Clinical risk management in High-Security Forensic Psychiatry Residences. Protecting patients and health professionals: perspectives and critical issues of the Law 81/2014.

The Italian Law n. 9/2012 provided the Italian Regions with a new decisional role by demanding the management/rehabilitation of prisoners judged as partially/fully mentally ill to care and protection delivered by the psychiatric services of the Regional Health Service. Healthcare has to be guaranteed by the so-called High-Security Forensic Psychiatry Residences (Italian: Residenze per l'Esecuzione delle Misure di Sicurezza: REMS) and by community mental health centres. Ensuring patients' and professionals' health and safety is a complex issue which requires effective strategies to cope with several structural, technological, and organisational problems. The present paper summarises the historical evolution of the Italian laws towards the development of the High-Security Forensic Psychiatry Residences in Italy, focusing specifically on the Tuscany Region situation. The paper also presents the key issues emerging after the implementation of the Law 81/2014 which complemented the Law 9/2012. Since these reforms included the need for assessing to what extent the patient may be considered as a danger to society and for ensuring the safety of National Health Service (NHS) professionals, they underscored the importance of a preventive use of specific clinical governance tools aimed to reduce risk of adverse events. The present work has the strength of proposing a new, evidence-based scientific approach to the implementation of assessment and care pathways in High-Security Forensic Psychiatry Residences.

Treatment decision-making capacity in non-consensual psychiatric treatment: a multicentre study.

AIMS: To evaluate treatment decision-making capacity (DMC) to consent to psychiatric treatment in involuntarily committed patients and to further investigate possible associations with clinical and socio-demographic characteristics of patients. METHODS: 131 involuntarily hospitalised patients were recruited in three university hospitals. Mental capacity to consent to treatment was measured with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T); psychiatric symptoms severity (Brief Psychiatric Rating Scale, BPRS-E) and cognitive functioning (Mini Mental State Examination, MMSE) were also assessed. RESULTS: Mental capacity ratings for the 131 involuntarily hospitalised patients showed that patients affected by bipolar disorders (BD) scored generally better than those affected by schizophrenia spectrum disorders (SSD) in MacCAT-T appreciation (p < 0.05) and reasoning (p < 0.01). Positive symptoms were associated with poorer capacity to appreciate (r = -0.24; p < 0.01) and reason (r = -0.27; p < 0.01) about one's own treatment. Negative symptoms were associated with poorer understanding of treatment (r = -0.23; p < 0.01). Poorer cognitive functioning, as measured by MMSE, negatively affected MacCAT-T understanding in patients affected by SSD, but not in those affected by BD (SSD r = 0.37; p < 0.01; BD r = -0.01; p = 0.9). Poorer MacCAT-T reasoning was associated with more manic symptoms in the BD group of patients but not in the SSD group (BD r = -0.32; p < 0.05; SSD r = 0.03; p = 0.8). Twenty-two per cent (n = 29) of the 131 recruited patients showed high treatment DMC as defined by having scored higher than 75% of understanding, appreciating and reasoning MacCAT-T subscales maximum sores and 2 at expressing a choice. The remaining involuntarily hospitalised patients where considered to have low treatment DMC. Chi-squared disclosed that 32% of BD patients had high treatment DMC compared with 9% of SSD patients (p < 0.001). CONCLUSIONS: Treatment DMC can be routinely assessed in non-consensual psychiatric settings by the MacCAT-T, as is the case of other clinical variables. Such approach can lead to the identification of patients with high treatment DMC, thus drawing attention to possible dichotomy between legal and clinical status.

Workers safety in public psychiatric services: problems, laws and protections.

The dramatic case of murder of a psychiatrist during her service in her public office (Centro di Salute Mentale of Bari-Libertà) has led the authors to reflect on the safety of workplaces, in detail of public psychiatric services. It is in the light of current legislation, represented by the Legislative Decree of April 9th, 2008 no. 81, which states the implementing rules of Law 123/2007. In particular, the Authors analyzed the criticalities of the application of this Law, with the aim of safeguarding the health and safety of the workers in all psychiatric services (nursing departments, outpatient clinics, community centers, day care centers, etc.). The Authors suggest the need to set up an articulated specific organizational system of risk assessment of psychiatric services, that can prevent and protect the workers from identified risks, and finally to ensure their active participation in prevention and protection activities, in absence of which specific profiles of responsibility would be opened up to the employers.

Stalking by females.

The aim of this review was to study "female stalking" in the sense of the specific traits characterizing the phenomenon of stalking behaviour committed by women. The main medical databases were searched (Medline, Social Science Research Network, Apa Psyc Net), and 67 articles were selected, reporting studies conducted in clinical populations, case series, reports, reviews, retrospective studies and original articles. We outline a variety of different tactics adopted by female stalkers and a lesser propensity to pass on to physical violence. Nevertheless, female stalkers are more frequently affected by erotomania, and this condition generally increases the risk of violence. If there have previously been intimate relations between the stalker and her victim, this will increase the risk of violence. In a significant proportion of female stalkers, the behavior is carried out in the occupational setting, especially in the field of psychotherapy, where the male-female ratio is reversed. No significant differences emerged between the motivations of heterosexual or homosexual stalkers. In the category of crimes of harassment committed by women, stalking, at least in Italy, seems to be among the most prominent.

Child witnesses: a study of memory and suggestibility.

AIM: To investigate the influence of various factors on the ability of primary school children (aged 6-9 years) to refer an event that occurred during their life. MATERIALS AND METHODS: The factors analyzed were: the time since the event occurred; the role the child had in the event; the type of questions asked to elicit the account. RESULTS: The results of this research indicate that 52.4% of 6-year old children are able to describe the main elements of the event if they are allowed to give a free account. Asking direct questions does not improve the quality of the narrative. By contrast, in 9-year-old children the quantity of data collected is improved if direct questions are asked. A role as a participant in the event improves the quality of the child's evidence but only in the group of children aged 9, whereas in younger children the difference is not significant. At the age of 9, the child's resistance to leading questions is already quite good (40.7%), whereas children of 6 are much more suggestible. CONCLUSIONS: The Authors conclude this work by making some reflections on the possible use of these findings in Law Courts, and on the need for a highly specific training of experts involved in the task of collecting evidence from young children.

[Some notes on psychopathological origins of maladjustment of young conscripts in national service: a methodological contribution in the diagnosis of personality disorders]. / Le basi psicopatologiche del disadattamento giovanile nel servizio di leva: un contributo metodologico nella diagnosi dei disturbi di personalità.

The authors analyse the phenomenon of maladjustment of young conscripts during national service and give a substantial methodological contribution to personality disorders diagnostic field. Working hypothesis is that personality disorders, suspected on the basis of anomalies of behaviour and of social interaction, defined through an appropriate clinical and phenomenological examination, may be confirmed and specified making use of personality tests. The authors examine 2 groups of young male subjects, both composed of 15 members, easily comparable and homogeneous with reference to sex, age, provenance, social class, standard of education, equally exposed to the same exacting or stressing social situation (national service). Research work is composed of 2 phases: 1. Out-patient observation (in the Psychiatric Clinic of Bari University), joined to exact diagnosis and to separation of the 15 maladjusted subjects of I group afflicted with structured personality disorders, from the 15 members of II group, considered sane. 2. Administration of personality tests--projective test ORT and autodescriptive test MMPI--to the components of both groups. The results of psychodiagnostic investigation confirm clinical diagnosis of personality disorders in the members of I group. It is easily comprehensible that psychodiagnostic personality tests may be largely used to realize effective work of specific primary prevention.