Forensic mental health professionals' perceptions of their dual loyalty conflict: findings from a qualitative study.

BACKGROUND: Mental health professionals (MHP) working in court-mandated treatment settings face ethical dilemmas due to their dual role in assuring their patient's well-being while guaranteeing the security of the population. Clear practical guidelines to support these MHPs' decision-making are lacking, amongst others, due to the ethical conflicts within this field. This qualitative interview study contributes to the much-needed empirical research on how MHPs resolve these ethical conflicts in daily clinical practice. METHODS: 31 MHPs working in court-mandated treatment settings were interviewed. The interviews were semi-structured and our in-depth analysis followed the thematic analysis approach. RESULTS: We first outline how mental health professionals perceive their dual loyalty conflict and how they describe their affiliations with the medical and the justice system. Our findings indicate that this positioning was influenced by situational factors, drawing the MHPs at times closer to the caring or controlling poles. Second, our results illustrate how participating MHPs solve their dual loyalty conflict. Participants considered central to motivate the patient, to see the benefits of treatment and its goals. Further, transparent communication with patients and representatives of the justice system was highlighted as key to develop a trustful relationship with the patient and to manage the influences from the different players involved. CONCLUSIONS: Even though individual positioning and opinions towards dealing with the influences of the justice system varied, the results of our research show that, in spite of varying positions, the underlying practice is not very different across participating MHPs. Several techniques that allow developing a high-quality therapeutic alliance with the patient are key elements of general psychotherapy. Transparency appears as the crucial factor when communicating with the patient and with representatives of the justice system. More specifically, patients need to be informed since the beginning of therapy about the limits of medical confidentiality. It is also recommended to develop guidelines that define the level of detailed information that should be disclosed when communicating with the authorities of the justice system.

[From running amok to mass shootings: a psychopathological perspective]. / De l'amok aux fusillades de masse†: une perspective psychopathologique.

The expression «â€…To run amok ¼ describes bouts of murderous madness. This clinical entity was originally described in the Malay Peninsula. Associated with a form of exoticism, literary and historical descriptions are available. For about twenty years, amok has been included in psychiatric classifications as a culture-bound syndrome. In the last quarter of the 20th century, some parallels were observed between amok and mass shootings. Although the weapon of choice has changed from dagger to gun, common traits are clearly identifiable. Anger, feelings of prejudice and paranoid thoughts -dominate the picture. The absence of an ideological claim distinguishes the mass shooter from the terrorist. The psychiatrist may have a role in prevention, but these acting outs -remain difficult to anticipate.

L'amok, ou accès de folie meurtrière, est une entité clinique qui a été décrite initialement dans la péninsule malaise. Associé à une forme d'exotisme, on en trouve des descriptions littéraires et historiques. Durant une vingtaine d'années, l'amok a figuré dans les classifications psychiatriques comme syndrome lié à la culture. Dans le dernier quart du 20e siècle, un parallèle entre l'amok et les fusillades de masse est évoqué. Bien que l'arme de prédilection ait changé, passant du poignard à l'arme à feu, des traits communs sont clairement identifiables. Colère, sentiment de préjudice et pensée paranoïde dominent le tableau. L'absence de revendication idéologique distingue le meurtrier de masse du terroriste. Le psychiatre peut avoir un rôle dans la  prévention, mais ces passages à l'acte restent difficiles à ­â€…­anticiper.

Schizophrenia and Criminal Responsibility: A Systematic Review.

The significant progress of psychiatry in the 20th century provided a sophisticated theoretical framework to analyze the complex relationships between crime and mental illness. Schizophrenia has been traditionally associated with severe cognitive and affective deficits that heavily influence empathy, judgment capacities, but also control of impulsiveness. Although there is an association between psychotic disorders and absence or decrease of legal responsibility, their relationship is also determined by sociodemographic, developmental, and clinical factors. These disorders are associated not only with abolished criminal responsibility but also with diminished responsibility. We conduct a systematic literature review to examine the relation between schizophrenia and criminal responsibility. We have found that this clinical entity is often associated with diminished or abolished criminal liability. We discuss these findings, focusing on the specific deficits found in patients with schizophrenia and examining how this problem affects their behavior and eventually their accountability for their crimes.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers.

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

What are the barriers to access to mental healthcare and the primary needs of asylum seekers? A survey of mental health caregivers and primary care workers.

BACKGROUND: We aimed to assess the opinion of primary care workers, social workers, translators and mental health caregivers who work with asylum seekers about the latter's unmet needs and barriers to access to mental healthcare. METHODS: We used a Likert scale to assess the opinion of 135 primary care workers (general practitioners, nurses, social workers and translators) and mental health caregivers about the proportion of asylum seekers with psychiatric disorders, their priority needs and their main barriers to mental health services. RESULTS: Insufficient access to adequate financial resources, poor housing and security conditions, access to employment, professional training and legal aid were considered as priority needs, as were access to dental and mental healthcare. The main barriers to access to mental healthcare for asylum seekers included a negative representation of psychiatry, fear of being stigmatized by their own community and poor information about existing psychiatric services. CONCLUSIONS: We found a good correlation between the needs reported by healthcare providers and those expressed by the asylum-seeking population in different studies. We discuss the need for greater mobility and accessibility to psychiatric services among this population.

[From perceived dangerousness to the dangerous individual: clinical challenges and vision of society]. / Du vécu de dangerosité à l'être dangereux: défis cliniques et vision de société.

It is a complex task to identify individuals who are persistently dangerous for others because of a mental disorder. The results of unstructured clinical interviews are poor. Risk assessment instruments statistically improve the prediction of violence. However, this prediction remains uncertain for a given individual. The perception of dangerousness is partly subjective and depends on the societal context among other factors. Compulsory therapy can be ordered by the judiciary system either in locked or in opened facilities, depending on the level of security which is required. The approach adopted in Geneva for forensic patients hospitalized in opened wards is inspired by the rehabilitation model, initially developed for severe mental disorders. The focus of treatment is put on dynamic, i.e. modifiable, determinants of criminal behavior.

Visual perspective taking neural processing in forensic cases with high density EEG.

This EEG study aims at dissecting the differences in the activation of neural generators between borderline personality disorder patients with court-ordered measures (BDL-COM) and healthy controls in visual perspective taking. We focused on the distinction between mentalizing (Avatar) and non-mentalizing (Arrow) stimuli as well as self versus other-perspective in the dot perspective task (dPT) in a sample of 15 BDL-COM cases and 54 controls, all of male gender. BDL-COM patients showed a late and diffuse right hemisphere involvement of neural generators contrasting with the occipitofrontal topography observed in controls. For Avatars only and compared to controls, the adoption of Self perspective involved a lower EEG activity in the left inferior frontal, right middle temporal cortex and insula in BDL-COM patients prior to 80 ms post-stimulus. When taking the Other-perspective, BDL-COM patients also showed a lower activation of superior frontal, right inferior temporal and fusiform cortex within the same time frame. The beta oscillation power was significantly lower in BDL-COM patients than controls between 400 and 1300 ms post stimulus in the Avatar-Other condition. These results indicate that BDL-COM patients display both altered topography of EEG activation patterns and reduced abilities to mobilize beta oscillations during the treatment of mentalistic stimuli in dPT.

Medical and legal professionals' attitudes towards confidentiality and disclosure of clinical information in forensic settings: a survey using case vignettes.

OBJECTIVE: When potentially dangerous patients reveal criminal fantasies to their therapists, the latter must decide whether this information has to be transmitted to a third person in order to protect potential victims. We were interested in how medical and legal professionals handle such situations in the context of prison medicine and forensic evaluations. We aimed to explore the motives behind their actions and to compare these professional groups. METHOD: A mail survey was conducted among medical and legal professionals using five fictitious case vignettes. For each vignette, participants were asked to answer questions exploring what the professional should do in the situation and to explain their justification for the chosen response. RESULTS: A total of 147 questionnaires were analysed. Agreement between participants varied from one scenario to another. Overall, legal professionals tended to disclose information to a third party more easily than medical professionals, the latter tending to privilege confidentiality and patient autonomy over security. Perception of potential danger in a given situation was not consistently associated with actions. CONCLUSION: Professionals' opinions and attitudes regarding the confidentiality of potentially dangerous patients differ widely and appear to be subjectively determined. Shared discussions about clinical situations could enhance knowledge and competencies and reduce differences between professional groups.

Impact of psychiatrists' qualifications on the rate of compulsory admissions.

Despite efforts to reduce coercion in psychiatry, involuntary hospitalizations remain frequent, representing more than half of all admissions in some European regions. Since October 2006, only certified psychiatrists are authorized to require a compulsory admission to our facility, while before all physicians were, including residents. The aim of the present study is to assess the impact of this change of procedure on the proportion compulsory admissions. All medical records of patients admitted respectively 4 months before and 4 month after the implementation of the procedure were retrospectively analyzed. This search retrieved a total of 2,227 hospitalizations for 1,584 patients. The overall proportions of compulsory and voluntary admissions were 63.9 % and 36.1 % respectively. The average length of stay was 32 days (SD ± 64.4). During the study period, 25 % of patients experienced two hospitalizations or more. The most frequent patients' diagnoses were affective disorders (30 %), psychotic disorders (18.4 %) and substance abuse disorders (15.7 %). Compared with the period before October 2006, patients hospitalized from October 2006 up were less likely to be hospitalized on a compulsory basis (OR = 0.745, 95 % CI: 0.596-0.930). Factors associated with involuntary admission were young age (20 years or less), female gender, a diagnosis of psychotic disorder and being hospitalized for the first time. Our results strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions.

Mentalizing and self-other distinction in visual perspective taking: the analysis of temporal neural processing using high-density EEG.

This high density EEG report dissects the neural processing in the visual perspective taking using four experimental comparisons (Arrow, Avatar and Self, Other). Early activation differences occurred between the Avatar and the Arrow condition in primary visual pathways concomitantly with alpha and beta phase locked responses predominant in the Avatar condition. In later time points, brain activation was stronger for the Avatar condition in paracentral lobule of frontal lobe. When taking the other's perspective, there was an increased recruitment of generators in the occipital and temporal lobes and later on in mentalizing and salience networks bilaterally before spreading to right frontal lobe subdivisions. Microstate analysis further supported late recruitment of the medial frontal gyrus and precentral lobule in this condition. Other perspective for the Avatar only showed a strong beta response located first in left occipito-temporal and right parietal areas, and later on in frontal lobes. Our EEG data support distinct brain processes for the Avatar condition with an increased recruitment of brain generators that progresses from primary visual areas to the anterior brain. Taking the other's perspective needs an early recruitment of neural processors in posterior areas involved in theory of mind with later involvement of additional frontal generators.

Seeing in my way or your way: impact of intelligence, attention, and empathy on brain reactivity.

Previous studies showed that neurotypical adults are able to engage in unconscious analyses of others' mental states in the context of automatic perspective taking and experience systematic difficulties when judging the conflicts between their own (Self) and another's (Other) perspective. Several functional MRI (fMRI) studies reported widespread activation of mentalizing, salience, and executive networks when adopting the Other compared to Self perspective. This study aims to explore whether cognitive and emotional parameters impact on brain reactivity in dot perspective task (dPT). We provide here an fMRI analysis based on individual z-scores in eighty-two healthy adults who underwent the Samson's dPT after detailed assessment of fluid intelligence, attention, levels of alexithymia and social cognition abilities. Univariate regression models were used to explore the association between brain activation patterns and psychological variables. There was a strong positive association between Wechsler Adult Intelligence Scale (WAIS) and fMRI z-scores in Self perspective. When the Other perspective is taken, Continuous Performance Test (CPT)-II parameters were negatively associated with fMRI z-scores. Individuals with higher Toronto Alexithymia scale (TAS) score and lower scores in mini-Social cognition and Emotional Assessment (SEA) displayed significantly higher egocentric interference-related fMRI z-scores. Our data demonstrate that brain activation when focusing on our own perspective depends on the levels of fluid intelligence. Decreased attentional recruitment and decreased inhibitory control affects the brain efforts to adopt the Other perspective. Egocentric interference-associated brain fMRI activation was less marked in cases with better empathy abilities but the opposite was true for persons who experience increased difficulties in the recognition of emotions.

Patterns of multiple brain network activation in dot perspective task.

In this functional MRI (fMRI) study on 82 healthy adults using the dot perspective task, inconsistency of perspectives was associated with a significant increase of the mean reaction time and number of errors both in Self and Other conditions. Unlike the Arrow (non-mentalizing), the Avatar (mentalizing) paradigm was characterized by the recruitment of parts of the mentalizing and salience networks. These data provide experimental evidence supporting the fMRI distinction between mentalizing and non-mentalizing stimuli. A widespread activation of classical theory of mind (ToM) areas but also of salience network and decision making areas was observed in the Other compared to Self-conditions. Compared to Self-Consistent, Self-Inconsistent trials were related to increased activation in the lateral occipital cortex, right supramarginal and angular gyrus as well as inferior, superior and middle frontal gyri. Compared to the Other-Consistent, Other-Inconsistent trials yielded strong activation in the lateral occipital cortex, precuneus and superior parietal lobule, middle and superior precentral gyri and left frontal pole. These findings reveal that altercentric interference relies on areas involved in self-other distinction, self-updating and central executive functions. In contrast, egocentric interference needs the activation of the mirror neuron system and deductive reasoning, much less related to pure ToM abilities.

Implementation and impact of anti-smoking interventions in three prisons in the absence of appropriate legislation.

OBJECTIVE: To assess the acceptability and impact of anti-smoking policies in three prisons in Switzerland. METHODS: A before-after intervention study in A) an open prison for sentenced prisoners, B) a closed prison for sentenced prisoners, and C) a prison for pretrial detainees. Prisoners and staff were surveyed before (2009, n=417) and after (2010-2011, n=228) the interventions. Medical staff were trained to address tobacco dependence systematically in prisoners. In prison A, a partial smoking ban was extended. No additional protection against second-hand smoke was feasible in prisons B and C. RESULTS: In prison A, more prisoners reported receiving medical help to quit smoking in 2011 (20%) than in 2009 (4%, p=0.012). In prison A, prisoners and staff reported less exposure to second-hand smoke in 2011 than in 2009: 31% of prisoners were exposed to smoke at workplaces in 2009 vs 8% in 2011 (p=0.001); in common rooms: 43% vs 8%, (p<0.001). No changes were observed in prisons B and C. CONCLUSIONS: Reinforcement of non-smoking rules was possible in only one of the three prisons but had an impact on exposure to tobacco smoke and medical help to quit. Implementing anti-smoking policies in prisons is difficult in the absence of appropriate legislation.

Use of healthcare services 8 years after the war in Kosovo: role of post-traumatic stress disorder and depression.

BACKGROUND: The aim of the present study was to examine the use of health-care services and medication, as well as health risk behaviours such as smoking, in relation with post-traumatic stress disorder (PTSD) and major depressive episode (MDE) in post-war Kosovo. METHODS: A sample of 864 adults was interviewed in 2007 of which 551 took part in a 2001 survey. They were assessed using the PTSD and MDE sections of the Mini International Neuropsychiatric Interview (MINI) and the Medical Outcomes Study 36-item Short Form Health Survey (SF-36). Use of health-care services, alcohol and tobacco were also recorded. RESULTS: Respondents were predominantly female (56.6%) with a median age of 36 years and a primary educational level (44.6%). While 11.9% of participants met diagnostic criteria for PTSD, MDE prevalence was 30.6%. Both PTSD and MDE were significantly associated with lower scores on the SF-36 physical component summary. After adjustment for sex, age, education, unemployment, municipality and SF-36 perceived physical health, no significant association was observed between PTSD and medical visits in the past 12 months, hospitalizations in the past 12 months and use of medication in the past 7 days. Results were similar for MDE, except for a significantly higher frequency of medication use that included psychotropic and other drug classes. CONCLUSION: Eight years after the war in Kosovo, poor perceived physical health displayed a long-lasting association with PTSD and MDE and was a major determinant of increased use of health-care services without additional contribution of PTSD per se.

Mental and physical health in Rwanda 14 years after the genocide.

PURPOSE: To examine the socio-demographic determinants of post-traumatic stress disorder (PTSD) and its association with major depressive episode and self-perceived physical and mental health in a large random sample of the Rwandan population 14 years after the 1994 genocide. METHODS: Using the Mini International Neuropsychiatric Interview and Medical Outcomes Study 36-Item Short-Form (SF-36) translated in Kinyarwanda, we interviewed 1,000 adult residents from the five provinces of Rwanda. Socio-demographic data and specific somatic symptoms were also recorded. Data analysis included 962 questionnaires. RESULTS: Participants were predominantly female (58.9%), aged between 16 and 34 years (53.2%), with a low level of education (79.7% below secondary school). Prevalence of PTSD was estimated to be 26.1%. In multivariable analysis, factors associated with PTSD were being aged between 25 and 34 years, living in extreme poverty, having endured the murder of a close relative in 1994, being widowed or remarried, having lost both parents and living in the South Province. Participants who fulfilled diagnostic criteria for PTSD were significantly more often affected with major depression (68.4 vs. 6.6%, P < 0.001) and substance dependence (7.6 vs. 3.5%, P = 0.013) than respondents without PTSD. They scored significantly lower on all SF-36 subscales. Somatic symptoms such as hiccups, fainting and loss of speech or hearing delineated a specific pattern of post-traumatic stress syndrome. CONCLUSIONS: PTSD remains a significant public health problem in Rwanda 14 years after the genocide. Facilitating access to appropriate care for all those who need it should be a national priority.

Health problems among detainees in Switzerland: a study using the ICPC-2 classification.

BACKGROUND: Little is known about the health status of prisoners in Switzerland. The aim of this study was to provide a detailed description of the health problems presented by detainees in Switzerland's largest remand prison. METHODS: In this retrospective cross-sectional study we reviewed the health records of all detainees leaving Switzerland's largest remand prison in 2007. The health problems were coded using the International Classification for Primary Care (ICPC-2). Analyses were descriptive, stratified by gender. RESULTS: A total of 2195 health records were reviewed. Mean age was 29.5 years (SD 9.5); 95% were male; 87.8% were migrants. Mean length of stay was 80 days (SD 160). Illicit drug use (40.2%) and mental health problems (32.6%) were frequent, but most of these detainees (57.6%) had more generic primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Furthermore, 7.9% reported exposure to violence during arrest by the police. CONCLUSION: Morbidity is high in this young, predominantly male population of detainees, in particular in relation to substance abuse. Other health problems more commonly seen in general practice are also frequent. These findings support the further development of coordinated primary care and mental health services within detention centers.

Mental and physical health of Kosovar Albanians in their place of origin: a post-war 6-year follow-up study.

PURPOSE: Long-term outcome of traumatic experiences among war-exposed civilians living in their home country has been seldom documented. The present study examined change in posttraumatic stress disorder (PTSD) frequency and perceived physical and mental health in a cohort of Kosovar Albanians over 6 years (2001-2007). METHODS: Of 996 Albanian Kosovar civilians included in the 2001 survey, 551 subjects (55.3%) were recalled and interviewed in 2007. Diagnoses of PTSD and major depressive episode were assessed using the Mini International Neuropsychiatric Interview. Subjective physical and mental health were investigated using the Medical Outcomes Study 36-Item Short-Form (SF-36). A list of traumatic events adapted from the Harvard Trauma Questionnaire and other stressful life events was also considered. RESULTS: Posttraumatic stress disorder was significantly less frequent in 2007 than in 2001 (14.5% vs. 23.2%, p < 0.001). For 18.0, 5.3 and 9.3% of participants, PTSD remitted, persisted and developed over the 6-year follow-up period, respectively. Ill health without having access to medical care and major changes in responsibilities at work were associated with both persistence and new occurrence of PTSD. While the SF-36 mental component summary score significantly improved (mean change +4.5, p < 0.001), the physical component summary score did not change between 2001 and 2007, after adjustment for age (mean change -0.8, p = 0.14). CONCLUSIONS: Results point at the importance of economic and health system reconstruction programs with respect to public health in post-conflict countries.

Religion and mental health during incarceration: a systematic literature review.

Religion and spirituality (RS) as a coping resource for facing stressful life events is encountered with increasing frequency in the medical literature. RS is associated with more favourable outcomes among people suffering from mental disorders. Detention is a stressful situation and the prevalence of mental disorders in places of detention is increased compared with the community. This literature review examined the association between RS and the mental health of detainees. PubMed, PsycINFO, Web of Science and the Internet were systematically searched from inception of each data base to August 1st 2010. Peer reviewed articles that reported primary empirical data about the impact of spirituality on the mental health and behaviour of detained persons were selected. Qualitative studies are also discussed. Twelve empirical studies including a total of 4,823 individuals met our inclusion criteria. RS is associated with lower frequency and severity of depressive episodes. The strongest reported effect of RS on prison life is a reduction of incidents and disciplinary sanctions. Prospective targeted studies are needed in order verify the hypothesis that RS reduces suicide among detainees.

[Ethical issues in psychiatry under coercion]. / Enjeux ethiques de la psychiatrie sous contrainte.

Psychiatry is now subject to two apparently contradictory movements. On the one hand, the need to respect the autonomy and rights of patients is reinforced and coercive measures are strictly defined and limited. On the other hand, security concerns in our society leads to prosecution of psychiatric disorders, especially when accompanied by behavioral problems or criminal acts. In these situations of compulsory treatment or care provided in prisons, a number of dilemmas emerge. The place of the healthcare professional in treatments ordered by the Judge and problems related to administrative detention are discussed in more detail.

The five-year evolution of a mixed psychiatric and somatic care unit: a European experience.

BACKGROUND: There are virtually no reported experiences of mixed medical/psychiatry inpatient units in Europe. Such a program was created in Geneva, Switzerland, in 1999. OBJECTIVE: The authors retrospectively analyzed clinical data from its first 5 years of operation. METHOD: These data represent 1,380 hospitalizations. A descriptive analysis was carried out on all collected data for each year of activity. RESULTS: The severity of physical disorders increased with time. The number of medical comorbidities, length of hospital stay, and compulsory admissions increased. The proportion of mood disorders decreased, whereas the proportion of psychotic and adjustment disorders increased. CONCLUSION: Patients with comorbid medical and psychiatric disorders are often refused admission to both medical and psychiatric wards. Once they are admitted, they are often released prematurely or transferred to another ward too quickly because of behavioral management difficulties. Physicians who refer patients to the unit recognize the complex nature of these cases and refer them because the unit is capable of offering acute psychiatric and medical treatments and provides an environment that encourages patient cooperation and treatment adherence.