Recent victimization increases risk for violence in justice-involved persons with mental illness.

A large body of research has examined relationships between distal experiences of victimization and the likelihood of engaging in violence later in life. Less is known about the influence of recent violent victimization on risk for violence perpetration. To our knowledge, this is the first study to examine prospectively whether recent victimization in adulthood increases the risk of future violence. Specifically, the present study assessed the incremental validity of recent violent victimization in the prediction of future violence in a sample of justice-involved adults with serious mental illness. The study examined (a) whether recent experiences of violent victimization (i.e., within 6 months of the baseline assessment) predicted a greater likelihood of perpetrating violence in the next year, and (b) whether inclusion of recent victimization enhanced the predictive validity of a model of violence risk in a sample of justice-involved adults with severe mental illness (N = 167). Hierarchical logistic regression analyses indicated that exposure to recent violent victimization at the baseline assessment predicted a greater likelihood of engaging in violent behavior during the year follow-up period. Additionally, recent exposure to violence at the baseline assessment continued to explain a significant amount of variance in a model of future violence perpetration above the variance accounted for by well-established violence risk factors. Taken together, the findings suggest that recent victimization is important to consider in understanding and evaluating risk of violence by persons with mental disorders who are involved in the criminal justice system.

The Evolving Standard of Care for Autoimmune Neuropsychiatric Illness.

In recent decades, there has been increasing biomedical and public understanding of the role of autoimmunity in neuropsychiatric illness. Popular media have highlighted patients with psychiatric illnesses who were eventually diagnosed with autoimmune neuropsychiatric illnesses such as anti- N-methyl-D-aspartate receptor encephalitis. Coverage of these cases has often drawn attention to the effects of misdiagnosis or delayed diagnosis of such diseases in psychiatric patients. Autoimmune encephalitis can have varied presentations and often involves evaluation and management from multiple medical specialties. As a result, there remains considerable uncertainty regarding how courts might gauge the legal standard of care with regard to psychiatric workup of new-onset psychiatric symptoms, and the degree to which autoimmune encephalitis must be considered. In this article we provide a brief overview of autoimmune encephalitis and autoimmune psychosis, including current diagnostic approaches to these conditions. We review case law regarding the standard of care for psychiatric disorders caused by general medical conditions. Finally, we provide a medicolegal perspective on the responsibilities of psychiatrists and other mental health professionals in the evaluation of possible autoimmune encephalitis.

The Forensic Mental Health Implications of Social Media Challenges.

Children and adults are increasingly spending time on social networking sites where they may be exposed to social media challenges. These challenges, which are essentially dares or competitions, often involve participants recording themselves performing various activities to create a short video which they then share online. Many social media challenges may be considered relatively benign, but others may involve behaviors or tasks that lead to adverse outcomes, including injury and death. In this article, the authors describe different types of social media challenges, susceptibility to risk-taking among social media users, and the potential criminal and civil legal aspects of these challenges. This article focuses on the forensic mental health implications of social media challenges, including considerations for forensic psychiatrists and other mental health professionals who may become involved in court cases related to these challenges.

Legal Implications of Psychiatric Assessment for Medical Aid in Dying.

In recent years, several jurisdictions have passed legislation to permit medical aid in dying (MAID) worldwide, with considerable expansion in the availability of this practice. MAID has been defined as the practice of a clinician prescribing lethal drugs in response to a direct request from the patient, with a shared understanding that the patient intends to use the medication to bring about the patient's death. Wider legalization of MAID has prompted debates and legal controversies regarding the extent to which MAID should be available and its application for people experiencing mental illness as the primary indication. This article examines shifting attitudes of professional medical organizations toward MAID. We discuss the existing statutory provisions for psychiatric assessment for MAID in the United States and the implications on such assessments should MAID be expanded to include mental illness as the primary indication. This article also assesses legal disputes concerning MAID regulations and explores the role of psychiatric experts in the practice of MAID.

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.

Cyberbullying and Adolescent Suicide.

The unprecedented exposure of today's youth to the Internet and technology carries many benefits but also risks such as cyberbullying and online predation. The incidences of both cyberbullying and adolescent suicide are rising in the United States, with recent Centers for Disease Control and Prevention data showing that 14.9 percent of adolescents have been cyberbullied and 13.6 percent of adolescents have made a serious suicide attempt. Cyberbullying has been associated with suicide of a victim in several recent cases, a phenomenon that has been newly termed cyberbullicide. Parents and youth are frequently unaware of the risks and potential criminal liability associated with cyberbullying. Legislation that protects against online bullying has developed from antibullying laws, and as an expansion of the requirement that schools prohibit any bullying at school or via technology that interferes with learning. Cyberbullying laws exist in certain states, but as there are no federal laws that address bullying or cyberbullying, cyberbullying is prosecuted federally via statutes governing cyberstalking. After examining the epidemiology of adolescent suicidality, cyberbullying, and cyberbullicide, this article reviews recent legislation governing cyberbullying. Finally, this article illustrates the role of the forensic psychiatrist in civil and criminal cases involving suspected cyberbullicide.

The Use of Electroconvulsive Therapy on Death Row.

Despite high rates of mental illness among incarcerated people in the United States, use of electroconvulsive therapy (ECT) remains limited in jails and prisons. There are some published guidelines regarding the provision of mental health care, including ECT, in U.S. correctional facilities, but little attention has been paid to the use of ECT for individuals sentenced to death. This article examines ECT within the context of the death penalty, including court consideration of ECT in capital cases and historic uses of ECT to facilitate execution of people on death row. Given the unique clinical, legal, and ethics considerations in the use of ECT for people sentenced to death, the authors call for greater attention to these practices and propose general guidelines regarding the use of ECT in this population.

Elder Financial Exploitation in the Digital Age.

Elder financial abuse violates the dignity, mental integrity, and fundamental rights of older adults. Reports of elder financial exploitation climbed during the COVID-19 pandemic, as many older adults were targeted by perpetrators seeking to take advantage of their worries about health and finances, increased isolation, and relative lack of familiarity with the digital technologies prevalent in their everyday lives. This article examines trends in usage of electronic financial technologies by older adults and describes new technology-based mechanisms of elder financial exploitation. We review the conceptual approaches and instruments used in financial capacity assessments, as well as the limitations of their applicability to the growing cohort of older adults who have adopted modern digital technologies to manage finances. We discuss elder abuse statutes and the variations in legal definitions of protected older adults and the perpetrators who can be held accountable for elder financial exploitation. In addition, we explore new directions for elaborating current approaches to financial capacity assessments and elder protection to address the demands and perils of the technology-driven postpandemic era.

Considerations for the Writing of Certification Letters Endorsing Use of Emotional Support Animals.

Emotional support animals (ESAs) are different from service animals, therapy animals, and other disability-related assistance animals. Although pet ownership may confer psychological benefits, limited research has supported the use of ESAs to realize such benefits. If clinicians are asked to write a letter of support for use of an ESA, they need to be familiar with relevant federal, state, and local laws that regulate ESAs and with the essential components of an ESA evaluation. This article provides an overview of terminology; federal, state, and local laws related to ESAs; and clinical and ethical considerations for clinicians who decide to write these letters. The authors also review liability issues related to writing these letters, including those related to ESA aggression.

A method for evaluating competency in assessment and management of suicide risk.

OBJECTIVE: Although health professionals increasingly are expected to be able to assess and manage patients' risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical examination (OSCE). METHOD: The authors developed the CAI-S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI-S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI-S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI-S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments. RESULTS: The CAI-S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI-S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision. CONCLUSION: The findings support the usefulness of the CAI-S for evaluating competency in suicide risk-assessment and management.

Grave Disability in U.S. Jails and Prisons.

Many states authorize involuntary psychiatric care on the basis of grave disability, a legal standard often defined as a person's inability to provide for basic needs because of mental illness. Mental illness is prevalent in U.S. jails and prisons, and although correctional facilities must generally provide incarcerated people with basic necessities (e.g., food, clothing, and shelter), incarcerated people may still meet criteria for grave disability. This Open Forum examines the assessment and treatment implications of grave disability in correctional contexts and ways to support the well-being of incarcerated people who may meet criteria for grave disability.

The Use of Battered Woman Syndrome in U.S. Criminal Courts.

Although not recognized by any edition of the Diagnostic and Statistical Manual of Mental Disorders, battered woman syndrome (BWS) has been offered as a defense in U.S. criminal courts for several decades. This article reviews examples of criminal cases in which BWS has been used in the United States as well as the implications of BWS for the practice of forensic psychiatry. Historically raised in cases of self-defense, BWS has also been used in criminal defenses involving duress, as well as by prosecutors to explain witness recantations. Case law suggests that expert witness testimony on BWS is often admissible in jurisdictions across the United States, yet its use in criminal defenses has received mixed responses from various courts. We examine limitations on the use of BWS in criminal courts and the potential use of posttraumatic stress disorder as an alternative and more reliable diagnosis in similar legal contexts.

The Evolving Medicolegal Precedent for Medications for Opioid Use Disorder in U.S. Jails and Prisons.

Medications for opioid use disorder, also known as medication-assisted treatment (MAT), are critical in the treatment of opioid use disorder. Historically, inmates with opioid use disorder in U.S. jails and prisons have had difficulty accessing these medications, particularly methadone and buprenorphine. A series of recent legal cases, however, have set an evolving precedent for prisoners' rights to medications for opioid use disorder during incarceration based on the Eighth Amendment and the Americans with Disabilities Act. In addition to reviewing these cases, this article evaluates the recent clinical and research landscape in which these cases arose and highlights the need for further study into the role of medications in reducing in-prison morbidity and mortality from opioid use disorder.

Estimating Annual Numbers of Competency to Stand Trial Evaluations across the United States.

In the United States, criminal proceedings must be halted or suspended if a defendant is determined to be incompetent to stand trial. Competency to stand trial (CST) is one of the most notable intersections between psychiatry and criminal law, and evaluating defendants for CST is a key role for many forensic psychiatrists and other mental health professionals. Despite the significance of CST evaluations in U.S. criminal justice, the number of CST evaluations conducted across the country each year remains largely unknown. National estimates dating back to the 1970s have ranged from approximately 19,000 to 94,000 CST evaluations each year, but these numbers vary considerably and often stem from imprecise calculations. This article examines estimates of annual numbers of CST evaluations across the United States, the need to develop more accurate statistics, and ways to implement systems for tracking the numbers of CST evaluations across the country.

Litigation Over Sleep Deprivation in U.S. Jails and Prisons.

Incarceration can disrupt healthy sleep, and insomnia is associated with psychiatric symptoms and poor general medical health among incarcerated people. In recent years, considerable litigation has arisen over sleep deprivation in U.S. jails and prisons. This column examines litigation over conditions of incarceration, such as noise, inadequate bedding, constant illumination, medication restrictions, and early wake-up times, that may affect sleep duration and quality. The potential adverse effects of inadequate sleep on incarcerated individuals, as well as associated litigation, suggest the need for policies that reduce unnecessary sleep deprivation and promote healthy sleep in correctional facilities.

Laws and Ethics Related to Emotional Support Animals.

The use of animals for therapeutic benefit is well-established. For example, for individuals with a disability such as blindness, trained service dogs can enhance the ability to live independently and participate fully in society. An emotional support animal (ESA) is an untrained animal that is used to support a person disabled by an emotional or mental disorder. For an animal to qualify as an ESA, a mental health or medical professional needs to write a letter saying that the animal is needed for the mental health of the person with the disability. This article describes the legal framework for service animals and ESAs, as well as the differences between them. We summarize information about the Americans with Disabilities Act, the Fair Housing Act, the Air Carrier Access Act, and other laws governing an individual's right to be accompanied by a support animal. We also summarize the clinical research on ESAs and argue that, although there are few studies on the clinical effectiveness of ESAs, a broader body of research indicates that animals may have positive clinical effects on medical and mental illness. Finally, we suggest there is a need for further research and provider education on ESAs.

A Review of Statutes and the Role of the Forensic Psychiatrist in Cyberstalking Involving Youth.

Adolescents are increasingly exposed to Internet-facilitated crime as they spend more time online. The mental health risks and legal consequences for youth involved in cyberstalking are growing areas of concern. The nature of online stalking presents several challenges regarding investigation, fair adjudication, fact-finding, and legislation. Laws governing online stalking behaviors inconsistently reference the age of a victim or perpetrator as a factor for consideration in case disposition. During adjudication, the forensic psychiatrist may be asked to evaluate the victim or perpetrator involved in cyberstalking. This article focuses on the current legal landscape governing cyberstalking behavior involving adolescents, the roles a forensic psychiatrist may assume in this context, and the opportunity to bring a developmental perspective to these cases.

A Systematic Approach to the Detection of False PTSD.

Posttraumatic stress disorder (PTSD) can occur after a traumatic experience and can cause severe symptoms that interfere with a person's psychological, physical, interpersonal, occupational, and social functioning. It is important to accurately identify genuine cases of PTSD and, as part of the differential diagnosis, to rule out instances of false PTSD. False PTSD diagnoses can adversely affect treatment planning, resource management, and research. The subjective nature of stressors, stereotypic presentation of symptoms, wealth of resources detailing how to malinger PTSD, and the high stakes for individuals involved in criminal, civil, and disability evaluations create challenges for making an accurate diagnosis. This article presents a systematic approach to help clinicians and forensic evaluators distinguish genuine PTSD from false variants of the disorder. It describes the types of false PTSD to be considered as alternative diagnoses, including malingered PTSD (for external gain, such as receiving a disability pension or evading criminal consequences), factitious PTSD (for internal gain, such as assuming the victim or hero/veteran role), and misattributed PTSD (legitimate psychopathology misdiagnosed as PTSD). The authors describe clinical features and psychological testing that may be leveraged to aid in reaching a more valid diagnosis.