Six things to know about the homicides of doctors: a review of 30 years from Italy.

BACKGROUND: Healthcare workers have a 16 times greater risk of suffering workplace violence than workers in other sectors and around 50% experience workplace violence in the course of their career. The objective of this study is to explore the characteristics and circumstances of work-related killings of doctors. METHODS: Work-related homicides of doctors over the period 1988-2019 were identified retrospectively through the Italian national statistical agencies. Variables such as perpetrator, motive and location of the crime were obtained through forensic psychiatric work. After classification, the absolute and percent values of the main characteristics of the homicides were calculated. RESULTS: Over the period considered, 21 doctors were killed in Italy in connection with their professional activity. In 52% (n = 11) of cases, the killer was one of the doctor's patients, in 29% (n = 6) of cases it was a patient's relative, in 19% (n = 4) an occasional patient (first consultation). The location of the homicide was a community clinic in 48% (n = 10) of cases, the street in 19% (n = 4) of cases, the doctor's home in 14% (n = 3), the hospital in 14% (n = 3) and the patient's home in 5% (n = 1). In 57% (n = 12) of cases the perpetrator was not affected by any mental disorders. The motive for the homicide was revenge in 66.7% (n = 14) of cases; in 28.6% (n = 6) the revenge was preceded by stalking. CONCLUSIONS: Doctors should be aware that the risk of being killed is not limited to hospital settings and that their patients' family members might also pose a threat to them.

[Guidelines in psychiatry: clinical and forensic issues]. / Linee guida in psichiatria: criticità cliniche e forensi.

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities.

[Professional liability in psychiatry: evolution and critical issues]. / La responsabilità professionale in psichiatria: evoluzione e criticità.

The aim of the article is to present the evolution of professional liability in psychiatry from law 36 of 1904 to today. Through an examination of the doctrinal positions and of the jurisprudential expression it was possible to highlight three distinct phases in which professional responsibility has declined over the years. A custodial phase, in which the spirit that animated the law of psychiatric assistance was inspired by principles of social defense and the responsibility of the psychiatrist was recognized mainly in the lack of custody of the psychiatric patient. A phase of indulgence, in which, like other disciplines, the psychiatrist was recognized with "reduced impunity" due to an alleged "special difficulty" in exercising the medical profession. A phase of empowerment, in which the doctor in general, and the psychiatrist in particular, was confronted with empowering positions that led to convictions. An examination of the application of the guarantee position to psychiatry allows us to highlight current difficulties, sometimes a legacy of the past.

[The psychiatrization and unpredictability of interpersonal violent behavior]. / Sulla psichiatrizzazione e imprevedibilità del comportamento violento sulla persona.

The relationship between mental illness and violent behavior is a complex phenomenon. Scientific literature indicates that the presence of a mental disorder, even severe, is not sufficient, alone, to predict or motivate violent behavior, which seems to be more associated with other intermediate variables. The phenomenon of psychiatrization of violent behavior can be defined, from a psychiatric-forensic point of view, as the prejudicial and erroneous attribution to mental illness as a causal factor in relation to violent behavior. This phenomenon has consequences in psychiatric clinical practice, but also at the level of social stigmatization, management of organizational and economic resources, and the judicial system. In this paper, clinical criticalities related to the psychiatrization of violent behavior will be analyzed, including the need to differentiate clinical etiology and legal causality, predictability and avoidability, protective clinical factors and clinical risk factors, the limits of categorical psychiatric diagnosis, the need for specific victimological information, the criticalities of pharmacotherapy. Some forensic criticalities will also be analyzed, including errors in clinical and forensic methodology (psychiatrization of the symptom, prejudicial contamination, diagnostic overshadowing, legal causalization of protective and risk factors, the use of categorical diagnosis in the forensic field, the psychiatrization of non-pathological human experiences, the criminalization of the subject with mental disorder). In conclusion, it is highlighted that an individual can have a psychic disorder, even severe, but this disorder is not necessarily in a causal relationship with violent behavior. The lack of a causal relationship makes predictability of violent behavior difficult, even impossible depending on the case, both in the general population and in individuals with psychiatric disorders.

[Homophobic bullying: critical considerations, and legal-institutional interventions]. / Bullismo omofobico: considerazioni critiche e interventi giuridico-istituzionali.

Instances in the increase of homophobic bullying mean a major interest in order to develop strong bullying prevention programming which should be a major priority for adults, governments and institutions responsible to promote and ensure a responsible development of society. The complexity of the problem requires a multidisciplinary approach of a comprehensive nature. Starting from the construction of gender identities, and taking into account and understanding the biological aspects, external influences, and arising contrasts during the process, a young person faces adolescence: a transition period when sexual orientation or preference faces higher risks as the person has to come to terms with a mismatch between scales of knowledge. The outcome will result in an inter-generational conflict which becomes a prejudice. By acquiring the desired characteristics of mind and body, adolescents develop their own cognitive skills. Thus we can consider homophobic bullying in its psycho-sociological implications. The aim of this paper is to delineate an explanation of the topic in a scientific, educational and professional way, and at the same time to take into account all legal and institutional issues.

[Regulatory evolution of the crime of infanticide]. / Evoluzione normativa del delitto di infanticidio.

The objective of the present study consists of the juridic-anthropological analysis of the infanticide, a phenomenon that nowadays is highly existent within the context of crime-settings. Particular consideration has been given to the legal developments of the infanticide act, which occurred simultaneously with the mutation of the socio-cultural contexts. Because the legislative process of the infanticide act has not evolved since 1981, it was possible to underline the criticisms and the inadequacy of such norm. Indeed, the legal norm has not always been able to provide an exhaustive answer concerning cases of infanticide. The process of humanisation of the law led to the introduction of a legal system, which describes the infanticide act as a condition of material and moral abandonment. This has become uncertain and ambiguous to interpret, risking to relegate the legislative matters of infanticide only to exceptional cases. The current study aims to highlight the criticisms and hypothesised different reform perspectives.

[Charges and convictions of psychiatrists for the violent behavior of the patient: psychiatric-forensic remarks]. / Osservazioni psichiatrico-forensi sulle imputazioni e condanne agli psichiatri per il comportamento violento del paziente.

Purpose of the present study is to point-out a number of psychiatric-forensic remarks about the management of violent behavior against the person (VBP) amongst psychiatric patients. The study is the authors' personal contribution based on clinical and forensic experience as experts in the management of psychiatric patients with VBP. Twelve psychiatric-forensic remarks have been highlighted in the present study: 1) VBP is a multifactorial event; 2) the risk of VBP against the person may change rapidly over time in quantity and quality; 3) there are no methods for reliable prediction of VBP in a single clinical-case; 4) there are no medications with an indication of "heal" the VBP; 5) there are no therapeutic measures that neutralize always, quickly and without recurrences VBP; 6) there exist clinical hypotheses to assess VBP; 7) there exist principles of victimology to assess VBP; 8) there are emotional reactions that can affect the evaluation and clinical and forensic management of VBP; 9) the responsibility of the psychiatrist has to be evaluated at the moment of the events; 10) the responsibility of the psychiatrist must be contextualized in the single clinical-case; 11) there is the need to clarify the individual professional responsibility of psychiatrists who treated a patient; 12) there is the need to clarify the criteria for the definition of the guarantee role. The above-mentioned twelve psychiatric-forensic remarks have implications in the assessment and management of psychiatric patients with violent behavior. They may constitute a basis for further discussion aiming to obtain consensus amongst psychiatrists about good clinical practice and forensic implication in the management of psychiatric patients with VBP and to avoid charges and convictions.

[Murder of the doctor]. / L'omicidio del medico.

AIM: To examine possible risk factors for the doctor to be killed by the patient in the clinical practice by examining a series of murders that involved physicians. METHODS: This aim has been achieved through a retrospective review on clinical cases of doctors killed by patients within the period between 1988 and 2013, in Italy. RESULTS: In this period 18 Italian doctors have been killed in the workplace, with a rate of 0.3/100,000. In 7 cases, the murder resulted in the context of doctor-dissatisfaction; in 7 cases the murder was committed by a psychiatric patient; 1 case in the context of a stalking; 3 cases occurred in a workplace which was not safe enough. Four categories of at-risk contexts have been identified. One category includes a murder in the context of a doctor-dissatisfaction, perceived by patient. The second category concerns murders committed by patients suffering from mental illness. A third category includes homicides in a workplace which is not safe. The last category comprises the murder in the context of stalking. CONCLUSIONS: These categories identify specific dangerous situations for physicians, in which are highlighted elements that have played a crucial role in the murder and for which special precautions are suggested preventive.

[Psychiatrist's professional liability for generic, brand, and off-label drug prescription]. / La responsabilità professionale dello psichiatra nella prescrizione di farmaci off-label e dei farmaci originali e generici.

At present, drug prescription is a hot topic in terms of professional responsibility. Psychiatric-forensic criteria are provided for appropriate drug prescription, focusing on off-label and generic drug prescription. Off-label prescription should be made in accordance with current regulations, in particular with the regulatory requirements related to patient consent. Generic drug prescription is affected by several critical issues, such as drug excipients, equivalence to original drug, correspondence of therapeutic indications. The different spheres of responsibility of physicians and apothecaries in prescribing and distributing drugs, respectively, are discussed. The knowledge of these issues can be helpful for physicians in their clinical practice, allowing preservation of professional autonomy and compliance with current regulations. The explanation of the most common mistakes about drug prescription that are examined in law courts can be the starting point of an interdisciplinary debate involving all interested parties that are called upon to judge psychiatrist responsibility in drug prescription.

Efficacy of pregabalin and venlafaxine-XR in generalized anxiety disorder: results of a double-blind, placebo-controlled 8-week trial.

The objective of this study was to evaluate the anxiolytic efficacy, and speed of onset of efficacy, of pregabalin (PGB) and venlafaxine-XR (VXR) in patients with generalized anxiety disorder (GAD). In this double-blind trial, outpatients, ages 18-65 years, who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for GAD were randomized to 8 weeks of flexible-dose treatment with PGB (300-600 mg/day), VXR (75-225 mg/day), or placebo (PBO). The intent-to-treat sample consisted of 121 patients on PGB [least square (LS) mean ± SE baseline Hamilton Anxiety Rating Scale (HAM-A), 27.6 ± 0.4], 125 patients on VXR (baseline HAM-A, 27.4 ± 0.4), and 128 patients on PBO (baseline HAM-A, 26.8 ± 0.4). Treatment with PGB was associated with a significantly greater LS mean change in the HAM-A total score at last observation carried forward endpoint versus PBO (-14.5 ± 0.9 vs. -11.7 ± 0.9; P = 0.028). Treatment with VXR was not significant versus PBO at endpoint (-12.0 ± 0.9; -11.7 ± 0.9; P =0.968). Treatment with PGB showed an early onset of improvement, with significantly greater LS mean change in the HAM-A by day 4 versus both PBO (-5.3 ± 0.5 vs. -3.4± 0.5; P = 0.008) and VXR (-2.9 ± 0.5; P = 0.0012). The proportion of patients reporting a severe adverse event was similar for PGB (9.1%) and PBO (7.8%), but higher for VXR (20.0%; P < 0.05). In conclusion, PGB was a safe and effective treatment of GAD, with a significantly earlier onset of anxiolytic activity than VXR.

Paroxetine versus amitriptyline in patients with recurrent major depression: A double-blind trial.

INTRODUCTION: Long-term exposure to antidepressants is required to prevent relapses and recurrences in patients with recurrent major depression. Furthermore, a good pharmacological compliance is the key to successful long-term treatment. Since the early phases of a treatment influence long-term compliance and compliance is adversely affected by poorly tolerated treatments, efficacy and tolerability of paroxetine and amitryptiline over 12 weeks were compared as an introduction to the issue of long-term compliance to these two agents. METHOD: A 12-week, randomized, double-blind, doubledummy, parallel-group trial which involved 129 patients with recurrent major depression. RESULTS: Both paroxetine and amitriptyline were effective in controlling the symptoms of depression, as shown by the reduction in HAMD total score and CGI severity-of-illness score at endpoint compared to baseline. There was no statistically or clinically significant difference between the two treatments in terms of efficacy. However, marked numerical differences were noted in tolerability: the percentage of patients who reported treatment-emergent adverse experiences was greater in the amitriptyline group (40.0% vs 28.1%). This difference was mainly due to anticholinergic adverse events, which were six times more frequent with amitriptyline than with paroxetine. CONCLUSION: When compared with amitriptyline, paroxetine should allow patients with recurrent major depression to receive an equally effective treatment with a relatively lower incidence of adverse experiences.