The case of Geneviève Lhermitte's euthanasia between psychiatric evaluation, legal aspects and ethical reflection.

A recent euthanasia case in Belgium has garnered attention due to its particularly dramatic aspects, sparking clinical and ethical questions about end-of-life choices in cases of mental suffering. A 56-year-old woman, convicted of the murder of her five minor children and sentenced to life imprisonment, has been granted euthanasia for "irreversible psychological suffering". The clinical and psychodynamic aspects of the case, primarily deduced from press reports, are highly complex and give rise to numerous clinical, medico-legal, and bioethical questions. These include inquiries into the true nature of psychopathology, its actual irreversibility, its impact on the ability to express a euthanasia request with adequate awareness, the preserved capacity for self-determination, and broader issues related to end-of-life requests from patients with mental disorders. These aspects are considered in the context of the legislation in various European countries. The unique details of this case underscore the critical challenges associated with these complex issues.

Psychiatric advance directives (Ulysses Contract): the need for a specific law and a criteria proposal for its introduction.

AIM: Advance healthcare directives in the psychiatric field raise more concerns and controversies compared to their use in other medical branches. We discuss the role of advance directives in this field and suggest a criteria proposal for the settlement of a comprehensive regulation on the matter. METHODS: We analyse the existing law and discuss the ethical points in the Italian context and, in comparison, with the United Kingdom context. RESULTS: Numerous studies have highlighted that psychiatric patients experience advance directives as an instrument to participate in therapeutic decision-making. Regarding the usefulness of advance directives, Italy and the United Kingdom did not approve deontological rules or laws. The United Nations Commission states that, based on the principles of the Convention on the Rights of Persons with Disabilities, it is necessary to respect the spatient's will, even if it is biased by psychic disorders. CONCLUSIONS: The Convention does not consider advance directives; instead, they just suggest using some support to have the patient regain their competence. In case this is unsuccessful, it is necessary to appoint a substitute decision-maker to express, even in the light of the advance directives, the will that the patient would have expressed if he had been competent.

A preliminary study on similarities and dissimilarities of Neurological Soft Signs in schizophrenic and obsessive-compulsive disorders suggests a common maldevelopmental model.

AIM: Neurological Soft Signs (NSS) represent minor neurological signs related to non-specific cerebral alterations. They have been documented in many psychiatric disorders including schizophrenia (SCZ) and obsessive-compulsive disorder (OCD). Aim of this study was to determine and compare the incidence and severity of NSS in patients with SCZ, in patients with OCD, and healthy control subjects (HCs). METHODS: Using the Neurological Evaluation Scale (NES), this study investigated NSS in 15 SCZ patients, 14 OCD patients, and 15 HCs. PANSS and Y-BOCS were used to evaluate clinical picture in both groups. RESULTS: Patients with SCZ showed significantly higher scores compared to HCs in the NES total and each of the three NES subscales (Integrative Sensory Function, Motor Coordination, and Sequencing of Complex Motor Acts). Patients with OCD also showed significantly higher scores compared to HCs in the NES total, Motor Coordination and Sequencing of Complex Motor Acts, but not in Integrative Sensory Function. No significant differences emerged in the NES total and the various subscales scores between the two patients' groups. CONCLUSIONS: Our results seem to confirm the presence of NSS in both SCZ and OCD. The different types of NSS presented by the two patients' groups versus HCs further supports the findings of widespread cerebral alterations in SCZ, on the other hand, with a preferential involvement of prefrontal and frontal cortex in OCD.

The Interaction Between Optimism and Pessimism Predicted the Perceived Risk of Infection During the Covid-19 Pandemic: An Exploratory Cross-Sectional Study.

In this study, we examined the relationship between optimism and pessimism associated with the Covid-19 pandemic, mental health, and perceived risk of infection. In particular, we tested the hypothesis that, when optimism and pessimism were high during the pandemic period, a worse mental health and a higher perception of risk would be reported. To this end, a convenience sample of 374 Italian adults was enrolled. Measures included perceived stress, optimism, and pessimism associated with the development of the pandemic situation, as well as the perceived risk of Covid-19 infection. The results showed that optimism and pessimism were associated with perceived stress and Covid-19 risk perception while controlling for demographic variables. Optimism and stress were negatively related, while pessimism was positively related to both stress and risk perception. Furthermore, the interaction between optimism and optimism was significant, with a higher perception of risk in the presence of both high optimism and pessimism, and a lower perception of risk with high optimism and low pessimism. These results support the hypothesis that optimism and pessimism interacted in predicting Covid-19 risk perception and show that they should be measured as partially correlated but independent constructs in future investigations.

Guselkumab for the treatment of severe plaque psoriasis in a schizophrenia patient.

A wide range of comorbid conditions are associated with psoriasis, many studies have drawn attention to a higher prevalence of psychiatric comorbidities in psoriatic population. Herein, we present a case of a Caucasian 44-years-old man suffering from a severe schizophrenia, who received guselkumab (a human monoclonal antibody targeting the p40 subunit of IL-23) for the treatment of a moderate-to-severe plaque type psoriasis. After 3 months, the patient reached complete resolution of psoriasis without any side effects, maintained at 6 months follow up visit. Some studies have highlighted the hypothesis that an hyperactivation of immune response appears to be one of the main mechanisms underlying the increased risk of this association. In particular, the axis il-17/il-23 plays a central role in the pathogenesis of this disease. Further research will be needed to assess whether anti-IL23 drugs could be a more suitable therapeutic option in psoriatic patients with schizophrenia.

Intimate Female Partner Homicide Suicide: demographic and psychopathology aspects of perpetrators and a potential not yet classified diagnostic entityAnalyses of data taken from newspapers in Italy from 2009 to 2019.

INTRODUCTION: The homicide of the female partner followed by suicide of the perpetrator (Intimate Female Partner Homicide Suicide - IFPHS) has been a growing phenomenon over last years, but its psychosocial and psychopathological aspects have not been analyzed in-depth yet. PURPOSE: The aim of this study was to investigate common psychopathological elements in different IFPHS and a specific risk profile for both the couple and the male partner, with the possibility to define a new serial mental condition not classified to date. METHODS: A series of 50 cases of greater media coverage was reconstructed from the Italian newspapers in the period from 2009 to 2019 and information was collected through a predefined form. The characteristics of the perpetrators and the modalities through which the events occurred have been considered. RESULTS: No definite mental disorder is present in the history of almost all cases. A more common psychological profile is found for the homicide/suicide male partner, mainly characterized by jealousy, possessiveness, mood reactivity, rage, and impulsiveness. CONCLUSIONS: It can be hypothesized that such a severe act may express a form of mental disorder not yet classified, with main features of an acute state of mixed depressive mood, emotional discontrol and aggressive impulsiveness, on a personality basis of jealousy and possessiveness, possibly reinforced by previous dependent traits of the female partner. But the methodological limitations of gathering information from the press make it necessary the study in depth, based on more direct and objective methodologies, of such a highly dramatic and heterogeneous phenomenon.

The Shanti De Corte case: euthanasia for mental disorder between clinic and bioethics, between law and medico-legal implications.

INTRODUCTION: In recent months, a great uproar has been aroused by the case of a 23-year-old Belgian woman who requested and obtained euthanasia because she was suffering from a mental disorder, in the absence of any somatic pathology. The news raises some questions and stimulates some reflections both on the general theme of euthanasia carried out for the simple presence of a mental disorder, and for the indefiniteness of the clinical information on the case in question, as well as on the ethical and medico-legal questions connected to such indefiniteness. CASE PRESENTATION: The information on the case was derived essentially from the press and from websites, with no specific access to actual clinical documentation and without in-depth knowledge of case details. One wonders what the real clinical diagnosis of the patient was, only hypothetically identifiable in a Post-traumatic Stress Disorder associated with Major or Chronic Depressive Disorder, probably on the basis of a possible Personality Disorder. One wonders if all the necessary therapeutic interventions had been implemented, in a clinical case that did not theoretically have the characteristics of incurability. One wonders why the death request was considered valid, in a subject perhaps suffering from a mental disorder of such severity as to alter the ability to express valid consent to medical treatment. One wonders why the death request was not considered as an indicator of the severity of the disease, rather than simply being considered as a free choice of a subject capable of self-determination. One wonders why the negative opinion of the patient's family members was not considered. CONCLUSIONS: Belgian legislation provides for euthanasia for patients suffering from mental disorders who, like those suffering from somatic disorders, experience a condition of constant, unbearable and incurable suffering. But the case in question raises numerous perplexities both on the clinical and ethical coherence of Belgian legislation and on the ways in which the rules of this legislation have been observed in this specific situation.

[The parallel epidemic.] / L'altra epidemia.

The paper is a reflection on the psychic phenomenon involving the denial of reality of covid-19 pandemic, the denial of data from scientific research about it and the denial of therapeutic purposes of vaccine and national and international health policies, as it emerges in the frame of the so-called no-vax movements. The possible basic or associated psychopathological pictures are described, analogies and differences respect to classic psychiatric nosology are evaluated, psychological and psychiatric interpretative hypotheses are considered, in what they can to some extent characterize a wide and complex reality, in whose knowledge and management psychiatrists could play a much more relevant role than they actually do.

A systematic review of (pre)clinical studies on the therapeutic potential and safety profile of kratom in humans.

INTRODUCTION: Kratom (Mitragyna speciosa) is a tropical plant traditionally used as an ethnomedicinal remedy for several conditions in South East Asia. Despite the increased interest in its therapeutical benefits in Western countries, little scientific evidence is available to support such claims, and existing data remain limited to kratom's chronic consumption. OBJECTIVE: Our study aims to investigate (pre)clinical evidence on the efficacy of kratom as a therapeutic aid and its safety profile in humans. METHODS: A systematic literature search using PubMed and the Medline database was conducted between April and November 2020. RESULTS: Both preclinical (N = 57) and clinical (N = 18) studies emerged from our search. Preclinical data indicated a therapeutic value in terms of acute/chronic pain (N = 23), morphine/ethanol withdrawal, and dependence (N = 14), among other medical conditions (N = 26). Clinical data included interventional studies (N = 2) reporting reduced pain sensitivity, and observational studies (N = 9) describing the association between kratom's chronic (daily/frequent) use and safety issues, in terms of health consequences (e.g., learning impairment, high cholesterol level, dependence/withdrawal). CONCLUSIONS: Although the initial (pre)clinical evidence on kratom's therapeutic potential and its safety profile in humans is encouraging, further validation in large, controlled clinical trials is required.

Gender differences in ultradian serum levels of NGF and BDNF correlate with psychophysical traits in healthy humans.

We aimed at investigating the gender and/or ultradian pattern of serum levels of the Nerve Growth Factor (NGF) and Brain-Derived Neurotrophic Factor (BDNF). Blood samples were collected at the 8.00, 13.00 and 20.00 hours of the day in healthy men and women, and the neurotrophins concentration was measured in the serum by ELISA. A further aim of the study was to evaluate whether or not the NGF/BDNF variations might be related to specific physiological or psychological traits as mood, feeling good and feeling rested, sexual desire and energy. Heart rate and blood pressure were also monitored at the same hours in each enrolled subject. The anxiety (STAI-T and STAI-S score) and sleeping quality were once evaluated in the morning too. We found that serum BDNF increases in men and decreases in women from morning to evening, while NGF shows a similar ultradian profile between men and women, but with higher concentrations in women. Both neurotrophins also show gender-related associations with psychophysiological variables. High NGF levels correlated with a high score for all the psychological variables in men, but with a low score in women. An inverse correlation was found between BDNF and energy and sexual desire in women, while no correlations were found in men. These data disclose that the condition of well-being (or activity/arousal status) is featured by an increasing NGF profile in men and a negative BDNF/NGF trend in women. The clinical relevance of the present data is discussed.

Mistrust and Beliefs in Conspiracy Theories Differently Mediate the Effects of Psychological Factors on Propensity for COVID-19 Vaccine.

Vaccination is considered a key factor in the sanitary resolution of the COVID-19 pandemic. However, vaccine hesitancy can undermine its diffusion with severe consequences on global health. While beliefs in conspiracy theories, mistrust in science and in policymakers, and mistrust in official information channels may also increment vaccine hesitancy, understanding their psychological causes could improve our capacity to respond to the pandemic. Thus, we designed a cross-sectional study with the aim of probing vaccine propensity in the Italian population and explored its relationship with sociodemographic and psychological variables, and with misbeliefs in COVID-19. A battery of questionnaires was administered to a sample of 374 Italian adults during the first national lockdown (April 2020). The materials included an original instrument-Beliefs in COVID-19 Inventory-and questionnaires measuring perceived stress, anxiety, death anxiety, psychological distress, psychoticism, paranoia, anger, and somatization. The exploratory factor analysis (EFA) on Beliefs in COVID-19 suggested the existence of three factors: belief in conspiracy theories, mistrust in medical information, and mistrust in medicine and science. These factors were positively correlated with female sex, age, religious beliefs, psychiatric conditions, and psychological variables, while negatively correlated with education levels. We conducted a mediation analysis by means of a structural equation model, including psychological factors as predictors, beliefs in COVID-19 scales as mediators, and vaccine propensity as an outcome. The model showed that death anxiety had a direct positive effect on the propensity to get vaccinated. It also showed that death anxiety reduced the propensity to get vaccinated through a mediated path in believing in conspiracy theories, whereas paranoia was linked to a reduction in vaccination adherence with the mediation effect of mistrust in medical science. Psychological distress reduced vaccination propensity by increasing both conspiracy beliefs and mistrust. On the other hand, anxiety increased the propensity to get vaccinated through a decrease in both belief in conspiracy theories and mistrust in science. Our results suggest that psychological dimensions are differentially related to belief in conspiracy theories, to mistrust in science, and to the propensity to get vaccinated. Based on this result, we propose an original interpretation of how conspiracy beliefs build on a paranoid and suspicious attitude. We also discuss the possible clinical implications of treatment for such pathological beliefs.

Exploring the Relationship Between Mental Well-Being, Exercise Routines, and the Intake of Image and Performance Enhancing Drugs During the Coronavirus Disease 2019 Pandemic: A Comparison Across Sport Disciplines.

Introduction: Physical distancing under the coronavirus disease 2019 (COVID-19) pandemic had a significant impact on lifestyles, including exercise routines. In this study, we examined the relationship between mental health and addictive behaviors, such as excessive exercise and the use of image and performance enhancing drugs (IPEDs) across 12 sport disciplines. Materials and methods: A large cross-sectional sample of the adult population (N = 2,295) was surveyed. The mean age was 33.09 (SD = 11.40). The number of male participants was 668 (30.0%). The use of IPEDs was assessed in conjunction with psychometric measures such as the Exercise Addiction Inventory (EAI) and the Appearance Anxiety Inventory (AAI). The participants were grouped into activity group (AG) and non-activity group (NAG) according to the presence or absence of their exercise habits. The results were compared between these groups, as well as across sport disciplines, while taking into account the relationship between different psychological measures and IPEDs consumption. Results: The frequency of IPEDs use was higher among AG (34.6%) than NAG (14.6%), although AG participants reported less history of addictions (7.1%) than NAG (11.8%). The logistic regression analysis revealed that scores equal to or above cutoff points, in both the EAI and AAI, predicted the IPEDs use. Regarding the differences across the various sport disciplines, those who were involved in practicing Weight Lifting and Cross Fit were found to be more at risk of excessive exercising and more inclined to use a wide range of IPEDs. Conclusions: Although exercise could help to increase well-being and prevent addictions during the COVID-19 pandemic, our results show that those in the AG are particularly vulnerable to excessive IPEDs use. Sport disciplines associated with higher EAI and AAI scores have also shown a higher tendency to excessive IPEDs use. Furthermore, the factor of having above the cutoff scores in EAI or AAI in each sport could indicate larger IPEDs consumption regardless of the discipline. In light of the current findings, it is necessary to better define the "non-excessive" levels of exercise in various sport disciplines and an adequate intake of IPEDs to ensure the safety and well-being of people during a pandemic.

Inverse correlation between plasma 2-arachidonoylglycerol levels and subjective severity of depression.

OBJECTIVE: Endocannabinoids have been implicated in the pathophysiology of Major Depressive Disorder (MDD) and might represent potential targets for therapeutic intervention. Objectives of the study were: (1) to measure plasma levels of endocannabinoids in a group of antidepressant-free depressed outpatients; (2) to explore their relationship with the severity of depressive symptoms as subjectively perceived by the patients; and (3) to investigate the effect of the selective serotonin reuptake inhibitor escitalopram on endocannabinoid levels. METHODS: We measured plasma levels of the two major endocannabinoids, 2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (anadamide), in 12 drug-free outpatients diagnosed with MDD and in 12 matched healthy controls. In the patient group, endocannabinoids plasma levels were assessed at baseline and after 2 months of treatment with escitalopram. RESULTS: Baseline plasma levels of the two endocannabinoids did not differ between depressed patients and healthy controls. However, there was a significant inverse correlation between 2-arachidonoylglycerol levels and the severity of subjectively perceived depressive symptoms. Treatment with escitalopram did not change endocannabinoid levels in depressed patients, although it caused the expected improvement of depressive symptoms. CONCLUSIONS: Our results suggest that 2-arachidonylglycerol, the most abundant endocannabinoid in the central nervous system, might act to mitigate depressive symptoms, and raise the interesting possibility that 2-arachidonylglycerol and anandamide are differentially regulated in patients affected by MDD. Also, our data suggest but do not prove that the endocannabinoid system is not regulated by serotonergic transmission, at least in depressed patients.

Help-Seeking as a Maladaptive Coping Style in the Pandemic Scenario: What Worked and What Did Not for Facing This New Stressor.

The spread of COVID-19 and its related confinement measures were important stressors for a large part of the global population, with massive effects on both physical and mental health. Assessing how individuals coped with such a stressor and which strategies were effective is one of the main challenges for psychological research. In this study, we aimed to investigate the coping strategies implied during the COVID-19 lockdown and their effectiveness. We recruited 374 Italian participants through convenience sampling during the first pandemic wave (April 2020). We administered to our participants an online battery of questionnaires including the Brief COPE, the use of alternative coping strategies proposed by the WHO to help people facing lockdown stress, and a range of psychological symptoms. An exploratory factor analysis conducted on the subscales of the Brief COPE revealed a three-factor structure. Following the previous literature, we named these factors engagement, disengagement, and help-seeking coping styles. In the pandemic scenario, the engagement and disengagement styles revealed the typical correlation patterns with psychological symptoms (i.e., the engagement was adaptive while the disengagement was maladaptive). Instead, contrary to previous literature, help-seeking was positively related to psychological symptoms, suggesting a mismatch between searching for help and finding it during the lockdown. This result supports the importance of evaluating the effectiveness of coping strategies in the pandemic scenario, to give more compelling and precise advice to the population.

[The psychiatrist's "voices" and the metamorphosis from thinker to operator]. / Le "voci" dello psichiatra e la metamorfosi da "pensatore" a "operatore".

Over the last few decades there has been a radical change in the education and social role of the psychiatrist, who from "thinker" has transformed into "operator". A large number of scientific, medical, educational, cultural, health, organizational, political and legal factors have contributed to this change. In the professional reality these factors can be symbolized as internal "voices" of the psychiatrists, who automatically limit or inhibit their aptitude for autonomous thinking, lapsed to the advantage of the need to operate practically in a professional role lived with ever less awareness and cultural depth. The impoverishment of the psychiatrist's sense of scientific and cultural identity who is being asked less and less to "think", corresponds to a change in expectations on the part of society, which essentially asks him to "operate". From a scientific metaphor perspective, the "breakdown" of the mental attitude dominated by these factors could restore strength to psychiatrist's cultural depth and social role.

Can Kratom (Mitragyna speciosa) Alleviate COVID-19 Pain? A Case Study.

Among the symptoms of COVID-19 fever, general malaise, pain and aches, myalgia, fatigue, and headache can affect the quality of life of patients, even after the end of the acute phase of the infection and can be long lasting. The current treatment of these symptoms, also because COVID-19 patients have been asked not to use non-steroidal anti-inflammatory drugs (NSAIDs), in particular ibuprofen are often unsatisfactory. Among the above mentioned symptoms malaise and fatigue seem the most difficult to treat. In this case report we describe the use of kratom (Mitragyna speciosa) by a patient with confirmed COVID-19 infection. What we observed was a fast and sustained relieve of the above mentioned symptoms.

CoViD-19 and psychiatry: can mental illness justify further exceptions to the obligation to stay at home?

INTRODUCTION: To face the CoViD-19 pandemic, the italian government has approved regulations which state, with no exceptions, that it is considered offence for people tested positive to the virus to leave their house, whereas other people are allowed to leave their house for proven needs such as work, health or emergencies. METHODS: The authors contextualize these regulations with European and international sets of principles, in the light of the characteristics that some psychiatric disorders can present. OBJECTIVES: Evaluate if such European principles need to be implemented with further specific exceptions to the obligation to stay at home for some people with mental disorders. RESULTS AND DISCUSSION: Prohibition to leave the house can aggravate mental disorders, resulting in the concrete risk of harmful actions, in particular in psychotic and bipolar patients, even with mild excitement, depressed patients, or in cases of delusional patients, resulting from uninterrupted cohabitation with emotionally significant family members. Even the health of subjects with anxiety pathologies, or with different forms of mental retardation can be prejudiced by forced permanence at home. From numerous provisions of the European Convention for the Protection of Human Rights and of the Charter of Fundamental Rights of the European Union there emerges that collective health must be balanced with individual health and with the dignity of the human person. CONCLUSIONS: As the European and international provisions are hierarchically above the national provisions, the latter should be interpreted so that the non-compliance to the obligation to stay at home: a) does not constitute offence for a person tested positive to the virus, if therapeutic treatments resulting in hospitalization are deemed necessary; b) it does not constitute administrative offence if the subject proves, based on clinical and factual documented evidence, that leaving the house is necessary to avoid recrudescence of mental disorder. In addition, for evaluation purposes, particular attention should be paid to the severity of psychiatric illness in the specific case. In order to distinguish suitable subjects from those not suitable for home isolation, the reference criterion cannot be the only diagnostic element, but it will be necessary to take into account above all the severity of the condition. In the absence of such a qualitative assessment, there would be a risk of unfounded infringements of the obligation to stay at home.

Novel Psychoactive Substances in Custodial Settings: A Mixed Method Investigation on the Experiences of People in Prison and Professionals Working With Them.

INTRODUCTION: Novel Psychoactive Substances (NPS), especially Synthetic Cannabinoid Receptor Agonists (SCRAs), pose a substantial challenge to health and the security of the prison environment. This study analyses the phenomenon from the perspective of people in prison and that of professionals working with them. METHODS: A phenomenological qualitative approach was used to analyze self-reported experiences with 'Spice' (NPS) among users in prison. A semi-structured questionnaire was also disseminated among professionals working in these settings to better understand (a) the impact of NPS on their work; (b) perceived issues on safety in their working environment; (c) approaches used to tackle the phenomenon and best practices. RESULTS: Psychotic events resulting from the collected Spice accounts (5) were marked by hallucinations, depression, self-harm, and suicidal ideations. Other emerging elements included fear, paranoia, inability to be with others, mistrust, breakdown and other risky behaviors. Overall, 186 responses from prison staff were collected across the country. 67% claimed NPS to have had a deep impact on their work as they commonly witnessed espisodes involving outbursts of anger, slurred speech, hallucinations, psychosis, and significant mental deterioration among those in prison. Some 91% have witnessed aggression at least once, with 53% experiencing direct harm. Suggested interventions included enhanced training and education (84%), improved detection (92%) and treatment and support services (93%). CONCLUSIONS: Findings highlight the urgent need for joint multi-disciplinary efforts to tackle the exponential escalation of NPS in prisons as well as to facilitate the recovery and societal reintegration of those affected. Phenomenology can be recommended as a valuable methods to study drug induced experiences.

Medico-legal and bioethical perspectives following the constitutional legitimacy of assisted suicide in Italy.

Assisted suicide is the subject of much debate throughout the world. In Italy, on 24 September 2019, the Italian Constitutional Court legitimised assisted suicide under certain conditions: self-determination capacity, irreversible illness and intense physical/psychological suffering of the patient. This historic judgement surely paved the way for an evolution of the Italian legal framework on the matter but also raised some challenging medico-legal and bioethical questions. This study aims at analysing two of the most controversial among them: the inclusion of psychiatric patients among eligible patients for assisted suicide and the position of physicians related to their right to conscientious objection.