The unconditional release of mentally ill offenders from indefinite commitment: a study of Missouri insanity acquittees

Using a database of all Missouri insanity acquittees committed on July 1, 1997 (N = 873) and all insanity acquittees unconditionally released from 1986 through 1997 (N = 193), this study calculated the lengths of commitment and identified variables associated with the unconditional release of insanity acquittees from indefinite commitment by the mental health and criminal justice systems. The study found that 85 percent of insanity acquittees were still under commitment 5 years after acquittal and 76 percent 10 years after acquittal. Factors that decreased the odds of being unconditionally released included never having been married; having a psychotic disorder, a mood disorder, a substance abuse disorder, or mental retardation/borderline intellectual functioning; and having committed a serious crime. These results support achievement of the intended goal of Missouri's insanity acquittee statute, which is to maximize public safety considerations, but have had the unintended effect of increasing the inpatient insanity acquittee population, resulting in fewer resources for voluntary patients.     

Commentary: Biases that affect the decision to conditionally release an insanity acquittee

The care and management of hospitalized insanity acquittees can be quite challenging. As patients progress in treatment, clinicians must invariably address whether the patient is ready to be returned to the community, balancing the liberty interests of the acquittee with the protection of society. The process by which this determination is made is far from simple and involves review of clinical interview and collateral information, identification of indicators of outcome post-discharge, and the use of structured risk assessment instruments. The decision to release an acquittee conditionally is also influenced by an array of factors that emanate from within the clinician, within the institution, the mental health system, the courts, and the broader society. While such biases affect a clinician's objectivity, they are also a natural part of the evaluation process. Their identification is essential so that the degree to which such biases influence the conditional release decision can be more fully understood and addressed.     

Psychiatric consultation to a state board of medical examiners

This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.     

Designing conditional release systems for insanity acquittees

Monitored treatment in the community, also known as conditional release, has been described as the most important advance in the treatment of insanity acquittees in the last decade. Despite the importance of the development of conditional release, however, there has been relatively little written about relevant issues and planning principles important in designing and implementing conditional release systems. The present paper discusses important considerations relevant to conditional release that are associated with key decision points within systems for persons found not guilty by reason of insanity (NGRI). Four planning principles, generalizable to all NGRI systems, are then presented in a way that integrates the previous discussion. It is concluded that conditional release plays a crucial role in the treatment of insanity acquittees and that mental health administrators may either proactively modify their systems, in a way that balances public safety with individual rights and treatment needs, or wait for the modification mandate to be forced upon them in the wake of a highly publicized, heinous offense.     

The insanity verdict,the psychopath,and post-acquittal confinement

Automatic post-acquittal confinement, an almost inevitable concomitant of a verdict of not guilty or not responsible by reason of insanity has for many acquittees been nothing more than punishment in disguise. Replacement of the insanity defense by statutes that provide for expert witness testimony to show that the defendant lacked the state of mind required as an element of the offense charged, has been found by two state supreme courts to be in accord with constitutional requirements. Procedures can be implemented, with due regard for public safety, so that all offenders, mentally disordered or otherwise, may be dealt with in an ethical, effective and humane manner. The 1992 decision of the Supreme Court of the United States in the case of Foucha v. Louisiana, holding that the Constitution does not permit the continued confinement of a still dangerous, but no longer mentally ill, insanity acquittee, makes it all the more necessary that the insanity defense be abolished and that an offender's mental illness be considered primarily in the context of mitigation, disposition and sentencing, rather than exculpation.     

Treatment delays for involuntary psychiatric patients associated with reviews of treatment capacity.

OBJECTIVE: To determine the duration of delays in treatment initiation when involuntary patients apply for a review of a finding of treatment incapacity and to estimate the cost of keeping patients hospitalized without treatment in these circumstances. METHOD: Using a computerized database and written records, we identified all patients at 2 psychiatric hospitals in Ontario who applied for a review of a finding of treatment incapacity during a 10-year period. We recorded clinical and demographic variables, dates of stopping and starting medication, and dates of review board hearings and outcomes. We also noted all cases in which a patient appealed a decision from the review board to the court. RESULTS: Two hundred and thirty-seven patients made 334 applications to the review board. The board overturned the physician's finding of incapacity in only 5 (1.5%) applications; 15 appealed the review board's finding to the courts. None of these appeals were successful. In the absence of an appeal to the courts, the average delay in initiating treatment was 25 days. For patients appealing to the court, the average delay was 253 days. The cost of hospitalizing untreated patients while their capacity was under legal review was estimated at $3,867,000, of which $1,333,000 could have been saved if treatment had started immediately after the review board confirmed incapacity. CONCLUSION: We have identified extensive delays in initiating psychiatric treatment for a number of patients. These delays are associated with legal review of treatment capacity. There are serious clinical risks and substantial costs associated with delay in treating patients with acute psychiatric illness. Where jurisdictions review treatment capacity, we recommend that treatment not be impeded once a review board has confirmed a clinical finding of incapacity.     

A follow-up of patients found "unfit to stand trial" or "not guilty" because of insanity.

Fifty-six patients who were found unfit to stand trial or not guilty by reason of insanity were followed up after their release from a maximum security psychiatric institution. At the time of follow-up 50 percent lived in the community, 43 percent were in psychiatric facilities and 5 percent were in correctional facilities -- 9 percent of the patients were either returned to the maximum security hospital or had committed new offences. The twenty-seven ex-patients who were interviewed generally exhibited little psychiatric symptomatology and there was evidence that they had adjusted well to the psychiatric facility or community in which they lived. As a group they appeared to have made a better vocational than social adjustment.     

L’unité pour malades difficiles de Cadillac en Gironde : données d’activité, pathologies et approches thérapeutiques

This communication presents a high security facility in the hospital of Cadillac, near Bordeaux (France). This structure provides intensive psychiatric care for patients with mental disorders and often violent or criminal propensities, all of them compulsorily hospitalized, who need particular security measures. The objective of the study was to describe activity data, characteristics of patients, main diagnoses for year 2018. Among 125 patients, about half (48%) came from Nouvelle-Aquitaine, a large administrative area, and the other came from other regions of France. Most patients were addressed by general psychiatric services (73%). Some were declared not guilty for insanity after a crime (18%), or were detainees (9%). Schizophrenia was the most frequent diagnostic (60%), often associated with substance use disorder. We purpose a clinical approach of different profiles of patients, and a review of therapeutics.     

Criminal Justice Outcomes of Those Appearing before the Mental Health Tribunal: A Record Linkage Study

To examine the utilisation of the insanity defence in Queensland and insanity acquittee reoffending, offences cleared by the police were compared with charges heard by the Mental Health Tribunal (MHT) and appearances before the MHT from 1985 to 2002 were cross-linked with police databases. Only 0.24% of cleared offences were heard by the MHT. This plea rate was similar to that in the US jurisdictions where the insanity defence has been extensively researched. Overall, persons not afforded an insanity defence reoffended more frequently, committed more offences, including more violent offences, and committed more serious offences as measured by the National Offence Index. Furthermore, offending occurred sooner than that of insanity acquittees. Evidence was not found for “over-use” of the insanity defence and overall, recidivism was lower and less serious for insanity acquittees. There is a need for further research to more comprehensively identify factors associated with positive outcomes.     

An outpatient psychiatry program for offenders with mental disorders found not guilty by reason of insanity

OBJECTIVE: Rehospitalization and criminal recidivism were examined among a group of offenders with mental disorders adjudicated as not guilty by reason of insanity and mandated to receive treatment in a forensic psychiatric outpatient program as a condition of release. METHODS: A retrospective chart review was conducted for 43 offenders with mental disorders who were acquitted as being not guilty by reason of insanity for the index offense and were active in the outpatient treatment program in 1996. Data were abstracted on sociodemographic, psychiatric, and criminal characteristics predating the index offense; rehospitalizations and new crimes and rearrests after the offense; and clinical and psychosocial functional outcomes after enrollment in the outpatient program. RESULTS: For the 43 patients, the mean length of stay in the program was 68 months, with a range of 4.9 months to 18.4 years. Almost two-thirds of the patients were diagnosed as having schizophrenia, schizoaffective disorder, or a nonaffective psychotic disorder; 58 percent had a comorbid substance use disorder, and 63 percent had an axis II diagnosis. Since program enrollment, 20 patients (47 percent) were rehospitalized at least once, and eight (19 percent) were rearrested or had committed a new crime. At the end of 1996, only nine (24 percent) were in full remission, and 26 (68 percent) showed at least one indicator of difficulty reintegrating into the community. CONCLUSIONS: Even after treatment in a specialized forensic program, this sample of offenders with serious mental disorders remained impaired symptomatically and functionally. Although avoidance of rehospitalization is considered a successful outcome, rehospitalization is preferable to rearrest for this forensic population.     

Effect of conditional release from hospitalization on mortality risk

OBJECTIVES: This study considered the protective value provided by conditional release. It assessed the contribution of conditional release to mortality risk among patients with mental disorders severe enough to require psychiatric hospitalization during a mental health treatment span of 13.5 years in Victoria, Australia. METHODS: Death records were obtained from the Australian National Death Index for a sample of 24,973 Victorian Psychiatric Case Register patients with a history of psychiatric hospitalizations: 8,879 had experienced at least one conditional release during community care intervals and 16,094 had not. Risk of death was assessed with standardized mortality ratios of the general population of Victoria. Relative risk of death among patients with and without past experience of conditional release was computed with risk and odds ratios. The contribution of conditional release to mortality, taking into account use of community care services, age, gender, inpatient experience, and diagnosis, as well as other controls, was assessed with logistic regression. RESULTS: Patients who had been hospitalized showed higher mortality risk than the general population. Sixteen percent (4,034) died. Patients exposed to conditional release, however, had a 14 percent reduction in probability of non-injury-related death and a 24 percent reduction per day on orders in the probability of death from injury compared with those not offered such oversight throughout their mental health treatment, all other factors taken into account. CONCLUSIONS: Conditional release can offer protective oversight for those considered dangerous to self or others and appears to reduce mortality risk among those with disorders severe enough to require psychiatric hospitalization.     

Monitored conditional release of persons found not guilty by reason of insanity

This article reviews the recent literature documenting changes that have taken place in the management and treatment of insanity defense acquittees with the development of conditional release and monitored community treatment. The review demonstrates that conditional release is particularly important as a means of balancing the protection of society with the treatment of insanity defense acquittees in the least restrictive environment. The review also highlights the development of community programs based on treatment models for the chronically mentally ill. In addition, monitored community treatment programs appear cost-effective when compared with hospital-based programs. These factors point to the development in the 1990s of program standards for the release of insanity defense acquittees.     

The involvement of schizophrenic insanity acquittees in the mental health and criminal justice systems.

This article described the mental health and criminal justice involvement of a large group of schizophrenic insanity acquittees and the program designed to manage and treat these individuals. Most insanity acquittees in our system are chronically mentally ill individuals who fit well into the psychosocial rehabilitation models that have developed over the past 15 years. In addition, the use of conditional release and monitored care in the community appears to be the most realistic approach to this group of individuals who show a high degree of involvement with the mental health and criminal justice service systems. This research has continued implications for the development of outpatient civil commitment and for the attempt to give people as much liberty as they are capable of handling while being realistic about their capacities to survive in the community.     

Court-mandated community outpatient treatment for persons found not guilty by reason of insanity: a five-year follow-up

The authors conducted a 5-year follow-up study of 79 persons found not guilty by reason of insanity who were referred to and accepted for court-mandated community outpatient treatment. This was a severely mentally ill and violent group with extensive experience in both the criminal justice and mental health systems. This program was not without risks despite a readiness to revoke the patients' conditional release status when indicated; during the 5-year follow-up period, 25 (32%) were rearrested (18 [72%] for crimes of violence), 37 (47%) were hospitalized, and 38 (48%) had their conditional releases revoked. The authors believe that members of this population need social controls and long-term treatment when they are in the community.     

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.     

Outcomes of assertive community treatment in an NGRI conditional release program

This study describes the five-year outcomes of an assertive community treatment (ACT) program that monitored 83 acquittees found not guilty by reason of insanity (NGRI) placed on conditional release (CR) into the community. Data were collected by retrospective review of court reports and a state computer database. Five arrests and 60 hospitalizations occurred during the study period; overall, the NGRI acquittees were in the community for 83 percent of the time they were eligible for conditional release. Multivariate logistic regression analysis showed that the duration of conditional release was a positive predictor, and paranoid schizophrenia was a negative predictor of hospitalization or arrest. The estimated annual rate (EAR) of hospitalization was 14.0 percent, and the arrest EAR was 1.4 percent. The ACT model for NGRI acquittees on CR yielded a low arrest rate, a moderate hospitalization rate, and good community tenure.     

Conditional release: a less restrictive alternative to hospitalization?

OBJECTIVE: This study examined conditional release--that is, involuntary outpatient commitment orders upon release from hospitalization--as a least restrictive alternative to psychiatric hospitalization in Victoria, Australia. METHODS: Records were obtained from the Victorian Psychiatric Case Register for patients who experienced psychiatric hospitalization: between 1990 and 2000 a total of 8,879 patients were given conditional release and 16,094 were not. RESULTS: Compared with the group that was hospitalized but did not receive a conditional release, the group that received a conditional release was more likely to have more prior hospitalizations of greater than average duration. Patients with schizophrenia were more likely to be given conditional release. Patients given conditional release experienced a care pattern involving briefer inpatient episodes (8.3 fewer days per episode), more inpatient days, and longer duration of restrictive care--that is, combined inpatient and conditional release periods (5.1 more days per month in care). CONCLUSIONS: For patients at risk of long-term hospitalization, conditional release may help to shorten inpatient episodes by providing a least restrictive alternative to continued hospitalization. However, patients who were given conditional release doubled the amount of days they spent under restrictive care, compared with the amount of time they previously spent in the hospital before entering a period of combined inpatient and conditional release commitment. Additional oversight may have led to more frequent hospitalization. This consequence raises new questions regarding the possible benefits of such extended oversight and new challenges for release planning using conditional release as a least restrictive method of care.     

Administrative issues in the follow-up treatment of insanity acquittees

This paper discusses issues in the community-based management of forensic patients. Community acceptance and safety demand a careful system of follow-up treatment for insanity acquittees. Many studies have examined the recidivism of this population, but few have dealt with administrative strategies to manage their care as outpatients. In this paper, we discuss our experiences in developing systems for follow-up care of insanity acquittees in the state of Maryland. Central to this work is the balancing of clinical, judicial and community concerns. The decision for outpatient care or movement of the patient to a non-forensic (regional) hospital is a significant turning point in the forensic patient's care. One of the major challenges faced by forensic mental health services is to develop consistency of practice throughout a state. A centralized system is easier to manage, but costly. A system embedded in community mental health centers is less duplicative, but requires major and ongoing educational support. A private practice model is flexible, but administratively challenging. The authors believe Maryland possesses well-developed approaches for the evaluation, treatment and conditional release of insanity acquittees. The state continues to study and redesign its systems toward increased effectiveness and efficiency.     

Psychiatric defenses in New York County: pleas and results

Studies that have investigated the use of the insanity defense have revealed that the defense is rarely interposed. Few of these studies provide information on the use of psychiatric defenses other than insanity or report on how such cases were adjudicated (e.g., by trial or plea agreement). The current investigation examined all defendants who were indicted for felonies and who proffered any type of psychiatric defense in New York County (one of the five counties that comprise New York City) from 1988 to 1997. Plea, acquittal, and success rates and the manner by which cases were adjudicated are summarized. Prior research reveals that the general public believes that the defense is frequently used and often succeeds. However, in New York County, psychiatric defenses were proffered by only .16 percent of all indicted defendants.