The Role of Apology Laws in Medical Malpractice.

Apologies are an integral part of human communication and can repair damaged relationships. Within the medical system, apologies remain controversial. Physicians often wish to apologize to patients harmed by medical errors, but they may not disclose errors to patients and their families because of the concern that disclosing errors could increase the likelihood of a malpractice claim. Yet physicians who apologize to patients may instead mitigate many of the communication problems known to prompt patients to pursue legal action. This idea has prompted many state governments to pass apology laws, legislation that aims to reduce rates of malpractice by encouraging physicians to apologize. These laws have not yet had their intended effect of reduced malpractice rates, likely because most apology laws protect expressions of regret but do not protect error disclosure. Apology laws therefore do not facilitate the type of communication that would improve physician transparency and overall patient satisfaction.

A Retrospective Review of the Use of Clozapine in Restoration of Competency to Stand Trial.

Most defendants found incompetent to stand trial have psychotic illnesses. Clozapine has been shown to be superior to other antipsychotic medications in treatment-resistant schizophrenia. It is vastly underutilized, however, including in forensic settings. To our knowledge, there have been no studies exploring the risks and benefits of clozapine for incompetent to stand trial defendants with severe mental illness. We sought to explore the characteristics of patients who were prescribed clozapine in a retrospective sample of defendants deemed incompetent to stand trial with diagnoses of psychotic and bipolar disorders. We found that 25 of 240 defendants (10%) were prescribed clozapine, with 15 (60%) eventually being discharged on it. Of those 15, 8 defendants were successfully restored to competency to stand trial. The restoration rate in the clozapine group was much lower than in the non-clozapine group (32% versus 87%). Our results emphasize the need for prospective comparative studies assessing the efficacy and tolerability of clozapine and other antipsychotic medications related to restoration of competency to stand trial.

Long-Acting Injectable versus Oral Antipsychotics for Restoration of Competency to Stand Trial.

Treatment with antipsychotics is a mainstay of trial competency restoration, particularly given that most defendants deemed incompetent to stand trial have psychotic illnesses. We explored the association between competency restoration and antipsychotic type in a retrospective sample of defendants diagnosed with psychotic disorders and deemed incompetent to stand trial. Using regression models, we calculated the odds ratio of being competent to stand trial, adjusting for relevant confounders. We found that the use of long-acting injectable antipsychotics was not significantly associated with increased odds of restoration of trial competency. Our results highlight the need for larger, longitudinal studies to further explore the efficacy and tolerability of long-acting injectable drugs compared with oral antipsychotics. Future research will help develop treatment guidelines within the setting of trial competency restoration.

Psychiatric Considerations Regarding Prehospital Administration of Ketamine for Agitation.

Recently, ketamine has seen increased use among emergency medical services in the prehospital setting as a first-line means of chemical restraint for agitated patients. In this case report, we explore an instance in which ketamine administration for nonpsychotic agitation before emergency department (ED) evaluation may have caused unexpected psychotic symptoms leading to a complicated ED course necessitating admission. As ketamine gains widespread use in the prehospital setting, the safety profile deserves reevaluation. In the following report, we review relevant literature and discuss important factors to consider regarding the use of prehospital ketamine, including psychiatric and substance abuse history.

Commonwealth v. Carter and Legal Interpretations of Facilitated Suicide.

In June 2017, a media frenzy ensued after Michelle Carter was convicted of involuntary manslaughter in the state of Massachusetts for facilitating the suicide of Conrad Roy. The verdict stirred controversy and cast a spotlight on facilitation of suicide, i.e., a person's act(s) done with the purpose of helping another to die by suicide. One form of facilitation, physician-assisted suicide, has been extensively debated in the existing literature. In this article, we set out to explore the legal and forensic ramifications of non-physician-assisted suicide, which we refer to as facilitated suicide. We first conducted a review of all fifty states' legislation regarding facilitated suicide: forty-four states prohibit it by statute, and three states prohibit it through common law. Thirteen states specifically outlaw verbal facilitation of suicide. We then surveyed the case law to identify legal precedent to the Commonwealth v. Carter verdict. Final Exit Network, Inc. v. State and State v. Melchert-Dinkel provide contrasting yet complementary perspectives on the interplay between speech and assisted suicide. Finally, we detailed the role of forensic psychiatry in investigating facilitated suicide, specifically among adolescents and youths.

Sexsomnia as a Defense in Repeated Sex Crimes.

Sexsomnia and related sexual behaviors during sleep may be diagnosed in individuals accused of sex crimes. Although sexsomnia is now formally recognized in the DSM-5, the variable presentation of such behaviors and the possibility of malingering in medicolegal situations can cause challenges for forensic evaluators and legal professionals alike. Review of the literature reveals a paucity of cases involving allegations of repeated incidents due to abnormal sexual behaviors or experiences in sleep. It is important for experts involved in such cases to understand how the courts have responded to sexsomnia defenses involving diverse alleged incidents. The authors review the case law and discuss methods of examining evaluees with suspected sexsomnia in cases of alleged sexual assault.

Insane Sex Offenders: Psychiatric and Legal Characteristics of Sexual Offenders Found Not Guilty by Reason of Insanity.

There is little known about sexual offenders hospitalized under forensic commitment statutes such as not guilty by reason of insanity (NGRI). We conducted a chart review to delineate the demographic, clinical, and legal characteristics of NGRI sexual offenders (n = 68) committed to the California Department of State Hospitals-Napa, including 41 found NGRI for a sexual offense and 27 found NGRI for a nonsexual offense. The two groups did not differ significantly in their demographics, psychiatric diagnoses, victim characteristics, or recidivism risk as measured by the Static-99R. Those found NGRI for a sexual offense were older at the time of their first criminal and first violent offense, younger at the time of their committing offense, and had fewer prior total convictions and sexual offense convictions. These findings may indicate that sexual offenders found NGRI for a sexual offense are less antisocial than those found NGRI for a nonsexual offense.

Characteristics of Misdemeanants Treated for Competency Restoration.

There are an estimated 60,000 evaluations annually for competence to stand trial for felony indictments and likely more for misdemeanor indictments. Thus, there is an increasing interest in determining factors associated with a defendant's likelihood of being restored to competence to stand trial. Although previous studies have found that a misdemeanor charge predicts significantly less likelihood of restoration of competence when compared with felony charges, states typically allow treatment facilities less time to restore misdemeanor defendants than felony defendants. As there are no studies examining factors associated with restoration of competence to stand trial for misdemeanor defendants, separately from felony defendants, we conducted a retrospective study to examine demographic, clinical, and forensic characteristics associated with restoration of competence to stand trial of misdemeanor defendants. Almost 70 percent of defendants regained competence to stand trial during the study period. When restorable, defendants regained competence in less than three weeks, on average, which addresses a current question in the field regarding time limits for restoration of competence to stand trial. Single marital status and length of stay in the treatment facility during restoration of competence to stand trial were significantly associated with restorability. States may consider such factors when developing and reviewing time limit policies in consideration of the Jackson v. Indiana ruling and when designing interventions aimed at restoring competence to stand trial to misdemeanor defendants in a cost-efficient manner.

Revenge Pornography: Mental Health Implications and Related Legislation.

Revenge pornography, also known as nonconsensual pornography, is a subtype of cyberharassment/cyberstalking, and a serious problem facing society in the Internet age. Revenge pornography can result in lifelong mental health consequences for victims, damaged relationships, and social isolation. Recently, a growing number of states have recognized the importance of this phenomenon and have enacted legislation that criminalizes it. The technology industry has also taken steps to assist victims of revenge pornography by creating web forms to request removal of links leading to the explicit content. The Cyber Civil Rights Initiative (CCRI) has been instrumental in promoting public awareness of this often overlooked problem and in providing services for victims. Although important steps have been made, greater recognition of the gravity of this problem and the mental health implications of revenge pornography is needed to expand legislation criminalizing such acts. A federal criminal law, in particular, is much overdue. Mental health professionals must understand the dimensions of revenge pornography to be able to identify and address the consequences in both forensic and clinical settings.

Childhood animal cruelty, bestiality, and the link to adult interpersonal violence.

Animal cruelty has been a concern of the legal and psychiatric communities for many years. Beginning in the early 1800s, state legislatures in the United States established laws to protect the basic safety and security of animals in their jurisdictions. Legislatures have differed in opinion on the animals to receive protection under the law and have instituted differing penalties for infractions of anti-cruelty measures. In the 1960s, the psychiatric community took notice of childhood animal cruelty as a potential risk factor for violent acts against humans. Since that time there has been increasing evidence that children who engage in animal cruelty may be at increased risk of interpersonal offenses in adulthood. Less is known about children and adults who engage in bestiality and the potential risk that these individuals may pose for interpersonal sexual or nonsexual violent acts. We review the legal status of animal cruelty in the United States, summarize the history of psychiatric interest in and research of animal cruelty, describe current knowledge regarding the link between animal cruelty and violence, and propose a novel classification scheme for individuals who engage in bestiality to assist forensic psychiatric examiners in determining the risk that such behavior poses for future interpersonal offending.

Recidivism Risk Assessment for Adult Sexual Offenders.

Sexual offending is a significant public health problem in the USA due to its prevalence and the substantial impact it has on victims, victims' families, and the legal and mental health systems. The assessment of sexual offender recidivism risk is an important aspect of developing effective management strategies for sexual offenders in terms of placement, treatment, and other interventions. Researchers have developed numerous tools to aid in the assessment of sexual violence recidivism risk, including actuarial measures, structured professional judgment methods, and psychophysiologic assessment of sexual interests. The Static-99R and Sexual Violence Risk-20 are two instruments that have received substantial research attention for their ability to accurately compare offenders' risk of recidivism to normative group data. Penile plethysmography and visual reaction time are used to evaluate subjects' responses to sexual stimuli in an effort to characterize offenders' sexual arousal and interest, respectively. Though current research has focused on risk assessment tools' predictive utility, future research will need to examine the impact that actuarial and structured professional judgment tools have on reducing recidivism if they are to have relevance in the management of sexual offenders.

Updates since Brown v. Plata: alternative solutions for prison overcrowding in California.

With the number of inmates under the care of the California Department of Corrections and Rehabilitation (CDCR) swelling over the past few decades, California faces a challenge. The U.S. Supreme Court ruled in their 2011 decision in Brown v. Plata that overcrowding violates inmates' Eighth Amendment rights, specifically that they are denied adequate medical and mental health care. Federally mandated release programs have historically raised some concerns regarding public safety and fiscal efficiency. Given the large number of mentally ill inmates in the United States, alternatives such as assisted outpatient treatment, mental health courts, and increased funding for substance use treatment can be used proactively to reduce the CDCR population and provide long-term solutions to the overcrowding problem. These alternatives have already shown long-term cost savings in addition to reducing the recidivism of individuals involved and would help provide appropriate diversion for mentally ill individuals.

Ferguson v. Florida: rationally understanding competence to be executed?

The U.S. Supreme Court addressed competency to be executed in Ford v. Wainwright, holding that execution of the insane violates the Eighth Amendment. More than 20 years later, the Court defined this standard in its landmark decision in Panetti v. Quarterman. The Panetti ruling held that an inmate's factual awareness of the reasons for his execution was not sufficient to determine his competence. The Court advised that a prisoner must have a rational understanding of the reasons for his death sentence. The Panetti Court declined to establish specific competency criteria and acknowledged that rational understanding is difficult to define. Following Ford and Panetti, lower courts have struggled to apply the standards articulated in these two landmark cases. This struggle was recently highlighted in Ferguson v. Florida (2013), a case that received substantial attention and was decided by the Florida Supreme Court and the Eleventh Circuit Court. Ferguson featured majority and concurring opinions that, although consistent in their ultimate conclusions, expressed differing interpretations of their application of the Panetti standard. Although the Panetti Court declined to set a national standard for competency to be executed, Ferguson v. Florida is a cautionary reminder that more tangible guidelines are necessary for consistent application of a conclusion that cannot be revised.

Brown v. Plata: prison overcrowding in California.

California's prisons are currently designed to house approximately 85,000 inmates. At the time of the U.S. Supreme Court's 2011 decision in Brown v. Plata, the California prison system housed nearly twice that many (approximately 156,000 inmates). The Supreme Court held that California's prison system violated inmates' Eighth Amendment rights. The Court upheld a three-judge panel's order to decrease the population of California's prisons by an estimated 46,000 inmates. They determined that overcrowding was the primary cause of the inmates' inadequate medical and mental health care. As a result, the California Department of Corrections and Rehabilitation (CDCR) has been working to redistribute inmates and parolees safely and decrease the overall population to the mandated levels. These large-scale adjustments to California's penal system create potential opportunities to study the long-term effects on affected inmates.

Psychopharmacologic management of aggression.

This article is designed to provide an overview of the existing literature on pharmacologically managing aggression, with a specific focus on psychiatric diagnoses commonly associated with increased aggression. Self-injurious behaviors and suicide are sometimes classified as forms of aggression, but information presented here focuses primarily on aggression toward others (physical and/or verbal).