Examiners' perceptions of forensic mental health assessments conducted via videoconferencing

The COVID-19 pandemic led to an acceleration in the adoption of videoconferencing (VC) for conducting forensic mental health evaluations (forensic mental health assessments [FMHA]). Two years into the COVID-19 pandemic, we administered a survey to 71 Minnesota-licensed forensic evaluators. Approximately two-thirds (65.7%) had started using VC for FMHA only after the pandemic, though a combined 84.5% reported performing FMHA via VC frequently at present. A striking 43.7% of respondents preferred VC for FMHA over in-person evaluation, and another 22.5% expressed no preference between modalities. Further, nearly 70% of respondents denied there were any populations for which they would never use VC to complete an FMHA. We conclude that the widespread adoption of VC for FMHA with the advent of the COVID-19 pandemic has induced a lasting change in the practice of FMHA. We postulate that with further advancements in technology and the development of testing instruments that can be administered online, the use of VC for FMHA will become standard practice.

Victim Intoxication and Capacity to Consent in Sexual Assault Statutes across the United States

Alcohol use is common in cases of sexual assault. These cases raise significant questions about a victim's capacity to consent to sexual intercourse. In many United States jurisdictions, intoxicated victims may be considered mentally incapacitated only if they have been administered alcohol or other substances involuntarily. A recent Minnesota Supreme Court case illustrated why reform is necessary in this area of criminal sexual conduct law. We present this case and the results of a review of felony criminal sexual conduct laws in the fifty states of the United States and the District of Columbia. We find that nearly half of the jurisdictions surveyed require that a victim must be involuntarily intoxicated to be considered incapacitated or impaired. We draw on Minnesota's experience with legislative reform of its sexual assault laws as well as judicially mediated reform mechanisms to present a roadmap for overcoming this voluntary intoxication caveat. Finally, we discuss the implications of these laws for victims of sexual assault and for the practice of forensic psychiatry in cases of criminal sexual conduct involving victim intoxication.

A Duty to Protect Our Patients from Physician Sexual Misconduct

In this issue of The Journal, MacIntyre and Appel have reviewed state laws and medical boards' policies to ascertain which states require reporting of sexually exploitive psychiatrists, specifically when the patient reveals the exploitation during treatment. They highlight the competing ethics duties faced by physicians who are in a position to report such conduct and provide guidance for future development of reporting laws to help balance the conflicting ethics principles at stake. In this commentary, I discuss the pros and cons of mandatory reporting laws and underscore the importance of physicians' ethics duty to report the sexual misconduct of other physicians even in the absence of a legal mandate. In light of recent high-profile cases that demonstrate a failure of medicine to self-regulate, I make the case for a cultural shift in our profession so that the subject of reporting physician sexual misconduct is viewed not from the lens of a duty to report, but that of a duty to protect.

Pakistan's Blasphemy Laws and the Role of Forensic Psychiatrists

Humans have been persecuted for the crime of blasphemy since biblical times. Today, about one quarter of the world's countries and territories, most of them Muslim-majority nations, still have anti-blasphemy laws. Pakistan is among the countries where blasphemy is punishable by death. In many instances, the accused are killed by mobs before legal proceedings even begin. Often, it is people with mental illness and members of religious minorities who end up being accused of blasphemy. A psychiatric evaluation can be beneficial in informing the court about symptoms of mental illness in the context of a blasphemy accusation. Psychiatrists can also provide crucial information to the courts and the general public about trauma, persecution, and safety in asylum cases where the asylum seeker is fleeing persecution after being accused of blasphemy in Pakistan or another country that criminalizes blasphemy.

Role of Forensic Psychiatry in Legislative Advocacy

Dr. Piel presents a model curriculum for elective legislative advocacy training of general psychiatry residents at the University of Washington. In this commentary, we discuss the role of the physician as a leader in legislative advocacy and emphasize the need for training in this neglected arena. We highlight the common ground between legislative advocacy and forensic psychiatry and make a case for increased involvement of forensic psychiatrists.

Competency to stand trial evaluations in a multicultural population: Associations between psychiatric, demographic, and legal factors

Data were examined from an archival sample of Competency to Stand Trial (CST) reports of 200 consecutive New York City pre-trial defendants evaluated over a five-month period. Approximately a fourth of defendants in the present study were immigrants; many required the assistance of interpreters. The examiners conducting the CST evaluation diagnosed approximately half of the defendants with a primary diagnosis of a psychotic disorder and deemed over half not competent. Examiners reached the same conclusion about competency in 96% of cases, about the presence of a psychotic disorder in 91% of cases, and affective disorder in 85% of cases. No significant differences between psychologists and psychiatrists were found for rates of competency/incompetency opinions. Compared to those deemed competent, defendants deemed not competent had significantly higher rates of prior psychiatric hospitalization and diagnosis of psychotic illness at the time of the CST evaluation but lower rates of reported substance abuse.

The neurocognitive performance of drug-free and medicated euthymic bipolar patients do not differ

OBJECTIVE

Although it is established that euthymic bipolar patients have neurocognitive deficits, the influence of medication on their cognitive performance is uncertain and requires investigation.

METHOD

Neuropsychological tests of executive function, memory and attention were performed on 44 prospectively verified, euthymic bipolar I patients, 22 of whom were drug-free. Residual mood symptom effects were controlled statistically using ancova.

RESULTS

Drug-free and medicated patients differed only in delayed verbal recall (Rey AVLT list A7, drug-free > medicated), and perseverations during the five-point test (drug-free > medicated). When residual mood symptoms were controlled statistically, differences between drug-free and medicated subjects became insignificant. Medication effect sizes were modest. Significant correlations were found between residual depression scores and measures of verbal learning.

CONCLUSION

Medications did not have any significant influence on neurocognitive performance, suggesting that neurocognitive deficits are an integral part of bipolar disorder.

Soft neurological signs do not increase with age in euthymic bipolar subjects

BACKGROUND

Soft neurological signs (SNS) are found to be in excess in bipolar disorder (BD). This paper explores changes in SNS with ageing to ascertain whether BD is associated with a progressive neurological decline or a relatively fixed, persistent deficit.

METHODS

53 euthymic BD subjects and controls, aged 15-55 years, were for examined for the presence of SNS which were rated using a modified Kolakowska battery.

RESULTS

In controls, SNS scores increased slowly and significantly with age whereas in BD subjects high scores occurred throughout the age range and were not age dependent. This confirms and extends an earlier, smaller, study which is reanalysed.

LIMITATIONS

The study design was cross-sectional whereas a longitudinal study would better reveal changes in soft signs with ageing.

CONCLUSIONS

The studies suggest strongly that BD is accompanied by a significant neurobiological deficit which may progress only minimally with increasing age.