Mitigating the Risk of Digital Financial Exploitation.

The article by Zhang and colleagues in this issue of The Journal calls attention to an important but underrecognized problem facing today's seniors and their loved ones. The risk of digital financial exploitation, particularly in the wake of the COVID-19 pandemic, has risen considerably in recent years and continues to rise today. Zhang et al. provide a helpful analysis of assessment tools currently available to forensic psychiatrists for the evaluation of financial capacity. Although many of these tools were not originally intended to encompass technologically based transactions, the risks of fraud and scams associated with payment apps, social media, and electronic fund transfers are considerable and growing. Fraudsters frequently target vulnerable older adults, and victims have lost large sums through some of the more prevalent schemes. Several strategies can help to mitigate the risk of severe losses and to increase the likelihood that lost assets can be recovered. Proactive education through increased awareness will prove helpful, but given the growing sophistication of modern digital cons, such as romance scams, increased technological safeguards are warranted in the setting of reduced financial capacity. When losses do occur, there are some resources for recovery and for filing complaints against perpetrators.

Daubert Considerations in Forensic Evaluations by Telepsychiatry.

The COVID-19 pandemic has increased demand for telepsychiatric services. Forensic psychiatrists can expect to receive more requests for assessments conducted via videoconferencing technology in the years to come. Under current rules of evidence in the United States, the testimony of expert witnesses is introduced as a form of scientific evidence and may be challenged by opposing counsel through Daubert hearings. In a Daubert challenge, courts may evaluate proposed expert testimony through four criteria relating to scientific reliability and validity: whether the testimony is based on methods that emerge from a testable hypothesis, whether the method has been subjected to peer review, the known or potential rate of error associated with the method, and whether the method has achieved general acceptance in the relevant scientific community. To date, courts have not addressed whether testimony based on a telepsychiatric assessment would meet standards of reliability and validity for admission into evidence, as applied in a typical Daubert hearing. This article explores the Daubert standards and other potential objections to telepsychiatry as they may apply to forensic psychiatric examinations conducted via videoconferencing technology. The discussion also provides suggestions to evaluators to increase the likelihood of such testimony surviving a Daubert challenge.

The Mental Status Exam at the Movies: The Use of Film in a Behavioral Medicine Course for Physician Assistants.

OBJECTIVE: This study evaluated student satisfaction with an educational exercise using feature films to learn about performing a psychiatric mental status examination. METHODS: Following the completion of an educational exercise designed by the first author, students in a behavioral medicine course completed surveys regarding their satisfaction with the exercise as a tool for learning how to perform a mental status examination. The educational exercise involved an initial didactic lecture followed by group exercises and individual presentations, utilizing feature films as tools for understanding the mental status examination. Each student selected a movie depicting a character with a psychiatric or substance-use disorder and performed a hypothetical mental status examination for the character, which they presented to their classmates. RESULTS: One hundred nine (109) students (97.3%) in the course completed evaluations of the educational exercise, and the majority found the exercise valuable; 93.6% of respondents felt that their ability to conceptualize a case had improved because of the exercise. In general evaluations of the course, this particular educational exercise was frequently mentioned in response to a free-form question about "the best part of the course." CONCLUSION: Movies depicting psychiatric illness and substance use disorders can be a fun and highly effective tool for helping students to learn and develop competency in the performance of mental status examinations.

Homicide and the Internet.

The Internet and social media have grown increasingly relevant in homicide cases in recent years. Although several recent studies have analyzed the relationship between homicide and the Internet, there is a dearth of rigorous scientific research on the subject to date. Although a statistically rare event, Internet-related homicide may be increasing, and forensic mental health professionals may experience growing demand for consultations in cases where the Internet and social media play a salient role. Understanding some of the ways in which homicide perpetrators have used the Internet can help to inform case formulation and threat assessments in these cases. This article reviews several key themes, including the use of the Internet as a source of information in the commission of homicide, its use to target victims, the spread of self-publishing and multimedia sharing, conflict escalation through social media, and the threat posed by Internet extremist communities. Finally, suggestions are made to help inform future research regarding the relationship between homicide and the Internet.

Ethical Considerations Regarding Internet Searches for Patient Information.

In 2010, the American Medical Association developed policies regarding professionalism in the use of social media, but it did not present specific ethical guidelines on targeted Internet searches for information about a patient or the patient's family members. The American Psychiatric Association (APA) provided some guidance in 2016 through the Opinions of the Ethics Committee, but published opinions are limited. On behalf of the APA Ethics Committee, the authors developed a resource document describing ethical considerations regarding Internet and social media searches for patient information, from which this article has been adapted. Recommendations include the following. Except in emergencies, it is advisable to obtain a patient's informed consent before performing such a search. The psychiatrist should be aware of his or her motivations for performing a search and should avoid doing so unless it serves the patient's best interests. Information obtained through such searches should be handled with sensitivity regarding the patient's privacy. The psychiatrist should consider how the search might influence the clinician-patient relationship. When interpreted with caution, Internet- and social media-based information may be appropriate to consider in forensic evaluations.

The Notion of Truth and Our Evolving Understanding of Sexual Harassment.

The notion of truth and its determination in legal proceedings is contingent on the cultural setting in which a claim is argued or disputed. Recent years have demonstrated a dramatic shift in the public dialogue concerning sexual harassment. This shift reflects changing cultural mores and standards in the workplace and society as a whole, particularly with respect to the validity of women's voices. The subjective reality experienced by victims of sexual harassment is inherently tied to the legal system's treatment of women throughout history. In determinations of truth, our understanding of which information and perspectives are relevant, and our expectations regarding the credibility of complainants and the accused, are undergoing a period of rapid change. The discourse surrounding the #MeToo movement suggests that the "reasonable-person" standard so often applied by courts is poorly suited to sexual-harassment litigation. As our understanding of what constitutes "severe," "pervasive," and "unwelcome" conduct continues to evolve, forensic psychiatrists must strive to uphold the values of respect for persons in the search for the truth.

New Technologies, New Problems, New Laws.

Forensic psychiatrists in the 21st century can expect to encounter technology-related social problems for which existing legal remedies are limited. In addition to the inadequate protection of adolescents using social media as outlined by Costello et al., current laws are often poorly suited to remedy problems such as cyberharassment, sexting among minors, and the publication of threatening or harmful communications online. Throughout history, technological developments have often preceded the introduction of new laws or the careful revision of existing laws. This pattern is evident in many of the newer social problems that involve technology, including cyberbullying, online impersonation, and revenge porn. As specialists working at the intersection of human behavior and the law, forensic psychiatrists are uniquely situated to help legal professionals and others understand the impact of internet-related problematic behaviors on victims and, perhaps, to assist in the development of new legal remedies that are better tailored to our increasingly digital society.

Outpatient Psychiatrists' Practices for Requesting Prior Treatment Records.

Patients' treatment records often contain information critical to risk assessment. We sought to determine whether psychiatrists treating outpatients agree about the standard of care (SOC) for requesting records from a patient's past clinicians. This web-based survey invited psychiatrists to review a hypothetical outpatient clinical vignette and to indicate whether they would request a release of information (ROI) from the patient for treatment records from past clinicians. Respondents also described the community SOC for similar scenarios and what they would do if a patient refused the ROI. Data were collected from June 15 through June 19, 2012. Most psychiatrists would try to obtain treatment records from any therapist, psychiatrist, or primary care physician seen by the patient within the past year. Some would require the patient's consent to ROI as a prerequisite to treatment. Few respondents felt that obtaining records from several years ago would be necessary in a typical, moderate-risk outpatient case. In an average outpatient scenario, the SOC would be to request treatment records from the past year. Psychiatrists rely heavily on clinical judgment when determining whether to obtain medical records from other providers.

Gender bias and judicial decisions of undue influence in testamentary challenges.

Allegations of undue influence constitute a common basis for contests of wills. Legal research from the 1990s suggests that gender bias factors significantly into judicial decision-making regarding alleged undue influence and testamentary intent. In this study, we sought to assess whether this bias is present today and to identify any factors that may be associated with it. Probate judges from several jurisdictions in the United States were asked to consider two hypothetical case vignettes drawn from actual published decisions. In our study, the gender of the testator played only a minor role in how judges weighed factors in the decision-making process and, overall, did not significantly influence opinions regarding the presence of undue influence. The specifics of the case and the gender of the judge emerged as the most consistent and robust potential influences on decision-making. Our results suggest that probate rulings involving undue influence are likely to represent a complex interaction of factors involving the testator's and judge's genders and the specifics of individual cases. The implications of these findings are discussed.

Adulthood animal abuse among men arrested for domestic violence.

Learning more about intimate partner violence (IPV), perpetrators could aid the development of more effective treatments. The prevalence of adulthood animal abuse (AAA) perpetration and its association with IPV perpetration, antisociality, and alcohol use in 307 men arrested for domestic violence were examined. Forty-one percent (n = 125) of the men committed at least one act of animal abuse since the age of 18, in contrast to the 1.5% prevalence rate reported by men in the general population. Controlling for antisociality and alcohol use, AAA showed a trend toward a significant association with physical and severe psychological IPV perpetration.

The implications of the ADA Amendments Act of 2008 for residency training program administration.

The Americans with Disabilities Act (ADA) is rarely invoked by medical residents in training. Dr. Martin Jakubowski, a family medicine resident with Asperger's disorder, was dismissed for communicating poorly with patients, peers, and supervisors and for issuing dangerous medical orders. In an attempt to become reinstated, he sued under the ADA (Jakubowski v. The Christ Hospital), arguing that the program had failed to make reasonable accommodation for his disability. The Sixth Circuit Court of Appeals ruled in favor of the hospital, finding that although the doctor was disabled under the ADA, he had failed to demonstrate that he was otherwise qualified for the position. This article comments on the ADA Amendments Act of 2008, the Equal Employment Opportunity Commission (EEOC) guidelines from 2011 and their application to medical residency training, and the Accreditation Council for Graduate Medical Education (ACGME) core competencies as essential job functions.

Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management.

Changing federal regulations, civil rights and malpractice cases, and new treatment methods have influenced the use of restraint and seclusion (R&S) in inpatient psychiatric treatment settings, such that restraint and seclusion today are among the most highly regulated practices in psychiatry. Despite increased pressure from regulatory bodies and litigation, the use of R&S remains controversial and risky. These procedures can compromise safety if performed incorrectly or monitored inadequately, but intervention by restraint or seclusion may be necessary to maintain safety on the treatment unit, especially during emergencies. Case law and medical research have demonstrated the importance of a patient-focused, treatment-oriented approach toward risk management. Analysis of specific clinical scenarios can help to develop risk mitigation strategies that are therapeutically conceptualized rather than driven by regulation. Insights drawn from clinical cases that have resulted in litigation can offer an opportunity to develop an approach oriented to patient care from a clinical or risk management perspective. In this article, we seek to provide a foundation for evaluation of current protocols, an analysis of adverse R&S events, and strategies to minimize risk.

Psychiatric residents' experience conducting disability evaluations.

OBJECTIVE: The increasing frequency and societal cost of psychiatric disability underscore the need for accuracy in evaluating patients who seek disability benefits. The authors investigated senior psychiatric residents' experiences performing disability evaluations, their self-assessment of competence for this task, and whether they perceived a need for more training. METHODS: Seventy-nine third- and fourth-year psychiatric residents in Massachusetts and Rhode Island training programs were surveyed from May to June in 2008. Participants were asked about the frequency of requests and completion of disability evaluations, the practice patterns followed when performing evaluations, the identification of role and potential conflict of interest in doing evaluations, and their sense of preparedness and need for more training. RESULTS: Residents reported having limited experience performing disability evaluations and followed a variety of practice patterns when performing evaluations. They reported having a limited understanding of what constitutes psychiatric disability and a lack of confidence in their ability to perform evaluations accurately. A significant minority had identified patients as disabled despite believing otherwise. A majority of residents reported receiving no didactics on psychiatric disability and desired more training. CONCLUSION: Residents may be unprepared to perform disability evaluations. Residency programs may need to provide additional training.

The mental status examination in the age of the internet.

The Internet has grown increasingly relevant in the practice of forensic psychiatry. To a psychiatrist conducting a forensic evaluation, the evaluee's Internet use can be relevant in nearly all aspects of the analysis. An evaluee's Internet presence may help to confirm, corroborate, refute, or elaborate on the psychiatrist's general impression of the person. Questions about the individual's choice of screen names, activities, images, and phrases can be valuable conversational tools to increase candor and self-disclosure, even among less cooperative evaluees. Difficulties in mood or affect regulation, problems with thought process or content, and impaired impulse control may be apparent in the evaluee's behavior in various Internet forums-for example, hostile or provocative behavior in social forums or excessive use of gaming or shopping websites. Discussions about the evaluee's behavior on the Internet can help the psychiatrist to assess for impaired insight and judgment. Perceptual disturbances, such as derealization and depersonalization, may be related to an evaluee's overidentification with the virtual world to the neglect of real-life needs and responsibilities. Furthermore, digital evidence can be especially useful in assessments of impairment, credibility, and dangerousness or risk, particularly when the evaluee is uncooperative or unreliable in the face-to-face psychiatric examination. This discussion will provide illustrative examples and suggestions for questions and topics the forensic psychiatrist may find helpful in conducting a thorough evaluation in this new age of the Internet.

Examining the interface between substance misuse and intimate partner violence.

There is considerable theoretical and empirical support for a link between substance misuse and perpetration and victimization of intimate partner violence. This review briefly summarizes this literature and highlights current research that addresses the interface between treatment for substance abuse and intimate partner violence. Suggestions for future research and clinical implications are provided.

Forensic evaluation of problematic Internet use.

Problematic Internet use appears to be a growing concern in many criminal and civil legal proceedings. Problems range from inappropriate personal use of the Internet in the workplace and excessive use of online games, pornography, and gambling, to cyberbullying among children and adolescents and numerous forms of criminal activity. Forensic psychiatric evaluations may help courts or other agencies to understand individual cases and to discern whether a psychiatric disability may be involved. Furthermore, the forensic psychiatrist may be asked to formulate a prognosis or to suggest which treatments may be helpful. Among the multiple underlying pathophysiologic mechanisms that explain problematic Internet use are: addiction, compulsion, impulse-control problems, and mood disorders. There is no definitive or standard treatment protocol for evaluation or treatment of problematic Internet use per se. A comprehensive evaluation should address the underlying psychopathology or personal problems that prompt or contribute to the problematic Internet use. This article suggests approaches that may help forensic psychiatrists to conduct a thorough evaluation with reasonable treatment recommendations. Different formulations of the problem and a discussion of DSM-IV factors are offered to provide starting points for the evaluation and to help psychiatrists to understand how problematic Internet use may relate to Axis I disorders or other factors.

Clinical practice guidelines as learned treatises: understanding their use as evidence in the courtroom.

It is important for forensic experts to understand how clinical practice guidelines may enter the courtroom, what role they may play in a trial, and how they relate to expert testimony. Guidelines enter the record in several different ways and in several types of cases, typically with the assistance of an expert witness. A common vehicle for their introduction is the learned-treatise exception to the hearsay rule. Case law before and after Daubert v. Merrell Dow Pharmaceuticals, Inc. helps to elucidate the scrutiny that courts may direct toward medical texts proffered as evidence. This article discusses the implications of different rules and relevant case law for the forensic psychiatrist. The discussion notes important considerations for the expert witness, such as how guidelines may affect the expert's role, concerns about the reliability and relevance of scientific evidence, and questions about whether guidelines will be used for inculpatory or exculpatory purposes in medical malpractice trials.

Googling suicide: surfing for suicide information on the Internet.

OBJECTIVE: This study examined the types of resources a suicidal person might find through search engines on the Internet. We were especially interested in determining the accessibility of potentially harmful resources, such as prosuicide forums, as such resources have been implicated in completed suicides and are known to exist on the Web. METHOD: Using 5 popular search engines (Google, Yahoo!, Ask.com, Lycos, and Dogpile) and 4 suicide-related search terms (suicide, how to commit suicide, suicide methods, and how to kill yourself), we collected quantitative and qualitative data about the search results. The searches were conducted in August and September 2006. Several coraters assigned codes and characterizations to the first 30 Web sites per search term combination (and "sponsored links" on those pages), which were then confirmed by consensus ratings. Search results were classified as being prosuicide, antisuicide, suicide-neutral, not a suicide site, or error (i.e., page would not load). Additional information was collected to further characterize the nature of the information on these Web sites. RESULTS: Suicide-neutral and anti-suicide pages occurred most frequently (of 373 unique Web pages, 115 were coded as suicide-neutral, and 109 were anti-suicide). While pro-suicide resources were less frequent (41 Web pages), they were nonetheless easily accessible. Detailed how-to instructions for unusual and lethal suicide methods were likewise easily located through the searches. CONCLUSIONS: Mental health professionals should ask patients about their Internet use. Depressed, suicidal, or potentially suicidal patients who use the Internet may be especially at risk. Clinicians may wish to assist patients in locating helpful, supportive resources online so that patients' Internet use may be more therapeutic than harmful.