An Educational Service for Mental Health Clinicians, Forensic Psychiatrists, Forensic Psychologists, Other Forensic Professionals, Attorneys, and Judicial Professionals (Trainees & Students Welcome, Too)
William H. Reid, M.D., M.P.H.
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Note: The material presented herein is greatly summarized or excerpted, and is not to be considered complete or exhaustive. Legal concepts or findings are summarized informally; they reflect the general understanding of Dr. Reid or his associates, and are not necessarily the official positions of any court, litigating party, government, or other body. Comments are welcome, and may be e-mailed to Dr. Reid's office.
Contents and concept copyright © 1998-2008 by William H. Reid, M.D., M.P.H., unless otherwise assigned. Full-text material from the Journal of Psychiatric Practice is copyrighted by Lippincott Williams & Wilkins, and is used with permission.
Current & "Basic" Updates and Full-Text Articles
A couple of news services (and the American Psychiatric Association Headlines email service) indicate that placebos and sham patients are back in the news. We all know that a placebo is a treatment that has no biological merit (such as a "sugar pill"), but used to be popular for treating psychosomatic or "imaginary" ills (two different concepts). Sham patients are actors who impersonate patients but are not really sick. They are common in doctor-testing settings and medical schools (where the doctor knows they are not real patients), but now they are being used secretly by some hospitals and clinics to evaluate physicians' care and the health care experience that real patients may encounter.
First the sham patients. If they were really being used to assess patients' treatment and increase consumer/patient satisfaction (as often happens when restaurants or retail stores want to evaluate customer service), I'd have little criticism. But one of their main purposes is apparently an effort by HMOs and other healthcare payers to catch doctors and other clinicians who may be offering "unnecessary" tests and services. Sure, I'd like to stop the few doctors who are ripping off insurance companies and government agencies in order to line their own pockets, and there are lots of watchdogs who monitor for that; but what about the physician who is simply trying to practice careful medicine, to reassure an anxious patient, or to go the extra mile in providing the kind of care we all want (rather than the bare-bones medical care many payers and health plans want to push down our throats). I don't want that doc punished, nor do I want him or her to have to think about whether or not he'll be criticized for trying to do the right thing. I don't want the new expectation for our health care system to be some low-ball, "adequate" level of service. And I don't want some fake patient coming to a crowded emergency room or office and making you or me wait while he plays "gotcha" with our doctor.
Incredibly, the American Medical Association Council on Ethics is apparently trying to get AMA members to endorse this fake-patient practice. That doesn't make sense to me (nor to a lot of other clinicians). Readers of this website are welcome to contact the AMA and voice their opinions. Mine would be that good care (not merely "adequate" care) and patient satisfaction are more important than intimidating the doctors who are trying to help us feel better.
Now on to placebos.
I have generally held the view that placebos are a form of lying to patients. In psychiatry and forensic psychiatry, particularly, we want our patients and evaluees to be open and honest about their symptoms, backgrounds, and feelings. It has thus never made sense to me that we should return the favor by tricking them with fake medicines.
Do placebos work? You bet, in many situations. But once one weighs the pros and cons of being essentially dishonest with the patient, the benefit often fails to outweigh the drawbacks.
A recent New York Times article (May 27, 2008) described a placebo product now being marketed in the U.S. by Efficacy Brands (pun intended?), designed for parents to give to their children "for minor ills, and reduce the unnecessary use of antibiotics and other medicines."
What a terrible idea! First, parents shouldn't lie to their children. Second, whatever happened to parents who take the time to sit and talk with their kids, offering parental reassurance and empathy (rather than a pill). Third, . . . well, my list of criticisms could go on and on.
Last, but not least, the product is called "Obecalp" ("placebo" spelled backward). Now, how do you think a curious, trusting kid is going to respond when he or she inevitably figures out (or is told by some friend) what Obecalp really spells, and what will that do to his or her relationship with Mom and Dad?
Say it ain't so, Joe.
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Is Overtime an Unfair Employee Stress?
I can see it now: the plaintiff's lawyer waves a sheaf of papers in front of the jury just before they begin deliberations. "This scientific study," he says fervently, "in a respected professional journal, proves that my client's painful anxiety and depression were intentionally and negligently caused by his employer, who knew that asking him to work overtime was like putting a gun to his head. Send a message to all the bosses out there, a big financial message, that we know overtime is dangerous and we're not going to take it anymore!"
Sound ridiculous? Not so fast. A Dr. Kleppa and colleagues recently asked 1350 Norwegian overtime workers and 9092 non-overtime workers whether or not they were depressed or anxious. The authors used a written symptom scale, though most of the information was subjective. The results may be summarized as indicating that there was a small but statistically significant increase in anxiety and depression expressed by the overtime group (taken as a whole, over thousands of participants, not individually), which varied by type of work and income. (Kleppa E et al. [2008]. Working overtime is associated with anxiety and depression: the Hordaland health study. J Occup Envir Med 50[6]:658-666)
Unfair and abusive conditions in the workplace should be corrected, sometimes via employment litigation, but let's be reasonable. In addition, forensic clinicians, lawyers, and courts should be aware that using clinical findings (assuming these are valid) in legal contexts requires a careful assessment of whether or not those findings are truly applicable to the legal situation at hand. Trial lawyers are entitled to wave studies in the jury members' faces during summation, but one hopes that there will have been adequate expert testimony about their credibility and applicability to the case. To do otherwise would be to risk misinterpretation of studies, which cannot be "cross-examined" in themselves (see Courts Really Do Need Expert Witnesses, below).
An employment attorney (admittedly defense-oriented) with whom I once worked had a saying that has stuck in my mind for years: "What's a job without stress? A hobby."
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Felony criminal defendants who are found not guilty by reason of insanity (NGRI, NGI, sometimes called "not responsible by reason of insanity" [NRRI] or "innocent by reason of insanity") are almost always sent to a state hospital or federal mental health facility for treatment and containment. The idea is that when they are no longer dangerous to others, they will be released. Most remain there for many years, however, even when treatment is successful and psychiatrists or other clinical consultants believe they are no longer dangerous.
The conundrum of clinical eligibility for discharge or transfer to a less restrictive level of care, but lack of judicial permission for such a discharge or transfer, is well known to those who work in forensic mental hospitals. The patient has usually been committed under a statute different from ordinary civil commitment, and although many such laws refer to hospitalization criteria that are similar to those of civil commitment, the judges and local officials in communities from which the patients come (where they may have committed heinous acts or garnered sensational media coverage) are often very reluctant to let them return. This is one reason that people found NGRI very often spend more time in a locked facility than those who are found guilty and sentenced to prison.
The hospitals that house and treat NGRI patients are experienced in combining psychiatric care with important security requirements. In large states, there is a hierarchy of security levels, often at different mental health facilities, ranging from prison-like architecture and rigid security procedures to settings that, although containing locked wards and carefully monitored, resemble any modern psychaitric hospital. Smaller states, however, may not be able to provide such a range of treatment settings. When that occurs, there arises an inevitable mismatch between some patients' security needs and the available civil facilities.
Kevin Johns is a young man found not criminally responsible for the 2005 killing of another prisoner while on a Maryland "Supermax" prison bus with guard nearby. It was his third killing. He murdered an uncle in 2002 and strangled his state prison cellmate in 2004. the NGRI verdict in the 2005 incident was apparently associated with hallucinations arising from bipolar disorder.
Officials at Maryland's secure psychiatric facility, Clifton T. Perkins Hospital, told the court that although they treat many patients who have committed killings, and have a secure wing, they could not reasonably protect other patients from Johns if he were hospitalized there. A Harford County judge (yes, it's "Harford") ruled June 23, 2008, that although Maryland law requires patients such as Johns to be committed to a Department of Health and Mental Hygiene (DHMH) facility such as Perkins, he would not specify treatment at Perkins. It is apparently up to the Maryland DHMH to decide where and how Johns should be treated, and whether or not the special dangers he exhibits can be safely managed in one of its hospitals. He is now in the Baltimore "supermax" prison, in spite of expected defense appeals asking that he be treated in a hospital.
This case may be unique in its housing of an NGRI acquitee in a prison rather than a non-prison setting (although nonprison NGRI settings are often very secure). It is not clear to me whether, assuming defense appeals are unsuccessful, the eventual justification for prison housing will be his unusual danger to others, the fact that he is still in the middle of a life sentence for earlier convictions, or both.
(See http://www.baltimoresun.com/news/local/baltimore_county/bal-inmate,0,1520472.storygallery for a series of articles about the case, and thanks to Dr. Natasha Cervantes for her help with this vignette.)
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Antiepileptic medications are often prescribed to stabilize mood in bipolar disorder serious depressive disorders, and sometimes to prevent recurrence of severe depression. Many anticonvulsants have clear mood-stabilization properties. Some now have FDA label indications for psychiatric use; a couple of others are often prescribed "off-label" (i.e., without FDA labeling for the psychiatric indication), based on research and clinical experience.
In late January, 2008, the U.S. Food and Drug Administration (FDA) published an FDA Alert concerning a possible increase in suicide risk for some patients who receive antiepileptic drugs,based on a meta-analysis of 199 placebo-controlled studies reported in the professional literature. The complete Alert reads:
The FDA has analyzed reports of suicidality (suicidal behavior or ideation) from placebo-controlled clinical studies of eleven drugs used to treat epilepsy as well as psychiatric disorders, and other conditions. These drugs are commonly referred to as antiepileptic drugs (see the list below). In the FDA’s analysis, patients receiving antiepileptic drugs had approximately twice the risk of suicidal behavior or ideation (0.43%) compared to patients receiving placebo (0.22%). The increased risk of suicidal behavior and suicidal ideation was observed as early as one week after starting the antiepileptic drug and continued through 24 weeks. The results were generally consistent among the eleven drugs. Patients who were treated for epilepsy, psychiatric disorders, and other conditions were all at increased risk for suicidality when compared to placebo, and there did not appear to be a specific demographic subgroup of patients to which the increased risk could be attributed. The relative risk for suicidality was higher in the patients with epilepsy compared to patients who were given one of the drugs in the class for psychiatric or other conditions.
All patients who are currently taking or starting on any antiepileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.
It is very important to understand the Alert in context, and not to jump to the conclusion that antiepileptic medications "cause" suicide. The Alert itself is followed by the FDA's own comment that "This information reflects FDA’s current analysis of available data concerning these drugs. Posting this information does not mean that FDA has concluded there is a causal relationship between the drug products and the emerging safety issue. Nor does it mean that FDA is advising health care professionals to discontinue prescribing these products. . . . "
The important message here, from the standpoints of psychiatric standard of care and clinical risk management, is that the treatment of serious depression and other mood disorders must not be limited simply to prescribing and occasional follow-up visits. Patients should be carefuly assessed, then monitored frequently, especially early in treatment and when their symptoms or disorders are associated with increased risk of suicide. Competent psychotherapy, or at least counseling, with communication between treaters, is often required. Writing a prescription and telling the patient to come back in a few weeks just isn't enough.
Complete FDA information is at http://www.fda.gov/Cder/Drug/InfoSheets/HCP/antiepilepticsHCP.htm.
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A vignette elsewhere on this website explains why courts sometimes need expert testimony. Critics of expert testimony occasionally allege biased or dishonest expert "opinions," but it's clear that no judge or jury can know enough to find the truth when cases involve special knowledge about medicine, psychology or some other field. I wish expert witnesses were always honest and objective. I know they're not, but most of us are striving for that goal.
A recent Virginia State Supreme Court ruling, reported in Volume 27, Issue e2 of e-Developments in Mental Health Law, found that a lawyer's merely citing scholarly articles or books (known in the law as "learned treatises") is not enough to create "expert testimony." The main reason that the Court gave was a legal one: expert opinion must be available for cross-examination by the opposing lawyer, and cited articles in professional journals can't be cross-examined.
Good for them, though I can come up with some other good reasons to have an in-person expert: Articles in the professional literature are very often misunderstood or misconstrued by readers, especially those without professional training or research experience. A qualified expert should be able to help the court understand the article, assess its validity and reliability, and view it in the special context of the case at hand.
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The MacArthur-Foundation-funded MacArthur Violence Risk Assessment Study, released its initial findings ten years ago (in 1998) and has added important data to the psychiatric literature ever since. The study is one of the best ever designed on the topic but, perfect being the enemy of good (a great old Oriental saying), it has been criticized. Some of the critics address scientific aspects of the work (sampling, sources of variance, etc.); others use it as a springboard for defending their stereotypes and "intuition" about violence and mental disorders. Some of the basic findings are summarized elsewhere on this page.
The February, 2008 issue of Psychiatriic Services, devoted to violence and mental illness, contains a "debate" between prominent members of the MacArthur Study Group (John Monahan, Henry J. Steadman, and others) and a prominent psychiatic gadfly, E. Fuller Torry, and his colleague attorney Johnathan Stanley. Not surprizingly, the results tend to favor the MacArthur group, if primarily because they point out the very targeted nature of their results and conclusions. Broader, somewhat vague questions about such things as "How should you feel when a discharged psychiatric patient moves in next door?" (p. 151) are fair game in real life, however, and practical for a public who must deal with both the totality and the perception of risk in their environments, not just statistical analyses of filtered events within highly-defined parameters.
The role of risk from a psychiatric diagnosis per se in outpatients, within the context of all violence, is generally small, but it varies substantially with the diagnosis, subtype, symptoms, and stage of illness (e.g., in remission, largely mitigated, acute, or fulminant), and particularly with nonpsychiatric correlates of violence (such as substance abuse), which increase risk of violent behavior in unstable persons even more than in the general population.
It's easy to criticize, but much more productive to design and implement follow-up studies to address one's criticisms. That hasn't happened on any large scale to date. (The MacArthur Violence Risk Assessment Study revisited: Two views ten years after its initial publication. Psychiatric Services 59(2):147-152, February, 2008)
Penile Plethysmography as an Indicator of Recidivism Probability
Sexual impulses, the ability to control them, and whether or not they have changed are all relevant to courts' sentencing of sex offenders, and relevant to treatment and discharge considerations. Penile plethysmography enjoyed a heyday of clinical popularity during the 1970s and 1980s, when attorneys and courts hoped it would prove to be a valid and reliable indicator of what was going on in the minds of pedophiles, other paraphiles, and non-paraphilic sex offenders.
Over the years, the stimulus material used in U.S. plethysmography has been modified to assuage public sensibilities concerning child pornography and blatantly obscenity (that is, stimulus photographs are often considerably less graphic, particularly those involving minors). The procedure, which is deceptively simple and requires skilled and experienced administration and interpretation, is common in treatment programs, where its use is generally limited to addressing patient denial and assessing treatment progress. Law enforcement officials, attorneys, and defendants/patients often want to introduce plethysmographic evidence when they believe it fits their purposes. Most courts agree that it is not sufficiently valid or reliable for use in criminal trials, but a few allow it to be introduced at sentencing or considered when discharge or lessened restrictions are being considered for defendants.
The Virginia State Supreme Court recently decided against allowing penile plethysmography to be relied upon for sentencing a teenager convicted of forcible sodomy. Although the presentence report accurately stated that "deviant sexual arousal" is an important factor in sex crimes and recidivism, and a lower court had accepted plethysmography as something that should be allowed in a sentencing hearing, the State Supreme Court applied trial court criteria to the sentencing process and opined that the "Spencer" test -- Virginia's version of the Daubert criteria for scientific merit of evidence -- applied. The defendant's life sentence was affirmed. (Billips v. Commonwealth, 652 S.E.2d 99 [ Va. 2007], as reported in e-DMHL for February, 2008).
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New Jail and Prison Health Services Standards Coming
The National Commission on Correctional Health Care (NCCHC) will soon release an ambitious revision of its Standards for Health Services for jails and prisons. The NCCHC Standards are widely recognized by correctional communities, medical providers, and courts as the benchmark for correctional health care delivery, and often establish a standard of care for jails and prisons. They guide NCCHC surveyors in the accreditation process. Compliance with the 2008 update will be required for NCCHC certification beginning in 2009.
Specific mental health standards (NCCHC Standards for Mental Health Services in Correctional Facilities) will also be introduced, along with a voluntary accreditation program which will begin in late 2008. For more information, visit the Resources page at www.ncchc.org.
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Sanity Evaluations and Criminal Responsibility
"Why do the courts get so many dangerous, violent people off using the insanity defense? If someone kills somebody, shouldn't he or she pay like anyone else? Is the insanity defense really necessary? Every big case I see on television and in the papers ends up as a battle of the shrinks, and some axe murderer goes to some cushy hospital instead of the prison he deserves."
J.Q. Public
I hear the above refrain a lot, but, contrary to popular belief, the insanity defense is rarely used; it's tough to win; the Constitution probably requires that it be available to qualified defendants, and defendants found not guilty by reason of insanity (NGRI, NGI, NRRI) often spend more time in locked mental hospitals than they would have spent incarcerated had they been found guilty.
For a pretty complete discussion of the insanity defense and how forensic psychiatrists and psychologists should evaluate defendants (for either the prosecution or the defense), go to Dr. Reid's article in Applied Psychology in Criminal Justice at www.apcj.org/VolumeII_IssueIII.htm. Access to this and other issues of this online journal is free (at this writing).
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No Duty to Warn Third Parties in Texas; Premission vs. Duty to Protect/Warn
It's fairly old news, but I'm often asked about it. Here's a post to clarify the current status of (1) duty to protect or warn a third party from violence by a patient and (2) whether one can notify third parties, in good faith, of potentially dangerous patients. Note that this information applies only in Texas, since such statutes and caselaw are limited by jurisdiction. (Thanks to Chris Lopez, counsel for the Texas Department of State Health Services, for providing the judgement.)
In 1999, the Texas Supreme Court decided Thapar v. Zezulka, an appeal by Dr. Thapar of a judgement against her for negligently failing to warn Henry Zezulka concerning his stepson's threats to kill him. The Court cited both Texas law (which, after the Tarasoff case in California, established strong confidentiality laws for Texas mental health professionals) and relevant Texas case law in declining to adopt a common-law duty for pschiatrists to warn third parties in Texas. Much of the logic for that decision arose from the lack of doctor-patient relationship with the third party (the doctor-patient or therapist-patient patient relationship is the foundation for much of the duty a psychiatrist, psychotherapist, or counselor owes to his or her patient). (Thapar v. Zezulka 994 SW2D 635 [1999])
The written decision also touches upon Texas case law governing whether or not a psychiatrist or other mental health professional is protected from liability for trying to warn others of such threats or dangers. The answer is a qualified "no," but psychiatrists are legally permitted to notify law enforcement agencies of their good-faith concerns about imminent danger to others in ccertain situations. That is different from the law regarding patient confidentiality that generally prohibits notifying other (nonclinical and non-law-enforcement) third parties (such as friends, coworkers, or family), but it's not a guarantee against liability for breach of privilege (for example, if the notification is not in good faith).
It is very important to differentiate requirement, prohibition, and permission (often misunderstood in this context). In general, within the exceptions often placed in rules and laws, if it's required, do it. If it's prohibited, don't do it. If it's allowed then you have the option and should use adequate judgement in deciding whether or not to act.
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Terminating Care: Ending the Doctor-Patient Relationship
A brief article in Psychiatric News (September 7, 2007, p. 11) recently touched on some common clinical practice questions: How best can a psychiatrist or other mental health professional stop seeing a patient when termination is indicated? What's fair for the patient? The clinician? Are there ethical guidelines? What if I'm accused of abandonment? Good communication with patients and their families is a big part of managing one's practice, and reduces the risk of lawsuits and complaints, but adhering to a few procedural principles helps, too.
This is not a simple topic. There are lots of reasons for which a clinician may legitimately terminate the doctor-patient relationship (I'll include other clinician-patient relationships in that phrase). Psychiatrists and other clinicians are generally allowed to choose whom they will see or treat. Stopping a patient's care may be indicated if the doctor isn't adequately compensated for his or her services; the patient doesn't (or can't) participate adequately in treatment; the patient is threatening to the clinician; the doctor believes a different clinician would be a better choice for the patient; the doctor retires, moves away, or becomes ill; the doctor is no longer in the patient's insurance network, and for several other reasons. Every situation is unique, but in a few situations, and when the termination of care is improperly done, stopping or decreasing treatment may constitute abandonment, may be unethical, and/or may simply be poor practice.
The doctor-patient relationship is the foundation for much of what we do; it is often (not always) the context in which we practice. It forms the basis for many of the duties we assume when we treat patients, and is the context in which much of our standard of care is created. When that relationship is terminated, most of our duties with regard to the patient are terminated with it. On the other hand, stopping the relationship does not erase actions that took place before the termination, and clinicians sometimes assume that the doctor-patient relationship, and the duties that come with it, is over when it really is not.
The Psychiatric News article, provided by the American Psychiatric Association Office of Healthcare Systems and Financing, makes the point that it is not appropriate to end the treatment relationship during an emergency unless the patient agrees, and/or has been properly transferred to adequate other emergency care (such as inpatient care). I would add that even those conditions may not be sufficient to end the doctor-patient relationship. An emergency situation is rarely the time to leave one's patient.
What if the patient's clinical need is acute, but not an emergency? First, the line between the two is not always clear. The point to remember has more to do with clinical need and continuity of care than with strict definitions of "emergency" or "acute." Advisors often speak of how much notice is reasonable and necessary (often "30 days") or how many names of alternative practitioners should be given (often "three"). That may be sufficient for relatively uncomplicated situations, but it is better to think of termination or transfer of care in terms of a range of acceptable options based on the patient's condition, his or her clinical needs, his or her ability to contact a new doctor or therapist, reasonableness of notice, and the availability of qualified alternative providers.
The fact, and the process, of terminating or transferring care should usually be conveyed to the patient in writing (and carefully documented in the chart). Opinions vary about whether or when to address the reasons with the patient, and whether or not to go into detail about those reasons. Some risk managers suggest a registered letter, with return receipt; many clinicians rely on first-class mail (but document the mailing). In either event, the letter should contain, as appropriate to the individual case, documentation of one's decision and a recitation of time-lines, future care alternatives, options for medical record transfer, and interim measures (such as the doctor's availability for a period of time, emergency availability, and offers to assist in the transfer of care).
Competence to be Executed: Panetti v. Quarterman
In 1986, the U.S. Supreme Court (USSC) ruled that in order for the State to execute a prisoner he must, among other things, understand that he was to be put to death and understand the reason the State was doing so (Ford v. Wainwright 477 US 399 [1986]). In June, 2007, the USSC moved closer to setting "rational understanding" of one's impending execution, not merely rote knowledge, as a requirement for carrying out the death penalty.
Scott Panetti, a man who had been hospitalized several times for severe and chronic mental illness, killed his wife's parents and held his wife and daughter hostage before surrendering to police. Although clearly psychotic while awaiting trial, he was allowed to represent himself and was found guilty of capital murder in 1992. The death sentence was imposed. In spite of many appeals based largely on incompetence of trial counsel, he remained on death row. A few weeks before he was to be executed in 2004, his attorney again appealed, this time on the basis of alleged incompetence to be executed.
Panetti understood that he was to be executed, and understood that the reason was his murder of his inlaws. However, the evidence showed that he had a continuous delusion (a fixed, false belief, counter to common or cultural norms, which is truly accepted by the person as fact) that his death was part of "spiritual warfare" between the "forces of darkness and God and the Angels and the forces of light." He believed the State was going to execute him in order to keep him from preaching the Gospel.
The Court ruled 5-4 that those delusions rendered Panetti incompetent for execution, saying (in the majority opinion) that ". . . (a) prisoner's awareness of the State's rationale for an execution is not the same as a rational understanding of it" (underlining mine). (Panetti v. Quarterman 127 S Ct 2842 [2007])
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Standard of Care for Releasing Jail Inmates and Arrestees from ER
From time to time, I review cases in which someone in police or jail inmate has been taken to an emergency room (emergency department, ER) for evaluation, often to assess psychiatric symptoms or suicide risk. By the time I see the records, the scenario is often one in which the patient was "cleared" for transport/return to jail and sometime later committed suicide. In other evaluation situations, the patient may have experienced complications of heart disease, diabetes, or some other condition after return to custody.
Judith A. Stanley, director of accreditation for the National Commission on Correctional Health Care (NCCHC), summarized the principles of "fit for confinement" examinations in a recent column in the NCCHC quarterly newspaper, Correct Care (Summer, 2007, p. 21, quoted and summarized with NCCHC permission). She referred to the NCCHC Standards for Health Services in Jails, particularly its sections on Access to Care, Screening, and Hospital and Specialty Care.
Jail inmates are entitled to access to care for significant health problems. That care may require transport or transfer to a community hospital or other facility, where the evaluating physician must consider the level of health or mental health services follow-up that is necessary and whether or not those services are available at the jail. ER physicians should have some prior idea of the services the jail can reasonably provide; an educational visit or detailed communication with local correctional facilities is recommended.
Although jails and lockups have substantial duties to monitor inmates whom they suspect (or should suspect) are at clinical or behavioral risk, the ER evaluator should not expect perfection. Unless the jail has 24-hour comprehensive health or mental health services and staff (a rarity except in large correctional systems), the physician may find it helpful to think of return to jail as similar to returning the patient to home care. Is mere observation sufficient, or is direct care and continued evaluation required. Are minimally-trained correctional officers acceptable for the task? What scope of care and observation is available in the infirmary or administrative segregation (often the place where mentally ill inmates end up)?
ER clinicians, including psychiatrists and counselors, often assume that jails have 24-hour health care staff. This may be true in very large systems, but not in most jails and lockups. Although there may be administrative pressure to release the patient, extended observation in the emergency room or a secured inpatient setting is often a better alternative.
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Misunderstanding Confidentiality and Privilege in Civil Commitment and Risk Assessment
Regular readers and professionals who sometimes hear me speak on suicide assessment, gathering collateral history, and similar topics know that I am greatly concerned about misplaced adherance to misunderstood confidentiality rules and laws. I have often argued (after disclaimers about not being a lawyer) with other clinicians who believe that "confidentiality" prevents them from gathering (or from appropriately releasing) important, potentially lifesaving, information from (to) other clinicians, hospitals, and/or family members.
There are many different clinical and administrative scenarios that involve assessing the risks associated with potential danger to oneself or others. Many psychiatrists, psychologists, and other clinical evaluators erroneously believe that some rule or law precludes their asking for, or reasonably sharing, risk-related information that can be vital to adequate diagnosis, treatment, protection from self-harm (such as suicide), or reducing danger to others. Further, some evaluators even fail to understand the very basic importance of collateral information in such situations, and make important admission, detention, commitment, discharge, and level-of-care recommendations or decisions without it.
In the wake of the recent Virginia Tech killings, the Virginia Office of the Inspector General for Mental Health, Mental Retardation, and Substance Abuse Services (OIG) investigated that state's civil commitment proceedings and published several deficiencies and recommendations. I want to focus on only one aspect of that investigation, the finding that psychiatrists in civil commitment roles often misunderstand the law concerning obtaining information from outside sources.
Some 16 months before the shootings, the perpetrator, Cho Seung-Hui, was evaluated for civil commitment based on reports of psychiatric symptoms and apparent dangerousness to himself or others. The OIG investigation revealed that during Cho's initial screening, a "certified prescreener" (LCSW) from the local Community Services Board reviewed evidence of "extremely odd, frightening and/or threatening behavior" and interviewed another Virginia Tech student and the detaining officer before recommending involuntary hospitalization. An initial hospital detention was accomplished, and Cho was evaluated by an "authorized independent examiner" (a licensed clinical psychologist) the next morning. The psychologist stated that he interviewed Cho for 15 minutes and reviewed the prescreener's report and medical records.
The examining psychologist apparently did not obtain any additional collateral information, saying that he rarely found it necessary to obtain collateral information from pertinent people in such an individual's life. Hospital staff reported to the OIG that additional collateral information is not sought before commitment hearings. Based on the brief interview and review, with apparently no corroborating information, the psychologist-examiner determined that Cho did not require involuntary hospitalization. After a hearing which did not include the independent examiner, the prescreener, the detaining officer, or any of the roommates/witnesses, Cho was released with to "outpatient commitment" with no specific treatment plan and no known follow-up to determine whether or not he attended treatment.
During its investigation, the OIG conducted an informal telephone survey of 20 attending psychiatrists at facilities approved to admit detained patients such as Cho. That survey found, in the words of e-Developments in Mental Health Law, "a very inconsistent understanding among them regarding their ability to access collateral information regarding their patient when the patient refuses to authorize this access."
An excellent summary and discussion of the complete report appears in the August issue of e-Developments in Mental Health Law (vol. 26, issue e7, see link at bottom of this page). The report itself (Investigation of April 16, 2007 Critical Incident at Virginia Tech, OIG Report #140-07 [2007]) may be obtained from the Virginia Office of the Inspector General for Mental Health, Mental Retardation and Substance Abuse Services at http://www.oig.virginia.gov/documents/VATechRpt-140.pdf .
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Mental Health Screening and Monitoring in Correctional Facilities:
Suicide, Psychiatric Care, Prison and Jail Safety
A recent article in Correct Care, the newsletter of the National Commission on Correctional Health Care (NCCHC), cites a National Institute of Justice (NIJ) report on screening for psychiatric concerns, including suicidal inmates (Correct Care 21[2], 2007, p.1). The NIJ was spot on in citing two primary screening needs, which I believe are far more problematic in jails than in prisons.
First, suicide risk among inmates. The combination of a population with higher than average prevalence of depression, bipolar disorder, and other serious mental illnesses; unusually stressful environments; and marked life change (usually for the worse) increases general risk, but some of the most dangerous times and settings occur in jails and lockups rather than prisons. (A "lockup" is usually a satellite jail, often in a suburban area, used for temporary holding of arrestees prior to transfer to the main jail).
Jails and lockups, particularly, should provide competent mental health screening, suicide risk assessment, and close monitoring of at-risk inmates. Even inmates who deny suicidal thoughts should be monitored and protected, since their risk can easily be masked and their condition and motivation may quickly change.
Jails are temporary domiciles, rarely offering extensive health or mental health services. Nevertheless, inmates and arrestees come to them in a state of flux, often intoxicated, withdrawing from substances, and/or confused. Their future is uncertain. The surroundings are often noisy and chaotic. Inexperienced inmates (first-time arrestees, first offenders), those caught in humiliating or embarassing acts such as many sex-related crimes (even minor ones), and those with mental illness are routinely frightened, anxious, confused, and/or acutely pessimistic about the future.
Second, providing continuing mental health care, especially psychiatric medications and oversight, for inmates who were receiving it before coming to the correctional facility. This, too, applies more acutely to jails than to prisons, since jails usually lack the organization and clinical facilities found in prisons (the latter being designed for a stable, long-term population). Arrestees may not be asked in detail about their medical/psychiatric histories. Those who are asked may not be capable of giving an accurate history. The jail may not have qualified psychiatric staff. The facility formulary may not include the particular medications the inmate needs. Medical information and prescription drug lists may not be promptly forwarded from prior treatment facilities or physicians.
All of the above issues combine to highlight the requirements, generally viewed as standards of care, that even small community correctional facilities (and certainly urban jails and state and federal prisons) implement adequate screening, monitoring, and treatment procedures; check those procedures regularly for compliance; employ competent screeners for both new and symptomatic inmates; and monitor incidents and trends carefully in order to find and fix reasonably discernable problems.
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There is a lot of confusion about both the role of mental illness in violence and dangerousness, and the state and federal laws regarding purchase or carrying of firearms by persons who have a history of psychiatric disorders. The American Psychiatric Association Council on Psychiatry and Law studied relevant state laws several years ago, and some members co-authored a paper summarizing the findings (Norris DM, Price M, Gutheil T, Reid WH [2006]: Firearm laws, patients, and the roles of psychiatrists. American Journal of Psychiatry 163[8]:1392-1396). The Council is currently discussing whether or not to develop and recommend an APA position paper on the somewhat different topic of mental illness, mental health, and firearms. e-Developments in Mental Health Law, a publication of the University of Virginia Institute on Law, Psychiatry and Public Policy, recently reported that the Governor of Virginia has issued an executive order banning firearm purchase by persons who have been involuntarily treated for mental illness (committed) as either inpatients or outpatients (Virginia Governor Issues Executive Order Banning Purchase of Firearms by Individuals with a Mental Illness Who Have Been Ordered to Receive Treatment in Either an Outpatient or an Inpatient Setting, Vol. 26, Issue e6). People with histories psychiatric treatment are sometimes prevented from owning or carrying guns, and often required to "pass" a psychiatric or psychological evaluation before obtaining such weapons or permits.
It is important to understand the context of firearm reports, statutes, and policies rather than prematurely judging their content or blythely criticizing social policy. First, "mental illness" is a very broad term. Patients and former patients include millions of Americans who should not be considered significantly impaired, or impaired at all. Second, while it is certainly reasonable to limit access to firearms by persons with substantial mental disorders, or to create procedures to examine their qualifications and potential risk, even seriously mentally ill people have a relatively low rate of violent behavior or use of firearms to harm others (and much of their increased risk, as a group, is associated with substance abuse).
It is also important to know something about the firearms themselves. Does the issue being considered address all guns? Handguns only? If "long guns" are being discussed, are shotguns distinguished from rifles? Is one speaking only of concealable weapons? Is the common, inflammatory term "assault rifle" being used to describe a true assault weapon (such as a military one with fully automatic capability), or simply a rifle superficially configured to appear more aggressive. Does the discussion confuse "automatic" with "semi-automatic," a common error in which discussants often don't understand that "automatic" is a very unusual configuration for civilian firearms (illegal without a difficult-to-obtain special federal permit) which allows continuous fire while holding down the trigger (repeated fire with repeated trigger-pulls but without re-cocking the weapon is called "semi-automatic," common in handguns and long guns used for sport or hunting).
Let's be careful out there, with both firearms and rhetoric.
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New "Basics" (Core Knowledge) Section for Lawyers & Clinicians
There is a new section of this website devoted to basic information about psychiatric expert witnesses and forensic psychiatry itself. The new page contains both brief vignettes and links to full-text articles. Although the new Basic Information page should make it much easier for both attorneys and psychiatrists to find practical, core information, and decrease clutter on this Updates page, the content will be duplicated on this Updates page for the next few weeks.
Click HERE to go to the Basics (Core Knowledge) page.
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False Memory/"Recovered Memory" in a Teenager
Teenagers can be victims of false memory just as young children can. A child psychiatrist friend of mine, Stephen P. Herman, M.D., recently wrote an interesting column for the American Academy of Psychiatry and the Law (AAPL) Newsletter about on a particular case that he described as involving so-called "recovered memories," incompetence and clinical abuse by a treatment facility, and tragic misunderstandings by two child protection agencies. I asked him to summarize the case for Psychiatry and Law Updates:
A 14-year-old boy was hospitalized in a facility that specializes in treating anorexia nervosa. As part of his treatment, he was "helped" to "remember" being sexually abused by his father. He was also diagnosed by facility staff (apparently without being evalulated by a psychologist or psychiatrist) as having Dissociative Identity Disorder (DID, formerly called multiple personality). The boy was encouraged to draw, and the staff interpreted every drawing as confirming the abuse. The young adolescent readily accepted the staff's diagnosis and began talking about his "system" of "alters" (other "personalities"). The staff, some of whom later said they had treated a great many victims of alleged "satanic ritual" abuse, supported and encouraged his discussions and revelations.
The staff notified their state child protective services, who notified their CPS colleagues in the child's home state. Before the dust had cleared, the boy had been placed under CPS control and his father had been ordered out of family home. Child Protective Services determined that two other children still in the home were in danger of being abused.
Multiple forensic evaluations failed to confirm any of the allegations or the diagnosis. The state CPS persisted, however, until court proceedings finally returned custody to the parents. The boy was sent to an experiential, "outward bound" type of program, during which he recanted his statements about abuse and recovered memory of abuse. He showed no evidence of DID.
It goes without saying that some children really do require protection. There is an obvious need for well-funded child protection agencies that rely on well-trained investigators & professionals, carefully-developed procedures, and experience. In situations such as the one just described, however, irresponsible and/or poorly-trained staff of mental health facilities or "therapeutic" boarding schools can do great damage to patients/students and their families by encouraging and supporting false memories. The damage may be compounded by poor agency investigation or premature action, with results that are tragic and costly for everyone concerned.
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A recent article by Amy Lyn Sorrel on amednews.com, an American Medical Association publication, addressed several common questions physicians, including psychiatrists, have about forensic psychiatry, forensic medicine, and expert testimony (www.ama-assn.org/amednews/2007/05/14/prsa0514.htm). Most of her comments are not new to regular readers and forensic professionals, but she raised a number of good points.
- Qualified expert opinion is a very important part of the judicial process of truth-seeking in malpractice and other cases.
- Over the past several years, many states have increased their rules and oversight regarding medical expert witnesses (including psychiatric expert witnesses).
- Much of that increase has been sparked by complaints, justified or not, that (a) plaintiffs' experts in civil matters such as malpractice, often from other states, often either engage in a sort of "drive-by" testimony (my words) against local physicians without having adequate and relevant clinical credentials and/or (b) out-of-state experts take forensic practice away from in-state doctors.
- Such complaints, some new state regulations, and fear of undeserved retribution can make it difficult for one side or the other to find a well-qualified expert who is willing to testify.
- Investigation of complaints about fraudulent expert testimony or perjury often reveal instead a simple disagreement between expert witnesses. Difference of opinion should never be confused with unfair, unethical, or illegal conduct.
- States' efforts to require local licensure in order to allow an expert to testify have largely been unsuccessful. According the the article, only one state (Georgia) has a statute requiring full licensure (I believe there are others). Some, such as South Carolina, have attempted to require a temporary license. Sorrel reported that "(t)he South Carolina Supreme Court suspended their licensing statute, saying it interferes with the judicial process." Like attorney Michael Sacopulos, one of Ms. Sorrel’s sources, I am unaware of any court decision that has upheld a licensing requirement for testimony itself. (If you know of one, please email the citation -- not just an anecdote -- to me.)
- The Federation of State Medical Boards (FSMB), the advisory umbrella organization for state medical licensing boards, considers fraudulent testimony unprofessional conduct. (Physicians can expect their state medical licensing agencies to agree.)
Credibility is the foundation of psychiatric expert testimony and forensic work in other other fields. Judicious regulation, forensic experience, working with good lawyers, solid qualifications, scrupulous ethics, and openness to peer review all help protect respectable experts from being accused of professional impropriety, and from contributing to unfair judgements and case resolutions.
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Antidepressants and Suicide Risk in Children and Adolescents
There is more research supporting the safety and effectiveness of second-generation antidepressants (selective serotonin reuptake inibitors [SSRIs, such as fluoxetine/Prozax®, quetiapine/Zoloft®, and paroxetine/Paxil®], nefazodone/Serzone®, venlafaxine/Effexor®, and mirtazapine/Remeron®) in children and adolescents.
Bridge et al. recently published a review of 27 clinical trials of antidepressants prescribed to thousands of patients up to 18 years old with significant depression and anxiety disorders. All studies were randomized and placebo controlled. Other sources of the author’s data included regulatory agency reports and clinical trial registries.
The authors concluded that "(r)elative to placebo, antidepressants are efficacious for pediatric MDD, OCD, and non-OCD anxiety disorders, although the effects are strongest in non-OCD anxiety disorders, intermediate in OCD, and more modest in MDD. Benefits of antidepressants appear to be much greater than risks from suicidal ideation/suicide attempt across indications, although comparison of benefit to risk varies as a function of indication, age, chronicity, and study conditions" (from the published abstract). "MDD" refers to major depressive disorder; "OCD" is obsessive-compulsive disorder.
These findings should increase the call from clinicians and researchers for the U.S. Food and Drug Administration (FDA) to modify the warnings that were recently placed in package inserts for these medications, mitigate clinical concern about suicide risk allegedly related to prescribing them, and provide important information to lawyers and courts currently engaged in related malpractice litigation. The work is published in the Journal of the American Medical Association (JAMA), volume 297, pages 1683-1696 (2007).
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The Bureau of Justice Statistics recently released a report on malpractice claims resolved in seven states (FL, IL, ME, MA, MO, NV, and TX) between 2000 an 2004. The states represented are those that require malpractice carrier data on closed claims to be submitted to a government agency. These data include all medical and surgical specialties, not just psychiatric malpractice claims or those involving other mental health professionals. Note that the information below does not address the many claims which are unsuccessful, but only those which led to a payment. Note also that some states (including Texas) have statutory limits on trial judgements. That markedly affects payouts in both settled and tried cases, and also limits the number and kinds of cases filed in the first place.
Over two-thirds of successful claims were paid less than $250,000. Fewer than 10% received more than $1,000,000. In the states with relevant data, successful claims for major and grave permanent injuries paid a median of $278,000 to $350,000. Temporary or emotional injury received median payouts of only $5000 to $79,000.
Almost all medical malpractice claims (over 95%) are settled prior to trial. Claims that were resolved early (such as before, or soon after, suit was filed) received the lowest compensation. Those cases that plaintiffs won at trial were much more highly paid, as much as a median 2-1/2 times more than otherwise settled claims in Florida, Nevada, and Texas. It is much more expensive either to pursue or to defend a case which actually goes to trial. Using Texas as an example, the payouts for claims resolved through "alternative dispute resolution" (such as mediation or binding arbitration) were about the same as those resolved in other ways.
Claims in the "emotional only" injury category (as defined by the National Association of Insurance Commissioners [NAIC]) received very small payouts, with a median of $25,000-33,000 depending on the state. Note that this category does not reflect psychiatric or mental hospital claims which involved such things as suicide or wrongful death, injury from suicide attempt, or physically adverse effects of treatment.
Median damages paid to malpractice claimants increased between about 1990 and 2004. The amounts of increase varied greatly among the states reporting, and have also been affected during the past decade by various kinds of state "malpractice reform" legislation (e.g., limits on amount and type of claimant compensation, limits on plaintiffs' attorney fees, changes in litigation procedures).
The wheels of justice turn slowly. Claims were made to malpractice insurers an average of 15-24 months after the alleged injury occurred (no doubt varying with the applicable state statute of limitations). Once reported, those claims destined to be paid took an average of two to almost four years to resolve (depending on the state). Many took far longer.
BJS reports are a useful service of the U.S. Department of Justice, Office of Justice Programs. One can receive National Criminal Justice Reference Service updates (which address more than just criminal justice, including information on statistics, offender treatment programs, grants and government publications) by emailing justinfo@ncjrs.gov. For the complete report on thiis BJS Report, go to http://www.ojp.usdoj.gov/bjs/abstract/mmicss04.htm
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Behaviors That Get Psychiatrists, Psychologists, and Psychotherapists into Trouble
Psychiatrists' Risk Management Services, which manages a liability insurance program for members of the American Psychiatric Association, recently published "20 Surefire Steps to Increase Risk of Malpractice Suit or (Licensing) Board Complaint." I won't plagiarize from that article, but the topics are well known to attorneys, and should be familiar to all mental health professionals. I have collapsed the list, omitted a couple of items, added one or two, reworded the concepts a little, and expanded the target audience a bit, since most of the points aren't limited to psychiatry. The original article can be read on page 32 of the March 2, 2007, issue of Psychiatric News. Information about PRMS can be obtained at www.psychprogram.com.
Remember, these are the opposite of what mental health clinicians should do.
- Document only your first suicide risk assessment. Don't worry about documenting follow-up risk assessemnts or monitoring. Or just let the patient be lost to follow-up.
- Don't document your clinical rationale for changes in level of care or supervision, especially for potentially suicidal patients. Don't explain your judgement and rationale for the treatment plan in the record. Stick to the bare facts. Save trees.
- Don't contact family members for additional information about the patient's condition (especially his/her suicide risk), especially when the patient hasn't signed an authorization for information release. Use the same logic when telling concerned family members that you can't discuss the patient’s suicide risk.
- Don't worry about the safety of the patient's environment when deciding to discharge, order a pass, or not admit a potentially suicidal patient. In particular, don't bother to ask about available firearms. While you're at it, allow the family to take full responsibility for monitoring the patient.
- When a patient appears to be dangerous to others, rely solely on your own clinical judgement and don't bother to notify appropriate people, seek consultation, and/or otherwise reasonably protect potential victims (especially if the patient has identified potential victims).
- When in a collaborative treatment relationship with other clinicians (such as when prescribing for a patient who is in psychotherapy with someone else, or following a patient for a primary care physician), employ a "hands-off," "arms' length" approach. Don't exchange information regularly with the other professional. Don't discuss treatment approaches. Don't have any prior agreement about care or professional roles. Don't bother to learn anything about the other clinician's qualifications. Assume the other treater knows when to contact you. Spend 15 or 20 minutes with the patient every few weeks or months, sign the prescriptions, and move on.
- Keep your "special" patients special. Don't record really sensitive information about people, especially those in sensitive positions, even when it's clinically relevant. Bend the rules for V.I.P.s, old friends, other (perhaps impaired) professionals, and that particularly interesting (or attractive) therapy patient.
- Have sex with a patient. Have sex with a former patient. Terminate a patient and then have sex. Have drinks with a patient and promise yourself you won’t have sex. Spend a lot of time talking with a patient about yourself or your own interests. When you feel sexual or other inappropriate feelings toward a patient, tell the patient and ask if the patient feels similarly. Do not seek competent consultation if the impulse to act on such feelings is getting really strong.
- Prescribe medications by telephone when you don't know the patient well or have not conducted a suffucient evaluation. Don't bother to document the call. Prescribe without establishing recommended baseline laboratory values (e.g., when prescribing lithium compounds); documenting a thorough discussion of potential effects, potential side effects, and the patient's consent; and recording the name, number, dosage schedule, and clinical rationale for each prescription or change in prescription.
- Assume that merely prescribing for a patient doesn't establish a doctor-patient relationship. (Not on their list, but on mine.)
- Believe that patients who cannot pay for their care (or for some options of care) can be treated below the standard of care for all patients, especially if you're nice to them. Rely on their gratitude to keep you out of trouble.
- When stopping care, don't attend to the termination principles you learned in residency or graduate school. Be modern. Let the patient go his own way. And if there's a big problem, discharge him from your practice. Don't worry about making a careful referral. Assume you've dodged a malpractice bullet.
- If something bad happens to your patient or the patient's care, change the clinical record. If you receive a subpoena about a patient (or a request for records or letter from a lawyer) decide what to keep and what to shred. Do not contact an attorney.
Clinicians: Does the above make you nervous? Do you want to email me and complain that your schedule, or the clinic in which you work, forces you to do some of these things even though you know better? Do you think "managed care" has changed the standard of care in the U.S.? Remember that you, not the clinic administrator or insurance company, are responsible for the quality of your care and for meeting the relevant standard of care when working with patients. (Malpractice juries just hate the "managed care" excuse.)
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Antidepressant Prescribing Down, Child and Adolescent Suicide Up
I'm not an adolescent psychiatrist, but I monitor suicide-related issues as they apply to all ages. I've watched the recent flap over purported dangers of antidepressant medications for children and adolescents (particularly selective serotonin reuptake inhibitors or "SSRIs") very closely. Various people, some well-meaning and some simply anti-psychiatry or anti-psychotropic-medication, pressured the FDA into requiring special warnings regarding prescribing antidepressants for children and adolescents. Those warnings appeared officially in 2005, but there was lots of very unfortunate (if predictable) media sensationalism about antidepressant drugs and children throughout 2003 and 2004. That media feeding frenzy frightened many patients and their famililes, intimidated some psychiatrists and other doctors, and contributed to a significant decrease in antidepressant prescriptions for patients in this age group.
Now, data reported from the federal Centers for Disease Control and Prevention (CDC) and published in the journal Pediatrics strongly suggests that the decrease in antidepressant prescriptions has led to a substantial increase in both the rate and number of suicides in U.S. children and adolescents.
From 2000 to 2003, suicide in childhood and adolescence in the U.S. decreased measurably every year. In 2004, however, the number of suicides (and suicide rate) for those age groups spiked to a level not seen since before the year 2000. The spike coincides with the decrease in antidepressant prescriptions caused by the public SSRI "controversy." No other cause of childhood or adolescent death increased during the same period.
Several well-known mental health researchers and advocates, including spokespersons for Mental Health America (formerly the Mental Health Association) and the American Psychiatric Association, have either voiced concerned about the rise in suicide and its apparent relationship to fewer antidepressant prescriptions, or specifically blame the increase on the decline of prescriptions caused, apparently, by media trumpeting and the FDA-mandated warning.
I rarely use this website as a soapbox, but this topic (and the lives of our children) is worth the departure. We must wait a while for data which will show whether or not the suicide rate remained unusually high through 2005 and 2006; however, it seems prudent to encourage, in both professionals and the public, careful consideration of all potentially effective antidepressant treatments, including medication, when symptoms suggest they are warranted. (Hamilton BE, Minino AM, Martin JA et al. [2007]. Annual summary of vital statistics: 2005. Pediatrics [special supplement] 119:345-60)
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Judges’ Impressions of Foreign-Trained Psychiatric Expert Witnesses
During the past two years, Dr. Suresh Durgam and I surveyed 100 experienced Texas judges about how they thought jurors would respond to psychiatric expert witnesses who received their medical degrees outside the U.S. or Canada ("International Medical Graduates," "IMGs") but had their postgraduate training in accredited U.S. psychiatry residency programs. The judges were primarily from criminal and civil trial courts, with some juvenile and family courts represented. The survey addressed experts’ country of origin, medical school, and ethnic characteristics. Many of the questions were drawn from 11 one-paragraph descriptive vignettes that contained ethnically diverse examples which each judge rated with respect to perceived expert credibility.
Results. 58.4% of the judges believed that juries have a negative perception of IMG experts generally; 39.3% predicted neutral perceptions, and 2.2 % predicted a positive impact of IMG status. 84.4% believed that the specific country of medical training is important to jurors' perceptions. 91.0% thought that prominent ethnic features (e.g., dress, facial features, accent) influence jurors, often (but not always) in a negative way.
Responses to the 11 example vignettes varied, but predicted negative juror reactions to many backgrounds and ethnic features (p<0.001 for 8 of the 11 vignettes). A heavy accent was the most negative factor, followed by "foreign" appearance, certain specific regional backgrounds (Middle-East, Pakistani, and "third world" countries associated with allegedly substandard medical schools), and non-Western attire.
The lowest ratings went to hypothetical Middle-Eastern, Nigerian, Pakistani and Jamaican experts. One of those was described in his/her vignette as wearing a dashiki and two with heavy accents. The three highest rated (Irish, German, and South African Caucasian) received varying responses but averaged "no effect" on jury perceptions. All of those were hypothetically light skinned, clean shaven, and wearing Western attire.
93% of respondents believed trial venue could affect jury perceptions. Some mentioned individual personal or professional factors that might overcome the stereotypes surveyed.
Conclusions. The results suggest that geographic and ethnic characteristics are relevant for attorneys to consider when retaining testifying psychiatric experts. The complete paper will be published later this year.
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Civil Commitment and the “Gravely Disabled” Criterion
People, even psychiatrists, often associate civil commitment (involuntary hospitalization in a psychiatric hospital) with danger to self or others (meaning danger of suicide or violence). States also allow commitment of patients who, because of severe mental illness or disorder, cannot care for themselves, are in marked danger of mental deterioration, and/or cannot make appropriate treatment decisions. In fact, far more seriously ill patients are unable to care for themselves than are specifically suicidal or a danger to others.
This commitment criterion, often worded in statute as “grave disability,” is almost never intended to be limited strictly to one’s ability to survive. It would be cruel and inhumane indeed to keep a treatable person from gett