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

Numerous recommendations have been made to address the high rates of mental health disorders among justice-involved youth. Few data are available on the use, quality, appropriateness, or availability of services to address these needs. This study examined the relationship between trauma-informed mental health screening, other referral pathways for diagnostic evaluation, subsequent DSM-5 diagnoses, and treatments for evaluated youth. Eligible participants were all youth admitted to New York City secure juvenile detention facilities from September 17, 2015 to October 30, 2016 who remained in the facility for at least five days (N = 786). Of those, 581 (73.9%) were voluntarily screened and 309 (53.2%) later received a diagnostic evaluation. Youth who screened positive for depression, posttraumatic stress disorder, and problematic substance use were more likely to be evaluated. Treatment received was related to diagnosis rather than reason for referral. For youth who were referred for behavioral or emotional concerns, 99.1 percent (114 of 115) of those diagnosed with a neurodevelopmental disorder had attention-deficit/hyperactivity disorder (ADHD). These data are among the first to describe DSM-5 diagnoses and treatment among youth detainees. They highlight the prevalence of ADHD in detained youth and argue for the coordination of universal trauma-informed mental health screening and a structured referral system for this population.

The four-skills model of decisional capacity for providing informed consent for medical treatment developed by Appelbaum and Grisso is codified into most state statutes in articulating the legal criteria for establishing capacity. Decisional capacity is traditionally determined at a point in time based on a narrow clinical question; however, there are clinical scenarios in which patients may currently have decisional capacity but their recurrent nonadherence to care places them at foreseeable risk of being acutely incapacitated, both decisionally and functionally, in the near future. There is a gap in terms of how these four skills ought to be adapted when applied to a patient with recurrent altered mental status, especially delirium, because of nonadherence. To describe this clinical situation, we introduce a new risk factor, "foreseeable risk of losing decisional and functional capacity," and discuss the clinical evaluation of a patient who currently has capacity but for whom this risk factor applies. We consider the implications of being at foreseeable risk of losing capacity and how foreseeable risk can be translated into a capacity determination in the present. We also describe interventions that can serve to protect the patient's rights and safety.

The rise in the U.S. prison population over the past 40 years has heightened scrutiny of the incarceration of children and adolescents. Correlates of later reincarceration in this group, especially correlates relating to psychiatric and substance use disorders, are understudied in the U.S. population. We aimed to establish the prevalence and correlates of the reincarceration as adults of people incarcerated before age 18. Data were derived from clinical interviews and from validated diagnostic and psychometric instruments. They were obtained as part of a cross-sectional representative survey of the civilian U.S. population, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III). We identified 1,543 adults (4.3% of the NESARC sample) who had been incarcerated before they were 18. Of these, 55.9 percent had subsequently been incarcerated as adults. In addition to variables that have been repeatedly identified in criminological research (less education, past antisocial behavior, and parental imprisonment), substance use disorder, bipolar disorder, and longer childhood incarceration were independently associated with incarceration as an adult. The possibility that psychiatric treatment could reduce reincarceration in this group warrants longitudinal and experimental research.

The goal of our study was to describe the availability of community child and adolescent mental health services, trauma-informed care, and the geographic accessibility of these services for juvenile justice-involved (JJ) youth who received mental health services while in secure detention. Data collection occurred through direct contact with the child and adolescent outpatient clinics listed on the New York State Office of Mental Health website. Zip codes were collected from the juvenile secure detention census. Of the clinics contacted, 88.5 percent accepted JJ youth; however, 43.5 percent accepted them on a conditional basis. Only 62.1 percent offered trauma-informed care, including evidence-based interventions and unspecified care. Although 84.5 percent of the clinics that would accept this population reported currently accepting new patients, reported wait times were as high as six or more months. When JJ residents' home zip codes and those of the clinics were geographically mapped, there were few clinics in the zip codes where most residents lived. The clinics that accepted youth on a conditional basis often refused high-risk patients, essentially ruling out a large majority of this population. The geographical inaccessibility of these clinics limits their ability to provide care for this vulnerable population.

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

Evaluating decisional capacity for patients seeking medical aid in dying (MAID) raises challenging legal, logistical, and ethics questions. The existing literature on the subject has been shaped largely by early disagreements over whether effective capacity assessment for such patients is ever possible, which in turn stemmed from debates over the ethics of MAID itself. In attempting to establish meaningful criteria for assessments, many jurisdictions have sought either to apply or to adapt models of capacity evaluation designed for other forms of medical decision-making, such as the widely used "four skills" model, failing to account for the fundamental differences in kind between these other decisions and MAID. This article seeks to reexamine these questions with a focus on two logistical matters (the appropriate credentialing for the evaluator and the potential liability of the evaluator) and three clinical matters (level of understanding, clinical scrutiny and certainty, and impairment) in an effort to raise legal and ethics concerns that remain unresolved, even as MAID is permitted in an increasing number of jurisdictions.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

In recent years, several jurisdictions have passed legislation to permit medical aid in dying (MAID) worldwide, with considerable expansion in the availability of this practice. MAID has been defined as the practice of a clinician prescribing lethal drugs in response to a direct request from the patient, with a shared understanding that the patient intends to use the medication to bring about the patient's death. Wider legalization of MAID has prompted debates and legal controversies regarding the extent to which MAID should be available and its application for people experiencing mental illness as the primary indication. This article examines shifting attitudes of professional medical organizations toward MAID. We discuss the existing statutory provisions for psychiatric assessment for MAID in the United States and the implications on such assessments should MAID be expanded to include mental illness as the primary indication. This article also assesses legal disputes concerning MAID regulations and explores the role of psychiatric experts in the practice of MAID.