Many patients with complicated psychiatric disorders – which we will define here as conditions involving multiple comorbidities, atypical or protracted symptoms, persistent functional impairment, and poor treatment response – often find themselves taking multidrug therapy regimens. Sometimes, combination therapies reflect wise, thoughtful, and even elegant amalgams crafted with careful deliberation. Such handiwork might capitalize on pharmacodynamic synergies and complementary, nonredundant mechanisms of action, or specific medications may make unique contributions to an overall regimen (such as drugs thought to exert anti-impulsivity, antisuicide, pro-cognitive, or anxiolytic effects). In a well-devised multidrug treatment plan, each component ideally has a well-defined job description and fills a particular role, much the way each player on a sports team covers a unique position, or every instrument in an orchestra makes its own distinct contribution to form a cohesive whole. In that sense, every drug within a psychopharmacology regimen should serve an identifiable and unambiguous function.

Nearly three times as many people detained in a jail have a serious mental illness (SMI) when compared to community samples. Once an individual with SMI gets involved in the criminal justice system, they are more likely than the general population to stay in the system, face repeated incarcerations, and return to prison more quickly when compared to their nonmentally ill counterparts.

This article explores how wide-ranging effects of exposure to psychological trauma in mentally ill individuals continue to be largely overlooked, contributing to poor outcomes and a flood of mentally ill individuals into the court system and correctional care. Even in state hospitals and community mental health settings, the consequences of trauma often go unrecognized and untreated in highly vulnerable individuals. The authors posit that a trauma-informed lens is needed to move “trauma-blind” systems forward to more enlightened, evidence-based care and treatment. The traditional criminalization hypothesis refers to the funneling of SMI individuals into the criminal justice system as a result of deinstitutionalization and inadequate community mental health resources. This article explores how expanding notions about criminalization that identify factors beyond SMI still miss the mark by underestimating or omitting the role of trauma.

State psychiatric hospitals face increasing referrals for the evaluation and restoration of individuals whose mental health symptoms render them incompetent to stand trial (IST). As referrals can overwhelm capacity for admission, state hospitals at times are unable to admit IST patients in a timely fashion. The resulting use of “waitlists” have the undesirable consequence of forcing symptomatic individuals to endure long waits (while jailed) for admission to a psychiatric hospital. These long wait times have been determined to be unconstitutional, resulting in litigation against the responsible state mental health authorities. Unfortunately, available options to expedite hospital admission of these IST patients can have significant clinical and economic consequences.

Lesbian, Gay, Bisexual, and Transgender (LGBT) people, are more likely to be disproportionally placed in a secured setting. Secured settings such jails, prisons, and forensic hospitals can be traumatizing, hostile, and dangerous – especially for those who are transgender, which is only compounded when responsive and appropriate policies, procedures and training are not in place to maintain safety, privacy, and dignity. All LGBT residents, and more importantly those suffering from mental illness, who are in secured environments should be free of discrimination, victimization, and abuse. They should have equal access to safe housing, vocational programs, rehabilitation services, as well as medical and mental health treatments. Many organizations such as National Center for Transgender Equality, National Institute of Corrections (NIC), the World Professional Association for Transgender Health (WPATH) and The Joint Commission (TJC) provide guidelines to ensure that LGBT residents are protected.

The California Department of State Hospitals (DSH) manages the psychiatric care of almost 7,000 patients admitted to any of its five hospitals. Over 90% of these patients have forensic commitments, meaning they have been charged with, or convicted of, a crime. Treating patients with mental illness and criminal behavior reflects a general trend within state psychiatric facilities.An increase in physical violence towards staff and patients has been attributed to this mandate to care for patients with both severe mental illness and criminal backgrounds. Addressing violence is a pressing need within state hospital systems, as a safe treatment environment is quintessential to the delivery of effective care.

Developments in threat assessment, particularly in the area of concerning communications and approaches to public figures, has led to the setting-up in a number of countries of a new style of service for assessing and managing risk to the prominent from the actions of lone individuals. Known as fixated threat assessment centres (FTACs), their central characteristic is that they are jointly staffed by police officers and by psychiatric staff from health services. They are based on the realization that the interests of the prominent in terms of protection overlap with those of the people harassing them in terms of medical care. Research over the last decade has re-established that the majority of those threatening, harassing, or attacking public figures have unmet mental health needs, and that attention to these is often the most effective way of reducing risk, whilst at the same time improving their lot and focusing on treatment, rather than criminalization. The approach has recently been expanded to encompass assessment and intervention in individuals suspected of being radicalised into extreme ideologies and at risk of proceeding to commit terrorist acts.

The history of serious mental illness (SMI) is grim, from a cultural as well as a treatment perspective. The conditions of individuals with psychotic disorders have swung, like a pendulum, from institutional neglect to community neglect and back again over the past several hundred years. At the core of treatment failure is a failure in mental health policy and funding, with the result usually framed as the degree of human institutionalization in jails, prisons and asylums. In the middle of the nineteenth century, institutions designed to deliver moral treatment were considered the humane answer to care properly for the SMI population. By the mid-twentieth century, those same, now overcrowded, institutions were blamed for the horrible conditions of mistreatment of individuals with SMI.

The insane criminal has nowhere any home: no age or nation has provided a place for him. He is everywhere unwelcome and objectionable. The prisons thrust him out; the hospitals are unwilling to receive him. And yet humanity and justice, the sense of common danger, and a tender regard for a deeply degraded brother-man, all agree that something should be done for him—that some plan must be devised different from, and better than any that has yet been tried, by which he may be properly cared for, by which his malady may be healed, and his criminal propensity overcome.

In community settings, the principle barriers to independent living, stable relationships, and gainful employment arise from the negative and cognitive symptom domains of schizophrenia spectrum disorders., In contrast, the positive symptoms of psychosis often are the gateway (e.g. via persecutory delusion associated with anger) to arrest and criminalization for the mentally ill. Since the clinical discovery of chlorpromazine in 1952, dopamine antagonism in the mesolimbic dopamine circuit has been central to treating the positive symptoms of psychosis. The hyperactivity of the mesolimbic circuit and the normalizing effects of the dopamine antagonist antipsychotics are illustrated in Figure 18.1.

Inpatient aggression within psychiatric facilities continues to demand attention. Aggressive acts often cause physical or psychological injury that impact the lives of the patients or staff victims of these incidents. However, it should be noted that the vast majority of psychiatric patients are not aggressive while hospitalized. Studies on inpatient aggression showed approximately 25%–35% of inpatients committed acts of aggression. For those inpatients who are aggressive, there is a substantial literature that that describes a small subset of “chronically aggressive” patients, who are responsible for the majority of inpatient aggression.

Recently, mental health officials have expressed concern regarding population shifts occurring in public psychiatric hospitals. Specifically, they have seen an increase in the number of “forensically involved” patients in these facilities. This trend is seen, in part, as an increase in the number of persons who have been brought to court on a criminal charge and subsequently court-ordered to receive inpatient services at state psychiatric hospitals. These “forensic patients’” are referred to the state psychiatric hospitals to be evaluated (e.g. to determine their mental status at the time of the crime and their ability to comprehend court proceedings and/or assist their attorney with their case because of an apparent mental illness) or to be restored (e.g. to receive treatment services and/or educational interventions aimed at helping defendants regain their ability to understand the court process) prior to adjudication.

Have you ever walked down the street and seen someone with mental illness, agitated and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?

Have you ever walked down the street and seen someone with mental illness, agitated and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?

The overarching aim of this editorial is to present a dream: a World Symposium in the eternal city of Rome in which prominent psychiatric experts, neuroethicists, and lawyers dialogue on severe mentally ill (SMI) patients as our global migrants. The aim is to foster an inclusive and fruitful interdisciplinary conversation and draw up practical proposals in order to protect and promote the dignity of human persons afflicted by severe mental disorders.

The United States’ incarceration rate of its national population is the highest in the world. The percentage of incarcerated individuals with a mental illness is substantial, with 10% to 15% of inmates suffering from a serious mental illness. Two-thirds of sentenced jail inmates met criteria for drug dependence or abuse. Many inmates experience both mental illness and a substance use disorder as co-occurring conditions.

U.S. health care costs are staggering, with spending at $3.5 trillion dollars in 2017. Additionally, criminal justice system expenditures are estimated at $270 billion dollars. Our nation’s most at-risk individuals are falling through the cracks and entering a vicious cycle of incarceration and temporary institutionalization, which only exacerbates these costs.

Forensic populations in the United States are increasing, driven largely by a rise in individuals determined to be incompetent to stand trial (IST). According to the California Department of State Hospitals’ 2017 Annual Report, the most common type of commitment (22% of all commitments) was defendants adjudicated IST. While just five years ago, 343 mentally ill inmates were awaiting placement for competency restoration services, as of 2018, that number has increased to a staggering 819. As defined by the Dusky v. United States (1960) standard, a competent defendant must have the capacity to understand the legal proceedings, which includes an understanding of the various participants in the justice process. Defendants must also be able to function within the legal system by consulting with their attorneys.