Paige M. Shaffer

Veterans involved in the criminal legal system (CLS) exhibit disproportionately high rates of comorbid mental health and substance use disorders (COD) and

Objective: To advance patient-centered care for high-need homeless-experienced patients, we identified the rates of various personal health goals, the broader domains that underlie these goals, and associations between these domains and the health-related needs of this population. Method: The sample consisted of 176 veterans from 3 VA Medical Centers who were enrolled in primary care, on VA’s Homeless Registry, and high utilizers of acute care. An interview was conducted with each participant to collect information on their personal health goals and health-related needs. Exploratory factor analysis was used to identify broad domains underlying endorsement of personal health goals. Associations between these broad goal domains and health-related needs (substance use, mental and physical health, treatment engagement, and psychosocial) were examined using an exploratory structural equation modeling-within-confirmatory factor analysis approach. Results: Three broad domains were found to underlie the personal health goals of the sample: social functioning, health promotion, and substance use. Social functioning and health promotion were highly correlated, whereas substance use was weakly correlated with both social functioning and health promotion. All substance use-related needs were positively associated with substance use goals. Mental and physical health needs were primarily associated with health promotion goals. Treatment engagement and psychosocial needs demonstrated associations across all 3 goal domains. Conclusions: Findings highlight the high value that many high-need homeless-experienced patients place on their social well-being and the potential benefits to measuring both deficiency and growth needs in this population. Clinical implications and future directions for research are discussed.

Background: Substance use and mental health are growing public health problems in the United States. People with co-occurring mental health and substance use disorders (COD) often have complex social determinants of health (SDOH) needs and struggle to engage in treatment. Linkage and multicomponent wraparound interventions, including maintaining independence and sobriety through systems integration, outreach and networking (MISSION), have gained popularity as solutions to increase treatment engagement and address behavioral health and SDOH needs of clients with COD. This protocol offers an overview of an effectiveness trial and a process evaluation of MISSION being delivered in a city public health setting. Methods: This study will use a hybrid type I effectiveness and implementation design with a randomized controlled trial. People with COD will be randomized to one of two treatments: a multicomponent COD intervention (MISSION), or a peer delivered linkage-only intervention (PLS). Secondary aims include the examination of mechanisms of action and a sequential mixed methods process evaluation to inform the sustainability and future implementation of MISSION. Conclusions: This trial will help determine the effectiveness of MISSION compared to PLS to improve engagement, and reduce substance use and mental health symptoms. This trial is the first to implement MISSION within a public health department setting which has important implications for policymakers and treatment providers within behavioral health fields. Trial Registration: Trial registration number is NCT05713695, registered on 27 January 2023.

Drug Treatment Courts (DTCs) serve as alternative to incarceration, addressing substance use and legal challenges of offenders. Many individuals enrolled in DTCs have co-occurring mental health and substance use disorders (CODs). Although multicomponent treatment like MISSION-CJ can improve outcomes for DTC clients with CODs, the impact of Adverse Childhood Experiences (ACEs) on outcomes remains unclear. This pilot study examined how criminal legal involvement, substance use and mental health functioning outcomes changed over time and differed based on ACEs levels. Sixty-two DTC clients with CODs received one-year of MISSION-CJ services. Generalized linear mixed models (GLMMs) assessed 6-month and 12-month outcomes, comparing low and high ACEs groups. Results showed significant overall improvement in outcomes, with greater mental health functioning improvements among clients with high ACEs. Although MISSION-CJ was not designed to address the needs of individuals with ACEs, these data suggest it might improve clinical outcomes for this vulnerable group.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: US Veterans Affairs (VA) Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) provide residential care for veterans experiencing homelessness. However, those with co-occurring mental health and substance use disorders (COD) and criminal legal involvement require additional interventions to address risk factors for recidivism. Objective: This study aims to evaluate (1) whether MISSION-CJ lowers criminal recidivism and health-related outcomes; (2) whether the effects of MISSION-CJ on these outcomes are mediated by several recidivism risk and protective factors; and (3) qualitatively assess the implementation of MISSION-CJ using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Methods: In a Hybrid Type 1 randomized control trial to test the effectiveness and implementation of MISSION-CJ, a multicomponent intervention for COD, veterans participating in MH RRTP (n = 226) will be randomized to enhanced usual care or MISSION-CJ. Results: The findings from this trial and qualitative evaluation will be available by 2026. Conclusions: If effective, implementation of MISSION-CJ alongside MH RRTP may be advantageous to address risk factors to address recidivism. Clinical Trial: ClinicalTrials.gov NCT04523337

BACKGROUND The US Veterans Affairs mental health residential rehabilitation treatment programs (MH RRTPs) provide residential care for veterans experiencing homelessness. However, those with co-occurring mental health and substance use disorders and criminal legal involvement require additional interventions to address risk factors for recidivism. OBJECTIVE We aimed to (1.1) evaluate whether the Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking Criminal Justice version (MISSION-CJ) intervention lowers criminal recidivism and improves health-related outcomes; (1.2) examine the mechanisms that impact outcomes; and (2) qualitatively assess the implementation of MISSION-CJ. METHODS Veterans participating in an MH RRTP (N=226) will be randomized to the enhanced usual care (EUC) or MISSION-CJ conditions in a hybrid type 1 randomized controlled trial to test the effectiveness and implementation of MISSION-CJ, a multicomponent intervention for co-occurring disorder. Both conditions will receive 6 months of services beginning within a week of MH RRTP enrollment (duration of stay: 3 months) and continue for 3 months after the MH RRTP in the community. The veterans in the EUC group (113/226, 50%) will receive a peer support curriculum and community outreach and linkage delivered by a peer support specialist. The veterans in the MISSION-CJ group (113/226, 50%) will receive team-based (case manager and peer support specialist) care, including treatment planning, case management using a critical time intervention model to promote referrals and linkages, enhanced dual recovery therapy sessions, and peer support sessions. Assessments, including questions regarding substance use and mental health history, criminal history and recidivism risk, housing, employment, medication adherence, mutual-help group attendance, antisocial attitudes, affiliations with peers, community involvement, and treatment services received, will be conducted at baseline and 6 months and 15 months after baseline. We will use generalized linear mixed effects regression models to evaluate MISSION-CJ based on outcomes (objective 1.1). We will conduct mediation analysis to examine mechanisms of action (objective 1.2). For the qualitative evaluation (objective 2), we will use thematic analysis to identify themes. RESULTS As of March 2025, 118 veterans (site 1: n=52, 44.1% and site 2: n=66, 55.9%) have been enrolled. Overall, 58 veterans (site 1: n=27, 47% and site 2: n=31, 53%) have been randomized to the MISSION-CJ group, and 60 veterans (site 1: n=25, 42% and site 2: n=35, 58%) have been randomized to the EUC group. Overall, 23 interviews for the qualitative evaluation have been completed with veterans. Veterans are continuing to receive treatment and completing follow-up assessments. The findings from this trial and qualitative evaluation will be available by 2026. The quantitative and qualitative components of this project are intended to work synergistically to reinforce knowledge of MISSION-CJ’s effectiveness, implementation, and scalability. CONCLUSIONS If effective, the implementation of MISSION-CJ alongside the MH RRTPs may be advantageous to address risk factors related to recidivism. CLINICALTRIAL ClinicalTrials.gov NCT04523337; https://clinicaltrials.gov/study/NCT04523337 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/70750

Objective: Posttraumatic stress disorder (PTSD) is positively associated with involvement in the criminal justice system among veterans. Research that examines whether this association is confounded by risk factors ("criminogenic needs") from the risk-need-responsivity model of correctional rehabilitation can inform risk management with this population.Hypotheses: We hypothesized that (a) veterans with probable PTSD would score higher on all criminogenic needs than veterans without PTSD and (b) probable PTSD would be associated with criminal history but not after accounting for criminogenic needs.Method: We conducted secondary analyses of data from 341 veterans (95.3% male; 57.8% White/non-Hispanic/Latinx; M-age = 46.2 years) with a history of criminal justice system involvement who were admitted to mental health residential treatment. At treatment entry, participants completed interviews to assess criminal history, risk-need-responsivity-based criminogenic needs, and PTSD symptom severity. Cross-sectional analyses tested for differences between participants with and without probable PTSD on criminogenic needs and criminal history, and a multiple regression model examined the unique contributions of probable PTSD and criminogenic needs on criminal history.Results: The majority of the sample (74%, n = 251) met probable criteria for PTSD. Compared with veterans without PTSD, those with probable PTSD scored significantly higher on criminogenic needs of antisocial personality patterns, antisocial cognitions, antisocial associates, substance use, and family/marital dysfunction but did not differ on multiple indices of criminal history (Cohen's ds = 0.60-0.86). In the regression model, higher age (beta = 0.52, p < .001) and higher scores on measures of antisocial personality patterns (beta = 0.19, p = .04) and antisocial cognitions (beta = 0.22, p = .02) were significantly associated with higher scores on a criminal history index.Conclusions: The findings suggest that veterans with probable PTSD may score higher on a number of criminogenic needs that are known to be drivers of recidivism. An approach that integrates trauma-informed and risk-need-responsivity principles to address veterans' dynamic criminogenic and clinical needs may be critical to risk management in this population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).