Psychiatric Reports Research Articles

Physical and/or Sexual Abuse Is Associated with Increased Psychological and Emotional Distress Among Transgender Women.

Transgender women have consistently reported elevated rates of lifetime physical and sexual abuse. This study examined the associations between reported physical and/or sexual abuse and symptoms of psychological and emotional distress among a sample of urban, high-risk transgender women. From June 2005 through July 2012, 99 transgender women enrolled in a Comprehensive Risk Counseling and Services program in Hollywood, CA. Seemingly unrelated regression equations (SURE) were used to simultaneously regress psychiatric symptom reports on participant sociodemographic characteristics and self-reported history of physical/sexual abuse. Participants were African American/Black (33.3%), Caucasian/White (28.3%), or Hispanic/Latina (24.2%). Average age was 35 years (standard deviation [SD] = 9), and 37.4% of participants self-reported an HIV-positive status. Most (84.9%) participants reported experiencing physical or sexual abuse at some point in their lifetime, and symptoms of psychological and emotional distress (as measured by the Brief Symptom Inventory) among those who reported abuse were more severe than those observed in cisgender psychiatric in-patient populations. After controlling for participant sociodemographics, prior experience of physical and/or sexual abuse was associated with significantly increased psychological and emotional distress across all measured symptom domains except psychoticism [χ2(9) = 17.56; p < 0.05]. Given these associations as well as the high prevalence of physical and/or sexual abuse among transgender women, mental health professionals and social service providers working with this population should be sensitive to the abuse history and mental health needs of the transgender women with whom they work.

Quantitative sensory testing measures individual pain responses in emergency department patients.

BackgroundRefining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients.Materials and methodsIn three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests.ResultsFirst, all QST measures had high inter-rater reliability and test–retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen’s dz 0.10–0.19). Verbal pain scores (0–10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen’s dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05–0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen’s dz 0.26–0.43) or with baseline hyperalgesia (Cohen’s dz 0.40–0.88).ConclusionQST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.

Trends in rates and characteristics of intimate partner homicides between 1990 and 2013

PurposeResearch addressing intimate partner homicide (IPH) across time and gender is lacking. The present study compares rates of IPH and non-intimate partner homicide (non-IPH) over time. Moreover, gender-specific trends of IPH rates and characteristics are examined. MethodsThe study is based on all solved homicides (N=1725) in Sweden between 1990 and 2013. The dataset is an extension of the European Statistical Database on Lethal Violence and holds information from police files, court verdicts and forensic psychiatric reports. ResultsThere has been a significant decrease of IPHs and non-IPHs, although, IPHs remained relatively stable until 2006. While there has been a modest decline in male-perpetrated IPHs, the low rates of female-perpetrated IPHs have remained stable. Male-perpetrated IPHs are gradually less likely to involve alcohol and be preceded by known history of IPV. The majority of female-perpetrated IPHs involved alcohol and history of known IPV, characteristics that remained stable over time. ConclusionsIt is crucial to consider intimate relationships as well as gender in order to gain nuanced insight to trends of homicide rates and characteristics. Our findings demonstrate distinct trends across homicide types, as well as gender-specific rates and characteristics of IPH.

Impact of the 2015 CMS Inpatient Psychiatric Facility Quality Reporting Rule on Tobacco Treatment.

In its fiscal year 2015 final rule, the Centers for Medicare & Medicaid Services (CMS) required reporting of tobacco treatment quality measures as part of the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS). This pre-intervention, post-intervention policy analysis evaluates the impact of that policy at a large academic medical center that opted to improve performance as it implemented reporting measures. Electronic medical record data were collected retrospectively for all adult (≥18 years) inpatient psychiatric admissions from January 1, 2014 to December 31, 2015. Data from admissions were analyzed to determine changes in the provision of tobacco treatment including the proportions of patients screened for tobacco use, receiving tobacco cessation counseling, and receiving tobacco cessation medication(s) using a chi-square test. Covariate analysis of treatment differences based on psychiatric diagnosis was analyzed using Cochran-Mantel-Haenszel and Breslow-Day test. Post-policy screening for admissions increased significantly (85% vs. 97%; p < .001). Referral to cessation counseling increased 18-fold (4% vs. 74%; p < .001). Receipt of Counselling (8% vs. 67%; p < .001) and referral for cessation medication (32% vs. 68%; p < .001) also increased dramatically. Though statistically non-significant, the number of tobacco users who actually received medications increased markedly between 2014 and 2015, 24% versus 35%. Gains in screening, referral, and treatment did not differ by psychiatric diagnosis. The Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program resulted in a 10-fold increase in the number of smokers who received inpatient tobacco treatment. Should CMS link prospective payment to performance, it could have a major impact on quality of care for tobacco dependence. This is the first study to examine the implementation and impact of new 2015 IPFQR program tobacco measures. This study may illustrate the potential effect that performance based penalties can have should facilities be required to do more than simply report on these tobacco measures. This study exemplifies the impact these new reporting measures can have when psychiatric facilities move beyond letter of the policy, to continually assess organizational performance and implement changes to improve treatment delivery.

Do seriously offending girls differ from their age- and offence type-matched male counterparts on psychopathic traits or psychopathy-related background variables?

BackgroundMore research is needed to improve our understanding of the manifestation of psychopathic traits in violently offending girls. Our aim here was to assess psychopathic traits and psychopathy-related background variables in a Finnish nationwide consecutive sample of girls charged with violent crimes and referred to a pretrial forensic psychiatric examination. These girls were then compared to their male counterparts.MethodsThe forensic psychiatric examination statements of 15- to 17-year-old juveniles who underwent a pretrial forensic psychiatric examination over a 31-year period (1980–2010) were reviewed. For each non-psychotic girl with a normal IQ (n = 25), an age- and offence type-matched male control was randomly selected. Offence and offender characteristics were collected from the forensic psychiatric examination reports, and a file-based assessment of psychopathic traits was performed using the Hare psychopathy checklist-youth version.ResultsApproximately every third girl exhibited high traits of psychopathy, and no significant difference was observed between the genders. Focusing on the underlying factor and item scores, the girls scored significantly lower than boys on the Antisocial factor. Their interpersonal relationships were significantly more unstable and they significantly more often exhibited a history of child sexual abuse. During the index offence the girls were significantly less frequently intoxicated, and their victims were significantly more often family members or current or ex-intimates but significantly less often strangers.ConclusionsAlthough violently offending girls and boys do not differ on psychopathy total scores, significant gender differences exist on underlying factor and item scores as well as in background- and offence-related variables. Interventions should take into account these special features of violent girls.

Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho, Rio de Janeiro, Brazil.

Objectives:To evaluate factors related to dangerousness cessation at the end of involuntary commitment based on an analysis of expert reports. In light of the current legal requirement of dangerousness cessation as a pre-requisite for prison or internment release of individuals subjected to the safety measure, we sought elements to reflect on the practice of expert examiners in charge of making this decision.Methods:The authors revised 224 expert psychiatric dangerousness cessation reports released 2011 through 2014 and collected data for a statistical analysis.Results:The following variables were associated with positive risk cessation assessments: no inadequate behavior (according to the assistant professionals), no productive psychotic symptoms, no negative symptoms, presence of insight, presence of a support network, and no psychoactive substance abuse. The following variables were associated with negative dangerousness cessation decisions: early onset of malfunction, lack of insight, negative attitudes, active signs of major mental illness, presence of impulsiveness, poor response to treatment, presence of plans lacking feasibility, exposure to destabilizing factors, lack of personal support, and presence of stress.Conclusions:In this study we were able to identify factors associated with dangerousness in a sample of expert reports. The knowledge of factors linked to a higher risk of recidivism in illegal activities or violent behavior is crucial for decision-making regarding the release of offenders after their legally established period of involuntary commitment.

Meaning Therapy for Addictions

Evidence from existential–humanistic psychology suggests that addiction is a response to boredom, loneliness, meaninglessness, and other existential struggles. This research is a case study of an existential, meaning-centered therapy practiced at an addiction treatment facility. Meaning therapy assumes that addiction is a response to a life that lacks personal meaning. The solution, therefore, is to help the client live a fulfilling life. The research question asked if, and in what ways, meaning therapy influenced how participants made sense of their addiction and recovery. The study used a mixed-methods design. Sources of qualitative data were pretreatment and posttreatment interviews, psychiatric reports, researcher field notes, and participants’ life stories. Quantitative data were pretreatment and posttreatment measures of items relevant to meaning and symptom reduction. Eleven participants volunteered for the study. Themes that emerged during a grounded theory thematic analysis revealed that therapy positively influenced nine (81.8%) participants in developing self-definition, interpersonal relatedness, and intrinsic motivation. Quantitative analysis revealed significant increases in measures of meaning and decreases in symptoms and daily problems for seven participants (63.6%). About 6 to 9 months posttreatment, eight participants (72.7%) who pursed self-definition, relatedness, and intrinsic motivation reported abstinence since discharge, fewer symptoms and problems in daily life, and the pursuit of personal goals. This study provides therapists with a better understanding of meaning therapy and suggests implications for addiction treatment.

Children's disclosure of sexual abuse during early forensic psychiatric evaluation in Southern Taiwan.

Many surveys of child sexual abuse (CSA) in Western countries focus on the victims' disclosures and their associated factors during forensic interviews, but similar data in Asian countries is scarce. We explored the disclosure rate of CSA allegations during forensic interviews in South Taiwan and the factors predicting such disclosure. We compared our findings with those of previous studies. Data were collected from written forensic psychiatric reports of CSA victims who underwent early forensic psychiatric evaluation at two hospitals in Kaohsiung City from 2010 to 2015. All cases were divided into categories of full or nonfull disclosures. We identified the variables that distinguished between the two groups in bivariate analyses using the independent t test and the Chi-square test. Binary logistic regression analysis was done to determine whether those significant correlates in the bivariate analyses were independent predictors of full disclosure. Among the 55 cases, 32 (58%) were full disclosures. Older age at first interview (odds ratio=1.39), no diagnosis of mental retardation (odds ratio=0.04), and experiencing sexual abuse more than once (odds ratio=5.90) were positive factors independently related to the full disclosure of CSA allegations. The rate of disclosure under the program was comparable to that of prior studies. This may suggest a role for early forensic psychiatric evaluation of children to promote disclosure of CSA allegations. We hope the findings may serve as a basis for future studies of CSA disclosure and associated factors in Taiwanese society.

Crossing the bridge – A prospective comparative study of the effect of communication between a hospital based consultation-liaison service and primary care on general practitioners' concordance with consultation-liaison psychiatrists' recommendations

ObjectiveConcordance with consultation-liaison (CL) psychiatrists' recommendations by general practitioners (GP) has hardly been studied systematically. We studied if telephone calls or written notes from a hospital based CL-service to GPs, whose patients were treated on medical-surgical wards, can improve GP-concordance, as compared to the usual communication pathway by standard discharge letters written by hospital physicians, and if higher GP-concordance improves outcomes of depressive and anxious symptoms. Methods116 inpatients of a general hospital referred to a CL-service with depression and anxiety were allocated to three groups of communication pathways between CL-service and GPs: (1) A telephone call (TC) by CL-psychiatrists with GPs, (2) a copy of the psychiatric consultation report (CR) was handed out to patients, (3) GPs received standard discharge letters of the hospital physicians (communication as usual, CAU). Six weeks after the CL-episode, patients were phoned at home and asked about implementation of recommendations by their GP's. The Hospital Anxiety and Depression Scale (HADS) was used to monitor anxious and depressive symptoms. ResultsGP-concordance was highest in the TC group, followed by the CR group with significant improvements in medication and psychotherapeutic recommendations compared to CAU. Higher concordance was associated with a significant greater decrease in HADS depression scores but not anxiety scores after 6weeks. ConclusionTelephone communication between CL-psychiatrists and GPs improve GPs' concordance with psychiatric recommendations. This easy-to-implement intervention takes about 10min time but prevents loss of information. It may enhance quality of GPs' mental health care and lead to improved outcomes.

Insane or evil? How Norway’s Dagbladet and Aftenposten newspapers covered the perpetrator of 22 July 2011

Abstract This article investigates how the two Norwegian newspapers Aftenposten and Dagbladet framed the reporting about Anders Behring Breivik (henceforth Breivik) in the aftermath of the terror attacks at the government building in Oslo, leaving eight dead behind, and the killing of 69 young people at the AUF youth summer camp on Utøya on 22 July 2011. On the basis of critical discourse analysis, Robert Entman’s framing theory and theories about enemy images, we have analysed a selection of articles from a total sample of 1323 articles covering landmark periods related to the attacks of 22 July 2011: the immediate reaction (22–29 July); the meeting in court to prepare the trial (14–15 November); and the presentation of first psychiatric report (29–30 November). Did the media speculate, before Breivik’s identity was known, on the possibility that Muslim extremists were responsible? An analysis of the editorials in Aftenposten and Dagbladet concludes that Aftenposten hypothesized that Muslims might be behind the attack, while Dagbladet mostly avoided such speculation. The divergence in representation is reiterated in the interviews the authors conducted with the two newspapers’ editors. After Breivik’s identity became known we found three dominating frames, the perpetrator as a ‘right-wing extremist’, as an ‘insane person’ or as an ‘attention-seeker’. The framing analysis show that the ‘insane’ frame was the most usual in both Aftenposten and Dagbladet, followed by the ‘extreme right wing’ frame and ‘the attention-seeker’ frame. The article discusses how this framing might have influenced the long-term consequence for public debate in Norway.

Madness and crime: Zefinha, the longest confined woman in Brazil.

Living in a forensic hospital for the last 38 years, Josefa da Silva is the longest female inhabitant surviving the penal and psychiatric regime in Brazil. This paper analyses dossier, judicial proceedings, interviews and photographs about her. The psychiatric report is the key component of the medical and penal doubling of criminal insanity. Twelve psychiatric reports illustrate three time frames of the court files: abnormality, danger, and abandonment. The psychiatric authority over confinement has moved from discipline to security, and from disciplinary security to social assistance. In the arrangement between the penal and psychiatric powers, the judge recognizes the medical authority over the truth of insanity. It is the medicine of the reasons for Zefinha's internment that altered over the decades.

Parricide cases of adult offenders from Turkey: A descriptive study

The aim of this study was to examine and compare similarities and differences among types of parricide committed by adult offenders. The forensic psychiatric evaluation reports of the 4th Specialization Board of the Council of Forensic Medicine from 2009 to 2011 in Turkey were screened retrospectively. One hundred thirty-five adult perpetrators of parricide (125 male, 10 female) were detected, 51.9% of whom committed patricide, 40% of whom matricide and 8.1% of the perpetrators committed double parricide. Most of the perpetrators used sharp instruments as the killing method. No mental disorders were detected in 58.5% of the perpetrators, while psychotic disorders were identified in 30.4% of the cases. This study supported the predominance of sharp instruments as the killing method and a preponderance of matricide among the offenders with psychotic disorders. Although psychotic disorders were the most commonly detected mental disorders in the parricide offenders, most of them did not suffer from mental disorders.

The temporal fluctuations and characteristics of psychiatric inpatient admissions in Ireland: data from the HRB's National Psychiatric In-Patient Reporting System.

This paper examines trends in psychiatric inpatient admissions from the 1960s to 2014 and uses data from the National Psychiatric Inpatient Reporting System (NPIRS) to review these trends. In the 1960s the Department of Health began an annual system of reporting on the activities in Irish psychiatric units and hospitals on foot of the recommendations of the Commission of Inquiry on Mental Illness. The National Psychiatric Inpatient Reporting System (NPIRS) was established shortly thereafter and this paper discusses the data from this database contained in these annual activity reports over the last 50 years.

Major mental disorders, gender, and criminological circumstances of homicide

ObjectiveTo examine the criminological circumstances of homicide in a group of French murderers with and without major mental disorders (MMD) stratified by the perpetrator's gender. MethodsSociodemographic, clinical, and criminological variables were collected from the psychiatric expert reports of 210 cases of homicide heard at the High Court of Angers, France. Murderers were categorized according to MMD diagnosis and gender. ResultsAmong 210 murderers, 17.6% (n = 37) had a MMD (20% of the female perpetrators). Logistic regression models showed that being a murderer with a MMD was associated with younger age (adjusted Odds Ratio OR = 1.03, P = 0.034), high school education (OR = 2.48, P = 0.036), previous use of psychiatric services (OR = 4.75, P = 0.003), alcohol intoxication (OR = 2.71, P = 0.027), and delusional state (OR = 3.96, P = 0.002) at the time of the homicide. Multiple correspondence analyses showed that female murderers with a MMD were more prone to have depression and to use drowning as a method than those without a MMD, and that male murderers with a MMD more often had a high school education and delusional beliefs at the time of the homicide than those without a MMD. ConclusionSpecific profiles of criminological circumstances of homicide could help to explore the risk of homicide in female and male patients with a MMD.

Homicide offending and its main determinants in patients with schizophrenia or bipolar mood disorders

Aim of the studyThis study aimed to assess the prevalence of homicide in those patients suffered from schizophrenia or bipolar mood disorders and also determine main underlying determinants of this violent behavior in the patients.Subject or material and methodsIn a retrospective study, the characteristics of 600 consecutive patients hospitalized at Farabi hospital in kermanshah with one of the main diagnosis of schizophrenia or bipolar mood disorders were reviewed. In this regard, diagnosis of schizophrenia (n = 300) and bipolar mood disorders (n = 300) was made by the psychiatric report and based on the DSM-IV criteria. Study information was collected by reviewing hospital recorded files.ResultsAmong schizophrenic patients, 13.3% were committing homicide and homicide offending was prevalent in 20.0% of those with the diagnosis of bipolar mood disorders. In both groups, more than two-third of offending homicide were male and more than half of them were younger than 30 years. In schizophrenics, the main trigger of homicide was delusional beliefs (50.0%) followed by auditory hallucinations (50.0%). Also, in those who suffered bipolar mood disorders, the main triggers of homicide included paranoid delusional beliefs in 73.3%, excitement, irritability and impulsive behavior in 20.0%, and auditory hallucinations in 6.6%.DiscussionThe observed high prevalence of homicide in these patients highlights the importance of psychopathy assessment among violence-prone individuals with schizophrenia and bipolar mood disordersConclusionsA notable number of our psychological affected patients with schizophrenia or bipolar mood disorders experience homicide that is considerably more prevalent in men, in younger ages, and in those with delusional beliefs

Assessing illness- and non-illness-based motivations for violence in persons with major mental illness.

Research on violence perpetrated by individuals with major mental illness (MMI) typically focuses on the presence of specific psychotic symptoms near the time of the violent act. This approach does not distinguish whether symptoms actually motivate the violence or were merely present at the material time. It also does not consider the possibility that non-illness-related factors (e.g., anger, substance use), or multiple motivations, may have been operative in driving violence. The failure to make these distinctions clouds our ability to understand the origins of violence in people with MMI, to accurately assess risk and criminal responsibility, and to appropriately target interventions to reduce and manage risk. This study describes the development of a new coding instrument designed to assess motivations for violence and offending among individuals with MMI, and reports on the scheme's interrater reliability. Using 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, we found that independent raters were able to assess different motivational influences for violence with a satisfactory degree of consistency. More than three-quarters (79.2%) of the sample were judged to have committed an act of violence as a primary result of illness, whereas 20.8% were deemed to have offended as a result of illness in conjunction with other non-illness-based motivating influences. Current findings have relevance for clarifying the rate of illness-driven violence among psychiatric patients, as well as legal and clinical issues related to violence risk and criminal responsibility more broadly.

A Retrospective Review of Screening Labs for Medical Clearance in a Military Population.

We determine the incidence of clinically significant findings within mandatory screening studies during medical clearance of patients for psychiatric care. This is a retrospective review of emergency department patients medically cleared for psychiatric care over 11 months. All patients evaluated for behavioral health-related issues are recorded on a daily report which was used to locate subjects. Laboratory studies were reviewed during that visit for the presence of abnormalities. If abnormalities were noted, the individual chart was reviewed. Our primary outcome was the incidence of clinically significant findings that warranted admission to a medical or surgical unit. 204 psychiatric patient reports were reviewed. 191 of these patients had screening studies performed. Seven patients were admitted to a nonpsychiatric unit. These admissions were all for elevated ethanol levels. These patients were admitted until their ethanol level decreased, and then transferred to a psychiatric facility. The total screening lab cost during this study period was $27,893. Routine screening has limited utility in this population and comes at significant cost. Further research should be directed to determine which patients may benefit from screening studies.

Developmental Timing of Trauma Exposure Relative to Puberty and the Nature of Psychopathology Among Adolescent Girls

Increased neuroplasticity and neural development during puberty provide a context for which stress and trauma can have dramatic and long-lasting effects on psychological systems; therefore, this study was designed to determine whether exposure to potentially traumatic events during puberty uniquely predicts adolescent girls' psychopathology. Because neural substrates associated with different forms of psychopathology seemingly develop at different rates, the possibility that the developmental timing of trauma relative to puberty predicts the nature of psychopathology (posttraumatic stress disorder [PTSD], depressive, and anxiety disorders) was examined. A subset of 2,899 adolescent girls from the National Comorbidity Survey Replication-Adolescent Supplement who completed the study 2+ years postmenarche was selected. Past-year psychiatric disorders and reports of age of trauma exposure were assessed using the Composite International Diagnostic Interview. Developmental stages were defined as the 2 years after the year of menarche ("postpuberty"), 3 years before and year of menarche ("puberty"), 2 to 6 years before the puberty period ("grade school"), and 4 to 5 years after birth ("infancy-preschool"). Compared to other developmental periods, trauma during puberty conferred significantly more risk (50.47% of model R(2)) for girls' past-year anxiety disorder diagnoses (primarily social phobia), whereas trauma during the grade school period conferred significantly more risk (47.24% of model R(2)) for past-year depressive disorder diagnoses. Recency of trauma best predicted past-year PTSD diagnoses. Supporting rodent models, puberty may be a sensitive period for the impact of trauma on girls' development of an anxiety disorder. Trauma prepuberty or postpuberty distinctly predicts depression or PTSD, suggesting differential etiological processes.

Resource Document on Psychiatric Violence Risk Assessment

The APA published a Task Force report, “Clinical Aspects of the Violent Individual,” in 1974 (1). Since then, the assessment of violence risk by psychiatrists has assumed increased prominence (2, 3). At the same time, significant changes have taken place both in the contexts in which psychiatrists assess risk and in the techniques that help them do so. Although violence risk assessment has become more prominent in the last 40 years, assessing the various forms of clinical risk has always been integral to psychiatry. It is a necessary part of providing safe and effective outpatient psychiatric care. It is essential element also of proper decision making around hospital admission and discharge and of providing a safe environment to patients and those who care for them. Risk assessment and risk management are practiced in a diverse array of settings, including emergency rooms, hospital consultation services and outpatient clinics. Like other aspects of psychiatric practice, risk assessment is a potential source of legal liability. Psychiatric risk assessments are also used by courts to help them make a range of important decisions, including the involuntary commitment of patients to hospitals and those concerning child custody. In criminal cases, psychiatric judgments inform decisions concerning the placement of mentally disordered defendants prior to trial and the sentences the same defendants receive if convicted (4). Often, as with civil commitment proceedings and the appointment of a conservator, psychiatrists have to provide evidence on risk while continuing to provide care to the patient. As with other aspects of risk assessment in legal settings, the needs of courts can present ethical challenges to clinicians which are different from those encountered in other areas of psychiatric practice. This document reviews the changes that have occurred since 1974 in the context in which psychiatric risk assessment is conducted, the processes by which risk is assessed, the accuracy that can be expected of psychiatrists seeking to assess risk and the ethics of risk assessment. The general principles outlined here are intended to provide a background to the detailed descriptions of risk assessment and management covering particular patient groups, such as children and adolescents, and particular areas of psychiatric practice, such as psychiatric report writing (5), that have been published since 1974.

Experience and Diagnostic Anchors in Referral Letters

Abstract. The present study investigated whether diagnostic anchors, that is: diagnoses suggested in referral letters, influence judgments made by clinical psychologists with different levels of experience. Moderately experienced clinicians (N = 98) and very experienced clinicians (n = 126) were randomly assigned to reading a referral letter suggesting either depression or anxiety, or no referral letter. They then read a psychiatric report about a depressed patient, and gave a preliminary and final diagnosis. Results showed that the correctness of the diagnoses by very experienced clinicians was unaffected by the referral diagnosis. Moderately experienced clinicians did use the suggested diagnosis as anchor; when they had read a referral letter suggesting depressive complaints they were more inclined to classify the patient with a depressive disorder. In conclusion, the diagnosis in a referral letter influences the diagnostic decision made by moderately experienced clinicians.