The role of correctional officers in multidisciplinary mental health care in prisons.

Prisons have become the homes of thousands of inmates who have mental disorders. The stress of incarceration can cause morbidity among these individuals, resulting in more severe symptoms and more disruptive behavior. Effective treatment for such inmates often involves services provided by a multidisciplinary treatment team that includes correctional officers. Correctional officers can assist in observations and interventions, and they play a unique role on specialized housing units. Successful collaboration between correctional officers and treatment teams requires a foundation of mutual respect, shared training, and ongoing communication and cooperation. With these elements in place, correctional officers can assist the treatment team and make important and constructive contributions to the assessment and management of offenders who have mental disorders.

General Electric Co. v. Joiner: lighting up the post-Daubert landscape?

The U.S. Supreme Court considered an appeal by the defendant, General Electric Co., in a products liability action. The appeal resulted from the ruling by the Court of Appeals for the Eleventh Circuit that overturned the district court's exclusion of evidence of cancer causation. The Supreme Court held that questions of the admissibility of such evidence are reviewable under the same standard--abuse of discretion--as are other decisions regarding evidentiary issues and are not subject to a more stringent standard of review. The Court further held that whether or not the evidence is excluded or is dispositive of the case does not change this standard of review. The Court then examined and upheld the decision by the trial court rather than remanding the action to the circuit court for reconsideration in light of the decision. Coupled with a series of recent circuit court of appeals decisions, the case establishes some guidance for the basis and methodology to be used to admit social science evidence in future cases.

Disabled doctors: the insurance industry seeks a second opinion.

This article focuses on disability in the professional work force, especially among physicians, and includes a background on private disability insurance in the United States, a discussion of problems experienced by the insurance industry over the past few years, a review of relevant case law on private disability, and legal and clinical issues involved in performing independent medical evaluations.

Judges' assumptions about the appropriateness of civil and forensic commitment.

The study examined judges' reasons for ordering pretrial forensic evaluation instead of civil commitment for persons with mental illness who are arrested. Fifty-five of 58 judges acknowledged having concerns about the adequacy of treatment or confinement in the civil mental health system, and 31 reported ordering pretrial forensic evaluations as a means of ensuring adequate treatment for patients who appear in their courts. Other frequently endorsed reasons for ordering these evaluations included lack of confidence in the ability to civilly commit mentally ill offenders and concerns about their being discharged prematurely. This study confirms suspicions that judges order pretrial evaluations to fill perceived gaps in the civil system.

Anatomy of a prison commission.

Although the epidemiology of mental disorders in the prison system has been investigated in the past, delivery of health services to prison inmates has not received similar scrutiny. Members of a state prison commission describe the process by which they developed their assessment of health care delivery. A model is offered for defining such a mission, selecting standards against which to test prison health services, choosing a testable focus, refining a valid and reliable methodology, and piloting the result.

Physician-assisted suicide and the Supreme Court: the Washington and Vacco verdicts.

In June 1997, the Supreme Court decided that statutes proscribing physicians from providing lethal medication for use by competent, terminally ill patients do not violate the Due Process or Equal Protection Clauses of the Constitution. The Court returned the question of physician-assisted suicide to the states, but did not foreclose future review of state laws that may be too restrictive of care at the end of life. The conceptual distinctions between assisted suicide, refusal of life-sustaining treatment, and administration of pain medication to terminally ill patients were endorsed as important guideposts for future analyses.

Epilepsy, aggression, and criminal responsibility.

Although epilepsy-related violence can occur, accounts of criminal behavior caused by epilepsy remain rare and unconvincing. The authors describe a case of apparent postictal aggression, resulting in felony assault charges, by a patient who had nocturnal complex partial seizures, followed by what appeared to be sleepwalking and periods of postictal wandering and confusion.

Privilege and discharge decisions for psychiatric inpatients with dysphagia.

Psychiatric patients have an increased risk for choking compared with the general population because of risk factors such as medication side effects and food gorging. A state hospital program for managing patients with dysphagia, or difficulty swallowing, includes interventions such as modified diets, mealtime monitoring, and adjusting psychotropic medications. Clinicians may find it difficult to make decisions about privileges and placement for dysphagic patients who do not comply with dietary modifications in unsupervised settings. For many such patients, close supervision and even placement on a locked ward may seem necessary. The authors recommend a risk-benefit approach: clinicians must balance the safety afforded by restrictions against the benefits of increased privileges or placement in a less restrictive setting. Quality of life and patients' preferences must also be considered.

Are pretrial commitments for forensic evaluation used to control nuisance behavior?

The shift to dangerousness-oriented civil commitment criteria has led to speculation that mentally ill persons who do not meet those criteria are being hospitalized under criminal commitment statutes. Using data on patients' psychiatric symptoms at admission to a state hospital in Massachusetts, the authors retrospectively assessed whether patients charged with minor criminal offenses who were committed for evaluation of competence to stand trial would have met civil commitment criteria. The data suggest that most mentally ill patients who were criminally committed could have been civilly committed. However, a relatively greater proportion of persons with substance abuse, mental retardation, or other conditions who did not meet civil commitment criteria for mental illness were committed for pretrial evaluation.

A model hospital policy on prosecuting patients for presumptively criminal acts.

Evidence suggests that violence by psychiatric inpatients, especially in public-sector hospitals, may be on the rise. The authors present a model policy developed at a state hospital for deciding whether to prosecute presumptively criminal assaults by patients. The policy addresses the circumstances under which it is ethically permissible to file a criminal complaint while emphasizing the need to use clinical interventions first and to consider the clinical sequelae of prosecution. The authors also review criticisms made of the policy, which reflect opposing views that prosecution is unjustified and that the policy unduly restricts the use of prosecution. In the first six months after the policy became effective, state hospital staff considered filing charges against five patients, but no case progressed beyond the first steps in the implementation procedure.

The designated forensic professional program: a state government-university partnership to improve forensic mental health services.

As the law/mental health field has expanded and matured in the last 20 years, the sophistication required by mental health professionals in order to respond appropriately to legal questions has grown significantly. Courts and legislatures define a growing number of legal competencies. Judges and attorneys are more familiar with mental health law than they were 10 or 20 years ago.

Criminal defendants who desire punishment.

Some defendants desire to be punished. Sometimes psychotic motivations underlie punishment-seeking behavior; sometimes they do not. The defendant's clinical status is relevant to his competency to stand trial and to waive other rights. These issues are illustrated by presentation of a case of a defendant who sought punishment. The importance of psychiatric assessments of these defendants is emphasized.