Determining competency to stand trial: An examination of evaluation procedures in an institutional setting.

Examined the procedures used by mental health professionals to decide whether a defendant is competent to stand trial in the context of evaluations conducted in an institutional setting. Analyses of psychiatric reports and other data revealed several differences between 140 competent and 130 incompetent defendants, largely in terms of traditional psychiatric criteria. Although there is evidence to suggest that decisions about competency are reliably made, the validity of such decisions is highly questionable. No evidence that supports the link between psychiatric symptomatology and incompetency is available. The data also suggest that lengthy institutional evaluations may be unnecessary, since it appears that the additional information obtained during hospitalization does not influence decisions about competency. Changes in the evaluation procedures that may increase the validity of the competency judgments are discussed. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A meta-analytic review of competency to stand trial research.

The present study is a meta-analysis of competency to stand trial research. One meta-analysis was previously conducted in this area, but the large number of empirical studies that have been conducted since and the introduction of new instruments and revision of old instruments warranted updating and expanding upon the previously conducted study via contemporary meta-analytic methods. We meta-analyzed 68 studies published between 1967 and 2008 that compared competent and incompetent defendants on a number of demographic, psychiatric, and criminological variables. Categorical and continuous variables commonly investigated in competency research were coded and aggregated to generate cumulative effect sizes in the form of odds ratios and Cohen's d statistics, and moderation was tested via meta-F and meta-regression analyses. The most robust findings were that defendants diagnosed with a Psychotic Disorder were approximately eight times more likely to be found incompetent than defendants without a Psychotic Disorder diagnosis and the likelihood of being found incompetent was approximately double for unemployed defendants as compared to employed defendants. The likelihood of being found incompetent was also double for defendants with a previous psychiatric hospitalization compared to those without a hospitalization history. Comparative data on 12 competency assessment instruments and three traditional instruments were also explored and the effect sizes associated with the competency measures were substantially larger (i.e., approximately one Cohen's d-point) than those for the traditional measures. Limitations of the primary research and the previous and present meta-analyses are presented and future directions in this area are outlined. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Instruments for assessing competency to stand trial: How do they work?

Previous research has demonstrated that the Competency Screening Test (CST) and a revised version of the Georgia Court Competency Test (GCCT-MSH [Mississippi State Hospital]) accurately predict competency decisions made by forensic examiners. We used internal consistency analyses, item analyses, and factor analyses to determine how the instruments predict the competency criterion. These analyses failed to reveal a clear basis for the predictive power of the CST. We were unable to establish correlates of the better predictors or to label the item clusters that emerged from the factor analyses. In contrast, analyses of the GCCT-MSH revealed a straightforward internal structure that comprised three factors. The factor that predicted staff decisions most accurately (Specific Legal Knowledge) consisted of items that were relevant for the individual defendant's case and that appeared to tap psychopathology as well as intellectual ability. This study highlights the need for investigators to examine the empirical relationships between psychological constructs and defendants' legally relevant functional abilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conceptualizing and assessing competency to stand trial: Implications and applications of the MacArthur Treatment Competence Model.

The MacArthur Treatment Competence Study ([MTCS] e.g., P. S. Appelbaum and T. Grisso, Grisso et al, and Grisso and Appelbaum; see records 82:39258, 82:35494, and 82:37814, respectively) teaches important lessons about the conceptualization and assessment of criminal competencies, particularly competency to stand trial. In this article, the MTCS model of competency is used as a framework for analyzing the similarities and differences between American and Canadian laws regarding competency to stand trial. General issues regarding the development and evaluation of forensic assessment procedures in relation to the MTCS competence measures are then discussed. The authors conclude that the MTCS model of competence has broad heuristic value; however, because the link between psycholegal constructs and forensic assessment procedures is complex and indirect, the MTCS competence measures may have some important limitations for research and for clinical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An introduction to survival analysis: Statistical methods for analysis of clinical trial data.

The randomized controlled clinical trial (RCT) is a prospective study using random assignment of subjects to treatment groups to compare the effect and value of a therapeutic intervention against a control. The RCT is the most definitive clinical research tool for evaluating the efficacy of a new therapy in human subjects. Often the outcome of interest in an RCT is the length of time until an event occurs after treatment or intervention. In this article we introduce statistical methods for evaluating differences in the patterns of time to response between two groups of subjects to determine whether one therapy is better than another. The collection of methods for analyzing such data, known as survival data, is called survival analysis. Using data from a hypothetical clinical trial for the prevention of the recurrence of depression, we illustrate two elementary methods for analyzing survival data. We also discuss generalizations of these methods to incorporate covariates and conclude with a general discussion of clinical trials of psychiatric therapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Competency to stand trial adjudication: a comparison of female and male defendants

Competency to stand trial adjudication is a decision point in the criminal justice system at which gender bias may result in different outcomes for female defendants as compared with males. However, this is an unexplored research area that lacks well-designed studies. The goals of this investigation, which used the largest known sample of U.S. female competency to stand trial defendants studied thus far, are to further understand this group of offenders and to address the gender bias issue as observed in a major southwestern urban court system. Multivariate logistic regression analyses on selected data for 157 female defendants and 187 of their male counterparts examined (1) variations within gender categories and (2) differences between men and women. The results of the within models showed some similarities, but also clear differences, in the determinants of court dispositions. The analyses failed to show an overall pattern of association between gender and competency adjudication. The influence of gender showed considerable variability across psychotic symptoms involving hallucinations and/or delusions: women with psychotic symptomatology were at high risk of being adjudicated incompetent. This study demonstrates how reliable data on female competency to stand trial defendants can assist the interface of the mental health and criminal justice systems in their adherence to the legal standard of competency. It also highlights the following research needs: (1) increased sample sizes of female evaluees; and (2) richer data sets with more and better information on how gender influences specific psychotic symptomatology, type of crime, and legally functional abilities.     

Instruments to evaluate fitness to stand trial:a review of recent literature

DNA index (DI) values seen in 86 sporadic colorectal adenocarcinomas were related to clinical, morphological, and disease progression features. DI, whose overall distribution was bimodal with peaks in the diploid and from hypotriploid to tetraploid ranges, was related to pathological lymph node staging (pN), staging, lymphoid reaction, and tubular configuration. With increasing severity in pathological features, an irregular shift in DI class prevalence was seen, with no steady increase from diploidy to higher degrees of aneuploidy. All UICC stage I tumors (13% of total) were aneuploid, 50% being hypertriploid; diploidy (35%) and hypertriploidy (22%) prevailed in stage II carcinomas (41% of total), diploidy (35%) and hypotriploidy (30%) in stage III (30% of total), and triploidy (33%) in stage IV (15% of total). Amongst features related to stage (lymphoid reaction, depth of neoplastic embolization, grading, tubular configuration, and polymorphism), few were associated with DI, and none influenced DI shift and class prevalence through the stages. The biological capabilities of colorectal adenocarcinoma in relation to stage are expressed by certain aneuploid DI classes (hypertriploidy: absence of extracolonic spread; hypotriploidy: lymph node metastases; triploidy: distant metastases). Diploidy is unrelated to criteria defining stage above I and predicts 50% of cases with development of metachronous metastases. Irregular DI class shift through the stages may be attributable to different pathways of cancerogenesis and disease progression in diploid versus aneuploid carcinomas. Alternatively, assuming that the diploid fraction in aneuploid tumors contains neoplastic cells, pure diploid carcinomas represent the selection of a vital clone that may give rise to a further mixed population whose aneuploid DI is different and best fitted to express the biological capabilities of that given stage.     

An investment appraisal approach to clinical trial design

In this paper, a general investment appraisal model is presented which shows how pharmaceutical companies could take profit considerations into account when making decisions about the design of randomized controlled trials. A general model is presented based on the net present value method of investment appraisal. The approach is illustrated with a hypothetical example which shows how optimal (net present value maximizing) designs can be determined based on choices about sample size and endpoint measurement. The method could be extended to accommodate considerations about other trial design features, and could be used to determine a portfolio of studies which maximizes the expected return on a given development or trial budget. Furthermore, the approach could be used by pharmaceutical companies to evaluate the incremental costs and benefits of incorporating non-clinical objectives into trials, such as quality of life research and economic evaluation studies. A number of practical difficulties would need to be overcome to utilize the approach. Directions for further research are therefore highlighted centred on the key components of the model: a trial cost function, a product demand function, innovation diffusion processes and Bayesian approaches to trial design.     

Clinician variation in findings of competence to stand trial.

Are some forensic evaluators more likely than others to find criminal defendants incompetent to stand trial (IST)? Although studies report aggregate IST rates of around 20% across large samples of criminal defendants, these aggregate rates tell us little about the patterns of findings among individual evaluators. This study uses 2 statewide samples to present the first available data addressing how individual clinicians vary in rates of IST opinions. Across 60 clinicians who conducted a combined total of more than 7,000 evaluations, the rates of IST findings varied considerably (range: 0% to 62%). Results suggested that some of the variability across evaluators may be attributable to the evaluator's discipline and how the evaluator considered the relationship between competence and psychosis. However, these findings raise questions about the many other evaluator, system, and policy-level characteristics that may influence evaluator variability. Thus, we suggest a research agenda that may better identify explanations for some of the variability in IST findings across evaluators. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Competency to stand trial evaluations: a study of actual practice in two states

A criminal defendant must be competent to stand trial (CST) to safeguard the fundamental right to a fair trial. If there is a question as to a defendant's ability to assist in his or her own defense, a mental health professional is asked to perform a CST evaluation. Forensic assessment is a growing field, and CST is the most frequent evaluation requested. Over the years, forensic examiners' reports to the courts have been criticized for lack of relevance, insufficiency, and invading the province of the judge. If mental health professionals wish to advance the field of forensic assessment and respond to these criticisms, research on current practice with suggestions for advancement are necessary. A total of 66 CST reports conducted within the last five years in two states were compared to a proposed model for CST assessment. Results indicated that although forensic examiners are maintaining legal relevance, some CST reports may lack thoroughness and/or provide information that exceeds their role responsibilities. The findings support the need for the development of a standardized method of conducting and writing CST evaluations that should improve the quality of such reports.     

Application of the competency model to clinical health psychology.

In response to the growing emphasis on defining professional competence within applied psychology (e.g., clinical, neuropsychology, counseling, school), in 2007 American Psychological Association Division 38 (Health Psychology) sponsored a summit meeting with a specific focus on revisiting the standards of graduate curricula and training in clinical health psychology. Using the cube model of core competency domains of professional psychology as a framework, summit participants were charged with identifying the foundational and functional competencies expected of a well-trained, entry-level clinical health psychologist. As a product of these discussions, the present article is presented as an initial effort to identify the competencies and begin the discussion in clinical health psychology. As such it is likely to be of interest to a wide audience, including clinical training programs with an existing or planned emphasis in clinical health psychology, practitioners interested in acquiring the competencies required to practice as a clinical health psychologist, and students evaluating potential graduate and postgraduate training options in clinical health psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Community examiners' evaluations of competence to stand trial: Common problems and suggestions for improvement.

With the exponential growth of forensic psychology over recent decades, increasing numbers of clinical psychologists with little specialized training are becoming principal providers of forensic assessments. On the basis of results from an empirical study, the authors analyze 3 fundamental problems with these psychologists' reports on competence to stand trial and provide recommendations for improvement based on legal, ethical, and professional standards of practice. The article focuses on the importance of (a) properly attending to the range of critical psycholegal abilities, including the defendant's decisional capacities; (b) explaining the critical reasoning that underlies one's psycholegal conclusions; and (c) using forensically relevant methods of assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward an integration of independent practice and clinical research.

For some time there has been tremendous debate about the viability of integrating clinical and scientific endeavors in the practice of clinical psychology. It is argued that clinically relevant research strategies are crucial to the process of treatment evaluation and therapist accountability and therefore are of great importance to clinicians. Furthermore, the clinical expertise of the independent practice sector is acknowledged as a valuable resource that will likely be more fully appreciated with greater practitioner involvement in various research-related activities. To this end, a number of ways in which independent practitioners may incorporate research activities in their clinical efforts are outlined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Occupational settings facilitating wisdom-related knowledge: The sample case of clinical psychologists.

Wisdom can be defined as expert knowledge in the fundamental pragmatics of life. Examined here is whether clinical practice may facilitate access to and acquisition of such knowledge. Spontaneous think-aloud responses to 2 wisdom-related dilemmas from 12 young (aged 26–37 yrs) and 12 older (aged 65–82 yrs) female clinicians were compared with responses obtained from 17 young (aged 28–37 yrs) and 19 older (aged 64–75 yrs) other female professionals. Raters judged clinicians' responses as higher on 5 criteria of wisdom: factual knowledge, procedural knowledge, life-span contextualism, value relativism, and management of uncertainty. Contrary to most studies of cognitive aging, young and older adults did not differ. Rather, each age-cohort group received highest ratings when responding to a life dilemma matched to their own life phase. The application of a wisdom framework to assessing therapeutic treatment goals and therapist interventions as well as global changes in client's beliefs during therapy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of an ambulatory care clinical pharmacist: a controlled trial

Medical therapy for duodenal or gastric ulcer disease has traditionally involved gastric acid antisecretory therapy for 4 to 8 weeks to promote initial healing and indefinitely to prevent recurrences of ulcer. The discovery of Helicobacter pylori in most patients with peptic ulcer disease has led to a change in this approach. Therapy designed to eradicate H pylori may facilitate ulcer healing with acid antisecretory agents and, more important, may greatly reduce the incidence of ulcer recurrence, obviating the need for maintenance antisecretory therapy. Regimens designed to eradicate H pylori are difficult to comply with, however, and are associated with adverse effects in some patients. In this article we review the diagnosis and treatment of H pylori infection in patients with peptic ulcer disease and make recommendations regarding the use of conventional ulcer therapies and therapies designed to eradicate H pylori.     

Use of cumulative meta-analysis in the design, monitoring, and final analysis of a clinical trial: a case study

From 1983 to 1987, the Department of Veterans Affairs (DVA) Cooperative Studies Program (CSP) conducted a multicenter clinical trial (CSP #207) to determine whether four different antiplatelet regimens compared to placebo could prevent the occlusion of grafts following coronary artery bypass surgery. The study showed that all of the active regimens tended to be better than placebo and that the three regimens containing aspirin were statistically significantly better. A cumulative meta-analysis of 12 trials performed shortly before the end of CSP #207 raised the issue as to whether the meta-analysis, if done earlier, would have changed the conduct of the trial. At the start of the planning period, one trail of size n = 37 had been published with a nonsignificant odds ratio (OR) of 0.74 (95% CI: 0.18, 3.12). At the time that CSP # 207 was approved by the DVA Cooperative Studies Evaluation Committee, two trials had been published (cumulative n = 150, OR = 0.44, 95% CI 0.19, 0.99). At the time patient intake started, five trials showed cumulative n = 769, OR = 0.42, 95% CI = 0.26, 0.68. Although the first 6-month CSP #207 progress report showed no treatment effect, by the time of the 12-month review by the Data Monitoring Board (DMB) a trend was developing in favor of active treatment. If the results of the meta-analysis had been available to the DMB at that time, conceivably the Board would have recommended stopping the placebo arm because of a convincing treatment effect based on the totality of the evidence. Cumulative meta-analysis could be useful as an adjunct in the planning, conduct, and final analysis of a clinical trial. It could also be used as one piece of evidence in the monitoring of the ongoing phase of a trial.