bluuebunny/crossref_metadata_2025 huggingface dataset:
Refugees, torture, and dehumanization
Authors: Jović Vladimir
Published: February 2021

Refugees and migrants are often victims of dehumanization and torture. At the beginning of the last refugee crisis, Serbia became part of the so-called ‘Balkan route’, which was used by hundreds of thousands of refugees. In this contribution we argue that (i) war conflicts are characterized by violence toward civilians as a weapon of war; (ii) refugees can and do become victims of human rights abuses and torture both within combat and in countries of transit; (iii) violence towards refugees can be understood as a consequence of dehumanization, implicitly or explicitly fostered by authorities; (iv) the suffering of refugees cannot be modelled only according to post-traumatic stress disorder; and (v) human rights are inseparable from refugee experiences, both as a causative factor and as a factor of recovery.
Media setting the agenda
Authors: Eide Elisabeth
Published: February 2021

Media play an important role in representing people with minority background, migrants and refugees. This chapter addresses how this representation may affect their lives and well-being in Europe, and more particularly in Norway. Currently, the multitude of media platforms seems to open up for increasing polarization in a fragmented public sphere. Simultaneously we witness an increased diversity of media actors, partially reflecting societal diversity. The levels of negative media representation of migrants, as well as serious threats and harassment, may contribute to individual withdrawals from the public sphere, and thus from democratic participation. Such representation may also enhance negative self-images and feelings of non-belonging and exclusion. Furthermore, a lack of media contextualization of the current migrant/refugee situation and the drivers behind it may encourage narratives where those suffering the consequences of war, conflict, and global inequality may be regarded as the ones to blame.
Safety for children
Authors: Dybdahl Ragnhild , Christie Helen Johnsen
Published: February 2021

Lack of safety poses a major threat to children who are asylum seekers in the post-migration period. Such lack of safety can concern physical safety, including domestic violence, and psychosocial safety, including feeling afraid and isolated. The context of families in reception centres and the resettlement period varies considerably, but relative poverty, perceived unpredictability, and isolation are common. In addition, language and cultural differences and lack of work and meaningful everyday life often pose a challenge, as does previous trauma exposure. One important issue concerns stressors parents face, and their ability to provide safety for their children in times of uncertainty and great adjustment. Addressing the need for safety, this chapter describes a Norwegian pilot project conducted by the Norwegian Directorate for Child, Youth and Family Affairs in 2015–16, which sought to address safety through supporting parents using the International Child Development Programme in asylum centres. This chapter describes the programme and experiences from this pilot project. We discuss safety for children in receptions centres and the resettlement phase, drawing on the pilot project and previous research in high-income countries. In addition, we present a case for the usefulness of knowledge from humanitarian and developmental contexts.
Children and vulnerable groups services
Authors: Miconi Diana , Rousseau Cécile
Published: February 2021

In this chapter on children and vulnerable groups services we discuss the challenges involved in the provision of services to migrant and refugee families and young people. Firstly, obstacles preventing migrant and refugee populations from accessing services are identified, and the importance of culturally adapted and culturally safe services is underlined. Secondly, an overview of available interventions at the individual, family, and community level is provided, emphasizing the role of schools as an important bridge between migrant families and the host society. Thirdly, the importance of a resilience-based and ecological approach to provision of services to these vulnerable populations is discussed, and an illustration of a multimodal intervention implemented in collaboration with local schools and communities is provided. Lastly, in light of the complex and heterogeneous needs of migrant and refugee populations, a pyramid, tiered model of provision of services to migrants and refugees is advocated.
Handling cultural differences between patient and clinician
Authors: Westermeyer Joseph , Kroll Jerome
Published: February 2021

This chapter proposes to aid clinicians in handling cultural differences encountered by patients and clinicians. Our overarching emphasis involves ‘migratory psychiatry’—a context in which patients may have migrated to an unfamiliar culture. We also include contexts in which clinicians have migrated to the patient’s culture, as this situation can produce similar problems that the clinician must manage. From innumerable possible topics, we have selected seven areas owing to their frequency and/or clinical importance: negotiated psychiatric encounters, dreams, and nightmares, social units as patient/pathogen/therapeutic resource, theories of psychiatric disorder, organic causes, managing differences, and culture-related attitudes and beliefs. Although this list does not cover all potential challenges, it does provide the reader with a format for handling other dilemmas arising between patient and clinician in psychiatric settings. The ‘Methods’ section specifies the means by which the reviewers and authors have approached such matters in their careers. The latter include being thoughtful in learning from their own experiences, benefitting vicariously from the experiences of teachers and colleagues, and reading journals and books on related topics.
Therapeutic skills and therapeutic expectations in the treatment of migrant individuals and their families
Authors: Okpaku Samuel O.
Published: February 2021

This chapter emphasizes the need to categorize migrants into three major subgroups. This is necessary as different categories may have different needs in terms of documentation, services, and opportunities. The central elements for effective therapeutic approaches are then reviewed. These include the establishment of a helping alliance, the client’s explanatory model, adherence to treatment, and the client’s expectations of the treatment. These expectations may be divided into ‘treatment expectations’ and ‘outcome expectations’. Therapists’ skills and characteristics are also explored. It is suggested that the salient factors in psychotherapy of locals are likely to be the same for migrants, but for this latter group there is a need to be mindful of cultural issues, the history of trauma, and the need for a family approach. The chapter concludes by emphasizing that therapists pay attention to their own values in addition to the issues relating to culture.
Psychiatric disorders in refugees and immigrants
Authors: Kinzie J. David
Published: February 2021

In setting treatment goals, the patient’s cultural values and goals, as well as diagnosis, need to be considered by the clinician. Psychiatrists are urged to use the Cultural Formulation Interview of the DSM-5 to aide in assessing patients. With the impacts of globalization and ubiquitous television viewing influencing the culture of the refugees and immigrants, clearly their cultures are in flux and not static, after they arrive in the new country. Doctors and medical approaches are well known to refugees and immigrants. However, they may experience resistance and fear on referral to psychiatrists for reasons of stigma. A sensitive medical approach can help reduce the resistance and fear on the part of the refugee. When a relationship forms, psychosocial issues can be addressed. Treatment guidelines for evidence-based treatments for Western patients exist, but these should be individualized for refugees with individual goals. Good clinical practice and cultural understanding must meet the patient’s personal goals.
Psychopharmacology and refugees, asylum seekers, and migrants
Authors: Henderson David C.
Published: February 2021

Refugee, asylum seeker, and migrant populations may have experienced many adverse life events during time in their country and during the time of migration. As a result, many will experience common mental health problems, including anxiety, post-traumatic stress disorder, and depression. This chapter reviews the genetic and environmental factors that impact pharmacological interventions for the common mental health problems of these groups. Cultural and explanatory models may play a role in help-seeking, as well as therapeutic alliances and adherence. Cultures may carry different explanations for the use of medication. Pharmacodynamics and pharmacokinetic properties will vary across cultures. These will be affected by dietary factors, as well as genetic and biological factors. Recommendations are also included regarding the safe and effective approaches for treating these groups of patients with psychotropic medications.
Psychiatric emergencies in asylum seekers
Authors: Schoretsanitis Georgios , Bhugra Dinesh , Exadaktylos Aristomenis
Published: February 2021

In this chapter, we review data on psychiatric emergencies and related symptoms in asylum seekers. In recent years, there has been an enormous increase in the migration of displaced people throughout the world, and mental health care for these highly vulnerable individuals is a major public health challenge for Western health systems. Current research often investigates asylum seekers and other immigrant or refugee groups on the basis of epidemiological data. Nevertheless, these people are exposed to different types of mental health risks and thus have to be assessed separately. This chapter will first consider available data on the prevalence of post-migratory stressors, psychiatric symptoms, and mental disorders that may underlie psychiatric emergencies for asylum seekers. How asylum seekers utilize mental health care services in the acute setting will be evaluated and current knowledge will be used to develop a decision-making algorithm for clinicians.
Suicide among refugees
Authors: Vijayakumar Lakshmi , John Sujit , Jotheeswaran A.T.
Published: February 2021

Suicide is a global public health problem, with the majority of suicides occurring in low- and middle-income countries. The UNHCR reported that in 2017 there were 25.4 million refugees, with the majority (85%) being hosted by developing countries, which have limited infrastructure, healthcare systems, and are often politically and economically unstable. A review of suicidal behaviour among refugees reveals a prevalence of 3.4–40%. Female sex, higher education and socio-economic status, exposure to trauma, presence of psychological disorders, long stay in detention centres, and rejection of asylum status are associated with increased suicidal risk. Globally, data for rates of suicide among refugee groups are not available and any interventions to reduce suicide among refugees have received scant attention. A theoretical model for understanding suicide risk in refugees is proposed in this chapter and the possible interventions discussed.
Transforming identities
Authors: Amias David , Partridge Karen , Rehim Sherry , Bisimwa Nsimire Aimee
Published: February 2021

In this chapter, a different approach for refugees and asylum-seeking children and young people referred to child and adolescent mental health services (CAMHS) is described. Clinicians working with this population group need to maintain a holistic, psychosocial perspective not constrained by CAMHS diagnostic categories. In many cases, the children and young people referred to CAMHS have functional family backgrounds with their ‘mental health disorder’ being the result of adverse experiences prior to or during the perilous journey they have undertaken before arriving in UK. Their essentially positive functioning provides the basis for a good recovery provided social conditions support them appropriately. Discerning when to offer what intervention is a crucial skill. Prosocial behaviours, resourcefulness, and strengths should be recognized and nurtured for these young people to develop their own preferred identities and start on a healthy process of integration into new society. Various types of intervention such as an emotional well-being group work and narrative-based interventions (for unaccompanied asylum seekers), community interventions, risk support to the professional network, direct work, as well as training frontline workers in assessing concerns about young people, offering effective emotional first aid and suitable referrals are described.
Developing psychiatric services for migrants, refugees, and asylum seekers
Authors: Yip Stanley , Javate Kenneth , Bhugra Dinesh
Published: February 2021

The healthcare needs of migrants, refugees, and asylum seekers are important to assess and meet because the majority of migrants are of a young age group, which is more prone to developing psychiatric disorders, particularly in response to the stress of migration, which may act as a precipitating factor. In addition, their healthcare models and explanations can be strongly influenced by their cultural models. Many migrant groups show higher-than-expected rates of psychiatric disorders for a number of reasons. Combined with discrimination and stigma, it is likely that there may well be delays in seeking help, thereby making their prognosis poor. When planning, developing, and delivering services for migrant groups it is important to remember guidelines for good practice and also engage the groups appropriately. In this chapter we highlight differences in rates of psychiatric disorders, vulnerability factors, and healthcare needs of migrants, refugees, and asylum seekers.
A Practical Guide to the Interpretation of Cardiopulmonary Exercise Tests
Authors: Kinnear William , Hull James H.
Published: February 2021

A Practical Guide to the Interpretation of Cardiopulmonary Exercise Tests is a short, but comprehensive, guide for those who are involved in the supervision of exercise tests and interpretation of cardiopulmonary exercise test (CPET) data. It is a clear and concise guide which will also be of interest to those who request CPETs and who wish to understand more about how to use the results. The first four chapters cover the reasons why a CPET may be requested, pre-test assessment, supervision of the test to ensure that it is safe, and the practicalities of the test itself. Subsequent chapters look in detail at the key CPET measurements of heart rate, ventilation, oxygen uptake, and carbon dioxide output. There are chapters on the parameters that can be derived from these basic measurements: ventilatory equivalents, oxygen pulse, and the respiratory exchange ratio. Further chapters show how the anaerobic threshold and respiratory compensation point are obtained, and how they can be used to interpret the physiological response to exercise. The role of monitoring oxygen saturation and flow–volume loops during the test is described. The third section of the book has chapters on presentation of results, interpretative strategies, and summaries of classical CPET patterns seen in different diseases. The final chapters consider the role of preoperative CPET testing and how to prescribe exercise. All chapters have pointers to further resources.
Pre-test assessment
Authors: Kinnear William J.M. , Hull James H.
Published: February 2021

Pre-test assessment describes the next step after deciding to do a cardiopulmonary exercise test (CPET). The indication for the test must be defined, with clear end points. A CPET is a very safe test. There are well-defined conditions which increase the risk. The most serious side effects are related to heart problems, most commonly seen in subjects with unstable heart disease. Careful scrutiny of the resting electrocardiogram (ECG) is imperative prior to the test. If the subject is unwell, e.g. with a viral illness or an exacerbation of asthma, the test should be postponed. On the day of the test, the subject should take their usual medication. Caffeine and alcohol should be avoided on the day of a CPET. A light meal should be taken at least 30 minutes beforehand.
How to do a CPET
Authors: Kinnear William J.M. , Hull James H.
Published: February 2021

This chapter describes how cycle ergometer and treadmill tests suit different subjects. A standard cardiopulmonary exercise test (CPET) involves a ramp increase in workload, until the subject’s symptoms prevent them from exercising any further. The exercise phase of the test is preceded by resting and then unloaded cycling, and followed by the recovery phase. Results are generally presented in a breath-by-breath format, with predicted values indicated on the display. The advantages and disadvantages of expressing CPET parameters as a function of weight are discussed, with particular reference to obesity
Ventilation
Authors: Kinnear William J.M. , Hull James H.
Published: February 2021

This chapter describes how the amount of air going in and out of the lungs increases on exercise. The predicted value for minute ventilation (VE) is calculated for each subject from their own forced expiratory volume in one second (FEV1), rather than taken from published tables. Normally, ventilation does not limit exercise and VE does not reach 80% of the predicted value. If VE at peak exercise is more than 80% of predicted, it is likely there is something wrong with the lungs. VE increases by a combination of a larger tidal volume and an increase in breathing frequency. The pattern of increase is normally gradual. An erratic pattern suggests dysfunctional breathing.
Anaerobic threshold
Authors: Kinnear William J.M. , Hull James H.
Published: February 2021

This chapter describes the changes that occur when anaerobic processes start to supplement aerobic metabolism during a cardiopulmonary exercise test (CPET). Lactic acid is produced, which is buffered by bicarbonate to produce carbon dioxide and water. The anaerobic threshold (AT) should be seen when VO2 is at least 40% of predicted maximum oxygen uptake (VO2max). A low AT indicates poor oxygen delivery to muscles. This can be seen in heart disease, peripheral vascular disease or anaemia. AT is useful for predicting operative risk.
A Buddhist perspective on suicide
Authors: Promta Somparn , Thomyangkoon Prakarn
Published: February 2021

The basic morality of Buddhism is based on the Five Precepts. Buddhism does not consider killing merely in its form but in its origin, and judges whether or not it is immoral case by case. Suicide is a type of killing, and the moral rules apply to all types of killing. Here, we discuss when suicide may be considered as morally wrong or morally acceptable. Suicide is not necessarily an evil in the Buddhist perspective: some are morally acceptable. All sects of Buddhism agree that death is a transformation of life, and that we live to die and die to live again. Therefore, suicide is viewed differently from other religions, which do not believe in life after death or reincarnation. We conclude with data concerning suicide in different Buddhist countries. In accordance with the statistics, the Buddhist religion may impact the suicide rate differently, depending on the national context.
Social theories of suicide
Authors: Mäkinen Ilkka Henrik , Rojas Yerko
Published: February 2021

In this chapter, some social theories in relation to suicide are presented together with examples from actual research. Although an individual act, suicide can be studied as a collective phenomenon, for example, as the relative number of cases that occur in different groups. Most social-scientific theories of suicide consider these not only as accumulations of individual observations, but also as results of social-level properties, events, and processes. The social environment in its different forms is thought to be connected with suicidal behaviour in multiple ways—the reasons for, the performance of, and the communication about the act all have strong social components. The currents in social research into suicide coincide largely with those in the social sciences more generally, with a preponderance, however, of structuralist studies following in the footsteps of Emile Durkheim.
Psychoanalytic theories of suicide
Authors: Ronningstam Elsa , Weinberg Igor , Maltsberger John T.
Published: February 2021

Psychoanalytic theories and studies have influenced the explorations of suicide over the past hundred years. Freud’s first observations of self-objectification in melancholic depression were followed by contributions from object relation theorists and self-psychologists, highlighting foremost the role of narcissistic rage and structural vulnerability. Several of the central clinical concepts that unfolded have more recently been subject to empirical testing. This text provides an overview and discussion of the different psychoanalytic formulations applied to suicide. Empirical studies of several assumptions and constructs related to emotions, defences, and structural deficits and vulnerabilities verify their association to or explanation of chronic and acute suicidality. Further conceptualizations and research, especially on subtypes of suicide and individual experiences leading up to and dominating suicidal states, are called for.
Labour market, work environment, and suicide
Authors: Mäkinen Ilkka Henrik , Rojas Yerko , Wasserman Danuta
Published: February 2021

Work is an important sphere of human life. Besides economic subsistence, it also furnishes workers with social status and influences their life conditions. Social class seems to be connected with suicidality, but studies on the effects of specific occupations have produced few lasting results. In addition, lack of adequate data and problems with the methods cause problems in the estimates of suicide mortality by class or occupation. However, it seems that the most vulnerable position is that of those who do not work at all. There is abundant empirical evidence of a surplus risk for suicide among the unemployed, but the causal nature of this relationship still needs clarification. Globally, the labour markets differ greatly, and so does their connection with suicide. Labour-market-oriented suicide prevention issues concern unemployment policies, reduction of work-related access to means of suicide, and the use of the workplace as a base for suicide prevention.
Alcohol, other psychoactive substance use disorders, and suicide
Authors: Maes Tine , Dom Geert
Published: February 2021

Up to 90% of the individuals who complete suicide meet criteria for a psychiatric disorder. Specifically, substance use disorders (SUD) are highly prevalent and frequently associated with an increased risk of suicidal behaviours. Growing evidence shows that this also counts for behavioural addictions, such as gambling. Comorbidity of psychiatric disorders such as major depression, bipolar disorder, schizophrenia, and personality disorder, with SUD, increase the risk. Pathways underlying the relationship between substance abuse and suicidality are multifactorial; the short-term effect of intoxication, impulsivity as trait and state, neurobiological consequences of chronic substance abuse, and accumulating adverse life events all contribute. Assessment and management of suicidality within SUD patients are mandatory for suicide prevention. Further, the evidence is growing that treatment of SUD in itself can reduce suicidality risk. Finally, and from a prevention perspective, decreasing substance use on a general population level is associated with decreases of population-level suicidality.
Suicide among people with psychosis in schizophrenia spectrum
Authors: Nordentoft Merete , Madsen Trine
Published: February 2021

This text summarizes the literature regarding suicide among people with psychosis. Psychotic disorders on schizophrenia spectrum are among the most severe psychiatric disorders, and are associated with a particularly high risk of suicide. Long-term follow-up studies have found that up to 6% of people with these disorders die from suicide. Young people with psychotic disorders have a 25-fold higher risk of suicide compared to age-matched people in the general population. Being recently diagnosed, an inpatient, or recently discharged from psychiatric with a psychotic disorder, all represent high-risk periods for suicide. Indicated prevention in these high-risk periods is crucial, but also selective interventions such as early detection and intensive treatment of first episode psychosis, have shown to have positive effects on suicidal behaviour. Moreover, universal interventions aimed at the whole population, such as restricting access to lethal means, are important to implement to prevent suicide in people with psychotic disorders.
Risk for suicidal behaviour in personality disorders
Authors: Stanley Barbara , Kandlur Raksha , Jones Jennifer
Published: February 2021

While it is well known that depression, substance dependence, and schizophrenia are strongly associated with suicide, personality disorder also confers a significant risk, but has been consistently understudied. Borderline personality disorder has been consistently associated with suicide risk; additionally, antisocial personality disorder, and avoidant personality disorder have also been found to have a significant risk but has received little research attention. Research also hints at the possibility that schizoid personality disorder and narcissistic personality disorder could increase the risk for suicide as well. Importantly, stressful life events, such as those involving interpersonal distress and loss, confer a significant risk for those with personality disorders, possibly due to poor coping strategies. Reliable instruments with good psychometric properties need to be established that are sensitive to detecting axis II personality disorders. This text reviews the literature on risk factors and treatment approaches to suicidal behaviour in personality disorders.
Somatic diseases and suicidal behaviour
Authors: Stenager Elsebeth , Stenager Egon , Erlangsen Annette
Published: February 2021

The association between somatic disorders and suicidal behaviour has been examined in many studies. Despite large variation in quality and study design, recent studies have improved our knowledge substantially, not only regarding the extent of risk but also factors influencing the risk. Most studies have been conducted in European countries, the US, Australia, Japan, and South Korea. A series of studies have examined suicide risk in relation to somatic disorders of older persons, while others addressed somatic disorders and attempted suicide in children and youth. Physical conditions may play an important role in medical settings, regardless of whether mental disorders are present or not, though especially when mental disorders are present. This chapter presents a review of present knowledge on suicide and suicidal behaviour in selected somatic disorders and pain syndromes, with a focus on studies from different parts of the world.
Women and suicidal behaviour
Authors: Canetto Silvia Sara
Published: February 2021

Women have higher rates of suicidal ideation and behaviour and lower rates of suicide mortality than men. This is a dominant but not a universal pattern, across and within countries. There is also cultural heterogeneity in beliefs and attitudes about women’s suicidal behaviour. For example, in some high-income countries, suicide is considered a masculine act. Furthermore, explanations of suicidal behaviour vary by culture. In high-income countries female suicidal behaviour is typically viewed as an individual problem, and a sign of mental illness. By contrast, in low- and middle-income countries, that is, where rates of female suicidality are most elevated, female suicidal behaviour is primarily viewed as a response to arduous circumstances. Evidence from a diversity of countries highlights cultural, social, and economic factors in women’s suicidality—with abuse in close relationships consistently showing a strong association with suicidality. In some countries suicide is women’s culturally scripted way to escape from the social and economic oppression, and the abuse they experience in their families and communities—in violation of their human rights. Women’s suicide rates are lower in countries with more egalitarian gender norms. Given the persistence, in high-income-countries, of individual-focused theories, despite the global evidence on the role of contexts in women’s suicidality, innovation in theory, research, and the prevention of women’s suicidality requires sustained attention to social, economic, and cultural factors, and adopting a human rights perspective.
The psychological and behavioural treatment of suicidal behaviour
Authors: David Rudd M. , Perez-Munoz Andrea
Published: February 2021

This text provides an updated review of currently available clinical trials targeting suicidal behaviour and suicidal ideation, with an emphasis on adult populations. The overriding aim is to identify elements that are common among the most efficacious treatment options, particularly those treatments that have demonstrated effectiveness in reducing suicidal behaviour (i.e. suicide attempts), a primary clinical outcome measure in suicide-based research. In doing so, we hope to uncover common core elements that appear to be central to reducing suicidal behaviour, attempts, and ideation. Similarly, we hope to provide information regarding efficacious treatments, along with clinically applicable implications and considerations for day-to-day clinical practice. We conclude with a discussion of limitations, future directions, and special considerations derived from the current research.
Online treatment programmes for suicidal persons
Authors: Meyer Björn
Published: February 2021

Online treatment programmes extend the reach and effectiveness of psychological interventions for suicide prevention. Such programmes could teach individuals relevant self-management techniques, including emotion regulation or other techniques used in cognitive behaviour therapy (CBT). Advantages such as privacy, low-threshold accessibility, scalability, flexibility, affordability, and standardization increase the appeal of online treatment programmes, but limitations and risks must be considered, including data security breaches, insufficient integration with other care services, lacking efficacy, and potential harm. Many online treatment programmes are broadly CBT-based, but evidence suggests that they might be improved by addressing suicide-specific issues in a more targeted manner. Because online programmes differ in content, interactivity, and other aspects, the safety and efficacy of each programme must be examined separately, but methodologically adequate trials are still rare. Research suggests that safe and effective online treatment programmes for suicide prevention should be developed, and must prove their merit in adequately designed studies.
Suicide loss
Authors: Andriessen Karl , Krysinska Karolina
Published: February 2021

Experiencing the suicide of a significant other, such as a family member or a friend, constitutes a major disruptive life event, which may exacerbate the risk of social, physical, and mental health problems, and suicidal behaviour in the bereaved individuals. This chapter describes how many people are bereaved by suicide, the possible grief reactions, and novel insights related to continuing bonds and personal growth that people bereaved by suicide may experience. The chapter also presents what types of support, either face-to-face or online, are available to people bereaved by suicide. While further research is needed to elucidate the effectiveness of support for people bereaved by suicide, the chapter concludes that all support should be offered in an involved, empathic, and educational climate.
Psychiatric disorders in youth suicide and suicide attempters
Authors: Frenk Mira Levis , Bursztein Cendrine , Apter Alan
Published: February 2021

This chapter reviews common psychiatric disorders and conditions which appear to be major risk factors for all types of suicidality, both non-fatal and fatal, among children and adolescents. Psychiatric illness remains the most well-defined risk factor for adolescent suicide and suicidality should be assessed in every young person suffering from a serious mental illness. These psychiatric conditions include personality disorders, conduct disorder, affective disorder, bipolar disorder, anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, schizophrenia, substance abuse, and eating disorders. Each psychiatric condition is described and discussed in terms of its unique features that are associated with suicidal behaviours and its risk for suicide behaviour.
Suicidal older people in clinical and community settings
Authors: De Leo Diego , Draper Brian , Krysinska Karolina
Published: February 2021

Despite the general decline in the number of suicides in the world, suicide rates among older adults remain the highest in most countries. Unfortunately, suicide in late life also remains a somewhat neglected topic, and ageistic visions of age-related problems often make suicidal behaviour a justifiable choice. This chapter examines the most important clinical aspects of suicidal behaviours among older adults, offering an overview of the many risk factors: from the role of depression and other mental disorders to the frequent physical diseases that accumulate at advanced age, plus a number of conditions typical of old age such as retirement or relocation to a nursing home. Main therapeutic approaches and elements of prevention at various levels (universal, selective, indicated) are also presented and discussed.
Restrictions of access to pesticides in suicide prevention
Authors: Phillips Michael R. , Gunnell David
Published: February 2021

Intentional pesticide ingestion is a common method of suicide, accounting for up to one-fifth of all suicides worldwide. The importance of intentional ingestion of pesticides was initially recognized in Asia and the Western Pacific but it is also a problem in Latin America, the Eastern Mediterranean, and in Africa. Organophosphate pesticides are responsible for a large proportion of pesticide self-poisonings and for the majority of deaths from pesticide ingestion. Limiting access to pesticides could substantially reduce the global burden of mortality due to suicide. Despite initial enthusiasm for restricting access to pesticides by promoting safe storage of these compounds, the definitive study on this method in Sri Lanka did not find a significant reduction in suicide rates. There is, however, growing evidence that national or regional bans on high toxicity pesticides lead to falls in pesticide-ingestion suicide rates, and overall, suicide rates without substantial substitution of other methods of suicide.
Suicide Prevention International (SPI)
Authors: Hendin Herbert
Published: February 2021

Suicide Prevention International (SPI) was developed with the intention of addressing the increasing rates of suicide and depression worldwide; with a specific focus on developing countries as well as large areas of industrialized countries. The organization is made up of an international network of experts in various areas related to suicide, mental health, and public health. SPI’s scientific advisory council includes representatives from 22 countries with expertise in suicide prevention, public health, healthcare economics, social medicine, youth suicide, suicide in the elderly, and in the problems of those who have lost a loved one to suicide. This chapter provides a description of the organization, as well as the important projects which are being undertaken by SPI in order to treat depression and prevent suicide.
A historical perspective
Authors: Charland Louis C.
Published: February 2021

Studying the history of ethics in psychiatry through the chronological development of ethical codes does not do justice to the manner in which ethical themes and issues vanish and recur in that history. This chapter considers some aspects of the history of these codes, though its primary aim is to explore major ethical themes and issues in the history of psychiatry. The humanity of the ‘mad’ and the increasing manner in which persons with mental disorders are thought to be autonomous individuals are two themes that will occupy us. Increasing recognition and acceptance of the autonomy and self-determination of persons with mental disorders is the crowning ethical achievement of the history of psychiatry recounted here. However, there are also reasons to be concerned about possible excesses that may be emerging in this regard in some sectors of psychiatric treatment and research—new historical developments that merit careful ethical scrutiny.
The philosophical dimension
Authors: Beauchamp Tom L.
Published: February 2021

This chapter provides an understanding of philosophical ethics sufficient as background reading for various other chapters and sufficient to appreciate the relevance of philosophical analysis for psychiatric ethics. Philosophical reflection is not by itself an adequate basis for professional ethics, but it does stand to facilitate impartial examination of assumptions commonly made in psychiatry. Also treated are problems of moral justification, classical ethical theories as found in the history of philosophy in utilitarian theories and Kantian theories, and alternatives to the classical theories in recent philosophy including virtue theories, the ethics of care, and casuistry. The chapter also presents the framework of moral principles for biomedical ethics in the theory often called principlism. The four basic principles constituting this framework are the principles of respect for autonomy, nonmaleficence, beneficence, and justice. These principles are suitable for both clinical ethics and research ethics. This chapter also discusses how principles provide a starting point for moral judgment and policy evaluation, but do not treat the subtleties of moral problems and ways in which the principles can and should be specified to address particular problems such as moral dilemmas of confidentiality as encountered in medical practice and research. Accordingly the chapter treats problems of the specification of principles and how principles can be overridden by other moral principles when they conflict. Finally, the chapter includes a discussion of the nature of a professional morality for psychiatry with standards that should be acknowledged by all in the profession.
Codes of ethics in psychiatry
Authors: Kenn Felicity , Bloch Sidney
Published: February 2021

Codes of ethics in psychiatry, as well as medical codes more generally, have continually evolved since the Oath of Hippocrates, and remain important in contemporary psychiatry practice. However not until the 1970s were unique ethical challenges facing psychiatrists specially addressed. Codes of ethics in psychiatry take many forms but, in general, responsible care of patients and professional integrity constitute their core. Additionally, they variously cover the human rights of patients and duties to society. Codes can be international or institutionally specific, with international declarations expected to be universally relevant. Adherence is recognized as a vital component of self-regulation, with codes giving support to disciplinary procedures. Using a range of codes and covenants as illustrative, in particular the code of ethics of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), the role of codes in promoting high standards of ethical practice, professionalism, and education in psychiatry is explored.
Confidentiality
Authors: Joseph David I. , Goldstein Melissa M. , Onek Joseph
Published: February 2021

Ethics involves wrestling with difficult, conflicting courses of action. Medical ethics, and psychiatric ethics in particular, is especially challenging, given the need to negotiate a course of action with patients and family. Confidentiality, which is at the centre of psychiatric practice, and is essential if psychiatric treatment is to be successful, has been challenged and even somewhat eroded by legal developments and social change. Psychiatrists cannot promise absolute confidentiality to their patients. While it is tempting to look to ‘the law’ to determine when breaking confidentiality is the ethical decision, psychiatrists must decide whether acting in accordance with the law is the more ethical choice to make when grappling with a difficult clinical situation. The need for strict confidentiality also places constant demands on the psychiatrist to be mindful lest inadvertent lapses in vigilance results in the unethical sharing of patient information. This chapter explores ethical dilemmas in confidentiality in a range of clinical situations involving hospitals, clinics, and private outpatient settings. The unique ethical issues that arise in the treatment of children, adolescents, families, and groups are discussed in detail. The chapter also examines the ethical dilemmas that are often encountered in academic settings, speaking, and publishing. Considerable attention is devoted to the implications of the Tarasoff decision in California and to the Health Insurance Portability and Accountability Act of 1996, which has had a profound impact on the practice of psychiatry in the United States, as well as influencing the law in other countries.
Physical treatments
Authors: Jayaram Mahesh , Farrand Sarah , Velakoulis Dennis , Pantelis Christos
Published: February 2021

Physical treatments in psychiatry form the mainstay of psychiatric treatments alongside other psychological therapies. Ethical decision-making in the best interest of the patient should always take precedence over any conflict of interest; however, this is a complex area given multiple competing interests and which requires careful evaluation and reflection. We explore the complex interplay between psychiatrists and the pharmaceutical industry with a particular focus on research, drug development and discovery, publication, and dissemination. We also focus on ethics relating to treatments in special groups such as those experiencing pregnancy and postnatal care, early intervention, pharmacogenomics, or treatment-resistant schizophrenia. We then discuss issues relating to consent that correlate with case law and precedents set, which have impact on daily clinical life. Ethical issues relating to neurostimulation including electroconvulsive therapy or newer treatments such as transcranial magnetic stimulation and deep brain stimulation are also explored, outlining historical issues and contemporary guidelines leading to improvements in care.
The psychotherapies
Authors: Adshead Gwen
Published: February 2021

In this chapter I review some of the ethical dilemmas that arise during the practice of the psychological therapies, as well as aspects of the literature about how these dilemmas might be understood and resolved, including how traditional accounts of health care ethics apply to psychotherapy. I also discuss contemporary dilemmas in psychotherapy. I suggest that the practice of psychotherapy and ethical reasoning have in common attention to values and attention to self -reflection and the capacity to think about mental experience. This chapter is based on the chapter in the first edition which was written with Professor Jeremy Holmes, and I acknowledge here with gratitude his wisdom and influence on my thinking in this area.
Psychiatry of the elderly
Authors: Oppenheimer Catherine , Hughes Julian C.
Published: February 2021

This chapter describes the ethical issues that arise in the setting of mental illness, and particularly dementia, in old age. It affirms the importance of understanding each older person as an individual, embedded in a unique history and in relationships which sustain their identity even in the face of cognitive decline. Autonomy and paternalism are discussed, and the alternative concept of ‘parentalism’ introduced. Decision-making capacity and competence are extensively analysed from both philosophical and practical viewpoints, with particular reference to the Mental Capacity Act 2005, and to mechanisms for decision-making for noncompetent patients. Topics briefly treated include predictive diagnosis and mild cognitive impairment, end-of-life care, truth telling, sexuality, and the UN Convention on the Rights of Persons with Disabilities. The text is aimed at old age psychiatrists and other practitioners in the field, as well as at those with an interest in ethical issues in old age.
Thrombotic complications in pregnant patients with rheumatic disease
Authors: Doyle Andrew James , Hunt Beverley Jane
Published: February 2021

Rheumatic disease and pregnancy are both associated with increased rates of venous thromboembolism. In pregnancy, the highest risk is in the later stages of pregnancy and postpartum. The management of anticoagulation to provide thromboprophylaxis, for treatment of acute thromboembolism or for prevention of secondary recurrence can cause issues throughout pregnancy for the clinician and patient, particularly around the time of delivery. In those with rheumatic disease, this can be complicated by the presence of antiphospholipid antibodies, which are associated with venous, arterial, and microvascular thromboembolism and obstetric complications. We discuss the management of thrombotic conditions during pregnancy and the post-natal period and considerations that the clinicians should be aware of.
Antibodies as risk factors for adverse maternal and foetal outcomes
Authors: Radin Massimo , Schreiber Karen , Sciascia Savino
Published: February 2021

A variety of autoantibodies associated with Rheumatic diseases have been associated with adverse maternal and foetal pregnancy outcomes. For instance, pregnancy morbidity in women with antiphospholipid antibodies (aPL) include unexplained consecutive recurrent 1st trimester pregnancy loss (<10 weeks’ gestation), any 2nd or 3rd trimester pregnancy loss, premature birth <34 weeks due to conditions associated with placental insufficiency including severe pre-eclampsia, eclampsia, placental abruption, foetal growth restriction, and intrauterine death. Moreover, antibodies against extractable nuclear antigens (ENA), such as anti-Ro/SSA and/or anti-La/SSB antibodies, have been associated with the development of congenital heart block (CHB) and neonatal lupus in the offspring. More recently, antibodies against U1-ribonucleoprotein (U1RNP) are suggested to be associated with adverse foetal and maternal pregnancy outcomes. In general, women with rheumatological diseases should receive pregnancy counselling. Moreover, women require follow up during pregnancy in order to maximize their chance to have a successful pregnancy.
Managing a patient exposed to a teratogenic drug at different stages of pregnancy
Authors: Schaefer Christof
Published: February 2021

Pregnancy-related information provided by leaflets usually contains inadequate data to interpret risks of teratogenicity; and in the absence of data, prescribing information often recommends discontinuing use in anticipation of and during pregnancy. In contrast, individual information on drug risk assessment addresses three different clinical perspectives: 1) looking for drugs of choice or planning pregnancy under medication; 2) assessment of drugs’ risk after exposure during an unplanned pregnancy; 3) assessment of causality in cases of adverse pregnancy outcomes in association with drug exposure. Unfortunately, for many women with chronic rheumatic diseases, discontinuation of all medication leaves an unacceptable risk of disease reactivation. Although, for the majority of drugs, human data are still insufficient to rule out developmental risks it is possible to distinguish antirheumatic drugs of choice with apparently low or negligible risks from those with scarce data or controversies on their safety and those with evidenced risk for the unborn.