PTSD and Trauma as Mitigating Factors in Sentencing in Capital Cases.

Posttraumatic stress disorder (PTSD) is commonly used as a mitigating sentencing factor, although how successfully it is used varies. In cases involving the death penalty, use of a PTSD diagnosis as a sentencing mitigating factor has been considered in the postconviction appeals process. This article analyzes a decade of American federal appellate case law regarding postconviction claims of ineffective assistance of counsel by capital defendants in regard to investigating and litigating trauma and PTSD. We found a high tolerance by the courts for deficient investigating, ruling against the petitioner in 20 of 23 (87%) of identified cases. The article discusses how these situations might be avoided and explores the critical role of forensic psychiatrists and mitigation specialists in investigating and presenting trauma to the court.

Practical Steps Towards Identifying and Assisting Victims of Domestic Violence.

Domestic violence is prevalent among psychiatric patients; however, utilization of screening, safety, and legal interventions is low among mental health practitioners. In this column, the authors review interventions that can assist with the identification of victims of domestic violence in daily practice and provide an overview of steps that can be taken to aid these victims and reduce the chance of future violence.

Prevalence Rates of Acute Stress Disorder Symptomatology and Association to Juvenile Crime Involvement.

Little is known about the relationship between acute stress disorder and criminal behavior among youth. This study examined data from the National Comorbidity Survey-Adolescent Supplement (NCS-A). Participants in this survey, which took place between February 2001 and January 2003, consisted of 10,148 youth between the ages of 13 and 18 years. Because the NCS-A was conducted prior to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), symptoms of posttraumatic stress disorder from the fourth edition of the DSM were mapped to DSM-5 criteria for ASD. Due to changes in the DSM-5 criteria for ASD, youth in this study were described as having "ASD symptomatology." Youth with ASD symptomatology were significantly more likely to report involvement in crimes than youth without any lifetime diagnosis, regardless of whether the crimes resulted in arrest. The data presented here provide a more accurate picture of the relationship between ASD and crime. These data suggest that it may be useful to develop prevention and intervention strategies that provide education and support to at-risk youth who develop ASD symptoms. The quality of life for untreated youth decreases significantly, and untreated youth are likely at risk for criminal involvement, suicide, and other comorbid psychiatric disorders.

Homicidal Ideation and Individuals on the Autism Spectrum.

Interest in the relationship between autism and violence has increased in recent years; however, no link has clearly been established between them. Researchers remain curious if autistic people with certain traits (e.g., a history of trauma) are at greater risk of violence than those individuals with autism alone. In this article, we detail two individuals with homicidal ideation (HI) admitted to inpatient psychiatric units who were found to have a diagnosis of autism without language impairment. These cases illustrate the need for mental health providers to consider autism in their differential diagnosis when evaluating an individual with HI. Broadly, we consider how an autistic individual could be susceptible to developing HI and explore treatments specific to autistic individuals that may be helpful in such cases.

Extreme Risk Protection Orders to Reduce Firearm Violence.

Many states have adopted risk-based, preemptive gun removal laws to reduce gun violence. In this column, the authors describe the general structure of these laws, consider arguments for and against them, and briefly review the evidence regarding their impact. As psychiatrists in a state that recently implemented such a law, the authors consider the possible impact of the law on their practice and the well-being of their patients and the public, including the possibility that they and other Oregon psychiatrists could be held liable for failing to address the topic of gun seizure with a patient's family.

Contemporary Routes of Cannabis Consumption: A Primer for Clinicians.

Although cannabis use is federally prohibited, medical cannabis is legal in some form in 30 states and the District of Columbia, and recreational use is legal in 8 states and the District of Columbia. The increasing legal acceptance of cannabis has led to a burgeoning industry that is producing an expanding variety of cannabis products. Physicians and other health care professionals should be aware of modern forms of cannabis consumption, as well as variations in tetrahydrocannabinol concentrations, to improve assessment of cannabis use and approach to treatment. This review aims to familiarize clinicians with modern forms of cannabis consumption and enable comparisons between disparate cannabis products.

Predictors of Competency to Stand Trial in Connecticut's Inpatient Juvenile Competency Restoration Program.

There are substantial differences between adults and juveniles in the context of competency restoration. Among juveniles, factors such as maturity level, age, intellectual functioning, and psychiatric diagnoses may affect competency to stand trial. In this study, subjects included all juveniles who were admitted to the Albert J. Solnit Children's Center for inpatient competency restoration in the period spanning January 1, 2005, through December 31, 2012. Sixty-one juveniles were referred during this period, and 58 were included in the final analyses. Several demographic and clinical variables were tested to identify which factors were associated with successful competency restoration. There was a high rate of psychiatric comorbidity in the sample, with 54 of 58 juveniles (93%), having more than one Axis I disorder. IQ was the only significant predictor of successful competency restoration. These findings suggest that cognitive limitations may be a robust predictor of competency restoration among juveniles who are deemed incompetent to stand trial. Furthermore, policy makers may want to consider more specialized services for youths whose intellectual deficits are severe enough to impact their ability to regain competency. Limitations of this study, policy recommendations, and suggestions for future research are discussed.

Oregon Supreme Court Ruling Prohibits Hospital from Refusing a Sell Order.

In a recent decision involving a capital murder case, Oregon State Hospital v. Butts, the Oregon Supreme Court conducted a mandamus hearing to ascertain whether Oregon State Hospital (OSH) had a legal duty to comply with a Sell order from a county trial court to provide antipsychotic medications to an incompetent defendant, despite its belief, as an institution, that medication was not clinically indicated. The case is reviewed and important implications, including the court's being granted the ability to circumvent the medical decision-making process, are discussed.

The Oregon Health and Science University-Oregon State Hospital Collaboration: Reflections on an Evolving Public-Academic Partnership.

This column describes the conceptualization and implementation of an innovative collaboration between Oregon State Hospital and Oregon Health and Science University that was created to address understaffing and improve the quality of care. The hospital created a forensic evaluation rotation to address the growing population of forensic patients, which created a valuable recruiting tool for the hospital. One of the authors, a recent recruit, provides a first-person account of his experience working within the collaboration. The model could be emulated by other public-sector facilities facing similar challenges with psychiatrist recruitment and retention.

Reflective team supervision after a frightening event on a psychiatric crisis service.

OBJECTIVE: The authors demonstrate the value of reflective team supervision as part of the informal curriculum in an emergency psychiatry setting after a potentially traumatizing adverse event. METHOD: The article gives a case presentation of a violent adolescent who eloped from his hospital Emergency Department and provides a description of team supervision sessions that facilitated informal learning for residents and medical students after this event. RESULTS: Reflective team supervision sessions after this event resulted both in improved resident well-being and learning opportunities, as well as hospital quality improvement designed to prevent future elopements. CONCLUSIONS: Reflective team supervision can be an essential component of trainee education to enhance residents' well-being and to promote both systems-based practice and practice-based learning. This can be an excellent forum to explore themes of humility, self-reflection, and professional growth.

Ethosuximide-induced mania in a 10-year-old boy.

Psychosis and suicidal ideation have been reported as side effects of ethosuximide treatment, but previous reports seldom place these symptoms in the context of mania. Given the recent renewed interest in ethosuximide as first-line therapy in children and adolescents, it is important for clinicians to be aware of the potential psychiatric complication of mania with this medication. Described here is the case of a 10-year-old boy who developed acute mania, as well as psychotic symptoms and suicidal ideation, on ethosuximide.