An Assessment of the Quality of Competence Restoration Research.

A systematic review of the literature on restoration of competence to stand trial identified a predominance of retrospective case studies using descriptive and correlational statistics. Guided by National Institutes of Health (NIH) quality metrics and emphasizing study design, sample size, and statistical methods, the authors categorized a large majority of studies as fair in quality, underscoring the need for controlled designs, larger representative samples, and more sophisticated statistical analyses. Implications for the state of forensic research include the need to use large databases within jurisdictions and the importance of reliable methods that can be applied across jurisdictions and aggregated for meta-analysis. More sophisticated research methods can be advanced in forensic fellowship training where coordinated projects and curricula can encourage systematic approaches to forensic research.

Criminal Justice and Suicide Outcomes with Indiana's Risk-Based Gun Seizure Law.

This article examines the application and effectiveness of a 2006 Indiana law designed to prevent gun violence by authorizing police officers to separate firearms from persons who present imminent or future risk of injury to self or others, or display a propensity for violent or emotionally unstable conduct. A court hearing is held to determine ongoing risk in these cases; a judge decides whether to return the seized firearms or retain them for up to five years. The study examines the frequency of criminal arrest as well as suicide outcomes for 395 gun-removal actions in Indiana. Fourteen individuals (3.5%) died from suicide, seven (1.8%) using a firearm. The study population's annualized suicide rate was about 31 times higher than that of the general adult population in Indiana, demonstrating that the law is being applied to a population genuinely at high risk. By extrapolating information on the case fatality rate for different methods of suicide, we calculated that one life was saved for every 10 gun-removal actions, similar to results of a previous study in Connecticut. Perspectives from key stakeholders are also presented along with implications for gun policy reform and implementation.

Sovereign Citizens and Competency to Stand Trial.

Urban and African-American sovereign citizens represent an underappreciated population of the sovereign citizen movement, who have adapted sovereign citizen beliefs to their own circumstances, overlooking the white supremacist origins of the sovereign citizen movement. The number of African-American sovereign citizens is not known, but though they appear to represent a very small percentage of criminal defendants referred for evaluation of competence to stand trial, they have a disproportionate impact on the court system because of their efforts to stymie the proceedings by asserting sovereign citizen beliefs. As a result, judges are often familiar with sovereign citizen beliefs and have adopted strategies to thwart the impact of sovereign citizens on their courts. Quantitative research on forensic evaluations of sovereign citizens, from all demographic groups, represents a challenge, given the low number of defendants referred for evaluation, but qualitative research on how they came to adopt sovereign citizen beliefs could be fruitful.

Court-Ordered Evaluations From a Mental Health Court.

Mental health courts (MHCs) have been in existence for more than 20 years, but little is known about the demographics, clinical features, and court outcomes of MHC defendants court-ordered for competence to stand trial (CST) evaluations. We examined these items in defendants who underwent CST evaluations for the Marion County, IN, MHC. The MHC defendants were significantly more likely than defendants referred from other courts to be male, black, unemployed, and on disability, and have a history of prior arrests and psychiatric treatment. MHC defendants found incompetent to stand trial (ICST) were significantly more likely to have a psychotic disorder and a high school education than MHC defendants found CST, and they were significantly less likely to have a mood disorder, to be on psychiatric medication, or to cooperate in forensic interviews. Evaluator concordance of primary diagnoses was linked to concordance of CST opinion. There were no significant differences in the outcome of charges between CST and ICST MHC defendants. This study highlights several important findings. First, evaluator concordance of diagnoses is linked to evaluator concordance of opinion. Second, the Marion County MHC functioned in a non-adversarial manner by not discriminating against defendants who were found ICST at the time of final judgment.

Circumstances and Outcomes of a Firearm Seizure Law: Marion County, Indiana, 2006-2013.

Indiana statute allows police to seize firearms without a warrant if the officer believes a person meets the law's definition of "dangerous." Review of the use of this law in Marion County (Indianapolis), Indiana, showed that prosecutors filed petitions in court to retain weapons seized by police under this law 404 times between 2006 and 2013. Police removed weapons from people due to identification of a risk of suicide (68%) or violence (21%), or the presence of psychosis (16%). The firearm seizures occurred in the context of domestic disputes in 28% of cases and intoxication was noted in 26% of cases. There were significant demographic differences in the circumstances of firearm seizures and the firearms seized. The seized firearms were retained by the court at the initial hearing in 63% of cases; this retention was closely linked to the defendant's failure to appear at the hearing. The court dismissed 29% of cases at the initial hearing, closely linked to the defendant's presence at the hearing. In subsequent hearings of cases not dismissed, the court ordered the destruction of the firearms in 72% of cases, all when the individual did not appear in court, and dismissed 24% of the cases, all when the individual was present at the hearing. Overall, the Indiana law removed weapons from a small number of people, most of whom did not seek return of their weapons. The firearm seizure law thus functioned as a months-long cooling-off period for those who did seek the return of their guns.

Competence to stand trial evaluations of sovereign citizens: a case series and primer of odd political and legal beliefs.

Sovereign citizens hold a variety of beliefs that challenge the legitimacy of the United States government and criminal justice system. In criminal cases, sovereign citizens typically raise a variety of seemingly strange objections to the proceedings that can cause court participants to believe the defendant is not competent to stand trial. The author's case files were reviewed to identify all defendants who espoused sovereign citizen beliefs during a court-ordered competence-to-stand-trial evaluation. This case series consisted of nine evaluations completed between 2003 and 2012. A review of the outcomes in these cases showed that sovereign citizens typically have the capacity to understand criminal proceedings and assist an attorney.

DSM-5 and psychotic and mood disorders.

The criteria for the major psychotic disorders and mood disorders are largely unchanged in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), with a few important exceptions: a new assessment tool for the psychotic disorders based on dimensional assessment, a new scheme of specifiers for the mood disorders, the addition of three new depressive disorders, and recognition of catatonia as a separate clinical entity. In addition, subtle changes to the diagnostic criteria for longstanding disorders may have important ramifications. There are forensic implications to these changes in the psychotic and mood disorders, but in most cases, these implications should be relatively modest, as the DSM-5 Work Groups ultimately adopted a cautious approach to changes in the psychotic and mood disorders.

An historical review of the legal and personal background to Jackson v. Indiana.

The landmark case of Jackson v. Indiana is well known to forensic psychiatrists, but little is known of the personal and legal background of this case. Mr. Jackson's state hospital records were reviewed, as were available transcripts and decisions of the Indiana court proceedings, before and after the U.S. Supreme Court decision, and local newspaper coverage, to understand how this case developed.

Application of a firearm seizure law aimed at dangerous persons: outcomes from the first two years.

OBJECTIVES: In 2005, in response to the shooting death of a police officer by a paranoid man, Indiana passed a law authorizing police to seize firearms without a warrant if they believe the person owning the firearm is dangerous because the person has a mental illness and is noncompliant with psychiatric medication or if the person has a propensity for violent or unstable conduct. This study sought to determine the use of this law in Indianapolis. METHODS: All Indianapolis firearm seizure cases that had a final hearing in 2006 and 2007 were identified; demographic information, seizure circumstances, and hearing outcome were recorded. RESULTS: A total of 55 cases were heard in 2006, and 78 were heard in 2007. The defendants were predominantly white (83%) and male (81%). Risk of suicide was the leading reason for confiscation (56% in 2006 and 71% in 2007), followed by substance abuse (29% and 27%, respectively), risk of violence (22% and 13%, respectively), and domestic disturbance (24% and 8%, respectively). Psychosis was a factor in only 11% and 9% of cases, respectively. A large majority of cases resulted in immediate detention (69% and 78%, respectively). In 2006, 95% of cases resulted in involuntary or voluntary surrender of the seized weapons to the court, but in 2007, only 22% of cases resulted in involuntary or voluntary surrender. However, in 2007 68% of cases resulted in court-ordered retention because of failure to appear (26%) or inability to be served (42%). CONCLUSIONS: Firearm seizure by police was rarely a result of psychosis; instead, risk of suicide was the leading reason. The application of the law by both police and the court changed over the first two years of its use.

The Dual Diagnosis Physician-infrastructure Assessment Tool: examining physician attributes and dual diagnosis capacity.

OBJECTIVE: Inadequate physician training and involvement in addictions treatment are barriers to integrating mental health and addiction services in public behavioral health care. The authors designed and implemented the Dual Diagnosis Physician-infrastructure Assessment Tool (DDPAT) to quantify statewide dimensions of this workforce problem. METHODS: The DDPAT examined institutional dual diagnosis capability and physician workforce, training backgrounds, and clinical roles across Indiana's 30 community mental health centers (CMHCs), six psychiatric hospitals, and 13 addiction treatment centers. RESULTS: All treatment centers and 75% of physicians responded. Sixty-nine percent of all treatment centers and 97% of CMHCs reported dual diagnosis capability. However, 29% of physicians treated both mental illness and addictions, and only 8% had certification in an addiction specialty. Overall workforce shortages, particularly of younger psychiatrists, contextualized these findings. CONCLUSIONS: The DDPAT identified multiple deficiencies in the physician workforce with respect to dual diagnosis and addictions care in Indiana. The DDPAT may be useful for characterizing similar trends in other states.

Indiana v. Davis: revisiting due process rights of permanently incompetent defendants.

With its landmark Jackson v. Indiana (406 U.S. 715 (1972)) decision, the United States Supreme Court ruled that states may not indefinitely confine criminal defendants solely on the basis of incompetence to stand trial. While this decision led to widespread state statutory and procedural changes, the Jackson court left unresolved whether states could indefinitely maintain criminal charges against incompetent defendants. Nearly four decades after the Jackson decision, the Indiana Supreme Court finally revisited this question in Indiana v. Davis (898 N.E.2d. 281 (Ind. 2008)), unanimously ruling that holding criminal charges over the head of a permanently incompetent defendant, when her pretrial confinement extended beyond the maximum period of any sentence the trial court could impose, violated the basic notions of fundamental fairness embodied in the Due Process Clause of the Fourteenth Amendment. In this analysis of Indiana v. Davis, the facts of the case and the court's rationale for its decision are discussed. This unique ruling is considered in light of the questions resolved and still unanswered since Jackson v. Indiana.

Impact of a mental health training course for correctional officers on a special housing unit.

OBJECTIVE: This study determined the impact of a ten-hour mental health training program developed by the Indiana chapter of the National Alliance on Mental Illness (NAMI-Indiana) for correctional officers on a prison special housing ("supermax") unit. METHODS: The training was delivered to all of the correctional officers on the unit in five weekly sessions and was repeated 15 months later for new unit staff. The number of incidents reported by unit staff in standard monthly reports, consisting of use of force by the officers and battery by bodily waste on the officers by the offenders, was compared for the nine months before and after both training sessions. RESULTS: Attendance at the initial training ranged from 48 to 57 officers per session, and on the basis of Likert ratings, training was well received by the officers. The total number of incidents, the use of force by the officers, and battery by bodily waste all declined significantly after the first mental health training, and the total number of incidents and battery by bodily waste declined significantly after the second training. CONCLUSIONS: The provision of ten hours of mental health training to correctional officers was associated with a significant decline in use of force and battery by bodily waste.

Effects of advanced age and dementia on restoration of competence to stand trial.

Elderly defendants (age 65+) and defendants with dementia adjudicated incompetent to stand trial and hospitalized for restoration to competence (RTC) often present unique challenges to clinicians charged with their restoration. In this study, we attempted to better identify predictors of successful RTC by building upon previous research correlating increased age with decreased likelihood of RTC. We identified elderly non-demented defendants (n=31) and defendants diagnosed with dementia (n=47) from a state database of 1380 individuals hospitalized for competence restoration from 1988-2004. Using regression analysis and correcting for demographic variables and common admission psychiatric diagnoses, we studied the relationship of age at hospital admission and dementia diagnosis on the likelihood of successful RTC. Both advanced age and dementia diagnosis were associated with decreased RTC. After correcting for dementia diagnosis, increased age retained its negative correlation with restoration success. Both elderly non-demented defendants and defendants diagnosed with dementia were significantly less likely to be restored to competence than all other RTC admissions (n=1302). However, a substantial percentage of both demented and elderly non-demented defendants were successfully restored to competence, potentially justifying restoration attempts for both of these groups of defendants.

Jackson's Indiana: state hospital competence restoration in Indiana.

Restoration to competence (RTC) of mentally disordered defendants has become increasingly important for state hospitals. In Indiana, most RTC admissions are sent to one primarily forensic state hospital, but many are admitted to other state hospitals. A state database of defendants admitted for RTC between 1988 and 2005 was analyzed for trends in annual admissions, length of stay (LOS), and success of restoration by hospital and by diagnostic category. Regression models were developed to identify factors associated with RTC success. Analysis of 1,475 RTC admissions showed increased annual admissions over the study period. While the forensic hospital restored a higher percentage of individuals than the other state hospitals, the percentage of RTC success decreased over time in all hospitals. Admission to the forensic hospital, female gender, and mood disorder diagnosis were associated with increased restoration success. Older age and psychotic disorder or mental retardation diagnoses were associated with decreased likelihood of restoration. Race was not significantly associated with RTC at six months, but white defendants were less likely to be restored within one year.

Outcomes of assertive community treatment in an NGRI conditional release program.

This study describes the five-year outcomes of an assertive community treatment (ACT) program that monitored 83 acquittees found not guilty by reason of insanity (NGRI) placed on conditional release (CR) into the community. Data were collected by retrospective review of court reports and a state computer database. Five arrests and 60 hospitalizations occurred during the study period; overall, the NGRI acquittees were in the community for 83 percent of the time they were eligible for conditional release. Multivariate logistic regression analysis showed that the duration of conditional release was a positive predictor, and paranoid schizophrenia was a negative predictor of hospitalization or arrest. The estimated annual rate (EAR) of hospitalization was 14.0 percent, and the arrest EAR was 1.4 percent. The ACT model for NGRI acquittees on CR yielded a low arrest rate, a moderate hospitalization rate, and good community tenure.