Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness—an observation that many argue reflects a process of “criminalizing” mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

Eligibility criteria for participation in mental health jail diversion programs often specify that, to be diverted, a candidate must not pose a level of threat to public safety that cannot be managed in the community. Risk assessment tools were developed to increase consistency and accuracy in estimates of threat to public safety. Consequently, risk assessment tools are being used in many jurisdictions to inform decisions regarding an individual’s appropriateness and eligibility for mental health jail diversion and the strategies that may be successful in mitigating risk in this context. However, their use is not without controversy. Questions have been raised regarding the validity and equity of their estimates, as well as the impact of their use on criminal justice outcomes. The purpose of this review is to provide an overview of the science and practice of risk assessment to inform decisions and case planning in the context of mental health jail diversion programs. Our specific aims include: (1) to describe the process and components of risk assessment, including differentiating between different approaches to risk assessment, and (2) to consider the use of risk assessment tools in mental health jail diversion programs. We anchor this review in relevant theory and extant research, noting current controversies or debates and areas for future research. Overall, there is strong theoretical justification and empirical evidence from other criminal justice contexts; however, the body of research on the use of risk assessment tools in mental health jail diversion programs, although promising, is relatively nascent.

Mr. A is 24 years of age with a history of schizophrenia (Slide 1). He has been living with his parents and has been ill for a few years. Police saw him on the street in a state of crisis and brought him to the emergency room (ER). He was very anxious and his delusions of being in great physical danger had worsened. He reported a history of asthma, but it was noted that his asthma occurred a long time ago and was inactive; however, due to his anxiety, his smoking had increased to where it was continuous. At the time he was brought to the ER, Mr. A was triaged to psychiatry and became agitated in the waiting area; hence, security was called. He was about to be restrained and given an intramuscular dose (IM) of lorazepam, but the psychiatrist noted that he was having trouble breathing and stopped the IM before it was given. The psychiatrist noticed that Mr. A was wheezing, had a rapid respiratory rate of 25/minute, was tachycardic, and sweating. His pulse oximeter measurement was 90% saturated, which is considered low.

Mr. A was re-interviewed and reported that he previously had asthma. His parents were contacted and agreed that he had active asthma, had stopped his psychiatric treatment several months ago, and, more recently, stopped his asthma medications when his prescriptions were not refilled ∼1 week prior to this episode. An emergency arterial blood gas showed a pH of acidosis at 7.27; a Po2 of 60 (normal is 80); and a Pco2 of 48 (normal is 40). The Pco2 was of particular concern because if he was retaining CO2, respiratory failure was imminent.

Progress in biological psychiatry is contingent upon progress in neurobiology and progress in research of proper characterization and assessment of abnormal behavior. Advances in neurobiology are rapid and steady; however, advances are few and far between in psychopathology. In many ways, developments over the past two decades run counter to what I believe to be diagnostic pre-requisites for fruitful biological research in psychiatry. I presume this to be a major reason why thus far biology has made no significant contributions to the diagnoses of mental disorders.

For progress to occur in biological psychiatry, the traditional diagnostic philosophies and attitudes must be reevaluated and alternative diagnostic approaches put into practice. This and the diagnostic method of functional psychopathology are reviewed in this article, with a focus on how the functional psychopathological approach could contribute to the advancement of the diagnostic process in psychiatry, and the opportunities it provides for biological psychiatric research.

Infection with human immunodeficiency virus type 1 (HIV-1 ) leads rapidly to infection of the brain and subsequent neuropsychological impairment, including subclinical impairment, minor cognitive-motor disorder, and HIV-1–associated dementia (HAD). This article reviews HAD and the factors involved in its pathogenesis; the effectiveness of antiretroviral therapy; the prevalence of HIV-1 and subtypes; and the role of chemokines and cytokines as the capstones associated with neuropathology due to inflammation.

In the last 20 years, research on substance addictions has changed its focus from the social foundations to the neurobiological foundations. Hence, some behaviors have begun to be considered as equivalent to addiction based on proposed criteria: salience, withdrawal symptoms, tolerance, conflicts, relapse, and mood modifications.

New knowledge about the brain's reward system suggests that “as far as the brain is concerned a reward is a reward, regardless of whether it comes from a chemical stimulus or an experience.”

Pathological gambling was the prototypical addiction disorder, sharing some hallmarks with substance addictions: a high rate of comorbidity and treatment response to pharmacotherapies, such as opioid antagonist. However, compulsive sexual behavior, compulsive exercise, food starving, binge eating, and, most recently, Internet addiction have been gradually conceptualized as non-substance addictions with overlapping features with substance dependence. Several definitions” have been adopted regarding these behaviors: natural addiction, non-chemical addiction, and negative dependence are only some examples. This issue of CNS Spectrums focuses on behavioral addictions.

Optimal treatment for patients with mental health illness depends upon accurate diagnosis, individualized treatment, patient adherence to effective agents, and an intact family support system. Healthcare system (eg, limited access to certain medications), provider (eg, bias and discrimination), and patient factors (eg, biologic and cultural) greatly influence the level of mental health care given, especially to minority populations. Furthermore, limited data in African Americans, Hispanics, and Asians suggest that there are racial, ethnic, and cultural variations in responsiveness to antipsychotic medications, as well as potential differences in the types, rates, and severity of adverse events. Non-Caucasian patients tend to receive older, less-expensive agents, sometimes at higher doses (African Americans, leading to potentially intolerable side effects and early withdrawal of therapy or a less than optimal therapeutic response, respectively. Differences in response may have a biologic, pharmacokinetic, or pharmacodynamic basis and may also be influenced by lifestyle factors (eg, diet, smoking). Variations in dopamine receptor occupancy and cytochrome P450 polymorphism may explain some racial/ethnic differences in antipsychotic effects and adverse-event profiles, suggesting that dosing may need to be individualized based on ethnicity. The newer atypical antipsychotics, while seemingly better tolerated compared with conventional antipsychotics, may not be totally devoid of bothersome side effects (eg, extrapyramidal side effects) in minorities. While further research is needed, recognition of potential interracial/ethnic pharmacogenetic differences may help minimize intolerable side effects and achieve optimal psychosis management.

A major challenge in the management of Alzheimer's disease (AD) is accurate diagnosis of the condition. Aging itself is associated with cognitive change, and physicians must first distinguish between age-associated complaints and true memory impairment as in AD before optimal management can begin. This article reviews tools used to assess and diagnose AD patients in both the primary care and clinical trial setting. AD assessment instruments commonly used in research may be too cumbersome for use in primary care. Tools specifically designed to meet the needs of busy practitioners that can accurately assess function, cognition, and global change will be reviewed. The issues of cognitive screening in old age and age-associated memory impairment will be discussed. Similarly, the pitfalls and advantages of routine cognitive screening in daily practice will be addressed.

This article reviews the development of forensic psychiatry and mental health services in Australia for the international reader. It covers the legacy of a series of colonial systems that have contributed to a modern health service that interacts with justice systems. The development of relevant legislation, hospitals, prison services, community, and courts services is reviewed. The training and academic development of professionals is covered. Gaps in service delivery and future directions are considered.

Unraveling the significant complexity of brain-immune interactions could provide essential new insights and potential treatment considerations for the clinical neurosciences. Despite considerable research relating immunological changes to major neuropsychiatric disorders, it has been difficult to establish that immunological processes are involved in the development of central nervous system pathology associated with these disorders. This brief article highlights some of the landmark basic studies and seeks to convey essential principles guiding research in brain-immune interactions. Research in this area often incorporates several disciplines, ranging from psychology and neuroscience to immunology and molecular genetics. The clinical implications of this area of research are discussed, with emphasis on the challenge of disentangling pathogenic factors and valid markers of disease from epiphenomena.

Bipolar disorder is a prevalent psychiatric disorder with a high rate of misdiagnosis and evidence of degenerative progression. Research indicates that the interval between bipolar episodes decreases steadily until the patient settles into a relatively frequent course of mania and depression. Various imaging techniques have been used in the understanding of the brain pathology underlying bipolar disorder through identification of patterns consistent with disruption of the normal brain activity in bipolar patients. These techniques have demonstrated evidence of abnormalities in the structure and function of the prefrontal cortex. In addition, the cerebellar vermis, which serves as an error-detection function to modulate the iterative network, appears to shrink with recurrent episodes. Functional imaging demonstrates that the anterior limbic network is overactivated and overresponsive in patients with bipolar disorder. In many patients, those deficits are often compensated for by activation of other brain areas. Ultimately, when the compensation fails, expression of bipolar symptoms arise. Using magnetic resonance spectroscopy, simple models can be constructed based on the hypothesis that mitochondrial function may be impaired in bipolar disorder. There is also increasing evidence that psychotropic medications can affect specific brain regions that are thought to be involved in the pathogenesis of psychiatric disorders. Glutamate levels appear to be elevated in untreated patients with bipolar disorder, which may cause glutamatergic neurotoxicity and negative therapeutic implications. Further advances in brain imaging may contribute to the improvement of available therapies and the understanding which treatments will be most suitable for specific patients.