Vox clamantis in deserto: a survey among Italian psychiatrists on defensive medicine and professional liability.

Due to recent events, professional liability for psychiatrists in Italy is currently a matter of lively debate. Specifically, overwhelming pressure on psychiatrists' duties has been brought by regulatory developments, such as the closure of forensic psychiatric hospitals, with the consequent return of offenders to community-based care, and the mental health consequences of the pandemic. According to Italian courts, psychiatrists are not only responsible for diagnostic and therapeutic appropriateness but also for the effects of their interventions on patients, and their behaviors. The aim of this study was to explore the attitude and behaviors of Italian psychiatrists regarding defensive medicine and professional liability. A total sample of 254 psychiatrists was surveyed by means of a quantitative online questionnaire. Most psychiatrists reported practicing defensive medicine (no. 153/254, 60.2%) and felt that their position of guarantee compromised their work in healthcare for patients (no. 138/253, 54.3%). Age correlated inversely with acknowledgment of defensive practices (r = -0.245, p < 0.001), with younger physicians more prone to defensive medicine (p = 0.013), particularly for patients at risk of suicide or violence. Psychiatrists in 'closed' settings (hospital wards, residential and rehabilitation centers, mental health service units in prison) reported more malpractice claims (p = 0.037) and complaints (p = 0.031), as well as a greater propensity to act defensively. In the treatment of patients with violent behavior, suicidal ideation, dual diagnoses, and criminal convictions, defensive practices were associated more with perceived legal risks (r = 0.306, p < 0.001) than actual legal involvement (p > 0.05). Anxiety, anger, and restlessness were common reactions to legal complaints, involving no. 50/254 (19.7%) respondents, with 40% reporting impaired functioning. Most psychiatrists (no. 175/253, 68.9%) were concerned about both civil and criminal laws regarding their professional responsibility, but many were not fully informed about recent legislative regulations and younger physicians resulted scarcely trained in risk management (p < 0.001). In conclusion, our findings suggest that defensive medicine is a common phenomenon among psychiatrists and their position of guarantee drives this attitude. Education on legal implications and risk management should be provided starting from the university and continuing over time, to improve the knowledge of young and senior doctors on professional liability and inform their decision-making processes. This would also reduce defensive practices and improve the quality of healthcare. Considering the concerns of younger physicians, as well as of professionals working in acute and high-intensity medical care facilities, there is also an urgent need for a revision of the medical liability to ensure the sustainability of the National Health Service.

Vulnerabilities in Mental Health due to Covid-19 Pandemic: The Response of the Italian Physicians.

COVID-19 pandemic has exacerbated the pre-existing vulnerabilities and inequalities in societies. In this paper we analyse the categories that have suffered more than others from the pandemic and the restrictions on social life in terms of mental health. We rely on the Serendipity project based on a survey administered between November 2021 and February 2022 to a sample of Italian physicians (n = 1281). The survey aimed to assess the perception of general practitioners, paediatricians, geriatricians, and mental health specialists (psychiatrists, neurologists, child neuropsychiatrists), about changes in the mental health of the population as an effect of the COVID-19 pandemic and the lockdown. The strategies implemented by the doctors interviewed in terms of the intensity of the prevention, emergence, and treatment of mental health interventions, and their association with physicians' characteristics and their opinions on patient vulnerability have been illustrated by means of a multiple correspondence analysis. An overall result of the survey is the consensus of doctors on the worsening of mental health in general population, especially among their patients, due to the pandemic and on the onset of new discomforts. The most exposed individuals to the risk of onset or worsening of mental disorders include women, young people, and patients with psychiatric comorbidity. The paper also illustrates the interventions put in place by the physicians and deemed necessary from a public heath response perspective, that include providing psychoeducation to the general population, improving telehealth services, and increasing financial and human resources for community-based care.

Mental health in Italy after two years of COVID-19 from the perspective of 1281 Italian physicians: looking back to plan forward.

BACKGROUND: The COVID-19 pandemic has generated an unprecedented global crisis that is profoundly affecting mental health and mental health care. The aim of this study was to survey a relatively large group of Italian physicians about their perceived impact of COVID-19 on the mental health of the Italian population and about their suggestions on the best strategies to address the current and future challenges. METHODS: One thousand two hundred eighty-one (1,281) physicians were surveyed between November 2021 and February 2022. RESULTS: Eighty-one percent of respondents reported an increase in the number of people with mental illness presenting to their practice during the COVID-19 pandemic. Thirty-four percent reported a 26-50% increase in the number of people with mental illness in their community; approximately 33% reported a 1-25% increase; and 26.9% reported a 51-75% increase. The most commonly reported mental issues that increased because of COVID-19 were agitation, mood and anxiety disorders. Regarding the suggested strategies to address future challenges related to the COVID-19 pandemic, 34.6% of respondents recommended providing psychoeducation to the general population for early detection of mental illness and developing strategies to reduce the impact of COVID-19-related stress. In addition, 12.6% of respondents suggested improving telehealth services, while 12.3% suggested the need for increased funding for community-based care. When asked about physicians' opinion on the possibility of an increased prevalence of mental illness in the next 12 months, more than 30% of them predicted an increase in stress-related illnesses, while 25.2% were more concerned about a worsening of the ongoing clinical conditions of patients with previous psychiatric disorders. However, 21% of respondents believed that people's ability to cope with the pandemic would increase in the next 12 months. CONCLUSIONS: This study confirmed a strong and negative impact on the mental health of the past 2 years of COVID-19 pandemic in the Italian population. Providing psychoeducation to the general population and improving the availability of telemedicine services could reduce the impact of future challenges related to the pandemic.

Assessment and Management of Cognitive and Psychosocial Dysfunctions in Patients With Major Depressive Disorder: A Clinical Review.

Background: Full functional recovery is defined as a state in which patients are again able to enjoy their usual activities, return to work, and take care of themselves, and it should represent the end goal of treatment in patients with major depressive disorder (MDD). Patients with MDD report many unmet needs, including residual cognitive symptoms, lack of improvement in psychosocial functioning and life satisfaction, even during mood symptom remission. In this paper, we aim to: (a) identify the available assessment tools for evaluating cognitive and psychosocial functioning in patients with MDD; (b) provide an overview of therapeutic options that can improve full functional recovery in MDD also by improving cognitive symptoms. Methods: The relevant databases MEDLINE, ISI Web of Knowledge - Web of Science Index, Cochrane Reviews Library and PsychoINFO were searched for identifying papers on validated tools for the assessment of cognitive and personal functioning in patients with MDD. Results: New assessment tools (such as the THINC-it TOOL, the COBRA, the SCIP-D, and the UPSA-D) have been developed for evaluating the cognitive dysfunction in MDD patients. Adopting these tools in the clinical routine practice is useful to evaluate the improvement in cognitive functioning and, therefore, the achievement of full functioning recovery. The optimal management of patients with MDD include the combination of pharmacological compounds and psychosocial interventions for achieving full functional recovery in patients with MDD. Conclusions: Full functional recovery must be the target of any treatment programme for patients with MDD. In order to achieve this goal, it is necessary to develop personalized treatment and integrate psychosocial and psychopharmacological interventions.

[Monoamine's role in depression and possible consequences for the clinical management of the core symptoms of major depression]. / Ruolo delle monoamine nella depressione e possibili implicazioni nella gestione clinica delle dimensioni core dell'episodio depressivo maggiore.

Major depression (MD) in a complex disorder, resulting from multidimensional pathogenetic factors. Its phenomenology is characterized by emotional, behavioural, cognitive, and physical symptoms. Recent advances in neuropharmacology and neuroimaging are clarifying the role of putative brain circuits in regulating mood. In this context, it appears that a relationship between the three monoamine neurotransmitters (i.e., serotonin, norepinephrine, and dopamine) and different malfunctioning neural circuits mediating specific clinical domains in MD does exist. Therefore, these symptoms may be targeted by using antidepressants that enhance monoaminergic transmission within the hypothetically brain structures involved. This, in turn, would improve the effectiveness of the treatment. It has been suggested, mostly on empirical evidence, that some dual-acting drugs, by extensively targeting both "core" and "associated" symptoms of MD, may offer some advantages, when compared with more selective antidepressants, in terms of clinical remission and improvement of patient's quality of life.

Is the time course of clozapine response correlated to the time course of clozapine plasma levels? A one-year prospective study in drug-resistant patients with schizophrenia.

The relationship between the time course of clinical response to clozapine and the time course of clozapine plasma levels has never been investigated. In the present study, we assessed prospectively the clinical response to clozapine and the plasma levels of the drug and its major metabolites in 32 drug-resistant patients with schizophrenia kept on a fixed dose of 600 mg/day for 1 year Four of the patients met response criteria at week 4 of treatment. At weeks 8, 12, and 24, new responders were 7, 6, and 6, respectively. Nine patients never achieved clinical response. In responders at week 4, clozapine and clozapine-N-oxide plasma levels were significantly higher than in both new responders at weeks 8, 12, and 24 and nonresponders. In new responders at weeks 8, 12, and 24, in spite of a fixed clozapine daily dose, mean drug plasma levels progressively rose up to when clinical response occurred; then, the levels remained stable over time. Nonresponders exhibited mean clozapine plasma levels constantly below the value of 260 ng/ml, with N-demethylation as the preferred metabolic route. The present findings show, for the first time, that the time course of the clinical response to clozapine may be linked to the time course of plasma levels of clozapine and its major metabolites.

Pronounced early increase in circulating leptin predicts a lower weight gain during clozapine treatment.

Weight gain is a widely reported side effect of clozapine, but no predictive factor has been identified so far. We investigated whether pretreatment values of circulating leptin or its early changes during clozapine administration could predict the long-term weight gain induced by the drug. Body weight and plasma levels of leptin were prospectively measured in 22 patients (13 men and 9 women) with drug-resistant schizophrenia undergoing a long-term treatment with clozapine. At the end of the second week of clozapine administration, circulating leptin increased much more than weight gain, and this increase was inversely correlated to body weight increase observed after 6 and 8 months of treatment. These findings suggest that early changes in leptin secretion may predict long-term weight gain in the course of clozapine administration.