Mute by Visitation of God, Competency to Stand Trial and Fitness to Plead.

Laws on competency to stand trial and fitness to plead are said to derive from "mute by visitation of God," a medieval English legal term referring to the inability to speak through no fault of one's own. The paper describes the relevant historical background, illustrative cases, and legal commentaries. Muteness by visitation of God arose to address a particular set of difficulties caused by the need to have medieval defendants agree to be tried. Competency to stand trial and fitness to plead, on the other hand, arose to address more general and enduring concerns, that putting people on trial when they were unable to understand or participate compromised the dignity and fairness of criminal proceedings. The origins of competency to stand trial and fitness to plead do not lie in medieval English attempts to persuade silent defendants to speak. They warrant their own historical exegesis.

Victimization in schizophrenia and its relation to violence.

BACKGROUND: People with schizophrenia are frequently victims of violence. Previous attempts to examine the reasons for this have mostly used cross-sectional designs that limit the ability to distinguish, among the correlates they identify, potential causes of victimization from its consequences. METHOD: We studied patients with schizophrenia participating in the NIMH-funded Clinical Antipsychotic Treatment for Intervention Effectiveness (CATIE) trial. The dependent variable was self-reported victimization during the 18-month CATIE follow-up. Independent variables were assessed at study entry and included demographics, childhood experiences, recent victimization and violent behavior, social circumstances, and mental health symptoms. Bivariate and multivariate analyses examined correlates of victimization and, among those victimized, the correlates of also acting violently oneself. RESULTS: Of 1179 participants, 206 (17.5 %) reported one or more incidents where they were victimized over the 18-months. Over a third had been hit with a fist or an object. Most perpetrators were family or acquaintances. Controlling for other variables, victimization was associated with having been recently victimized at baseline as well as with sexual abuse in childhood, frequent interactions with close friends and depressive, but not schizophrenia, symptoms. Victimized participants who reported acting violently themselves (113; 55%) were more likely to report violent behavior at baseline and frequent interactions with close friends. CONCLUSIONS: Victimization in schizophrenia is often associated with aggressive behavior by the victim and is more often related to social involvement, past trauma, substance use and depression than to schizophrenia symptoms. Treatments that encourage socialization may incur an unintended risk of victimization.

Psychosocial function, legal involvement and violence in mental disorder.

BACKGROUND: The correlates of legally significant outcomes that have been identified in people with mental disorders are of limited value in understanding the mechanisms by which these outcomes occur. AIMS: To describe the relationships between mental disorder, impaired psychosocial function, and three legally significant outcomes in a representative sample of the US population. METHODS: We used a population survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III, sample size 36,309), to identify people who self-reported serious trouble with the police or the law over the past 12 months and two lifetime outcomes, being incarcerated and engaging in violence to others. DSM-5 categories were generated using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Psychosocial function was assessed using social and role-emotional function scores of the 12-Item Short-Form Health Survey Version 2. RESULTS: Participants with mental disorder, but not people with no diagnosis, who reported serious trouble with the police or with the law during the previous 12 months reported significantly worse psychosocial function than those who did not report such trouble. The size of the statistical effect varied by diagnosis, moderate for some forms of mental illness and for alcohol abuse and nonsignificant for drug abuse and the personality disorders. Effect sizes were largest for diagnoses where legally significant outcomes were least common. CONCLUSIONS: The effect of impaired psychosocial function, for instance in disrupting family and social networks that would otherwise protect against these legally significant outcomes, warrants further investigation in studies with longitudinal designs.

An 18-month longitudinal study of suicidality in patients diagnosed with schizophrenia.

BACKGROUND: Suicide kills over 30,000 people annually in the US. Schizophrenia increases the risk, even in psychiatric populations. Identifying high-risk groups within this patient population is central to suicide prevention. We tested the effects of known and putative risk factors for suicide in a clinically recognizable population with symptoms of schizophrenia and unstable illness. METHODS: We studied 1439 subjects with schizophrenia participating in the NIMH-funded Clinical Antipsychotic Treatment for Intervention Effectiveness (CATIE) trial and followed for 18 months. The dependent variable was moderate to severe self-reported suicidal thinking and self-reported suicide attempts. The independent variables comprised potential risk factors for suicidality including measures of clinical change during follow-up. Proportional hazards models of time to first suicidality generated bivariate and multivariate hazard ratios (HRs). RESULTS: Altogether 96 patients (7.6%) experienced moderate to severe suicidality in the course of 18 months. Multivariate analyses showed that baseline moderate or severe suicidality was the strongest correlate of subsequent moderate or severe suicidality (HR 5.1). An increase in a subject's depression score during follow-up was also independently and strongly associated with suicidality (HR 3.5). A change in psychotic symptoms was not. CONCLUSIONS: Depression and despair may be more important risk factors for suicidality among people with schizophrenia than psychotic decompensation. Strategies for prevention that seek to identify groups at high risk of suicide should focus on these variables, as well as the effect of prior suicidality.

Correlates of Future Violence in People Being Treated for Schizophrenia.

OBJECTIVE: Violent behavior is infrequent among individuals with schizophrenia but is clinically important. The purpose of this study was to provide data on the correlates of violence, which may allow better risk assessment and care. METHODS: A total of 1,435 individuals with schizophrenia who participated in the National Institute of Mental Health's Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and were followed for 18 months were examined. The dependent variables were self-reported injurious and noninjurious violence during follow-up. The independent variables, assessed at study entry, comprised participants' recent injurious and noninjurious violence, demographic and background variables, childhood risk factors, clinical condition, current circumstances, and recent contact with hospitals and prisons. Proportional hazards models of time to first injurious violence were used to generate bivariable and multivariable hazard ratios for all participants and, separately, for participants with no injurious violence at study entry. RESULTS: Seventy-seven participants (5.4%) reported engaging in injurious violence during follow-up, and 119 (8.3%) reported engaging in exclusively noninjurious violence. In the multivariable analysis, baseline injurious violence (hazard ratio=4.02), recent violent victimization (hazard ratio=3.52), severity of drug use (hazard ratio=2.93), baseline noninjurious violence (hazard ratio=2.72), childhood sexual abuse (hazard ratio=1.85), and medication nonadherence (hazard ratio=1.39) were associated with future injurious violence. For participants with no history of injurious violence at study entry, baseline noninjurious violence was the strongest predictor (hazard ratio=3.02). Recent violent victimization was no longer a significant correlate. The remaining correlates and the strength of their association with future injurious violence were similar to those for all participants. CONCLUSIONS: This is the first longitudinal multivariable analysis of predictors of injurious violence in a large cohort of patients with schizophrenia followed over 18 months. The results revealed simultaneous strong effects of baseline injurious violence and recent violent victimization on future injurious violent behavior. Among clinical variables, poor medication adherence, but not baseline symptoms of psychosis or depression, significantly predicted injurious violence. Treatment strategies to reduce risk should emphasize medication adherence.

Psychiatric Disorders and Crime in the US Population: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Wave III.

OBJECTIVE: Current knowledge regarding the intersection of psychiatric disorders and crime in the United States is limited to psychiatric, forensic, and youth samples. This study presents nationally representative data on the relationship of DSM-5 psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized US adults. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012-2013; N = 36,309). Logistic regressions were used to examine the association of specific disorders (eg, mood, anxiety, eating, posttraumatic stress, substance use), comorbid substance use and mental health disorders, and multimorbidity with lifetime criminal behavior, incarceration experience, and past-12-month general, alcohol-related, and drug-related legal problems. RESULTS: Overall, 28.5% of participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current general legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems. The presence of any disorder was associated with a 4 to 5 times increased risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime (adjusted odds ratio [AOR] = 6.8; 95% CI, 6.1-7.6) and incarceration (AOR = 4.7; 95% CI, 4.1-5.3) and current legal problems (AOR = 3.3; 95% CI, 2.6-4.2). Multimorbidity and comorbid substance use and mental health disorders were associated with additional risk. Controlling for antisocial personality disorder did not change the findings. CONCLUSIONS: Community adults with substance use disorders, comorbid substance use and mental health disorders, and increasing multimorbidity are most at risk of crime and justice involvement, highlighting the importance of community-based addiction treatment.

Logic Model of the Department of Veterans Affairs' Role in Veterans Treatment Courts.

Veterans Treatment Courts (VTCs) grew exponentially in the last decade with more than 550 courts, dockets and tracks operating in the U.S. Eligibility criteria and operating practices of VTCs vary widely. Existing logic models guide the activities of these courts, but do not explicitly address the distinct missions and priorities of different agencies that support VTCs. To facilitate communication and research to address this gap, we propose a logic model of the Department of Veterans Affairs' (VA) role in VTCs. To construct the VA-VTC logic model, we adapted an existing logic model and held expert panels with VA staff, clinical leaders and researchers to discuss and refine the model. The VA-VTC logic model is a novel contribution to current thinking about VTCs and clarifies the potential resources, activities, outputs, outcomes and population impacts that are under the purview of the VA. Explicitly recognizing the VA as a separate partner in VTCs, this logic model can be a tool for communication with criminal justice agencies to facilitate broader discussions about the mechanisms driving VTC outcomes. This model can also be continuously updated as we learn from research and evaluation efforts about VTCs, ultimate improving the effectiveness of the VA's role in these courts.

Correlates of Reduced Violent Behavior Among Patients Receiving Intensive Treatment for Posttraumatic Stress Disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has been linked to violent behavior, especially among military personnel returning from service in a war zone. Little is known, however, about whether the extent of violent behavior among persons with PTSD changes in response to intensive treatment or about the predictors and correlates of any such change. METHODS: The study examined data from over 35,000 U.S. military veterans treated in specialized intensive Veterans Health Administration PTSD programs. Data were collected at program entry and four months after discharge. Variables studied documented sociodemographic and biographical data, program participation, and clinical factors such as PTSD symptom severity and substance use. Violence was assessed by a self-report measure that addressed property damage, threatening behavior, and physical assault. RESULTS: Violence declined significantly between program entry and four-month postdischarge, with a moderate effect size. Most of the variance was explained by baseline levels of violence; those who reported the most violent behavior at baseline showed the largest reductions four months after discharge. The reduction in violence was more strongly correlated with reductions in patients' PTSD symptomatology and substance use than with their incarceration history or with other sociodemographic and biographical variables. CONCLUSIONS: Although an observational study cannot identify specific causes of reductions in violent behavior, these data suggest that the short-term support, shelter, and asylum that formed part of intensive treatment are associated with reduced violent behavior and that such services play an important role in the spectrum of care for war-related PTSD.

A Consultation and Supervision Model for Developing the Forensic Psychiatric Opinion.

Receiving feedback on one's work from colleagues is an essential part of clinical and forensic psychiatric practice. Often the material on which feedback is sought concerns past cases. When the material relates to current cases, particular safeguards are needed to protect important interests. This paper lists the interests that must be protected when feedback is provided through clinical consultation and supervision meetings in a forensic psychiatric training program. These are the interests of the person being evaluated, the attorneys, the people providing feedback to the evaluator, and the employers of the people providing feedback. The principles that the training program applies in determining attendance at, and participation in, these meetings are described. Finally, scenarios are presented that illustrate the application of these principles. Such application has allowed trainees and others to receive the benefits of consultation and supervision in the course of developing their opinions while protecting the interests of those involved.

Who needs capacity?

The UK Law Commission's Discussion Paper, Criminal Liability: Insanity and Automatism, recommends introducing the concept of capacity to the insanity defence. The concept of capacity has an established role in those parts of the law that concern the validity of the decisions that people make, for instance in composing a will or entering into a contract. Making mental capacity a criterion for criminal responsibility in a mentally disordered defendant, however, is potentially problematic. First, the term capacity already has several different meanings in the literature on the jurisprudence of mental abnormality. Second, using the concept of capacity in the way that the Law Commission proposes poses difficulties that relate to the provision of testimony by expert witnesses.

Respect for dignity and forensic psychiatry.

Respect for persons is one of forensic psychiatry's ethical principles. It is a principle that is usually laid down without conditions, raising the question of what aspect of someone's "personhood" might deserve our unconditional respect. This paper nominates dignity. One argument against respect for dignity as a principle is that anything it stands for can be subsumed into respecting people's autonomy. This seems not to be correct. Another argument has been that the term dignity has too often been used loosely and vaguely. This does not mean that the term itself is necesarily without value. Dignity seems to refer to something close to the moral meaning of "worth". Respecting dignity has a role in protecting the vulnerable. Respecting a client's dignity is an important aspect of the ethical practice of forensic psychiatry.

Rates of violence in patients classified as high risk by structured risk assessment instruments.

BACKGROUND: Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies. AIMS: To analyse the variation in rates of violence in individuals identified as high risk by SRAIs. METHOD: A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity. RESULTS: Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study. CONCLUSIONS: After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.

So you're sorry? The role of remorse in criminal law.

The role of remorse in judicial decisions in the criminal justice system has been addressed in scholarship and remains controversial. The purpose of this qualitative research was to examine the views of sitting criminal judges on remorse, its assessment, and its relevance in their decision-making. After approval of the study design by the institutional review board, 23 judges were interviewed in an open-ended format. Transcriptions of these audio-recorded sessions were analyzed phenomenologically by the research team, using the method of narrative summary. The results showed that the judges varied widely in their opinions on the way remorse should be assessed and its relevance in judicial decision-making. They agreed that the relevance of remorse varied by type of crime and the stage of the proceedings. The indicators of remorse for some judges were the same as those that indicated the lack of remorse for others. All the judges recognized that assessment of remorse, as well as judicial decision-making in general, must be altered for defendants with mental illness. The judges varied in their views of the relevance of psychiatric assessments in determining remorse, although most acknowledged a role for forensic psychiatrists.