Evaluations of competence to stand trial are evolving amid a national "competency crisis".

Across the United States, court orders for competence to stand trial (CST) evaluations and competence restoration services have been increasing much more rapidly than states can provide these services, prompting what has been called a national "competency crisis." The challenge in providing timely competence restoration services has, in several jurisdictions, prompted a change in competence evaluations. Evaluators are more often required to address broader clinical issues-such as recommending placement or addressing the urgency of hospitalization-rather than addressing only CST. This marks an evolving practice in forensic evaluation, which moves evaluators beyond the very narrow forensic question of competence and into more traditionally clinical recommendations. We describe several state examples of changing practice in order to highlight the initial barriers, and potential benefits, to addressing additional clinical issues in competence evaluations, amid a national competence crisis.

Substance use treatment services utilization and outcomes among probationers in drug courts compared to a matched cohort of probationers in traditional courts.

BACKGROUND AND OBJECTIVES: Drug courts provide an array of substance use treatments and community-based services for probationers struggling with substance use disorders. We assessed substance use treatment services utilization and related expenditures and relapse and recidivism outcomes and identified predictors of cost of provision of substance use treatment services in a matched cohort of Massachusetts probationers in drug courts and traditional courts. METHODS: This was an observational quasi-experimental study with 542 propensity-score-matched probationers initiating drug court between August 1, 2015 and February 28, 2018 and a minimum 6-month follow-up period. RESULTS: A significantly greater proportion of probationers in drug courts were female, self-reported opioids as their primary drug of choice, had a history of substance use treatment, and a high and very high risk of recidivism than their counterparts in traditional courts. We estimated that the provision of substance use treatment services was $1498 more expensive for probationers in drug courts than traditional courts (p = .054). There were no statistically significant differences in relapse or recidivism rates between court systems. DISCUSSION AND CONCLUSIONS: Probationer's age, gender, risk of recidivism at court intake, and enrollment length were strong predictors of expenditures on substance use treatment services. SCIENTIFIC SIGNIFICANCE: This was the first study to assess substance use treatment services utilization and outcomes among probationers in drug courts and traditional courts. Drug courts served the needs of probationers disproportionally impacted by nonserious drug-related offenses struggling with substance use disorders who were at a high and very high risk of recidivism at court intake.

Influence of the HCR-20, LS/CMI, and PCL-R on decisions about parole suitability among lifers.

Among 5,181 inmates indeterminately sentenced to life in California who were evaluated for parole suitability between January 2009 and November 2010, 11% were granted parole. After administration of the HCR-20, LS/CMI, and PCL-R, psychologists judged most inmates (78%) to be at low or moderate risk for future violence. This overall risk rating (ORR) was significantly associated with parole suitability decisions. Moderate to large associations were observed between the ORR and all risk indices. The HCR-20 Clinical and Risk Management scales demonstrated the strongest associations with parole suitability decisions. Among the LS/CMI scales, Procriminal Attitudes and Leisure/Recreation were most predictive of failure to obtain parole. PCL-R scores had little influence on parole suitability decisions beyond the HCR-20 and LS/CMI. Overall, findings suggest parole board members' decisions were consistent with empirically supported practice, in that individuals assessed to be at relatively low risk were far more likely to be granted parole than those assessed to be at moderate or high risk for future violence.

Estimating the Size of the Los Angeles County Jail Mental Health Population Appropriate for Release into Community Services.

In 2015, the Office of Diversion and Reentry Division (ODR), an internal department of the Los Angeles County Department of Health Services, was created to redirect individuals with serious mental illness from the criminal justice system. Part of ODR's mission is to identify individuals currently incarcerated in a Los Angeles County jail who are experiencing a serious mental health disorder and, to the extent practical, provide them with appropriate community-based care with the goals of reducing recidivism and improving health outcomes. Such redirection from the traditional criminal justice process is often characterized as diversion. To better build and scale efforts to support this work, in 2018, the Los Angeles County's Board of Supervisors asked for a study of the existing county jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors. Researchers found that an estimated 61 percent of the jail mental health population were likely appropriate candidates for diversion; 7 percent were potentially appropriate; and 32 percent were likely not appropriate candidates for diversion. These findings will help the county determine how it would need to scale community-based treatment programs to accommodate these individuals. The authors also provide recommendations for future programming and research. This study will be of interest to state and county governments as well as other organizations serving criminal justice-involved populations with serious mental illness.

Gender and the experience of mental health expert witness testimony.

Mental health expert witness testimony involves complex tasks, and the capacity to perform under pressure is a fundamental skill of a forensic professional. In this context, it is important to understand the nuances of the provision of expert witness testimony. There have been several efforts to examine gender bias across legal and medical systems. Despite these reviews, little is known about how men and women differ or are similar with regard to performing expert witness functions. The purpose of this pilot study was to examine whether the testimony experiences of psychiatry and psychology experts vary by gender. Differences across certain domains, such as the sense of never experiencing anxiety and the sense of one's impact on case outcome were seen across genders. Few other gender-based differences in the experience of providing expert witness testimony were seen. Although the findings of this study raise further questions, they highlight some of the important subtleties noted in forensic practice and the work of the expert witness. In future studies, researchers should continue to explore these findings on the influence of gender and expand to consider culture and race as additional factors in the experience of expert witness testimony. As forensic professional practice evolves, it is important to understand unique aspects of forensic practice, to improve training of forensic experts, and to assist forensic experts in anticipating what they may experience related to the provision of expert testimony.

Relationship between race and ethnicity and forensic clinical triage dispositions.

OBJECTIVE: Racial and ethnic disparities in the criminal justice system have been widely reported, as have racial and ethnic disparities in diagnoses and certain aspects of clinical management. This study examined the association between race and ethnicity and dispositions for pretrial defendants who were referred for forensic mental health evaluations. METHODS: Available data were reviewed for all defendants in Massachusetts who were referred to a Massachusetts court clinic from 1994 to 2001 for a screening evaluation of their competence to stand trial, their criminal responsibility, or both. Logistic regression models were developed to assess the relationship between defendants' race and ethnicity and the likelihood that they would be referred for inpatient evaluation and the likelihood that they would be evaluated within a strict-security facility. Race or ethnicity of the pretrial defendants was identified by clinicians. RESULTS: Blacks, but not Hispanics, were significantly more likely than whites to be referred for an inpatient evaluation after an outpatient forensic screening evaluation. Among male defendants, both Hispanics and blacks were more likely than whites to be referred for an inpatient evaluation in a strict-security facility, regardless of diagnoses and the level of severity of the criminal charges. CONCLUSIONS: Racial and ethnic disparities in disposition decisions exist within the forensic mental health system. These disparities, however, likely reflect numerous clinician and nonclinician variables.

Use of a state inpatient forensic system under managed mental health care.

OBJECTIVES: One of the goals of managed mental health care has been to lower the use of inpatient psychiatric treatment. In the past, interventions that have limited hospitalization for persons with severe mental illness have led to greater involvement of these individuals with the criminal justice and forensic mental health systems. The authors examined associations between Medicaid managed mental health care in Massachusetts and rates of admission to the inpatient forensic mental health service maintained by the state's mental health department. METHODS: A total of 7,996 persons who were receiving services from the department before and after the introduction of managed care were studied. A logistic regression model based on generalized estimating equations was used to identify associations between Medicaid beneficiary status and forensic hospitalization before and after the introduction of managed care. RESULTS: The overall rate of forensic hospitalization declined in the study cohort in both periods. However, no significant decline was observed in the risk of forensic hospitalization among Medicaid beneficiaries whose care had become managed. CONCLUSIONS: Although the results of this study warrant further exploration, the risk of forensic hospitalization among Medicaid beneficiaries should be considered by policy makers in the design of mental health system interventions.

Self-reported lifetime psychiatric hospitalization histories of jail detainees with mental disorders: comparison with a non-incarcerated national sample.

Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mentally ill jail inmates have reduced access to psychiatric inpatient treatment, without addressing the adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.