Civil liability for clinical misdiagnosis of suicidal intention: procedure and guidelines to minimize fatal diagnostic error / La responsabilidad civil por el diagnóstico clínico erróneo de la intención suicida: procedimiento y pautas para minimizar el error diagnóstico mortal

Background/Objectives: A fatal diagnostic error of suicidal intention, i.e., an error implying death or serious injuries (i.e., incapacitating, chronic injury) to the patient, may have civil liability (punishable error) for the clinician. The Scale for Suicidal Ideation (SSI) is the reference psychometric instrument used to measure suicidal intention. A meta-analytical review was designed with the aim of estimating the true reliability of the SSI in general and in different settings (moderators) with the aim of correcting unreliability raw scores. Method: A total of 90 primary studies reporting SSI's reliability (internal consistency) was found in the literature, yielding a total of 92 effect sizes. Bare-bones meta-analysis of correlation coefficients correcting effect by sampling error were run. Results: The results showed an overall mean true internal consistency of .8904, 95% CI [.8878, .8930], meaning that 42.6% of the population standard deviation is error and 18.11% of an individual's measure is error. Additional estimations (moderators) of SSI's reliability for gender (men: .8873, women: .8808) adaptation version (English: .9212, Korean: .9052, Chinese: .8402, Italian: .9163, Persian: .8612), and population (subclinical: .8769, general: .9230, mental illness: .9040) were obtained. All mean true estimations were under the desirable standard for applied settings where critical decisions are made, .95. Furthermore, for populations with risk of suicide, such as prison inmates and militaries, mean true reliability could not be computed as k was insufficient. Conclusion: Implications of true reliabilities obtained for the estimation of individuals' true scores and population standard deviations are discussed. Examples of computation of true scores to minimize fatal diagnosis errors were performed for both known reliability and unknown reliability settings (e.g., risk populations). (AU)

Antecedentes/Objetivo: Un error diagnóstico mortal de intención suicida, es decir, un error que implique la muerte o lesiones graves (es decir, incapacitantes, crónicas) para el paciente, puede tener responsabilidad civil (error punible) para el clínico. La Escala de Ideación Suicida (SSI) es el instrumento psicométrico de referencia utilizado para medir la intención suicida. En este estudio se diseñó una revisión metaanalítica para medir la fiabilidad real de la SSI en general y en diferentes ámbitos (moderadores), con el fin de corregir las puntuaciones brutas por la falta de fiabilidad de la medida. Método: En la búsqueda de estudios se encontró un total de 90 estudios primarios que trataban de la fiabilidad (consistencia interna) del SSI, lo que arrojó un total de 92 tamaños del efecto. Se ejecutaron meta-análisis del tipo bare-bone corrigiendo el efecto por el error de muestreo. Resultados: Se obtuvo una consistencia interna verdadera media global de .8904, IC 95% [.8878, .8930], es decir, el 42.6% de la desviación estándar de la población es error y el 18.11% de la medida de un sujeto es error. Se obtuvieron estimaciones adicionales (moderadores) de la fiabilidad del SSI para el género (hombres: .8873, mujeres: .8808), versión de adaptación (inglés: .9212, coreano: .9052, chino: .8402, italiano: .9163, persa: .8612) y población (subclínica: .8769, general: .9230, enfermedad mental: .9040). Todas las estimaciones verdaderas medias estaban por debajo del estándar deseable para entornos aplicados donde se toman decisiones críticas, .95. Además, para las poblaciones de riesgo de suicidio, como reclusos y militares, no se pudo calcular la fiabilidad media verdadera, ya que k era insuficiente. Conclusiones: Se discuten las implicaciones de la fiabilidad verdadera obtenida para la estimación de las puntuaciones verdaderas de los individuos y las desviaciones típicas de las poblaciones. ... (AU)

Means restriction for the prevention of suicide by jumping.

BACKGROUND: Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established. OBJECTIVES: To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures. SEARCH METHODS: We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions. SELECTION CRITERIA: Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach. MAIN RESULTS: We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality. AUTHORS' CONCLUSIONS: The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis.

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

A retrospective cohort study describing the characteristics of patients under 18 years old in one section 136 suite.

Section 136 of the Mental Health Act 1983 is an authority allowing police officers to remove a person 'who appears to him to be suffering from mental disorder' from a public area. There has been much media coverage regarding the inappropriate detention of minors under section 136 and the suggestion that many were taken to police cells, as there were no suitable places of safety. Although previous studies describe characteristics of a typical individual detained under section 136, few distinguish the differences between adults and adolescents. Profiling these adolescents can help to identify adolescents at risk, allowing for earlier intervention and prevent the inappropriate detention of individuals. Data were collected retrospectively for all patients under 18 years of age who were brought to a section 136 suite in south-west London over a five-year period. The typical profile of an adolescent presenting to this suite was a 16-year-old female of white ethnicity who was sectioned in a public area due to attempted suicide or deliberate self-harm. The individual is more likely to have mental or behavioural difficulties, a history of abuse, be under the care of local authorities and have had previous convictions compared to adolescents in the general population.

Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA.

BACKGROUND: Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested. MATERIALS AND METHODS: The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race. RESULTS: 27,566 children analyzed in the study. Most were adolescents aged 15-19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R2 = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0-4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0-4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (2.03, 1.30-3.17) and suicide attempts (15.6, 11.6-20.9) had higher odds of in-hospital mortality. CONCLUSIONS: Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.

Suicide attempters in Abu Dhabi: Is criminal prosecution associated with patients' guardedness?

The objective of this study was to examine the relationship between legal status and guardedness in patients who attempted suicide in Abu Dhabi, United Arab Emirates. The consultation-liaison team assessed 355 patients admitted for suicidal/self-injurious behavior, recording their guardedness before knowing whether they were legally charged. Patients who were legally charged for the suicidal act (n = 139) were 1.6 times (p = .03) more guarded in volunteering information than patients who were not legally charged. Legally charging suicide attempters might have a negative impact on risk assessment and psychiatric care.

"We Now Have a Patient and Not a Criminal": An Exploratory Study of Judges and Lawyers' Views on Suicide Attempters and the Law in Ghana.

This study explored the views of judges and lawyers of the superior courts of Ghana on the law criminalizing attempted suicide. Qualitative data were collected from 12 experienced legal practitioners of the superior courts (five judges and seven lawyers) using a semi-structured interview schedule. Thematic analysis of the data yielded three main perspectives: In defence of the Law, Advocating a Repeal, and Pro-Health Orientation. Although exploratory, the findings of this study offer cues for stepping up suicide literacy and advocacy programmes toward either a repeal of the law or a reform.

[Treatment against the patient's will exemplified by electroconvulsive therapy : Clinical, legal and ethical aspects]. / Behandlung gegen den natürlichen Willen am Beispiel der Elektrokonvulsionstherapie : Klinische, juristische und ethische Aspekte.

BACKGROUND: Severe affective and psychotic disorders may be accompanied by legal incapacity. If in this case the patient refuses treatment and in parallel there is a risk of serious damage to health, treatment can be carried out against the patient's non-autonomous will under defined prerequisites. Due to its good and partly superior effectiveness in the treatment of severe and pharmacotherapy-resistant affective and psychotic disorders, electroconvulsive therapy (ECT) is an important treatment option in such constellations. AIM: Description of the general principles and prerequisites of therapeutic measures against the patient's will. METHODS: Based on a case report, the application of ECT as a medical measure against the patient's will is discussed and assessed in an interdisciplinary approach from clinical, legal, and ethical perspectives. RESULTS AND DISCUSSION: The (empirical) evidence on the general effectiveness of ECT, as well as its application against the will of patients with legal incapacity, clearly shows a positive benefit-risk ratio. When performed against the patient's will, ECT as all compulsory medical interventions, represents a severe encroachment on the individual's fundamental rights of both physical integrity and self-determination. Nevertheless, its application may be medically indicated, legally admissible and ethically appropriate in individual cases to prevent the threat of serious damage to the patient's health. Ethical and legal prerequisites of treatment against the patient's will should be evaluated by a multiprofessional team and the patient's legal guardian should be involved from an early stage.

Preventing Prison Suicide With Life-Trajectory-Based Screening.

We describe the application of a life-trajectory model of suicide to the prison setting and its implication for suicide risk detection. A model has been developed that describes two distinct trajectories culminating in suicide: one with large amounts of adversity early in life with a young age of suicide and another with chronic, gradually accumulating adversity with a later age of suicide. Support for applying the life-trajectory model to the prison population is found in prison-centric models of suicidal behavior and clinical profiles of individuals at high risk of suicide in prisons. We also describe how the life-trajectory model applies to two recent high-profile suicides within the Canadian prison system. Finally, we propose a screening tool based on the life-trajectory model to quantify an individual's adversity burden at intake and subsequently throughout incarceration. We describe how this proposed tool may improve detection of individuals with increased risk of suicide and describe the steps necessary for the development of this tool.

[Under scrutiny by the state prosecutor : Legal pitfalls in emergency medicine]. / Im Visier des Staatsanwalts : Juristische Fallstricke in der Notfallmedizin.

Physicians who allow a suicide attempt to happen, which from an ex ante viewpoint was completely voluntary, cannot be held punishable for homicide or failing to provide medical assistance when the suicide corresponds to the putative will of the patient according to plausible information supplied by an authorized person with healthcare proxy. Guidelines for resuscitation also play a central role in the forensic practice for assessment of whether and when resuscitation can be terminated; therefore, it is urgently advised to follow and implement these guidelines: deviations are possible if they can be factually justified. The currently declared will of a Jehovah's Witness to refuse an allogeneic blood transfusion is binding for the physician. If the patient does not have the ability to reason at the decisive time for evaluating the indications for a blood transfusion and an advance directive has been made, this directive is the guiding principle for medical actions. If such a directive is not available, the putative will must be elucidated. If this is not possible, the objective welfare of the patient must be upheld and the blood transfusion carried out (in dubio pro vita).

Evaluating the association between childhood sexual abuse and attempted suicide across the lifespan: Findings from a nationwide study of women in jail.

Previous studies have found childhood sexual abuse to predict suicidal behavior in adulthood. Women in jail suffer disproportionately high rates of childhood sexual abuse and attempted suicide relative to women in the general population. Thus, better understanding the association between childhood sexual abuse and attempted suicide among women in jail may inform prevention, assessment, and treatment initiatives for this at-risk population. This study examined the association between childhood sexual abuse and the onset of attempted suicide across the life span in a nationwide sample of women in jail. Participants included a randomly selected subsample of women (N = 115), drawn from a larger probability sample (N = 491), who completed Life History Calendars, which were coded for the presence/absence of attempted suicide and childhood sexual abuse across life history stages. Survival analysis and Cox regression indicated that women with histories of childhood sexual abuse perpetrated by an adult or a peer were significantly more likely to have attempted suicide across the life span, including increased risk for the onset of attempted suicide in adulthood. This study demonstrates the salience of childhood sexual abuse as a predictor of suicidal behavior among women in jail, and extends previous research by demonstrating the temporal sequence of childhood sexual abuse relative to attempted suicide across the life span. Given these findings, researchers, clinicians, and policymakers should consider further the influence of childhood sexual abuse with regard to the high rates of attempted and completed suicide among women in jail. (PsycINFO Database Record

The legal status of suicide: A global review.

Copies were obtained of the criminal codes from 192 countries and states; in 25 suicide is currently illegal, and an additional 20 countries follow Islamic or Sharia law where suicide attempters may be punished with jail sentences. The vast majority of countries have laws making it illegal to abet, aid or encourage suicide, but the nature and punishment of the actions that are illegal varies. Laws in places with Civil, Common Law, Islamic Law and Traditional Law systems are compared. Great variances in application were noted, sometimes within countries. It is impossible to estimate the number of persons currently in jail for having attempted suicide, but jail sentences are still given to suicide attempters. Some countries do not prosecute suicide attempters despite the laws, while others consistently jail suicide attempters. In countries where suicide attempts have been decriminalized, attempters may still face prosecution when another person is injured or dies as a result of their suicide attempt or where the attempter is a member of the military. We discuss the roots of laws making suicide, aiding, and encouraging suicide illegal and examine prospects for future changes. The recent Supreme Court Decision in Canada, invalidating the law making it illegal to assist in the suicide of physically ill people who are suffering (abeit with restrictive conditions) illustrates current trends towards "liberalization" of assisted suicide.

Letter to the Editors. Professional confidentiality applicable to psychiatrists.

Psychiatrists performing activities under the Mental Health Protection Act who in connection with their performance of such activities become aware of information that, if kept confidential, can constitute a threat to the life or health of the patient or other people, are released from the duty to keep such information confidential. In such a case, they have a moral and legal duty to disclose such information to law enforcement authorities and cannot be prosecuted under criminal law for disclosing such confidential information. An attempt to interrogate a physician who files such a report regarding circumstances of which he became aware while performing activities under the Mental Health Protection Act will, however, be illegal. Yet, that leads to disputes and controversies in the medical and legal communities, and, therefore, the issue requires a prompt, uniform interpretation. Due to the expected increase in attempted dyadic deaths (after the Germanwings plane crash,) the problem should be carefully regulated so that psychiatrists know the legal boundaries of dealing with patients - potential suicides.