Forensic psychiatry and the forensic sciences: in memory of Peter J. Batten, MD

This commentary is dedicated to the memory of Peter J. Batten, MD. He was a public health physician, a psychiatrist, and a medical examiner who spent his entire career in Salem, the capital of the State of Oregon. Salem was a unique place to work because, early in the history of Oregon, the state elected to build all of its original public institutions in the environs of the city. As the county medical examiner, Dr. Batten reviewed all questionable deaths that occurred within the county and in particular within the public institutions. Many of his findings were subsequently published, and these reports influenced the direction of mental health policy in these same institutions. He also used his position as county medical examiner to examine deaths in road rage incidents and those occurring at railroad crossings in Salem. The commentary also emphasizes the benefits of collaboration within the forensic sciences.

Commentary: 1982 was AAPL's year of living dangerously

In 1982, the American Academy of Psychiatry and the Law (AAPL) was a growing and ambitious professional organization. Its membership was a small but vigorous group united by the desire to develop the emerging psychiatric subspecialty of forensic psychiatry within the larger context of psychiatry. The organization was 13 years old. It was devoted to the goal of uplifting the practice of forensic psychiatry in the United States through continuing education and specialty training. AAPL was well positioned to achieve its goal. Its leaders were fairly single-minded and many were strategically placed within the hierarchy of the American Psychiatric Association. Subspecialty recognition within psychiatry and medicine appeared attainable. Then came the United States v. Hinckley case. Every aspect of the case was controversial: the facts of the case itself, the use of the insanity defense, the contradictory psychiatric testimony and, finally, the verdict. Forensic psychiatry was put on the defensive, and at the height of the controversy the former President of the American Psychiatric Association and the nation's most prominent Professor of Law and Psychiatry delivered a simple luncheon speech. As is evident from this article and from this edition of the Journal, now, some 25 years later, we are still talking about what he had to say.

Telepsychiatry with rural American Indians: issues in civil commitments

The use of live interactive videoconferencing to provide psychiatric care, telepsychiatry, has particular relevance for improving mental health treatment to rural American Indian reservations. There is little literature on civil commitments in telepsychiatry and none specifically addressing this topic among American Indians. This article reviews telepsychiatry in the mental health care of American Indians, civil commitments and telepsychiatry in general, and the current state of civil commitments in American Indian communities. We conclude by considering commitment through telepsychiatry in rural reservations and offering guidelines to assist practitioners in navigating this challenging landscape. Civil commitments of American Indian patients residing in rural reservations can be successfully accomplished through videoconferencing by thoughtful and informed clinicians. However, much more work is needed in this area, including research into the cultural attitudes and perspectives towards commitments and further inquiry regarding potential legal precedents, as well as case reports and examples of this work.

Ethnic segregation in Kosovo's post-war health care system

BACKGROUND

Seven years after the end of war in Kosovo, Final Status Negotiations have begun to determine the long-term political future of the province. This article provides an overview of the present situation regarding ethnic groups and their relations in Kosovo's health care system that might be helpful in preparing for the array of potential ramifications and repercussions that could arise at the conclusion of the negotiations.

METHODS

A review of the literature (including grey) was performed, and 16 interviews and two focus groups with key informants were conducted in Kosovo during October and November 2004. In addition, six informal discussions were held in-person or by telephone in London. Information collected in 2004 was re-confirmed and partially updated in October and November 2005, when three additional interviews were conducted in Kosovo.

RESULTS

Ongoing ethnic tensions in Kosovo, mainly between the Albanian and Serb populations, perpetuate a rigidly segregated health care system. Some other minority communities, such as the Roma, Ashkali and Egyptians, are afflicted by the double burden of getting caught up in the middle of these ethnic disputes and at the same time suffering from poverty and discrimination.

CONCLUSION

While efforts have been put forward to promote peace-building within Kosovo's post-war health sector, very little progress has been achieved in fostering ethnic integration, reconciliation, cooperation or even co-existence. This failure reflects Kosovo's broader unresolved inter-ethnic problems. Final Status Negotiations are one of the last opportunities for the international community to address the problems of ethnic segregation in the province.

Oregon's Juvenile Psychiatric Security Review Board

In 2005, the Oregon Legislature passed a bill modifying the existing Psychiatric Security Review Board (PRSB) statute, creating a juvenile panel for management of juvenile insanity acquittees. Dubbed the Juvenile PSRB (JPSRB), it borrows heavily from the 30 years of experience of its adult predecessor. Statutory language was also modified to create a plea of "responsible except for insanity" for juveniles in Oregon. The authors discuss the similarities of the JPSRB to the adult PSRB system and highlight the differences that take into account the unique needs of juvenile defendants. They go on to discuss potential problems foreseen with implementation of the JPSRB system and to recommend possible solutions.

The evolution of the american law institute test for insanity in Oregon: focus on diagnosis

In 1962, the American Law Institute published its Model Penal Code, which includes an insanity test later adopted by many states. The second paragraph of the test excludes people with certain psychiatric conditions manifested by repeated criminal or antisocial conduct from using them as a basis for an insanity defense. Oregon adopted this test in 1971. Since then, its legislature and courts have added to the conditions excluded in the second paragraph. In this article, we look at how recent Oregon appellate court decisions have culminated in a narrower and less contentious notion of which psychiatric diagnoses serve as a basis for an insanity defense. Then we discuss Oregon's expansion of the second paragraph of the American Law Institute Insanity Test in a national context.

Commentary: authorship and training in forensic psychiatry

This commentary is written in praise of Dr. Simon's Presidential Address with exemplification of certain of his themes. Forensic fellowships have now become the training ground for the next generation of forensic psychiatrists, who need to be encouraged to find their own best way to write. They should also be encouraged to participate in research with senior mentors and researchers, as published research will lead to the challenging of stereotyping and misinformation about the populations served by forensic psychiatry.

Civil commitment is disappearing in Oregon

Over the past 20 years, in Oregon, the number of individuals entered into the civil commitment process has risen, but the number of those actually committed has gone down dramatically. This commentary compares commitment data during a time when the state's population has increased substantially, while commitment rates have dropped by 50 percent. There are many possible factors that have contributed to this decline in commitment rates, including a stricter functional definition of "danger to self or others," but perhaps the most significant reason is the shortage of the acute psychiatric beds that are essential in the commitment process. It is hard not to conclude that civil commitment in this state is headed toward functional extinction.

A comparison study of career satisfaction and emotional states between primary care and speciality residents

OBJECTIVE

To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Education's (ACGME) duty hour requirements.

DESIGN

Cross-sectional survey.

MEASUREMENTS

All 581 residents in the academic health centre were asked to participate voluntarily in a confidential survey; 327(56%) completed the survey.

RESULTS

Compared to their primary care colleagues, speciality residents had higher levels of satisfaction with career choice, feelings of competence and excitement, lower levels of inferiority and fatigue and different perceptions of positive and negative training experiences. However, 77% of all respondents were consistently or generally pleased with their career choices. The most positive residents' experiences related to interpersonal relationships and their educational value; the most negative experiences related to interpersonal relationships and issues perceived to be outside of residents' control. Age and training level, but not gender also influenced career satisfaction, emotional states and positive and negative opinions about residency.

CONCLUSIONS

Less satisfaction with career choice and more negative emotional states for primary care residents compared to speciality residents probably relate to the training experience and may influence medical students' selections of careers. The primary care residents, compared to speciality residents, appear to have difficulty in fulfilling their ideals of professionalism in an environment where they have no control. These data provide baseline information with which to compare these same factors after the implementation of the ACGME duty hours' and competency requirements.

A comparison study of career satisfaction and emotional states between primary care and speciality residents

OBJECTIVE

To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Education's (ACGME) duty hour requirements.

DESIGN

Cross-sectional survey.

MEASUREMENTS

All 581 residents in the academic health centre were asked to participate voluntarily in a confidential survey; 327(56%) completed the survey.

RESULTS

Compared to their primary care colleagues, speciality residents had higher levels of satisfaction with career choice, feelings of competence and excitement, lower levels of inferiority and fatigue and different perceptions of positive and negative training experiences. However, 77% of all respondents were consistently or generally pleased with their career choices. The most positive residents' experiences related to interpersonal relationships and their educational value; the most negative experiences related to interpersonal relationships and issues perceived to be outside of residents' control. Age and training level, but not gender also influenced career satisfaction, emotional states and positive and negative opinions about residency.

CONCLUSIONS

Less satisfaction with career choice and more negative emotional states for primary care residents compared to speciality residents probably relate to the training experience and may influence medical students' selections of careers. The primary care residents, compared to speciality residents, appear to have difficulty in fulfilling their ideals of professionalism in an environment where they have no control. These data provide baseline information with which to compare these same factors after the implementation of the ACGME duty hours' and competency requirements.

The use of the insanity defense as a jail diversion mechanism for mentally ill persons charged with misdemeanors

Heightened awareness and concern regarding the large number of mentally ill misdemeanants in jails has led to a search for alternatives to jail and to the development nationwide of jail diversion programs for offenders with mental illness. Two such mechanisms-diversion to civil commitment and the use of mental health courts-are briefly reviewed. In Oregon, however, a rather unique mechanism is used to defer mentally ill misdemeanants (in addition to felons) from the criminal justice system: the insanity defense, with subsequent placement of the individual under Psychiatric Security Review Board jurisdiction. Statistics regarding such use from 1978 to 2001 are provided. The authors compare and contrast this jail alternative with both mental health courts and diversion to civil commitment, and discuss questions related to the feasibility of larger-scale use of this mechanism.

Subspecialization in psychiatry: third-generation programs

Psychiatry, unlike internal medicine, was slow to develop subspecialty certification. For many years, child and adolescent psychiatry was the only major subspecialty recognized by the American Board of Psychiatry and Neurology (ABPN). The situation changed in the early 1990s with the recognition by the ABPN of additional subspecialties of psychiatry including forensic psychiatry. Using the experience of the American Board of Internal Medicine as a guide, this commentary asks what comes next? What are our options as it becomes clear that there is a deepening of knowledge in the field of forensic psychiatry? Are we ready for, or interested in, the development of so-called third-generation certification programs?

Cultural considerations in the criminal law: the sentencing process

In forensic psychiatry, there is increasing recognition of the importance of culture and ethnicity in the criminal justice process as the population becomes more culturally diverse. However, there has been little consideration of the role of cultural factors in the trial process for criminal defendants, particularly in the sentencing phase of trial. Using a capital murder case study, this article explores the role of cultural forensic psychiatric consultation, focusing on the sentencing phase of trial as the place where the full scope and power of a cultural evaluation can be brought most effectively to the attention of the court. Cultural psychiatric perspectives can enrich a core forensic evaluation and be maximally helpful to the court, by exploring family dynamics and psychological health influenced by cultural history, immigrant and refugee experiences, and sociocultural environment. Specific recommendations and cautions for effective cultural consultation in forensic psychiatry are discussed.

Thirty-five years of working with civil commitment statutes

This commentary reflects my 35 years of working with civil commitment statutes, first in Alaska, then in Oregon, and on various committees on the national level. Coming from a background in community and public psychiatry, I have always considered civil commitment to be the most important forensic mental health statute, as the commitment process in any state greatly influences the lives of many severely mentally ill individuals. Over the course of the past 35 years, many changes have occurred in civil commitment law, resulting in the gradual de-emphasis of the importance of these statutes. The ability of clinicians to use these statutes effectively has diminished. Herein, I review some of the areas of conceptual and practical problems related to the use of these statutes and, in effect, make a plea for a re-examination of the importance of civil commitment and for an attempt to fix some of the problems that have led to the loss of effective and rational civil commitment laws.

Physician reporting of impaired drivers: a new trend in state law?

The State of Oregon recently enacted legislation that increases physician responsibility for reporting medically at-risk drivers. The legislation comes at a time when the public is closely scrutinizing the question of the elderly and driving and the role of physicians in the reporting of potentially dangerous drivers. The evolution of Oregon's law is somewhat unique and offers an opportunity to examine what perhaps is to come in other states. The law broadened the role of the physician in assessment and reporting of impaired drivers. It also opened the door for new tort, that of "negligent failure to report," before input from physicians and other health care providers led to important revisions in the final statute. Physicians must look to current statutes to guide the legislative process in their own states, so that new law aimed at maintaining safe highways also preserves the physician-patient relationship and allows for a collaborative assessment of driving skill in the physician's office.

Bidirectional amyloid fiber growth for a yeast prion determinant

The polymerization of many amyloids is a two-stage process initiated by the formation of a seeding nucleus or protofibril. Soluble protein then assembles with these nuclei to form amyloid fibers. Whether fiber growth is bidirectional or unidirectional has been determined for two amyloids. In these cases, bidirectional growth was established by time lapse atomic-force microscopy. Here, we investigated the growth of amyloid fibers formed by NM, the prion-determining region of the yeast protein Sup35p. The conformational changes in NM that lead to amyloid formation in vitro serve as a model for the self-perpetuating conformational changes in Sup35p that allow this protein to serve as an epigenetic element of inheritance in vivo. To assess the directionality of fiber growth, we genetically engineered a mutant of NM so that it contained an accessible cysteine residue that was easily labeled after fiber formation. The mutant protein assembled in vitro with kinetics indistinguishable from those of the wild-type protein and propagated the heritable genetic trait [PSI(+)] with the same fidelity. In reactions nucleated with prelabeled fibers, unlabeled protein assembled at both ends. Thus, NM fiber growth is bidirectional.

Novel class of thiourea compounds that inhibit herpes simplex virus type 1 DNA cleavage and encapsidation: resistance maps to the UL6 gene

In our search for novel inhibitors of herpes simplex virus type 1 (HSV-1), a new class of thiourea inhibitors was discovered. N-(4-[3-(5-Chloro-2,4-dimethoxyphenyl)-thioureido]-phenyl)-acetamide and its 2-fluoro-benzamide derivative inhibited HSV-1 replication. HSV-2, human cytomegalovirus, and varicella-zoster virus were inhibited to a lesser extent. The compounds acted late in the replication cycle by impairing both the cleavage of concatameric viral DNA into progeny genome length and the packaging of the DNA into capsids, indicative of a defect in the encapsidation process. To uncover the molecular target of the inhibition, resistant HSV-1 isolates were generated, and the mutation responsible for the resistance was mapped using marker transfer techniques. Each of three independent isolates had point mutations in the UL6 gene which resulted in independent single-amino-acid changes. One mutation was located in the N terminus of the protein (E121D), while two were located close together in the C terminus (A618V and Q621R). Each of these point mutations was sufficient to confer drug resistance when introduced into wild-type virus. The UL6 gene is one of the seven HSV-1 genes known to play a role in DNA packaging. This novel class of inhibitors has provided a new tool for dissection of HSV-1 encapsidation mechanisms and has uncovered a new viable target for the treatment of herpesviral diseases.

A 36-year history of fatal road rage in Marion County, Oregon: 1963-1998

This paper documents the 36-year history, with five examples, of fatal road rage in Marion County, Oregon. Relevant details (all that were available) from each case are presented. Alcohol intoxication was present in four of our five cases. We include two deaths by gunshot at close range, two deaths as a result of a motor vehicle traffic accident, and one natural death. All subjects were males. Three were Caucasian and two were Hispanic. The three subjects in Cases 1, 2 and 3 were complete strangers to the occupants of the other involved vehicles. The subjects in Cases 4 and 5 (along with the occupants of their own vehicles) were acquaintances of the occupants of the involved vehicle. There appears to be no previous forensic, medical or psychiatric literature on road rage as such. We present an initial psychiatric evaluation of the perpetrators of this type of fatal assault. There are no specific statutes in Oregon, at the state or county levels, regarding road rage. However, the city of Gresham, Oregon, recently enacted an ordinance regarding road rage. We stress the need for further study of this phenomenon, especially through the use of the psychological-psychiatric autopsy.

Ensuring the survival of academic psychiatry in the new health care era

The authors contend that academic psychiatry will only survive in the future if it helps to fulfill the crucial requirement of academic medicine in the new health care era. They present six basic requirements of academic medicine: 1) effective, efficient, and responsible organizations; 2) quality educational programs of appropriate type and size; 3) linkage to health care networks; 4) primary care capacity and services; 5) restructured systems for research; and 6) effective leadership. Specific strategies for departments of psychiatry to help meet the requirements of academic medicine are outlined. The authors present major implications of these proposed strategies for psychiatric chairs, faculty, and the professional organizations that serve them.

Long-term follow-up of rural involuntary clients

A cohort of 72 persons who had entered a rural Oregon county's involuntary treatment system in 1979 through 1982 was followed for six years. While schizophrenia was the most frequent diagnosis, several other conditions were represented including adjustment disorders, organic mental disorders, and substance abuse. The majority (55%) of persons with organic mental disorders died as did 12% of the individuals with schizophrenia. The overall mortality rate was three times the expected figure (p = .002). During the follow-up period, only 39% of the initial cohort received treatment from a community mental health program whereas 28% were newly admitted (involuntarily) to a state mental hospital. Hospital recividism was most likely among individuals who had had prior involuntary treatment. At least in rural areas, the civil commitment system seems to serve both "infrequent" and "persistent" users. Infrequent users mainly have diagnoses of adjustment disorders and/or substance abuse. Persistent users chiefly have diagnoses of organic mental disorders, mood disorders, or schizophrenia. Modifying the involuntary treatment system to take account of this heterogeneous population's diverse needs is discussed.

Inhibition of influenza A virus replication by compounds interfering with the fusogenic function of the viral hemagglutinin

Several compounds that specifically inhibited replication of the H1 and H2 subtypes of influenza virus type A were identified by screening a chemical library for antiviral activity. In single-cycle infections, the compounds inhibited virus-specific protein synthesis when added before or immediately after infection but were ineffective when added 30 min later, suggesting that an uncoating step was blocked. Sequencing of hemagglutinin (HA) genes of several independent mutant viruses resistant to the compounds revealed single amino acid changes that clustered in the stem region of the HA trimer in and near the HA2 fusion peptide. One of the compounds, an N-substituted piperidine, could be docked in a pocket in this region by computer-assisted molecular modeling. This compound blocked the fusogenic activity of HA, as evidenced by its inhibition of low-pH-induced cell-cell fusion in infected cell monolayers. An analog which was more effective than the parent compound in inhibiting virus replication was synthesized. It was also more effective in blocking other manifestations of the low-pH-induced conformational change in HA, including virus inactivation, virus-induced hemolysis of erythrocytes, and susceptibility of the HA to proteolytic degradation. Both compounds inhibited viral protein synthesis and replication more effectively in cells infected with a virus mutated in its M2 protein than with wild-type virus. The possible functional relationship between M2 and HA suggested by these results is discussed.

An administrative model for close monitoring and managing high risk individuals

The public expects central government to have immediate knowledge of the condition and circumstances of certain vulnerable or dangerous individuals such as insanity acquittees, and to take action in individual cases to protect the individual and the public. Therefore, such persons conditionally released to community settings require an unusual degree of close monitoring and management. Being immediately aware of the condition and circumstances of its assignees, together with other duties of a board or commission responsible for that monitoring and management, is largely an information management function. The Psychiatric Security Review Board in Oregon is used to illustrate this unique mission, operations, and information management. In this paper, the Psychiatric Security Review Board is described in terms of its core and secondary businesses, together with a model information system that is based on information and information management processes actually employed by the Board.