Loren H. Roth, MD, MPH served as the 10th President of the American Academy of Psychiatry and the Law (AAPL) from 1983 to 1984. For a quick glimpse into his professional and personal import, we can immediately turn to other prominent leaders from our field.
Paul Appelbaum, MD describes working with Dr. Roth as “the single most important influence on my career.” He notes, “Loren’s great contribution was a unique ability to combine theoretical analyses of medicolegal issues with meticulously conducted empirical research” (Appelbaum P, personal communication, August 2024). Phillip Resnick, MD shares, “I recall being on a flight to an APA meeting in the mid 1970s when Loren told me that I should get seriously involved in AAPL because it was a great organization. He was an important mentor who encouraged me to write my first article about being an expert witness” (Resnick P, personal communication, August 2024). Ken Hoge, MD places Dr. Roth as one of three psychiatrists on his “personal Mt. Rushmore of law and psychiatry, dating from the beginning of my career” (Hoge S, personal communication, July 2024).⇓
Loren H. Roth, MD, MPH
Dr. Roth’s monumental career, now spanning over five decades, has had far-reaching influence in psychiatry, public health care, and hospital administration. He has been a major thought leader, clinician-scholar, and inspiring mentor. He continues to serve as Distinguished Professor Emeritus of Psychiatry at the University of Pittsburgh, remains dedicated to teaching and mentoring, and now hosts a podcast series.1 This biography specifically aims to capture his impact in forensic psychiatry as one of our foundational figures. Interspersed are personal accounts from friends and colleagues and Dr. Roth’s own reflections.
Personal Background
Dr. Roth was born in Cleveland, Ohio. He describes his parents as philanthropic and community supporters. He jokingly acknowledges as an only child he was a “smart aleck…but tried not to be spoiled or self-centered.” He identifies his Jewish faith as “very important to me.” He attended and continues to advocate for public schools. He also notes, when he was 17 years old, he was “the second-best young golfer in Cleveland.” He reflected his values have not changed since high school, and friends would recognize him as the same person: “I like people…I care about people…there’s no person in the world who’s not interesting to me” (Roth L, personal communication, 2024).
Dr. Roth speaks glowingly of his wife Ellen A. Roth, PhD, three children, and eight grandchildren. He states, “My wife made my life…She’s a magnificent woman, and she’s been magnificent for 50 years.” They continue to reside in Pittsburgh and promote the excellence of southwestern Pennsylvania. His wife is an author and wrote the fantasy fiction “Ten Fingers Touching.”2 She also served as the cartoonist for the early AAPL Newsletters, of which Dr. Roth was the first Editor in 1976. Medical careers have become a family tradition, with Dr. Roth’s father (urological surgeon) and son (pediatric urological surgeon) and now two grandchildren pursuing medical school. Dr. Roth endearingly describes strong family ties and their annual gatherings for the past 30 years (Roth L, personal communication, 2024).
Early Experience with Prison Medicine
After graduating from Harvard Medical School in 1966 and completing an internal medicine internship in 1967, Dr. Roth worked as a general medical officer in a federal penitentiary in Lewisburg, Pennsylvania until 1969. This early experience proved vital for his career. Dr. Roth said it significantly challenged, educated, and engaged him; provided him an “architecture” for his thoughts; and “concretized” various concerns faced by large, closed systems (Roth L, personal communication, 2024).
Dr. Roth described a pivotal incident of a disruptive inmate being dragged down to “the hole” by prison guards and his head hitting each step of the stairs. Dr. Roth urged the guards to stop and allow him to manage the inmate’s aggressive behavior by meeting with him and listening to his side of the story (Roth L, personal communication, 2024).3 This led to one of Dr. Roth’s first academic publications, “Treating the Incarcerated Offender,” in the Corrective Psychiatry and Journal of Social Therapy in 1969,4 with his concepts included in The National Institute of Mental Health’s (NIMH) “interesting ideas” abstracts.3 During his time as a general prison physician, because there was no active psychiatrist on staff, Dr. Roth also performed competency to stand trial evaluations (Roth L, personal communication, 2024). These experiences culminated in pursuing psychiatry residency at Yale University in 1969.
Developing a Career in Forensic Psychiatry
Dr. Roth identifies his first American Psychiatric Association (APA) meeting in 1969 as significant in his life. Chester Pierce, MD, whom Dr. Roth idolized, was his Massachusetts General Hospital psychiatry residency supervisor and Chair of APA’s Ad Hoc Committee on Black Psychiatry. Dr. Pierce, as he had to many, tremendously influenced Dr. Roth on matters of justice, diversity, and humanity (Roth L, personal communication, 2024).5 At that APA meeting, Dr. Roth gained exposure to founding AAPL members. Notably, he met first AAPL President Jonas Rappeport, MD. Although his prison experience was a main driver for his interest in forensic psychiatry, Dr. Roth was broadly drawn to the field’s ethics and practical questions and logical and rational approaches. After the first AAPL meetings in the early 1970s, he was hooked (Roth L, personal communication, 2024).6
From 1972 to 1974, Dr. Roth served as a Staff Psychiatrist with the NIMH’s Center for Studies of Crime & Delinquency. Under guidance from Saleem Shah, PhD, internationally renowned in law and mental health, Dr. Roth examined subjects such as biological factors in criminality and mental health care delivery in correctional settings. In 1974, he was recruited by Thomas Detre, MD, who was previously Dr. Roth’s supervisor at Yale University, to the University of Pittsburgh, where Dr. Roth has remained for his career.
In Pittsburgh, around 1974, Dr. Roth and Alan Meisel, JD created the Law and Psychiatry Program, with Dr. Roth serving as Director for the next three decades. Dr. Roth regards Professor Meisel as his major teacher of law and his lifelong friend and colleague. Building on his epidemiological and grant writing experiences from NIMH, Dr. Roth assembled one of the first interdisciplinary teams to focus on research and academic scholarship in legal and ethics topics in mental health care. Among others, this talented team included sociologist Charles Lidz, PhD; psychologist Ed Mulvey, PhD; and psychiatrist Paul Appelbaum, MD (Hoge S, personal communication, July 2024; Mulvey E, personal communication, August 2024).7 Dr. Appelbaum joined the team in the early 1980s after completing psychiatry residency, as Alan Stone, MD advised him to “go work with Loren Roth for five years and you’ll be able to do anything you want after that” (Appelbaum P, personal communication, August 2024).
Dr. Mulvey says Dr. Roth worked closely with the team “to build a framework for thinking about, researching, and improving the practice of informed consent with individuals with mental illnesses…his ability to frame clinical realities into abstract constructs opened the way for research and writings that improved clinical practice significantly” (Mulvey E, personal communication, August 2024).
Dr. Roth’s persistence and dedication to Pittsburgh’s program is mentioned by multiple colleagues. Robert Wettstein, MD notes that Drs. Roth and Appelbaum “brought me from Chicago to Pittsburgh 40 years ago, certainly a life changing event.” He recalls Dr. Roth going to work seven days a week “always wearing his signature solid dark suit and white Oxford cloth button down dress shirt and tie, even on the weekends - his signature uniform, so to speak” (Wettstein R, personal communication, August 2024). Christine Martone, MD, founder and first Program Director (2001-2008) of the University of Pittsburgh’s Forensic Psychiatry Fellowship, credits Dr. Roth with developing Pittsburgh’s law and psychiatry program “when forensic psychiatry wasn’t yet recognized.” She shared stories of his loyalty and recruitment efforts (Martone C, personal communication, July 2024).
In the late 1970s and 1980s, Dr. Roth’s national involvement in law and psychiatry also grew. In addition to AAPL President, he served as Chair for APA’s Committee on Judicial Action, Chair for APA’s Council on Psychiatry and Law, and Chair of the Committee on Psychiatry and Law of the Group for the Advancement of Psychiatry (GAP) (Roth L, personal communication, 2024).
Contributions to Forensic Psychiatry
It is a tall order to succinctly convey Dr. Roth’s pathbreaking influence in forensic psychiatry. Here, based on novel and sustained impact, four areas are highlighted in chronological order. His vision and leadership; motivation for patient rights and social justice; ability to synthesize ethics, legal, and practical complexities; and being a voice for the profession are common threads.
Informed Consent
Our current medical conceptualization of informed consent and patient’s decisional capacity can be traced to Professor Meisel, Charles Lidz, PhD, and Dr. Roth and his team while Dr. Roth was Director of Pittsburgh’s Law and Psychiatry Program in the 1970s. Regarding their research proposals to the NIMH, Dr. Lidz has reflected, “After much debate, we settled on the somewhat obscure legal and ethical doctrine of informed consent. Federal regulations requiring informed consent to participate in research were just being implemented, and the doctrine had been the subject of relatively little academic attention” (Ref. 7, p 90-91).
In 1977, Roth, Meisel, and Lidz published two landmark papers in the American Journal of Psychiatry: “Tests of Competency to Consent to Treatment” and “Toward a Model of the Legal Doctrine of Informed Consent.”8,9 In a recent book on capacity and informed consent, Jacob Appel, MD notes these as “the most significant early development…These two pieces examined existing approaches to decisional capacity, reviewing the benefits and shortcomings of each method” (Ref. 10, p 5). Their studies were influential, such as with the President’s Commission for the Study of Ethical Problems in Medicine and Appelbaum and Grisso’s well-known “four skills” model (communicating, understanding, appreciating, reasoning) for assessing patient’s decisional capacity.10
Dr. Appelbaum shares an anecdote of when he joined Dr. Roth’s research team in the 1980s. They noticed what Dr. Appelbaum would term “therapeutic misconception,” where research subjects confuse research with treatment. He recalls, “Loren, who was a cautious scholar, liked the paper but not the term. He said it was ‘too Hollywood.’ But when I said that I thought it really captured what we were seeing, he let it remain in the paper—and the phenomenon has been known as therapeutic misconception ever since. How many senior mentors would let a very junior faculty member make a decision like that? But what a great way to encourage a young researcher to grow” (Appelbaum P, personal communication, August 2024).
Insanity Defense
Major public outrage followed John Hinckley’s not guilty by reason of insanity (NGRI) verdict in 1982 after his attempted assassination of President Reagan. In response to calls to abolish the insanity defense, the APA appointed a task force led by Dr. Roth. Dr. Roth was the primary drafter of the APA’s first comprehensive statement on the insanity defense. The position included considerations and limits of existing NGRI standards, psychiatric testimony, and procedures following NGRI verdicts.11 As he would on other occasions, Dr. Roth provided expert testimony at a U.S. Congressional Hearing. Dr. Roth has stated, “The statement was clearly designed to preserve the insanity defense for the good of society and of mentally ill persons at a time when it was being criticized, and it was successful in doing that” (Ref. 12, p 38).
The APA statement came at a critical time for AAPL as a growing organization but with forensic psychiatry still not officially recognized as a subspecialty. At a 1982 AAPL luncheon, Alan Stone, MD delivered his famous speech “The Ethics of Forensic Psychiatry: A View from the Ivory Tower,” challenging some of the ethics foundations of the field just months after the Hinckley verdict. As Bloom and Dick described, “The task force [led by Dr. Roth] produced a position paper that was developed quickly and efficiently. More importantly, the paper ultimately was successful in bringing balance back to the discussion of where the insanity defense fit into the criminal law, of the role of psychiatry in the implementation of the defense, and of the important question of the disposition of those mentally ill individuals after a successful insanity defense” (Ref. 13, p 179).
Soviet Political Abuse of Psychiatry
In 1989, Dr. Roth was selected by the APA to lead a historic U.S. delegation to the U.S.S.R. to evaluate the state of human rights and whether psychiatry was still being used to oppress dissidents. Dr. Roth undertook complex negotiations with Soviet officials to establish terms of this mission. The delegation included three patient-interviewing teams each composed of a well-known forensic psychiatrist or psychologist (Joseph Bloom, MD; John Monahan, PhD; or Jonas Rappeport, MD), an NIMH research psychiatrist, and a Russian-speaking clinical psychiatrist.6,14
With the Helsinki Accords in the backdrop, one goal of the U.S. delegation’s visit was to help decide whether to readmit Soviet psychiatrists to the World Psychiatric Association after they were forced out in 1983 amid allegations of political abuse of psychiatry. Additional goals included: ensure victims were released from unwarranted hospitalizations, document evidence of psychiatric abuse of human rights, and promote worldwide collaboration among psychiatrists toward common diagnostic approaches and ethics principles.6
Their examinations involved a specially constructed protocol and lengthy interviews of 27 alleged victims of psychiatric abuse. The U.S. team found that psychiatric diagnoses and hospitalization were not warranted for many of these patients. The initial hospitalizations were run by the Ministry of the Interior (rather than Ministry of Health) and were found to use primitive and punitive treatments in dismal hospital conditions. After the Soviet Union fell, Dr. Roth received a grant and traveled three more times to Kiev to provide former Soviet psychiatrists education on modern psychiatric care. He also collaborated to help destigmatize mental illness and establish National Alliance on Mental Illness (NAMI) chapters in Kiev, Moscow, and St. Petersburg.6,15
As Professor Meisel describes, “In addition to his intelligence and sharp insights, Loren’s trademarks are optimism, enthusiasm, and perseverance. Dealing with the Soviets to free political prisoners is not the only, but perhaps the best, example. These are qualities he brings to all his professional pursuits” (Meisel A, personal communication, September 2024).
Dr. Mulvey similarly adds, “Loren has long had a concern for the ethical use of psychiatry and human rights…This involvement [with the former Soviet Union] excited Loren’s interest in social justice and put his clinical skills to great use…Loren had a deep professional and personal interest in assuring justice for the people in these facilities that motivated a range of subsequent activities to promote human rights” (Mulvey E, personal communication, August 2024).
Violence Risk Studies
Dr. Roth helped pave the way for, and was a key member of, the landmark MacArthur Violence Risk Assessment Study. Dr. Roth is also quick to point out the collaborative effort and authoritative expertise of colleagues, such as Henry Steadman, PhD. Conducted from 1992 to 1995, this has been considered the most comprehensive investigation on violence risk among individuals with mental illness. It involved 951 psychiatric patients discharged from inpatient units in Kansas, Pittsburgh, and Massachusetts. Two of their publications have each been cited over 2,000 times (per Google Scholar as of September 27, 2024).16,17
Dr. Hoge identifies a major component of Dr. Roth’s legacy as the “rise of empirical research and a more academic approach to law and psychiatry.” With Pittsburgh’s Law and Psychiatry Program “he built the most important group in the field…selected the best, protected them, and nurtured their work…No group was more important and the contributions, as mentioned earlier, were incredibly important in violence risk…laying the groundwork for the MacArthur studies, in which he and Ed [Mulvey] were key players” (Hoge S, personal communication, July 2024).
Dr. Mulvey reflects, “Loren and I were both members of the MacArthur Network on Mental Health and the Law from 1989 to 1996…Loren masterfully interpreted his clinical experiences with difficult or potentially dangerous patients into broadly applicable approaches for intervention and research. His insights were often then translated into measurable general constructs that guided the seminal work done by this network to advance practice in dealing with the quandaries confronted in assessing competence or risk of violence and possibly exerting coercion in situations where violence was a realistic concern” (Mulvey E, personal communication, August 2024).
“Of particular note,” Dr. Mulvey emphasizes, “was Loren’s insistence that methods for consulting with individuals in treatment about their perceptions of the role of violence in their lives and the development of a scale for measuring perceived coercion would be of great value to the field. His vision regarding these issues spawned considerable research and better training approaches on both topics” (Mulvey E, personal communication, August 2024).
Administrative Leadership at UPMC
A separate biography could be dedicated to Dr. Roth’s consequential role in building the University of Pittsburgh Medical Center (UPMC), now a health enterprise with over 40 hospitals and 100,000 employees. Dr. Roth has said his recruitment to the University of Pittsburgh in 1974 came when “[Dr. Thomas Detre] was one of the first to make the leap from psychiatry as an art to psychiatry as medical science…Tom was ‘re-medicalizing’ American psychiatry, putting it in the mainstream of American medicine” (Ref. 18, p 32). Dr. Roth was part of Dr. Detre’s early team that drove the University of Pittsburgh’s Western Psychiatric Institute and Clinic (WPIC) into being a national leader in biological psychiatry and clinical research. For example, their NIH research grants increased from $450,000 in 1973 to $9.5 million in 1983, ranking third nationally. WPIC’s successful model was applied across the hospital departments, eventually developing into today’s UPMC.19
Dr. Roth connects his early prison experience of providing general medical care as a strength that allowed him to advocate for primary medicine and better communicate with nonpsychiatric medical providers (Roth L, personal communication, 2024). Among his many high-ranking roles at UPMC (beyond Psychiatry), he served as the first Chief Medical Officer. He has been the Senior Advisor for Quality for UPMC Health Plan and an Associate Senior Vice Chancellor for the University of Pittsburgh’s Health Sciences and for Clinical Policy and Planning.3,15
Recognition
Touching on a few of Dr. Roth’s honors and awards, in 1988, he received the APA’s Isaac Ray Award for Outstanding Career Accomplishments in Law & Psychiatry. In 1992, he was named to the Shaker Heights High School Hall of Fame for Outstanding Graduates. He identifies his 2016 Chancellor’s Distinguished Public Service Award from the University of Pittsburgh as “very important to me,” as it represents his contributions to public health and the community at large. UPMC also hosts the Loren Roth UPMC Annual Quality and Safety Symposium (Roth L, personal communication, 2024).
Recently, in 2023, Dr. Roth received the Heinz History Maker in Health Care Award and the American College of Psychiatrists Distinguished Lifetime Service Award. Both awards note his national and international influence on health policy, especially through his medicolegal expertise.3,15 As stated by Charles F. Reynolds III, MD, “Many people have received the Distinguished Service in Psychiatry Award, but Loren is the only one who has received it on the basis of his contributions to law and psychiatry.”15
Personal Notes, Meet Your Heroes
I disagree with the saying “never meet your heroes,” although you may not realize at the time that you are meeting one. As a PGY-2 psychiatry resident in Pittsburgh, I first met Dr. Roth during a group mentorship for residents. He introduced himself as a “PGY-42.” His sharp humor, wisdom, and stature were evident. Yet many of us at that early career stage did not quite know how or where to place him and his teaching anecdotes. Something about creating UPMC in the 1970s? Testifying to Congress in the 1980s? Former Soviet Union in the 1990s?
As part of this small group, coresident Nolan Hughes, MD and I undertook an educational project on informed consent and capacity and presented it with Dr. Roth in attendance. I was proud of our work, citing Dr. Appelbaum’s newly published 2007 New England Journal of Medicine article20 and other recent papers. Dr. Roth graciously and patiently provided feedback. I remained naively self-congratulatory until a senior resident nudged me afterward and said, “You do know who did the early studies on capacity, right?” I responded, “Dr. Appelbaum?” He said, “Yeah, but look at some of the older work Paul Appelbaum cites. Loren Roth was his mentor.” I was starting to get a fuller picture of Dr. Roth.
Through my forensic psychiatric career, Dr. Roth has remained a central inspiration and generous mentor. His friendship and insights remain invaluable. Simply sitting in a room with him, even over casual conversation, it is still inevitable to gain wisdom or experience a light bulb moment. For one, I remember his point about developing “intellectual hooks,” an expertise in one area can help build knowledge on many other topics (e.g., a disease specialist needs to be able to rule out other conditions that mimic that disease).
Jack Rozel, MD similarly describes his experience when Dr. Roth was “immeasurable layers of hospital and academic hierarchy above” him. He shares, “Nearly 25 years ago, as an intern in psychiatry, I was burrowing down a rabbit hole on informed consent and capacity assessments…I stumbled upon one of Dr. Roth’s pieces from the early 1980s…I decided to take a chance and email him…Within a few hours, I received a reply from Dr. Roth…to find us a half hour to meet face to face…We kept in touch throughout my residency. When I returned to UPMC in 2010 as an attending, he became my primary mentor and has been with me through any number of twists and turns in my academic and clinical career and he remains a treasured friend, mentor, and colleague” (Rozel J, personal communication, August 2024).
Dr. Hoge also fondly recalls, “[Dr. Roth] often had key insights that had escaped the recognition of others, in part because they were difficult to conceptualize and articulate. He often was able to capture these insights through a process of thought and expression that was winding and challenging to follow. Those who knew his brilliance and hung on as his thoughts tumbled out were well-rewarded” (Hoge S, personal communication, July 2024).
Aptly capturing these sentiments is Dr. Mulvey: “Loren Roth is one of a kind. If you know him, you realize that there is really no comparison to anyone else you have known in your lifetime…He can engage trainees and colleagues constructively on issues that surface in the course of a polite conversation, a discussion of abstract issues, or simple shared observations of common experiences. It is that quality of consistent breadth and depth that has made him such a powerful influence to aspiring forensic practitioners, researchers, and program planners” (Mulvey E, personal communication, August 2024).
Conclusion
Not only is today’s forensic psychiatry story impossible to be told without Dr. Roth, his works and legacy serve as our “intellectual hooks” to appreciate the broader evolution of our field. Over the past 50 years, he has been a pioneer in areas of informed consent and violence research. On the insanity defense and political abuse of psychiatry (critical historical inflection points for our field), he served as a voice for the profession. He has built multidisciplinary scientific teams, advanced paradigmatic frameworks for medicolegal investigations, and been a torchbearer for other prominent leaders. It is fitting to conclude with Dr. Roth’s own words: “Forensic psychiatry is a profession that will never go away. It’s an inevitable part of societal functioning…Just how will expertise and training efforts persist remains to be seen. But it can never go away” (Roth L, personal communication, 2024). Thanks to Dr. Roth himself, our field benefits from a solid bedrock and blueprint to carry forward.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2025 American Academy of Psychiatry and the Law
