Abstract
The prevalence of psychiatric conditions among prisoners in Latin America is greatly underestimated, and because of the lack of awareness about mental illness among service providers in Latin American prisons, oftentimes these conditions go unrecognized or are not treated properly. In the worst-case scenarios, human rights violations occur. Despite the high levels of need, many prisoners have not received adequate or timely treatment. The sparse existing literature documents prison conditions throughout Latin American countries, ranging from poor to extremely harsh, overcrowded, and life threatening. Most prison systems do not meet international prison standards. The information on forensic mental health services and the treatment of offenders with mental illness have been less extensively studied and compared with forensic practices in developed American nations. This study analyzes the existing literature on forensic psychiatry, focusing on nine socioeconomically developing nations in Latin America, to improve understanding of treatment approaches for offenders with mental illness and identify emerging themes. A review was conducted and data were included in regression analyses to investigate information relative to the treatment of offenders with mental illness and its interaction with the mental health system.
Jails, prisons, and mental health hospitals are present in all cultures, although different societies use them very differently. But in all societies, some persons who are mentally ill also commit crimes and some persons who are criminal are also mentally ill.1
Latin America is a subregion of the Americas where the Romance languages, Spanish and Portuguese, are primarily spoken. As of 2013, its population was estimated at more than 588 million. Latin America is made up of three regions: South America, the Caribbean, and Central America.2,3 Most of the Latin American nations follow the Roman jurisdictional tradition (also called civil law), which is considered a continuation of Roman law.4
According to the United Nations Development Programme, the Latin American region has established itself firmly on the international stage and is making progress on reduction of poverty and inequality and on economic growth and financial stability. However, the region as a whole carries a heavy burden of violence, registering more than 100,000 homicides per year. Most countries in the region have homicide rates so high that the World Health Organization classifies it as epidemic.5
Recent studies have shown that Latin American countries have among the highest incarceration rates in the world; it has been estimated that the median rate of incarceration in South American countries is 202 per 100,000 people, whereas in Caribbean countries it is 376 per 100,000 people. There are more people incarcerated in Brazil (548,003) than in any other country in Latin America, and it has the fourth highest prison population total in the world after the United States (2,228,424), China (1,701,344), and Russia (676,400).6,7 Most European countries, such as Spain and England, have incarceration rates that range between 50 and 150 prisoners per 100,000 people.7
In Latin American countries, the high incarceration rates are inversely related to the level of service access and investment. The expenditure allocated to mental health barely exceeds two percent of the total health budget.8 There is also a shortage of forensic beds and mental health care workers in prison systems. Most Latin American countries have 0.5 beds per 100,000 people. With the rapid growth of the prison population, this shortage and low level of investment are likely to become more pronounced.
International studies have found that prison conditions throughout Latin American countries range from poor to extremely harsh, overcrowded, and life threatening. Most prison systems do not meet international prison standards. Research studies have evaluated the impact of overcrowding in prisons and have found that it negatively affects the physical and mental health of the people living in these conditions. It also can be detrimental to their general well-being, as it can increase the prevalence of infectious disease and psychiatric disorders.9,–,11
Countries in the Latin American region show large deficits in capacities concerning justice and security, which are reflected in the alarming crises in their prison systems, and in citizens' feelings of mistrust regarding the institutions of justice and law enforcement.5 The general public's frustration with increasing incidents of violence has led law enforcement to increase arrests, causing prison systems sometimes to reach two to three times their capacity.
Programs designed to address the needs and treatment of mentally ill offenders are not widely available, and the number of specialized psychiatric programs are limited in most developing Latin American nations. In South America, only 1 to 20 percent of prisons have been reported to have specialized mental health services.8 According to the United Nations' minimum rules of treatment of prisoners, “At every institution there shall be available the services of at least one qualified medical officer who should have some knowledge of psychiatry. They shall include a psychiatric service for the diagnosis and, in proper cases, the treatment of states of mental abnormality.”12
Time in prison can present a valuable opportunity to address untreated mental illness.13 Criminal offenders with mental disorders who do not undergo adequate treatment during or after prison may enter into a cycle of recidivism regarding both mental disorders and criminal offenses.14,15
Mental disorders have consistently high rates of occurrence among jail inmates. Studies estimate that 3.7 percent of the prison population has a psychotic disorder not otherwise specified, whereas 10 percent have depression, and 42 percent have personality disorders.16 Other international studies have estimated a prevalence of mental illness in correctional facilities that varies widely, from 7 to 90 percent. In many countries, severe mental disorders have been reported to occur 5 to 10 times more frequently among people in prison than in the general population,17,–,20 and lifetime prevalence rates higher than 80 percent have been estimated among the male prison population.21,–,23
Despite the high incarceration rates and substantial prison overcrowding in Latin American countries, epidemiological studies addressing the overall prevalence of psychiatric conditions among offenders are sparse, and only two Latin American countries (Brazil and Chile) have performed scientifically rigorous studies that shed light on the prevalence of mental illness among prisoners and the need for mental health care in this population.24,–,27 A few studies have been conducted in Mexico, Brazil, and Argentina, estimating the prevalence of affective disorders, substance abuse, and suicide in prison systems.28,29
A pioneering study conducted by Andreoli and colleagues25 in Sao Paulo, Brazil, found that lifetime and 12-month prevalence of any mental disorder was, respectively, 68.9 and 39.2 percent among women, and 56.1 and 22.1 percent among men. For severe mental disorders (psychotic and bipolar disorders and severe depression), the lifetime and 12-month prevalence rates were, respectively, 25.8 and 14.7 percent among women and 12.3 and 6.3 percent among men.
In contrast to that study, a recent Chilean study conducted by Mundt et al.26 found a low prevalence of mental disorders in prison systems when compared with prevalences in prison systems in high-income countries. They found a 12-month prevalence rate of 26.6 percent for any mental disorder, 12.2 percent for any substance use disorder, 8.3 percent for anxiety disorders, and 8.1 percent for affective disorders. Within that group, 6.9 percent had major depressive disorders. Even though Chile is not considered to be a developing country, it has 305 prisoners per 100,000 persons, which is one of the highest prison population rates in Latin America and more than double that of the worldwide and South American averages.
Another important forensic mental health concern is the shortage of mental health care workers and the lack of training and expertise in forensic psychiatry in Latin American nations. According to Taborda,30 professionals who are not specialists in forensic psychiatry perform most of the expert assessments in Latin America. This lack of experienced professionals leads to the occurrence of ethics-related faults for technical reasons. However, continuous progress has been observed in the professional formation of new experts, since learning opportunities, both in theory and in practice, are increasing in this area of scientific knowledge.4
According to Murguía and Ojeda,31 in Mexico there are approximately 3,000 psychiatrists for a population of 100 million. Approximately 10 percent of the psychiatrists in Mexico have a forensic practice, they have frequently learned independently without receiving formal training in the field. Most of those practicing forensic psychiatry do an acceptable job, but sometimes they are faced with cases that go beyond their knowledge. The main problem occurs when a psychiatrist without experience in the field of forensics undertakes a case that requires forensic expertise, and the outcome is unsatisfactory.
The number of specialized forensic psychiatrists in Latin American countries is unknown. In 2011, there were 226 board-certified forensic psychiatrists in Brazil, but the number of general psychiatrists that work in the forensic field is approximately 1500 (Taborda JGV, personal communication, April 2014).
Another important aspect is the lack of specific legislation and laws devoted to mental health. Only a few Latin American countries have specific legislation that is entirely devoted to mental health. There is a deficit in legislation in all the Latin American subregions, because the existing legislation predates the relevant international conventions.8
As mentioned earlier, forensic psychiatry is still an evolving specialty in a large number of Latin American nations. The information on forensic mental health services and the treatment of mentally ill offenders, as well as the legal and sociopolitical frameworks of those respective nations, has been less extensively studied and compared with forensic practices in the developed American nations, Canada and the United States. We sought to analyze the existing literature on forensic psychiatry in nine socioeconomically developing nations in Latin America to gain a better understanding of the treatment approaches to mentally ill offenders and identify emerging themes.
Methods
Search Strategy
A systematic search of peer-reviewed literature in English, Spanish, and Portuguese from December 2013 through April 2014 was conducted in the following databases: PubMed, MedLine, PsychInfo, Google Scholar, and Scopus. We used the following search terms: forensic psychiatry, prison system, inmate, jail, psychiatric disorder, mental illness, mental disorder, Latin-America, developing countries, mental health, and criminal justice system.
The International Centre for Prison Studies (ICPS)7 and U. S. Department of State Country Reports on Human Rights32 websites were also used as a source of information. In addition, data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS)8 were included in regression analyses to investigate information relative to the treatment of mentally ill offenders.
We identified 20 publications estimating the prevalence of psychosis and mental retardation and 5 publications estimating the prevalence of other major psychiatric conditions among prisoners in developing countries, as well as the number of forensic beds, treatment approaches and level of mental health education among criminal justice system workers. We also consulted with local experts in the field of forensic psychiatry in Latin America whom we believe to be representative of the profession in this part of the world.
Inclusion and Exclusion Criteria
The study included data from nine Latin American countries that met the following criteria: availability of reliable data, socioeconomically developing nations as defined by gross national income (GNI) at the level of U.S. $11,905 per capita per year or less (specified by the World Bank, 2012),3 incarceration rate above 140 per 100,000 people, and prison occupancy above 100 percent. We excluded Cuba, Venezuela, and Chile from this study because of their markedly different sociopolitical systems. We thus included El Salvador, Panama, Costa Rica, Uruguay, Brazil, the Dominican Republic, Mexico, Peru, and Argentina.
We collected data on country population, total prison population, incarceration rate, prevalence of mental illness (psychosis), percentage of health care budget, forensic services within prisons, forensic beds, forensic hospitals and conventional psychiatric hospitals, number of psychiatrists per 100,000 people, prison occupancy level, and prison conditions. We also obtained data from seven developed countries (United States, Canada, Spain, England, Germany, The Netherlands, and Sweden) on the number of forensic beds, number of psychiatrists per 100,000 people, incarceration rates, prison occupancy, and prison conditions. The first author then systematically reviewed, collected, and organized the respective data into Tables 1 through 4.
Results
Table 1 shows each country's population, legal system, prisoner population, and incarceration rate.
Demographic Information of the Latin American Countries
With populations of 199,800,000 and 120,286,655, respectively. Brazil and Mexico are the two most populous Latin American countries of the nine, trailed by Argentina (42,192,500) and Peru (29,399,817).
Of all of the countries, two-thirds have civil law systems, whereas the rest (Mexico, El Salvador, and the Dominican Republic) have combinations of common and civil law systems.
Brazil (548,003) has the largest prisoner population in Latin America, followed by Mexico (246,334), Peru (67,597), Argentina (62,263), El Salvador (26,796), the Dominican Republic (24,986), Costa Rica (14,963), Panama (14,170), and Uruguay (9,829). By incarceration rate, however, of the nine Latin American countries, El Salvador has the highest (424 prisoners per 100,000 people) followed by Panama (383 per 100,000), Costa Rica (314 per 100,000), Uruguay (289 per 100,000), Brazil (274 per 100,000), the Dominican Republic (247 per 100,000), Peru (220 per 100,000), Mexico (212 per 100,000), and Argentina (149 per 100,000).
Among the seven developed countries, the United States has the highest prisoner population rate (716 per 100,000), which is also the highest rate worldwide (Table 2). The other six developed countries have incarceration rates per 100,000 ranging from 60 (Sweden) to 149 (England). Most of the nine Latin American countries studied have incarceration rates two or three times greater than those of developed countries. The exception here is Argentina, which has an incarceration rate comparable with England's.
Incarceration Rate and Estimated Number of Psychiatrists and Forensic Beds per 100,000 People in Latin American and Other countries
For nearly all Latin American countries, data regarding the prevalence of major psychiatric conditions among prisoners are either limited or unavailable. Gauging the prevalence of mental illness in the prisoner population in Latin American countries must rely on extrapolation from smaller studies and population data from countries that completed the WHO-AIMS.34
Most countries sampled have reported a substantially low prevalence of psychotic disorders, starting as low as two percent. Brazil is the exception, yet the high end of its range does not exceed five percent. Panama, Uruguay, and Peru have reported an unknown number of inmates with psychotic symptoms. No data are available regarding the prevalence among prisoners of suicide or major psychiatric conditions, such as mood disorders, anxiety disorders, personality disorders, and substance abuse disorders.
As for available mental health resources, Table 3 describes both general and forensic mental health resources available in these countries, including their mental health expenditures. In the nine Latin American countries evaluated, the mental health budget as a percentage of the total health budget ranged from 0.4 percent (Dominican Republic) to 7 percent (Uruguay), with a median of 2.05 percent. In nearly all of these countries, the budget allocated to mental health as a percentage of the total health budget barely exceeds two percent.
Mental Health and Forensic Mental Health Services Available in the Latin American Countries and Their Expenditures on Mental Health
Slightly more than half of the countries studied have either one or two general psychiatric hospitals, with the exception of Brazil, 228; Mexico, 46; Argentina, 29; and Peru, 3. More than half of the countries have also reported a lack of specialized forensic hospitals, while Brazil, Mexico, and Argentina have claimed 31, 2, and 2 forensic psychiatric institutions, respectively.
Compared with rates of forensic beds in the developed countries studied, the rates of beds in the nine Latin American countries are far lower (Table 2). There is an average of 0.5 beds per 100,000 people in Central America, Mexico, and the Latin Caribbean countries, whereas there is an average of 1.6 beds per 100,000 people in South American countries. The United States has reported an average of 14.1 forensic beds per 100,000 people, Canada has 6.1 forensic beds per 100,000 people, whereas England has 1.8; Germany, 7.8; The Netherlands, 11.4; and Sweden 14.3. Spain is the exception, where the rate of forensic beds is estimated to be roughly 1.5 per 100,000 people.
Findings regarding the availability of forensic services within prison and jail systems show that eight of the nine countries sampled have no forensic services available in their prison systems, with Mexico being the exception.
Table 3 shows the percentage of police officers who have received training in mental health in the past five years. Police officers in Brazil and the Dominican Republic do not receive any formal training in mental health, which contrasts with Panama, which has the highest percentage of the nine countries of police officers educated in mental health (51–89%), followed by Costa Rica (21–50%). The percentage of judges and lawyers who have received mental health education in the past five years in most Latin American countries was less than 20 percent, with the exception of Costa Rica and Argentina, which reported rates from 21 to 50 percent.
Table 4 describes the characteristics of the prison and jail systems in the nine Latin American countries studied alongside those of their developed counterparts. Findings reveal the gaps in human resources and disparities in mental health care between the country groups.
Estimated Occupancy and Conditions of Prisons in the Latin American and Developed Countries
In nearly all Latin American countries, prison conditions were found to range from poor to extremely harsh, as well as overcrowded and life threatening. In Salvadoran prisons, overcrowding is a serious threat to prisoners' health and lives, and in many facilities, provisions for sanitation, potable water, ventilation, temperature, medical care, and lighting are inadequate (see Table 4 for details). Overcrowding poses problems in nearly all Latin American prison systems, the occupancy of which can be two or three times beyond the maximum. For example, occupancy rates in Salvadoran prisons are 320 percent (three times capacity), whereas Peru's figures are 218.9 percent (two times capacity), followed by the Dominican Republic's occupancy rate of 174 percent. By contrast, in the United States, prison occupancy has been estimated to be 99 percent and in Canada 96.4 percent, followed by 88.0 percent in Spain, 111.6 percent in England, 81.8 percent in Germany, 77.0 percent in The Netherlands, and 86.3 percent in Sweden.
Latin American countries also exhibit a significant shortage of psychiatrists, with only 1.5 psychiatrists per 100,000 people in Central America, Mexico, and the Latin Caribbean. This figure is in stark contrast with the 14.1 psychiatrists per 100,000 people in the United States, 15.8 in Canada, and 20.9 and 22 in Germany and Sweden, respectively.
Discussion
Our findings indicate that information on the prevalence of mental illness among prisoners in Latin American countries is limited or unavailable.
Several factors may be involved in the low rate of psychotic disorders reported in Latin American nations, including the lack of standardized mental health services, assessments, and screening tools designed to identify inmates at risk of having mental health problems. Another important aspect is scarce human resources and the shortage of mental health care workers. Our study found consistent absence of mental health and forensic services in most prison systems, as well as a remarkably limited number of forensic beds in most of the countries. Brazil is the country with the most forensic hospitals, but they are still not likely to be sufficient to cope with the demand. This dearth causes these hospitals to operate more like asylums. Often, mentally ill offenders have to remain mixed with the general prison population or are placed in general psychiatric hospitals and do not receive care from a special staff with forensic training (Folino JO, personal communication, April 2014).38,39
Another potential reason contributing to the limited access to mental health services in prison systems is the low-level priority given to these services, even though the prison population is at a high-risk for psychiatric problems. In many low-income countries, human and economic resources for mental health practices are often unequal to the task of addressing the range of mental health conditions that confront the population, especially in prison systems. Nevertheless, the amount of resources allocated to mental health as a percentage of the total health budget barely exceeds two percent in most countries, which can be a reflection of its low priority on government agendas.
It is difficult to evaluate the full extent of the problems that affect mentally ill offenders in Latin America, partly because of the scarcity of information on forensic and mental health services. However the high level of prison overcrowding, the high incarceration rate, and limited availability of resources in most Latin American prison systems, render it unlikely that most prisoners with mental illnesses receive appropriate or timely mental health care.
Several aspects of inadequate prison systems may imperil the mental health of inmates, including confinement, social isolation, massive overcrowding, poor sanitation, lack of health services, inadequate security, and violence. These risks could exacerbate or prolong psychiatric symptoms in mentally disordered inmates, and even those with no prior history of mental illness who are exposed to these risks may be vulnerable to physical and psychological symptoms.
According to the World Health Organization, in Latin America and the Caribbean, the burden of mental and neurological disorders accounts for 22.2 percent of the total burden of disease, measured in disability-adjusted life years (DALYs). With regard to all neuropsychiatric disorders, the most common are the unipolar depressive disorders (13.2%) and those produced by excessive use of alcohol (6.9%). Despite the magnitude of the burden of mental and neurological disorders, the percentage of people with mental disorders who do not receive any treatment in overwhelming.8
Mental health illiteracy and the stigma attached to mental illness have been strongly related to under-recognition of mental disorders.40 Our study revealed that a minority of police officers had received training in mental health within the previous five-year period. Consequently, officers may not understand the nature of mental illness and its behavioral impact.
Mentally ill offenders may lack the capacity to comply with prison. Because of low awareness about mental illness among service providers in Latin American prisons, oftentimes mentally disordered prisoners are mistreated, and, at worst, human rights violations occur.
Forensic psychiatry, as a subspecialty, and the development of forensic mental care, face serious limitations and obstacles in Latin American countries. One of the greatest challenges is the lack of specific legislation. In many Latin American countries, there are differences in judicial practices, and many countries do not have mental health legislation. This lack of a legal framework presents an obstacle for standardization in the practice of forensic psychiatry.
According to Abdalla-Filho and Bertolote,4 the existing relationship between the health and the legal systems is generally unsatisfactory; both systems operate in an isolated and unintegrated way. The same unsatisfactory relationship is found among the professionals working in the fields of psychiatry and the law, a relationship equally marked by a lack of greater integration. Although a process of psychiatric reform has also been initiated in Latin America, this movement has not reached the forensic sphere, and the prison population has not been invited to participate in it.
According to Alarcon,41,42the three main problems in Latin American psychiatry are the lack of adequate legislation, a deficit in solid epidemiological research, and the almost complete absence of the implementation of evaluation systems.
In their discussion of similarities and differences in the different practices of forensic psychiatry in the world, Velinov and Marinov43 found that despite some similarities, there are important differences. First, in many countries, forensic psychiatry is not identified as a distinct subspecialty. Second, even when it is, there are significant variations in the duration of training and in the curriculum. Third, the differences in judicial practice worldwide do not allow for the development of unified standards in forensic psychiatry practice. Fourth, there are vast differences from one country to another in the range of forensic psychiatry services available and in the modalities in which these services are used.
It is also important to highlight that there are several differences between the common law and civil law as well as court proceedings and insanity defense regulations that exemplify how some of these concepts are not universally applied. For example, in Latin American countries, fitness to stand trial is not relevant, and in some Latin American countries, including Brazil, even if the defendant is incompetent or mentally ill, the court proceedings are not stopped. In the absence of any concept of incompetence to stand trial in its procedural law, Brazil instead appoints a guardian and allows the proceedings to continue to final sentencing. Taborda et al.38,39 have repeatedly emphasized that the concept of competence to stand trial is missing from Latin American legal traditions.
The absence of consideration of trial competence may have implications for the evaluation of those mentally disordered offenders who come from Latin American Caribbean nations but become entangled in the criminal justice systems in the United States or Canada, where determining competence to stand trial is a fundamental first step in moving through the criminal justice system. Those persons may not understand or even appreciate the importance of being found competent or incompetent to stand trial.
Another striking difference between criminal law under the adversarial system and the inquisitorial system used in most Latin American countries is the lack of cross-examination in court proceedings (Taborda JGV, personal communication, April 2014). In adversarial trials, the opposing sides present evidence and conduct cross-examinations in an effort to elicit information beneficial to its side of the case. This is in contrast to the inquisitorial system used in civil law systems, where a judge or judges investigate the case.
For forensic psychiatrists who practice in Latin American civil law nations, the inquisitorial system can be problematic. For example, in the common law nations, preparation for anticipated cross-examination arguably helps the forensic psychiatrists prepare and solidify their positions and arguments. It also helps to develop their skills with respect to testifying under oath and necessitates a thorough investigation to present one's opinions. However, not having to anticipate cross-examination might lead those forensic psychiatrists in civil law nations to be less prepared for legal proceedings, because errors and weaknesses in their reasoning and testimony may go unnoticed or unexposed in court. There are some other considerable differences between the forensic psychiatric practices in Latin American countries and the rest of the world that are beyond the scope of this article.
We believe that despite all the limitations, interested forensic psychiatrists in the developed world can play an important part in helping to change these circumstances, whether by piecemeal change within the correctional systems in the developing countries of Latin America or by working for change in the overall mental health system of these countries. In our experience working as general psychiatrists in a range of low and middle-income countries in this region and elsewhere, one of the most common requests we receive from local mental health colleagues is for help with forensic psychiatric evaluations. Absent from their own training and absent adequate mental hygiene laws, they rely on forensically attuned mental health colleagues from the United States and elsewhere for assistance. Forensic psychiatrists have unique expertise to offer to the legal and human rights dimensions of the burgeoning field of global mental health. Not only are they likely to make a difference around the world, but they are also likely to find their own forensic knowledge and insights sharpened by the experience.
The treatment of mentally ill offenders is becoming increasingly important worldwide as the prison population in many countries continues to increase.11 Areas that should be considered for future research include accurate assessment of the prevalence of mental disorders in prison systems. Such an assessment would enable better understanding of the needs of the population and a better allocation of resources and would facilitate more humane treatment of mentally ill persons who are confined. Continued research is also needed on the implementation of educational programs aimed at empowering jail and prison personnel and professionals of the justice systems to identify, understand, and respond to early signs of mental illnesses. It is clear that more forensic training programs are needed to improve knowledge and expertise of general psychiatrists about the interaction of mental illness and legal systems. Future work should also include assessments of the state of criminal mental health law and policy in these countries.
Conclusion
Forensic psychiatry as a subspecialty is yet to be formally recognized in many Latin American countries, where psychiatrists continue to struggle to provide basic mental health services for mentally ill offenders, even while facing abundant forensic and correctional challenges. Factors such as the lack of adequate legislation, lack of access to mental health care, lack of investment and education in mental health are some of the greatest challenges that these developing nations face. All of this is compounded by the reality that such countries struggle to provide adequate access to comprehensive mental health care for their general populations and may also lack comprehensive, current, or simply any, national mental health legislation or policy. It is difficult to overstate the socioeconomic and political challenges that affect the safety, health, and educational levels, and overall developmental states of these nations. Latin American leaders should prioritize their investments in mental health and work at the national and international levels to improve access to mental health services. International collaboration across all areas of human rights, mental health, and criminal justice, will continue to have a profound impact on the collective mental health of Latin American and Caribbean countries. Forensic mental health deficiencies in Latin America appear to pose pressing problems unto themselves while serving as barometers for how a society addresses mental health and human rights in general.
Acknowledgments
The authors thank Drs. José G. V. Taborda (Associate Professor of Psychiatry and founder of the Forensic Psychiatry Fellowship, Federal University of Health Sciences, Porto Alegre, RS, Brazil), Jorge O. Folino (Director of the Risk Assessment Program, General Attorney's Office, La Plata, Argentina), Carlos Hugo Isaac (Secretary of the Latin American Academic of Forensic Psychiatry, Mexico), Fernanda Porteiro (former Associate Professor of Clinical Psychiatry, Universidad de la Republica, School of Medicine, Uruguay), and James B. Reynolds (Assistant Professor of Psychiatry, University of Missouri, Kansas City, Medical Director, NMPRC) who provided valuable input for this article.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2015 American Academy of Psychiatry and the Law
