PSYCHIATRIC HOSPITAL CAPACITY,HOMELESSNESS, AND CRIME AND ARREST RATES*

As a result of developments in pharmacology, stricter standards for involuntary commitment, and changes in public expenditures, there has been a dramatic decline in the capacity of public psychiatric hospitals to maintain America's most severely mentally ill. Psychiatric deinstitutionalization has led to an increased presence of persons with mental illness in urban areas, many “falling through the cracks” of community‐based services. This is hypothesized to have contributed to homelessness, crime, and arrests. Individual‐level research has documented disproportionate and increasing numbers of mentally ill persons in jails and prisons. It has also found higher rates of violence and arrest among persons with mental illness compared to the general population. This study takes a macro‐level social control approach and examines the relationships between psychiatric hospital capacity, homelessness, and crime and arrest rates using a sample of eighty‐one U.S. cities. I find that public psychiatric hospital capacity has a statistically significant negative effect on crime and arrest rates, and that hospital capacity affects crime and arrest rates in part, through its impact on homelessness. In addition, I find no crime‐reducing effect of private and general psychiatric hospital capacity.     

Forensic psychiatric inpatients and aggression: An exploration of incidence,prevalence, severity,and interventions by gender

BackgroundPrevious investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.ObjectiveThe goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.MethodThe population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.ResultsWomen were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.DiscussionFemale forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.     

Psychiatric disorder,IQ, and emotional intelligence among adolescent detainees: A comparative study

Objectives. To document criminality, psychiatric difficulty, IQ, EQ, and EI amongst Irish, male juvenile detainees (Detainee Group). To compare their IQ, EQ, and EI to non‐offending boys attending a child psychiatry clinic (Psychiatric Group) and boys without offending or psychiatric problems (Community Group). To compare psychiatric morbidity between the detainee and psychiatric groups. Method. Criminality levels of 30 detainees were evaluated using official court charge sheets. Psychiatric status was assessed through structured clinical interview (DISC‐IV); IQ through an individually administered IQ‐scale (WASI); EQ using the BarOn EQi:Youth Version (EQi:YV); and EI using the MSCEIT: Youth Version – Research Edition (MSCEIT:YV‐RE). IQ, EQ, and EI levels in the psychiatric and community groups were compared. Psychiatric morbidity between detainee and psychiatric groups were compared. Results. A total of 335 crimes led to the detention of detainees. Eighty‐three percent of detainees had a psychiatric disorder compared to 60% of young people in the psychiatric group. Detainees had 3.1 disorders each compared to 1.4 disorders in the psychiatric group. A total of 63.3% of detainees had an externalizing problem, 37.9% an internalizing problem, and 66.7% a substance dependency or use problem. A total of 21.4% of detainees had an IQ score below 70. The detainee and psychiatric groups had similar deficits in EI and significantly lower EI than the community groups. Conclusions. Serious levels of criminality and psychiatric disorder exist amongst Irish detainees. They have significantly lower IQ than young people attending a psychiatry clinic and both share deficits in the ability to accurately identify emotions, use emotions to guide thought processes and to prioritize thinking and to effectively regulate emotions.     

The role of the psychiatrist in evaluating a prison mental health system in litigation

Federal courts during the past 14 years have recognized that many prisons in the United States have provided constitutionally inadequate medical and psychiatric services. Our recent national survey indicates that at least 20 states have had at least one part of their correctional system included in a certified class action suit that alleged insufficient mental health services for inmates. This article reviews the role of the expert psychiatric witness during the phases of litigation that involve proposed remedial plans and compliance in implementing remedial plans. Available epidemiologic data about psychiatric disorders among prison inmates, standards for correctional mental health care, and various mental health system models are briefly reviewed. A comprehensive approach to evaluating proposed remedial plans and assessing issues of compliance with accepted plans is described. Special attention is directed toward psychiatric issues unique to a correctional system.     

Contacts with public services, with special reference to mental health care, preceding a serious crime: a retrospective study of 268 subjects of forensic psychiatric investigations

Between July 1995 and June 1996, 533 subjects underwent forensic psychiatric investigation I Sweden. Odd case numbers (n = 268) were included in the study. Of these 268 people, 50% had been in contact with psychiatric services during the six-month period preceding the crime leading to forensic psychiatric assessment. Contacts with psychiatric services during the six-month period preceding the crime were significantly more common in three categories of individuals than others. These were: women, individuals who were diagnosed as having a psychotic disorder during the forensic psychiatric investigation, and individuals found to suffer from a serious mental disorder as defined in the legislation. Subjects who were found not to suffer from a serious mental disorder and were thus not eligible for special sanctions on medicolegal grounds had significantly less psychiatric contacts before the crime, as did subjects under 20 years of age. However, these two groups still had considerably more psychiatric contacts than the general population. The present results suggest that the patient category studied requires special monitoring and case management in general psychiatry in Sweden. To this end, we call for closer studies of high-risk individuals, particularly of previously violent offenders and potentially violent offenders, and closer studies of their psychiatric contacts. This will provide a basis for the development of adequate programs and guidelines for effective care and treatment within the psychiatric sector.     

The Relationship between Meteorological Conditions and Homicide,Suicide, Rage,and Psychiatric Hospitalization

This study focuses on the relationship between the incidence of homicide, rage, suicide, and psychiatric hospitalization as violent behaviors with temperature, humidity, and air pressure as specific meteorological variables in the city of Mashhad, in the northeast of Iran. The data were obtained from Iran Meteorological Organization, official registry of Legal Medicine Organization and the local psychiatric hospital, March 2009 to Feb 2010 daily and were analyzed with SPSS‐14 using Pearson correlation coefficient, ANOVA, and post hoc analysis tests. The rates of rage and psychiatric admission had a significant relationship with the daily mean air temperature, minimum relative humidity, maximum relative humidity, minimum daily pressure, and maximum daily air pressure (p < 0.0001). There was no significant correlation between homicide and suicide rates with any meteorological variables (p > 0.05). We concluded that, the possibility of nonfatal violence and psychiatric hospitalization would increase in hot and arid weather with low air pressure.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

Standardized assessment of substance-related, other psychiatric, and comorbid disorders among probationers

This study examined the prevalence of alcohol- and substance-related disorders in a random sample of 627 adult probationers in Illinois. The investigation also explored the prevalence of major psychiatric disorders and their co-occurrences with alcohol and substance use disorders. To detect the presence of psychiatric disorders, researchers employed standardized assessment tools based on Diagnostic and Statistical Manual of Mental Disorders criteria. Overall, results showed that probationers had significantly higher rates of psychiatric disorders, substance use disorders, and co-occurring disorders compared with persons in the general population. In light of these findings, probation administrators are urged to invest more resources in treating drug use, mental illness, and codisorders, the latter of which is associated with a higher risk of violent behaviors.     

The Criminogenic,Clinical, and Social Problems of Forensic and Civil Psychiatric Patients

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.     

Call 911: psychiatry and the new Emergency Medical Treatment and Active Labor Act (EMTALA) regulations

The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985, aims to prevent "patient dumping" by requiring hospitals to screen and stabilize patients who come to an emergency room seeking medical attention. For many reasons, recovery under EMTALA is rare, especially when psychiatric treatment is called for. New regulations of EMTALA went into effect on November 10, 2003. These new regulations helpfully clarify the applicability of EMTALA. However, the bias against recovery in cases involving psychiatric emergencies is likely to remain.     

Claims of amnesia for criminal offenses: psychopathology, substance abuse, and malingering

The forensic psychiatric examiner often encounters defendants who deny memory for their offense. Past research proposes a variety of factors to account for offense amnesia. To date there have been few systematic studies of offense amnesia in relation to psychiatric diagnosis, either alone or in combination with other known factors such as substance use and malingering. We studied 53 pretrial felony defendants who had been referred for psychiatric examination; 40% claimed amnesia for their offense. Examinees with psychotic disorders in general, and schizophrenia in particular, were relatively less likely to claim amnesia than were examinees with other diagnoses. Substance use at the time of the offense and associated substance use disorder diagnoses were positively associated with offense amnesia. Malingering diagnosed by general clinical criteria was a poor predictor of amnesia claims. These data suggests that two prominent reasons for referral for forensic psychiatric evaluation include the presence of psychotic symptoms and claims of amnesia for the offense.     

The character of danger in psychiatric practice: are the mentally ill dangerous?

This paper explores the question of dangerousness and the mentally ill. Research for this paper was stimulated by the death by homicide of two psychiatrists in Oregon in 1985. The paper reviews three distinct areas in the psychiatric literature: the arrests of mental patients, assaults against psychiatrists and other mental health professionals, and assaultive behaviors exhibited by patients in hospitals and other psychiatric settings. The author concludes that the risks are real but are dependent, for the most part, on setting and the acuteness of illness. Realism in regard to risk is critical for the mentally ill, their families, professional caregivers, and society in general.     

History of interpersonal violence, abuse, and nonvictimization trauma and severity of psychiatric symptoms among children in outpatient psychiatric treatment

In a clinical sample of child psychiatry outpatients, chart review data were collected for 114 consecutive admissions over a 1-year period at a Child and Adolescent Outpatient Psychiatry Clinic. Data included history of documented maltreatment, potentially traumatic domestic or community violence, neglect or emotional abuse, and noninterpersonal stressors as well as demographics, psychiatric diagnoses, and parent-rated child emotional and disruptive behavior problems. On a bivariate and multivariate basis, any past exposure to interpersonal violence-but not to noninterpersonal traumas-was related to more severe disruptive behavior problems, independent of the effects of demographics and psychiatric diagnoses. Noninterpersonal trauma and psychiatric diagnoses were associated with emotional problems; exposure to interpersonal violence appeared to partially account for this relationship despite not being independently associated with emotional problem severity. History of exposure to interpersonal violence warrants clinical and research attention as a severity marker and potential treatment focus in psychiatric outpatient services for children, particularly those with disruptive behavior problems.     

Validity and reliability of the VRAG in a forensic psychiatric medium security population in Flanders

Since the development of the Violence Risk Appraisal Guide (VRAG), one of the most widely used actuarial risk assessment instruments, numerous replication studies have shown its usefulness in predicting (violent) recidivism among various offender populations. It is not clear, however, whether these findings can be generalized to forensic psychiatric patients admitted to a medium security forensic psychiatric unit in the Flemish part of Belgium. Therefore, the main aim of this study was to test the predictive validity and reliability of the VRAG in a sample of 191 Flemish medium security patients. The mean follow-up period was 2.4 years. Contrary to the expectations, the VRAG was unable to significantly predict any kind of outcome. Possible explanations are discussed and further research with the VRAG in Flanders, and its recently revised version, is recommended.     

Post traumatic stress disorder, neuroscience, and the law

Post-Traumatic Stress Disorder (PTSD) is a complex psychiatric condition, the effects of which can be seriously debilitating. As it originates from a specific traumatic event, it often impacts soldiers and victims of violent crime. It is currently one of the most frequently litigated mental diseases. Neuroscience is slowly discovering the neural bases of PTSD and other psychiatric ailments and is building tests to distinguish actual patients from non-suffering individuals. We examine the current state of neuroscientific research on PTSD and its biomarkers, focusing on a recent experiment by Apostolos Georgopoulos and coworkers. Then we analyze the legal consequences of these scientific advances, both in civil and criminal law, from a comparative perspective. Neuro-technology is likely to provide courts with a new kind of evidence, which will not replace but add to older behavioral evidence. Furthermore, it will weaken the so far standing distinction between physical and emotional harm. However, even extremely sensitive tests (>95%) can have insufficient accuracy if the prevalence of a condition in the tested population is low. Therefore, the law ought to take into account the prevalence of PTSD and other psychiatric conditions when the decision whether to admit neuro-evidence in courts or not is made.     

The future of homicide offenders. Results from a homicide project in Copenhagen

As a part of a Copenhagen homicide project, 52 released homicide offenders were followed during a mean period of 9 years. Pessimistic expectations were confirmed as post-release rates of criminality, psychiatric admission, and suicide were all very high. By logistic regression analyses, young age by release, and long stay in prison were found to increase the risk of further criminality, and previous psychiatric admission was found predictive of future admission. The problems in using logistic regression analysis on variables--all of whom may be viewed as "parallel" indicators of a common tendency to adverse behaviors--are discussed. In conclusion, the results have been used for a tentative division of homicide according to the offender-victim relationship into intra-family homicide and extra-family homicide. In intra-family homicide the most important dimension seems to be the psychic state of the offender, in extra-family homicide more impact should be attributed to the social dimension.     

The frequency and nature of resolution of potential police provoked shooting encounters

Helping people in acute psychiatric crisis has become an increasingly common part of modern community policing. In certain extreme cases, police may be faced with a suicidal individual who intends to intentionally provoke police to shoot them. While fatalities are fortunately rare, anecdotal reports from frontline police suggest that these kinds of encounters are occurring on a regular basis. This paper explores 2350 psychiatric crisis incidents over an eight-month period in Victoria, Australia, and assesses the frequency and nature of potential police-provoked shootings resolved through non-fatal means. Contextual factors relating to the person's behaviour and police responses, and the person's psychiatric and criminal histories were considered to elucidate characteristics common to these incidents. Results suggest that police are potentially encountering a person who is suicidal and trying to provoke police to shoot them more than twice a week. These individuals share a number of common characteristics with those who have been fatally shot in similar circumstances and are quite different from those who attempt self-inflicted suicide. Results are discussed in relation to the impact of previous criminal contact from both the suspect and police perspectives.     

Psychiatric history,due procedural safeguards,and the use of discretion in the criminal justice process

Using a stratified random sample of all male inmates released from one state's correctional facilities during a 13-month period (N = 550), this research investigates the impact of an extralegal variable (history of psychiatric hospitalization) on decisionmaking in stages in the criminal justice system at which defendants are granted more and fewer due procedural safeguards. On the basis of the work of Goffman and Green, it is hypothesized that this variable will not equally affect decisions made at various points in the criminal justice process. Instead, psychiatric history will have less impact at points in the process where the defendant is granted more due procedural safeguards (e.g., sentencing), with its significance increasing where the defendant receives fewer due procedural safeguards (e.g., parole). The results are consistent with the hypothesis: A history of psychiatric hospitalization was not significant in the decision regarding sentence length, though it became highly critical in the decision to parole, even after other legal and extralegal variables were controlled. The context in which these decisions are made may also be relevant to a fuller understanding.     

Sexual assault,irresistible impulses,and forensic psychiatry in Sweden

After forensic psychiatry was firmly established in Sweden in the 1930s, many rapists and individuals charged with assaulting children underwent a forensic psychiatric examination. The physicians found that most of them had not been “in control” of their senses or not “in complete control” of their senses at the time of the crime. If the court ordered a forensic psychiatric examination, the defendant had a very good chance of either being discharged or having his sentence reduced considerably. By the 1950s psychological perspectives began to dominate in forensic psychiatry. In the forensic records of the 1950s we can notice a shift from a biomedical to a socio-psychological perspective, and crime was increasingly related to conditions that were not seen as mental derangement from a legal point of view. As a result, it became less and less common, from the 1950s onwards, for sentences to be commuted or defendants discharged.     

Psychiatrists,criminals, and the law: Forensic psychiatry in Switzerland 1850–1950

Between 1880 and 1950, Swiss psychiatrists established themselves as experts in criminal courts. In this period, the judicial authorities required psychiatric testimonies in a rising number of cases. As a result, more offenders than ever before were declared mentally deficient and, eventually, sent to psychiatric asylums. Psychiatrists also enhanced their authority as experts at the political level. From the very beginning, they got involved in the preparatory works for a nationwide criminal code. In this article, I argue that these trends toward medicalization of crime were due to incremental processes, rather than spectacular institutional changes. In fact, Swiss psychiatrists gained recognition as experts due to their daily interactions with judges, public prosecutors, and legal counsels. At the same time, the spread of medical expertise had serious repercussions on psychiatric institutions. From 1942 onwards, asylums had to deal with a growing number of “criminal psychopaths,” which affected ward discipline and put psychiatry's therapeutic efficiency into question. The defensive way in which Swiss psychiatrists reacted to this predicament was crucial to the further development of forensic psychiatry. For the most part, it accounts for the subdiscipline's remarkable lack of specialization until the 1990s.