Psychiatry, the law and the death penalty

For more than 30 years a Yale program has examined the interface of law and psychiatry.

Although death penalty decisions are always controversial, the case of convicted serial murderer Michael B. Ross has proven to be one of the most complex legal battles seen in Connecticut in recent years. Ross, who was found guilty of murdering six young women in the early 1980s, was sentenced to death 18 years ago. Since then, a series of appeals, hearings and overturned decisions has involved not only the courts but also two of Yale’s forensic psychiatrists. Howard V. Zonana, M.D., professor of psychiatry, interviewed Ross before his 1987 trial, and Michael A. Norko, M.D., associate clinical professor of psychiatry, evaluated Ross in 1995, in 2004 and again in March when Ross attempted to waive his right to appeal. Norko found no evidence that Ross suffered from “death row syndrome” or that he was incompetent to waive his right to appeal. Ross was executed on Friday, May 13.

The Ross case is one of about 1,000 consultations for court cases both local and national that the Law and Psychiatry Division at the School of Medicine tackles each year. What began in 1973 as an elective for residents examining the interface between law and psychiatry has grown into a division of five units and 23 staff members that offers a one-year fellowship in forensic psychiatry, as well as courses for psychiatric residents.

“Forensic psychiatry is defined as the use of psychiatric expertise to aid in the resolution of legal problems, and it also deals with patients in settings like prisons, where there are special needs that have to be accounted for,” explained Zonana, who directs the division.

That definition brings forensic psychiatrists into the courtroom as well as the clinic. They consult on everything from insanity defenses to the termination of parental rights. As part of their training, law and psychiatry fellows rotate through various settings: they work with law students in the Jerome N. Frank Legal Services Organization, they see the victim’s perspective through postings with the state’s attorney and they may work in the federal public defender’s office or at the Connecticut Juvenile Training School run by the Department of Children and Families.

The division also contracts with the state of Connecticut to evaluate the competency of defendants in the New Haven region to stand trial—almost 200 cases a year. Under close faculty supervision, residents conduct evaluations, write reports and testify in court.

“We try to get them to approach each case from an objective, critical viewpoint, which may be different from the objective in clinical work, where you’re trying to establish a rapport with the patient,” said Norko. “In forensic psychiatry that’s not necessarily the goal, because the outcome of your evaluation may or may not be helpful to the person.”

On a broader scale, the division frequently examines legal issues such as a statute on the competency of juveniles to stand trial or the legal regulation of psychiatry. “Psychiatry is the most legally regulated subspecialty in medicine because of the fact that we can detain people against their will,” explained Zonana. The division also created a jail diversion project in 1995 that places a clinician in the court to assess defendants charged with drug-related misdemeanors and develop treatment plans as alternatives to incarceration. Thanks to the success of the project, the Connecticut legislature has since expanded it to all lower criminal state courts.

“It’s a very diverse program, which I think is probably one of our biggest strengths,” said Norko, who is the division’s deputy training director. “The other is that we make a conscious effort to present more than one viewpoint about how forensic psychiatry should be done.”

—Jill Max

Complex congenital heart patients live longer, need new treatment paradigm

“Sometime in the next decade,” said James C. Perry, M.D., professor of pediatrics (cardiology) and chief of the Section of Pediatric Cardiology, “there will be, for the first time, more people over 18 living with congenital heart disease than people under 18.”

Congenital heart disease (CHD), the most common of birth defects, affects 0.8 percent of all live births in any given year in the United States. Thanks to advances in surgical and medical management techniques for treating children born with structural abnormalities of the heart, many children for whom CHD would once have been an early death sentence can now expect to live well into adulthood.

That fact underlies the work of the Yale-New Haven Adult Congenital Heart Program, the first of its kind in Connecticut and one of only two dozen in the country. The outpatient clinic is staffed by Perry and coordinator Nicole K. Boramanand, A.P.R.N. ’99, and the program provides a collaborative and multidisciplinary approach to monitoring and treating adult survivors of pediatric CHD. The most common problems experienced by these patients are arrhythmias and heart failure.

“Pediatric heart patients in the past were often discharged from pediatric care based on age, but adult cardiologists are not usually trained to manage congenital heart disease. Those patients had nowhere to go,” Perry said. “Our program offers access to pediatric and adult cardiologists, heart failure specialists, pulmonologists, transplant specialists, specialists in high-risk obstetrics and other medical staff with essential expertise.”

Patient education is also critical. “Our focus is on preventive maintenance,” Boramanand said. “What treatments and lifestyle adjustments can increase the length and quality of life? For instance, we emphasize to our patients that the old notion that all people with adult CHD should avoid exercise is no longer accepted.”

Boramanand notes that another aspect of education and prevention is obtaining extensive diagnostic information up front. “If we get readings early and track them regularly, we can see situations that may require treatment.”

Perry points out that individuals who survive into adulthood with CHD also experience the full range of health concerns, from catching the flu to developing arthritis to managing pregnancy and childbirth, and notes that the center helps clinicians learn more about this population.

As of this spring the Yale-New Haven Adult Congenital Heart Program, which began in July of 2004, had seen nearly 100 patients ranging in age from 17 to their late 50s. “Life expectancies vary,” said Perry, “and this is a group of patients we are just beginning to learn about. But to see people with complex congenital heart defects going strong into middle age is remarkable.”

—Rhea Hirshman

et cetera

Molecule linked to immune attack

A Yale scientist has found that blocking a key molecule protects implants, pacemakers, artificial joints and other foreign biomaterials from attack by the immune system.

“Implantation of biomaterials, devices, and tissue-engineered constructs into tissues causes the development of a foreign-body reaction that can lead to implant failure,” said Themis R. Kyriakides, Ph.D., assistant professor of pathology and biomedical engineering, a member of the interdepartmental program in Vascular Biology and Transplantation and lead author of a study published in December in The American Journal of Pathology.

Kyriakides and his team focused on areas where tissue and implants meet and foreign body giant cells form. In studies with mice, the team genetically eliminated the molecule, CC chemokine ligand 2 (CCL2), or blocked its action with decoy proteins.

The success of the experiments with mice opens up the possibility of finding targets for drugs to sustain implants.

—John Curtis

Yale to lead stroke study

The School of Medicine will lead a $33 million trial to examine a novel approach for preventing stroke—the Insulin Resistance Intervention after Stroke (IRIS) trial. Sponsored by the National Institute of Neurological Disorders and Stroke, the IRIS trial will test the effectiveness of reducing insulin resistance with pioglitazone, compared with placebo, for preventing recurrent stroke and myocardial infarction among nondiabetic stroke patients with a recent ischemic stroke and insulin resistance.

“This is the first trial that will look at the effect of this drug specifically to prevent clinically significant vascular events in nondiabetic patients,” said principal investigator Walter N. Kernan, M.D., associate professor of medicine.

Researchers at Yale designed the study and will coordinate its conduct at more than 60 research sites in the United States and Canada, recruiting more than 3,000 nondiabetic men and women over 45 who have insulin resistance and have had a recent ischemic stroke.

—J.C.


			Originally published in Yale Medicine, Summer 2005. Copyright © 2005 Yale University School of Medicine. All rights reserved.