Clozapine Use and Forensic Outcomes in Psychiatric Inpatients Deemed Incompetent to Stand Trial.

Referrals for competency restoration increased in the past decade, with the majority of incompetent to stand trial (IST) patients having schizophrenia; 25 percent of schizophrenia patients are treatment resistant. Clozapine is superior to other antipsychotics for treatment resistance but remains underutilized, particularly in forensic settings. Despite the impact of treatment resistance on the legal system, the literature on clozapine for IST patients is limited to two papers comprising 26 patients. A retrospective chart review was conducted of all IST admissions to a California hospital for 2014 to -2018, examining clinical and forensic outcomes in those newly started on clozapine and discharged. There were 191 new clozapine starts among IST patients, 92.7 percent of whom were diagnosed with schizophrenia or another psychosis. Over 90 percent were discharged on clozapine, and 36.1 percent were discharged on clozapine as trial competent; moreover, this cohort also had the shortest length of stay. This analysis indicates that most IST patients needing clozapine can be successfully treated, with a substantial proportion restored to trial competency. These data and earlier studies reinforce the concept that forensic programs have a medical duty to offer IST patients with severe mental illness a clozapine trial when indications exist for its use.

Large-Scale Implementation of a Daily Rapid Antigen Testing Program in California for Detecting SARS-CoV-2.

Objectives. To evaluate a daily antigen testing program for health care personnel. Methods. We examined antigen testing results between December 13, 2020, and April 30, 2021, from 5 forensic psychiatric inpatient hospitals throughout California. Results. Among 471 023 antigen tests administered, 449 positives (0.0036% false positives) were detected. Conclusions. Antigen tests had low false-positive rates, high positive predictive value, and high levels of acceptability, important characteristics when considering their application in the community. Public Health Implications. Daily antigen testing was feasible and should be considered to reduce COVID-19 transmission. (Am J Public Health. 2022;112(3):467-471. https://doi.org/10.2105/AJPH.2021.306588).

Lifetime History of Suicide Attempts among Not Guilty by Reason of Insanity State Hospital Inpatients: The Roles of past Harmful Substance Use and Current Social Support.

This study tested current perceived social support (CPSS) as a moderator of the relation between previous substance use (PSU) and lifetime suicide attempt (SA) history among 200 NGRI inpatients. Results indicated no significant CPSS main effect. PSU was associated with greater odds of multiple prior lifetime SA. Moderation indicated those low in PSU but high in CPSS were least likely to report multiple prior lifetime SA. Conversely, NGRI inpatients with high CPSS and high PSU were most likely to report multiple lifetime SA. Our study suggests CPSS and PSU assessments may inform suicide risk assessments and interventions among NGRI inpatients.

The Cal-DSH diversion guidelines.

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

Breaking down long-term chronic aggression within a forensic hospital system.

OBJECTIVE: Historically, patients with multiple acts of aggression, or chronic aggressors, have been studied as one large group. It was our objective to subdivide this group into those patients who engage in physical aggression consistently over multiple years and see if common characteristics of chronic aggressors could classify patients into an aggressive or nonaggressive group. METHOD: Within a forensic hospital system, patients who had committed 5 acts of physical aggression, per year, for 3 years (2010 and 2015) were reviewed. Data was collected on clinical and demographic characteristics that have shown to be associated with chronically aggressive patients and compared to nonaggressive matched controls. Data collection and analysis were completed to determine if the variables could classify patients into an aggressive or nonaggressive group. RESULTS: Analysis showed that 2 variables, the presence of a cognitive disorder and a history of suicidal behaviors were significant in the univariate and multivariate analyses. The 2 variables were able to correctly classify 76.7% of the cases. CONCLUSION: A cognitive disorder, a history of suicidal behavior, and increased age were factors associated with this subgroup of aggressive patients. Clinicians may want to explore treatment programs aimed at these clinical factors including cognitive rehabilitation and social cognition treatments, which have been shown to reduce aggression in cognitively impaired populations.

Examining violence among Not Guilty by Reason of Insanity state hospital inpatients across multiple time points: the roles of criminogenic risk factors and psychiatric symptoms.

OBJECTIVE: Institutional violence in state hospitals is a public health problem that has been severely understudied. Given the personal (ie, staff and patients) and fiscal harms associated with institutional violence, more research into contributing factors for violence is needed. The overarching aim of this study then was to examine associations among psychiatric symptoms, criminal risk factors, and institutional violence. METHODS: Participants were 200 male, female, and transgender forensic mental health inpatients adjudicated Not Guilty by Reason of Insanity and committed to the California Department of State Hospitals. Participants completed a psychiatric symptom measure, and measures of and associated with criminal risk. Institutional violence was recorded from file review and includes physical violence toward staff or patients for 6-months prior to and post patient participation in this study. RESULTS: After adjusting for previous institutional violence, results indicated that psychiatric symptoms were not associated with follow-up institutional violence; however, criminal risk was associated with follow-up institutional violence. Unexpectedly, 2 aspects of criminal risk, antisocial cognitions and associates, were not associated with follow-up institutional violence after adjusting for previous institutional violence. Results also provided a tentative cutoff score on the Self-Appraisal Questionnaire for predicting follow-up institutional violence. CONCLUSIONS: These results have important implications for treating and managing patients at risk for institutional violence, including the need to assess criminogenic risk and leverage treatments that target these risk factors as a best practice approach.

Economics of decriminalizing mental illness: when doing the right thing costs less.

The United States' criminal justice system has seen exponential growth in costs related to the incarceration of persons with mental illness. Jails, prisons, and state hospitals' resources are insufficient to adequately treat the sheer number of individuals cycling through their system. Reversing the cycle of criminalization of mental illness is a complicated process, but mental health diversion programs across the nation are uniquely positioned to do just that. Not only are these programs providing humane treatment to individuals within the community and breaking the cycle of recidivism, the potential fiscal savings are over 1 billion dollars.

Psychiatric symptom severity, criminal risk, and suicidal ideation and attempts among not guilty by reason of insanity state hospital inpatients.

Individuals forensically committed to a state hospital are at an increased risk of suicide; however, there is extremely limited research examining suicide risk estimates and risk factors among inpatients deemed not guilty by reason of insanity (NGRI). This study aimed to determine (a) rates of suicidal ideation history, suicide attempt history, and current distress due to suicidal ideation, and (b) the associations between psychiatric symptom severity, criminal risk factors, and suicide risk. NGRI inpatients (n = 207) from 2 state hospitals were administered assessments of psychiatric symptom severity and criminal risk factors (i.e., criminal tendencies and antisocial personality traits). Results indicated 46.4% of participants reported at least 1 previous suicide attempt, 58% reported previous suicidal ideation, and 10.1% reported some level of current distress due to suicidal ideation. Binary logistic regression results indicated psychiatric symptom severity, not criminal tendencies or antisocial personality traits, was associated with a greater likelihood of current distress due to suicidal ideation. There was a significant interaction between criminal tendencies and antisocial personality, which indicated that individuals higher in criminal tendencies and lower in antisocial personality traits are predicted to have the greatest probability of reporting current distress due to suicidal ideation. Additionally, psychiatric symptom severity and antisocial personality traits were associated with a greater likelihood of a suicide attempt history, whereas criminal tendencies were associated with a decreased likelihood. Clinical implications are discussed, particularly the need for suicide risk assessments and management to consider both psychiatric symptoms and criminal risk factors. (PsycINFO Database Record

California State Hospital Violence Assessment and Treatment (Cal-VAT) guideline.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.