Mental Health and Social Welfare Research Group

Outpatient Civil Commitment has become quite controversial, particularly due to studies that have reported "failure to find" differences in outcomes of those patients placed on outpatient orders and those simply released from hospital without such oversight. My work has pointed to the deficiencies of these investigations in the Lancet and begun the building of a knowledge base on the utility of outpatient commitment for reducing threats to health and safety, and providing needed treatment to those refusing treatment.

• The Utility of Outpatient Commitment: A need for treatment and a least restrictive alternative to psychiatric hospitalization. Segal SP, Hayes SL, Rimes L (2017). Psychiatric Services. 68(12): 1247-1254 (APPI-PS-2016-00161.R5)
• Mortality risk, protecting health, safety, and quality of life. Segal SP, Hayes SL, Rimes L (2017). Psychiatric Services. 68(12): 1255–1261 (APPI-PS-2016-00164.R5)
• Acute medical care access and protecting health. Segal SP, Hayes SL, Rimes L (2018). Social Psychiatry and Psychiatric Epidemiology 53(6), 597-606. DOI: 10.1007/s00127-018-1510-5\
• Reduced-risks of victimization and crime perpetration. Segal SP, Hayes SL, Rimes L (2019). European Psychiatry. 56, 97–104. DOI:10.1016/j.eurpsy.2018.12.001

Working with colleagues in and from the Middle East and support from the Milton and Florence Krenz Mack Chaired Professorship, in 2009 MHSRG founded the Mack Center on Mental Health and Social Conflict. Given the fact that of forty-plus million refugees in 2014 only a half of one percent returned home or were repatriated to another country in that year, the Mack Center on Mental Health and Social Conflict sought to find solutions to improve the situation of refugees in situ. See:

• Contributors to Screening Positive for Mental Illness in Lebanon's Shatila Palestinian Refugee Camp. Segal SP, Khoury VC, Salah R, Ghannam J. (2018). Journal of Nervous and Mental Disease. 2018 Jan; 206(1):46-51. doi: 10.1097/NMD.0000000000000751.
• Wellbeing and Growth among Syrian Refugees in Jordan. Rizkalla N, Segal SP (2018). Journal of Traumatic Stress, 31(2):213-222. doi: 10.1002/jts.22281. Epub 2018 Mar 31
• War can harm intimacy: Consequences for refugees who escaped Syria. Rizkalla N, Segal SP (2019). Journal of Global Health. December 2019 9(2) doi: 10.7189/jogh.09.020407
• Trauma during humanitarian work: the effects on intimacy, wellbeing and PTSD-symptoms. Rizkalla N, Segal SP (2019). European Journal of Psychotraumatology. 10:1, 1679065, DOI: 10.1080/20008198.2019.1679065

Since 2016, the Mack Center on Mental Health and Social Conflict has been part of Risk Resilience Research group.

Working with consumers, MHSWRG helped develop the Center for Self Help Research (CSHR) have developed a knowledge base related to consumer driven service. The Center for Self Help Research — an organization with half professional and half consumer researchers jointly funded by NIMH and SAMHSA —  helped in conceptualizing and measuring consumer valued concepts.

• Measuring empowerment in client-run self-help agencies. Segal SP, Silverman C, & Temkin T (1995) Community Mental Health Journal, 31(3), 215-227.

Among other investigations conducted were clinical trials involving ten consumer led agencies and companion community mental health agencies that have demonstrated the importance of empowering procedures in consumer-led organizations — procedures distinguishing these agencies from other NGOs. See:

• Outcomes from consumer-operated and community mental health services: A randomized controlled trial. Segal SP, Silverman C, & Temkin T (2011). Psychiatric Services. 62(8), 915-921.
• Self-help and community mental health agency outcomes: A recovery-focused randomized trial. Segal SP, Silverman C, Temkin T (2010). Psychiatric Services, 61(9), 905-910.
• Self-stigma in consumer-operated and community mental health services: Two randomized controlled trials. Segal, S. P., Silverman, C., & Temkin, T (2013) Psychiatric Services. 64(10): 990-996

Service Impacts: A finding of significantly higher dosing of chlorpromazine equivalent medication given to African American males compared to other patients in PES evaluations, led to changes in PES procedures around the country and better evaluations of the posology of such medications by race. It changed PES dosing procedures. See:

• Race, quality of care, and antipsychotic prescription practices in the psychiatric emergency service. Segal SP, Bola JR, & Watson M (1996). Psychiatric Services, 47(3), 282-286.

Service Utilization: Studies have enhanced the understanding of minority service utilization and helped to target services to the most needy among minority group populations. See:

• African-Americans and comprehensive service use. Theriot MT, Segal SP, Cowsert MJ (2003). Community Mental Health Journal, 29(3), 225-237.
• Criminal Justice System Involvement among New Clients at Outpatient Mental Health Agencies. Theriot M, Segal SP (2005). Psychiatric Services. 56(2): 179-185.
• Asian American Mental Health Services Utilization. Barretto R, Segal SP (2005). Psychiatric Services, 56(6):1-3.

The American Psychiatric Association (APA) proposed changes in civil commitment criteria based on assumptions indicating that dangerousness could not be reliably assessed, that individual coming to psychiatric emergency service(PES) were dangerous and not the most severely mentally ill, and that disposition of individuals was not dependent on the severity of their disorder. Our research showed these assumptions were not correct and changed the direction of APA advocacy. The group completed a study that in concert with psychiatric emergency services (PES) staff developed The TRIAD Simulation of Clinical Judgment. TRIAD (Three Ratings of Involuntary Admissibility) simulates clinical judgment by scoring patterns of behavior and circumstance as more or less dangerous. TRIAD was developed through an iterative process resulting in the identification and ranking of patterns of behavior and circumstance more or less likely to lead to the determination that a patient is involuntarily admissible by the standards of California LPS Act 5150. TRIAD consists of three checklists with a total of 88 numbered items that can be combined to yield 166 patterns of behavior and circumstance relevant to the clinical prediction of violence and suicide and the assessment of grave disability. In our recorded observational assessments of 710 patients evaluated in ten PESs in California, TRIAD scores correctly predicted disposition, a concurrent measure of perceived dangerousness, in 82% cases observed. The use of TRIAD in addition to other measures on the project enabled the assessment of quality of care in the PES, workload limitations, and revealed needs for training staff in de-escalation skills. See for example:

• Denial of access to individuals seeking inpatient care: disposition determinants and 12-month outcomes. Segal, SP and Franskoviak, P (2017). Journal of Forensic Sciences & Criminal Investigation. 2017; 2(4): 555592. DOI: 10.19080/JFSCI.2017.02.555592. 
• The quality of psychiatric emergency evaluations and patient outcomes in county hospitals. Segal SP, Egley L, Watson M, Goldfinger S (1995). American Journal of Public Health, 85(10), 1429-1431.
• Civil commitment in the psychiatric emergency room: Assessment of dangerousness by emergency room clinicians. Segal SP, Watson M, Goldfinger S, Averbuck D (1988) Archives of General Psychiatry, 45,748-52.
• Civil commitment in the psychiatric emergency room: Mental disorder indicators & three dangerousness criteria. Segal SP, Watson M, Goldfinger S, Averbuck D (1988). Archives of General Psychiatry, 45, 753-758.
• Civil commitment in the psychiatric emergency room: Disposition as a function of mental disorder and dangerousness indicators. Segal SP, Watson M., Goldfinger S., & Averbuck D (1988). Archives of General Psychiatry, 45, 759-763.

Conceptualization and Measurement of the Social Integration of a probability sample of all people leaving state psychiatric hospitals for residential care facilities in California: 427 people, in 211 facilities, in 157 census tracts. The sample was followed for 10 years with NIMH and RWJ support. We determined factors associated with enhancing their involvement in the community of the facility and the external community, addressed factors associated with improving resident health and mental health, evaluated medication practices, assessed the quality of the facilities and suggested ways to improve community, facility, and person fit. The Segal & Aviram book on the topic remains one of the most cited in the field. See sample of publications:

• The Mentally Ill In Community-based Sheltered Care: A Study of Community Care and Social Integration. Segal SP, Aviram U (1978). New York: Wiley-Interscience.
• Neuroleptic medication and prescription practices for mentally ill sheltered care residents. Segal SP, Cohen D, & Marder S (1992). American Journal of Public Health, 82(6), 846-852.
• Residential status and the physical health of a mentally ill population. Segal,SP, VanderVoort, DJ, & Liese L H (1993). Health & Social Work, 18(3), 208-214.
• Sheltered-care residence and personal outcomes ten years later. Segal SP, & Kotler PL (1993). American Journal of Orthopsychiatry, 63(1), 80-91.