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.     

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.     

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.     

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.     

Stopping (or Slowing) the Revolving Door: Factors Related to NGRI Acquittees' Maintenance of a Conditional Release

The current study sought to extend the knowledge about factors associated with NGRI acquittees' maintenance of a conditional release after hospital discharge. The medical and forensic records of 125 NGRI acquittees were reviewed to collect a variety of demographic, clinical, criminal, and aftercare factors. A hierarchical survival analysis approach to determining success was compared to data analysis strategies typically employed in the area. Survival analysis, which accounts for both conditional release success status and time on conditional release, revealed that minority status, substance abuse diagnosis, and a prior criminal history were the factors that significantly predicted conditional release revocation. Treatment and policy implications of these results are discussed.     

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.     

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.     

The processing and disposition of incompetent mentally ill offenders

Pretrial hospitalization of mentally ill offenders has been increasing in recent years and a number of abuses have been noted with respect to competency to stand trial. This is a report on 431 male felony defendants who were found incompetent to stand trial, hospitalized, and returned to court for a final disposition. Approximately one-half of those brought back to the court gained release to the community, with one-half continuing to be held in a hospital or a prison, and with 70% continuing in treatment in one setting or another. Disposition was significantly related to race, criminal history, severity of charges, and the recommendations of mental health professionals. Offenders were found to have spent unnecessarily long periods of time in jail and in the hospital awaiting court processing, raising questions about the fairness and efficiency of current procedures.     

Characteristics of successful and unsuccessful insanity pleas

Thirty men acquitted not guilty by reason of insanity (NGRI) were matched on type of violent crime and compared to 30 men who unsuccessfully raised the insanity defense. Demographic, legal process, and psychological variables were compared. Eighty percent of successful acquittees previously had been found incompetent to stand trial, compared to only 33% of those found guilty and sentenced to prison. Ninety-six percent of NGRI acquittees opted for trial before a judge rather than a jury; 76% of cases raising an unsuccessful defense were heard in front of a jury. Unsuccessful attemptees also had significantly higher IQ scores and personality profiles characterized by acting-out potential and intact reality testing compared to profiles of NGRIs. The ability of the legal system to identify those meeting criteria for the insanity defense is discussed.     

Comparing females acquitted by reason of insanity,convicted, and civilly committed in Florida 1977–1984

Females who had been acquitted by reason of insanity (N=41), convicted of comparable offenses (N=41), and involuntarily hospitalized without criminal involvement (N=41) were matched for age and race. The psychiatric histories of the acquitted and civilly committed women were similar, and significantly more extensive than the convicted group. The acquitted women had been arrested significantly more often than the civilly committed women but less frequently than the convicted women. Total length of stay (hospitalization or imprisonment) reflected a similar pattern, with civilly commited women hospitalized for the shortest period, acauitted women an intermediate period, and convicted women the longest. Regression-based prediction of length of stay reflected a number of common predictors for the acquitted and convicted women, with offense type one of the most powerful for both groups.     

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.     

Not guilty by reason of insanity: a research note

The question of the insanity defense centers around the moralist-determinist debate. Insanity defense laws are premised on the assumption that individuals choose between right and wrong, and are responsible for that choice. Mental disease, however, can overpower, and thus, not of their own volition, insane persons become out-of-control. Hence, they cannot be held responsible for their behavior or subject to criminal punishment. It is the purpose of the insanity defense, of course, to distinguish between offenders in need of punitive disposition and ones where a medical-custodial disposition is best. The research presented here indicates that defendants who successfully raise the plea of NGRI do not beat the rap. In other words, they do not spend fewer days in confinement via an NGRI plea than had they been convicted and sentenced. Thus, for the reasons of justice, equity, and fairness the insanity defense should be kept intact. The wave of public fear and reaction to the decision in a few highly publicized cases is insufficient grounds for eliminating the plea. Not only is the use of the insanity defense infrequent, but defendants who select it give up important safeguards. Namely, they are unable to plea bargain, are stigmatized as "mad and bad," have no access to probation or parole, and are confined for an indeterminate amount of time. That some would call this leniency we find surprising. And, of course, we should not forget the findings reported here. NGRI acquittees spend more time being locked up. Defendants who successfully raise the NGRI plea are confined until professionals say they are no longer dangerous.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Detention Patterns of Successful and Unsuccessful Insanity Defendants

This study examines the detention patterns of the insanity defendant who is successful with the plea and hospitalized, or unsuccessful and incarcerated. Further comparisons are made with felony defendants who never entered a plea of not guilty by reason of insanity (NGRI). From existing data it is unclear to what extent detention may vary if the plea is successful as compared to if it is not successful. Of all defendants who entered a plea of NGRI in Erie County, New York (Buffalo) between 1970 and 1980, 128 were institutionalized as a result of their disposition. Sociodemographic, institutionalization histories, arrest, and disposition information were collected and analyzed for all 128 individuals. The research evaluates differences in the likelihood and length of either institutionalization or incarceration and in the rates of release between successful NGRI defendants, those who entered the plea unsuccessfully, and those who did not plead NGRI. From the findings reported here the authors conclude that pleading NGRI in Eric County may not be quite as advantageous for a defendant as commonly is believed.     

Judicial oversight of release of patients committed after being found not competent to stand trial or not guilty by reason of insanity in violent crimes

In 1981, North Carolina joined a growing number of states in passing legislation requiring judicial concurrence with discharge decisions for civilly committed patients who had been found either not competent to proceed to trial or not guilty by reason of insanity. The authors studied all such patients at one of North Carolina's four state mental hospitals during the first year of the new law's operation, and found that there were only 16 of them. These patients were compared to a control sample of civilly committed patients without criminal charges; it was found that the forensic patients spent longer in the hospital than the controls, but still significantly less time than reported in studies from other states. The authors discuss possible reasons for these differences and comment on the effectiveness of such legislation.     

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.     

After Oregon's insanity defense: : A comparison of conditional release and hospitalization

This paper is one in a series of reports on the characteristics of persons committed to the Oregon Psychiatric Security Review Board (PSRB) and their treatment and disposition while subject to its jurisdiction. For the purpose of this discussion, we have focused on conditional release and attempt to answer a number of questions. How do the individuals who are placed in the community differ from those who remain hospitalized? Do the two mechanisms of conditional release in this system, by judges or the PSRB, differ in terms of the kinds of people that they are likely to release? Lastly, what features distinguish those individuals who manage to succeed in their release plans from those who do not?     

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.