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We aimed to systematically review risk factors for criminal recidivism in individuals given community sentences. We searched seven bibliographic databases and additionally conducted targeted searches for studies that investigated risk factors for any repeat offending in individuals who had received community (non-custodial) sentences. We included investigations that reported data on at least one risk factor and allowed calculations of odds ratios (ORs). If a similar risk factor was reported in three or more primary studies, they were grouped into domains, and pooled ORs were calculated. We identified 15 studies from 5 countries, which reported data on 14 independent samples and 246,608 individuals. We found that several dynamic (modifiable) risk factors were associated with criminal recidivism in community-sentenced populations, including mental health needs (OR = 1.4, 95% confidence interval (CI): 1.2-1.6), substance misuse (OR = 2.3, 95% CI: 1.1-4.9), association with antisocial peers (OR = 2.2, 95% CI: 1.3-3.7), employment problems (OR = 1.8, 95% CI: 1.3-2.5), marital status (OR = 1.6, 95%: 1.4-1.8), and low income (OR = 2.0, 95% CI: 1.1-3.4). The strength of these associations was comparable to that of static (non-modifiable) risk factors, such as age, gender, and criminal history. Assessing dynamic (modifiable) risk factors should be considered in all individuals given community sentences. The further integration of mental health, substance misuse, and criminal justice services may reduce reoffending risk in community-sentenced populations.

Reports linking the deinstitutionalisation of psychiatric care with homelessness and imprisonment have been published widely. To identify cohort studies that followed up or traced back long-term psychiatric hospital residents who had been discharged as a consequence of deinstitutionalisation. A broad search strategy was used and 9435 titles and abstracts were screened, 416 full articles reviewed and 171 articles from cohort studies of deinstitutionalised patients were examined in detail. Twenty-three studies of unique populations assessed homelessness and imprisonment among patients discharged from long-term care. Homelessness and imprisonment occurred sporadically; in the majority of studies no single case of homelessness or imprisonment was reported. Our results contradict the findings of ecological studies which indicated a strong correlation between the decreasing number of psychiatric beds and an increasing number of people with mental health problems who were homeless or in prison.

Purpose Over the past 50 years, deinstitutionalization changed the face of psychiatry. However, outpatient treatment in the community does not always fit the needs of those who left institutions and sometimes leads to frequent re-hospitalizations, a mechanism known as the “revolving door” phenomenon. The study aim was to identify different typologies of hospitalization trajectories. Methods Records of 892 inpatients from the Department of Psychiatry of Lausanne University Hospital were analyzed over a 3-year period with discrete sequential-state analysis. Results Trajectories could be split between atypical users (4.9% of patients totalling 30.6% of hospital days) and regular users. Within the atypical users group, three categories were identified: “Permanent stays” (3 patients totalling 6.3% of hospital days), “long stays” (1.7% patients/8.6% hospital days) and “revolving door” stays (2.9% patients/15.8% hospital days). The remaining 95.1% of the patients were classified into “unique episodes” (70.0% patients/24.5% hospital days) and “repeated episodes” (25.0% patients/44.9% hospital days). Diagnoses of schizophrenia were overrepresented among heavy users. Conclusions Most patients went through a unique or low number of brief hospital admissions over the 3 years of the study. While the shift of previously institutionalized individuals towards high users of psychiatric hospital seems limited, this phenomenon should not be neglected since 4.9% of patients use about a third of hospital beds. Early identification of problematic profiles could allow the implementation of relapse prevention strategies and facilitate the development of alternatives to hospitalization such as assertive community treatment or housing first programs.

The objective of this study was to evaluate the impact of Minnesota's Return to Community Initiative (RTCI) on postdischarge outcomes for nursing home residents transitioned through the program. Secondary data were from the Minimum Data Set and RTCI staff (January 2015 to December 2016), state Medicaid eligibility files and death records. The sample consisted of 29,201 nursing home discharges in Minnesota occurring in 2015. Cox proportional hazard models were used to compare 1-year postdischarge outcomes of nursing home readmission, mortality, and Medicaid conversion for RTCI assisted community discharges and a propensity-matched sample of unassisted community discharges. The majority (60%) of RTCI assisted discharges remained alive, in the community and not having converted at Medicaid at 1 year after discharge. Time to mortality was significantly lower for the assisted group than the unassisted group, but time to readmission and Medicaid conversion were similar. The RTCI assisted residents fared well postdischarge in their time to mortality, nursing home readmission, and Medicaid conversion; they lived longer than a propensity-matched sample of their peers.

Too often, gun rights advocates point to the flaws of the mental health system as the cause of mass gun violence. Consider President Trump's response to the February 14 massacre at Marjory Stoneman Douglas High School. He said that psychiatric hospitals should be reopened to prevent more carnage. You know in the old days we had mental institutions, had a lot of them, and you could nab somebody like this.\"2 Trump was referring to the closure of psychiatric hospitals during deinstitutionalization-the result of ideological, economic, and political factors-which began in the 1960s, peaked in the 1970s and 1980s, and continues today.Is deinstitutionalization to blame for the regularity of mass shootings in America? Deinstitutionalization occurred not only here but also across other highincome democracies. Major international organizations, such as the World Health Organization, have supported the reduction of hospital psychiatry.3 Comparing cross-national data of mass shootings-typically defined as four or more fatalities-with the decline of inpatient psychiatric capacity offers little evidence to support this association.

Closing long-stay psychiatric beds remains contentious. The review by Winkler et al in this issue examines 23 studies of deinstitutionalisation for the outcomes of people discharged from psychiatric hospitals after an admission of 1 year or longer. The majority of these studies identified no cases of homelessness, incarceration or suicide after discharge from hospital.

The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers. The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century. Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings. Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.

Background Despite its inclusion as a key aspect of successful mental health care service provision by the World Health Organization, there exists a lack of consensus regarding the definition, key components and implementation of deinstitutionalisation. This lack of consensus has also contributed to subjectivity in assessments of countries’ progress towards deinstitutionalisation which act as a barrier to its evaluation and success. In order to provide for reliable within and cross country evaluations of the success of deinstitutionalisation we aimed to develop a quantitative measure of country-level progress towards deinstitutionalisation through the (1) identification of key markers of deinstitutionalisation; (2) development of an assessment tool based on the identified markers; (3) evaluation of the tool’s psychometric properties; and (4) comparison of progress towards deinstitutionalisation across Europe. Methods National care standards from 10 European countries and World Health Organization recommendations were used to identify items for the tool. A draft version was reviewed by an international expert panel and assessed for test-retest reliability and internal consistency. Once a final version had been agreed, progress towards deinstitutionalisation was assessed for 30 European countries. We used this opportunity to test convergent validity through comparison with local experts’ assessments. Country total as well as individual item scores were described and compared. Results The five-item Mental Health Services Deinstitutionalisation Measure (MENDit) is an objective tool with moderate to very good test-retest reliability (Kappa range: 0.46-1.00) and internal consistency (α = 0.70, 95 % CI 0.25, 0.92). A statistically significant difference between groups was found by one-way ANOVA ( F (3,26) = 6.77, p  = 0.002). Post-hoc testing found significant differences between MENDit scores of countries categorised as having advanced levels of deinstitutionalisation and not started or just started. Across Europe, MENDit scores suggest substantial variety in progress towards deinstitutionalisation. Conclusions The MENDit has good psychometric properties which support its use in research and as a benchmarking tool to measure national progress towards deinstitutionalisation by policy makers. Across Europe a high proportion of psychiatric beds are still located in psychiatric hospitals. Additionally, low numbers of mental health professionals in many countries may hinder further deinstitutionalisation. These findings corroborate previous mental health systems research and highlight some of the difficulties of deinstitutionalisation.

Treatment within medium secure forensic psychiatry services is expected to reduce risk to the public. To measure the period prevalence and incidence of offending following discharge and identify associated risk factors. Follow-up of patients from 7 of 14 regional services in England and Wales who spent time at risk (n=1344) for a mean of 6.2 years. Outcome was obtained from offenders index, hospital case-files and the central register of deaths. One in 8 men and 1 in 16 women were convicted of grave offences. Incidence rates indicated low density and most patients were not subsequently convicted. Offence predictors included gender, younger age, early-onset offending, previous convictions and a comorbid or primary diagnosis of personality disorder. Longer in-patient stay and restriction on discharge were protective. Risks of reoffending remain for a subgroup of discharged patients. Future research should aim to improve their identification and risk management following discharge.

The American system of prisons and prisoners—described by its critics as the prison–industrial complex—has grown rapidly since 1970. Increasingly punitive sentencing guidelines and the privatization of prison-related industries and services account for much of this growth. Those who enter and leave this system are increasingly Black or Latino, poorly educated, lacking vocational skills, struggling with drugs and alcohol, and disabled. Few correctional facilities mitigate the educational and/or skills deficiencies of their inmates, and most inmates will return home to communities that are ill equipped to house or rehabilitate them. A more humanistic and community-centered approach to incarceration and rehabilitation may yield more beneficial results for individuals, communities, and, ultimately, society.