Involuntary admissions to the emergency department: a retrospective observational study.

AIMS: The main objective of this study was to describe patients who were involuntarily admitted to the emergency department of Lausanne University Hospital on involuntary admission in 2018 in terms of age, gender, emergency department length of stay, the motive for involuntary admission, use of psychoactive substances, diagnosis, and destination at emergency department discharge, with or without discontinuation of involuntary admission. METHODS: This retrospective, observational, and monocentric study included patients 18 years and older admitted to the emergency department of Lausanne University Hospital on involuntary admission from January 1, 2018, to December 31, 2018. Patients were identified by the Cantonal Medical Office of Vaud. The emergency department length of stay and patient destination on discharge from the emergency department were extracted from the patient flow database, and discharge letters and involuntary admission were extracted from the electronic archiving software. Descriptive statistics were processed by using means and standard deviations for quantitative variables with a normal distribution and median and interquartile range for non-normally distributed data. RESULTS: During the study period, 83 patients were admitted on involuntary admission to the emergency department. The majority of the patients were male (58%) with a mean age of 55 (±20) years. The median emergency department length of stay of patients with an involuntary admission was between 9 and 16 hours, depending on whether the involuntary admission was confirmed or discontinued after patient assessment in the emergency department. In comparison, the median emergency department length of stay was 6 hours for patients overall. The two principal diagnoses described were psychiatric (schizophrenia) and mental and behavioural disorders due to psychoactive substance use. Half of the patients on involuntary admission consumed psychoactive substances, primarily alcohol, and had a mean ethanolaemia of 53 (±32) mmol/l. CONCLUSIONS: Only a third of patients admitted on involuntary admission saw this measure confirmed after their assessment in the emergency department. Involuntary admissions with admission to the emergency department is used to force patients to be examined by an emergency physician or even a psychiatrist. On-call and primary care physicians seemed to lack the time or resources to set up alternatives to emergency department admissions on involuntary admission, especially in situations in which the involuntary admission was discontinued after an emergency department assessment. This demonstrates the inappropriate use of this measure because a patient cannot be involuntarily hospitalised in an emergency department.

The Link Between Cannabis Use and Violent Behavior in the Early Phase of Psychosis: The Potential Role of Impulsivity.

Introduction: Recently, the literature has shown that Cannabis Use (CU) was a risk factor for Violent Behavior (VB) in patients with psychosis, and those in the early phase of psychosis (EPP). These findings are relevant because of the high prevalence of CU in this EPP, and the potential for prevention during this phase of illness. However, there is still a lack of clear explanations, supported by empirical evidence, about what underlies the link between CU and VB against other. Method: This viewpoint reviews the scientific literature on the link between CU and VB, and the involvement of impulsivity in this relationship. This last point will be addressed at clinical and neurobiological levels. Results: Recent studies confirmed that CU is particularly high in the EPP, and is a risk factor for VB in the EPP and schizophrenia. Studies have also shown that impulsivity is a risk factor for VB in psychosis, is associated with CU, and may mediate the link between CU and VB. Research suggests a neurobiological mechanism, as CU affects the structures and function of frontal areas, known to play a role in impulsive behavior. Conclusion: Scientific evidence support the hypothesis of an involvement of impulsivity as a variable that could mediate the link between CU and aggression, particularly, when CU has an early onset. However, this hypothesis should be confirmed with longitudinal studies and by taking into account confounding factors. The studies highlight the relevance of early prevention in the EPP, in addition to interventions focusing on psychotic disorders.

The Utility of Physiological Measures in Assessing the Empathic Skills of Incarcerated Violent Offenders.

Since lack of empathy is an important indicator of violent behaviors, researchers need consistent and valid measures. This study evaluated the practical significance of a potential physiological correlate of empathy compared to a traditional self-report questionnaire in 18 male violent offenders and 21 general population controls. Empathy skills were assessed with the Interpersonal Reactivity Index (IRI) questionnaire. Heart-Rate Variability (HRV) was assessed with an electrocardiogram. The RMSSD (Root Mean Square of the Successive beat-to-beat Differences), an HRV index implicated in social cognition, was calculated. There were no group differences in IRI scores. However, RMSSD was lower in the offender group. Positive correlations between RMSSD and IRI subscales were found for controls only. We conclude that psychometric measures of empathy do not discriminate incarcerated violent offenders, and that the incorporation of psychophysiological measures, such as HRV, could be an avenue for forensic research on empathy to establish translatable evidence-based information.

Factors associated with repetitive violent behavior of psychiatric inpatients.

A small number of psychiatric inpatients displays a large proportion of Violent Behaviors (VB). These can have a major impact on both victims and patients themselves. This study explored personal, situational and institutional risk factors and their combined effects, which could lead to repetitive VB (three or more assaults). Data from 4518 patients, aged 18 to 65, admitted to an acute psychiatric care facility, were included in the analysis. VB, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale-Revised. 414 VB were reported during the study period, involving 199 patients. 0.75 % of all patients were repetitively violent and committed 43% of all VB. Factors that were linked to repetitive VB were living in sheltered housing before hospitalization, suffering from schizophrenia with substance abuse comorbidity, cumulating hospitalization days and some situational factors, like the fact of being in nursing offices and pharmacies. When all personal, situational and institutional factors were considered together, the combined effects of length of stay and living in sheltered housing increased the risk of repetitive VB. We have identified a small group of vulnerable patients for whom new modalities of inter-institutional networking should be developed to prevent repetitive VB.

[Interests and need for strengthening home care in the context of psychological crisis situations - The result of a strong public health policy]. / Intérêts et nécessité du renfort des soins à domicile dans le cadre des situations de crise psychique - Le résultat d'une politique de santé publique forte.

With the constant increase in life expectancy and the development of chronic diseases in the elderly population, the General Direction of Health of the Canton of Vaud has developed a community plan to strengthen the care of residents in psychological crisis. This strong position of Public Health has made it possible to carry out an ambitious project, with a view to « care management ¼ in elderly psychiatry, involving partners from the care network and promoting care at the place of residence of the individual. This project made it possible to develop recommendations for the strengthening of local and outpatient care, in order to reduce the systematic recourse to hospitalization, and the increase in functional dependence of the elderly on leaving the hospital.

Avec l'augmentation constante de l'espérance de vie et le développement des maladies chroniques, la Direction générale de la santé du canton de Vaud a développé un dispositif communautaire de renforcement des soins pour les résidents en situation de crise psychique. Cette prise de position forte a permis la réalisation d'un projet ambitieux, dans une optique de care management en psychiatrie de l'âge avancé, impliquant les partenaires du réseau de soins et favorisant la prise en soins sur le lieu de vie de l'individu. Ce projet a permis d'élaborer des recommandations quant au renforcement des soins communautaires et ambulatoires, afin de lutter contre le recours systématique à l'hospitalisation, et l'augmentation de la dépendance fonctionnelle des âgés au sortir de l'hôpital.

Early onset of cannabis use and violent behavior in psychosis.

BACKGROUND: Although evidence from psychosis patients demonstrates the adverse effects of cannabis use (CU) at a young age and that the rate of CU is high in subgroups of young violent patients with psychotic disorders, little is known about the possible effect of the age of onset of CU on later violent behaviors (VB). So, we aimed to explore the impact of age at onset of CU on the risk of displaying VB in a cohort of early psychosis patients. METHOD: Data were collected prospectively over a 36-month period in the context of an early psychosis cohort study. A total of 265 patients, aged 18-35 years, were included in the study. Logistic regression was performed to assess the link between age of onset of substance use and VB. RESULTS: Among the 265 patients, 72 had displayed VB and 193 had not. While violent patients began using cannabis on average at age 15.29 (0.45), nonviolent patients had started on average at age 16.97 (0.35) (p = 0.004). Early-onset CU (up to age 15) was a risk factor for VB (odds ratio = 4.47, confidence interval [CI]: 1.13-20.06) when the model was adjusted for age group, other types of substance use, being a user or a nonuser and various violence risk factors and covariates. History of violence and early CU (until 15) were the two main risk factors for VB. CONCLUSIONS: Our results suggest that early-onset CU may play a role in the emergence of VB in early psychosis.

[Psychiatry in the time of pandemic†: forging new ways without getting lost]. / La psychiatrie face à la pandémie†: se réinventer sans se perdre.

Coronavirus pandemic challenges mental health care providers in different ways. At an individual level, they have to adapt their clinical practice and consider specific issues of teleconsultations to address patient's needs. At a population level, dedicated interventions (e.g. hotlines, health professionals' support) have to strike a balance between «â€…pathologizing ¼ people's reactions and trivializing the psychological effects of a pandemic. Finally, psychiatric leaders must be able to advise decision-makers on mental-health policy and communication.

La pandémie de coronavirus oblige les soignants en santé mentale à réinventer leur manière de travailler et à penser de nouveaux cadres thérapeutiques, les patients réagissant de manière singulière à cette situation extraordinaire. Sur un plan populationnel, les interventions envisagées (e.g. hotlines, soutien aux professionnels et aux équipes) doivent trouver un équilibre entre une «â€…psychiatrisation ¼ des vécus d'ordre existentiel et une banalisation des effets psychologiques d'une pandémie. Sur les plans institutionnel et politique, la psychiatrie peut conseiller les décideurs quant aux impacts psychologiques et à la communication.

Predicting physically violent misconduct in prison: A comparison of four risk assessment instruments.

Violence in correctional facilities is an important issue for both prisoners and prison staff. Risk assessment instruments have demonstrated their accuracy in predicting the risk of (re) offending and institutional violence in psychiatric settings, but less is known about their ability to predict violent misconduct in prison. The present study applied four risk assessment instruments (Structured Assessment of Protective Factors for violence risk, Historical Clinical Risk Management-20, Psychopathy checklist - Revised, and Violent Risk Appraisal Guide) to 52 violent offenders in a Swiss prison in order to evaluate the instruments' predictive validities. Outcomes were instances of physically violent, other and any misconduct as recorded in prison files during the 12 months following the prisoners' assessments. Approximately 15% of offenders committed physically violent misconduct and approximately 42% committed any misconduct. The results show that mainly dynamic assessment tools are as good predictors of physically violent misconduct as mainly static assessment tools. Targeting dynamic factors could increase the effectiveness of interventions to reduce the risk of physical violence in prison.

Neuroimaging in criminal trials and the role of psychiatrists expert witnesses: A case study.

Various neuroscientific techniques are increasingly being used in criminal courts causing a vivid debate on the way that this kind of techniques will and should be used as scientific evidence. The role of experts in this context is important, since it is them that analyse, present, interpret and communicate the results of these techniques to the judges and the jury. In an attempt to contribute to the discussion about the role of the experts in criminal cases where neuroimaging evidence was introduced, we examined twenty seven cases from the US and Europe. Focusing on the role of experts and their presentation of neuroscientific evidence, we aimed to examine the extent to which neuroimaging data can contribute to the construction of a solid and more objective, "scientifically - based" case. We found that neurobiological information introduced through experts' testimony is generally used in order to demonstrate some physical, organic base of a psychiatric condition, or/and in order to make visible some brain lesion, (structural or functional), susceptible to have affected the capacity to reason and to control one's impulses. While neuroimaging evidence is often presented by the defence as a scientific method able to offer a precise diagnosis of the pathology in question, our case analysis shows that the very same neurobiological evidence can be interpreted in different - sometimes diametrically opposed - ways by defence and State experts. Conflicting testimony about the same empirical evidence goes against the hypothesis of neuroscientific techniques constituting "objective and hard evidence", able to reach solid, scientific and objective conclusions. Frequent conflicts between neuroimaging experts require the courts to deal with the resulting uncertainty. As the law changes with technology, it is necessary for legal professionals to train and be prepared for the new issues they may encounter in light of new developments in neuroscience, so that they become more vigilant as to the interpretation of neuroscientific data.

Judges' perceptions of expert reports: The effect of neuroscience evidence.

This article explores the impact of neuroscience evidence on how expert reports are perceived and their effects on the decisions made by trial judges. Experimental psychology has demonstrated a number of cognitive effects arising from exposure to neuroimaging data which may bias judgments and lead to (mis)interpretations that can affect decisions. We conducted a study on a sample of 62 Swiss and French judges in order to determine whether their perceptions of the credibility, quality and scientific basis of a psychiatric evaluation of a criminal defendant vary according to whether or not the evaluation includes neuroscientific data. Quantitative analyses were conducted in order to evaluate significant differences between the two conditions (one-way analyses of variance) and moderation and conditional analyses to examine whether the participants' sex and length of professional experience moderated the effect of the conditions. Terminological and thematic analyses were carried out on open questions. Quantitative and qualitative results suggest that the presence of neuroscience data in an expert report affects judges' perceptions of the quality, credibility, and scientificity (reliability, objectivity, scientific basis) of the report, and the persuasiveness of the evidence it provided. Moreover, this phenomenon was stronger in more experienced judges than in less experienced judges.

[Coordination meeting during psychiatric hospitalization : expectations, challenges and solutions]. / Entretien de réseau à l'hôpital psychiatrique : attentes, embûches et solutions.

Psychiatric treatments often involve numerous partners. The organization of coordination meetings during in-patient admissions is necessary in order to harmonize interventions. The expectations of each partner during such meetings may however differ and some issues that may seem important to some of them may be neglected. In this paper, we report the results of a survey conducted among the various partners involved in psychiatric patient's treatment in order to identify their expectations, the challenges they may have faced and the solutions they would propose. If perfection ca not be warrantied in all situations, taking these elements into account may improve these meetings and allow to better respect the role of each actor while giving to the patient the central role that they should play when defining their treatment.

Les traitements psychiatriques impliquent souvent plusieurs partenaires et nécessitent une coordination des interventions à travers des réunions de réseau, en particulier en cas d'hospitalisation. Les attentes à l'égard de ce genre de réunion sont différentes pour chacun des acteurs impliqués et les besoins de certains partenaires sont parfois négligés. Dans cet article, nous rapportons les avis de plusieurs de ces acteurs sur les attentes qu'ils ont à l'égard de ces rencontres, les difficultés qu'ils y rencontrent et les solutions qu'ils proposent. Si la perfection ne peut pas être garantie à chaque fois, la prise en compte de ces éléments permettrait d'améliorer le déroulement des entretiens de réseau, de mieux respecter la place de chacun et de laisser au patient le rôle central qu'il doit jouer dans l'élaboration de sa prise en charge.

[Adverse effects of psychotropic drugs : when and how to talk to patients ?] / Effets indésirables des psychotropes : quand et comment en parler aux patients ?

The way the potential adverse effects are presented during the introduction of a new medication in the context of psychiatric care can be decisive for subsequent care. This issue is approached from the testimonies of patients who have received multiple treatments over a long period of time and by several therapists. After describing the main adverse effects of psychotropic drugs, this article proposes a method to help patients documenting the adverse effects they experienced, in a way which should improve the dialogue with their therapists.

La manière de présenter les potentiels effets indésirables lors de l'introduction d'une nouvelle médication psychotrope dans le cadre des soins psychiatriques peut être déterminante pour la suite de la prise en charge. Cette problématique est abordée à partir de témoignages de patients qui ont reçu de multiples traitements sur une longue durée et par plusieurs thérapeutes. Après une description des principaux effets indésirables des psychotropes, cet article propose une méthode de documentation par le patient des effets secondaires négatifs ressentis ; celle-ci devrait aider au dialogue avec ses thérapeutes.

[State of the art about credibility assessment of minors]. / Actualité de l'expertise de crédibilité chez les mineurs.

The issue of the credibility of a child's or adolescent's testimony in judicial sexual allegations has already been developed in many articles and books of the scientific literature. This article reports on the expert practices in the field of child psychology and legal psychiatry for credibility expertise in Switzerland. After illustrating the issues at stake in the analysis of various testimonies in the context of a recent trial (the Outreau case), we will describe the Statement Validity Analysis, a credibility assessment methodology recognized by the scientific literature and Swiss case law.

La thématique de la crédibilité du témoignage d'un enfant ou d'un adolescent dans le contexte d'allégations sexuelles judiciarisées a déjà été développée dans de nombreux articles et ouvrages de la littérature scientifique. Cet article fait le point sur les pratiques expertales dans le champ de la pédopsychologie et la pédopsychiatrie légale en matière d'expertise de crédibilité en Suisse. Après avoir démontré les enjeux essentiels de l'analyse des différents témoignages dans un procès récent (l'affaire d'Outreau), nous décrivons une méthode reconnue par la littérature scientifique et la jurisprudence suisse, la « Statement Validity Analysis ¼ (SVA).

Cannabis, a Significant Risk Factor for Violent Behavior in the Early Phase Psychosis. Two Patterns of Interaction of Factors Increase the Risk of Violent Behavior: Cannabis Use Disorder and Impulsivity; Cannabis Use Disorder, Lack of Insight and Treatment Adherence.

Background: Previous literature suggests that prevalence of cannabis use in the early phase of psychosis is high, and that early psychosis patients are at high-risk for violent behavior. However, the link between cannabis use and violent behavior in early psychosis patients is unclear. We carried out a study on a sample of early psychosis patients, in order to explore the impact of cannabis use on the risk of violent behavior (VB), while taking into account (1) potential confounding factors and, (2) interactions with other dynamic risk factors of VB. Method: In a sample of 265 early psychosis patients, treated at the Treatment and Early Intervention in Psychosis Program (TIPP) in Lausanne, we used logistic regression models to explore the link between various dynamic risk factors of VB [positive symptoms, substance use disorder (drugs including cannabis, alcohol and others drugs), insight, impulsivity, affective instability, and treatment adherence], and VB occurring during treatment. In order to understand hierarchical effects attributable to the combinations of risk factors on VB we conducted a Classification and Regression Tree (CART). Results: Our results show that cannabis use disorder is a risk factor for VB. The associations among risk factors suggest the presence of two patient profiles with an increased rate of VB: the first is composed of patients with cannabis use disorder and impulsivity, and the second of patients combining cannabis use disorder, absence of insight and non-adherence to treatment. The results also show the moderating role of insight and adherence to treatment on the rate of VB in patients with cannabis use disorder. Conclusion: This study suggests that cannabis use disorder is a significant risk factor for VB amongst early psychosis patients, particularly when combined with either impulsivity, lack of insight and non-adherence to treatment. These results suggest that preventive strategies could be developed on the basis of such patient profiles.