Giancarlo Nivoli

Murder of the doctor

Methods We review and discuss the recent evidence on the presence of mixed features during mania and depression and summarise findings on the conceptualisation of mixed states. Electronic searches of all English-language papers were performed in the MEDLINE and PUBMED database using and cross-listing key words: mixed state, mixed features, bipolar disorder, major depressive disorder, mania, hypomania, depression.AIM To examine possible risk factors for the doctor to be killed by the patient in the clinical practice by examining a series of murders that involved physicians. METHODS This aim has been achieved through a retrospective review on clinical cases of doctors killed by patients within the period between 1988 and 2013, in Italy. RESULTS In this period 18 Italian doctors have been killed in the workplace, with a rate of 0.3/100,000. In 7 cases, the murder resulted in the context of doctor-dissatisfaction; in 7 cases the murder was committed by a psychiatric patient; 1 case in the context of a stalking; 3 cases occurred in a workplace which was not safe enough. Four categories of at-risk contexts have been identified. One category includes a murder in the context of a doctor-dissatisfaction, perceived by patient. The second category concerns murders committed by patients suffering from mental illness. A third category includes homicides in a workplace which is not safe. The last category comprises the murder in the context of stalking. CONCLUSIONS These categories identify specific dangerous situations for physicians, in which are highlighted elements that have played a crucial role in the murder and for which special precautions are suggested preventive.

[Psychiatrist's professional liability for generic, brand, and off-label drug prescription].

At present, drug prescription is a hot topic in terms of professional responsibility. Psychiatric-forensic criteria are provided for appropriate drug prescription, focusing on off-label and generic drug prescription. Off-label prescription should be made in accordance with current regulations, in particular with the regulatory requirements related to patient consent. Generic drug prescription is affected by several critical issues, such as drug excipients, equivalence to original drug, correspondence of therapeutic indications. The different spheres of responsibility of physicians and apothecaries in prescribing and distributing drugs, respectively, are discussed. The knowledge of these issues can be helpful for physicians in their clinical practice, allowing preservation of professional autonomy and compliance with current regulations. The explanation of the most common mistakes about drug prescription that are examined in law courts can be the starting point of an interdisciplinary debate involving all interested parties that are called upon to judge psychiatrist responsibility in drug prescription.At present, drug prescription is a hot topic in terms of professional responsibility. Psychiatric-forensic criteria are provided for appropriate drug prescription, focusing on off-label and generic drug prescription. Off-label prescription should be made in accordance with current regulations, in particular with the regulatory requirements related to patient consent. Generic drug prescription is affected by several critical issues, such as drug excipients, equivalence to original drug, correspondence of therapeutic indications. The different spheres of responsibility of physicians and apothecaries in prescribing and distributing drugs, respectively, are discussed. The knowledge of these issues can be helpful for physicians in their clinical practice, allowing preservation of professional autonomy and compliance with current regulations. The explanation of the most common mistakes about drug prescription that are examined in law courts can be the starting point of an interdisciplinary debate involving all interested parties that are called upon to judge psychiatrist responsibility in drug prescription.

La pericolosità sociale psichiatrica tra attualità e criticità

L’evoluzione della legislazione in tema di assistenza psichiatrica a partire dal 1978 non e stata accompagnata da una parallela trasformazione dell’interfaccia giuridica; la posizione del malato di mente autore di reato considerato incapace di intendere e volere continua ad essere sottoposta al giudizio di pericolosita sociale psichiatrica con le conseguenti misure di sicurezza, su cui si regge l’esistenza dell’Ospedale Psichiatrico Giudiziario. In questa prospettiva il trattamento del paziente psichiatrico autore di reato si configura come estremamente complesso e gravato dalla irrisolta antinomia cura/custodia. Tuttavia l’abolizione della presunzione di pericolosita ha modulato l’applicazione stessa delle misure di sicurezza verso assetti piu terapeutici. Le criticita di percorso riguardano la valutazione della pericolosita sociale, la individuazione di luoghi di trattamento appropriati, la opportunita di interventi mirati al comportamento violento e non ultimo il profilo di responsabilita dello psichiatra.

Problemi gestionali delle gravi manifestazioni aggressive : Criminalità e spettro dell'umore

La maggior parte dei crimini con violenza sulla persona non avviene, come sembrerebbe ad un’analisi superficiale, in modo improvviso, come un «fulmine a ciel sereno», ma segue varie «tappe progressive», non sempre facili da identificare ma indispensabili per una comprensione del crimine e soprattutto per la sua prevenzione. La diagnosi psichiatrica del paziente formulata il giorno successivo alla messa in atto di un gesto criminale o violento e indispensabile, ma non e sufficiente. Non e necessariamente la stessa diagnosi dell’esame psichiatrico anamnestico prima del fatto e soprattutto non e necessariamente uguale alla diagnosi psichiatrica durante il fatto. Ad esempio, molte donne che hanno ucciso il figlio nel corso di una psicosi post-partum si presentano dopo l’omicidio con una sintomatologia prevalentemente depressiva, mentre al momento del gesto presentavano una sintomatologia piu facilmente riconducibile ad uno stato espansivo o misto, ed ancora prima del gesto presentavano non solo un temperamento irritabile in un contesto d’incapacita genitoriale. Ignorare l’evoluzione della psicopatologia psichiatrica, in generale e soprattutto in relazione alla criminalita, non permette una valutazione e un trattamento adeguati. E infine utile e necessario ricordare che comportamenti criminali e suicidio sono fenomeni ad eziologia multifattoriale in cui entrano in gioco variabili biologiche, psicologiche, psichiatriche, sociali, ideologiche ecc. In questo senso la diagnosi e la terapia (farmacologica o psicoterapica) sono di stretta competenza psichiatrica ed utili per la comprensione della criminalita ma non sufficienti perche non costituiscono gli unici fattori causali.