Genetic risk: the new frontier for the duty to warn.

Mental health professionals usually think of the "duty to warn" in the context of mental illness. However, two state appellate courts have endorsed a duty to warn when children of a patient may be at risk genetically for acquiring the disease of their parents. In these cases, the courts held that a physician's legal obligations extended beyond his or her patient to the patient's children. This article discusses these cases, as well as issues regarding implementation of such a duty and the implications for the physician-patient relationship in a health care environment that will be dominated increasingly by genetics issues. The article concludes that it is premature to apply a duty to warn to the treatment of mental illness and to concerns regarding future criminal behavior.

Mental illness and changing definitions of disability under the Americans With Disabilities Act.

The Americans With Disabilities Act (ADA) prohibits employment discrimination on the basis of disability. Originally, an assessment of whether a person had a disability and thus was protected by the ADA examined the person's impairment in its uncorrected state. Thus it was comparatively easy for people with mental illness to meet the threshold requirement for having a disability. However, in 1999 the U.S. Supreme Court issued three decisions holding that, for the purposes of the ADA, disability had to be assessed in its corrected state. Since those decisions were issued, the courts have increased the burden on individuals, including people with mental illness, to prove that they have a disability. In several cases, courts ruled that people with serious mental illnesses do not have a disability and are not protected by the ADA. This article discusses these cases and their implications for people with mental illness and for practitioners.

Juveniles adjudicated incompetent to proceed: a descriptive study of Florida's Competence Restoration program.

Although competence to stand trial is perhaps the most studied area of mental health law, most of the research has been focused on adults. This study describes a population of 471 juveniles committed for treatment/habilitation and restoration of their competence to proceed in the delinquency process. This population differed from their adult counterparts in important ways. For example, 58 percent of the juveniles had a diagnosis of mental retardation, and 57 percent of the juveniles with an Axis I diagnosis also had a diagnosis of conduct disorder. Only 17 percent had a diagnosed psychotic disorder. Diagnoses among cohorts of adults found incompetent differ markedly. However, similar to adult defendants who are adjudicated incompetent to proceed, the majority of these children were returned to court after treatment staff determined that they were competent to proceed. Contrary to expectation, there were no significant age-related differences with respect to the recommendation of clinical staff regarding restoration of competence. The data suggest the need for further research examining that subset of children in the juvenile justice system whose competence to proceed is questionable.

Who will pay for involuntary civil commitment under capitated managed care? An emerging dilemma.

Involuntary civil commitment in managed care settings may create conflicts between providers and payers. Providers may determine that a patient, particularly one who presents a risk to self or others, must be confined beyond the period reimbursed by the payer. Court decisions have upheld clinicians' ethical obligations to provide care in these situations. In addition, civil commitment may be used to shift costs of long-term care to another provider. The author explores these issues and suggests six strategies that providers can use to address them. They include avoiding negotiations with payers over individual patients' care by ensuring that contracts with payers address civil commitment and patients at risk of harming themselves or others, identifying and creating services and social supports to reduce the necessity for commitment and allowing creative use of benefits, adopting formal risk assessment protocols to standardize the process for all patients and and clinicians, conducting research on the use of civil commitment and coercion in managed care settings, ensuring that incentives do not exist in states' Medicaid managed care programs to use civil commitment to shift costs, and holding discussions with treatment staff about the growing encroachment of financial considerations into treatment decisions.

Can state mental health agencies survive health care reform?

State mental health systems have undergone dramatic changes in the last 40 years, including decreases in state hospital capacity and increases in the proportion of mental health care provided in ambulatory settings and in general hospital units and private psychiatric hospitals. Health care reform is likely to accelerate these changes. The authors consider whether state mental health agencies have a future, given that they were created to operate state hospitals, a role that has been greatly diminished. The authors suggest that state mental health agencies will continue to exist, but that their role will change significantly.

Dialogue: ethical hazards of capitation contracting. Legal and ethical concerns.

In summary, the challenge to managed care is whether it ultimately will fulfill its potential to create comprehensive, coordinated systems of care which have the potential to ease rather than exacerbate the legal and ethical dilemmas noted in this discussion.

Enforcing the Fair Housing Amendments Act to benefit people with mental disability.

Housing is integral to successful community care for many people with mental disabilities. To try to eliminate discrimination in access to housing for people with physical or mental disability and to support their right to live in the community of their choice, Congress enacted the Fair Housing Amendments Act of 1988. The author examines representative court cases that have applied the act to restrictions related to people with mental disabilities; they include cases testing restrictions applicable only to mentally disabled people, restrictive covenants, failure to make "reasonable accommodation," state and municipal laws that predate the 1988 act, and exclusion because of dangerousness to others. To date, the courts have been receptive to the use of the act in challenging laws and practices that create barriers for people with mental disability.

Confidentiality and the family as caregiver.

Many families provide mentally ill relatives with a residence and other support. Although professionals increasingly acknowledge the importance of the supportive role families play, families continue to report that they receive too little information from professionals about the patient, particularly when the family acts as caregiver. The authors suggest that mental health professionals' views about confidentiality may prevent them from providing information to families and urge professionals to rethink the issue of confidentiality and its application to families acting as caregivers. The authors conclude that certain information about a patient can--and should--be shared with families who are in a caregiver role without violating clinical, legal, or ethical principles.

A computer-supported information system for forensic services.

Recently many state departments of mental health have decentralized their forensic services programs. This trend has increased administrative needs for accurate, easily accessible information on the forensic services' caseload. The Missouri Department of Mental Health and the Missouri Institute of Psychiatry have developed and implemented a computer-supported system that provides data on the number of cases referred by criminal courts, the questions asked by the courts, the clinical answers to those questions, and demographic information about the evaluated population. The system is a part of the department's other computer systems so that forensic clients may be tracked through various mental health facilities. Mental health administrators may use the system to monitor department policies, ensure appropriate allocation of resources, and improve the quality of forensic reports.