Journal of the American Academy of Psychiatry and the Law最新文献

Burnout and well being in forensic psychiatrists have been insufficiently examined, with most research focusing on vicarious trauma, compassion fatigue, or posttraumatic stress disorder among forensic mental health professionals. Previous research in Canada from 2023 highlighted a high prevalence of burnout among forensic psychiatrists, particularly among early-career psychiatrists, those whose values were misaligned with their institution, and those who had a low perceived control over their workload. Building upon this, the current study provides an assessment of the U.S. workforce in forensic psychiatry, identifying aspects of practice that contribute to, or mitigate, burnout and enhance professional fulfillment. Survey results of American Academy of Psychiatry and the Law (AAPL) members (response rate 11%) indicated that those experiencing burnout were younger, female, perceived to have had less control over their workload, spent more time on the electronic medical record (EMR), and felt their values were misaligned with leadership and colleagues. Factors predicting professional fulfillment were overall job satisfaction, value alignment with colleagues, and mentoring others. The findings of this survey will help to identify interventions at institutional and systems levels to address contributors to burnout, promote professional fulfillment and well being, and enhance recruitment and retention in the field of forensic psychiatry.

Childhood lead toxicity remains a nationwide problem, despite significant progress in reducing exposure sources in the United States since the 1970s. Neurodevelopmental sequelae of lead exposures often persist into adulthood, with limited reversibility. These include long-lasting deficits in intelligence, impulse control, and emotional and behavioral regulation, which can increase one's propensity for aggression and criminality. Yet, despite the strong association between lead poisoning and criminality, there is little agreement thus far among U.S. jurisdictions about how to apply such knowledge to criminal legal proceedings. Here, we explore forensic considerations of childhood lead toxicity for evaluation, sentencing, and staff support in the criminal justice system. We cite both clinical science and case law in navigating this complex intersection of forensic psychiatry, public health, and the environment. We aim to provide preliminary guidance on how forensic psychiatrists can approach and refer to lead toxicity in their medicolegal work. This article may hopefully inspire further forensic research on the topic and the eventual creation of standardized, lead-related guidelines for criminal legal proceedings.

The quack expert pretends to have some peculiar knowledge or skill that the expert does not possess or that may not even exist at all. Within forensic psychiatry, the response to quack experts has been varied and largely ineffective in mitigating their effect. Previous efforts to address quack experts have primarily relied on the courts, sanctions from professional organizations, or state board intervention. A shift to more globally addressing the misinformation itself and creating education of what appropriate testimony entails is likely far more helpful than trying to identify and punish each quack expert. At the individual level, new avenues of intervention include forensic psychiatrists taking advantage of educational opportunities and engaging in self-reflection. At the regional and national level, potential interventions include the American Academy of Psychiatry and the Law's educating courts and attorneys, developing resource documents conveying basic principles of appropriate practice, and expanding peer review.

Borderline personality disorder is unique in many ways from other diagnoses contained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Most salient, however, are the negative connotations often associated with the label itself and the resulting bias of providers. The ways in which these biases manifest are especially problematic in violence risk assessment, wherein evaluators are tasked with systematic consideration of data, with most data coming from available records. In this article, we describe some of the ways in which bias and objectivity are encountered in risk assessment with this population, describe a relevant case example, and offer practical recommendations for evaluators.

In Canada, the insanity defense is outlined in both legislation and judicial case law and finds original basis in M'Naughten's case. Federal jurisprudence in Canada has addressed the second and more complicated branch of the not criminally responsible on account of mental disorder (NCRMD) test on wrongfulness, yet legal ambiguity persists in provincial courts. A recent Supreme Court of Canada decision, R v. Bharwani, adds clarity. Finding agreement on the primary matter of fitness, the Court's dissenting opinion, delivered by two of its esteemed jurists and joined by a third, casts aside the obiter dictum of the court of appeal on NCRMD and was unrefuted by the majority. Thus, Bharwani resists easy classification as to its jurisprudential authority. We review the relevant case law and consider application of hybrid authority to the NCRMD portion of the Bharwani dissent.

Psychiatrists who treat mental disorders in pregnancy must navigate the risks associated with prescribing medication to pregnant and breastfeeding people alongside the risks associated with untreated mental illness. This article examines how U.S. courts have engaged with this complex landscape when tasked with evaluating allegations of clinician and pharmaceutical negligence in cases involving pharmacological management of perinatal mental health disorders (PMHDs). We begin first with a review of the legal theories that form the basis of negligence lawsuits related to PMHDs. We then explore cases of both pharmaceutical negligence (which are usually pursued under product liability claims) and professional negligence (i.e., malpractice), distinguishing how the courts' interpretation of liability has varied for errors of omission and errors of commission. We then provide an analysis of relevant themes in this area of case law with the goal of informing expert witnesses of considerations when called to opine upon questions related to negligence in the treatment of PMHDs.

Structured risk assessment tools are essential in forensic psychiatry to evaluate the likelihood of recidivism. The Violence Risk Appraisal Guide-Revised (VRAG-R) was developed as an update to the VRAG, but its predictive validity across offender populations remains underexamined. Our study aimed to examine the predictive validity of the VRAG-R for general, violent (including and excluding sexual offenses), and sexual recidivism. We conducted a systematic review and meta-analysis, searching 10 databases and gray literature sources for studies reporting psychometric outcomes for the VRAG-R published since 2013. Risk of bias was assessed using Prediction Model Risk of Bias Assessment (PROBAST) and data extraction followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) checklist. Area under the curve (AUC) values were pooled using random-effects meta-analysis. In total, 15 studies comprising 3,932 participants were included. The VRAG-R showed acceptable predictive validity for general recidivism (pooled AUC = .71, 95% CI: .67 to .75) and violent recidivism (AUC = .72, 95% CI: .69 to .75). Predictive validity for sexual recidivism was modest (AUC = .65, 95% CI: .61 to .68). In conclusion, the VRAG-R demonstrates acceptable predictive validity for general and violent recidivism, comparable with other tools. Its performance in predicting sexual recidivism, however, is limited and concerns about generalizability remain. Future research should prioritize diverse samples, reporting of calibration, and continued evaluation of performance.

Professional, political, and public debates are ongoing regarding the best way to assess risk and monitor individuals who have been found not guilty by reason of insanity (NGRI). Political and public impressions are often confounded by few, often dramatic and highly publicized cases of NGRI acquittees reoffending, rather than by an accurate understanding of the process and actual rearrest rates. States have implemented their own policies and practices for NGRI pleas (if allowed) and the subsequent evaluations, monitoring, and care for acquitted individuals, resulting in significant variation across jurisdictions. In the last five years, Arizona dissolved its Psychiatric Security Review Board (PSRB) and there were calls for ending the Connecticut PSRB. We review some of the past and current practices and evidence from PSRBs in Oregon, Arizona, Connecticut, and Washington. We discuss the challenges of comparing state practices because of variation in the connections between policy and practice and competing stakeholders' interests.