Conducting Veteran Dependency and Indemnity Compensation Exams: Establishing a Nexus Between Mental Health and Death

Forms of financial compensation have been paid to the beneficiaries of deceased service members since the Revolutionary War. In its current version, Dependency and Indemnity Compensation (DIC) is a tax-free monetary benefit paid to eligible survivors of veterans whose death resulted from a service-related disability. Mental health professionals are called upon to provide medico-legal opinions in DIC claims involving questions of whether a veteran’s service-connected mental illness contributed substantially to their death. The U.S. Department of Veterans Affairs (VA) does not currently employ training programs, competency standards, or best practice recommendations for these specialized evaluations. This article seeks to fill this gap and provide a resource for mental health professionals providing medical opinions in DIC claims.     

Factors related to suicide in New York state prisons

OBJECTIVE: Examine factors related to prison suicides to aid prevention. METHOD: Review the mental health records of all 76 suicides that occurred between 1993 and 2001 in New York State Department of Correctional Services (NYSDOCS) prisons that had some contact with mental health services during their incarceration. (This represented 84% of all NYSDOCS suicides.) Extract data from the psychological autopsies for a sample of 40 of these suicides. RESULTS: Of the suicide victims with some mental health contact, 95% had a substance abuse history, 70% displayed agitation or anxiety prior to the suicide, and 48% had a behavioral change. Common stressors preceding the suicide were inmate-to-inmate conflict (50%), recent disciplinary action (42%), fear (40%), physical illness (42%), and adverse information (65%) such as loss of good time or disruption of family/friendship relationships in the community. Forty-one percent had received a mental health service within 3 days of the suicide. Compared to the about 7200 inmates actively receiving mental health services in state prison, African-Americans and patients with a Major Mood (Bi-polar or Major Depression) were under-represented. Adjustment Disorder, Schizophrenia, and Personality Disorder diagnoses were over-represented. Suicide victims were more likely to have been incarcerated for a violent crime. CONCLUSION: Mental illness, anxiety/agitation, behavior change, stressors, history of substance abuse, and non-African-American were important risk factors.     

Comparing persons found not criminally responsible on account of mental disorder for sexual offences versus nonsexual violent offences

Using data from the National Trajectory Project, we compared 50 individuals found Not Criminally Responsible on account of Mental Disorder (NCRMD) for sexual offences with 50 age- and gender-matched individuals found NCRMD for nonsexually violent offences. We also described the concurrent offenses, the symptoms at the time of the offense and the characteristics of the victims of offenders found NCRMD for sexual offences. Persons found NCRMD for sexual offences were less likely to be employed and were significantly younger at time of first psychiatric contact, but did not differ in other sociodemographic characteristics, other aspects of their psychiatric histories or in criminal history. Despite no differences in recidivism and no differences in behaviours between Review Board hearings when adjusting for unequal time at risk, persons found NCRMD for sexual offences had longer tenures under a Review Board mandate than persons found NCRMD for nonsexually violent offences. Given the many similarities between the two groups, this finding suggests that Review Boards may be unnecessarily conservative in how they manage sexual offenders.     

Mental disorder and criminality in Canada

This article examines the relationship between mental disorder and criminality in Canada from the colonial period to the landmark 1992 Mental Disorder Amendments that followed the passing of Bill C-30. The history of this relationship has been shaped by longstanding formal and informal systems of social regulation, by the contests of federal–provincial jurisdiction, by changing trends in the legal and psychiatric professions, and by amendments to the federal Criminal Code. A study of these longer-term features demonstrates that there has been no linear path of progress in Canada's response to mentally unwell offenders. Those caught in the web of crime and mental disorder have been cast and recast over the past 150 years by the changing dynamics of criminal law, psychiatry, and politics. A long historical perspective suggests how earlier and more contemporary struggles over mental disorder and criminality are connected, how these struggles are bound by historical circumstance, and how a few relatively progressive historical moments emerging from these struggles might be recovered, and theorized to advantage.     

Military Service Records: Searching for the Truth

In conducting Compensation and Pension (C&P) examinations, one of the most significant sources of evidence supporting a veteran’s claim for service connection are found in the veteran’s service medical records and service personnel records. Although specific numbers are unknown, a majority of mental health providers who conduct C&P examinations are not veterans and have limited knowledge and understanding of the records they are being asked to review. In cases of an initial posttraumatic stress disorder (PTSD) examination, the Federal Register requires C&P examiners to determine if the veteran’s claim is consistent with the places, types, and circumstances of the veteran’s service. This article reviews specific data within personnel records to help verify those elements. Additionally, perhaps one of the most difficult types of evaluations faced by any C&P examiner is a PTSD claim for personal assault (e.g., military sexual trauma). This article reviews the types of information within the records to help identify specific “Markers” associated with personal trauma.     

Biology, childhood trauma, and murder: rethinking justice

This article reviews recent findings in the developmental neurophysiology of children subjected to psychological trauma. Studies link extreme neglect and abuse with long-term changes in the nervous and endocrine systems. A growing body of research literature indicates that individuals with severe trauma histories are at higher risk of behaving violently than those without such histories. This article links these two research areas by discussing how severe and protracted child abuse and/or neglect can lead to biological changes, putting these individuals at greater risk for committing homicide and other forms of violence than those without child maltreatment histories. The implications of these biological findings for forensic evaluations are discussed. Based on new understanding of the effects of child maltreatment, the authors invite law and mental health professionals to rethink their notions of justice and offender accountability, and they challenge policymakers to allocate funds for research into effective treatment and for service delivery.     

Psychiatric correlates of medical care costs among veterans receiving mental health care

Research on increased medical care costs associated with posttraumatic sequelae has focused on posttraumatic stress disorder (PTSD). However, the provisional diagnosis of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) encompasses broader trauma-related difficulties and may be uniquely related to medical costs. We investigated whether DESNOS severity was associated with greater nonmental health medical care costs in veterans receiving mental health care. Participants were 106 men and 105 women receiving VA outpatient mental health treatment. A standardized interview assessed DESNOS severity. The dependent variables consisted of primary and specialty medical treatment costs. Sequential zero-inflated negative binomial regression was used to evaluate the variance in medical costs accounted for by DESNOS severity, controlling for PTSD severity and established predisposing, enabling, and need-based health care factors. Contrary to our hypothesis, in fully adjusted models, DESNOS severity independently added a significant amount of variance to lower specialty medical care costs, whereas PTSD did not consistently account for significant variance in medical care costs. Greater DESNOS severity appears to be associated with lower specialty medical care costs but not primary care costs. These findings may indicate that patients with DESNOS symptoms are at risk for being underreferred for specialty care.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

The social,relational and mental health characteristics of justice-involved men in the south-west England

The aim of this article is to describe the social, relational and mental health characteristics of a sample of offenders serving prison or community sentences in the south-west England. About 100 adult male offenders were screened for anxiety and depressive disorders, post-traumatic stress disorder (PTSD), drug and alcohol dependence, and likely personality disorder using validated instruments. Fifty-eight per cent of the sample reported at least one common mental health problem, of these only 26% reported receiving treatment. Participants exposed to traumatic events and/or participants with past mental health problems were more likely to score positive for current common mental health problems. Our study identified factors that may increase the risk of a first episode or recurrent anxiety and/or depression for offenders. Health and criminal justice services should create partnerships and develop interventions that address the risk factors which lead and/or contribute to offenders' mental health difficulties.     

"Chartering" the limits of involuntary psychiatric treatment in Victoria: interpreting the Mental Health Act 1986 (Vic) in the age of the Charter of Human Rights and Responsibilities Act 2006 (Vic)

The Mental Health Act 1986 (Vic) allows for individuals with a serious mental illness to be treated on an involuntary basis either in a psychiatric hospital (on an involuntary treatment order) or in the community (on a community treatment order). The Act also establishes the Mental Health Review Board with the authority to review these orders within eight weeks of those orders being made and at least once every 12 months thereafter. This article analyses a recent decision of the board, Re Appeal of 09-085 [2009] VMHRB 1, in which the appellant challenged a decision of a psychiatrist to extend his community treatment order for a further 12 months. The appellant argued that aspects of his involuntary treatment under the Act amounted to "cruel, inhuman or degrading" treatment and therefore breached his right to freedom from "cruel, inhuman or degrading" treatment under s 10(b) of Victoria's recently enacted Charter of Human Rights and Responsibilities Act 2006 (Vic). Thus, the board was asked to consider whether the definition of "treatment" under the Act was compatible with the rights and freedoms enacted by the Charter. This was the first time that a Victorian court or tribunal had considered the impact of the Charter on involuntary psychiatric treatment. The decision was also a prelude to the Victorian Government's announcement that it would comprehensively review its mental health legislation, now the oldest in Australia. As this case highlights, in determining the future direction of mental health legislation and policy in Victoria, the Charter has been crucial.     

The use and readability of mental health self-help in Scottish prisons

Prisoners are at higher risk of mental health problems than people in the general community. One possible way of optimising mental health care resources in prisons is to offer self-help materials. In order for these to be effective, they must be appropriate for the reading ability of the patient. This study aimed to determine, by way of a survey distributed to Scottish mental health care teams, how self-help resources are being used currently in the Scottish prison system, and to analyse the materials using four different readability tools: FRE, FKGL, SMOG and the Drivel Defence programme. It was found that there is currently widespread provision of self-help to Scottish prisoners; however, only 53% of these materials are suitable for the quoted average prisoner reading age. Mental health practitioners should be aware of this when providing self-help to patients, and consider easy-read options where available.     

Beyond PTSD: mental health consequences of violence against women: a response to Briere and Jordan

This article proposes that we move beyond posttraumatic stress disorder (PTSD) in our conceptualization of traumatic stress responses of victimized women exposed to serial forms of unrelenting violence, such as intimate partner violence and stalking. It is argued that the traditional PTSD framework is ill fitting in the context of some forms of violence against women (VAW), and these limits have consequences for developing appropriate interventions for some victimized women. The article further suggests going beyond PTSD by developing a more nuanced understanding of the ways in which PTSD and other mental health symptoms contribute to the vast array of deleterious personal, societal, and economic costs of VAW.     

Reforming the Mental Health Act 1983: an approved social worker perspective

The government green paper, 'Reform of the Mental Health Act 1983', was published in November 1999, for consultation by end of March 2000. This article offers comment on the operation of the Mental Health Act 1983 and the proposals for change, from an approved social worker perspective. Under the Mental Health Act 1983, approved social workers undertake social assessments of mental health crises, deciding upon the need for compulsory admission and treatment. To the debate on legislative change they bring a detailed social perspective on the processes and outcomes of statutory mental health intervention. Approved social workers' main concerns relate to the social context of mental health need, the availability of social resources, civil liberties, protections for people subject to statutory mental health interventions and the effective regulation of practice and services. Current proposals include options that would significantly reduce approved social worker involvement in decisions about compulsory admission and treatment; the implications of this are discussed.     

Patient inducement, provider priorities, and resource allocation in public mental health systems

Public mental health systems are increasingly facing demands from the criminal justice system and social services agencies to provide services and support in cases in which mental illness contributes to crime, homelessness, or poverty. In this article we analyze how policies from outside public mental health systems affect resource allocation within these systems, using examples from criminal justice. These policies use two types of mechanisms: inducing patients to consume treatment (by offering rewards or imposing penalties) and inducing clinicians to provide treatment (by creating priorities). We propose a classification of these social policies based on whether they affect demand through rewards or penalties or supply through priorities. We then relate the classification to data on patients treated in public systems to evaluate the current prevalence and potential for growth in these outside demands. These inducements impose a set of nonobvious costs on other patients who are not targeted by the policies. Furthermore, they create incentives for both patients and providers to modify their behavior in order to take advantage of rewards, avoid penalties, or better compete for resources with prioritized patients. We consider some policy implications for avoiding unintended consequences of these policies.     

The Place for Custody Evaluations in Family Peacemaking

Custody evaluations can serve the dual purpose of providing neutral, objective information to the court while also contributing to the possibility of earlier settlement, which coincides with the therapeutic jurisprudence goal of more positive outcomes for children and families. Research suggests that most cases settle after custody evaluations. However, most of the literature is focused on the use of custody evaluations for litigation. Evaluators, attorneys, and mental health consultants can influence parents to focus more on children's needs and less on their conflict as they go through the evaluation process. This article urges family courts to develop processes and require professionals to learn skills needed for an interdisciplinary process to utilize evaluations in peacemaking.

Key Points for the Family Court Community:
• All custody evaluation processes should aim to reduce and/or shorten children's exposure to parental conflict.
• Evaluators, attorneys, and mental health professional consultants should use the evaluation process to influence parents to be more aware of their children's needs and less invested in their adversarial positions.
• Evaluators should learn to write and orally present information and state opinions with consideration of the parents themselves as consumers of the custody evaluation as well as the court.
• Attorneys and mental health professional consultants should help clients review the report, process their emotional reactions, and consider their options for settlement versus litigation in terms of emotional and financial costs to the family.
• Court processes should be developed to contain the time and cost of custody evaluations and provide dispute resolution after custody evaluations.

     

Current psychopathology in previously assaulted older adults

Older adult women age 55+ years (N = 549) were interviewed as part of a population-based epidemiological research study of lifetime experiences with physical and sexual assault and current mental health problems. Although overall rates of psychopathology were low, producing very small cells for comparison, women who reported experiencing physical assault an average of 28 years previously were more likely to present with past year substance abuse, depression, and avoidance and reexperiencing symptoms of posttraumatic stress disorder (PTSD) than those with no previous physical or sexual assault. Women who reported experiencing sexual assault an average of 50 years previously were more likely to present with autonomic arousal and avoidance symptoms of PTSD than those with no prior sexual assault. The aforementioned findings should be considered with caution, however, as sample cell sizes were minimal for all but the PTSD symptom subtypes. Mental health service implications for older adults are discussed.     

THE USE OF PSYCHOLOGICAL TESTING IN CHILD CUSTODY EVALUATIONS

Evaluation of families for purposes of assisting the court in making decisions about custody is perhaps the most complicated forensic evaluation. Mental health professionals conducting such evaluations must ensure that their evaluations validly assess areas of concern deemed relevant by the judiciary and legislature. Evaluators sometimes use psychological measures in the evaluation process, and in recent years, a number of tests designed specifically for use in child custody evaluation contexts have been developed. Because some published tests do not meet basic professional standards, child custody evaluators should carefully review any test and its supporting documentation before including it in their examination procedures. In this article, the authors discuss the rationale for using psychological tests in child custody evaluations, describe current testing practices, review and critique contemporary custody evaluation instruments, and offer a template for mental health professionals to use when considering use of a particular test.     

Investigating Differences in Truthful and Fabricated Symptoms of Traumatic Stress over Time

False allegations of victimization typically are accompanied by malingered emotional symptomology to corroborate claims. This analog study was designed to compare truthful and fabricated symptom profiles on measures of post-traumatic stress (i.e., Revised Impact of Event Scale, Post-Traumatic Stress Disorder (PTSD) Checklist, Trauma Symptom Inventory) and levels of symptom consistency over time. Participants (undergraduate students) described their mental health symptoms for both traumas at time 1 (N?=?291), time 2 (N?=?252, 3 month), and time 3 (N?=?181, 6 months). Results indicated that fabricated traumas were associated with inflated symptom profiles. Validity scales were not effective at discerning symptom veracity, although reports could be discriminated somewhat by atypical responding and clinical scales. PTSD symptoms in malingerers also were reported more consistently over time. This research offers applicable information for identifying feigned traumatic stress.     

The unintended impact of the therapeutic intentions of the New Zealand Mental Health Review Tribunal? Therapeutic jurisprudence perspectives

Mental health review bodies engage in complex decision-making that may explicitly incorporate a therapeutic philosophy. Examination of select decisions of the New Zealand Mental Health Review Tribunal offers a foundation for understanding some implications of a pro-therapeutic approach. This analysis draws upon therapeutic jurisprudence scholarship in relation to three aspects of the hearings as documented in the written decisions: advocacy, therapeutic intervention, and the dignitary potential of the proceedings. The research explores the unintended consequences of a pro-therapeutic approach and evaluates the potential application of therapeutic jurisprudence within a mental health law context.     

Failings of Trauma‐Specific and Related Psychological Tests in Detecting Post‐Traumatic Stress Disorder in Forensic Settings

Judges and juries tend to be particularly impressed by test data, especially quantitative test data. Psychometric tests specific for assessing the presence of post‐traumatic stress disorder (PTSD) are commonly employed by forensic mental health evaluators. Most of these instruments, however, have been designed to detect PTSD in treatment or research, and not forensic, settings. Those who rely on these measures without adequate awareness of their often significant limits in correctly identifying malingering may induce finders of fact to inordinately confidently accept the presence of PTSD. This article reviews problematic structural and content components of trauma‐specific and related instruments used to evaluate PTSD and discusses the utility of specific techniques liable to be used in forensic settings to “fool” these measures.