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Freitag S, Au JS, Liu DY, Mekawi Y, Lamis DA. Do bipolar disorder symptom profiles matter for suicide risk? A latent class approach to investigating differences in suicidal desire and acquired capability. Suicide Life Threat Behav 2024; 54:24-37. [PMID: 37937748 DOI: 10.1111/sltb.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Depressive and mixed symptoms in bipolar disorder (BD) have been linked to higher suicide risk. Based on Klonsky and May's three-step theory and Joiner's Interpersonal Psychological Theory of Suicide, we hypothesized that patients diagnosed with BD who reported severe levels of depressive symptoms and mixed depressive and manic symptoms would also report higher levels of suicidal desire and acquired capability of suicide, as well as suicidal thoughts and behaviors. METHODS The sample included 177 outpatients diagnosed with BD. Latent class analysis was conducted to replicate the identified groups of a previously conducted study using a smaller but overlapping dataset. Between-class and pairwise analyses with measures of suicidal desire and acquired capability were conducted. RESULTS As expected, the classes characterized by severe depressive symptoms and mixed symptoms reported higher levels of suicidal desire. However, the results regarding acquired capability were less consistent. CONCLUSION Given the overall elevated suicide risk of BD and the consistent relationship between depressive symptoms and other strong correlates of suicide, clinicians who work with patients diagnosed with BD should closely monitor changes in their depressive symptoms.
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Affiliation(s)
- Stephanie Freitag
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Josephine S Au
- Harvard T. H. Chan School of Public Health/Brigham and Women's Hospital/McLean Hospital, Boston, Massachusetts, USA
| | - Daphne Y Liu
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Dorian A Lamis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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2
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Bo S, Sharp C, Lind M, Simonsen S, Bateman A. Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study. Nord J Psychiatry 2023; 77:547-559. [PMID: 36897045 DOI: 10.1080/08039488.2023.2186483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/09/2023] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia. METHOD AND MATERIALS In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending. RESULTS Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles. CONCLUSIONS Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.
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Affiliation(s)
- Sune Bo
- Department of Psychology, University of Copenhagen, DK and Department of Psychiatry, Denmark
| | - Carla Sharp
- Department of Psychology, University of Houston, USA
| | - Majse Lind
- Department of Psychology, University of Aalborg, Denmark
| | - Sebastian Simonsen
- Department of Psychology, University of Copenhagen, and Stolpegaard Psychotherapy Centre, Denmark
| | - Anthony Bateman
- Psychoanalysis Unit, University College London, United Kingdom
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Deng H, He L, Wang C, Zhang T, Guo H, Zhang H, Song Y, Chen B. Altered gut microbiota and its metabolites correlate with plasma cytokines in schizophrenia inpatients with aggression. BMC Psychiatry 2022; 22:629. [PMID: 36167540 PMCID: PMC9513873 DOI: 10.1186/s12888-022-04255-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The pathophysiological mechanisms of aggression are manifold and they may closely interconnect. Current study aimed to determine the gut microbiota and its metabolites, and clarify their correlations with inflammation, oxidation, leaky gut and clinical profiles underlying aggression in schizophrenia (ScZ). METHODS Serum and stool specimens from ScZ inpatients with (ScZ-Ag, 25 cases) and without aggression (NScZ-Ag, 25 cases) were collected. Systemic inflammation, oxidation and leaky gut biomarkers were determined by ELISA, gut microbiota by 16S rRNA sequencing, short-chain fatty acids (SCFAs) by gas chromatography-mass spectrometry analysis and neurotransmitters by liquid chromatograph mass spectrometry analysis. RESULTS Significantly higher systemic pro-inflammation, pro-oxidation and leaky gut biomarkers were observed in ScZ-Ag than NScZ-Ag group (all P<0.001). Compared to NScZ-Ag group, the alpha-diversity and evenness of fecal bacterial community were much lower, the abundance of fecal genera Prevotella was significantly increased, while that Bacteroides, Faecalibacterium, Blautia, Bifidobacterium,Collinsella and Eubacterium_coprostanoligenes were remarkably reduced in ScZ-Ag group (all corrected P<0.001). Meanwhile, 6 SCFAs and 6 neurotransmitters were much lower in ScZ-Ag group (all P<0.05). Finally, a few strongly positive or negative correlations among altered gut microbiota, SCFAs, systemic pro-inflammation, leaky gut, pro-oxidation and aggression severity were detected. CONCLUSIONS These results demonstrate that pro-inflammation, pro-oxidation and leaky gut phenotypes relating to enteric dysbacteriosis and microbial SCFAs feature the aggression onset or severity in ScZ individuals.
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Affiliation(s)
- Hongxin Deng
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Lei He
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Chong Wang
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Teng Zhang
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Hua Guo
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Hongwei Zhang
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Yanning Song
- Department of Psychiatry, Zhumadian Psychiatric Hospital (The Second People’s Hospital of Zhumadian), Zhumadian, 463003 China
| | - Bangtao Chen
- Department of Dermatology, Chongqing University Three Gorges Hospital, School of Medicine, Chong University, Chongqing, 404000, China.
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Impulsivity in early psychosis: A complex link with violent behaviour and a target for intervention. Eur Psychiatry 2020; 49:30-36. [DOI: 10.1016/j.eurpsy.2017.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/06/2017] [Accepted: 12/09/2017] [Indexed: 12/15/2022] Open
Abstract
AbstractBackgroundViolent behaviour (VB) occurs in first episode of schizophrenia and can have devastating impact both on victims and patients themselves. A better knowledge of the underlying mechanisms of VB may pave the way to preventive treatments.Objectives1) To explore the nature of the link between impulsivity and VB in early psychosis (EP) patients; 2) To explore the interactions between impulsivity and substance abuse, insight, and positive symptoms, the main dynamic risk factors of VB described to date.Design and methodsPost hoc analysis of data acquired in the frame of a 36-months EP cohort study. A total of 265 EP patients, aged 18 to 35, treated at TIPP (Treatment and early Intervention in Psychosis Program), at the Department of Psychiatry in Lausanne, Switzerland, were included in the study. Logistic regression analyzes were performed as well as mediation analysis and interaction analysisResultsOur data suggest that impulsivity is a predictor of VB when analyzed independently and as part of a multi-factorial model. Impulsivity continues to differentiate violent patients from non-violent ones at the end of the program. In addition, the relationship between impulsivity and VB is not mediated by substance abuse. Finally, the effect of impulsivity on the probability of VB is potentiated by the interaction of different levels of insight and positive symptoms.ConclusionsEarly intervention strategies in psychotic disorders should include evaluation of impulsivity considering it is linked to increased risk of VB and may respond to treatment.
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Candini V, Ghisi M, Bianconi G, Bulgari V, Carcione A, Cavalera C, Conte G, Cricelli M, Ferla MT, Ferrari C, Iozzino L, Macis A, Nicolò G, Stefana A, de Girolamo G. Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders. Ann Gen Psychiatry 2020; 19:36. [PMID: 32518577 PMCID: PMC7271462 DOI: 10.1186/s12991-020-00286-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior. METHODS In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores. RESULTS The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior. CONCLUSIONS This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.
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Affiliation(s)
- Valentina Candini
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
| | - Marta Ghisi
- Department of General Psychology, University of Padova, Padova, Italy
| | | | - Viola Bulgari
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
| | - Antonino Carcione
- Training School in Cognitive Psychotherapy, Terzo Centro di Psicoterapia Cognitiva-Scuola Italiana di Cognitivismo Clinico (SICC), Rome, Italy
| | - Cesare Cavalera
- Department of Psychology, Catholic University of the Sacred Heart, Milano, Italy
| | - Giovanni Conte
- Department of Mental Health, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Marta Cricelli
- Department of Mental Health, Asst-Rhodense G.Salvini di Garbagnate, Milano, Italy
| | - Maria Teresa Ferla
- Department of Mental Health, Asst-Rhodense G.Salvini di Garbagnate, Milano, Italy
| | - Clarissa Ferrari
- Unit of Statistics, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Brescia, Italy
| | - Laura Iozzino
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
| | - Ambra Macis
- Unit of Statistics, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Brescia, Italy
| | - Giuseppe Nicolò
- Training School in Cognitive Psychotherapy, Terzo Centro di Psicoterapia Cognitiva-Scuola Italiana di Cognitivismo Clinico (SICC), Rome, Italy
| | - Alberto Stefana
- Department of Mental Health, ASST Spedali Civili of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giovanni de Girolamo
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Via Pilastroni 4, Brescia, Italy
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Moulin V, Palix J, Golay P, Dumais A, Gholamrezaee MM, Azzola A, Baumann PS, Alameda L, Conus P. Violent behaviour in early psychosis patients: Can we identify clinical risk profiles? Early Interv Psychiatry 2019; 13:517-524. [PMID: 29143486 DOI: 10.1111/eip.12512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/07/2017] [Accepted: 09/13/2017] [Indexed: 01/29/2023]
Abstract
AIMS The objective of this study is to explore, within a sample of early psychosis patients (EPP), if subgroups regarding rate of violent behaviour (VB) against others can be identified on the basis of dynamic risk factors (treatment modifiable characteristics). METHODS In a sample of 265 EPP, treated at the Treatment and Early Intervention in Psychosis Program in Lausanne, we conducted a latent-class analysis on the basis of the main dynamic VB risk factors (substance use disorder [SUD], positive symptoms, insight, and impulsivity). VB were restricted to "serious violence" and were assessed through patients self-report, interview with relatives or forensic services and with a standardized instrument. RESULTS The analysis confirmed the heterogeneity of the sample regarding rate of VB. Patients could be stratified within 4 subgroups, 3 of which were at increased risk of VB. The two groups with the highest rates of VB displayed specific clinical profiles. The first one was characterized by high levels of impulsivity, hostility, positive symptoms and SUD, and the second, by low level of insight and low social functioning. These patterns suggest that significant difficulties in social interaction may contribute to the emergence of aggressive reactions against others. CONCLUSIONS Identification of EPP at increased risk of VB seems possible on the basis of dynamic risk factors. If confirmed prospectively, this could pave the way to the development of preventive strategies and specific interventions.
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Affiliation(s)
- Valerie Moulin
- Unit for Research in Legal Psychiatry and Psychology, Institute of Forensic Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Julie Palix
- Unit for Research in Legal Psychiatry and Psychology, Institute of Forensic Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Philippe Golay
- Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alexandre Dumais
- Institut Philippe-Pinel de Montréal and Department of Psychiatry, Faculty of Medicine, University of Montréal, Quebec, Canada
| | - Mohammad Mehdi Gholamrezaee
- Centre for Psychiatric Epidemiology and Psychopathology, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Agathe Azzola
- Unit for Research in Legal Psychiatry and Psychology, Institute of Forensic Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Philipp S Baumann
- Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Luis Alameda
- Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Philippe Conus
- Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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7
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Moulin V, Alameda L, Baumann PS, Gholamrezaee MM, Palix J, Gasser J, Conus P. [Three clinical risk profiles of violent behavior in a cohort of early psychosis patients]. L'ENCEPHALE 2018; 45:214-220. [PMID: 30446287 DOI: 10.1016/j.encep.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aims to determine whether it is possible to identify clinical profiles at risk of violent behaviors (VB) in the early phase of psychotic disorders, on the basis of the main dynamic psychopathological risk factors and describe characteristics of the groups with highest levels of violent behaviors. METHOD A total of 265 patients, aged 18 to 35, treated at the Treatment and early Intervention in Psychosis Program (TIPP-Lausanne), a specialized early psychosis program, were included in this study. We conducted a latent-class analysis and a discriminative analysis on the basis of the main dynamic VB risk factors: substance use disorder, impulsivity, positive symptoms, insight, aggression, hostility, anger, emotional instability and adherence to treatment. These factors were evaluated by specialized scales and on the basis of the Positive and Negative Syndrome Scale (PANSS). VB were restricted to physical aggression against people, defined as "serious violence". They were assessed on the basis of a questionnaire listing violent offenses (Swiss Criminal Code) and VB such as assault and battery, information through the forensic psychiatric services and on the basis of the Staff Observation Aggression Scale (SOAS-R scale) during inpatient treatment phase. RESULTS Four heterogeneous subgroups were identified with respect to the studied clinical characteristics, including two groups with high rates of VB. The first group, comprising 46% of patients with VB, is distinguished by the prevalence of a range of dimensions related to hostility, impulsivity and emotional instability, associated with high levels of substance abuse and positive symptoms. These clinical dimensions are very significant at the statistical level, since they explain 70% of the construction of subgroups (discriminant analysis). The second group with 37% of patients with VB, is characterized by a lack of insight, lack of adherence to treatment and substance use. These two clinical profiles could increase the impairment of cognitive, functional and relational abilities and contribute to the development of VB in this early phase of psychosis. The third subgroup, with a violent behaviors rate of 28.6%, is distinguished by its high proportion of diagnoses of substance abuse (100%) and women (54%). A last subgroup of patients, the largest quantitatively, has a low proportion of VB (15%) and the lowest levels on the studied factors, suggesting that the majority of patients with this profile commit few VB. CONCLUSION Our results show that it is possible to identify groups at risk of violent behaviors during the early phase of psychosis on the basis of clinical characteristics that may evolve and therefore be the focus of preventive care. These results highlight the need to target substance use, impulsivity and lack of insight at follow-up in order to prevent VB.
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Affiliation(s)
- V Moulin
- Unité de recherche en psychiatrie et psychologie légales, institut de psychiatrie légale, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), site de Cery, bâtiment Les Cèdres, 1008 Prilly-Lausanne, Suisse.
| | - L Alameda
- Service de psychiatrie générale, centre de neuroscience psychiatrique, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse; Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P S Baumann
- Service de psychiatrie générale, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse
| | - M M Gholamrezaee
- Centre d'épidémiologie psychiatrique et psychopathologie, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse
| | - J Palix
- Unité de recherche en psychiatrie et psychologie légales, institut de psychiatrie légale, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), site de Cery, bâtiment Les Cèdres, 1008 Prilly-Lausanne, Suisse
| | - J Gasser
- Institut de psychiatrie légale, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse
| | - P Conus
- Service de psychiatrie générale, département de psychiatrie du centre hospitalier universitaire Vaudois (CHUV), Lausanne, Suisse
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Fornells-Ambrojo M, Pocock P, Mintah R, Barker C, Craig T, Lappin JM. Co-morbid personality disorder in early intervention psychosis clients is associated with greater key worker emotional involvement. Early Interv Psychiatry 2018; 12:143-152. [PMID: 26552836 DOI: 10.1111/eip.12286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 09/21/2015] [Indexed: 11/30/2022]
Abstract
AIM Co-morbid personality disorder (PD) is associated with poorer outcomes in psychosis patients, but it is not known whether these patterns are present at illness onset. This study investigated the prevalence of co-morbid PD in clients of an Early Intervention in Psychosis Service (EIPS) and compared key worker engagement and service use between patients with and without co-morbid PD. METHOD Forty-nine participants were recruited from an inner London NHS EIPS. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) Axis II Disorders was administered to identify whether participants met criteria for a diagnosis of PD. Key workers completed measures investigating the therapeutic relationship and emotional involvement. Data on service use over a 2-year period from the date on which the patient was accepted by the EIPS were collected from electronic clinical records. Service use and key worker informed data were collected blind to PD diagnosis. RESULTS Twenty-two of the 49 (45%) patients met criteria for co-morbid PD. Keyworker worry and tension were significantly higher in relation to patients with co-morbid PD compared with those without. There were no significant differences between groups in appointments offered or attended, but patients with co-morbid PD were significantly less likely to be admitted to hospital than those without. CONCLUSIONS Co-morbid PD is common in EIPS patients. The EIPS model is both assertive and intensive; although this appears to be effective in preventing hospital admissions, this does not equip professionals to manage the higher emotional burden associated with a co-morbid PD diagnosis.
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Affiliation(s)
- Miriam Fornells-Ambrojo
- Research Department of Clinical, Education and Health Psychology, University College London, London, UK.,Southwark Team for Early Intervention in Psychosis, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Phil Pocock
- Research Department of Clinical, Education and Health Psychology, University College London, London, UK
| | - Ruth Mintah
- Southwark Team for Early Intervention in Psychosis, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Chris Barker
- Research Department of Clinical, Education and Health Psychology, University College London, London, UK
| | - Thomas Craig
- Health Services Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Julia M Lappin
- Southwark Team for Early Intervention in Psychosis, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Moulin V, Baumann P, Gholamrezaee M, Alameda L, Palix J, Gasser J, Conus P. Cannabis, a Significant Risk Factor for Violent Behavior in the Early Phase Psychosis. Two Patterns of Interaction of Factors Increase the Risk of Violent Behavior: Cannabis Use Disorder and Impulsivity; Cannabis Use Disorder, Lack of Insight and Treatment Adherence. Front Psychiatry 2018; 9:294. [PMID: 30022956 PMCID: PMC6039574 DOI: 10.3389/fpsyt.2018.00294] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/14/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Previous literature suggests that prevalence of cannabis use in the early phase of psychosis is high, and that early psychosis patients are at high-risk for violent behavior. However, the link between cannabis use and violent behavior in early psychosis patients is unclear. We carried out a study on a sample of early psychosis patients, in order to explore the impact of cannabis use on the risk of violent behavior (VB), while taking into account (1) potential confounding factors and, (2) interactions with other dynamic risk factors of VB. Method: In a sample of 265 early psychosis patients, treated at the Treatment and Early Intervention in Psychosis Program (TIPP) in Lausanne, we used logistic regression models to explore the link between various dynamic risk factors of VB [positive symptoms, substance use disorder (drugs including cannabis, alcohol and others drugs), insight, impulsivity, affective instability, and treatment adherence], and VB occurring during treatment. In order to understand hierarchical effects attributable to the combinations of risk factors on VB we conducted a Classification and Regression Tree (CART). Results: Our results show that cannabis use disorder is a risk factor for VB. The associations among risk factors suggest the presence of two patient profiles with an increased rate of VB: the first is composed of patients with cannabis use disorder and impulsivity, and the second of patients combining cannabis use disorder, absence of insight and non-adherence to treatment. The results also show the moderating role of insight and adherence to treatment on the rate of VB in patients with cannabis use disorder. Conclusion: This study suggests that cannabis use disorder is a significant risk factor for VB amongst early psychosis patients, particularly when combined with either impulsivity, lack of insight and non-adherence to treatment. These results suggest that preventive strategies could be developed on the basis of such patient profiles.
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Affiliation(s)
- Valerie Moulin
- Unit for Research in Legal Psychiatry and Psychology, Department of Psychiatry, Institute of Forensic Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Switzerland
| | - Philipp Baumann
- Service of General Psychiatry, Department of Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Mehdi Gholamrezaee
- Department of Psychiatry, Center for Psychiatric Epidemiology and Psychopathology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Unit for Research in Schizophrenia, Departement of Psychiatry, Center for Psychiatric Neuroscience and Service of General Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Switzerland
| | - Julie Palix
- Unit for Research in Legal Psychiatry and Psychology, Department of Psychiatry, Institute of Forensic Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Switzerland
| | - Jacques Gasser
- Unit for Research in Legal Psychiatry and Psychology, Department of Psychiatry, Institute of Forensic Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Switzerland
| | - Philippe Conus
- Service of General Psychiatry, Department of Psychiatry, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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10
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Do cognitive deficits predict negative emotionality and aggression in schizophrenia? Psychiatry Res 2018; 259:350-357. [PMID: 29120842 DOI: 10.1016/j.psychres.2017.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 10/12/2017] [Accepted: 11/01/2017] [Indexed: 11/20/2022]
Abstract
Schizophrenia is associated with an elevated risk of aggression. Cognitive deficits have been associated with inpatient aggression and future violence. The relationship between cognitive deficits and violent behavior has however been inconsistent across studies. In addition, studies have failed to inform how cognitive deficits may contribute to aggression in schizophrenia. The current study examined the association of cognitive deficits with schizophrenia-related aggression and violent offending. It also explored the putative mediating role of negative emotionality on the impact of cognitive deficits on aggression. People with schizophrenia and schizoaffective disorder (N = 78) were recruited from a state hospital. Participants were classified based on their history of violent offending. Participants completed measures of cognition, symptoms, and aggression. Deficits in working memory, reasoning/problem-solving, and verbal learning were the most prioritized for the prediction of violent offender status. Violent offenders demonstrated greater impairments in most cognitive domains especially working memory and verbal learning. Offenders also demonstrated greater negative emotionality, excitement/agitation, and incidents of verbal and physical aggression. Negative emotionality and excitement/agitation fully transmitted the effect of cognitive deficits on impulsive aggression in meditational models. Cognitive deficits increase the risk of impulsive aggression in schizophrenia via inefficient regulation of negative affective states.
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Brissos S, Vicente F, Oliveira JM, Sobreira GS, Gameiro Z, Moreira CA, Pinto da Costa M, Queirós M, Mendes E, Renca S, Prata-Ribeiro H, Hoffmann MS, Vieira F. Compulsory psychiatric treatment checklist: Instrument development and clinical application. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2017; 54:36-45. [PMID: 28962685 DOI: 10.1016/j.ijlp.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 05/19/2017] [Accepted: 07/31/2017] [Indexed: 06/07/2023]
Abstract
Instruments designed to evaluate the necessity of compulsory psychiatric treatment (CPT) are scarce to non-existent. We developed a 25-item Checklist (scoring 0 to 50) with four clusters (Legal, Danger, Historic and Cognitive), based on variables identified as relevant to compulsory treatment. The Compulsory Treatment Checklist (CTC) was filled with information on case (n=324) and control (n=251) subjects, evaluated under the Portuguese Mental Health Act (Law 36/98), in three hospitals. For internal validation, we used Confirmatory Factor Analysis (CFA), testing unidimensional and bifactor models. Multilevel logistic regression model (MLL) was used to predict the odds ratio (OR) for compulsory treatment based on the total scale score. Receiver Operating Characteristic analysis (ROC) was performed to predict compulsory treatment. CFA revealed the best fit indexes for the bifactor model, with all items loading on one General factor and the residual loading in the a priori predicted four specific factors. Reliability indexes were high for the General factor (88.4%), and low for specific factors (<5%), which demonstrate that CTC should not be performed in the subscales to access compulsory treatment. MLL reveals that for each item scored in the scale, it increases the OR by 1.26 for compulsory treatment (95%CI 1.21-1.31, p<0.001). Based on the total score, accuracy was 90%, and the best cut-off point of 23.5 detects compulsory treatment with a sensitivity of 75% and specificity of 93.6%. The CTC presents robust internal structure with a strong unidimensional characteristic, and a cut-off point for compulsory treatment of 23.5. The improved 20-item version of the CTC could represent an important instrument to improve clinical decision regarding CPT, and ultimately to improve mental health care of patients with severe psychiatric disorders.
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Affiliation(s)
- Sofia Brissos
- Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal.
| | | | | | | | - Zita Gameiro
- Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal
| | | | - Mariana Pinto da Costa
- Hospital Magalhães Lemos, Porto, Portugal; Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal; Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, United Kingdom
| | | | - Eva Mendes
- Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Susana Renca
- Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Moeller SB, Novaco RW, Heinola-Nielsen V, Hougaard H. Validation of the Novaco Anger Scale–Provocation Inventory (Danish) With Nonclinical, Clinical, and Offender Samples. Assessment 2016; 23:624-36. [DOI: 10.1177/1073191115583713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anger has high prevalence in clinical and forensic settings, and it is associated with aggressive behavior and ward atmosphere on psychiatric units. Dysregulated anger is a clinical problem in Danish mental health care systems, but no anger assessment instruments have been validated in Danish. Because the Novaco Anger Scale and Provocation Inventory (NAS-PI) has been extensively validated with different clinical populations and lends itself to clinical case formulation, it was selected for translation and evaluation in the present multistudy project. Psychometric properties of the NAS-PI were investigated with samples of 477 nonclinical, 250 clinical, 167 male prisoner, and 64 male forensic participants. Anger prevalence and its relationship with other anger measures, anxiety/depression, and aggression were examined. NAS-PI was found to have high reliability, concurrent validity, and discriminant validity, and its scores discriminated the samples. High scores in the offender group demonstrated the feasibility of obtaining self-report assessments of anger with this population. Retrospective and prospective validity of the NAS were tested with the forensic patient sample regarding physically aggressive behavior in hospital. Regression analyses showed that higher scores on NAS increase the risk of having acted aggressively in the past and of acting aggressively in the future.
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Affiliation(s)
- Stine Bjerrum Moeller
- Psychiatric Center Capital Region, Psychiatric Research Unit, North of Zealand, Denmark
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Keune LH, de Vogel V, van Marle HJC. Methodological development of the Hoeven Outcome Monitor (HOM): A first step towards a more evidence based medicine in forensic mental health. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2016; 45:43-51. [PMID: 26922409 DOI: 10.1016/j.ijlp.2016.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.
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Affiliation(s)
- Lobke H Keune
- Research Department Van der Hoeven Kliniek, P.O. Box 174, 3500 DA, Utrecht, The Netherlands.
| | - Vivienne de Vogel
- Research Department Van der Hoeven Kliniek, P.O. Box 174, 3500 DA, Utrecht, The Netherlands.
| | - Hjalmar J C van Marle
- Forensic Psychiatry, Erasmus University Medical Centre and Erasmus School of Law Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, DP-0424, The Netherlands
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Cook TB, Brenner LA, Cloninger CR, Langenberg P, Igbide A, Giegling I, Hartmann AM, Konte B, Friedl M, Brundin L, Groer MW, Can A, Rujescu D, Postolache TT. "Latent" infection with Toxoplasma gondii: association with trait aggression and impulsivity in healthy adults. J Psychiatr Res 2015; 60:87-94. [PMID: 25306262 DOI: 10.1016/j.jpsychires.2014.09.019] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/03/2014] [Accepted: 09/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Latent chronic infection with Toxoplasma gondii (T. gondii), a common neurotropic pathogen, has been previously linked with suicidal self-directed violence (SSDV). We sought to determine if latent infection with T. gondii is associated with trait aggression and impulsivity, intermediate phenotypes for suicidal behavior, in psychiatrically healthy adults. METHODS Traits of aggression and impulsivity were analyzed in relationship to IgG antibody seropositivity for T. gondii and two other latent neurotropic infections, herpes simplex virus 1 (HSV1) and cytomegalovirus (CMV). One thousand community-residing adults residing in the Munich metropolitan area with no Axis I or II conditions by SCID for DSM-IV (510 men, 490 women, mean age 53.6 ± 15.8, range 20-74). Plasma samples were tested for IgG antibodies to T. gondii, HSV-1 and CMV by ELISA. Self-reported ratings of trait aggression scores (Questionnaire for Measuring Factors of Aggression [FAF]) and trait impulsivity (Sensation-Seeking Scale-V [SSS-V]) were analyzed using linear multivariate methods. RESULTS T. gondii IgG seropositivity was significantly associated with higher trait reactive aggression scores among women (p < .01), but not among men. T. gondii-positivity was also associated with higher impulsive sensation-seeking (SSS-V Disinhibition) among younger men (p < .01) aged 20-59 years old (median age = 60). All associations with HSV-1 and CMV were not significant. CONCLUSIONS Aggression and impulsivity, personality traits considered as endophenotypes for SSDV, are associated with latent T. gondii infection in a gender and age-specific manner, and could be further investigated as prognostic and treatment targets in T. gondii-positive individuals at risk for SSDV.
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Affiliation(s)
- Thomas B Cook
- Department of Public Health, Mercyhurst Institute for Public Health, Mercyhurst University, Erie, PA, USA
| | - Lisa A Brenner
- Veterans Integrated Service Network (VISN) 19, Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, USA; Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA; Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA; Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - C Robert Cloninger
- Department of Psychiatry, Sansone Centre for Well-Being, Washington University, St. Louis, MO, USA
| | - Patricia Langenberg
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ajirioghene Igbide
- DC Department of Behavioral Health, Saint Elizabeths Hospital, Psychiatry Residency Program, Washington, DC, USA
| | - Ina Giegling
- Department of Psychiatry, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Annette M Hartmann
- Department of Psychiatry, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Bettina Konte
- Department of Psychiatry, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Marion Friedl
- Department of Psychiatry, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lena Brundin
- Division of Psychiatry and Behavioral Medicine, College of Human Medicine, Michigan State University, Van Andel Research Institute, Grand Rapids, MI, USA
| | | | - Adem Can
- Department of Psychiatry, University of Maryland-Baltimore School of Medicine, Baltimore, MD, USA
| | - Dan Rujescu
- Department of Psychiatry, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Teodor T Postolache
- Veterans Integrated Service Network (VISN) 19, Mental Illness Research Education and Clinical Center (MIRECC), Denver, CO, USA; Department of Psychiatry, University of Maryland-Baltimore School of Medicine, Baltimore, MD, USA; Veterans Integrated Service Network (VISN) 5, Mental Illness Research Education and Clinical Center (MIRECC), Baltimore, MD, USA.
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Abstract
Schizophrenia without any comorbidity confers a modest, but statistically significant elevation of the risk for violence. That risk is considerably increased by comorbid antisocial personality disorder or psychopathy as well as by comorbid substance use disorders. These comorbidities are frequent. Conduct disorder and conduct disorder symptoms elevate the risk for aggressive behavior in patients with schizophrenia. Violence among adults with schizophrenia may follow at least two distinct pathways-one associated with premorbid conditions, including antisocial conduct, and another associated with the acute psychopathology of schizophrenia. Aggressive behavior in bipolar disorder occurs mainly during manic episodes, but it remains elevated in euthymic patients in comparison with controls. The risk of violent behavior is increased by comorbidity with borderline personality disorder, antisocial personality disorder, and substance use disorders. These comorbidities are frequent. Borderline personality disorder and bipolar disorder are related in their phenomenology and response to medication. These two disorders share a tendency to impulsiveness, and impulsive behavior, including impulsive aggression, is particularly expressed when they co-occur.
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Affiliation(s)
- Jan Volavka
- Emeritus of Psychiatry, New York University School of Medicine, PO Box 160663, Big Sky, MT, 59716, USA,
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Intracellular pathways of antipsychotic combined therapies: implication for psychiatric disorders treatment. Eur J Pharmacol 2013; 718:502-23. [PMID: 23834777 DOI: 10.1016/j.ejphar.2013.06.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/11/2013] [Accepted: 06/21/2013] [Indexed: 01/06/2023]
Abstract
Dysfunctions in the interplay among multiple neurotransmitter systems have been implicated in the wide range of behavioral, emotional and cognitive symptoms displayed by major psychiatric disorders, such as schizophrenia, bipolar disorder or major depression. The complex clinical presentation of these pathologies often needs the use of multiple pharmacological treatments, in particular (1) when monotherapy provides insufficient improvement of the core symptoms; (2) when there are concurrent additional symptoms requiring more than one class of medication and (3) in order to improve tolerability, by using two compounds below their individual dose thresholds to limit side effects. To date, the choice of drug combinations is based on empirical paradigm guided by clinical response. Nonetheless, several preclinical studies have demonstrated that drugs commonly used to treat psychiatric disorders may impact common intracellular target molecules (e.g. Akt/GSK-3 pathway, MAP kinases pathway, postsynaptic density proteins). These findings support the hypothesis that convergence at crucial steps of transductional pathways could be responsible for synergistic effects obtained in clinical practice by the co-administration of those apparently heterogeneous pharmacological compounds. Here we review the most recent evidence on the molecular crossroads in antipsychotic combined therapies with antidepressants, mood stabilizers, and benzodiazepines, as well as with antipsychotics. We first discuss clinical clues and efficacy of such combinations. Then we focus on the pharmacodynamics and on the intracellular pathways underpinning the synergistic, or concurrent, effects of each therapeutic add-on strategy, as well as we also critically appraise how pharmacological research may provide new insights on the putative molecular mechanisms underlying major psychiatric disorders.
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Richard-Devantoy S, Bouyer-Richard AI, Jollant F, Mondoloni A, Voyer M, Senon JL. [Homicide, schizophrenia and substance abuse: a complex interaction]. Rev Epidemiol Sante Publique 2013; 61:339-50. [PMID: 23816066 DOI: 10.1016/j.respe.2013.01.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 01/15/2013] [Accepted: 01/29/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND AIM The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia. METHODS A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively. RESULTS Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not. CONCLUSION Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.
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Affiliation(s)
- S Richard-Devantoy
- McGill University, Department of Psychiatry & Douglas Mental Health University Institute, McGill Group for Suicide Studies, FBC building, 3rd floor, 6875, boulevard Lassalle, Montréal (Qc), H3W 2N1, Canada.
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