Barriers to Clozapine Use for Competency Restoration and the Value of Further Study.

Hospital-based restoration of adjudicative competence can be challenging, especially for patients who have treatment-resistant psychosis. Clozapine, which has helped many such individuals in the community, has not been well-studied in individuals who are incapable of proceeding with trial. In their small study, Ghossoub and colleagues have brought attention to the potential for this protocol and advocate for further study. This commentary examines potential barriers to conducting larger studies, including Institutional Review Board requirements for research with individuals who are under court supervision. Also, factors that can result in patients relapsing and being readmitted to the hospital for competency restoration due to poor treatment adherence are described. This adverse outcome burdens the judicial and health care systems and prolongs the time between the patient's arrest and trial. Clozapine may be a promising treatment for competency restoration as long as we are cognizant of barriers to further study and treatment adherence.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

(Reprinted with permission from Am J Psychiatry 2018; 175:86-90).

Caring for juveniles with mental disorders in adult corrections facilities.

Although juveniles have developmental, educational, healthcare, and rehabilitation needs that differ from adults, thousands of them have been confined in adult corrections facilities in the past 30 years. This manuscript will review how and why juveniles end up in adult corrections facilities, who they are, their rehabilitative needs, and how they differ from adults in corrections facilities and youths in the juvenile justice system. The importance of providing developmentally-informed mental health services to youths in adult corrections facilities is examined, along with barriers to traditional adolescent psychiatric practice. Recommendations for future directions in adolescent psychiatric care are presented.

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

(Reprinted with permission from American Journal of Psychiatry 2016; 173:543-546).

DSM-5 and neurodevelopmental and other disorders of childhood and adolescence.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the classification of mental disorders for children and adolescents has been revised. Although some changes are welcome and needed, others have been controversial. In this article, I examine the diagnostic changes along with some of the associated controversies and resolutions. The implications for the practice of child forensic psychiatry, including problems that may be encountered by forensic psychiatrists who evaluate adults with childhood-onset mental disorders, are examined. The pitfalls associated with improper use of The Manual by legal professionals are also reviewed.

Custodial evaluations of Native American families: implications for forensic psychiatrists.

Native American children in the United States have been adopted by non-Indian families at rates that threaten the preservation of their Indian history, traditions, and culture. The Indian Child Welfare Act (ICWA), which established restrictive parameters that govern the placement of Native American children into foster care and adoptive homes, was ratified in an effort to keep American Indian families intact. This article addresses matters of importance to psychiatrists who conduct custody evaluations of Native American children and families. A summary of events that preceded enactment of the ICWA is given, along with guidelines for forensic psychiatrists who conduct foster and adoptive care evaluations of Native American children. We use clinical vignettes to illustrate how the ICWA informs the custody evaluation process as well as approaches to cultural concerns, including biases that forensic evaluators may encounter during these evaluations.

The CHESS method of forensic opinion formulation: striving to checkmate bias.

Expert witnesses use various methods to render dispassionate opinions. Some forensic psychiatrists acknowledge bias up front; other experts use principles endorsed by the American Academy of Psychiatry and the Law or other professional organizations. This article introduces CHESS, a systematic method for reducing bias in expert opinions. The CHESS method involves identifying a Claim or preliminary opinion; developing a Hierarchy of supporting evidence; examining the evidence for weaknesses or areas of Exposure; Studying and revising the claim and supporting evidence; and Synthesizing a revised opinion. Case examples illustrate how the CHESS method may help experts reduce bias while strengthening opinions. The method also helps experts prepare for court by reminding them to anticipate questions that may be asked during cross-examination. The CHESS method provides a framework for formulating, revising, and identifying limitations of opinions, which allows experts to incorporate neutrality into forensic opinions.

Post-Katrina juvenile competency determinations: a tale of two systems.

Natural disasters such as Hurricane Katrina have resulted in the displacement of families to locations throughout the nation. Juvenile courts have been affected by this mass migration of youths. Post-disaster recovery has been slow. Consequently, a cohort of youths has aged out of the juvenile justice system before their juvenile competency hearings could be held. Some of these young adults now face charges as adults in criminal courts. The author explores what happens when youths awaiting juvenile competency determinations age out of the system and face charges as adults. The evolution of the problem, the current situation, case examples, and possible solutions are reviewed.

PRAMS: a systematic method for evaluating penal institutions under litigation.

Forensic psychiatrists serve as expert witnesses in litigation involving the impact of conditions of confinement, including mental health care delivery, on the emotional well-being of institutionalized persons. Experts review volumes of data before formulating opinions and preparing reports. The author has developed PRAMS, a method for systematically reviewing and presenting data during mental health litigation involving detention and corrections facilities. The PRAMS method divides the examination process into five stages: paper review, real-world view, aggravating circumstances, mitigating circumstances, and supplemental information. PRAMS provides the scaffolding on which a compelling picture of an institution's system of care may be constructed and disseminated in reports and during courtroom testimony. Also, PRAMS enhances the organization, analysis, publication, and presentation of salient findings, thereby coordinating the forensic psychiatrist's efforts to provide expert opinions regarding complex systems of mental health care.