CILR

O R I G I N A L P A P E R

Characteristics of Patients Referred to Psychiatric Emergency Services by Crisis Intervention Team Police Officers

Beth Broussard • Joanne A. McGriff •

Berivan N. Demir Neubert • Barbara D’Orio •

Michael T. Compton

Received: 29 September 2009 / Accepted: 20 January 2010 / Published online: 7 February 2010

� Springer Science+Business Media, LLC 2010

Abstract The Crisis Intervention Team (CIT) program

trains police officers in crisis intervention skills and local

psychiatric resources. Because the safety and appropriate-

ness of any new intervention is a crucial consideration, it is

necessary to ensure that CIT training does not result in

excessive or inappropriate referrals to psychiatric emer-

gency services (PES). Yet, aside from one prior report by

Strauss et al. (2005) in Louisville, Kentucky, little is known

about the comparability of patients referred to PES by CIT-

trained officers in relation to other modes of referral. The

research questions driving this retrospective chart review

of patients referred to PES were: (1) What types of patients

do CIT-trained officers refer to PES?, and (2) Do mean-

ingful differences exist between patients referred by family

members, non-CIT officers, and CIT-trained officers?

Select sociodemographic and clinical variables were

abstracted from the medical records of 300 patients during

an eight-month period and compared by mode of referral.

Differences across the three groups were found regarding:

race, whether or not the patient was held on the locked

observation unit, severe agitation, recent substance abuse,

global functioning, and unkempt or bizarre appearance.

However, there were virtually no differences between

patients referred by CIT-trained and non-CIT officers.

Thus, while there were some expected differences between

patients referred by law enforcement and those referred by

family members, CIT-trained officers appear to refer

individuals appropriately to PES, as evidenced by such

patients differing little from those referred by traditional,

non-CIT police officers. Trained officers do not have a

narrower view of people in need of emergency services

(i.e., bringing in more severely ill individuals), and they do

not have a broader view (i.e., bringing in those not in need

of emergency services). Although CIT training does not

appear to affect the type of individuals referred to PES,

future research should examine the effect of CIT training

on the frequency of referrals or proportion of subjects

encountered that are referred, which may be expected to

differ between CIT-trained and non-CIT officers.

Keywords Crisis intervention team � Law enforcement � Police officers � Psychiatric emergency services

Introduction

As first responders in crisis situations involving persons

with serious mental illnesses, law enforcement officers are

often the principal source of referral to psychiatric emer-

gency services (PES) and play an important role in the

initiation of mental health treatment. Violent behavior,

male gender, experiencing more severe psychosocial

stressors, and spending more time in the emergency setting

have been found to characterize those patients referred by

law enforcement officers to PES compared to other modes

of referral, such as referral by health care providers, self-

referral, and other referral sources (Redondo and Currier

B. Broussard � J. A. McGriff � B. D’Orio � M. T. Compton (&) Department of Psychiatry and Behavioral Sciences, Emory

University School of Medicine, 49 Jesse Hill Jr. Drive, S.E.,

Room #333, Atlanta, GA 30303, USA

e-mail: [email protected]; [email protected]

M. T. Compton

Department of Behavioral Sciences and Health Education,

Rollins School of Public Health of Emory University,

Atlanta, GA, USA

B. N. Demir Neubert

Department of Health Policy and Management, Rollins School

of Public Health of Emory University, Atlanta, GA, USA

123

Community Ment Health J (2010) 46:579–584

DOI 10.1007/s10597-010-9295-3

2003; Way et al. 1993). Furthermore, race/ethnicity and its

socioeconomic correlates may play a role in pathways to

care, as exemplified by research indicating high rates of

police involvement and police referral to psychiatric ser-

vices for ethnic minorities with psychotic disorders (Bhu-

gra et al. 2000; Burnett et al. 1999; Commander et al. 1999;

Compton et al. 2006a, Fisher et al. 2004; Garety and Rigg

2001; Jarvis et al. 2005; Morgan et al. 2004, 2005a, b). In

recognition of the role that police officers often assume in

psychiatric referral and mental health crisis situations, as

well as the widespread problem of criminalization of

people with mental illnesses, many law enforcement

agencies have implemented crisis intervention programs in

collaboration with community partners.

The Crisis Intervention Team (CIT) program trains

officers in crisis intervention skills to adequately handle

interactions with individuals with mental illnesses or

substance use disorders. Furthermore, in addition to the

training, the program was developed in an effort to pro-

mote partnerships among law enforcement, mental health

professionals, and advocates. The training component of

CIT provides police officers with 40 h of lectures and

role-playing activities based on the Memphis Model of

CIT (Bower and Pettit 2001; Dupont and Cochran 2000).

As described in detail elsewhere (Oliva and Compton

2008), implementation of CIT trainings in Georgia began

in 2005 and is supported by a multi-disciplinary collabo-

ration among numerous organizations (e.g., Georgia

Bureau of Investigation, Georgia Department of Behav-

ioral Health and Developmental Disabilities, Georgia

affiliate of the National Alliance on Mental Illness). The

Georgia CIT training curriculum is approved by Georgia

Peace Officer Standards and Training to assure quality and

consistency of training in localities throughout the state.

The week-long course is comprised of: (1) approximately

20 h of lectures on psychiatric disorders and related topics

(e.g., signs and symptoms of mental illnesses, schizo-

phrenia, suicide prevention, addictive disorders, cultural

sensitivity, mental health laws) delivered by local mental

health professionals, advocates, and attorneys; (2) roughly

6 h visiting local emergency facilities and inpatient psy-

chiatric units, in part to hear the experiences of patients;

and (3) about 10 h of performance-based de-escalation

training that relies partly on role playing. Each class

accommodates 15–25 officers.

Most evaluation studies of CIT have focused on officer-

level data. For instance, research has examined improve-

ments in officers’ knowledge of and attitude towards

specific mental illnesses, officers’ enhanced self-efficacy,

officers’ decreased desire for social distance, increased

referrals to psychiatric services, reductions in the use of

force, and reductions in officer injuries (Bahora et al. 2008;

Borum et al. 1998; Compton et al. 2006b, 2010; Dupont

and Cochran 2000). However, additional outcomes

research on CIT is seriously needed (Compton et al. 2008).

While positive findings at the officer level are beneficial

and encouraging, research must begin to examine the effect

of CIT at the consumer level to determine whether CIT is

accomplishing its overall goal of facilitating mental health

referral for individuals with mental illnesses—in lieu of

incarceration—when appropriate. One example is the work

of Strauss et al. (2005), who utilized a chart review design

involving 485 patients referred to the emergency psychi-

atric services in Louisville, Kentucky, to examine charac-

teristics of patients brought in by CIT-trained officers

compared to those brought in by other sources (mental

inquest warrant or self-referral). Data collected from charts

included demographics, disposition, and diagnosis (pre-

sumably categorized generally into schizophrenia-related

disorders, mood disorders, or other diagnoses). CIT-trained

officers were found to refer individuals appropriately; those

referred by CIT-trained officers were not significantly

different from those referred by other sources, except in

diagnosis. A higher proportion of people brought in by

CIT-trained officers had a diagnosis of schizophrenia

(Strauss et al. 2005).

The current study attempted to replicate these previous

findings by conducting an exploratory, retrospective chart

review that assessed the sociodemographic and clinical

characteristics of patients referred to PES of a large, urban,

public-sector, county hospital in the southeastern United

States. Patients were classified by mode of referral; having

been referred by family members, traditional non-CIT

officers, or CIT-trained officers. The two research ques-

tions driving this study were: (1) What types of patients are

CIT-trained officers referring to PES? and (2) Do mean-

ingful differences exist between patients referred by family

members, patients referred by non-CIT officers, and

patients referred by CIT-trained officers? Because the

safety of any new intervention designed to improve health

is an initial research priority (‘‘first, do no harm’’), it is

necessary to ensure that CIT training does not result in

excessive or inappropriate referrals to PES. Do trained

officers have a narrower view of people in need of emer-

gency services, bringing in only severely ill individuals; do

they have a broader view, bringing in those not in need of

emergency services; or do they make appropriate referrals,

as indexed by such individuals being comparable with

those referred through other means? This study did not

attempt to address whether or not CIT-trained officers

bring in more patients (i.e., a greater frequency of referrals)

or a greater proportion of individuals with whom they

interact. Those issues, which should be addressed in other

research, could not be examined through a retrospective

chart review design because the number of individual

officers’ referrals would need to be counted and the number

580 Community Ment Health J (2010) 46:579–584

123

of CIT-trained and non-CIT officers would need to be

known, or a denominator (the total number of interactions

the individual officers have) would be necessary.

Methods

For the chart review, 300 patients were identified by

reviewing medical records of individuals referred to PES

during the May 2008–December 2008 period. This repre-

sented a sample of charts, rather than a review of each and

every consecutive medical record. Inclusion criteria were

that patients were 18 years or older at the time of PES

evaluation, and that patients were referred to PES by

family members, non-CIT officers, or CIT-trained officers.

In an effort to include a diverse representation of patients

seen in PES, charts were reviewed from PES regardless of

the patients’ hospital course or final disposition (i.e., dis-

charge from PES versus admission to the inpatient psy-

chiatric unit or crisis stabilization unit). Patients from these

two units are referred from PES, and their PES charts

become part of their inpatient medical record.

Select sociodemographic, referral-related, and clinical

variables were abstracted from the medical records in a

standardized way. These variables included: age, gender,

race, diagnosis (schizophrenia or a related primary psy-

chotic disorder versus a primary affective disorder versus

another primary diagnosis), whether or not the patient was

held in the locked observation unit after triage, presence of

suicidal ideation, presence of homicidal ideation, severe

disorganization, severe agitation, recent substance abuse,

the Global Assessment of Functioning (GAF) scale score

(Endicott et al. 1976), and whether or not the patient was

discharged from PES (versus referral for hospitalization).

Only three broad diagnostic categories, rather than specific

diagnoses, were used due to limited sample sizes of

patients with individual diagnoses. In this PES setting,

diagnoses are made and recorded in the medical record by

the evaluating physician, based on the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition

(American Psychiatric Association 2000a). Symptoms and

risks (e.g., presence of suicidal ideation) are assessed by a

nurse or social worker, and then reviewed by the evaluating

physician. Forms in the medical record allow these clini-

cians to tick boxes to record the presence of symptoms.

The GAF scale score is a widely used, reliable, and valid

100-point range that indicates overall current symptoms

and psychosocial functioning (American Psychiatric

Association 2000a, b; Goldman et al. 1992). The scale is

divided into 10 intervals with anchoring descriptions for

each (American Psychiatric Association 2000a). In addi-

tion to these variables, 10 mental status exam items were

assessed: appearance (e.g., neat versus unkempt or bizarre),

behavior, interaction, cooperativeness, speech, thought

content, affect, hallucinations, judgment, and insight.

The selection of variables was dependent on, and limited

by, information written in the medical record during rou-

tine clinical interactions in PES. Abstracted variables were

entered directly into a database in a password-protected

laptop computer. For the purpose of data collection,

patients were assigned a unique study number. No identi-

fying information was collected. The study protocol was

approved by the university’s institutional review board and

the hospital’s research oversight committee. The authors

have no known conflicts of interest pertaining to this study,

and all authors certify responsibility for the results and this

publication.

Data analysis was conducted using the SPSS version

16.0 statistical software package. Basic descriptive statis-

tics depicted the overall sample in terms of sociodemo-

graphic and clinical variables. Bivariate analyses, including

chi-square tests of independence and analyses of variance,

were used to compare the three subgroups (patients refer-

red by family members, those brought in by non-CIT

officers, and patients referred by CIT-trained officers)

along these sociodemographic and clinical variables. To be

conservative, data imputation techniques were not

employed for missing data points.

Results

Between May 2008 and December 2008, 300 charts were

reviewed. Two hundred thirteen charts (71.0%) were in

PES, 11 (3.7%) were in the inpatient psychiatric unit, and 8

(2.7%) were in the crisis stabilization unit. Chart reviews in

the latter two settings involved the PES portion of the chart

rather than the inpatient record. As shown in Table 1, 127

patients (42.3%) were brought in by family members, 132

(44.0%) were brought in by non-CIT officers, and 41

Table 1 Sociodemographic characteristics of the 300 patients

Age, years (mean ± standard deviation) 38.4 ± 13.6

Gender

Female 128 (42.7%)

Male 172 (57.3%)

Race (n = 286)

African American 234 (81.8%)

European American 44 (15.4%)

Hispanic/Latino 8 (2.8%)

Mode of referral

Family 127 (42.3%)

Non-CIT Police Officers 132 (44.0%)

CIT-Trained Officers 41 (13.7%)

Community Ment Health J (2010) 46:579–584 581

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(13.7%) were brought in by CIT-trained officers. The mean

age of patients was 38.4 ± 13.6 years (range = 18–78)

and 128 patients (42.7%) were female. The majority of the

sample (234, 81.8%) was African American.

As shown in Table 2, when associations between mode

of referral and the sociodemographic and clinical variables

of patients were examined, five variables were significantly

associated with mode of referral: (1) race (v2 = 7.90, df = 2, P = 0.02), (2) whether or not the patient was held

on the locked observation unit (v2 = 146.10, df = 2, P \ 0.001), (3) severe agitation (v2 = 7.60, df = 2, P = 0.02), (4) substance abuse (v2 = 15.42, df = 2, P \ .001), and (5) GAF scale score (F = 3.68, df = 2, 260, P = 0.03).

Several post-hoc chi-square tests were conducted to clarify

where, among the three modes of referral, significant dif-

ferences occurred when it was not clear by examining the

proportions. With regard to race, an additional chi-square

test indicated that the proportions of African American

patients did not differ between non-CIT and CIT referrals

(P = 0.23), but that the proportions of African American

patients did differ by family members versus non-CIT

officer referrals (P = 0.006). For substance abuse, an

additional chi-square test similarly revealed that the pro-

portions with substance abuse did not differ between

non-CIT and CIT referrals (P = 0.10). In terms of GAF

scores, Tukey’s HSD post-hoc tests revealed that patients

brought in by family members had a higher GAF score

(40.7 ± 13.0) than those brought in by CIT-trained officers

(34.2 ± 10.6). Again, there was no difference between

patients brought in by non-CIT versus CIT-trained officers.

Regarding the mental status examination characteristics

of patients (data not shown), the proportion of patients with

unkempt or bizarre appearance noted on the mental status

examination differed significantly across the three modes

of referral. Specifically, both non-CIT and CIT-trained

officers brought in a higher percentage of patients with an

unkempt or bizarre appearance (63, 51.2% and 22, 61.1%)

compared to family members (28, 23.03%; v2 = 27.86, df = 2, P \ 0.001). No other mental status examination items differed across the three groups.

Discussion

Findings of the current study were remarkably similar to

those of the report by Strauss et al. (2005) in terms of

sample characteristics. For example, approximately 42% of

both samples were female (42.7% in the current study and

Table 2 Sociodemographic and clinical variables by mode of referral

Variable (number included in the test

of association, if \300) Family members

(n = 127) Non-CIT officers

(n = 132) CIT-Trained officers

(n = 41) Test statistic, df, P

Age 38.5 ± 14.7 39.0 ± 12.9 36.1 ± 12.4 NS

Gender, male 70 (55.1%) 78 (59.1%) 24 (58.5%) NS

Race, African American (n = 286) 107 (88.4%) 95 (74.8%) 32 (84.2%) v2 = 7.90, df = 2, P = 0.02

a

Diagnosis of schizophrenia or a related primary

psychotic disorder (n = 289) 76 (61.8%) 73 (57.9%) 29 (72.5%) NS

Diagnosis of a primary affective disorder (n = 289) 31 (25.2%) 23 (18.3%) 6 (15.0%) NS

Held on the locked observation unit (n = 274) 17 (16.2%) 115 (89.1%) 36 (90.0%) v2 = 146.10, df = 2, P \ 0.001

Presenting problem noted on the triage form:

Suicidal ideation (n = 274) 14 (11.8%) 21 (17.5%) 8 (22.9%) NS

Homicidal ideation (n = 269) 2 (1.7%) 8 (7.0%) 3 (8.6%) NS

Severe disorganization (n = 266) 24 (21.1%) 33 (28.0%) 10 (29.4%) NS

Severe agitation (n = 268) 12 (10.3%) 28 (23.9%) 7 (20.0%) v2 = 7.60, df = 2, P = 0.02

Substance abuse (n = 251) 24 (22.6%) 52 (48.1%) 12 (32.4%) v2 = 15.42, df = 2, P \ .001a

GAF scale score (n = 263) 40.7 ± 13.0 38.8 ± 12.5 34.2 ± 10.6 F = 3.68, df = 2, 260, P = 0.03

b

Discharged from PES (n = 274) 28 (52.8%) 35 (50.7%) 16 (64.0%) NS

df degrees of freedom; NS non-significant; GAF Global Assessment of Functioning a

Post-hoc chi-square tests revealed a statistically significant difference in race and substance abuse between patients brought in by family

members and those brought in by non-CIT officers (but no difference between those brought in by non-CIT vs. CIT-trained officers) b

Post-hoc tests revealed a statistically significant difference in mean GAF scale scores between patients brought in by family members and those

brought in by CIT-trained officers

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41.3% in the Strauss et al. sample) and roughly 15% of the

two samples were referred by CIT-trained officers (13.7%

in this study and 16.3% in the Strauss et al. study). In

addition, the mean age of participants in the current study

(38.4 years) was very similar to that of the Strauss et al.

sample (37.4 years). Thus, in many respects, such as

sample characteristics, the present study serves as a well-

matched replication of the Strauss et al. report.

Differences in characteristics of patients by mode of

referral were found in several domains: race, whether or not

they were held on the locked observation unit, severe agi-

tation, substance abuse, GAF score, and unkempt or bizarre

appearance. A number of explanations seem plausible.

First, non-CIT officers in this setting appear to be referring a

lesser proportion of African American patients than are

family members. The study was conducted in an urban,

public-sector hospital where approximately 90% of patients

are African American. Because this hospital serves as an

emergency receiving facility for all police officers to bring

in people from the city and surrounding areas (which

are characterized by a higher proportion of European

Americans, as well as lower saturation of the CIT training

program compared to the inner-city), the non-CIT police-

referred group had a lesser percentage of African Ameri-

cans. Second, the prominent difference in proportions of

patients that were located on the locked observation unit is

driven by hospital policy in this setting. That is, all patients

brought in by police officers on a peace officer’s report (a

temporary commitment that can be completed by officers)

are immediately taken to this locked unit. Third, the results

indicated that patients referred by law enforcement officers

(both CIT-trained and non-CIT) were more agitated, more

likely to have a history of abusing substances, and more

likely to be unkempt or bizarre in appearance than those

referred by family members. These findings may be con-

sistent with previous reports indicating that officer

involvement often occurs with potentially dangerous or

violent individuals (Redondo and Currier 2003). Fourth,

and related, patients referred by family members had sig-

nificantly higher GAF scores compared to those referred by

CIT-trained and non-CIT officers, indicating that family

members bring in patients with a milder severity of illness

and dysfunction than those brought in by officers. No sig-

nificant differences were found between patients brought in

by CIT-trained and non-CIT officers. The current findings

differ from those of Strauss et al. (2005) in that no differ-

ence was found across groups in terms of diagnosis.

Several methodological limitations should be considered

in the interpretation of the present findings. First, multiple

nurses and social workers conducted the initial assessment

in PES, and there are no measures of their inter-rater

reliability in the recording of data in patients’ charts. Thus,

discrepancies between ratings of symptoms and risks could

have been introduced, though there is no reason to believe

that this would have been a systematic bias. Second,

because of the retrospective design, missing data points

were relatively common, though more in some variables

than other. Only available data were used; to be conser-

vative, techniques for the imputation of data were not

employed. Third, some charts were missing the mode of

referral, excluding them from review which could have

biased the results. However, it is not expected that missing

referral modes would be concentrated in one referral type.

Results from this retrospective chart review reveal that

patients brought in by CIT-trained officers are similar to

those brought in by non-CIT officers. Furthermore, patients

brought in by police officers generally resemble those

brought in by family members in many respects. Thus,

CIT-trained officers are referring individuals appropriately

to emergency psychiatric services. Trained officers do not

have a more narrow view of people in need of emergency

services, bringing in more severely ill individuals; neither

do they have a broader view, bringing in those not in need

of emergency services. CIT training does not appear to

affect the type of individual referred to PES. Future

research should examine whether or not CIT-trained offi-

cers bring in more patients (i.e., a greater frequency of

referrals) or a greater proportion of individuals with whom

they interact, now that it has been established that CIT-

referred patients are appropriate referrals and differ little

from patients referred through other modes.

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