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Introduction Self-immolation is the centuries-old act of setting fire to oneself. Recent spikes in self-immolation events have been noticed in the Arab world, specifically in the aftermath of the Arab Spring in 2011. Objectives To examine the literature assessing the characteristics and patterns of suicide by self-immolation in the Arab world. Methods We registered our systematic review in Prospero [CRD42020207164]. We searched PubMed, Medline, PsycInfo, Embase, and Scopus databases from inception until 6 September 2021. We collected relevant articles via title and abstract screening followed by full-text screening. We then conducted a narrative synthesis of the results. Results We found 31 out of 314 articles that fit our inclusion criteria: 4 qualitative and 27 quantitative cross-sectional studies. The quantitative studies had a sample size ranging from 22 to 600 self-inflicted burn victims. The studies emanated from Iraq (n=16), Tunisia (n=6), Saudi Arabia (n=2), Libya (n=2), Jordan (n=2), and Egypt, Palestine and Bahrain collectively (n=3). Studies showed that self-immolators are commonly married females, age ranging between 13 and 66 years old, having no education or solely primary education, and of low socioeconomic status. Self-immolation was more likely to happen at home, usually following marital conflicts, with the primary motive being suicide. Studies highlighted an increase of self-immolation as a form of protest. Kerosene was the most commonly used accelerant. Depression was the most comorbid mental health diagnosis. Conclusions Self-immolation is not uncommon in the Arab world. Specific interventions directed at the population at risk are warranted. Disclosure No significant relationships.

Substance misuse is prevalent among older adults involved in the criminal justice system. The different classes of older offenders, primarily defined as individuals 50 years and older, as well as their offending behaviors vary in their association with substance misuse. Most prison health care systems do not adequately integrate substance use services. Screening for and treatment of substance misuse should be part of comprehensive mental health programs tailored to older offenders. This article reviews different types of offenses among older offenders, their association with substance misuse, and available treatment services.

Cannabis is the most widely used drug worldwide. Data about the association of cannabis use with aggression is heterogeneous. The objective of the current study was to assess the nature of the association between cannabis use disorder (CUD) and self-directed, other-directed, and combined aggression. We used data from the National Survey on Drug Use and Health across 2008 to -2014, with a pooled sample of 270,227 adult respondents. We used regression models to estimate the odds ratios (ORs) for those having CUD perpetrating each form of aggression compared with no aggression and other-directed compared with self-directed aggression. CUD was associated with significantly increased odds of committing other-directed (adjusted OR [aOR] = 1.42, 95 percent CI = 1.26-1.60) and combined aggression (aOR = 2.11, 95 percent CI = 1.36-3.26) compared with no aggression. CUD was associated with a nonstatistically significant risk of other-directed compared with self-directed aggression (aOR = 1.29, 95 percent CI = .97-1.69). In those 18 to 25 years old, CUD was significantly associated with an increased differential risk of other-directed versus self-directed aggression (aOR = 1.29, 95 percent CI = 1.03-1.62). Cannabis use disorder seems to increase the risk of other-directed aggression compared with self-directed aggression, especially among youths.

OBJECTIVE Individuals with mental illness may fall victim to stigma. In this cross-sectional study, the authors aimed to explore correlates of stigma towards mental health in a Lebanese private university and its associated tertiary medical center. METHODS The authors surveyed students, staff, and faculty at the American University of Beirut and its associated medical center. They assessed stigmatizing behaviors via the Reported and Intended Behavior Scale (RIBS), perceived stigma via the Perceived Devaluation and Discrimination Scale (PDDS), and attitudes towards collaborating with mental health professionals via the Doctors' Attitudes toward Collaborative Care for Mental Health (DACC-MH). RESULTS A total of 270 participants (response rate of 18%) provided their responses. The mean scores on the RIBS and PDDS were 15.26 ± 4.75 and 32.25 ± 2.70, respectively. Participants who had higher scores on RIBS were more likely to be younger than 25 years of age (OR=1.869; p=0.026), to have a history of mental illness (OR=2.657; p=0.003), and to interact with individuals with a psychiatric disorder (OR=2.287; p=0.028). CONCLUSIONS Results show a mixed pattern of stigmatizing behaviors and perceptions towards mental illness. This highlights the need for mental health awareness campaigns and interventions in the country.

Identify patients who are at risk, and implement measures to protect them.

Aggression and mental illness have been classically interlinked, often causing controversy and debate. Previous studies have shown that mental illness can be a risk factor to self- and other-directed aggression. However, these associations have rarely been simultaneously studied within the same population. Therefore, we aimed to study whether psychiatric disorders differentially increase the likelihood of one subtype of aggression over the other. We used the publicly available data of the National Survey on Drug Use and Health (NSDUH) from 2008 through 2014, for a total sample of 270,227 adult respondents. We designed our independent variable according to three categories: no mental illness (NMI), low or moderate (LMMI) and serious (SMI). We constructed regression models to estimate the odds ratios for those having a mental illness committing (a) a subtype of aggression over the past year compared with no aggression and (b) other-directed compared to self-directed aggression. We found that most respondents with mental illness reported no past-year aggression of any type. However, respondents with mental illness had higher odds of perpetrating all subtypes of aggression. Additionally, respondents with LMMI and SMI were respectively 1.7 and 3 times more likely to engage in self- rather than other-directed aggression. Future research should focus on identifying accurate and reliable predictors of self- and other-directed aggression among individuals with mental illness.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with the emergence of various psychiatric illnesses, although very little literature has focused on the effect of COVID-19 on psychosis. Preliminary data have shown possible increases in new-onset psychosis.Using MEDLINE, we performed a review of the current literature to identify the mechanisms by which pandemics may increase psychosis risk and generate evidence-based recommendations to control surges of psychosis. We identified 85 relevant studies, of which 34 were case reports on psychosis during the COVID-19 pandemic.Underlying mechanisms of psychosis include "direct viral mechanisms," such as neuroinflammation linked with the coronavirus, and "nonviral mechanisms," such as stress, isolation, and uncertainty.Improvement of our understanding of the pathophysiology of psychosis related to COVID-19 along with implementation of strategies to fight against stress and social isolation in addition to awareness campaigns regarding new-onset psychotic symptoms are much needed to optimize early detection and management of psychosis.

Our study's objective is to determine whether substance use disorders' association with aggression differs according to the type of substance and/or the form of aggression, within the same population. We used data from the National Survey on Drug Use and Health across 2008-2014, with a pooled sample of 270,227 adult respondents. We used regression models to estimate the odds ratios for those having alcohol and/or drug use disorder(s) perpetrating (a) each form of aggression compared with no aggression and (b) other-directed compared with self-directed aggression. Alcohol use disorder alone and drug use disorder(s) alone were both associated with significantly increased odds of committing self-directed, other-directed, and combined aggression. Individuals with drug use disorder(s) alone were more likely to commit other-directed than self-directed aggression (adjusted odds ratio = 1.46, 95% CI = 1.04-2.05). Individuals with alcohol use disorder alone were not likely to commit one over the other (adjusted odds ratio = 1.20, 95% CI = 0.90-1.61). In conclusion, the integrated model of aggression based on the stress-diathesis model is a relevant framework to study risk factors for aggression. Further research is needed to identify longitudinal predictors of directionality of aggression.

Most defendants found incompetent to stand trial have psychotic illnesses. Clozapine has been shown to be superior to other antipsychotic medications in treatment-resistant schizophrenia. It is vastly underutilized, however, including in forensic settings. To our knowledge, there have been no studies exploring the risks and benefits of clozapine for incompetent to stand trial defendants with severe mental illness. We sought to explore the characteristics of patients who were prescribed clozapine in a retrospective sample of defendants deemed incompetent to stand trial with diagnoses of psychotic and bipolar disorders. We found that 25 of 240 defendants (10%) were prescribed clozapine, with 15 (60%) eventually being discharged on it. Of those 15, 8 defendants were successfully restored to competency to stand trial. The restoration rate in the clozapine group was much lower than in the non-clozapine group (32% versus 87%). Our results emphasize the need for prospective comparative studies assessing the efficacy and tolerability of clozapine and other antipsychotic medications related to restoration of competency to stand trial.

PURPOSE To explore the association between religiosity, aggression (self- and other-directed) and law-breaking behaviors. METHODS We used data from the National Survey on Drug Use and Health (NSDUH) in the United States of America across 2008-2014, with a pooled sample of 270,227 adult respondents. We categorized respondents as religious if they considered religious beliefs to be important parts of their lives and/or to be influential in making decisions and/or if they considered it important that friends share their beliefs and/or if they reported attending at least one service over the past 12 months. We used regression models to calculate the odds ratio for committing different forms of aggression and for breaking the law when measuring positively on religiosity and its parameters. RESULTS More than 85% of our sample qualified as religious. A positive religiosity was correlated with a statistically significant lower risk of self-directed aggression [aOR = 0.83, 95% CI (0.69-0.99)]. Importance of religious beliefs and influence of religious beliefs were inversely correlated to perpetration of self-directed aggression [aOR = 0.81, 95% CI (0.70-0.95)] and [aOR = 0.82, 95% CI (0.70-0.96)], respectively. Positive religiosity was not significantly correlated to lower odds of other-directed aggression. All religiosity parameters were associated with significantly reduced odds of breaking the law, except for infrequent service attendance which was associated with a significantly higher risk of breaking the law [aOR = 1.07, 95% CI (1.03-1.12)]. CONCLUSION Religiosity has components with a differential impact on aggressive and law-breaking behaviors. Future longitudinal studies are needed to analyze whether religiosity protects against suicidality and promotes pro-social actions.

Objective To explore the characteristics of older adult first-time sex offenders (who offended for the first time at the age of 65 years or above). Design The authors retrieved and analyzed data from the publicly available Missouri sex offender registry database up to December 2018 and the Missouri public case management system website. Participants Registered older (≥65 years) sex offenders in the state of Missouri, United States. Measurements Sociodemographic characteristics of the offender, offense type(s), offense, and conviction dates; age and sex of the victim(s); and case disposition information (whether the trial was waived or not and what were the sentences imposed). Results One hundred and ninety-four older adult sex offenders all males were identified, of which 172 were first-time offenders. The majority were white; the median age of offense was 68.6 years old. One hundred and thirty-nine (80.8%) first-time offenders were convicted strictly of non-pornography offenses, with prepubescent girls the predominant victim pool. The most prevalent charge in this subgroup was Child Molestation, First Degree (36.5%). Twenty-eight (16.3%) offenders were convicted strictly of pornography offenses, the most prevalent one being Possession of Child Pornography (96.6%). The recidivism rate among first-time offenders was close to 1%. Conclusion A substantial proportion of older registered sex offenders are first-time sex offenders and most of them have underage victims. Although the offense and recidivism rates seem to be low, future longitudinal studies should focus on the predictors of sexual offending in the older population, in order to design targeted preventive measures, risk assessment, and treatment options.

Objectives: First to explore the prevalence of criminal behavior committed by the non-institutionalized geriatric American population. Second to determine the correlates of criminal behavior among this population. Methods: We used data of the non-institutionalized adults aged ≥65 years in the National Survey on Drug Use and Health from 2008 through 2014. We compared socio-demographic and mental health profiles of arrestees to non-arrestees and lawbreakers to non-lawbreakers and then determined the correlates of being arrested and breaking the law through regression analyses. Results: Around 0.4% of the population reported being arrested, and 5% reported breaking the law in the past year. The most prevalent offense was driving while intoxicated. Arrestees were significantly more likely to be male and to have had an alcohol or a drug(s) use disorder in the past year. Lawbreakers had a significant likelihood of being male, having a high educational level, and having an alcohol or a drug(s) use disorder in the past year. Conclusions: Elderly lawbreakers seem to have distinct characteristics that not just separate them from non-offenders but also probably from younger lawbreakers.

Background Violent and aggressive interpersonal behavior is a serious public health concern. Evidence for management approaches of violence in non-psychiatric populations is limited. Although it is widely used as an off-label treatment to manage aggression and impulsivity, there is a lack of systematically collected evidence on the efficacy and safety of carbamazepine for this indication. Aim Determine the efficacy and safety of carbamazepine in non-institutionalized adults without severe mental illness, with aggressive and violent interpersonal behavior. Methods We systematically searched PubMed, Medline, CINAHL, EMBASE, PsycInfo, CENTRAL, OpenGrey and ClinicalTrials.gov . We included randomized controlled trials assessing the efficacy of carbamazepine in adults without severe mental illness in reducing violent interpersonal behavior, compared to no carbamazepine or other pharmacological treatment modalities. We extracted data from published reports and planned to conduct meta-analyses. Results We reviewed 3447 citations, retrieved 17 full-texts and identified 2 eligible studies. Carbamazepine significantly reduced interpersonal aggression among women with borderline personality disorder but not so among men with impulsive aggression. Given the paucity of results, we could not perform a quantitative analysis. Conclusions Quality evidence supporting the use of carbamazepine in the management of aggressive interpersonal behavior in adults without severe mental illness is lacking. Further studies are warranted.

Background This study aims to investigate the prevalence, correlates and treatment seeking behavior related to ADHD among adolescents from Lebanon. Methods Five hundred and ten adolescents were recruited through multistage stratified cluster sampling of households in Beirut, and separately interviewed along with one parent/legal guardian, using the DAWBA. All adolescents completed the PRQ and the SDQ; the parent/legal guardian also completed the SDQ and provided basic demographic information, including attitudes towards seeking mental health services. Results 10.20% of the adolescents were diagnosed with ADHD. Having ADHD was associated with having academic difficulties and being involved in bullying. Adolescents with ADHD also had higher odds of drinking alcohol, smoking cigarettes, and having comorbid emotional and conduct disorders (compared to those without ADHD). Adolescents with ADHD and their parents reported a higher burden of illness and were more likely to consider seeing a mental health professional than healthy adolescents and their parents. Conclusion ADHD among adolescents in Lebanon warrants closer attention, mainly increased awareness in the larger public, and stronger commitment to increase treatment resources to the community.

Treatment with antipsychotics is a mainstay of trial competency restoration, particularly given that most defendants deemed incompetent to stand trial have psychotic illnesses. We explored the association between competency restoration and antipsychotic type in a retrospective sample of defendants diagnosed with psychotic disorders and deemed incompetent to stand trial. Using regression models, we calculated the odds ratio of being competent to stand trial, adjusting for relevant confounders. We found that the use of long-acting injectable antipsychotics was not significantly associated with increased odds of restoration of trial competency. Our results highlight the need for larger, longitudinal studies to further explore the efficacy and tolerability of long-acting injectable drugs compared with oral antipsychotics. Future research will help develop treatment guidelines within the setting of trial competency restoration.

Objectives Monoclonal antibodies such as antagonists of tumor necrosis factor-alpha have been shown to have beneficial effects on the well-being of patients with inflammatory illnesses. However, mood episodes triggered by such agents have been reported. We herein report the case of mania induced by adalimumab treatment in an adult with ankylosing spondylitis, which later resolved once adalimumab was discontinued and mood stabilizers were initiated. Methods A 25-year-old man, with prior history of dysthymia, was diagnosed with ankylosing spondylitis and started on adalimumab. He gradually developed manic symptoms over seven to eight months, while maintained on adalimumab. As his condition did not improve with outpatient management, the patient was admitted to the Psychiatry inpatient unit. Results Valproate and aripiprazole were initiated, and adalimumab was substituted with non-steroidal anti-inflammatory agents. Mood symptoms resolved within days, and the patient was discharged. Upon follow-up, the patient was euthymic and compliant to his psychotropic medications. He was started on certolizumab, a different immunomodulatory, for his ankylosing spondylitis. Conclusions Immunological modulation might be a key factor in triggering, maintaining, or treating mood symptoms. Further research in this field is warranted to better understand the pathophysiology of mania. To our knowledge, manic symptoms induced by adalimumab have not been previously reported in the literature, which is why our case report can have an impact in recognizing this important clinical adverse effect.

Given the failure to develop disease-modifying therapies for Alzheimer’s disease (AD), strategies aiming at preventing or delaying the onset of the disease are being prioritized. While the debate regarding whether depression is an etiological risk factor or a prodrome of AD rages on, a key determining factor may be the timing of depression onset in older adults. There is increasing evidence that untreated early-onset depression is a risk factor and that late-onset depression may be a catalyst of cognitive decline. Data from animal studies have shown a beneficial impact of selective serotonin reuptake inhibitors on pathophysiological biomarkers of AD including amyloid burden, tau deposits and neurogenesis. In humans, studies focusing on subjects with a prior history of depression also showed a delay in the onset of AD in those treated with most selective serotonin reuptake inhibitors. Paroxetine, which has strong anticholinergic properties, was associated with increased mortality and mixed effects on amyloid and tau deposits in mice, as well as increased odds of developing AD in humans. Although most of the data regarding selective serotonin reuptake inhibitors is promising, findings should be interpreted cautiously because of notable methodological heterogeneity between studies. There is thus a need to conduct large scale randomized controlled trials with long follow up periods to clarify the dose-effect relationship of specific serotonergic antidepressants on AD prevention.

In June 2017, a media frenzy ensued after Michelle Carter was convicted of involuntary manslaughter in the state of Massachusetts for facilitating the suicide of Conrad Roy. The verdict stirred controversy and cast a spotlight on facilitation of suicide, i.e., a person's act(s) done with the purpose of helping another to die by suicide. One form of facilitation, physician-assisted suicide, has been extensively debated in the existing literature. In this article, we set out to explore the legal and forensic ramifications of non-physician-assisted suicide, which we refer to as facilitated suicide. We first conducted a review of all fifty states' legislation regarding facilitated suicide: forty-four states prohibit it by statute, and three states prohibit it through common law. Thirteen states specifically outlaw verbal facilitation of suicide. We then surveyed the case law to identify legal precedent to the Commonwealth v.

Objectives Monoclonal antibodies such as antagonists of tumor necrosis factor-alpha have been shown to have beneficial effects on the well-being of patients with inflammatory illnesses. However, mood episodes triggered by such agents have been reported. We herein report the case of mania induced by adalimumab treatment in an adult with ankylosing spondylitis, which later resolved once adalimumab was discontinued and mood stabilizers were initiated. Methods A 25-year-old man, with prior history of dysthymia, was diagnosed with ankylosing spondylitis and started on adalimumab. He gradually developed manic symptoms over seven to eight months, while maintained on adalimumab. As his condition did not improve with outpatient management, the patient was admitted to the Psychiatry inpatient unit. Results Valproate and aripiprazole were initiated, and adalimumab was substituted with non-steroidal anti-inflammatory agents. Mood symptoms resolved within days, and the patient was discharged. Upon follow-up, the patient was euthymic and compliant to his psychotropic medications. He was started on certolizumab, a different immunomodulatory, for his ankylosing spondylitis. Conclusions Immunological modulation might be a key factor in triggering, maintaining, or treating mood symptoms. Further research in this field is warranted to better understand the pathophysiology of mania. To our knowledge, manic symptoms induced by adalimumab have not been previously reported in the literature, which is why our case report can have an impact in recognizing this important clinical adverse effect.

Alzheimer's disease is the most common neurodegenerative disorder and no disease-modifying treatment is currently available. Research has shown that while brain neurogenesis continues in adult life, it declines with age. Using parabiosis, plasma transfusions and direct administration of neural growth factors, animal studies have demonstrated the positive impact of exposure to young blood products on neurogenesis and synaptic plasticity in an aging brain. The hippocampus and the sub-ventricular zones were identified as the main regions affected. Promising findings have prompted researchers to experiment their effects in subjects with an established neurocognitive disorder, such as Alzheimer's disease. They argued that modification of brain vasculature, reactivation of adult neural stem cells, and remodeling of their synaptic activity/plasticity may lead to cognitive enhancement and increased neurogenesis. One pilot human study found that young donor plasma infusion protocols for adults with Alzheimer's disease were safe and feasible; however, no statistically significant improvements in cognition were detected. There is a need to conduct additional placebo-controlled human studies in larger samples. Future studies should focus on identifying an “optimal age” at which an intervention in humans may yield significant cognitive enhancement, as well as determining the types of transfusions with the best efficacy and tolerability profiles.

It is well documented in the literature that noradrenergic pathways are key in the manifestation of opioid withdrawal symptoms, which is why clonidine is used as an off-label agent in opioid detoxification regimens given its anti-sympathetic properties. Moxonidine is a selective I1-imidazoline receptor agonist, similar to clonidine but with no α2-adrenergic agonist activity and subsequently fewer side effects. We report the case of a 33-year-old woman with a 15-year history of tramadol use who was admitted voluntarily for detoxification. She was started on moxonidine and had an uneventful detoxification. Two months after discharge, the patient maintained tramadol abstinence with good tolerability to moxonidine. To the best of our knowledge, this has not been previously reported in the medical literature.