Psychotropic Medication and Competence to Stand Trial

At any given time, as many as 15,000 persons are hospitalized for study or treatment regarding their competence to stand trial. Although most of the defendants found incompetent to stand trial "could rapidly be returned to competence and so maintained were the facilities and treatments of modern psychiatry made available to them", the impact of recent advances in psychiatry—particularly drug therapy—has not been fully absorbed by the legal system. Defendants restored to competence by psychotropic drugs frequently require ongoing medication. Some courts, mistakenly assuming that psychotropic drugs produce a "chemical sanity" that is unacceptable for participation in a trial, have adopted a practice—the "automatic bar rule"—of automatically prohibiting the return for trial of defendants under the influence of such drugs. A lack of statutory, regulatory, or judicial guidance leaves the question largely to the discretion of individual trial judges. This article critically examines the automatic bar rule in light of the effects of various psychotropic drugs and of the consequences of the rule both to defendants and to the state.     

Drug screening and confirmation by GC-MS: comparison of EMIT II and Online KIMS against 10 drugs between US and England laboratories

Drug screening through urinalysis is a widely accepted tool for rapid detection of potential drug use at a relatively low cost. It is, therefore, a potentially useful method for detecting and monitoring drug use in a variety of contexts such as the criminal justice system, pre-employment screening and a variety of treatment centers. This article explores the efficacy of two commercially available drug-screening assays: Online KIMS assay (Roche) and EMIT II assays. First, we evaluate the sensitivity and specificity of two immunoassays. A total of 738 urine samples were collected among adult arrestee populations from Chicago, New Orleans and Seattle through the Arrestee Drug Abuse Monitoring (ADAM) program. Partial samples were split within one laboratory and analyzed by both enzymes multiplied immunoassay technique (EMIT) II and kinetic interaction of microparticle in solution (KIMS) assays for a 10-drug panel (amphetamine, barbiturates, benzodiazepines, marijuana, cocaine, methadone, methaqualone, opiate, phencyclidine and propoxyphene). Gas chromatography-mass spectrometry (GC-MS) was used as a confirmation method for all positives from either EMIT II or KIMS for all experiments. Second, the paper examines whether using different testing laboratories plays a role in the final results. The same experiments were repeated at two different testing locations: one in California and one in London and England. Third, the paper studies whether drug testing results vary between two laboratories when each of them had used their own routine screening method: the Forensic Science Service (FSS) at Birmingham, United Kingdom with KIMS assay and Medscreen Limited at London, United Kingdom with EMIT II. In summary, both EMIT II and KIMS assays generate fairly consistent results. The concordance rate against each of the 10 drugs tested is relatively high (97.4-100%). The discrepancies, in most cases, occurred at drug concentrations near the cut-off levels. There were more discrepant results between two laboratories compared to when specimens were analyzed at the same laboratory using two different assays.     

Accurately assessing elderly fall deaths using hospital discharge and vital statistics data

Historically, fatal injury monitoring and surveillance have relied on mortality data derived from death certificates (DC). However, problems associated with utilizing DC have been well documented. Recently, access to and utilization of hospital discharge data (HDD) have offered a new and important secondary source of data regarding in-hospital deaths. However, studies have shown that discrepancies between the HDD and the corresponding DC often exist. This discrepancy was especially evident when comparing HDD to the vital statistics data (VSD) for deaths by falls among those aged 65 and over in 19 states.This was a retrospective forensic review of elderly (age 65 and over) fall-associated fatalities (E880-E888) identified from HDD and VSD in Allegheny County, Pennsylvania, between 1997 and 1998. Seventy-seven cases were identified, with the original manner of death listed as natural (34), suicide (1), and accidental (42) on the DC. Following a forensic review of the cases, the manner of the death on the DC should have been changed from natural to accidental in 28% (n = 12) of the cases, representing an undercount in the VSD. Undercounts were due to a failure of clinicians to account for the significance of a fall event that contributed to subsequent pathology and death. In addition, in that 22% (n = 17) of the HDD fall-associated deaths, the fall did not contribute directly or sequentially to the underlying cause of death, thereby representing an overcount in the HDD.Based on these findings we recommend (1) elderly fall surveillance systems should only count HDD E-coded falls that demonstrate a serious traumatic injury which directly or subsequently results in death, (2) all in-hospital fall-associated deaths should be reported to and reviewed by coroner/Medical Examiner offices for determination of the cause and manner of death, and (3) physicians should be better educated in properly completing death certificates.