Preliminary research shows the psychedelic psilocybin to be a promising potential treatment for psychiatric illnesses. Recent U.S. government legislation and policy indicate that access to psilocybin, which remains illegal on the federal level despite increasing efforts to decriminalize it at the state and local levels, will be expanded to enable further research into its treatment potential. It remains unclear how psilocybin will be regulated and who will have access to this new treatment, raising important legal and ethics questions psychiatrists must consider. This article reviews the current legal regulation of psilocybin and matters related to standard of care, right to effective treatment, and the respectable minority doctrine. It concludes with a discussion of the ethics matters surrounding the use of psilocybin as medicine, including provider bias, the interpersonal dynamic between providers and patients, informed consent, and equity and access.

In 1991, Canada introduced Bill C-30 to amend the Criminal Code (mental disorder). Bill C-30 codified accumulated law specifying the criteria for fitness to stand trial. This test was clarified in a landmark case, , which appeared to accept the limited cognitive capacity test. This explanation has guided the assessment of fitness to stand trial in courts across Canada for three decades. It was recently tested in an Ontario Court of Appeal case, , which ruled that the common interpretation of was insufficient. The court ruled there is one test for fitness, which is contextual and nuanced, and this test is spelled out in the Criminal Code. This will likely change the test and manner for assessing fitness to stand trial in Canada from how it has evolved over the last three decades.

Asylum seekers in the United States face complex legal processes that require the construction of coherent and credible narratives to establish eligibility for legal status or immigration relief. In this article, we review clinical and legal considerations involved in optimizing trauma narratives in forensic psychiatric evaluations for immigration courts. We highlight significant challenges faced by asylum seekers, including the emotional impact of trauma and cultural factors affecting their ability to disclose their experiences, including the roles of symptoms and cultural and situational elements in disclosure and narrative development. We emphasize the importance of creating a therapeutic and empathetic environment to facilitate disclosure and partnering with interpreters across multiple culturally sensitive evaluations. We address the roles of common traumatic stressors in narrative development, including cultural challenges related to histories of torture, abduction, sexual violence, and human trafficking prevalent among asylum seekers, providing insights and guidance on each. Further, we address specific potential challenges to the forensic psychiatric evaluator during the narrative development process, such as transference, countertransference, malingering, and vicarious traumatization. We aim to provide guidance on the development of trauma narratives of asylees developed for both therapeutic and medico-legal effectiveness.

Since the 1980s, the four skills criteria have become the most widely accepted mechanism for the assessment of decisional capacity in the United States. These criteria emerged in response to the paternalistic approach to clinical decision-making that had been widely accepted in an earlier era and offered a means of ensuring that physicians honored the rights of capacitated patients to make their own medical decisions. Unfortunately, the criteria are now applied to situations for which they are not suited and in a manner that is often highly inflexible. In an article in this issue of The Journal, Matthew Dernbach and colleagues describe one potential scenario that requires a flexible approach to using the four skills model: situations in which a patient stands at high risk of losing decisional capacity in the near future. Using Dernbach as a starting point, this article offers specific ways in which the four skills model can be improved upon or augmented without abandoning its key principles. These advances include adjusting to empirical evidence, re-emphasizing the importance of autonomy maximization and restorability, and embracing novel conceptual and technological innovations.

Numerous recommendations have been made to address the high rates of mental health disorders among justice-involved youth. Few data are available on the use, quality, appropriateness, or availability of services to address these needs. This study examined the relationship between trauma-informed mental health screening, other referral pathways for diagnostic evaluation, subsequent DSM-5 diagnoses, and treatments for evaluated youth. Eligible participants were all youth admitted to New York City secure juvenile detention facilities from September 17, 2015 to October 30, 2016 who remained in the facility for at least five days ( = 786). Of those, 581 (73.9%) were voluntarily screened and 309 (53.2%) later received a diagnostic evaluation. Youth who screened positive for depression, posttraumatic stress disorder, and problematic substance use were more likely to be evaluated. Treatment received was related to diagnosis rather than reason for referral. For youth who were referred for behavioral or emotional concerns, 99.1 percent (114 of 115) of those diagnosed with a neurodevelopmental disorder had attention-deficit/hyperactivity disorder (ADHD). These data are among the first to describe DSM-5 diagnoses and treatment among youth detainees. They highlight the prevalence of ADHD in detained youth and argue for the coordination of universal trauma-informed mental health screening and a structured referral system for this population.

Evaluating decisional capacity for patients seeking medical aid in dying (MAID) raises challenging legal, logistical, and ethics questions. The existing literature on the subject has been shaped largely by early disagreements over whether effective capacity assessment for such patients is ever possible, which in turn stemmed from debates over the ethics of MAID itself. In attempting to establish meaningful criteria for assessments, many jurisdictions have sought either to apply or to adapt models of capacity evaluation designed for other forms of medical decision-making, such as the widely used "four skills" model, failing to account for the fundamental differences in kind between these other decisions and MAID. This article seeks to reexamine these questions with a focus on two logistical matters (the appropriate credentialing for the evaluator and the potential liability of the evaluator) and three clinical matters (level of understanding, clinical scrutiny and certainty, and impairment) in an effort to raise legal and ethics concerns that remain unresolved, even as MAID is permitted in an increasing number of jurisdictions.

The rise in the U.S. prison population over the past 40 years has heightened scrutiny of the incarceration of children and adolescents. Correlates of later reincarceration in this group, especially correlates relating to psychiatric and substance use disorders, are understudied in the U.S. population. We aimed to establish the prevalence and correlates of the reincarceration as adults of people incarcerated before age 18. Data were derived from clinical interviews and from validated diagnostic and psychometric instruments. They were obtained as part of a cross-sectional representative survey of the civilian U.S. population, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III). We identified 1,543 adults (4.3% of the NESARC sample) who had been incarcerated before they were 18. Of these, 55.9 percent had subsequently been incarcerated as adults. In addition to variables that have been repeatedly identified in criminological research (less education, past antisocial behavior, and parental imprisonment), substance use disorder, bipolar disorder, and longer childhood incarceration were independently associated with incarceration as an adult. The possibility that psychiatric treatment could reduce reincarceration in this group warrants longitudinal and experimental research.

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

In recent years, several jurisdictions have passed legislation to permit medical aid in dying (MAID) worldwide, with considerable expansion in the availability of this practice. MAID has been defined as the practice of a clinician prescribing lethal drugs in response to a direct request from the patient, with a shared understanding that the patient intends to use the medication to bring about the patient's death. Wider legalization of MAID has prompted debates and legal controversies regarding the extent to which MAID should be available and its application for people experiencing mental illness as the primary indication. This article examines shifting attitudes of professional medical organizations toward MAID. We discuss the existing statutory provisions for psychiatric assessment for MAID in the United States and the implications on such assessments should MAID be expanded to include mental illness as the primary indication. This article also assesses legal disputes concerning MAID regulations and explores the role of psychiatric experts in the practice of MAID.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

Opioid use disorder is common in incarcerated persons, and concern about the diversion of buprenorphine is a barrier to treatment. We conducted a retrospective chart review of incarcerated persons in the New Jersey Department of Corrections who received charges for misuse of medication, including buprenorphine, hypothesizing that the prescription of buprenorphine monoproduct, multiple tabs or films of buprenorphine, or higher doses of buprenorphine would be associated with more diversion incidents. Within the dosing range of 2 to 12 mg, there were more incidents of diversion of buprenorphine monoproduct (24.3%) compared with buprenorphine-naloxone (10.7%, = .004). More incidents of diversion were seen when multiple films or tabs of buprenorphine product were prescribed (21.7%, comparison 12.7%, = .01). This observation held when considering multiple buprenorphine-naloxone films, but not multiple buprenorphine tablets. No statistically significant association was found for institutional diversion charges related to higher doses of buprenorphine products. These results suggest that, within the dosing range of buprenorphine used in the New Jersey Department of Corrections, misuse charges were not associated with higher doses although were associated with prescribing buprenorphine monoproduct and multiple films of buprenorphine-naloxone.

Concerns about sexual misconduct by health care professionals have been highlighted by recent high-profile cases. Professional health monitoring programs (PHPs) offer an additional layer of protection when health care professionals with a history of unprofessional sexual behavior (USB) return to practice; however, little is known about the characteristics or outcomes of clinicians referred to a PHP because of USB. Data were extracted from over 35 years of PHP records involving USB-related referrals ( = 570). The majority of cases were deemed ineligible for PHP monitoring and handled by other entities (e.g., licensing board, legal system). Of the 232 monitored cases (46.84 ± 9.42 years; 95.7% male), most were physicians ( = 156, 67.2%), with 75.9 percent of monitored cases involving USB with at least one patient. Most (74.9%) PHP monitoring outcomes were classified as "successful" or "very successful." Only three individuals (1.3%) who completed their monitoring were rereferred to the PHP. Monitored professionals exhibited less severe USB and were less likely to experience legal or disciplinary consequences (57.3% versus 69.8%, Cramer's V = .174, < .0001) compared with unmonitored professionals. Findings enhance transparency of the PHP process and highlight its utility in safely returning clinicians to practice. Results may inform policies to prevent USB by health care professionals.

The four-skills model of decisional capacity for providing informed consent for medical treatment developed by Appelbaum and Grisso is codified into most state statutes in articulating the legal criteria for establishing capacity. Decisional capacity is traditionally determined at a point in time based on a narrow clinical question; however, there are clinical scenarios in which patients may currently have decisional capacity but their recurrent nonadherence to care places them at foreseeable risk of being acutely incapacitated, both decisionally and functionally, in the near future. There is a gap in terms of how these four skills ought to be adapted when applied to a patient with recurrent altered mental status, especially delirium, because of nonadherence. To describe this clinical situation, we introduce a new risk factor, "foreseeable risk of losing decisional and functional capacity," and discuss the clinical evaluation of a patient who currently has capacity but for whom this risk factor applies. We consider the implications of being at foreseeable risk of losing capacity and how foreseeable risk can be translated into a capacity determination in the present. We also describe interventions that can serve to protect the patient's rights and safety.

The goal of our study was to describe the availability of community child and adolescent mental health services, trauma-informed care, and the geographic accessibility of these services for juvenile justice-involved (JJ) youth who received mental health services while in secure detention. Data collection occurred through direct contact with the child and adolescent outpatient clinics listed on the New York State Office of Mental Health website. Zip codes were collected from the juvenile secure detention census. Of the clinics contacted, 88.5 percent accepted JJ youth; however, 43.5 percent accepted them on a conditional basis. Only 62.1 percent offered trauma-informed care, including evidence-based interventions and unspecified care. Although 84.5 percent of the clinics that would accept this population reported currently accepting new patients, reported wait times were as high as six or more months. When JJ residents' home zip codes and those of the clinics were geographically mapped, there were few clinics in the zip codes where most residents lived. The clinics that accepted youth on a conditional basis often refused high-risk patients, essentially ruling out a large majority of this population. The geographical inaccessibility of these clinics limits their ability to provide care for this vulnerable population.

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

Laws on competency to stand trial and fitness to plead are said to derive from "mute by visitation of God," a medieval English legal term referring to the inability to speak through no fault of one's own. The paper describes the relevant historical background, illustrative cases, and legal commentaries. Muteness by visitation of God arose to address a particular set of difficulties caused by the need to have medieval defendants agree to be tried. Competency to stand trial and fitness to plead, on the other hand, arose to address more general and enduring concerns, that putting people on trial when they were unable to understand or participate compromised the dignity and fairness of criminal proceedings. The origins of competency to stand trial and fitness to plead do not lie in medieval English attempts to persuade silent defendants to speak. They warrant their own historical exegesis.

The Criminal Sentiments Scale-Modified (CSS-M) has been widely used as a measure of criminal attitudes. This analysis examined CSS-M scores in a large sample of outpatients with serious mental illnesses and a criminal legal system history. We compared total and subscale scores in our sample to scores from two other previously published U.S. studies in which the CSS-M was used, and evaluated associations between total CSS-M score and nine variables (age, educational attainment, gender, race, marital status, employment status, diagnostic category, substance use disorder comorbidity, and adverse childhood experiences (ACE) score). Scores were higher than in two prior U.S. studies involving other types of samples. Independently significant predictors of higher CSS-M scores included being younger ( < .001), having a higher ACE score ( < .001), being male ( =03), not identifying as White ( <001), not having a psychotic disorder ( <001), and having a comorbid substance use disorder ( =002). Future research should test the hypothesis that these factors increase risk for arrest and that arrest events, and subsequent criminal legal system involvement, are characterized by negative experiences and perceptions of poor procedural justice, which in turn underpin the negative opinions referred to as "criminal sentiments" or criminal attitudes.

There is a clear need for experts with the requisite knowledge and experience to offer medicolegal opinions pertaining to various neuropsychiatric conditions. There is also an important distinction between clinical and medicolegal roles, and the need for training and expertise applicable to forensic assessment. But there remain few available experts with credentials spanning neuropsychiatry and forensic assessment. This creates a dilemma whereby parties involved in litigation featuring neuropsychiatric illness or injury are frequently forced to choose between experts with either knowledge and skills applicable to neuropsychiatric conditions or experts with skills and experience applicable to forensic assessment. Either choice introduces risk. Whether flawed medicolegal opinions are a consequence of deficient medical knowledge or an inadequate forensic evaluation process, the result remains the same, with triers of fact potentially being exposed to problematic testimony. There is, however, a more fundamental problem that implicates patient care more broadly: spurious dichotomies created by the historical segregation of psychiatry and neurology. Optimizing clinical care for patients with neuropsychiatric conditions, improving medical education in support of such care, and enabling forensic neuropsychiatric assessment must then start with more proactive efforts to reintegrate psychiatry and neurology.

A systematic review of the literature on restoration of competence to stand trial identified a predominance of retrospective case studies using descriptive and correlational statistics. Guided by National Institutes of Health (NIH) quality metrics and emphasizing study design, sample size, and statistical methods, the authors categorized a large majority of studies as fair in quality, underscoring the need for controlled designs, larger representative samples, and more sophisticated statistical analyses. Implications for the state of forensic research include the need to use large databases within jurisdictions and the importance of reliable methods that can be applied across jurisdictions and aggregated for meta-analysis. More sophisticated research methods can be advanced in forensic fellowship training where coordinated projects and curricula can encourage systematic approaches to forensic research.