Punishment or treatment?

Although there is strong support among the general public for providing insanity acquittees with mental health treatment, it is also believed that insanity acquittees should be punished when they break the law. Prior studies of the lengths of confinement of insanity acquittees have yielded inconsistent results. This article draws upon a large-scale, multistate study of insanity pleas to explore the question: Is society able to withhold punishment against persons acquitted of criminal charges due to insanity? Results indicate that offense seriousness is a more important factor than mental disorder in determining the lengths of confinement of persons foundNot Guilty by Reason of Insanity and that persons found guilty are more likely to be released without ever having been confined than persons acquited by reason of insanity. Implications for invoking offense seriousness as a primary criterion in assessments of dangerousness are discussed.     

Part I: The NGRI Registry: initial analyses of data collected on Connecticut insanity acquittees

The NGRI Registry is a comprehensive census database collected by the Law and Psychiatry Division of the Department of Psychiatry at the Yale University School of Medicine. This longitudinal database was compiled following a systematic search of all available docket books from the superior courts and mental health records from the state hospitals in Connecticut beginning in January 1970. Detailed life span information is available for 364 insanity acquittees identified during the search. Comparative analyses with four other locales suggested that there were regional differences in diagnoses of and crimes committed by the acquittees. These initial analyses demonstrate the promise of this registry becoming one tool for collaborative research on issues relevant to law and mental health.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--DoD. Final rule

This final rule is to reform CHAMPUS quality of care standards and reimbursement methods for inpatient mental health services. The rule updates existing standards for residential treatment centers (RTCs) and establishes new standards for approval as CHAMPUS-authorized providers for substance use disorder rehabilitation facilities (SUDRFs) and partial hospitalization programs (PHPs); implements recommendations of the Comptroller General of the United States that DoD establish cost-based reimbursement methods for psychiatric hospitals and residential treatment facilities; adopts another Comptroller General recommendation that DoD remove the current incentive for the use of inpatient mental health care; and eliminates payments to residential treatment centers for days in which the patient is on a leave of absence.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--Department of Defense. Final rule

This final rule establishes a mandatory preadmission authorization program for mental health services under CHAMPUS. Such a program is needed to promote quality assurance and contain rapidly increasingly costs in inpatient psychiatric care under CHAMPUS. By maintaining most of the procedures of the current voluntary preadmission authorization program, the final rule minimizes inconveniences for providers.     

Drug treatment refusal and length of hospitalization of insanity acquittees

Thirty-three insanity acquittees who had refused drug treatment were matched to a sample of nonrefusing hospitalized insanity acquittees in an attempt to measure the effect of treatment refusal on length of hospital stay. No measurable effects on the length of hospitalization were found. However, upon comparing the amount of time under court jurisdiction spent in the hospital and on conditional release in the community, it becomes evident that refusers spent significantly greater proportions of time hospitalized than the average hospitalized insanity acquittee, who had less hospitalization and spent more time on conditional release. These differences do not seem to be related to the issue of treatment refusal.     

Community-based care for people with severe mental illness in Canada

The development of mental health services for people with severe mental illness has in many ways paralleled that in other countries, particularly the United States. As reliance on inpatient psychiatric care has been sharply reduced, a wide range of community supports have been developed. Several distinct institutional and legal features have contributed to shaping the nature of these community supports, which are described herein. At present, the result is a highly fragmented system of care. Key evidence-based practices, notably assertive community treatment, supported employment, and integrated treatment for concurrent severe mental illness and substance use disorder, achieve considerable integration at the clinical level, but remain relatively unavailable in most provinces. The policy of regionalization of services risks inhibiting the development of such practices, which require more centralized technical assistance and monitoring. An evolutionary approach of gradually introducing integrated, evidence-based programs may provide the most feasible strategy for improving the system.     

Ironies of inclusion: social class and deinstitutionalization

This paper discusses changes in the social organization of mental institutionalization as they relate to developments in the wider social and economic environment. Despite dramatic changes in the system of inpatient psychiatric care during the last three decades, the historic division of labor between the private and the public system (with the latter treating the poor, the unemployed, and the nonwhite) has not ceased to exist. At the same time, under the influence of the postwar trend towards greater political integration of disadvantaged and marginal groups into society's central value systems, treatment of the mentally ill has become less segregated and more voluntary. An important implication of these two interacting trends--the changed legal position of the patient vis-à-vis the provider and the deteriorating economic position of the user of public psychiatric facilities--has been the exceeding irrelevance of one of the basic tenets of psychiatric care: that clinical treatment precedes social functioning. With two vignettes of chronic patients the article illustrates how symptoms and survival are fused in the contemporary, inclusionary system of care.     

Follow-up after release of insanity acquittees, mentally disordered offenders, and convicted felons

The authors compared 127 insanity acquittees in the state of Maryland with a matched prisoner control group of 127 convicted felons and a comparison group of 135 mentally disordered prisoners transferred for hospital treatment. Subjects were followed from five to 17 years after discharge from hospital or release from prison. Subsequent arrests, hospitalizations, employment, and functioning of these large cohorts were studied and compared. The study focused on outcome data at five years after release. The authors found that, at five years postrelease, 54.3 percent of the insanity acquittees, 65.4 percent of the prisoner control group, and 73.3 percent of the mentally disordered prison transfers were rearrested. At 17 years postrelease, rearrest rates increased to 65.8 percent of the insanity acquittees, 75.4 percent of the prisoner controls, and 78.4 percent of the prison transfers. Significantly more mentally disordered prison transfers than NGRIs were rehospitalized during the follow-up period. Overall, the prison transfers had significantly poorer outcomes on nearly all variables studied compared with the other two groups. The authors conclude that although there were a substantial number of rearrests among insanity acquittees, that group had a statistically significantly lower rate of criminal activity compared with the other two groups of offenders.     

Demythologizing inaccurate perceptions of the insanity defense

Public opinion data show that the most prevalent concern expressed regarding the insanity defense is that it is a loophole through which would-be criminals escape punishment for illegal acts. This article examines the extent to which the public's perceptions of the insanity defense are consistent with newly collected empirical data. Specifically, it compares perceptions of the use, success, and outcomes associated with the insanity defense to data derived from a large-scale study of insanity pleas in eight states. The analysis reveals that the public overestimates the use and success of an insanity defense and underestimates the extent to which insanity acquittees are confined upon acquittal. The role of selective media reporting in the formation of public perceptions is discussed.An earlier version of this paper was presented at the 1992 meetings of the Society for the Study of Social Problems. Special thanks go to John Monahan and Joel Dvoskin for reviewing an earlier draft and to Sharon Steadman for providing editorial comments.     

The psychiatrist's guide to right and wrong: Part IV: The insanity defense and the Ultimate Issue Rule

In the wake of Hinckley, widespread public dissatisfaction with the role of psychiatrists in insanity defense litigation prompted Congress in 1984 to amend the Federal Rules of Evidence to prohibit psychiatric testimony on the ultimate legal issue of whether or not a defendant is insane. APA's Statement on the Insanity Defense served as the ably articulated premise for this evidentiary amendment. APA argued that in going beyond their psychiatric expertise by answering ultimate issue questions as to whether defendants are legally insane, experts are likely to confuse the jury and undermine public confidence in psychiatry. APA also asserted that there was an impermissible logical leap between scientific psychiatric inquiry and moral-legal conclusions on the ultimate issue of insanity. This article reviews the origins, history, and vicissitudes of the Ultimate Issue Rule and analyzes the Statement on the Insanity Defense from both a legal and psychiatric perspective on the issue of whether psychiatrists should answer the ultimate question in insanity cases. The analysis suggests that APA's conclusions are not supported on scientific or evidentiary grounds, but may be warranted as a policy consideration to safeguard the public image of psychiatry.     

The New York State Insanity Defense Reform Act of 1980: a legislative experiment

Through a statistical analysis of major changes in postacquittal procedures of the Insanity Defense Reform Act of 1980 (IDRA 1980), the study reveals the Act's success in formalizing, regularizing, juridicizing, accelerating, and extending to all acquittees psychiatric examinations and review and release procedures. Although more persons are reviewed and released at postacquittal hearings than in the matched pre-1980 cohort, fewer enter nonsecure facilities at commitment or during first 18 months of hospitalization, and fewer are released at the six-month review. After 18 months more acquittees remain inmates in secure facilities. Interviews with leading figures in the formulation and enactment of IDRA provide retrospective and prospective judgments on insanity defense reform issues.     

Post-Hinckley insanity reform in Oregon

The 1983 Oregon legislature responded to public pressure to narrow the application of the insanity defense by eliminating personality disordered individuals from consideration for an insanity verdict. This article examined the effects of the statutory change, and found no significant change in the frequency of insanity acquittals of personality disordered subjects between the three pre-reform years (n = 21) and the three post-reform years (n = 14). We also reviewed how the Psychiatric Security Review Board handled these patients once committed to their jurisdiction. We constructed a matched comparison group of psychotic acquittees and found that in the pre-reform years the personality disordered subjects spent less time in the system and less time in the hospital than the psychotic patients. However, in the post-reform years their time in the system and time in the hospital was the same as the psychotic controls. There were fewer decisions to discharge personality disordered patients from the system after the reform, although this difference may be due to factors other than the statutory reform itself. The conclusion is that narrowing the insanity defense is a worthy goal which may be difficult to achieve.     

Insane Arsonists: An Early 21st Century Sample

We studied all individuals (n = 41) who had been found not guilty by reason of insanity for arson and who were committed to a California state psychiatric hospital on October 1, 2016 in a cross‐sectional analysis. This group of insane arsonists contained 33 (80.5%) males and eight (19.5%) females with a mean age at the time of the index arson of 35.9 years. At least 87.8% (n = 36) were considered to not have been participating in psychiatric treatment at the time of the index arson. Five (12.2%) of the insane arsonists had previously been found not guilty by reason of insanity for arson or had been convicted of having committed arson. Our findings suggest that lack of participation in psychiatric treatment was the most important factor in contributing to the index arson and the most important problem to be addressed in subsequent psychiatric treatment plans.     

Redefining mental health law

Mental health law traditionally focuses on preserving the civil and constitutional rights of people labeled mentally ill. However, because of fundamental changes in the public mental health system. most people labeled mentally ill no longer reside in state psychiatric hospitals. As a result, the core policy issue in mental health today is assuring access to community based services, supports, and housing which enable people to live successfully in the community. Because of this different environment, the definition and scope of mental health law must be expanded dramatically if those interested in the subject are to continue to influence mental health policy. This article examines five contemporary mental health policy issues, including changes in reimbursement systems and the growth of the consumer and family movements, that illustrate the legal, policy, and research questions which will emerge in an expanded and redefined mental health law agenda. The author thanks Ingo Keilitz, Thomas Hafemeister, and Pamela Casey for their review of earlier drafts of this article.     

HELP IS ON THE WAY (OUT): PROHIBITING THE USE OF NONCOMPETITION AGREEMENTS IN THE MENTAL HEALTH PROFESSION

The use of noncompetition agreements in the mental health profession has created unfortunate consequences for patients and families seeking and receiving care within their respective communities. In addition to exacerbating issues in access and the availability of care in the mental health delivery system, noncompetition agreements (1) undermine the goals of therapy and injure the public's welfare; (2) potentially conflict with professional ethics and standards of practice guiding the mental health profession; and (3) conflict with promising proposals to reform mental health care delivery. This Note advocates that states adopt a statute prohibiting mental health practitioners from entering into noncompetition agreements with their employers as against public policy.     

The United Nations Convention on the Rights of Persons with Disabilities and Mental Health Law

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) took effect in 2008. This paper discusses a number of flashpoints where the CRPD will require real and significant reconsideration of English mental health and mental capacity law. The CRPD introduces a new paradigm into international disability law, relying on the social model of disability. While that is no doubt a good thing, there is as yet no clear sense as to how that is to be implemented. After providing an introduction to the Convention, the paper considers four specific areas: mental capacity law (focussing on the provisions of the Mental Capacity Act 2005), psychiatric treatment without consent, civil detention of people with mental disabilities, and mental disability in the criminal system (fitness to plead, insanity and diminished responsibility).     

Self‐reported Mental Health Issues Among Arrestees in the Paris,France Area

We studied (May–September 2014) all arrestees who reported mental health issues during the medical examination performed by a forensic physician for the assessment of fitness for detention. Among 4814 arrestees, 420 (9%) reported a current mental health issue. The suspected crimes among arrestees reporting a current mental health issue were more often related to violent behaviors (physical assault, 23% vs. 16%, p < 0.001, sexual assault, 3% vs. 1%, p = 0.01) and less often drug offenses (18% vs. 29%, p < 0.001). Among arrestees reporting mental health issues, 80% reported psychiatric or psychological care, of whom 33% reported previous mental health care. Decisions of unfitness for detention were more frequent among arrestees reporting mental health issues than in other detainees (3% vs. 1%, p < 0.001). The high proportion of patients with interrupted mental health care among those reporting mental disorders suggests that the medical examination during custody could be a significant opportunity to restore psychiatric care.     

The Swedish mental health system. Past, present, and future

In sum, the evolution, strengths, and weaknesses of the Swedish mental health system are quite similar to mental health systems in other Western countries; early reliance on stand-alone, state psychiatric hospitals, followed by deinstitutionalization and development of largely ambulatory, community mental health care. This evolution has been complicated in Sweden by the multiple levels and system components, the state, the county councils and the municipalities. Unlike the United States, but similar to Britain, community mental health care in Sweden is provided by two systems; treatment (and forensic services) by the county councils' mental health providers, and generic services by the municipalities' social welfare system. The resulting division of roles and responsibilities creates a strong need for collaboration and coordination of activities on behalf of consumers. It can also have the unintended disincentives to serving more difficult consumers. All these difficulties not withstanding, the Swedish mental health system has made major stride in providing quality, appropriate care.