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State Hospital staff dealing with more forensic evaluations

JAMESTOWN - As the population of North Dakota has risen over the last six years, so has the number of forensic evaluations conducted at the North Dakota State Hospital in Jamestown.

A forensic evaluation is a process in which a psychiatrist conducts multiple interviews with a person, reviews his or her responses and makes determinations of that person's mental health and possible treatments.

Between 2007 and 2012, forensic evaluations more than doubled, going from 38 annual evaluations to 80 per year. Dr. Rosalie Etherington, the State Hospital's clinical director for adult inpatient psychiatric and chemical dependency services, said that through the end of June this year, she and her staff completed 38 forensic evaluations.

"We're averaging between seven and eight (evaluations) a month," she said. "If we keep up this pace we will have done between 90 to 100 forensic evaluations this year."

More competency evaluations

In 2007 and 2008, most of the forensic evaluations done at the hospital were for drug and alcohol addictions, Etherington said.

As the number of forensic evaluations increased from 2009, Etherington saw that most of the evaluations were competency evaluations for people charged with serious crimes. Etherington said she also noticed more of the people sent for a competency evaluation had a mental illness, weren't being treated for it and were already violent.

"When you couple somebody's willingness to commit crimes with a mental illness, that's not a good combination," she said.

Etherington said the increase in forensic evaluations overall, and competency evaluations, are tied to the state's robust economy. With more people moving here looking for work and possibly not being successful, those with mental illness may be cut off from their sources of medication.

"That (moving here looking for a job) is already a lot of stress for anyone," she said. "If you have a mental illness, that stress can be a trigger, especially if that person isn't taking (his or her) medication."

Overall, Etherington said the vast majority of people who undergo forensic evaluations do not end up staying at the State Hospital. But she said the staff has seen an increase of people found not competent to stand trial.

"Those found not competent must come back for treatment until they are competent to stand trial," Etherington said. People required to return to the hospital for treatment to become competent to stand trial become patients of the hospital.

One problem the hospital staff faces is that some patients won't take their medications. Etherington said patients who refuse to take medication for their mental illnesses further complicate matters.

"The process to get permission to force a patient to take medications is difficult and time consuming," she said.

If a patient refuses medication, the staff will try to work with that person to persuade him or her to take the medication. If the patient still refuses and the staff considers that person a danger, they will proceed with getting a court order to force that person to take medication. Etherington said that process can take as little as two to four weeks or, for someone who was admitted due to a competency determination, it can take months.

She said the danger with someone refusing to take medication is the longer it takes to get the forced medication order, the longer that person is not under proper medication and can become more psychotic and possibly more violent.

"It's difficult to treat someone when they aren't medicated, and manage them, when they are in a psychotic state," Etherington said. "That patient's trigger for violence is unknown to the staff and that trigger could be something that is completely in the patient's head."

Patients who reach this high level of psychosis required one-on-one attention and interactions with the patient need to be planned out. Etherington said annually the State Hospital has three to five patients who require this level of attention.

The state has a network of agencies and community groups that can help the mentally ill get the medications they need.

"The state has a crisis line, 211, that can give you access to anything from homeless shelters and food pantries to programs that provide low-cost or free medications," Etherington said.

The State Hospital administration has tried to keep staffing levels up to meet the increasing demand for forensic evaluations. Etherington said the State Hospital is the sole provider of forensic evaluation services in North Dakota, so it will have to keep pace as the demand grows.

Etherington said she has four full-time forensic psychiatrists who conduct the evaluations.

"If we get behind, I have access to another three forensic psychiatrists, to help us catch up," she said.

Etherington has a staff of 11 direct care associates to take care of patients who are undergoing treatment.