Using intensive case management to reduce violence by mentally ill persons in the community.

Aggressive and intensive case management and a comprehensive array of community support services are the keys to reducing the risk of violence by people with serious mental illness in the community. The authors describe the elements of intensive case management for potentially violent clients, including use of individual case managers responsible for small caseloads, 24-hour availability of case managers, and strong linkages to agencies providing mental health services, substance abuse treatment, and social services as well as to the criminal justice system. They summarize the results of three recent studies of intensive case management programs suggesting that this intervention is effective in reducing clients' dangerousness in the community. They discuss cultural and human resource issues that affect planning of intensive case management services. Intensive case managers need to be "boundary spanners" with the training, experience, and personality to bridge the often-broad gap between human service and criminal justice systems.

Intermediate care programs for inmates with psychiatric disorders.

Inmates with psychiatric disorders are a growing and difficult to manage population in federal and state prisons. An exploratory study was done of New York State's Intermediate Care Programs for inmates with psychiatric disorders. The study assessed whether there was a reduction in disruptive and harmful behaviors, and in the correctional restrictions and mental health services used to address those behaviors, among admissions to programs. Data came from corrections and mental health records of 209 inmates who had been in the program and prison for at least six months. Significant reductions were found in very serious rules infractions, suicide attempts, correctional discipline, and three mental health services: crisis care, seclusion, and hospitalization.

The debate on treating individuals incompetent for execution.

The question of whether to provide mental health treatment to prisoners under death sentence who have been judged incompetent for execution presents a powerful ethical dilemma for mental health professionals. Arguments that favor or oppose the provision of treatment are discussed in the context of the nature of the disorder to be treated, the type of treatment to be provided, the goals of treatment, and the relevant legal standard for determining competency for execution. Arguments against treating the incompetent include 1) the need to avoid harming those who are treated, 2) the risk that disclosures in therapy will be used for assessment purposes, 3) the need for paternalism when sufficient harm is necessary, 4) the adverse impact on the clinician, 5) the potential undermining of patient and public perceptions of mental health professionals, and 6) the poor allocation of limited resources. Arguments for treating the incompetent include 1) respect for the wishes of the prisoner, 2) the need to clarify the values underlying the refusal to treat, 3) the low risk of harm from some forms of treatment, and 4) the adverse impact on the milieu stemming from failure to treat. The authors conclude that treating incompetent prisoners may not violate ethical standards under some circumstances, and that some forms of treatment will require the informed consent of the prisoner.

New York State's system of managing insanity acquittees in the community.

New York State's Insanity Defense Reform Act of 1980 outlined specific procedures for conditional release to the community of persons found not guilty of a criminal offense by reason of insanity. To assess how well the procedures were working, the authors examined data on all clients placed on conditional release in the state between 1980 and 1987. The majority of the 331 clients so identified had been found to be dangerously mentally ill and were subsequently released to the community after extensive periods of involuntary inpatient treatment. The most common condition for community release was participation in a treatment program. While in the community, 22 percent of the clients were arrested, and 5 percent had their conditional releases revoked and were recommitted. The authors compare the New York program with similar programs elsewhere. They believe the key features of a successful program include centralized responsibility, a uniform system of treatment and supervision, and a network of community services.

Estimating mental health needs and service utilization among prison inmates.

A sample of 3,684 inmates in the New York State prison system was surveyed in May 1986 to determine the prevalence of psychiatric and functional disability and service utilization. It was estimated that 5 percent had a severe psychiatric disability, and 10 percent had significant psychiatric disability. The higher the level of disability, the greater the proportion of inmates that had received mental health services in the last 30 days and in the last year. Still, 45 percent of the severe disability group had no service contacts in the last year. Patterns of utilization differed significantly by sex (a greater proportion of women received services) and by race (a greater proportion of whites received services). The clinical factors associated with receipt of services varied considerably between men and women.

Forensic psychiatric inpatients served in the United States: regional and system differences.

This research note presents data about regional and system variations in psychiatric inpatient services for forensic patients provided in state operated psychiatric inpatient programs in the United States in 1986. Patient census by legal status and service provision information were collected from state forensic directors. In 1986, about 5,400 patients found not guilty by reason of insanity (NGRI) and 3,200 patients found incompetent to stand trial (IST) were being served in state operated inpatient units. About 70 percent of both groups were being served in designated forensic beds. There were wide differences among the states in the volume and rates for NGRI, IST, forensic exams, and dangerous civil patients (DCP). The regional analyses revealed large variability among states within each region.

Staffing of forensic inpatient services in the United States.

Data on patient census, bed capacity, and staffing levels in state-operated forensic psychiatric inpatient programs in 1986 were collected from forensic mental health directors of the 50 states and the District of Columbia. Of the 75 programs identified, 54 were based in units within larger psychiatric hospitals and 21 in freestanding hospitals. For all programs, direct-care staff-patient ratios ranged from .35 to 4, with a mean of 1.3. The ratio of filled beds to bed capacity ranged from .5 to 1.54, with a mean of .95. Nearly a fourth of the programs were over capacity. A negative relationship between filled-bed ratios and direct-care staff-patient ratios was found.

AIDS-related dementia and competency to stand trial: a potential abuse of the forensic mental health system?

Public health officials, hospital administrators, forensic directors, jail wardens, judges, prosecutors, and defense attorneys must confront the issue: how should cases of individuals with AIDS dementia be treated when they are found to be permanently incompetent to stand trial? Although charges are sometimes dismissed in advanced cases of dementia, the more common pattern involves placement of the defendant in a public facility while awaiting trial. The refusal of some state facilities to accept these patients raises a host of legal, moral, and medical questions that virtually every urban state's forensic system will have to consider in the near future.

A survey of mental disability among state prison inmates.

To obtain a comprehensive picture of the levels of mental disability in the general state prison population in New York State, the authors gathered data on a random sample of inmates using a survey instrument adapted from the state's level-of-care surveys of the psychiatric population. The sample consisted of 3,332 inmates in the general prison population (9.4 percent) and 352 inmates in prison mental health units. The survey results showed that 8 percent of the state's prison inmates have severe psychiatric or functional disabilities that clearly warrant some type of mental health intervention, and another 16 percent have significant mental disabilities that require periodic services. The specific nature and extent of these disabilities need to be assessed before appropriate services can be developed.

Quality of life for the mentally disabled.

Case illustrations are given to suggest the complexity of the effects on the quality of life of developments in psychotropic medicines, deinstitutionalization, and patients' rights. Community services often do not provide the mentally disabled with the benefits predicted for such programs. Whether the net effect of the revolutionary extrusion of the mentally disabled from public hospitals will be beneficial remains for history to judge.