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.     

司法精神病鉴定中限定刑事责任能力评定(附95例分析)

目的：对司法精神病鉴定中评定为限定刑事责任能力进行讨论。方法：对95例司法精神病鉴定中评为限定刑事责任能力案例进行分析。结果：限定刑事责任能力的评定在鉴定中可酌情应用。结论：限定责任能力大致可见于以下几种：①精神病性症状与作案无直接关系；②继发性人格障碍而非疾病直接导致；③轻、中度精神发育迟滞；④其他精神活动障碍。     

Jeu d’argent problématique et responsabilité pénale

ObjectivesIn total, 14% to 30 % of individuals with gambling disorder engage in illegal acts to finance such behavior. This clinical situation could be explained by higher gambling severity, associated substance use disorder, antisocial personality disorder and economic factors (debts, financial problems). The present work focuses, more broadly, on criminal responsibility of problematic gamblers.MethodsWe will discuss this question through different typical situations that medical experts of criminal responsibility may have to face. We will address each of the following cases: 1) isolated problematic gambling; 2) problematic gambling associated with antisocial personality disorder; 3) problematic gambling associated with a manic episode; 4) problematic gambling associated with substance use disorders; and 5) problematic gambling associated wiht dopamine agonist treatment.ResultsIsolated problematic gambling, (not associated with any psychiatric or addictive disorder): it seems consensual that individuals committing infractions in this case are criminally responsible. However, impeded ability to action control and possible sentence attenuation could be discussed in case of severe gambling disorder. Problematic gambling associated with antisocial personality disorder: if the penal offence reports solely to personality disorder, criminal responsibility would be attributed. However, if illegal or violent acting is directly linked to co-cocurrent delusional symptoms, it could be a cause of criminal non-responsibility. Problematic gambling associated with manic episode: manic episode related offence could lead to negation of criminal responsibility, while a hypomanic episode may provide grounds for sentence reduction. Problematic gambling associated with substance use disorders: in France, addiction is not considered to remove nor to impede a person's ability to understand or control his actions and is excluded from criminal non-responsibility causes. However, substance induced delusional or confusional episodes could abolish a subject's discernment or his ability to control his actions yielding to penal non-responsibility. Problematic gambling associated with dopamine agonist treatment: Criminal responsibility for dopamine agonist induced gambling related illegal acts is still controversial. Nevertheless, people committing an infraction linked to associated dementia or dopamine agonist induced mania should be considered as criminally non-responsible.ConclusionsSome clinical dimensions such as craving intensity, compulsivity, disorder's severity, volitional control might be forensic targets to assess criminal responsibility.     

Evolving systems of care: Individuals found not criminally responsible on account of mental disorder in custody of civil and forensic psychiatric services

Following psychiatric deinstitutionalization and changes in involuntary civil commitment laws, many individuals with severe mental disorders have been receiving mental health services through the back door, that is, the criminal justice system. Significant changes to the section of Criminal Code of Canada dealing with individuals with mental disorders have led to significant annual increases in the number of individuals declared Not criminally responsible on account of mental disorder (NCRMD), many of whom are directed to civil psychiatric settings. The goal of the present study was to describe the psychosociocriminological and risk characteristics of individuals found NCRMD remanded to civil psychiatric hospitals (CPH) compared to a forensic psychiatric hospital (FPH). This study was conducted between October 2004 and August 2006 in the sole FPH of the province of Québec and two large CPH in the Montréal metropolitan area. The final sample for the current study consisted of 96 men: 60 from the FPH and 36 from the two CPH. Results indicate that individuals in both settings have similar psychosociocriminal profiles, including PCL-R scores, but that individuals in CPH have higher scores in the Risk subscale of the HCR-20 than do their counterparts in the FPH. This difference is due to a higher score on two items: exposure to destabilizing factors and noncompliance with remediation attempts. Results are discussed in terms of the need for civil psychiatric settings to implement risk assessment and management programs into their services, and the need for further research into forensic mental health services.     

2006年度我国司法精神病鉴定状况调查

目的了解我国司法精神病鉴定的现状。方法向全国的司法精神病鉴定机构发出《2006年度司法精神病鉴定机构及业务调查表》,收集各机构年度鉴定业务信息,将资料汇总后进行统计分析。结果共发出调查表225份,收回105份。现行鉴定人员中专职鉴定人员占26.66%。在鉴定委托机构中,公安局占64.81%,法院占11.23%。鉴定案件中,刑事案件占64.57%,伤残鉴定案件占第二位(14.30%)。刑事案型分布,依次为杀人(22.07%)、伤害(18.31%)、被奸(12.75%)、盗窃(9.79%)。刑事案件中,鉴定诊断有精神疾病的依次为:精神分裂症(33.93%),精神发育迟滞(18.04%),情感性障碍(7.44%)。民事案件中,鉴定诊断为脑器质性精神障碍的比例最高,占29.55%。结论本研究一定程度上反映了当前我国司法精神病鉴定的特点,为今后提高司法精神病鉴定工作提供参考。     

Are stalkers disordered or criminal? Thoughts on the psychopathology of stalking

Although stalking is a widespread phenomenon that can be caused by different motives, consideration of the psychopathological underpinnings of stalking behaviour is scarce. In rare cases, stalking can be an expression of mental disorder. Psychotic stalking, for example, can occur as a symptom of schizophrenia or erotomania. Psychotic stalkers are criminally not responsible for their acts and have to be treated in a psychiatric hospital. The majority of stalkers, however, do not suffer from a disorder in need of treatment, and therefore their criminal responsibility is not diminished. Although legislative approaches to protecting victims of stalking differ widely in the European Union, mentally not severely disturbed stalkers can be prosecuted and punished according to criminal law in most countries. In some cases, the differentiation between mentally sane and mentally disturbed stalkers is difficult. This paper focuses on the psychopathology of such 'borderline cases', using the example of a court decision in Germany.     

Demographic,clinical and forensic characteristics of alleged offenders referred to West End Specialised Hospital,Kimberley, South Africa

The study investigated demographic, clinical and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders'' clinical records. The subjects were mainly young males, aged between 18 and 35 years, with low educational levels and high unemployment rate. The most common diagnoses were substance-related and addictive disorders, and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. In total, 55.5% of the offenders were found competent to stand trial, and 46.5% were declared criminally responsible. Offenders presenting with schizophrenia and intellectual disabilities were often declared incompetent to stand trial and were generally not responsible for alleged crimes. There was association between adjudicative competence and criminal responsibility. The results highlight effect of substances on mental illness and crime. Key words: clinical, competency, criminal responsibility, demographic, forensic, law, mental health, offenders     

Major affective disorders and forensic psychiatry.

Major mental illnesses, such as major affective disorders and schizophrenias, form a relatively small diagnostic group among mentally disordered offenders. The major affective disorders are less common when compared with schizophrenics among such offenders. Yet, some of the most violent crimes, such as murder, attempted murder, and serious assaults, especially intrafamilial violence, are committed by major affective disorder patients. The offenses by this group of patients are committed while suffering from active symptoms of the illness. As such, a substantial majority is not considered fully criminally responsible for the offense. Many such offenders are found not guilty by reason of insanity and are sent to psychiatric hospitals.     

A follow-up study of persons found not criminally responsible on account of mental disorder in British Columbia.

OBJECTIVE: To describe the characteristics of individuals found not criminally responsible on account of mental disorder (NCRMD) after the 1992 Criminal Code amendments and to track their movement through the forensic system, as well as to unveil the changes to British Columbia's forensic psychiatric system that resulted from Bill C-30. METHOD: Profile information relating to persons found NCRMD between February 4, 1992, and February 4, 1998, in British Columbia was collected and analyzed. Community follow-up data was collected and analyzed for a 24-month period following a subject's discharge from hospital. RESULTS: A substantially greater number of individuals entered the forensic psychiatric system in British Columbia after Bill C-30 was implemented. The post-1992 forensic psychiatric population contained fewer persons charged with serious index offences and a greater number of persons charged with relatively minor offences. The length of hospitalization for the NCRMD cohort decreased substantially after the 1992 Criminal Code amendments. CONCLUSION: The Bill C-30 provisions have made the NCRMD defence an attractive option for defendants and legal counsel.     

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder. Part 5: How Essential Are Gender-Specific Forensic Psychiatric Services?

Objective:

To state the sociodemographic characteristics, mental health histories, index offence characteristics, and criminal histories of male and female forensic psychiatric patients. Clinicians and researchers advocate that mental health and criminal justice organizations implement gender-specific services; however, few studies have sampled forensic patients to evaluate the extent to which men’s and women’s treatment and management needs are different.

Method:

Data were collected from Review Board files from May 2000 to April 2005 in the 3 largest Canadian provinces. Using official criminal records, participants were followed for 3 to 8 years, until December 2008. The final sample comprised 1800 individuals: 15.6% were women and 84.4% were men.

Results:

There were few demographic differences, but women had higher psychosocial functioning than men. Both men and women had extensive mental health histories; women were more likely diagnosed with mood disorders and PDs and men were more likely diagnosed with schizophrenia spectrum disorders and SUDs. The nature of the index offence did not differ by gender, except women were more likely to have perpetrated murders and attempted murders. For offences against a person, women were more likely to offend against offspring and partners and less likely to offend against strangers, compared with men. Women had significantly less extensive criminal histories than men.

Conclusions:

Not criminally responsible on account of mental disorder–accused women have a distinct psychosocial, clinical, and criminological profile from their male counterparts, which may suggest gender-specific assessment, risk management, and treatment in forensic services could benefit patients. The findings are also consistent with traditional models (Risk-Need-Responsivity) and ultimately demonstrate the importance of individual assessment and client-centred services.     

早期精神分裂症刑事作案的责任能力相关因素分析

目的探寻在刑事作案中早期精神分裂症患者的特点及影响责任能力评定的相关因素。方法回顾性调查本中心司法鉴定室1991年至2000年间所作的本中心司法鉴定刑事案例资料，将早期精神分裂症患者与非早期精神分裂症患者和正常者进行分组比较，对家族史、案型、案前精神状况、作案诱因、作案动机、隐蔽性、作案对象、自我保护、鉴定诊断、症状特点、责任能力评定等相关因素用SPSS软件作统计分析。结果早期精神分裂症患者组在精神病家族史、文化程度、职业等方面与其他组相比有显著差异：自我保护、思维障碍、行为障碍等变量对三组被鉴定人具有差别效应。结论为提高在司法精神医学鉴定实践中对早期精神分裂症鉴定的准确性，应重视精神病家族史、作案动机、自我保护、思维障碍、行为障碍诸因素。     

Dangerous or merely ‘difficult’? The new population of forensic mental hospitals

BackgroundDuring recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development.ObjectiveOur study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI).MethodsWe analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources.ResultsDuring the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged.ConclusionOur results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for “difficult” but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of “difficult” patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.     

A questionnaire survey on judgment of criminal responsibility]

The authors conducted questionnaire surveys utilizing model cases with the aim of investigating the current views of psychiatrists regarding criminal responsibility judgments in forensic psychiatric evaluations. Six model cases-injury by a person with acute schizophrenia, indecent assault by a person with chronic schizophrenia, attempted murder by a woman with depression, arson by an alcohol abuser, burglary by an amphetamine abuser, rape and indecent assault by a person with personality disorder-were presented to 345 psychiatrists, who were asked about criminal responsibility and appropriate treatment for each of the cases. One hundred eighty-five of the psychiatrists responded. In the case of acute schizophrenia with hallucination and delusion, the case of severe depression, and the personality disorder case, there was a high level of agreement between the evaluations of criminal responsibility made by the different respondents, but in the case of chronic schizophrenia, the case of alcohol-induced psychotic disorder, and the case of amphetamine abuse, there were variations in the evaluation of criminal responsibility, with many respondents emphasizing the patient's symptoms and condition at the time of the offense, and relatively few emphasizing whether the disorder was endogenous. Regarding the form of treatment, many of the respondents recommended compulsory hospitalization for the case of acute schizophrenia with hallucination and delusion, while at the same time recommending treatment in a prison environment for the personality disorder case. In contrast, for the case of chronic schizophrenia and the case of alcohol-induced psychotic disorder, opinion was divided as to whether the subject should be handled with a medical or a judicial approach. Regarding treatment for the case of alcohol-induced psychotic disorder and the case of amphetamine abuse, there was a tendency to make a judgment based on the subject's condition at the point of psychiatric evaluation, which was not necessarily linked to the criminal responsibility.     

The Role of Psychiatry in the Management of Acute Trauma Surgery Patients

BACKGROUND: Trauma is a leading cause of death and disability in the United States, with high prevalence and recidivism in individuals with psychiatric and substance abuse disorders. Half of these disorders go undiagnosed by the trauma team, resulting in adverse public health and economic consequences. METHOD: In a 16-week pilot study in the emergency department of an inner-city tertiary care hospital, a psychiatrist was integrated into the trauma surgery team by responding to all traumas and rounding with the staff 1 shift per week (March 1, 2000, through June 31, 2000). During this 16-week period, 375 patients passed through the trauma surgery service. Data on the frequency of psychiatric consultations were compared with those for a retrospectively selected control group consisting of all 360 patients passing through the trauma surgery service during the corresponding 16 weeks of the previous year (March 1, 1999, through June 31, 1999). To determine the prevalence of psychopathology, eligible patients seen during the psychiatrist's shift (N = 28) were assessed with a semistructured interview, and charts for eligible patients seen in the corresponding shift during the previous year (N = 18) were assessed according to the same criteria. Before the study, a 10-item, self-report questionnaire was completed by 16 (73%) of the 22 emergency medicine physicians who serve as front-line staff members. The survey assessed physicians' attitudes toward psychiatric consultation for psychopathology and addictions in trauma patients. RESULTS: Based on DSM-IV screening criteria, the prevalence of preexisting psychopathology was 68% (19/28), but before the psychiatrist's involvement, only 12% (2/16) of physicians surveyed had considered consulting psychiatry, even for patients with gross psychopathology. Before the psychiatrist's integration into the 16-week study period, 75% (9/12) of trauma patients were discharged without psychiatric consultation despite the fact that more than half had documented substance abuse. After the psychiatrist joined the team, staff awareness of psychopathology sharpened. The number of patients treated for a psychiatric disorder that was often the proximal cause of the traumatic event nearly doubled, even on shifts not covered in the study. CONCLUSIONS: The ability to identify and treat coexisting psychopathology requires trauma surgeons to routinely incorporate a psychiatrist into their evaluation and treatment algorithm. Such a change in physician awareness and motivation hinges on a psychiatrist's visible presence (even if brief) and regular, active participation in the emergency department.     

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.     

Parcours de soins et expertises psychiatriques pré-sentencielles : une étude descriptive au centre pénitentiaire de Château-Thierry

ContextThe high prevalence of psychiatric disorders among people in prison is well documented, and several hypotheses have been proposed to explain this overrepresentation. In France, the decrease in the number of people found by the judge to be not criminally responsible on account of mental disorder after a psychiatric expertise could play a crucial role. The Château-Thierry prison is a high-security correctional facility where prisoners whose integration into a “standard” prison is complicated because of behavioural problems, reside. We conducted the first study to describe the judicial and healthcare trajectories of people incarcerated in this facility.MethodAll the people incarcerated in the Château-Thierry prison between May and September 2019 were included in this cross-sectional study. In addition to sociodemographic characteristics, data on the psychiatric care before and during incarceration as well as information on the judicial and prison history were collected. We also analyzed all the pre-sentencing psychiatric reports in order to collect the degree of discernment determined by the psychiatrist expert for each included individual.ResultsSixty-eight (97%) of the 70 people detained at the Château-Thierry prison during the study period were included and 92 pre-sentencing psychiatric reports were analyzed. The population studied was exclusively male, with an average age of 40 years, low socio-economic status and frequent criminal history (79%). About half of them (46%) had already been hospitalized in a psychiatric community hospital prior to incarceration, and 79% have been hospitalized in a psychiatric facility during their incarceration. Disciplinary sanctions were frequent (72%) as well as convictions for offenses committed while in prison (57%). When at least one pre-sentencing psychiatric report was carried out (29 persons had a single psychiatric forensic evaluation and 27 ones had multiple evaluations), at least one psychiatric expert had concluded to a diminished (but not lack of) criminal responsibility in almost half of the cases (44%).ConclusionThis study shows the extent to which people incarcerated in the Château-Thierry prison are affected by psychiatric disorders. It also highlights the difficulties of coping with the prison environment for people suffering from psychiatric disorders. Finally, it raises the question of the lack of diversion programs for the individuals in France with mental health problems whose responsibility has been considered as full or diminished.     

Criminal harassment by patients with mental disorders.

OBJECTIVE: To assess whether there is a subgroup of persons with mental disorders who engage in criminal harassment and to determine whether substance abuse is a cofactor in this behaviour. METHOD: A cross-sectional casenote study was used to examine incidents of harassment by patients prior to admission to acute and forensic wards (n = 106) at a provincial psychiatric hospital. RESULTS: Of 106 patients, 8 (7.5%) were found to have engaged in behaviour defined as criminal harassment prior to admission. Only 1 was charged under Section 264 of the Criminal Code. Alcohol was a cofactor in only 1 case. CONCLUSIONS: The number of persons with a mental disorder who engage in criminal harassment prior to admission is relatively small. The behaviour is not usually identified at any stage of the admission as criminal harassment. Although substance-abuse problems were prevalent, substance use was not a concomitant risk factor for behaviour defined as criminal harassment.     

Monitoring insanity acquittees: Connecticut's psychiatric security review board

In 1985 Connecticut established an administrative psychiatric security review board to monitor the postverdict disposition of defendants found not guilty by reason of mental disease or defect. The five-member board may confine an insanity acquittee in a mental hospital, grant temporary leave, order conditional release, and terminate confinement or conditional release. Judicial review is required before a patient is discharged from the board's custody. Between 1985 and 1989, a total of 173 insanity acquittees were under the board's jurisdiction; most were hospitalized in state psychiatric facilities. The authors discuss issues that must be addressed in creating a psychiatric security review board, including the conflict between protecting the public and treating insanity acquittees, clinicians' resistance to treating these patients, and problems posed by patients who do not appear to be mentally ill or who are well known to the public.     

精神疾病患者的暴力行为及其责任能力评定

精神疾病与暴力行为之间存在着较为密切的联系。精神疾病患者暴力作案的责任能力评定是司法鉴定中的常见和难点问题。本文从患者暴力行为特征、责任能力相关影响因素以及未来发展趋势等方面,结合国内外研究进展进行了综合评述,以期对精神疾病患者刑事责任能力评定的研究和实践提供理论参考。