American Academy of Psychiatry and the Law (AAPL): Annual Meeting

BOSTON – A person with mental illness who insists on defending himself in court should not be allowed to sink or swim on his own, said a forensic psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

A survey of forensic evaluators suggests that a minimum standard for determining pro se competency should include the defendant’s willingness to accept standby counsel, appraise legal defenses, plan legal strategy, and question and challenge witnesses.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman from the State University of New York Upstate Medical Center in Syracuse.

"To represent yourself, there are several things you have to do: You have to be able to organize your defense, make motions, argue points, participate in jury selection, question witnesses, read legal documents, address the court – a very complex skill set," he said.

Dr. Kaufman noted that the case of Indiana v. Edwards, decided by the U.S. Supreme Court in 2008, established that the state standard for determining competence required for self-defense may be higher than that for determining whether a defendant is competent to stand trial, with the trial judge having the final burden of making the determination.

In the Edwards case, a man who had fired at a security guard and wounded a bystander while attempting to steal a pair of shoes was twice found incompetent to stand trial by a judge and appealed for the right to represent himself.

The minority held that, in the words of Justice Antonin Scalia, "the dignity at issue is the supreme dignity of being master of one’s own fate rather than a ward of the state – the dignity of individual choice."

But Justice Stephen Breyer, writing for the majority, said that "a self-representation right at trial will not ‘affirm the dignity’ of a defendant who lacks the mental capacity to conduct his defense without assistance of counsel." To allow a defendant to act as his own lawyer in such a case "may undercut the most basic of the Constitution’s criminal law objectives: providing a fair trial," the opinion stated.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman.

The Supreme Court failed, however, to provide much guidance for trial court judges who are charged with determining whether someone found competent to stand trial is also competent to conduct his own legal defense, Dr. Kaufman said.

He and his colleagues initially sent an open-ended survey to 400 New York trial court judges, and received 18 responses. The respondents said that they would consider cognitive disorders (mental retardation, dementia) and that psychosis as conditions that would limit pro se competence.

The judges expressed eagerness for expert assistance in determining competence, and said that the domains that should be assessed in individual cases include the defendant intellectual and analytic abilities, legal knowledge and experience, language ability, and issues of severe mental illness and behavioral control.

The investigators then used the pilot data from that survey to create a new survey of forensic mental health experts, asking whether scores on individual items of the Competency Assessment Instrument (CAI), established by A. Louis McGarry and widely used to assess competence to stand trial, would need to be the same, somewhat higher, or much higher to determine pro se competence. They also asked about suitable levels of cognitive abilities, whether standby counsel should be mandatory, and whether the presence of standby counsel would change the level of competence require for self-defense.

Of the 300 contacted, 68 (23%) responded. In all, 58 of the 68 respondents were forensic psychiatrists with a mean 16.6 years if experience, and a mean number of competence-to-stand-trial evaluations of 263.

The respondents said the ability to take advantage of and plan legal strategies, to question or challenge witnesses, to understand court procedures, and to appraise likely outcomes needed to be higher or much higher than those for a standard competence determination. Other domains, such as self-serving motivation, the ability to appreciate change, appropriate behavior, role of court personnel, and ability to testify relevantly could be the same.

Nearly two-thirds of the respondents (60.3%) said that standby counsel should be mandatory, 22.1% disagreed, and 17.6% expressed no opinion. Additionally, 76% said the defendant needed at least average intelligence, 69% said at least average literacy, and 71% said at least average verbal communication abilities to be judged competent for self defense.

"As in other criminal competencies, there should be a presumption of competence, and since pro se competency in our opinion should be a higher standard – the court said ‘may be’ a higher standard, we believe it should be – the defendant must of course meet competency to stand trial criteria," Dr. Kaufman said.

To be declared incompetent, there must be a mental disease or defect and not simply poor judgment as the cause for incompetence, he added.

The study was internally funded. Dr. Kaufman reported that he had no financial disclosures.

BOSTON – A person with mental illness who insists on defending himself in court should not be allowed to sink or swim on his own, said a forensic psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

A survey of forensic evaluators suggests that a minimum standard for determining pro se competency should include the defendant’s willingness to accept standby counsel, appraise legal defenses, plan legal strategy, and question and challenge witnesses.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman from the State University of New York Upstate Medical Center in Syracuse.

"To represent yourself, there are several things you have to do: You have to be able to organize your defense, make motions, argue points, participate in jury selection, question witnesses, read legal documents, address the court – a very complex skill set," he said.

Dr. Kaufman noted that the case of Indiana v. Edwards, decided by the U.S. Supreme Court in 2008, established that the state standard for determining competence required for self-defense may be higher than that for determining whether a defendant is competent to stand trial, with the trial judge having the final burden of making the determination.

In the Edwards case, a man who had fired at a security guard and wounded a bystander while attempting to steal a pair of shoes was twice found incompetent to stand trial by a judge and appealed for the right to represent himself.

The minority held that, in the words of Justice Antonin Scalia, "the dignity at issue is the supreme dignity of being master of one’s own fate rather than a ward of the state – the dignity of individual choice."

But Justice Stephen Breyer, writing for the majority, said that "a self-representation right at trial will not ‘affirm the dignity’ of a defendant who lacks the mental capacity to conduct his defense without assistance of counsel." To allow a defendant to act as his own lawyer in such a case "may undercut the most basic of the Constitution’s criminal law objectives: providing a fair trial," the opinion stated.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman.

The Supreme Court failed, however, to provide much guidance for trial court judges who are charged with determining whether someone found competent to stand trial is also competent to conduct his own legal defense, Dr. Kaufman said.

He and his colleagues initially sent an open-ended survey to 400 New York trial court judges, and received 18 responses. The respondents said that they would consider cognitive disorders (mental retardation, dementia) and that psychosis as conditions that would limit pro se competence.

The judges expressed eagerness for expert assistance in determining competence, and said that the domains that should be assessed in individual cases include the defendant intellectual and analytic abilities, legal knowledge and experience, language ability, and issues of severe mental illness and behavioral control.

The investigators then used the pilot data from that survey to create a new survey of forensic mental health experts, asking whether scores on individual items of the Competency Assessment Instrument (CAI), established by A. Louis McGarry and widely used to assess competence to stand trial, would need to be the same, somewhat higher, or much higher to determine pro se competence. They also asked about suitable levels of cognitive abilities, whether standby counsel should be mandatory, and whether the presence of standby counsel would change the level of competence require for self-defense.

Of the 300 contacted, 68 (23%) responded. In all, 58 of the 68 respondents were forensic psychiatrists with a mean 16.6 years if experience, and a mean number of competence-to-stand-trial evaluations of 263.

The respondents said the ability to take advantage of and plan legal strategies, to question or challenge witnesses, to understand court procedures, and to appraise likely outcomes needed to be higher or much higher than those for a standard competence determination. Other domains, such as self-serving motivation, the ability to appreciate change, appropriate behavior, role of court personnel, and ability to testify relevantly could be the same.

Nearly two-thirds of the respondents (60.3%) said that standby counsel should be mandatory, 22.1% disagreed, and 17.6% expressed no opinion. Additionally, 76% said the defendant needed at least average intelligence, 69% said at least average literacy, and 71% said at least average verbal communication abilities to be judged competent for self defense.

"As in other criminal competencies, there should be a presumption of competence, and since pro se competency in our opinion should be a higher standard – the court said ‘may be’ a higher standard, we believe it should be – the defendant must of course meet competency to stand trial criteria," Dr. Kaufman said.

To be declared incompetent, there must be a mental disease or defect and not simply poor judgment as the cause for incompetence, he added.

The study was internally funded. Dr. Kaufman reported that he had no financial disclosures.

BOSTON – A person with mental illness who insists on defending himself in court should not be allowed to sink or swim on his own, said a forensic psychiatrist at the annual meeting of the American Academy of Psychiatry and the Law.

A survey of forensic evaluators suggests that a minimum standard for determining pro se competency should include the defendant’s willingness to accept standby counsel, appraise legal defenses, plan legal strategy, and question and challenge witnesses.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman from the State University of New York Upstate Medical Center in Syracuse.

"To represent yourself, there are several things you have to do: You have to be able to organize your defense, make motions, argue points, participate in jury selection, question witnesses, read legal documents, address the court – a very complex skill set," he said.

Dr. Kaufman noted that the case of Indiana v. Edwards, decided by the U.S. Supreme Court in 2008, established that the state standard for determining competence required for self-defense may be higher than that for determining whether a defendant is competent to stand trial, with the trial judge having the final burden of making the determination.

In the Edwards case, a man who had fired at a security guard and wounded a bystander while attempting to steal a pair of shoes was twice found incompetent to stand trial by a judge and appealed for the right to represent himself.

The minority held that, in the words of Justice Antonin Scalia, "the dignity at issue is the supreme dignity of being master of one’s own fate rather than a ward of the state – the dignity of individual choice."

But Justice Stephen Breyer, writing for the majority, said that "a self-representation right at trial will not ‘affirm the dignity’ of a defendant who lacks the mental capacity to conduct his defense without assistance of counsel." To allow a defendant to act as his own lawyer in such a case "may undercut the most basic of the Constitution’s criminal law objectives: providing a fair trial," the opinion stated.

The defendant also should have at least average cognitive abilities, including intelligence, literacy, and verbal ability, said Dr. Andrew R. Kaufman.

The Supreme Court failed, however, to provide much guidance for trial court judges who are charged with determining whether someone found competent to stand trial is also competent to conduct his own legal defense, Dr. Kaufman said.

He and his colleagues initially sent an open-ended survey to 400 New York trial court judges, and received 18 responses. The respondents said that they would consider cognitive disorders (mental retardation, dementia) and that psychosis as conditions that would limit pro se competence.

The judges expressed eagerness for expert assistance in determining competence, and said that the domains that should be assessed in individual cases include the defendant intellectual and analytic abilities, legal knowledge and experience, language ability, and issues of severe mental illness and behavioral control.

The investigators then used the pilot data from that survey to create a new survey of forensic mental health experts, asking whether scores on individual items of the Competency Assessment Instrument (CAI), established by A. Louis McGarry and widely used to assess competence to stand trial, would need to be the same, somewhat higher, or much higher to determine pro se competence. They also asked about suitable levels of cognitive abilities, whether standby counsel should be mandatory, and whether the presence of standby counsel would change the level of competence require for self-defense.

Of the 300 contacted, 68 (23%) responded. In all, 58 of the 68 respondents were forensic psychiatrists with a mean 16.6 years if experience, and a mean number of competence-to-stand-trial evaluations of 263.

The respondents said the ability to take advantage of and plan legal strategies, to question or challenge witnesses, to understand court procedures, and to appraise likely outcomes needed to be higher or much higher than those for a standard competence determination. Other domains, such as self-serving motivation, the ability to appreciate change, appropriate behavior, role of court personnel, and ability to testify relevantly could be the same.

Nearly two-thirds of the respondents (60.3%) said that standby counsel should be mandatory, 22.1% disagreed, and 17.6% expressed no opinion. Additionally, 76% said the defendant needed at least average intelligence, 69% said at least average literacy, and 71% said at least average verbal communication abilities to be judged competent for self defense.

"As in other criminal competencies, there should be a presumption of competence, and since pro se competency in our opinion should be a higher standard – the court said ‘may be’ a higher standard, we believe it should be – the defendant must of course meet competency to stand trial criteria," Dr. Kaufman said.

To be declared incompetent, there must be a mental disease or defect and not simply poor judgment as the cause for incompetence, he added.

The study was internally funded. Dr. Kaufman reported that he had no financial disclosures.

BOSTON – "Justice delayed is justice denied" applies to both a defendant’s right to a speedy trial and a mentally ill defendant’s right to get medical help, investigators said at the annual meeting of the American Academy of Psychiatry and the Law.

A study of people with mental illness arrested in New York City found that proximity to inpatient psychiatric services appeared to be associated with a more rapid time to arraignment in Manhattan, compared with either Brooklyn or Queens, reported Dr. Susan M. Gray and her colleagues from the Bellevue Hospital Center and New York University, both in New York City.

In New York state, detainees are supposed to be arraigned within 24 hours of arrest, giving them prompt access to counsel and the beginnings of a legal defense. But detainees with mental illness might go for more than a month without an arraignment hearing. That gives them time for treatment, but it also delays their access to legal counsel, said Dr. Gray, who encountered such patients at Bellevue while doing a fellowship at NYU.

"I would be taking care of patients who were in custody for 3 or 4 weeks with no legal counsel and no opportunity for mental fitness exams, and yet they’re getting treated. Later, if they get a mental fitness exam, they might pass it when they wouldn’t have if they had been arraigned within the first couple of days, which can affect the outcomes of their cases," she said in an interview.

If people with mental illness received a timely arraignment as they are entitled to by law, however, the disposition of their cases might be very different, such as a finding of being unfit to stand trial, or a transfer of their case to civil rather than criminal court, Dr. Gray said.

The investigators conducted a retrospective chart review of patient detainees who were admitted to the forensic psychiatric inpatient service at Bellevue through the hospital’s Comprehensive Psychiatric Emergency Program (CPEP). Out of 202 patients admitted from February 2010 through March 2011, 181 had data on arrest and arraignment dates available.

The authors identified for each record patient demographics, admission diagnosis, discharge diagnosis, borough of arrest, date of admission to the CPEP (the presumed arrest date), date of arraignment or discharge to police custody (with the assumption that arraignment would be within 24-48 hours), and a top criminal charge.

They found that there were no significant differences in time to arraignment by age group or race/ethnicity, but patients with a discharge diagnosis of psychosis had significantly longer mean times to arraignment than those with a nonpsychotic diagnosis (8.6 vs., 7.19 days, P less than .004).

Those with a top criminal charge of a misdemeanor waited significantly less for arraignments than those with felony charges (7.28 vs., 9.18 days, P less than .022).

The borough of arrest also made a difference, with those nabbed in Manhattan being arraigned within a mean of 6.4 days, vs. 10.66 days in Brooklyn (P less than .000 vs. Manhattan), and 11.05 days in Queens (P less than .003; P for Manhattan vs. all boroughs less than .000). No significant differences were found between Manhattan and either the Bronx (8.3 days) and Staten Island (7.0 days).

The results jibe with the impressions of clinicians that times to arraignment in Brooklyn and Queens are longer than those in the other boroughs, the authors noted. They pointed out that there are weekly in-house arraignments for male detainees hospitalized at Bellevue, and that these services are performed with more dispatch for those arrested in Manhattan or the Bronx, which are geographically more convenient to the hospital’s Manhattan campus. In Brooklyn, such arraignments previously had been performed at Kings County Hospital, but that facility closed in 2004.

"While we do not have data regarding time to arraignment prior to 2004, it is likely that the closing of this service, which accepted male pre-arraignment detainees and was much more convenient for Brooklyn and Queens, had an impact on how and when arraignments are scheduled for these patient-detainees. This may demonstrate an unforeseen consequence of closing an important psychiatric service and should be considered in light of increasing local and national restrictions on health care funding," the investigators wrote.

The authors did not disclose a funding source. Dr. Gray said she has no relevant conflicts of interest.

BOSTON – "Justice delayed is justice denied" applies to both a defendant’s right to a speedy trial and a mentally ill defendant’s right to get medical help, investigators said at the annual meeting of the American Academy of Psychiatry and the Law.

A study of people with mental illness arrested in New York City found that proximity to inpatient psychiatric services appeared to be associated with a more rapid time to arraignment in Manhattan, compared with either Brooklyn or Queens, reported Dr. Susan M. Gray and her colleagues from the Bellevue Hospital Center and New York University, both in New York City.

In New York state, detainees are supposed to be arraigned within 24 hours of arrest, giving them prompt access to counsel and the beginnings of a legal defense. But detainees with mental illness might go for more than a month without an arraignment hearing. That gives them time for treatment, but it also delays their access to legal counsel, said Dr. Gray, who encountered such patients at Bellevue while doing a fellowship at NYU.

"I would be taking care of patients who were in custody for 3 or 4 weeks with no legal counsel and no opportunity for mental fitness exams, and yet they’re getting treated. Later, if they get a mental fitness exam, they might pass it when they wouldn’t have if they had been arraigned within the first couple of days, which can affect the outcomes of their cases," she said in an interview.

If people with mental illness received a timely arraignment as they are entitled to by law, however, the disposition of their cases might be very different, such as a finding of being unfit to stand trial, or a transfer of their case to civil rather than criminal court, Dr. Gray said.

The investigators conducted a retrospective chart review of patient detainees who were admitted to the forensic psychiatric inpatient service at Bellevue through the hospital’s Comprehensive Psychiatric Emergency Program (CPEP). Out of 202 patients admitted from February 2010 through March 2011, 181 had data on arrest and arraignment dates available.

The authors identified for each record patient demographics, admission diagnosis, discharge diagnosis, borough of arrest, date of admission to the CPEP (the presumed arrest date), date of arraignment or discharge to police custody (with the assumption that arraignment would be within 24-48 hours), and a top criminal charge.

They found that there were no significant differences in time to arraignment by age group or race/ethnicity, but patients with a discharge diagnosis of psychosis had significantly longer mean times to arraignment than those with a nonpsychotic diagnosis (8.6 vs., 7.19 days, P less than .004).

Those with a top criminal charge of a misdemeanor waited significantly less for arraignments than those with felony charges (7.28 vs., 9.18 days, P less than .022).

The borough of arrest also made a difference, with those nabbed in Manhattan being arraigned within a mean of 6.4 days, vs. 10.66 days in Brooklyn (P less than .000 vs. Manhattan), and 11.05 days in Queens (P less than .003; P for Manhattan vs. all boroughs less than .000). No significant differences were found between Manhattan and either the Bronx (8.3 days) and Staten Island (7.0 days).

The results jibe with the impressions of clinicians that times to arraignment in Brooklyn and Queens are longer than those in the other boroughs, the authors noted. They pointed out that there are weekly in-house arraignments for male detainees hospitalized at Bellevue, and that these services are performed with more dispatch for those arrested in Manhattan or the Bronx, which are geographically more convenient to the hospital’s Manhattan campus. In Brooklyn, such arraignments previously had been performed at Kings County Hospital, but that facility closed in 2004.

"While we do not have data regarding time to arraignment prior to 2004, it is likely that the closing of this service, which accepted male pre-arraignment detainees and was much more convenient for Brooklyn and Queens, had an impact on how and when arraignments are scheduled for these patient-detainees. This may demonstrate an unforeseen consequence of closing an important psychiatric service and should be considered in light of increasing local and national restrictions on health care funding," the investigators wrote.

The authors did not disclose a funding source. Dr. Gray said she has no relevant conflicts of interest.

BOSTON – "Justice delayed is justice denied" applies to both a defendant’s right to a speedy trial and a mentally ill defendant’s right to get medical help, investigators said at the annual meeting of the American Academy of Psychiatry and the Law.

A study of people with mental illness arrested in New York City found that proximity to inpatient psychiatric services appeared to be associated with a more rapid time to arraignment in Manhattan, compared with either Brooklyn or Queens, reported Dr. Susan M. Gray and her colleagues from the Bellevue Hospital Center and New York University, both in New York City.

In New York state, detainees are supposed to be arraigned within 24 hours of arrest, giving them prompt access to counsel and the beginnings of a legal defense. But detainees with mental illness might go for more than a month without an arraignment hearing. That gives them time for treatment, but it also delays their access to legal counsel, said Dr. Gray, who encountered such patients at Bellevue while doing a fellowship at NYU.

"I would be taking care of patients who were in custody for 3 or 4 weeks with no legal counsel and no opportunity for mental fitness exams, and yet they’re getting treated. Later, if they get a mental fitness exam, they might pass it when they wouldn’t have if they had been arraigned within the first couple of days, which can affect the outcomes of their cases," she said in an interview.

If people with mental illness received a timely arraignment as they are entitled to by law, however, the disposition of their cases might be very different, such as a finding of being unfit to stand trial, or a transfer of their case to civil rather than criminal court, Dr. Gray said.

The investigators conducted a retrospective chart review of patient detainees who were admitted to the forensic psychiatric inpatient service at Bellevue through the hospital’s Comprehensive Psychiatric Emergency Program (CPEP). Out of 202 patients admitted from February 2010 through March 2011, 181 had data on arrest and arraignment dates available.

The authors identified for each record patient demographics, admission diagnosis, discharge diagnosis, borough of arrest, date of admission to the CPEP (the presumed arrest date), date of arraignment or discharge to police custody (with the assumption that arraignment would be within 24-48 hours), and a top criminal charge.

They found that there were no significant differences in time to arraignment by age group or race/ethnicity, but patients with a discharge diagnosis of psychosis had significantly longer mean times to arraignment than those with a nonpsychotic diagnosis (8.6 vs., 7.19 days, P less than .004).

Those with a top criminal charge of a misdemeanor waited significantly less for arraignments than those with felony charges (7.28 vs., 9.18 days, P less than .022).

The borough of arrest also made a difference, with those nabbed in Manhattan being arraigned within a mean of 6.4 days, vs. 10.66 days in Brooklyn (P less than .000 vs. Manhattan), and 11.05 days in Queens (P less than .003; P for Manhattan vs. all boroughs less than .000). No significant differences were found between Manhattan and either the Bronx (8.3 days) and Staten Island (7.0 days).

The results jibe with the impressions of clinicians that times to arraignment in Brooklyn and Queens are longer than those in the other boroughs, the authors noted. They pointed out that there are weekly in-house arraignments for male detainees hospitalized at Bellevue, and that these services are performed with more dispatch for those arrested in Manhattan or the Bronx, which are geographically more convenient to the hospital’s Manhattan campus. In Brooklyn, such arraignments previously had been performed at Kings County Hospital, but that facility closed in 2004.

"While we do not have data regarding time to arraignment prior to 2004, it is likely that the closing of this service, which accepted male pre-arraignment detainees and was much more convenient for Brooklyn and Queens, had an impact on how and when arraignments are scheduled for these patient-detainees. This may demonstrate an unforeseen consequence of closing an important psychiatric service and should be considered in light of increasing local and national restrictions on health care funding," the investigators wrote.

The authors did not disclose a funding source. Dr. Gray said she has no relevant conflicts of interest.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

BOSTON – A traumatic injury to the brain can cause even the most mild-mannered person to act like a hostile, aggressive sociopath, a neuropsychiatrist said at the annual meeting of the American Academy of Psychiatry and the Law.

Agitation and aggression, often lumped together as "socially inappropriate behavior," are common after a traumatic brain injury (TBI), said Dr. Hal S. Wortzel, director of neuropsychiatric consultation services at the Denver VA Medical Center.

But a TBI does not pre-ordain violent or aggressive behavior, and there might be other explanations for antisocial actions, Dr. Wortzel commented.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury," he said. "But as forensic evaluators, we’re often times asked to comment on a specific act of aggression. We have to think about the typologies of violence, because not all aggressive acts are the same," he said.

The link between TBI and aggression has been well known since the famous case of Phineas Gage, Dr. Wortzel noted. Gage was a Vermont railroad worker who in 1848 survived, and, remarkably, recovered rapidly from an accident in which a heavy iron tamping rod more than 3 feet in length was driven by an explosion completely through his skull. After the accident, Gage underwent a dramatic personality change, and began to display irreverent and antisocial behavior, use of sexually explicit language, apparent lack of moral conscience, impulsiveness, irritability and aggressiveness, and an inability to focus on work or plan for the future.

Posttraumatic aggression is a common problem after TBI, usually manifesting within the first year post-injury. It has been associated with frontal lobe lesions and with the presence of major depression. In addition, it is more often occurs in patients who prior to their injury had a history of substance abuse or impulsive aggression.

The severity of a TBI is graded from mild to severe, according to the physical, neurologic, and psychiatric findings at the time of the injury, and not by the subsequent neuropsychiatric changes, Dr. Wortzel emphasized.

"Mild traumatic injuries are different from moderate and severe traumatic brain injuries in terms of outcomes, expected recovery, and the likelihood that neuropsychiatric symptoms, whether [they] be aggression or others down the road, are directly referable to neuronal injury from that event," he said.

Neurobehavioral outcomes after a TBI arise from a combination of pre-injury factors, the nature of the injury itself, and post-injury psychosocial factors. Changes might be come in the domains of cognition (such as disturbed consciousness or impaired attention), emotion (depression, anxiety, lability), behavior (aggression, disinhibition, apathy), and physical (visual problems, vertigo, seizures).

Pre-injury factors contributing to acquired aggression include age and gender, baseline intellectual function, psychiatric problems and substance abuse, sociopathy, risk-taking/novelty seeking behaviors, premorbid behavioral problems, social circumstance, and neurogenetic factors, such as the apolipoprotein E4 allele.

Factors that might exacerbate neuropsychiatric problems after an injury include medical complications, delay in receiving rehabilitative services, lack of education about the course of recovery and interpretation of symptoms, poor family or social support, premature return to work or school, and litigation or other legal problems.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury."

Most people who sustain a mild TBI will recover fully and fairly quickly, Dr. Wortzel said. However, anywhere from 35% to 60% of people who sustain moderate to severe TBI develop chronic neurobehavioral and/or physical symptoms related to the injury, and the more severe the initial injury, the lower the chance of full neurological, neurobehavioral, and functional recovery, Dr. Wortzel said.

He noted that the nature and quality of violent behavior, plus the circumstances under which it occurs, provide clues to whether the aggression might be related to TBI or to some other cause, such as intoxication, delirium, or premorbid antisocial traits.

In a study of 279 Vietnam War veterans with penetrating TBIs, Jordan Grafman, Ph.D., and his colleagues found that frontal ventromedial lesions were significantly associated with higher scores for aggression and violence, although the higher scores were generally associated more with verbal confrontations than with physical assaults (Neurology 1996;46:1231-8).

"It is worth keeping in mind that injury is not destiny, and that most people who sustain brain injuries don’t hurt other people," he said.

Dr. Wortzel’s work is supported in part by the Veterans Affairs’ Mental Illness Research, Education and Clinical Centers. He reported having no relevant financial disclosures.

BOSTON – A traumatic injury to the brain can cause even the most mild-mannered person to act like a hostile, aggressive sociopath, a neuropsychiatrist said at the annual meeting of the American Academy of Psychiatry and the Law.

Agitation and aggression, often lumped together as "socially inappropriate behavior," are common after a traumatic brain injury (TBI), said Dr. Hal S. Wortzel, director of neuropsychiatric consultation services at the Denver VA Medical Center.

But a TBI does not pre-ordain violent or aggressive behavior, and there might be other explanations for antisocial actions, Dr. Wortzel commented.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury," he said. "But as forensic evaluators, we’re often times asked to comment on a specific act of aggression. We have to think about the typologies of violence, because not all aggressive acts are the same," he said.

The link between TBI and aggression has been well known since the famous case of Phineas Gage, Dr. Wortzel noted. Gage was a Vermont railroad worker who in 1848 survived, and, remarkably, recovered rapidly from an accident in which a heavy iron tamping rod more than 3 feet in length was driven by an explosion completely through his skull. After the accident, Gage underwent a dramatic personality change, and began to display irreverent and antisocial behavior, use of sexually explicit language, apparent lack of moral conscience, impulsiveness, irritability and aggressiveness, and an inability to focus on work or plan for the future.

Posttraumatic aggression is a common problem after TBI, usually manifesting within the first year post-injury. It has been associated with frontal lobe lesions and with the presence of major depression. In addition, it is more often occurs in patients who prior to their injury had a history of substance abuse or impulsive aggression.

The severity of a TBI is graded from mild to severe, according to the physical, neurologic, and psychiatric findings at the time of the injury, and not by the subsequent neuropsychiatric changes, Dr. Wortzel emphasized.

"Mild traumatic injuries are different from moderate and severe traumatic brain injuries in terms of outcomes, expected recovery, and the likelihood that neuropsychiatric symptoms, whether [they] be aggression or others down the road, are directly referable to neuronal injury from that event," he said.

Neurobehavioral outcomes after a TBI arise from a combination of pre-injury factors, the nature of the injury itself, and post-injury psychosocial factors. Changes might be come in the domains of cognition (such as disturbed consciousness or impaired attention), emotion (depression, anxiety, lability), behavior (aggression, disinhibition, apathy), and physical (visual problems, vertigo, seizures).

Pre-injury factors contributing to acquired aggression include age and gender, baseline intellectual function, psychiatric problems and substance abuse, sociopathy, risk-taking/novelty seeking behaviors, premorbid behavioral problems, social circumstance, and neurogenetic factors, such as the apolipoprotein E4 allele.

Factors that might exacerbate neuropsychiatric problems after an injury include medical complications, delay in receiving rehabilitative services, lack of education about the course of recovery and interpretation of symptoms, poor family or social support, premature return to work or school, and litigation or other legal problems.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury."

Most people who sustain a mild TBI will recover fully and fairly quickly, Dr. Wortzel said. However, anywhere from 35% to 60% of people who sustain moderate to severe TBI develop chronic neurobehavioral and/or physical symptoms related to the injury, and the more severe the initial injury, the lower the chance of full neurological, neurobehavioral, and functional recovery, Dr. Wortzel said.

He noted that the nature and quality of violent behavior, plus the circumstances under which it occurs, provide clues to whether the aggression might be related to TBI or to some other cause, such as intoxication, delirium, or premorbid antisocial traits.

In a study of 279 Vietnam War veterans with penetrating TBIs, Jordan Grafman, Ph.D., and his colleagues found that frontal ventromedial lesions were significantly associated with higher scores for aggression and violence, although the higher scores were generally associated more with verbal confrontations than with physical assaults (Neurology 1996;46:1231-8).

"It is worth keeping in mind that injury is not destiny, and that most people who sustain brain injuries don’t hurt other people," he said.

Dr. Wortzel’s work is supported in part by the Veterans Affairs’ Mental Illness Research, Education and Clinical Centers. He reported having no relevant financial disclosures.

BOSTON – A traumatic injury to the brain can cause even the most mild-mannered person to act like a hostile, aggressive sociopath, a neuropsychiatrist said at the annual meeting of the American Academy of Psychiatry and the Law.

Agitation and aggression, often lumped together as "socially inappropriate behavior," are common after a traumatic brain injury (TBI), said Dr. Hal S. Wortzel, director of neuropsychiatric consultation services at the Denver VA Medical Center.

But a TBI does not pre-ordain violent or aggressive behavior, and there might be other explanations for antisocial actions, Dr. Wortzel commented.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury," he said. "But as forensic evaluators, we’re often times asked to comment on a specific act of aggression. We have to think about the typologies of violence, because not all aggressive acts are the same," he said.

The link between TBI and aggression has been well known since the famous case of Phineas Gage, Dr. Wortzel noted. Gage was a Vermont railroad worker who in 1848 survived, and, remarkably, recovered rapidly from an accident in which a heavy iron tamping rod more than 3 feet in length was driven by an explosion completely through his skull. After the accident, Gage underwent a dramatic personality change, and began to display irreverent and antisocial behavior, use of sexually explicit language, apparent lack of moral conscience, impulsiveness, irritability and aggressiveness, and an inability to focus on work or plan for the future.

Posttraumatic aggression is a common problem after TBI, usually manifesting within the first year post-injury. It has been associated with frontal lobe lesions and with the presence of major depression. In addition, it is more often occurs in patients who prior to their injury had a history of substance abuse or impulsive aggression.

The severity of a TBI is graded from mild to severe, according to the physical, neurologic, and psychiatric findings at the time of the injury, and not by the subsequent neuropsychiatric changes, Dr. Wortzel emphasized.

"Mild traumatic injuries are different from moderate and severe traumatic brain injuries in terms of outcomes, expected recovery, and the likelihood that neuropsychiatric symptoms, whether [they] be aggression or others down the road, are directly referable to neuronal injury from that event," he said.

Neurobehavioral outcomes after a TBI arise from a combination of pre-injury factors, the nature of the injury itself, and post-injury psychosocial factors. Changes might be come in the domains of cognition (such as disturbed consciousness or impaired attention), emotion (depression, anxiety, lability), behavior (aggression, disinhibition, apathy), and physical (visual problems, vertigo, seizures).

Pre-injury factors contributing to acquired aggression include age and gender, baseline intellectual function, psychiatric problems and substance abuse, sociopathy, risk-taking/novelty seeking behaviors, premorbid behavioral problems, social circumstance, and neurogenetic factors, such as the apolipoprotein E4 allele.

Factors that might exacerbate neuropsychiatric problems after an injury include medical complications, delay in receiving rehabilitative services, lack of education about the course of recovery and interpretation of symptoms, poor family or social support, premature return to work or school, and litigation or other legal problems.

"Sometimes as clinicians, it’s sufficient to say that aggression in general might be related to this traumatic brain injury."

Most people who sustain a mild TBI will recover fully and fairly quickly, Dr. Wortzel said. However, anywhere from 35% to 60% of people who sustain moderate to severe TBI develop chronic neurobehavioral and/or physical symptoms related to the injury, and the more severe the initial injury, the lower the chance of full neurological, neurobehavioral, and functional recovery, Dr. Wortzel said.

He noted that the nature and quality of violent behavior, plus the circumstances under which it occurs, provide clues to whether the aggression might be related to TBI or to some other cause, such as intoxication, delirium, or premorbid antisocial traits.

In a study of 279 Vietnam War veterans with penetrating TBIs, Jordan Grafman, Ph.D., and his colleagues found that frontal ventromedial lesions were significantly associated with higher scores for aggression and violence, although the higher scores were generally associated more with verbal confrontations than with physical assaults (Neurology 1996;46:1231-8).

"It is worth keeping in mind that injury is not destiny, and that most people who sustain brain injuries don’t hurt other people," he said.

Dr. Wortzel’s work is supported in part by the Veterans Affairs’ Mental Illness Research, Education and Clinical Centers. He reported having no relevant financial disclosures.

BOSTON – U.S. correctional institutions are estimated to be housing 1 million men and women with serious mental illnesses such as schizophrenia or a major affective disorder, investigators reported at the annual meeting of the American Academy of Psychiatry and the Law.

The estimated prevalence of serious mental disorders among U.S. inmates ranges from 7% to 16%. Men with mental illness are four times more likely to be incarcerated than the general population, and women with mental illness have an eightfold higher risk, reported Georgia Stathopoulou, Ph.D., and her colleagues from Massachusetts General Hospital and Harvard Medical School, both in Boston.

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population, and is associated with specific sociodemographic characteristics like male gender, younger age, and non-white race. Severe psychopathology is also associated with higher recidivism and more serious criminal offenses," wrote Dr. Stathopoulou and colleagues Dr. Fabian Saleh and Kristen Czarnecki in a poster presentation.

The investigators reviewed the medical literature and U.S. Department of Justice statistics to get a handle on the size of the problem.

They found that about 804,000 people with severe mental disorders are jailed annually, and that 72% of both men and women with serious mental illness who are in jail had a co-occurring substance use disorder.

The high rates of substance use and abuse is one of the primary factors contributing to the high incarceration rate of the mentally ill, they said. Other factors, they said, are:

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population."

• Insufficient community resources.

• A national drug policy that emphasizes interdiction over treatment.

• Delays in release from prisons and jails to the community.

• Insufficient inmate access to evidence-based mental health therapies.

• Insufficient planning for reentry of mental health inmates into the community.

Jail inmates with mental health disorders are twice as likely as inmates without mental illness to have been homeless in the year before their arrest (13% vs. 6%), 3 times more likely to report a history of sexual or physical abuse (24% vs. 8%), and twice as likely to have lived in a foster home or institution when they were growing up, the authors found.

Specific criminal actions associated with mental disorder diagnoses include higher rates of assault among inmates with bipolar disorder, and higher assault, homicide, and drug possession rates among those with schizophrenia or nonschizophrenic psychosis.

High Recidivism Rates

The investigators cited a retrospective study of more than 79,000 Texas inmates, which found that inmates with bipolar disorder were more than 3 times more likely than inmates without psychiatric disorders to be incarcerated 4 or more times during a 6-year period (Am. J. Psychiatry 2009;166:103-9).

Inmates with major depressive disorder, schizophrenia, and nonschizophrenic psychotic disorders also were significantly more likely to be imprisoned repeatedly, compared with the general prison population.

In all, 89% of the state public and private adult correctional facilities provide some type of mental health services to inmates. Of this group, 51% provide around-the-clock services, 71% offer therapy or counseling from trained mental health professional, and 73% dispense psychotropic drugs.

"We need new treatments, and these treatments have to be evidence based. These treatments have to address both public safety and the clinical needs of inmates," Dr. Stathopoulou said in an interview.

The authors did not disclose a funding source for the study. Dr. Stathopoulou reported that she had no relevant conflicts of interest.

BOSTON – U.S. correctional institutions are estimated to be housing 1 million men and women with serious mental illnesses such as schizophrenia or a major affective disorder, investigators reported at the annual meeting of the American Academy of Psychiatry and the Law.

The estimated prevalence of serious mental disorders among U.S. inmates ranges from 7% to 16%. Men with mental illness are four times more likely to be incarcerated than the general population, and women with mental illness have an eightfold higher risk, reported Georgia Stathopoulou, Ph.D., and her colleagues from Massachusetts General Hospital and Harvard Medical School, both in Boston.

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population, and is associated with specific sociodemographic characteristics like male gender, younger age, and non-white race. Severe psychopathology is also associated with higher recidivism and more serious criminal offenses," wrote Dr. Stathopoulou and colleagues Dr. Fabian Saleh and Kristen Czarnecki in a poster presentation.

The investigators reviewed the medical literature and U.S. Department of Justice statistics to get a handle on the size of the problem.

They found that about 804,000 people with severe mental disorders are jailed annually, and that 72% of both men and women with serious mental illness who are in jail had a co-occurring substance use disorder.

The high rates of substance use and abuse is one of the primary factors contributing to the high incarceration rate of the mentally ill, they said. Other factors, they said, are:

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population."

• Insufficient community resources.

• A national drug policy that emphasizes interdiction over treatment.

• Delays in release from prisons and jails to the community.

• Insufficient inmate access to evidence-based mental health therapies.

• Insufficient planning for reentry of mental health inmates into the community.

Jail inmates with mental health disorders are twice as likely as inmates without mental illness to have been homeless in the year before their arrest (13% vs. 6%), 3 times more likely to report a history of sexual or physical abuse (24% vs. 8%), and twice as likely to have lived in a foster home or institution when they were growing up, the authors found.

Specific criminal actions associated with mental disorder diagnoses include higher rates of assault among inmates with bipolar disorder, and higher assault, homicide, and drug possession rates among those with schizophrenia or nonschizophrenic psychosis.

High Recidivism Rates

The investigators cited a retrospective study of more than 79,000 Texas inmates, which found that inmates with bipolar disorder were more than 3 times more likely than inmates without psychiatric disorders to be incarcerated 4 or more times during a 6-year period (Am. J. Psychiatry 2009;166:103-9).

Inmates with major depressive disorder, schizophrenia, and nonschizophrenic psychotic disorders also were significantly more likely to be imprisoned repeatedly, compared with the general prison population.

In all, 89% of the state public and private adult correctional facilities provide some type of mental health services to inmates. Of this group, 51% provide around-the-clock services, 71% offer therapy or counseling from trained mental health professional, and 73% dispense psychotropic drugs.

"We need new treatments, and these treatments have to be evidence based. These treatments have to address both public safety and the clinical needs of inmates," Dr. Stathopoulou said in an interview.

The authors did not disclose a funding source for the study. Dr. Stathopoulou reported that she had no relevant conflicts of interest.

BOSTON – U.S. correctional institutions are estimated to be housing 1 million men and women with serious mental illnesses such as schizophrenia or a major affective disorder, investigators reported at the annual meeting of the American Academy of Psychiatry and the Law.

The estimated prevalence of serious mental disorders among U.S. inmates ranges from 7% to 16%. Men with mental illness are four times more likely to be incarcerated than the general population, and women with mental illness have an eightfold higher risk, reported Georgia Stathopoulou, Ph.D., and her colleagues from Massachusetts General Hospital and Harvard Medical School, both in Boston.

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population, and is associated with specific sociodemographic characteristics like male gender, younger age, and non-white race. Severe psychopathology is also associated with higher recidivism and more serious criminal offenses," wrote Dr. Stathopoulou and colleagues Dr. Fabian Saleh and Kristen Czarnecki in a poster presentation.

The investigators reviewed the medical literature and U.S. Department of Justice statistics to get a handle on the size of the problem.

They found that about 804,000 people with severe mental disorders are jailed annually, and that 72% of both men and women with serious mental illness who are in jail had a co-occurring substance use disorder.

The high rates of substance use and abuse is one of the primary factors contributing to the high incarceration rate of the mentally ill, they said. Other factors, they said, are:

"The prevalence of serious mental health issues is higher among incarcerated individuals than in the general population."

• Insufficient community resources.

• A national drug policy that emphasizes interdiction over treatment.

• Delays in release from prisons and jails to the community.

• Insufficient inmate access to evidence-based mental health therapies.

• Insufficient planning for reentry of mental health inmates into the community.

Jail inmates with mental health disorders are twice as likely as inmates without mental illness to have been homeless in the year before their arrest (13% vs. 6%), 3 times more likely to report a history of sexual or physical abuse (24% vs. 8%), and twice as likely to have lived in a foster home or institution when they were growing up, the authors found.

Specific criminal actions associated with mental disorder diagnoses include higher rates of assault among inmates with bipolar disorder, and higher assault, homicide, and drug possession rates among those with schizophrenia or nonschizophrenic psychosis.

High Recidivism Rates

The investigators cited a retrospective study of more than 79,000 Texas inmates, which found that inmates with bipolar disorder were more than 3 times more likely than inmates without psychiatric disorders to be incarcerated 4 or more times during a 6-year period (Am. J. Psychiatry 2009;166:103-9).

Inmates with major depressive disorder, schizophrenia, and nonschizophrenic psychotic disorders also were significantly more likely to be imprisoned repeatedly, compared with the general prison population.

In all, 89% of the state public and private adult correctional facilities provide some type of mental health services to inmates. Of this group, 51% provide around-the-clock services, 71% offer therapy or counseling from trained mental health professional, and 73% dispense psychotropic drugs.

"We need new treatments, and these treatments have to be evidence based. These treatments have to address both public safety and the clinical needs of inmates," Dr. Stathopoulou said in an interview.

The authors did not disclose a funding source for the study. Dr. Stathopoulou reported that she had no relevant conflicts of interest.

BOSTON – When courts decide which parent gets custody in a divorce or separation, the emotional stability of the mother and the criminal record – or lack thereof – of the father appear to matter most, researchers reported at the annual meeting of the American Academy of Psychiatry and the Law.

Mothers are about 4-5 times more likely to receive sole custody when the father has a history of arrests. Fathers, in contrast, are nearly 10 times more likely to be granted custody if the mother has been involved with family services, found Dr. Jonathan M. Raub and his colleagues from the Cambridge Health Alliance, Boston.

Previous studies of the factors influencing custody decision have been qualitative. The authors of the current study, outlined in a poster presentation, wanted to paint a quantitative picture of specific variables that predict current custody and the recommendations of family service providers.

They reviewed 183 charts from the Middlesex County (Mass.) Probate and Family Court clinic. The records included items from intake questionnaires and clinic recommendations that were coded for outcome variables such as custody prior to clinic evaluation, and predictor variables specific to the biological parents, including factors such race/ethnicity, income, education level, history of outpatient mental health treatment and psychiatric hospitalizations, substance use, arrest history, and history of family services contact. Interparental hostility characterized by both parents also was a predictor variable.

The authors hypothesized that sole custody awards would be negatively correlated with low income, lack of education, arrest history, family service involvement, and mental health treatment/hospitalization. They also postulated that the flip side would be true – that sole custody would positively correlate with higher income and education levels.

Furthermore, they further predicted that having at least one child with a history of mental health problems would be associated with a lower likelihood that the father would get sole custody. In addition, the researchers predicted that joint custody would be more likely when parents reported communicating with each other.

In multiple logistic regression analysis, they found the factors that mitigated against the mother’s sole custody were history of psychiatric hospitalizations (odds ratio, 0.24), her involvement with family services (OR, 0.25 for current custody status; 0.35 for recommendation of sole custody), annual income below $20,000 (0.28), father’s lower education level (0.35), and history of substance use (0.37). In contrast, mothers were more likely to have sole custody at the time of evaluation if the father has an arrest record (5.7) and to be recommended for sole custody if the father previously had been arrested (4.53).

Factors counting against the fathers’ chance of sole custody were his arrest history (OR, 0.31 for current custody; 0.37 for recommendation of sole custody), lower education level (0.35), and having a child treated for mental health issues (0.28 for current custody; 0.36 for recommended). Fathers were more likely to be (or be recommended as) the sole custodial parent if the mother had involvement with family services (9.82 current, 3.46 recommended), and if the mother had low income (8.18).

"These results suggest that emotional stability appears to be more relevant for mothers and a criminal record more relevant for fathers in both pre-evaluation custody arrangements and court clinic recommendations," wrote the investigators, who also are affiliated with Harvard Medical School and Harvard School of Public Health, both in Boston.

The study was supported by the Cambridge Health Alliance. The authors reported that they had no relevant conflicts of interest.

BOSTON – When courts decide which parent gets custody in a divorce or separation, the emotional stability of the mother and the criminal record – or lack thereof – of the father appear to matter most, researchers reported at the annual meeting of the American Academy of Psychiatry and the Law.

Mothers are about 4-5 times more likely to receive sole custody when the father has a history of arrests. Fathers, in contrast, are nearly 10 times more likely to be granted custody if the mother has been involved with family services, found Dr. Jonathan M. Raub and his colleagues from the Cambridge Health Alliance, Boston.

Previous studies of the factors influencing custody decision have been qualitative. The authors of the current study, outlined in a poster presentation, wanted to paint a quantitative picture of specific variables that predict current custody and the recommendations of family service providers.

They reviewed 183 charts from the Middlesex County (Mass.) Probate and Family Court clinic. The records included items from intake questionnaires and clinic recommendations that were coded for outcome variables such as custody prior to clinic evaluation, and predictor variables specific to the biological parents, including factors such race/ethnicity, income, education level, history of outpatient mental health treatment and psychiatric hospitalizations, substance use, arrest history, and history of family services contact. Interparental hostility characterized by both parents also was a predictor variable.

The authors hypothesized that sole custody awards would be negatively correlated with low income, lack of education, arrest history, family service involvement, and mental health treatment/hospitalization. They also postulated that the flip side would be true – that sole custody would positively correlate with higher income and education levels.

Furthermore, they further predicted that having at least one child with a history of mental health problems would be associated with a lower likelihood that the father would get sole custody. In addition, the researchers predicted that joint custody would be more likely when parents reported communicating with each other.

In multiple logistic regression analysis, they found the factors that mitigated against the mother’s sole custody were history of psychiatric hospitalizations (odds ratio, 0.24), her involvement with family services (OR, 0.25 for current custody status; 0.35 for recommendation of sole custody), annual income below $20,000 (0.28), father’s lower education level (0.35), and history of substance use (0.37). In contrast, mothers were more likely to have sole custody at the time of evaluation if the father has an arrest record (5.7) and to be recommended for sole custody if the father previously had been arrested (4.53).

Factors counting against the fathers’ chance of sole custody were his arrest history (OR, 0.31 for current custody; 0.37 for recommendation of sole custody), lower education level (0.35), and having a child treated for mental health issues (0.28 for current custody; 0.36 for recommended). Fathers were more likely to be (or be recommended as) the sole custodial parent if the mother had involvement with family services (9.82 current, 3.46 recommended), and if the mother had low income (8.18).

"These results suggest that emotional stability appears to be more relevant for mothers and a criminal record more relevant for fathers in both pre-evaluation custody arrangements and court clinic recommendations," wrote the investigators, who also are affiliated with Harvard Medical School and Harvard School of Public Health, both in Boston.

The study was supported by the Cambridge Health Alliance. The authors reported that they had no relevant conflicts of interest.

BOSTON – When courts decide which parent gets custody in a divorce or separation, the emotional stability of the mother and the criminal record – or lack thereof – of the father appear to matter most, researchers reported at the annual meeting of the American Academy of Psychiatry and the Law.

Mothers are about 4-5 times more likely to receive sole custody when the father has a history of arrests. Fathers, in contrast, are nearly 10 times more likely to be granted custody if the mother has been involved with family services, found Dr. Jonathan M. Raub and his colleagues from the Cambridge Health Alliance, Boston.

Previous studies of the factors influencing custody decision have been qualitative. The authors of the current study, outlined in a poster presentation, wanted to paint a quantitative picture of specific variables that predict current custody and the recommendations of family service providers.

They reviewed 183 charts from the Middlesex County (Mass.) Probate and Family Court clinic. The records included items from intake questionnaires and clinic recommendations that were coded for outcome variables such as custody prior to clinic evaluation, and predictor variables specific to the biological parents, including factors such race/ethnicity, income, education level, history of outpatient mental health treatment and psychiatric hospitalizations, substance use, arrest history, and history of family services contact. Interparental hostility characterized by both parents also was a predictor variable.

The authors hypothesized that sole custody awards would be negatively correlated with low income, lack of education, arrest history, family service involvement, and mental health treatment/hospitalization. They also postulated that the flip side would be true – that sole custody would positively correlate with higher income and education levels.

Furthermore, they further predicted that having at least one child with a history of mental health problems would be associated with a lower likelihood that the father would get sole custody. In addition, the researchers predicted that joint custody would be more likely when parents reported communicating with each other.

In multiple logistic regression analysis, they found the factors that mitigated against the mother’s sole custody were history of psychiatric hospitalizations (odds ratio, 0.24), her involvement with family services (OR, 0.25 for current custody status; 0.35 for recommendation of sole custody), annual income below $20,000 (0.28), father’s lower education level (0.35), and history of substance use (0.37). In contrast, mothers were more likely to have sole custody at the time of evaluation if the father has an arrest record (5.7) and to be recommended for sole custody if the father previously had been arrested (4.53).

Factors counting against the fathers’ chance of sole custody were his arrest history (OR, 0.31 for current custody; 0.37 for recommendation of sole custody), lower education level (0.35), and having a child treated for mental health issues (0.28 for current custody; 0.36 for recommended). Fathers were more likely to be (or be recommended as) the sole custodial parent if the mother had involvement with family services (9.82 current, 3.46 recommended), and if the mother had low income (8.18).

"These results suggest that emotional stability appears to be more relevant for mothers and a criminal record more relevant for fathers in both pre-evaluation custody arrangements and court clinic recommendations," wrote the investigators, who also are affiliated with Harvard Medical School and Harvard School of Public Health, both in Boston.

The study was supported by the Cambridge Health Alliance. The authors reported that they had no relevant conflicts of interest.

BOSTON – Family violence is not limited to spousal or child abuse: Adolescents and preteens are also capable of violent, destructive behavior against family members, said an Australian investigator at the annual meeting of the American Academy of Psychiatry and the Law.

Nearly half of all restraining-order applications from a large children’s court in Australia were related to child-to-parent violence, reported Mr. Gennady Baksheev, a research fellow at the University of Melbourne.

Most of the violence was related to long-standing behavioral problems, with the perpetrators primarily being males and the victims primarily females. In 58% of the cases, the violent episodes occurred in single-parent households.

"Family violence perpetrated by children against their parents or siblings has received little attention, although it is increasingly being recognized as a serious problem for social services, law enforcement, and the courts," Mr. Baksheev said.

The medical literature has consistently shown that the "battered parent syndrome" is most frequently perpetrated by boys against their mothers, and that boys are more likely to engage in physically abusive behaviors, whereas girls are more likely to be emotionally or verbally abusive, he said.

Estimates of the prevalence of child-to-parent violence range from 7% to 56%, with differences in research methods and definitions accounting for the discrepancy. Explanations for this type of behavior include disturbances in family hierarchy, parents with harsh or punitive control strategies, familial conflict (including witnessing and modeling of parental violence), and psychiatric and/or behavioral disturbances among juveniles, Mr. Baksheev noted.

He and his colleagues conducted a retrospective audit of consecutive court records from the Melbourne Children’s Court, looking for applications for restraining orders against juvenile defendants. The records included the characteristics of the victims and perpetrators, the nature of the behavior prompting the applications, and the precipitants of the perpetrators’ behavior.

In all, 438 of the 928 applications filed during the study period met the criteria for juvenile family violence. Half of the applications (50%) were filed by the primary victim; most of the remaining half (49.4%) were filed by an adult on behalf of the victim. Nearly one-third of the applications (30%) were filed outside of normal court hours, suggesting emergencies.

Of the 438 perpetrators, 300 (69%) were boys. The mean age was 15.9 years (range, 12-18 years). Two-thirds of the sample (66%) were living in single-parent households, and 19.5% were living with both parents. (The remaining living arrangements were not specified.) In all, 14% of the perpetrators had a diagnosis of mental illness.

More than three-fourths of the victims (77%) were female, with a mean age of 40.2 years (range, 5-78 years). The victim was a parent in 78% of the cases, a sibling in 11%, and another relative, such as a stepsibling or grandparent, in 9%. (The remaining 2% were not specified.)

About 50% of the cases involved threats to the victim, 55% involved assaults, and 60% involved damage to property.

The motivation for violence was attributed to behavioral problems in 52% of cases, intimidation in 13%, family problems in 10%, retaliation in 9%, drug issues in 8%, mental disorders in 6%, and sexual predation in 2%.

In all, 56% of applications for restraining orders were not granted, but fewer than a third of these were attributable to court refusal. The majority were not granted because the victim refused to proceed. An analysis showed that not proceeding with a restraining order was significantly associated with the applicant being the primary victim (P less than .001).

In a post hoc analysis, the authors found that restraining orders were nearly 1.8 times more likely to be granted against male vs. female defendants. One-third of all restraining orders (32%) issued were subsequently breached, Mr. Baksheev said.

"The legal and social consequences of this are serious and sobering both for the family and the defendant who may be subject to criminal charges," Mr. Baksheev said.

Mr. Baksheev’s study was supported by the Ian Potter Foundation. He reported that he had no relevant financial disclosures.

BOSTON – Family violence is not limited to spousal or child abuse: Adolescents and preteens are also capable of violent, destructive behavior against family members, said an Australian investigator at the annual meeting of the American Academy of Psychiatry and the Law.

Nearly half of all restraining-order applications from a large children’s court in Australia were related to child-to-parent violence, reported Mr. Gennady Baksheev, a research fellow at the University of Melbourne.

Most of the violence was related to long-standing behavioral problems, with the perpetrators primarily being males and the victims primarily females. In 58% of the cases, the violent episodes occurred in single-parent households.

"Family violence perpetrated by children against their parents or siblings has received little attention, although it is increasingly being recognized as a serious problem for social services, law enforcement, and the courts," Mr. Baksheev said.

The medical literature has consistently shown that the "battered parent syndrome" is most frequently perpetrated by boys against their mothers, and that boys are more likely to engage in physically abusive behaviors, whereas girls are more likely to be emotionally or verbally abusive, he said.

Estimates of the prevalence of child-to-parent violence range from 7% to 56%, with differences in research methods and definitions accounting for the discrepancy. Explanations for this type of behavior include disturbances in family hierarchy, parents with harsh or punitive control strategies, familial conflict (including witnessing and modeling of parental violence), and psychiatric and/or behavioral disturbances among juveniles, Mr. Baksheev noted.

He and his colleagues conducted a retrospective audit of consecutive court records from the Melbourne Children’s Court, looking for applications for restraining orders against juvenile defendants. The records included the characteristics of the victims and perpetrators, the nature of the behavior prompting the applications, and the precipitants of the perpetrators’ behavior.

In all, 438 of the 928 applications filed during the study period met the criteria for juvenile family violence. Half of the applications (50%) were filed by the primary victim; most of the remaining half (49.4%) were filed by an adult on behalf of the victim. Nearly one-third of the applications (30%) were filed outside of normal court hours, suggesting emergencies.

Of the 438 perpetrators, 300 (69%) were boys. The mean age was 15.9 years (range, 12-18 years). Two-thirds of the sample (66%) were living in single-parent households, and 19.5% were living with both parents. (The remaining living arrangements were not specified.) In all, 14% of the perpetrators had a diagnosis of mental illness.

More than three-fourths of the victims (77%) were female, with a mean age of 40.2 years (range, 5-78 years). The victim was a parent in 78% of the cases, a sibling in 11%, and another relative, such as a stepsibling or grandparent, in 9%. (The remaining 2% were not specified.)

About 50% of the cases involved threats to the victim, 55% involved assaults, and 60% involved damage to property.

The motivation for violence was attributed to behavioral problems in 52% of cases, intimidation in 13%, family problems in 10%, retaliation in 9%, drug issues in 8%, mental disorders in 6%, and sexual predation in 2%.

In all, 56% of applications for restraining orders were not granted, but fewer than a third of these were attributable to court refusal. The majority were not granted because the victim refused to proceed. An analysis showed that not proceeding with a restraining order was significantly associated with the applicant being the primary victim (P less than .001).

In a post hoc analysis, the authors found that restraining orders were nearly 1.8 times more likely to be granted against male vs. female defendants. One-third of all restraining orders (32%) issued were subsequently breached, Mr. Baksheev said.

"The legal and social consequences of this are serious and sobering both for the family and the defendant who may be subject to criminal charges," Mr. Baksheev said.

Mr. Baksheev’s study was supported by the Ian Potter Foundation. He reported that he had no relevant financial disclosures.

BOSTON – Family violence is not limited to spousal or child abuse: Adolescents and preteens are also capable of violent, destructive behavior against family members, said an Australian investigator at the annual meeting of the American Academy of Psychiatry and the Law.

Nearly half of all restraining-order applications from a large children’s court in Australia were related to child-to-parent violence, reported Mr. Gennady Baksheev, a research fellow at the University of Melbourne.

Most of the violence was related to long-standing behavioral problems, with the perpetrators primarily being males and the victims primarily females. In 58% of the cases, the violent episodes occurred in single-parent households.

"Family violence perpetrated by children against their parents or siblings has received little attention, although it is increasingly being recognized as a serious problem for social services, law enforcement, and the courts," Mr. Baksheev said.

The medical literature has consistently shown that the "battered parent syndrome" is most frequently perpetrated by boys against their mothers, and that boys are more likely to engage in physically abusive behaviors, whereas girls are more likely to be emotionally or verbally abusive, he said.

Estimates of the prevalence of child-to-parent violence range from 7% to 56%, with differences in research methods and definitions accounting for the discrepancy. Explanations for this type of behavior include disturbances in family hierarchy, parents with harsh or punitive control strategies, familial conflict (including witnessing and modeling of parental violence), and psychiatric and/or behavioral disturbances among juveniles, Mr. Baksheev noted.

He and his colleagues conducted a retrospective audit of consecutive court records from the Melbourne Children’s Court, looking for applications for restraining orders against juvenile defendants. The records included the characteristics of the victims and perpetrators, the nature of the behavior prompting the applications, and the precipitants of the perpetrators’ behavior.

In all, 438 of the 928 applications filed during the study period met the criteria for juvenile family violence. Half of the applications (50%) were filed by the primary victim; most of the remaining half (49.4%) were filed by an adult on behalf of the victim. Nearly one-third of the applications (30%) were filed outside of normal court hours, suggesting emergencies.

Of the 438 perpetrators, 300 (69%) were boys. The mean age was 15.9 years (range, 12-18 years). Two-thirds of the sample (66%) were living in single-parent households, and 19.5% were living with both parents. (The remaining living arrangements were not specified.) In all, 14% of the perpetrators had a diagnosis of mental illness.

More than three-fourths of the victims (77%) were female, with a mean age of 40.2 years (range, 5-78 years). The victim was a parent in 78% of the cases, a sibling in 11%, and another relative, such as a stepsibling or grandparent, in 9%. (The remaining 2% were not specified.)

About 50% of the cases involved threats to the victim, 55% involved assaults, and 60% involved damage to property.

The motivation for violence was attributed to behavioral problems in 52% of cases, intimidation in 13%, family problems in 10%, retaliation in 9%, drug issues in 8%, mental disorders in 6%, and sexual predation in 2%.

In all, 56% of applications for restraining orders were not granted, but fewer than a third of these were attributable to court refusal. The majority were not granted because the victim refused to proceed. An analysis showed that not proceeding with a restraining order was significantly associated with the applicant being the primary victim (P less than .001).

In a post hoc analysis, the authors found that restraining orders were nearly 1.8 times more likely to be granted against male vs. female defendants. One-third of all restraining orders (32%) issued were subsequently breached, Mr. Baksheev said.

"The legal and social consequences of this are serious and sobering both for the family and the defendant who may be subject to criminal charges," Mr. Baksheev said.

Mr. Baksheev’s study was supported by the Ian Potter Foundation. He reported that he had no relevant financial disclosures.

BOSTON – Children singled out for abuse either in person or through cyberbullying are more prone to long-term depression, significantly poorer mental and physical health, and suicidal thoughts and actions than their peers who are spared from bullying, said investigators at the annual meeting of the American Academy of Psychiatry and the Law.

Children seen as outsiders by their peers – those with developmental disabilities, mental health problems, and gays or lesbians – are the most common targets of bullies both in the schoolyard and online, said Dr. Eileen P. Ryan from the University of Virginia in Charlottesville.

With cyberbullying – a term that encompasses remote, electronic bullying done on e-mail, role-playing game sites, YouTube, Facebook, and other online venues – the perpetrator doesn’t need to be in the same room or the same town as the victim. In addition, the bully can be physically weaker than his target.

"This is where the little red-headed, freckled, pale child is able to bully the quarterback of the high school football team," said Dr. Bradley Freeman of Vanderbilt University in Nashville, Tenn.

Dr. Ryan cited a definition of bullying by Dan Olweus, Ph.D., a Swedish psychologist and bullying expert: "A person is bullied when he or she is subjected repeatedly and over time to negative action on the part of one or more people."

The U.S. attorney general’s office defines cyberbullying as "use of electronic devices and information such as e-mail instant messaging, text messages, mobile phones, pager, and websites to send or post cruel or harmful messages or images about an individual or group."

Both forms of bullying can have severe mental health consequences for both the victim and the bully, Dr. Ryan said. Although it is widely thought to become less prevalent with age, 20%-30% of 8th through 12th graders have reported frequent involvement in bullying as a victim, bully, or both. A 2001 study from the National Institute for Child Health and Human Development found that nearly 30% of a representative sample of 15,686 6th through 10th graders reported moderate or frequent involvement in bullying: 13% as bullies, 10.6% as victims, and 6.3% as both, with boys more frequently being both the bully and the bullied (JAMA 2001;285:2094-100).

In the Pittsburgh Youth Study, a prospective cohort study of 503 boys followed from ages 6 through 19, being a bully at age 10 was the strongest predictor of delinquency. The study showed that 32.6% of bullies become delinquents, compared with 22.5% of nonbullies. In addition, being a victim at age 19 was the strongest predictor of depression, with 32% of victims having depression, compared with 22.7% of nonvictims, Dr. Ryan said (J. Aggress. Confl. Peace Res. 2011 June 9 [10.1108/17596591111132882]).

A recent meta-analysis from investigators at the University of Cambridge (England), found that the probability of being depressed up to 36 years later was much higher among people who had been bullied at school, compared with nonvictims. The authors also found that the probability of offending up to 11 years later was much higher for school bullies than noninvolved students, she noted (Crim. Behav. Ment. Health 2011;21:80-9).

Girls who bully, even infrequently, appear to be at increased risk for suicide, while among boys, only those who bully frequently are at increased risk.

"Suicidal behavior among male bullies may be a function of psychopathology rather than bullying, per se," Dr. Ryan said.

Equal Opportunity Bullies

Cyberbullies often carry out their abuse anonymously, but according to a 2004 survey of Internet users, 84% of cyberbullies knew their victim in person, and 31% of victims said they knew the bullies.

Cyberbullying increases with age, with males about twice as likely as females to be the electronic bullies (22% to 12%, respectively), Dr. Freeman said. He pointed to a 2007 studywhich found that 38% of cyberbullies said they participated in the activity for fun, 25% for retaliation, and 6% because they felt bad about themselves (J. Adolesc. Health 2007;41[6 suppl. 1]:S1-5).

As with old-fashioned bullying, victims might experience loss of self-esteem, depression, hopelessness, psychosomatic symptoms, or attempted or actual suicide.

Antibullying Legislation

At least 23 states have enacted laws directing school districts to draft policies against bullying, harassment, and intimidation among students; seven states require schools to have disciplinary procedures or consequences, said Dr. Karen Rosenbaum, of New York University.

Many of the laws have been enacted in response to high profile cases of teens who committed suicide after being bullied online and in person.

For example, after the 2010 bullying-induced suicide of Phoebe Prince, a 15-year-old Irish immigrant who had recently enrolled at a high school in South Hadley, Mass., the state of Massachusetts enacted a law that bans bullying on all school grounds, buses, and activities. The law also mandates that every incident be investigated by school officials and reported to the parents of the students involved.

StopBullying.gov, a federal government website, recommends a number of steps to prevent or stop bullying.

The researchers did not disclose funding sources for their studies. Dr. Ryan, Dr. Freeman, and Dr. Rosenbaum each declared that they have no financial conflicts of interest.

BOSTON – Children singled out for abuse either in person or through cyberbullying are more prone to long-term depression, significantly poorer mental and physical health, and suicidal thoughts and actions than their peers who are spared from bullying, said investigators at the annual meeting of the American Academy of Psychiatry and the Law.

Children seen as outsiders by their peers – those with developmental disabilities, mental health problems, and gays or lesbians – are the most common targets of bullies both in the schoolyard and online, said Dr. Eileen P. Ryan from the University of Virginia in Charlottesville.

With cyberbullying – a term that encompasses remote, electronic bullying done on e-mail, role-playing game sites, YouTube, Facebook, and other online venues – the perpetrator doesn’t need to be in the same room or the same town as the victim. In addition, the bully can be physically weaker than his target.

"This is where the little red-headed, freckled, pale child is able to bully the quarterback of the high school football team," said Dr. Bradley Freeman of Vanderbilt University in Nashville, Tenn.

Dr. Ryan cited a definition of bullying by Dan Olweus, Ph.D., a Swedish psychologist and bullying expert: "A person is bullied when he or she is subjected repeatedly and over time to negative action on the part of one or more people."

The U.S. attorney general’s office defines cyberbullying as "use of electronic devices and information such as e-mail instant messaging, text messages, mobile phones, pager, and websites to send or post cruel or harmful messages or images about an individual or group."

Both forms of bullying can have severe mental health consequences for both the victim and the bully, Dr. Ryan said. Although it is widely thought to become less prevalent with age, 20%-30% of 8th through 12th graders have reported frequent involvement in bullying as a victim, bully, or both. A 2001 study from the National Institute for Child Health and Human Development found that nearly 30% of a representative sample of 15,686 6th through 10th graders reported moderate or frequent involvement in bullying: 13% as bullies, 10.6% as victims, and 6.3% as both, with boys more frequently being both the bully and the bullied (JAMA 2001;285:2094-100).

In the Pittsburgh Youth Study, a prospective cohort study of 503 boys followed from ages 6 through 19, being a bully at age 10 was the strongest predictor of delinquency. The study showed that 32.6% of bullies become delinquents, compared with 22.5% of nonbullies. In addition, being a victim at age 19 was the strongest predictor of depression, with 32% of victims having depression, compared with 22.7% of nonvictims, Dr. Ryan said (J. Aggress. Confl. Peace Res. 2011 June 9 [10.1108/17596591111132882]).

A recent meta-analysis from investigators at the University of Cambridge (England), found that the probability of being depressed up to 36 years later was much higher among people who had been bullied at school, compared with nonvictims. The authors also found that the probability of offending up to 11 years later was much higher for school bullies than noninvolved students, she noted (Crim. Behav. Ment. Health 2011;21:80-9).

Girls who bully, even infrequently, appear to be at increased risk for suicide, while among boys, only those who bully frequently are at increased risk.

"Suicidal behavior among male bullies may be a function of psychopathology rather than bullying, per se," Dr. Ryan said.

Equal Opportunity Bullies

Cyberbullies often carry out their abuse anonymously, but according to a 2004 survey of Internet users, 84% of cyberbullies knew their victim in person, and 31% of victims said they knew the bullies.

Cyberbullying increases with age, with males about twice as likely as females to be the electronic bullies (22% to 12%, respectively), Dr. Freeman said. He pointed to a 2007 studywhich found that 38% of cyberbullies said they participated in the activity for fun, 25% for retaliation, and 6% because they felt bad about themselves (J. Adolesc. Health 2007;41[6 suppl. 1]:S1-5).

As with old-fashioned bullying, victims might experience loss of self-esteem, depression, hopelessness, psychosomatic symptoms, or attempted or actual suicide.

Antibullying Legislation

At least 23 states have enacted laws directing school districts to draft policies against bullying, harassment, and intimidation among students; seven states require schools to have disciplinary procedures or consequences, said Dr. Karen Rosenbaum, of New York University.

Many of the laws have been enacted in response to high profile cases of teens who committed suicide after being bullied online and in person.

For example, after the 2010 bullying-induced suicide of Phoebe Prince, a 15-year-old Irish immigrant who had recently enrolled at a high school in South Hadley, Mass., the state of Massachusetts enacted a law that bans bullying on all school grounds, buses, and activities. The law also mandates that every incident be investigated by school officials and reported to the parents of the students involved.

StopBullying.gov, a federal government website, recommends a number of steps to prevent or stop bullying.

The researchers did not disclose funding sources for their studies. Dr. Ryan, Dr. Freeman, and Dr. Rosenbaum each declared that they have no financial conflicts of interest.

BOSTON – Children singled out for abuse either in person or through cyberbullying are more prone to long-term depression, significantly poorer mental and physical health, and suicidal thoughts and actions than their peers who are spared from bullying, said investigators at the annual meeting of the American Academy of Psychiatry and the Law.

Children seen as outsiders by their peers – those with developmental disabilities, mental health problems, and gays or lesbians – are the most common targets of bullies both in the schoolyard and online, said Dr. Eileen P. Ryan from the University of Virginia in Charlottesville.

With cyberbullying – a term that encompasses remote, electronic bullying done on e-mail, role-playing game sites, YouTube, Facebook, and other online venues – the perpetrator doesn’t need to be in the same room or the same town as the victim. In addition, the bully can be physically weaker than his target.

"This is where the little red-headed, freckled, pale child is able to bully the quarterback of the high school football team," said Dr. Bradley Freeman of Vanderbilt University in Nashville, Tenn.

Dr. Ryan cited a definition of bullying by Dan Olweus, Ph.D., a Swedish psychologist and bullying expert: "A person is bullied when he or she is subjected repeatedly and over time to negative action on the part of one or more people."

The U.S. attorney general’s office defines cyberbullying as "use of electronic devices and information such as e-mail instant messaging, text messages, mobile phones, pager, and websites to send or post cruel or harmful messages or images about an individual or group."

Both forms of bullying can have severe mental health consequences for both the victim and the bully, Dr. Ryan said. Although it is widely thought to become less prevalent with age, 20%-30% of 8th through 12th graders have reported frequent involvement in bullying as a victim, bully, or both. A 2001 study from the National Institute for Child Health and Human Development found that nearly 30% of a representative sample of 15,686 6th through 10th graders reported moderate or frequent involvement in bullying: 13% as bullies, 10.6% as victims, and 6.3% as both, with boys more frequently being both the bully and the bullied (JAMA 2001;285:2094-100).

In the Pittsburgh Youth Study, a prospective cohort study of 503 boys followed from ages 6 through 19, being a bully at age 10 was the strongest predictor of delinquency. The study showed that 32.6% of bullies become delinquents, compared with 22.5% of nonbullies. In addition, being a victim at age 19 was the strongest predictor of depression, with 32% of victims having depression, compared with 22.7% of nonvictims, Dr. Ryan said (J. Aggress. Confl. Peace Res. 2011 June 9 [10.1108/17596591111132882]).

A recent meta-analysis from investigators at the University of Cambridge (England), found that the probability of being depressed up to 36 years later was much higher among people who had been bullied at school, compared with nonvictims. The authors also found that the probability of offending up to 11 years later was much higher for school bullies than noninvolved students, she noted (Crim. Behav. Ment. Health 2011;21:80-9).

Girls who bully, even infrequently, appear to be at increased risk for suicide, while among boys, only those who bully frequently are at increased risk.

"Suicidal behavior among male bullies may be a function of psychopathology rather than bullying, per se," Dr. Ryan said.

Equal Opportunity Bullies

Cyberbullies often carry out their abuse anonymously, but according to a 2004 survey of Internet users, 84% of cyberbullies knew their victim in person, and 31% of victims said they knew the bullies.

Cyberbullying increases with age, with males about twice as likely as females to be the electronic bullies (22% to 12%, respectively), Dr. Freeman said. He pointed to a 2007 studywhich found that 38% of cyberbullies said they participated in the activity for fun, 25% for retaliation, and 6% because they felt bad about themselves (J. Adolesc. Health 2007;41[6 suppl. 1]:S1-5).

As with old-fashioned bullying, victims might experience loss of self-esteem, depression, hopelessness, psychosomatic symptoms, or attempted or actual suicide.

Antibullying Legislation

At least 23 states have enacted laws directing school districts to draft policies against bullying, harassment, and intimidation among students; seven states require schools to have disciplinary procedures or consequences, said Dr. Karen Rosenbaum, of New York University.

Many of the laws have been enacted in response to high profile cases of teens who committed suicide after being bullied online and in person.

For example, after the 2010 bullying-induced suicide of Phoebe Prince, a 15-year-old Irish immigrant who had recently enrolled at a high school in South Hadley, Mass., the state of Massachusetts enacted a law that bans bullying on all school grounds, buses, and activities. The law also mandates that every incident be investigated by school officials and reported to the parents of the students involved.

StopBullying.gov, a federal government website, recommends a number of steps to prevent or stop bullying.

The researchers did not disclose funding sources for their studies. Dr. Ryan, Dr. Freeman, and Dr. Rosenbaum each declared that they have no financial conflicts of interest.

BOSTON – Laws intended to keep convicted sex offenders far away from schools, playgrounds, shopping malls, and other places where children might gather don’t appear to work or aren’t being vigorously enforced in parts of the United States. And when the laws are adhered to, they often keep offenders far away from needed psychiatric services, job prospects, and social support, researchers said at the annual meeting of the American Academy of Psychiatry and the Law.

In Buffalo, N.Y., sex offenders are legally barred from living in all but 6.5% of the city’s total area, but more than 90% of sex offenders in the county live within that city’s limits, said Dr. Jacqueline A. Berenson, a forensic psychiatrist in private practice in New York City.

©Debra Morgan

"One of the conclusions that has come from a number of studies is that the legislation is not only not helping with the recidivism rate of sex offenders in the community, but may actually be worsening recidivism rates, and that the collateral damage being done by this legislation nationally is self-defeating," she said.

Residence restriction laws vary considerably in their components (who is an offender, where can’t they live, how far they must stay away), and in terms of complexity and ambiguity of the statutes, which vary in their definition, measurement of distance, and enforcement, Dr. Berenson noted.

For example, in Erie County, N.Y., alone, rules vary from one municipality to the next. In the city of Lackawanna, level 3 registered sex offenders or any registered offender over the age of 17 convicted of an offense (including statutory rape) upon a child age 16 or under is forbidden from living within 2,000 feet of any school, park, playground, athletic field, or day care center. In contrast, the Town of Evans and the Village of Sloan set a 1,500-foot boundary, with Sloan bylaws adding teen/community centers, dance halls, and skating rinks to exclusion zones. The law does not specify what constitutes a "teen/community center" or "dance hall."

Such laws, Dr. Berenson said, often force offenders to live in more rural areas where they might not have community or social support or access to services, or to violate the laws by living within an off-limits area and risk parole violation, rearrest, and imprisonment.

"Do they understand what the legislation means? Do their parole officers understand? And if they don’t understand, does that make them not culpable if they’re living in a restricted area? And the answer to that is ‘No’; if they’re living in a restricted area, the potential for being arrested and charged with a felony is real," she said.

A researcher who also studies housing issues of sex offenders, Andrew J. Harris, Ph.D., from the University of Massachusetts Lowell, cited the example of Miami-Dade County, Fla., where sex offenders were living in a makeshift encampment under a bridge on the Julia Tuttle Causeway, the only place they could find that didn’t violate that county’s residence restrictions. Some offenders even received state-issued IDs listing the causeway as their place of residence.

Mapping Offenders

Dr. Berenson reported results of a study that she and Dr. Paul S. Appelbaum of Columbia University, New York, conducted on the effect of residence statutes on the availability of residences for registered sex offenders in both urban and rural areas of Erie and Schenectady counties in New York.

They collected parcel data from the New York State Department of Cyber Security and the Schenectady County geographic information services department, and created overlay maps showing restricted locations according to statute, and residential locations of registered sex offenders.

Although they expected to find that most offenders were living in rural areas, where schools and playgrounds are more widely dispersed, they found that the opposite was true. In Erie County, 90% of offenders were living in restricted areas, and nearly all were within the city limits of Buffalo (91% of the city dwellers were living in restricted areas of Buffalo). Similarly, 90% of offenders in Schenectady County were living in restricted zones, and 100% of offenders living within the City of Schenectady were doing so afoul of the law.

In both counties, only a small percentage of rural residences were in restricted zones, whereas the large majority of multiple family residences or apartments, more commonly found in urban areas, were not legally available to offenders.

The implications of these findings, Dr. Berenson said, are that there may be inadequate resources or an unwillingness on the part of law enforcement agencies to follow the restriction statutes. She noted that courts have overturned sex offender residency laws in eight New York counties, and that the Washington County board of supervisors recently voted to repeal that county’s law.

"Policy makers should be pulling out the [geographic information services] software themselves and asking, ‘What is the actual impact of this legislation? What’s going to happen? Where are these guys going to go?’ " Dr. Harris said. "Housing is a matter of managing this inherent risk that people have for public safety and minimizing the collateral risk."

Dr. Berenson’s study was internally funded. Dr. Berenson and Dr. Harris reported that they had no relevant financial disclosures.

BOSTON – Laws intended to keep convicted sex offenders far away from schools, playgrounds, shopping malls, and other places where children might gather don’t appear to work or aren’t being vigorously enforced in parts of the United States. And when the laws are adhered to, they often keep offenders far away from needed psychiatric services, job prospects, and social support, researchers said at the annual meeting of the American Academy of Psychiatry and the Law.

In Buffalo, N.Y., sex offenders are legally barred from living in all but 6.5% of the city’s total area, but more than 90% of sex offenders in the county live within that city’s limits, said Dr. Jacqueline A. Berenson, a forensic psychiatrist in private practice in New York City.

©Debra Morgan

"One of the conclusions that has come from a number of studies is that the legislation is not only not helping with the recidivism rate of sex offenders in the community, but may actually be worsening recidivism rates, and that the collateral damage being done by this legislation nationally is self-defeating," she said.

Residence restriction laws vary considerably in their components (who is an offender, where can’t they live, how far they must stay away), and in terms of complexity and ambiguity of the statutes, which vary in their definition, measurement of distance, and enforcement, Dr. Berenson noted.

For example, in Erie County, N.Y., alone, rules vary from one municipality to the next. In the city of Lackawanna, level 3 registered sex offenders or any registered offender over the age of 17 convicted of an offense (including statutory rape) upon a child age 16 or under is forbidden from living within 2,000 feet of any school, park, playground, athletic field, or day care center. In contrast, the Town of Evans and the Village of Sloan set a 1,500-foot boundary, with Sloan bylaws adding teen/community centers, dance halls, and skating rinks to exclusion zones. The law does not specify what constitutes a "teen/community center" or "dance hall."

Such laws, Dr. Berenson said, often force offenders to live in more rural areas where they might not have community or social support or access to services, or to violate the laws by living within an off-limits area and risk parole violation, rearrest, and imprisonment.

"Do they understand what the legislation means? Do their parole officers understand? And if they don’t understand, does that make them not culpable if they’re living in a restricted area? And the answer to that is ‘No’; if they’re living in a restricted area, the potential for being arrested and charged with a felony is real," she said.

A researcher who also studies housing issues of sex offenders, Andrew J. Harris, Ph.D., from the University of Massachusetts Lowell, cited the example of Miami-Dade County, Fla., where sex offenders were living in a makeshift encampment under a bridge on the Julia Tuttle Causeway, the only place they could find that didn’t violate that county’s residence restrictions. Some offenders even received state-issued IDs listing the causeway as their place of residence.

Mapping Offenders

Dr. Berenson reported results of a study that she and Dr. Paul S. Appelbaum of Columbia University, New York, conducted on the effect of residence statutes on the availability of residences for registered sex offenders in both urban and rural areas of Erie and Schenectady counties in New York.

They collected parcel data from the New York State Department of Cyber Security and the Schenectady County geographic information services department, and created overlay maps showing restricted locations according to statute, and residential locations of registered sex offenders.

Although they expected to find that most offenders were living in rural areas, where schools and playgrounds are more widely dispersed, they found that the opposite was true. In Erie County, 90% of offenders were living in restricted areas, and nearly all were within the city limits of Buffalo (91% of the city dwellers were living in restricted areas of Buffalo). Similarly, 90% of offenders in Schenectady County were living in restricted zones, and 100% of offenders living within the City of Schenectady were doing so afoul of the law.

In both counties, only a small percentage of rural residences were in restricted zones, whereas the large majority of multiple family residences or apartments, more commonly found in urban areas, were not legally available to offenders.

The implications of these findings, Dr. Berenson said, are that there may be inadequate resources or an unwillingness on the part of law enforcement agencies to follow the restriction statutes. She noted that courts have overturned sex offender residency laws in eight New York counties, and that the Washington County board of supervisors recently voted to repeal that county’s law.

"Policy makers should be pulling out the [geographic information services] software themselves and asking, ‘What is the actual impact of this legislation? What’s going to happen? Where are these guys going to go?’ " Dr. Harris said. "Housing is a matter of managing this inherent risk that people have for public safety and minimizing the collateral risk."

Dr. Berenson’s study was internally funded. Dr. Berenson and Dr. Harris reported that they had no relevant financial disclosures.

BOSTON – Laws intended to keep convicted sex offenders far away from schools, playgrounds, shopping malls, and other places where children might gather don’t appear to work or aren’t being vigorously enforced in parts of the United States. And when the laws are adhered to, they often keep offenders far away from needed psychiatric services, job prospects, and social support, researchers said at the annual meeting of the American Academy of Psychiatry and the Law.

In Buffalo, N.Y., sex offenders are legally barred from living in all but 6.5% of the city’s total area, but more than 90% of sex offenders in the county live within that city’s limits, said Dr. Jacqueline A. Berenson, a forensic psychiatrist in private practice in New York City.

©Debra Morgan

"One of the conclusions that has come from a number of studies is that the legislation is not only not helping with the recidivism rate of sex offenders in the community, but may actually be worsening recidivism rates, and that the collateral damage being done by this legislation nationally is self-defeating," she said.

Residence restriction laws vary considerably in their components (who is an offender, where can’t they live, how far they must stay away), and in terms of complexity and ambiguity of the statutes, which vary in their definition, measurement of distance, and enforcement, Dr. Berenson noted.

For example, in Erie County, N.Y., alone, rules vary from one municipality to the next. In the city of Lackawanna, level 3 registered sex offenders or any registered offender over the age of 17 convicted of an offense (including statutory rape) upon a child age 16 or under is forbidden from living within 2,000 feet of any school, park, playground, athletic field, or day care center. In contrast, the Town of Evans and the Village of Sloan set a 1,500-foot boundary, with Sloan bylaws adding teen/community centers, dance halls, and skating rinks to exclusion zones. The law does not specify what constitutes a "teen/community center" or "dance hall."

Such laws, Dr. Berenson said, often force offenders to live in more rural areas where they might not have community or social support or access to services, or to violate the laws by living within an off-limits area and risk parole violation, rearrest, and imprisonment.

"Do they understand what the legislation means? Do their parole officers understand? And if they don’t understand, does that make them not culpable if they’re living in a restricted area? And the answer to that is ‘No’; if they’re living in a restricted area, the potential for being arrested and charged with a felony is real," she said.

A researcher who also studies housing issues of sex offenders, Andrew J. Harris, Ph.D., from the University of Massachusetts Lowell, cited the example of Miami-Dade County, Fla., where sex offenders were living in a makeshift encampment under a bridge on the Julia Tuttle Causeway, the only place they could find that didn’t violate that county’s residence restrictions. Some offenders even received state-issued IDs listing the causeway as their place of residence.

Mapping Offenders

Dr. Berenson reported results of a study that she and Dr. Paul S. Appelbaum of Columbia University, New York, conducted on the effect of residence statutes on the availability of residences for registered sex offenders in both urban and rural areas of Erie and Schenectady counties in New York.

They collected parcel data from the New York State Department of Cyber Security and the Schenectady County geographic information services department, and created overlay maps showing restricted locations according to statute, and residential locations of registered sex offenders.

Although they expected to find that most offenders were living in rural areas, where schools and playgrounds are more widely dispersed, they found that the opposite was true. In Erie County, 90% of offenders were living in restricted areas, and nearly all were within the city limits of Buffalo (91% of the city dwellers were living in restricted areas of Buffalo). Similarly, 90% of offenders in Schenectady County were living in restricted zones, and 100% of offenders living within the City of Schenectady were doing so afoul of the law.

In both counties, only a small percentage of rural residences were in restricted zones, whereas the large majority of multiple family residences or apartments, more commonly found in urban areas, were not legally available to offenders.

The implications of these findings, Dr. Berenson said, are that there may be inadequate resources or an unwillingness on the part of law enforcement agencies to follow the restriction statutes. She noted that courts have overturned sex offender residency laws in eight New York counties, and that the Washington County board of supervisors recently voted to repeal that county’s law.

"Policy makers should be pulling out the [geographic information services] software themselves and asking, ‘What is the actual impact of this legislation? What’s going to happen? Where are these guys going to go?’ " Dr. Harris said. "Housing is a matter of managing this inherent risk that people have for public safety and minimizing the collateral risk."

Dr. Berenson’s study was internally funded. Dr. Berenson and Dr. Harris reported that they had no relevant financial disclosures.

BOSTON – Quetiapine might be a drug of choice among substance abusers behind bars, said researchers at the annual meeting of the American Academy of Psychiatry and the Law.

An atypical antipsychotic with potent sedative and anxiolytic properties, quetiapine (Seroquel) is, along with olanzapine (Zyprexa), one of only two agents in its class to have a "street value," said Dr. Amanda Pearce Roper and Dr. Leonard Mulbry Jr., from the Medical University of South Carolina, Charleston.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it," Dr. Mulbry said in an interview.

He said he also has heard anecdotal reports of quetiapine misuse and abuse in the community but has seen little in the way of evidence to support it.

"We had seen so much desire for it in the correctional system, but then when we did the literature search, there was virtually nothing there," he said.

Quetiapine is an antagonist of dopamine, serotonin, and adrenergic receptors, and it is a potent antihistamine with only negligible anticholinergic effects. It strongly binds serotonin receptors but is rapidly dissociated from D2 receptors, which minimizes its effects on the nigrostriatal and tuberoinfundibular pathways, said Dr. Roper.

Stopping the drug abruptly can lead to withdrawal symptoms because of compensatory changes in the aforementioned receptors. The British National formulary recommends that patients on quetiapine be gradually withdrawn from the drug to avoid withdrawal symptoms, Dr. Roper noted.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it."

The drug is approved by the Food and Drug Administration for the treatment of bipolar affective disorder in the depressed phase and in mania maintenance, schizophrenia, and as an adjunct to treatment for major depressive disorder.

"Its impact on these symptoms may explain why its misuse is so widespread institutionally and on the street," Dr. Roper commented.

She pointed to a 2004 report that found that about 30% of inmates in the Los Angeles County Jail faked symptoms in order to obtain quetiapine, and that many of the malingerers were substance abusers who would snort the crushed tablets (Am. J. Psychiatry 2004;161:1718).

Other observers reported inmates or patients intravenously injecting crushed tablets or inserting them into the rectum (Am. J. Psychiatry 2005;162:1755-6; Pain Med. 2007;8:171-83).

"We have also gotten anecdotal reports of people using quetiapine on the outside and mixing it with other drugs, particularly cocaine," Dr. Mulbry said.

Dr. Roper noted that several correctional facilities have reported either removing quetiapine from their formulary or restricting its access in attempts to reduce abuse of the drug.

For example, the Santa Rita, Calif., jail removed quetiapine and several other drugs from its formulary out of concerns about abuse. The result was a drop in both medication abuse case reports and the cost of psychotropic agents for the jail, as well as a stabilizing of overall medication costs.

The prescribing information for quetiapine extended-release formulation states in part that "patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of misuse or abuse of SEROQUEL, e.g., development of tolerance, increases in dose, drug-seeking behavior."

The study was internally funded. Dr. Mulbry and Dr. Roper each reported that they had no relevant financial disclosures.

BOSTON – Quetiapine might be a drug of choice among substance abusers behind bars, said researchers at the annual meeting of the American Academy of Psychiatry and the Law.

An atypical antipsychotic with potent sedative and anxiolytic properties, quetiapine (Seroquel) is, along with olanzapine (Zyprexa), one of only two agents in its class to have a "street value," said Dr. Amanda Pearce Roper and Dr. Leonard Mulbry Jr., from the Medical University of South Carolina, Charleston.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it," Dr. Mulbry said in an interview.

He said he also has heard anecdotal reports of quetiapine misuse and abuse in the community but has seen little in the way of evidence to support it.

"We had seen so much desire for it in the correctional system, but then when we did the literature search, there was virtually nothing there," he said.

Quetiapine is an antagonist of dopamine, serotonin, and adrenergic receptors, and it is a potent antihistamine with only negligible anticholinergic effects. It strongly binds serotonin receptors but is rapidly dissociated from D2 receptors, which minimizes its effects on the nigrostriatal and tuberoinfundibular pathways, said Dr. Roper.

Stopping the drug abruptly can lead to withdrawal symptoms because of compensatory changes in the aforementioned receptors. The British National formulary recommends that patients on quetiapine be gradually withdrawn from the drug to avoid withdrawal symptoms, Dr. Roper noted.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it."

The drug is approved by the Food and Drug Administration for the treatment of bipolar affective disorder in the depressed phase and in mania maintenance, schizophrenia, and as an adjunct to treatment for major depressive disorder.

"Its impact on these symptoms may explain why its misuse is so widespread institutionally and on the street," Dr. Roper commented.

She pointed to a 2004 report that found that about 30% of inmates in the Los Angeles County Jail faked symptoms in order to obtain quetiapine, and that many of the malingerers were substance abusers who would snort the crushed tablets (Am. J. Psychiatry 2004;161:1718).

Other observers reported inmates or patients intravenously injecting crushed tablets or inserting them into the rectum (Am. J. Psychiatry 2005;162:1755-6; Pain Med. 2007;8:171-83).

"We have also gotten anecdotal reports of people using quetiapine on the outside and mixing it with other drugs, particularly cocaine," Dr. Mulbry said.

Dr. Roper noted that several correctional facilities have reported either removing quetiapine from their formulary or restricting its access in attempts to reduce abuse of the drug.

For example, the Santa Rita, Calif., jail removed quetiapine and several other drugs from its formulary out of concerns about abuse. The result was a drop in both medication abuse case reports and the cost of psychotropic agents for the jail, as well as a stabilizing of overall medication costs.

The prescribing information for quetiapine extended-release formulation states in part that "patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of misuse or abuse of SEROQUEL, e.g., development of tolerance, increases in dose, drug-seeking behavior."

The study was internally funded. Dr. Mulbry and Dr. Roper each reported that they had no relevant financial disclosures.

BOSTON – Quetiapine might be a drug of choice among substance abusers behind bars, said researchers at the annual meeting of the American Academy of Psychiatry and the Law.

An atypical antipsychotic with potent sedative and anxiolytic properties, quetiapine (Seroquel) is, along with olanzapine (Zyprexa), one of only two agents in its class to have a "street value," said Dr. Amanda Pearce Roper and Dr. Leonard Mulbry Jr., from the Medical University of South Carolina, Charleston.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it," Dr. Mulbry said in an interview.

He said he also has heard anecdotal reports of quetiapine misuse and abuse in the community but has seen little in the way of evidence to support it.

"We had seen so much desire for it in the correctional system, but then when we did the literature search, there was virtually nothing there," he said.

Quetiapine is an antagonist of dopamine, serotonin, and adrenergic receptors, and it is a potent antihistamine with only negligible anticholinergic effects. It strongly binds serotonin receptors but is rapidly dissociated from D2 receptors, which minimizes its effects on the nigrostriatal and tuberoinfundibular pathways, said Dr. Roper.

Stopping the drug abruptly can lead to withdrawal symptoms because of compensatory changes in the aforementioned receptors. The British National formulary recommends that patients on quetiapine be gradually withdrawn from the drug to avoid withdrawal symptoms, Dr. Roper noted.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it."

The drug is approved by the Food and Drug Administration for the treatment of bipolar affective disorder in the depressed phase and in mania maintenance, schizophrenia, and as an adjunct to treatment for major depressive disorder.

"Its impact on these symptoms may explain why its misuse is so widespread institutionally and on the street," Dr. Roper commented.

She pointed to a 2004 report that found that about 30% of inmates in the Los Angeles County Jail faked symptoms in order to obtain quetiapine, and that many of the malingerers were substance abusers who would snort the crushed tablets (Am. J. Psychiatry 2004;161:1718).

Other observers reported inmates or patients intravenously injecting crushed tablets or inserting them into the rectum (Am. J. Psychiatry 2005;162:1755-6; Pain Med. 2007;8:171-83).

"We have also gotten anecdotal reports of people using quetiapine on the outside and mixing it with other drugs, particularly cocaine," Dr. Mulbry said.

Dr. Roper noted that several correctional facilities have reported either removing quetiapine from their formulary or restricting its access in attempts to reduce abuse of the drug.

For example, the Santa Rita, Calif., jail removed quetiapine and several other drugs from its formulary out of concerns about abuse. The result was a drop in both medication abuse case reports and the cost of psychotropic agents for the jail, as well as a stabilizing of overall medication costs.

The prescribing information for quetiapine extended-release formulation states in part that "patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of misuse or abuse of SEROQUEL, e.g., development of tolerance, increases in dose, drug-seeking behavior."

The study was internally funded. Dr. Mulbry and Dr. Roper each reported that they had no relevant financial disclosures.