Employing the Risk-Need-Responsivity (RNR) model and predicting successful completion in an alternative drug court program: Preliminary findings from the Orleans Parish Drug Court

Drug courts have been in operation for decades to provide treatment alternatives to individuals whose substance use and related behaviors have brought them into contact with the criminal justice system. As research on drug courts have evolved, it has been demonstrated that different types of offenders have different mental health and substance use treatment needs. One way of approaching treatment in court-mandated substance use treatment is by the application of the risk-need-responsivity (RNR) model (Andrews, Zinger et al., 1990). The Orleans Parish Drug Court expanded assessment and treatment services to determine whether the implementation of alternative substance use programming within a traditional drug court model improved outcomes. The goals of the current study were to describe the process of implementing risk and need principles, provide a description of client characteristics, examine the factors related to successful completion of drug court, and investigate completion rates across risk and need groups. Results demonstrated that risk and need groups differed on several demographic variables, levels of substance use, mental health concerns, and legal issues, suggesting assessment and triage procedures were successful. Comparisons between individuals who successfully completed drug court and those who were terminated prematurely also showed significant differences. Specifically, baseline age, education, substance use problems and frequency, and days in jail/prison were unique predictors of successful drug court completion. Finally, as predicted, individuals in the group with the lowest risk and need had the highest graduation rate, despite receiving less intensive services. Overall, creation of specialized treatment tracks within a traditional drug court program appears to be an effective strategy to target the wide range of offenders typical of drug court participants.

Teaching Cultural Competence to Psychiatry Residents: Seven Core Concepts and Their Implications for Therapeutic Technique

The authors describe the Tulane Model for teaching cultural competence to psychiatry residents in order to outline an innovative approach to curricula development in academic psychiatry. The authors focus on the didactic experience that takes place during the first and second postgraduate years and present seven core concepts that should inform the emerging clinician's thinking in the formulation of every clinical case. The authors discuss the correspondence between each core concept and the Outline for Cultural Formulation, introduced in Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and updated in DSM-5. The authors illustrate how each of the core concepts is utilized as a guideline for teaching residents a process for eliciting culturally relevant information from their patients and their personal histories and how to apply that knowledge in the assessment and treatment of patients in clinical settings.

Competency restoration treatment: differences between defendants declared competent or incompetent to stand trial

Archival data of inpatient defendants referred for competency restoration were used to make comparisons between those who were restored to competency (CST; n = 43) and those who remained incompetent (IST; n = 15). The groups did not differ on demographic variables, intellectual capacity, type of offense (violent versus nonviolent), clinical diagnoses, substance abuse, or psychotic symptomatology, as measured by the Brief Psychiatric Rating Scale. However, the CST group performed significantly better than the IST group on both the initial and final Georgia Court Competency Test and Global Assessment of Functioning scale. Psychotic symptom severity decreased significantly only in the CST group, and the CST group was discharged significantly sooner (7.7 ± 8.6 months) than the IST group (17.9 ± 7.0 months). While consistent with prior research, this is the first study to compare both psycholegal comprehension and specific clinical symptoms in defendants before and after competency restoration treatment.

Commentary: Helling v. Carey, Caveat Medicus

Forensic experts should be aware of the increasing importance of clinical practice guidelines (CPGs) in various legal settings. CPGs are a type of learned treatise and are accepted into court proceedings under hearsay exception provisions. The courts now use CPGs as shorthand for the standard of care in making malpractice determinations. However, medical guidelines can function as a sword or a shield in the courtroom arena. The Helling v. Carey medical malpractice case serves as a frightful reminder of the potential consequences of allowing courts to craft their own standards of medical care.

Psychological distress and burden among female partners of combat veterans with PTSD

Psychological distress among cohabitating female partners of combat veterans with posttraumatic stress disorder (PTSD) was examined in a cross-sectional study using a modified version of the Health Belief Model. A convenience sample of 89 cohabitating female partners of male veterans in outpatient PTSD treatment was interviewed by telephone using a structured interview. Partners endorsed high levels of psychological distress with elevations on clinical scales at or exceeding the 90th percentile. Severe levels of overall psychological distress, depression, and suicidal ideation were prevalent among partners. Multivariate analyses revealed that perceived threat, recent mental health treatment, and level of involvement with veterans predicted global partner psychological distress. Partner burden was predicted by partner self-efficacy, perceived threat, barriers to mental health treatment, and partner treatment engagement. These findings are compelling since they demonstrate that partners of veterans with combat-related PTSD experience significant levels of emotional distress that warrant clinical attention. Psychological distress and partner burden were each associated with a unique combination of predictors, suggesting that although these constructs are related, they have distinct correlates and potentially different implications within the family environment. Future research should examine these constructs separately using causal modeling analyses to identify modifiable targets for interventions to reduce psychological distress among partners of individuals with PTSD.

Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects

BACKGROUND

Recent studies have reported a high comorbidity between posttraumatic stress disorder (PTSD) and psychotic symptoms, and it has been hypothesized that PTSD with comorbid psychosis is a severe form of PTSD. Few studies have examined the neurobiology of PTSD with comorbid psychosis. If PTSD with secondary psychotic symptoms (PTSD-SP) is a severe form of PTSD, then it might be expected to show more extreme perturbations in the neuroendocrine patterns that characterize PTSD.

METHODS

Patients with PTSD with secondary psychotic symptoms (PTSD-SP), PTSD without psychosis, and healthy comparison subjects were compared for differences in cerebrospinal fluid concentrations of corticotropin-releasing factor (CRF) and somatotropin-release-inhibiting hormone (SRIF).

RESULTS

The PTSD-SP subjects had significantly higher mean levels of CRF than either the PTSD or control subjects (p <.01). The three groups showed similar SRIF levels.

CONCLUSIONS

These data implicate abnormalities in the secretion of CRF with the production of secondary psychotic symptoms in PTSD. This finding supports the validity of PTSD-SP as a PTSD subtype and as a severe form of PTSD.

Differences in smooth pursuit eye movement between posttraumatic stress disorder with secondary psychotic symptoms and schizophrenia

Studies show high comorbidity between post-traumatic stress disorder and psychotic symptoms. Despite this fact, there has been only one published study of the neurobiology of this enigmatic disorder. This preliminary study examines the relationship between psychotic symptoms in post-traumatic stress disorder (PTSD) and schizophrenia by measuring smooth pursuit eye movement (SPEM) in subjects with PTSD and secondary psychotic symptoms, schizophrenia, and healthy controls. The results show that PTSD with secondary psychotic symptoms is associated with a SPEM deficit that is different from the SPEM deficit associated with schizophrenia.