RIFLESSIONI SULL’ESECUZIONE DELLA MISURA DI SICUREZZA IN REMS

Laws 81/2014 and 9/2012 regulate the progressive overcoming of the Judicial Psychiatric Hospitals (O.P.G.) and the consequent openingof the Residences for the Execution of Security Measures (R.E.M.S), thus advancing an inevitable reform to limit the duration of the securitymeasure within the maximum legal limit, and to put before the requirement and the claim of treatment before to the custodialconcept. However, these two fundamental conditions have concealed what should have been a thorough psychiatric-forensic analysis forthe identification of an organizational model based on clinical evidence. An accurate critical analysis of the current normative frameworkmust face the problem of the structural model of the REMS for the management of the different degrees of violence that an infirmsubject can carry out, the problem of the insufficiency of beds and the variability in the application of measure safety.Therefore, the purpose of this work is to discuss some problems that we consider should be examined by the scientific community, underliningalso the necessity of a new dialectical institutional phase to propose a different clinic-forensic model based on the scientific evidenceobtained in this first period of evaluation.Con le Leggi 81/2014 e 9/2012 si è assistito al progressivo superamento degli Ospedali Psichiatrici Giudiziari (O.P.G.) e alla conseguenteapertura delle Residenze per l’Esecuzione delle Misure di Sicurezza (R.E.M.S), dando così inizio ad un’inevitabile riforma per limitarela durata della misura di sicurezza entro il limite massimo di legge e per anteporre al concetto custodialista la necessità e il diritto alle cure.Queste due condizioni fondamentali, hanno però offuscato quella che sarebbe dovuta essere una più approfondita analisi psichiatricoforenseper l’individuazione di un modello organizzativo basato su evidenze cliniche. Un’accurata analisi critica sull’attuale impianto normativodeve affrontare il problema del modello strutturale delle REMS per la gestione dei diversi gradi di violenza che un soggettoinfermo può esprimere, il problema della scarsità di posti letto, e la variabilità nell’applicazione della misura di sicurezza.Lo scopo di questo lavoro è pertanto quello di affrontare alcune problematiche che riteniamo debbano essere prese in esame dalla comunitàscientifica, sottolineando anche l’esigenza di una nuova fase dialettica-istituzionale per proporre un nuovo modello clinico-forense chetenga conto delle evidenze scientifiche raccolte in questi primi anni di osservazione

Soggetti psicopatici e socialmente pericolosi: uno studio caso-controllo per valutare i fattori di rischio per la recidiva di comportamento violento

Background Since 2008 people considered Non-Guilty in Reason of Insanity (NGRI) and socially dangerous, are sectioned in the residential forensic units called R.E.M.S (Residences for Execution of Security Measures), exclusively managed by health operators, without policemen support. In judiciary laws, social danger is considered as the risk for a person to commit future crimes in reason of mental disorder. For this reason, the assessment of mental and behavioral parameters is fundamental to connect clinical facets with recidivism and to predict the risk of violence. Violent behavior can occurs in Psychosis and Mood Disorder, often in acute phases, whereas is very common in about 80% of people Personality Disorder, above all Borderline and Antisocial too. Literature suggest that Psychopathy represent the trans-dimentional clinical condition that correlates with longer criminal careers and high level of violent behavior. In fact psychopathic suffer from a profound affective deficit, including shallow emotion and inability to experience empathy, guilt or remorse. Methods We developed a protocol to assess both psychological and biological aspects in patients admitted in R.E.M.S. of Mental Health Department of ASL Rm5 in order to evaluate neurocognitive/psychiatric pathways and to compare differences between psychopathic and non-psychopathic groups. Psychopathy assessment require PCL-r, that is the gold standard reference scale. Case and Control are adults male 20 admitted in REMS since 2016, classified as psychopathic if their PCL-r scores is ≥ 20. All participants underwent clinical evaluation and MRI (Magnetic Resonance Imaging) study with specific sequences to examine possible dysfunction in neural connectivitiy. Results Preliminary results demonstrate that psychopathic participants (7 adults, mean age: 42,71 yo, PCl-r: 23,92) had many lifetime’s criminal records, while non-psychopatic (6 adults, mean age 46,17 yo, PCL-r: 10,35) are admitted in forensic units for the first time in their life. First results suggest that PCL-r total score represent the most important pathway to predict recidivism of violent acts, measured with Harm-FV (Hamilton anatomy of Risk Managent – forensic version), instead of PD (psychopathic deviation) scale of MMPI-II that appears elevated in both groups, without differences between psychopathic and non-psychopathic. Moreover, psychopathic traits may be correlated with different patterns of atypical neural connective activity

Decisional Capacity to Consent to Clinical Research Involving Placebo in Psychiatric Patients

Evidence from a few studies indicates the existence of several issues related to psychiatric patients' decisional capacity to give informed consent to clinical research. Clinicians often face difficulties in acquiring valid informed consent in clinical practice and even more so in drug trials. Participants often fail to fully understand or retain information regarding the actual implications of research protocols. The Brief Assessment for Consent to Clinical Research (BACO) was developed to investigate capacity to consent to clinical trials and further compare patients with schizophrenia and healthy comparisons' decisional capacity. A method to avoid possible confounding effects of choosing a treatment regarding a current disease was applied. The study groups were administered the BACO and the MacArthur Competence Assessment Tool for Clinical Research. Psychiatric patients performed poorer in comprehending, appreciating, and reasoning abilities, than their healthy counterparts. Impaired cognitive functioning and psychiatric symptoms severity were associated with reduced capacity to consen

Valutazione della pericolosità sociale e del rischio di recidiva criminale attraverso un sistema di assessment integrato

L’attuale scenario della psicologia e della psichiatria forense richiede sempre più ai clinici capacità e competenze relative alla stima del potenziale rischio che ciascun individuo costituisce per gli altri e per la società. Tali valutazioni hanno lo scopo di orientare sia la pratica giuridica sia quella clinica e riabilitativa. Il presente lavoro ha l’obiettivo di proporre una nuova modalità di valutazione strutturata della pericolosità sociale e del rischio futuro di recidiva criminale attraverso l’utilizzo combinato dei tre strumenti Psychopathy Checklist – Revised, Personality Inventory for DSM-5, and Historical Clinical Risk Management-20, Version 3. Questo modello di valutazione diagnostica si propone di migliorare l’assessment e il management di autori di reato (in particolare di reati violenti) in attesa di giudizio e nelle strutture detentive, diffondendo una buona ed accurata prassi nei contesti giudiziari e clinico-forensi. Tale prassi viene mostrata nella sua applicazione pratica attraverso la presentazione di un caso di interesse psichiatrico-forense valutato con i suddetti strumenti.The current field of forensic psychiatry and psychology requires that professionals have adequate skills to assess the potential risk that a criminal poses to the society. The aim of such assessments is to indicate a viable and effective path to follow in juridical, clinical and rehabilitative practices. The aim of this article is to propose a structured model of risk assessment and prediction of criminal recidivism, by combining the results from three different measures, namely, the Psychopathy Checklist – Revised (PCL-R), the Personality Inventory for DSM-5 (PID-5), and the Historical Clinical Risk Management-20, Version 3 (HCR-20 V3). This assessment procedure is intended to improve the quality of the diagnosis as well as the management of individuals who committed crimes (particularly violent crimes) and who are waiting for trials in detention centers or in mental health institutions. This can be achieved by spreading a good and accurate practice in the judiciary and clinical-forensic contexts. The assessment procedure is illustrated in its more practical implication by presenting a forensic case in which the three measures have been used together

Dialectical behaviour therapy (DBT) for forensic psychiatric patients: An Italian pilot study

Background: Several previous randomised controlled trials of dialectical behaviour therapy (DBT) since Linehan's original have shown that it has an advantage over standard care or other psychological treatments, but focus is usually on suicide-related behaviours, and little is known about its effect with offender-patients. Aims: To evaluate DBT with a group of offender-patients in the Italian high intensity therapeutic facilities—the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS), established under the Italian Law 81/2014. Methods: Twenty-one male forensic psychiatric in-patients with borderline personality disorder were enrolled and randomly assigned to 12 months of standard DBT together with all the usual REMS treatments (n = 10) or usual REMS treatments alone (n = 11). All participants completed the same pretreatment and posttreatment assessments, including the Barratt Impulsiveness Scale (BIS-11), Difficulties in Emotion Regulation Scale (DERS), and Toronto Alexithymia Scale 20 (TAS-20). Results: Men receiving DBT showed a significantly greater reduction in motor impulsiveness, as measured by the BIS-11, and emotional regulation, as reflected by the DERS total score, than the controls. There were no significant differences between groups in alexithymia scores. Conclusions: Italy has innovative forensic psychiatric facilities with a new recovery–rehabilitation approach, but the ambitious goals behind these cannot be achieved by pharmacology alone. For the first time in clinical forensic settings in Italy, there has been limited access to DBT. This small pilot study suggests this is likely to help ameliorate traits associated with violent and antisocial behaviours, so a full-scale randomised controlled trial should follow

A novel SCL-90-R six-item factor identifies subjects at risk of early adverse outcomes in public mental health settings

To increase access to treatment, Italy made assessment at community mental health centers (CMHCs) independent of medical referral, resulting in increased numbers of patients to be triaged efficiently. To support this process, we evaluated SCL-90-R item-ratings to identify factors that best predicted adverse early outcomes among persons seeking first-time CMHC care in a 24-month period in Rome. A psychiatric nurse screened subjects with a brief interview and self-administered SCL-90-R and psychiatrists provided CGI ratings and ICD-9 diagnosis. Of 832 screened subjects, 32 (3.85%) were hospitalized or attempted suicide within 90 days. Six SCL-90 items (15,41,55,57,78,88) scored much higher with than without such adverse outcomes; their sum is proposed as a predictive measure (“SCL-6″). In binary multivariable logistic modeling, this factor, but not age, sex, diagnosis, or other SCL-90-derived subscales strongly predicted adverse outcomes. A ROC curve for SCL-6 reflected a strong separation between subjects with versus without adverse outcomes (AUC = 0.76). This simple screening tool may support timely identification of patients at risk of early adverse clinical outcome who require especially close follow-up

Hemochromatosis-induced bipolar disorder: A case report

Objective: A patient presenting with. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, bipolar disorder was found to be affected by high iron hemochromatosis. This prompted us to explore the relation between bipolar disorder and iron overload. Method: We report the case and review the peer-reviewed literature focusing on mood symptoms in patients with hemochromatosis or iron overload. Animal studies of brain effects of iron overload are summarized. High iron hemochromatosis was confirmed by genetic testing, and treatment was instituted to address iron overload. Results: Patient's bipolar symptoms completely subsided after phlebotomic reduction of iron overload. Conclusion: Clinicians should explore the possibility of iron overload and seek genetic confirmation of hemochromatosis in resistant bipolar disorder to avoid unnecessary medication. © 2012 Elsevier Inc