Problemy sotsial'noi gigieny, zdravookhraneniia i istorii meditsinyA V Dyakov
The article offers systematic consideration of epistemology of psychiatry as section of medicine which examination permits to analyze dispositif of science successfully implementing conceptual theoretical constructs in everyday practice. The various versions and trends in this area are considered, from traditional history of medicine with its positive or negative models of development of psychiatry to historical epistemology and history of ideas striving to create conceptualized picture of permanent scientific revolution or explosive evolution of psychiatry. The number of key moments are marked representing crystallization points of epistemology of psychiatry as systematic form of research: 1) the question about area of knowledge that is provide space for research in this direction; 2) creation of space of reflexive thinking where internal problematization of psychiatric theory and practice will be possible, excluding development of general theory of psychiatry that is externally imposed on it as general guidelines; 3) problematization of modus of openness of psychiatry to related areas of knowledge and public practice, minimizing interference of non-professionals in professional activities of psychiatrists.
Personality and mental healthBarbera E Van Reijswoud, Nikola Doubkova, Gina Rossi, Arno van Dam, Wiebren Markus, Kasia Uzieblo
Personality disorders (PDs) are associated with significant clinical and societal consequences and are highly comorbid with other psychiatric conditions. In forensic mental health settings, PD diagnoses are particularly relevant because they are linked to antisocial behavior, recidivism risk, and specific treatment needs. However, empirical knowledge about the prevalence of PD diagnoses in outpatient forensic mental health (OFMH) care is limited. We aimed to conduct a comprehensive study of the prevalence of PD diagnoses in OFMH institutions and to describe the demographic, clinical, and legal characteristics of individuals with PD diagnoses. Data were collected from OFMH institutions across the Netherlands for all adult individuals who received treatment in 2023. Fifteen institutions provided usable data, resulting in a total sample of 10,560 individuals. Descriptive analyses were conducted to estimate the prevalence of PD diagnoses and to examine differences across individual characteristics and treatment variables. Overall, 19.3% of all individuals were diagnosed with at least one PD. PD was the primary diagnosis in 12% of all individuals and an additional diagnosis in 7.3%, which seems to indicate that PD diagnoses are under-recognized. The most frequently recorded specific PD diagnoses were other specified or unspecified PD, followed by borderline PD and antisocial PD. PD diagnosis prevalence was higher among female individuals, middle-aged individuals, individuals receiving voluntary treatment, and those involved in more serious violent offenses. These findings provide large-scale prevalence data on PD diagnoses in Dutch OFMH and highlight the importance of systematic assessment of personality pathology in forensic outpatient populations.
BACKGROUND: Health care organizations increasingly rely on business associates (BAs) to provide clinical, administrative, and technology services that require access to protected health information. While the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule extended legal liability to BAs, the frequency and characteristics of data breaches involving BAs have not been systematically tracked across the entire post-HITECH reporting era. Understanding these trends is critical for health information managers and cybersecurity professionals who are directly responsible for managing third-party risk. OBJECTIVE: The author examined the longitudinal trends in BA involvement in health care data breaches reported to the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) from 2009 to 2025, including changes in frequency, breach mechanisms, breach locations, and severity profiles of BA-involved incidents across 3 regulatory periods. METHODS: The author conducted a retrospective longitudinal analysis of health care data breaches (N=6612) reported to the HHS OCR breach portal between October 2009 and December 2025. The author operationalized BA involvement as breaches reported by BA entities or flagged as BA-related. Using logistic regression models, the author estimated annual trends in BA involvement, breach mechanism, and breach location. Chi-square tests assessed associations between BA status and breach characteristics across 3 regulatory periods: pre-Omnibus (2009-2013), post-Omnibus (2014-2019), and 2020-2025. Proportion tests compared BA-involvement rates across periods. RESULTS: BA-involved breaches accounted for 1950 of 6612 (29.5%) incidents and 285,718,494 (48.8%) of all affected individuals. The annual BA-involvement rate increased from 22.1% in the pre-Omnibus period to 36.6% in the 2020-2025 period (z score=8.29, P<.001). Logistic regression confirmed an 8% annual increase in the odds of BA involvement (odds ratio [OR] 1.08, 95% CI 1.07-1.10; P<.001). Hacking/IT incidents shifted from a minority of incidents to the dominant breach mechanism (OR 1.41 per year, 95% CI 1.39-1.44; P<.001), and the odds of network server breaches increased by 29% per year (OR 1.29, 95% CI 1.26-1.31; P<.001). BA-involved breaches were significantly more concentrated in hacking (1282/1950, 65.7% vs 2351/4662, 50.4%) and network server locations (1084/1950, 55.6% vs 1435/4662, 30.8%) compared with non-BA breaches (P<.001). The proportion of mega breaches (≥100,000 individuals) also increased annually (OR 1.16, 95% CI 1.13-1.19; P<.001), with BA-involved breaches exhibiting a significantly higher rate of mega breaches (12.4% vs 8.2%; χ21=28.44; P<.001). CONCLUSIONS: Building on prior evidence linking BA involvement to breach severity, this study demonstrates that BA-involved health care data breaches accelerated substantially across the post-HITECH reporting era, with the steepest increase beginning in 2020. The concurrent growth of hacking and the concentration of breaches on network servers coincided with digital transformation, cloud migration, and the ransomware epidemic, which may have amplified third-party risk exposure. Health information managers and cybersecurity professionals should prioritize BA risk management strategies that account for the evolving threat landscape, including enhanced vendor security assessments and data compartmentalization requirements.
Nature communicationsConrad O Iyegbe, Melek Chaouch, Itunuoluwa Isewon, Lerato Majara, Olatunde Ayinde, Michaela A O'Hare, Mary Mufford, Ofure A Ubah, Amine Larnaout, Anje-Lore Gro…
Across Africa, rising mental health needs coincide with rapid advances in genomics, digital health and continental policy reform. Yet research into the genetic, environmental and social determinants of neuropsychiatric illness remains sparse and underfunded. This review argues that African leadership in neuropsychiatric genetics can strengthen discovery, guide prevention and care, and support equitable precision public health, provided that investment in cohorts, informatics, governance and workforce development is sustained and scaled. By linking the advancement of genomics to health systems, biobanking and translational innovation, Africa can define globally-relevant models of inclusive mental health research, care and sustainable development.
Journal of medical Internet researchLuis Madeira, Cíntia Águas, Meryam Schouler-Ocak, Jerzy Samochowiec, Silvana Galderisi, Mariana Pinto da Costa
AI is increasingly incorporated into psychiatric triage, risk prediction, passive monitoring, clinical documentation, and patient-facing conversational systems. These applications may improve access, continuity, efficiency, and pattern recognition, but they also redistribute epistemic authority and complicate responsibility when harm occurs. European regulation is developed in relation to market access, data governance, risk management, and product safety, yet remains fragmented regarding civil liability, organizational negligence, and the psychiatric standard of care. This Viewpoint examines how liability and standard of care should be understood when AI becomes part of psychiatric reasoning in Europe. It advances one central thesis: psychiatric AI requires justified integration supported by layered accountability within, but not determined by, European regulation. It presents a targeted doctrinal and normative synthesis of binding European Union instruments, regulatory guidance, selected national governance materials, and psychiatric, bioethical, legal, and digital mental health literature. It distinguishes binding law from guidance and policy, and separates ex ante regulation from ex post liability, and from professional standards of care. Four illustrative domains are analyzed: conversational or therapeutic chatbots, suicide prediction, digital phenotyping and passive monitoring, and large language model documentation. Psychiatric AI raises distinctive concerns because psychiatric judgment depends heavily on testimony, contextual meaning, therapeutic trust, risk interpretation, privacy, and liberty-sensitive decisions. Existing European instruments, including the AI Act, Medical Device Regulation, General Data Protection Regulation, revised Product Liability Directive, and European Health Data Space Regulation, establish governance duties, but do not provide a harmonized fault-based liability framework for AI-assisted health care. Regulatory compliance may inform later legal assessment, but it does not determine whether psychiatric care was reasonable. The proposed standard of justified integration requires knowledge of intended use and model limits, assessment of local and patient-level applicability, active clinical interpretation, disclosure when AI use is material to consent or trust, documentation in high-stakes decisions, and organizational audit. Accountability should be distributed across developers, deployers, and clinicians according to control and preventability. Mixed-fault scenarios are therefore likely to be common. The augmented-clinician model and layered accountability are offered as normative proposals rather than settled European legal standards. Clinicians should remain responsible for contextual, patient-centered judgment; developers for design, validation, documentation, and foreseeable misuse; and deployers for procurement, training, workflow integration, local validation, monitoring, and escalation. Future empirical research should evaluate effects on clinician reliance, documentation burden, patient outcomes, coercive interventions, therapeutic trust, and feasibility across differently resourced services.
Recenti progressi in medicinaNicola Gentili, Valentina Danesi, Raffaella Gaggeri, Riccardo Tessarini, Oriana Nanni, Maria Livia Rizzo, Sara Ehsani, Mario Fregonara, Martina Farina, Valeria…
This position paper examines the strategic value of clinical and outcome research data for the National Health Service, with a specific focus on the dual mandate of Scientific Institutes for Research, Hospitalization and Healthcare (IRCCS) and the role of Local Health Authorities as custodians of extensive Real World Data repositories. Although the European regulatory framework - represented by the GDPR (Art. 89) and the upcoming European Health Data Space (EHDS) - alongside the Italian Privacy Code (Art. 110), provides solid legal bases for the secondary use of health data for scientific purposes, a significant gap persists between the potential of these informational assets and their effective exploitation. The document, resulting from a multidisciplinary collaboration involving researchers, legal experts, decision-makers, Data Protection Officers, Ethics Committees, and patient representatives, identifies current operational criticalities and proposes three priority strategic directions. First, it is imperative to systematize research governance to optimize resource allocation by integrating privacy by design principles and promoting interoperability standards and Federated Learning architectures. Second, the paper advocates transparency in management processes, urging institutions to move beyond the ineffective paradigm of security through obscurity in favor of verifiable architectures and clear traceability of data flows. Finally, the systematic development of the data stewardship function is recommended. Rather than acting as a bureaucratic control, the data steward should provide strategic mentorship and high-level consultation, bridging scientific research needs and regulatory compliance requirements. In conclusion, personal data protection must not be perceived as a barrier to biomedical progress, but as an enabling framework based on shared responsibility, safeguarding patients' rights while ensuring high standards of research excellence.
Australian occupational therapy journalAleksandra Westcott, Lorrae Mynard, Gabrielle Pitt, Susan Darzins
INTRODUCTION: Identifying and addressing the support needs of forensic mental health patients in daily life occupations is critical yet complex due to the health comorbidities and environmental restrictions impacting their participation. Occupational therapists support forensic patient recovery by facilitating their performance in daily life occupations required at home and in the community. Standardised assessments of daily living are important for guiding interventions. The Home Support Needs Assessment (HSNA) is a standardised measure identifying unmet support needs in daily life occupations. The aim of this study was to evaluate its initial acceptability and feasibility for occupational therapists' use in a forensic mental health setting. METHODS: An exploratory convergent, parallel mixed-methods design was used. Semi-structured interviews with five forensic occupational therapists explored their perspectives about using the HSNA in practice. Interview transcripts were analysed using reflexive thematic analysis. HSNA data were extracted from 13 patient medical records and summarised using descriptive statistics. CONSUMER AND COMMUNITY INVOLVEMENT: There was no consumer and community involvement in this research as the focus of the study was on occupational therapists. FINDINGS: Three overarching themes were generated: value of the assessment, informed care planning, and applicability to the environment. The HSNA was found to structure observations, facilitate discussions about daily life occupations, and clarify ongoing support needs. An over-support of some needs emerged as a unique factor of the forensic mental health environment. Some items were viewed as not applicable to the setting. CONCLUSION: The HSNA highlighted that the safety focus of the secure environment inadvertently limited opportunities for patients' involvement in daily life occupations. Acceptability was associated with enabling holistic occupational assessment. Further tailored training may increase overall implementability.
Adaptive neuromodulation offers a path toward personalized neuropsychiatric treatment by allowing therapy to respond to clinically meaningful neurophysiological and behavioral changes. Its clearest clinical precedents are responsive neurostimulation for epilepsy and adaptive deep brain stimulation for movement disorders. Both rely on signals that can be measured reliably and linked directly to stimulation. Psychiatric disorders pose a different problem: symptoms are heterogeneous, evolve over multiple timescales, and are observed only indirectly through noisy and incomplete measurements. Artificial intelligence can provide data-driven components of an adaptive neuromodulation system, connecting multimodal sensing, inference of patient state, prediction of treatment response, and constrained therapeutic adaptation. Interpretability is required throughout to support clinician and patient trust. Clinical evidence, however, remains limited to small proof-of-concept studies. Translation to practice will require replicated biomarkers and prospective multisite validation. It will also require explicit management of uncertainty and system designs that match adaptation to symptom and treatment timescales. Clinician and patient oversight must be preserved throughout, alongside safety constraints and governance across the treatment life cycle. This review presents a system-design view of how these components combine into a single adaptive architecture for psychiatric neuromodulation.
The American journal of psychiatryHarold A Sackeim, Mark S George
Brain stimulation interventions alter neural activity by applying electrical, magnetic, sonic, or other forms of energy to the nervous system, using invasive or noninvasive methods. In recent years, the basic science and clinical science of neuromodulation have markedly advanced, and the evidence for clinical utility has resulted in new U.S. Food and Drug Administration (FDA) clearance for multiple forms of brain stimulation and multiple indications in neuropsychiatry. This review summarizes the status of the major brain stimulation interventions for neuropsychiatric disorders, emphasizing key strengths and challenges in their therapeutic application. It also discusses opportunities for additional breakthroughs in treatment in this rapidly advancing field. These topics include noninvasive techniques for focal intracerebral drug delivery that bypass the adverse effects linked to systemic pharmacologic administration; interventions that noninvasively stimulate deep or superficial brain targets without impacting surrounding tissue; interventions that, in addition to or instead of altering symptomatic expression, reduce stress sensitivity, enhance resilience, and prevent manifestation of neuropsychiatric disorders; and the development of responsive or closed-loop stimulation techniques whereby the timing and nature of the stimulation are adjusted based on personalized biomarkers of future pathological brain states. Finally, noninvasive brain stimulation interventions intended for home use have recently shown clinical utility and have received FDA clearance. The field of brain stimulation represents a paradigm shift that is revolutionizing therapeutics and mechanistic understanding in neuropsychiatry.
Nursing philosophy : an international journal for healthcare professionalsTove Stenman
Confidential conversations constitute an important, still insufficiently explored, aspect of palliative care. While described as valuable in clinical practice, their relational and existential significance remains difficult to conceptualise. This article examines confidential conversations through a philosophical dialogue between empirical insights from specialised palliative care and Paul Ricœur's philosophy of Homo Capax. Ricœur is not applied as a theoretical framework; rather, confidential conversations both illuminate and invite further reflection on his understanding of capability, vulnerability, practical wisdom, solicitude, and narrative identity. The article is based on a philosophical reflection of a synthesis of four qualitative studies conducted in specialised palliative care. It begins from recurring tensions within confidential conversations concerning spontaneity and structure, safety and uncertainty, everyday small talk and existential disclosure, professional responsibility and interpersonal presence. These tensions remain unresolved and are understood as relational conditions through which confidential conversations become possible. Dialogue with Ricœur suggests that confidential conversations can be understood as fragile relational events in which capability and vulnerability are mutually constitutive rather than opposed. This interpretation invites further philosophical reflection on autonomy, asymmetrical vulnerability, and the limits of practical wisdom. To deepen these questions, perspectives from Martin Buber and Hartmut Rosa are brought into dialogue with Ricœur, illuminating how confidential conversations become encounters characterised by responsiveness and resonance while remaining situated within asymmetrical relationships of care. This article suggests that confidential conversations are less understood as communicative interventions or professional techniques than as relational events in which meaning emerges through responsiveness under conditions of suffering, finitude, and institutional constraint. Their significance lies in the possibility that patient and nurse become responsive to one another within a relationship that neither fully controls. The article offers a philosophical interpretation of confidential conversations grounded in empirical experience.
Mayo Clinic proceedingsPritish K Tosh, Brian W Decker, Ashton L Boon
Cybersecurity has become a critical determinant of patient safety, business continuity, and organizational resilience in health care. Health care organizations are increasingly targeted by ransomware, data theft, and related attacks that disrupt clinical operations, threaten patient safety, delay care, and compromise sensitive information. Although often viewed as technical failures, many incidents originate in routine human behaviors, including phishing responses, credential misuse, unsafe downloads, and inappropriate use of personal devices or applications. This review focuses on clinician-level actions that can reduce both personal and organizational risk, including strong and unique passwords, multifactor authentication, phishing recognition and reporting, timely software updates, secure network use, careful management of personal devices and apps, and avoidance of risky removable media or untrusted downloads. It also emphasizes preparedness for extended network downtime, including familiarity with business continuity processes for documentation, ordering, communication, and care coordination when core digital systems are unavailable.
The Australian journal of rural healthLuke Sy-Cherng Woon, Tarun Bastiampillai, David Smith, Paul A Maguire, Rebecca E Reay, Jeffrey C L Looi
OBJECTIVE: To examine the trend of locational equity in utilising Medicare-reimbursed psychiatric consultations (face-to-face and telepsychiatry) across states/territories. DESIGN: Time series analysis of administrative data. SETTING: Medicare-reimbursed private psychiatric consultations. MAIN OUTCOME MEASURES: Greater coefficients of variation (CVs) represented higher state/territory variations in per capita consultations (2005 Q3-2023 Q4). We ran an autoregressive integrated moving average model for telepsychiatry-related CV change, with restricted rural-remote telepsychiatry items (2005-2022) and unrestricted telepsychiatry items (2020 Q1-2023 Q4) as the predictors. We examined the association between distance from mean per capita consultations and the fraction of per capita telepsychiatry consultations using state/territory-level data in another regression analysis, with telehealth legislative policy changes as another independent variable. RESULTS: Including telepsychiatry items since their introduction resulted in lower all-item CVs (i.e., reduced state/territory variation) than the corresponding CVs for face-to-face items only. The rural-remote-restricted telepsychiatry items had a larger effect than the unrestricted ones. Every 1000 restricted consultations were associated with 0.287 units of CV improvement (i.e., reduction in regional variation), in contrast to 0.007 units per 1000 consultations for unrestricted items. Telehealth-enabling policy changes significantly modified the association between distance from mean per capita face-to-face consultations and the fraction of telepsychiatry consultations. Lower per capita face-to-face consultations were associated with higher telepsychiatry fractions. CONCLUSION: Telepsychiatry may help improve mental health equity. Bulk-billed, incentivised telepsychiatry for rural and remote areas may enhance regional health access.
BACKGROUND AND PURPOSE: Numerous studies in the international literature address workplace traumatic experiences affecting psychiatry residents and their impacts. No such survey has been conducted in Hungary so far, so I set as my goal to assess the occurrence of stressful situations affecting Hungarian psychiatry residents and their psychological consequences. Emphasizing the mental health of psychiatry residents and improving prevention in specialist training is an essential condition for training stable, well-prepared specialists. METHODS: A total of 80 psychiatry residents from the specialist training programs of the 4 Hungarian universities were included in the survey. The questionnaire consisted of 5 parts: occurrence of stressful situations; psychological reactions; Mini-Oldenburg Burnout Inventory (MOLBI); coping mechanisms; needs for specialist training development. RESULTS: Among stressful situations, verbal abuse and discriminatory remarks were the most common. Physical assault affected 34.6% of respondents, and patient suicide occurred in 34.5% of cases. Burnout criteria were met in 62.5% of residents. High scores were achieved on the MOLBI Disengagement subscale by 65% and on the Exhaustion subscale by 90%. Although burnout and disengagement levels were similar, the proportion of those with significant exhaustion was significantly higher in the Budapest sample compared to the national average (94.2% vs. 84.6%). For processing cases, young residents most commonly chose discussion with fellow residents. 100% of respondents supported the development of specialist training programs that would aid the professional processing of difficult situations. CONCLUSION: The occurrence of stressful situations shows similar trends to international literature data. However, burnout and exhaustion levels are significantly higher, which may have several explanations. The two most important factors to build future development strategies around are more thorough preparation for difficult situations and the programmatic implementation of professional and regular case processing.
Global health actionAugustus Osborne, Ahmed Vandy, Camilla Bangura
BACKGROUND: Gender-based violence (GBV) intensifies during emergencies, yet health and protection systems in Sierra Leone remain inadequately prepared to respond. Survivors face barriers including stigma, breaches of confidentiality, and weak referral pathways. OBJECTIVE: This study explored how health and protection systems in three districts of Sierra Leone respond to GBV during emergencies. METHODS: A qualitative descriptive study was conducted across three districts, integrating semi-structured interviews with referral pathway mapping. Purposive sampling recruited 54 participants: 48 key informants across eight stakeholder groups and 6 survivors identified through referral organisations. Data were analysed using the framework method. Data collection took place outside an active emergency; emergency-specific findings therefore reflect participant recollection rather than direct observation. RESULTS: Four themes emerged: fragmented and under-resourced clinical readiness; confidentiality failures and stigma as structural barriers; dysfunctional referral pathways and coordination gaps; and limited, inconsistent survivor-centred psychosocial care. Participants reported that emergency contraception was frequently unavailable and, in some accounts, withheld on moral grounds. Referrals to police and social welfare were described as ad hoc, reliant on personal relationships, and severely disrupted when GBV was excluded from emergency coordination structures. Counsellors were largely absent from peripheral facilities. A minority of participants reported functioning one-stop centre care. CONCLUSIONS: Participants described GBV response arrangements that were fragile in stable periods and, in their recollection of previous emergencies, substantially weakened, alongside a smaller set of components that functioned. Emergency preparedness planning would benefit from explicit attention to survivor-centred GBV care; the applicability of these district-level findings elsewhere requires further study.
JMIR formative researchEmmanuel Chevallier, Catherine Letord, Jean Charlet, Marie-Odile Krebs, Emmanuelle Advenier-Iakovlev, Stefan J Darmoni, Julien Grosjean, Romain Leguillon
BACKGROUND: Off-label drug prescribing is prevalent across medicine, including psychiatry, often due to unmet therapeutic needs and inadequate responses to standard treatments. The PSYHAMM (Psychotropes Hors Autorisation de Mise sur le Marché) project, funded by the French Research Agency, investigates these practices. To support this research, a clinical data warehouse (CDW) with advanced data analysis tools was developed and deployed. This system integrates both structured and unstructured data from electronic health records, facilitating comprehensive data analysis. The goal is to improve understanding, regulation, and safety of off-label drug use in psychiatry by providing insights into prescribing patterns and their impacts, ultimately contributing to better clinical guidelines and patient care. OBJECTIVE: This study aimed to evaluate the precision (positive predictive value) of a CDW in identifying candidate off-label prescriptions in psychiatry among the cases automatically flagged by the system, rather than its overall accuracy, sensitivity, or specificity. METHODS: The PSYHAMM data analysis involved a retrospective study of pathology-medication pairs to evaluate the precision of a computerized system among system-flagged cases. This system was compared with manual checks performed by a psychiatrist. The evaluation process included verifying if the condition identified by PSYHAMM was documented in the medical record, assessing diagnostic agreement with tolerance for schizoaffective disorders, and ensuring the identified treatment was current or prescribed in the past. Precision was measured as the number of relevant documents retrieved divided by the total number of documents proposed and was computed for the precise diagnosis, the broad diagnosis, and the identified treatment among the flagged cases. RESULTS: The study analyzed 197 records, identifying 14 unique drug-pathology combinations. Bipolar disorder treated with sodium valproate represented the most cases (108/197, 54.8%), followed by schizophrenia treated with sodium valproate (37/197, 18.8%). The overall precision for detecting off-label situations was 51.3% (101/197). The precise diagnosis achieved a precision of 75.6% (149/197), while the broad diagnosis showed a higher precision of 84.8% (167/197). The identified treatment had a precision of 61.4% (121/197). The primary challenge was temporal discrepancies, such as distinguishing between acute and chronic conditions, which accounted for most of the 48.7% (96/197) of cases that were incorrectly classified. CONCLUSIONS: As a single-center, proof-of-concept evaluation, the PSYHAMM project demonstrates the potential of automated systems to support the identification of off-label prescriptions in psychiatry as a sensitive prescreening step requiring expert validation. The relatively high false-positive rate was driven mainly by temporal discrepancies (drugs prescribed before the index stay, discontinued during the stay, or only hypothetically mentioned) rather than by semantic errors. Future research should focus on integrating real-time data analytics and expanding to multiple institutions to improve the utility of off-label detection systems.
Health research policy and systemsJustin Aunger, Jane Ferguson, Esra Alkim Karaagac, Tommer Spence, Jill Maben, Ashok Patnaik, Russell Mannion, Yingxi Zhao, Nathan Proudlove, Helen Bodenham-Chi…
Sensitive healthcare workforce research relies on credible assurances of confidentiality for participating staff and organizations. Yet, National Health Service (NHS) research governance processes can compromise these assurances even before recruitment begins, particularly through processes such as site documentation, local principal investigator (PI) requirements, research passports, and portfolio reporting. These risks are especially important for studies examining organizationally sensitive topics such as bullying, speaking up, or patient safety issues, where perceived employer awareness may reduce participation or encourage self-censorship. From March 2026, the Health Research Authority introduced reforms for staff-only studies, including streamlined site set-up, reduced site visibility, and fewer requirements for local PIs or research passports in remote studies. However, further changes are needed to better balance transparency, oversight and confidentiality. Potential improvements include dedicated pathways for sensitive organizational research, restricted-access portfolio reporting, and more centralized governance documentation. Future changes should be co-designed with researchers and NHS research and development departments to protect confidentiality and improve research productivity, while maintaining ethical standards and accountability.
Journal of forensic and legal medicineİlker Güneysu, Ahmet Depreli, Seda Güneysu, Fatih Güler, Ahmet Can
OBJECTIVE: Retrospective forensic and psychological autopsy materials are central to suicide research, but they are shaped by source availability, recall, retrospective meaning-making, investigative priorities, and documentation practices. Rather than developing a suicide risk model or clinical subtype classification, this study examined whether forensic suicide narratives could be transformed into a reliability-screened documentation matrix without treating documented content as verified occurrence, causal evidence, or individual-level risk information. METHOD: We conducted a retrospective forensic-record framework-evaluation study of 152 anonymized suicide death cases examined in a regional forensic branch in Türkiye between April 2021 and March 2025. Fourteen predefined clinical, psychosocial, interpersonal, and contextual documentation indicators were coded using conservative documented-presence criteria. Interrater reliability, appraisal-dependency assessment, pairwise co-documentation analysis, and a final latent class summary were used to evaluate reproducibility, empirical separability, and record-level documentation configurations. RESULTS: Eight indicators met the predefined κ ≥ .60 pragmatic documented-presence reliability threshold and were retained as primary direct documentation indicators. Two appraisal-dependent indicators were frequently documented but showed poor reliability. Pairwise analysis identified near-redundant co-documentation between interpersonal or relationship crisis and family or partner conflict, supporting their collapse into a single relational-documentation indicator. The final seven-indicator latent class analysis supported a parsimonious two-class documentation-configuration summary, interpreted descriptively rather than as clinical subtypes or risk profiles. CONCLUSIONS: Forensic suicide narratives can be transformed into auditable documentation-level data when direct documentation, appraisal-dependent reconstruction, insufficient documentation, and operationally overlapping indicators are kept analytically distinct. This framework strengthens evidentiary discipline in retrospective forensic suicide research before broader pattern analysis.
The International journal of psycho-analysisAnat Tzur Mahalel
This essay explores the role of visual images in dream imagery as a space where unconscious processes intersect with historical forces. It offers a comparative reading in Freud's Interpretation of Dreams (1900) and Benjamin's Arcades Project (1982). Freud conceptualizes dream images as condensed memory traces that navigate between perception and hallucination, revealing repressed desires. Conversely, Benjamin's dream images critique modernity's loss of aura, offering moments of "Now-Time" as opportunities for historical creation. The essay argues that both Freud and Benjamin share a foundational premise: turning a blind eye to the obscure and unknown dimensions of individual and collective experience fosters crises and destruction, whereas striving to reveal these hidden areas promotes transformation. Exploring disruptions and ruptures in the continuity of experience challenges the inclination to act according to Freud's concept of repetition compulsion or Nietzsche's eternal return, as interpreted by Benjamin. These ideas are explored through the dream of the burning child presented by Freud and the ghost dream presented by Benjamin. The dialectic of insight and blindness, alongside the image of open doors in both dreams, invite us to consider how, even amidst loss and rupture, dream images can open pathways to new realms of experiencing and remembering.
The International journal of psycho-analysisHarriet Wolfe, Kai Ogimoto, Tomas Plaenkers
For the 2023 IPA Asia-Pacific Congress in Delhi, the authors of this paper prepared a panel titled "Reflections on National Stereotypes and Prejudices: The View of Others from One's Own Perspective" with the aim to stimulate further reflection and discussion on this topic among the Asia-Pacific analytic groups. Authors invited psychoanalysts from the six psychoanalytical groups in the Asia-Pacific region to participate. Those psychoanalysts provided analytic perspectives to shed light on the historical context and psychological factors that contribute to national stereotypes and prejudices, the dynamics of splitting and projection, and the idealization of one's own country. These processes not only impact individual psyches but also shape societal attitudes and interactions. The papers highlighted the need for deeper understanding and empathy, emphasizing the importance of listening to and being curious about the other, especially within the six psychoanalytic groups represented. The collective reflection on the shared, conflict-ridden history and its unconscious underpinnings represents the beginning of a process within the envisioned Asia-Pacific region of the International Psychoanalytical Association.
The International journal of psycho-analysisJessica Tran The, François Ansermet
Lacan's reinterpretation of Freud's theory on trauma Abstract In this article we consider the Lacanian theory of trauma, with the aim of demonstrating which of Freud's theories Lacan sought to build on and develop in his own model. This approach highlights the continuity, as well as the divergences, between Lacanian psychoanalysis and the Freudian model of trauma. Approaching Lacanian psychoanalysis through the concept of trauma reveals how his theories did not focus only on the subject as determined by the register of language. Rather, Lacanian psychoanalysis emphasises the intimate relationship between the unconscious and the sexual. The Lacanian model of trauma is also of interest for clinical practice, since it provides a better understanding of the Lacanian concept of 'structure'. This is a concept that considers the impact of events experienced on the psychic functioning of the subject. It can guide the analytical listening during therapeutic work with patients. Aside from its clinical relevance, approaching Lacan's work through trauma makes it possible to clarify the fundamental difference between psychoanalysis and contemporary nosographic approaches to the treatment of trauma, and aetiology in psychopathology.
The International journal of psycho-analysisGeorg Augusta
The intention of this paper is to trace the family history of Sigmund Freud's mother Amalia. It is the influence of the intellectual, cultural and religious values of the mother's side of the family over several generations that has remained underestimated in previous biographical research. For more than two centuries, the Nathansohns were among the most influential upper-class Jewish families in the city of Brody, an important trading center in Poland and in the Habsburg Monarchy. Specific religious, economic and political upheavals led to several members of the Nathansohn family settling elsewhere, including Sigmund Freud's grandfather Jacob and his family, who came to Vienna in 1854. Furthermore, knowledge of the biographies of close relatives enables a more nuanced perspective on Freud's own specific development.
We conducted a systematic review of literature on teaching psychiatric formulation with the aim of reflecting on the findings and proposing recommendations for enhancing formulation pedagogy within psychiatric education. We found categories of publication on formulation tools, educational strategies, and evaluation of outcomes with little continuity between them. Fourteen themes were identified that helped to understand the gaps in the evidence and the unresolved issues of conceptualization. Our review revealed a striking paradox: despite widespread agreement on the centrality of formulation as a core clinical competency in psychiatry, how to teach it remains fragmented, methodologically weak, and conceptually inconsistent. Based on the findings we propose eight recommendations to aid advance in the research of teaching psychiatric formulation.
PloS oneMatthieu Lebrat, Ahava Cohen, Rachel Megard, Nicolas Franck, Claude Dussart, Marion Perin-Dureau
PURPOSE: Multi-professional medication reviews (MPMRs) are structured, collaborative processes designed to optimize medication management and promote evidence-based practice. Yet, their impact in psychiatric settings remains understudied. This study aimed to retrospectively assess the impact of hospital-based MPMRs on medication prescriptions in psychiatric inpatients. METHODS: An observational, retrospective, pre-post study in four psychiatric wards of a French university hospital was conducted. Participants had two hospital stays: one before and one after MPMR implementation (August 2017-December 2023). Data collection was performed from electronic medical records. The primary outcome was the change in the number of prescribed medications between admission and discharge, compared pre- and post-MPMR implementation. Secondary outcomes included changes in specific drug classes. Data were analyzed using paired tests and mixed linear models (MLM), adjusting for age, sex, hospitalization duration, and ward. RESULTS: MPMR implementation was associated with a significant reduction in the total number of prescribed medications (-1.1 drugs, p = 0.044 or 0.001 with a MLM, Cohen's d = 0.18). Significant decreases were observed in overall psychotropic medications (-1.5, p < 0.001), benzodiazepines (-0.8, p < 0.001), antipsychotics (-0.3, p < 0.05), anticholinergics (-0.7, p ≤ 0.05), and laxatives (-0.2, p ≤ 0.05). No significant changes were found for antidepressants, mood stabilizers, or analgesics. Sex differences were noted in overall psychotropic deprescribing, with men showing greater reduction. CONCLUSION: MPMRs in psychiatric inpatient settings may improve prescribing practices, particularly by reducing high-risk and potentially inappropriate medications. While the overall reduction in total medications was modest, targeted decreases in psychotropics and anticholinergics suggest clinically meaningful benefits for patient safety and medication appropriateness. Further research with randomized designs is warranted to confirm these findings and explore long-term outcomes.
The journal of the American Academy of Psychiatry and the LawLindsey D Ryan-Jones, Richard Rogers, Mackenzie S Baranski, Ayomide V Ayoola
Forensic evaluators commonly conduct evaluations of sexually violent persons (SVPs) but often retrofit generic risk assessments to assess SVP legal criteria. As a 20-year follow-up to "The Risky Enterprise of Risk Assessment," this article critically evaluates updated versions of common risk measures (Historical-Clinical-Risk Management Scale 20 (HCR-20V3), Sexually Violent Risk 20 (SVR-20 V2), Violence Risk Appraisal Guide-Revised (VRAG-R), Static-99R, and Risk for Sexual Violence Protocol (RSVP V2)) to determine their appropriateness for SVP evaluations. For more balanced appraisals, risk assessments have more recently considered protective factors (Inventory of Offender Risk, Needs, and Strengths (IORNS), Structured Assessment of Protective Factors-Sex Offenders (SAPROF-SO), and Short-Term Assessment of Risk and Treatability (START)), given their growth in forensic research. Importantly, some risk measures demonstrated substantial improvements. Empirical support for predicting violent sexual recidivism, the legal standard in many SVP jurisdictions, has yet to be reached. Most studies assess general sexual recidivism rather than sexual violence, per se This disconnect presents a professional challenge for evaluators in determining whether previously convicted offenders pose such a risk of sexual violence, following their criminal sentence, as to warrant indefinite civil commitment. This review underscores the need for stronger alignments between SVP legal criteria and forensic assessment instruments to solidly support their empirical use in SVP determinations.
The journal of the American Academy of Psychiatry and the LawJoseph M Pierre, Andrew Lustig, Christine M Sarteschi, Joseph R Simpson
Gangstalking is a persecutory belief system espoused by targeted individuals who report being followed, monitored, harassed, or otherwise persecuted by groups of people in their community, often through the coordinated efforts of the government, law enforcement agencies, and strangers. Although the alleged harassment can take the form of conventional stalking, stereotypical gangstalking claims often include added victimization by street theater and directed energy weapons, along with psychotronic warfare, mind control, and voice-to-skull technologies that strain credibility. Although such claims suggest the presence of psychosis, the considerable volume of informational sources that support, validate, and reinforce gangstalking claims expands the differential diagnosis to include persecutory concerns fueled by shared conspiracy theory beliefs as well as mass sociogenic illness. A subset of targeted individuals find themselves in the forensic arena after resorting to violence in the name of perceived self-defense when attempts to seek help have been thwarted or exhausted. With claims of gangstalking on the rise, it is increasingly likely that forensic psychiatrists will be called upon for consultation in such cases. This article provides a concise primer on gangstalking to guide forensic evaluation.
Studies in health technology and informaticsJulian Flake, Christian Henke, Alessandra S Kuntz, Matthias Löbe, Harshvardhan J Pandit, Christian Draeger
Finding, sharing, and reusing data requires common interoperable vocabularies to adequately describe machine-actionable data policies. Semantic Web standards are a proven way to express such information describing data access and reuse. Narrative descriptions get a stable and agreed meaning by formal definitions of terms that have a globally unique identifier. The Data Privacy Vocabulary (DPV) represents a community standard for privacy, data protection, and related topics. DPV uses modular namespaces to define jurisdictions, such as "EU", and to represent concepts from laws within that jurisdiction, such as the General Data Protection Regulation (GDPR) and the European Health Data Space (EHDS). In this work, we present the creation of a DPV extension representing the German Health Data Use Act (Gesundheitsdatennutzungsgesetz (GDNG)) that has been set into force in March 2024. The GDNG regulates sharing and using health data for secondary use, such as research purposes and policymaking. It builds the German legal foundation for the future EHDS as the European initiative and regulation providing rules for sharing of health data within Europe. The parallel development of the EHDS and GDNG extensions resulted in many shared concepts, which contributed to an overarching extension: the DPV sector health extension. It sets the foundation of aligned privacy terms for future EHDS member states looking to build a national vocabulary aligned with the EHDS. All extensions were released as draft extensions with the latest DPV version 2.3, released 25th of February 2026.
International journal of population data scienceLucas van der Meer, Ahmad Hesam, Jetze Touber, Ricarda Braukmann, Deborah Thorpe, Emilie Kraaikamp, Tom Emery
INTRODUCTION: While many countries have invested heavily in secure technical infrastructures such as Trusted Research Environments (TREs), the rules that determine who may access which data, under what conditions, and for which purposes are still expressed primarily as natural language legal and administrative documents, with little or no accompanying machine-readable representation. This limits automation, interoperability, and scalability, particularly for research that spans multiple data holders. OBJECTIVES: This paper examines these challenges through the Dutch social science data landscape and presents a framework for standardising access governance using machine-actionable access conditions, with the aim of bridging the gap between secure technical environments and scalable access governance. METHODS: Building on the Open Digital Rights Language (ODRL), we propose a library of reusable access condition templates and a Data Access Broker service. The framework was developed through iterative consultation with data holders in the Dutch SSH domain and draws on ongoing developments within the European Open Science Cloud (EOSC) and related data sharing initiatives. RESULTS: We demonstrate that machine-actionable access conditions can operationalise legal and organisational oversight in a transparent, auditable, and interoperable way without replacing it. The proposed framework addresses key challenges identified in the Dutch context - including fragmentation, administrative burden, and inconsistent decision-making - and is applicable across European data infrastructures. CONCLUSIONS: The approach does not replace legal or organisational oversight, but operationalises it in a transparent, auditable, and interoperable way. While grounded in the Dutch context and the ODISSEI infrastructure, the challenges addressed are common across Europe. The paper presents a concrete implementation pathway supporting ongoing developments within EOSC and related data sharing initiatives.
Studies in health technology and informaticsEva-Maria Riess, Robert Kossen, Dagmar Krefting, Kevin Alejandro Molina, Heiko Scheel, Sabine Hanß
INTRODUCTION: The secondary use of clinical study data and biological samples holds substantial potential for advancing biomedical research. The German Centre for Cardiovascular Research (DZHK) research platform made the secondary use of study data possible through standardized data collections and centralized data management. However, identifying suitable datasets and estimating cohort sizes prior to formal data access requests remains challenging due to restricted access to data and metadata. To address this gap, we developed the Feasibility Explorer (FE), a privacy-preserving tool that enables researchers interested in using the DZHK research data to explore data availability and assess study feasibility. METHODS: The FE was designed based on requirements for multi-study research environments, analysis of existing cohort discovery tools, and DZHK-specific governance and data protection policies. It follows a layered architecture comprising presentation, application, and data-processing layers, enabling distributed querying across heterogeneous data sources, including clinical data, imaging data, and biological samples. A web-based user interface allows intuitive query construction via filters and presents aggregated results using predefined visualizations. RESULTS: To ensure compliance with data protection regulations, including the General Data Protection Regulation (GDPR), the FE restricts outputs to aggregated data, suppresses small cohort sizes, and implements a blurring mechanism to mitigate inference attacks. Data integration is performed on demand using pseudonym mapping, and no individual-level data are exposed or persistently stored. DISCUSSION: Since its productive deployment, the FE has supported researchers in assessing data availability and estimating cohort sizes prior to submitting formal applications. While initial experiences indicate improved transparency and usability, formal evaluation is ongoing. The Feasibility Explorer provides a practical approach to support feasibility assessments in a federated research data environment, enabling efficient and informed study planning while maintaining strict data protection constraints.
Studies in health technology and informaticsSameeksha Sriram, Sin-Yin Huei, Marie Haucke, Ulrich Sax
INTRODUCTION: The European Health Data Space (EHDS) is one of the European Union's most ambitious data-governance projects. It aims to create a common framework through which electronic health data can be accessed and reused across Member States for care, research, innovation, policy, and public-interest purposes. Its practical viability depends not only on digital infrastructure, but also on legal, ethical, and organisational harmonisation, particularly for genetic and genomic data. METHODS: This paper examines the EHDS with emphasis on the secondary use of health data. It reviews the EHDS institutional architecture, discusses Finland's Findata as a national model for structured access, and analyses challenges for data holders and data donors, including interoperability, governance burdens, privacy protection, residual re-identification risk, and genomic-data sensitivity. RESULTS: A cross-border cancer-genomics case study shows that the EHDS can streamline data discovery and the routing of access requests, but does not by itself eliminate legal fragmentation, heterogeneous ethics review, and consent-related barriers. DISCUSSION: Effective implementation will require harmonisation beyond infrastructure, including clearer consent standards, more consistent ethics procedures, interoperable metadata, and proportionate safeguards for genomic data.
Health differences between women and men are explained not only by biological sex but also by gender, which encompasses the roles, norms, and social relations that shape living conditions and access to healthcare. In psychiatry, a gender-sensitive approach places mental disorders within their social context, leading to a more comprehensive patient care. In research, moving beyond simple comparisons between women and men requires integrating gender-related variables to better understand the mechanisms underlying health inequalities. Within the Gender*CoLaus project, several methodological approaches are being explored to capture these dimensions in the Lausanne population, with the aim of advancing both research and clinical practice towards greater precision and equity.
Nederlands tijdschrift voor geneeskundeRagnhild J Davidse, Mahlet Beyene, Renske Leistra, Marieke Perry
In this article, we answer questions from doctors and other healthcare providers regarding the evaluation of fitness to drive. We describe who decides on medical fitness to drive and which diseases, medical conditions, and medications may affect fitness to drive. Additionally, we discuss the role of doctors and pharmacists in fitness-to-drive evaluations and how, as a healthcare provider, to deal with clients who continue to drive despite an advice to stop. Whether or not to breach confidentiality is also addressed.
Archives of women's mental healthYasin Kavla, Muhammed Emin Boylu, Büşra Kavla, Hüseyin Çağrı Şahin, Güniz Ergin, Mehmet Zahit Serefoglu, Şenol Turan, Alaattin Duran
PURPOSE: Maternal neonaticide (< 24 h), infanticide (< 1 year), and filicide (> 1 year and < 18 years) refer to the killing of a child by the mother; however, these acts differ substantially in their underlying sociodemographic, clinical, and criminological characteristics. As no previous study has examined these three groups together within a single comparative framework, this research is the first to simultaneously investigate maternal neonaticide, infanticide, and filicide in a large-scale sample to determine their distinct sociodemographic, clinical, and criminological variables. METHODS: Data were retrospectively obtained from cases who underwent forensic psychiatric evaluation at the Department of Psychiatric Observation and the 4th Specialized Board of the Council of Forensic Medicine (CFM) in Türkiye between June 1, 2014, and June 1, 2024. RESULTS: Among 113 cases (28 neonaticide, 35 infanticide, and 50 filicide), women in the neonaticide group were significantly younger and more frequently single and had lower rates of documented psychiatric disorders. The most frequently recorded motive in this group was the child being unwanted. The infanticide group had significantly higher documented rates of severe psychiatric disorders and previous psychiatric treatment. Almost all women in the neonaticide and filicide groups were assessed as having full criminal responsibility, whereas 34.3% of those in the infanticide group were assessed as lacking criminal responsibility. CONCLUSION: The findings suggest that maternal neonaticide, infanticide, and filicide are associated with different sociodemographic, psychiatric, and medicolegal patterns. Recognizing these differences may contribute to more informed forensic psychiatric evaluations and may help identify areas relevant to risk assessment and prevention.
Frontiers in public healthNasser Allheeib, Salman Khan, Farah Mohammad, Dost Muhammad Khan
Digital health applications and social-network-enabled healthcare platforms have transformed healthcare delivery by facilitating health communication, patient engagement, and access to medical information. However, the continuous exchange of sensitive biomedical data across interconnected digital environments raises significant ethical, privacy, and security challenges that may compromise user trust and the effective adoption of digital health technologies. Existing studies primarily address individual security and privacy concerns, with limited attention to integrated frameworks that simultaneously support ethical data governance, secure communication, and digital health education. This study proposes a privacy-preserving digital health communication framework that integrates social-network-based healthcare applications with a multi-cloud infrastructure, distributing healthcare data and services across multiple independent cloud service providers to support system availability, reliability, fault tolerance, and secure information management. The proposed methodology combines a healthcare communication architecture, role-based access control, and stakeholder specific privacy policies to facilitate secure information exchange among patients, healthcare professionals, caregivers, and emergency responders while supporting the ethical handling of biomedical data. The framework is conceptually evaluated by analyzing healthcare communication workflows, user roles, privacy requirements, and security threats across representative healthcare communication scenarios, including chronic disease monitoring, emergency response, and post-discharge care coordination. This analysis suggests that the proposed framework may support secure information sharing, improve coordination among healthcare stakeholders, strengthen patient awareness and health literacy, and facilitate timely healthcare decision-making while preserving data confidentiality and user privacy. By integrating privacy-preserving mechanisms with digital health communication, the proposed framework is designed to support secure digital health education and public health promotion, contributing conceptually to Sustainable Development Goals 3 (Good Health and Well-being), 4 (Quality Education), and 17 (Partnerships for the Goals).
Psychiatry sometimes treats patients who do not acknowledge or resist treatment and who continue to face stigma in our society. Across the country, psychiatric inpatient units operate under a wide variety of service models, which influences how patients' rights are exercised and the nature of the caregiving work. Healthcare professionals from Brittany and Île-de-France highlight the importance of an ethical approach that fosters the therapeutic alliance. Breaking down barriers will help bring psychiatry further into the community and foster a different perspective on the "strangeness" of psychotic patients.
The concept of causality helps distinguish neuroscience from psychoanalysis. However, it is the Real and its effects that separate them on a conceptual level. Indeed, when it comes to organic and psychic causality, the two paradigms approach the question of disorder or symptom differently. Psychoanalysis does not readily lend itself to measurable, objectifying scientific methods. It takes into account singular subjectivity within a speaking body subject to lack and desire. Conversely, neuroscience promotes a neurological causality to explain the entirety of psychic life based on neural mechanisms localized in the brain.
Despite their distinct theoretical and methodological frameworks, the two fields - psychoanalysis and cognitive neuroscience - nevertheless converge on the idea that a large part of psychological functioning eludes consciousness. While psychoanalysis conceives of the unconscious as dynamic, conflict-ridden, and meaningful, neuroscience views it as a set of non-conscious neural processes. Parallels are drawn between cognitive psychology, relational neuroscience, and psychoanalysis.
The psychoanalytic unconscious is a concept with multiple meanings. Its first, positivist interpretation opens the door to a psychological debate with the neurosciences on the nature of the psyche, provided that the differences in methods and languages are respected. The second, hermeneutic interpretation views the unconscious as meaning to be interpreted or a narrative to be coconstructed. The third, which is emphasized here, offers a concrete definition of the unconscious within and through the pragmatics of psychoanalytic communication, in the here and now of the encounter. It is from this perspective that psychoanalysis's contribution to psychiatry seems most relevant today - as a tool for training in encounter and active listening within the realm of intersubjectivity, which lies at the heart of all clinical practice.
JMIR medical informaticsSanthosh Parampottupadam, Andrés Martínez Mora, Dimitrios Bounias, Sinem Sav, Klaus Maier-Hein, Ralf Floca
BACKGROUND: Federated learning (FL) enables multi-institutional model training on clinical text without sharing raw data; however, gradient inversion methods can reconstruct sensitive information from shared model updates. The extent of such privacy leakage in FL applied to radiology reports, and the role of tokenizer design, remains unclear. OBJECTIVE: This study aimed to quantify gradient-based reconstruction of radiology report text in an FL setting and to compare privacy risk across 3 transformer tokenization strategies in a controlled, tokenizer-aware evaluation. METHODS: Six FL clients trained a GPT-2-style transformer (sequence length 32) on 2 public clinical-text corpora comprising 368,751 diagnostic reports, 98,206 discharge summaries, and 1500 MIMIC-CXR (Medical Information Mart for Intensive Care Chest X-Ray) radiology reports. Models were trained using 3 tokenizers (GPT-2, RadBERT, and LLaMA-2) with batch sizes of 64, 128, and 256. An active malicious-server threat model was assumed, and analytic gradient inversion was applied to recover text. Reconstruction fidelity was measured over 5 runs using exact sentence accuracy, sentence-level bilingual evaluation understudy (S-BLEU), and recall-oriented understudy for gisting evaluation (ROUGE-L). RESULTS: Exact sentence reconstruction ranged from 27% to 75% across tokenizers, datasets, and batch sizes. At batch size 64 on the discharge dataset, accuracy was 64.7% (GPT-2), 70% (RadBERT), and 67.5% (LLaMA-2), decreasing to 27.3%, 28.5%, and 27.5% at batch size 256. S-BLEU declined with increasing batch size (eg, discharge reports from 0.69 to 0.31). Reconstruction fidelity did not differ significantly across tokenizers (all but one of 27 comparisons nonsignificant; none significant after Holm correction), and approximately 75% of clinical concepts were represented in the reconstructed text (a corpus-level upper bound), regardless of tokenizer. Batch size was the dominant factor governing leakage. CONCLUSIONS: Under a worst-case malicious server that tampers with the shared model and observes unprotected per-client gradients (no secure aggregation or differential privacy), substantial portions of radiology-report text can be reconstructed, with up to approximately 75% of reconstructed 32-token sequences and 75% of clinical concepts (not direct patient identifiers) recovered from FL gradients. In a controlled ablation holding model architecture fixed, tokenizer choice, including domain-specific tokenizers, did not significantly affect leakage under the evaluated conditions, whereas batch size was the primary determinant, and no tokenizer significantly reduced the risk. Tokenizer selection should therefore not be treated as a privacy safeguard in this setting. Safeguards such as secure aggregation and differential privacy should therefore be evaluated as candidate protections for FL deployments that must satisfy Health Insurance Portability and Accountability Act (HIPAA) and General Data Protection Regulation (GDPR) requirements in radiology natural language processing (NLP); legal compliance additionally depends on organizational safeguards, risk assessment, and governance beyond the scope of this study.
European psychiatry : the journal of the Association of European PsychiatristsGiovanni Stanghellini, George Ikkos
Contemporary psychiatry suffers from an epistemological impoverishment that weakens its capacity to encounter the intricacy of human suffering. Because psychopathological conditions are intrinsically ambiguous, contradictory, and affectively charged, psychiatric training cannot rely exclusively on rational-conceptual language and rigid operational categories. This article advances the claim that residents in psychiatry must also be trained in psychiatric poetics, that is, a paradoxical and poetic language and mode of thinking. Utilizing a hermeneutic approach, we analyze the structural role of language in psychiatric education and clinical care. We examine how human existence is fundamentally constituted through language and evaluate the epistemological limitations of purely standard diagnostic frameworks. We demonstrate that the rich and paradoxical language of psychiatric poetics is not aesthetic ornamentation, but a disciplined clinical capacity to tolerate ambiguity, hold contradictions together, and remain responsive to the existential texture of patients' lives. Poetic language operates as a rigorous epistemological instrument, an ethical stance, and an essential clinical skill that enables clinicians to access the pre-reflective density of human lived experience. Because psychiatry deals directly with human forms of existence, it necessarily depends upon forms of expression that are adequate to the complexity of living. Integrating poetics into psychiatric education provides an indispensable framework to restore depth, ethical responsiveness, and diagnostic precision to contemporary clinical practice.