Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Hospital treatment of persons found not guilty by reason of insanity.

After being found not guilty by reason of insanity (NGRI), individuals are typically admitted to a secure forensic hospital for evaluation and treatment. This patient population can pose a challenge to clinicians in the hospital setting due to significant violence risk, complex psychiatric presentations, and scrutiny from oversight boards and the public. This article reviews the scientific literature around several key aspects of hospital-based treatment of insanity acquittees, including the management of inpatient aggression, the provision of specific treatments to acquittees, the assessment of violence risk and readiness for release, and the process of community transition. The authors conclude that the existing literature is heavily weighted toward the study of risk assessment and recidivism, with relatively little attention paid to the study of therapeutic modalities and recovery-oriented care in this population.

Attitudes of Forensic Fellowship Psychiatry Directors towards an Applicant Match.

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

Extreme Risk Protection Orders in Connecticut, 2013-2020.

Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.

Suicide Prevention Effects of Extreme Risk Protection Order Laws in Four States.

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

A multi-state evaluation of extreme risk protection orders: a research protocol.

BACKGROUND: Extreme Risk Protection Orders (ERPOs) are civil court orders that prohibit firearm purchase and possession when someone is behaving dangerously and is at risk of harming themselves and/or others. As of June 2024, ERPOs are available in 21 states and the District of Columbia to prevent firearm violence. This paper describes the design and protocol of a six-state study of ERPO use. METHODS: The six states included are California, Colorado, Connecticut, Florida, Maryland, and Washington. During the 3-year project period (2020-2023), ERPO case files were obtained through public records requests or through agreements with agencies with access to these data in each state. A team of over four dozen research assistants from seven institutions coded 6628 ERPO cases, abstracting 80 variables per case under domains related to respondent characteristics, events and behaviors leading to ERPO petitions, petitioner types, and court outcomes. Research assistants received didactic training through an online learning management system that included virtual training modules, quizzes, practice coding exercises, and two virtual synchronous sessions. A protocol for gaining strong interrater reliability was used. Research assistants also learned strategies for reducing the risk of experiencing secondary trauma through the coding process, identifying its occurrence, and obtaining help. DISCUSSION: Addressing firearm violence in the U.S. is a priority. Understanding ERPO use in these six states can inform implementation planning and ERPO uptake, including promising opportunities to enhance safety and prevent firearm-related injuries and deaths. By publishing this protocol, we offer detailed insight into the methods underlying the papers published from these data, and the process of managing data abstraction from ERPO case files across the multi-state and multi-institution teams involved. Such information may also inform future analyses of this data, and future replication efforts. REGISTRATION: This protocol is registered on Open Science Framework ( https://osf.io/kv4fc/ ).

Restraint and Seclusion Practices and Policies in U.S. Forensic Psychiatric Hospitals.

Over the last 30 years, there have been significant efforts to reduce the use of restraint and seclusion in psychiatric hospitals. Although authors have previously described restraint policies and practices in general psychiatry settings across the United States, this study is the first to attempt to describe policies regarding those practices in forensic hospital settings. We review the history of restraint and seclusion use in the United States, placing it within an international context. We then describe the results of a national survey of state forensic services directors regarding restraint modalities and policies in forensic hospital facilities. Twenty-nine respondents representing 25 states completed the survey. The results indicate that physical holds are the most frequently available method of restraint and that restraint chairs are the least frequently available. Most respondents reported having a policy regulating the use of restraint in their facilities, most commonly at the institutional level.

Forensic evaluations and mandated reporting of child abuse.

Statutes requiring physicians to report suspected cases of child abuse create a potential conflict for psychiatrists working in the forensic setting. What happens in the case in which a forensic psychiatrist, during the course of an evaluation requested by a defense attorney, learns about child abuse perpetrated by the evaluee? A complicated legal, ethics-related, and interpersonal dilemma emerges. Reporting the abuse may contribute directly to further legal harm to the evaluee and place a strain on the relationship with the attorney. However, not reporting the abuse potentially involves ignoring a legal mandate and risking further harm to a child. This article first reviews mandated reporting statutes across the states. Next, the arguments for and against reporting are outlined. Existing solutions to the problem are reviewed, and several alternative solutions are explored. Finally, an approach to negotiating the dilemma that can be used by forensic psychiatrists in practice is suggested.

A Continuum of Competency Restoration Services Need Not Include Jail.

Competency restoration in jails has grown steadily over the past decade, driven primarily by cost considerations and long wait times for inpatient restoration programs. Although jail-based programs may offer an attractive temporary solution to the shortage of beds, a longer-term solution involves enhancing the continuum of competency restoration services available outside of the correctional system. Such a continuum includes inpatient, supportive residential, and outpatient services. If these services were adequately funded and managed, jail-based competency restoration services would provide no additional benefit to patients, mental health professionals, or the criminal justice system.

The Management of COVID-19 in Forensic Psychiatric Institutions.

Specific guidance on how to manage COVID-19 in forensic psychiatric institutions is necessary because these settings differ substantially from both acute-care psychiatric hospitals and correctional institutions. The challenges raised by COVID-19 in these settings are unique, given the nature of the patients treated, length of stay, and need to collaborate with various partners in the criminal justice system during both the admission and discharge planning processes. This column outlines these specific challenges, which are likely to recur in subsequent epidemics, and suggests potential strategies to address them.

Violent Video Games in Forensic Psychiatric Hospitals.

Popular media and the lay public have long expressed concerns about the association between violent video games and violent behavior. The current scientific literature exploring this connection focuses primarily on the relationship between violent video games and aggression in healthy populations. We are unaware of prior publications exploring the effect of such games on aggression in institutional settings or with forensic populations. Here we examine whether state psychiatric institutions, particularly forensic hospitals, have set policies to govern the use of violent video games for patients under their care. We present data from a national survey of such institutions in the United States, with some anecdotal international data included. The results demonstrate that hospital policies, when they exist, are inconsistent in their approaches to the use of violent video games. We argue that hospitals should devise policies that acknowledge the limited evidence in this area and that optimally balance the relevant stakeholders' interests. We propose guiding principles that balance these competing interests for institutions to consider when developing such policies. Finally, we advocate for further research regarding the safety and potential therapeutic effects of video games in forensic settings so that an evidence-based approach can be initiated future.

Resource Document on Risk-Based Gun Removal Laws.

(Reprinted with permission from APA Resource Document, June 2018).

Employee Health in the Mental Health Workplace: Clinical, Administrative, and Organizational Perspectives.

Issues of mental health and employee health have risen to increasing prominence in recent years. However, there have been few explorations of the clinical and administrative challenges that these issues raise, particularly in settings that are themselves mental health workplaces. In order to identify and understand such challenges, a brief case of acute employee illness in a mental health workplace is described followed by a discussion of salient clinical, administrative, and organizational considerations. The case raises questions about medicolegal responsibilities and relationships between clinicians and patients in mental health settings, illuminates tensions between clinical staff and human resources processes, and draws attention to the need for illness prevention and mental health promotion initiatives in the workplace. Increased awareness of these issues, complications, and potential solutions would benefit clinicians, administrators, and mental health institutions.

Cultural competence in correctional mental health.

Cultural competence is an essential aspect of competence as a mental health professional. In this article, the framework of cultural competence developed in general psychiatry-acquiring knowledge, attitudes, and skills necessary to understand the interaction between culture and the individual-is applied to the prison setting. Race and ethnicity, extremes of age, gender, and religion are highlighted and examined as elements of the overall culture of prisons. The model of the cultural formulation from the DSM-IV is then adapted for use by clinicians in the correctional setting, with particular emphasis on the interaction between the inmate's culture of origin and the unique culture of the prison environment.

Commentary: Jail-based competency restoration.

Many factors influence restoration of competence to stand trial: age, IQ, severity of mental illness, criminal history, treatment history, and others. This commentary poses the question of whether competency to stand trial is also influenced by the setting in which restoration treatment occurs. Jail-based competency-restoration programs, which are in their infancy and have yet to produce large-scale data demonstrating their efficacy, are examined. Several factors related to jail-based restoration are considered: choosing the right candidates for the program, impact of treatment in a punitive setting, ability to maintain separation between treaters and forensic evaluators, procedures for involuntary medication, aggregation of incompetent defendants in regional jails, effect on malingering, and cost savings.