Introduction

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.^1‒5 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.^1–8 Forensic patients can also consist of patients who have been court-ordered to receive inpatient services after a verdict has been reached on their case (e.g. individuals found to be not guilty but mentally ill, inmates who were transferred from a correctional facility for inpatient services, or individuals involved in the criminal justice system who were involuntarily civilly committed^I to a state psychiatric hospital for continued treatment).^2,7‒9 As can be seen, there are a variety of different types of forensic patients. This descriptive presentation is based on the major findings from a national study.^II For the purposes of this study, this paper focuses solely on: (1) the overall forensic population, (2) patients who had been court-ordered to receive pre-trial evaluations at a state psychiatric hospital, and (3) defendants who were found incompetent to stand trial (IST) and court-ordered to receive competency restoration services at a state psychiatric hospital. The term “forensic patients” is used in this paper to refer to all persons found “not guilty by reason of insanity,” persons found “guilty but mentally ill,” individuals transferred from correctional facilities seeking treatment services that are not available in the correctional setting, and, in some states, individuals involved in the criminal justice system who have been civilly committed to a state psychiatric hospital.

A large portion of forensic patients receiving services at state psychiatric hospitals consist of defendants who have been deemed IST^III and court-ordered to receive competency restoration services.^2,3,7,10 These services typically involve treatment and/or educational interventions aimed at helping defendants regain their ability to understand the court process and/or assist their attorneys in their defense.^2,6 The apparent growth of this forensic population, in particular, has sparked the concerns of state officials. Many state officials have queried the National Association of State Mental Health Program Directors Research Institute (NRI) as to whether the rising forensic population in state psychiatric hospitals in their state, particularly IST patients, is a phenomenon that is unique to their state, or if this is a national trend.

Despite the growing concern centered around this trend, there are few national studies that have examined this “forensification”^IV of state hospitals.⁷ This is indeed a valid concern. Forensic patients differ from civil patients^V and patients who are involuntarily civilly committed.^2,7‒9 In cases where a patient is being civilly admitted to a hospital, the hospital has the authority to determine who is to be admitted or discharged. Conversely, the admission and discharge of forensic patients is primarily controlled by the courts. Very few state psychiatric hospitals have the authority to discharge patients who have been court-ordered to receive inpatient services.² Even though the admission and discharge process for forensic patients diverges from that of civil patients, the funding for these hospitalizations and their effect on bed supply are the concerns of the mental health system.⁹

Data from a national study are needed for policymakers to be able to address whether or not: the perceived “forensification” process is “real” and the rise in forensic patients is not a result of a declining civil population (e.g. the trend among forensic patients has remained steady, but the decline in civil patients has made it to appear as if the forensic population is growing).

Due to a lack of information on the scope of the issue and the potential factors that may be contributing to this apparent shift, this national study was developed to examine these factors. In doing so we address three questions regarding the perceived increase in the number of forensic patients: (1) Has there been an increase in the rate of state hospital admissions and census for all forensic statuses? (2) Are forensic patients becoming an increasing proportion of these hospitals’ census? (3) Has the absolute number of patients receiving pre-trial evaluations and the number of IST patients who have been court-ordered to receive competency restoration services in state psychiatric hospitals services increased?