International Journal of Law and Psychiatry 67 (2019) 101507
Contents lists available at ScienceDirect
International Journal of Law and Psychiatry
journal homepage: www.elsevier.com/locate/ijlawpsy
Mentally disordered offenders and the law: Research update on the insanity T
defense, 2004–2019
Samuel Adjorloloa,b,⁎, Heng Choon (Oliver) Chanc, Matt DeLisid
a Department of Mental Health, University of Ghana, Legon, Accra, Ghana
b Research and Grant Institute of Ghana, P. O. Box GP 2543, Accra, Ghana
c Teaching Laboratory for Forensics and Criminology, Department of Social and Behavioral Sciences, City University of Hong Kong, Tat Chee Avenue, Kowloon, Hong Kong
d Criminal Justice Studies, Iowa State University, Ames, Iowa 50011-1070, USA
A R T I C L E I N F O A B S T R A C T
Keywords: The insanity defense is among the most controversial legal constructs that has attracted the attention of scholars,
Insanity defense practitioners and policy makers. Here, we conducted a systematic review of the literature spanning 2004 to 2019
Insanity plea that produced 58 studies of insanity defense research. Findings are organized according to: (1) assessments and
Psychopathology assessment-related issues, (2) juror decision-making in defense trials, (3) characteristics of insanity acquittees,
Mentally disordered offenders (4) release recommendations for insanity acquittees, (5) revocation of conditional release status of insanity
acquittees, and (6) additional areas of insanity defense research. Implications of the research for the insanity
defense and cognate legal issues are proffered.
1. Introduction the codification of jurisprudential criteria for insanity claims ubiqui-
tously referred to as the M'Naghten rules. According to M'Naghten
The criminal law of most jurisdictions contains provisions that when rules, for the insanity defense plea to be successful, it must be proven
invoked offer protection to individuals whose criminal actions resulted that: (a) the party accused was laboring under such a defect of reason,
from mental incapacitation. For instance, the insanity defense legisla- from a disease of the mind, as not to know the nature and quality of the
tion which holds that offenders who commit heinous and reprehensible act being committed or (b) if the accused did know it, that he or she did
acts (e.g., homicide but under the influence of mental disorder(s)) not know that the act was wrong (Wondemaghen, 2014). The
should not be held criminally responsible as they lack the guilty mind M'Naghten rules have influenced the criminal laws of common law
or intent (mens rea; Desmarais, Hucker, Brink, & De Freitas, 2008). The countries across the globe (Adjorlolo, Chan, & Agboli, 2016; Bloechl,
core issue pertaining to the insanity defense provision is whether an Vitacco, Neumann, & Erickson, 2007; Wondemaghen, 2014; Yeo,
individual had “adequate” and rational mental capacity that could have 2008).
prevented him/her from committing a crime. As a construct derived A successful insanity plea traditionally leads to NGRI verdict.
from psychiatry and the law (Thom & Finlayson, 2013), the insanity However, acquittals based on the insanity law have met strong oppo-
defense has generated several controversies in academic and public sition and resistance, culminating into public mistrust and negative
discourses. The present study provides a systematic review of the in- attitudes in the United States (Bloechl et al., 2007), United Kingdom
sanity defense literature from 2004 to 2019. (Wondemaghen, 2014) and in other countries such as Russia
Contemporary insanity defense provisions arguably date to the case (Raimundo Oda, Banzato, & Dalgalarrondo, 2005). Reports suggest
involving Daniel M'Naghten (also variously spelled as McNaughton) public dissatisfactions with the verdict of NGRI, especially in high
who mistakenly shot and killed Robert Peel, the private secretary of the profile cases such as John Hinckley Jr.'s attempted assassination of the
then Prime Minister of England (Wondemaghen, 2014). At trial, then- United States president, Ronald Reagan (Bloechl et al., 2007;
M'Naghten was found to be mentally ill and was acquitted of the Kivisto & Swan, 2011). Consequently, the insanity defense standards
charges with a Not Guilty by Reason of Insanity (NGRI) verdict. The have undergone several transformations with some states in the United
acquittal of M'Naghten caused a major uproar from the public and States, for instance, adopting a second verdict choice: Guilty but Men-
professionals alike. Anger surrounding the acquittal eventually led to tally Ill (GBMI), while others completely abolished the insanity defense
⁎ Corresponding author at: Department of Mental Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, P.O. Box LG 43, Legon,
Accra, Ghana.
E-mail address: sadjorlolo@ug.edu.gh (S. Adjorlolo).
https://doi.org/10.1016/j.ijlp.2019.101507
Received 17 April 2019; Received in revised form 10 September 2019; Accepted 6 October 2019
0160-2527/ © 2019 Elsevier Ltd. All rights reserved.
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
Fig. 1. Discursive framework of insanity defense literature from 2004 to 2019.
(Costanzo & Krauss, 2012). medico-legal advancements and societal changes. These developments
The above developments have generated parallel interests across provide the impetus for an update and the current review examined
several professional and human right groups. Scholarly interests have insanity defense research from 2004 to 2019.
culminated in research on this topical issue (Zapf, Roesch, & Pirelli,
2014). Examination of the literature reveals several topical issues re- 2. Method
lating to the defense have been investigated (e.g., Green, Stedman,
Chapple, & Griffin, 2010; Manguno-Mire, Thompson Jr., Bertman-Pate, 2.1. Search strategy and results
Burnett, & Thompson, 2007). As a result, the literature is so diverse that
it is challenging to have a full understanding of developments in in- We searched ProQuest, EBSCOhost, Scopus, Social Science Citation
sanity defense research, a situation necessitating the need for a sys- Index, and PsychInfo using the following search terms: “insanity defen*
tematic summary of the literature. Although insanity defense and and insanity plea*.” Additionally, we searched Google Scholar for ad-
competence to stand trial are contested areas in forensic mental health ditional literature and the reference sections of the retrieved articles.
practice, research updates on the former lags behind when compared The search was restricted to articles, theses/dissertations, conference
with latter which has received at least three recent systematic reviews proceedings, and books that were available electronically and in
(seeFogel, Schiffman, Mumley, Tillbrook, & Grisso, 2013; Pirelli, English from January 1, 2004 to April 15, 2019. No effort was made to
Gottdiener, & Zapf, 2011; White, Meares, & Batchelor, 2013). Effort to retrieve materials that were not available electronically as it may pre-
summarize the literature on insanity defense was undertaken over two sent a peculiar challenge that the authors may not be able to overcome
decades ago spanning 1993 to 1997 (Lymburner & Roesch, 1999). (e.g., the authors may not be able to be certain if the authors could get a
However, there have been significant developments over the years in hold of the materials in hardcopy). We retrieved 2115 articles and after
terms of research output on insanity defense in the face of increasing removed the duplicates, the number reduced to 1497. To be included in
2
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
the review, the following inclusion criteria have to be met: Data for the insanity defense, whereas 51 (9%) met the criterion for irresistible
study were collected from institutional databases or directly from re- impulse. The authors also found that psychotic and affective disorders,
spondents where insanity defense is the primary focus, regardless of the and previous psychiatric histories significantly influenced the FMHPs
population used and the research approach (quantitative, qualitative or opinion regarding whether the defendant labored under mental defect.
both) adopted. The exclusion criteria were: (1) papers with discussion In contrast, prior criminal history, intoxication at the time of offense,
on court decisions where the insanity defense was invoked, (2) opinions and drug charges were not significantly associated whether the de-
on the insanity defense, (3) review articles, (4) articles on mentally fendant labored under mental defect. The authors further found that
disordered offenders who were not rendered an insanity verdict, and (5) FMHPs are more likely to declare racial minorities to be clinically sane
articles with discussion on mentally disordered offenders with and compared with their white counterparts, regardless of the differences or
without the insanity verdict. The articles were assessed for relevance similarities in their demographic, psychiatric and criminal histories. In
using the inclusion and exclusion criteria. a related study, 44 (11%) of the defendants were found to be have
impaired ability to make rational decision (volitional impaired; VI), few
3. Results were cognitively impaired (CI), whereas the majority (n=372, 89%)
were found to be both volitionally and cognitively impaired (Donohue,
After performing the inclusion and exclusion criteria, 58 articles Arya, Fitch, & Hammen, 2008). Defendants who met the criterion for CI
were deemed appropriate and included herein. Thirty (51.7%) and 28 were found to have committed more assaults, attempted homicide,
(48.3%) of the articles were based on archival (databases) and non- arson or arson related offense, sex offense, child abuse, burglary, rob-
archival data (firsthand data) respectively. The non-archival data were bery, carjacking or related offenses and used deadly weapons than their
collected mostly via experimental or survey studies. Of the 58 papers, counterparts with VI. However, no significant difference was observed
45 (77.6%) were from the United States, 4 (6.9%) from Australia, 3 between the VI and CI groups on demographic variables (marital status,
(5.2%) from Canada, 2 (3.4%) from New Zealand, 3 (5.2%) from race, sex, prior outpatient treatment). In terms of psychiatric disorders,
Europe (Sweden, Portugal, and Israel), and 1 (1.7%) from Malaysia. We it was found that psychotic disorder was the highest occurring disorder
examined the retained articles to identify aspects of insanity defense (n=229, 62%) in the CI group, whereas schizophrenia was diagnosed
that were investigated, resulting in the following thematic areas: (1) almost equally in the CI and VI group. In general, individuals who ex-
assessments and assessment-related issues in insanity defense, (2) juror hibited psychiatric symptoms such as delusions, mania, lack of plan-
decision-making in defense trials, (3) characteristics of insanity ac- ning, hallucinations and disorganizations were found to have labored
quittees, (4) release recommendations for insanity acquittees, (5) re- under mental defect at the time of offense. In a related study, Spencer
vocation of release recommendations in insanity acquittees, and (6) and Tie (2013) found that various mental incapacitations such as in-
additional areas of insanity defense research (see Fig. 1). This approach ability to self-control, impaired ability to understand the criminal act
is consistent with prior systematic reviews on the insanity defense and inability to resist from engaging in criminal act were influenced by
(Lymburner & Roesch, 1999) and competence to stand trial (Fogel mental and personality disorders. For example, insanity acquittees who
et al., 2013; White et al., 2013) literatures. The next sections synthe- lack the capacity to understand their criminal acts were significantly
sized the findings of the individual studies based on the aforementioned more likely to be diagnosed with delusional disorders.
thematic areas.
4.2. Quality of report and agreement among FMHP
4. Assessments and related issues in the insanity defense
The quality of forensic examinations, and in particular insanity
Assessment of mental state at the time of the offense (MSO) is evaluations, has received substantial attention among researchers (e.g.,
among the major challenges confronting forensic mental health pro- Fuger et al., 2014; Gowensmith, Murrie, & Boccaccini, 2013; Large,
fessionals (FMHPs). Assessments of MSO are conducted meticulously so Nielssen, & Elliott, 2009; Murrie & Warren, 2005; Nguyen et al., 2011;
that the outcome can assist the courts determining the appropriateness Stredny, Parker, & Dibble, 2012). Likewise, the extent of agreements
of the application of insanity defense. In conducting the assessment, the among FMHPs has also attracted considerable attention. Murrie and
FMHPs are also guided by the public perception that they are “hired Warren (2005) found that among 59 clinicians who conducted 4498
guns” who can assist criminals to escape punishment under the pretext evaluations, the rate of rendering opinion supportive of mental defect
of mental disorders (Wrightsman & Fulero, 2005). Criticisms regarding varies considerably from 0% to 50%. Inexperienced evaluators (i.e.,
the quality of forensic mental health report have largely shaped the those conducting fewer evaluations) were more likely to opine that a
depth and content of assessment of MSO (Fuger, Acklin, Nguyen, defendant labored under mental defect than those who have conducted
Ignacio, & Gowensmith, 2014; Nguyen, Acklin, Fuger, Gowensmith, & more evaluations. Examination of 110 insanity evaluations conducted
Ignacio, 2011). Studies in this arena are discussed under the following in the United States found a moderate agreement among the evaluators
subheadings: (1) assessments and opinion formation, (2) quality of re- (Large et al., 2009).
port and agreement among FMHPs, and (3) assessment measures in In terms of the quality of reports on MSO, Nguyen et al. (2011)
insanity defense. found that none of the 150 reports submitted to Hawai'i judiciary
achieved a predetermined report quality of 80%. In fact, some pertinent
4.1. Assessments and opinion formation information such as informed consent, social history, and family history
were missing from the reports. Furthermore, information regarding the
To undertake MSO evaluations and to form an opinion on MSO, relationship among the diagnoses and defendants' capacity for release
FMHPs solicit and integrate information obtained from several sources and risk for violence were also missing from the report. Indeed,
such as the criminal justice system, social welfare system, hospital re- Wettstein (2005) argued that failure to link clinical opinion to the
cords, neighborhood, family records and other sources of collateral psycholegal issue of interest has been acknowledged as the most
information such as witnesses and victims (Warren, Murrie, Chauhan, common problem in forensic evaluations.
Dietz, & Morris, 2004). In the course of the assessment, the FMHPs are In rendering an opinion on whether insanity acquittees should be
anticipated to have evidence to support that the defendant labored hospitalized or not, Stredny et al. (2012) found that both psychiatrists
under mental defect at the time of the offense before a clinical diagnosis and psychologists agreed on recommendations for hospitalizations in
of insanity (mental disorder) would be rendered. 78% of 160 cases. Yet, Gowensmith et al. (2013) reported that out of
Warren et al. (2004) in a study found that, out of 563 defendants 483 insanity evaluations conducted on 165 defendants, only 55.1%
diagnosed as insane, 91% met the cognitive impairment criterion of agreement was reached by forensic practitioners, and this agreement
3
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
was not influenced by the evaluators' characteristics in the professional 24.5% substituted the GBMI definition for NGRI. Similarly, 37.2%
category (i.e., psychologist or psychiatrist). Disagreement was, how- correctly identified the legal definition of GBMI whereas 27.7% sub-
ever, pronounced when the defendants were under the influence of stituted NGRI for GBMI. Furthermore, among jurors who correctly
alcohol, illegal drugs, or both, at the time of the offense. The de- identified the definition of GBMI, those with less education were more
fendants' diagnostic status was also partly influenced the extent of the punitive in their attitudes. In another study, Peters and Lecci (2012)
evaluators' agreement, which was high when the defendants were di- reported that participants who were told by a judge that NGRI would
agnosed with schizophrenia (Gowensmith et al., 2013). The foregoing result in indeterminate hospitalization or confinement were more likely
notwithstanding, Gowensmith et al. (2013) reported that judges fol- to render NGRI verdict. However, in the absence of such information,
lowed the majority (91%) of the sanity or insanity opinions provided by 54.6% of the participants erroneously indicated that a defendant who is
the evaluators, with only about 9% disagreements which mostly results eventually convicted of the crime would be sent to psychiatric hospital,
in the defendant being found legally sane rather than insane. instead of prison. Furthermore, more than half of the participants who
rendered a guilty verdict inaccurately believed that NGRI acquittees
4.3. Assessment measures in insanity defense would be released instead of being committed to psychiatric institution
for treatment. To validly measure knowledge about the insanity de-
Following the development of the Mental State at the Time of fense, the Knowledge towards Insanity Defense Scale (KIDS; Daftary-
Offense Screening Evaluation and Rogers Criminal Responsibility Kapur, Groscup, O'Connor, Coffaro, & Galietta, 2011) was developed.
Assessment Scales (Zapf et al., 2014), there have been interest in de- The KIDS consist of nine subscales (i.e., overused, violent crime, no risk,
veloping and/or validating similar measures to assist in clinical deci- quick release, custody time, faking, experts as hired guns, battle of
sion making involving MSO. In 2005, the Alabama Structured Assess- experts, and defense strategy), with each subscale comprising four
ment of Treatment Completion for insanity acquittees (The AlaSATcom) items. The KIDS demonstrate convergent validity with the strict liability
was developed to estimate acquittees compliance with treatment for and the injustice and danger subscales of the insanity defense attitude
transfer or release decisions, as opposed to predicting future violence or scale-revised. The KIDS also has a good divergent validity with the
risk (Hooper, McLearen, & Barnett, 2005). The AlaSATcom is completed Legal Attitude Questionnaire-Revised 23 (please refer to Daftary-Kapur
by extracting salient information from a range of sources, including et al., 2011 for more details).
institutional records and interview.
Wright, Piazza, and Laux (2008) also examined the utility of the 5.2. Jurors' attitude towards insanity defense
Substance Abuse Subtle Screening Inventory-3 (SASSI-3; Lazowski,
Miller, Boye, & Miller, 1998) in the early detection of substance use Attitudes towards the insanity defense have the potential to affect
disorders in acquittees. This inventory is particularly important because jurors' decision-making process, judgments and verdict types (Louden &
substance abuse is a common occurrence in insanity acquittees Skeem, 2007) by influencing, for instance, jurors' adherence to the in-
(Vitacco, Vauter, Erickson, & Ragatz, 2014). Therefore, detecting structions provided by judges (Peters & Lecci, 2012). In this regard, Hui
(subtle) substance abuse disorder and providing treatment early enough (2005) found that Chinese participants reported more negative atti-
may help ameliorate acquittees psychosocial and cognitive functioning tudes towards the insanity defense (e.g., not a good defense) than
to contribute to a reduction in recidivism. The SASSI-3, which com- Caucasians. However, no difference was observed between the Chinese
prises seven subscales, is a simple, quick, and inexpensive screening and Caucasians on opinion formation regarding insanity verdict. A
tool to use in clinical assessments, diagnosis and in treatment planning. study by Bloechl et al. (2007) found that, gender, ethnicity and re-
The SASSI-3 has a good concurrent validity with therapists' diagnosis of ligious beliefs do not significantly predict attitude towards the insanity
substance use disorder. defense. Political affiliation, however, was a significant predictor, with
republicans (conservatives) holding negative attitudes, compared with
5. Jurors' decision-making and the insanity defense democrats (liberals). Furthermore, individuals who overestimated the
number of insanity defense pleas and the success rates of invoking the
Jurors' decision-making in insanity defense trials has received re- defense were significantly more likely to be negative in their attitudes
search attention partly because it has significant influence on the towards the defense. Contrary to Bloechl et al. (2007), Kivisto and Swan
sanctity of the judicial process, including perceptions on justice delivery (2011) found that religion (i.e., orthodoxy) and political-orientation
(Torrey, 2012; Vitacco et al., 2009; Willmott, Boduszek, Debowska, & were predictors of attitude towards insanity defense. More specifically,
Woodfield, 2018). Understanding the factors that may affect or bias the authors found that religious fundamentalist and socio-political
jurors' decision-making may help to institute measures to ensure fair conservatist held negative attitude towards the insanity defense. Like-
judicial outcomes in criminal proceedings. Recent developments in the wise, participants who appeared to be pro-prosecution bias tend to hold
study of jurors' decision-making are: (1) jurors' knowledge of insanity negative attitude towards the insanity defense (e.g., not a good de-
defense, (2) jurors' attitude towards insanity defense, (3) demographic fense). This is also true for participants who approved of the death
factors affecting jurors' decision-making, (4) experts and laypersons penalty, thereby supporting the findings of an earlier study (Butler &
testimonies and jurors' decision making, and (5) neuroimaging evidence Wasserman, 2006). Specifically, Butler and Wasserman (2006) reported
and jurors' decision making. that among death qualified venirepersons, a defendant charged with
homicide is more likely to be convicted of the crime even when his-
5.1. Jurors' knowledge of insanity defense tories of psychiatric problems were presented to the court. Death-qua-
lified venirepersons are also more likely to sentence a defendant to
Knowledge about the insanity defense and the various dispositions death and more likely to endorse certain insanity myths such as the
for a successful invocation of insanity defense are very instrumental in defense is a loophole, and insanity acquittees are released immediately
the judicial system. It is therefore extremely important that jurors and back into the community (Butler & Wasserman, 2006).
all actors in the judicial decision-making process possess relevant and In another study, mock jurors who convicted a defendant of a crime
adequate knowledge of the defense and dispositions associated with it. scored significantly higher on legal authoritarianism and negative at-
A study by Sloat and Frierson (2005) on 96 qualified jurors found that, titude towards the insanity defense (Rendell, Huss, & Jensen, 2010).
only 4.2% correctly identified the meanings and outcomes of both NGRI Kardis (2013) found that participants who hold negative views towards
and GBMI. Instead, the jurors substituted the legal definitions and the the insanity defense were significantly more likely to render a guilty
dispositions associated with NGRI for GBMI, and vice versa. With re- verdict. Consistent with the above, another study found that positive
spect to the legal definition of NGRI, 55.3% answered correctly while attitude towards the insanity construct was associated with the
4
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
tendency to ascribe more weights to the factors depicting diminished on perceptions of criminal responsibility. Although the participants in
culpability (i.e., the defendant should not be held fully criminally liable general rendered NGRI/GBMI verdict, they rated female defendants as
for the criminal act in view of his/her impaired mental functions) less dangerous relative to male defendants. Yourstone et al. (2008)
(Stasiak, 2010). found that students and forensic psychiatrists were more likely to
The above studies have largely shown that negative attitude to- render NGRI/GBMI verdict when the defendant was a female. Also, the
wards the insanity defense is more likely to result in a guilty verdict. male and female judges rendered insanity verdicts consistent with si-
These findings have pragmatic implications for empaneling jurors, milarity leniency and the black sheep effects hypotheses (Breheney
thereby highlighting the need to examine juror attitude especially et al., 2007). In similarity leniency effect, members of an in-group
during the voir dire (Butler, 2006). The ability to validly and reliably (same gender) are more likely to be lenient and soft towards another in-
assess jurors' attitude towards the insanity defense is therefore ex- group member, whereas in the black sheep effect, the in-group mem-
tremely important. The Insanity Defense Attitude Scale-Revised (IDA-R; bers are more likely to be harsher towards another in-group member
Skeem & Golding, 2001) was developed as a measure of attitude to- who might be perceived as denigrating the group. In yet another study,
wards insanity defense. The IDA-R has 29 items that map onto two it was reported that females are not only likely to be found guilty but
subscales: Injustice and Danger, and Strict Liability (Louden & Skeem, also likely to be assigned more criminal responsibility (Breheney et al.,
2007; Skeem, Jennifer Eno, & Evans, 2004). However, Vitacco et al. 2007). However, females are likely to be assigned less criminal re-
(2009) noted that the high cross-loading of the items on the scale sponsibility when they are proved to have acted under the influence of
weakens its discriminant and construct validity. The scale was subse- mental illness.
quently revised using 239 venirepersons and validated on 567 under- Similar to gender, the exact influence of race is unclear in this study.
graduates' students. The result yielded two subscales: Unprofessional A study by Kardis (2013) failed to document the persuasive effect of
Behavior and Safety Concerns (UBS; bias on the part of attorneys and race on juror decision making. Kardis (2013) reported that when mock
mental health professionals to free dangerous people) and Strict Lia- jurors were presented with race (African-American, and Caucasian),
bility (SL; inclination to hold people accountable for their actions). A facial maturity (baby-faced and matured-faced) and hygiene of the
recent study conducted in Ghana, a West African State, found that a defendant (disheveled and non-disheveled), racial influence on NGRI or
third factor underpinned IDA-R, in addition to UBS and SL. This factor, guilty verdict was not supported. Rather, the participants rendered
labelled as Expression of Sympathy, conveyed the idea that the parti- NGRI when the defendant was non-disheveled, baby-faced appearance,
cipants were concerned and worried about the trouble, grief, and the compared to defendant with non-disheveled, mature-faced appearance.
misfortune of defendants pleading insanity at the time of offense Other demographic characteristics affecting jurors' decision-making
(Adjorlolo, Abdul-Nasiru, Chan, & Bentum Jr, 2017). Perhaps it may are described. Kivisto and Swan (2011) found a relationship between
relate to a possible cultural factor as it was evident in this African Christianity Orthodoxy and attitude towards the insanity defense.
sample. Smith (2014), however, reported a converse finding. More specifically,
Smith (2014) established that both Christian fundamentalists and non-
5.3. Demographic factors affecting jurors' decision-making fundamentalist Christians do not differ in their propensity to accept
NGRI plea when the defendant was diagnosed with delusions or hal-
In addition to the knowledge and attitude towards insanity defense, lucinations of a religious content. The author further noted that the
empirical studies (e.g., Breheney, Groscup, & Galietta, 2007; Butler, extent of Christian fundamentalism did not influence or impact on
2006; Dunn, Cowan, & Downs, 2006; Kardis, 2013; Smith, 2014; whether NGRI will be rendered. In another study, Butler (2006) found
Yourstone, Lindholm, Grann, & Svenson, 2008) have also investigated that increasing social support for the insanity defense was significantly
the influence of other factors, notably gender, race and religious af- related to the following: (1) likelihood of rendering NGRI verdict, (2)
filiation on juror decision making with respect to verdict and senten- receptability of legal insanity standard, (3) positive attitude towards
cing options. Gender is found to be an influential factor in legal deci- mental illness, and (4) low endorsement of insanity myths. Demo-
sion-making. Prior research has revealed that females are more likely to graphic variables such as age (older), education (college and above),
invoke the psychiatric defense in filicide cases (Wilczynski, 1997), and occupation (i.e., teachers), liberalist, and prior experience as a juror on
are more likely to be cleared of their criminal charges than males a criminal case were strongly correlated with the propensity to render
(Armstrong, 1999; Lymburner & Roesch, 1999). It is also generally NGRI verdict.
believed that females are less aggressive compared with men (White &
Kowalski, 1998). In view of this, females exhibiting behaviors that 5.4. Expert and layperson testimony and jurors' decision making
contradict the law and societal expectations are more likely to be seen
as acting under the influence of mental incapacitation. Nevertheless, Experts diagnosis of mental disorder when the defendant placed his/
the unaddressed question relates to the extent to which gender impacts her mental state at issue and the testimonies provided by FMHPs have
judicial decision making in insanity defense trials. Dunn et al. (2006) contributed in several ways to jurors' decision-making on verdict op-
examined the role of gender, race and method of killing on jurors' re- tions and sentencing recommendations during insanity defense pro-
sponsibility assignments and verdict types. The authors found that ceedings (Breheney et al., 2007; Gonzales, 2011; Green & Follingstad,
gender alone does not play a significant role on mock jurors' decision to 2009; Stasiak, 2010). Psychiatric diagnosis may corroborate or counter
label defendants as insane. However, gender interacted with race and a defendant claim of insanity. Likewise, laypersons or non-expert tes-
method of engaging in a crime to influence jurors' decision-making in timonies or accounts may be influential during insanity defense trials.
several unpredictable ways. Dunn et al. (2006) observed that a white Green and Follingstad (2009) examined the potential impacts of non-
female who shot at her children received severe outcomes, largely be- expert testimonies in a study in which three levels of third party in-
cause, the use of a gun is considered a “male” form of violence and so its formation (TPI: eyewitness testimony, prior mental health records, and
usage by a female is inconsistent with gender norms (i.e., sex-incon- family member testimony) were presented to support or counter NGRI
sistent hypothesis). Contrary to the sex-inconsistent axiom, Dunn et al. plea. When a psychologist initially testified that the defendant had
(2006) found that a black female who smothered her victims was delusions and should be rendered the NGRI verdict, only 69 (46%) of
treated more harshly than another black female who used a gun. Si- the participants agreed with the psychologist, while the majority
milarly, a white male who killed with a gun received less severe (n=81, 54%) disagreed. However, when the psychologist claim was
judgment compared to when a black male killed using a gun. supported by TPI, majority of the participants agreed to render NGRI
Mossière and Maeder (2016) surveyed 242 jury-eligible under- verdict, compared to when the TPI contradicted the psychologist tes-
graduates in Canada to determine the role of gender and mental illness timony. Green and Follingstad (2009) further found that, prior mental
5
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
health history appeared to have less effect on NGRI verdict compared or psychological evidence suggesting that the defendant had schizo-
with testimonies about the state of mind of the defendant prior to the phrenia. In contrast, the prosecution expert testified that the defendant
killing. was psychopathic, had a personality disorder, or was not mentally ill.
Expert testimonies may not only serve to exculpate defendants, but The result indicates that the defendant was more likely to receive in-
also could lead to a guilty verdict (Rendell et al., 2010; Stasiak, 2010). sanity verdict and mental treatment when the defense expert in-
Gonzales (2011) found that psychological diagnosis and crime type did troduced biological evidence rather than psychological evidence
not impact significantly on the verdict choice in insanity defense trials. (Rendell et al., 2010).
The type of mental disorder plays a significant influence in decision
making relating to whether a criminal activity was planned (Elmore, 6. Characteristics of insanity defense acquittees
2013). Elmore (2013) found that, compared with a schizophrenic pa-
tient who was charged with a physical assault, jurors rated a bipolar Understanding the characteristics of defendants who have benefited
defendant who was charged with a sexual assault to have planned the from the insanity defense has implications for assessments, treatment
act. In addition, where the defendant charged with sexual assault was and release planning. Research in this area has been mounting over the
perceived to be mentally incapacitated, the jurors appeared to exhibit years (Crutchfield, 2009; Ferranti, McDermott, & Scott, 2013; Fong
positive attitude. Breheney et al. (2007) also found that defendants et al., 2010; McDermott et al., 2008; Novak, McDermott, Scott, &
whose mental conditions were regarded as occurring for the first time Guillory, 2007). This section is discussed under the following sub-
were more likely to be exculpated from their crimes. In sum, both ex- headings: Demographic, clinical and offense characteristics.
perts and layperson's testimonies have significant influence on jurors'
decision-making. The effect is likely to be stronger when experts and 6.1. Demographic characteristics
layperson's accounts converge. Similarly, whereas the type of clinical
diagnosis and the type of offense may not independently influence Out of 84 insanity acquittee reports evaluated in Louisiana from
jurors' decision-making, the interaction between them may prove very 1997 to 1999, 74% were African-Americans, with males constituting
influential. the majority (87%; McDermott & Thompson Jr, 2006). Male dominance
in the insanity acquittee population has been reported by other studies
5.5. Neuroimaging and/or biological evidence and Jurors' decision-making to be as high as 90% (Ferranti et al., 2013; Skipworth, Brinded,
Chaplow, & Frampton, 2006). With regard to age at first offense, males
With continuous growth and advancement in neuroscience imaging committed their first offense at a significantly lower age than their fe-
technologies, there is a debate over the potential biasing effects of male counterparts. Among Malaysian insanity acquittees, majority had
neuroimaging of the brain on jurors' decision-making. Most opinions secondary education (n=67), followed by primary education (n=37),
have been that neuroimaging evidence of the brain's functional and 74% were employed, whereas 68.8% were deemed to have some form
structural impairments will sway juror decision making (Batts, 2009; of social support (Fong et al., 2010). The inpatient hospitalization for
Brown & Murphy, 2009; Compton, 2009; McCabe & Castel, 2008). the Malaysian acquittees ranged from three (3) months to 47 years, and
Perhaps, the first study to have examined the impacts of neuroimaging this was highly associated with factors such as age, good family sup-
evidence on decision-making is McCabe and Castel (2008) who found port, and index offense: homicide. Among New Zealand insanity ac-
that neuroimaging of the brain played an influential role on the stu- quittees, age was a significant predictor of the length of hospitalization
dents' decision-making. Gurley and Marcus (2008) built on this pre- such that the aged (> 35 years) were more likely to stay longer at
vious research to examine the influence of neuroimaging evidence on mental health institutions (Skipworth et al., 2006). Similarly, among
mock juror decision to render NGRI. The result suggests that when a NGRI acquittees in Virginia, United States, the average time spent at
defendant was diagnosed with psychotic disorder, the jurors were in- treatment centers before release ranged from 61.63months to
fluenced by the history of brain injury and neuroimaging of the brain to 77.23months, with longer inpatient hospitalization predicted by high
render NGRI. However, the combined effect of the neuroimaging and risk of escape from the facility and non-adherence to treatment regimen
brain injury evidence supersedes neuroimaging or brain injury only (Vitacco et al., 2014).
evidence. Several studies found some significant findings that are noteworthy.
Contrary to the previous findings, subsequent studies found no or For example, Ferranti et al. (2013) reported almost the same proportion
limited evidence for the potential of neuroimaging evidence to bias of homicides in Caucasian females (n=33; 70%) and males (n=30;
judicial decision making. Schweitzer and Saks (2011) in a study ma- 64%), while females were significantly more likely to commit homicide
nipulated neuroimaging, neuro-no-image, neuro-graph conditions, in the study by Dirks-Linhorst and Kondrat (2012). In Novak et al.'s
psychological evidence, and a family member account to determine (2007) study, child molesters were more likely to be young Caucasians
verdict type in insanity trials. It emerged that there were no differences (86%), whereas adult offenders were more likely to be older individuals
among the neuroimaging, the neuro-no image, and the neuro-graph from African-American origin (72%). A study of insanity acquittees
conditions on GBMI verdict. However, the neuroscience evidence to- over three decades revealed that majority were Caucasians who were
gether was found to be more persuasive than psychological evidence never married (McDermott et al., 2008), while the study by Ferranti
and family member account. Another study by Schweitzer, Baker, and et al.'s (2013) reported found that thirty-one (31) of the females re-
Risko (2013) found no statistically significant effect of neuroimaging of ported ever married while twenty-nine (29) of the males were re-
the brain and a graph containing neuroimaging evidence on verdict portedly single.
decision making. Even after replicating McCabe and Castel (2008) In summary, insanity acquittees are more likely to be males of
methodology, Schweitzer et al. (2013) found no effect of neuroimaging African-American origin, whereas their female counterparts are likely
on verdict options. In a recent study, although unrelated to insanity to be Caucasian. On the average, male acquittees are more likely to
defense, the result suggests that neuroimaging evidence did not sig- commit their first offense at a younger age than their female counter-
nificantly influence participants' decisions on prediction of future parts.
dangerousness, responsibility and death sentence decisions beyond
clinical, genetic, and neurological evidence (Saks, Schweitzer, Aharoni, 6.2. Clinical characteristics
& Kiehl, 2014).
Rendell et al. (2010) found that biological evidence significantly According to Crutchfield (2009), mental disorders are considered as
influenced jurors' decision-making more than psychological evidence. an important factor in the successful application of the insanity plea.
In this study, the defense expert testified by presenting either biological Among 83 insanity acquittees, 71% were diagnosed with schizophrenia
6
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
(Parker, 2004). The above finding was confirmed by studies from New future crimes, (2) decongesting forensic psychiatric institutions, and (3)
Zealand (Skipworth et al., 2006) and Malaysia (Fong et al., 2010) protecting the fundamental human rights of the insanity acquittees.
where 59% and 89.3% of the primary diagnosis was schizophrenia, Recommendations from clinicians regarding the release of insanity
respectively. Studies from other jurisdictions have reported similar acquittees are mostly based on the presence and the severity of mental
findings, including from Portugal (Almeida, Graca, Viera, Almeida, & illness, and the dangerousness or the risk posed to the community
Santos, 2010), Australia (Spencer & Tie, 2013), Canada (Desmarais (McDermott & Thompson Jr, 2006). There are different facets of the
et al., 2008) and United States (McDermott et al., 2008; McDermott & release recommendations.
Thompson Jr, 2006; Novak et al., 2007). Other common psychiatric As stakes are high in release recommendations, so are the interest of
disorders reported among insanity acquittees are substance abuse, bi- researchers in examining and evaluating the processes to identify fac-
polar and mood disorders, mental retardation and antisocial personality tors that are to be associated with release recommendations. Among 91
disorder (Almeida et al., 2010; Miraglia & Hall, 2011; Nielssen, Yee, NGRI insanity acquittees in a maximum security, length of stay was not
Millard, & Large, 2011; Vitacco et al., 2014). There is evidence to a significant predictor of release recommendations in a study by
suggest that the severity of offense is not necessarily correlated with Manguno-Mire et al. (2007). Race, however, had a significant impact
severity of the psychiatric diagnosis. For instance, insanity acquittees such that most African-Americans were released based on no mental
whose index crime was homicide do not differ from other acquittees of illness condition. In this sample, the type of crime, whether violent or
lesser offenses on the following psychiatric diagnoses: psychotic dis- nonviolent, did not predict whether acquittees received conditional,
order, mood disorder, and substance abuse disorder: however, differ- unconditional or civil commitment. Another study found that acquittees
entials were noted for personality disorders, intellectual disorders and who scored low on psychopathic traits and those whose offenses occur
other Axis I disorders (Dirks-Linhorst & Kondrat, 2012). at an older age were more likely to be released (Manguno-Mire et al.,
Data from the few studies that have considered the sex of the ac- 2007). An analysis of over three decades data on insanity acquitteess
quittees suggest a trend that is not entirely different from the studies revealed that compliance with and responsiveness to treatment, pa-
reviewed above. That is, the following diagnoses have been reported tients' substance use history, and risk of violence as factors that have
among female insanity acquittees: schizophrenia, bipolar disorder, de- influenced release recommendations (McDermott et al., 2008). In a
pression, substance abuse, personality disorders, and mental retarda- related study in which the records of 84 insanity acquittees from 1997
tion (Dirks-Linhorst, 2014; Ferranti et al., 2013; Vitacco et al., 2011). to 1999 in Louisiana were examined, the community readiness profile,
Females committing homicide have been found to have histories of gender, psychiatric history and type of crime were significant predictors
childhood physical and sexual abuse, and intimate partner violence of release decision (McDermott & Thompson Jr, 2006). When females
than males (Ferranti et al., 2013). Religious delusions were reported were recommended for release, it was to civil facilities and with mod-
among females who kill infants (0–1 year old) and children between 2 erate levels of symptoms; while males with moderate symptoms, low
and 18 years of age (Ferranti et al., 2013). Clearly, mental disorders, PCL-R scores were correlated with recommendations for release. High
notably psychotic-spectrum disorders, are common disorders among PCL-R scores were associated with recommendations for continued
insanity acquittees. More specifically, both male and female insanity commitment for males.
acquittees are likely to be diagnosed with schizophrenia. Stredny et al. (2012) also found that demographic factors (gender,
marital status, ethnicity, and age) and offense type did not significantly
6.3. Offense characteristics influence the release of insanity acquittees. Acquittees with a history of
suicide attempt and self-injury and those admitted directly from jail to
Violent offenses, particularly homicide appear to be the most the hospital were more likely to be recommended for hospitalization, as
common offense committed by insanity acquittees (Almeida et al., opposed to those with a history of substance abuse. Data on 179 ac-
2010; Dirks-Linhorst & Kondrat, 2012; Fong et al., 2010; McDermott quittees revealed that static factors such as racial status and dynamic
et al., 2008; Skipworth et al., 2006; Vitacco et al., 2014). Other offenses factors such as the absence of structured daily activities and less than
include assault, use of dangerous weapons, threat to burn or arson, weekly treatment are not significantly associated with release re-
theft, and sex offenses. The type of offense and the manner in which it commendation (Norwood, 2013). There is evidence that females are
was committed are partly determined by the sex of the offender. more likely to be released, both conditionally and unconditionally, than
Ferranti et al. (2013) reported that males have friends/acquaintance/ males (Dirks-Linhorst, 2014). Some other common documented risk
stranger and adults as their victims while females on the other hand factors influencing release recommendations include: (1) aggression,
prefer infants and children. More males used firearms in killing their (2) being transferred to hospital from jail, (3) previous psychiatric
victims, whereas females' preferred weapon is knife. In another study, hospitalizations, (4) substance abuse, (5) denial or lack of insight, (6)
females were found to have committed more burglary and arson, while history of medication noncompliance, (7) lack of meaningful employ-
males were charged with homicide, sexual offenses and robbery (Dirks- ment or daytime activity, (8) family or psychosocial problems, and (9)
Linhorst, 2014). The severity of the index offense significantly predict use of weapons (Stredny et al., 2012). This notwithstanding, there is a
the duration of stay at inpatient facility. For instance, insanity acquittes trend suggesting that the type of offense, compliance with treatment,
who committed homicide are hospitalized much more longer than their type of diagnosis and age at first offense are more likely to predict re-
counterparts committing other violent and nonviolent offenses (Dirks- lease recommendations. Similarly, females are more likely to be re-
Linhorst & Kondrat, 2012). In summary, insanity acquittees are more leased than males. However, cautious interpretation is required as
likely to commit homicide, particularly among males. Existing litera- findings found in these studies were limited by their sampling popu-
ture indicates that, relative to females, males are more associated with lations and other study limitations.
the use of lethal weapons. Females are likely to attack children and
infants, while males are also more likely to target strangers as their
victims. 8. Revocation of release recommendations of insanity acquittees
7. Release recommendations for insanity acquittees The main focus of research in this arena is to elucidate the factors
associated with the revocations of the release recommendations. In this
Releasing insanity acquittees back to the community is a very de- section, we discussed the prevalence as well as factors affecting re-
licate decision that carries huge implications, including risk of re- vocation of release.
offending. In particular, the decision to release insanity acquittees
could be influenced by the following; (1) protecting communities from
7
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
8.1. Prevalence of revocation of conditional release 9. Additional areas of insanity defense research
Examining the records of 83 insanity acquittees in Ohio from 1996 9.1. Insanity plea statistics and judicial use of assessment report
to 2000, Parker (2004) observed that 5 arrests and 60 hospitalizations
were made. The low re-arrest was largely attributed to the in- A 2-year (2000–2002) data from Israel indicate that both the in-
stitutionalization of Assertive Community Treatment (ACT) program: sanity plea and CST were raised in 0.9% of cases, with 0.07% average
inpatient-like community health services provided by group of mental acceptance rate for insanity plea alone (Toib, 2008). Also, the insanity
health professionals. Data from New Zealand indicate that of the 135 plea rate in severe crime is not> 15%, contrasting the 60% acceptance
insanity acquittees released before 2004, violent re-offending was re- rate in United States. Data from Australia indicate that, the overall
ported for only 6% of the acquittees (Skipworth et al., 2006). In another success rate for insanity defense plea stood at 64.8%. Homicide-related
study involving 363 insanity acquittees, 240 (66.12%) were found to offenses had a higher plea rate of 8%, but a low success rate of 33% in
maintain their conditional release for an average of 3.66 years, while comparison with all the offenses brought before and heard by the
123 (33.88%) acquittees had their conditional release revoked either mental health tribunal (Green et al., 2011).
because of committing a new offense (7.11%) or failure to adhere to the Kazmierczak (2004) investigated how courts examine sanity using
rules of conditional release (Vitacco et al., 2008). Vitacco et al. (2011) the content of the Rogers Criminal Responsibility Assessment Scales (R-
also found that, out of 76 NGRI female acquittees, 24 (31.6%) had their CRAS). It emerged that on average only 30% of the R-CRAS variables
conditional release revoked on grounds of violations of the release were addressed during trials. Similarly, only 8% of the variables used in
rules, instead of violent offenses. Furthermore, among 386 NGRI ac- determining legal insanity were coded from the defendant's past psy-
quittees, it was reported that 20.8% and 10.6% had one or more re- chiatric histories.
arrest in the post release period and one or more arrests for violence,
respectively (Miraglia & Hall, 2011). Among 127 NGRI acquittees, 9.2. Policy change and insanity acquittees
majority (n=96, 75.6%) were able to maintain their release, thirty-one
(n=31, 24.4%) had their release revoked, with seven rearrested for For every insanity defense policy change, researchers and other
new offense while the remaining violated the release conditions advocates are not just interested in the reform, but rather the real im-
(Vitacco et al., 2014). Another data from 1148 insanity acquittees pacts of such legislative reforms. Desmarais et al. (2008) reported on
spanning 30 years found that more females received conditional and the impact of the Winko decision: Canadian Supreme Court decision in
unconditional release and were able to keep their release better than Winko v. British Columbia (Forensic Psychiatric Institute) in 1999 on in-
the males (Dirks-Linhorst, 2014). sanity acquittees (See Desmarais et al., 2008 for more details). The
Compared with previous review (Lymburner & Roesch, 1999), the authors compared the characteristics and outcomes for insanity 592
rate of recidivism in the current review is relatively low. This might be acquittees released before and after the Winko decision from British
as result of interest in reducing recidivism, which has seen the estab- Columbia, Ontario, and Quebec. Statistically significant difference was
lishment of requisite systems and institutions to deal with released- observed for only substance abuse. The Winko decision partly con-
acquittees. In most jurisdictions, besides the intensive care management tributed to differences in the characteristics of insanity acquittees
set up to monitor the implementation of conditional release plans, across jurisdictions: reduction in personality disorders in British Co-
several adjunct treatments such as day treatment, psychosocial treat- lumbia (27% versus 11%), increase personality disorders in Quebec
ment, structured daily activities, and employment training were pro- (28% versus 40%), and increase in substance abuse in Quebec (29%
vided to the acquittees, when necessary. An example of such initiatives versus 51%). The rate of personality disorders remains stable in On-
include the Assertive Community Treatment (ACT) found in Ohio tario, while both British Columbia and Ontario reported no significant
(Parker, 2004). Indeed, the efficacy of community treatment programs difference in substance abuse. There were no significant differences in
may have contributed to the observation that re-offense among insanity outcomes before and after the Winko decision, except that the average
acquittees was lower than non-beneficiaries of the insanity defense in age at discharge was lower for Quebec sample postWinko. Regardless of
Australia (Green et al., 2011). the above, the key question is whether the above findings could be
attributed to Winko effect. For instance, as noted previously that sub-
8.2. Factors affecting revocation of release stance abuse is a common problem among insanity acquittees (Fong
et al., 2010; Novak et al., 2007), it is not clear the extent to which
The effects of demographic factors and criminal history on the re- Winko decision may account for this for the increase in substance abuse.
vocation of release have been inconsistently reported. For instance, the In a related development, Dirks-Linhorst and Kondrat (2012) ob-
type of diagnosis and the duration of inpatient hospitalization did not served that changes made to the procedures regarding the release of
predict recidivism, whereas prior offending, age at release, ethnicity insanity acquittees in Missouri in 1996 were intended to tighten and
and gender significantly predicted reoffending (Skipworth et al., 2006). harden the insanity defense system. Empirical analysis of the effects of
This finding was supported by Vitacco et al. (2011) who found that the changes revealed that the get-tough-on crime policy has led to
gender and age at release significantly predict revocation of conditional longer hospitalization for the acquittees: both NGRI homicide and NGRI
release. Contrary to the above findings, Vitacco et al. (2008) reported non-homicide acquittees (Dirks-Linhorst & Kondrat, 2012). As noted in
that gender, ethnicity, age, relationship status, years of education and different studies, it appears that the real punitive effect of this policy
living placement were significantly unrelated to release revocations. has not been achieved, and, thus, may not be different from other po-
This was also confirmed in a study by Vitacco et al. (2014) where licies implemented elsewhere (Balachandra, Swaminath, & Litman,
characteristics such as age, gender, ethnicity, number of years of edu- 2004; Desmarais et al., 2008; Jacobson, 2006).
cation, previous violent offense, and total number of criminal charges
were not predictive of revocation of conditional release. Other factors 10. Discussion
contributing to the revocation of release include substance abuse, an-
tisocial personality disorder, brief inpatient hospitalization, intensive The present review examined the literature on insanity defense from
supervision, problems with previous release (Vitacco et al., 2008; 2004 to 2019. The outcome of this review has significant implications
Vitacco et al., 2011). In summary, the following variables appear to for advancing both theory and practice in relation to insanity defense.
consistently predict revocations: being categorized into high risk su- With respect to assessment of MSO, the review found that assessors
pervision group, history of previous revocation, violations of release mostly proffer contradictory opinion, partly because of the poor quality
rules, and substance abuse. of the assessment process and report. These findings are consistent with
8
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
similar findings reported for CST assessments (see Robinson & Acklin, females. Female acquittees, on the other hand, are more likely to be
2010 for details). The evaluations may be enhanced beyond the current diagnosed with mood, bipolar, and schizoaffective disorders. In con-
standard if clinicians endeavor to reexamine the previously conducted clusion, the most prevalent psychiatric diagnosis was schizophrenia.
evaluations for possible mistakes that might inform and help improve Notwithstanding the prevalence of schizophrenia in insanity, the type
upon subsequent evaluations (Murrie & Warren, 2005). Similarly, fa- of schizophrenia associated with violent crimes is a grey area necessi-
miliarity with the literature on best practices in forensic assessments tating future research. This will be relevant for understanding the re-
and evaluations may also contribute towards improving the quality of lationship between schizophrenic diagnosis and violent offenses.
the reports, as well as minimizing evaluator disagreements (Murrie & Regarding release recommendations, there is a trend suggesting that
Warren, 2005). Forensic assessment of MSO can also be enhanced if the type of offense, compliance with treatment, type of diagnosis and
practitioners endeavor to undertake holistic and comprehensive eva- age at first offense are more likely to be influential. Similarly, failure to
luations, as required by clinical assessment lore. In addition to the comply with release rules was associated revocation of release. The
above, more research explicating the factors associated with producing prevalence of revocation of conditional release or recidivism among
poor MSO reports as well as factors accounting for the differences in insanity acquittees was relatively low, compared with previous findings
opinion formation in insanity evaluations is needed, although the work (Lymburner & Roesch, 1999). This may be as a result of several com-
of Murrie and Warren (2005) and others are recognized. The re- munity programs instituted to rehabilitate and reintegrate acquittees,
commendations from these sorts of studies may help in narrowing the although studies are yet to comprehensively report on the effectiveness
noticeable differences in opinion formation, thereby helping to improve of community-based programs (exception: Parker, 2004).
MSO evaluations. In general, studies on jurors' decision-making, release re-
Similarly, all the studies into evaluator disagreements and report commendations and revocations of releases are riddled with incon-
qualities are based on databases. This may not help in identifying and sistent and inconclusive results, partly because of variations in the
addressing the factors contributing to poor report quality or evaluator measurements and operationalizing of study constructs, different data
disagreements. It would be useful if researchers broaden their research source, time span of the data (recent versus old data), differences in
focus beyond the databases to the collect firsthand empirical data from sample size and sample characteristics. In addition to the above, it was
the evaluators. The outcomes of this line of research may have utilities observed that with the exception of studies into jurors' decision-making
for improving the quality of MSO. Discussions are ongoing regarding that are largely informed by experimental studies; almost all other
the introduction of neuroscience technologies into forensic assessments. studies have used data from existing databases. Primary data or first-
In this respect, research may also be interested in examining whether hand data may help explain some observations made using the data
neuroscience techniques may enhance MSO evaluations, hence the ac- from database. For instance, qualitative studies exploring the chal-
curacy of MSO reports. Thus, it will be of both professional and scho- lenges and experiences of insanity acquittees discharged into the
larly interests to examine the modalities through which MSO ex- communities would be helpful to understand why some recidivate and
aminations may benefit from neuroscience advancement and growth. others do not. In effect, a change in research focus to collect first hand
Studies on factors affecting jurors' decision have been inconsistent data may add to the explanatory powers of the database findings.
and inconclusive, although attitude towards and knowledge of the in- In conclusion, research on insanity defense since 2004 has been
sanity appears to have significant influence. It is important that careful informative. As research continues to expand the understanding of the
considerations are given not only to jurors' knowledge and attitude insanity defense construct, several challenges associated with MSO
towards insanity defense when empanelling a jury, but also extralegal evaluations, opinion formation in MSO, and release recommendations,
factors such as gender, race, religious fundamentalism, and political maintenance of release conditions, improving jurors' decision-making
orientations. This may contribute to impartial judicial outcome. An could be addressed pragmatically.
observable trend is that combination of several factors may influence
juror decision making, even in unpredictable ways. For this reason, References⁎⁎
research into jurors' decision-making may be interested in examining
how different legal and extralegal factors (e.g., demographics) interact Adjorlolo, S., Abdul-Nasiru, I., Chan, H. C., & Bentum, F., Jr. (2017). Attitudes toward the
to influence verdict choice in insanity defense trials. The extralegal insanity defense: Examination of the factor structure of Insanity Defense Attitude-
Revised (IDA-R) scale in Ghana. International Journal of Forensic Mental Health, 16(1),
factors should include the background characteristics of the jurors, the 33–45.
defendants, and the defense and prosecution teams. Research activities **Adjorlolo, S., Chan, H. C. O., & Agboli, J. M. (2016). Adjudicating mentally disordered
into the range of factors that moderate or mediate jurors' decision- offenders in Ghana: The criminal and mental health legislations. International Journal
making during insanity trials would also be informative and insightful. of Law and Psychiatry, 45, 1–8.Almeida, J., Graca, O., Viera, F., Almeida, N., & Santos, J. C. (2010). Characteristics of
An emerging trend in the studies above is that biological or neu- offenders not guilty by reason of insanity in Portugal. Medicine, Science and the Law,
robiological evidence may have more persuasive influence on jurors' 150(3), 136–139. https://doi.org/10.1258/msl.2010.10003.
decision-making than psychological and psychiatric evidence. It is also **Armstrong, I. (1999). Women and their ‘uncontrollable impulses’: The medicalisation of
women's crime and differential gender sentencing. Psychiatry, Psychology and Law,
important noting that the studies reviewed above may have methodo- 6(1), 67–77. https://doi.org/10.1080/13218719909524949.
logical weaknesses. For instance, none of the studies significantly mir- **Balachandra, K., Swaminath, S., & Litman, L. (2004). Impact of Winko on absolute
rored a typical jury trial since there were no deliberations among the discharges. Journal of the American Academy of Psychiatry and the Law Online, 32(2),
173–177.
participants in the study. Thus, studies in which the mock jurors are **Batts, S. (2009). Brain lesions and their implications in criminal responsibility.
allowed to deliberate might be more informative on how neuroimaging Behavioral Sciences & the Law, 27(2), 261–272. https://doi.org/10.1002/bsl.857.
influences their decision-making. Future studies may be interested in Bloechl, A. L., Vitacco, M. J., Neumann, C. S., & Erickson, S. E. (2007). An empirical
investigation of insanity defense attitudes: Exploring factors related to bias.
jurors' deliberations when neuroimaging evidence is presented. In ad- International Journal of Law and Psychiatry, 30(2), 153–161. https://doi.org/10.1016/
dition, research may seek to examine legal and extra-legal factors in- j.ijlp.2006.03.007.
fluencing (i.e., moderating or mediating), if any, the relationship be- Breheney, C., Groscup, J., & Galietta, M. (2007). Gender matters in the insanity defense.
Law & Psychology Review, 31, 93–123.
tween neuroimaging evidence and juror decision-making. **Brown, T., & Murphy, E. (2009). Through a scanner darkly: Functional neuroimaging as
In line with previous findings (e.g., Lymburner & Roesch, 1999), the evidence of a criminal defendant’s past mental states. Standford Law Review, 62, 1119.
present review has found that there are more male insanity acquittees Butler, B. (2006). NGRI revisited: venirepersons' attitudes toward the insanity defense.
than their female counterparts. It was further observed that the most Journal of Applied Social Psychology, 36(8), 1833–1847. https://doi.org/10.1111/j.0021-9029.2006.00084.x.
occurring psychiatric disorders in acquittees are schizophrenia, schi-
zoaffective disorders, substance abuse, and psychotic spectrum dis-
orders. However, the above disorders were prevalent in males than ⁎⁎Denotes reference not used in the review.
9
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
Butler, B., & Wasserman, A. W. (2006). The role of death qualification in venirepersons’ 11(4), 311–329. https://doi.org/10.1080/15228932.2011.562811.
attitudes toward the insanity defense. Journal of Applied Social Psychology, 36(7), Large, M., Nielssen, O., & Elliott, G. (2009). Reliability of psychiatric evidence in serious
1744–1757. https://doi.org/10.1111/j.0021-9029.2006.00079.x. criminal matters: Fitness to stand trial and the defence of mental illness. Australian
**Compton, E. S. (2009). Not guilty by reason of neuroimaging: The need for cautionary and New Zealand Journal of Psychiatry, 43(5), 446–452. https://doi.org/10.1080/
jury instructions for neuroscience evidence in criminal trials. Vanderbilt Journal of 00048670902817745.
Entertainment and Technology Law, 12, 333. Lazowski, L. E., Miller, F. G, Boye, M. W., & Miller, G. (1998). Efficacy of the Substance
Costanzo, M., & Krauss, D. A. (2012). Forensic and Legal Psychology: Psychological Science Abuse Subtle Screening Inventory–3 (SASSI–3) in Identifying Substance Dependence
Applied to Law. New York, NY: Worth Publishers. Disorders in Clinical Settings. Journal of Personality Assessment, 71(1), 114–128.
Crutchfield, C. P. (2009). This is insanity! Offender mental diagnosis on trial. A doctoral Louden, J. E., & Skeem, J. L. (2007). Constructing insanity: Jurors’ prototypes, attitudes,
dissertation submited to Tennessee State University. Retrieved from http://search. and legal decision-making. Behavioral Sciences & the Law, 25(4), 449–470. https://
proquest.com/docview/622199961?accountid=10134. doi.org/10.1002/bsl.760.
Daftary-Kapur, T., Groscup, J. L., O’Connor, M., Coffaro, F., & Galietta, M. (2011). **Lymburner, J. A., & Roesch, R. (1999). The insanity defense: Five years of research
Measuring knowledge of the insanity defense: Scale construction and validation. (1993–1997). International Journal of Law and Psychiatry, 22(3–4), 213–240 (doi:
Behavioral Sciences & the Law, 29(1), 40–63. https://doi.org/10.1002/bsl.938. 10.1016/S0160-2527(99)00006-0).
Desmarais, S. L., Hucker, S., Brink, J., & De Freitas, K. (2008). A Canadian example of Manguno-Mire, G. M., Thompson, J. W., Jr., Bertman-Pate, L. J., Burnett, D. R., &
insanity defence reform: Accused found not criminally responsible before and after Thompson, H. W. (2007). Are release recommendations for NGRI acquittees informed
the Winko decision. International Journal of Forensic Mental Health, 7(1), 1–14. by relevant data? Behavioral Sciences & the Law, 25(1), 43–55. https://doi.org/10.
https://doi.org/10.1080/14999013.2008.9914399. 1002/bsl.724.
Dirks-Linhorst, P. A. (2014). Missouri’s not guilty by reason of insanity acquittees, **McCabe, D. P., & Castel, A. D. (2008). Seeing is believing: The effect of brain images on
1980–2009: Is gender important when comparing female and male insanity acquit- judgments of scientific reasoning. Cognition, 107(1), 343–352.
tees and convicted offenders? Women & Criminal Justice, 24(3), 252–277. https://doi. McDermott, B. E., Scott, C. L., Busse, D., Andrade, F., Zozaya, M., & Quanbeck, C. D.
org/10.1080/08974454.2014.890160. (2008). The conditional release of insanity acquittees: Three decades of decision-
Dirks-Linhorst, P. A., & Kondrat, D. (2012). Tough on crime or beating the system: An making. The Journal of the American Academy of Psychiatry and the Law, 36(3),
evaluation of Missouri Department of Mental Health’s not guilty by reason of insanity 329–336.
murder acquittees. Homicide Studies, 16(2), 129–150. https://doi.org/10.1177/ McDermott, B. E., & Thompson, J. W., Jr. (2006). The review panel process: An algorithm
1088767912438711. for the conditional release of insanity acquittees. International Journal of Law and
Donohue, A., Arya, V., Fitch, L., & Hammen, D. (2008). Legal insanity: Assessment of the Psychiatry, 29(2), 101–111. https://doi.org/10.1016/j.ijlp.2003.12.008.
inability to refrain. Psychiatry (Edgmont), 5(3), 58–66. Miraglia, R., & Hall, D. (2011). The effect of length of hospitalization on re-arrest among
Dunn, K. F., Cowan, G., & Downs, D. (2006). Effects of sex and race of perpetrator and insanity plea acquittees. Journal of the American Academy of Psychiatry and the Law
method of killing on outcome judgments in a mock filicide case. Journal of Applied Online, 39(4), 524–534.
Social Psychology, 36(10), 2395–2416. https://doi.org/10.1111/j.0021-9029.2006. Mossière, A., & Maeder, E. M. (2016). Juror decision making in not criminally responsible
00109.x. on account of mental disorder trials: Effects of defendant gender and mental illness
Elmore, S. K. (2013). The insanity defense: Public opinion and the public’s tendency to im- type. International Journal of Law and Psychiatry, 49A, 47–54. https://doi.org/10.
plicate mental illness in high-profile crimes. Alliant International University. Retrieved 1016/j.ijlp.2016.05.008.
from http://search.proquest.com/docview/1520021550?accountid=10134. Murrie, D. C., & Warren, J. I. (2005). Clinician variation in rates of legal sanity opinions:
Ferranti, J., McDermott, B. E., & Scott, C. L. (2013). Characteristics of female homicide Implications for self-monitoring. Professional Psychology: Research and Practice, 36(5),
offenders found not guilty by reason of insanity. Journal of the American Academy of 519–524. https://doi.org/10.1037/0735-7028.36.5.519.
Psychiatry and the Law Online, 41(4), 516–522. Nguyen, A. H., Acklin, M. W., Fuger, K., Gowensmith, W. N., & Ignacio, L. A. (2011).
**Fogel, M. H., Schiffman, W., Mumley, D., Tillbrook, C., & Grisso, T. (2013). Ten year Freedom in paradise: Quality of conditional release reports submitted to the Hawaii
research update (2001−2010): Evaluations for competence to stand trial (adjudicative judiciary. International Journal of Law and Psychiatry, 34(5), 341–348. https://doi.
competence). Vol. 31, US: John Wiley & Sons165–191. org/10.1016/j.ijlp.2011.08.006.
Fong, C. L., Kar, P. C., Huei, L. T., Yan, O. L., Daud, T. I. M., Zakaria, H., & Mohd, R. Nielssen, O. B., Yee, N. L., Millard, M. M., & Large, M. M. (2011). Comparison of first-
(2010). Factors influencing inpatient duration among insanity acquittees in a ma- episode and previously treated persons with psychosis found NGMI for a violence
laysian mental institution. ASEAN Journal of Psychiatry, 11(1), 25–35. offense. Psychiatric Services, 62(7), 759–764 (doi: 10.1176/appi.ps.62.7.759).
Fuger, K. D., Acklin, M. W., Nguyen, A. H., Ignacio, L. A., & Gowensmith, W. N. (2014). Norwood, A. E. Q. (2013). Factors associated with successful conditional release for in-
Quality of criminal responsibility reports submitted to the Hawaii judiciary. dividuals found not criminally responsible (NCR) in the state of Maryland (3594598
International Journal of Law and Psychiatry, 37(3), 272–280. https://doi.org/10.1016/ Ph.D.) Baltimore County: University of Maryland. Retrieved from http://search.
j.ijlp.2013.11.020. proquest.com/docview/1442584600?accountid=10134.
Gonzales, P. S. (2011). Mitigating effects of psychological diagnosis and type of crime on juror Novak, B., McDermott, B. E., Scott, C. L., & Guillory, S. (2007). Sex offenders and insanity:
decision making. Fullerton: California State University. Retrieved from http://search. An examination of 42 individuals found not guilty by reason of insanity. Journal of the
proquest.com/docview/1018353100?accountid=10134. American Academy of Psychiatry and the Law Online, 35(4), 444–450.
Gowensmith, W. N., Murrie, D. C., & Boccaccini, M. T. (2013). How reliable are forensic Parker, G. (2004). Outcomes of assertive community treatment in an NGRI conditional
evaluations of legal sanity? Law and Human Behavior, 37(2), 98–106. https://doi.org/ release program. Journal of the American Academy of Psychiatry and the Law Online,
10.1037/lhb0000001. 32(3), 291–303.
Green, B., Stedman, T., Chapple, B., & Griffin, C. (2011). Criminal justice outcomes of Peters, M., & Lecci, L. (2012). Predicting verdicts, adherence to judge's instructions, and
those appearing before the mental health tribunal: A record linkage study. Psychiatry, assumptions about the disposition of the defendant in a case involving the insanity
Psychology and Law, 18(4), 573–587. https://doi.org/10.1080/13218719.2010. defense. Psychology, Crime & Law, 18(9), 817–831. https://doi.org/10.1080/
509036. 1068316X.2011.566872.
Green, E. P., & Follingstad, D. R. (2009). Third-party information in retrospective as- **Pirelli, G., Gottdiener, W. H., & Zapf, P. A. (2011). A meta-analytic review of compe-
sessment of NGRI: Impact of source and supportive versus contradictory content. tency to stand trial research. Psychology, Public Policy, and Law, 17(1), 1–53. https://
Journal of Forensic Psychology Practice, 9(1), 35–56. https://doi.org/10.1080/ doi.org/10.1037/a0021713.
15228930802426991. **Raimundo Oda, A. M. G., Banzato, C. E. M., & Dalgalarrondo, P. (2005). Some origins of
Gurley, J. R., & Marcus, D. K. (2008). The effects of neuroimaging and brain injury on cross-cultural psychiatry. History of Psychiatry, 16(2), 155–169. https://doi.org/10.
insanity defenses. Behavioral Sciences & the Law, 26(1), 85–97. https://doi.org/10. 1177/0957154x05048595.
1002/bsl.797. Rendell, J. A., Huss, M. T., & Jensen, M. L. (2010). Expert testimony and the effects of a
Hooper, J. F., McLearen, A. M., & Barnett, M. E. (2005). The Alabama structured as- biological approach, psychopathy, and juror attitudes in cases of insanity. Behavioral
sessment of treatment completion for insanity acquittes (the AlaSATcom). Sciences & the Law, 28(3), 411–425. https://doi.org/10.1002/bsl.913.
International Journal of Law and Psychiatry, 28(6), 604–612. https://doi.org/10.1016/ **Robinson, R., & Acklin, M. W. (2010). Fitness in paradise: Quality of forensic reports
j.ijlp.2004.09.007. submitted to the Hawaii judiciary. International Journal of Law and Psychiatry, 33(3),
Hui, I. (2005). The role of culture in insanity defense verdicts: Do Chinese have a different 131–137. https://doi.org/10.1016/j.ijlp.2010.03.001.
conceptualization and render different verdicts in the insanity defense cases. Master's **Saks, M. J., Schweitzer, N. J., Aharoni, E., & Kiehl, K. A. (2014). The impact of neu-
thesis submitted to Simon Fraser University (Canada). Retrieved from http://search. roimages in the sentencing phase of capital trials. Journal of Empirical Legal Studies,
proquest.com/docview/305356707?accountid=10134. 11(1), 105–131.
**Jacobson, M. (2006). Reversing the punitive turn: The limits and promise of current Schweitzer, N. J., Baker, D. A., & Risko, E. F. (2013). Fooled by the brain: Re-examining
research. Criminology & Public Policy, 5(2), 277–284. https://doi.org/10.1111/j.1745- the influence of neuroimages. Cognition, 129(3), 501–511. https://doi.org/10.1016/j.
9133.2006.00377.x. cognition.2013.08.009.
Kardis, E. A. (2013). Does insanity have a face? An examination of defendant appearance and Schweitzer, N. J., & Saks, M. J. (2011). Neuroimage evidence and the insanity defense.
juror attitudes that affect juror decisions in insanity defense cases (3629222 Psy.D.) Ann Behavioral Sciences & the Law, 29(4), 592–607. https://doi.org/10.1002/bsl.995.
Arbor: The Chicago School of Professional Psychology. Retrieved from http://search. **Skeem, J. L., & Golding, S. L. (2001). Describing jurors’ personal conception of insanity
proquest.com/docview/1561342188?accountid=10134. and their relationships to cases judgments. Psychology, Public Policy, and Law, 7(3),
Kazmierczak, J. D. (2004). The psychology behind legal insanity: A content analysis of 561–621. https://doi.org/10.1037/1076-8971.7.3.561.
criminal felony trial transcripts involving an insanity defense. Roosevelt University. Skeem, J. L., Jennifer Eno, L., & Evans, J. (2004). Venirepersons’s attitudes toward the
Retrieved from http://search.proquest.com/docview/305040518?accountid= insanity defense: Developing, refining, and validating a scale. Law and Human
10134. Behavior, 28(6), 623–648. https://doi.org/10.1007/s10979-004-0487-7.
Kivisto, A. J., & Swan, S. A. (2011). Attitudes toward the insanity defense in capital cases: Skipworth, J., Brinded, P., Chaplow, D., & Frampton, C. (2006). Insanity acquittee out-
(Im)partiality from Witherspoon to Witt. Journal of Forensic Psychology Practice, comes in New Zealand. Australian and New Zealand Journal of Psychiatry, 40(11−12),
10
S. Adjorlolo, et al. International Journal of Law and Psychiatry 67 (2019) 101507
1003–1009. https://doi.org/10.1111/j.1440-1614.2006.01924.x. Virginia. Law and Human Behavior, 38(4), 346–356. https://doi.org/10.1037/
Sloat, L. M., & Frierson, R. L. (2005). Juror knowledge and attitudes regarding mental lhb0000071.
illness verdicts. The Journal of the American Academy of Psychiatry and the Law, 33(2), Warren, J. I., Murrie, D. C., Chauhan, P., Dietz, P. E., & Morris, J. (2004). Opinion for-
208–213. mation in evaluating sanity at the time of the offense: An examination of 5175 pre-
Smith, N. A. (2014). The insanity defense: A study of the fundamentalist christian per- trial evaluations. Behavioral Sciences & the Law, 22(2), 171–186. https://doi.org/10.
spective. A doctoral dissertation submitted to Alliant International University. 1002/bsl.559.
Retrieved from http://search.proquest.com/docview/1615411644?accountid= **Wettstein, R. M. (2005). Quality and quality improvement in forensic mental health
10134. evaluations. The Journal of the American Academy of Psychiatry and the Law, 33(2),
Spencer, J., & Tie, A. (2013). Psychiatric symptoms associated with mental health defence 158–175.
for serious violent offences in Queensland. Australasian Psychiatry, 21(2), 147–152. **White, A. J., Meares, S., & Batchelor, J. (2013). The role of cognition in fitness to stand
https://doi.org/10.1177/1039856212470501. trial: A systematic review. The Journal of Forensic Psychiatry & Psychology, 25(1),
Stasiak, B. D. (2010). Juror decision-making in an insanity defense murder trial of an in- 77–99. https://doi.org/10.1080/14789949.2013.868916.
voluntarily medicated schizophrenic defendant. Boston University. Retrieved from **White, J. W., & Kowalski, R. M. (1998). Deconstructing the myth of the nonaggressive
http://search.proquest.com/docview/858289483?accountid=10134. woman: A feminist analysis. In D. L. Anselmi, & A. L. Law (Eds.). Questions of gender
Stredny, R. V., Parker, A. L. S., & Dibble, A. E. (2012). Evaluator agreement in placement (pp. 390–404). Boston: McGraw-Hill.
recommendations for insanity acquittees. Behavioral Sciences & the Law, 30(3), **Wilczynski, A. (1997). Mad or bad?: Child-killers, gender and the courts. British Journal
297–307. https://doi.org/10.1002/bsl.1995. of Criminology, 37(3), 419–436.
Thom, K., & Finlayson, M. (2013). They're not really doing "normal" psychiatry': The **Willmott, D., Boduszek, D., Debowska, A., & Woodfield, R. (2018). Introduction and
socio-legal shaping of psychiatric expertise in insanity trials. Psychiatry, Psychology validation of the juror decision scale (JDS): An empirical investigation of the story
and Law, 20(1), 46–59. https://doi.org/10.1080/13218719.2011.619060. model. Journal of Criminal Justice, 57, 26–34.
Toib, J. A. (2008). Civil commitment and the criminal insanity plea in Israeli law. **Wondemaghen, M. (2014). Depressed but not legally mentally impaired. International
International Journal of Law and Psychiatry, 31(4), 308–318. https://doi.org/10.1016/ Journal of Law and Psychiatry, 37(2), 160–167. https://doi.org/10.1016/j.ijlp.2013.
j.ijlp.2007.11.012. 11.010.
Torrey, E. F. (2012). The insanity offense: How America’s failure to treat the seriously men- Wright, E. E., Piazza, N. J., & Laux, J. M. (2008). The utility of the SASSI-3 in early
tally ill endangers its citizens. New York, NY: W.W. Norton & Company. detection of substance use disorders in not guilty by reason of insanity acquittees: An
Vitacco, M. J., Erickson, S. K., Kurus, S., Apple, B. N., Lamberti, J., & Gasser, D. (2011). exploratory study. Journal of Addictions & Offender Counseling, 28(2), 119–127.
Evaluating conditional release in female insanity acquittees: A risk management https://doi.org/10.1002/j.2161-1874.2008.tb00037.x.
perspective. Psychological Services, 8(4), 332–342. https://doi.org/10.1037/ **Wrightsman, L. S., & Fulero, S. M. (2005). Forensic psychology (2nd ed.). Belmont, CA:
a0025613. Wadsworth.
Vitacco, M. J., Malesky, L. A., Erickson, S., Leslie, W., Croysdale, A., & Bloechl, A. (2009). Yeo, S. (2008). The insanity defence in the criminal laws of the commonwealth of nations.
Measuring attitudes toward the insanity defense in venirepersons: Refining the IDA-R Singapore Journal of Legal Studies, 229–241.
in the evaluation of juror Bias. International Journal of Forensic Mental Health, 8(1), Yourstone, J., Lindholm, T., Grann, M., & Svenson, O. (2008). Evidence of gender bias in
62–70 (doi: 10.1080/14999010903014754). legal insanity evaluations: A case vignette study of clinicians, judges and students.
Vitacco, M. J., Van Rybroek, G. J., Erickson, S. K., Rogstad, J. E., Tripp, A., Harris, L., & Nordic Journal of Psychiatry, 62(4), 273–278. https://doi.org/10.1080/
Miller, R. (2008). Developing services for insanity acquittees conditionally released 08039480801963135.
into the community: Maximizing success and minimizing recidivism. Psychological **Zapf, P. A., Roesch, R., & Pirelli, G. (2014). Assessing criminal responsibility. In I. B.
Services, 5(2), 118. https://doi.org/10.1037/1541-1559.5.2.118. Weiner, & R. K. Otto (Eds.). The handbook of forensic psychology(4th ed.). United
Vitacco, M. J., Vauter, R., Erickson, S. K., & Ragatz, L. (2014). Evaluating conditional States: Wiley Press.
release in not guilty by reason of insanity acquittees: A prospective follow-up study in
11