Psychiatric Disorders and Crime in the US Population: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Wave III.

OBJECTIVE: Current knowledge regarding the intersection of psychiatric disorders and crime in the United States is limited to psychiatric, forensic, and youth samples. This study presents nationally representative data on the relationship of DSM-5 psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized US adults. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012-2013; N = 36,309). Logistic regressions were used to examine the association of specific disorders (eg, mood, anxiety, eating, posttraumatic stress, substance use), comorbid substance use and mental health disorders, and multimorbidity with lifetime criminal behavior, incarceration experience, and past-12-month general, alcohol-related, and drug-related legal problems. RESULTS: Overall, 28.5% of participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current general legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems. The presence of any disorder was associated with a 4 to 5 times increased risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime (adjusted odds ratio [AOR] = 6.8; 95% CI, 6.1-7.6) and incarceration (AOR = 4.7; 95% CI, 4.1-5.3) and current legal problems (AOR = 3.3; 95% CI, 2.6-4.2). Multimorbidity and comorbid substance use and mental health disorders were associated with additional risk. Controlling for antisocial personality disorder did not change the findings. CONCLUSIONS: Community adults with substance use disorders, comorbid substance use and mental health disorders, and increasing multimorbidity are most at risk of crime and justice involvement, highlighting the importance of community-based addiction treatment.

Geriatrics and the Legal System.

Correctional systems, already struggling to meet the basic and functional requirements of older prisoners, will be further challenged by the increasing medical and psychiatric needs of this population. Mental health and general medical care for older adults requires specific on-site or consultation expertise in geriatric medicine and psychiatry, as well as potential changes in infrastructure, both of which may be prohibitively expensive. However, compassionate and effective treatment of older prisoners requires that prison and legal systems facilitate this expert care. To address this situation, strategic revisions of the criminal justice system are needed to alleviate prison overcrowding and consequent inadequate medical care for inmates, especially the elder ones. The unique, age-related demands of this older population predict an increased need for forensic psychiatrists with a thorough knowledge and expertise in geriatrics, as more forensic psychiatric evaluations will be needed before trial in both civil and criminal cases, during incarceration, and at the time of parole. In this article, we review the current state of elder inmates in correctional institutions and advocate for increased geriatric training for forensic psychiatrists in anticipation of this growing need.

Crime and psychiatric disorders among youth in the US population: an analysis of the National Comorbidity Survey-Adolescent Supplement.

OBJECTIVE: Current knowledge regarding psychiatric disorders and crime in youth is limited to juvenile justice and community samples. This study examined relationships between psychiatric disorders and self-reported crime involvement in a sample of youth representative of the US population. METHOD: The National Comorbidity Survey-Adolescent Supplement (N = 10,123; ages 13-17 years; 2001-2004) was used to examine the relationship between lifetime DSM-IV-based diagnoses, reported crime (property, violent, other), and arrest history. Logistic regression compared the odds of reported crime involvement with specific psychiatric disorders to those without any diagnoses, and examined the odds of crime by psychiatric comorbidity. RESULTS: Prevalence of crime was 18.4%. Youth with lifetime psychiatric disorders, compared to no disorders, had significantly greater odds of crime, including violent crime. For violent crime resulting in arrest, conduct disorder (CD) (odds ratio OR = 57.5; 95% CI = 30.4, 108.8), alcohol use disorders (OR = 19.5; 95% CI = 8.8, 43.2), and drug use disorders (OR = 16.1; 95% CI = 9.3, 27.7) had the greatest odds with similar findings for violent crime with no arrest. Psychiatric comorbidity increased the odds of crime. Youth with 3 or more diagnoses (16.0% of population) accounted for 54.1% of those reporting arrest for violent crime. Youth with at least 1 diagnosis committed 85.8% of crime, which was reduced to 67.9% by removing individuals with CD. Importantly, 88.2% of youth with mental illness reported never having committed any crime. CONCLUSION: Our findings highlight the importance of improving access to mental health services for youthful offenders in community settings, given the substantial associations found between mental illness and crime in this nationally representative epidemiological sample.

So you're sorry? The role of remorse in criminal law.

The role of remorse in judicial decisions in the criminal justice system has been addressed in scholarship and remains controversial. The purpose of this qualitative research was to examine the views of sitting criminal judges on remorse, its assessment, and its relevance in their decision-making. After approval of the study design by the institutional review board, 23 judges were interviewed in an open-ended format. Transcriptions of these audio-recorded sessions were analyzed phenomenologically by the research team, using the method of narrative summary. The results showed that the judges varied widely in their opinions on the way remorse should be assessed and its relevance in judicial decision-making. They agreed that the relevance of remorse varied by type of crime and the stage of the proceedings. The indicators of remorse for some judges were the same as those that indicated the lack of remorse for others. All the judges recognized that assessment of remorse, as well as judicial decision-making in general, must be altered for defendants with mental illness. The judges varied in their views of the relevance of psychiatric assessments in determining remorse, although most acknowledged a role for forensic psychiatrists.

AAPL Practice Guideline for the forensic psychiatric evaluation of competence to stand trial.

Competence to stand trial is a legal construct used to identify those criminal defendants who have the requisite mental capacity to understand the nature and objective of the proceedings against them and to participate rationally in preparing their defense. This Practice Guideline has described how psychiatrists should evaluate individuals concerning their competence to stand trial. The Guideline describes acceptable forensic psychiatric practice for such evaluations. Where possible, it specifies standards of practice and principles of ethics and also emphasizes the importance of analyzing an individual defendant's case in the context of statutes and case law applicable in the jurisdiction where the evaluation takes place. The recommendations in the Guideline both reflect and are limited by evolving case law, statutory requirements, legal publications, and the current state of psychiatric knowledge. The authors have taken note of nationally applicable case law, federal constitutional standards, statutory language, and federal and state interpretations of the rights or statutes, recognizing that jurisdictions may differ in their specific interpretation or application of statutes or general constitutional standards. The review of cases concerning specific psychiatric diagnoses illustrates general U.S. trends, and psychiatrists must remain cognizant of their jurisdictions' interpretations of statutes or constitutional requirements. By surveying a variety of practices and approaches to data gathering and case analysis, the authors believe that this Guideline will stimulate additional collegial discussion about what is necessary and sufficient for adequate evaluations of adjudicative competence. The notion that psychiatrists should apply expertise to competence assessments stems from the principal that, before allowing a defendant to face criminal prosecution and possible punishment, courts need reasonable assurance--based, if necessary, on a careful, individualized evaluation--that the defendant has adequate mental capacity to make a defense. At a minimum, a psychiatrist's opinion about adjudicative competence should reflect an understanding of the jurisdictional standard and of how the defendant's mental condition affects competence as defined with the jurisdiction. The psychiatrist's report should clearly describe the opinion and the reasoning that leads to it. Psychiatrists who provide mental health expertise concerning adjudicative competence give trial courts information needed to assure that defendants can appropriately protect themselves and that criminal proceedings will be accurate, dignified,and just.

Legal considerations in the child psychiatric emergency department.

Clinicians who practice in the child psychiatric emergency department have the complex task of evaluating the mental health or substance abuse needs of children, adolescents, and their families during times of crisis. Adding to this challenging clinical task are multiple legal considerations with which the clinician must be familiar. The precise impact of these legal issues varies from state to state. Some of these legal considerations are present at the start of the evaluation (consent for evaluation or treatment), during the evaluation (psychiatric hospitalization), and at the end of an evaluation (mandatory reporting of suspected child abuse and duty to warn or protect third parties from harm). Other issues (confidentiality and consent for release of information) are present at all stages of the evaluation and continue long after the evaluation has been completed. Clinicians who evaluate the psychiatric needs of children and adolescents are urged to review their local state laws relating to civil commitment, confidentiality, and mandatory reporting.

Competency to be executed and forced medication: Singleton v. Norris.

Singleton v. Norris is a decision by the Eighth Circuit Court of Appeals stating that forced psychotropic medication can be continued after the date of execution is set if the medication had been given previously to prevent the inmate from being dangerous in the prison setting under a Harper-type review. The defendant had argued that after the date of execution was set, it was no longer in his medical interests to continue the medication. In the decision, the majority held that the fact that an execution is in the offing does not alter the medical interests for which the medication had been prescribed, and physicians should just continue to treat the medical condition. This decision may raise ethics problems for physicians in such settings, because they may be in violation of the American Medical Association (AMA) Code of Ethics if the original override is dubious.