Search PubMed⌕ Search

Biomedical subjects

Nancy Wolff

Publications and source records attributed to Nancy Wolff.

At least 19 recordsLinked to original sources
PubMed2006

Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes.

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.

Adolescent↗
PubMed2006

Beyond criminalization: toward a criminologically informed framework for mental health policy and services research.

The problems posed by persons with mental illness involved with the criminal justice system are vexing ones that have received attention at the local, state and national levels. The conceptual model currently guiding research and social action around these problems is shaped by the "criminalization" perspective and the associated belief that reconnecting individuals with mental health services will by itself reduce risk for arrest. This paper argues that such efforts are necessary but possibly not sufficient to achieve that reduction. Arguing for the need to develop a services research framework that identifies a broader range of risk factors for arrest, we describe three potentially useful criminological frameworks-the "life course," "local life circumstances" and "routine activities" perspectives. Their utility as platforms for research in a population of persons with mental illness is discussed and suggestions are provided with regard to how services research guided by these perspectives might inform the development of community-based services aimed at reducing risk of arrest.

Criminal Law↗
PubMed2006

Sexual violence inside prisons: rates of victimization.

People in prison are exposed to and experience sexual violence inside prisons, further exposing them to communicable diseases and trauma. The consequences of sexual violence follow the individual into the community upon release. This paper estimates the prevalence of sexual victimization within a state prison system. A total of 6,964 men and 564 women participated in a survey administered using audio-CASI. Weighted estimates of prevalence were constructed by gender and facility size. Rates of sexual victimization varied significantly by gender, age, perpetrator, question wording, and facility. Rates of inmate-on-inmate sexual victimization in the previous 6 months were highest for female inmates (212 per 1,000), more than four times higher than male rates (43 per 1,000). Abusive sexual conduct was more likely between inmates and between staff and inmates than nonconsensual sexual acts. Sexual violence inside prison is an urgent public health issue needing targeted interventions to prevent and ameliorate its health and social consequences, which spatially concentrate in poor inner-city areas where these individuals ultimately return.

Adolescent↗
PubMed2006

Availability of behavioral health treatment for women in prison.

OBJECTIVES: This study examined whether women with behavioral health needs are more likely to receive treatment for these problems in prison or in the community and to what extent prison disrupts or establishes involvement in treatment for these women. METHODS: Data were collected in August 2004 as part of a population survey of female inmates in the only state correctional facility for women in New Jersey. RESULTS: A total of 908 women were surveyed. Fifty-six percent of the women surveyed reported needing behavioral health treatment before incarceration, but only 62 percent of this group reported receiving such treatment in the community. The rate at which treatment matched need within this population before incarceration varied by type of treatment needed: it was the highest (58 percent) for women who needed treatment for mental health problems, lower (52 percent) for those who needed substance abuse treatment, and lowest (44 percent) for those who needed treatment for comorbid mental health and substance abuse problems. In comparison, the rate of match between need for and receipt of treatment in prison was higher for all three types of behavioral health treatment (78 percent, 57 percent, and 65 percent, respectively). Additionally, the findings suggest that prison did not disrupt the type of behavioral health treatment that inmates had previously received in the community. CONCLUSIONS: At least in New Jersey, prison appears to improve access to behavioral health treatment among female inmates. Although this conclusion is consistent with the rehabilitation goals of incarceration, it also suggests that some women may have been able to avoid prison if treatment had been provided in the community, especially for substance-related problems.

Behavior Therapy↗
PubMed2006

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers.

OBJECTIVE: Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients. METHODS: The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined. RESULTS: About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types. CONCLUSIONS: The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Adolescent↗
PubMed2006

Modeling costs and burden of informal caregiving for persons with bipolar disorder.

BACKGROUND: Informal caregiving contributes significantly to the health and well being of chronically ill persons. While a vast literature demonstrates this connection, the cost and financial burden of informal caregiving has received considerably less research attention, especially as it-pertains to bipolar disorder. AIMS OF THE STUDY: This paper develops an integrated burden model of informal caregiving, which is contrasted with other more traditional models of caregiving costs, and then uses these models to estimate the financial burden of bipolar disorder. The "goodness" of these various models is measured in terms of their correlation with measures of objective and subjective burden for caregivers of persons with bipolar disorder. METHODS: The study was an ancillary protocol to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and included primary caregivers of 500 people with bipolar disorder. Approximately 96% (n=486) caregivers participated in the study. Caregivers were interviewed at baseline, and six and 12 months after an initial interview. The semi-structured interview included questions on (i) subjective distress; (ii) the types of support and services; (iii) caregiver use of formal and informal services and support; and (iv) contributions received from the relative with bipolar over the past month. RESULTS: The correlations between financial burden and psychological burden measures were positive and statistically significant in cases where all resource costs were measured but adjusted for reciprocated giving and customary generosity (the integrated model). The strength of correlations was greater when time is valued at its opportunity cost (and not imputed) and the caregiving costs based on this valuation approach were logarithmically transformed. DISCUSSION: The magnitude of the correlations is consistent with the notion that caregiver burden is a coherent construct with multiple different dimensions. Financial burden appears to be a unique dimension that is significantly intercorrelated with psychological measures but is not redundant with them. The robustness of these findings need to be tested with larger samples and across caregiver illness groups. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Caregiving is likely to have health and stress-related consequences that increase caregiving costs. Understanding which costs are associated with feelings of burden can be used to inform the design of interventions to minimize the stressful or burdensome aspects of caregiving. Giving back reduces the magnitude of caregiving costs and the sense of psychological burden. Interventions that develop the potential to "give back" are likely to be beneficial for both the caregiver and the care receiver as it increases reciprocity and decreases dependency. IMPLICATIONS FOR FURTHER RESEARCH: Caution is needed in estimating the costs of informal caregiving needs as many costs are possible but their relationship to burden varies in strength and significance. Assumptions related to what is given and received and how this relates to expected patterns of giving and receiving in measuring and determining financial burden and costs are particularly important, as is the valuation of time.

Bipolar Disorder↗
PubMed2005

Gender-specific behavioral health and community release patterns among New Jersey prison inmates: implications for treatment and community reentry.

OBJECTIVES: We describe behavioral health diagnoses and community release patterns among adult male and female inmates in New Jersey prisons and assess their implications for correctional health care and community reentry. METHODS: We used clinical and classification data on a census of "special needs" inmates (those with behavioral health disorders) in New Jersey (n=3189) and a census of all special needs inmates released to New Jersey communities over a 12-month period (n=974). RESULTS: Virtually all adult inmates with special needs had at least 1 Axis I mental disorder, and 68% of these had at least 1 additional Axis I mental disorder, a personality disorder, or addiction problem (67% of all male and 75% of all female special needs inmates). Of those special needs inmates released, 25% returned to the most disadvantaged counties in New Jersey (27% of all male and 18% of all female special needs inmates). CONCLUSIONS: Two types of clustering were found: gender-specific clustering of disorders among inmates and spatial clustering of ex-offenders in impoverished communities. These findings suggest a need for gendered treatment strategies within correctional settings and need for successful reentry strategies.

Adult↗
PubMed2005

Behavioral health problems, ex-offender reentry policies, and the "Second Chance Act".

The federal "Second Chance Act of 2005" calls for expanding reentry services for people leaving prison, yet existing policies restrict access to needed services for those with criminal records. We examined the interaction between individual-level characteristics and policy-level restrictions related to criminal conviction, and the likely effects on access to resources upon reentry, using a sample of prisoners with Axis I mental disorders (n=3073). We identified multiple challenges related to convictions, including restricted access to housing, public assistance, and other resources. Invisible punishments embedded within existing policies were inconsistent with the call for second chances. Without modification of federal and state policies, the ability of reentry services to foster behavioral health and community reintegration is limited.

Adolescent↗
PubMed2005

Community reintegration of prisoners with mental illness: a social investment perspective.

Responding effectively and efficiently to the needs of persons with mental illness returning to the community from prison requires identifying their differences in need and placement difficulties upon return and targeting reintegration investments to reflect these differences. This paper has three parts. The first part profiles the male special needs population in New Jersey prisons. These profiles describe behavioral health and criminal justice characteristics of 2715 male inmates with mental health problems, and are used to identify the scope and nature of the public's investment opportunity. The next part describes the costs associated with possible "investments." The special needs population is classified by need and placement difficulty, and then matched to reentry and community-based treatment programs. Costs are estimated for reentry planning and community-based treatment for the first year post-release. The third part recommends an investment strategy and a set of operational changes that might minimize the loss and maximize the return on the public's investment dollar in mental health.

Adult↗
PubMed2005

Understanding community re-entry of former prisoners with mental illness: a conceptual model to guide new research.

Criminal justice, mental health, and social service professionals face a myriad of role expectations in working with prisoners with mental illness to facilitate community re-entry. These expectations include those related to law enforcement, social welfare, and administrative efficiency. The challenge for front line workers and the multiple systems that employ them is to integrate all these expectations effectively on behalf of the individual as well as the community. Current models of re-entry for individuals leaving prison with mental illness focus on the management and interaction of service systems. This paper presents a model of prisoner re-entry that incorporates a larger social context, illustrating dynamics related to both individuals with mental illness leaving prison and their interaction with the community setting. This model was generated through an interdisciplinary team effort. It was refined through a focus group process that included advocates, community members and other informants from mental health and criminal justice systems in five states. The model is designed to generate new questions for research that address both individual and community level issues.

Community Mental Health Services↗
PubMed2002

Clinicians as advocates: an exploratory study of responses to managed care by mental health professionals.

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

Behavioral Medicine↗
PubMed2002

State mental hospitals and their host communities: the origins of hostile public reactions.

This article examines the hostile public reactions of a community that, through a state policy to consolidate all long-term behavioral health services, was to become the site of the state's only mental hospital. A telephone survey conducted in the host community (n = 800) and a matched community (n = 800) was used to test whether the origins of hostility toward consolidation were related to the public's negative attitudes toward mental illness and homelessness or to the beliefs about the discharge and supervisory behavior of the hospital. The host community was not found to have more negative views of mental illness, although it did have significantly more negative views about the homeless. Disapproval of consolidation was unrelated to negative views of mental illness or homelessness but was strongly related to the expected "bad" behavior of the hospital. These results suggest that the best way to improve relations between hospitals and their host communities is for hospitals to behave like "good" neighbors.

Attitude to Health↗
PubMed2002

The impact of drug pricing policies on the health of the elderly.

BACKGROUND: Prices for prescription drugs vary widely in the United States, from the prices charged by retail pharmacies to 50% below average wholesale prices (AWP), depending on the purchaser's bargaining power. At higher drug prices, expenditures for essential preventive interventions, such as those aimed at hypertension and hypercholesterolemia, buy less health for the elderly. The magnitude of this effect, however, is unknown. METHODS: Cost-effectiveness analyses of drug interventions, which estimate their health effects and costs, sometimes include analyses of the impact of drug prices. We use results from studies of preventive drugs used by the elderly to calculate the life-years that could be purchased for $1 million of expenditure at the AWP, and at prices 20% and 40% below the AWP. This range reflects the range of prices in the United States today. RESULTS: Drug prices have a substantial effect on the amount of health that can be purchased for $1 million, especially among elderly people with several health conditions. For example, at 40% below the AWP, $1 million spent on statins yields 90 years of life for patients aged 75 to 84 with a history of myocardial infarction. At the AWP, the number of life-years for $1 million drops to 48--a loss of 42 life-years. CONCLUSIONS: A Medicare drug benefit program that supports prices at the high end of the current range could yield substantially less health for the elderly, and one that promotes differential pricing could promote unequal access to preventive medications--and thus to health--by Medicare beneficiaries across the country.

Aged↗
PubMed2002

Release planning for inmates with mental illness compared with those who have other chronic illnesses.

The authors evaluated the effort of New Jersey jails to plan for the postrelease treatment needs of inmates with mental illness compared with inmates with heart disease and HIV infection or AIDS. Seventy percent of interviewees expressed a belief that release planning for persons with serious mental illness is very or extremely important. However, virtually all the jails reported providing "no real release planning." A majority of the jails provide aftercare plans for fewer than 10 percent of inmates with serious mental illness. A lack of release planning was noted for the other chronic conditions. Release planning for particular chronic problems is most common and complete in facilities with special treatment programs, such as a mental health unit.

Chronic Disease↗
PubMed2002

Risk, response, and mental health policy: learning from the experience of the United Kingdom.

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.

Attitude to Health↗
PubMed2000

Using randomized controlled trials to evaluate socially complex services: problems, challenges and recommendations.

BACKGROUND: Following the lead of evidence-based medicine, practice based on effectiveness research has become the new gold standard of contemporary public policy. Studies of this sort are increasingly demanded to evaluate services provided by mental health, social services and criminal justice systems. AIMS: The paper questions whether the simple randomized controlled trial (RCT) paradigm as applied in clinical trials can be used "off the rack" to evaluate socially complex service (SCS) interventions. These are services that are characterized by complex, diverse and non-standardized staffing arrangements; ambiguous protocols; hard-to-define study samples and unevenly motivated subjects and dependence on broader social environments. The difficulty of ensuring precise protocols, equivalent groups (tied to a meaningful target population) and neutral and equivalent trial environments under real world conditions are explored, as are the implications of not achieving standardization and equivalence. METHODS: Limitations of effectiveness research as a research tool and information source are examined by comparing the assumptions underpinning the simple RCT to the characteristics of SCS interventions, as illustrated by programs targeted to mentally disordered offenders in Britain. RESULTS: SCSs violate the assumptions underpinning the simple RCT model in ways that draw into sharp question the validity, reliability and generalizability of inferences of SCS trials. DISCUSSION: The RCT is not a panacea. Effectiveness research of SCS interventions that is based on the RCT model is unlikely to yield valid, reliable and generalizable inferences without becoming more complex in design and more sensitive to issues of selection bias, unmeasured variables and endogeneity. Ten recommendations are offered for stylizing the RCT design to the characteristics of socially complex services. IMPLICATIONS: It remains an empirical issue whether RCT-based services effectiveness research can inform mental health policy. Without major design innovations, it is more likely that the information generated by this research will have limited practical use, especially if the RCT model is unable to control for the effect of social complexity and the interaction between social complexity and dynamic systemic change. Scientific evaluations of services make clinical and economic sense so long as they are designed to meet the challenges of the services of which they promise greater knowledge.

Journal Article↗