Is There a Relationship between Psychotic Disorders and the Radicalization Process? A Systematic Review.

Background and Objectives: Radicalization, a complex and multifaceted phenomenon, has been a subject of increasing concern in recent years, particularly due to its potential connection to acts of mass violence and terrorism. This systematic review examines the intricate link between radicalization and psychotic disorders, utilizing various sources such as observational studies, case reports, and series. It aims to highlight the prevalence of schizophrenia spectrum and other psychotic disorders among radicalized individuals and to define the role of mental health professionals in dealing with this issue, contributing to the development of prevention and treatment strategies. Materials and Methods: The methodology involved an extensive literature search across PubMed, Scopus, and APA PsycINFO up to 1 February 2024, adhering to PRISMA guidelines. The study focused on radicalization and psychotic disorders as defined by DSM-5 criteria, excluding other mental disorders. A population sample of 41 radicalized individuals diagnosed with psychotic disorders was selected, among which schizophrenia was identified as the predominant condition. Results: It was observed that 24% of these individuals passed away soon after committing their crimes, leading the researchers to rely on retrospective data for their diagnoses. The use of diverse assessment tools for psychiatric diagnosis and the lack of a standardized method for diagnosing or assessing involvement in the radicalization process were also noted. Despite limitations like reliance on observational studies and case reports, which result in low evidence quality and varied methodologies, our work provides a valuable contribution to clarifying the relationship between radicalization and psychotic disorders. However, further clinical studies are needed to delve deeper into these aspects. Conclusions: In conclusion, our review points out that individuals with psychotic disorders do not have a higher crime rate than the general population and warns against associating crimes with mental illness due to the stigma it creates. The lack of uniform psychiatric diagnostic tools and radicalization assessment highlights the need for more standardized risk assessment tools and validated scales in psychiatric diagnosis to better understand the relationship between radicalization and psychotic disorders and to develop integrated protocols.

Content and implementation of clinical decisions in the routine care of people with severe mental illness.

BACKGROUND: Clinical decision making (CDM) in the treatment of people with severe mental illness relates to a wide range of life domains. AIMS: To examine content of CDM in mental health care from the perspectives of service users and staff and to investigate variation in implementation of decisions for differing content. METHOD: As part of the European multicenter study clinical decision making and outcome in routine care for people with severe mental illness (ISRCTN75841675), 588 service users and their clinicians were asked to identify the decisions made during their last meeting. Decisions were then coded into content categories. Two months later, both parties reported if these decisions had been implemented. RESULTS: Agreement between patients and staff regarding decision making was moderate (k = 0.21­0.49; p < 0.001). Decisions relating to medication and social issues were most frequently identified. Overall reported level of implementation was 73.5% for patients and 74.7% for staff, and implementation varied by decision content. CONCLUSIONS: A variety of relevant decision topics were shown for mental health care.Implementation rates varied in relation to topic and may need different consideration within the therapeutic dyad.

First-episode psychosis and migration in Italy (PEP-Ita migration): a study in the Italian mental health services.

BACKGROUND: It has been frequently reported a higher incidence of psychotic disorders in immigrants than in native populations. There is, however, a lack of knowledge about risk factors which may explain this phenomenon. A better understanding of the causes of psychosis among first-generation migrants is highly needed, particularly in Italy, a country with a recent massive migration. METHODS/DESIGN: The "Italian study on first-episode psychosis and migration (PEP-Ita)" is a prospective observational study over a two-year period (1 January 2012-31 December 2013) which will be carried out in 11 Italian mental health centres. All participating centres will collect data about all new cases of migrants with first-episode psychosis. The general purpose ("core") of the PEP-Ita study is to explore the socio-demographic and clinical characteristics, and the pathways to care of a population of first-episode psychosis migrants in Italy. Secondary aims of the study will be: 1) to understand risk and protective factors for the development of psychotic disorders in migrants; 2) to evaluate the correlations between psychopathology of psychotic disorders in migrants and socio-demographic characteristics, migration history, life experiences; 3) to evaluate the clinical and social outcomes of first-episode psychoses in migrants. DISCUSSION: The results of the PEP-Ita study will allow a better understanding of risk factors for psychosis in first-generation migrants in Italy. Moreover, our results will contribute to the development of prevention programmes for psychosis and to the improvement of early intervention treatments for the migrant population in Italy.

The crisis in psychiatry: a public health perspective.

The role and responsibilities of psychiatry and psychiatrists have changed significantly in recent decades as a consequence of changes in society. The target of psychiatrists has moved from the treatment of specific mental disorders to the management of a wide range of psychological conditions. Following these changes, a public health approach has been claimed as necessary for psychiatric practice and research, given the current ongoing crisis in mental health. If we want to promote a public health approach, the following actions should be responsibly taken by modern mental health professionals: (1) the identification of causes of mental disorders, (2) the refinement of diagnoses, (3) the social inclusion of patients, (4) the involvement of users and carers in mental health research and practice, and (5) the improvement of psychiatric treatments and services. This crisis should represent a stimulus for all psychiatrists and a reconceptualization of psychiatry as public health is not in question.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study.

BACKGROUND: Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment. AIMS: To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment. METHOD: A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission. RESULTS: A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement. CONCLUSIONS: Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

The family in Italy: cultural changes and implications for treatment.

In Italy family is characterized by strong ties and is based on mutual aid of all its members. In the last 20 years, the structure of families has been significantly influenced by demographic, economic and professional changes, determining a transition from a patriarchal to a nuclear family model, with a higher number of single-parent families, single-person households, childless couples, same-sex couples. However, this transition has been slower than that occurring in other countries, probably as an ongoing impact of prevalent Catholic ideology. Major demographic changes in Italian families include, 1) a decrease in the number of marriages, delays in getting married and an high number of civil ceremonies, 2) a reduced birth rate; Italy is becoming one of the European countries with lowest growth rate, and with an increasing number of births out of wedlock, 3) an increased marital instability, with a constantly growing number of legal separations. Like many countries, relatives in Italy are highly involved in the care of patients with physical and mental disorders. There are a number of psychosocial interventions used in Italy including the 'Milan Systemic Approach' and family psycho-educational interventions. However, there are difficulties in implementing these interventions which are highlighted in this paper. We recommend research strategies to identify the best options to involve families in the care of mentally ill patients and to adequately support them.

Perceived Coercion Among Patients Admitted in Psychiatric Wards: Italian Results of the EUNOMIA Study.

The decision to use coercive measures (restraint, seclusion and forced medication) in psychiatric practice is controversial in mental health care. The EUNOMIA study was funded by the European Commission and carried out in 11 countries in order to develop European recommendations for good clinical practice on the use of coercive measures. The aim of the study is to identify sociodemographic and clinical predictors of the levels of perceived coercion in a sample of Italian patients with severe mental disorders at hospital admission. A total of 294 patients were recruited in five Italian psychiatric hospitals and screened with the MacArthur Perceived Coercion Scale to explore the levels of perceived coercion. Patients were assessed three times: within the first seven days after admission as well as after 1 and 3 months. At each time point, data on changes of perceived coercion, assessed by the Cantril Ladder of Perceived Coercion Scale, information on coercive measures received during hospitalization and the levels of satisfaction with the received treatments were collected. According to the multivariable regression model, being compulsorily admitted (OR: 2.5; 95% CI: 1.3-3.3, p < .000), being male (OR: 0.7; 95% CI: 0.9-1.4; p < .01), being older (OR: 0.03; 95% CI: 0.01-0.06) and less satisfied with received treatments (OR: -0.2; 95% CI: -0.3 to -0.1; p < .05) are all associated with higher levels of perceived coercion, even after controlling for the use of any coercive measure during hospitalization. Satisfaction with received treatment predicts the levels of perceived coercion and this should represent an important challenge for mental health professionals.

How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study.

BACKGROUND: The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication. METHODS: The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document. RESULTS: Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times. CONCLUSION: The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study.

Background: Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients' personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives' coping strategies in BD. Methods: A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania "Luigi Vanvitelli" has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group. Results: The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as "maintenance of social interests" (odds ratio [OR]=0.309, CI=0.04-0.57; p=0.023), "positive communication with the patient" (OR=0.295, CI=0.13-0.46; p=0.001), and "searching for information" (OR=0.443, CI=0.12-0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt "resignation" (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and "coercion" (OR=-0.268, CI=-0.46 to -0.08; p=0.006) strategies, compared to TAU relatives. Conclusion: PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions.

INTRODUCTION: People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Clinical Decision Making and Mental Health Service Use Among Persons With Severe Mental Illness Across Europe.

OBJECTIVE: The study explored relationships between preferences for and experiences of clinical decision making (CDM) with service use among persons with severe mental illness. METHODS: Data from a prospective observational study in six European countries were examined. Associations of baseline staff-rated (N=213) and patient-rated (N=588) preferred and experienced decision making with service use were examined at baseline by using binomial regressions and at 12-month follow-up by using multilevel models. RESULTS: A preference by patients and staff for active patient involvement in decision making, rather than shared or passive decision making, was associated with longer hospital admissions and higher costs at baseline and with increases in admissions over 12 months (p=.043). Low patient-rated satisfaction with an experienced clinical decision was also related to increased costs over the study period (p=.005). CONCLUSIONS: A preference for shared decision making may reduce health care costs by reducing inpatient admissions. Patient satisfaction with decisions was a predictor of costs, and clinicians should maximize patient satisfaction with CDM.

Social network in long-term diseases: a comparative study in relatives of persons with schizophrenia and physical illnesses versus a sample from the general population.

This study compares the social network of a sample of 709 relatives of patients with schizophrenia, 646 relatives of patients with physical diseases, and 714 lay respondents, recruited in 30 randomly selected Italian areas, stratified for geographic location and population density. Each respondent was asked to fill in the Social Network Questionnaire. The social network was less extended and supportive in relatives of patients with schizophrenia than in those of patients with physical diseases and in the general population. Multivariate analyses revealed that social contacts were similarly reduced in relatives of patients with schizophrenia and physical diseases, while social support was significantly lower in relatives of patients with schizophrenia than in the other two groups. Social resources were higher in young respondents and in those living in rural areas. These results highlight the need to provide the families of those with long-term diseases with interventions aimed at increasing their social resources.

Implementing psychoeducational interventions in Italy for patients with schizophrenia and their families.

OBJECTIVE: This study explored the feasibility of providing psychoeducational interventions for persons with schizophrenia and their families. METHODS: The study was carried out in 23 Italian mental health centers. Two professionals from each center attended three monthly training sessions on psychoeducational interventions. After the training, each professional provided informative sessions on schizophrenia to five families of service users with schizophrenia, which consisted of three meetings with each family on clinical aspects of schizophrenia, drug treatments, and detection of early signs of relapse. Each professional then provided the intervention to families for six months. RESULTS: Thirty-eight of the 46 participants completed the training course, and 34 provided the intervention to 71 families. Twenty-nine of the 34 provided the entire intervention to the families and five of the 34 held only informative sessions on schizophrenia. Ninety-one percent of the participants who completed the study reported difficulties in integrating the intervention with their other work responsibilities, and 96 percent acknowledged the positive effect that the intervention had on the center's relationship with patients with schizophrenia and their families. CONCLUSIONS: These results support the idea that it is possible to introduce psychoeducational interventions in mental health services after a relatively brief period of training and supervision.

Patient functioning and family burden in a controlled, real-world trial of family psychoeducation for schizophrenia.

OBJECTIVE: This study explored the effectiveness of a psychoeducational family intervention for schizophrenia on patients' personal and social functioning as well as on relatives' burden and perceived support. METHODS: Thirty-four mental health professionals from 17 public mental health centers in Italy selected 71 families of consumers with schizophrenia. Forty-two families were randomly assigned to a group that received the intervention for six months, and 29 families were assigned to a waiting list for six months. At baseline and six months later, validated tools were used to assess patients' clinical status, personal and social functioning, and social network as well as relatives' burden, social resources, and perception of professional support. RESULTS: In the intervention group the number of patients with poor or very poor global personal and social functioning decreased significantly, from 17 (47 percent) at baseline to nine (25 percent) at follow-up. A significant improvement was found for the intervention group in patients' social relationships, interests in obtaining a job, maintenance of social interests, and management of social conflicts. Twenty-seven patients (74 percent) reported that their social relationships had improved during the six-month period. For both the intervention and control groups, family burden significantly improved. Relatives' social contacts and perception of professional support significantly increased only in the intervention group. CONCLUSIONS: The results suggest that a psychoeducational family intervention may have a significant impact on functional outcomes of schizophrenia when provided to patients and caregivers in real-world settings.

Effects of Clinical Decision Topic on Patients' Involvement in and Satisfaction With Decisions and Their Subsequent Implementation.

OBJECTIVE: Clinical decision making is an important aspect of mental health care. Predictors of how patients experience decision making and whether decisions are implemented are underresearched. This study investigated the relationship between decision topic and involvement in the decision, satisfaction with it, and its subsequent implementation from both staff and patient perspectives. METHODS: As part of the Clinical Decision Making and Outcome in Routine Care for People With Severe Mental Illness study, patients (N=588) and their providers (N=213) were recruited from community-based mental health services in six European countries. Both completed bimonthly assessments for one year using the Clinical Decision Making in Routine Care Scale to assess the decision topic and implementation; both also completed the Clinical Decision Making Involvement and Satisfaction Scale. RESULTS: Three categories of decision topics were determined: treatment (most frequently cited), social, and financial. The topic identified as most important remained stable over the follow-up. Patients were more likely to rate their involvement as active rather than passive for social decisions (odds ratio [OR]=5.7, p<.001) and financial decisions (OR=9.5, p<.001). They were more likely to report higher levels of satisfaction rather than lower levels for social decisions (OR=1.5, p=.01) and financial decisions (OR=1.7, p=.01). Social decisions were more likely to be partly implemented (OR=3.0, p<.001) or fully implemented (OR=1.7, p=.03) than not implemented. CONCLUSIONS: Patients reported poorer involvement, satisfaction, and implementation in regard to treatment-related decisions, compared with social and financial decisions. Clinicians may need to employ different interactional styles for different types of decisions to maximize satisfaction and decision implementation.

[Critical evaluation of current diagnostic classification systems in psychiatry: the case of DSM-5]. / Critiche e prospettive degli attuali sistemi di classificazione in psichiatria: il caso del DSM-5.

Since its first edition, the Diagnostic and Statistical manual of Mental disorders (DSM) has had a great impact on the scientific community and the public opinion as well. In 2013, the American Psychiatric Association released the fifth edition of the manual and - as for the previous versions - several criticisms raised. In particular, the persistence of the categorical approach to mental disorders represents one of the main debated topics, as well as the introduction of new diagnostic syndromes, which are not based on an adequate evidences. Moreover, the threshold of diagnostic criteria for many mental disorders has been lowered, with the consequence that the boundaries between "normality" and "pathology" is not so clear. In this paper, we will: 1) report the historical development of the DSM from the publication of its first edition; 2) describe the main changes introduced in the DSM-5; 3) discuss critical elements in the DSM-5. The current debate regarding the validity of diagnostic manuals and its criteria is threatening the psychiatric discipline, but a possible solution should be represented by the integration of diagnostic criteria with the in-depth description of patient's psychopathological experiences.

Family burden in long-term diseases: a comparative study in schizophrenia vs. physical disorders.

This study explored burden and social networks in families of patients with schizophrenia or a long-term physical disease. It was carried out in 169 specialised units (mental health department, and units for the treatment of chronic heart, brain, diabetes, kidney, lung diseases) recruited in 30 randomly selected geographic areas of Italy. The study sample consisted of 709 key relatives of patients with a DSM-IV diagnosis of schizophrenia and 646 key relatives of patients with physical diseases. Each relative was asked to fill in the Family Problems Questionnaire (FPQ) and the Social Network Questionnaire (SNQ). In all selected pathologies, the consequences of caregiving most frequently reported as always present in the past 2 months were constraints in social activities, negative effects on family life, and a feeling of loss. Objective burden was higher in brain diseases, and subjective burden was higher in schizophrenia and brain diseases than in the other groups. Social support and help in emergencies concerning the patient were dramatically lower among relatives of patients with schizophrenia than among those of patients with physical diseases. In the schizophrenia group, both objective and subjective burden were significantly higher among relatives who reported lower support from their social network and professionals. The results of this study highlight the need to provide the families of those with long-term diseases with supportive interventions, including: (a) the management of relatives' psychological reactions to patient's illness; (b) the provision of information on the nature, course and outcome of patient's disease; (c) training for the relatives in the management of the patient's symptoms; and (d) the reinforcement of relatives' social networks, especially in the case of schizophrenia.

[Should we continue to use benzodiazepines in clinical practice?]. / Dovremmo continuare a utilizzare le benzodiazepine nella pratica clinica?

The discovery of benzodiazepines has represented a milestone in the history of pharmacological treatments and in relation to the management of anxiety, sleep and other psychiatric disorders. After several decades, these agents still represent one of the largest and most widely prescribed groups of medications, not only in the psychiatric clinical practice, but also in the whole medical field. Over the last decade, however, multiple concerns have been raised on the risks related to the prescription of benzodiazepines, for their addictive potential and for cognitive side-effects. Therefore, benzodiazepines are today considered as a double-edge sword, which should be carefully handled and preferentially prescribed by specialists (or at least under their supervision), after an adequate training. Unfortunately, this is not the case in many situations, and the need to improve training on benzodiazepines management has been recently emphasized.

The role of relatives in pathways to care of patients with a first episode of psychosis.

AIMS: To explore the role of relatives in pathways to care of patients with a recent onset of psychosis. METHODS: A total of 34 consecutive patients and their relatives from the Department of Psychiatry of the University of Naples SUN participated in the study. Pathways to care were retrospectively evaluated by administering the Pathways to Care Form and the Nottingham Onset Schedule (NOS) to patients, relatives and treating physicians. Relatives were addressed with the Family Involvement in Pathways to care Schedule (FIPS). RESULTS: Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were 145.4 (±141.9) and 33.3 (±54.0) weeks, respectively. Help-seeking delay was 17.6 (±45.0) weeks. The first request for help was made by relatives in 76% of cases. Among health professionals, general practitioners were those most frequently contacted, followed by psychiatrists, neurologists or psychologists. Stigma and wrong attribution of psychotic symptoms were the main reasons for help-seeking delays. CONCLUSIONS: Relatives play a crucial role in pathways to care of patients with psychosis. DUI and DUP could be reduced by interventions aimed at increasing knowledge of early symptoms in the general population, and by the provision of psychiatric consultations in non-stigmatizing settings for young people with psychological distress.