Mental health criminal defenses in persons with neuropsychiatric disorders.

Persons with neuropsychiatric disorders present specific and unique challenges for forensic experts and defense attorneys in the criminal justice system. This article reviews two potential criminal defenses: legal insanity and the various legal standards or tests of criminal responsibility that are used in jurisdictions throughout the United States (i.e., the M'Naghten standard and the American Law Institute's Model Penal Code), and the partial legal defense of diminished capacity (lacking the mental state necessary to be found guilty of a specific intent crime). The process of evaluating criminal responsibility or diminished capacity is also presented with a specific emphasis on common issues that arise in evaluating defendants with Intellectual Developmental Disorder (Intellectual Disability), Parasomnias, Seizure Disorders, and Neurocognitive Disorders.

Forensic Psychiatry Milestones: Experience After 1 Year.

OBJECTIVE: In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties identified six core competencies for medical practice. In 2013, the milestones were introduced to demonstrate these educational outcomes across each specialty. This study represents the first examination of the sub-specialty Forensic Psychiatry Milestones. METHODS: Members of the Association of Directors of Forensic Psychiatry Fellowships were surveyed. Areas of inquiry included whether milestones assisted in identifying areas of deficiency in fellows or programs, whether the graduation milestones matched the goals of training, and what changes were planned, or had been made, based on their implementation. RESULTS: Twenty-six of 35 programs responded, for a response rate of 74%. The majority found the milestones somewhat or very useful, half found the graduation-level milestones matched the program's graduation goals, and a significant majority reported that the milestones assisted in identifying improvements, change, or intended change. In choosing terms to describe the milestones, however respondents chose a variety of negative or neutral terms, rather than positive ones. CONCLUSIONS: The milestones provided a standard mechanism for identifying areas for improvement and a common language to standardize practice. However, due to the variability across fellowship programs and the limitations of educational resources and time, implementation of the new ACGME requirement was characterized in largely negative terms. Recommendations for improvement included modification of the milestones themselves, flexibility in their implementation, and evidentiary support for their use.

Knowledge and Attitudes of Psychiatrists About the Gun Rights of Persons With Mental Illness.

Individuals with mental illness have often been misperceived by the public to pose a higher risk of violence to others. Consequently, the United States government and many individual states have enacted laws barring firearm access for certain individuals with mental illness. Many of these laws allow for eventual restoration of firearm access (i.e., relief from firearm disability (RFD)). This study assesses the knowledge base and attitudes of psychiatrists practicing in South Carolina regarding these gun laws. Results of this study indicate that psychiatrists in South Carolina have significant knowledge deficits pertaining to gun laws that both restrict gun ownership and allow restoration of gun ownership rights for persons with mental illness; these deficits may apply to practitioners in other states as well. The only variable that predicted a greater knowledge about limitations on gun rights was whether a psychiatrist had a patient who was prohibited from gun ownership. South Carolina psychiatrists had more favorable attitudes about restricting gun access for persons with mental illness than about supporting the right of persons with mental illness to own a gun. Finally, if psychiatrists owned a firearm, they were more likely to support the right of persons with mental illness to own a firearm.

Examining the Past and Advocating for the Future of Forensic Psychiatry Training.

The American Academy of Psychiatry and the Law (AAPL) has been devoted to the teaching of forensic psychiatry, and as AAPL celebrates its 50th Anniversary, it seems fitting to examine the history and the current status of forensic psychiatry teaching in general psychiatry residencies and forensic psychiatry fellowships. After a brief review of the history of AAPL and forensic psychiatry training, this article explores the current state of graduate medical education (GME) in the United States, the growing popularity of psychiatry as a specialty and forensic psychiatry as a subspecialty, the Accreditation Council for Graduate Medical Education's requirements for forensic training, and the methods currently used to teach forensic psychiatry to general psychiatry residents. This article also examines the current status of forensic psychiatry fellowship training in the United States. Finally, future challenges to forensic training in both residencies and fellowships will be discussed, as well as the need for AAPL and others in the profession to advocate for increased forensic teaching in a manner that leads to the production of both general and forensic psychiatrists who are competent to practice independently and who are sufficient in number to meet the growing demands for forensic expertise.

Commentary: core competencies and the training of psychiatric residents in therapeutic risk management.

The treatment of patients who, due to their clinical presentation, pose potential liability risks to the psychiatrist is one of the more stressful aspects of modern psychiatric practice. The need to educate psychiatric residents about the principles of risk management that guide the safe provision of good patient care in such patients is paramount in the current malpractice environment. In this commentary, we discuss the teaching of therapeutic risk management, as described by authors Simon and Shuman, in general psychiatry residency, particularly as it can be integrated within the existing core competencies established by the Accreditation Council on Graduate Medical Education (ACGME). A model outline of this integration for suicide risk management within each of the existing core competencies is presented.

Malpractice Law and Psychiatry: An Overview.

Fortunately, psychiatrists are less likely to be sued for malpractice than most physicians in other specialties. However, once sued, psychiatrists must navigate a complicated and nonintuitive legal process. This article reviews the major elements of a malpractice claim, the litigation process in medical malpractice cases, and the common allegations of negligence that are encountered in such cases. The major types of malpractice insurance coverage are reviewed, and recommendations about liability prevention and how to best respond to a malpractice action are presented.

Pro se competence in the aftermath of Indiana v. Edwards.

The right to represent oneself at trial is well-established, but not absolute. Recently, in Indiana v. Edwards, the United States Supreme Court considered whether states may demand a higher standard of competence for criminal defendants seeking to represent themselves at trial than that necessary for standing trial with attorney representation. Ultimately, the Court ruled that the Constitution allows states to employ a higher competency standard for pro se defendants. In this analysis of the Court's decision, the authors describe the facts of this case, the legal precedents framing the issues facing the Court, and the Court's rationale for its opinion. The ruling is considered in light of available research involving pro se defendants and whether this ruling is consistent with professional guidelines related to forensic psychiatric practice. Implications of the decision for forensic clinicians and limitations of the decision are discussed.

Implications of Pseudologia Fantastica in Criminal Forensic Evaluations: A Review and Case Report.

Pseudologia fantastica, a psychological phenomenon that has been described in the literature for at least a century, is an understudied and poorly understood entity. Sometimes referred to as pathological lying, pseudologia fantastica involves disproportionate fabrication that may be present for many years or a lifetime. In a forensic context, it can significantly complicate the evaluation of capacity to stand trial and, in certain jurisdictions, criminal responsibility. We review the current literature regarding pseudologia fantastica and present a case to highlight the clinical and forensic challenges it may create. We specifically discuss the complications that pseudologia fantastica may have on the assessment of a defendant's rational ability to consult with an attorney, a required element of capacity to stand trial. In addition, we discuss the implications of pseudologia fantastica in the evaluation of criminal responsibility.

The presence of low IQ and mental retardation among murder defendants referred for pretrial evaluation.

After an overview of definitions of mental retardation and recent case law regarding mental retardation and the death penalty, this paper presents a study of factors associated with a mental retardation (MR) diagnosis among murder defendants. Subjects with a full-scale IQ< or =70 (n=42) were compared with other pretrial murder defendants (n=228) referred for forensic evaluation over a 5-year period. Subjects with an IQ< or =70 who were diagnosed with MR were compared with subjects with an IQ< or =70 who did not receive this diagnosis. Female murder defendants were more likely to receive a diagnosis of MR (p=0.03). MR was also more commonly diagnosed in subjects with an Axis I cognitive disorder (p=0.018). Having an IQ< or =70 was more common in subjects with a psychotic and substance use disorder (p=0.03) and did not necessarily lead to a diagnosis of MR in this subgroup. Implications for diagnosing MR among murder defendants are discussed.

Shared psychotic disorder and criminal responsibility: a review and case report of folie à trois.

We present a case of shared psychotic disorder involving three sisters who were successful in establishing an insanity defense on numerous felony charges in the South Carolina criminal court system. Two of the authors of this article were court-appointed examiners in this case. We then present a history of shared psychotic disorder, an overview of the use of this diagnosis in the defense of insanity, and a discussion of the disposition of individuals with "temporary insanity." Finally, we compare shared psychotic disorder, culturally based belief systems, and religious cults, with a focus on their common and contrasting characteristics.

Implications of the Group Model of Supervision and Consultation in Forensic Training.

The clinical case conference has been a hallmark of undergraduate and graduate medical education for decades and affords attendees the opportunity to hear about interesting and difficult cases and to learn from a discussion of the complexities of diagnosis and treatment. In forensic psychiatry, the complexities in a case conference also extend to the formation of a forensic opinion. The application of the clinical case conference to forensic psychiatry has not been described in the literature, although many fellowship programs engage in this activity. In the forensic arena, special ethics concerns may arise regarding confidentiality, dual agency, and conflicts of interest. In this commentary, we discuss the implications of using the group approach to supervision and consultation outlined by Buchanan et al., as it relates to professional development and understanding of ethics among forensic psychiatry trainees. We also discuss the usefulness of this type of group consultation in faculty development, including the satisfaction of the Accreditation Council of Graduate Medical Education's (ACGME) Common Program Requirements and, potentially, one part of the Maintenance of Certification requirements of the American Board of Psychiatry and Neurology, Inc.

Unsolicited E-mails to Forensic Psychiatrists.

E-mail communication is pervasive. Since many forensic psychiatrists have their e-mail addresses available online (either on personal websites, university websites, or articles they have authored), they are likely to receive unsolicited e-mails. Although there is an emerging body of literature about exchanging e-mail with patients, there is little guidance about how to respond to e-mails from nonpatients. Therefore, we used a Delphi technique to develop a consensus about salient points for the forensic psychiatrist to consider regarding responding to e-mails from nonpatients and the risks entailed. Four scenarios are described, including e-mails from nonpatients and unknown others requesting advice or help. The potential ethics-related, legal, moral, and practical concerns for forensic psychiatrists are discussed. Finally, potential pitfalls for forensic psychiatrists are described.

Juror knowledge and attitudes regarding mental illness verdicts.

We begin with a brief overview of the Not Guilty by Reason of Insanity (NGRI) and Guilty but Mentally Ill (GBMI) verdicts in the United States and then report on a study of qualified jurors (n=96) in which we examined jurors' understanding and attitudes about mental illness verdicts and the disposition of mentally ill defendants. Results indicate that although the jury pool was highly educated, only 4.2 percent of jurors could correctly identify both the definitions and dispositions of defendants found NGRI and GBMI. Jurors with lower educational levels were less likely to identify the dispositional outcome of a GBMI verdict (p<.05). Eighty-four percent of respondents believed that juries should be informed of dispositional outcome before deciding a verdict. Also, 68.4 percent of jurors erroneously believed that a defendant found GBMI could not receive the death penalty. Among jurors who correctly identified the definition of GBMI, those with lower educational levels were more punitive in their attitudes toward disposition of the GBMI defendants, believing they should eventually be sent to prison (p<.05).

Mental Illness and Mental Health Defenses: Perceptions of the Criminal Bar.

As the number of state mental hospital beds declines, persons with persistent mental illness are increasingly encountered by those working in the legal system. Attorneys may have little experience in working with this population. This research involved a 32-item written survey of the 492 members of the criminal bar in South Carolina. Demographic variables were surveyed, and attorneys were asked to define two common terms describing mental illnesses (delusion and psychosis) and the legal criteria for verdicts of not guilty by reason of insanity and guilty but mentally ill. They were also asked to identify the most severe mental illness (schizophrenia). Attitudes about these verdicts and about working with defendants who are mentally ill were also surveyed. Results indicate that attorneys are fairly knowledgeable about mental illness, but not verdicts involving mental illness, particularly the verdict of guilty but mentally ill. Most attorneys prefer to work with clients who do not have mental illness. However, as they become more experienced interacting with defendants who are affected by mental illness, they become more knowledgeable and are more willing to defend them. A large majority believe that their law school education about mental illness was inadequate. When comparing attorney occupations, public defenders were the most knowledgeable about mental illness and mental health defenses, followed by prosecutors and private defense attorneys. Judges were the least knowledgeable group.

Psychiatric and neurological characteristics of murder defendants referred for pretrial evaluation.

After literature review, this paper presents the largest study to date (n = 270) of psychiatric and neurological characteristics of accused murderers in the United States. This retrospective record review of pretrial detainees undergoing competency to stand trial and criminal responsibility evaluations examined demographic characteristics, psychiatric diagnosis, substance use patterns, Intelligence Quotient (IQ), and results of electroencephalogram (EEG), neuroimaging (MRI or CT) and neurological examination. Substance use and mood/adjustment disorders were common. Neuroimaging was abnormal in 18% of subjects and was associated with lower Performance IQ. EEG and neurological exam findings were not associated with measured cognitive impairment. While 16% of subjects had a FS IQ < 70, only 6% were diagnosed with mental retardation. Subjects with a psychotic disorder (p = 0.001) or an anxiety disorder (p = 0.005) were more likely to use a knife than other subjects in the study. Violence risk assessment in these patients must not only involve inquiry about firearm availability.

Principles of suicide risk assessment. How to interview depressed patients and tailor treatment.

Suicide is a significant cause of death in the United States. Because many patients who commit suicide visit their primary care physician in the weeks before their death, physicians need to be familiar with suicide risk assessment techniques. In this article, Drs Frierson, Melikian, and Wadman discuss the demographics and risk factors of suicide and propose a methodical, practical approach to assessing and managing suicide risk in depressed patients.

Competence-to-stand-trial evaluations of geriatric defendants.

This descriptive study compares geriatric defendants (n = 57) found competent to stand trial (n = 36) with those found incompetent (n = 21). A review of the records of 57 consecutive pretrial geriatric detainees who underwent competence-to-stand-trial evaluation was conducted. The review included comparison of demographic and historical variables, mental status examination (MSE) elements, and trial abilities. Incompetent subjects were older and more frequently had dementia, but did not necessarily have other psychiatric illnesses. Deficits in orientation, memory, abstraction, concentration, calculation, and thought process were associated with incompetence. Deficits in orientation and memory correlated most highly with incompetence. Trial-related deficits associated with incompetence included failure to understand Miranda warnings, legal charges, potential penalties, roles of court officers, pleas, and plea-bargaining and inability to consult with an attorney and be self-protective. The ability to maintain appropriate courtroom behavior was not different between groups. The inability to consult with an attorney and understand Miranda was most predictive of incompetence-to-stand-trial opinions.

The educational mission in forensic publishing.

Organizing frameworks that affect medical education include requirements for residency education set out by the Accreditation Council for Graduate Medical Education (ACGME), board certification requirements of the American Board of Psychiatry and Neurology (ABPN), and requirements of the Accreditation Council for Continuing Medical Education (ACCME) for awarding continuing medical education (CME) credits. Physicians rely on a variety of sources to meet these requirements, including medical journals. It is unclear, however, whether journals actually assist physicians in meeting these educational requirements. In this review of articles, we make the first known attempt at a systematic comparison of an academic journal's content areas to national standardized educational indices for physicians. Findings from the 2008 to 2012 content of The Journal of the American Academy of Psychiatry and the Law demonstrated that The Journal's articles cover the gamut of board certification examination topics, although content areas are not weighted in parallel with the examination. Some overlap and differences were seen when comparing journal content with ACGME topic areas. The Journal appears to meet identified gaps in knowledge that CME can address. The importance of balancing readers' educational needs with the ability to provide a resource for unique topics is discussed, along with other implications of these findings.

Combat-related posttraumatic stress disorder and criminal responsibility determinations in the post-iraq era: a review and case report.

Since 2002, hundreds of thousands of United States troops have returned from the Iraq and Afghanistan theaters, many after multiple deployments. The high suicide rate and high prevalence of mood disorders, substance use disorders, and posttraumatic stress disorder (PTSD) in this population have been widely reported. Many returning soldiers have had difficulty adjusting to civilian life, and some have incurred legal charges. In this article, I review the prevalence and legal implications of combat-related PTSD in this population, including how symptoms of PTSD may be relevant in criminal responsibility determinations in jurisdictions that use a M'Naughten standard or American Law Institute (ALI) Model Penal Code test for criminal responsibility. Finally, an actual case in which a criminal defendant was found to lack criminal responsibility in a M'Naughten jurisdiction because of PTSD symptoms at the time of the alleged offense will be presented.

Commentary: Police officers and persons with mental illness.

Silverstone et al. present a study outlining the success of a novel training program implemented in Edmonton, Alberta, Canada, to train police officers to interact with persons who may have a psychiatric disorder. The training was well accepted by the participants and was novel in its use of professional actors to portray persons with mental illness across six model scenarios. I outline the need for such training and comment on certain aspects of this particular program, including overall design, usefulness, and limitations.