Forensic psychiatry Core features and implementations in General

Forensic psychiatry Core features and implementations in General Medicine and Psychiatric practice Vesselin Tenev, MD Psychiatry Resident vesselin-tenev@uiowa. edu 1

Outline • Privilege & confidentiality • Civil commitment • Competency • Insanity defense 2

Privilege & Confidentiality • Confidentiality – patient-doctor communication Jaffe vs Redmon, 1996 included psychotherapist – patient communication. • Privilege – right to maintain confidentiality even when subpoenaed – Exempt: • Federal/military issues • Patient admits to mental health issues • Court commitment hearings for psychiatric tx • 3 rd party payers & supervision • Child abuse – DHS – 1 800 362 2178 3

Tarasoff I & II • 1976 -Tarasoff v Regents of University of California I – “Duty to warn” - physician/psychotherapist must warn potential victims of threats – intended homicide, not fantasies. • 1982 - Tarasoff v Regents of University of California II – “Duty to protect” - contact police & ensure safety The harm needs to be imminent, serious or severe. 4

Outline √ Privilege & confidentiality • Civil commitment • Competency • Insanity defense 5

Civil Commitment • Coercive tx for patients who are: “mentally impaired” or a “chronic substance abuser” • Always a conflict between rights of the person & safety of society 6

Mental Impairment 1. Mental illness documented & defined by a physician 2. Patient lacks insight and/or decision making ability 3. Dangerousness *All the above have to be present to be mentally impaired 7

48 -Hour Hold For Mental Health Evaluation • Petition filed at county court office – By two concerned citizens in one’s own county – Health a care provider (at UIHC filed on line by social worker and physician) • Legal decision made only by a judge or magistrate • Police acquire patient for a medical evaluation • Patient is legally held in hospital for psych evaluation 8

Civil Commitment • Psychiatric exam done within 24 hours • Hearing held 3 -5 days (excluding holidays) • Judge evaluates psychiatrists recommendations & then makes legal decision • Substance abuse terminates in 30 day • Mental health – indefinite, but requires periodic reports to the court 9

Case #1 • Mr. Smith was brought to the ER in the winter with overt psychosis. He was found wandering the streets and shouting at trash cans, exhibiting threatening behavior. He was admitted on a 48 -hr hold and demanded to leave the next day. • Differential diagnosis of psychosis: - intoxication, delirium - acute paranoid psychosis - exacerbation of chronic psychosis 10

Assessment n UDS / history n Course of psychosis n Lack/presence of a long-standing addiction n Lack/presence of a General medical condition n history of psychiatric disorder n Illness Behavior – compliance with treatment 11

Consequences of Breaking Confidentiality • Negative transference • Could be accused of financial incentives for hospitalizing patient • However, most frequent malpractice claims against psychiatrists are for not preventing suicide or suicide attempts 12

Outline √ Privilege & confidentiality √ Civil commitment • Competency • Insanity defense 13

Competency vs Capacity • Competency is a legal term – determined by a judge • Capacity to consent for treatment, stand trial, or make a will is evaluated by a psychiatrist/psychologist 14

Capacity to Consent • In your medical judgment does the patient: 1. Understand the treatment process 2. The side effects of the treatment 3. What will happen if he doesn’t accept tx 15

Informed consent • Diagnosis – description of the condition or the problem • Treatment – nature and purpose of the proposed treatment • Consequences – risks and benefits of the proposed treatment • Alternatives – viable alternatives to the proposed treatment, including risks and benefits • Prognosis – projected outcome with or without treatment. 16

Capacity to Stand Trial • Patient understands the legal process (what is the function of his lawyer, the judge, the jury etc. ) and the charges against him, as well as the penalties • His mental status is such he can assist his lawyer in his defense 17

Capacity to Write a Will • Know the extent and nature of their assets • Know they are making a bequest • Know the identities of natural beneficiaries 18

Case #2 • Nephew said his 85 year old aunt had Alzheimer’s disease and isn’t competent to write a will and since he is the primary heir feels that her estate should be his when she dies • Upon interview with the Aunt, she was found to have short term memory impairment and not oriented to time, but knew generally how much money and land she had, and wanted to give most to her church 19

Assessment • It was known she did not like nephew and that she had planned to give money to church for years • Psychiatrist suggested she had capacity to make that decision • Differential diagnostic thinking: - Neurocognitive Disorders - Major and Mild Neurocognitive Disorder (DSM 5), Dementia, Amnestic disorder, Cognitive disorder – all chronic course - Delirium – including due to a general medical condition. Acute changes. 20

Durable Power of Attorney / Guardianship • DPOA – making provisions before loss of decision making capacity • Guardianship – another person makes medical decisions regardless of decision making capacity 21

Outline √ Privilege & confidentiality √ Civil commitment √ Competency • Insanity defense 22

Insanity Defense Definition of Insanity Early Thinking • Marcus Aurelius Madness is its own sole punishment • Shakespeare’s Hamlet “If I wrong someone when not myself, then Hamlet does it not, Hamlet denies it. Who does it then? His madness. ” 23

Insanity Defense Historic timeline I • 1278 First NGRI, Hugh de Misyn killed his daughter. King Edward “Hugh hanged his daughter whilst suffering from madness, and not by felony or of malice aforethought. ” Released to the custody of 12 men who pledged to keep him under control. • 1307 King Edward II – A person is insane if their mental ability is no greater than a “wild beast” • 1581 Difference between “good or evil” rule • 1838 Isaac Ray published “ A treatise of medical jurisprudence” 24

Insanity Defense Historic timeline II • 1581 - English law recognized – insanity as possibly allowing criminal defendants to not be responsible for their crimes • 1843 - Daniel M’Naughten shot & killed secretary to the prime minister of England due to delusions. He was initially acquitted because many thought he was insane. Queen Victoria was not happy – judges deliberated and came up with a new rule. 25

M’Naghten Rule • A defendant shall not be held responsible for their actions if as a result of their mental illness they could not tell their actions were wrong when they committed them • Standard adopted by the UK & US for nearly 100 yrs 26

Irresistible Impulse & Durham Rule • 1922 – a person isn’t responsible for their crime if unable to resist due to mental illness (policeman at the elbow test) • 1953 – Monte Durham was a 17 YO who knew the difference between right & wrong, but couldn’t resist committing a crime • Eventually rejected by federal courts as too broad, but still used by ½ of US state courts 27

American Law Institute Standard n n 1972 - not criminally responsible if “as result of the mental illness (s)he lacks substantial capacity either to appreciate criminality of his/her conduct or to conform his/her conduct to the requirements of the law” 1982 - “clear and convincing evidence, " that a mental illness exists 28

Case #3 • John Hinkley wanted to impress Jodi Foster w/ assassination attempt of Reagan in Washington, DC • Assessment: American Law Institute Standard enforced • Not guilty by reason of insanity (NGRI) • Resides indefinitely at St. Elizabeth’s Hospital in DC 29

Guilty but Mentally Ill 4 outcomes possible under an insanity plea: • Not guilty by reasons of insanity (NGRI) • Guilty, but mentally ill • Guilty 30

Guilty but Mentally Ill - 2 • Legally guilty but mentally ill is a newer type of ruling • Receive mental health treatment while institutionalized • When well, serve out their prison term (Competence to stand trial and serve a sentence is implied). 31

Case #4 • Mark Becker – killed HS Football Coach in Iowa due to delusions that the coach was the devil and turned others into “dead people” • Suffered with schizophrenia & not taking his medications 32

Assessment • Guilty of 1 st degree murder, attempted murder and child endangerment • M’Naghten rule enforced in Iowa 33

Outline √ Privilege & confidentiality - When can patient-doctor communication be shared? √ Civil commitment - What 3 aspects are necessary to commit someone for mental health treatment? √ Competency - Can a psychiatrist determine competency? √ Insanity defense - What exemptions are there to the insanity defense? 34