Melanie Cole, MS (Host): This is Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we're here today to gain a deeper understanding of the field of forensic psychiatry. Joining me is Dr. Michael Brook. He's an Associate Professor of Psychiatry and Behavioral Sciences at Northwestern Medicine.

Dr. Brook, it's a pleasure to have you with us. And I'm so interested to hear what you have to tell us about this field. So, start by telling us a little bit about your role within Northwestern Medicine's Division of Psychiatry and the Law and the services that it offers. While you're doing that, Dr. Brook, tell us what forensic psychiatry really is.

Dr. Michael Brook: Sure. Well, thank you for having me, first of all, Melanie. So, the Division of Forensic Psychiatry is a division within the Department of Psychiatry and Behavioral Sciences here at Northwestern Medicine. The composition of the division is psychiatrists and psychologists. We're all on staff at Northwestern Medicine, and all of us have our unique expertise clinically and research-wise.

I am a clinical neuropsychologist by training. So, my work involves working with patients and, in this case, attorneys on the courts in the area of brain behavior relationships. When the courts require an expert opinion about a mental health issue or a brain-based issue in my case, they retain one of our experts to lend their expertise to the courts on matters having to do with criminal or civil litigation.

Melanie Cole, MS: Well, thank you for that. What a fascinating field you are in. So, what methods does the Division of Psychiatry and the Law employ in performing psychiatric and psychological examinations? Give us some examples of how psychological and neuropsychological testing can really help to inform legal questions. Explain that role of a forensic psychiatrist within the legal system.

Dr. Michael Brook: Sure. When the courts are faced with difficult questions related to human behavior, they retain experts in psychiatry, psychology, and neuropsychology to help inform issues related to, for example, fitness to stand trial, or malpractice, or in civil cases, disability or mental health injury, or Workers Compensation.

For criminal cases, there are really two stages of the adjudication process. There's the guilt innocence stage, as we've all seen on TV, where the defendant is found guilty or innocent. And if the defendant is found guilty, there's the sentencing stage. Mental health experts are retained by the courts, for example, to provide an opinion about insanity. Now, what I'm talking about is, of course, a legal definition of insanity. Each state has one. In Illinois, for example, where we are, the legal definition of sanity is that the defendant should be able to appreciate the criminality of their actions at the time they committed some offense.

So then, what the mental health expert does is they conduct an independent examination of the defendant, and they provide an opinion to the court whether or not the defendant was suffering from a mental health condition that would have prevented them or would have significantly interfered with their ability to appreciate the criminality of their action. I was recently on a case, for example, where there was a defendant with an intellectual disability and the opinion was because of the extent of their intellectual disability, they were not actually able to appreciate the criminality of what they were doing.

And then during sentencing, the defense attorneys will often hire psychologists or psychiatrists to examine the defendant and provide an opinion whether or not the defendant had a mental health condition like a bipolar disorder or, again, intellectual disability that can serve as a mitigating factor when assigning the appropriate punishment. So, that's criminal cases, but we also get retained in civil cases.

In civil litigation, a plaintiff party brings a suit against another party, which is a defendant in the case. And then, the amount of damages is awarded to the plaintiff based on the severity of the injury sustained. So then, the psychiatrist and psychologist, when they're retained by the courts, can help the courts figure out the extent of the damages and whether or not the damages are causally related to the injury in question.

Melanie Cole, MS: Isn't that so cool what you do? So. I'd like you to tell us about the Isaac Ray Research Program within the Division of Psychiatry and the Law and its mission. Tell us a little bit about that.

Dr. Michael Brook: Sure. So, this is the research arm of our division. The Isaac Ray Research Program is an endowed research program, which I've directed since its inception in 2018. Our main mission is really to bring together multidisciplinary research collaborations that can answer important questions at the intersection of human behavior and the law.

Melanie Cole, MS: Well, Dr. Brooke, you're currently conducting research on community violence, specifically in Chicago, called the Safer Together Coalition. Tell us a little bit more about how this project came to fruition and the study's strategic objectives and the funding you received from Blue Cross Blue Shield, because this is such an important research study. Tell us about it.

Dr. Michael Brook: That's right. So, this project is funded by Blue Cross Blue Shield through their Affordability Cures Initiative, which funds innovative solutions to important public health problems. We've realized for a while now that community violence is a public health problem that disproportionately affects black and brown communities that already suffer from, disinvestment and inadequate access to resources.

But violence research has not traditionally been conducted using public health research methodology. We typically in the past applied what's called a syndromic model to the study of violence, which is a lot of clinicians and clinical researchers will be very familiar with. This is where we study clinical conditions. We recruit from the population. We divide the population into groups that have and don't have certain conditions, then we study differences between those two groups. And that's supposed to tell us something about the disease we're studying.

Well, we realize that violence is not a disease. No one is born violent. It's not something that you contract. Violence is an event. And whether or not someone is going to be involved in an incident of community violence is determined by a very complex interaction of individual environmental factors. So, we don't imply the syndromic model, but this is a really innovative approach. And Blue Cross Blue Shield was interested in funding this as part of this Innovative Cures initiative.

So, what we wanted to do in this project is really capitalize on the very rich public health research infrastructure and existing community relationships here at Northwestern Medicine. And we're able to put together a study that can investigate the complex risk and protective factors for involvement in community violence. And really, the only way to do this is to use something called community-based participatory research, which puts community partners in the driver's seat when it comes to research design and implementation. And through this prospective designs, we're able to really comprehensively study the complex interactions between risk and protective factors that can increase or decrease someone's risk of being involved in a violent incident.

Melanie Cole, MS: So comprehensive, and yet, as you say, so complex. Can you elaborate a little bit more on the multidimensional statistical modeling that's used to understand the complex determinants of community violence, as you were just touching on? Tell us how the study analyzes the interaction between that static, dynamic, and socio-ecological pressures to understand the likelihood of violent occurrences. Dr. Brook, describe while you're doing that, the importance of cultural competency in forensic psychiatry, how that would impact your work with diverse populations and how that all ties together.

Dr. Michael Brook: This is really the crux of a prospective research design like this. Now, we assume that whether or not someone will be involved in an incident of community violence is a dynamic decision or a dynamic process that at any given point is influenced by a number of individual variables like, for example, mood states or trauma; a number of socioecological variables, such as where they are at the moment, the quality of neighborhood resources, access to mental health and physical health; and dynamic factors, such as using substances at the moment or peer pressures. And these factors don't impact people in a static way, they are inherently dynamic. So, the interaction of these factors are going to be different as the individual moves throughout their lifetime, but it's also going to be different throughout the day.

So, what we can do in a design like this is actually follow individuals over time and then study the complex events that happen around each incident of community violence. Then, once we collect enough data, we'll be able to plug these factors into a really complex computational model. And what we will get in the end is an understanding of the most important risk and protective factors for community violence that are, by the way, unique to each community with the end goal of then structuring community-based interventions around these most important factors.

Melanie Cole, MS: Wow. That is so interesting. Now, tell us a little bit about the project currently running at the Cook County Jail in the Chicago suburbs as an implementation trial using digital technology to improve access to mental health assessment for justice-involved populations. How fascinating is this?

Dr. Michael Brook: Yes. This is another major project we have underway right now at the Isaac Ray Research Program. So, we know that the rates of mental illness are incredibly high among justice-involved populations. These are folks who are undergoing a court process for an offense or are incarcerated in jails and prisons. We know that mental health issues contribute to higher rates of reincarceration. They contribute to poorer individual outcomes. But in order for us to address mental health issues among this population, we need to be able to reliably assess symptoms of depression, anxiety, posttraumatic stress and other mental health conditions.

The problem is that access to reliable mental health assessment is limited in justice-involved populations because traditionally it requires a clinician. It's time-intensive, it's expensive, and a lot of these systems, as you know, don't really have a lot of resources. So, this project investigates if digital mental health assessment technologies can provide a solution to this problem.

So, we're using something called CAT–MH. It's a digital mental health assessment tool that is self-administered on any internet-connected device and in an average of something like 10 minutes. It can reliable diagnosis across important diagnostic categories like depression, anxiety, PTSD, substance abuse. That track very well with clinician ratings. So over the past year and a half, we've been administering this measure at weekly intervals to detainees at the Cook County Jail who participate in group therapy, essentially in the jail. It's been very well tolerated. Our dropout rates have remained at less than 5%, which is, if you know anything about clinical research, is pretty incredible. We've found that the rates of mental illness are indeed very high when people come into the jail. But then, we also found that detainees experience a significant reduction in symptoms if group therapy services are provided during their time in the jail.

Our probably most exciting finding from this project is that a reduction in specifically PTSD symptoms translates into a significantly reduced risk for reincarceration, for coming back to the jail on a different event. So, this project arguably provides the first empirical evidence that actually addressing trauma for justice-involved individuals results in better outcomes for the individuals and the system as a whole. So, we're hoping to translate this project into a federal grant in the future that'll extend this assessment to also individuals in the community who are participating in the electronic monitoring program for example. So, there's lot of exciting things to come.

Melanie Cole, MS: Well, certainly they are. And as we get ready to wrap up, in the realm of forensic psychiatry, Dr. Brook, what emerging methodologies and research findings do you believe hold the most promise for advancing our understanding of the complex relationship between mental disorders and criminal actions, which ultimately shape more effective intervention strategies? Give us your best advice here.

Dr. Michael Brook: What a great question, Melanie, and we think about this all the time. I would say this, problems that exist at the intersection of human behavior and the law are incredibly complex. And as such, they require multidisciplinary solutions. I think the time has passed where we can answer important questions in behavioral science and the law using research that is siloed within behavioral science or social science or genetics or bench research.

I think we must apply a truly multidisciplinary if we were ever to make headway on some of these questions. In our research program, we apply a research model called convergence research. This is where multidisciplinary science is conducted in collaboration with community and institutional partners, and everyone's input is valued equally. And then, the very research design is not siloed within a certain methodology or discipline. But it's truly multidimensional and multidisciplinary. So, I think this is indeed the future of research in behavioral sciences and the law.

Melanie Cole, MS: Dr. Brook, I hope you will join us again and update us as you are learning more. This is just such an educational episode you've just given us here today. I thank you so much for joining us. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine Podcasts. Until next time, I'm Melanie Cole.