Violence Against Physicians in the Workplace: Trends, Causes, Consequences, and Strategies for Intervention.

PURPOSE: Violence against healthcare professionals has become an emergency in many countries. Literature in this area has mainly focused on nurses while there are less studies on physicians, whose alterations in mental health and burnout have been linked to higher rates of medical errors and poorer quality of care. We summarized peer-reviewed literature and examined the epidemiology, main causes, consequences, and areas of intervention associated with workplace violence perpetrated against physicians. RECENT FINDINGS: We performed a review utilizing several databases, by including the most relevant studies in full journal articles investigating the problem. Workplace violence against doctors is a widespread phenomenon, present all over the world and related to a number of variables, including individual, socio-cultural, and contextual variables. During the COVID-19 pandemic, incidence of violence has increased. Data also show the possible consequences in physicians' deterioration of quality of life, burnout, and traumatic stress which are linked to physical and mental health problems, which, in a domino effect, fall on patients' quality of care. Violence against doctors is an urgent global problem with consequences on an individual and societal level. This review highlights the need to undertake initiatives aimed at enhancing understanding, prevention, and management of workplace violence in healthcare settings.

Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders.

PURPOSE OF REVIEW: Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT). RECENT FINDINGS: Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.

The screen for cognitive impairment in psychiatry in patients with borderline personality disorder.

Cognitive deficits are common in borderline personality disorder (BPD) and appear to be associated with psychopathology, functioning and outcome. The availability of a cognitive screening instrument could be of use in clinical settings in order to assess neurocognition in BPD patients. The Screen for Cognitive Impairment for Psychiatry (SCIP) proved to be reliable in different psychiatric populations, but it has not yet been validated in personality disorders. The purpose of this study is therefore to evaluate its psychometric properties in a sample of 58 BPD patients. The SCIP was validated against the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Trail Making Test A and B (TMT A and B). The receiver operator curve analysis displayed an acceptable convergent validity (total score AUC: 0.78, 95% CI: 0.70-0.86; Se: 75%, Sp: 72%). A cut-off total score of 80 identified 81% of patients as cognitively impaired. The exploratory factor analysis displayed a one-factor solution explaining 55.8% of the total variance. The SCIP displayed adequate psychometric properties in BPD and could be integrated in the routine clinical assessment to provide a preliminary evaluation of cognitive features for BPD.

A comparison of Dignity Therapy narratives among people with severe mental illness and people with cancer.

OBJECTIVE: To examine Dignity Therapy (DT) narratives in patients with severe mental illness (SMI) and a control group of cancer patients. METHODS: 12 patients with SMI (schizophrenia, bipolar disorders, sever personality disorders) and 12 patients with non-advanced cancer individually participated to DT interviews. DT was tape-recorded, transcribed verbatim and shaped into a narrative through a preliminary editing process. A session was dedicated to the final editing process along with the participant, with a final written legacy (generativity document) provided to the participant. Interpretative Phenomenological Analysis was used to qualitatively analyze the generativity documents. RESULTS: Patients with SMI and patients with cancer presented similar main narrative categories relative to dignity, such as "Meaning making", "Resources", "Legacy", "Dignity"; in addition, inpatients with SMI "Stigma" and inpatients with cancer "Injustice" emerged as separate categories. Patients in both groups strongly appreciated DT as an opportunity to reflect on their life story and legacy. CONCLUSIONS: The study showed that DT is a valuable intervention for people with SMI, grounded in a practical, person-centered approach. All patients found DT as an opportunity to describe their past and present, highlighting changes in the way they relate to themselves and others. These results can guide implementation of DT in mental health settings for people with SMI, as it is for people with cancer.

Knowledge about risk factors for cancer and cancer risk behavior among patients with severe mental illness.

OBJECTIVE: To examine knowledge about, perception of and current risk factors for cancer, among patients with severe mental illness (SMI) and to compare these variables with patients without SMI. METHODS: A series of patients affected by SMI (i.e., schizophrenia spectrum disorders, bipolar disorders and severe personality disorders) and a matched (gender, age) control group of primary care attenders were assessed, by using an ad hoc semi-structured interview and a short true/false 17-item questionnaire, about family history of cancer, cancer risk-related lifestyles, personal perception and knowledge of risk for cancer. RESULTS: Patients with SMI (n = 185, mainly schizophrenia spectrum disorders, 48%, and mood disorders, 33%) significantly differed from primary care attenders (n = 173) for: lower participation to occult stool blood screening test, Pap smear test and mammography; higher prevalence of current and past smoking habits; lower awareness towards their own physical symptoms and their perception of risks for cancer; lower physical exercise practicing; lower knowledge about risk factors for cancer (e.g. familiarity for cancer, smoke-habits, breast and uterine cancer). CONCLUSIONS: Patients suffering from SMI had higher at-risk behavior for cancer and showed fewer concerns and less knowledge about risk for cancer than primary care attendees. These findings can guide to implement screening for cancer (e.g., Pap test, blood) and to design evidence-based interventions to reduce cancer risk (e.g., educational and behavioral change for smoking cessation, dietary habits) among patients with SMI.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience.

PURPOSE OF REVIEW: We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience. RECENT FINDINGS: A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

The Relationship Between Cognitive Abilities and Trait Clinical Features in Patients With Borderline Personality Disorder.

Very few studies have focused on the relationship between cognitive functions and clinical features in borderline personality disorder (BPD). Subjects with BPD and healthy controls were administered the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test A and B, and the Wisconsin Card Sorting Test. The Brief Symptom Inventory (BSI-53) was used to assess the severity of current symptoms. Attachment style was assessed with the Experiences in Close Relationship Questionnaire, identity integration with the Personality Structure Questionnaire, and other domains of personality dysfunction with the RUDE Scale for Personality Dysfunction. Patients with BPD performed significantly worse than healthy controls in all cognitive domains. Cognitive functions, particularly delayed memory and visuospatial abilities, displayed meaningful associations with trait-like clinical features, above the effect of global cognition and state psychopathology. These findings highlight the need to evaluate effects of cognitive rehabilitation on trait features among individuals with BPD.

Exploring and assessing demoralization in patients with non-psychotic affective disorders.

BACKGROUND: Demoralization, as assessed through the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) interview or the Demoralization Scale (DS), has been found to affect about 30% of patients with medical disorders, while few studies have been done in patients with psychiatric disorders. METHODS: A convenience sample of 377 patients with ICD-10 diagnoses of mood, anxiety, stress-related disorders or other non-psychotic disorders was recruited from two Italian university psychiatry centers. The DCPR/D interview and the Italian version of the DS (DS-IT) were used to assess demoralization and the Patient Health Questionnaire-9 (PHQ-9) to assess depression. RESULTS: Demoralization was diagnosable in more than 50% of the patients. Factor analysis of the DS-IT indicated four main factors, Meaninglessness/Helplessness, Disheartenment, Dysphoria and Sense of Failure, explaining 62% of the variance of the scale. Patients with bipolar or unipolar major depression and personality disorders had the highest prevalence of demoralization (DCPR/D) and the highest scores on all the DS-IT factors in comparison with patients with adjustment or anxiety disorders. About 50% of patients with moderate demoralization (DS-IT) were not clinically depressed (PHQ-9 <10), while almost all with severe demoralization were depressed. LIMITATIONS: Prospective studies on larger samples with other psychiatric disorders, also taking into account subjective incompetence, are needed. Since the DCPR/D assesses demoralization as a categorical construct, a dimensional framework should be necessary. CONCLUSIONS: The findings enrich the research on demoralization, showing for the first time the importance of this construct, as measured by the DCPR/D and the DS-IT, in patients with psychiatric disorders.

Italian Validation of the Screen for Cognitive Impairment in Psychiatry.

Cognitive impairments have profound implications for the management of severe mental disorders; however, they are rarely assessed in everyday clinical practice due to constraints in time, resource and expertise. Novel and short instruments, such as the Screen for Cognitive Impairment in Psychiatry (SCIP), which overcome such limitations are greatly needed. The study aims to assess the validity and reliability, among healthy subjects, of the Italian translation of the SCIP, a brief, accessible tool to detect cognitive impairments among individuals suffering from mental disorders, as the first step to validate the instrument in clinical settings. One-hundred and twenty healthy subjects completed two of the three alternative forms of the SCIP. Cronbach Alpha (0.70) supported the reliability of the SCIP scores. Correlation coefficients supported the test-retest reliability of the tool. Learning effects were observed despite the use of alternative forms. Factor analysis indicated a two-factor solution explaining 55.4% of the total variance: the first factor ("memory") loading for VLT-I and VLT-D and less for WMT; the second factor ("executive function") loading for VFT and PST and less for WMT. The study proved the validity and reliability of the Italian version of the SCIP as a reliable and simple instrument to screen for cognitive impairment in the general population.

Screening for cognitive impairment in non-affective psychoses: A comparison between the SCIP and the MoCA.

BACKGROUND: Neuropsychological performance has a strong impact on real-life functioning and clinical outcomes in psychosis. However, conducting lengthy cognitive assessments may not be feasible in routine clinical practice. Brief, reliable and cost-effective tools are highly needed, but few studies are available to guide clinician choice. METHODS: The purpose of this study was to compare the performance of two widely used, short instruments: the Screen for Cognitive Impairment in Psychiatry (SCIP) and the Montreal Cognitive Assessment (MoCA). These instruments were validated in a sample of patients with psychotic disorders and healthy controls, using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and other instruments to assess executive functions, as comparators. RESULTS: Patients fared worse than controls across almost all cognitive domains, with effect sizes ranging from 0 (MoCA naming) to 2.08 (SCIP total). Receiver Operator Curve analysis of patient and control performance suggested a better convergent validity for the SCIP (total score AUC: 0.85; 95%CI: 0.79-0.90; Se: 76%, Sp: 83%, PPV: 85%, NPV: 73%) than the MoCA (AUC: 0.78; 95%CI: 0.72-0.85; Se: 69%, Sp: 76%, PPV: 78.7%, NPV 66%). CONCLUSIONS: The Screen for Cognitive Impairment in Psychiatry seems to be a more sensitive and specific screening tool than the MoCA to identify cognitive impairment among patients with psychotic disorders.

Pre-loss symptoms related to risk of complicated grief in caregivers of terminally ill cancer patients.

PURPOSE: A number of studies have underlined a 10-20% prevalence of complicated grief (CG) among caregivers of cancer patients. The study aimed at examining the relationship between pre-loss criteria for CG and post-loss diagnosis of CG and at evaluating the validity and factor structure of a predictive tool, the Inventory of Complicated Grief (ICG), in order to identify the risk of developing CG in a sample of Italian caregivers. METHODS: Sixty family members of terminally ill patients admitted to hospice and receiving a Palliative Prognostic Score (PaP) predictive 30 day survival time <30% completed the Pre-Death ICG (ICG-PL) (T0). Family members were met again 6 months after the death of their loved one (T1) and submitted to the interview for Complicated Grief (Post-loss interview-PLI). RESULTS: Caseness for CG was shown in 18.3% of caregivers at T1. ICG-PL score (T0) were higher among those who developed CG at T1 than non-cases. A cut off score ≥49 on the ICG-PL (AUC=0.98) maximized sensitivity (92%) and specificity (98%) on caseness at T1. Pre-loss criteria related to traumatic distress, separation distress and emotional symptoms in general were significantly related to a post-loss diagnosis of CG, while no effect was shown on duration of pre-loss distress. CONCLUSIONS: The use of short screening tools, like the ICG-PL, may help health care professionals to identify subjects at risk for CG.

Exploration of experiences in therapeutic groups for patients with severe mental illness: development of the Ferrara group experiences scale (FE- GES).

BACKGROUND: Group therapies are routinely provided for patients with severe mental illness. The factors important to the group experience of patients are still poorly understood and are rarely measured. To support further research and practice, we aimed to develop a questionnaire that captures how patients experience groups within a community mental health context. METHODS: An initial pool of 39 items was conceptually generated to assess different aspects of group experiences. Items were completed by 166 patients with severe mental illness attending group therapies in community mental health services in Italy. Patients with different psychiatric diagnoses who attended at least 5 group sessions were included. An exploratory factor analysis was used to identify different dimensions of group experiences and to reduce the number of items for each dimension. RESULTS: The resulting questionnaire has five subscales: 1) sharing of emotions and experiences, 2) cognitive improvement, 3) group learning, 4) difficulties in open expression and 5) relationships. Each subscale has 4 items. The scale and sub-scales have good internal consistency. CONCLUSIONS: The Ferrara Group Experiences Scale is conceptually derived and assesses dimensions of group experience that are theoretically and practically relevant. It is brief, easy to use and has good psychometric properties. After further validation, the scale may be used for research into patient experiences across different group therapy modalities and for evaluation in routine care.

Working with the 'difficult' patient: the use of a contextual cognitive-analytic therapy based training in improving team function in a routine psychiatry service setting.

The clinical management of 'difficult' patients is a major challenge which exposes mental health teams to an increased risk of frustration and stress and may lead to professional burnout. The aim of the present study was to investigate whether a cognitive-analytic therapy (CAT) based training undertaken by a mental health team working with 'difficult' patients reduced professional burnout symptoms, improved patients' service engagement and increased the levels of team-cohesion. Twelve mental health staff members from different professional and educational backgrounds took part in five 2-hour sessions providing a basic CAT training intervention, an integrative and relational model of psychotherapy for the treatment of borderline personality disorders. Participants were administered the Maslach Burnout Inventory (MBI), the Service Engagement Scale (SES) and the Group Environment Questionnaire (GEQ) before (T0) and after (T1) CAT training, and at 1-month follow-up (T2). A significant decrease were found, at T2, on the MBI Emotional Exhaustion scores, the SES Availability subscale, the GEQ Attraction to Group-Social and Group Integration-Social, while the MBI-Personal Accomplishment scores increased from baseline.The results of this study suggest that a CAT-based training can facilitate team cohesion and patient engagement with a service and reduce burnout levels among mental health team members dealing with 'difficult' patients.

[Diagnostic revision of De Chiricos' case]. / Revisione diagnostica del "caso" De Chirico.

An interesting field of psychopathology has been historically oriented towards identifying the links between artistic expression and psychological problems, searching the biographies of various artists for the deep psychological origins of their art. The painter Giorgio De Chirico has been the object of many studies and recently his documented suffering was diagnosed as problems with migraines and temporal epilepsy. However, a precise psychiatric diagnosis is still missing. The authors, using autobiographical and biographical resources, attempt to reconstruct the psychopathological medical history of the painter and subsequently classify the psychiatric diagnoses using the DSM-IV. With this methodology the authors proposed that the artist displayed a personality disorder with narcissistic and paranoid traits and had suffered from somatization disorder and adjustment disorders in three-year periods, from 1909-1911 and 1915-1918.

Sales of antidepressants, suicides and hospital admissions for depression in Veneto Region, Italy, from 2000 to 2005: an ecological study.

BACKGROUND: Increased prescription of antidepressants has been consistently associated with a decrease in suicide rates in several countries. The aim of this study is to explore antidepressant consumption, suicide rates and admission for depression in the Veneto Region, Italy, in order to see whether the same pattern could be detected. METHODS: Data from the Italian Ministry of Health (admissions for depression), the Pharmacy Service of a Local Health Unit (antidepressant prescribing) and from the Epidemiological System of the Veneto region (suicide rates) were collected from 2000 to 2005 for the Veneto region. RESULTS: Suicide rates did not show any marked increase but were stable in males and females. Antidepressant prescribing increased exponentially over the period examined, whilst admissions for depression markedly decreased. The trend for an exponential increase in antidepressant prescribing in the Veneto region is shared with other countries and locales. CONCLUSIONS: It is possible that the increase in antidepressant prescribing might be associated with earlier treatment of depression, thus decreasing the likelihood of aggravation of depression.

Patient opinions on the helpfulness of external rehabilitative activities in residential psychiatric care: a pilot study.

INTRODUCTION: This study explores the patient opinions about the helpfulness of the External Rehabilitative Activities (ERA) delivered in two residential facilities for psychiatric rehabilitation. METHODS: We administered a Questionnaire developed to assess general helpfulness, helpfulness of specific therapeutic processes and satisfaction with the ERA to a sample of 46 psychiatric patients participating in at least three external activities. RESULTS: The External Rehabilitative Activities, tested by the ERA-Questionnaire, were considered helpful or very helpful by most of the patients. The therapeutic process with the highest score was "relaxation", followed by "general helpfulness", "socialization", "knowledge of social context", "community integration". The least-valued process was "autonomy". CONCLUSION: This pilot study has shown that psychiatric patients consider ERA helpful and rate more helpful the specific therapeutic processes, such as relaxation and socialization, that assure symptomatic relief and interaction with the outside world.

Hopelessness and related variables among cancer patients in the Southern European Psycho-Oncology Study (SEPOS).

BACKGROUND: Although hopelessness has been studied in cancer, no data are available in non-English-speaking countries. OBJECTIVE: The authors sought to amass data from Southern European countries (Italy, Portugal, Spain, and Switzerland) in order to fill this void. METHOD: A group of 312 cancer patients completed the Mini-MAC Hopelessness subscale, the Hospital Anxiety and Depression Scale (HADS), the Cancer Worry Inventory (CWI), and a six-item Visual Analog scale (VAS) to measure intensity of physical symptoms, general well-being, difficulty in coping with cancer, intensity of social support from close relationships, leisure activity, and support from religious beliefs. RESULTS: Regression analysis indicated that HADS-Depression, VAS Maladaptive Coping and Well-Being, and the CWI explained 42% of the variance. CONCLUSION: Hopelessness in cancer patients seems not exclusively to correspond to depression, but is related to various other psychosocial factors, such as maladaptive coping, as well.

Depression and serotonin transporter (5-HTTLPR) polymorphism in breast cancer patients.

BACKGROUND: Mixed evidence in the general population and medically ill patients has suggested that homozygous carriers of the short allele (s/s) of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) may increase the risk of depression in comparison with carriers of the long allele (l/l) or s/l. Given the lack of data in oncology, we examined the relationship of depression with the 5-HTTLPR and psychosocial variables among breast cancer patients. METHODS: A sample of 145 breast cancer patients were studied as regards to depression, psychosocial-related variables (coping, Type D-personality, life events, and social support), and the 5-HTTLPR, which was genotyped by using a standard protocol with DNA extracted from the blood. RESULTS: No difference was found between s/s, s/l and l/l patients on depression and any other psychosocial variable. No gene-by environment (GxE) interactions were observed between the 5-HTTLPR and recent life events. CONCLUSIONS: The study did not provide support of a possible association between 5-HTTLPR polymorphism, alone or in conjunction with life events, and depression in newly diagnosed breast cancer. Further follow-up studies are however necessary to confirm these data.

Factor structure of the Brief Psychiatric Rating Scale in unipolar depression.

BACKGROUND: In clinical practice patients with unipolar depression present with a variety of symptom clusters that may combine together in many different ways. However, only few factor analytic studies used general psychopathology scales to investigate the symptom structure of unipolar depression. METHODS: The study included 163 consecutive inpatients with an ICD-10 diagnosis of depressive disorder (ICD-10 codes F32 to F33). All patients were assessed with the 18-item version of the Brief Psychiatric Rating Scale (BPRS) within 3days from admission. Exploratory factor analysis with Varimax rotation was performed on BPRS items. RESULTS: Four factors were extracted, explaining 52% of total variance. They were interpreted as Apathy, Dysphoria, Depression and Psychoticism. The distribution of factor scores was approximately normal for Apathy, while it displayed a slight negative skewness for Depression, a slight positive skewness for Dysphoria, and a marked positive skewness for Psychoticism. Patient sex, family history of depression, lifetime history of suicide attempt, and recent serious family conflict were not associated with any factor. Occupational status, age, and age at onset displayed a positive correlation with Apathy. Duration of illness and number of previous admissions were positively correlated with Dysphoria. LIMITATIONS: Patients were not administered a structured diagnostic interview, and no detailed assessment of personality disorders was performed; also, patients were recruited only at a single site, which reduces the generalizability of the results. CONCLUSIONS: Our findings suggest that in depressive disorders there are psychopathological dimensions other than depressed mood that are worthy of greater clinical attention and research. Dimensions such as apathy and dysphoria may play an important part in the clinical phenomenology of unipolar depression and deserve systematic and careful assessment in order to provide patients with the best possible treatment and improve clinical outcomes.

Effects of supportive-expressive group therapy in breast cancer patients with affective disorders: a pilot study.

BACKGROUND: So far, no study has tested supportive-expressive group therapy (SEGT) in cancer patients with an established psychiatric diagnosis. The aim of this 6-month follow-up study was to evaluate breast cancer patients with an ICD-10 diagnosis of affective syndromes participating in SEGT and a group of breast cancer patients with no ICD-10 diagnosis. METHODS: A total of 214 patients were examined in the screening phase (T0) using the ICD-10, the Brief Symptom Inventory (BSI), the Mini-Mental Adjustment-to-Cancer Scale (Mini-MAC), the Multidimensional Scale of Perceived Social Support, the Openness Scale and the Cancer Worries Inventory (CWI). Those with an ICD-10 diagnosis of affective syndromes received 16-24 sessions of SEGT (90-min sessions, once a week), while those with no ICD-10 diagnosis were followed up. A second assessment for both sam- ples took place 6 months later (T1). RESULTS: Seventy-eight (36.4%) patients were positive for an ICD-10 diagnosis of affective syndromes at T0, while 127 (59.4%) did not meet any ICD-10 diagnosis. Among the former, 54 patients participated in the SEGT. At T1, significant differences were observed in all the dimensions of the BSI, hopelessness and anxious preoccupation subscales of the Mini-MAC, the Openness Scale and the CWI. No variable at T0 was a predictor of BSI distress as measured at T1. Among those with no ICD-10 diagnosis at T0, 8.2% were positive for affective disorders at the 6-month follow-up. CONCLUSIONS: This study suggested that SEGT is effective for breast cancer patients with affective disorders, and indicates the need for prospective evaluations in order to identify those who may develop psychopathology over time.