Stigmatization of psychiatrists and general practitioners: results of an international survey.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17% of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Measuring the stigma of psychiatry and psychiatrists: development of a questionnaire.

The stigma of mental illness is a severe burden for people suffering from mental illness both in private and public life, also affecting their relatives, their close social network, and the mental health care system in terms of disciplines, providers, and institutions. Interventions against the stigma of mental illness employ complementary strategies (e.g., protest, education, and contact) and address different target groups (e.g., school children and teachers, journalists, stakeholders). Within this framework, the World Psychiatric Association has adopted an Action Plan with the goal to improve the image of psychiatry and to reduce potential stigmatizing attitudes toward psychiatry and psychiatrists. To evaluate such interventions, a questionnaire has been developed that assesses opinions and attitudes toward psychiatrists and psychiatry in different samples of medical specialists (psychiatrists and general practitioners). The questionnaire comprises scales about perceived stigma in terms of the perception of societal stereotypes, self-stigma in terms of stereotype agreement, perceived stigma in terms of structural discriminations, discrimination experiences, stigma outcomes, and attitudes toward a second medical discipline. It is available in several languages (Arab, English, German, Japanese, Polish, and Spanish) and can easily be adapted for utilization in other medical specialties.

[A study of level of knowledge about depressive disorders among general practitioners in Argentina]. / Estudio del conocimiento sobre los Trastornos Depresivos entre los médicos asistenciales en Argentina.

OBJECTIVES: To determine the level of knowledge about depressive disorders including their treatment, comorbidities and suicide potential among a number of general practitioners who agreed to fill out a questionnaire and provided information about their professional activities. METHOD: Exploratory cross-sectional study among a number of general practitioners who answered voluntarily and anonymously to a questionnaire consisting of twelve questions. Data collected from 288 physicians were analyzed. RESULTS: The majority of physicians (97.6%, n=281) considered that depression was a disease, but 39.6% (n=114) believed that it was caused by lack of will power or characterological weaknesses, which create a dissonance with the concept of disease. They also felt that they did not have enough knowledge about Depressive Disorders such as their origins, type of medications and length of treatment, comorbidities and suicide potential. CONCLUSIONS: The results point to the need for continuous medical education about Depressive Disorders among general practitioners.

Cluster analysis of a forensic population with antisocial personality disorder regarding PCL-R scores: differentiation of two patterns of criminal profiles.

Fifty six cases of a forensic population were submitted to a cluster analysis to observe the aglomerative behavior in relation to the total scores of the items comprising the PCL-R Psychopathy Checklist Revised [R.D. Hare, Manual for the Hare Psychopathy Checklist-Revised, Multi-Health System, Toronto, 1991]. The analysis indicated two independent types of antisocial personality disorders, not identified in the PCL-R in its standardized form, one of them being strongly associated with criminal conduct and the other with psychopathic personality. Such clusters were stable when the analysis was replicated with other hierarchical algorithms, and also, they were independently extracted via the k-means method without having previously fixed the value for k. One of the clusters concentrated the PCL-R highest scores, indicating that it is the prototypical psychopathic character determinant.

The ethics of forensic psychiatry.

PURPOSE OF REVIEW: Forensic psychiatrists find themselves at the crossroads of disparate ethical demands stemming from their basic identification as physicians versus obligations of their professional activities that often involve working for third parties and upholding the principles of law. Ethical demands in law may collide with those of the ethics of medicine. RECENT FINDINGS: This review focuses on theoretical articles in which the two ethical paradigms impacting the forensic practice are discussed. In addition, this review includes some articles that bring new insights into old problems such as coercion and articles dealing with an emerging controversy, the use of medical information or medical personnel in interrogations. SUMMARY: The controversy on the two paradigms under which forensic psychiatrists operate has not been exhausted; no definite position has been advanced about the virtues of one over the other or how best to reconcile the two. Old issues such as coercion remain topics of concern and new areas of debate such as intelligence interrogations, which eventually will have an impact on forensic psychiatry, are now starting to permeate the ethical discourse.

[Forensic psychiatry ethics: expert and clinical practices and research on prisoners]. / Etica em psiquiatria forense: atividades pericial e clínica e pesquisa com prisioneiros.

OBJECTIVE: Review the most relevant ethical issues of the tripartite aspects on which forensic psychiatry is based: expert activity, treatment of the mentally ill in prisons, and research on prisoner subjects. RESULTS AND DISCUSSION: The principles of General Medical Ethics and those of Forensic Medical Ethics are discriminated and confronted and the steps the psychiatrist should take both as an expert and as a clinician to follow the ethical principles of his profession are indicated. A succinct résumé of the research on prisoners is offered and the basic principles, which, if respected, would keep a balance between the need for carrying out research in prisonal environments and the safeguard of prisoners' rights are suggested. CONCLUSION: It is fundamental for the forensic psychiatrist the knowledge and implementation of the ethical principles that govern his practice so that he will effectively respect the basic rights of the individuals he treats or researches with.

[The scope of forensic psychiatry: ethical responsibilities and conflicts of values]. / Psychiatrie médico-légale. Envergure, responsabilités éthiques et conflits de valeurs.

To write about ethics in specialties that straddle the lines of multiple systems cannot be done without discussing values and decisional rules that underlie each one of those systems. By virtue of its multiple associations, forensic psychiatry is an archetype of such specialties ; it works within a set of values that might be viewed as antithetical, even irreconcilable, with other aspects of psychiatry. The extensive scope of action of forensic psychiatry compels its practitioners to hold alternate world views and to apply decisional rules that may clash with the classical values and ethical considerations of medicine (Weisstub, 1980). In this article, following an historical précis, the authors review the scope of action of forensic psychiatry as the basis for the definition of this subspecialty. The concepts, themes and controversies pertaining to the ethical practice of this specialty will be reflected upon in the light of issues encountered in actual practice.

[Canadian mental health rights in an international perspective]. / Les droits en santé mentale au Canada: une perspective internationale.

This article surveys the status of people with mental disorders in the light of international human rights law and assesses if their rights are respected in the Canadian context. The authors recognize that although the national systems of countries such as Canada provide significant civil and constitutional protections on the positive rights of its citizens, including those who suffer from intellectual disability, the same cannot be said with respect to entitlements to the provision of social services. The authors argue that this shortcoming must be remedied. Finally, the authors conclude that it is paramount to closely monitor the apparent dissonance between internationally recognized rights to adequate healthcare and freedom from discrimination and their strict application in the Canadian context.

Identifying the cutoff score for the PCL-R scale (psychopathy checklist-revised) in a Brazilian forensic population.

This study introduces a Portuguese-language version of psychopathy checklist-revised (PCL-R) [Harv. Mental Health Lett. 12 (1995) 4] in the Brazilian penitentiary system. Hare's scale is used extensively in many other countries. In a forensic population sample of 56 male subjects classified as psychopaths and non-psychopaths [Manual for the Hare Psychopathy Checklist-Revised, Multi-Health System, Toronto, 1991], 33 correlated to global personality disorder (GPD) and 23 to partial personality disorder (PPD), respectively, subtypes of antisocial personality disorder [Manual for the Hare Psychopathy Checklist-Revised, Multi-Health System, Toronto, 1991]. Subjects were evaluated through psychiatric and neurological examinations, review of judicial records, Rorschach and PCL-R. A control group of 30 subjects without criminological or psychiatric history was also evaluated with the same instruments. PCL-R validation and identification of cutoff score for Psychopathy (GPD group) was assessed through the concurrent use of the Rorschach. PCL-R cutoff score for the Brazilian population was set at 23. Sensitivity was determined at 84.8%, and reliability was high (Kappa index = 0.87). GPD individuals were characterized as clearly psychopathic according to PCL-R criteria while PPD individuals can only be considered mildly psychopathic, with better chance of rehabilitation.

Competence to be sentenced.

PURPOSE OF REVIEW: Competence to be sentenced, or lack thereof, is not frequently claimed in legal proceedings. This paper reviews the concept and possible forensic psychiatric applications. RECENT FINDINGS: This topic has achieved prominence because of recent rulings imposed by the US Supreme Court that prohibit execution of mentally impaired and under-age individuals. The most recent contributions focus on standards for evaluating competence to be sentenced and on analyzing the need for involuntary treatment of those who for psychiatric reasons have lost the capacity to stand trial. SUMMARY: Competence to be sentenced may be defined as a component of a general capacity to undergo legal proceedings, beyond just fitness to stand trial. It applies specifically to the time between the moment the process ends and the moment a sentence is rendered. This paper reviews general capacity to participate in legal proceedings as a concept that allows a person to intervene fully in his or her defence in a trial that is just and fair, and the different moments at which mental capacity to proceed may be limited or absent. There are no specific guidelines for evaluating competence to be sentenced, so instead we review the basic criteria for general capacity to participate in legal proceedings, including the capacity to mount a defence, to be sentenced and to serve a sentence. Because forensic evaluations are needed for assessment of capacity, the paper provides guidelines on how to organize the assessment and the report.

From sin to science: fighting the stigmatization of mental illnesses.

Our paper provides an overview of current stigma discourse, the origins and nature of the stigma associated with mental illnesses, stigmatization by health providers, and approaches to stigma reduction. This is a narrative review focusing on seminal works from the social and psychological literature, with selected qualitative and quantitative studies and international policy documents to highlight key points. Stigma discourse has increasingly moved toward a human rights model that views stigma as a form of social oppression resulting from a complex sociopolitical process that exploits and entrenches the power imbalance between people who stigmatize and those who are stigmatized. People who have a mental illness have identified mental health and health providers as key contributors to the stigmatization process and worthy targets of antistigma interventions. Six approaches to stigma reduction are described: education, protest, contact-based education, legislative reform, advocacy, and stigma self-management. Stigma denigrates the value of people who have a mental illness and the social and professional support systems designed to support them. It creates inequities in funding and service delivery that undermine recovery and full social participation. Mental health professionals have often been identified as part of the problem, but they can redress this situation by becoming important partners in antistigma work.

Forensic psychiatry in Chile.

Mental disorders are among the most prevalent of chronic disorders, and a high prevalence of these disorders has been consistently found in jails and prisons. This study was a retrospective case series that described the population of adults charged with a criminal offense who were court ordered to undergo a psychiatric assessment within the Medical Legal Service in Santiago, Chile from 2005 to 2006. Characteristics were explored in order to better understand this population in light of the recent reforms in the judicial and health systems of Chile. Ninety percent of sampled individuals were male, primarily between the ages of 18-39 years. Seventy percent of the evaluations came from the pre-reformed judicial system and 30% were from the reformed system. Approximately 63% of evaluated offenders were considered to have a psychiatric pathology, the most common being the personality disorders. Of the evaluated offenders, approximately 84% were considered by a psychiatrist to be criminally responsible for their crime, 7% were regarded as having diminished criminal responsibility, 4% were considered to be not criminally responsible for their crime, and 4% were cases where criminal responsibility was not applicable. Profession status, municipality of residence, type of residence, ICD-10 diagnosis, treatment recommendation, and criminal responsibility were found to be significantly different between male and female evaluated offenders. Results from this investigation will contribute to knowledge about forensic psychiatry and mental health in Latin America, and will hopefully pave the way for more research and international comparisons.

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists.

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force's findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.