Biomedical subjects
Publications and source records attributed to L E Weinberger.
One of the greatest problems of deinstitutionalization has been the very large number of persons with severe mental illness who have entered the criminal justice system instead of the mental health system.
Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of non-offenders. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals.
Mental health consultation is provided to a municipal court that recommends court-mandated interventions for mentally ill persons who have committed minor crimes. This study demonstrates that a significantly better outcome results when the judge not only mandates but monitors mental health treatment.
Mental health conservatorship can play an important role in the clinical management and treatment of persons with severe mental illness.
We examined all completed suicides by children and adolescents in Los Angeles County who died during 1996 and 1997. There were 46 subjects, aged 11 through 16. The majority of the decedents were males and over age 14. The predominant racial group was Hispanic. There was an almost even split between firearms and hanging as the means of death. Females had a statistically significantly higher rate of prior suicide attempts than males. Over one-third left a suicide note, almost one-half were noted to be depressed, and 22% tested positive for alcohol or illicit drugs. Less than one-quarter were in mental health treatment. Eighty-seven percent had difficulty transitioning to or during adolescence; e.g., problems at home, legal and school difficulties, and relationship losses. These findings are discussed in terms of Eriksonian developmental theory. We offer recommendations for intervention and prevention of suicide.
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Self-inflicted contact gunshot wounds to the head have usually been considered presumptive of suicide. This study evaluates whether sufficient psychological data are gathered in such cases to support a manner of death determination of suicide. We suggest that law enforcement agencies and coroner's departments do not fully explore the decedent's state of mind at the time of death. We studied the first 50 consecutive deaths in 1993 in a major metropolitan county due to self-inflicted gunshot wounds to the head. The sample consists primarily of unmarried, white males, with a median age of 35 years, who displayed psychiatric disturbance, primarily depression, before their death. Younger individuals were often under the influence of alcohol and/or drugs at the time of death. Stressors, such as the loss of a loved one, are common among young and middle-aged persons, while serious health problems are found among the majority of middle-aged and elderly individuals. Many of the findings of this study are consistent with the literature regarding individuals who commit suicide. Although data on many important psychological risk factors are missing in most cases, sufficient psychological material is gathered about the decedent's mental condition at the time of death to support a suicide determination.
Risk assessment in the area of identification of violence has been dichotomized by several prominent researchers as the "clinical approach" versus the "actuarial method". The proponents of the actuarial approach argue for actuarially derived decisions to replace existing clinical practice. The actuarial method requires no clinical input, just a translation of the relevant material from the records to calculate the risk score. A risk appraisal approach based upon a sole actuarial method raises several questions: those of public safety, peer-accepted standards of practice, liability issues, and concordance with evidence-based medicine practice. We conclude that the sole actuarial approach fails to satisfy these critical issues.
California's civil commitment statute serves as a model for many other states. A move to update the California law may set national precedent.
OBJECTIVE: Very large numbers of severely mentally ill persons now fall under the jurisdiction of the criminal justice system. A number of conditions are placed on those who are returned to the community, including specific ones related to treatment. This paper reviews the principles and practice of forensic outpatient mental health treatment. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1978, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of nonoffenders, which focuses on alleviation of symptoms. Patients must comply with legal restrictions on their behavior, and treatment first addresses a patient's risk of harm to the community. Mentally ill offenders are often resistant to treatment. The mental health system may be disinclined to treat them due to their resistance and their criminal history, especially a history of violence. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals, a close liaison between treatment staff and the criminal justice system, adequate structure and supervision, treatment staff who are comfortable with using authority, interventions for managing violence, incorporation of the principles of case management, appropriate and supportive living arrangements, and a recognition of the role of family members and significant others in treatment.
OBJECTIVE: The presence of severely mentally ill persons in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1970, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Clinical studies suggest that 6 to 15 percent of persons in city and county jails and 10 to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and chronic mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of mentally ill persons are arrested compared with the general population. Factors cited as causes of mentally ill persons' being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of mentally ill persons who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.
Mental health clinicians are increasingly held civilly liable for the dangerous acts of their psychiatric patients. One area of liability is the negligent release of involuntarily committed patients who engage in dangerous acts after their hospital discharge. All states have provisions for extended involuntary commitment for mentally ill dangerous patients. We examined extended civil commitment petitions in Los Angeles County, California, and found that the great majority were rejected. While the standard for extended civil commitment in California includes verbal threats of substantial physical harm, deputy district attorneys tended to reject petitions initiated by clinicians when verbal threats were the sole criterion of dangerousness. This tendency by deputy district attorneys can be quite confusing for clinicians. Mental health professionals' liability has sensitized them to the legal implications of patients' verbal threats of harm; attorneys do not incur the same legal liability and are not so sensitized.
When searching for new leads, testing molecules that are too "similar" is wasteful, but when investigating a lead, testing molecules that are "similar" to the lead is efficient. Two questions then arise. Which are the molecular descriptors that should be "similar"? How much "similarity" is enough? These questions are answered by demonstrating that, if a molecular descriptor is to be a valid and useful measure of "similarity" in drug discovery, a plot of differences in its values vs differences in biological activities for a set of related molecules will exhibit a characteristic trapezoidal distribution enhancement, revealing a "neighborhood behavior" for the descriptor. Applying this finding to 20 datasets allows 11 molecular diversity descriptors to be ranked by their validity for compound library design. In order of increasing frequency of usefulness, these are random numbers = log P = MR = strain energy < connectivity indices < 2D fingerprints (whole molecule) = atom pairs = autocorrelation indices < steric CoMFA fields = 2D fingerprints (side chain only) = H-bonding CoMFA fields.
OBJECTIVE: The authors examined the outcomes of mental health consultation provided to a municipal court and the court's resulting interventions for mentally ill persons who committed minor crimes. One aim of the consultation program was to avoid criminalization of mentally ill people who committed minor offenses. METHODS: Clinical and forensic records of 96 persons charged with misdemeanors and referred to a clinical psychologist court consultant for evaluation were studied. Determination of good versus poor outcome during a one-year follow-up period was based on clients' status during the year after the court's disposition. Poor outcome was defined as the occurrence of one or more of four events during the follow-up year: psychiatric hospitalization, arrest, significant physical violence against persons, and homelessness. RESULTS: Fifty-six defendants (58 percent) were mandated to receive judicially monitored mental health treatment, as recommended by the psychologist court consultant, and 33 of them (59 percent) had a good one-year outcome. The relationship was statistically significant. CONCLUSIONS: Nonclinicians in the criminal justice system should have psychiatric assistance in making appropriate dispositions for mentally ill persons. If the judge is considering mental health treatment as a condition for eliminating or reducing punishment, then, to the extent justified by the law and the nature of the offense, the judge should both mandate and monitor the treatment on an ongoing basis.
Historically, the use of the insanity defense has been limited although not exclusively to those with a psychotic mental disorder at the time of the crime. Occasionally, an insanity acquittee may primarily suffer from a personality disorder at the time of commitment to the psychiatric hospital. Such examples can include someone with a personality disorder who malingers psychosis and legal insanity or who at the time of the crime may have been suffering from a drug-induced or brief reactive psychosis. One such case will be presented as well as dilemmas created for the clinician and forensic evaluator. In addition, pertinent medical and psychological literature and legal case precedents will be discussed. Finally, a proposed guideline for the treatment and evaluation of the personality-disordered insanity acquittee will be offered, focusing specifically on the aspects of the personality disorder that contribute to the individual's dangerousness.
In California conservatorship is a legal mechanism that allows an individual or agency (the conservator) to act on behalf of a gravely disabled mentally ill person (the conservatee) to determine what arrangements are necessary to provide adequate food, clothing, shelter, and treatment, including hospitalization when indicated. Conservatorship can play an important role in clinical management and treatment, particularly if the gravely disabled person does not have close family involvement and support, as case histories indicate. The benefits of conservatorship can be greatly enhanced by combining it with case management. When family members are appointed as conservators, skilled clinical staff can help them use the leverage of conservatorship therapeutically. By giving up some of their freedom, many conservatees who would ordinarily need to be hospitalized for long periods are able to retain most of their independence and their community status.
OBJECTIVE: The authors examined the conservatorship process in California by studying a group of psychiatric patients for whom conservatorship was sought; their goal was to determine its effectiveness both during and after the period of conservatorship. METHOD: The subjects were 60 county psychiatric hospital inpatients 18-60 years old for whom temporary (30-day) conservatorships were obtained and who were followed for 4 years. The patients' courses over the 4 years were assessed in terms of whether 1-year conservatorships were obtained, stability (number and length of psychiatric hospitalizations, arrests, serious physical violence, and homelessness), and presence or absence of family support. RESULTS: The patients proved to be a severely mentally ill and disabled group. Thirty-five (58%) were granted a 1-year conservatorship sometime during the 4-year study period, and 25 (42%) were not. Both family support and conservatorship appeared to be related to the patients' stability. When one or both were present, there was a significantly greater likelihood of stability. CONCLUSIONS: The authors believe that for a considerable number of chronically and severely mentally ill individuals, conservatorship would play an important role in their clinical management and treatment by helping to eliminate their chaotic life styles, their cycle of admission and discharge from hospitals and jails, and/or their living on the streets, particularly when family support is absent.
The authors offer psychotherapists a proposed exception to strict acquired immune deficiency syndrome (AIDS)-related confidentiality laws. The proposal is based on previously established exceptions to the psychotherapist-patient privilege. The recommended breach of confidentiality applies only to cases that meet all of the following criteria: (1) A patient knows that he or she has a human immunodeficiency virus (HIV) positive blood test and has been informed of AIDS-related safety precautions, (2) the HIV-positive patient has a mental disorder, and (3) it is reasonable to believe that the mental disorder has significantly impaired or may significantly impair the patient's ability and behavior to follow AIDS-related safety precautions.