Friday, September 20, 2019

Iris Publishers-Open access Journal of Modern Concepts in Material Science | Nano Carbon as the Anode of Li Ions Batteries

Authored by Xiaofeng Fan


Lithium ions batteries (LIBs) have been used in portable devices wildly and have potential applications in hybrid vehicles, electric vehicles and smart grids. The graphite-like carbon materials make a vital role in the development of LIBs. It is predictable that the development of carbon materials and related techniques will boost the performances and applications of LIBs further. Here we glance over the progress of carbon materials and the application as anodes in LIBs.


Among the different kinds of electrochemical energy storage systems, lithium ions batteries (LIBs) have been one of the most promising. In LIBs, the charge/discharge is based on the mechanism of rocking chair in which Li ions shift back and forth easily between cathode and anode by crossing the electrolyte with a porous polymer separator. The cathodes are usually made with Li transition metal oxide, such as LiCoO2 and LiMn2O4 on Al foil. The electrolyte is composed by the organic liquids, such as PC, EC and DEC, with Li salts, such as LiPF6 and LiBF4. The anode can be Li metal on Cu foil with high theoretical capacity of 3860 mA h/g. However, the formation of Li dendrite on the Li metal surface results in the serious safety issues and cycle stability. The use of carbonaceous materials (introduced by Sony Corporation, 1991) in anode promotes obviously the solution of safety issues and results in the broad use of LIBs in modern life, especially in portable electronic devices, such as laptops, mobile phones, cardiac pacemakers, and so on [1].
Hard carbons and soft carbons
Carbonaceous materials are obtained by heat treating of the carbon-contained precursors, such as polymers, fibers and cokes. With the heating temperature and time, there are significant changes in the microstructure, texture and morphology. Typically, there are two kinds of carbonaceous materials including hard carbon and soft carbon [2]. Hard carbons, also named by non-graphitic carbons, are prepared by pyrolysis of precursors under low temperature less than 1800K. Soft carbons, also named graphite-like crystallites, are produced by high temperature heating of precursors around 3300K. In hard carbons, there are graphitic-like segments cross linked strongly by sp3-hyrbidized carbon atoms with amorphous embedding areas. In soft carbon, the interaction between layers is weak. In high temperature, the cross linking between layers is weakened and the layers can be free to mobile to form graphiticlike structures. Compared to hard carbons, the soft carbons in intercalation/deintercalation processes of Li ions have good rate performance and stable insert potential. In recent most LIBs, soft carbons or graphitic structures are used as the anode.
Nano structuring of materials and carbon nanotubes
The disadvantage of graphite-like carbon structures is the low theoretical capacity of 372 mAh/g. One of promising ways to enhance the capacity of batteries is to use the Nano structures as the electrodes [3]. Among the different carbon nanostructures, such as disordered carbon and acid treated graphite, carbon nanotubes (CNTs) have been explored widely to use in LIBs, especially as the conductive additives [4]. Single wall CNTs (SWCNTs) can be regarded as the single-atom layer cylinder by rolling up graphene seamlessly. Multiple sheets are rolled up together to form multi-walled CNTs (MWCNTs) with the distance of about 0.34 nm between concentric layers, like that in graphite. The electronic properties of SWCNTs are decided by its chirality and the considerable effort is on developing methods to control the chirality and purity of CNTs. CNTs can be synthesized by different methods, such as arc-discharge, laser vaporization and chemical vapor deposition with appropriate catalyst. CNTs are with a high electrical conductivity (5x105 S/m at room temperature) and can be used as conductive additives for either anode or cathode. In the electrode, by just merging into SWCNTs with mass loadings of 0.2%, a good conductivity can be achieved [5]. The capacity of free-standing SWCNT as the anode of LIBs is between 400-460 mAh/g [6]. By shortening the SWCNTs and introducing defects in sidewall, the capacity is evaluated to approach to about 700 mAh/g [7]. Flexible electrode can be made by CNT papers. The reversible capacity of CNT/carbon layer paper can approach to 572 mAh/g [8]. Li can be stored between graphitic-like layers and inside of central tubes. The strain on the planar carbon six ring induced by the small diameters of CNTs is considered to make the structure more electronegative and enhance the adsorption of Li ions. The introduction of defects and more edge states due to the shorting of length can enhance the Li adsorption and decrease the diffusion length of Li in CNTs. These factors can boost the storage ability of Li in CNTs, compared to graphite.
Doped graphene, defective graphene and graphdiyne
In graphite, six carbon atoms can hold one Li to form LiC6 with the intercalation of Li between carbon layers. It is proposed that graphene can store more Li atoms than graphite, due to its double atomic surfaces. The interaction between Li and graphene is by the charge transfer and van der Waals (vdW) effect. The coulomb interaction is controlled by the charge transfer and therefore decided mainly by electronic structure. Therefore, the coulomb interaction in graphene is like in graphite. With the vdW effect, the adsorption of Li on graphene is a little weaker than in graphite. In the pristine graphene, the capacity should be less than 372 mAh/g, with the possible formation of small Li clusters [9]. By introducing the vacancies/pores or defects on graphene, the adsorption of Li becomes to be stronger, with the enhancement of capacity [10]. The reversible capacity of disordered graphene nanosheets can be up to 794-1054 mAh/g [11]. Oxidized graphene nanoribbons have a reversible capacity of 800 mAh/g [12]. The doped graphene, such as B-doping and N-doping, shows a high reversible capacity of more than 1040 mAh/g at rate of 50mA/g [13]. Graphdiyne is a single atomic layer with high pore ratio, since it is composed by the carbon six rings and short carbon chains. It is proposed that graphdiyne sheets have potential high capacities. It is reported that the revisable capacity of graphdiyne can be up to 520 mAh/g at rate of 0.5 A/g [14].
Nano composites with CNTs/graphene
CNTs/graphene can offer a lightweight and stable supporting structure for other ultra-high capacity active materials which usually have the issues of volume expansion, due to the incorporation of Li, such as Si, Ge, Sn, SnO2, SnSb, and Fe3O4. For examples, the freestanding SWCNT electrode with the incorporation of Nano-silicon particles (size of 50nm) shows a high reversible capacity of 584 mAh/g after 20 cycles [15]. CNT@TiO2 nanoparticles can deliver a capacity of 850 mAh/g after 65 cycles [16]. SnO2/graphene nanocomposites exhibit a reversible capacity of 810 mAh/g at 50 mA/g [17]. The composite of graphene nanosheets with Fe3O4 particles can deliver 580 mAh/g at 700 mA/g after 100 cycles [18].


From the soft carbons/graphite to carbon nanostructures, such as graphene/CNTs/graphdiyne and nanocomposites with CNTs/graphene, the capacities have been boosted obviously and thus the performance of anode has been enhanced. Nano carbons can be also used in cathode as efficient conductive additives. It is foreseeable that Nano carbons will make a major role in the coming new-generation LIBs.

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Iris Publishers-Open access Journal of Material Science | Natural Clay Supported Zerovalent Iron Nanoparticles as a Potential Coagulant for Ammonia Reduction from Industrial Wastewater Effluents

Authored by Wighens I Ngoie

Currently in South Africa, many wastewater resources are polluted by anthropogenic sources, including household, agricultural waste and industrial processes. Though several conventional wastewater treatment techniques (among others, physical decantation, chemical oxidation, and disinfection) have been applied to remove contaminants, there are still some limitations, for the removal of chemicals such as ammonia [1,2]. It has been noticed that the level of ammonia of the effluents treated was comparatively higher [3] (277mg/L) than what is required according to the South Africa National Standards [4] of Wastewater before being discharged into the environment (10mg/L). Public concern over the environmental impact of wastewater pollution has increased. To address this issue, experiments were carried out over a Jar Tester on sequential velocities (rapid mixing at 150rpm for 1min and slow mixing at 20rpm for 20min) using activated clay (bentonite) in the attempt to remove ammonia from the wastewater effluent. The natural clay was activated with 5 M sulphuric acid and amalgamated with Zerovalent Iron Nanoparticles (ZVINPs) in a mass ratio of 99:1. The physico chemically modified clay samples were characterized using X-ray fluorescence to have an idea about the mineralogical aspect of the coagulant before and after activation, and Brunner-Emmet-Teller (BET) method for surface area. The optimum dosage of coagulant to treat 1L of wastewater effluents was 61.6mg and the concentration of ammonia in the final product was about 8.71mg/L, approximately a reduction of 97%. All parameters, such as pH, conductivity complied with the Department of Water Affairs and Forestry.
Keywords:Activation; Clay; Zero valent iron nanoparticles; Ammonia; Wastewater effluents


Water pollution is one of the largest environment problems in several countries. It mainly arises from wastewater released from household, industrial and agricultural processes. These effluents typically contain high concentrations of organic and inorganic chemicals such as hydrocarbon solvents, heavy metals, pesticides, dyes and so on. The toxicity, persistency and concentration of the contaminants result in serious environmental, public health and economic impacts [5]. Consequently, treatment of wastewater effluents before release into the environment is required. There are several wastewater treatment techniques including physical, chemical or biological processes i.e. coagulation, flocculation, adsorption, reverse osmosis, activated sludge and so on, which are used to remove pollutants from wastewater influents. Nevertheless, these conventional techniques have shown limitations, for the removal of ammonia. Use of activated clay, is one of the most promising techniques because the natural clay is of low-cost, is easy to obtain, and has good effectiveness and ability of degrading contaminants due to its adsorptive properties enhanced by sulphuric acid, which will supply charges to break the stability of ammonia in water by attracting them at the coagulant surface, then the activated clay will secondly be supported by zero valent iron nanoparticles in a homogenous mixture to increase the surface area on which the adsorption of pollutants will effectively take place [6,7,8]. Ion exchange and reverse osmosis have failed to destroy efficiently nitrate species and regenerate secondary brine wastes; electro-catalytic process necessitates higher potential to reduce nitrate into nitrogen. Basically, according to samples that were collected from several Wastewater plants in Cape Town, for instance, here below is the concentration trend of ammonia from the current WWTPs (red) comparatively to the standards (blue) (Figure 1).

Wastewater effluents, containing a certain amount of persistent organic pollutant, are released daily from the plants and discharged into the environment. They are undeniably harmful to the entire ecosystem. “Ion exchange and reverse osmosis have failed to destroy efficiently the ammonia content from industrial wastewater effluents, due to inherent limitations” (DWA, 2012); (See Figure 1). The appearance of ammonia related to Persistent Organic Pollutants (POPs) in wastewater is likely to continue if the problem is not addressed with urgency. 2 As it can be noticed, on the picture below showing the quality of wastewater exiting the Mitchells Plain Wastewater Plants to the Indian Ocean, its quality is really a matter of concern.
Wastewater or sewage water results from household wastes, human and agricultural wastes, industrial effluents, storm run-off and ground water infiltration. Wastewater is extremely hazardous both to health and to the environment; if not well-treated, this wastewater can seriously alter the total ecosystem of the planet. Thus, the motivations for treating wastewater include the following:
a) Pollution reduction; so that the environment can be safe and clean to live in;
b) Industrial reuse of the reclaimed water;
c) Recreational and environmental uses of lakes, rivers and stream flow augmentation. This project is proposing a way of treating wastewater effluent and reducing the contamination, and thereby to make it comply with required standards prior its release back to the natural environment. Hence, the following are questioning this study will attempt to answer:
Can natural clay (Bentonite, Montmorillonite) be used as coagulant to efficiently remove ammonia in the wastewater effluents?
d) Will the addition of Nano materials such as zero valent iron nanoparticles into the mixture containing natural clay effectively play a role in the removal of POPs including ammonia from the wastewater effluent?

Materials and Methodology

a) Ash grayish bentonitic clay supplied by Kimix Chemicals & Laboratory Suppliers located in Eppindust (South Africa), was used as the primary raw material,
b) Sulphuric acid as oxidizing agent to activate the clay to enhance its adsorptive properties [9],
c) Iron sulphate with sodium borohydride as reducing reagent, to prepare the Zero Valent Iron Nano Particles via the sulphate synthesis method or type II [10],
d) Sodium hydroxide used for mainly regulating the pH [11],
e) Ethanol in a specific mixture ratio with distilled water (20:80) to clean clay sample until it does not contain any SO42- ions [12].
The treatment of wastewater effluents was done at the Cape Peninsula University of Technology in the chemical engineering laboratory and the methodology will be schematically elaborated with a synoptic flow diagram process described below:
Coagulant preparation
a) Clay activation: (Figure 2)
b) Zero valent iron nanoparticles synthesis [13]
The development of the sulphate method for producing ZVINPs arose from two fundamental concerns associated with the chloride method which displays potential health-and-safety concerns associated with handling the highly acidic and very hygroscopic ferric chloride salt and deleterious effects of excessive chloride levels from the ZVINPs matrix in batch degradation tests where chlorinated hydrocarbons are the contaminant of concern. In addition, the reduction of the iron feedstock from Fe (II) requires less borohydride than the chloride method; because this method represented the second generation of iron nanoparticles, the iron is referred to as Type II ZVINPs Sulphate-method. ZVINPs were

Coagulant characterization [14,15]: The chemical and mineralogical compositions of the natural and activated clay samples were determined. The chemical composition was determined using the Transmission Electron Microscopy (FEI Tecnai F30, FEG 1K CCD, EDX, GIF, HAADF, STEM); and the mineralogical composition was studied using the X-ray diffractometer (Shimadzu XRD-6000) The specific surface area was measured at 77K by BET method with a Micrometrics Gemini 2360 instrument using N2 gas.
a) Clay (Bentonite)
Relative particle size (1 – 2μm)
Average composition: 53.2% SiO2, 18.8%
Al2O3, 5.1% Fe2O3, 2.9% CaO, 2.8% MgO
b) ZVINPs:
Relative particle average size (TEM): 40-50nm
Average composition (XRD): Fe0, Fe3O4, FeSO4
Surface area (BET): 40m2/g
Coagulant testing conditions – Wastewater treatment [16]
a) Water sample: 1L;
b) Catalyst loading: In a range of 0.00671 to 5.0505g loaded into 6 different beakers of a Jar tester (99 % Clay; 1% ZVINPs);
c) Mixing time: 1min rapid mixing at 150rpm and 20min slow mixing at 20rpm;
d) Settling time: 10min;
e) Operating pressure: 1atm;
f) Filtration through Membrane/normal paper filter:
Millipore nitrocellulose membrane 0.22μm.
Methodology flow diagram (Figure 3)
Ammonia analysis [16]
a) Apparatus: Spectrophotometer, or Nessler tube tall form (50mL or 100mL capacity), pH meter
b) Reagents: Zinc sulphate solution; EDTA reagent as stabilizer; Nessler’s reagent; Stock ammonium solution 1.00 mL = 1.00mg.
c) Procedure:
1. Residual chlorine was removed by means of a dechlorinating agent (one or two drops sodium thiosulphate solution)
2. 100 mL ZnSO4 solution was added to 100mL sample and to it was added 0.5 mL of NaOH solution to obtain a pH of 10.5. This was mixed thoroughly
3. The floc formed could settle and the clear supernatent was taken for Nesslerisation.
4. To this was added 2 mL of Nessler’s reagent.
5. A blank using distilled ammonia free water was treated with Nessler’s reagent as above. The absorbance was fixed as zero.
6. Then the sample was put in 1cm standard tubes of spectrophotometer and the absorbance noted at 400-500nm wavelengths.
7. A calibration curve was prepared as follows, with 0, 0.2, 0.4, 0.7, 1.0, 1.4, 1.7, 2.0, 2.5, 3.0, 4.0, 5.0mL of standard NH4Cl solution in 50 mL distilled water standard diluted samples were prepared.
8. Each sample was Nesslerised as indicated earlier and the absorbance was noted down.
9. A graph with mg of NH3 along x-axis and absorbance along y-axis was plotted and a straight-line graph was drawn.
10. From the absorbance of a solution of unknown concentration, the μg of NH3 present can be read from the calibration curve.

Results and Discussion

The experiment was performed on a Jar tester apparatus and operating parameters, such as, impeller rotational speed, coagulation and resting time were constant except the H2SO4 concentrations, which was varying (0.5M; 1M; 3M; 5M; 6M; 9M; and 18.4M). Those samples had a constant volume of 400cm3 to activate 200g of bentonitic clay. The table below represents the value of Clay and ZVINPs dosage used to treat 1L of wastewater (Table 1&2).
Table 1: Jar tester specification during the wastewater treatment.

Table 2: Determination of Ammonia concentration from the beer Lambert Law.

After getting the different values of the absorbance, from the methodology described previously, the calibration curve was plotted to express the amount of ammonia present in the final wastewater obtained after treatment (Figure 4).

Previous work showed that nitrate, nitrite as well as ammonia have a similar sensitivity to pH with an almost 100-fold decrease in rate constant over a pH range of 5.5 to 9.0 [17]. As pH increases beyond 8.5, nitrate/nitrite reduction generally slows down to a greater extent [17].
The maximum reduction obtained at 5M+ZVINPs with a neutral pH is defined by the maximum surface area obtained at 5M during acid treatment.
It was expected for ammonia to be reduced to an extent level for 18.4M+ZVINPs because of the acidic environment, and researchers proposed that reduction of nitrate/nitrite and ammonia by granular iron is favoured at low pH (2-4.5) [18]. Therefore the 18.4M+ZVINPs did not reduce ammonia even though the environment was acidic because of the smectite structure destruction; these results are consistent with previous studies [19,20].
It can be viewed from the obtained results that the increase in catalysts dosage had no effect on the contaminants removal efficiency for most samples. It had been reported that increase in catalysts dosage increases the reduction efficiency; this means that at maximum dosage the highest contact surface between catalysts and contaminants is obtained [21]. Previous research showed that nitrite was rapidly removed in the presence of 7 g /L of Fe0 over a temperature range of 25 to 50°C [19].
Thus, the highest amount of catalysts dosage was 5g for clay and 0,0505g of iron metal, the iron metal amount is low compared to previous research.
The mixing intensity was kept constant of 20rpm during treatment processes; the impeller provides proper mixing and enhances the transport of mass on granular iron surface [16].
The 5M bentonite+ZVINPs gave the most ammonia removal efficiency and it can be predicted that the best adsorption capacity of acid treatment was obtained at 5M which yield the best results of conductivity at dosages jar 1(0.0616g), jar 2(1.0586g), jar 3(2.0566g), jar 4(3.0545g), jar 5(4.0525g), jar 6(5.0505g). The significantly slower removal observed at higher pH values was consistent with previous research study [16].


The raw water had an amount of ammonia of 277mg/L, which was more than the standards set by the Department of Water Affairs and Forestry (<10mg/L). However, the results obtained from this research showed that ammonia content was reduced for most of the sample. The best ammonia reduction was obtained at 5M+ZVINPs for a dosage of 61.6mg coagulant. The ammonia was reduced from 277mg/L to 8.71mg/L as shown in Figure below yielding a removal efficiency of 96.85%.
The coagulant used, clay, is among cheaper catalysts that can alleviate the cost of water treatment on a large scale when combined with ZVINPs (Figure 5).


The authors appreciate the support of the Chemical Engineering laboratory at the Cape Peninsula University of Technology (Bellville campus) in South Africa, in which almost the entire part of this work was done, and the Food Technology department of the same University where most analyses especially the Ammonia test were performed.

Conflict of Interest

No conflict of interest.

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Thursday, September 19, 2019

Iris Publishers-Open access Journal of Complementary & Alternative Medicine | Seclusion and Restraint Using Among Psychiatric Patients

Authored by Qusai Mohammed Harahsheh

Every person in our world adapt with live challenges in different way, but some people cannot develop ways to cope with this challenge which resulted to mental disorders among these persons as a chain of destructive behaviors images. In general, mental illness are inability to cope with different stressors which developed by environment internally or externally, this failure of coping reflected as incongruent feelings, thoughts and behaviors with norms which used locally or culturally, on the same time this maladaptive interfere with people function socially, physically and occupationally [1]. Mental and psychiatric science developed many methods to control this destructives behaviors such as medication, technique, and seclusion, the point here about using seclusion from legal and ethical dimensions, is it acceptable or not? Seclusion defined as involuntary isolation of patient in specific room, this room named as seclusion room, and has many characteristics focusing on non-stimulating place, it must be locked, supervised by window, and contain the safety measurements as a hole (Health Care Commission, 2008), On the other hand the mental health commission defined the seclusion as a place has locked door designed in way which prevent going outside, this person stay in this room alone and on a specific time.
The Evidence Based Practice considered as the best way to develop any action or any decision during caring process, the integration of clinical expertise, patient values, and the best research evidence into the decision-making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology.
The current author used PICOT question which reflect Population, Intervention, Comparison, Outcome and Time to clarify seclusion and physical restrain effectiveness. According to PICOT question: The first question: among psychiatric patients’ seclusion is effective in controlling aggressiveness comparing with physical restrain during treatment period? The second question: among psychiatric patients’ seclusion is effective in controlling aggressiveness comparing with not using seclusion during treatment period? The purpose of this study is to clarify the effectiveness of using seclusion and physical restrain to control aggressive behaviors among mentally ill patients in psychiatric sittings.

Literature Review

This literature review will explain and clarify the effectiveness of using seclusion and physical restrain in controlling aggressiveness among mentally ill patient in psychiatric sittings and describe the power and limitations of every study depending on specific standers and items in specific tables. Actually seclusion and restraint still widely used in our world, an Italian systematic review study examine the effect of coercive procedures to control the aggressive behaviors among psychiatric patients in different psychiatric sittings, this systematic review use 74 studies after excluding 768 study which didn’t met the author criteria, the study found that there are a variations of using seclusion and restraint from center to another [2], similar prevalent were founded in united states, Australia, Germany and Switzerland [3]. On the other hand, the review founded that seclusion and restraint used among females more than male patients, and among borderline or antisocial personality disorder higher than other psychiatric disorders [4].
Furthermore, in case control study in Denmark which includes 235.000 patients between violent and non-violent psychiatric patients using seclusion and restraint, the authors founded that there is increasing in using seclusion and restraint among female patients who have mania, experiencing drug abuse or alcohol abuse more than other psychiatric patients [5]. About voluntary and involuntary admission to psychiatric sittings [6], they founded that there is a positive correlation between restraint using and involuntary admission cases, and to be more specific they found that 11% of 282 patients faced seclusion and restraint; 9.5% of them faced seclusion and 1.8% of them faced restrain, concluded by retrospective cohort study. Other study founded that 424 patients have been secluded from 1214 in voluntary admission cases which reflected 35% of admission cases as a hole, and 117 cases was restrained which also reflected 10% from same sample [7]. Related to aggression, a prospective study on 148 aggressive patients, 70% of them faced restrain which mean that there is a strong positive correlation between aggressions and restrain [8]. Another systematic review in UK on 2007, focused on interventions used to decrease using of seclusion and restrain, this systematic review worked on randomized control trails of non-pharmacological interventions. Moreover, an old study shown that seclusion and restrain highly effective to control aggressive behaviors and protect patients and staff [9], on the other hand.
Other studies in 2005 founded that seclusion and restrain have harmful effects and traumatic experiences to the patients and staff. The systematic review focused on regulations and policies changes in UK and concluded that there are tighter controls on how, when and where seclusion and restrain should be used, on the same time this standard should followed by post-seclusion debriefings with staff and patients [10].
On the other hand focusing on support level such as regular visits to the patients in psychiatric sittings, frequent active listening to the patients, discussion between staff and patients, individual crises preventions plans, peer to peer support; all of them help to reduce seclusion and restrain especially when we taking about child and adolescent in-patients [11]. Moreover, many ideas may help to stop or at least reduce using of seclusion and restraint focused on leadership seclusions such as sitting new expectations to staff [12], reassess policies [13], change practice system on way which put seclusion and restraint as a last choice in treatment process [14]. On the same point [10] founded that increasing number of staff playing major role in reducing use of seclusion and restraint, other study find that using of cross-displenarry staff such as nurses and social workers can positively affect caring process by decrease using of seclusion and restraint by providing support for those patients [15].
Furthermore staff education considered as a central point of caring process and of decreasing seclusion and restrain cases [10,12,15], on this point education divided to two main dimensions the first one focusing on new care model which working on decrease conflict incidences and high-therapy [16], the second dimension focused on alternative behavioral intervention off education which working on problem solving and de-escalating techniques [17].
Moreover, to decrease needs of seclusion, the psychiatric emergency response team was founded, this team present in many states’ hospitals [10], this team skillful and have extra training related to rapid effective actions, qualified in using verbal deescalating technique and conflict resolving skills [18]. Another new systematic review and quantitative synthesis in Australia 2013, worked on reducing seclusion and restraint among disable people, they founded that health care providers can reduce restrain among disable people who have aggression, agitation and self-harm attempts, on the same time the literatures concluded that when health care providers know the reason of self-harm and aggression then they can develop ideas to prevent or at least reduce seclusion and restraint using. On the other hand the literature founded that there is a differences between period of using restrain between day and night shift duty in psychiatric sittings, to be more specific they founded that 81% reduction of median time of restrain in AM shift and 10% reduction of median time of restrain in PM shift [19].
Furthermore, there is a redactor from 54% to 11% of using mechanical restrain by inerratic of behavior in terveations programs from 59 to 124 program as organization behavior of manger it, on the other hand there is no changing on injuries percentages which resulted for aggression behavior [20].
To be more focus on changes among am and pm shift [21] use three phases in they trail to measure the presenting of decreafiy seclusion and restrain usage among psychiatric patients, the phase classified as active phase , training phase , practice phase , depending on single subject , multiple – baseline design and 23 staff members, 20 individuals who have intellectual disabilities, the staff worked on 12cession training program about verbal redirection, , verbal exchanges which lead to aggression and stat medications, finally they founded that there is a reduction on incident of seclusion and restraint using from 2.67/week in AM shift to 2.00/week, and 2.67/ week to 1.50/week in PM shift after training phase, and to 0.20/ week in AM shift and 0.35/week in PM shift after practice phase.
Another systematic review working to assess the effectiveness and the level of safety of seclusion and restrain among adult psychiatric in-patients as a short term violence management in psychiatric sittings and emergency departments, the review done in united kingdom in 2006 and include systematic reviews, qualitative studies and before-after studies, the other collect all researches which related to the main topic from 1985 to 2002, and concluded that there are insufficient evidences available to detect if restrain and seclusion considered as safe short time intervention for aggressive and violated patients in the psychiatric and emergency sittings. On the other hand, the systematic review founded that the seclusion and restrain must use as the last choice of intervention after failing of the service users to response to other alternatives and other claiming situations measures demonstrated to the patients without any effective results.
Regarding to [22] they advocate to reduce using of seclusion and restrain as a type of treatments for mentally ill patients, on the same time and according to Royal Collage of Psychiatry in UK; there is no sufficient evidences to consider restrain and seclusion safe and effective intervention must use or not among psychiatric and mentally ill patients, on the other hand a small old , descriptive study suggest that using of seclusion and restrain help to develop safe caring process and decrease of violence incident [23]. On the same point [24] suggest in their descriptive study that using management participation, education and improving staff patterns play very important role in reduce using seclusion and restrain among psychiatric patients. About the relationship between death and restrain, three experimental studies founded that there is no relationship between prone position restrain and death; which mean that restrain is safe from this dimension. [25-27].
Another review worked on restrain and seclusion among serious mentally ill patients published by John Wiley and Sors in 2012 in Finland, the literature worked on comparing between the effectiveness of seclusion and restrain with other alternative measures, on the same time the literature worked on examine effects of strategies which used to prevent using of seclusion and restrain. The review founded that there are many unwanted harm effects, other studies shown that there is improvement in control for aggression by using medication [28]. On the other hand the literature founded that no controlled studies support using of seclusion and restrain among psychiatric and mentally ill patients, moreover the review founded that using of seclusion and restrain may lead to increasing of mortality and morbidity more than other alternative choices such as drug and non-drug approaches. Moreover a systematic review of restraint intervention for challenging behaviors among persons who have intellectual disabilities which applied in UK 2015, the author used research syntheses which divided to meta-analysis and qualitative meta synthesis techniques, the review amid to examine if restrain interventions are effective in reducing challenging behaviors for intellectual disable patients, finally and after using 76 related studies they concluded that restrain interventions behaviors can be improved by specific model while Appling it for intellectual disable patients.


After collecting a huge number of articles, the current author founded that many articles founded that seclusion is effective to control aggressiveness more than physical restrain during treatment period among psychiatric patients, strongest design found the same results but its advocate to apply other alternatives. On the same time, old studies founded that seclusion is effective comparing non seclusion, but updated studies founded that there are many harm effects of using seclusion, the current author with the second idea because the sample size where higher and the date of articles was more updated.


Seclusion ethical dilemma which discussed in this paper guide the current author to develop important recommendation should be followed in the near future especially in Jordan, the first one focused on staff education about communication skills and deescalating technique to eliminate all factors which push the staff to use seclusion. The second one focused on pharmacological education for staff to use a a-typical antipsychotic medication rather than seclusion on the same time provide courses about signs of agitation and aggressiveness of patients to take the correct precautions and interventions to prevent increasing symptoms severity which considered the only rational to use seclusion. Finally, the new science focused on providing training and courses for staff who working on psychiatric field to enhance their ability to use other measurement with psychiatric patient especially with aggressive and violated patients to decrease seclusion usage in psychiatric sittings.

Summary and Conclusion

The main reason to use seclusion is to protect patient and others safety as most of studies mentioned, on the other hand there are many other alternatives may use to meet this goal. To be more specific there is no specific and clear law to prevent using seclusion in psychiatric sittings as the current author searching process, but there are huge studies advocate to decrease using seclusion related to ethical considerations. Finally, the new science direction is focusing on providing trainings and courses about communication skills de-escalating techniques and other alternative measure for staff who are working on psychiatric field to decrease using of seclusion.


The current author would like to gratefully acknowledge his direct instructor Mr. Asem Alhmoud MSN, RN, all other instructors at Hashemite University, especially the mental health department in the faculty of nursing, all health care providers’ team at the Jordanian Center for Psychiatric Health.

Conflict of Interest

No conflict of interest.

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Iris Publishers- Open access Journal of Forensic Science & Medicine | Crime Labs Should be Privatized

Authored by Pamela Newell


Crime labs take evidence from police investigation and test them for DNA evidence to help include or exclude a suspect from the defendant pool. Sometimes, crime labs look for fingerprints, although many law enforcement agencies have employees who can do that in the office. Crime lab technicians look for biological matter such as analyzes evidence such as blood, semen, saliva, plant matter, and insects. Usually, law enforcement collects evidence from a crime scene and witnesses and sends it to a crime lab. The collection and storage of the evidence has been problematic for state-run crime labs, which are frequently accessible to law enforcement and the prosecution. However, to minimize possible biases, make crime labs more efficient, and clear backlogs, crime labs should be independent of law enforcement agencies and privatized.
The prosecution and law enforcement should strive to avoid impropriety or the appearance of impropriety. Ethical behavior is paramount in criminal investigations. Once there is one story about unethical behavior by the government, the public’s trust falls even lower. There should be no bias in favor of the state. For instance, in Raleigh, North Carolina, “two blood-spatter specialists were caught on video high-fiving one another after running through multiple experiments until they found one that supported the prosecution’s theory of a case” [1]. Additionally, “many lab workers’ performance reviews were actually written by prosecutors” [1]. According to a 2009 report on forensic science by the National Academy of Sciences, more than fifty percent of U.S. crime labs report directly to a law enforcement organization. “In some cases, this can lead to overt pressure from police officers and prosecutors to produce desirable results. But most of the time the bias is more subtle, and unintentional” [1].
In another example, Fred Zain, a former head serologist at the West Virginia state police crime laboratory, falsified test results in numerous cases for over a decade. Giannelli [2] Zain sent numerous people to prison, including Glen Dale Woodall, who was sentenced to two life terms without parole and 203 to 335 years imprisonment for double rape. During the Woodall trial, Zain’s testimony was contrary to his notes. Woodall was eventually released after newer DNA testing was available, but he never should have been arrested. The American Society of Crime Laboratory Directors investigated Zain and wrote a caustic report, find that Zain erred by:
1. Overstating the strength of results.
2. Overstating the frequency of genetic matches on individual pieces of evidence.
3. Misreporting the frequency of genetic matches on multiple pieces of evidence.
4. Reporting that multiple items had been tested when only a single item had been tested.
5. Reporting inconclusive results as conclusive.
6. Repeatedly altering laboratory records.
7. Grouping results to create the erroneous impression that genetic markers had been obtained from all samples tested.
8. Failing to report conflicting results.
9. Failing to conduct or to report conducting additional testing to resolve conflicting results.
10. Implying a match with a suspect when testing supported only a match with the victim.
11. Reporting scientifically impossible or improbable results.
In addition, non-Americans have discussed the effect that race has on DNA testing. In a study, researchers found that via the use of DNA sweeps, local police exploit laws to expand the scope of DNA profiling, collection, and storage to apprehend unknown miscreants on the strength of nonspecific physical descriptors. But the ethnically heterogeneous nature of US society and the overwhelming racial disparities in arrest and incarceration present largely ignored challenges Washington [3]. This is exactly what California elected to do under Proposition 69 in 2004. “The approved ballot initiative authorized DNA collection and retention from all felons, any individuals with past felony convictions – including juveniles – and, beginning in 2009, all adults arrested for any felony offense.” Simoncelli & Steinhardt [4]. Note that DNA collection is approved for arrested individuals, even if they are never convicted of a crime.
On the other hand, a molecular biologist, Tony Frudakis developed a product that he called the DNA Witness Test [5]. With the test, he was able to identify a suspect’s race within a small margin of error in a Louisiana serial killer case. Although the test worked in this instance, law enforcement in general were hesitant to use the technology due to the possible appearance of bias. Frudakis’s company eventually went out of business [5].
Another reason why crime labs should be independent of the police is because of botched handling of evidence. For example, in the infamous O.J. Simpson trial, there were several mishaps involving criminal evidence. An important bloody fingerprint located on the gateway at Nicole Brown’s house was not properly collected and entered the chain of custody when it was first located. Although it was documented in his notes by Detective Mark Fuhrman, one of the first to arrive on the scene, no further action was taken to secure it. The detectives who took over Fuhrman’s shift apparently were never aware of the print and eventually it was lost or destroyed without ever being collected. Other items of evidence were also never logged or entered the chain of custody, which gave the impression that sloppy forensic collection had been carried out at the scene.
The prosecution had expert witnesses who testified that the evidence was often mishandled. Photos were taken of critical evidence without scales in them to aid in measurement taking. Items were photographed without being labeled and logged, making it difficult, if not impossible, to link the photos to any specific area of the scene. Separate pieces of evidence were bagged together instead of separately, causing cross-contamination. Wet items were also packaged before allowing them to dry, causing critical changes in evidence. Police even used a blanket which came from inside the house to cover Nicole Brown’s body, contaminating the body and anything surrounding it. Beyond poor evidence collection techniques, sloppy maneuvering at the scene caused more bloody shoe prints to be left behind by LAPD than by the perpetrator.
Crime Museum [6] Furthermore, witnesses testified that “The security of LAPD storage and labs was also brought under scrutiny when it was discovered that some pieces of evidence had been accessed and altered by unauthorized personnel. Simpson’s Bronco was entered at least twice by unauthorized personnel while in the impound yard; Nicole Simpson’s mother’s glasses had a lens go missing while it was in the LAPD facility.” (Crime Museum) The majority of Americans believe that Simpson was guilty. Ross [7,8]. However, with the careless and slipshod way evidence was handled, the prosecution was unable to secure a conviction.
Other American cities are known to have neglected crime labs as well, including New York City. Hansen [9]. New York had a former employee who was not well-trained. She worked at the crime lab for over ten years. Other cities with similar problems are Boston, which had an employee who tampered with results, Saint Paul, Minnesota, which voluntarily shut down due to unreliable results, and Oklahoma City, which had an unqualified director [9]. All these state crime labs had employees who intentionally falsified records, some at the behest of the district attorney.
Even if a given state crime lab has trustworthy employees, the backlog is unfathomable. According to the National Institute of Justice, there are two types of backlogs: (1) casework; and (2) convicted offender and arrestee DNA, National Institute of Justice [10]. Casework backlogs occur when law enforcement submits evidence to the crime lab, which must analyze the evidence to determine whether there is enough biological material in/on the evidence to test that has not degraded or been contaminated. Convicted offender and arrestee DNA backlogs occur when crime labs test convicted people and arrestees pursuant to statutory law for identification purposes [10].
The major problem with casework backlogs is that individuals regularly sit in jail until forensic results come back [11]. In some cases, the individuals falsely plead guilty simply to get out of jail. As of June 2019, CBS News found that at least seven states had average lab result turnaround times greater than 100 days in 2019. Rhode Island, West Virginia, and South Carolina all had average turnaround times greater than 150 days. In Illinois, there’s a backlog of more than 23,000 cases. In South Carolina, it could take more than nine months to get results back on DNA or firearms testing. In Rhode Island, the backlog is almost 10 months for non-violent crimes. In Idaho, the average DNA and rape-kit testing takes 92 days, but they do have examples of cases that have been pending 615 days -- almost two years.
It’s an issue in Arkansas, too, where crime lab director Kermit Channel says the problem escalated about six years ago in connection with the opioid crisis. In his lab alone, DNA and drug cases have nearly doubled since 2014.

CBS News [11] As a result, the National Institute of Justice implemented the DNA Capacity Enhancement and Backlog Reduction Program [10]. It seeks to assist eligible states and local government to “process, record, screen and analyze forensic DNA and/or DNA database samples[, while increasing the capacity of public forensic DNA and DNA database laboratories to process more DNA samples, thereby helping to reduce the number of forensic DNA and DNA database samples awaiting analysis.” (National Institute of Justice). The National Institute of Justice grants awards based on need. And here, it seems that the need is great.
Other than giving money to existing inefficient crime labs, there is a viable argument in privatizing crime labs [1]. Whereas many state crime labs are sloppy and biased, private labs have an incentive to protect themselves from liability. It is nearly impossible to sue the government. Individual crime lab workers employed by state or local governments are protected by qualified immunity, making it difficult to sue them as well. Private labs do not have these protections, so they are more likely not only to be careful, but to preserve evidence in the case of litigation [1]. Furthermore, private labs do not answer to or work with law enforcement and the prosecution, which eliminates the problem of bias in favor of the state. The answer is in the private sector, with federal oversight.

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Wednesday, September 18, 2019

Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | The Impact of High Intensity Interval Training and Anthropometric Changes in Women

Authored by Joan A Cebrick Grossman

This mini review highlights three recent pilot studies that have shown promising results in women, specific to the impact of high intensity interval training (HIIT) and changes in anthropometric measurements in women. The first study observed the effects of HIIT on anthropometric, body composition and resting metabolic rate (RMR) measurement changes in sedentary, overweight, middle-aged women over a 12-week period [1]. The subjects (N=9) were female volunteers (51.3±5.5years; 77.20±6.12 kg body wt; BMI=28.9±2.1 kg/m2; mean+SD) who exercised five out of seven days for 12 weeks. The exercise program (15.0±3.0 min) consisted of five different exercise routines that included total body, lower extremity, yoga, cardio and abdominal segments. Relative body fat was measured via air displacement plethysmography, along with five anthropometric measurements and RMR (Vmax metabolic system) prior to and after 12 weeks. Dependent t-tests probed for significant differences (p≤0.05). Pre-post body weight and RMR were not statistically significantly different. However, four of the five pre-post anthropometric measurements were significantly reduced for the abdomen, hips, waist and thigh measurements (97.79±5.11 vs. 91.95±5.64; 104.90 ±5.33 vs.100.84±5.33; 84.25±7.57 vs. 80.26±7.36; 62.99±5.08 vs.59.18±4.82 cm, mean±SD). This work is suggestive that HIIT contributes to significant anthropometric reductions, in the abdomen, hips, waist and thighs, which may decrease chronic disease development, such as obesity, cardiovascular disease and diabetes.

The mode and duration of exercise necessary to change body composition and reduce weight remains debatable. A second study compared the effects of HIIT and traditional exercise, (walking) on anthropometric and body composition measurement changes in post-menopausal women over a 12-week period [2]. The study subjects (N=18) were sedentary, overweight, post-menopausal females, who were randomly assigned into one of two exercise groups. Both groups exercised five out of seven days for 12 weeks. The resistance group (n=8) (54.3±7.3years; BMI=28.0±2.1 kg/ m2;mean±SD) exercised for 15.0±3.5 min, which consisted of five different exercise routines including upper and lower extremity, a cardio segment, yoga and abdominal exercises. The walkers (n=10) (56.6±5.2 years; BMI =29.2±2.6 kg/m2) exercised for 40.0±5.0 min at 65% of their age-predicted maximum heart rate. Relative (percent) body fat was measured via DEXA scan, along with five anthropometric measurements (waist, abdomen, hips, thigh and biceps), all of which were taken prior to and after 12 weeks. Independent sample t-tests were probed for differences, (p≤0.05). Although no statistically pre-post measures were determined, most likely due to the small sample size, all outcome variables indicated promising trends of significance. This work provides a foundation for future comparisons of HIIT and traditional exercise, regarding anthropometric and body composition measurement changes in sedentary, overweight, post-menopausal females.

The third study was a 16-week behavioral weight loss program that incorporated wearable activity sensors to facilitate self-monitoring exercise [3]. Participants (N=11) were obese, post-menopausal, sedentary women (59.5±3.3years; BMI=32.08±2.18kg/m2;mean±SD) who were randomly assigned to a HIIT or an endurance exercise group. Both groups followed a calorie-restricted diet, attended monthly in-person meetings, weekly weigh-ins and electronic check-ins to review behavioral skills, and monitored their exercise via a Fitbit Charge HR. Adherence to exercise programs, assessed with the Fitbit sensor, was used to determine feasibility. The results of the study indicated that participants in the HIIT group (N=6) adhered to their program, while 3 of 5 adhered to the Endurance program. Participants in the HIIT group lost twice as much weight as those in the Endurance group (8.7% vs. 4.3% of initial body weight), and lost an additional 15.24cm of body mass. In addition, only the HIIT group significantly changed pre-post measures of fat mass (41.6±3.46kg vs. 29.12±5.59kg), fat-free mass (42.99±3.31kg vs. 42.58±4.6kg) and BMI (30.67±2.16 vs. 27.76 ±2.76) (p≤0.04), respectively. The findings support the feasibility and potential effectiveness of HIIT for weight loss and body composition changes in obese, postmenopausal women, and indicate that additional investigation of this approach is warranted to reduce post-menopausal chronic disease risk.

Although the sample sizes for each of these studies were small, the outcome measures provided promising results for sedentary, overweight and obese women later in life. A primary barrier to exercise for women is time, and a short duration exercise program, such as HIIT may be a possible answer to this a barrier. These works were supportive in identifying the impact of HIIT, resulting in favorable anthropometric, body mass and body composition changes reducing chronic disease risk, in this at-risk population.
No conflict of interest.

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Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | Massage and Its Effect on Some Health Conditions

Authored by Elizabeta Popova Ramova

The massage is the first therapy that every child comes in contact after its born, every mammal after its born. We see on massage from medical science on its effect by many illnesses on cellular level. The aim of our research is to make one rewire for therapy effect of massage by some illnesses, and prove it, by medical assessment tools.
Material and method: We have made one investigation on medical data bases, to resolve all our knowledge and compare with other researchers world way for therapy effect of massage.
Results: We have represented our research in three parts: effect of aromatherapy, application of massage by some illnesses and side effects from massage.
Discussion: Many researchers proved the therapy effect of some traditional form of massage and medical massage too. It is accept from Association of Physical medicine doctors of Europe, like a therapy modality.
Conclusion: Massage has many positive health effects, but medical staff and massage practioners must be careful and to expect some complications specially in area of osteoporotic bones and vessels.
Keywords: Massage; Physical medicine modality; Effects


The massage is the first therapy that every child comes in contact after its born, every mammal after its born. It is the first touch from the mother that mimics and conveys positive energy [1]. Viewed from today’s distance, during the study for the effects of the massage as a therapy, when we get the information we formed the mosaic called massage. We see on massage from medical science on its effect by many illnesses on cellular level[2,3].The word massage comes from the Latin word “massare”, which means grunting or from the Arabic word “mas” meaning pressing. It is found in the literature for the first time in 1813 used in France by Lepage [4]. The massage exists from time immemorial. Man is instinctively rubbing in pain and swelling throughout the body, which is likely to have been used for treatment since ancient times. Massage data as a treatment for the first time meets 3000 years ago. BC, and was carried out in ancient Asian cultures in India and China [5,6].

The massage was used by the Egyptians, the Assyrians, the Persians, and the ancient Greeks and Romans as a method of treating diseased and injured parts of the body. Famous doctors Hippocrates and Galen recommended it as a way of treatment [7]. The first entries for a sports massage date from the Roman period, and modern medicine is thought to have been introduced by the Swedes Per Henrik Ling in the 18th century. The names of Mason A., Johann Metzger, Von Mosengeil, etc. are related to the massage. The popularity of massage in different cultures during the millennia has been increasing and decreasing.

During the Renaissance, medical scientists renewed the massage and tried to understand the physiology and anatomy influenced by this method. The French medical community supported the “friction of the skin - and allowed many different massage techniques” [8]. Many of the terms for these techniques, such as effleurage, petrissage, tapotement and friction massage, are used today in English medical terminology.
The popularity of massage as a therapeutic intervention has changed considerably, even over the past few decades. This change took place due to the influence of medical professionals, who believed that medications and surgical procedures needed to reduce disease and suffering. But in recent years there has been a renewed interest in massage, which has led to scientific research on its use as a therapeutic method [9].

As time went on, as we grew up as applicators in the field of Physical Therapy and Rehabilitation, our understanding for the specific possibilities of the massage for different patient’s disease and the human’s difficulties also grew. After more than 20 years, also we have personal experiences. It was difficult for us to get good literature, but today with the possibilities of electronic communication we can check whether our knowledge has been noted by other massage practitioners around the world. This study is dedicated to all supporters of physical therapy and rehabilitation that our experiences can check in their patients, as we have shared with many, around the world [10].
The aim of our research is to make one rewire for therapy effect of massage by some illnesses, and prove it, by medical assessment tools.

Material and Method

We have made one investigation on medical data bases, to resolve all our knowledge and compare with other researchers world way for therapy effect of massage. Its effect was analyzed during centuries, from records in medical books. The key words of our investigations were massage, history of application, application by some illness, and proved effect with medical scale or measurable parameters. We have analyzed 38 ill conditions, side effects of massage and aroma massage like a combination of two therapy effects. From all our research we have consulted 505 publications. It is published in March 2018, like a Guide book with educational purpose for doctors, physiotherapists, nurses and masseurs. We shall represent it by disease, area of application of massage and proved medical effect.


We represent our results in follow tables:


Since ancient times, massage therapy has been used to promote healing by people of all backgrounds and cultures [32]. In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, is noted that massage is one of physical agents used in treatment of people with many illnesses [33].This finding has the importance of recognizing the massage as a scientific method for the treatment of multiple diseases. Traditional median and masses are applied in more pain conditions in patients with malignant disease, on palliative care, and are consistently standardized protocols for the treatment of persons with pain [34,35]. The low coat of pain is a common phenomenon in the doctoral practice, and the reason for the absence of work among the employees [36]. The symptoms of pain can be alleviated with appropriate mass and inhibitory techniques for the pain in the subcutaneous and chronic stage. Massage applied as traditional Tuina massage had an effect in children with scoliosis and can prevent the progression of scoliosis [37]. Massage is one of treatment of central spascity by patient with cerebral palsy [38], Multiple sclerosis [39], Parkinson disease [40] and after Stroke [41] increasing quality of life.
Massage is not safe for all conditions, and medical staff must know it possibilities of complications, like fracture in osteoporotic spine, jugular vein thrombosis and risk of thrombosis by patients with vein vessels insufficiency [42,43].


Massage is an first form of all therapy, it is essential for child after born, has long ancient history, but it has his place in modern physical medicine, proved by science. Massage has many positive health effects, but medical staff and massage practioners must be careful and to expect some complications specially in area of osteoporotic bones and vessels.


Authors are Acknowledgement to Prof.BorisAngelkov, President of TIC, Bitola, for all support in personal and science work.

Conflict of Interest

Authors Declare, that they have not any conflict of interest.

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Tuesday, September 17, 2019

Iris Publishers-Open access Journal of Clinical & Medical Sciences | Adult Suicidal Behaviour of Native Psychiatric Inpatients: A Retrospective, Record-Based Study

Authored by Saeed Shoja Shafti

Introduction: Suicidal behaviour is seen in the context of a variety of mental disorders and while many believe that, in general, first episode psychosis is a particularly high-risk period for suicide, no general agreement regarding higher prevalence of suicide in first episode psychosis is achievable. In the present study, suicides and suicide attempts among psychiatric in-patients has been evaluated to assess the general profile of suicidal behaviour among native psychiatric inpatients and probing any relationship between serum cholesterol level and suicidal behaviour.
Methods: Five acute academic wards, which have been specified for admission of first episode adult psychiatric patients, and five acute nonacademic wards, which have been specified for admission of recurrent episode adult psychiatric patients, had been selected for current study. All inpatients with suicidal behaviour (successful suicide and attempted suicide, in total), during the last five years (2013-2018), had been included in the present investigation. Also, assessment of serum lipids, including triglyceride, cholesterol, low density lipoprotein and high-density lipoprotein, had been accomplished, for comparing the suicidal subjects with non-suicidal ones.
Results: Among 19160 psychiatric patients hospitalized in razi psychiatric hospital during a sixty months period, 63 suicidal behaviours, including one successful suicide and sixty-two suicide attempts, had been recorded by the safety board of hospital. The most frequent mental illness was bipolar I disorder, which was significantly more prevalent in comparison with other mental disorders (p<0.04, p<0.02, p<0.007, and p<0.003 in comparison with schizophrenia, depression, personality disorders and substance abuse, respectively). Self-mutilation, self-poisoning and hanging were the preferred methods of suicide among 61.11%, 19.44% and 19.44% of cases, respectively. In addition, no significant difference was evident between the first admission and recurrent admission inpatients, totally and separately, particularly with respect to psychotic disorders. Besides, with respect to different components of serum lipids, no specific or significant pattern was evident.

Conclusion: While in the present study the suicidal behaviour was significantly more evident in bipolar disorder in comparison with other psychotic or no-psychotic disorders, no significant difference was evident between first admission and recurrent admission psychiatric inpatients. Moreover, no significant relationship between suicidal behaviour and serum lipids was palpable.
Suicide is derived from the Latin word for “self-murder” It is a fatal act that represents the person’s wish to die. A suicide attempt is a behaviour that the individual has undertaken with at least some intent to die. The behaviour might or might not lead to death, injury or serious medical consequences. Several factors can influence the medical consequences of the suicide attempt, including poor planning, lack of knowledge about the lethality of the method chosen, low intentionality or ambivalence, or chance intervention by others after the behaviour has been initiated [1]. Determining the degree of intent can be challenging. Individuals might not acknowledge intent, especially in situations where doing so could result in hospitalization or cause distress to loved ones.

Markers of risk include degree of planning, including selection of a time and place to minimize rescue or interruption; the individual’s mental state at the time of the behaviour, with acute agitation being especially concerning; recent discharge from inpatient care; or recent discontinuation of a mood stabilizer such as lithium or an antipsychotic such as clozapine in the case of schizophrenia. Approximately 25%-30% of persons who attempt suicide will go on to make more attempts. Suicidal behaviour is seen in the context of a variety of mental disorders, most commonly bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders, substance use disorders, borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is rarely manifested by individuals with no discernible pathology, unless in specific circumstances, like medical, political, or religious conflicts [1].

According to the findings of a study, among male psychiatric population, the absolute risk of suicide was highest for bipolar disorder, followed by unipolar affective disorder and schizophrenia. Among female psychiatric population, as well, the highest risk was found among women with schizophrenia, followed by bipolar disorder [2]. According to data, approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions, and many more have significant suicidal ideation. Suicidal behaviour is sometimes in response to command hallucinations to harm oneself or others. Suicide risk remains high over the whole lifespan for males and females, although it may be especially high for younger males with comorbid substance use. Other risk factors include having depressive symptoms or feelings of hopelessness and being unemployed and the risk is higher, also, in the period after a psychotic episode or hospital discharge [3].

It is interesting that Bleuler had drawn clinicians’ attention that the most serious of the schizophrenic symptoms is the suicidal drive. [4]. Up to 50 percent of suicides among patients with schizophrenia occur during the first few weeks and months after discharge from a hospital; only a minority commit suicide while inpatients [3]. Having three or four hospitalizations during their 20s probably undermines the social, occupational, and sexual adjustment of possibly suicidal patients with schizophrenia. Consequently, potential suicide victims are likely to be male, unmarried, unemployed, socially isolated, and living alone-perhaps in a single room. After discharge from their last hospitalization, they may experience a new adversity or return to ongoing difficulties. As a result, they become dejected, experience feelings of helplessness and hopelessness, reach a depressed state, and have, and eventually act on, suicidal ideas. [5].

Abrupt discontinuation of medication, poor treatment compliance, social isolation, and increased expectation of good performance from others and from patients themselves, are risk factors for suicide in schizophrenics [6]. Also, the lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one-quarter of all completed suicides [7]. Many believe that, in general, first episode psychosis (FEP) is a particularly high-risk period for suicide, in which risk elevates by 60% within a first year of treatment as compared to later stages of illness. In this regard, longer duration of untreated psychosis, greater symptoms of depression, and positive symptoms of psychosis were found to increase the odds of experiencing suicidal ideation [8].

While according to some studies depressive symptoms during the index psychotic episode and comorbidity with stimulant abuse at baseline were relevant predictive factors for suicidal behaviour during the first years of first affective and non-affective psychotic episodes [9], more depressive symptoms, higher insight, and negative beliefs about psychosis increase the risk for suicidality in FEP [10]. Impulsive behaviour such as self-harm, as well as having a family history of severe mental disorder or substance use, have been stated as important risk factors for suicide in FEP [11,12]. Furthermore, low levels of cholesterol have been described in suicide behaviour including among those individuals who have an increased tendency for impulsivity [13,14].

While, as a kind of psychological explanation, some scholars believe that young men in the early stages of their treatment are seeking to find meaning for frightening, intrusive experiences with origins which often precede psychosis, and these experiences invade personal identity, interactions and recovery [15], some suggests that personality characters, specifically, passive-dependent traits can be a predictor of first suicide attempts FEP [16]. On the other hand, no general agreement regarding higher prevalence of suicide in FEP is so far achievable. For example, while researchers like [2,8,17,18] have stated that FEP is a particularly high-risk period for suicide, with a risk as high as 10-60% during the first year of treatment, other scholars like [19-22] have expected a lower risk or stated that suicide rates are difficult to measure in FEP patients, even in carefully defined samples. In the present study, suicides and suicide attempts among psychiatric in-patients, during the last five years, in Razi psychiatric hospital, as the largest national psychiatric hospital in Iran and region, has been evaluated to assess the general profile of suicidal behaviour among native psychiatric inpatients, comparing first admission with recurrent admission patients, and probing any relationship between serum cholesterol level and suicidal behaviour.
Razi psychiatric hospital in south of capital city of Tehran, as one of the largest and oldest public psychiatric hospitals in the Middle East, which has been established formally in 1917 and with a capacity around 1375 active beds, had been selected as the field of study in the present retrospective assessment. Amongst its separate existent sections, five acute academic wards, which have been specified for admission of first episode adult psychiatric patients, and five acute non-academic wards, which have been specified for admission of recurrent episode adult psychiatric patients, with a collective capacity around two hundred active beds in each cluster (four hundreds beds, totally), had been selected for current study. Among the aforesaid academic divisions, two wards included female inpatients, with around eighty beds, and the remaining three wards included male inpatients.
All non-academic wards involved male inpatients. For valuation, all inpatients with suicidal behaviour (successful suicide and attempted suicide, in total), during the last sixty months, had been included in the present investigation. Besides, clinical diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [23]. Also, assessment of serum lipids, including triglyceride (TG), cholesterol, low density lipoprotein (LDL) and high density lipoprotein (HDL), which was part of routine laboratory checkups for all patients upon admission, whether for the first time or periodically, had been accomplished, for comparing the suicidal subjects with non-suicidal ones, incidentally.
Statistical analyses
While ‘t-test’ has been used for comparison of means as regards mean total level of serum lipids, difference of suicidal behaviour between first admission and recurrent admission patients, had been analyzed by ‘comparison of proportions. Statistical significance as well, had been defined as p value ≤0.05. MedCalc Statistical Software version 15.2 was used as statistical software tool for analysis.
As said by the results, among 19160 psychiatric patients hospitalized in razi psychiatric hospital, during a sixty months period (2013-2018), sixty-three suicidal behaviours, including one successful suicide and sixty-two suicide attempts, had been recorded by the security board of hospital (Table 1). Thirtythree of patients were male and thirty of them were female, with no significant difference about quantity (Table 2). The most frequent mental illness was bipolar I disorder (34.92%), which was significantly more prevalent in comparison with other mental disorders (p<0.04, p<0.02, p<0.007, and p<0.003 in comparison with schizophrenia, depression, personality disorders and substance abuse, respectively).

The other disorders included schizophrenia (19.04%), major depressive disorder (MDD) (17.46%), personality disorders (borderline & antisocial) (14.28%), substance abuse disorders, especially methamphetamine induced psychosis (MIP) (12.69%), and adjustment disorder (1.58%) (Table 3) (Figure1). Also, no significant difference was evident between the first admission and recurrent admission inpatients, totally (p<0.31) and separately, particularly with respect to psychotic disorders (Table 3) (Figure 2). The annual incidences of suicidal behaviour in both groups were comparable, and they were around 0.035% and 0.030%, in first admission and recurrent admission psychiatric inpatients, respectively (Table 1). While self-mutilation, self-poisoning and hanging were the preferred methods of suicide among 61.11%, 19.44% and 19.44% of cases, respectively, the first style was significantly more prevalent than the other ways (Z=1.96, P<0.059, CI: -0.0088,0.4532). Furthermore, no significant gender-based difference was evident with respect to the style of suicide in the present assessment (Figure 3). Besides, with respect to different components of serum lipids, no specific or significant pattern was evident, except that all hypolipidemic patients (n=7) were diagnosed as major depressive disorder, while 80% of hyperlipidemic patients (n=5) were diagnosed as bipolar I disorder (Table 4).

Always in psychiatry, when giving information about the diagnosis, course of illness, and treatment, the therapist should not ignore the risk of suicide [1]. Also, there is a high proportion of young people with first-episode psychosis who attempted suicide before their first contact with mental health services. This finding suggests that the mortality rates associated with psychotic disorders may be underreported because of suicide deaths taking place before first treatment contact [24]. It should constantly be considered that in the psychiatric hospital setting the inpatient at risk for suicide has previously exhibited suicidal behaviour, suffers from schizophrenia, was admitted involuntarily, and lives alone [24].

It is interesting that among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for post discharge period, particularly for patients with schizophrenia and patients with affective disorders. Thus, not only the restructuring and downsizing of mental health services was not associated with any increase in suicides, the risk of suicides decreased significantly between the two time periods among several diagnostic categories. But, while in terms of post-discharge suicides, the downsizing of psychiatric hospitals has been a success, there is still a substantial need for better recognition of suicidal risk among psychiatric patients [25].

According to a survey, there are 2 sharp peaks of risk for suicide around psychiatric hospitalization, one in the first week after admission and another in the first week after discharge; suicide risk is significantly higher in patients who received less than the median duration of hospital treatment; affective disorders have the strongest impact on suicide risk in terms of its effect size and population attributable risk; and suicide risk associated with affective and schizophrenia spectrum disorders declines quickly after treatment and recovery, while the risk associated with substance abuse disorders declines relatively slower [26].

The accessibility to one or more means of suicide is a recognized factor in psychiatric institutions. The same is true for the conditions of care: inadequate supervision, the underestimation of the risk of suicide by teams, poor communication within the teams and the lack of intensive care unit promote suicide risk [27]. But according to another study in FEP, most attempts occurred when patients were treated as outpatients and were in regular contact with the service [17]. As suicide is a relatively rare event in psychotic disorders, general population-based prevention strategies may have more impact in this vulnerable group as well as the wider population [28,29].

While the immediate post-discharge period is a time of marked risk, rates of suicide remain high for many years after discharge and patients admitted because of suicidal ideas or behaviours and those in the first months after discharge should be a focus of concern [30]. Back to our discussion and according to the findings of the present study, The most common principal diagnoses among the suicide subjects were bipolar I disorder and schizophrenia, which was similar to the findings [2], except that no gender difference regarding prevalence of these disorders among male and female patients was repeatable here.

But, our findings were not in complete agreement with the conclusion of Thong JY et al., who had found only schizophrenia and depression as the most common principal diagnoses among their suicide subjects [31] and Roy et al., who had declared schizophrenia as the major diagnosis among suicide victims [24]. Meanwhile other psychiatric disorders, like personality disorders and substance abuse disorders, in addition to the diagnoses, had been designated in the present study, as remarkable diagnoses among suicide subjects; though fewer than the aforementioned diagnoses. The higher prevalence of bipolar disorder in the present assessment is likewise comparable to the outcomes of a further study regarding suicidal behaviour among Iranian inpatient youngsters [32].

In the same way, the higher incidence of self-mutilation, as the preferred method of suicide in the present evaluation, was parallel to the said study, except than its significantly higher prevalence amongst female adolescents [33]. Also, in keeping with the results, while the annual incidences of suicidal behaviour in both groups were comparable, they were lower than assessments [11,34], and higher than approximations [35], which could be stemmed from cultural, instrumental, diagnostic and methodical differences. Also, in accordance with the outcomes of the present assessment, no significant difference was evident between the first admission and recurrent admission inpatients, totally and separately, particularly with respect to psychotic disorders.

Such an outcome is clearly incongruous with the findings [2,8,17,18] who have stated that first episode psychosis is a particularly high-risk period for suicide and first-episode psychotic disorder , in general, has seemed to be a high-risk population for suicidal behaviour during the first year of treatment. On the other hand, our findings are compatible with the stances [19-22], who have estimated a lower risk or indicated that suicide rates are difficult to measure in FEP patients, and there is relatively little specific information about the risk of suicide at illness onset or retrospectively concerning the untreated psychotic period.

Above and beyond, with respect to relationship between serum lipids and suicidal behaviour, outcome of the present assessment was not in harmony with the findings [13, 14], because while there was a couple of patients with higher or lower serum level of cholesterol, triglyceride, LDL and HD, no specific or significant pattern was evident in this regard; so, it seems that maybe such a difference was associated more to alteration of appetite, as a secondary phenomenon, rather than core variation of metabolism, as a primary etiologic issue. Anyhow, disregard to outcomes of the present study and its similarities or differences with comparable studies, elements of an inclusive prevention policy can be grouped under five items: securing the hospital environment, optimization of the care of the patients at suicidal risk, training of the medical teams in the detection of the risk and in the care of the suicidal subjects, involvement of the families in the care and implementation of postevent procedures following a completed suicide or an attempt [36].

Also, to reduce the number of suicide attempts among individuals treated for FEP, psychiatric services could consider: restricting the amount of medication prescribed per purchase; individualized suicide risk management plans for all newly admitted patients, including those who do not appear to be at risk; stringent reviews of inpatient psychiatric units for potential ligature points; providing information and psycho-education for significant others in recognition and response to suicide risk; fostering patients’ problem solving and conflict resolution skills; and regular risk assessment and close monitoring of patients, particularly during the high risk period of 3 months after a suicide attempt [17]. Also, along with enhancement of insight, coping strategies should be boosted with a goal of minimizing depression and preventing suicidality [37].

Absence of post- discharge following program, deficiency of documented data regarding the suicidal behaviour or its idea before admission, allocating wards to academic and non-academic, which could impact the quality of care, lack of female gender in the nonacademic wards for making it more similar to the academic wards, which included an equal mixture of male and female inpatients, were among the weaknesses of the present assessment. In spite of remarkable findings of the current study, more methodical and comprehensive investigations in future, with taking into account the above shortages, can improve the quality and amendment of mental health services for proper response to patients’ unavoidable problems.
While in the present study the suicidal behaviour was significantly more evident in bipolar disorder in comparison with other psychotic or no-psychotic disorders, no significant difference was evident between first admission and recurrent admission psychiatric inpatients. Moreover, no significant relationship between suicidal behaviour and serum lipids was palpable.
No conflict of Interest.

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