The United States Supreme Court and psychiatry in the 1990s.

In the 1990s, the Supreme Court has decided several cases that have had an impact on psychiatry and psychiatric patients in the criminal justice system, on psychiatric hospitalization, and on psychotherapist-patient privilege. Of the seven cases discussed in this article, Chief Justice Rehnquist and Justice Scalia voted similarly in all seven cases. Since joining the court, Justice Thomas has voted with them. Justice Scalia interprets the Constitution, using what has been termed "textualism": avoid reference to legislative history, and interpret the Constitution according to the plain language meaning of the relevant section. Chief Justice Rehnquist and Justices Scalia and Thomas are inclined to protect states' rights from court decisions that expand US Constitutional power in cases involving civil plaintiffs and criminal defendants. They seek to protect states from being sued in federal courts, and, if there is doubt, lean toward not interfering with state prerogatives. They tend to not find unenumerated rights and prefer clear-cut rules over amorphous standards. Justices Kennedy and O'Connor, at times joined by Justice Souter in the middle of the court, provide the deciding votes in many cases. They seem to prefer a case-by-case pragmatism over a global jurisprudential philosophy. Approaching cases one at a time, they usually avoid broad philosophic pronouncements when they join with Chief Justice Rehnquist. Justice Stevens, joined by Justices Breyer and Ginsburg since they have been appointed to the court, is more likely to favor a broader reading of the 14th Amendment's Due Process and Equal Protection clauses. Of the seven cases, Kennedy and O'Connor voted with the majority in five cases, the dissent in one case (Zinermon v Burch), and split their votes in one case (Foucha v Louisiana, with O'Connor siding with the Court and Kennedy with the dissent). Commager, a noted historian, believed that political issues can be explored, explained, and debated and that the people of the new American democracy, armed with knowledge and freedom to defend, argue, and choose, will make the right decisions for their common welfare. This theory applies equally to the court: Whenever questions involving psychiatry and psychiatric patients are brought to the court, American psychiatry must make its views known in that forum. To do so requires awareness and knowledge of the cases that involve psychiatry and psychiatric patients that the court has decided, including those decided in the 1990s. To participate effectively, psychiatrists must understand the political landscape in which the cases arrive at the court's doorstep and the composition and leanings of the court and examine carefully the fact patterns (understanding that some fact patterns are more sympathetic than others). This awareness should result in amicus briefs that are scholarly, rely on empiric data, and are scrupulously honest about the limitations of our knowledge. In this way, psychiatrists may fully participate in the debate and aid the court in its exploration and analysis of the issues involving psychiatry and psychiatric patients.

Teaching forensic psychiatry to psychiatric residents.

This study outlines current trends in the education of psychiatric residents in forensic psychiatry. As general psychiatrists are more frequently confronted with issues pertaining to psychiatry and the law, residency training in these areas becomes increasingly important. In order to study the educational experience of psychiatric residents in forensic psychiatry, a survey was sent to all residency training directors in the United States and Canada. The findings of the study included a description of didactics and experiential rotations in forensic psychiatry, the background of those teaching forensics, inclusion of key topics in the curriculum, and the training directors' opinions of both the importance of forensic education and the inclusion of these specific topics in the curriculum.

Involuntary hospitalization and police referrals to a psychiatric emergency department.

This study compares the demographic and clinical characteristics of police referrals with referrals from other sources to the psychiatric emergency department of a university hospital and the demographic and clinical characteristics of police referrals who were involuntary hospitalized with police referrals who were discharged from the emergency department (ED). In our study, 182 cases were seen in the psychiatric ED over the one-month period; 32 (17.6%) were police referrals. Police referrals were not more frequently hospitalized than referrals from other sources. Police referrals were, however, more likely to have been violent towards others preceding admission (59.4% versus 20.0%; chi 2 = 20.8; df = 1; p < .01) and to be intoxicated on presentation (31.3% versus 10.7%; chi 2 = 91; df = 1; p < .01). Police referrals also were significantly more likely to be violent in the psychiatric ED than referrals from other sources (37.5% versus 3.4%, chi 2 = 36.5, df = 1, p < .01) and to be restrained or secluded (34.4% versus 4.0%; chi 2 = 28.8; df = 1; p < .01). Involuntarily hospitalized police referrals were significantly more likely to be suffering from a major psychiatric disorder than police referrals not hospitalized (83.3% versus 11.8%; chi 2 = 14.7; df = 1; p < .01). They also were significantly more likely to have been violent towards other ED (66.7% versus 23.5%; Fisher test, p < .05) and to have been restrained or secluded in the ED (58.3% versus 23.5%; Fisher test, p < .05) than police referrals who were not admitted.

Medication refusal and judicial activism: a reexamination of the effects of the Rivers decision.

OBJECTIVE: In 1986 New York State courts in Rivers v. Katz mandated judicial review of cases in which involuntarily hospitalized psychiatric patients formally refuse medications; previously only a clinical-administrative review was required. In an earlier study the authors found that formal refusals of medications declined significantly in the year after the Rivers decision and that length of time between refusal and its resolution increased. To determine whether these effects were maintained over time, data for the second year after the Rivers decision were examined. METHODS: Chi square analysis and analysis of variance were used to compare data from both a private and a state-operated hospital for the year before the Rivers decision with data from the first and second years after. RESULTS: The significant declines in the number of patients formally refusing medications were maintained in the second year after Rivers at both hospitals, as were the significant increases in the length of time to resolution. In the second year, judges continued to uphold the treating psychiatrists' recommendations. The decline in the refusal rates was not found to be part of a broader trend that had been manifest before the Rivers decision. CONCLUSIONS: The sharp decline in refusals resulted in fewer patients having their medications reviewed by others not directly involved in their care. Increased time to resolution has diminished quality of care and has resulted in increased patient decompensation and staff injuries.

Murder, insanity, and medical expert witnesses.

Recent advances in the ability to study brain anatomy and function and attempts to link these findings with human behavior have captured the attention of the legal system. This had led to the increasing use of the "neurological defense" to support a plea of not guilty by reason of insanity. This article explores the history of the insanity defense and explores the role of the medical expert witnesses in integrating clinical and laboratory findings, eg, computed tomographic scans, magnetic resonance scans, and single-photon emission computed tomographic scans. Three cases involving murder and brain dysfunction are discussed: the first case involves a subarachnoid hemorrhage resulting in visual perceptual and memory impairment; the second case, a diagnosis of Alzheimer's disease; and the third case, the controverted diagnosis of complex partial seizures in a serial killer.

Right to refuse treatment: impact of Rivers v. Katz.

This article examines the impact of the New York court decision, Rivers v. Katz, which in June 1986 dramatically changed the state procedure for responding to involuntarily committed psychiatric patients who formally refused psychopharmacologic treatment. The court rejected the medically administered review process that had been used to respond to involuntarily committed psychiatric patients who formally refused medication, and replaced it with a judicial determination of competent and "substituted judgment" provided by the court. Post-Rivers, the rate of patients consistently refusing treatment decreased, and the time from refusal to resolution increased. The clinical, legal, and economic implications of the Rivers procedure are discussed.

The insanity defense: asking and answering the ultimate question.

The authors address the main questions in the insanity defense debate: Should it be abolished? Should psychiatrists participate as expert witnesses? Is the profession damaged by such testimony? Is there a logical leap between providing psychiatric findings and providing an opinion to the ultimate question? Because the free will/determinism model underlying the current insanity defense positions can be used to argue either side of the debate, it does not supply any rational answers. The authors reframe the discussion, using a systems approach, and suggest answers to these questions that are in line with the clinical realities and on a firmer philosophic ground.

Case report of a possible interaction between neuroleptics and carbamazepine.

A 52-year-old woman with bipolar disorder, rapid-cycling type, developed delirium while taking therapeutic doses of carbamazepine and neuroleptics. Her cognitive changes were attributed to a drug interaction at the CNS level.

Forensic psychiatry and applied clinical ethics: theory and practice.

The authors briefly describe and then apply a new method--applied clinical ethics--for identifying and working with ethical problems. This method, starting from the clinical context, develops ethical constructs that may be tested in clinical practice and revised if required. The work was done in the context of a combined university-county forensic psychiatric service. The authors discuss three of the identified ethical issues: effects of deinstitutionalization, countertransference with forensic populations, and prediction of dangerousness. They discuss the basis for developing ethical norms from clinical experience and suggest ethical guidelines for medical practice.

Effects of lithium on evoked potentials and performance during sustained attention.

Two versions of the continuous performance test (CPT) differing in complexity were administered to 15 patients with bipolar affective disorder, manic type before and after treatment with lithium. Reaction time, performance accuracy, and the late positive component (LPC) of the event related potential evoked by the task were measured concurrently. Lithium treatment decreased errors of commission on both CPT tasks, although the difference was significant only for the simpler task. Reaction time was significantly increased by lithium treatment on the more difficult CPT task, LPC amplitude to the target stimulus on the difficult CPT was significantly increased by lithium. The data are interpreted as consistent with an attention-enhancing effect of lithium, coupled with a general reduction in the tendency to respond to stimuli.