T. Finnerty, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200170
View Author and Article Information

Dr. Beach is the Chair of the Forensic Psychiatry Division, Western University, London, Ontario, Canada.
Dr. Dykema is with the University of Michigan School of Medicine, Ann Arbor, and Ann Arbor Veterans Affairs Medical Center.
Dr. Appelbaum is with the Department of Psychiatry, Columbia University, and the New York State Psychiatric Institute, New York City.
Dr. Deng, Dr. McReynolds, and Dr. Finnerty are with the New York State Office of Mental Health, New York City. Dr. Finnerty is also with the Department of Child and Adolescent Psychiatry, New York University, New York City.
Dr. Leckman-Westin is with the New York State Office of Mental Health, Albany, and the Department of Epidemiology and Biostatistics, School of Public Health, University at Albany–State University of New York.
Dr. Manuel is with the Virginia Commonwealth University School of Social Work, Richmond, Virginia.
Send correspondence to Dr. Finnerty, New York State Office of Mental Health, 1051 Riverside Dr., Unit 100, New York, NY 10040 (e-mail: molly.finnerty@omh.ny.gov).

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors.

Methods  Data were extracted from the New York State Office of Mental Health’s Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time.

Results  Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up.

Conclusions  Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.

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Table 1Characteristics of assertive community treatment clientele, by forensic involvement (N=4,756)
Table Footer Note

a Because of missing data, the percentage (mean) for some characteristics is based on slightly reduced Ns.

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b Comparisons were of white versus black, Latino, and other.

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c Paid or nonpaid positions

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d Past 6 months

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e Alcohol and drug use with impairment, abuse, dependence, or dependence with institutionalization

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f Possible scores range from 0 to 100, with higher scores indicating better functioning.

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*p<.05, **p<.01, ***p<.001

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Table 2Three-year outcomes for assertive community treatment (ACT) clients with recent, remote, or no forensic involvement
Table Footer Note

a Significant difference between recent and remote (p<.01), recent and nonforensic (p<.001), and remote and nonforensic for years 1, 2, and 3 (p<.001). The within-group effect was significant (p<.001) for recent.

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b No significant differences between groups for any year. The within-group effect was significant for recent (p<.001), remote (p<.05), and nonforensic (p<.001).

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c Significant difference between recent and remote (p<.001), recent and nonforensic (p<.001), and remote and nonforensic (p<.001) for year 1; significant difference between recent and nonforensic (p<.001) for year 2; no significant differences among groups for year 3. The within-group effect was significant for recent, remote, and nonforensic (p<.001 for each group).

Table Footer Note

d Significant difference between recent and remote (p<.05) and recent and nonforensic (p<.01) for years 1, 2, and 3. The within-group effect was significant for recent (p<.001), remote (p<.05), and nonforensic (p<.001).

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Table 3Predictors of three-year outcomes for assertive community treatment (ACT) clients, by generalized linear multilevel modelsa
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a All demographic characteristics and drug use with impairment and clinical variables included in the multivariate logistic regression models were measured at baseline.

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b Interaction term not included in final model for arrest or incarceration, psychiatric hospitalization, or discharge from ACT outcomes

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c Comparison of white versus black, Latino, and other

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d Alcohol and drug use with impairment, abuse, dependence, or dependence with institutionalization

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