Patient Characteristics and Outcomes Related to Successful Outpatient Competency Restoration.

Criminal defendants have a fundamental right to a fair and speedy trial. However, individuals found incompetent to stand trial are unable to move forward in the adjudication process and are often mired in protracted legal proceedings. If competency restoration is statutorily permissible and can be conducted in the outpatient setting, we propose that it should be considered based on burgeoning empirical data. We present data from an outpatient forensic clinic in which individuals are conditionally released to receive competency restoration in the community. Results indicated that three variables, including being single/never married, having comorbid intellectual disability and mental illness, and having one's conditional release revoked, were negatively related to successful restoration. The final model explained approximately one-third of the variance in restorability and correctly classified 75% of cases. Results demonstrate that individuals can be safely released to the community and successfully restored to competency in the outpatient setting. Utilizing outpatient competency restoration would not only reduce strain on inpatient facilities, but would also reduce the cost of treatment. Copyright © 2017 John Wiley & Sons, Ltd.

Teaching Cultural Competence to Psychiatry Residents: Seven Core Concepts and Their Implications for Therapeutic Technique.

The authors describe the Tulane Model for teaching cultural competence to psychiatry residents in order to outline an innovative approach to curricula development in academic psychiatry. The authors focus on the didactic experience that takes place during the first and second postgraduate years and present seven core concepts that should inform the emerging clinician's thinking in the formulation of every clinical case. The authors discuss the correspondence between each core concept and the Outline for Cultural Formulation, introduced in Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and updated in DSM-5. The authors illustrate how each of the core concepts is utilized as a guideline for teaching residents a process for eliciting culturally relevant information from their patients and their personal histories and how to apply that knowledge in the assessment and treatment of patients in clinical settings.

What factors are related to success on conditional release/discharge? Findings from the New Orleans forensic aftercare clinic: 2002-2013.

The present study investigated the empirically based factors that predicted success on conditional release among a sample of individuals conditionally discharged in Louisiana. Not guilty by reason of insanity acquittees and individuals on conditional release/discharge for incompetency to stand trial were included in the study. Success on conditional release was defined as maintenance of conditional release during the study period. Recidivism (arrest on new charges) and incidents were empirically evaluated. Success on conditional release was maintained in over 70% of individuals. Recidivism was low, with only five arrests on new charges. Success on conditional release was predicted by financial resources, not having a personality disorder, and having fewer total incidents in the program. After controlling for the influence of other variables, having an incident on conditional release was predicted by a substance use diagnosis and being released from jail. Individuals conditionally released from jail showed fewer number of days to first incident (67 vs. 575 days) compared with individuals discharged from the hospital. These data provide support for the successful management of forensic patients in the community via conditional release, although they highlight specific factors that should be considered when developing community-based release programming. Conditional release programs should consider empirical factors in the development of risk assessment and risk management approaches to improve successful maintenance of community-based forensic treatment alternatives.

Employing the Risk-Need-Responsivity (RNR) model and predicting successful completion in an alternative drug court program: Preliminary findings from the Orleans Parish Drug Court.

Drug courts have been in operation for decades to provide treatment alternatives to individuals whose substance use and related behaviors have brought them into contact with the criminal justice system. As research on drug courts have evolved, it has been demonstrated that different types of offenders have different mental health and substance use treatment needs. One way of approaching treatment in court-mandated substance use treatment is by the application of the risk-need-responsivity (RNR) model (Andrews, Zinger et al., 1990). The Orleans Parish Drug Court expanded assessment and treatment services to determine whether the implementation of alternative substance use programming within a traditional drug court model improved outcomes. The goals of the current study were to describe the process of implementing risk and need principles, provide a description of client characteristics, examine the factors related to successful completion of drug court, and investigate completion rates across risk and need groups. Results demonstrated that risk and need groups differed on several demographic variables, levels of substance use, mental health concerns, and legal issues, suggesting assessment and triage procedures were successful. Comparisons between individuals who successfully completed drug court and those who were terminated prematurely also showed significant differences. Specifically, baseline age, education, substance use problems and frequency, and days in jail/prison were unique predictors of successful drug court completion. Finally, as predicted, individuals in the group with the lowest risk and need had the highest graduation rate, despite receiving less intensive services. Overall, creation of specialized treatment tracks within a traditional drug court program appears to be an effective strategy to target the wide range of offenders typical of drug court participants.

Commentary: Helling v. Carey, Caveat Medicus.

Forensic experts should be aware of the increasing importance of clinical practice guidelines (CPGs) in various legal settings. CPGs are a type of learned treatise and are accepted into court proceedings under hearsay exception provisions. The courts now use CPGs as shorthand for the standard of care in making malpractice determinations. However, medical guidelines can function as a sword or a shield in the courtroom arena. The Helling v. Carey medical malpractice case serves as a frightful reminder of the potential consequences of allowing courts to craft their own standards of medical care.

The use of telemedicine to evaluate competency to stand trial: a preliminary randomized controlled study.

To investigate whether forensic evaluations can be performed reliably using telemedicine, we compared the results on a standard competency assessment instrument using telemedicine (TM) and live interviews (LI). Two board-certified forensic psychiatrists used the Georgia Court Competency Test (GCCT) to evaluate 21 forensic psychiatric inpatients. Half of the patients were randomly assigned to a telemedicine interview and half were assigned to a live interview. Total scores on the GCCT were similar for both raters, indicating high levels of agreement between telemedicine and live interviews. Patient and provider satisfaction were measured and indicated that, although patients did not express a preference for a particular interview modality, providers reported greater satisfaction with live interviews. Findings suggest that one aspect of competency to stand trial can be reliably evaluated using telemedicine and that patients perceive telemedicine as an acceptable alternative to a standard live interview. The limited sample size precludes definite conclusions and further studies involving a larger forensic study population are warranted.

Anxiety-related differences in affective categorizations of lexical stimuli.

Effects of emotional valence on attention have been shown to occur even when stimuli are presented outside awareness. The impact of negative valence on stimulus processing has been demonstrated to be particularly salient in anxiety. Therefore, it has been hypothesized that compared to nonanxious individuals, anxious individuals have an enhanced ability to detect the valence of negative stimuli. However, it remains unclear whether anxious individuals are better at identifying the valence of threatening stimuli or, rather, more likely to label ambiguous stimuli as threatening. To investigate these hypotheses, high and low anxious participants categorized lexical stimuli as "safe" or "dangerous." Stimuli were presented at durations that allowed for both conscious (unmasked) and nonconscious (masked) processing. Results show that on masked trials, anxious individuals evidenced an enhanced ability to correctly classify threatening information, whereas nonanxious participants demonstrated an enhanced ability to correctly classify neutral or positive information. Signal detection analyses indicated results were explained by a response bias, whereby anxious individuals were more likely than nonanxious individuals to categorize masked words as threatening and nonanxious individuals were more likely to categorize masked words as nonthreatening. No group differences for nonword stimuli emerged, suggesting that anxiety-related response bias tendencies are activated only after detection of a weak semantic signal.

Mental health needs of cohabiting partners of Vietnam veterans with combat-related PTSD.

The objectives of this study were to perform an initial needs assessment of partners of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD) and to assess the partners' current rates of treatment use. A telephone survey was conducted with 89 cohabitating female partners of male combat veterans who were receiving outpatient PTSD treatment at two Department of Veterans Affairs medical centers. Although large majorities of partners rated individual therapy and family therapy to help cope with PTSD in the family as highly important, only about one-quarter of the partners had received any mental health care in the previous six months. The most commonly requested service was a women-only group.

Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects.

BACKGROUND: Recent studies have reported a high comorbidity between posttraumatic stress disorder (PTSD) and psychotic symptoms, and it has been hypothesized that PTSD with comorbid psychosis is a severe form of PTSD. Few studies have examined the neurobiology of PTSD with comorbid psychosis. If PTSD with secondary psychotic symptoms (PTSD-SP) is a severe form of PTSD, then it might be expected to show more extreme perturbations in the neuroendocrine patterns that characterize PTSD. METHODS: Patients with PTSD with secondary psychotic symptoms (PTSD-SP), PTSD without psychosis, and healthy comparison subjects were compared for differences in cerebrospinal fluid concentrations of corticotropin-releasing factor (CRF) and somatotropin-release-inhibiting hormone (SRIF). RESULTS: The PTSD-SP subjects had significantly higher mean levels of CRF than either the PTSD or control subjects (p <.01). The three groups showed similar SRIF levels. CONCLUSIONS: These data implicate abnormalities in the secretion of CRF with the production of secondary psychotic symptoms in PTSD. This finding supports the validity of PTSD-SP as a PTSD subtype and as a severe form of PTSD.

Differences in smooth pursuit eye movement between posttraumatic stress disorder with secondary psychotic symptoms and schizophrenia.

Studies show high comorbidity between post-traumatic stress disorder and psychotic symptoms. Despite this fact, there has been only one published study of the neurobiology of this enigmatic disorder. This preliminary study examines the relationship between psychotic symptoms in post-traumatic stress disorder (PTSD) and schizophrenia by measuring smooth pursuit eye movement (SPEM) in subjects with PTSD and secondary psychotic symptoms, schizophrenia, and healthy controls. The results show that PTSD with secondary psychotic symptoms is associated with a SPEM deficit that is different from the SPEM deficit associated with schizophrenia.

Scylla and Charybdis: dual roles and undetected risks in campus mental health assessments.

Recent high-profile events involving the mental health of students and the subsequent impact on the campus community have focused attention on the need for quality mental health care and informed risk assessment on college campuses. When on-campus clinicians are asked to provide direct clinical care to students and to perform objective evaluations of at-risk students at the request of university administrators, there is a potential for multiple role conflict. Campus clinicians may find themselves involved in maintaining a difficult balance between student and university interests. We describe some of the problems that arise in balancing decisions between the two, with a specific emphasis on threats to confidentiality and informed consent, dual role conflicts, and the limits of clinical expertise.

Competency restoration treatment: differences between defendants declared competent or incompetent to stand trial.

Archival data of inpatient defendants referred for competency restoration were used to make comparisons between those who were restored to competency (CST; n = 43) and those who remained incompetent (IST; n = 15). The groups did not differ on demographic variables, intellectual capacity, type of offense (violent versus nonviolent), clinical diagnoses, substance abuse, or psychotic symptomatology, as measured by the Brief Psychiatric Rating Scale. However, the CST group performed significantly better than the IST group on both the initial and final Georgia Court Competency Test and Global Assessment of Functioning scale. Psychotic symptom severity decreased significantly only in the CST group, and the CST group was discharged significantly sooner (7.7 ± 8.6 months) than the IST group (17.9 ± 7.0 months). While consistent with prior research, this is the first study to compare both psycholegal comprehension and specific clinical symptoms in defendants before and after competency restoration treatment.

Are release recommendations for NGRI acquittees informed by relevant data?

We conducted a retrospective review of factors involved in clinical recommendations for release of patients adjudicated not guilty by reason of insanity (NGRI). Medical records from 91 patients in a maximum security forensic hospital who participated in a formal hearing process to determine suitability for release were reviewed. The purpose of the study was twofold: (1) to examine the process involved in day to day clinical decision-making regarding release from a maximum security forensic hospital and (2) to determine what factors in a patient's clinical and legal history were related to recommendation decisions. Multivariate statistical methods revealed that among the clinical, demographic, and legal information available to clinicians at the time a formal release recommendation was made two factors emerged that were significantly related to release recommendations: PCL-R score and the age at which the patient committed his first criminal offense. Patients with high levels of psychopathy and those who engaged in criminal behavior at a younger age were less likely to be recommended for release from a maximum security forensic hospital.

Psychological distress and burden among female partners of combat veterans with PTSD.

Psychological distress among cohabitating female partners of combat veterans with posttraumatic stress disorder (PTSD) was examined in a cross-sectional study using a modified version of the Health Belief Model. A convenience sample of 89 cohabitating female partners of male veterans in outpatient PTSD treatment was interviewed by telephone using a structured interview. Partners endorsed high levels of psychological distress with elevations on clinical scales at or exceeding the 90th percentile. Severe levels of overall psychological distress, depression, and suicidal ideation were prevalent among partners. Multivariate analyses revealed that perceived threat, recent mental health treatment, and level of involvement with veterans predicted global partner psychological distress. Partner burden was predicted by partner self-efficacy, perceived threat, barriers to mental health treatment, and partner treatment engagement. These findings are compelling since they demonstrate that partners of veterans with combat-related PTSD experience significant levels of emotional distress that warrant clinical attention. Psychological distress and partner burden were each associated with a unique combination of predictors, suggesting that although these constructs are related, they have distinct correlates and potentially different implications within the family environment. Future research should examine these constructs separately using causal modeling analyses to identify modifiable targets for interventions to reduce psychological distress among partners of individuals with PTSD.