The Impact of Insanity Acquittees on Missouri's Public Mental Health System

Even though state departments of mental health have primary responsibility for the care, custody, and treatment of insanity acquittees, the impact of insanity acquittees on the public mental health system is generally lacking in policy discussions and as a topic for policy research. This issue has received increased attention in Missouri, where insanity acquittees now occupy half of the long-term public psychiatric hospital beds. This article examines the presence of Missouri's insanity acquittees on the state's public mental health system and includes the impact on goals, fiscal costs, inpatient and community psychiatric services, and inpatient treatment staff. As states consider managed care and other cost containment measures, it remains to be seen if the high costs associated with extensive use of hospitalization of insanity acquittees to promote public safety will influence policy changes to more community-based insanity acquittee systems.     

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.     

Evaluation and treatment of insanity acquittees in the community

This paper describes the monitored outpatient treatment program for Psychiatry Security Review Board (PSRB) clients in the largest single community treatment agency in the Oregon system. We describe 161 persons referred to this agency for evaluation and treatment. Ninety-one PSRB clients received treatment and of this group 51% had their conditional release revoked by the PSRB. The most frequent cause of revocation was noncompliance with treatment. There were only 11 crimes committed during the study period, four of which were in the felony range. The majority of PSRB clients are chronically mentally ill persons. We discuss both the treatment approach and our results in light of a recently published research agenda for insanity acquittees.     

The review panel process: an algorithm for the conditional release of insanity acquittees

The release of insanity acquittees requires making informed decisions regarding both the presence and severity of an individuals' mental illness and the dangerousness of these individuals. This study evaluated the usefulness of employing structured assessments of mental health and violence risk factors in the conditional release decision-making process. All persons found Not Guilty by Reason of Insanity at East Louisiana Mental Health System, Forensic Division who underwent a review panel between July 1, 1997 and July 1, 1999 were included in this study. The Classification and Regression Tree analysis was utilized to arrive at cutpoints that would optimize the predictive ability of the decision tree analysis. The results indicated that the Community Outpatient Treatment Readiness Profile score was the strongest predictor -- all patients receiving a score of 62 or greater on this scale were recommended to remain at the facility. When women were recommended for release, it was to civil facilities and with moderate levels of symptoms. For males with moderate symptoms, low PCL-R scores were associated with recommendations for release, whereas high scores were associated with recommendations for continued commitment. Our data suggests that algorithms may be useful to governing bodies when making release decisions.     

Forensic psychiatry and malpractice

This paper concerning the last 87 malpractice cases referred to the Department of Psychiatry and Law, Menninger Clinic, includes 57 suits against mental health practitioners and/or institutions, and 30 nonpsychiatric suits against general hospitals, surgeons, obstetricians, etc. A patient was available for interview in only 12 percent of the psychiatric cases; in 88 percent we reviewed medical records and consulted with attorneys. In the psychiatric cases the crucial question was whether a generally accepted standard of care was breached. The inherent problems of applying appropriate criteria to standards of care by practitioners and institutions are discussed. In half the psychiatric cases we found no significant deviation from acceptable clinical performance; in half we concluded that negligent practice had occurred. We did see a litigant for evaluation in 90 percent of the nonpsychiatric cases. The main issue involving them concerned harm or disability related to presumed negligence by medical personnel. How we evaluate such cases and apply disability criteria is discussed.     

Darfur refugees in Cairo: mental health and interpersonal conflict in the aftermath of genocide

Hundreds of thousands of Darfur people affected by the Sudanese genocide have fled to Cairo, Egypt, in search of assistance. Collaborating with Africa and Middle East Refugee Assistance (AMERA), the authors conducted a mental health care needs assessment among Darfur refugees in Cairo. Information was collected using individual and focus group interviews to identify gaps in mental health care and develop understandings of emotional and relationship problems. The refugee mental health care system has a piecemeal structure with gaps in outpatient services. There is moderate to severe emotional distress among many Darfur refugees, including symptoms of depression and trauma, and interpersonal conflict, both domestic violence and broader community conflict, elevated relative to pregenocide levels. Given the established relationships between symptoms of depression/traumatic stress and interpersonal violence, improving mental health is important for both preventing mental health decompensation and stemming future cycles of intra- and intergroup conflict.     

Public Mass Murderers and Federal Mental Health Background Checks

The litany of public mass murders, from Aurora, Newtown, Charleston, Las Vegas, and Parkland to less well‐known incidents that occur yearly, has focused national attention on federally mandated mental health background checks of prospective gun purchasers. The call has been to put more gun‐disqualifying mental health records into the National Instant Criminal Background Check System database to prevent “deranged” murderers from buying guns and running amok. Our study examines whether increasing the robustness of the mental health background database will likely prevent potential public mass murderers from buying guns. Building on research that shows that serious mental illness contributes little to the risk of interpersonal violence and, further, that few persons with serious mental illness acquire gun‐disqualifying mental health records, we examine whether public mass murderers are among the small percentage of those with serious mental illness who do have gun‐disqualifying mental health records. Using a large sample of 106 US offenders who used a firearm to commit a public mass murder from 1990 to 2014, we find that half of the offenders had a history of mental illness or mental health treatment but that less than 5 percent had gun‐disqualifying mental health records. Implications of these findings and recommendations for further research are discussed.     

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.     

Prison mental health services: results of a national survey of standards, resources, administrative structure, and litigation

The formation of adequate mental health systems within prisons has accelerated as a result of successful class action lawsuits. Our recent national survey questioned all state correctional departments about the existence of standards in each system, compliance with such standards, prevalence of class action lawsuits involving the issue of providing adequate mental health services for inmates, issues related to consent decrees, available mental health resources within the correctional system, and the administrative structure of the mental health system. Our purpose was to identify those factors correlated with certified class action lawsuits involving issues related to mental health services. Twenty-one states were involved in such litigation. Only the presence of psychiatric hospitals operated by the department of corrections correlated with the presence of certified class action lawsuits involving mental health services. Prison systems larger than 15,000 inmates were at higher risk for such litigation. Smaller systems having psychiatric hospitals run by the state mental health agency appeared to be at less risk for such litigation.     

Mentally ill offenders in prison: the Belgian case

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments.Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.     

Factors that influence jury decision making

Investigated whether information regarding the disposition of insanity acquittees and the defendant's mental state at the time of the trial, had a significant effect on mock jurors' verdicts. Two trials were used to assess whether results generalize across cases. participants read excerpts from a trial in which the accused's mental state at the time of the trial (symptom free, neurotic symptoms, or psychotic symptoms) and the disposition instructions (no instructions, indeterminate disposition, and capped disposition) were varied. Participants then rendered a verdict of guilty, not guilty, or not criminally responsible on account of mental disorder (NCRMD). Participants who thought the accused was psychotic at the time of the trial were more likely to render a verdict of NCRMD than guilty, and they were more likely to render a verdict of NCRMD than those who thought the accused was normal. No significant differences were found for disposition. Finally, a significant difference for verdicts was found between trials.     

Suicide in children,adolescents and young adults

As suicides of children, adolescents and young adults occur very seldom and only few case reports and more comprehensive studies are available in forensic literature, the autopsy records of the Bonn Institute of Forensic Medicine and the database of the Bonn police authorities from 1989 to 1998 were retrospectively analysed for this phenomenon. This search revealed 37 respective suicides involving 23 male (62%) and 14 female (38%) victims. The ages ranged from 10 to 21 years with the prevalence sharply increasing in adolescents and young adults. Independent from sex, the victims almost unexceptionally applied hard suicide methods like hanging, running over by a train or jump from the height. As for the psychological background, current conflicts with a sweetheart, within the family or at school on the background of mental illness or chronically disturbed family structures were encountered as prevailing factors.     

Examining the Impact of Proximate Culpability Mitigation in Capital Punishment Sentencing Recommendations: The Influence of Mental Health Mitigators

In spite of the ruling in Atkins v. Virginia (2002), concerns remain that individuals with mental illness and reduced capacity are eligible for the death penalty. When mental illness or reduced capacity is not enough to preclude death-eligibility, these factors are often discussed at the sentencing phase as mitigators. Mitigation remains an under-researched avenue in the sentencing literature, particularly when it comes to the influence of specific types of mitigation. The present study contributes to knowledge on mental health mitigation by examining five mitigators relevant to the mental health and capacity of defendants. Using data from 834 capital sentences in North Carolina, the influence of these proximate culpability mitigators on jury sentence recommendations is examined. Results indicate that acceptance of certain mental health mitigators reduces the probability of death, but acceptance of others is not significantly related to death recommendations. These findings and their implications are discussed.     

The nature of police involvement in mental health transfers

During the course of their duties, police regularly have contact with mentally ill persons who are experiencing psychiatric crisis and require some form of mental health transfer. This study examined 2611 unique mental health transfers completed by police in the Australian state of Victoria over an eight-month period in 2009–2010. The overwhelming majority of mental health transfers performed by police during this period were the result of unplanned calls for assistance. Although police frequently requested assistance from other services, these were often not available. The study findings support a substantial body of anecdotal evidence from police citing lengthy involvement with people experiencing mentally illness, with the average mental health transfer consuming 2.5?h of police time. The frontline responses of police to people in psychiatric crisis need to be more formally acknowledged and creative solutions need to be sought with health and welfare services to better meet the needs of those who are falling between the cracks of community mental health care services.     

Compulsory mental health care in Norway: The treatment criterion

The Norwegian government has chosen to retain a treatment criterion in the Mental Health Care Act despite the opposition of several user organizations. From a critical user perspective, the only reason for using coercion to require mental health treatment is that the individuals are in a state where they are an immediate danger to themselves and/or their surroundings. This articles aims, first, to provide an overview of research studies concerning the benefits or harmfulness of involuntary treatment after coerced admission and, second, to evaluate studies that try to compare involuntary with voluntary treatment. A systematic overview of studies of compulsory mental health care with regard to treatment criteria, coercion in mental health, and involuntary admission published over the last decade was examined in detail, along with a secondary manual search of references cited in identified publications. Few studies have been conducted on the effect of compulsory mental health care, and the results have been contradictory. More randomized studies are needed to document the kinds of effects that the use of compulsory treatment has on treatment results. Another issue that needs further examination is whether the use of coercion should be transferred to legal bodies with an adjudicatory process.     

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.     

The Empirical Limits of Forensic Mental Health Assessment

This article introduces a special issue of Law and Human Behavior, including five articles describing the limits of forensic mental health assessments of (a) risk of violence in female adolescents, (b) sexually violent predators, (c) dangerousness in capital murder cases, (d) child sexual abuse, and (e) PTSD litigants. Knowing the limits of forensic mental health assessment methods is essential in order to recognize their strengths, increase the credibility of forensic mental health assessment, and drive research that will enhance the value of assessments for the courts.