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

The increased visibility of the patients' rights movement in medicine in recent years has left the erroneous impression that patients and their physicians are on equal footing in the physician-patient relationship. The reality is that vulnerability of patients in this relationship leaves them at the mercy of health care professionals. This is most acute in psychiatry, where patients reveal aspects of their inner being to their psychiatrist, including strange beliefs they would never disclose to their closest friends and family members, whereas psychiatrists, in contrast, reveal close to nothing of themselves to patients. Additionally, distortions of reality can strip patients of social mores and basic humanity and sometimes cause them to commit crimes. American Academy of Psychiatry and the Law (AAPL) scholars have espoused the values of treating evaluees professionally and with compassion and respect while upholding their dignity and humanity. These worthy forensic psychiatric writings, however, have unfortunately not always transitioned into the clinical treatment of forensic patients. Reports of patient abuse by staff in psychiatric hospitals, including forensic psychiatric hospitals, remain rampant. Using real-life examples, I apply forensic psychiatric ethics to patient care and offer suggestions of practices and policies that would enhance treatment of patients and decrease the potential for patient abuse in psychiatric hospitals.

Hunger strikes are a common occurrence in carceral settings accompanied by serious health risks and intensive health care utilization. A 2017 study on hunger strikes within the New Jersey Department of Corrections found these events most often occurred in a disciplinary setting. We undertook this study after a new state law, the Isolated Confinement Restriction Act (ICRA), improved conditions of confinement in part by reducing the utilization, nature, and duration of disciplinary housing. We hypothesized that ICRA would reduce the frequency of hunger strikes. Although the frequency of strikes was unchanged, the mean hunger strike duration declined from 28.9 days to 9.7 days (p = .034). The typical strike was modestly briefer, with the median duration before ICRA being four days and after being three days. The rate of hunger strikes greater than three days declined (from 60.3% to 45.2%; p = .049). There was no difference in the rate of hunger striking in disciplinary housing before or after ICRA. Although hunger strikes remain a frequently used method of protest for incarcerated persons, reform to the conditions of confinement was associated with reducing the health-related dangers and associated health care costs of these phenomena and arguably was a factor in this reduction.

Bias can vitiate the quality and credibility of a mental health professional's forensic evaluations as well as scientific and scholarly contributions to the forensic process in forensic psychiatry publications. Our attention here is on this latter influence of bias, although the genres of bias identified here can as well occur in forensic practice and writings. Attention is given to multiple forms of bias in peer review: ad hominem, ideological, confirmatory, hindsight, the halo effect, gender, publication, conflict of (financial) interest, political, religious, nationality or country of origin, esthetic or linguistic, racial or ethnicity, and herding. No doubt much bias in peer review goes undetected and no absolute purification process exists. Nonetheless, as with almost any problem, the first step toward a remedy is recognition.

Stimulants are among the most widely used substances in the world after cannabis, with a rapid rise in methamphetamine use in the last 15 years. Methamphetamine has a high propensity to cause psychosis ranging from transient psychosis during acute intoxication to persisting psychosis with similarities to schizophrenia. Although the former condition may not abrogate criminal responsibility, the latter is recognized as a basis for an exculpatory mental state in a majority of jurisdictions across the United States. Methamphetamine use can therefore complicate criminal responsibility evaluations. We present the literature on methamphetamine-induced psychosis, underscoring the shortfalls in existing classificatory schemes for methamphetamine-associated psychosis that can complicate forensic mental health evaluators' opinions in criminal responsibility evaluations. We offer practical considerations for forensic mental health professionals performing criminal responsibility evaluations where methamphetamine use is a concern.

This article discusses the relevance of delusions for a finding of criminal insanity. The authors start from the recognition that the psychiatric notion of delusion is considered relevant to criminal insanity in most jurisdictions and therefore integrates psychiatric perspectives to define delusions. The key focus is on the differences regarding how and why delusions matter legally between the Anglo-American and the Norwegian approach to criminal insanity. The authors argue that Norwegian law provides a new point of entrance to clarify legal implications of delusions but also uncovers further challenges and targets for future research regarding how the law relies upon psychiatric constructs.

Forensic psychiatry has been developing ethics guidelines over the last 50 years. The forensic psychiatry guidelines have taken a somewhat different path from traditional medical ethics based on beneficence and nonmaleficence. In particular, for forensic psychiatrists, the ethics concept of the primacy of striving for an individual's benefit may conflict with duties to the justice system. I posit that correctional psychiatry is a branch of forensic psychiatry that has ethics characteristics of both systems and discuss a way of resolving some of these dilemmas. Even if it is practiced by suitably qualified forensic psychiatrists, correctional psychiatry demands its own variation of ethics principles. This variation involves the additional variable of acknowledgment of the duty to the security of the institution. I develop this theory and apply it to some day-to-day ethics dilemmas with which correctional psychiatrists deal. Developing a code of ethics for correctional psychiatry is important. I apply a theoretical code of ethics to the many daily dilemmas experienced by correctional psychiatrists.

Malingering is defined as the intentional falsification or exaggeration of symptoms for secondary gain. The prevalence of malingering varies widely among different medicolegal contexts, emphasizing the need to identify additional predictive factors when considering the diagnosis. This study measured rates of malingering in a sample of 1,300 subjects from a forensic psychiatry practice located in Lexington, Kentucky. Among those who failed at least three symptom or performance validity scales, odds ratios for malingering were approximately twice as high in subjects with less than a college education (p = .011), those referred by the opposing counsel (p = .001), and those meeting criteria for a mental illness in three or more DSM-5 diagnostic categories (p = .015). Those evaluated for worker's compensation and head injury were more likely to malinger than other case types (p = .028). Men were found to malinger at a higher rate than women (p = .014), and no significant differences were observed based on race. These results indicate that education, gender, psychiatric history, case type, and referral type may be important factors to consider when assessing for malingering.

This practice resource seeks to describe salient problems within reproductive psychiatry (also known as women's mental health) for the practice of forensic psychiatry. Understanding is critical and can help combat gender bias in such evaluations. Forensic psychiatric evaluations in the criminal realm, including evaluations related to neonaticide, infanticide, filicide, child abuse, and kidnapping by cesarean, require an understanding of reproductive psychiatry. Civil forensic evaluations requiring knowledge about reproductive psychiatry include parenting evaluations and risk assessments in the postpartum. Similarly, forensic psychiatrists performing a treatment role within corrections or forensic hospitals recognize the importance of understanding mental illness in pregnancy and postpartum, lactation, mother-baby units, and forced separation or custody loss. In addition to menstruation, pregnancy, and postpartum, specific concerns that bear consideration within reproductive forensic psychiatry include the periods of girlhood and menstruation. Finally, eating disorders and substance misuse bear additional attention in this group.