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Individuals with intellectual and developmental disabilities (IDD) are at high risk of co-occurring mental health conditions, including major depressive disorder, bipolar disorder, anxiety disorders, psychotic illnesses, impulse control disorders, and others. Because of symptoms associated with these illnesses and with the disabilities themselves, these individuals are often served in a mental health service system framework. However, treatment for them in these settings has typically not been sufficiently nimble, knowledgeable, or adept. Most mental health professionals receive little training about the needs of this population, and system structures typically bifurcate care, when, in reality, conditions can be complex and overlapping. In this first of two articles on care for persons with IDD in the mental health system, the authors provide a clinical overview of these neurodevelopmental disorders and of mental health and other conditions that co-occur with IDD. Considerations and challenges for treating this population in the mental health system include early recognition of mental health conditions, which often requires caregiver and family input, as well as information from a variety of additional collateral sources; the importance of trauma-informed and person-centered care; the promotion of self-determination through use of decision supports; use of approaches such as applied behavior analysis to develop a frame to address challenging behaviors; and the need to properly assess and provide thoughtful pharmacologic intervention when appropriate. The ability of individuals with IDD to thrive in a wide range of community integration opportunities depends on many factors, and clinicians must understand and use the available approaches for treating them.

Individuals with intellectual and developmental disabilities (IDD) are at high risk of co-occurring mental health conditions, including major depressive disorder, bipolar disorder, psychotic disorders, anxiety disorders, impulse control disorders, and others. Because of symptoms associated with these illnesses and with the disabilities themselves, these individuals are often served in a mental health service system framework. In this second of two articles on care for persons with IDD in the mental health system, the authors focus on policy and systems considerations to assist practitioners and administrators to provide high-quality mental health services for these individuals by recognizing existing infrastructures of support. The authors describe historical factors, including legislation and case law, that have led to greater inclusion of persons with IDD in mainstream settings; systemic barriers to integrating services for persons with IDD and Medicaid waivers and provisions of the Affordable Care Act designed to overcome such barriers; and considerations for treating persons with IDD in various settings, such as emergency departments and forensic settings. They propose approaches to developing the workforce, such as by training direct service professionals and utilizing the services of board-certified behavioral analysts. A robust continuum of care and service delivery system that is increasingly sophisticated in working with persons with IDD, with and without co-occurring mental illness, is critical to maximize the autonomy and community inclusion of these individuals.

While perceptions of voluntary consent have been studied among participants in Mental Health Courts (MHC), little is known about coercion among participants in Drug Treatment Courts (DTC), the most common type of specialty court. The purpose of the present study was to examine perceptions of coercion at enrollment among participants (N = 85) in two Massachusetts DTCs. Results indicated that, on average, participants reported low levels of perceived coercion (M = 1.67, SD = 1.23), which suggests that most individuals did not perceive their decision to enroll in DTC to be coercive. However, further research is needed to delineate whether clinical or procedural variations exist within DTCs, if levels of perceived coercion predict DTC participant outcomes, and if subpopulations experience higher or lower levels of coercion.

Mental Health Courts (MHCs), an alternative to incarceration, aim to address behavioral health, social needs, and criminal recidivism and serve many adults with co-occurring mental health and substance use disorder (COD). Despite the growth in MHCs, little research has examined ethnic/racial differences in behavioral health and service needs of individuals with COD. This study used data from behavioral health and social assessments administered to 146 adults with COD entering a Massachusetts MHC. Multivariate linear and logistic regression controlling for key demographics tested differences between racial/ethnic groups on current and lifetime substance use, mental health symptoms, and history of criminal legal system involvement. Hispanic participants were more likely than non-Hispanic White participants to report current and lifetime serious mental illness and lifetime Emergency Department (ED) mental health treatment. Non-Hispanic White participants were more likely to report current and lifetime use of illicit substances, more recent outpatient and overall lifetime treatment attempts for substance use, and higher number of lifetime arrests compared to non-Hispanic Black participants. Lastly, non-Hispanic White participants also reported more recent outpatient and overall lifetime treatment attempts for substance use compared to Hispanic participants. Racial/ethnic differences in behavioral health and social needs of MHC enrollees with COD exist and should be considered in the planning and delivery of psychological and social services. Understanding the diverse population of new MHC enrollees is an important first step in identifying and addressing racial and ethnic disparities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

PurposeMany individuals in drug treatment courts (DTCs) have co-occurring mental health and substance use disorders (COD), which can negatively impact treatment engagement, behavioral health and criminal justice outcomes. This paper aims to report results of DTC participants with a COD, who received a 12-month wraparound treatment intervention called MISSION-Criminal Justice (MISSION-CJ) alongside DTC to improve treatment engagement and behavioral health outcomes and reduce reincarcerations.Design/methodology/approachIn this pre-post, single-group pilot, 48 clients enrolled and 81% completed 12-month follow-up assessments (N = 39) and weekly MISSION-CJ fidelity for type and intensity of services delivered. Generalized linear mixed models (GLMMs) were computed with a fixed term for fidelity (e.g. high or low MISSION-CJ), time and a fidelity x time interaction term.FindingsAmong participants, at 12 months, 81% of the participants remained engaged in treatment at study completion, and 89% had high MISSON-CJ fidelity. Clients demonstrated significant reductions from baseline to 12 months in average nights in jail (B = −0.1849511, p < 0.0344), mental health symptoms via the Behavior and Symptom Identification Scale (BASIS) total and subscale scores (B = −0.121613,p< 0.0186) and trauma symptoms on the PTSD Checklist-5 (PCL-5) (B = −0.928791, p < 0.0138). High MISSION-CJ fidelity further improved criminal justice, and behavioral health outcomes.Originality/valueThis was the first reported 12-month MISSION-CJ trial. While feasible to implement, given the design limitations, future research should include a large randomized controlled trial.

The global experience of the COVID-19 pandemic is unprecedented. The magnitude, pace, and uncertainty of the pandemic have taxed systems and catalyzed innovation in many fields, including behavioral health. Behavioral health leaders have absorbed changing information about regulations and laws, proper use of personal protective equipment, isolation and quarantine, telepsychiatry practices (broadly defined here as the use of virtual and telephonic means to provide behavioral health care), and financial opportunities and challenges while attending to the mental health needs of local populations. This Open Forum reviews many of the adaptations of the behavioral health system in response to COVID-19 on the basis of a point-in-time snapshot and describes needed multidimensional policy and practice considerations for the future.

Many mental health and justice professionals have noted that the system that manages both competence to stand trial (CST) evaluation and competence restoration (CR) processes in criminal cases is in crisis. Public mental health services often are inundated with court referrals and are challenged to address them in a timely manner, resulting in waits for competence-related services for people in jail as well as substantial risks to criminal defendants for whom competence issues are raised. In this review, the authors describe the current CST-CR system and offer preliminary solutions to its challenges. In addition, they examine published works on the legal foundation of CST to help support the basis for this analysis. The results of this review point to the need to more effectively address the complexities of the CST-CR systems and highlight the importance of collaboration across legal and clinical systems. Guidance to states can be best facilitated by support for empirical research on the individual- and system-level factors that contribute to the waitlists and system paralysis that have a negative impact on people with serious mental illness in the criminal justice system.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

Since the Tarasoff case of 1976, mental health professionals are recognized to have a "duty to protect" third-party targets from violence-threatening patients, but little is known about what happens after clinicians warn law enforcement. In 2000, Huber et al. published a study that surveyed Michigan police about "Tarasoff warnings." We conducted a 20-year follow-up study, inviting all Michigan police and sheriff departments to participate. There were no significant differences between studies about knowledge of Tarasoff-related policies, which was low in both surveys. We found significant decreases in the number of officers who had ever intervened due to warning calls. Of the survey respondents, 83% supported documenting warning calls. For those who received warnings, 96% followed up with at least one intervention. In both studies, notifying other officers was the most common action taken. 56% said they would take action to remove a firearm. We identified opportunities for training law enforcement.

Competency to stand trial policies and processes vary significantly across jurisdictions, and, increasingly, state policymakers are looking for ways to improve their efficiency, equity, and effectiveness. This commentary describes the importance of certain data, including the number of evaluations ordered, to inform state policymaking, drawing on the strategies highlighted in a recently released guide for policymakers

Mental health courts provide an alternative to incarceration and address both mental health and criminal justice needs. Many individuals within these treatment courts also have co-occurring substance use disorders. This pilot study examined the preliminary effectiveness of Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice (MISSION-CJ), an intervention that targets co-occurring disorders and criminal justice risk factors within a mental health court.Participants (N=97) were enrolled in mental health court and MISSION-CJ community wraparound services.Participants were primarily male with an average age of 34, had spent an average of more than 5 years incarcerated, and had an average of 13.94 years of illegal drug use; 91% had experienced depression. Preliminary 6-month outcomes showed significant reduction in nights incarcerated (p0.002), illegal drug use (p0.003), trauma symptoms (p0.004), and behavioral health symptoms (p0.006).Preliminary findings suggest promise for delivery of MISSION-CJ to participants in a mental health court.

Objective: Despite the growing research on the effectiveness of specialty courts, including drug treatment courts (DTCs) and veterans treatment courts (VTCs), little is known about the unique treat...

(Reprinted with permission from APA Resource Document, June 2018)

This chapter examines violence risk assessments of sex offenders. The impact of a clinician providing an assessment of an individual's risk of violence, just like assessment of risk of sexual re-offending, can be great, influencing determinations that may result in loss of liberty and even death. Overlap often exists between the need to assess risk factors related to harmful sexual behaviors and the need to assess risk of future violence. As the two lines of research in sex offender risk assessment and violence risk assessment continue to expand, clinicians in the position of assessing risk among sex offenders will also need to maintain an awareness of the literature related to general violence risk assessment. The chapter reviews research and current knowledge related to general violence risk assessment and its overlap with mental illness, and delineates approaches to violence risk assessments based on current understanding of risk factors.

The sequential intercept model (SIM) is used to reduce the penetration of persons with mental illness and substance use disorders in the criminal legal system. Its framework recommends identifying individuals with mental illness at various decision points of criminal case processing, from arrest to return from incarceration, so that they can be diverted toward treatment rather than permeate deeper into the criminal justice system. Communities frequently use the model to augment and inform jail diversion services. Despite the model's widespread adoption, individuals with serious mental illness, intellectual and developmental disabilities, and disorders affecting neurocognition and behavior are often found ineligible for such diversion because their competence to stand trial (CST) warrants evaluation, which effectively pauses their criminal case processes. If found incompetent to stand trial, these people can be ordered for competence restoration treatment, creating a pathway that is different from jail diversion options. Traditional community mental health services and courts await resolution by the "forensic system" before linking these individuals to needed services, and often these linkages are lacking. This review aims to describe and demystify these forensic processes and to highlight the potential use of the SIM to decrease jail stays and maximize community service connections for individuals with some of the most impairing mental health conditions who are involved in the justice system and for whom diversion is a safe option. The authors offer specific examples of intercept opportunities at each step involved in evaluations of CST and in the competence restoration processes.

The general public often looks to mental health professionals to predict or somehow stop acts of gun violence, especially after highly publicized mass shootings. What is often less sought by the public, but no less critical, is the role of mental health professionals in examining risk of suicide related to firearms. Therefore, it is important for mental health professionals to understand the current data about firearms as they relate to violence against others, suicide, and mental illness, as well as the associated clinical implications. Understanding the general public's conceptions related to gun violence and mental illness, as well as the background and current developments of these important issues, will aid the mental health professional on legal and clinical matters, including variations of legislation related to guns and mental illness, gun violence–restraining orders, firearm-related clinical conversations, and risk assessments. [ Psychiatr Ann. 2018;48(9):416–420.]

Little research has focused on systematically integrating clinical treatment within existing drug court procedures. This could be particularly useful for clients with substance use disorders, who comprise those on court dockets and often have co-existing mental health issues. This article reports on the preliminary outcomes of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use wraparound intervention, within two Massachusetts drug courts. In this open pilot, clients completed intake and 6-month follow-up assessments. The participants were primarily Caucasian (86%), male (82%), had at least 2 prior arrests, and received outpatient treatment for mental health (54%), alcohol use (51%), or drug use (88%) prior to enrolling in MISSION-CJ. Six-month follow-up data suggested that participants showed statistically significant reductions in average number of nights spent in jail, alcohol use, and drug use, as well as an increase in full time employment.

In March 2015, a co-pilot flying Germanwings Flight 9525 deliberately pointed his airplane into a descent, killing himself, five other crew members, and 144 passengers. Subsequent investigation and review teams examined the incident and considered potential lessons to maximize air safety. In this article, aviation industry clinical leaders, including the U.S. Federal Air Surgeon and Chief Psychiatrist from the Federal Aviation Administration (FAA), along with a professional pilot and collaborating forensic psychiatrists, discuss suicide-by-plane, evolving themes related to public safety responsibilities for psychiatrists treating pilots, and forensic trends in pilot evaluation for medical certification from an aerospace psychiatric perspective. We explore how psychiatric aspects of pilot fitness and aviation safety are examined across perspectives, including unsafe acts, preconditions, organizational factors, and unsafe supervision. We explore practices for civilian pilots and offer information related to military pilot fitness. Lessons from Germanwings are presented, as is the need for increased support for pilots who might be concerned about revealing mental health challenges for fear of loss of medical certification and pilot employment. The Air Line Pilots Association Pilot Assistance Network is highlighted as one example of pilots supporting pilots to increase airway safety.

Veterans treatment courts (VTCs) have expanded dramatically despite their limited empirical base. This pilot study examined MISSION-Criminal Justice (CJ), a co-occurring disorders wraparound intervention, delivered alongside two VTCs. Baseline data from 26 male veterans enrolled in two VTCs and MISSION-CJ, and 6-month follow-up data for 18 of the 26 veterans, are presented. Veterans on average were 37.5 years old, 85% Caucasian, had significant histories of criminal justice involvement (14.3 lifetime arrests), had an average of 14.7 years of alcohol use and 9.3 years of illicit drug use, and roughly three-quarters reported mental health symptomatology. At 6-month follow-up, veterans demonstrated improvements in behavioral health, substance use, and criminal justice outcomes. This study demonstrated promising preliminary outcomes of MISSION-CJ in VTCs. A randomized controlled trial is a critical next step to examine whether these outcomes remain consistent with a more rigorous design.

Gun violence and mental illness is a major area of media attention, especially because highly publicized mass shootings seem to have become more commonly reported in the press. Gun access also is undergoing a highly politicized debate in the United States. It is important for mental health practitioners to understand the background and context of laws related to firearms access, and to understand data related to risk of suicide and violence toward others caused by gun violence among persons with mental illness. In addition, clinically driven risk assessments with specific inquiry related to firearms can be important for identifying individuals for whom firearm-focused clinical risk mitigation may be warranted.

This pilot study examined whether substance use or mental illness was more stigmatizing among individuals with co-occurring mental health and substance abuse problems.This study included 48 individuals with co-occurring substance use and mental health problems enrolled in a Substance Abuse and Mental Health Services funded treatment program. Subjects received a baseline assessment that included addiction, mental health, and stigma measures.The sample consisted primarily of White males with an average age of 38 years. Substance abuse was found to be more stigmatizing than mental illness, F(1, 47) = 14.213, p.001, and stigma varied across four different levels of stigma (Aware, Agree, Apply, and Harm), F(2.099, 98.675) = 117.883, p.001. The interaction between type and level of stigma was also significant, F(2.41, 113.284) = 20.250, p.001, indicating that differences in reported stigma between types varied across levels of stigma. Post hoc tests found a significant difference between all levels of stigma except for the comparison between Apply and Harm. Reported stigma was significantly higher for substance abuse than mental illness at the Aware and Agree levels. In addition, pairwise comparisons found significant differences between all levels of stigma with the exception of the comparison between Apply and Harm, indicating a pattern whereby reported stigma generally decreased from the first level (Aware stage) to subsequent levels.These results have important implications for treatment, suggesting the need to incorporate anti-stigma interventions for individuals with co-occurring disorders with a greater focus on substance abuse.

Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justice-involved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation. The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures. This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.

Full Document: Wall BW, Ash P, Keram E, et al: AAPL Practice Resource for the Forensic Psychiatric Evaluation of Competence to Stand Trial Update 2018. Journal of the American Academy of Psychiatry and the Law Online Supplement 2018, 46 (3). Available at: http://www.jaapl.org/content/46/3_Supplement.

This article reports on the implementation, evaluation, and policy implications of MISSION-Criminal Justice (CJ), an innovative intervention used to treat justice-involved veterans with co-occurring mental health and substance use disorders (CODs). In this pilot feasibility study, MISSION-CJ was embedded into four Massachusetts courts and their probation services as an alternative to incarceration. Seventy-six veterans were diverted from jail to MISSION-CJ and completed intake and six-month follow-up assessments. The MISSION-CJ participants were primarily white, had at least two prior arrests, served in a war combat zone, had a trauma before age 18, and had previously received mental health and substance use treatments. Preliminary six-month follow-up data suggested that the MISSION-CJ participants showed improvements in COD problems, trauma symptoms, and a nonsignificant reduction in hospitalization/ER visits. MISSION-CJ was feasible to implement and seemed to show some preliminary program success. A randomized controlled trial of MISSION-CJ is a necessary next step in determining program efficacy. Policy implications for tailoring interventions for justice-involved veterans such as MISSION-CJ and their delivery alongside the court and probation are discussed.

The standards used to select, train, certify, and retain forensic evaluators of Competency to Stand Trial (CST) vary widely across states. Despite the very important ramifications that CST evaluations have for the defendants who undergo them, little is currently known about how states ensure that evaluators provide the highest-quality work possible. A survey was sent to all 50 states and Washington, DC, to solicit information regarding evaluator selection and certification processes, payment of CST evaluators, and other related topics. Results were compared to previous studies completed in 1997 and 2006 to allow for a longitudinal analysis. Results indicate that although some progress has occurred since the publication of those studies, most states still do not have a formal process for selecting or certifying their CST evaluators. Also, professional qualifications for CST evaluations are loosening, and payment remains relatively low. These findings, as well as the importance of retaining high standards f...

Before the Supreme Court's 2008 decision in District of Columbia v. Heller, the American Psychiatric Association's position on gun policy reflected the strong gun control perspective championed by the nation's public health establishment. After Heller declared that an individual's right to bear arms is constitutionally protected, the APA refocused its attention on the specific aspects of firearm policy that implicate the interests and rights of persons with mental illness. Psychiatrists are mindful of the need to curtail firearm access by persons with mental disorders that elevate the risk of suicide or violence to others, but they are also opposed to stigmatization, discrimination, and unfair treatment of individuals based on mental illness. Although civil commitment is an acceptable basis for prohibiting access to firearms, other adjudications of conduct indicative of elevated risk should also be included. Every state should provide a fair and reasonable process for restoring firearm rights after a suitable waiting period based on individualized assessment of whether the person remains at an elevated risk. However, restricting firearm rights of persons solely on the basis of a diagnosis of a mental disorder or voluntary treatment, whether in-patient or outpatient, discourages treatment and would be counterproductive.

The American Psychiatric Association, ("APA"), with more than 36,000 members at present, is the Nation's leading organization of physicians who specialize in psychiatry. APA provides for education and advocacy and develops policy through Position Statements. It promotes enhanced knowledge of particular topics relevant to psychiatric practice and patient care through Resource Documents. Since 1993, the APA has developed various positions and resource materials related to firearms and mental illness, incorporating evolving themes as new issues emerge. This paper reflects the APA's 2014 Resource Document on "Access to Firearms by People with Mental Disorders." This article is derived from work done on behalf of American Psychiatric Association and remains the property of APA. It has been altered only in response to the requirements of peer review.

Criminal conduct is not always violent, and violence does not always lead to criminal charges. Moreover, crime and violence have multifaceted etiologies. Most violence in society is not attributable to mental illness. Where there is a small relationship between violence and mental illness, the risk of violence increases for individuals with substance use histories. Underlying trauma can also play a role. Antisocial attitudes, behaviors, and peer groups further increase the risk that individuals, including those with mental illness, will find themselves at risk of criminal recidivism. Criminal histories among public mental health populations, and mental health and substance use disorders among criminal populations are each higher than general population comparisons. Care within behavioral health settings should therefore target decreased criminal recidivism and decreased violence as part of recovery for those individuals at risk, using trauma-informed approaches and peer supports. Interventions that show promise bring criminal justice and behavioral health systems together, and include police-based diversion, specialty courts, court-based alternatives to incarceration, and coordinated re-entry programs. This article reviews these options along with specific risk management strategies, such as using risk, needs, and responsivity factors as a means of improving overall outcomes for persons with mental illness, while minimizing their risk of further criminalization and victimization.

Management of treatment refusal can be legally and ethically complicated. Patients may refuse various types of treatment, including medications, group and individual psychotherapy, electroconvulsive therapy (ECT), and surgical procedures. Historically, patients with mental illness have had limited rights to refuse treatment. This chapter explores the factors that led to an increased recognition of these rights and provides an overview of current legal approaches to the adjudication of treatment refusal. It focuses primarily on the refusal of antipsychotic medications in inpatient settings, because many of the original court cases and much of the literature and research pertain to this issue. However, restrictions on the administration of antipsychotic medication over the patient’s objection extend beyond inpatient settings to nursing homes, medical and surgical inpatient services, and psychiatric outpatient settings. The chapter also discusses refusal of ECT and presents recommendations for the clinical care of a patient who refuses treatment.

This study assessed perceptions of voluntary consent among 69 veterans who enrolled in a "jail diversion" program for co-occurring disorders. Perceptions were measured using modified items from the MacArthur Perceived Coercion and Negative Pressure Scales. A majority reported that they "chose to" (88.4%) or "felt free to" (85.5%) enroll. Most reported having "control over" (69.6%) and "more influence than anyone else" regarding (60.9%) their participation. About half reported that enrollment was "their idea" (49.3%). Fewer reported perceptions of negative pressure, including the feeling that someone "talked them into" enrolling (24.6%), "threatened them with the maximum criminal punishment" (13.0%), "offered or promised them something" (5.8%), or "forced" them to enroll (5.8%). Nobody felt "tricked, lied to, or fooled into" participating. Total negative pressure scores were higher in those with combat experience, U = 406.50, p = .016. Although potentially inappropriate pressures were reported, these data suggest that the majority perceived enrollment as voluntary.

This study assesses the likelihood of rearrest among a cohort of all adults ( N = 1,438) released from the Massachusetts state prison system who received mental health services while they were incarcerated. All individuals were followed for 24 months. The analysis focused on four classes of variables: demographic characteristics, clinical history, criminal justice history, and postrelease supervision. These analyses showed that criminal history factors—a juvenile record and a history of multiple previous incarcerations—were significant risk factors, but that clinical factors, including a history of substance abuse, were not. Overall, the models developed here look much like the ones that would be observed in the general offender population. The implications of these findings for criminal justice and mental health policy are discussed.

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.

E-mail communication is pervasive. Since many forensic psychiatrists have their e-mail addresses available online (either on personal websites, university websites, or articles they have authored), they are likely to receive unsolicited e-mails. Although there is an emerging body of literature about exchanging e-mail with patients, there is little guidance about how to respond to e-mails from nonpatients. Therefore, we used a Delphi technique to develop a consensus about salient points for the forensic psychiatrist to consider regarding responding to e-mails from nonpatients and the risks entailed. Four scenarios are described, including e-mails from nonpatients and unknown others requesting advice or help. The potential ethics-related, legal, moral, and practical concerns for forensic psychiatrists are discussed. Finally, potential pitfalls for forensic psychiatrists are described.

Providers can optimize care for high-risk adolescents by understanding the health risks among the 1 million US adolescents who interact with the justice system each year. We compared the prevalence of physical health, substance use, and mood disorders among adolescents with and without recent justice involvement and analyzed differences according to race/ethnicity.Cross-sectional analysis using the 2009 to 2014 National Survey on Drug Use and Health. Prevalence data were adjusted for sociodemographic differences between adolescents with and without justice involvement. Justice-involved adolescents had a history of past year arrest, parole/probation, or juvenile detention.Our sample consisted of adolescents aged 12 to 17 years with (n = 5149) and without (n = 97,976) past year justice involvement. In adjusted analyses, adolescents involved at any level of the justice system had a significantly higher prevalence of substance use disorders (P .001), mood disorders (P .001), and sexually transmitted infections (P .01). Adolescents on parole/probation or in juvenile detention in the past year had a higher prevalence of asthma (P .05) and hypertension (P .05) compared with adolescents without justice involvement. Among justice-involved adolescents, African American adolescents were significantly less likely to have a substance use disorder (P .001) or mood disorder (P .01) compared with white or Hispanic adolescents, but had significantly higher prevalence of physical health disorders (P .01).Adolescents involved at all levels of the justice system have high-risk health profiles compared with the general adolescent population, although these risks differ across racial/ethnic groups. Policymakers and health care providers should ensure access to coordinated, high-quality health care for adolescents involved at all levels of the justice system.