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Mass shootings account for a small fraction of annual worldwide murders, yet disproportionately affect society and influence policy. Evidence suggesting a link between mass shootings and severe mental illness (i.e. involving psychosis) is often misrepresented, generating stigma. Thus, the actual prevalence constitutes a key public health concern.
We examined global personal-cause mass murders from 1900 to 2019, amassed by review of 14 785 murders publicly described in English in print or online, and collected information regarding perpetrator, demographics, legal history, drug use and alcohol misuse, and history of symptoms of psychiatric or neurologic illness using standardized methods. We distinguished whether firearms were or were not used, and, if so, the type (non-automatic v. semi- or fully-automatic).
We identified 1315 mass murders, 65% of which involved firearms. Lifetime psychotic symptoms were noted among 11% of perpetrators, consistent with previous reports, including 18% of mass murderers who did not use firearms and 8% of those who did (χ2 = 28.0, p < 0.01). US-based mass shooters were more likely to have legal histories, use recreational drugs or misuse alcohol, or have histories of non-psychotic psychiatric or neurologic symptoms. US-based mass shooters with symptoms of any psychiatric or neurologic illness more frequently used semi-or fully-automatic firearms.
These results suggest that policies aimed at preventing mass shootings by focusing on serious mental illness, characterized by psychotic symptoms, may have limited impact. Policies such as those targeting firearm access, recreational drug use and alcohol misuse, legal history, and non-psychotic psychopathology might yield more substantial results.
Although the DSM is a widely used diagnostic guide, lengthy criteria sets can be problematic and provide the primary motivation to identify short-forms. Using the 11 diagnostic criteria provided by the DSM-5 for alcohol use disorder (AUD), the present study develops a data-driven method to systematically identify subsets and associated cut-offs that yield diagnoses as similar as possible to use all 11 criteria.
Relying on data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), our methodology identifies diagnostic short-forms for AUD by: (1) maximizing the association between the sum scores of all 11 criteria with newly constructed subscales from subsets of criteria; (2) optimizing the similarity of AUD prevalence between the current DSM-5 rule and newly constructed diagnostic short-forms; (3) maximizing sensitivity and specificity of the short-forms against the current DSM-5 rule; and (4) minimizing differences in the accuracy of the short-form across chosen covariates. Replication is shown using NESARC-Wave 2.
More than 11 000 diagnostic short-forms for DSM-5 AUD can be created and our method narrows down the optimal choices to eight. Results found that ‘Neglecting major roles’ and ‘Activities given up’ could be dropped with practically no change in who is diagnosed (specificity = 100%, sensitivity ⩾ 99.6%) or the severity of those diagnosed (κ = 0.97).
With a continuous improvement model adopted by the APA for DSM revisions, we offer a data-driven tool (a SAS Macro) that identifies diagnostic short-forms in a systematic and reproducible way to help advance potential improvements in future DSM revisions.
Whole genome and exome sequencing (WGS/WES) techniques raise hope for a new scale of diagnosis, prevention, and prediction of genetic conditions, and improved care for children. For these hopes to materialize, extensive genomic research with children will be needed. However, the use of WGS/WES in pediatric research settings raises considerable challenges for families, researchers, and policy development. In particular, the possibility that these techniques will generate genetic findings unrelated to the primary goal of sequencing has stirred intense debate about whether, which, how, and when these secondary or incidental findings (SFs) should be returned to parents and minors. The debate is even more pronounced when the subjects are adolescents, for whom decisions about return of SFs may have particular implications. In this paper, we consider the rise of “genomic citizenship” and the main challenges that arise for these stakeholders: adolescents' involvement in decisions relating to return of genomic SFs, the types of SFs that should be offered, privacy protections, and communication between researchers and adolescents about SFs. We argue that adolescents' involvement in genomic SF-related decisions acknowledges their status as valuable stakeholders without detracting from broader familial interests, and promotes more informed genomic citizens.
Large-scale sequencing tests, including whole-exome and whole-genome sequencing (WES/WGS), are rapidly moving into clinical use. Sequencing is already being used clinically to identify therapeutic opportunities for cancer patients who have run out of conventional treatment options, to help diagnose children with puzzling neurodevelopmental conditions, and to clarify appropriate drug choices and dosing in individuals. To evaluate and support clinical applications of these technologies, the National Human Genome Research Institute (NHGRI) and National Cancer Institute (NCI) have funded studies on clinical and research sequencing under the Clinical Sequencing Exploratory Research (CSER) program as well as studies on return of results (RoR). Most of these studies use sequencing in real-world clinical settings and collect data on both the application of sequencing and the impact of receiving genomic findings on study participants. They are occurring in the context of controversy over how to obtain consent for exome and genome sequencing.
In an explicit attempt to reduce physician paternalism and encourage patient participation in making health care decisions, the informed consent doctrine has become a foundational precept in medical ethics and health law. The underlying ethical principle on which informed consent rests — autonomy — embodies the idea that as rational moral agents, patients should be in command of decisions that relate to their bodies and lives. The corollary obligation of physicians to respect and facilitate patient autonomy is reflected in the rules that have been created to implement consent procedures, especially those requiring disclosure of relevant information.
However, there are many practical impediments to patient self-determination in health care decisionmaking. Well-meaning physicians often lack the time to live up to the ideal of facilitating genuine, informed deliberation with and by their patients, and many lack the motivation or skill to do so successfully.
Background: This study aimed to assess if decisional capacity and the four decision-making abilities related to decisions concerning medication management were impaired among community-dwelling Chinese older persons in Hong Kong with amnestic mild cognitive impairment (MCI) and mild Alzheimer's disease (AD), as compared with cognitively normal older adults.
Methods: Two hundred and ninety-one Chinese community-dwelling older adults were recruited. The four decision-making abilities and decisional capacity were assessed by using the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED) and independent clinician ratings based on the definition in the UK Mental Capacity Act 2005, respectively.
Results: Ninety-nine participants (34%) were diagnosed with MCI and ninety-five (33%) with mild AD. Although almost all (96%) of the participants in the MCI group were found to be mentally competent to make decisions on medication management in clinician ratings, their decision-making abilities as measured by the ACED were significantly lower than those of the cognitively normal controls.
Conclusions: Results from this study suggest that abilities related to decisions on medication management are impaired before the clinical diagnosis of dementia is made. Use of specific and structured assessment of the relevant decisional abilities may enhance clinical judgment.
Recent studies indicate that patients who are diagnosed with vegetative states may retain more awareness than their clinical assessments suggest. Disorders of consciousness traditionally have been diagnosed on the basis of outwardly observable behaviors alone, but new functional imaging studies have shown surprising levels of brain activity in some patients, indicating that even higher-level cognitive functions like language processing and visual imagery may be preserved. For example, one recently developed method purports to detect voluntary mental imagery solely on the basis of neural response patterns observed with functional magnetic resonance imaging (fMRI). This line of research has already led to some widely reported cases of patients who were discovered to have more brain activity than expected. In November 2009, Rom Houben, a Belgian man who was thought to be in a coma for 23 years, was diagnosed with locked-in syndrome through the use of neuroimaging; however, that assessment was later overturned by further testing.
Although people with schizophrenia display impaired abilities for consent, it is not known how much impairment constitutes incapacity.
To assess a method for determining the categorical capacity status of potential participants in schizophrenia research.
Expert-judgement validation of capacity thresholds on the sub-scales of the MacArthur Competence Assessment Tool – Clinical Research (MacCAT–CR) was evaluated using receiver operating characteristic (ROC) analysis in 91 people with severe mental illness and 40 controls.
The ROC areas under the curve for the understanding, appreciation and reasoning sub-scales of the MacCAT–CR were 0.94 (95% CI 0.88–0.99), 0.85 (95% CI 0.76–0.94) and 0.80 (95% CI 0.70–0.90). These findings yielded negative and positive predictive values of incapacity that can guide the practice of investigators and research ethics committees.
By performing such validation studies for a few categories of research with varying risks and benefits, it might be possible to create evidence-based capacity determination guidelines for most schizophrenia research.
Interpersonal violence is an inescapable reality of contemporary society. Pick up any newspaper or listen to any news broadcast and witness the litany of violence it reveals. Murder, sexual assault, child abuse, hate crimes, terrorism – the list seems endless, the details numbingly familiar, until the day's stories blend into yesterday's, and those into the accounts of last week and the week before.
Only a fraction of this violence, of course, comes to clinical attention and that is either because the victims seek assistance or, more pertinent to the focus of this volume, because the perpetrators believe themselves or are believed by others to have a mental disorder. Indeed, although persons with mental disorders account for a small proportion of violence in most societies, the public, stoked by the media, are disproportionately concerned about the risks posed by this group. A recent estimate in the United States put percentage of violent acts accounted for by the mentally ill at about three percent, (Swanson, 1994) and data from England suggest that the proportion of murders attributable to persons with mental illness has actually been falling over time. (Taylor & Gunn, 1999) But popular estimates of the proportion of psychiatric patients who are likely to commit violent crimes vastly exceed the actual number (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999).
The simultaneous fascination with and terror of violence committed by persons with mental disorders was illustrated graphically quite recently in the pages of a major newspaper.
A new actuarial method for violence risk assessment – the Iterative Classification Tree (ICT) – has become available. It has a high degree of accuracy but can be time and resource intensive to administer.
To increase the clinical utility of the ICT method by restricting the risk factors used to generate the actuarial tool to those commonly available in hospital records or capable of being routinely assessed in clinical practice.
A total of 939 male and female civil psychiatric patients between 18 and 40 years old were assessed on 106 risk factors in the hospital and monitored for violence to others during the first 20 weeks after discharge.
The ICT classified 72.6% of the sample as either low risk (less than half of the sample's base rate of violence) or high risk (more than twice the sample's base rate of violence).
A clinically useful actuarial method exists to assist in violence risk assessment.
A conflict between the right to free exercise of religion and concern about self-harm.
The patient was a 30-year-old, single man from India who was raised as a Muslim. He had been hospitalized three times in the past year; this admission was occasioned when he assaulted a passerby. At the time, the patient was under the influence of a psychotic delusion that he was a secret agent whose cover had been betrayed by his therapist.
Upon his admission, the patient refused medication on the ground that he was a Christian Scientist. The surprised resident learned that the patient had, while psychotic on his last admission, encountered a Christian Science practitioner who was visiting the ward and decided to join the Christian Science Church. Consultation with the practitioner raised the question of the extent to which the patient's choice of Christian Science should be seen as a free choice, especially since the practitioner did not view the patient as a true Christian Scientist. On the other hand, the patient, although delusional, was able to cite chapter and verse of Christian Science literature in support of his drug refusal. The dilemma facing the resident was whether this patient's religious choice was suspect because of his concurrent delusional state, and thus whether his drug refusal based on this choice was competent.
(1) The First Amendment gives us a right to freedom of religion. Would this right be violated if this patient were forced to take medication?
When a therapist and a patient meet to address the needs created by mental disorder, their developing relationship is bounded by rules that determine the appropriateness of interventions considered and performed. These rules are based not only on knowledge about the biological and psychological bases of disorder, but also on values which, like the therapies that can be employed, not only provide a range of alternatives, but also set limits on actions.
This book is about a particular subset of values dealing with ethics. Ethics is a discipline concerned with understanding the right-making and wrong-making characteristics of actions. The practitioners who analyze the ethical dimensions of human thought and interaction must examine deeply held beliefs derived from personal experience concerning right and wrong, cultural mores founded on the conventions of tradition, values received from and embodied in decisions of courts and legislatures, historical conventions developed by the health care professions over time and embodied in documents such as ethical codes, and scholarly works on ethics.
In this book, we approach ethics through case studies. Our goal is to present case material that can provide clinicians with a basis for learning and reflection, preferably in interaction with their colleagues. The cases used are real and are derived from clinical situations and consultative experiences of the authors, and their colleagues. The use of the case method, as applied to problems of mental illness, was developed by the authors at the Massachusetts Mental Health Center, where ethics rounds were begun in 1979 and continue in the present.
When is it appropriate for therapists to override parental wishes?
A 9-year-old girl was admitted to the Children's Psychiatric Unit with a history of multiple somatic complaints, refusal to go to school, and in the past year, although not currently, a history of such minor self-abuse as inflicting scratches on herself. The patient evidently had been having trouble for some time, but only recently had the parents agreed to bring her in for psychiatric evaluation. When she does attend school, she does well. She has a 6-year-old sibling who, according to the clinicians in the Children's Unit, has attempted suicide recently, certainly an unusual occurrence in a child that young. In addition, it is reported that prior to admission the patient was sleeping up to 17 hours a day.
Five days after admission the patient's mother called, saying that she intended to take the patient home with her that afternoon. The clinicians at the Children's Unit do not view this family sympathetically. The father was described as withdrawn and anxious, and the mother as anxious with pressured speech. The ostensible reason for their wanting to take the child out of care was that the child's grandmother had just been hospitalized for a bleeding ulcer, and the family wanted to have her back home so that they would not worry about her as well. The clinicians thought that perhaps the real reason they wanted her at home was to care for her younger brother while the mother was off tending to grandmother.
Now that the reader is familiar with the historical and theoretical aspects of ethics in mental health practice, a more practical issue must be addressed: How does one teach mental health ethics? To answer that question, this chapter examines the possible goals of instruction in this area, the variety of approaches taken to the teaching of mental health ethics, and the use of case-oriented material, which the authors have found to be especially useful in the clinical mental health setting. Given the sparseness of the literature on teaching mental health ethics and the commonalities with pedagogic efforts in biomedical ethics as a whole, the works in these areas are cited interchangeably. The subsequent section of the book provides sample case materials that can be employed for case-oriented learning and teaching.
GOALS OF TEACHING MENTAL HEALTH ETHICS
There is widespread agreement among those who teach professional ethics that one goal must serve as the predicate to all others in this discipline. That goal is to heighten the sensitivity of trainees and clinicians to the ethical dilemmas they are likely to confront in routine clinical practice (1–7). In the words of Clouser, “One of the most surprising phenomena about students and professionals is their inability to recognize moral problems as such” (8). Yet, unless the participants in an ethics program begin by acknowledging the relevance of the material to be discussed to their own professional lives, motivation and interest will evaporate, and any more elaborate objectives will remain unfulfilled.