Assessment of mental illness, violence risk and readiness for release in a forensic facility

Principal Investigator:  Barbara McDermott, Ph.D.

Forensic facilities are charged with two unique and at times divergent tasks: remediation of an individual's mental disorder that led to the commission of his/her crime and determining when the individual can be returned to the community safely.  The recent proliferation of structured assessments of violence risk and dangerousness have assisted greatly in the latter task.  The violence risk literature has suggested that predictions of dangerousness often overestimate risk because of the low base rates of violent behavior.  A recent critique of the MacArthur Risk Assessment Study indicated that actuarial methods may be best employed to predict with more accuracy those patients that will NOT be violent, rather than those patients who will.  This issue is of critical concern to forensic facilities charged with making decisions regarding release that balance the protection of a patients civil liberties with public safety.

Follow-up studies of forensic patients conditionally released into the community evidence revocation rates that range from 35 to 50%.  Although all revocations are not related to reoffending, much of this research indicates that relatively static factors often are more useful in predicting successful reintegration into the community, rather than factors that may be more amenable to treatment.  However, some researchers have found that an assessment of clinical improvement while in the hospital accurately predicted success in the community.  This study suggests that one factor associated with positive reintegration into the community may be successful treatment in the hospital.

We are prospectively evaluating patients using a variety of standardized assessments to evaluate factors associated with institutional aggression and outcome in the community.  We are carefully conducting violence risk assessments, diagnostic assessments, assessments of symptoms and readiness for release.  The primary goal of this research is to evaluate whether, by employing structured assessments of mental illness, dangerousness and readiness for release, we can characterize the differences between patients who succeed in CONREP versus patients who do not.  We will carefully document the date of the patient's release, date of rehospitalization (if any), reason for rehospitalization, date of revocation (if any) and reason for revocation.  Additionally, these assessments will allow us to more accurately characterize those patients who are more likely to exhibit aggressive behavior while hospitalized.

Success in CONREP as a tool for program evaluation: The development of an exemplary program

Principal Investigator:  Barbara McDermott, Ph.D.

This study examines the records of patients released to the Conditional Release Program (CONREP) from Napa State Hospital (NSH).  We want to more accurately characterize the differences between patients who have succeeded in CONREP versus patients who have not.  Previous research has indicated that the reasons for CONREP failure may provide important information for the development of treatment programs.  It is imperative that this preliminary research be conducted so that treatment programs can be developed that target issues identified in this research.  A treatment program designed to meet the needs of a patient revoked for psychiatric decompensation is unlikely to be effective in maintaining conditional release of a patient who is ultimately revoked for dangerousness.

Currently, 437 patients have been released from NSH to CONREP since 1986.  Of these, 202 have been returned to custody.  We will randomly sample a subset of the patients who succeeded in CONREP for further review.  We will also sample a subset of patients currently active in CONREP.  We will randomly sample from each of the following subgroups: psychiatric decompensation, substance use, dangerousness, non-compliance and reoffending.  Patient outcome will be characterized by examining the CONREP database maintained by the state.  In this way, we hope to further define issues relevant to outcome and methods for improving treatment to address the needs of specific types of patients.

Capacity of forensic patients to consent to clinical research

Principal Investigator:  Barbara McDermott, Ph.D.

It is widely recognized that research plays an essential role in advancing medical and behavioral sciences and improves our ability to understand and treat illness and modify human behavior.  Whereas clinical care is intended for the direct and sole benefit of the patient, research has the broader goal of advancing knowledge and often does not provide the patient/subject with an ensured medical/clinical benefit.  This raises obvious ethical concerns, especially in subject populations who may not be able to make informed, voluntary decisions about participation, either because of impairments in cognition or reasoning or because they live in an environment that can be coercive.  The Common Rule provides additional protections to research subjects deemed "vulnerable" and whose ability to provide informed consent may be compromised.  These vulnerable populations include pregnant women, human fetuses and neonates, prisoners and children.  "Prisoners" are defined as "any individual involuntarily confined or detained in a penal institution."  The term "prisoner" includes patients committed to forensic hospitals in lieu of prisons  In 1998, the National Bioethics Advisory Commission (NBAC) issued a report outlining recommendations for conducting research with individuals with psychiatric disorders.  NBAC expressed concern that certain psychiatric disorders might place individuals at increased risk of being unable to provide informed consent.  The NBAC viewed persons with mental illnesses as an additional vulnerable population and recommended that the federal guidelines for research with vulnerable populations include persons with certain psychiatric disorders. 

Currently there is one research protocols approved at NSH that involves the use of the The MacArthur Competence Assessment Tool for Clinical Research MacCAT-CR: "The Assessment of Mental Illness, Violence Risk and Readiness for Release in a Forensic Facility."  All competence assessments will be gathered from the subjects who had expressed interest and completed a MacCAT-CR, whether or not they consented to the research project for which they were recruited.  Scores on this assessment will be related to diagnosis and symptom ratings.  The purpose of this research is to carefully evaluate the capacity issues in patients with dual vulnerability: psychiatric diagnosis and prisoners, using a structured interview and to carefully define the areas of deficiencies that individuals with these dual vulnerabilities may possess.

Retrospective study of female homicide offenders found not guilty by reason of insanity

Principal Investigator:  Barbara McDermott, Ph.D.
Co-Investigator:  Kimberly Hardison

The general phenomenon of women who kill has not been thoroughly investigated by researchers.  The first reports of women who kill were conveyed in sensational accounts portrayed by the media rather than systematic scholarly research. When empirical studies were conducted, the focus was on women who kill an abusive spouse in self-defense.  More recently, women killing their children has received much attention, likely secondary to the highly publicized acts of a few women.

An important goal of this study is to examine the differences between male and female homicide offenders to better inform current treatment practices.  These data may contribute to the understanding of whether treatment methods for women found not guilty by reason of insanity for homicide offenses should differ from treatment for similar men.  A study of gender differences with particular attention to homicide offenses may provide information regarding intervention and prevention strategies for these highly unique groups.

The purpose of this research is threefold:

  1. To identify patient characteristics of female homicide offenders found not guilty by reason of insanity.
  2. To carefully examine differences between men and women who have been found not guilty by reason of insanity for homicide offenses. 
  3. To provide more information about the characteristics of women found not guilty by reason of insanity for homicide offenses in order to inform treatment of this population and to identify special needs of this group that may differ from their male counterparts.  This research can be instrumental in developing proactive programs to assist women with mental illness who are at risk for committing a homicide offense.

The assessment of malingering in a jail setting

Principal Investigators:  Barbara McDermott, Ph.D. and Gregory Sokolov, M.D.

Malingering is defined in the DSM-IV TR as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as … evading criminal prosecution or obtaining drugs.  The accurate assessment of real versus feigned psychiatric illness is especially critical in a correctional setting.  Estimates of the percentage of inmates who malinger vary from a low of 8% in pretrial evaluations to a high of 46% in inmates claiming psychological disturbances.  Recently, Pierre et al. (2004) expressed concern that the inability to detect malingering in jail inmates may lead to the inappropriate administration of antipsychotic medication. 

Various methods have been used to detect malingering in correctional settings, including the use of structured interviews and self-report instruments.  The Structured Interview of Reported Symptoms (SIRS) (Rogers, Bagby, & Dickens, 1992) is a structured interview that was designed to assess malingered psychiatric symptoms.  The SIRS has been shown to be a highly reliable measure and has been validated in community, clinical, forensic, and correctional populations.

The UC Davis Department of Psychiatry and Behavioral Sciences, through a formal contract with the Sacramento County Sheriff's Department, provides psychiatric services to inmates in need of psychiatric treatment (Jail Psychiatric Services, JPS).  A forensic psychologist provides consultative services in the assessment of malingering.  The SIRS has been used as a clinical tool to aid in the determination of whether or not the inmate requesting a JPS appointment is exaggerating or frankly malingering his/her symptoms.  Since June 2002 approximately 150 inmates have been referred for testing to rule-out malingered psychosis and depression.  We will conduct a thorough record review of psychiatric records maintained by JPS on those inmates who were administered the SIRS.

The purpose of this research is threefold:

  1. To identify characteristics of patients who were shown to be malingering on the SIRS.
  2. To carefully examine differences between inmates who were shown to malingering on the SIRS versus those who were not identified as malingering.
  3. To carefully evaluate the relationship between results of a structured assessment of malingering and other factors more readily available to most correctional facilities.  In this way, we may be able to identify characteristics of inmates most likely to malinger and resources used for the detection of malingering can be more specifically focused on such inmates.