CJ Discussion

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Mental health court is one type of special jurisdiction court that has proliferated

during the past decade (1). Although no prototypical mental health court exists (2,3), one characteristic shared by this type of court is the goal of di- verting defendants from the criminal justice system into treatment (4).

Little evidence exists that supports the effectiveness of these treatment-

oriented courts (2–5). Comparison of one-year outcomes of defendants who received mandated court-monitored treatment with the outcomes of those who did not showed that a significantly higher percentage of defendants who received this treatment had positive outcomes (59 percent compared with 28 percent), as defined by fewer arrests and psychiatric hospitalizations and less homelessness and violence (6).

Findings from the evaluation of Kings County, Washington, and Seat- tle municipal mental health courts showed that the courts in both areas were effective in reducing crime and increasing treatment referrals and en- gagement for persons with mental ill- ness (5). It was further noted that the effect sizes associated with these out- comes were in the medium to medi- um-large range and thus have practi- cal consequences for defendants.

A study examined 121 defendants from Broward County mental health court and 101 defendants from a reg- ular court in Hillsborough County to determine the impact of the mental health court on defendants’ access to behavioral health services and con- cluded that the mental health court had a meaningful role in enhancing defendants’ access to care (7). The study showed that the percentage of defendants from the mental health court who received behavioral health services significantly increased, from 36 percent during the eight months before their initial court appearance to 53 percent during the eight months after their initial appearance. In con- trast, the likelihood of receiving treat- ment among defendants in the regu- lar court remained virtually un- changed during this time frame (29 to 28 percent). Also, a study of a mental health court in Santa Barbara, Cali- fornia, reported improvements in quality of life for individuals who par- ticipated in the court (8).

Despite the promising findings of these studies, it remains unknown whether increased access to services results in measurable clinical im-

Clinical Outcomes of Defendants in Mental Health Court RRooggeerr AA.. BBooootthhrrooyydd,, PPhh..DD.. CCyynntthhiiaa CCaallkkiinnss MMeerrccaaddoo,, PPhh..DD.. NNoorrmmaann GG.. PPooyytthhrreessss,, PPhh..DD.. AAnnnneettttee CChhrriissttyy,, PPhh..DD.. JJoohhnn PPeettrriillaa,, JJ..DD..,, LLLL..MM..

Dr. Boothroyd, Dr. Poythress, Dr. Christy, and Mr. Petrila are affiliated with the Florida Mental Health Institute at the University of South Florida, 1330 N. Bruce B. Downs Boulevard, Tampa, Florida 33612 (e-mail, boothroy@fmhi.usf.edu). Dr. Mercado is with Monash University in Melbourne, Australia.

Objective: Mental health courts successfully divert defendants into treat- ment. However, few studies have examined whether this increased access to services positively affects client outcomes. This study compared changes in symptoms in a sample of defendants in Broward County men- tal health court with such changes in a comparison sample of defendants in a regular court. Methods: Participants included 116 defendants from mental health court and 101 defendants from a magistrate court who were assessed one, four, and eight months after an initial court appearance by using the Brief Psychiatric Rating Scale (BPRS). Both administrative and self-report data were used to identify defendants who received treatment after their initial court appearance. Participants were included in our analysis if they had at least one follow-up interview. Results: A total of 97 defendants from mental health court and 77 from the regular court were included in our analysis. Analyses of covariance performed on changes in BPRS scores revealed no significant main effects by type of court, receipt of treatment, or the interaction between type of court and receipt of treatment. Conclusions: Although mental health courts have been found to increase defendants’ access to mental health services, they have little control over the type and quality of services that defendants receive. The fact that reductions in symptoms were not observed among defendants who received treatment in either court setting more likely reflects the chronic nature of their disorders and concerns about the adequacy of our public mental health system, rather than a failure of the mental health court. (Psychiatric Services 56:829–834, 2005)

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provement—for example, reduced symptoms. Hence the goal of our study was to examine changes in symptoms of defendants whose cases were processed in a mental health court in Broward County or a regular court in Hillsborough County. This study specifically addressed three questions: Did changes occur in de- fendants’ symptoms over time? Were changes in symptoms associated with receipt of treatment? Was there a change in symptoms by type of court?

Background The mental health court in Broward County began in June 1997 to “pro- vide for the expeditious evaluation and treatment of defendants with mental disability” (9). Access to the court is limited to individuals charged with nonviolent misde- meanors, ordinance violations, or criminal traffic charges (excluding charges for domestic violence and driving under the influence). Be- cause the court was designed to per- mit broad access to defendants in need of treatment, no formal diag- nostic criteria are used (10). Instead, defendants are typically referred to the court by magistrates who con- duct initial hearings that include a mental health screening by students who are earning their doctoral de- gree in clinical psychology (11). However, multiple stakeholders— including judges, mental health staff of the jail, mental health advocates, and family members—may refer cas- es to the mental health court.

Although mental health courts pro- vide an important gateway to treat- ment, it is important to note that these courts have little influence or control over the type and quality of services that defendants receive. This finding is consistent with the explicit objectives in creating the Broward County mental health court, which included to “efficiently move people from an overcrowded jail system into the mental health system” (12). Thus the Broward County mental health court was created without any new funding or staff resources that were dedicated specifically for purchasing or monitoring clinical services, and it relies almost exclusively on the sys- tem of community providers to deter-

mine, prescribe, and monitor the ap- propriate clinical services.

Our observations show that the Broward County mental health court facilitates positive features of proce- dural justice (13). We have observed, as have others, that this mental health court is informal and involves interac- tion and dialogue between the judge and the participant about problems and treatment options (4,13). This mental health court is respectful of participants and has adopted a sup- portive, instructive, and problem- solving style designed to improve the mental health of its participants. The speedy disposition of cases is not a high priority of the court. Instead the court places greater emphasis on en- suring that defendants comprehend and understand the proceedings in which they are engaged. These issues are important insofar as theorists have argued that enhancing proce- dural justice features may lead to im- proved therapeutic outcomes for per- sons with mental illness who are di- rected into mental health treatment by way of the legal system (14,15). In contrast, observations of the regular court (13) used for comparison in this study suggest that such features are largely absent. Hearings are conduct- ed by remote video, the judge and at- torneys do most of the talking, and the implicit, if not explicit, agenda ap- pears to be quick resolution of the charges. A plea agreement is often of- fered by the judge and agreed to by counsel, and defendants usually are not encouraged to speak except in re- sponse to plea offerings.

Methods Participants Our study’s evaluation used a non- equivalent comparison group design (16) to compare the clinical outcomes of defendants who were involved in the Broward County mental health court with those of a matched sample of defendants from a misdemeanor court in another county. The regular court was selected from Hillsborough County because it closely represent- ed the site of the mental health court on various demographic and census variables. Delayed enrollment was used in the comparison sample to en- sure that defendants in both courts

had similar demographic and clinical characteristics. Although diagnoses were not obtained as part of this eval- uation, progress reports from the mental health court indicated that 17 percent of the defendants were given a diagnosis of schizophrenia; 25 per- cent, major depression; 24 percent, bipolar disorder; and 34 percent, oth- er diagnoses (17). No information on diagnoses was available for defen- dants in the regular court.

Measures Clinical status. The Brief Psychiatric Rating Scale–Anchored Version (BPRS) was used to assess and moni- tor the clinical status of defendants in the two courts (18). This version of the BPRS consists of 18 symptoms (for example, suspiciousness, disori- entation, and anxiety) that are rated for frequency and severity on a 7- point scale. The scale ranges from “not present” to “extremely severe” and includes anchors in the form of behavior examples for each item rat- ing option. The BPRS yields a global index of the severity of current psy- chopathology and four subscores asso- ciated with psychoticism, emotional withdrawal, hostility, and depression. Scoring is based on self-report and be- havioral observations during a clinical interview. Possible scores of the glob- al index range from 18 to 126, with higher scores indicating greater sever- ity (18). The BPRS was designed to measure change across groups of indi- viduals to evaluate outcomes and as- sess change resulting from treatment (19). The reliability and validity of the BPRS have been well documented across studies (20). The BPRS was ad- ministered by highly trained research assistants who, to the extent possible, clinically assessed and interviewed the same defendants for the duration of the study. The anchored version of the BPRS used in this study has been shown to produce acceptable inter- rater reliability (18).

Service use. Two data sources were used to determine whether partici- pants received treatment during the eight months after their initial court appearance. First, data were obtained from administrative records on all mental health and substance abuse services that were paid for by either

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Medicaid or state general revenue dollars. Second, self-reported service use was obtained directly from partic- ipants during face-to-face interviews (10), involving procedures detailed elsewhere (21). Defendants were considered to have received treat- ment if they either had an administra- tive service record or reported using services during the follow-up inter- views. The rationale for the decision to use both methods to denote service was based on the fact that the admin- istrative data sources were limited to specific payer sources (that is, Medic- aid and state general revenue) and did not include other potential sources of service (for example, fed- eral and county). Stiles and col- leagues (22) have described issues re- lated to operationalizing service.

Procedures Each day, project staff monitored the mental health court and attempted to contact each new defendant after the hearing to solicit his or her participa- tion in the study. To ensure that the two samples were closely matched on demographic and clinical variables, recruitment of defendants in the reg- ular court was lagged two months be- hind that of defendants in the mental health court and involved multiple strategies. To recruit defendants for the regular court sample, project staff obtained a list of defendants who were referred for psychiatric care while in jail or who were housed in the jail’s mental health units. Staff also attended the magistrate court to observe whether defendants’ behav- iors were suggestive of possible men- tal disorder. These processes pro- duced a list of defendants from the magistrate court who could be poten- tially recruited for our study. Demo- graphic features of defendants from the mental health court were contin- ually monitored, and defendants in the comparison group were recruited to mirror the characteristics of the sample from the mental health court.

Before the start of the study, all pro- cedures were reviewed and approved by the institutional review board of the University of South Florida. In- formed consent was obtained on en- rollment, and trained research assis- tants contacted participants one, four,

and eight months after enrollment for subsequent administrations of the protocol. Participants were paid $20 for each completed interview. Data collection occurred between Decem- ber 1999 and August 2003. More complete details of this evaluation are provided elsewhere (10,21).

Analyses An analytic approach was used that examined the average change from baseline to follow-up. This approach determined whether significant changes occurred in defendants’ clin- ical status during the eight months af- ter their initial court appearance. First, each defendant’s total BPRS score at intake was subtracted from the total BPRS score at each of the follow-up interviews (one, four, and eight months). Then all the changes in scores were averaged. These same procedures were used for each of the four subscales of the BPRS. This ap- proach permitted the inclusion of participants even when fewer than all three follow-up interviews had been completed. Participants were includ- ed in our analysis if they had at least one follow-up interview. A total of 68 participants (39 percent) had one fol- low-up interview, 54 (31 percent) had two follow-up interviews, and 52 (30 percent) had three follow-up inter- views. A total of 121, or 70 percent,

were interviewed at eight months. The use of summary measures to compare program outcomes is well documented in the literature (23,24). However, to ensure that the use of the average change did not mask ini- tial changes in one direction with sub- sequent changes in the opposite di- rection, the average deviations from baseline at each period were exam- ined. These results indicated that all effects sizes were small (that is, less than .15) and nonsignificant (25).

After the average change in score from baseline was calculated, changes in scores were analyzed by whether the defendant received treatment, by the type of court, and by the interaction between type of court and receipt of treatment. Analysis of covariance (ANCOVA) procedures were used in which the intake BPRS scores were included as a covariate. Because previous studies have found client outcomes to be as- sociated with treatment dosage (26), defendants were reclassified into multiple treatment categories based on varying levels of treatment and the data were reanalyzed.

Results Sample Table 1 shows that the matching process was successful; no significant differences were found between de-

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TTaabbllee 11

Comparison of defendants in the mental health court and in the regular courta

Mental health court Regular court (N=116) (N=101)

Characteristic N % N %

Gender Male 79 68 61 60 Female 37 32 40 40

Race or ethnicity White 71 61 58 57 Black 28 24 26 26 Hispanic 10 9 16 16 Other 7 6 13 13

Age (mean±SD years)b 36.4±10.4 37.7±9.6 BPRS score (mean±SD)c 34.6±9.8 34.1±7.8

a All differences between groups were nonsignificant. b Age ranged from 18 to 63 years for defendants in the mental health court and from 20 to 57 years

for those in the regular court. c Brief Psychiatric Rating Scale. Possible scores range from 18 to 126, with higher scores indicating

greater severity. Scores ranged from 18 to 65 for defendants in the mental health court and from 18 to 55 for those in the regular court.

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fendants in the two courts in terms of gender, race or ethnicity, age, or over- all level of psychopathology, as meas- ured by the BPRS.

A total of 116 defendants from mental health court and 101 defen- dants from the regular court original- ly agreed to participate in our study. Some defendants from both sites were lost to attrition, requested to be disenrolled from the study, or had fol- low-up data collection conducted by telephone, which precluded adminis- tration of the BPRS, leaving 97 de- fendants from mental health court and 77 from the regular court who were included in our analysis. As shown in Table 2, defendants who were excluded from our analyses did not differ significantly from those who were included in terms of gen- der, race or ethnicity, age, or overall level of psychopathology.

Symptom change over time Mean±SD BPRS total scores for all participants were 34.3±9.0 at the time of the enrollment interview. As shown in Table 3, all defendants showed greater severity of psy- chopathology over time. During the eight-month follow-up period defen- dants’ total BRPS scores increased an average of .7±10.4, representing a nonsignificant effect size of .08. Al- though defendants’ scores on the psy- choticism, depression, and hostility subscales dropped during the eight- month follow-up period, these de- creases were also not significant and the effect sizes were small. On the emotional withdrawal subscale, de- fendants’ scores increased an average of .8±3.1, representing a small to moderate effect size (24).

Symptom change and receipt of treatment Defendants with either a behavioral health service claim or self-reported use of behavioral health services were classified as having received treat- ment. Table 3 reveals that defendants who were treated experienced an av- erage .8±9.9 point increase in total BPRS scores over the eight month follow-up period, and defendants who did not receive any services aver- aged a .6±12.1 point increase. The ef- fect size associated with this differ-

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TTaabbllee 22

Comparisons of defendants retained during follow-up and those who dropped out of the studya

Completed the Dropped study (N=174) out (N=53)

Characteristic N % N %

Gender Male 108 62 30 57 Female 66 38 23 43

Race or ethnicity White 99 57 32 60 Black 39 22 12 23 Hispanic 17 10 4 8 Other 19 11 5 9

Age (mean±SD years)b 38.5±10.2 37.3±9.9 BPRS score (mean±SD)c 33.7±8.9 36.5±8.7

a All differences between groups were nonsignificant. b Age ranged from 18 to 63 years for defendants who completed the study and from 18 to 57 years

for those who dropped out of the study. c Brief Psychiatric Rating Scale. Possible scores range from 18 to 126, with higher scores indicating

greater severity. Scores ranged from 18 to 65 for defendants who completed the study and from 19 to 64 for those who dropped out of the study.

TTaabbllee 33

Average change in Brief Psychiatric Rating Scale (BPRS) scores from the initial court appearance to each follow-up visit and effect size estimates among defen- dants in a mental health court and a regular court who did not receive treatment

Mean±SD change from baseline score

Effect Group Mean SD sizea

All participants (N=174) Subscales

Psychoticismb –.1 2.4 –.04 Depressionb –.2 4.2 –.05 Hostilityb –.1 2.5 –.04 Emotional withdrawalb .8 3.1 .35

Total BPRS scorec .7 10.4 .08 Received treatment (N=135)

Subscales Psychoticismb –.2 2.5 –.08 Depressionb –.1 3.9 –.02 Hostilityb –.1 2.5 –.04 Emotional withdrawalb 1.0 2.9 .52

Total BPRS scorec .8 9.9 .09 Did not receive treatment (N=39)

Subscales Psychoticismb .1 1.8 .05 Depressionb –.4 5.1 –.08 Hostilityb –.3 2.6 –.14 Emotional withdrawalb .3 3.9 .19

Total BPRS scorec .6 12.1 .07

a The respective intake BPRS standard deviations were used to estimate effect sizes. Negative ef- fect sizes reflect an improvement in symptoms.

b Possible scores range from 3 to 21, with higher scores indicating greater severity. c Possible scores range from 18 to 126, with higher scores indicating greater severity.

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ence between the treatment groups was only .02, a nonsignificant effect (25). In addition to this nonsignifi- cance, the direction of the effect was contrary to what would be expect- ed—that is, defendants who received treatment actually exhibited a greater increase in symptoms than those who were not in treatment. Examination of the effect sizes associated with changes in clinical status on the four subscales of the BPRS also showed extremely small nonsignificant differ- ences, with the exception of the hos- tility subscale in which a small to moderate effect of .43 was noted fa- voring the group that did not receive treatment (25). Analyses based on varying levels of treatment or dosage also resulted in a nonsignificant dif- ference among groups of varying treatment levels.

Change in symptoms by type of court An ANCOVA was conducted to assess whether change in BPRS total scores over time were associated with type of court, receipt of treatment, or in- teraction between type of court and receipt of treatment, while the analy- ses controlled for defendants’ intake BPRS scores. The results of this analysis are summarized in Table 4, and Table 5 presents the descriptive statistics associated with this analysis. As can been seen in Table 4, no sig- nificant main effects were found for type of court, receipt of treatment, or the interaction between type of court and receipt of treatment. During the eight-month follow-up period, BPRS scores of defendants in the mental health court increased an average of 1.3±11.6, and scores for defendants in the regular court decreased .05± 8.8. Separate ANCOVAs conducted on each of the four BPRS subscales did not indicate any significant main effects or interactions.

Discussion The results of these analyses did not document any significant change in defendants’ clinical status, as meas- ured by the BPRS, associated with re- ceipt of treatment or participation in the mental health court.

Although these results suggest that defendants are not obtaining clinical

benefit from receiving mental health services, it should be noted that the classification of defendants into treat- ment and nontreatment groups was based on the documented or self-re- ported use of service and units of service provided but not on the type, appropriateness, or quality of the services received. A better under- standing of the services that defen- dants received and the appropriate- ness and quality of these services might offer more insight into these findings. The fact that positive changes in defendants’ clinical out- comes were not detected likely speaks more to the adequacy of the mental health service systems in these counties than to the effective- ness of the mental health court in meeting the court’s articulated goals.

Alternatively, it may be that defen- dants in both courts predominately

had chronic illnesses in which, bar- ring recurrent acute psychotic episodes, substantial changes in clini- cal presentation are infrequent irre- spective of treatment. Although more detailed clinical information was not available from our evaluation, this in- formation would have been helpful. Future studies of mental health courts and the examination of other outcome measures should gather this information. This finding also raises questions about whether mental health courts should have greater control over the services to which de- fendants are referred.

Although this study cannot com- pare outcomes by the types of servic- es that defendants received, this com- parison might be informative. Our findings raise broader policy ques- tions about the creation of courts as a gateway into treatment in the absence

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Results of an analysis of covariance that analyzed the average change in Brief Psy- chiatric Rating Scale (BPRS) scores from the initial court appearance to each fol- low-up (one, four, and eight months after the initial court appearance) among de- fendants in a mental health court and a regular court (N=174)

Source Mean square F df p

Intake BPRS score 6,884.24 98.1 1 <.001 Type of court 45.35 .6 1 ns Receipt of treatment 8.34 .1 1 ns Type of court × receipt

of treatment 5.95 .1 1 ns Error 70.18 169

TTaabbllee 55

Treatment status and average change in Brief Psychiatric Rating Scale (BPRS) scores from the initial court appearance to each follow-up visit among defendants in both mental health court and a regular court (N=174)

Mean±SD change Effect Variable N % in baseline score sizea

Mental health court Treatment status

Received treatment 83 48 1.4±10.9 –.01 Did not receive treatment 14 8 1.3±15.6

Total 97 56 1.3±11.6 Regular court

Treatment status Received treatment 52 30 –.13±8.2 .11 Did not receive treatment 25 14 .12±10.0

Total 77 44 –.05±8.8

a Average change in total BPRS standard deviation was used to estimate all effect sizes. Negative ef- fect sizes infer that the non-treatment group had a more positive change (or less regression) com- pared with the treatment group.

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of existing—or the simultaneous cre- ation of—effective community-based services.

Finally, the fact that positive change in defendants’ clinical status was not detected within the eight- month follow-up period may suggest that a longer follow-up period (for ex- ample, one year) is necessary for pos- itive effects to be realized.

It should be noted that limitations to this study include the nonequiva- lent comparison-court design and the loss of participants at follow-up. Giv- en these limitations, caution should be exercised when interpreting the results.

Conclusions This study offers preliminary data on changes in symptoms as a function of receipt of services and involvement with a mental health court. Although previous research has shown that de- fendants from a mental health court are more likely to be linked to serv- ices (7) and to perceive their involve- ment in the court as less coercive (13), this study found that receipt of treatment alone is not sufficient to effect positive changes in clinical sta- tus. Additional studies that examine the quality of care that individuals receive may offer more insight about the impact of treatment on clinical outcomes. ♦

Acknowledgments

This research was supported by grants from John D. and Catherine T. Mac- Arthur Foundation and the Florida legis- lature. The authors thank Steven M. Banks, Ph.D., for his consultation on the analysis of these data.

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