Relationship between Massachusetts Youth Screening Instrument-second version and psychiatric disorders in youths in welfare and juvenile justice institutions in Switzerland.

BACKGROUND: There is growing evidence that it is important to have well-standardized procedures for identifying the mental health needs of youths in welfare and juvenile justice institutions. One of the most widely used tools for mental health screening in the juvenile justice system is the Massachusetts Youth Screening Instrument-second version (MAYSI-2). To contribute to the body of research examining the utility of the MAYSI-2 as a mental health screening tool; the first objective of the current study was to examine the relationship between the MAYSI-2 and the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime version (K-SADS-PL) in a sample of Swiss youths in welfare and juvenile justice institutions using a cross-sectional design. Secondly, as the sample was drawn from the French-, German- and Italian-speaking parts of Switzerland, the three languages were represented in the total sample and consequently differences between the language regions were analyzed as well. The third objective was to examine gender differences in this relationship. METHODS: Participants were 297 boys and 149 girls (mean age = 16.2, SD = 2.5) recruited from 64 youth welfare and juvenile justice institutions in Switzerland. The MAYSI-2 was used to screen for mental health or behavioral problems that could require further evaluation. Psychiatric classification was based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime version (K-SADS-PL). Binomial logistic regression analysis was used to predict (cluster of) psychiatric disorders from MAYSI-2 scales. RESULTS: The regression analyses revealed that the MAYSI-2 scales generally related well to their corresponding homotypic (cluster of) psychiatric disorders. For example, the alcohol/drug use scale identified the presence of any substance use disorder and the suicide ideation scale identified youths reporting suicide ideation or suicide attempts. Several MAYSI-2 scales were also related to heterotypic (cluster of) psychiatric disorders. For example, the MAYSI-2 scale alcohol/drug use, was positively related to any disruptive disorder. Furthermore, the results revealed gender differences in the relationship between the MAYSI-2 and K-SADS-PL (e.g., in the boys' subsample no MAYSI-2 scale was significantly related to any affective disorder; whereas, in the girls' subsample the MAYSI-2 scales depressed-anxious and somatic complaints were significantly related to any affective disorder). CONCLUSIONS: Overall, The MAYSI-2 seems to serve well as a first-stage screen to identify service needs for youths in welfare and juvenile justice institutions in Switzerland. Its effectiveness to identify the presence of (cluster of) psychiatric disorders differs between genders.

The relationship between criminal charges, diagnoses, and psycholegal opinions among federal pretrial defendants.

This study analyzed data from 1710 criminal defendants referred by federal courts throughout the United States. We examined 12 categories of criminal charges with respect to diagnosed psychopathology and opinions related to competence to stand trial (CST) and criminal responsibility (CR) at the time of the alleged offense. Overall, 18% of the present sample were found to be incompetent to stand trial, while 12% were found to be not criminally responsible or 'insane.' In this study, crimes were associated with rates of psychopathology and rates of opinions regarding CST and CR. The findings of this study suggest that individuals who are charged with different crimes have different mental states and psychopathology and are therefore found to have differential rates of competence and sanity.

Massachusetts Youth Screening Instrument for mental health needs of juvenile justice youths.

OBJECTIVE: This report describes the development of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), a brief screening measure to identify youths with potential mental, emotional, or behavioral problems at entry points in the juvenile justice system. METHOD: This 52-item self-report measure, with content relevant to common mental health problems in delinquent populations, was administered to 1,279 male and female youths, aged 12 to 17, in Massachusetts juvenile justice facilities. A subsample of youths also received the Millon Adolescent Clinical Inventory (MACI) and the Youth Self-Report (YSR). The instrument was subsequently administered to 3,804 male and female youths in California Youth Authority custody. RESULTS: Factor analyses of the 52 items identified seven scales that were conceptually associated with various mental, emotional, and behavioral problems of youths, which were generally confirmed by separate factor analyses with the California sample. The scales manifested adequate internal consistency and test-retest reliability. Most scales were substantially correlated with conceptually similar scales in the MACI and YSR, and they identified most youths who scored at clinically significant levels on those instruments. CONCLUSIONS: The MAYSI-2 shows promise as a reliable and valid screening tool to assist juvenile justice staff in identifying youths who may need an immediate response to mental or emotional problems.

Violent thoughts and violent behavior following hospitalization for mental disorder.

Using a standardized schedule of questions, this study examined (a) the prevalence of self-report of violent thoughts by patients hospitalized for mental disorders compared with nonpatients, (b) the persistence of violent thoughts after discharge, and (c) the relation between patients' violent thoughts while hospitalized and violent acts within 20 weeks after hospital discharge. About 1/3 of the patients reported thoughts of violence while hospitalized, more than twice the proportion found among nonpatients. Reporting violent thoughts in hospital was significantly related to engaging in violent acts within 20 weeks after discharge for non-White patients, patients without major mental disorder but with substance abuse diagnoses, patients with high symptom severity, and patients whose reports of violent thoughts persisted after discharge. Reporting violent thoughts was significantly related to measures of psychopathy, anger, and impulsiveness.

Developing a clinically useful actuarial tool for assessing violence risk.

BACKGROUND: A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has become available. It has a high degree of accuracy but can be time and resource intensive to administer. AIMS: To increase the clinical utility of the ICT method by restricting the risk factors used to generate the actuarial tool to those commonly available in hospital records or capable of being routinely assessed in clinical practice. METHOD: A total of 939 male and female civil psychiatric patients between 18 and 40 years old were assessed on 106 risk factors in the hospital and monitored for violence to others during the first 20 weeks after discharge. RESULTS: The ICT classified 72.6% of the sample as either low risk (less than half of the sample's base rate of violence) or high risk (more than twice the sample's base rate of violence). CONCLUSIONS: A clinically useful actuarial method exists to assist in violence risk assessment.

A classification tree approach to the development of actuarial violence risk assessment tools.

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.

From case management to court clinic: examining forensic system involvement of persons with severe mental illness.

The study examined the flow of a state mental health agency's case-managed clients into its forensic mental health court clinic systems for evaluation of competency to stand trial (CST) for a criminal offense. An analysis of merged encounter data from the case management and court clinic systems revealed that roughly 2% of the case-managed population were referred to court clinics for evaluation of CST during a 1-year period, but that these 2% represented roughly one eighth of that year's court clinic evaluees. The likelihood of this involvement was higher for males, African-Americans, and Latinos, and for persons with a history of substance abuse, and also was associated with higher levels of previous hospitalization. In addition, CST evaluees were more likely to be non-White, male, and uninsured than were case-managed evaluees. These data indicate that demographic characteristics, substance abuse, and lack of insurance are potential risk factors for forensic and, by inference, criminal justice system involvement among persons with mental illness.

Competence of depressed patients for consent to research.

OBJECTIVE: The capacities of depressed patients to consent to research have been questioned by commentators who fear that the cognitive effects of a disorder may impair subjects' abilities to protect their interests. This study used a new instrument for assessing depressed patients' capacities to consent to research and examined their performance, including the relation between severity of depression and extent of impairment. METHOD: Twenty-six female outpatients with major depression (assessed with the Schedule of Affective Disorders and Schizophrenia-Lifetime Version) enrolled in a study of maintenance psychotherapy were recruited for this project. Consent-related abilities were measured with the MacArthur Competence Assessment Tool-Clinical Research (MacCAT-CR) 1 week after intake and again 8-10 weeks later. Depressive symptoms were measured by the Hamilton Depression Rating Scale. RESULTS: Almost all subjects performed quite well on the capacity measures and maintained that level of performance over time. There was no correlation between performance and degree of depressive symptoms and little relation to prior research experience. Some subjects appeared confused about the extent to which decisions about assignment to treatment groups would be made on the basis of their clinical condition rather than randomly. CONCLUSIONS: This outpatient group with major depression showed few impairments in their decision-making capacities related to research. As in other studies, some concerns were raised about subjects' appreciation that treatment assignments would not be individualized for their needs. Examination of hospitalized patients and those with psychotic depression would help to determine whether they show greater degrees of impairment. The MacCAT-CR was easily adapted for use with this depressed group.

Competence to consent to voluntary psychiatric hospitalization: a test of a standard proposed by APA. American Psychiatric Association.

OBJECTIVE: In the wake of the U.S. Supreme Court's 1990 decision in Zinermon v. Burch, renewed attention has been given to capacities patients must have to be considered competent to consent to voluntary hospitalization. An American Psychiatric Association (APA) task force suggested that strong policy interests support the establishment of a low threshold for competence in this situation. The study examined whether, as previous research suggested, patients would have difficulty meeting even this lenient standard. METHODS: One hundred voluntarily hospitalized psychiatric patients were read two brief paragraphs, one explaining the purposes of psychiatric hospitalization and and the other explaining policies for discharge. The paragraphs' readability measured about eighth-grade level. After each paragraph, participants were read two sets of questions, one testing recall of the presented information and the other testing recognition of the information in a true-false format. The scores of patients grouped by selected demographic and clinical variables were compared. RESULTS AND CONCLUSIONS: The vast majority of patients were able to comprehend the information that the APA task force suggested was relevant to their decision. However, a subgroup of patients who were initially admitted involuntarily had significantly poorer performance and may constitute a group who need special educational efforts focused on the consequences of voluntary admission.

Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.

BACKGROUND: The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed. METHODS: We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks. RESULTS: There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home. CONCLUSIONS: "Discharged mental patients" do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.

The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions.

OBJECTIVE: The feasibility, reliability, and validity of a new instrument, the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), which was developed for use by clinicians, was tested. The instrument assesses patients' competence to make treatment decisions by examining their capacities in four areas--understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice. METHOD: The MacCAT-T and instruments to measure symptom severity were administered to 40 patients recently hospitalized with schizophrenia or schizoaffective disorder and 40 matched subjects in the community without mental illness. RESULTS: A high degree of ease of use and interrater reliability was found for the MacCAT-T. Overall, the hospitalized patients performed significantly more poorly than the community subjects on understanding and reasoning, although many patients performed as well as community subjects. Poor performance was related to higher levels of some psychiatric symptoms, such as conceptual disorganization, hallucinations, and disorientation. CONCLUSIONS: The MacCAT-T offers a flexible yet structured method with which caregivers can assess, rate, and report patients' abilities relevant for evaluating competence to consent to treatment.

Five year research update (1991-1995): evaluations for competence to stand trial.

This article reviews and evaluates publications during 1991-1995 with relevance for assessments of competence to stand trial. The review focuses specifically on articles that provide new concepts or data supported by research or case analyses. The studies are reviewed under the following headings: (a) the systemic context of competence to stand trial (CST) evaluations, (b) conceptual definitions of CST, (c) research on CST assessment methods, (d) characteristics of incompetent defendants, (e) interpretation and communication of CST evaluation data, (f) issues in CST assessment of special populations (juveniles, persons with mental retardation), and (g) treatment to restore competence. Suggestions are offered for further research to advance the quality of clinical evaluations for competence to stand trial.

Capacities of hospitalized, medically ill patients to consent to treatment.

This study was designed to compare the abilities of hospitalized, medically ill patients with non-ill comparison subjects to engage in an informed consent process. Eighty-two inpatients under the age of 70 were recruited from patients admitted for evaluation or treatment of ischemic heart disease (N = 675). The comparison subjects (n = 82) were matched person-to-person on age, gender, race, educational level, and occupation and did not have histories of ischemic heart disease. The hospitalized subjects did not differ from the non-ill comparison subjects on three instruments developed to assess abilities related to decision-making competence. Demographic and mental state variables did not correlate with performance, except for verbal cognitive functioning. There is no reason to believe that hospitalized patients similar to this sample--even if being treated for potentially life-threatening conditions--are at increased risk of inability to engage in a meaningful informed consent process.

A national survey of hospital -and community-based approaches to pretrial mental health evaluations.

To document the scope of recent trends in performing pretrial mental health evaluations, telephone interviews were conducted with 157 authorities in 50 states and the District of Columbia. These authorities included forensic mental health program directors and forensic clinical professionals. In all states, evaluations were made on an outpatient basis to some extent, and 45 states used inpatient evaluations. However, only ten states relied primarily on inpatient pretrial evaluations, generally in facilities with statewide catchment areas. A total of 32 states relied primarily on outpatient evaluations, generally conducted by providers with regional or local catchment areas.

Establishing standards for criminal forensic reports: an empirical analysis.

Forensic psychologists and forensic psychiatrists (about 80% of whom were certified by a specialty board) were surveyed regarding their beliefs about the necessary and appropriate content for reports on competency to stand trial (CST) (N = 102) and criminal responsibility/not guilty by reason of insanity (CR) (N = 96). Report elements concerning the identification of the defendant and evaluation methods (e.g., names, relevant dates, charges, data sources, notification to defendant of the purpose of the evaluation, and limits on confidentiality) were generally seen as "essential." Clinical data such as psychiatric history, current mental status, and current use of psychotropic medication were also seen as essential, as were data elements specific to each forensic question (e.g., understanding charges/penalties, possible pleas, and roles of trial participants for CST, and collateral information and defendant's description of alleged offense for CR). While most respondents agreed that it was important to provide an opinion about and reasoning for any diagnosis and its relation to the psycholegal question, there was lack of consensus regarding the propriety of offering "ultimate opinions," particularly concerning CR. Although there was general cross-disciplinary agreement regarding the appropriate content for criminal forensic reports, there was some disagreement as to the degree of importance of certain elements. Implications for practice and the development of professional standards are discussed, including advantages and cautions about using these data to influence issues of standards and policy.

Comparison of standards for assessing patients' capacities to make treatment decisions.

OBJECTIVE: This study investigated the proportion of psychiatric and medical patients who are impaired in their decision-making abilities in relation to each of several major legal standards for determining competence to consent to treatment. METHOD: The subjects were hospitalized patients with diagnoses of schizophrenia (N = 75), major depression (N = 92), and ischemic heart disease (N = 82) and equal numbers of community comparison subjects matched on age, race, gender, education, and occupation. Three instruments measuring abilities related to the legal standards for competence were administered to each group. Impaired functioning was defined as scores two standard deviations below the means for all subjects combined or lower. RESULTS: Although similar percentages of subjects with impaired performance were found for each of the measures, different groups of patients were identified as impaired depending on the measure used. The proportion of patients identified as impaired increased when compound standards were used, i.e., when impairment was defined as poor performance on any of two or three measures. Despite previous suggestions that the legal standards might form a hierarchy of rigorousness, the data did not support this hypothesis. CONCLUSIONS: Choice of standards for determining competence, including compound standards, will affect the identity and proportion of patients classified as impaired. Clinicians should be aware of applicable standards in their jurisdictions. Use of compound standards requires independent evaluation of performance on abilities related to each relevant standard, because standards do not appear to be hierarchical. Policies relating to the characterization of persons as incompetent must be fashioned with caution.

Use of posttraumatic stress disorder to support an insanity defense.

OBJECTIVE: The authors examine the allegation that the diagnosis of posttraumatic stress disorder (PTSD) is frequently abused in the legal system as the basis for a defense of not guilty by reason of insanity. METHOD: Data for the investigation were drawn from a study of insanity pleas gathered from court records in 49 counties in eight states. Data on the 28 insanity plea defendants for whom PTSD was diagnosed before or immediately after trial were compared with data on 8,135 defendants whose insanity pleas were based on other diagnoses. RESULTS: Insanity pleas by defendants with diagnoses of PTSD constituted only 0.3% of the cases. There were few significant differences between the two groups on demographic variables, psychiatric histories, previous involvement in crime, or current charges. The defendants with PTSD were more likely to have been married, less likely to have been arrested as juveniles, and less likely to have been detained after trial. CONCLUSIONS: Contrary to previously expressed concerns, PTSD was infrequently associated with an insanity defense in the cases in this study. In the cases in which pleas based on PTSD were used, they were no more likely to succeed than pleas based on any other diagnosis. Defendants with PTSD-related insanity defenses differed little from other insanity defendants, contradicting the stereotype of the person who is driven by PTSD to commit crimes. The data do not support fears of widespread misuse of the diagnosis of PTSD in connection with the insanity defense.