Treatment decision-making capacity in children and adolescents hospitalized for an acute mental disorder: The role of cognitive functioning and psychiatric symptoms

OBJECTIVE: This study was conducted to assess treatment decision-making capacity (TDMC) in a child and adolescent psychiatric sample and to verify possible associations between TDMC, psychiatric symptom severity, and cognitive functioning. METHODS: Twenty-two consecutively recruited patients hospitalized for an acute mental disorder, aged 11-18 years, underwent measurement of TDMC by the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). The MacCAT-T interview focused on patients' current treatment, which comprised second-generation antipsychotics (45.5%), first-generation antipsychotics (13.6%), antiepileptic drugs used as mood stabilizers or lithium carbonate (45.5%), selective serotonin reuptake inhibitors (32%), and benzodiazepines (18%). We moreover measured cognitive functioning (Wechsler Intelligence Scale for Children III) and psychiatric symptom severity (Brief Psychiatric Rating Scale v 4.0). RESULTS: Patients' TDMC varied within the sample, but MacCAT-T scores were good in the sample overall, suggesting that children and adolescents with severe mental disorders could be competent to consent to treatment. The TDMC proved independent of psychiatric diagnosis while being positively associated with cognitive functioning and negatively with excitement. CONCLUSION: The MacCAT-T proved feasible for measuring TDMC in a child and adolescent psychiatric sample. TDMC in minors with severe mental disorders was not necessarily impaired. These results deserve reconsidering the interplay between minors and surrogate decision-makers as concerning treatment decisions

Free will, neuroscience, and choice: towards a decisional capacity model for insanity defense evaluations

Il libero arbitrio è stato spesso considerato una tematica centrale nella dottrina della responsabilità criminale. Ciononostante, il concetto stesso di libero arbitrio presenta intrinseche problematiche nella sua definizione teorica e applicazione pratica in un contesto clinico/ forense ed è intensamente dibattuto. Nello specifico, l’esistenza stessa del libero arbitrio è stata recentemente posta in discussione anche sulla base di alcune evidenze sperimentali neuroscientifiche. Questo dibattito ha implicazioni significative in quei campi in cui l’associazione tra libertà di scelta è comportamento costituisce il focus di interesse, quali la psichiatria forense. Esiste inoltre una sorta di conflittualità tra la centralità e concezione teorica del libero arbitrio (free will) e il suo status e applicazione pratica. Questo problema ha bisogno di essere affrontato, specialmente all’interno della psichiatria forense, dal momento che risulta rilevante per l’effettiva valutazione dell’infermità di mente. Nel presente articolo cercheremo di rendere operativo il concetto del “libero arbitrio” utilizzando il modello a quattro dimensioni utilizzato per la capacità decisionale, che può essere impiegato nella valutazione forense dell’infermità di mente. Descriveremo i suoi vantaggi e applicazioni per guidare la valutazione dell’infermità di mente. Mentre il libero arbitrio è spesso considerato problematico dal punto di vista delle neuroscienze, questo modello, a nostro avviso, è compatibile con le neuroscienze; inoltre, le valutazioni che utilizzino questo modello possono anche essere arricchite e rafforzate dalle scoperte neuro scientifiche, per esempio riguardo il controllo inibitorioFree will has often been considered central to criminal responsibility. Yet, the concept of free will is also difficult to define and operationalize, and, moreover, it is intensely debated. In particular, the very existence of free will has been denied based on recent neuroscience findings. This debate has significant implications on those fields in which the link between free will and behaviour is the main focus of interest, such as forensic psychiatry. In fact, a tension is often experienced between the centrality of the notion of free will on the one hand, and its controversial status on the other. This tension needs to be addressed, especially in forensic psychiatry, since it is relevant for actual assessments of legal insanity. In the present paper we will try to operationalize “free will” using a fourpartite decision-making capacity model, which can be used in forensic assessment of insanity. We will describe its advantages and application to guide mental insanity assessments. Whereas free will is often considered problematic from a neuroscience perspective, this model, we argue, is compatible with neuroscience; moreover, evaluations using this model can also be informed and strengthened by neuroscientific findings, for example regarding inhibitory control

The admission experience survey italian version (I-AES). a factor analytic study on a sample of 156 acute psychiatric in-patients

Coercive treatments are often regarded as an inevitable and yet highly debated feature of psychiatric care. Perceived coercion is often reported by patients involuntarily committed as well as their voluntary counterparts. The Admission Experience Survey (AES) is a reliable tool for measuring perceived coercion in mental hospital admission. We developed the Italian AES (I-AES) through translation back-translation and administered it to 156 acutely hospitalized patients (48% women, 69% voluntarily committed) in two university hospitals in Rome (Policlinico Umberto I, Sant'Andrea Hospital). A principal component analysis (PCA) with equamax rotation was conducted. The I-AES showed good internal consistency (Cronbach's alpha = 0.90); Guttmann split-half relia- bility coefficient was 0.90. AES total score significantly differed between voluntary and involuntary committed patients (5.08 ± 4.1 vs. 8.1 ± 4.9, p < .05). PCA disclosed a three-factor solution explaining 59.3 of the variance. Some discrepancies were found between the factor structure of the I-AES and the original version. I- AES total score was positively associated with numbers of previous involuntarily hospitalization (r = 0.20, p < .05) and psychiatric symptoms' severity (r = 0.22, p < .02). I-AES and its proposed new factor structure proved to be reliable to assess perceived coercion in mental hospital admission. Consequently, it may represent a helpful instrument for the study and reduction of patients' levels of perceived coercion

The impact of machine learning in predicting risk of violence: a systematic review

Background: Inpatient violence in clinical and forensic settings is still an ongoing challenge to organizations and practitioners. Existing risk assessment instruments show only moderate benefits in clinical practice, are time consuming, and seem to scarcely generalize across different populations. In the last years, machine learning (ML) models have been applied in the study of risk factors for aggressive episodes. The objective of this systematic review is to investigate the potential of ML for identifying risk of violence in clinical and forensic populations.Methods: Following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a systematic review on the use of ML techniques in predicting risk of violence of psychiatric patients in clinical and forensic settings was performed. A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Risk of bias and applicability assessment was performed using Prediction model Risk Of Bias ASsessment Tool (PROBAST).Results: We identified 182 potentially eligible studies from 2,259 records, and 8 papers were included in this systematic review. A wide variability in the experimental settings and characteristics of the enrolled samples emerged across studies, which probably represented the major cause for the absence of shared common predictors of violence found by the models learned. Nonetheless, a general trend toward a better performance of ML methods compared to structured violence risk assessment instruments in predicting risk of violent episodes emerged, with three out of eight studies with an AUC above 0.80. However, because of the varied experimental protocols, and heterogeneity in study populations, caution is needed when trying to quantitatively compare (e.g., in terms of AUC) and derive general conclusions from these approaches. Another limitation is represented by the overall quality of the included studies that suffer from objective limitations, difficult to overcome, such as the common use of retrospective data.Conclusion: Despite these limitations, ML models represent a promising approach in shedding light on predictive factors of violent episodes in clinical and forensic settings. Further research and more investments are required, preferably in large and prospective groups, to boost the application of ML models in clinical practice

Le differenze di genere nella genetica dei comportamenti aggressivi

In recent literature, there is an growing interest about the aggressive behavior’s genetics, with the specific aim of identify specific alterations of genes involved in dopaminergic and serotonergic systems. Given that aggressive behavior is regarded as an alteration of catecholaminergic system, a reduction in COMT and MAOA, the two major enzymes responsible for the catabolism of brain catecholamines, should indirectly increase these behaviors. While there is and there has been a substantial attention in males and neutral gender with regard to aggressive and/or antisocial behaviors, females have been a research group less considered, both due to social and cultural factors, and to the difficulty pointed out different forms of aggression, often minor and less urgent from the point of view of the response of the society. For this reason, only recently the importance of considering the women’s aggressiveness through a dynamic development due to a cumulative effect of risk and protective factors that occur over time as been understood. In this article, we stress the importance of including these genetic gender differences, in order to understand the phenomenon of violence, being in agreement with recent literature on these options, still to consider, especially with the hormonal hypothesis of testosterone/estrogen balance.In letteratura si è andato sviluppando un crescente interesse circa la genetica dei comportamenti aggressivi, in particolare rispetto alle alterazioni specifiche dei geni coinvolti nei sistemi dopaminergico e serotoninergico. Il comportamento aggressivo è modulato dall’attività catecolaminergica e una riduzione dell’attività di COMT e MAOA, i due principali enzimi responsabili del catabolismo cerebrale delle catecolamine, dovrebbe aumentare indirettamentela possibilità di un comportamento aggressivo. Mentre vi è e vi è stata una sostanziale attenzione in soggetti di sesso maschile e di genere neutro per quanto riguarda i comportamenti aggressivi e/o antisociali, le donne sono state un gruppo di ricerca meno considerato, sia a causa di fattori socioculturali, sia per la difficoltà nell’evidenziarne le forme di aggressività, spesso minori e meno urgenti dal punto di vista della risposta della società. Per tale motivo solo recentemente si è intesa l’importanza di comprendere l’aggressività femminile, attraverso un quadro dinamico di sviluppo dovuto ad un effetto cumulativo di fattori di rischio e di protezione che occorrono nel corso del tempo, così come è accaduto per gli uomini. In questo articolo, si sottolinea l’importanza di includere queste differenze di genere di tipo genetico al fine di comprendere il fenomeno stesso della violenza, trovandoci in accordo con la recente letteratura in merito alle ipotesi ancora da vagliare, in particolare con l’ipotesi ormonale del bilancio testosterone/estrogeni

Applicazioni forensi del MMPI-2

Il contributo affronta il tema della validità diagnostica e descrittiva dei questionari della famiglia MMPI nei contesti diapplicazione forensi. Sono confrontate le scale di validità del MMPI-2, MMPI-2-RF e del MMPI-A, suddividendo le stessein stili di risposta. È affrontato il tema della modalità di discriminazione tra simulazione, dissimulazione e autenticità delsoggetto. Sono inoltre delineati gli sviluppi futuri dell’interpretazione dei questionari in ambito forense

Epidemiologia dell’omicio-suicidio passionale in Italia

A survey has been carried out on the Italian newspapers over the years 1985- 2008. 662 cases of homicide-suicide occurred in Italy in that time span, 560 committed by men and 102 by women. About 24% of the cases (156) is ascribable to jealousy: 92.3% (144) was committed by men and 7.7% (12) by women. The homicide-suicide that can be explained through jealousy is the most common category among the cases considered. In about 34% of the cases the perpetrator had a criminal record, even specific to the category. The data raise questions about the actual possibility of protecting the victims and the need for preventive measures.Si è effettuata una ricerca tramite indagine sui giornali italiani nel periodo 1985 e il 2008. Nell’arco di tempo esaminato in Italia si sono verificati 662 casi di  micidio suicidio, di cui 560 perpetrati da uomini e 102 da donne. Circa il 24% dei casi (156) è attribuibile alla gelosia. Di questi il 92,3% (144) è stato commesso da uomini e il 7,7% (12) da donne. L’omicidio suicidio motivato da ragioni di gelosia risulta la categoria più frequente all’interno della casistica esaminata. In circa il 34% dei casi l’autore aveva dei precedenti penali, anche specifici. I dati sollevano il problema relativo alla effettiva possibilità di tutela delle vittime e la necessità di misure sociale di prevenzione

Valutazioni psichiatriche-forensi e intelligenza artificiale: nuovi scenari possibili

Cognitive biases are defined as mental processes which can lead to the elaboration of misjudgements. Biases can influence thoughts, opinions, behaviours, and they are inevitably involved in psychiatricforensic evaluations. The delicate role that the mental health expert plays in the psy-chiatric examinations makes these mistakes highly relevant. Make sure that such a complex decision-making process is set up with care and attention is fundamental to guarantee the best protection of the individual rights, but also to avoid a mismanagement of government money. In order to avoid the possible use of cognitive biases in psychiatric-forensic assessments, it has been suggested to increase the standardization of evaluation procedures, but scientific literature shows that experts working in this area are often reluctant to question their own work. Recently, the application of Artificial Intelligence (AI) to the forensic field has opened new possibilities, but, on the other hand, it has generated new questions. AI seems to be beneficial for those decision-ma-king processes where greater standardization is required, but attempts to use AI tools in the field of forensic psychiatry have highlighted some critical issues. In this article, after discussing the problems that characterize both human and computational decision-making, we will propose possible solutions.Si definiscono “bias cognitivi” quei processi mentali che possono condurre a elaborare giudizi imprecisi o errati. I bias possono influenzare pensieri, opinioni, condotte e sono inevitabilmente implicati anche nelle valutazioni psichiatriche-forensi. Il delicato ruolo che l’esperto in salute mentale riveste all’interno del processo peritale rende questi errori particolarmente rilevanti. Assicurarsi che un pro-cesso decisionale così complesso sia messo in atto con la dovuta attenzione e cura risulta di fondamentale importanza per garantire la maggiore tutela possibile del singolo, ma anche per evitare una mala gestione dei soldi dello Stato. Per sfuggire all’eventuale utilizzo di bias cognitivi nelle valutazioni psichiatriche-forensi, si è suggerito di standardizzare maggiormente le procedure di valutazione, ma dalla letteratura emerge che gli esperti che operano in quest’ambito sono spesso restii a mettere in di-scussione il proprio stesso operato. Di recente, l’applicazione dell’Intelligenza Artificiale (IA) al campo forense ha aperto nuove possibilità, ma, d’altro canto, ha generato nuovi interrogativi. L’IA sembra essere vantaggiosa per quei processi decisionali in cui maggiore standardizzazione è richiesta, ma i ten-tativi di utilizzo di strumenti dotati di IA in campo forense hanno messo in evidenza alcune criticità. In questo articolo, dopo aver discusso i problemi che caratterizzano sia il processo decisionale umano che quello computazionale, proporremo possibili soluzioni

Synthetic cannabinoid use in a case series of patients with psychosis presenting to acute psychiatric settings : Clinical presentation and management issues

Background: Novel Psychoactive Substances (NPS) are a heterogeneous class of synthetic molecules including synthetic cannabinoid receptor agonists (SCRAs). Psychosis is associated with SCRAs use. There is limited knowledge regarding the structured assessment and psychometric evaluation of clinical presentations, analytical toxicology and clinical management plans of patients presenting with psychosis and SCRAs misuse. Methods: We gathered information regarding the clinical presentations, toxicology and care plans of patients with psychosis and SCRAs misuse admitted to inpatients services. Clinical presentations were assessed using the PANSS scale. Vital signs data were collected using the National Early Warning Signs tool. Analytic chemistry data were collected using urine drug screening tests for traditional psychoactive substances and NPS. Results: We described the clinical presentation and management plan of four patients with psychosis and misuse of SCRAs. Conclusion: The formulation of an informed clinical management plan requires a structured assessment, identification of the index NPS, pharmacological interventions, increases in nursing observations, changes to leave status and monitoring of the vital signs. The objective from using these interventions is to maintain stable physical health whilst rapidly improving the altered mental state.Peer reviewedFinal Published versio