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PubMed1988

Psychiatry and the criminal justice system: testing the myths.

Several states are changing legislation and treatment programs for mentally ill offenders without knowing how current laws and programs operate. To address this problem the authors linked data from police records, court reports, and clinical files for 2,735 psychiatric referrals from the criminal justice system of Alaska from 1977 through 1981. They found that only 0.2%-2.0% of all schizophrenic persons in the community were arrested for violent crimes each year, accounting for 1.1%-2.3% of all arrests for violent crimes; that psychiatrists agreed about competency and responsibility in 79% of the cases evaluated by more than one clinician; and that a successful insanity defense occurred in 0.1% or less of all criminal cases.

Adolescent↗
PubMed1988

Effects of diagnosis and context on dangerousness.

The authors extensively reviewed the medical records of 253 patients hospitalized on a locked, university-based psychiatric unit. They found that schizophrenic and manic patients were more likely than patients with other diagnoses to be assaultive before admission. In the hospital, however, manic patients were the most likely to be assaultive. The results of this study show that the risk of violence among different diagnostic groups of patients varies according to context and is moderated by situational variables. These findings have implications for the assessment of dangerousness before and during hospitalization.

Acute Disease↗
PubMed1988

The new preventive detention: psychiatry's problematic responsibility for the control of violence.

The legal doctrine of the duty to protect potential victims of patients' violent acts has created problems beyond those usually discussed, which involve breach of patients' confidentiality. Fear of liability has led some psychiatrists to hospitalize, solely for the purpose of preventing violence, patients who do not otherwise require inpatient care. The result has been the creation of a de facto system of preventive detention that consumes psychiatric resources intended to serve therapeutic ends and compels psychiatrists to share the social control responsibilities of the criminal justice system. The author explores the costs and benefits of various means of removing the burden of preventive detention from psychiatry.

Commitment of Persons with Psychiatric Disorders↗
PubMed1989

An empirical comparison of the stone and dangerousness criteria for civil commitment.

Massachusetts civil commitment criteria were compared in an emergency setting with a set of criteria developed by Dr. Alan Stone. Contrary to expectations, the Stone criteria proved to be more restrictive in a sample of 503 patients. Few patients would be newly committable under the Stone criteria; of the 35 patients committable under the Stone standard, 32 also met the current Massachusetts criteria for commitment. The clinical and policy implications of the adoption of the Stone criteria are discussed.

Adult↗
PubMed1989

Commitment: the consistency of clinicians and the use of legal standards.

The reliability and validity of the application of legal criteria for commitment were investigated as part of a larger study. Evaluations of 411 patients by 96 different clinicians showed good interrater reliability for assessment of dangerousness and committability. A strong relationship between ratings of committability and ratings of dangerousness suggests that clinicians were conforming to the logic of the commitment law. Discrepant cases involved patients who desired voluntary admission or whose commitment was completed elsewhere. Results suggest fair application of commitment standards but that two issues of statutory interpretation confused participating clinicians.

Commitment of Persons with Psychiatric Disorders↗
PubMed1989

An empirical study of emergency commitment.

The authors examine the emergency commitment process in one Oregon county and present data that document the impact of a local detention facility. The study reconfirms the dependence of commitment processes on the mental health system in which they occur, illustrates the relative inability of specific laws to determine the actual nature of commitment processes, provides support for the concept of community care for the people involved, and points to the need for additional research to clarify the effects of commitment procedures.

Commitment of Persons with Psychiatric Disorders↗
PubMed1989

Civil commitment standards and patient mix in England/Wales, Italy, and the United States.

Although England/Wales, Italy, and the United States share a common policy of deinstitutionalization, their mental health systems differ considerably. Each country's civil commitment standards define patient eligibility criteria along one of two primary dimensions--need for treatment or degree of dangerousness. These differential selection criteria result in mental health systems serving different subgroups of the total population. The criteria in England/Wales target older women; in the United States, younger men; and in Italy, a group balanced in age and sex. Implications for the current debate on civil commitment policies are considered.

Adolescent↗
PubMed1991

Decision making in psychiatric civil commitment: an experimental analysis.

OBJECTIVE: Legislation in Canada and the United States that was intended to decrease the use of civil commitment has resulted in a paradoxical increase in involuntary hospital admissions. To elucidate the reasons for this increase, this study was designed to assess the relative importance of various factors involved in the decision to commit a patient. METHOD: All psychiatrists in Ontario were sent a questionnaire asking them to make commitment decisions based on hypothetical case vignettes. Four factors were systematically varied in the vignettes: the patients' legal commitability, clinical treatability, alternative resources, and psychotic symptoms. Completed questionnaires, with three vignettes each, were returned by 495 respondents. RESULTS: All four variables were statistically significant in the expected direction; legal commitability (i.e., dangerousness to self and/or others, inability to care for self) and presence of psychotic symptoms accounted for the majority of the variance in the final decision to commit. CONCLUSIONS: These results suggest that psychiatrists in Ontario rely primarily on legally mandated factors (i.e., psychosis and dangerousness) in making their decisions to commit, although a considerable amount of individual variation is also evident.

Adult↗
PubMed1991

Monitored conditional release of persons found not guilty by reason of insanity.

This article reviews the recent literature documenting changes that have taken place in the management and treatment of insanity defense acquittees with the development of conditional release and monitored community treatment. The review demonstrates that conditional release is particularly important as a means of balancing the protection of society with the treatment of insanity defense acquittees in the least restrictive environment. The review also highlights the development of community programs based on treatment models for the chronically mentally ill. In addition, monitored community treatment programs appear cost-effective when compared with hospital-based programs. These factors point to the development in the 1990s of program standards for the release of insanity defense acquittees.

Civil Rights↗
PubMed1991

Outcome of involuntary medication in a state hospital system.

OBJECTIVE: The purpose of the study was to examine the course of involuntarily administered medication in a state hospital population. METHOD: The authors retrospectively examined the records of all 51 involuntarily medicated patients in six state hospitals in New York City in a single calendar year. Clinical course was recorded for the period of involuntary medication and for 12 months thereafter. These patients were compared to 51 patients on the same wards who accepted medication. RESULTS: Clinicians assessed involuntarily medicated patients as more dangerous to themselves or others and less delusional after treatment than the comparison patients. Long-acting intramuscular antipsychotics were prescribed more frequently for involuntarily medicated patients. No differences were observed in rates of discharge, outpatient cooperation, or rehospitalization. Half of the patients in both groups remained continuously institutionalized, and of those who left the hospital, only 30% of the involuntarily medicated group and 40% of the comparison group took medication as outpatients. CONCLUSIONS: For these chronically severely ill patients, involuntary medication did not appear to enhance insight or cooperation or result in rapid return to the community. Involuntary medication is often a necessary short-term, in-hospital management strategy, but it does not replace the need to develop comprehensive, long-term inpatient and community-based approaches to the management of treatment refusal.

Adult↗