Jail-Based Competency Restoration Services in the United States: The Need, the Controversy, the Impact of COVID-19, and Implications for Future Treatment Delivery.

Jail-based competency restoration largely emerged as a method to address the backlog at forensic hospitals around the United States, as the number of justice-involved persons in need of restoration outgrew available beds. Jail-based competency restoration units (JBCRUs) appear to be highly effective and cost-saving. However, after the COVID-19 outbreak, services at some JBCRUs were stalled, as providers were forced to either quickly initiate or ramp up technology use to maintain services. The present study describes the course of programming for a JBCRU in Fulton County, Georgia, prior to and after the onset of COVID-19, during which time all treatment shifted to telehealth. A matched comparison group of prepandemic defendants was used to compare in-person versus telehealth services and findings indicated that while defendants' length of stay remained effectively the same, the restoration rate for telehealth increased remarkably over prepandemic levels (χ2 = 10.1, p = .001). Such findings suggest that telehealth services are an effective mode of delivery for competency restoration.

WISE program analysis: Evaluating the first 15 months of progress in a novel treatment diversion program for women.

Like other counties across the nation, Fulton County, GA, has seen a significant increase in the number of arrests of people with serious mental illness. While Fulton County has accountability courts, some defendants with mental illness are not able to take advantage of these options due to their mental illness rendering them incompetent to understand the expectations required by these courts. The WISE (Women's Initiative for Success with Early Intervention) pilot project created a pathway for incompetent women to be diverted out of jail and into mental health treatment that was faster than the traditional evaluation for competency to stand trial pathway. A total of 16 female misdemeanants with non-violent charges were referred to the program. All women in WISE received intensive case management services. Some women were sent to a psychiatric hospital for involuntary hospitalization, some were released back to the community, and some were sent to a state forensic hospital for competency restoration services. Compared with a similar group of female misdemeanants prior to inception of the pilot project, women in the WISE group spent significantly fewer days in jail (mean of 64.9 days versus 163.46 days). Thus, preliminary findings from the pilot project indicate that referral to the WISE program significantly reduced the burden of excess time in jail associated with having an untreated mental illness.

Lack of relationship between acoustic startle and cognitive variables in schizophrenia and control subjects.

Measures of acoustic startle such as prepulse inhibition (PPI) and startle latency have been found to be impaired in schizophrenia, and are commonly thought to be related to cognitive deficits in this disease. However, findings about the relationship between startle variables and cognitive performance have been equivocal. In this study, we examined correlations between startle measures (baseline startle magnitude, latency, habituation and PPI) and cognitive performance (using the Benton Visual Retention Test, Conner's Continuous Performance Test, California Verbal Learning Test, Finger Tapping Test, and Wisconsin Card Sort Test) in 107 schizophrenia patients and 94 healthy controls. Overall, there was a lack of any significant relationship between these constructs in both populations when correcting for multiple comparisons. This suggests that alterations in startle measures seen in schizophrenia may not reflect elements of information processing that cause cognitive deficits in the disease.

Declarative memory and WCST-64 performance in subjects with schizophrenia and healthy controls.

The Wisconsin Card Sorting Test (WCST) is a set-switching task used extensively to study impaired executive functioning in schizophrenia. Declarative memory deficits have also been associated with schizophrenia and may affect WCST performance because continued correct responding depends on remembering the outcome of previous responses. This study examined whether performance in visual and verbal declarative memory tasks were associated with WCST performance. Subjects comprised 30 patients with schizophrenia or schizoaffective disorder (SCZ) and 30 demographically matched healthy controls (CON) who were tested on the WCST, the Benton Visual Retention Test (BVRT), the California Verbal Learning Test (CVLT), and the Continuous Performance Test (CPT). SCZ subjects showed significant correlations between visual and verbal declarative memory and performance on the WCST-64 that were in the hypothesized direction such that worse memory performance was associated with worse performance on the WCST. CON subjects did not show a significant relationship between visual or verbal memory and WCST-64 performance. Fisher's r to z transformations indicated that the associations between declarative memory and WCST-64 performance in the SCZ subjects differed significantly from those of CON subjects. The findings suggest that interpretations of WCST-64 scores for subjects with schizophrenia should be considered in light of their declarative memory functioning.

A Jail-Based Competency Restoration Unit as a Component of a Continuum of Restoration Services.

This study reports on restoration outcomes of a sample of pretrial defendants (n = 877, 69% male) who were found incompetent to stand trial and underwent restoration services in a large urban county. Each male defendant was initially assigned to restoration in one of four settings on a continuum of services of varying intensity (ie, outpatient, jail general population, dedicated jail-based restoration unit, or forensic hospital inpatient unit) based on the defendant's assessed clinical need. Of those who received services on the jail-based restoration unit (n = 398), 40 percent were restored to competency, 31 percent were diverted out of the criminal justice system, and 29 percent were referred for more intensive inpatient services, primarily because of refusal of medication (i.e., the jail would not allow involuntary medication, even if court-ordered). Advantages of restoration on the jail unit compared with inpatient hospitalization included more rapid institution of restoration services and higher rates of diversion out of the criminal justice system at one-third of the cost of inpatient restoration services. A continuum of restoration services that allows the type of restoration service to be matched to the needs of the individual incompetent defendant has significant advantages over routine transfer to a forensic hospital for restoration.

Medication status affects the relationship of symptoms to prepulse inhibition of acoustic startle in schizophrenia.

Inhibition of the acoustic startle response by a smaller preliminary nonstartling stimulus is termed prepulse inhibition (PPI). Schizophrenia patients have impairments in PPI that may not fully normalize even when they are clinically stable on medication, particularly typical antipsychotics. There is evidence that more severe symptoms are associated with more severe PPI abnormalities, but the effect of antipsychotics on this relationship is not clear. Seventy-three male schizophrenia patients underwent acoustic startle and PPI testing. Symptom ratings were performed using the Brief Psychiatric Rating Scale (BPRS) and its subscales. Fifty-two subjects were treated with antipsychotic medication at time of testing; 21 were unmedicated. For all subjects, PPI was negatively correlated with the BPRS psychological discomfort subscale but not with BPRS total symptoms, BPRS positive symptoms or BPRS negative symptoms. For medicated subjects analyzed separately, there were no correlations with BPRS total scores or any subscales. For the unmedicated subjects analyzed separately, there were significant correlations of lower PPI with greater severity of BPRS total symptoms, positive symptoms and the psychological discomfort subscale. These data indicate that more severe symptoms are associated with lower PPI, but that medication status is an important factor in the relationship between symptom severity and sensorimotor gating.

Civilian PTSD symptoms and risk for involvement in the criminal justice system.

Posttraumatic stress disorder (PTSD) has received considerable attention with regard to the ongoing wars in Iraq and Afghanistan. In studies of veterans, behavioral sequelae of PTSD can include hostile and violent behavior. Rates of PTSD found in impoverished, high-risk urban populations within U.S. inner cities are as high as in returning veterans. The objective of this study was to determine whether civilian PTSD is associated with increased risk of incarceration and charges related to violence in a low-income, urban population. Participants (n = 4,113) recruited from Grady Memorial Hospital in Atlanta, Georgia, completed self-report measures assessing history of trauma, PTSD symptoms, and incarceration. Both trauma exposure and civilian PTSD remained strongly associated with increased risk of involvement in the criminal justice system and charges of a violent offense, even after adjustment for sex, age, race, education, employment, income, and substance abuse in a regression model. Trauma and PTSD have important implications for public safety and recidivism.

Dissociable neural pathways are involved in the recognition of emotion in static and dynamic facial expressions.

Facial expressions of emotion powerfully influence social behavior. The distributed network of brain regions thought to decode these social signals has been empirically defined using static, usually photographic, displays of such expressions. Facial emotional expressions are however highly dynamic signals that encode the emotion message in facial action patterns. This study sought to determine whether the encoding of facial expressions of emotion by static or dynamic displays is associated with different neural correlates for their decoding. We used positron emission tomography to compare patterns of brain activity in healthy men and women during the explicit judgment of emotion intensity in static and dynamic facial expressions of anger and happiness. Compared to judgments of spatial orientation for moving neutral facial expressions, the judgment of anger in dynamic expressions was associated with increased right-lateralized activity in the medial, superior, middle, and inferior frontal cortex and cerebellum, while judgments of happiness were associated with relative activation of the cuneus, temporal cortex, and the middle, medial, and superior frontal cortex. In contrast, the perception of anger or happiness in static facial expressions activated a motor, prefrontal, and parietal cortical network previously shown to be involved in motor imagery. The direct contrast of dynamic and static expressions indicated differential activation of visual area V5, superior temporal sulcus, periamygdaloid cortex, and cerebellum for dynamic angry expressions and differential activation of area V5, extrastriate cortex, brain stem, and middle temporal cortical activations for dynamic happy expressions. Thus, a distribution of neural activations is related to the analysis of emotion messages in the nearly constant biological motion of the face and differ for angry and happy expressions. Static displays of facial emotional expression may represent noncanonical stimuli that are processed for emotion content by mental strategies and neural events distinct from their more ecologically relevant dynamic counterparts.