Evaluations of competence to stand trial are evolving amid a national "competency crisis".

Across the United States, court orders for competence to stand trial (CST) evaluations and competence restoration services have been increasing much more rapidly than states can provide these services, prompting what has been called a national "competency crisis." The challenge in providing timely competence restoration services has, in several jurisdictions, prompted a change in competence evaluations. Evaluators are more often required to address broader clinical issues-such as recommending placement or addressing the urgency of hospitalization-rather than addressing only CST.

Tipping the scales of justice: the role of forensic evaluations in the criminalization of mental illness.

An unprecedented number of individuals with mental illness are represented in the criminal justice system. The unending growth of mentally ill populations in the justice system has led to jails and court dockets being increasingly overwhelmed with cases involving mental illness, state hospitals devoting far more beds and resources to forensic cases, and people without a criminal commitment left waiting for mental health services as forensic cases are prioritized. Although a forensic mental health evaluation is only one component of this larger system, common problems with forensic mental health evaluations can exacerbate the criminalization of persons with mental illness in many ways.

Field reliability influences field validity: Risk assessments of individuals found not guilty by reason of insanity.

Individuals acquitted as not guilty by reason of insanity (NGRI) are usually committed to psychiatric hospitals for treatment until they are considered suitable for conditional release back to the community. The clinical evaluations that inform conditional release decisions have rarely been studied but provide an ideal opportunity to examine the reliability and validity of complex evaluations in the field. For example, to what extent do forensic evaluators agree about an acquittee's readiness for conditional release? And how accurate are their opinions? We reviewed 175 evaluation reports across 62 cases from Hawaii, which requires 3 separate evaluations from independent clinicians for each felony NGRI acquittee referred for conditional release evaluation.

Diagnostic field reliability in forensic mental health evaluations.

How likely are multiple forensic evaluators to agree on defendants' diagnoses in routine forensic mental health evaluations? A total of 720 evaluation reports were examined from 240 cases in which 3 evaluators, working independently, provided diagnoses for the same defendant. Results revealed perfect agreement across 6 independent diagnostic categories in 18.3% of cases.

New Frontiers for Conditional Release: Applying Lessons Learned from Other Offenders with Mental Illness.

There is relatively little research in the literature on insanity acquittees as compared with the large number of studies focused on the supervision and treatment of probationers and parolees with mental illness. Ideally, the latter literature could be successfully applied to insanity acquittees discharged from an inpatient hospital on "conditional release." This article describes the challenges faced by persons on conditional release as well as the gaps in extant conditional release literature.

Decision-making in post-acquittal hospital release: how do forensic evaluators make their decisions?

A large number of individuals are acquitted of criminal charges after being found "not guilty by reason of insanity." Most of these individuals are hospitalized and later seek hospital discharge under a court-ordered provision called conditional release ("CR"). Courts rely on opinions from forensic evaluators to determine acquittees' readiness for CR.

Quality of criminal responsibility reports submitted to the Hawaii judiciary.

This paper is the third in a series of research reports on quality of forensic mental health evaluations submitted to the Hawaii judiciary. Previous studies examined quality of reports assessing competency to stand trial (CST) and post-acquittal conditional release, in felony defendants undergoing court-ordered examinations. Utilizing a 44-item quality coding instrument, this study examined quality of criminal responsibility reports in a sample of 150 forensic mental health evaluations conducted between 2006 and 2010 by court-appointed panels.

How reliable are forensic evaluations of legal sanity?

When different clinicians evaluate the same criminal defendant's legal sanity, do they reach the same conclusion? Because Hawaii law requires multiple, independent evaluations when questions about legal sanity arise, Hawaii allows for the first contemporary study of the reliability of legal sanity opinions in routine practice in the United States. We examined 483 evaluation reports, addressing 165 criminal defendants, in which up to three forensic psychiatrists or psychologists offered independent opinions on a defendant's legal sanity. Evaluators reached unanimous agreement regarding legal sanity in only 55.

Field reliability of competence to stand trial opinions: How often do evaluators agree, and what do judges decide when evaluators disagree?

Despite many studies that examine the reliability of competence to stand trial (CST) evaluations, few shed light on "field reliability," or agreement among forensic evaluators in routine practice. We reviewed 216 cases from Hawaii, which requires three separate evaluations from independent clinicians for each felony defendant referred for CST evaluation. Results revealed moderate agreement.

Freedom in paradise: quality of conditional release reports submitted to the Hawaii judiciary.

Annually thousands of insanity acquitees are released from mental hospitals when they are no longer determined to be dangerous. This research examined quality of post-acquittal Conditional Release (CR) reports submitted to the Hawaii Judiciary. Hawaii utilizes a "three panel" system for assessing trial felony competency, criminal responsibility, and conditional release, where typically two psychologists (one Department of Health and one community-based) and one community-based psychiatrist submit independent reports to the Court.