The cost of safety: Balancing risk and liberty in psychiatric units.

The systems approach is a widely accepted method for addressing healthcare adverse events. However, when adverse events are behavioral in nature, such as self-injury or aggression, a systems approach can restrict patient autonomy. We propose guidelines for balancing safety and autonomy considerations when developing systems for behavioral adverse events: interventions that do not limit patient liberty, or that therapeutically address the root causes of behavioral adverse events, should be fully utilized. Clinicians should collaborate with patients when designing systems that may restrict patient liberty. And clinicians should be supported in managing the stress that accrues from working in hazardous environments.

Racial and Ethnic Differences in Psychiatry Resident Prescribing: a Quality Improvement Education Intervention to Address Health Equity.

OBJECTIVE: Quality improvement (QI) tools can identify and address health disparities. This paper describes the use of resident prescriber profiles in a novel QI curriculum to identify racial and ethnic differences in antidepressant and antipsychotic prescribing. METHODS: The authors extracted medication orders written by 111 psychiatry residents over an 18-month period from an electronic medical record and reformatted these into 6133 unique patient encounters. Binomial logistic models adjusted for covariates assessed racial and ethnic differences in antipsychotic or antidepressant prescribing in both emergency and inpatient psychiatric encounters. A multinomial model adjusted for covariates then assessed racial and ethnic differences in primary diagnosis. Models also examined interactions between gender and race/ethnicity. RESULTS: Black (adjusted OR 0.66; 95% CI, 0.50-0.87; p < 0.01) and Latinx (adjusted OR, 0.65; 95% CI, 0.49-0.86; p < 0.01) patients had lower odds of receiving antidepressants relative to White patients despite diagnosis. Black and Latinx patients were no more likely to receive antipsychotics than White patients when adjusted for diagnosis. Black (adjusted OR 3.85; 95% CI, 2.9-5.2) and Latinx (adjusted OR 1.60; 95% CI, 1.1-2.3) patients were more likely to receive a psychosis than a depression diagnosis when compared to White patients. Gender interactions with race/ethnicity did not significantly change results. CONCLUSIONS: Our findings suggest that racial/ethnic differences in antidepressant prescription likely result from alternatively higher diagnosis of psychotic disorders and prescription of antipsychotics in Black and Latinx patients. Prescriber profiles can serve as a powerful tool to promote resident QI learning around the effects of structural racism on clinical care.

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.

The Benefits of Required Forensic Clinical Experiences in Residency.

OBJECTIVE: The growth of forensic psychiatry has spurred efforts to improve forensic psychiatry training in general psychiatry residency. The Accreditation Council for Graduate Medical Education requires that residencies provide an experience that "exposes" residents to forensic issues, but leaves the specifics to individual programs. However, there is growing need for psychiatrists to understand the unique circumstances of individuals with mental illness involved in the criminal justice system. METHODS: The authors developed a new mandatory forensic rotation for general psychiatry residents and conducted a pilot study to assess its impact on residents' interest and comfort working with criminal justice-involved patients, interest in forensic fellowship, and knowledge of available resources for consultation and supervision. RESULTS: Rotation completion was associated with a significantly increased interest in working with forensic populations and pursuing forensic fellowship, but no changes in residents' level of comfort or knowledge of supervisory and consultative resources. CONCLUSIONS: This study adds to the growing body of literature describing the benefits of expanding forensic education for residents.

Sociodemographic and clinical correlates of the frequently hospitalized African American patients with severe and persistent mental illness.

BACKGROUND: Many researchers and clinicians are becoming increasingly concerned about the phenomenon of frequent psychiatric inpatient hospitalization in those with severe and persistent mental illness. This study aims to shed light on this occurrence in the African American psychiatric inpatient population by examining their sociodemographic and clinical correlates. METHODS: We retrospectively reviewed the medical charts of 39 African American patients who have had ≥3 inpatient psychiatric admissions in a year at Howard University Hospital, an urban, academically-affiliated hospital serving a predominantly African American population in Washington, DC. RESULTS: Most frequently readmitted African American inpatients were male (62%), unmarried (95%), homeless (62%), intoxicated at admission (90%), unemployed (97%), and age ≥35 (87%); expressed suicidal ideations (85%); had a DSM-5 diagnosis of a psychotic spectrum disorder (59%) and less than fair insight into their illness (56%); and stayed in the hospital for ≤4 days (82%). CONCLUSIONS: Many lessons can be learned from this study on African American psychiatric inpatient treatment recidivists, despite the work's limitations. Among these lessons are the need for strong case management, creative aftercare planning, and well-orchestrated, multifaceted services focused on these sociodemographic and clinical correlates- especially homelessness, unemployment, substance use, mood dysregulation, and psychosis-to successfully meet this patient populations' clinical needs.

Assessing Insanity Acquittee Recidivism in Connecticut.

For over 30 years now the movement and status of insanity acquittees in Connecticut has been supervised by the Psychiatric Security Review Board (PSRB). During this time, 365 acquittees have been committed to the jurisdiction of the PSRB, 177 individuals have achieved conditional release (CR) and 215 acquittees have been discharged from PSRB jurisdiction. This article examines revocation of CR by the PSRB, arrests of acquittees on CR, and provides the first report of arrests following discharge from the PSRB's jurisdiction. The literature on relevant aspects of recidivism is reviewed and compared with findings in Connecticut. There is little available literature about recidivism of insanity acquittees following release from supervision. In the present sample of individuals discharged from the PSRB, 16% were rearrested, a rate that compares favorably with other discharged populations of offenders. For discharged acquittees, community supervision on CR prior to discharge from the PSRB had a statistically significant effect on decreasing the risk of subsequent rearrest, as did both the length of stay in the hospital and the duration of commitment to the PSRB. This article presents descriptive information about revocations, arrests on CR, and arrests following discharge. These data are consistent with criminal justice studies demonstrating the value of community supervision in lowering recidivism. Copyright © 2016 John Wiley & Sons, Ltd.

How do we keep our residents safe? An educational intervention.

OBJECTIVE: Recent evidence suggests that 25-64 % of psychiatry residents are the victims of assault by patients; only a minority, however, feel they receive adequate safety and violence training during residency. To address this disparity, the author designed, implemented, and assessed the effectiveness of a brief educational intervention focused on improving the residents' ability to recognize violence risk and increase attention to safety in the psychiatric interview. METHODS: The subjects were 13 second-year psychiatry residents. Effectiveness was evaluated via the assessment of the residents' written responses describing their first clinical intervention after hearing a case vignette of a potentially violent patient (before and 1 month following the intervention). Responses were evaluated for any evidence of concerns for safety. RESULTS: The number of residents citing safety concerns increased (38 to 92 %), as did the level of sophistication in their proposed interventions. CONCLUSIONS: A brief educational intervention focused on violence risk and interview safety may be effective in increasing residents' attention to safety concerns in their clinical care, and further work will be beneficial to confirm and expand upon these findings.

A Proposal for the Capacity to Stipulate to Civil Commitment and a 50-State Review of Statutes.

Civil commitment is a legal process in which persons may be involuntarily detained for psychiatric evaluation and treatment if, because of mental illness, they are at imminent risk of harming themselves or others. Procedures that protect such persons from undue infringements of their personal liberties vary by state. Some jurisdictions permit individuals to waive their right to contest a hearing and instead stipulate to civil commitment. This differs from voluntary hospitalization in that the individuals accede to treatment for the term of commitment and forgo the possibility of either subsequent voluntary consent or withdrawal of consent. The authors describe a 50-state review examining whether statutory law permits these waivers. We show that many states allow a waiver but do not require that the person have decision-making capacity. Capacity assessment is essential because persons with impaired decision-making may accept a commitment that might otherwise have been successfully challenged, and commitment can have unwanted consequences, including extended hospitalization, loss of rights, and stigma. We propose procedures and criteria for assessing capacity to stipulate that include not only understanding that stipulation will result in commitment but also understanding the nature, purposes, consequences, and processes involved in commitment.

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.

Effects of Online Distance Learning on Violence Risk Knowledge and Competencies.

Behavioral health professionals are charged with providing effective outpatient services while addressing patient and public safety, yet training in empirically-informed violence risk assessment strategies remains inaccessible. The authors developed and evaluated an online distance learning (ODL) course on clinical risk assessment targeting frontline providers and trainees in the United States. The ODL consisted of three modules: confidentiality, duty to third parties, and clinical assessment of violence risk. We evaluated the response characteristics and reach among different disciplines, as well as training satisfaction, change in knowledge, self-perceived competence, and self-reported impact on practice at six-week follow-up among 221 learners. Self-perceptions of competence and knowledge in the focal areas increased immediately after completing the training; self-perceived competence increased again by a significant margin at six-week follow-up. Participants reported a moderate-high positive impact of the training on practice.

A Multi-Site Survey of General Psychiatry Residents' Forensic Training.

The authors surveyed general psychiatry residents across the United States to better understand residents' experiences with forensic training and to identify variables with the greatest impact on residents' exposure to, comfort with, and desire to learn more about forensic populations and settings. The survey inquired about these topics and the forensic psychiatry resources available at residents' training institutions. Respondents (n = 129) spanned eight of ten U.S. census regions. Residents' comfort with forensic psychiatry was low, whereas desire to learn was high. Residents' number of exposures and comfort increased with greater forensic experience in residency. Fewer than half of residents had completed a forensic rotation, were required to complete a forensic rotation, or had robust forensic resources available to them. Residents who had completed a dedicated forensic rotation had significantly greater forensic exposures and comfort; a finding that remained significant even after controlling for participants' PGY status. Among residents pursuing fellowship training, residents interested in forensic fellowship had more exposures during residency. This study represents the first published effort to survey general psychiatry residents from multiple residency programs regarding their forensic experiences in training. These results have implications for educators interested in developing broader exposure to and comfort with forensic psychiatry.

Characteristics of Assaultive Patients Whom Inpatient Psychiatric Staff Report to Law Enforcement.

OBJECTIVE: The authors sought to identify factors that affect hospital staff's decision to pursue criminal charges against patients who assault staff on inpatient psychiatric units. METHODS: Data on assaults occurring on inpatient psychiatric units in one hospital system were collected over 32 months, from November 1, 2016, to July 1, 2019. The events were grouped by whether staff pursued criminal charges after the incident. Descriptive statistics and regression models were used to describe the data and identify predictive variables. RESULTS: Data were reviewed from 9,654 admissions, of which 124 patient encounters involved assaults on staff. Overall, 27 (22%) of 124 assaults on staff resulted in staff pursuing criminal charges. Regression models indicated that criminal history (odds ratio [OR]=2.18, 95% CI=1.26-3.78, p=0.006), age (OR=0.92, 95% CI=0.91-0.94, p<0.001), and diagnosis of chronic mental illness with psychotic symptoms (OR=7.23, 95% CI=1.49-35.04, p=0.01) predicted patient assaults resulting in contact with law enforcement. Several variables were not statistically significantly associated with filing of criminal charges, including race, gender, degree of injury from the assault, number of instances of restraint, and number of as-needed medications. CONCLUSIONS: This is the largest quantitative study to examine the demographic and clinical factors that may play a role in whether staff pursue criminal charges against patients on inpatient psychiatric units. The results suggest that certain patients are more likely to be reported to law enforcement. Institutions should monitor factors that increase the likelihood of assaults on staff resulting in criminal charges and create policies that mitigate discrepancies in criminal justice involvement.

An Analysis of Risk-Assessment Driven Security Restraint Use during the Transport of Forensic Patients.

Transporting forensic psychiatric patients outside of forensic hospitals has significant risks that pose competing safety and patients' rights interests. Psychiatrists and hospital administrators have a duty to keep their staff and the community safe, but this must be carefully balanced with their obligation to uphold the civil rights and liberty interests of their patients. A critical decision in this balancing is whether to utilize security restraints during patient transportation. Addressing these competing interests while striving to safely transport forensic hospital patients to the community can be challenging as hospital staff and patient advocates may voice strong, and sometimes opposing, opinions about this debate. Very little research has been conducted about these high risk and often contentious actions. Here, we describe the process for assessing risk for violence, self-harm, and elopement prior to transportation at one state forensic hospital using a pretransport risk-assessment tool created specifically for that purpose. We then present the results of research identifying which clinical and legal factors identified by our risk-assessment tool correlate with patients being transported with restraints. We also evaluated the potential for racial/ethnic and gender biases in this transportation risk-assessment process.