Violence prevention in psychiatry: an umbrella review of interventions in general and forensic psychiatry.
ABSTRACT: Relative risks of violence in psychiatric patients are high compared to the general population and existing evidence in non-psychiatric populations may not translate to reductions in violence in psychiatric populations. We searched 10 databases including Medline, EMBASE, CINAHL and Scopus, from inception until August 2015 for systematic reviews and meta-analyses of violence prevention interventions in psychiatry. Reviews were included if they used a hard outcome measure (i.e. police or hospital recorded violence, or reincarceration) and contained randomized or non-randomized controlled studies. Five reviews met our inclusion criteria (n = 8876 patients in total), of which four received a GRADE rating of 'low' or 'very low'. Three randomized studies (n = 636) reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with co-occurring mental illness ('moderate' GRADE rating). The lack of intervention research in violence prevention in general and forensic psychiatry suggests that interventions from non-psychiatric populations may need to be relied upon.
Project description:Swift medically led scientifically informed responses to the Covid-19 epidemic nationally have been demonstrably superior to other, non-scientific approaches. In forensic psychiatry and across all psychiatric services, urgent and clinically led responses have underlined redundancies and confusions in the governance of mental health services and a vacuum in policy makers. For the future, a greater emphasis on services for patients with schizophrenia and other severe, enduring mental disorders must aim at reducing standardised mortality ratios, managing risk of violence and improving hard outcomes such as symptomatic remission, functional recovery and forensic recovery of autonomy. This will require more use of information technology at service level and at national level where Scandinavian-style population-based data linkage research must now become legally sanctioned and necessary. A national research and development centre for medical excellence in forensic psychiatry is urgently required and is complimentary to and different from quality management.
Project description:Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.
Project description:Today, psychiatrists are focusing on genetics aspects of various psychiatric disorders not only for a future classification of psychiatric disorders but also a notion that genetics would aid in the development of new medications to treat these disabling illnesses. This review therefore emphasizes on the basics of genetics in psychiatry as well as focuses on the emerging picture of genetics in psychiatry and their future implications.
Project description:<h4>Objective</h4>To find out if there is evidence on interventions to prevent aggression against doctors.<h4>Design</h4>This systematic review searched the literature and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.<h4>Data sources</h4>Pubmed, Embase, Turning Research into Practice (TRIP), Cochrane and Psycharticle, GoogleScholar and www.guideline.gov were consulted.<h4>Eligibility criteria</h4>Abstracts published in English between January 2000 and January 2018 were screened. Eligible studies focused on prevention and risk factors of type II workplace violence in general healthcare, psychiatric departments, emergency departments, emergency primary care, general practice.<h4>Data extraction and synthesis</h4>The selected intervention studies were grouped into quantitative and qualitative studies. Systematic reviews were reported separately. For each study, the design, type of intervention and key findings were analysed. Quality rating was based on Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and GRADE-Confidence in the Evidence from Reviews of Qualitative Research (CERQUAL).<h4>Results</h4>44 studies are included. One randomised controlled trial (RCT) provided moderate evidence that a violence prevention programme was effective in decreasing risks of violence. Major risk factors are long waiting times, discrepancy between patients' expectations and services, substance abuse by the patient and psychiatric conditions. Appropriate workplace design and policies aim to reduce risk factors but there is no hard evidence on the effectiveness. One RCT provided evidence that a patient risk assessment combined with tailored actions decreased severe aggression events in psychiatric wards. Applying de-escalation techniques during an aggressive event is highly recommended. Postincident reporting followed by root cause analysis of the incident provides the basic input for review and optimisation of violence prevention programmes.<h4>Conclusions</h4>This review documented interventions to prevent and de-escalate aggression against doctors. Aggression against physicians is a serious occupational hazard. There is moderate evidence that an integrated violence prevention programme decreases the risks of patient-to-worker violence. The review failed to gather sufficient numerical data to perform a meta-analysis. A large-scale cohort study would add to a better understanding of the effectiveness of interventions.
Project description:Advances in the use of neuroimaging in combination with A.I., and specifically the use of machine learning techniques, have led to the development of brain-reading technologies which, in the nearby future, could have many applications, such as lie detection, neuromarketing or brain-computer interfaces. Some of these could, in principle, also be used in forensic psychiatry. The application of these methods in forensic psychiatry could, for instance, be helpful to increase the accuracy of risk assessment and to identify possible interventions. This technique could be referred to as 'A.I. neuroprediction,' and involves identifying potential neurocognitive markers for the prediction of recidivism. However, the future implications of this technique and the role of neuroscience and A.I. in violence risk assessment remain to be established. In this paper, we review and analyze the literature concerning the use of brain-reading A.I. for neuroprediction of violence and rearrest to identify possibilities and challenges in the future use of these techniques in the fields of forensic psychiatry and criminal justice, considering legal implications and ethical issues. The analysis suggests that additional research is required on A.I. neuroprediction techniques, and there is still a great need to understand how they can be implemented in risk assessment in the field of forensic psychiatry. Besides the alluring potential of A.I. neuroprediction, we argue that its use in criminal justice and forensic psychiatry should be subjected to thorough harms/benefits analyses not only when these technologies will be fully available, but also while they are being researched and developed.
Project description:Background: Pharmacological treatment is of great importance in forensic psychiatry, and the vast majority of patients are treated with antipsychotic agents. There are several systematic differences between general and forensic psychiatric patients, e.g. severe violent behavior, the amount of comorbidity, such as personality disorders and/or substance abuse. Based on that, it is reasonable to suspect that effects of pharmacological treatments also may differ. The objective of this systematic review was to investigate the effects of pharmacological interventions for patients within forensic psychiatry. Methods: The systematic review protocol was pre-registered in PROSPERO (CRD42017075308). Six databases were used for literature search on January 11, 2018. Controlled trials from forensic psychiatric care reporting on the effects of antipsychotic agents, mood stabilizers, benzodiazepines, antidepressants, as well as pharmacological agents used for the treatment of addiction or ADHD, were included. Two authors independently reviewed the studies, evaluated risk of bias and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: The literature search resulted in 1783 records (titles and abstracts) out of which 10 studies were included. Most of the studies included were retrospective and non-randomized. Five of them focused on treatment with clozapine and the remaining five on other antipsychotics or mood stabilizers. Five studies with a high risk of bias indicated positive effects of clozapine on time from treatment start to discharge, crime-free time, time from discharge to readmission, improved clinical functioning, and reduction in aggressive behavior. Psychotic symptoms after treatment were more pronounced in the clozapine group. Mainly due to the high risk of bias the reliability of the evidence for all outcomes was assessed as very low. Conclusion: This systematic review highlights the shortage of knowledge on the effectiveness of pharmacological treatment within forensic psychiatry. Due to very few studies being available in this setting, as well as limitations in their execution and reporting, it is challenging to overview the outcomes of pharmacological interventions in this context. The frequent use of antipsychotics, sometimes in combination with other pharmacological agents, in this complex and heterogeneous patient group, calls for high-quality studies performed in this specific setting.
Project description:<b>Background:</b> Although psychoactive substance use disorders (PSUDs) are a domain of mental health, addiction psychiatry is only formally recognized as a subspecialty in a few European countries, and there is no standardized training curriculum. <b>Methods:</b> A 76-item questionnaire was developed and disseminated through an online anonymous data-collecting system and hand-to-hand amongst psychiatric trainees from the 47 European countries of the Council of Europe plus Israel and Belarus. <b>Results:</b> 1,049/1,118 psychiatric trainees from 30 European countries completed the questionnaire. Fifty-nine-point nine percent of trainees stated to have training in addictions. Amongst the trainees who described having training in addictions, 43% documented a not well-structured training and 37% an unsatisfactory training, mainly due to poor acquired knowledge. Overall, 97% of trainees stated that addiction represents a core curriculum for their training. Overall, general adult psychiatric trainees reported a better knowledge in addictions, compared to trainees in child and adolescent psychiatry. <b>Conclusion:</b> Despite a growing spread of PSUDs in European countries, addiction psychiatry is a relatively poorly trained field within psychiatry training programs. Further research should investigate reasons for poor training and timings of the educational activities to optimize experiential education training in addiction psychiatry.
Project description:The significant proportion of patients suffering from subthreshold diagnoses such as partial posttraumatic stress disorder (PTSD) shows that today's diagnostic entities do not fully meet the reality and needs of clinical practice. Moreover, as stated also in the recently announced concept of research domain criteria (RDoC), the use of today's traditional diagnostic systems in psychiatric research does not sufficiently promote an integrative understanding of mental disorders across multiple units of analysis from behavior to neurobiology. Besides RDoC, core symptom-based research concepts have been proposed to bridge the translational gap in psychiatry, but, unfortunately, have not yet become the rule.First, this article briefly reviews literature on subthreshold PTSD (as an example for subthreshold diagnoses) and, second, pleas for and proposes a modified symptom-based research concept in psychiatry.Subthreshold PTSD has, like other subthreshold psychiatric diagnoses, not yet been clearly defined. Diagnostic entities such as subthreshold PTSD are subject to a certain arbitrariness as they are mainly the result of empiricism. This fact stresses the urgent need for neurobiologically-informed psychiatric diagnoses and motivated the here-presented proposal of a symptom-based research concept. As proposed here, and before by other researchers, symptom-based research in psychiatry should refrain from studying patient cohorts compiled according to diagnoses but, instead, should focus on assessing cohorts grouped according to chief complaints or predominant psychopathological symptoms.The linkage of the RDoC concept and symptom-based psychiatric research might probably speed up the definition of biologically or symptom-based psychiatric diagnoses, which might replace the auxiliary constructs of "traditional" diagnoses such as full and subthreshold PTSD, and promote the development of novel psychological and pharmacological treatments.
Project description:The high heterogeneity of psychiatric disorders leads to a lack of diagnostic precision. Therefore, the search of biomarkers is a fundamental aspect in psychiatry to reach a more personalized medicine. The endocannabinoid system (ECS) has gained increasing interest due to its involvement in many different functional processes in the brain, including the regulation of emotions, motivation, and cognition. This article reviews the role of the main components of the ECS as biomarkers in certain psychiatric disorders. Studies carried out in rodents evaluating the effects of pharmacological and genetic manipulation of cannabinoid receptors or endocannabinoids (eCBs) degrading enzymes were included. Likewise, the ECS-related alterations occurring at the molecular level in animal models reproducing some behavioral and/or neuropathological aspects of psychiatric disorders were reviewed. Furthermore, clinical studies evaluating gene or protein alterations in post-mortem brain tissue or in vivo blood, plasma, and cerebrospinal fluid (CSF) samples were analyzed. Also, the results from neuroimaging studies using positron emission tomography (PET) or functional magnetic resonance (fMRI) were included. This review shows the close involvement of cannabinoid receptor 1 (CB1r) in stress regulation and the development of mood disorders [anxiety, depression, bipolar disorder (BD)], in post-traumatic stress disorder (PTSD), as well as in the etiopathogenesis of schizophrenia, attention deficit hyperactivity disorder (ADHD), or eating disorders (i.e. anorexia and bulimia nervosa). On the other hand, recent results reveal the potential therapeutic action of the endocannabinoid tone manipulation by inhibition of eCBs degrading enzymes, as well as by the modulation of cannabinoid receptor 2 (CB2r) activity on anxiolytic, antidepressive, or antipsychotic associated effects. Further clinical research studies are needed; however, current evidence suggests that the components of the ECS may become promising biomarkers in psychiatry to improve, at least in part, the diagnosis and pharmacological treatment of psychiatric disorders.
Project description:Vocal and/or instrumental sounds combined in such a way as to produce beauty of form, harmony and expression of emotion is music. Brain, mind and music are remarkably related to each other and music has got a strong impact on psychiatry. With the advent of music therapy, as an efficient form of alternative therapy in treating major psychiatric conditions, this impact has been further strengthened. In this review, we deliberate upon the historical aspects of the relationship between psychiatry and music, neural processing underlying music, music's relation to classical psychology and psychopathology and scientific evidence base for music therapy in major psychiatric disorders. We highlight the role of Indian forms of music and Indian contribution to music therapy.