A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States

Abstract

Objective.Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level.Methods.The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted.Results.A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth.Conclusions.Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

The impact of misdemeanor arrests on forensic mental health services: A state-wide review of Virginia competence to stand trial evaluations.

“…In Virginia, site of the present study, court orders for stand-alone competence evaluations of adults increased 218% from 690 in 2007 to 1,507 in 2018 (unpublished data from the Virginia Department of Behavioral Health and Developmental Services provided July 22, 2020) 1 . Indeed, in a recent survey of forensic administrators and experts from nearly every state, 70% reported that they perceived referrals for competency evaluations of felony defendants were increasing, and 71% reported that they perceived referrals for competence evaluations of misdemeanor defendants were increasing (Warburton et al, 2020).…”

“…The increase in IST cases is notably sharp in the most recent statistics available. From 2014 to 2015, IST cases increased by 48%. Similarly, in the recent survey of forensic administrators and experts from nearly every state, 65% reported that they perceived increased competence restoration orders for those defendants charged with felonies, and nearly 69% reported that they perceived increased restoration orders for defendants charged only with misdemeanors (Warburton et al, 2020).…”

“…The wide-scale substantial increase in orders for competence evaluation and competence restoration has created what many authorities are describing as a national “competency crisis” (e.g., Callahan & Pinals, 2020; Gowensmith, 2019; Warburton et al, 2020; Wortzel et al, 2007). In short, many state systems, particularly psychiatric hospitals, have been unable to accommodate the rapidly increasing orders for competence evaluation and restoration.…”

Legally involved individuals in state hospitals and community mental health settings: Introduction to the special section.

“…The number of individuals with SMI found IST, in particular, has increased exponentially in recent years, leading to explosive growth in admissions to state psychiatric hospitals and an inability, in many states, to provide adequate and timely assessment and treatment (Callahan & Pinals, 2020). In a recent survey, 82% of states reported a significant increase in the numbers of individuals referred for evaluation of competency to stand trial (CST; Warburton et al, 2020), and data from the State Profiling System maintained by the National Association of State Mental Health Program Directors Research Institute suggest that the number of forensic patients in state psychiatric hospitals increased, on average, by 76% between 1999 and 2014, primarily due to an increase in the numbers of individuals found IST (Wik et al, 2020). Limited space, due to reductions in available inpatient psychiatric beds (Gao, 2021), as well as a shortage of skilled assessors and overwhelming demand, has led to significant delays in both assessment and treatment (Callahan & Pinals, 2020).…”

An overview of jail-based competency restoration

“…For example, the United States District Court of Washington case of Trueblood, et al v. Washington State Department of Health and Human Services et al 7 (2015) found that it is a violation of due process for defendants adjudicated incompetent to be held in jail for longer than 7 days awaiting competency restoration services. In California, a recent Superior Court order in the case of Stiavetti, et al v. Ahlin, et al 8 (2016) imposed a 28-day limit to the time a defendant can await competency restoration services, and this trend in litigation can be seen throughout the United States as jails are filling with patients awaiting state hospital admissions (Warburton et al, 9 in press). As such, alternatives to state hospitalization for IST patients have been developed, including communitybased restoration programs, and jail-based competency (JBCT) restoration programs.…”