Publications by authors named "Michael Liebrenz"

38 Publications

Evaluating the reliability of hair analysis in monitoring the compliance of ADHD patients under treatment with Lisdexamphetamine.

PLoS One 2021 30;16(3):e0248747. Epub 2021 Mar 30.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Considering the high clinical and forensic relevance of pharmaco-adherence during lisdexamphetamine (LDX) treatment for attention-deficit/hyperactivity disorder (ADHD), the aim here was to evaluate hair analysis as a tool for monitoring compliance in patients currently undergoing long term treatment with LDX, by detecting possible interruptions of medication intake or changes in dosage. For this purpose, a total of 24 patients from an outpatient clinic for ADHD were recruited. Hair and urine samples were taken after three consecutive therapy sessions over a 7-month period and analyzed for amphetamine (AMP) enantiomers and other drugs, using chiral and achiral liquid chromatography-tandem mass spectrometry (LC-MS/MS). Participants also provided information on the condition of their hair, the consumption of illegal psychotropic substances and the regularity of taking LDX. Two participants withdrew from the study early. Urine analyses were positive for D-AMP in all urine samples and therapy sessions, except in two patients who did not take LDX on a daily basis. D-AMP was detected in all hair samples; however, no correlation was found between prescribed dose/day and D-AMP concentrations in proximal hair segments. Qualitative interpretation of hair analysis showed that 18 of the 22 study completers were compliant concerning the intake of LDX without additional consumption of illegal D,L-AMP. Analysis of urine taken during the therapy sessions showed no correlation between D-AMP concentrations and prescribed dosage, with or without normalization for creatinine. In conclusion, chiral LC-MS/MS hair analysis might represent a non-invasive way to confirm LDX use within the approximate period covered by the hair segment tested, but it does not allow for quantitative therapeutic drug monitoring because of interindividual variability of concentrations in hair. Drug concentrations in hair at different stages of long-term treatment should thus be interpreted with caution by clinicians and forensic experts alike when making assessments of treatment adherence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248747PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009440PMC
March 2021

Perceptions and Attitudes of Correctional Staff Toward ADHD-A Challenging Disorder in Everyday Prison Life.

Front Psychiatry 2020 28;11:600005. Epub 2021 Jan 28.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is associated with risk-taking behaviors, poor self-control, and interpersonal difficulties. Affected individuals have an increased probability of involvement with the criminal justice system, contributing to a higher rate of arrest, and imprisonment compared with the general population; they are also inadequately treated once sentenced. Because prison staff play a central role in the identification of inmates with mental disorders, they could well be key to improving provision of care. There is however little knowledge of the conceptions, perceptions, and attitudes of prison staff toward ADHD. Such information could help to identify starting points for awareness training and further implementation of specific ADHD treatment. To bridge this gap, we undertook a study based on a qualitatively-driven mixed methods design, combining qualitative data collection in the form of narrative interviews with 19 prison staff from a Swiss correctional facility with quantitative data collection in the form of a survey that included the Attitudes toward Prisoners scale. The interviews were analyzed with QSR NVIVO 11 and a qualitative content analysis approach was used to evaluate findings. Prison staff were generally aware of ADHD and its symptomology, believing it to a be "real," but "fashionable" disorder and favoring hereditary-genetic or biological explanatory models for its development. They viewed inmates with ADHD rather negatively, as complicating correctional efforts, and perceived them as sticking out, as tying up more resources and as frequently being involved in confrontations. Our findings suggest that difficulties in pragmatic aspects of communication and language comprehension may be perceived "as not listening or following instructions," creating additional tensions. Consequently, inmates with ADHD are more often exposed to disciplinary sanctions, such as solitary confinement-an intervention deemed "necessary" by staff. Therefore, staff training on ADHD might need to cover evidence on adverse effects. Non-pharmacological interventions for treatment were preferred and considered to be highly efficacious. Skepticism toward pharmacological treatment prevailed, even when benefits from stimulant medication were described. Interestingly, this skepticism was not the result of negative experiences with the misuse and diversion of stimulants. Acceptance of multimodal treatment among prison staff may require customized strategies.
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http://dx.doi.org/10.3389/fpsyt.2020.600005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901975PMC
January 2021

Court-Mandated Patients' Perspectives on the Psychotherapist's Dual Loyalty Conflict - Between Ally and Enemy.

Front Psychol 2020 6;11:592638. Epub 2021 Jan 6.

Insitute for Biomedical Ethics, University of Basel, Basel, Switzerland.

Background: Mental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma.

Methods: This qualitative interview study investigates patients' perceptions of their therapists' dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis.

Results: We first present the patients' perceptions of their treating psychotherapist's dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants' reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: (1) respecting the patient's pace and perceived coercion; (2) patient health needs to be first priority; (3) clarity in roles and responsibilities; and (4) the art of communication - between transparency and unchecked information sharing.

Discussion: Developing a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists' characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist' characteristics promoting a trustful relationship in correctional settings.
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http://dx.doi.org/10.3389/fpsyg.2020.592638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815763PMC
January 2021

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study.

Harm Reduct J 2020 10 13;17(1):67. Epub 2020 Oct 13.

Swiss Research Institute for Public Health and Addiction ISGF, University of Zurich, Zurich, Switzerland.

Background: In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims: Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design: Retrospective cohort study SETTING: An open prison with 120 places SUBJECTS: Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements: Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings: Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions: This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.
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http://dx.doi.org/10.1186/s12954-020-00412-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552491PMC
October 2020

The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids.

Front Psychiatry 2020 14;11:395. Epub 2020 May 14.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Background: Opioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.

Aims: The present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.

Methods: Using a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.

Results: Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.
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http://dx.doi.org/10.3389/fpsyt.2020.00395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240251PMC
May 2020

Reducing recidivism using the Reasoning and Rehabilitation program: a pilot multi-site-controlled trial among prisoners in Switzerland.

Int J Public Health 2020 Jul 21;65(6):801-810. Epub 2020 Apr 21.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objectives: This study evaluated whether the Reasoning and Rehabilitation (R&R2) program was effective in reducing recidivism, minimizing dropout rates, and improving outcomes related to attitudes, behaviors, and personality among people living in detention.

Methods: Data were collected in eight Swiss German-speaking prisons among males detained for violent offenses using a quasi-experimental controlled design (R&R2: n = 129, treatment as usual [TAU]: n = 84). Measures included recidivism, dropout rate, and self-report questionnaires (hostile attribution bias, aggressiveness, interpersonal problems, and willingness to accept responsibility). Data were analyzed using mixed-effect models.

Results: Participants in the R&R2 group were less likely to reoffend in comparison with the TAU group in the intention-to-treat (n = 51, odds ratio = 0.75, p = .060) and the per-protocol (excluding dropouts; n = 38, odds ratio = 0.65, p = .068) analyses. They also had lower self-reported scores of spontaneous and reactive aggressiveness (p = .047 and p = .070) and excitability (p = .086).

Conclusions: The findings of this pilot project were promising, with the R&R2 program leading to reduced recidivism and dropout rate. Even though these results should be considered preliminary, the R&R2 program appeared to be a relevant approach in reducing recidivism after prison.
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http://dx.doi.org/10.1007/s00038-020-01372-9DOI Listing
July 2020

Do Overcrowding and Turnover Cause Violence in Prison?

Front Psychiatry 2019 24;10:1015. Epub 2020 Jan 24.

Division of Prison Health, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.

Violence is common in prison and its individual risk factors are well documented. However, there is a mixed evidence on the relationship between prison violence and institutional factors, such as overcrowding and turnover, and recent research suggested that these factors may not be important or relevant. This study investigated the association between prison violence and institutional factors in a Swiss pre-trial prison between 2013 and 2018. Measures included violence (assaults requiring immediate medical attention) as well as the annual overcrowding and turnover rates. Using a meta-regression, the results showed that prison violence was higher when overcrowding and turnover increased. Overall, our study highlighted that institutional prison factors might have notable detrimental effects on prison life. Reduction of prison overcrowding and turnover appear critical to reduce prisoners' vulnerability. Turning prison into safe places designed to promote desistance would probably not be achievable without considering these crucial factors.
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http://dx.doi.org/10.3389/fpsyt.2019.01015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992601PMC
January 2020

How Do Legal Experts Cope With Medical Reports and Forensic Evidence? The Experiences, Perceptions, and Narratives of Swiss Judges and Other Legal Experts.

Front Psychiatry 2019 13;10:18. Epub 2019 Feb 13.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Expert scientific knowledge, including medical knowledge, is relevant for the legal profession and can strongly influence rulings and sentencing in criminal law, civil law, and insurance law. The way in which this medical evidence is understood and evaluated thus has an impact both on individuals and on society as a whole. It enters legal procedures in various forms, for example, as expert witness statements and/or as a legal expert's own acquired medical knowledge. On the other hand, a legal expert may be confronted with expert medical opinions that differ in quality or content and thus have to decide which ones to follow. The aim of this qualitative study was to investigate legal experts' perceptions, experiences, and narratives regarding medical knowledge, particularly the skills and general knowledge used in their branch of the legal profession. A total of 51 semi-structured interviews with judges and prosecutors from different courts of law and from the public prosecutor's office in six different German-speaking (Zurich, Luzern, Aagrau, Obwalden, Nidwalden, Zug) and German/French-speaking (Bern) cantons of Switzerland were conducted, coded, and analyzed using Nvivo. We used a comparison thematic approach identifying common and new themes related to the research aims. Our findings suggest that Swiss judges and prosecutors believe that possessing and developing the skills and terminology required for processing medical information is important but complex, and time-consuming for their work. Additionally, several legal experts reported that their understanding of medical evidence was limited or even non-existent. Moreover, the acquisition of skills related to the assessment of medical reports and forensic evidence appeared to be unstructured. Participants reported having no formal instruction in how to evaluate or deal with medical knowledge. The sources they used to answer questions arising appeared to be in part problematic and non-standardized (internet, newspapers, etc.). Medical literature from peer-reviewed journals was used only rarely. The findings from this study suggest that law departments might wish to evaluate whether their graduates are sufficiently equipped with scientific literacy skills and appropriate skills to evaluate medical information for their later careers. At the same time, medical knowledge pertinent to forensics published in local legal journals may be more effective in reaching the legal expert audience than in medical journals.
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http://dx.doi.org/10.3389/fpsyt.2019.00018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381858PMC
February 2019

Online Survey of Medical and Psychological Professionals on Structured Instruments for the Assessment of Work Ability in Psychiatric Patients.

Front Psychiatry 2018 25;9:453. Epub 2018 Sep 25.

Institute of Forensic Medicine, Department of Forensic Psychiatry, University of Bern, Bern, Switzerland.

To evaluate perceived needs and difficulties related to instruments for assessing work ability in individuals with mental disorders. We conducted an online survey of 104 German-speaking medico-legal experts (forensic psychiatric and psychology experts, insurance physicians) and therapists. The large majority of respondents reported they would welcome a standardized, structured instrument for the assessment of work ability. High predictiveness, inter-rater agreement, comprehensibility for laymen, and symptom validity were desired in roughly equal measure as the main characteristic of such an instrument. More women than men, and more medico-legal experts than therapists, considered symptom validation as always necessary. Pain, personality, and affective disorders were perceived to be the most difficult disorders in the context of work ability assessments. Our survey documents professionals' wish for a structured assessment of work ability in both medico-legal and therapeutic settings.
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http://dx.doi.org/10.3389/fpsyt.2018.00453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6167551PMC
September 2018

[ICD-11 posttraumatic stress disorder (PTSD) in male prisoners].

Fortschr Neurol Psychiatr 2019 02 13;87(2):112-120. Epub 2018 Aug 13.

Forensisch-Psychiatrischer Dienst, Institut für Rechtsmedizin, Universität Bern, Schweiz.

Theoretical Background: The eleventh version of the ICD, expected to be published in 2018, leads to changed criteria for post-traumatic stress disorder (PTSD) according to the online beta version. Such changes are likely to affect previously known features of PTSD, including the prevalence rate. Little is known about the prevalence of ICD-11 PTSD in imprisoned men. The present study examined this issue in this high-risk group for trauma disorders, as male prisoners are known to be more often affected by traumatic events compared to the general population.

Method: In n = 49 men imprisoned in Switzerland, cross-sectional and standardized self-assessment procedures (ACE, Cidi list, IES-R) were used to record traumatic events and possible trauma symptoms. The frequency of ICD-11 PTSD was calculated using the diagnostic heuristic of Hyland et al. (2017), on the basis of which ICD-11 PTSD is estimated by means of the IES-R.

Results: Overall, 88 % of the detained men examined had been traumatized during childhood and / or life span; 78 % reported at least one event on the ACE, on average 1.5, with 25 % reporting four or more events. Emotional abuse was reported most frequently (51 %). Furthermore, 71 % reported at least one event on the Cidi list, on average 1.8, with 45 % reporting serious physical threat. The analysis of ICD-11 PTSD was carried out with n = 34 inmates after exclusion of those without a traumatic event and those who did not complete the IES-R, and ICD-11 PTSD was estimated at 26.5 %.

Conclusion: The study shows that imprisoned men are likely to be a high risk group for the development of PTSD even according to the new ICD. Considering the high prevalence of traumatic events and the numerous negative consequences for mental as well as physical health, specific psychotherapeutic programs and a trauma-informed imprisonment are necessary.
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http://dx.doi.org/10.1055/s-0044-101545DOI Listing
February 2019

[Assessment of complex posttraumatic stress disorder with the revised Trauma Symptom Inventory (TSI-2)].

Fortschr Neurol Psychiatr 2019 Jun 13;87(6):364-371. Epub 2018 Jul 13.

Background: This study tested whether it is possible to diagnose complex posttraumatic stress disorder (CPTSD) according to the beta version of ICD-11 by means of the Trauma Symptom Inventory 2 (TSI-2). Currently, there is no established measurement for this.

Methods: An algorithm for the TSI-2 was developed. This was tested in a sample of 100 psychiatric patients, who had experienced aversive and/or traumatic events. The frequency of CPTSD and differences regarding gender, age and traumatic events will be reported.

Results: On the basis of this TSI-2 algorithm, 5% of the sample were estimated to suffer from CPTSD. A trend towards more women being affected was observed, and younger patients were more affected than older ones. Traumatized individuals reported more mental health problems than non-traumatized ones.

Conclusion: Tentatively, these results indicate that it may be possible to use a combination of certain scales of the TSI-2 to diagnose CPTSD in line with its current definition by the ICD-11.
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http://dx.doi.org/10.1055/s-0044-101034DOI Listing
June 2019

Status quo of German-speaking medical students' attitudes toward and knowledge about central aspects of forensic psychiatry across four European countries.

Int J Law Psychiatry 2018 May - Jun;58:9-16. Epub 2018 Mar 3.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Falkenplatz 16-18, 3012 Bern, Switzerland. Electronic address:

While forensic psychiatry is of increasing importance in mental health care, limited available evidence shows that attitudes toward the discipline are contradictory and that knowledge about it seems to be limited in medical students. We aimed to shed light on this subject by analyzing medical students' central attitudes toward and their association with knowledge about forensic psychiatry as well as with socio-demographic and education-specific predictor variables. We recruited N = 1345 medical students from 45 universities with a German language curriculum across four European countries (Germany, Switzerland, Austria and Hungary) by using an innovative approach, namely snowball sampling via Facebook. Students completed an online questionnaire, and data were analyzed descriptively and multivariably by linear mixed effects models and multinomial regression. The results showed overall neutral to positive attitudes toward forensic psychiatry, with indifferent attitudes toward the treatment of sex offenders, and forensic psychiatrists' expertise in the media. Whereas medical students knew about the term 'forensic psychiatry', they showed a lack of specific medico-legal knowledge. Multivariable models on predictor variables revealed statistically significant findings with, however, small estimates and variance explanation. Therefore, further research is required along with the development of a refined assessment instrument for medical students to explore both attitudes and knowledge in forensic psychiatry.
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http://dx.doi.org/10.1016/j.ijlp.2018.02.003DOI Listing
April 2019

Predicting Medical Students' Current Attitudes Toward Psychiatry, Interest in Psychiatry, and Estimated Likelihood of Working in Psychiatry: A Cross-Sectional Study in Four European Countries.

Front Psychiatry 2018 12;9:49. Epub 2018 Mar 12.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Psychiatry as a medical discipline is becoming increasingly important due to the high and increasing worldwide burden associated with mental disorders. Surprisingly, however, there is a lack of young academics choosing psychiatry as a career. Previous evidence on medical students' perspectives is abundant but has methodological shortcomings. Therefore, by attempting to avoid previous shortcomings, we aimed to contribute to a better understanding of the predictors of the following three outcome variables: current medical students' attitudes toward psychiatry, interest in psychiatry, and estimated likelihood of working in psychiatry. The sample consisted of  = 1,356 medical students at 45 medical schools in Germany and Austria as well as regions of Switzerland and Hungary with a German language curriculum. We used snowball sampling Facebook with a link to an online questionnaire as recruitment procedure. Snowball sampling is based on referrals made among people. This questionnaire included a German version of the Attitudes Toward Psychiatry Scale (ATP-30-G) and further variables related to outcomes and potential predictors in terms of sociodemography (e.g., gender) or medical training (e.g., curriculum-related experience with psychiatry). Data were analyzed by linear mixed models and further regression models. On average, students had a positive attitude to and high general interest in, but low professional preference for, psychiatry. A neutral attitude to psychiatry was partly related to the discipline itself, psychiatrists, or psychiatric patients. Female gender and previous experience with psychiatry, particularly curriculum-related and personal experience, were important predictors of all outcomes. Students in the first years of medical training were more interested in pursuing psychiatry as a career. Furthermore, the country of the medical school was related to the outcomes. However, statistical models explained only a small proportion of variance. The findings indicate that particularly curriculum-related experience is important for determining attitudes toward psychiatry, interest in the subject and self-predicted professional career choice. We therefore encourage the provision of opportunities for clinical experience by psychiatrists. However, further predictor variables need to be considered in future studies.
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http://dx.doi.org/10.3389/fpsyt.2018.00049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857547PMC
March 2018

Sociodemographic Information, Aversive and Traumatic Events, Offence-Related Characteristics, and Mental Health of Delinquent Women in Forensic-Psychiatric Care in Switzerland.

Int J Offender Ther Comp Criminol 2018 09 28;62(12):3815-3833. Epub 2017 Dec 28.

1 Department of Forensic Psychiatry, Institute of Legal Medicine, University of Bern, Switzerland.

The present study describes a much understudied group-namely, female prisoners under forensic-psychiatric care in the German-speaking part of Switzerland-to improve understanding of their risks and their needs. Data were derived from internal databases of a Forensic-Psychiatric Service. Data were collected in the form of their sociodemographic characteristics, prevalence of aversive and traumatic events, type of offence committed, and mental health conditions. Based on a full-sample approach, a total of 1,571 files were analysed. Results reveal that two thirds of the participants were not in a stable relationship, more than half did not complete a school degree, and three quarters were without stable employment prior to their incarceration. Two thirds were mothers and about one third did not grow up with their parents. Almost half grew up with an alcohol abusing parent, about half experienced violence and/or neglect in childhood, and about a quarter of the cases sexual abuse. About 95% had a mental health diagnosis according to International Classification of Diseases-Version 10 (ICD-10), and the most prevalent mental and behavioural disorder was due to psychoactive substance abuse. The most frequent offence type was drug-related crimes. Women convicted for drug-related crimes were more likely to have an ICD-10 F1 disorder compared with those convicted for other crimes. Conversely, women with violent offences were less likely to suffer from ICD-10 F1 disorder than those who had committed nonviolent offences. Findings have implications for practitioners and policy makers, and contribute to the cycle of violence theory discussion. In conclusion, future research areas are suggested.
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http://dx.doi.org/10.1177/0306624X17749638DOI Listing
September 2018

Duration of Absence from Work Is Related to Psychopathology, Personality, and Sociodemographic Variables in a Longitudinal Cohort.

Front Psychiatry 2017 29;8:252. Epub 2017 Nov 29.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objective: To examine, in a non-clinical sample, the association of psychopathology, personality, sociodemographic information, and psychosocial indicators of non-occupational functioning with the duration of absence from work in the past 12 months.

Method: A longitudinal community cohort of 591 adults from Switzerland was analyzed using multilevel ordered logistic regression, with several alternative models as robustness checks. Psychopathology was assessed using the total score (Global Severity Index) of the Symptom Check List-90 Revised.

Results: The highest psychopathology levels were associated with absences of 3 or more week duration, largely independently of age. Extraversion and being divorced, widowed or separated also corresponded with longer absences from work in some analyses. No effect of sex was found. Most effects tested were not statistically significant and estimates showed large uncertainty.

Conclusion: Although tentative, our results suggest a possible influence of psychopathology on work participation. It may thus be desirable in insurance-medical appraisals of work ability to include instruments for measuring psychopathology.
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http://dx.doi.org/10.3389/fpsyt.2017.00252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712568PMC
November 2017

Skills and compensation strategies in adult ADHD - A qualitative study.

PLoS One 2017 27;12(9):e0184964. Epub 2017 Sep 27.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objective: The primary objectives of this study were to investigate how adult patients with ADHD coped with their symptoms prior to diagnosis and treatment, what skills and compensation strategies they had developed and what their self-perceptions of these strategies were.

Methods: We used a qualitative approach to analyze interviews with 32 outpatients of a specialty care unit at a university hospital.

Results: Patients reported frequent use of diverse compensatory strategies with varying degrees of effectiveness. These were classified into five categories (organizational, motoric, attentional, social, psychopharmacological). In certain circumstances, ADHD symptoms were even perceived as useful.

Conclusion: Before diagnosis and treatment, patients with ADHD may develop a variety of skills to cope with their symptoms. Several of these skills are perceived as helpful. Knowledge of self-generated coping strategies may help better understand patients and their histories and thus facilitate patient cooperation. Moreover, knowing ways in which such patients cope with their symptoms may help elucidate reasons for late or under-diagnosing of the disorder.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184964PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617155PMC
October 2017

Interpersonal Sensitivity as a Mediator Between Cumulative Childhood Traumatic Events and Adult Sexual Disturbance.

J Sex Marital Ther 2018 Feb 11;44(2):213-220. Epub 2017 Aug 11.

a Forensic Psychiatric Services, Institute for Legal Medicine , University of Bern , Bern , Switzerland.

Previous research has shown that cumulative childhood traumatic events are stronger predictors of sexual disturbances than childhood sexual abuse. Additional factors are likely to influence this relationship. Whereas socio-interpersonal factors such as interpersonal sensitivity have repeatedly been shown to be salutogenic in the aftermath of traumatic events, the specific underlying mechanisms are little understood. The aim of the present study was to examine the relationship between cumulative childhood traumatic events and adult sexual disturbances (i.e., the avoidance of sexual contacts, disruptive sexual behavior, poor sexual boundaries, decreased regulation of sexual impulses) and to investigate the role of interpersonal sensitivity as a potential mediator. The sample comprised 100 adult psychiatric in-patients. As expected, cumulative childhood traumatic events were found to be strong predictors of sexual disturbances, with interpersonal sensitivity partially mediating this relationship.
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http://dx.doi.org/10.1080/0092623X.2017.1354343DOI Listing
February 2018

Attitudes Toward Stimulant Treatment of Offspring of Adult Patients with Attention-Deficit/Hyperactivity Disorder.

J Child Adolesc Psychopharmacol 2017 Jun 19;27(5):422-428. Epub 2017 Apr 19.

1 Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern , Bern, Switzerland .

Aim: The objective of this study was to investigate how adult patients with attention-deficit/hyperactivity disorder viewed the testing and use of stimulants in their children.

Methods: Using a qualitative approach, we interviewed 32 outpatients from a special care unit of a university hospital.

Results: Emerging themes centered around concerns about the right age to test children and opinions about stimulant treatment ranging from unreserved agreement to reluctance, as well as the need for a shared decision with the child.

Conclusions: Our results suggest that better psychoeducational programs are needed, especially for adults with attention-deficit/hyperactivity disorder, in which long-term consequences of the disorder, areas of impairment, and possible treatment effects in their children are explained and concerns about unknown side effects and the right time to test and treat are addressed.
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http://dx.doi.org/10.1089/cap.2016.0197DOI Listing
June 2017

Could Google Trends Be Used to Predict Methamphetamine-Related Crime? An Analysis of Search Volume Data in Switzerland, Germany, and Austria.

PLoS One 2016 30;11(11):e0166566. Epub 2016 Nov 30.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objective: To compare the time trends of Google search interest in methamphetamine and criminal offences related to this drug.

Methods: Google Trends data for the search term "meth" was compared to methamphetamine-related crime statistics (incl. use, possession, and dealing) in Switzerland, Germany, and Austria for the years 2004-2016. Google data was availably monthly. Crime data was available yearly, and monthly values were imputed.

Results: On the country level, internet search trends for "meth" roughly paralleled relevant criminal activity. State-level data, which was available for Austria, showed more heterogeneity. Cross-correlations for yearly data almost always peaked at a lag time of 0 and coefficients were mostly between 0.7 and 1.0 on the country level, and between 0.5 to 1.0 on the state level. Monthly cross-correlations based on imputed values were substantially lower, ranging from 0 to 0.6.

Conclusions: These results encourage the further evaluation by law enforcement authorities of Google search activity as a possible predictor of methamphetamine-related crime. However, several limitations, in particular the crude temporal resolution of available crime data, precluded a detailed assessment of the relationship between internet search trends and the development of methamphetamine-related crime in central Europe.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166566PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130206PMC
July 2017

High-Dose Benzodiazepine Users' Perceptions and Experiences of Anterograde Amnesia.

J Am Acad Psychiatry Law 2016 Sep;44(3):328-37

Dr. Liebrenz is Head of the Research Division, Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland. Mr. Schneider is Resident Physician, Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland. Dr. Buadze is Attending Physician, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Ms. Gehring is a Psychologist and Head of the Residential Rehabilitation Treatment Program, Ulmenhof, Sozialtherapie, Ottenbach, Switzerland. Dr. Dube is Attending Physician, County of Santa Barbara, Department of Behavioral Wellness, Santa Barbara, California. Dr. Caflisch is Attending Physician, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Dr. Liebrenz was financially supported by the Prof. Dr. Max Cloëtta Foundation, Zurich, Switzerland and the Uniscientia Foundation, Vaduz, Principality of Liechtenstein.

Associations between criminal activity and the use of psychotropic substances are well established. Flunitrazepam, specifically, has been suspected of triggering, per se, violent criminal behavior and severe memory disturbances in the form of anterograde amnesia. However, data from investigations of this relationship are scarce and have been primarily derived from forensic institutions, where there may be a reporting bias. This study was a qualitative exploration of high-dose benzodiazepine users' experiences of anterograde amnesia symptoms and their beliefs about their behavior during the phases of memory impairment in a nonforensic setting. Users subjectively reported experiencing symptoms of anterograde amnesia, especially after combining short-acting benzodiazepines with alcohol, but only rarely when using slow-onset, long-acting compounds. They perceived their experiences as unpleasurable, unpredictable, and embarrassing. Their awareness developed with time, triggered by descriptions of disinhibited and erratic behavior by others. Users described being victimized during phases of anterograde amnesia in addition to engaging in violent and criminal activities themselves. Although unable to recall, many participants believed that they had been able to make rational decisions while intoxicated with flunitrazepam, disregarding notions of diminished insight. In light of the varying terminology used for the phases of memory disturbance and these findings, we suggest that forensic experts additionally explore evaluees' beliefs about amnestic periods and their self-perceptions about their behaviors during these episodes, when evaluating high-dose benzodiazepine-dependent patients.
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September 2016

Adult attention-deficit/hyperactivity disorder and nicotine withdrawal: a qualitative study of patient perceptions.

BMC Psychiatry 2016 07 4;16:208. Epub 2016 Jul 4.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: Nicotine use has been reported to ameliorate symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Furthermore, adults with ADHD have a relatively high prevalence of cigarette smoking and greater difficulty abstaining from smoking. Overall, though, there is scant literature investigating the beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal.

Methods: Our participants (n = 20) fulfilling criteria for ADHD and a past or current dependence from nicotine were recruited from the in- and outpatient clinic of the Zurich University Psychiatric Hospital and the Psychiatric Services Aargau (Switzerland). We conducted in-depth interviews to explore their motivations to quit, past experiences with and expectations about quitting using a purposeful sampling plan. The sample was selected to provide diversity in relation to level of nicotine dependence, participation in a smoking-cessation program, gender, age, martial status and social class. Mayring's qualitative content analysis approach was used to evaluate findings.

Results: Adult smokers with ADHD had made several attempts to quit, experienced intense withdrawal symptoms, and relapsed early and often. They also often perceived a worsening of ADHD symptoms with nicotine abstinence. We identified three motives to quit smoking: 1) health concerns, 2) the feeling of being addicted, and 3) social factors. Most participants favored a smoking cessation program specifically designed for individuals with ADHD because they thought ADHD complicated their nicotine withdrawal and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder.

Conclusions: Since treatment initiation and adherence associate closely with perception, we hope these findings will result in better cessation interventions for the vulnerable subgroup of smokers with ADHD.
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http://dx.doi.org/10.1186/s12888-016-0911-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932755PMC
July 2016

Attitudes towards a maintenance (-agonist) treatment approach in high-dose benzodiazepine-dependent patients: a qualitative study.

Harm Reduct J 2016 Jan 8;13. Epub 2016 Jan 8.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: High-dose benzodiazepine dependence constitutes a major clinical concern. Although withdrawal treatment is recommended, it is unsuccessful for a significant proportion of affected patients. More recently, a benzodiazepine maintenance approach has been suggested as an alternative for patients' failing discontinuation treatment. While there is some data supporting its effectiveness, patients' perceptions of such an intervention have not been investigated.

Methods: An exploratory qualitative study was conducted among a sample of 41 high-dose benzodiazepine (BZD)-dependent patients, with long-term use defined as doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use, such as mixing substances, dose escalation, recreational use, or obtainment by illegal means. A qualitative content analysis approach was used to evaluate findings.

Results: Participants generally favored a treatment discontinuation approach with abstinence from BZD as its ultimate aim, despite repeated failed attempts at withdrawal. A maintenance treatment approach with continued prescription of a slow-onset, long-acting agonist was viewed ambivalently, with responses ranging from positive and welcoming to rejection. Three overlapping themes of maintenance treatment were identified: "Only if I can try to discontinue…and please don't call it that," "More stability and less criminal activity…and that is why I would try it," and "No cure, no brain and no flash…and thus, just for everybody else!"

Conclusions: Some patients experienced slow-onset, long-acting BZDs as having stabilized their symptoms and viewed these BZDs as having helped avoid uncontrolled withdrawal and abstain from criminal activity. We therefore encourage clinicians to consider treatment alternatives if discontinuation strategies fail.
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http://dx.doi.org/10.1186/s12954-015-0090-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4705614PMC
January 2016

[Assessment of Functioning when Conducting Occupational Capacity Evaluations--What is "Evidence-Based"?].

Psychiatr Prax 2016 Mar 10;43(2):74-81. Epub 2015 Nov 10.

Gutachtenstelle für Zivil- und Öffentlichrechtliche Fragestellungen, Klinik für Psychiatrie, Psychotherapie und Psychosomatik der Psychiatrischen Universitätsklinik Zürich, Zürich, Schweiz.

Aim: Occupational capacity evaluations have previously been subject to criticism for lacking in quality and consistency. To the authors' knowledge, there is no clear consensus on the best way to formally assess functioning within capacity evaluations. In this review we investigated different instruments that are used to assess functioning in occupational capacity evaluations.

Methods: Systematic review of the literature.

Results: Though several instruments that assess functional capacity were found in our search, a specific validated instrument assessing occupational capacity as part of a larger psychiatric evaluation was not found. The limitations of the existing instruments on assessing functional capacity are discussed.

Conclusion: Medical experts relying on instruments to conduct functional capacity evaluations should be cognizant of their limitations. The findings call for the development and use of an instrument specifically designed to assess the functional and occupational capacity of psychiatric patients, which is also likely to improve the quality of these reports.
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http://dx.doi.org/10.1055/s-0035-1552762DOI Listing
March 2016

High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients' Perceptions on Initiation, Reasons for Use, and Obtainment.

PLoS One 2015 10;10(11):e0142057. Epub 2015 Nov 10.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: High-dose benzodiazepine (BZD) dependence is associated with a wide variety of negative health consequences. Affected individuals are reported to suffer from severe mental disorders and are often unable to achieve long-term abstinence via recommended discontinuation strategies. Although it is increasingly understood that treatment interventions should take subjective experiences and beliefs into account, the perceptions of this group of individuals remain under-investigated.

Methods: We conducted an exploratory qualitative study with 41 adult subjects meeting criteria for (high-dose) BZD-dependence, as defined by ICD-10. One-on-one in-depth interviews allowed for an exploration of this group's views on the reasons behind their initial and then continued use of BZDs, as well as their procurement strategies. Mayring's qualitative content analysis was used to evaluate our data.

Results: In this sample, all participants had developed explanatory models for why they began using BZDs. We identified a multitude of reasons that we grouped into four broad categories, as explaining continued BZD use: (1) to cope with symptoms of psychological distress or mental disorder other than substance use, (2) to manage symptoms of physical or psychological discomfort associated with somatic disorder, (3) to alleviate symptoms of substance-related disorders, and (4) for recreational purposes, that is, sensation-seeking and other social reasons. Subjects often considered BZDs less dangerous than other substances and associated their use more often with harm reduction than as recreational. Specific obtainment strategies varied widely: the majority of participants oscillated between legal and illegal methods, often relying on the black market when faced with treatment termination.

Conclusions: Irrespective of comorbidity, participants expressed a clear preference for medically related explanatory models for their BZD use. We therefore suggest that clinicians consider patients' motives for long-term, high-dose BZD use when formulating treatment plans for this patient group, especially since it is known that individuals are more compliant with approaches they perceive to be manageable, tolerable, and effective.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0142057PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640837PMC
July 2016

Adult attention-deficit/hyperactivity disorder: Associations between subtype and lifetime substance use - a clinical study.

F1000Res 2015 28;4:407. Epub 2015 Jul 28.

Psychiatric University Hospital, Research Group on ADHD, Zurich, 8032, Switzerland.

ADHD is the one of the most prevalent childhood disorders and has been associated with impairments persisting into adulthood. Specifically, childhood ADHD is an independent clinical risk factor for the development of later substance use disorders (SUD). Moreover, adults who meet diagnostic criteria for ADHD have shown high rates of comorbid SUDs. Few studies, however, have reported on the relationship between ADHD subtypes and SUD in adult samples. The purpose of this study was to characterize a clinical sample of adults with ADHD and to identify possible associations between ADHD subtypes, lifetime substance use, and if ADHD subtypes may be preferentially associated with specific substances of abuse. We recruited 413 adult ADHD patients, performed an evaluation of their ADHD and conducted an interview on their use of psychotropic substances. Complete data was obtained for 349 patients. Lifetime substance abuse or dependence was 26% and occasional use was 57% in this sample. The inattentive subtype was significantly less likely to abuse or be dependent on cocaine than the combined subtype. Our findings underscore the high rate of comorbidity between substance use and ADHD in adults. The more frequent abuse/dependence of cocaine by adult patients with hyperactive-impulsive symptoms should be kept in mind when treating this patient group.
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http://dx.doi.org/10.12688/f1000research.6780.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089146PMC
July 2015

High-dose benzodiazepine dependence: a qualitative study of patients' perception on cessation and withdrawal.

BMC Psychiatry 2015 May 13;15:116. Epub 2015 May 13.

Psychiatric University Hospital, Lenggstrasse 31, 8032, Zurich, Switzerland.

Background: Benzodiazepine withdrawal syndrome has been reported following attempts to withdraw even from low or therapeutic doses and has been compared to barbiturate and alcohol withdrawal. This experience is known to deter patients from future cessation attempts. Research on other psychotropic substances shows that the reasons and motivations for withdrawal attempts - as well as the experiences surrounding those attempts - at least partially predict future efforts at discontinuation as well as relapse. We therefore aimed to qualitatively explore what motivates patients to discontinue this medication as well as to examine their experiences surrounding previous and current withdrawal attempts and treatment interventions in order to positively influence future help-seeking behavior and compliance.

Methods: To understand these patients better, we conducted a series of 41 unstructured, narrative, in-depth interviews among adult Swiss patients with a long-term dependent use of benzodiazepines in doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use (mixing benzodiazepines, escalating dosage, recreational use or illegal purchase). Mayring's qualitative content analysis was used to evaluate findings.

Results: These high-dose benzodiazepine-dependent patients decision to change consumption patterns were affected by health concerns, the feeling of being addicted and social factors. Discontinuation attempts were frequent and not very successful with fast relapse. Withdrawal was perceived to be a difficult, complicated, and highly unpredictable process. The first attempt at withdrawal occurred at home and typically felt better than at the clinic. Inpatient treatment was believed to be more effective with long term treatment (approaches) than short term. Patients preferred gradual reduction of usage to abrupt cessation (and had experienced both). While no clear preferences for withdrawal were found for benzodiazepines with specific pharmacokinetic properties, participants frequently based their decision to participate in treatment on the availability of their preferred brand name and furthermore discarding equivalent dosage rationales.

Conclusions: Our findings provide greater understanding of the factors that motivate high-dose benzodiazepine-dependent individuals to stop taking these medications, and how they experience withdrawal and treatment strategies. They underscore how patients' perceptions of treatment approaches contribute to compliant or non-compliant behavior.
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http://dx.doi.org/10.1186/s12888-015-0493-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443548PMC
May 2015

[Use of interpreters in the context of insurance psychiatric expert assessment].

Praxis (Bern 1994) 2015 Mar;104(6):293-300

Gutachtenstelle für Zivil- und Öffentlichrechtliche Fragestellungen, Klinik für Psychiatrie, Psychotherapie und Psychosomatik der Psychiatrischen Universitätsklinik Zürich und Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, USA.

Limited knowledge of the German language represents a serious barrier for migrants into Switzerland to communicate successfully in a variety of health care settings, which may result not just in delayed access to treatment and poorer outcome, but also in difficulties judging eligibility for health and other social benefits. Especially when conducting disability and other occupational capacity evaluations, clinicians of all medical fields, but particularly psychiatrists, are required to obtain abundant information to allow them to perform a thorough mental health examination and to form a differentiated view of an evaluee's work capacity. Within a clinical context different translation and interpreting strategies are in use, and each strategy has its advantages and disadvantages. This mini-review describes the legal and modal aspects as well as the clinical-practical implications of the use of such interpreting services during disability evaluations.
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http://dx.doi.org/10.1024/1661-8157/a001915DOI Listing
March 2015

Temperamental differences between bipolar disorder, borderline personality disorder, and attention deficit/hyperactivity disorder: some implications for their diagnostic validity.

J Affect Disord 2014 Dec 29;169:101-4. Epub 2014 May 29.

Psychiatric University Hospital, Research Department, Lenggstrasse 31, 8032 Zurich, Switzerland.

Background: The relationship between borderline personality disorder (BPD), bipolar disorder (BD), and attention deficit/hyperactivity disorder (ADHD) requires further elucidation.

Methods: Seventy-four adult psychiatric in- and out-patients, each of them having received one of these diagnoses on clinical assessment, were interviewed and compared in terms of diagnostic overlap, age and sex distribution, comorbid substance, anxiety and eating disorders, and affective temperament.

Results: Diagnostic overlap within the three disorders was 54%. Comorbidity patterns and gender ratio did not differ. The disorders showed very similar levels of cyclothymia.

Limitations: Sample size was small and only a limited number of validators were tested.

Conclusions: The similar extent of cyclothymic temperament suggests mood lability as a common denominator of BPD, BD, and ADHD.
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http://dx.doi.org/10.1016/j.jad.2014.05.028DOI Listing
December 2014

Ethnic- and gender-specific differences in the prevalence of HIV among patients in opioid maintenance treatment-a case register analysis.

Harm Reduct J 2014 Aug 18;11:23. Epub 2014 Aug 18.

Research Group on Substance Use Disorders, Psychiatric University Hospital, Selnaustrasse 9, 8001 Zurich, Switzerland.

Background: We have sought to identify ethnic- and gender-specific differences in HIV prevalence among heroin users receiving opioid maintenance treatment in the canton of Zurich, Switzerland.

Methods: We used a generalized linear model (GEE) to analyze data from the anonymized case register for all opioid maintenance treatments in the canton of Zurich. Patients who received either methadone or buprenorphine between 1991 and 2012 (n=11,422) were evaluated for gender (male vs. female), ethnic background (Swiss vs. non-Swiss), and lifetime method of drug use (ever injector vs. non-injector). We addressed missing data by multiple imputation.

Results: The overall prevalence of HIV among patients declined substantially from 33.7% in 1991 to 10.6% in 2012 in the complete dataset. In the imputed datasets, the respective prevalence dropped from 32.8% in 1991 to 9.7% in 2012. Non-injectors had a four to five times lower risk ratio (RR) compared to the reference group, 'Swiss males who ever injected'. In addition, we found a significantly higher risk ratio of HIV prevalence among females who had ever injected; this was true both for the complete dataset and the imputed dataset (Swiss RR 1.18 CI 95% 1.04-1.34, non-Swiss RR 1.58 CI 95% 1.18-2.12).

Conclusion: In this population, gender, ethnic background, and lifetime method of drug use influenced the risk of being HIV positive. Different access to treatment and different characteristics of risk exposure among certain subgroups might explain these findings. In particular, the higher risk for women who inject drugs-especially for those with an immigrant background-warrants additional research. Further exploration should identify what factors deter women from using available HIV-prevention measures and whether and how these measures can be better adapted to high-risk groups.
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http://dx.doi.org/10.1186/1477-7517-11-23DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4178317PMC
August 2014

Adult attention-deficit/hyperactivity disorder and nicotine use: a qualitative study of patient perceptions.

BMC Psychiatry 2014 May 16;14:141. Epub 2014 May 16.

Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA.

Background: Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with high rates of comorbid substance use disorders, and cigarette smoking has a particularly high prevalence in this population. However, there is an ongoing debate as to whether this tobacco use is an attempt at "self-medication" or due to behavioral disinhibition. There is a surprising lack of qualitative studies that investigate the subjective perceptions of adults with ADHD regarding cigarette smoking. The present study was designed to fill this gap in the literature.

Methods: We recruited twelve adult patients with ADHD and comorbid tobacco use from our ADHD consultation service, an outpatient facility of the Zurich University Psychiatric Hospital. Subjects were interviewed using qualitative methodology, and Mayring's qualitative content analysis was used to evaluate findings.

Results: We identified two explanatory models linking ADHD and tobacco use: smoking as an attempt at self-medication and "smoking as a social behavior". On one hand, subjects considered tobacco a therapeutic aid, reporting positive effects on "inner tension" and cognitive function, and noted possible antidepressant properties as well. On the other hand, subjects considered smoking to enhance social functioning and to have a positive impact on interpersonal relationships. The majority believed that stimulant medications offered only a transient decrease in patterns of tobacco use because their ability to reduce nicotine cravings wore off quickly. Others believed that stimulants had no effect or even reinforced cigarette use.

Conclusions: Participants had different views about the link between cigarette smoking and ADHD. While the majority thought of nicotine as a sort of therapy, viewing smoking as a way to self-medicate symptoms of ADHD, motivations for nicotine use were also related to self-image, desire to belong to a peer-group, and a drive to undermine perceived social norms. Ultimately, these findings can be used by clinicians to improve treatment alliance and collaboration.
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http://dx.doi.org/10.1186/1471-244X-14-141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037284PMC
May 2014