LAUSR

Editor, It is generally held that drug-induced psychoses do not qualify as mental diseases or defects for the purposes of the insanity defense; this tends to hold true even when a voluntarily consumed illicit drug brings about a psychotic state (1-4). Whether a mental condition is considered a “mental disease” or a “severe mental disease” is of crucial importance, because the insanity statute in many states requires that a mental disease or severe mental disease or defect causes the defendant to fail to know or appreciate the wrongfulness or illegality of his actions (1). If extensive substance use brings about a sufficiently chronic psychotic condition, an “organic mental disease,” this is considered a “settled insanity” which may qualify as a mental disease for the purposes of the insanity defense (Ref. [1], p 229). Methamphetamine-induced psychosis, sometimes referred to as METHassociated psychosis (MAP) (5), is divided into acute and chronic variants (5). Researchers in the area of MAP tend to use the DSM-5 30-day criteria (6) to separate a drug-induced psychosis from a persistent psychotic mental illness (5,7), although there is mounting evidence suggesting that chronic MAP may be a separate mental illness, not just schizophrenia or an unspecified psychosis precipitated by methamphetamine use (5,7). Chronic MAP is quite similar to schizophrenia symptomatically (5,7-9) and can last for up to 6 months or even much longer after cessation of drug use (5,7,8). Accumulated evidence suggests that chronic MAP potentially shares some neurocognitive (5,7,9), neurobiological (5,8), and genetic features of schizophrenia (5,7). A main difference between schizophrenia and chronic MAP is that persons with schizophrenia display more negative symptoms (5), although some sources do note negative symptoms with MAP (7-9). Many meth-abusing individuals who are psychotic and who pass the 30-day mark without additional drug use, however, are ultimately diagnosed with schizophrenia or has having another serious mental illness (5,7-8,10). One review found that individuals who have methamphetamine-induced psychosis have an intermediate rate of being later diagnosed with schizophrenia, although people with cannabis-induced psychosis have a higher rate of transition to a schizophrenia diagnosis (10). Researchers find that individuals who have chronic MAP share possibly as many as seven genes which are thought to lead to vulnerability to schizophrenia; and family history of schizophrenia is a risk factor for MAP (5). There is evidence for neurodegeneration resulting from chronic methamphetamine use (5,8,9). There is a strong case for chronic MAP being a mental illness with an organic component which should qualify as a “mental disease” for the purposes of forensic evaluation, whether MAP is a distinct mental illness, or whether methamphetamine precipitates other serious mental illnesses, including schizophrenia. Although some type of time limit is needed for forensic examiners to differentiate a temporary drug-induced psychosis from chronic mental illness or a persistent condition affecting mental abilities, using any set amount of time for this purpose is not without complications. If the DSM-5 30-day limit is the criterion that is used by forensic examiners to differentiate a drug-induced psychosis from a persistent psychotic illness, one might ask what is the neurobiological, neurocognitive, and symptomatic difference between day 29 and day 31? In the context of sanity evaluations, a philosophical issue also emerges. If a disorder is a drug-induced psychosis (lasting less than 30 days), this generally does not qualify as a mental disease for purposes of qualifying for insanity, and thus, the defendant is held responsible for his unlawful behavior. The behavior of such individuals can be viewed as a function of “voluntary intoxication,” which is not exculpatory (1). In this case, the situation is viewed in terms of free will—voluntary behavior. After the 30-day limit, however, the matter may be viewed deterministically. The person is said to have persistent symptomatology which may be a qualifying mental disease of defect under state insanity laws, and if they fail to know the wrongfulness of their actions as the result of a severe mental disease, for instance in Ohio (11), they are not held responsible for their criminal actions. But, if we have no temporal criterion to differentiate a temporary drug-induced psychosis from a persistent mental condition, this would complicate forensic evaluations by making it difficult to conclude that a sanity defense is untenable because drug-induced psychosis, in the absence of settled insanity, does not qualify as a threshold mental condition under insanity laws. Having a drug-induced psychosis time limit makes formulation of forensic opinions easier (for better or worse). If the psychosis went away within 30 days, it does not qualify as a requisite mental disease for the purposes of insanity. If the methamphetamine psychosis extends beyond 30 days, it can be said to reflect chronic MAP or a different persistent mental illness precipitated by methamphetamine. Given the inherent difficulties in knowing whether a substance-abusing individual has actually gone 30 days without abusing methamphetamine, however, and also given a degree of skepticism about a set number of days selected by a group of experts, the longer the subject has gone without using methamphetamine and is still showing symptoms and signs of psychosis, the greater one’s confidence should be that the individual in question has MAP or persistent psychotic illness. All of the issues raised in this letter are captured in Sprouse v. Thaler (2013), which involved a man accused of murdering, in 2002, a customer at a gas station as well as the police officer who responded to the scene (12). In the course of the capital murder trial and subsequent appeals for the defendant, multiple forensic mental health evaluations were conducted, and results of these assessments varied between his probably having schizophrenia, to his not being psychotic, to his having lingering psychosis, probably neurologically based, from chronic methamphetamine abuse. The defendant was found guilty and sentenced to death, but in one of his appeals he claimed inadequate representation by counsel based on his not raising a “settled insanity” defense. In its ruling, the United States District Court for the Northern District of Texas noted that in Texas there is no “settled insanity defense,” only an insanity defense. They stated, however, that settled insanity can be incorporated into the insanity defense. Perhaps tellingly, in response to the defense questioning why issues of settled insanity were not previously brought to the forefront by a past attorney, the court stated (Ref