Paul P. Christopher

Arrest Types and Co-occurring Disorders in Persons with Schizophrenia or Related Psychoses

This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.

Prevalence of Involvement in the Criminal Justice System During Severe Mania and Associated Symptomatology

OBJECTIVE This study sought to determine the prevalence of criminal justice involvement during episodes of mania and to identify whether specific manic symptoms contribute to this risk. METHODS Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of noninstitutionalized U.S. adults (N=43,093), were analyzed to determine the rate of legal involvement (being arrested, held at the police station, or jailed) of individuals with bipolar I disorder during the most severe lifetime manic episode. RESULTS Among the 1,044 respondents (2.5%) who met criteria for having experienced a manic episode, 13.0% reported legal involvement during the most severe manic episode. Unadjusted analyses found legal involvement more likely among those with episode-specific symptoms of increased self-esteem or grandiosity, increased libido, excessive engagement in pleasurable activities with a high risk of painful consequences, having six or more criterion B manic symptoms, and having both social and occupational impairment. The risk was lower among those with hypertalkativeness or pressured speech. When analyses adjusted for other manic symptoms and static variables, males, those with a first episode at age 23 or younger, and persons with mania-associated social indiscretions, excessive spending or reckless driving, and both social and occupational impairment were at greater risk. CONCLUSIONS A large percentage of persons experience legal involvement during a manic episode, and it is associated with specific symptoms of mania. Efforts to reduce such involvement among persons during manic episodes may be enhanced by focusing attention and resources on this high-risk group.

Participants’ Perceptions of Deep Brain Stimulation Research for Treatment-Resistant Depression: Risks, Benefits, and Therapeutic Misconception

Background: Deep brain stimulation (DBS) for treatment-resistant depression (TRD) is the focus of great interest and numerous studies. Given the state of this research, the risks of DBS, the uncertainty of direct benefits, and the potential for therapeutic misconception (TM), examination of research participants’ perspectives is critical to addressing concerns about the adequacy of consent among people with TRD. Methods: Among 31 participants considering DBS studies at two sites, self-report questionnaires were used to examine three dimensions of TM (eight true/false items). Additional Likert-scale items assessed perceptions of risks, potential benefits, and altruistic motivations. Results: Participants correctly identified the surgery itself as the riskiest study procedure, although only four participants rated the surgery as “high risk.” Most participants rated the entire DBS study as “moderate” or lower risk. Participants rated the likelihood of others benefiting in the future more strongly than they did the likelihood of personal benefit. Participants held positive attitudes toward research, and were moderately altruistic. Nearly two-thirds of the 31 participants (64.5%) answered at least one of the true/false TM items incorrectly. Conclusions: Individuals considering DBS studies for TRD demonstrated reasonable perceptions of risks and benefits, distinguished among procedural risks, and expressed hopes for personal benefit as well as altruism. Findings related to TM were mixed: Participants understood the experimental stage of DBS for depression and endorsed the possibility of no personal benefit, yet there was some evidence for TM. Although these findings are reassuring, investigators must nevertheless remain vigilant about identifying and addressing potential misconceptions.

Predictors of criminal justice involvement in severe mania

BACKGROUND Criminal justice problems among those with bipolar disorder lead to disruption in social functioning, treatment, and recovery. Understanding factors that contribute to arrest during episodes of illness can help inform approaches to risk management and improve clinical care. METHODS Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey conducted in two waves were used to identify factors that predicted inter-wave criminal justice involvement during bipolar I manic episodes. RESULTS Over 10% of respondents experienced legal involvement during their most severe manic episode. Risk was found in a range of historical, clinical, and contextual factors. Multivariate analyses suggest risk is particularly high for those who are unemployed, non-white, have past juvenile detention, have a prior arrest (while using substances or when manic), used an illicit drug in the past year, and whose mania is characterized by both social and occupational impairment. Legal problems were particularly elevated among those who lacked health insurance while experiencing both social and occupational impairment. LIMITATIONS Respondents did not include prisoners and hospital inpatients; criminal justice problems were only assessed with regard to the most severe manic episode. CONCLUSIONS The particular array of factors that elevate the risk of legal involvement during manic episodes offers guidance when identifying prevention strategies and evaluating patients in clinical and forensic settings. Reducing such involvement will require that these issues be dealt with in the broader context of mental health and other services, which in turn necessitates providing adequate access to healthcare.

An Empirical Ethics Agenda for Psychiatric Research Involving Prisoners

In the past 30 years, the incarcerated population in the United States has more than quadrupled to 2.3 million adults. With an alarmingly high prevalence of mental illness, substance use, and other serious health conditions compounding their curtailed autonomy, prisoners constitute perhaps the nations most disadvantaged group. Scientifically rigorous research involving prisoners holds the potential to inform and enlighten correctional policy and to improve their treatment. At the same time, prisoner research presents significant ethical challenges to investigators and institutional review boards (IRBs) alike, by subjecting participants to conditions that potentially undermine the validity of their informed consent. In 2006, the Institute of Medicine Committee on Ethical Considerations for Revisions to the Department of Health and Human Services (DHHS) Regulations for Protection of Prisoners Involved in Research recommended both further protections and a more permissive approach to research review that would allow inmates greater access to potentially beneficial research. These recommendations have sparked renewed debate about the ethical trade-offs inherent to prisoner research. In this article, the authors review the major justifications for research with prisoner subjects and the associated ethical concerns, and argue that the field of empirical ethics has much to offer to the debate. They then propose a framework for prioritizing future empirical ethics inquiry on this understudied topic.

Psychiatric Residents’ Experience Conducting Disability Evaluations

ObjectiveThe increasing frequency and societal cost of psychiatric disability underscore the need for accuracy in evaluating patients who seek disability benefits. The authors investigated senior psychiatric residents’ experiences performing disability evaluations, their self-assessment of competence for this task, and whether they perceived a need for more training.MethodsSeventy-nine third- and fourth-year psychiatric residents in Massachusetts and Rhode Island training programs were surveyed from May to June in 2008. Participants were asked about the frequency of requests and completion of disability evaluations, the practice patterns followed when performing evaluations, the identification of role and potential conflict of interest in doing evaluations, and their sense of preparedness and need for more training.ResultsResidents reported having limited experience performing disability evaluations and followed a variety of practice patterns when performing evaluations. They reported having a limited understanding of what constitutes psychiatric disability and a lack of confidence in their ability to perform evaluations accurately. A significant minority had identified patients as disabled despite believing otherwise. A majority of residents reported receiving no didactics on psychiatric disability and desired more training.ConclusionResidents may be unprepared to perform disability evaluations. Residency programs may need to provide additional training.

SYMPTOM AND FUNCTIONAL TRAITS OF BRIEF MAJOR DEPRESSIVE EPISODES AND DISCRIMINATION OF BEREAVEMENT.

Despite the removal of the bereavement exclusion from DSM‐5, clinicians may feel uncertain on how to proceed when caring for a patient who presents with depressive symptoms following the death of someone close. The ability to better distinguish, on a symptom and functional level, between patients who experience depression in the context of bereavement and those with nonbereavement‐related depression, could help guide clinical decision making.

Reducing therapeutic misconception: A randomized intervention trial in hypothetical clinical trials

Background Participants in clinical trials frequently fail to appreciate key differences between research and clinical care. This phenomenon, known as therapeutic misconception, undermines informed consent to clinical research, but to date there have been no effective interventions to reduce it and concerns have been expressed that to do so might impede recruitment. We determined whether a scientific reframing intervention reduces therapeutic misconception without significantly reducing willingness to participate in hypothetical clinical trials. Methods This prospective randomized trial was conducted from 2015 to 2016 to test the efficacy of an informed consent intervention based on scientific reframing compared to a traditional informed consent procedure (control) in reducing therapeutic misconception among patients considering enrollment in hypothetical clinical trials modeled on real-world studies for one of five disease categories. Patients with diabetes mellitus, hypertension, coronary artery disease, head/neck cancer, breast cancer, and major depression were recruited from medical clinics and a clinical research volunteer database. The primary outcomes were therapeutic misconception, as measured by a validated, ten-item Therapeutic Misconception Scale (range = 10–50), and willingness to participate in the clinical trial. Results 154 participants completed the study (age range, 23–87 years; 92.3% white, 56.5% female); 74 (48.1%) had been randomized to receive the experimental intervention. Therapeutic misconception was significantly lower (p = 0.004) in the scientific reframing group (26.4, 95% CI [23.7 to 29.1] compared to the control group (30.9, 95% CI [28.4 to 33.5], and remained so after controlling for education (p = 0.017). Willingness to participate in the hypothetical trial was not significantly different (p = 0.603) between intervention (52.1%, 95% CI [40.2% to 62.4%]) and control (56.3%, 95% CI [45.3% to 66.6%] groups. Conclusions An enhanced educational intervention augmenting traditional informed consent led to a meaningful reduction in therapeutic misconception without a statistically significant change in willingness to enroll in hypothetical clinical trials. Additional study of this intervention is required in real-world clinical trials.

Enrolling in Clinical Research While Incarcerated: What Influences Participants’ Decisions?

As a 2006 Institute of Medicine report highlights, surprisingly little empirical attention has been paid to how prisoners arrive at decisions to participate in modern research. With our study, we aimed to fill this gap by identifying a more comprehensive range of factors as reported by prisoners themselves during semistructured interviews. Our participants described a diverse range of motives, both favoring and opposing their eventual decision to join. Many are well-recognized considerations among nonincarcerated clinical research participants, including a desire for various forms of personal benefit, altruism, and concern about study risks and inconveniences. However, a number of influences seem unique to prisoners. Participants did not report that they were not coerced into enrolling, and they have even been under pressure not to enroll. However, many sought to enroll in order to obtain access to better health care, raising a concern about whether they were unfairly exploited.

Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work?

Many states are turning to civil commitment for substance use disorders as a potential solution to address rising rates of overdose deaths. Civil commitment allows family members or others to seek court-ordered involuntary treatment for a substance-abusing person. In contrast to mandatory treatment ordered by drug courts, civil commitment does not require involvement with the criminal justice system. Although these laws are understandably appealing, statutes and their implementation are highly variable, ethical concerns about deprivation of liberty continue to be raised, and outcome data are limited and often not generalizable. Above all, more studies are needed to determine effectiveness.