Association of Changes in Missouri Firearm Laws With Adolescent and Young Adult Suicides by Firearms.

Importance: Suicide by firearm is a major cause of mortality in young Missouri residents. Changes in statewide firearm policy may have contributed to changes in suicide rates. Objective: To evaluate if changes in Missouri permit-to-purchase (PTP) and concealed carry firearm laws were associated with changes in rates of suicide by firearms in young Missouri residents. Design, Settings, and Participants: This cross-sectional study examined rates of suicide by firearm in Missouri among adolescents (ages 14-18 years) and young adults (ages 19-24 years) from January 1999 to December 2018, following changes to state PTP and concealed carry law, in comparison with a donor state pool with existing firearm laws (13 states in PTP pool; 42 states in concealed carry pool) that did not make changes during this period. This study used a quasiexperimental, synthetic control design at the state level that defined Missouri as the treated state and treatment as changes in firearm laws. Exposures: Legislative changes to Missouri's PTP and concealed carry firearm laws. Main Outcomes and Measures: Age-adjusted annual rates of firearm-related suicide mortality per 100 000 people for adolescents (aged 14-18 years) and young adults (aged 19-24 years). Results: Repeal of the PTP law was associated with a 21.8% increase in firearm suicide rates in young adults aged 19 to 24 years in Missouri. Lowering the minimum age of concealed carry to 19 years in Missouri was associated with a 32.0% increase in firearm suicide rates and a 29.7% increase in nonfirearm suicide rates in adolescents aged 14 to 18 years, and a 7.2% increase in firearm suicide rates in young adults aged 19 to 24 years. Conclusions and Relevance: Increases in rates of suicide by firearms in adolescents and young adults were seen following repeal of Missouri's PTP law and lowering of the minimum age for concealed carry in 2014. Changes in Missouri's firearm policies may be an important contributor to rates of suicide by firearm in young Missouri residents.

The American Academy of Psychiatry and the Law Practice Resource for Prescribing in Corrections.

The practice of prescribing in jails and prisons is often different from that in the community. Serious mental illness is common among inmates, and so are co-morbidities such as substance use, impulse-control, attention-deficit/hyperactivity, and personality disorders. Operational requirements, staffing, and the physical plant of the institution may complicate the provision of treatment according to community standards. Problems related to medication nonadherence, as well as the pursuit of medications for nonmedical reasons, are often seen in these settings and may be managed differently than they are elsewhere. Existing practice resources rarely account for these challenges. Pursuant to a recommendation by the Correctional Committee of the American Academy of Psychiatry and the Law (AAPL), the AAPL Council in May 2015 approved the creation of a task force charged with producing a document on prescribing in correctional facilities.Full Document: Tamburello A, Metzner J, Ferguson E, et al: AAPL practice resource for prescribing in corrections. Journal of the American Academy of Psychiatry and the Law Online Supplement 2018, 46 (2). Available at: http://www.jaapl.org/content/46/2_Supplement.

A longitudinal study of administrative segregation.

The use of administrative segregation for inmates with and without mental illness has generated considerable criticism. Segregated inmates are locked in single cells for 23 hours per day, are subjected to rigorous security procedures, and have restricted access to programs. In this study, we examined whether inmates in segregation would show greater deterioration over time on psychological symptoms than would comparison offenders. The subjects were male inmates, with and without mental illness, in administrative segregation, general population, or special-needs prison. Subjects completed the Brief Symptom Inventory at regular intervals for one year. Results showed differentiation between groups at the outset and statistically significant but small positive change over time across all groups. All groups showed the same change pattern such that there was not the hypothesized differential change of inmates within administrative segregation. This study advances the empirical research, but replication research is needed to make a better determination of whether and under what conditions harm may or may not occur to inmates in solitary confinement.

A national survey of self-injurious behavior in American prisons.

OBJECTIVE: This study sought information about the prevalence, epidemiology, and management of self-injurious behavior by inmates in U.S. prison systems. Although self-injurious behavior has long been the source of significant challenges in correctional settings, limited research is available on this topic. METHODS: Mental health directors in all 51 state and federal prison systems were invited to respond to a 30-item questionnaire available online or in hard copy. Univariate statistics were used to describe significant aspects of the national experience with self-injurious behavior, and bivariate statistics were used to examine relationships between variables. RESULTS: Thirty-nine systems (77%) responded to the survey. Responses indicated that <2% of inmates per year engage in self-injurious behavior, but such events were reported to occur at least weekly in 85% of systems, with occurrences more than once daily in some systems, thus causing substantial disruptions to operations and draining resources. The highest rates of occurrence of these behaviors were in maximum-security and lockdown units and most often involved inmates with axis II disorders. Despite the seriousness of the problem, systems typically collect few, if any, data on self-injurious behaviors, and management approaches to dealing with them lack consistency within and across systems. Eighty-four percent of respondents expressed interest in participating in further studies on this topic. CONCLUSIONS: The survey responses indicated the disruptive effects of self-injurious behavior in the nation's prisons, a need for better epidemiologic monitoring and data on such behavior, and the importance of developing and widely using effective interventions. The high response rate and expressed interest in follow-up projects suggest that state and federal correctional mental health directors see a need for better information and management in this area.

Commentary: the mental status examination in the age of the internet--challenges and opportunities.

In her Presidential address, Dr. Recupero shows us how the Internet and changes in electronic communications have affected the forensic evaluation process in multiple ways. These developments provide the forensic psychiatrist with new tools and new sources of information, and their novelty brings about new challenges and opportunities. This commentary focuses on the use of information and communication technology (ICT) for purposes of obtaining collateral information in addition to a sample of other likely uses of ICT in the practice of forensic psychiatry. Collateral information from electronic communications such as e-mails, web postings, texting, and social networking sites provides useful data but also raises challenges in interpretation. Digital information about the expert can be used by cross-examining attorneys. Electronic tools can help the forensic psychiatrist to be more efficient. Correctional systems have a great deal to gain by adopting more efficient information systems. Continuing evolution of these technologies assures that we can expect more rapid change in these areas in the future.

Solitary confinement and mental illness in U.S. prisons: a challenge for medical ethics.

In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence. Prison rules for isolated prisoners, however, greatly restrict the nature and quantity of mental health services that they can receive. In this article, we describe the use of isolation (called segregation by prison officials) to confine prisoners with serious mental illness, the psychological consequences of such confinement, and the response of U.S. courts and human rights experts. We then address the challenges and human rights responsibilities of physicians confronting this prison practice. We conclude by urging professional organizations to adopt formal positions against the prolonged isolation of prisoners with serious mental illness.

Monitoring a correctional mental health care system: the role of the mental health expert.

Class action litigation has been instrumental in jail and prison reform over the past four decades. This article provides a very brief introduction underlying the legal basis for such litigation. It focuses on the role of the mental health expert in monitoring a correctional mental health care system as a result of class action litigation including issues related to selection of the expert, development of the remedial plan, and monitoring of the implementation of the remedial plan. The importance of policies and procedures and a quality improvement process is emphasized. Essential elements of the monitoring process, prior to and during the site assessment, are described. Inmates and correctional staff alike have benefited substantially from such litigation in the form of increased resources and positive changes in institutional culture.

Resource document on the use of restraint and seclusion in correctional mental health care.

This resource document discusses the use of seclusion or restraint for purposes of mental health intervention in correctional facilities. Correctional mental health standards essentially state that seclusion or restraint, when used for health care purposes, should be implemented in a manner consistent with current community practice. The community practice was significantly impacted and revised during July 1999, after the Health Care Financing Administration defined rules for the use of seclusion and restraint in facilities that participate in Medicare and Medicaid. Since few correctional facilities are Medicare or Medicaid participants, these rules had little impact on the use of seclusion or restraint for mental health care purposes in correctional systems. Consequently, many correctional health care systems have not developed policies, procedures, or practices that are consistent with current community practice. This document provides guidance in remedying such problems, with a focus on areas relevant to timeframes, settings, and monitoring.

Clark v. Arizona: diminishing the right of mentally ill individuals to a full and fair defense.

In Clark v. Arizona, the U.S. Supreme Court was faced with two main questions: Does Arizona's insanity defense statute, with its abridged M'Naughten standard, violate the Fourteenth Amendment? And does Arizona case law, with its complete prohibition on the use of mental disease or defect evidence to combat required mens rea elements of a crime, violate due process? In a six-three decision, the Court answered both of these questions in the negative.

Psychiatric employment evaluations and theHealth Insurance Portability and Accountability Act.

This review was intended to familiarize psychiatrists with the implications of the Health Insurance Portability and Accountability Act of 1996 on the provision of third-party employment evaluations. Understanding the provisions of the act relative to third-party evaluations can assist psychiatrists in avoiding some of the conflicts that arise in performing such evaluations.

An overview of correctional psychiatry.

Supermax facilities may be an unfortunate and unpleasant necessity in modern corrections. Because of the serious dangers posed by prison gangs, they are unlikely to disappear completely from the correctional landscape any time soon. But such units should be carefully reserved for those inmates who pose the most serious danger to the prison environment. Further, the constitutional duty to provide medical and mental health care does not end at the supermax door. There is a great deal of common ground between the opponents of such environments and those who view them as a necessity. No one should want these expensive beds to be used for people who could be more therapeutically and safely managed in mental health treatment environments. No one should want people with serious mental illnesses to be punished for their symptoms. Finally, no one wants these units to make people more, instead of less, dangerous. It is in everyone's interests to learn as much as possible about the potential of these units for good and for harm. Corrections is a profession, and professions base their practices on data. If we are to avoid the most egregious and harmful effects of supermax confinement, we need to understand them far better than we currently do. Though there is a role for advocacy from those supporting or opposed to such environments, there is also a need for objective, scientifically rigorous study of these units and the people who live there.