Patients in specialist mental healthcare services who are at risk of suicide may experience their struggles as existential in nature. Yet, research on meaning in life has been relatively scarce in suicidology. This qualitative study aimed to explore how patients at risk of suicide perceived their encounters with specialist healthcare professionals after a suicide attempt (SA), with special reference to meaning in life experiences. The study was conducted in specialised mental healthcare services in (...) Norway. Data were collected via individual interviews with eight patients aged 20–75 years. Using a four-step procedure, the interviews were analysed by systematic text condensation. The participants understood their feelings of shame, self-contempt and challenging life experiences as contributing factors to their SA. They perceived that existential themes in relation to financial difficulties, shame and trauma were resolved, while issues associated with the SA, such as death, loss and beliefs, were given less attention. The participants were either ambivalent about continuing to live or wished to rebuild a meaningful life. Overall, their experiences of meaningfulness were hampered. Assisting patients with meaning in life experiences may help them alter their life interpretations and increase their ability to rebuild their lives as meaningful. The present study should be seen as a contribution to meaning-informed approaches in specialist mental healthcare services. More research is needed to equip healthcare personnel in their overall aims of preventing suicide and supporting patients at risk in their efforts to live a meaningful life. (shrink)

The legalization of physician-assisted suicide remains a hotly debated issue throughout the United States, and continues to capture the attention of government officials at both the state and federal levels. While the practice is currently legal in Oregon, some federal lawmakers and officials from the U.S. Department of Justice have attempted to outlaw that state's practice through legislation, or through a strained interpretation of the federal Controlled Substances Act. And while several citizen groups throughout the United States have attempted (...) but failed to legalize PAS through popular initiative, several state lawmakers have succeeded in specifically outlawing the practice. Yet even though physician-assisted suicide remains unlawful in every state except Oregon, there is ample evidence that American physicians throughout the United States have participated in PAS by providing their terminally ill patients with lethal prescriptions. (shrink)

The legalization of physician-assisted suicide remains a hotly debated issue throughout the United States, and continues to capture the attention of government officials at both the state and federal levels. While the practice is currently legal in Oregon, some federal lawmakers and officials from the U.S. Department of Justice have attempted to outlaw that state's practice through legislation, or through a strained interpretation of the federal Controlled Substances Act. And while several citizen groups throughout the United States have attempted (...) but failed to legalize PAS through popular initiative, several state lawmakers have succeeded in specifically outlawing the practice. Yet even though physician-assisted suicide remains unlawful in every state except Oregon, there is ample evidence that American physicians throughout the United States have participated in PAS by providing their terminally ill patients with lethal prescriptions. (shrink)

Nurses and midwives are the majority of healthcare professionals globally, including Africa, and they provide care at all levels of the health system including community levels. Nurses and midwives contribute to the care of patients with rigid or dogmatic religious beliefs or those with suicidal ideations. This review paper discusses acute and chronic diseases that have suicidal tendencies such as terminal cancer, diseases with excruciating pain, physical disability, stroke, end-stage renal failure, and diabetics who are amputated. It was reiterated (...) that nurses and midwives taking care of these patients should be alert and observant to identify their suicidal tendencies. The paper also discusses religious or spiritual inclinations that negatively affect healthcare access and adherence, especially to biomedical or western medicine. It was emphasized that some religious beliefs do not allow their followers to employ biomedical treatment and nurses and midwives should not impose their faith on patients and their families. The paper ends with a discussion on the specific roles of nurses and midwives in the care of patients with suicidal ideations such as assessment, counseling, administering medication, observation, social interaction, ensuring safety measures, and providing an enabling environment for the family to part of the care and for the observation of religious coping strategies. Nurses and midwives should enhance their knowledge and skills on suicide and increase public education on suicide prevention and identification of those at risk. (shrink)

In Europe the elderly population is projected to increase from 18.5% (93.9 million) in 2014 to 28.7% (149.1 million) by 2080. In the USA it is estimated that by the year 2030 more than 20% of the population will be aged 65 years or over. This specific population is at high risk of unrecognised or untreated psychiatric illnesses and suicide. It is well known that completed suicide rate increases with age in both men and women. Although elderly (...) people attempt suicide less often than other age groups, they show a higher completion rate. Generally the methods chosen by elderly are more lethal, the intent is more serious, they are more determined and they show fewer warning sign than the younger population. A recent systematic review and meta-analysis of psychosocial intervention following self-harm in adults found that cognitive behavioural therapy was the most effective in these patients. Unfortunately there have been few reported trials of other potentially effective interventions. Because the scientific literature on psychosocial suicide prevention interventions in the elderly is still scant we decided to conduct a mini-review in order to take stock of the situation. Studies were identified through electronic searches of the Cochrane library, MEDLINE, Scopus and Web of Science databases. PRISMA guidelines were followed and only 7 articles met the inclusion criteria. No firm conclusions can be drawn about this topic because there is still little data and studies used inconsistent outcome measures and designs. Nonetheless, the existing data suggests that psychosocial interventions are promising. (shrink)

The original “Dutch Protocol”—the treatment model comprised of puberty blockers, cross‐sex hormones, and surgery—was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions’ effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to (...) significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender‐affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's “embodiment goals.” In this article, I raise objections to autonomy‐based justifications for pediatric gender‐affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision‐making and, consequently, put patients at risk of medical harm. (shrink)

Elderly persons are living longer with debilitating illnesses and are at risk for suicide. They are also more likely to have a living will with a DNR order. With the medical culture’s emphasis on patient autonomy, an ethical approach that respects the dignity of these suffering human persons is needed. Suicide must be viewed as an act against the principle of life and the intrinsic good of the human being. Beneficence outweighs autonomy in such cases. Medical providers (...) are at risk of mediate material cooperation with the evil of such an act if they fail to preserve a life that can be saved. DNR orders should be reversed in these situations until these patients receive psychological treatment and pain relief. National Catholic Bioethics Quarterly 14.4 : 661–671. (shrink)

Volume 19, Issue 10, October 2019, Page 97-98.

Over the past decade or so, no issue in medical ethics or bioethics law has raised more concerns about federal intervention in the practice of medicine, about judicial attempts to craft health policy, or about the wisdom of public mandates directing specific health care initiatives than the issue of physician-assisted suicide. State voter referenda, lower and federal court cases, proposed legislation in both houses of Congress, and orders and determinations from agencies within the executive branch of two administrations are (...) representative of the kinds of actions taken in the last ten years implicating medical care at the end of life. Whether the intent was to codify into law physician-assisted suicide, to deny a constitutional right of assisted suicide, or to make “easier” physicians' efforts to alleviate intractable suffering at the risk of hastening death, or to prohibit physician aid in dying altogether, the impact on the patient-doctor relationship and on our understanding of what constitutes dignified and humane care at the end of life is undeniable. (shrink)

IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with room (...) for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time. (shrink)

The doctrine of double effect is a principle of crucial importance in law and medicine. In medicine, the principle is generally accepted to apply in cases where the treatment necessary to relieve pain and physical suffering runs the risk of hastening the patient’s death. More controversially, it has also been used as a justification for withdrawal of treatment from living individuals and physician-assisted suicide. In this paper, I will critique the findings of the controversial Victorian Civil and Administrative (...) Tribunal hearing Syme vs the Medical Board of Australia. In that hearing, Dr Rodney Syme, a urologist and euthanasia advocate, was defending his practice of prescribing barbiturates to terminally ill patients. Syme claimed that he prescribed the drugs with the intention of relieving their existential suffering and not to assist in suicide; he argued that the DDE could be applied. Pace VCAT, I argue that this is an illegitimate application of DDE. I argue that a close scrutiny of Syme’s actions reveals that, at the very least, he intended to give patients the option of suicide. He furthermore used what on a traditional definition of DDE would be considered a ‘bad’ means—the prescription of Nembutal—to achieve a ‘good’ end—the relief of suffering. The case demonstrates the crucial importance of analysing an agent’s ‘intention’ and the ‘effects’ of their actions when applying DDE. Ethicists and, indeed, the judiciary need to attend to the ethical complexities of DDE when they assess the applicability of DDE to end of life care. If they fail to do this, the doctrine risks losing its legitimacy as an ethical principle. (shrink)

The relationship between traumatic life events and increased suicide risk has been well reported in literature. However, the complex nature of suicidality phenomena still hinders our ability to comprehend the mediation mechanism underlying this association. In this study, we examined the mediating role of adult attachment and reflective functioning in the relationship between traumatic life events and suicidal ideation. Nine hundred and fifty Italian adults completed an online survey evaluating traumatic life events, adult attachment, reflective functioning and suicidal (...) ideation. The path analysis showed that the positive relationship between traumatic life events and suicidal ideation was partially mediated by attachment anxiety and reflective functioning. From a clinical point of view, these results support the relevance of evaluating and improving patients’ ability to mentalize as a part of psychotherapeutic intervention aimed at reducing suicidality in people with a history of traumatic experiences and attachment anxiety. (shrink)

It's not unusual to hear someone say, ‘I'd rather be dead than have Alzheimer's’. In ‘Alzheimer Disease and Preemptive Suicide’,1 Dena Davis explains why this is a reasonable position. People taking this position will welcome the discovery of biomarkers permitting very early AD diagnosis, Davis suggests, for this will enable more of them to end their lives while they remain motivated and able to do so. At the same time, Davis observes, people would have less reason to resort to (...) the drastic remedy of pre-emptive suicide if they had absolute authority over the medical treatment they received as patients with dementia; but the threat of pre-emptive suicide is not, in my view, a sufficient reason to grant competent individuals that authority.If preclinical diagnosis of AD becomes possible, some pre-emptive suicides will probably occur. There would be no ethical or practical way to ban such suicides, and it would be silly to try. Clinicians will undoubtedly try to discourage people seeking biomarker information in furtherance of a suicide plan, but savvy individuals will simply conceal their true motivation for having the tests. The real problem for people intent on self-destruction is that biomarkers are unlikely to deliver a clear suicide signal.First, as Davis notes, work on biomarkers remains in the research stage. No one yet knows whether biomarker tests will prove accurate enough to warrant clinical use. Second, even clinically accepted biomarker tests will generate imperfect information about future disease. Biomarkers may produce more accurate estimates of a person's risk of developing AD, but like all predictive tests, they will also yield false positive and negative results. The …. (shrink)

This article critically evaluates the Medicines and Healthcare products Regulatory Agency’s announcement, in March 2008, that GlaxoSmithKline would not face prosecution for deliberately withholding trial data, which revealed not only that Seroxat was ineffective at treating childhood depression but also that it increased the risk of suicidal behaviour in this patient group. The decision not to prosecute followed a four and a half year investigation and was taken on the grounds that the law at the relevant time was insufficiently (...) clear. This article assesses the existence of significant gaps in the duty of candour which had been assumed to exist between drugs companies and the regulator, and reflects upon what this episode tells us about the robustness, or otherwise, of the UK’s regulation of medicines. (shrink)

Battin et al examined data on deaths from physician-assisted suicide in Oregon and on PAS and voluntary euthanasia in The Netherlands. This paper reviews the methodology used in their examination and questions the conclusions drawn from it—namely, that there is for the most part ‘no evidence of heightened risk’ to vulnerable people from the legalisation of PAS or VE. This critique focuses on the evidence about PAS in Oregon. It suggests that vulnerability to PAS cannot be categorised simply (...) by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. It also argues, on the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, that, contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et al reported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS. (shrink)

At the heart of the debate over assisted suicide is the recognition that not all persons can be healed and not all suffering can be relieved. This article addresses the ethical, professional and legal issues to be considered by the nurses in the United States who are facing patients’ requests for assisted suicide. Both personal and professional risks, and the consequences of an action must be evaluated. Ultimately, a decision is based on some ranking of: patient values; (...) personal values and beliefs; professional codes, standards and other guidelines; and societal laws and regulations. (shrink)

At the heart of the debate over assisted suicide is the recognition that not all persons can be healed and not all suffering can be relieved. This article addresses the ethical, professional and legal issues to be considered by the nurses in the United States who are facing patients’ requests for assisted suicide. Both personal and professional risks, and the consequences of an action must be evaluated. Ultimately, a decision is based on some ranking of: patient values; (...) personal values and beliefs; professional codes, standards and other guidelines; and societal laws and regulations. (shrink)

Over the past decade or so, no issue in medical ethics or bioethics law has raised more concerns about federal intervention in the practice of medicine, about judicial attempts to craft health policy, or about the wisdom of public mandates directing specific health care initiatives than the issue of physician-assisted suicide. State voter referenda, lower and federal court cases, proposed legislation in both houses of Congress, and orders and determinations from agencies within the executive branch of two administrations are (...) representative of the kinds of actions taken in the last ten years implicating medical care at the end of life. Whether the intent was to codify into law physician-assisted suicide, to deny a constitutional right of assisted suicide, or to make “easier” physicians' efforts to alleviate intractable suffering at the risk of hastening death, or to prohibit physician aid in dying altogether, the impact on the patient-doctor relationship and on our understanding of what constitutes dignified and humane care at the end of life is undeniable. (shrink)

The philosophy of Josiah Royce has recently begun to regain attention; Griffin Trotter, in particular, has utilized Royce in questions concerning medical ethics. This resurgence in attention is for good reason—Royce's philosophies of loyalty and community provide both a descriptively accurate picture of the self and a prescriptively solid ethical system. Royce recognized, as do all pragmatic philosophers, that persons only exist socially, and this sociality will necessarily influence the individual ethically, but also epistemologically. What we know, how we act, (...) how we think we ought to act are not individual questions, but rather questions that arise for individuals only in the context of a larger community. (shrink)

Advances in genetic diagnostics lead to more patients being diagnosed with hereditary conditions. These findings are often relevant to patients’ relatives. For example, the success of targeted cancer prevention is dependent on effective disclosure to relatives at risk. Without clear information, individuals cannot take advantage of predictive testing and preventive measures. Against this background, we argue that healthcare professionals have a duty to make actionable genetic information available to their patients’ at-risk relatives. We do not (...) try to settle the difficult question of how this duty should be balanced against other duties, such as the duty of confidentiality and a possible duty not to know one’s genetic predisposition. Instead, we argue for the importance of recognising a general responsibility towards at-risk relatives, to be discharged as well as possible within the limits set by conflicting duties and practical considerations. According to a traditional and still dominant perspective, it is the patient’s duty to inform his or her relatives, while healthcare professionals are only obliged to support their patients in discharging this duty. We argue that this perspective is a mistake and an anomaly. Healthcare professionals do not have a duty to ensure that their patients promote the health of third parties. It is often effective and desirable to engage patients in disseminating information to their relatives. However, healthcare professionals should not thereby deflect their own moral responsibility. (shrink)

A virtually infinite array of new discoveries are bringing increasingly evident transformations to all that we do, how we live, how all of us relate to each other, ourselves and the world. To think about this new time, it is necessary to experience the vertigo of placing our mind at risk. We are immersed in a comparatively new context of existence. A new humanity is being built, and it will thus represent a new society and a unique conception of (...) what a person is. We have established ourselves as the cities we pass through daily, as sets of flows, relations of power and strengths. Like a city, we are also information networks; power fields constantly brought into play, as we connect with spaces in an imbricated and interdependent way. We are a kind of species that, in face of its desire, is capable of putting this very existence at risk; of suicidal artists, kamikazes, who risk themselves and the planet. What is the specificity of this species? What is the possible (psycho)analysis? The aim of this article is to present and articulate the current changes and the absolute artificialism of our species in the transformation of its corporeity that devours and appropriates whatever presents itself, and which produces means and prostheses for the compulsive realization of our fantasies; new realities that increasingly appear on the horizon and affect our daily lives. The mind at risk is the state that enables the craziness of any act of creation. (shrink)

Background Clinical papers so flawed that they are eventually retracted may put patients at risk. Patient risk could arise in a retracted primary study or in any secondary study that draws ideas or inspiration from a primary study. Methods To determine how many patients were put at risk, we evaluated 788 retracted English-language papers published from 2000 to 2010, describing new research with humans or freshly derived human material. These primary papers—together with all secondary studies (...) citing them—were evaluated using ISI Web of Knowledge. Excluded from study were 468 basic science papers not studying fresh human material; 88 reviews presenting older data; 22 case reports; 7 papers retracted for journal error and 23 papers unavailable on Web of Knowledge. Overall, 180 retracted primary papers (22.8%) met the inclusion criteria. Subjects enrolled and patients treated in 180 primary studies and 851 secondary studies were combined. Results Retracted papers were cited over 5000 times, with 93% of citations being research related, suggesting that ideas promulgated in retracted papers can influence subsequent research. Over 28 000 subjects were enrolled—and 9189 patients were treated—in 180 retracted primary studies. Over 400 000 subjects were enrolled—and 70 501 patients were treated—in 851 secondary studies which cited a retracted paper. Papers retracted for fraud (n=70) treated more patients per study (p<0.01) than papers retracted for error (n=110). Conclusions Many patients are put at risk by retracted studies. These are conservative estimates, as only patients enrolled in published clinical studies were tallied. (shrink)

The Journal of Medical Ethics can sometimes read part Men Like Gods and part A Brave New World. At times, we learn how all controversies can resolved with reference to four principles. At other times, we learn how “every discovery in pure science is potentially subversive”.1 This issue is no exception. Here, we can read about the utopia of gene editing, manufactured organs, and machine learnt algorithmic decision-making. We can also read about the dystopia of inherited disorders from edited germlines, (...) the testing of xenotransplants on braindead patients, and misdiagnosis by artificial intelligence. What we see in the three papers that I will foreground here is the application of medical ethics to avoid the dystopia while preserving the promises of medical science. But as I seek to explain here, our ability to address the controversies that we anticipate in medical science depend on our ability to refine our understanding of what medical ethics requires of us now. From the diagnosis of eye diseases from fungus images to predicting the risk of imminent risk of suicide attempts, machine learnt medical decision making has, in some high profile instances, outperformed clinicians in medical diagnosis and treatment recommendations. While clinician and machine learnt diagnoses will both involve degrees of uncertainty and fallibility, Thomas Grote2 asks us to consider is how much weight a clinician ought to give an algorithmic diagnosis which she disagreements with. Since a clinician is held to account for …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Legal CommentarySumy Menon, Senior Associate in ResearchThis case involves the balancing of a young person’s right to autonomy and the desire to protect her from harm. No Singapore court decision has determined whether the doctor owes a duty to the parents of the doctor’s 16-year-old patient, to warn them that their child is engaging in sexual activities, and who subsequently has had an abortion. Similarly, the issue of whether (...) the doctor has a duty to protect the minor in such circumstances has also not been tested in the Singapore courts. Nonetheless, it is very unlikely that either duty will be found in this case.The general rule is that doctors owe a duty of confidentiality to their patients. This duty extends to children, and although no Singapore court has ruled on the matter, the law in England is clear.1 It is enshrined in section 4.2.3.1 of the Ethical Code & Ethical Guidelines of the Singapore Medical Council. It is not absolute and a number of exceptions have been carved out. The confidentiality duty can be overridden by legislation, court order, the public interest, or other justifiable circumstances that the doctor believes warrants disclosure.The age of consent for non-commercial consensual sexual activities in Singapore is 16.2 Therefore, there is no statutory responsibility on Dr. C under the criminal law to report the patients’ sexual activities to the authorities or anyone else. There is no other legislation or court order that compels disclosure. It is highly unlikely that the public interest would be served by disclosure. The consequences of such disclosure to the public interest were aptly put in a recent English case, when J. Silber held that if a confidentiality duty was not imposed, it “would probably or might well deter young people [End Page 262] from seeking advice and treatment on contraception, sexually transmitted diseases and abortion, and this would have undesirable and troubled consequences”.3 The last exception offers the greatest latitude for doctors to disclose if they believe there are other justifiable circumstances that would shift the balance in favour of disclosure. There are strong reasons to maintain confidentiality in Miss M’s case and although an argument can be made for disclosure, that argument is relatively weak.Miss M’s parents are understandably worried about her but Dr. C should not breach the duty of confidentiality owed to the patient even though she is only 16 years old. It is irrelevant that Miss M’s parents are paying for their daughter’s treatment. The doctor-patient relationship is between Dr. C and Miss M, and her parents have never been involved in the consultations or treatment decision-making process. They have not insisted on attending the consultations with their daughter, nor did they appear to object to Miss M consenting to treatment. Prior to their complaint, they had not sought any update or information about their daughter’s condition from Dr. C. Miss M specifically asked Dr. C not to reveal the contents of their conversations to her parents at the first consultation and the doctor agreed after attempting to convince her that it would be preferable to include her parents in the consultations. Miss M was obviously concerned about confidentiality and sought clarification from Dr. C. It appears as though Dr. C determined that Miss M had the capacity to exclude her parents from the consultations, and later to make her own treatment decisions, as a mature minor, and their doctor-patient relationship proceeded on that basis.It may be in the public interest for Dr. C to disclose confidential information about Miss M, even if she refuses to consent to it, if the doctor believes it is necessary to protect her from serious harm. Any such decision must be made with the patient’s best interests in mind. Examples of such harm include situations where the patient is at risk of serious physical abuse or has voiced a desire to commit suicide. Engaging in sexual activity with an older boy is unlikely to result in such serious harm, although harm may result. In this case, that harm manifested itself in an unwanted pregnancy... (shrink)

The doctor-patient relationship -- Consent, choice, and refusal : adults with capacity -- Treating adults who lack capacity -- Children and young people -- Confidentiality -- Health records -- Contraception, abortion, and birth -- Assisted reproduction -- Genetics -- Caring for patients at the end of life -- Euthanasia and physician assisted suicide -- Responsibilities after a patient's death -- Prescribing and administering medication -- Research and innovative treatment -- Emergency situations -- Doctors with dual obligations -- Providing (...) treatment and care in detention settings -- Education and training -- Teamwork, referral, delegation, and shared care -- Public health dimensions of medical practice -- Reducing risk, clinical error, and poor performance. (shrink)

Background:Suffering in a suicidal crisis includes feelings such as despair, loneliness, anxiety, fear, shame, guilt and hopelessness. This study highlights the experiences of patients in the aftermath of suicide attempts. The research question was, what do suicidal patients see as meaningful help in care and treatment situations?Methodology:The methodology is inspired by Gadamer’s hermeneutics, where the parts are understood in light of the whole, and the whole is understood in light of the parts. Qualitative interviews were employed.Participants and (...) research context:A total of 10 persons, 4 women and 6 men 21–52 years old, were informed and asked to participate by specialists in psychology at two emergency psychiatric wards and by one crisis resolution team. Nine of the participants had experienced one or more suicide attempts using drugs and alcohol. Forced hospitalization prevented one of the 10 participants from attempting suicide.Ethical considerations:Before the participants signed an informed consent form, the interviewer met all participants to provide the written information, talking about the interview. A meeting to terminate contact was arranged after the participants had read their own interviews.Findings:Three themes were generated by the methodology we applied: experiencing hope through encounters, experiencing hope through the atmosphere of wisdom and experiencing a ray of hope from taking back responsibility.Discussion:The findings are discussed in the light of Eriksson’s suffering theory and Lindström’s theory about psychiatric care, as well as earlier research and theories about suicidality.Conclusion:The study reinforces possibilities that hope in suicidal patients can be inspired in encounters with healthcare personnel and within caring cultures. Through dialogue and cooperation, patients’ safety and ability to cope with suffering is created and thereby the hope and will to struggle for life. (shrink)

Suicide is a public health problem which will require an integrated cross-sector approach to help reduce prevalence rates. One strategy is to include the legal system in a more integrated way with suicide prevention efforts. Caine explored a public health approach to suicide prevention, depicting risk factors across the socio-ecological model. The purpose of this paper is to examine laws that impact suicide prevention at the individual, relational, community, and societal levels. These levels are fluid, (...) and some interventions will fall between two, such as a community-level approach to training that enhances provider-patient relationships. At the individual level, we will review laws to improve screening requirements across systems. At the relational level, we note interventions with couples having conflict, such as protection orders and access to attorney consultations, which have been known to be injury prevention mechanisms. At the community level, we discuss legislation that recommends suicide prevention efforts for key individuals working as frontline providers in the medical and educational systems. At the societal level, we explore public awareness campaigns that target stigma reduction for those suffering from mental health burden and enhance linkage to care. The article closes with the discussion that laws are good, but their implementation is essential. (shrink)

Background Cancer patients are at risk of developing blood clots in their veins - venous thromboembolism - which often takes the form of a pulmonary embolism or deep vein thrombosis. The risk increases with advanced disease. Evidence based treatment is low molecular weight heparin by daily subcutaneous injection. The aim of this research is to explore the barriers for doctors in the UK when diagnosing and treating advanced cancer patients with VTE. Method Qualitative, in-depth interview study (...) with 45 doctors. Doctors were from three specialties: oncology, palliative medicine and general practice, with a mixture of senior and junior staff. Framework analysis was used. Results Doctors opinions as to whether LMWH treatment was ethically appropriate for patients who were symptomatic from VTE but at end of life existed on a shifting continuum, largely influenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of a daily injection had influenced some doctors not to prescribe LMWH. The point at which LMWH injections should be stopped in patients at the end of life was ambiguous_._ Some perceived ‘overcaution’ in their own and other clinicians’ treatment of patients_._ Viewpoints were divergent on whether dying of a PE was considered a “good way to go”. The interventionalism and ethos of palliative medicine was discussed. Conclusions Decisions are difficult for doctors to make regarding LMWH treatment for advanced cancer patients with VTE. Treatment for this patient group is bounded to the doctors own moral and ethical frameworks. (shrink)

This paper examines whether physician-assisted suicide is morally permissible, and whether it should be legalised in the sense that those seeking or performing such procedure will be immune from prosecution. The issues of moral and legal permissibility1 are closely connected. One way to argue for the permissibility of PAS is grounded in the argument that a patient has the right to refuse life-saving equipment, or to have it withdrawn,2 and then to further argue that there is no relevant distinction (...) between refusal/withdrawal and PAS, if the patient consents. This is essentially the argument raised in “The Philosophers’ Brief ”, filed by six distinguished philosophers. However, this argument has been soundly criticised. Frances Kamm points out that the general claim on which Dworkin et al. rely—that there is no moral difference per se between killing and letting die—is false. This is because a patient has the right to refuse treatment even when this is against his interest because the alternative would be forced treatment, but it is not true to say that a patient has the right to PAS even when it is against his interest. Also at issue is the Doctrine of Double Effect, according to which there is a moral distinction between an action that is intended to cause death and one that is merely foreseen to cause death. [End Page 224] In section I of this paper, I shall argue against DDE, which purports to disallow PAS but not refusal/withdrawal. I shall argue that since it is permissible for a physician to prescribe morphine to a patient suffering excruciating pain, it is also permissible for her to prescribe such a drug to a patient suffering pain, with the intention that he be killed and hence relieved of the suffering. The grounds on which I rely is the thesis that intention is irrelevant to permissibility, as proposed by Judith Thomson and T.M. Scanlon. In section II, I shall discuss David Velleman’s argument that termination of life is morally impermissible. I proceed to examine in section III the theoretical version of the Slippery Slope Argument. In section IV, I shall consider the practical version of the Slippery Slope Argument. In section V, I shall discuss other consequentialist objections to the legalisation of PAS. In the final section, I shall consider the view that even if PAS is morally permissible, it does not follow that it should be legalised. The argument I consider is the consequentialist one that legalising PAS may have a very different significance—when we consider the total consequences—than if there is only a single act of PAS, considered in isolation. While I agree that consequences are generally very important, I shall argue that we should approach the issue from a contractualist rather than a utilitarian perspective.3. (shrink)

In suicidology, the common view is that ‘rational’ suicides occur only rarely, because the competence of people who want to end their lives is compromised by mental illness. In the Netherlands and Flanders, however, patients’ requests for euthanasia or assistance in suicide are granted in 5300 and 1400 cases a year respectively, and in all these cases at least two doctors have confirmed the patient's competence. The combination of these two findings is puzzling. In other countries one would (...) expect at least some of these people to end their own lives. The article argues that we can distinguish between two types of suicide with clustering characteristics. In cases of the first type, the agent doesn't carefully plan his action, doesn't communicate his plans to relatives or others, and uses violent means. In such cases it is reasonable to presume lack of competence. The other type has the opposite characteristics. The most plausible explanation of our problem is that suicides of the second kind are invisible to suicidology, because they tend not to be registered as suicides at all. (shrink)

While changes in response to the different stages of the pandemic remain unknown, this study investigated the longitudinal impact of the COVID-19 pandemic on depressive symptoms in Japanese university students and identified factors associated with new onset of depression and suicidal ideation. Two surveys were conducted at one university in Akita, Japan, during the first COVID-19 outbreak period and 1 year later. Moderate depressive symptoms were defined as a Patient Health Questionnaire-9 score ≥ 10 and suicide-related ideation score ≥ (...) 1 on question 9 of the questionnaire. Among 985 students who completed surveys in T1 and T2, participants with moderate depressive symptoms and suicide-related ideation increased from 11 to 17% and from 5.8 to 11.8%, respectively. Among 872 students at risk after excluding those with moderate depressive symptoms at T1, 103 students developed moderate depressive symptoms at T2. Among the 928 students at risk, after excluding those who had suicidal ideation at T1, 79 developed suicidal ideation. Multivariate logistic modeling revealed financial insecurity and academic performance as risk factors, while having someone to consult about worries was a coping factor for depressive symptoms and suicidal ideation. Our findings demonstrated that socioenvironmental factors may determine depressive symptoms of university students. (shrink)

Edmund Pellegrino and David Thomasma’s writings have had a worldwide impact on discourse about the philosophy of medicine, professionalism, bioethics, healthcare ethics, and patients’ rights. Given their works’ importance, it is surprising that commentators have ignored their admission of an unresolved and troubling dilemma and inconsistency in their theory. The purpose of this article is to identify and state what problems worried them and to consider possible solutions. It is argued that their dilemma stems from their concerns about how (...) to justify professional rules restricting colleagues from performing acts they view as direct, active, and formal killings, such as physician-assisted suicide, mercy killing, and abortion. It is further argued that their inconsistency is that they both assert and deny that professional colleagues should not use their moral or theological values to impose professional restrictions on other colleagues without adequate philosophical grounds. At risk are their arguments about the nature of an internal morality for medicine, a secular and multicultural basis for medical ethics, and a nonarbitrary way to determine what acts fall outside the ends of medicine. These are arguments they claim also apply to other healthcare professions. The article begins with a brief overview of their key positions to provide the context in which they make their admission. (shrink)

The complex health and social circumstances of living-at-risk, frequent users of emergency departments (aREDFUs) in the health jurisdictions of high-income countries, and the related, significant challenges posed for emergency departments and the health care providers working within them, are identified and explored in the paper. Ethical analyses of a set of relevant domains are performed, i.e., individual and relational autonomy considerations, relevant social construction and personal responsibility conceptions, patient welfare principles (beneficence, nonmaleficence, continuity of care), harm reduction methodologies and (...) their applications, health equity, and justice considerations of the distributive, formal and social types. The outcomes of these analyses demonstrate that there are ethically compelling reasons for emergency departments to adopt an ethics-informed, policy-based approach to the longitudinal care and management of living-at-risk, frequent users of emergency departments. From a formal justice perspective, the development and uses of such an approach are justified by a demonstrable relevant difference between living-at-risk, frequent users of emergency departments and other persons and groups of patients who visit emergency departments. We propose an example of such a policy-based approach. Examples of possible, pragmatic applications of this approach, which help ensure that aREDFUs who present to the ED are managed in a fair and optimally consistent manner, are provided for the consideration of an urban emergency department’s policymaking working group. (shrink)

As in other areas of medical practice, relatives accompany patients to genetic consultations. However, unlike in other areas, the consultations may be relevant to the relatives’ health because they may be at risk of developing the same genetic condition as the patient. The presence of relatives in genetic consultation may affect the decision‐making process and it raises questions about the perception of patient autonomy and the way it is practiced in genetics. However, these issues have not been examined (...) in previous empirical studies. This article aims to fill this gap by reporting findings from a qualitative study with clinicians working in the area of inherited breast cancer. The findings indicate that family presence has an impact on the patient's decisions to undergo genetic testing and preventative operations when she is diagnosed as a carrier. The findings further indicate that, unlike in other areas of medical practice, blood relatives who are present in consultations are perceived by clinicians as patients or potential patients, and this in turn increases their involvement in discussions in the consultation room. Finally, the findings indicate that in genetics, a relational approach to autonomy is applied. Decisions are made in a social context, where the relatives’ views are heard and taken into account. The findings suggest that the conventional bioethical approach to autonomy, which perceives the decision‐making unit as comprising a clinician and an individual patient, is challenged in genetics. The findings thus suggest that bioethicists, lawyers and policy‐makers should consider whether this individualistic approach is still valid and applicable. (shrink)

In this piece I discuss when care providers should not contact suicidal patients’ families to get collateral information from them or hospitalize patients over their objections. I suggest that when these patients are chronically suicidal, overriding these wants may be best in the short run but increase their net risk in the longer run. I also discuss in this regard how contacted families may become overprotective and how hospitalization can be traumatic. I present an alternative approach (...) that can increase these patients’ safety over the longer run and relate three practical approaches care providers may find useful: explaining their decisions to patients, monitoring their own fear, and instilling hope. (shrink)

IntroductionSwitzerland lacks specific legal regulation of assistance in suicide. The practice has, however, developed since the 1980s as a consequence of a gap in the Swiss Criminal Code and is performed by private right-to-die organisations. Traditionally, assistance in suicide is considered contrary to the philosophy of palliative care. Nonetheless, Swiss palliative care physicians regularly receive patient requests for suicide assistance. Their attitudes towards the legal regulations of this practice and their experience in this context remain unclear.ObjectivesOur study (...) aimed to explore and describe the attitudes and experiences of Swiss palliative care physicians concerning the legal situation of suicide assistance.MethodsIn 2019, we performed an exploratory interview study with 12 Swiss palliative care physicians on palliative sedation as an alternative to assisted suicide. In this paper, we present the results that emerged from a thematic subanalysis of the data.ResultsParticipants stated that assistance in suicide and palliative care are based on opposing philosophies, but they admitted a shift in paradigm over the last years in the sense that one practice does not necessarily exclude the other. They reported various roles in suicide assistance and considered that the current activities of Swiss right-to-die organisations were problematic and needed to be regulated by law.Discussion and conclusionThese results could enrich national and international reflection on suicide assistance in the context of palliative care by reducing confusion between the two practices and strengthening the confidence of patients and their relatives. (shrink)

Background: Cancer patients are at risk of developing blood clots in their veins - venous thromboembolism(VTE) - which often takes the form of a pulmonary embolism or deep vein thrombosis. Therisk increases with advanced disease. Evidence based treatment is low molecular weightheparin (LMWH) by daily subcutaneous injection. The aim of this research is to explore thebarriers for doctors in the UK when diagnosing and treating advanced cancer patients withVTE.MethodQualitative, in-depth interview study with 45 doctors (30 across Yorkshire, (...) England and 15across South Wales). Doctors were from three specialties: oncology, palliative medicine andgeneral practice, with a mixture of senior and junior staff. Framework analysis was used. Results: Doctors opinions as to whether LMWH treatment was ethically appropriate for patients whowere symptomatic from VTE but at end of life existed on a shifting continuum, largelyinfluenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of adaily injection had influenced some doctors not to prescribe LMWH. The point at whichLMWH injections should be stopped in patients at the end of life was ambiguous. Someperceived overcaution in their own and other clinicians treatment of patients. Viewpointswere divergent on whether dying of a PE was considered a "good way to go". Theinterventionalism and ethos of palliative medicine was discussed. Conclusions: Decisions are difficult for doctors to make regarding LMWH treatment for advanced cancerpatients with VTE. Treatment for this patient group is bounded to the doctors own moral andethical frameworks. (shrink)

Genetic testing has familial implications. Counsellors find themselves in (moral) conflict between medical confidentiality (towards the patient) and a potential right or even duty to warn at-risk relatives. Legal regulations vary between countries. English literature about German law is scarce. We reviewed the literature of relevant legal cases, focussing on German law, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This article aims to familiarise counsellors with their responsibilities, compare the situation between countries and point (...) out legally unresolved areas.According to the German Genetic Diagnostics Act (Gendiagnostikgesetz) in case of an ‘avoidable or treatable’ genetic disorder, geneticists ought to confine themselves to the obligated advice to the patient. Whether a breach of the duty of confidentiality can be justified in exceptional cases by ‘necessity as justification’ for actively informing relatives at risk remains legally unclear. In case of a ‘neither avoidable nor treatable’ genetic disease, geneticists should also refrain from actively informing relatives as the justifiable state of emergency does not permit to break the duty of confidentiality. (shrink)

The American Medical Association opposes physician-assisted suicide on the grounds that it “would ultimately cause more harm than good,” because it is “fundamentally incompatible with the physician’s role as healer,” and because it “would be difficult or impossible to control and would pose serious societal risks”. It condemns the practice of euthanasia as conducted by physicians for these reasons as well, and adds, by way of clarifying the serious risks at hand, that “euthanasia could readily be extended to incompetent (...) patients and other vulnerable populations”. In this essay I will attempt to rebut these charges. I will devote most of my attention to the... (shrink)

ObjectiveHead and neck cancer treatments are known to significantly affect functionality and appearance, leading to an increased risk for body image disturbances. Yet, few longitudinal studies exist to examine body image in these patients. Based on a conceptual model, the current study aimed to determine, in patients newly diagnosed with HNC: the prevalence, level, and course of body image concerns; correlates of upon cancer diagnosis body image concerns; predictors of immediate post-treatment body image concerns; and association between (...) body image concerns and levels of anxiety, depression, suicidal ideation, support, and alcohol and drug misuse.MethodsTwo hundred and twenty-three, newly diagnosed with a primary HNC were assessed using structured clinical interviews and psychometric measures at three, and 6 months after diagnosis. Primary outcome was 3-month, as it was most salient to body image disturbance. Multiple linear regression analyses were conducted on the potential body image predictors, based on the model.ResultsSixty-eight percent of patients with HNC presented some level of body image concerns. Body image concerns at baseline and post-treatment were significantly related and significantly increased from pre- to post-treatment. Immediately post-treatment, 89% presented some level of body image concerns. Correlates of body image concerns in patients with HNC at baseline included: physical symptom burden, difficulties with communication and eating, coping with the cancer diagnosis using denial, suicidal ideation, and having had a past anxiety diagnosis. When controlling for sociodemographic and medical variables, body image concerns in patients with HNC in the immediate post-treatment were predicted by: baseline body image, physical symptom burden, and neuroticism.ConclusionThis longitudinal study helps identify patients more susceptible to experience body image disturbance following head and neck cancer. Clinicians ought to pay special attention to body image concerns upon cancer diagnosis, physical symptom burden, and neuroticism, and may want to target these factors in future preventive interventions. (shrink)

Rationale Treatment guidelines recommend a more conservative surgical approach than mastectomy for early stage breast cancer and a stronger emphasis on adjuvant therapy. Registry data at South Australian teaching hospitals have been used to monitor survivals and treatment in relation to these guidelines.Aims and objectives To use registry data to: (1) investigate trends in survival and treatment; and (2) compare treatment with guidelines.Methods Registry data from three teaching hospitals were used to analyse trends in primary courses of treatment of breast (...) cancers during 1977–2003 (n = 4671), using univariate analyses and multiple logistic regression. Disease-specific survivals were analysed using Kaplan–Meier product limit estimates and multivariable Cox proportional hazards regression.Results The 5-year survival was 79.9%, but with a secular increase, reaching 83.6% in 1997–2003. The relative risk of death (95% confidence limits) was 0.74 (0.62, 0.88) for 1997–2003, compared with previous diagnoses, after adjusting for tumour node metastasis stage, grade, age and place of residence. Treatment changes included an increase in conservative surgery (as opposed to mastectomy) from 51.7% in 1977–1990 to 76.8% in 1997–2003 for stage I (P < 0.001) and from 31.1% to 52.2% across these periods for stage II (P < 0.001). Adjuvant radiotherapy also became more common (P < 0.001), with 20.6% of patients receiving this treatment in 1977–1990 compared with 60.7% in 1997–2003. Radiotherapy generally was more prevalent when conservative surgery was provided, although also relatively common in mastectomy patients when tumour diameters exceeded 50 mm or when there were four or more involved nodes. The proportion of patients receiving chemotherapy increased (P < 0.001), from 19.6% in 1977–1990 to 36.9% in 1997–2003, and the proportion having hormone therapy also increased (P < 0.001), from 34.3% to 59.4% between these periods.Conclusions Survivals appear to be increasing and treatment trends are broadly consistent with guideline directions, and the earlier research on which these recommendations were based. (shrink)

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centred outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively (...) remediated patients’ real-world “quality of life” experiences. We propose a novel precision medicine approach to improving patient-centred TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centred TKA outcomes. Of particular importance to the model’s predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centred outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarised, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilisation of multivariate prediction models to inform individually-tailored interventions targeting a range of health conditions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Stories of Families with Chronically Ill Pediatric Patients during the War in UkraineVita VoloshchukFebruary 24th was a day that has left a mark in the memory and on the lives of every Ukrainian person. My husband and I work together [End Page E5] in a hospital. He had gone into work early to conduct a kidney transplant that had been scheduled for that day. Suddenly, whilst on my (...) way to work that morning, I heard a strange sound—it was an air-raid siren. Before that, I had never heard such a sound. I went through all the possible options of what it could be. Of course, watching the morning news had never been a habit either. The next thing that astonished me was that the taxi I had ordered was taking an unnaturally long time to turn up. When I got into the taxi, I noticed that the taxi driver was really upset and silent for half of the journey. He then said, “A war has begun...”“War? So? The war has been going on since 2014.”“You don’t understand,” he said. “Russia is launching missile attacks all over the territory of Ukraine; Russian troops are coming from the east and north of Ukraine. They want to capture the capital of Ukraine.” (Kyiv).Arriving at the hospital, I saw confused faces everywhere. The morning meeting began with a discussion of how we were to act in any possible situation that may occur. We were to discharge patients from the hospital, as many as possible. The arrangement of a bomb shelter began (although I didn’t even think that such a thing existed in our hospital), along with the strengthening of the hospital’s windows, and the increase of supplies such as medicine and food. Of course, the boy who expected a kidney transplant did not receive it because no one knew what to expect at any second or where a hostile Russian missile might hit, as Russian missiles hit not only military objects but residential buildings, hospitals, and memorials as well.Children who had to continue therapy remained in the hospital. As soon as we heard the sound of an air-raid siren, we had to go down into the bomb shelter. This happened 5-10 times per day. Families with palliative and chronically ill children began to call and ask for advice on how to proceed in such a situation. As many children were on artificial respiration devices, others needed oxygen therapy, and sputum of mucus from the upper respiratory tract. All this required uninterrupted power supplies and appropriate equipment. Later that day, a doctor from Poland called me and asked if our pediatric patients needed help, saying it would be better if they were moved to Poland, where they would be safer and have the correct equipment. We started organizing evacuations for chronically ill and palliative patients.Seven days after the war began, parents from other regions, where the situation was more dangerous, began calling, asking for help evacuating. The hospital began to work intensively round the clock. Some patients moved in, and others were evacuated abroad. Some did not want to go. They continued treatment in the hospital, which turned into a hub for patients who had come from more dangerous, occupied territories; patients who were forced to leave their motherland to continue treatment.Since the beginning of the war, I have been responsible for transferring palliative patients and other patients with gastrointestinal diseases abroad. After the massive invasion, everything changed in our country. It is important to say that during the war, Lviv is safer than any other Ukrainian city, still air-raid sirens often go off, and everyone needs to run immediately to shelters for their safety. Palliative patients need special care. It is very difficult to run with patients several times per day during an air-raid siren or live with these children for a long time (2-3 weeks) in shelters because of the explosions occurring around them.It is impossible to move some patients to safety because they need appropriate medical equipment or mechanical ventilation is necessary. In shelters, there are crowds, and the high risk of... (shrink)

BackgroundCognitive Behavioral Therapy is delivered in most of the early intervention services for psychosis in different countries around the world. This approach has been demonstrated to be effective in decreasing or at least delaying the onset of psychosis. However, none of them directly affect the comorbidity of these types of patients that is often the main cause of distress and dysfunctionality. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders is a psychological intervention that combines cognitive-behavioral and third-generation (...) techniques that address emotional dysregulation as an underlying mechanism that these disorders have in common. The application of this intervention could improve the comorbid emotional symptoms of these patients.Materials and methodsThe study is a randomized controlled trial in which one group receives immediate UP plus standard intervention and the other is placed on a waiting list to receive UP 7 months later, in addition to standard care in one of our early psychosis programs. The sample will be 42 patients with UHR for psychosis with comorbid emotional symptoms. The assessment is performed at baseline, at the end of treatment, and at 3-months’ follow-up, and includes: general psychopathology, anxiety and depression, positive and negative emotions, emotional dysregulation, personality, functionality, quality of life, cognitive distortions, insight, and satisfaction with the UP intervention.DiscussionThis will be the first study of the efficacy, acceptability, and viability of the UP in a sample of young adults with UHR. The results of this study may have clinical implications, contributing to improving the model of care for young people who consult for underlying psychotic, anxiety, and/or depressive symptoms that can lead to high distress and dysfunctionality.Clinical trial registration[https://clinicaltrials.gov/], identifier [NCT04929938]. (shrink)