Patterns of psychiatric hospitalizations of Arab and Jewish adults with chronic psychotic disorders, before and after national mental health reforms, Israel, 1991-2016.

BACKGROUND: Members of the Arab minority in Israel are at increased risk of developing mental illness, although less likely to seek care and have accessible treatment. This study compares trends in psychiatric hospitalizations between Arabs and Jews with chronic psychotic disorders, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000, and governmental recognition of the need to allocate resources for patients with co-occurring substance use disorder and mental illness in 2010. METHODS: The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorder, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of population-group (Arabs and Jews), time-period (Period1: 1991-2000, Period2: 2001-2009, Period3: 2010-2016) and sex, on average length of stay (LOS), annual number of hospitalizations and hospitalization days. RESULTS: The proportion of Arab patients hospitalized with a diagnosis of chronic psychotic disorder (14.4%) was significantly lower than their proportion in the general population (21%), and their average age at first hospitalization (28.4 years) was older than that of Jewish inpatients (27.0 years). The average number of hospitalization days and LOS of Jewish patients were double that of Arab patients in Period1. Following implementation of the Rehabilitation Law, hospitalization days increased among Arab patients and decreased slightly among Jewish patients, such that by Period3 the average number of hospitalization days was similar among Jewish (41) and Arab (37) patients. The increase in hospitalization days among Arab patients was limited to men with no change noted among women. The number of hospitalization days among Arab women was about half that of Jewish women (p < 0.0001). CONCLUSIONS: The findings reveal a narrowing of disparities in psychiatric hospitalizations between Arab and Jewish patients in Israel over time. However, among Arab women the number of hospitalization days remains considerably lower than that of Jewish women, raising concerns that Arab women may be receiving insufficient care. Further study is needed to fully understand the underpinnings of these disparities, although increasing the number of Arabic-language mental health services and providing psycho-education, will help further close the gap.

Ethnic inequalities in community rehabilitation use and psychiatric hospitalizations among people with chronic psychotic disorder.

PURPOSE: Community rehabilitation is crucial for the long-term treatment of people with chronic psychotic disorder. Ethnic minorities are less likely to seek care and have accessible treatment. This study examines whether the use of rehabilitation services and the relationship between rehabilitation and number of hospitalization days differ between Arabs and Jews. METHODS: Data from the Israel National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963-2016 were merged with data from the national Mental Rehabilitation Register. Associations between the use of rehabilitation services and demographic and clinical characteristics were assessed through logistic regression modeling. Associations between ethnicity and duration of rehabilitation (housing or vocational) and annual hospitalization days during Period1: 2001-2009 and Period2: 2010-2016 were analyzed using ANOVA. RESULTS: Among Jewish patients (N = 2556), 37% and 57% used rehabilitation services during Period1 and Period2, respectively, compared with 18% and 40% among Arab patients (N = 15,145) (p < 0.0001). The use of rehabilitation services was significantly higher among Jews (adjusted OR = 2.26, 95% CI 2.07-2.47). Average duration of housing and vocational rehabilitation services did not differ between Arab and Jewish patients. In both groups, duration of rehabilitation was inversely associated with annual hospitalization days. CONCLUSIONS: The ethnic disparity in the use of rehabilitation services has narrowed over time, yet remains. Although fewer Arab patients use rehabilitation, Jewish and Arab benefit similarly from the services with regard to reduced hospitalization days. To further close the ethnic gap, greater efforts must be made to expand the availability of culturally appropriate rehabilitation services for the Arab minority.

Substance use, harm reduction attitudes and behaviors among attendees of nature rave parties in Israel.

BACKGROUND: Few studies have analyzed harm reduction behaviors and attitudes among rave party attendees. Since the late 1980s, there has been a large Israeli rave scene, also known as 'Nature Parties'. However, only a few studies have been conducted among nature party attendees and almost all of them are from a qualitative perspective. This study's aim was to fill the gap and conduct quantitative research to investigate the patterns of substance use, harm reduction attitudes and behaviors among Israeli nature rave party attendees. METHODS: A cross-sectional online survey recruited 1,206 people who reported having attended nature rave parties. All of the participants were aged 18-60 years (M = 29.9; SD = 7.4), and 770 (64%) were male. RESULTS: The most common illicit substances used at Israeli nature rave parties in the past year were cannabis (62.2%), followed by LSD (41.4%), MDMA (31.7%), mushrooms/psilocybin (23.9%), ketamine (19.6%) and cocaine (17.2%). A significant but weak association was found between harm reduction behaviors and attitudes toward harm reduction interventions (r = .26, p < .001) and attitudes toward drug testing kits (r = .33, p < .001). It seems that although we found higher positive harm reduction attitudes, it is harder to implement harm reduction behaviors. Logistic regressions demonstrated stronger associations with high harm reduction behaviors and higher levels of positive attitudes toward drug testing kits (OR = 4.53; CI 2.97-6.90; p < .001), higher levels of positive attitudes toward harm reduction interventions (OR = 4.06; CI 2.62-6.29; p < .001), marital status of widower/divorced (OR = 2.22; CI 1.49-3.32; p < .001), using MDMA (OR = 1.63; CI 1.19-2.23; p < = .01) and using LSD (OR = 1.41; CI 1.03-1.94; p < = .05). CONCLUSIONS: Formal harm reduction policies and interventions are needed for Israeli nature rave parties in addition to prevention and information programs, which are also very rare. Future studies should examine the subjects of harm reduction attitudes and behaviors among the public, policy makers and professionals.

Why Switch? - Motivations for Self-Substitution of Illegal Drugs.

BACKGROUND: Self-substitution is the conscious switch from one drug to another for reasons such as price, availability, desired effect, or perceived benefit of the substitute drug. Purpose/Objectives: This study aimed to describe drug use patterns and motivations associated with substitution. We examined correlates of lifetime substitution among individuals with substance use disorder. Methods: A cross-sectional study of 771 treatment-enrolled individuals. We used self-report for determining the lifetime prevalence, correlates, and motivations for substitution. Results: Of the 771 respondents, 570 (73.9%) reported ever substituting their preferred substance. The main incentives for substitution were availability (23.7%) and curiosity (20.2%). Among heroin or cannabis preferers, improved effects or less adverse effects of the substitute drug, self-medication, and managing withdrawal symptoms were significant substitution incentives. Increased odds for substitution were observed for past 12 months use of cannabis (OR = 1.51, CI = 1.06-4.52), prescription opioids (OR = 2.86, CI = 1.81-4.52), novel psychoactive substances (OR = 2.68, CI = 1.64-4.36), and repeated admission (OR = 1.50, CI = 1.05-2.14). Older age at onset-of-use was negatively associated with substitution (OR = 0.95, CI = 0.93-0.98). Conclusions: Self-substitution of one substance for another is a highly prevalent behavior among treatment-enrolled patients with substance use disorder. Clinicians caring for substance use disorder patients should be aware of substitution patterns involving the use of highly potent substances, which constitutes a risk to patients. Results underscore the benefit of substitution patterns analyses, as they reveal important information on the characteristics of persons who use drugs and their motivations.

[ESKETAMINE FOR TREATMENT RESISTANT DEPRESSION: RESEARCH AND RISK MANAGEMENT].

INTRODUCTION: About 15-18% of the population will experience depression in their lifetime. One third among them will suffer from treatment resistant depression (TRD) which does not respond to two accepted treatment protocols. There is a pressing need for effective TRD treatments and especially for a rapid-acting drug for patients with suicidal ideation. Nasal spray esketamine, the S-enantiomer of the anesthetic agent and dissociative drug ketamine, was approved by the FDA to treat TRD in 2019 and was included in the 2020 Israeli Healthcare Basket. Clinical research suggests that esketamine, combined with an oral antidepressant, has a sustainable antidepressant effect as well as a manageable safety profile. However, ketamine has abuse potential and may cause adverse effects that require medical attention. The risk management plan includes administration under direct medical supervision in ambulatory care, and monitoring of blood pressure, awareness changes, dissociation, and dependence symptoms.

Routine Drug Screening for Patients in the Emergency Department of a State Psychiatric Hospital: A Naturalistic Cohort Study.

OBJECTIVE: This study investigates the proportion of drug users among patients with mental disorders who attended the emergency department of one major psychiatric hospital in Northern Israel, the most frequent psychiatric diagnoses associated with drug use, and the impact of confirmed drug use on hospital admission. We hypothesized that the proportion of individuals with positive urine drug test results presenting at the psychiatric emergency department during the study period would be 20% to 30%. METHODS: An unselected cohort of 2,019 adult patients who visited the emergency department of Sha'ar Menashe Mental Health Center, a university-affiliated government facility, was evaluated and underwent routine urine drug testing between April 2012 and February 2014. Clinical, demographic, and urine drug test data were collected from medical records and statistically analyzed, comparing diagnostic evaluation at admission and after discharge from either the emergency department or the hospital. Univariate and logistic regression analyses were used to identify the possible variables associated with drug use in this sample. RESULTS: Urine drug test results showed that 194 of the 2,019 subjects (9.6%) had used a psychoactive substance before attending the emergency department. Among patients with positive urine drug test results, the majority (77.8%) used cannabis, 25.8% used opiates, 24.7% used ecstasy, and 5.2% used cocaine. Differences in the prevalence of positive urine drug test results between admitted and nonadmitted patients did not reach a statistically significant level. The frequency of positive urine drug test results across lifetime International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) diagnoses was 27.2% for substance-related disorders, 4.8% for psychotic disorders, 4.2% for mood disorders, 11.0% for personality disorders, and 11.5% for nonpsychotic disorders. Both univariate and logistic regression analyses revealed that younger age (18-40), male sex, fewer years of education, single marital status, and ICD-10 diagnosis of substance-related, personality, and nonpsychotic disorders were indicators of higher likelihood of positive urine drug test findings. CONCLUSIONS: Results suggest that routine urine toxicology screening is not necessary in the psychiatric emergency department as an adjunct to a thorough psychiatric clinical examination. However, urine drug tests should be performed when the clinical evaluation cannot determine whether the mental disorder is the result of illicit drug use or clearly non-drug-related.

Changes and trends in medication-assisted treatment in Israel.

BACKGROUND: As opioid prescription in Israel is increasing, there is a growing need for monitoring opioid use disorder and providing opioid agonist therapy. Our goal is to describe, sub-analyze, and identify obstacles in the treatment of opioid misuse in the Israeli medication assisted treatment centers. METHODS: Data on methadone, buprenorphine, and buprenorphine combined with naloxone for the indication of opioid addiction treatment for the period 2013-2020 were obtained from pharmaceutical companies that distribute them in Israel. Data on utilization of these drugs were also extracted from the database maintained by the Israel Ministry of Health's Pharmaceutical Administration Division. The data were converted to defined daily doses (DDD)/1000 inhabitants/day. RESULTS: The number of patients receiving medication assisted treatment increased by 10% since 2013, with a shift from buprenorphine alone to buprenorphine/naloxone in government-run centers. Methadone remains the most popular maintenance drug. CONCLUSIONS: The change in opioid maintenance prescription does not match the significant increase in opioid consumption. Optimization of treatment can be achieved by the creation of a comprehensive database, cooperation between healthcare organizations and the government and further development of non-stigmatic and accessible services.

Schizophrenia or schizoaffective disorder? A 50-year assessment of diagnostic stability based on a national case registry.

BACKGROUND: Schizoaffective disorder (SAD) remains a controversial diagnosis in terms of necessity and reliability. OBJECTIVES: We assessed diagnostic patterns of SAD and schizophrenia (SZ) among hospitalized psychiatric patients over a fifty-year period. METHOD: Data from the Israeli National Psychiatric Registry on 16,341 adults diagnosed with SZ or SAD, hospitalized at least twice in 1963-2017, were analyzed. Stability between most-frequent, first and last diagnosis, and diagnostic-constancy (the same diagnosis in >75 % of a person's hospitalizations) were calculated. Three groups were compared: People with both SAD and SZ diagnoses over the years (SZ-SAD), and people with only one of these diagnoses (SZ-only; SAD-only). The incidence of SAD and SZ before and after DSM-5 publication was compared. RESULTS: Reliability between last and first diagnosis was 60 % for SAD and 94 % for SZ. Agreement between first and most-frequent diagnosis was 86 % for SAD and 92 % for SZ. Diagnostic shifts differ between persons with SAD and with SZ. Diagnostic-constancy was observed for 50 % of SAD-only patients. In the SZ-SAD group, 9 % had a constant SAD diagnosis. Compared to the other groups, the SZ-SAD group exhibited a higher substance use prevalence, younger age at first-hospitalization, and more hospitalizations/person (p < 0.0001). The incidence of a first-hospitalization SAD diagnosis increased by 2.2 % in the 4-years after vs. prior to DSM-5. CONCLUSIONS: A SAD diagnosis is less stable than SZ. The incidence of a SAD diagnosis increased after DSM-5, despite stricter diagnostic criteria. The SZ-SAD group exhibited the poorest outcomes. SAD may evolve over time necessitating periodic re-evaluation.

Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel.

BACKGROUND: In the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl. METHODS: A longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015-2021, and six-year opioid-related mortality data for 2015-2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting. RESULTS: Between 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74-0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58-0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020. CONCLUSION: Data shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.

The Effect of Dehydroepiandrosterone Administration during Rehabilitation on White Matter Integrity Among Individuals With Polysubstance Use Disorder.

OBJECTIVES: Individuals with polysubstance use disorder (pSUD) exhibit vulnerability to relapse even after prolonged abstinence, with rehabilitation efforts achieving limited success. Previous studies highlighted dehydroepiandrosterone (DHEA) as a putative therapeutic agent that may aid rehabilitation, potentially by impacting white matter (WM) properties. The current study tested, for the first time, the effect of DHEA administration during rehabilitation on WM integrity among pSUD individuals, while assessing its putative association with long-term relapse rates. METHODS: Immediately after admission to rehabilitation, 30 pSUD individuals were assigned to receive either placebo or DHEA (100 mg) daily for 3 months, via a randomized double-blind counterbalanced design. Participants also provided blood samples to assess circulating DHEA levels at treatment initiation and completed a diffusion tensor imaging (DTI) scan approximately 1 month after treatment initiation. Clinical status was evaluated 16 months after treatment initiation. Thirty matched healthy controls also underwent a DTI scan without any intervention. RESULTS: DHEA administration was not associated with reduced relapse rates compared with placebo. Nevertheless, exploratory analysis revealed that DHEA was associated with successful rehabilitation among pSUD individuals with low circulating DHEA levels at treatment initiation. White matter integrity in the splenium corpus callosum (CC) was reduced in pSUD individuals compared with healthy controls, yet pSUD individuals receiving DHEA exhibited recovery of splenium CC WM integrity. CONCLUSIONS: DHEA administration during rehabilitation may restore WM integrity in the CC among pSUD individuals. Although DHEA was not associated with reduced relapse rates in here, its therapeutic efficacy may depend on circulating DHEA levels at treatment initiation.

Early-life trauma, negative and positive life events, compulsive sexual behavior disorder and risky sexual action tendencies among young women with substance use disorder.

Although significant advances have been made in the field to date, gender-based issues for women remain a neglected area in much of substance abuse research. In the current study we examined two gaps in the literature: the co-occurrence of compulsive sexual behavior disorder (CSBD) and risky sexual action tendencies among women with substance use disorders (SUDs), and their shared antecedents in the form of early life adversity and negative life events. The sample comprised 132 women of whom 62 had substance use disorder (drug and alcohol) and 70 were healthy controls. Each participant completed self-report measures of drug abuse and alcoholism, compulsive sexual behavior disorder and risky sexual action tendencies as well as early-life trauma and negative and positive life events. Results indicate that young women with substance use disorder have higher compulsive sexual behavior disorder symptoms and more prevalent risky sexual action tendencies than controls. Compulsive sexual behavior was also found to mediate the association between substance use and risky sexual action tendencies. In addition, all addictive behaviors were linked with emotional abuse at childhood but not with other types of abuse. Conversely, negative life events in adulthood were only linked with CSBD and not with substance use. The findings provide deeper insights into the comorbidity of addictive behaviors and an opportunity for developing more effective treatments for women who suffer from these addictions.

Community Rehabilitation and Hospitalizations Among People With Chronic Psychotic Disorder: Is There a Differential Association by Co-occurring Substance Use Disorder?

Objective: Co-occurrence of chronic psychotic disorders and substance use disorder (SUD) is clinically challenging and increasingly prevalent. In 2000, legislation was passed in Israel to foster rehabilitation and integration in the community of persons with mental health disorders. In 2010, the need to allocate resources for patients with these co-occurring disorders (COD) was officially recognized. Yet, most rehabilitation services were not specifically designed for COD. This study examines the relationship between duration of community rehabilitation and number of psychiatric hospitalization days among persons with/without COD in Israel. Methods: Data from the National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963-2016, was merged with data from the Israel Mental Rehabilitation Register. Associations and interactions between COD-status (COD/non-COD), time-period (Period1: 2001-2009, Period2: 2010-2016), duration of housing or vocational rehabilitation on hospitalization days per year were analyzed using repeated-measures ANOVA. Results: The proportion of non-COD chronic psychotic patients who received rehabilitation services increased from 56% in Period1 to 63% in Period2, as it did among COD patients-from 30 to 35%. The proportion of non-COD patients who received longer-duration vocational rehabilitation (≥1 year) was significantly higher (43%) than among COD patients (28%) in both time periods. For housing rehabilitation, these proportions were 79 and 68%, respectively. Persons with COD experienced more hospitalization days annually than non-COD patients. Duration of rehabilitation (less/more than a year) was inversely associated with annual number of hospitalization days (p < 0.0001). This pattern was noted in both COD and non-COD groups and remained significant after controlling for age, sex, COD group, percent of hospitalizations with SUD, and age at first hospitalization. Conclusions: COD patients with prolonged rehabilitation seemingly achieve long-term clinical improvement similar to non-COD patients, despite most rehabilitation settings in Israel not being designed for COD patients. Yet, COD patients receive overall less rehabilitation services and for shorter periods than non-COD patients. Long-term rehabilitation services should be provided to COD patients, who may need more time to commit to treatment. To achieve better long-term mental health improvements, a continued expansion of community-based integrative treatment and rehabilitation services for COD patients is needed in Israel.

Novel Opipramol-Baclofen Combination Alleviates Depression and Craving and Facilitates Recovery From Substance Use Disorder-An Animal Model and a Human Study.

Substance use disorders (SUDs) are associated with depression and anxiety, with the latter being one of the major factors in substance-seeking and relapse. Due to dose-dependent sedative side effects there is limited efficacy of baclofen treatment for SUDs. Here we suggest the use of a novel combination of opipramol and baclofen (O/B) which is known to attenuate anxiety and depression, for the facilitation of recovery from SUDs. Since both opipramol and baclofen have a common downstream signal transduction, their individual doses could be reduced while still maintaining the benefits of the combination. We tested the O/B combination in both animals and patients. Rats treated with O/B showed significant attenuation in craving behavior and in relapse rate during withdrawal from cocaine. In a double-blind, placebo-controlled pilot study, conducted in a residential detoxification center, 14 males and 3 females, aged 28-60 years were assigned to a study (n = 6) and a placebo (n = 11) group (placebo group: 40 ± 10.5 years; O/B group 40 ± 10.8 years). The participants completed scales measuring depression, anxiety and craving symptoms and provided saliva samples for stress hormone examination [cortisol and dehydroepiandrosterone-sulfate (DHEA-S)]. Participants with polysubstance use disorder (PsUD) treated with O/B showed a reduction in cravings and depression and an increase in DHEA-S and in the DHEA-S/cortisol ratio. Our findings indicate a beneficial effect of O/B treatment. This study suggests a novel candidate for pharmacological treatment of patients with SUD and comorbid mood/anxiety disorders that may facilitate their rehabilitation.

Recent Use of Synthetic Cannabinoids, Synthetic Opioids, and Other Psychoactive Drug Groups among High-risk Drug Users.

The use of synthetic cannabinoids receptor agonists (SCRA) and synthetic opioids is associated with significant morbidity and mortality. This study examined the patterns-of-use of prescription oral opioids or transdermal fentanyl formulations, and SCRA, among 342 patients enrolled in treatment for drug-dependence in Israel. 16.1% of participants reported recent (past-12 months) SCRA use, while 24.9% reported recent use of prescription oral opioids, transdermal fentanyl patches, or both. Odds of reporting recent use of SCRA were positively and significantly associated with reporting recent use of cannabis (Adjusted Odds Ratio [AOR] 9.86, 95% Confidence Interval [CI] 4.44-21.90) and synthetic cathinones (AOR 5.47, CI 2.50-11.96). Recent use of prescription oral opioids or transdermal fentanyl formulations use was positively and significantly associated with recent use of gabapentinoids (AOR 14.33, CI 7.10, 28.90), stimulants (AOR 7.12, CI 3.82,13.28), heroin (AOR 5.81, CI 3.39,9.97), benzodiazepines (AOR 4.63, CI 2.74,7.84), synthetic cathinones (AOR 4.12, CI 1.95, 8.70), and hallucinogens (AOR 2.48, CI 1.24, 2.96). Clinicians should be informed about the extent of prescription oral opioids or transdermal fentanyl formulations and SCRA use among high-risk drug users, and the associated higher odds of concomitantly using other psychoactive substance, for they represent actual risk to patients and complicate treatment.

The switch from one substance-of-abuse to another: illicit drug substitution behaviors in a sample of high-risk drug users.

BACKGROUND: Substitution can be defined as the consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions. Substitution represents a potential risk to drug users, mainly when substitutes are of higher potency and toxicity. This study offers a basic conceptualization of illicit substitution behavior and describes substitution patterns among users of two highly prevalent drugs of abuse-heroin and cannabis. METHODS: Here, 592 high-risk drug users undergoing pharmacological and psycho-social treatment were interviewed. Patients were asked questions about current drug use, lifetime substitution, and substitution patterns. Descriptive statistics, chi-square tests of independence, and multinomial logistic regressions were used to identify and test correlates of substitution patterns for heroin and cannabis. RESULTS: Of the 592 drug users interviewed, 448 subjects (75.7%) reported having substituted their preferred drug for another illicit substance. Interviews yielded a total of 275 substitution events reported by users of cannabis, and 351 substitution events reported by users of heroin. The most frequently reported substitution substances for responders who preferred heroin were illicit non-prescribed "street" methadone (35.9%), followed by oral and transdermal prescription opioids (17.7%). For responders who preferred cannabis, substitution for synthetic cannabinoid receptor agonists (33.5%) followed by alcohol (16.0%) were the most commonly reported. Age at onset-of-use (p < 0.005), population group (p = 0.008), and attending treatment for the first time (p = 0.026) were significantly associated with reported lifetime substitution. Past-year use of stimulants, heroin, hallucinogens, methylenedioxymethamphetamine (MDMA), and novel psychoactive substances were-at the 95% confidence level-also significantly associated with reported lifetime substitution. In multivariate analysis, the odds for methadone substitution among heroin users were significantly affected by age at onset-of-use, type of treatment center, and education. Odds for substitution for synthetic cannabinoid receptor agonists among cannabis users were significantly affected by age, population group, type of treatment center, and education. CONCLUSION: Self-substitution behavior should be considered by clinicians and policymakers as a common practice among most drugusers. Substitution for street methadone provides evidence for the ongoing diversion of this substance from Opioid Maintenance Treatment Centers, while the prominence of substitution of synthetic cannabinoids among dual-diagnosis patients should be regarded as an ongoing risk to patients that needs to be addressed by clinicians. Analysis of additional substitution patterns should provide further valuable insights into the behavior of drugusers.

Chronic Use of Synthetic Cannabinoids Is Associated With Impairment in Working Memory and Mental Flexibility.

BACKGROUND: We have recently shown that chronic use of Synthetic Cannabinoids (SCs) has been associated with mood disorders and impairments in executive functions. There is also evidence indicating that chronic SC users have higher rates of comorbidity with depression and psychotic symptoms. Here, we investigate performance on executive function and emotional processing tasks in regular SC users and a measure of schizotypal traits. METHOD: Thirty chronic SC users, 32 recreational cannabis users, and 32 non-using control participants, without history of mental disorder, or current substance abuse diagnosis (mean age 26 ± 4.27 years; 85 males, 9 females), were tested in addiction treatment centers in Israel. Computerized neurocognitive function tests; the N-back task, Go/No-Go task, Wisconsin Sorting Card-like Task (WSCT), and emotional face recognition task and questionnaires of depression, anxiety and schizotypal traits and symptoms were used. RESULTS: SC users have performed worse than recreational cannabis users and non-cannabis users on the N-back working-memory task (lower accuracy) and the WSCT cognitive flexibility task. SC users showed greater schizotypal traits and symptoms compared with recreational cannabis users and non-user control participants. A positive association was found in cannabinoid-user groups between schizotypal traits and symptoms and cognitive and emotional processing measures. Finally, SC users have scored higher on depression and state-trait anxiety measures than recreational cannabis users or healthy control participants. CONCLUSIONS: Repeated use of SCs is associated with impairment in executive functions and emotional processing. These alterations are associated with depression and schizotypal traits and symptoms. This adds to existing evidence on the long-term consequences of SC drugs and their risks for mental health.

Personality Traits and Psychotic Proneness Among Chronic Synthetic Cannabinoid Users.

OBJECTIVE: Chronic use of synthetic cannabinoids (SCs) has been associated with a wide range of negative consequences for health including psychotic and affective disturbances. Accumulating evidence indicates that cannabinoids use may be a risk factor for schizophrenia, and chronic natural cannabis users score higher than non-users on measures of schizotypal personality traits. However, little is known regarding the personality characteristics of SC users, especially in comparison with recreational cannabis users and healthy individuals. This study aimed to examine the differences in personality characteristics and schizotypy between SC users, regular cannabis users, and non-users and to compare these measures between groups. METHODS: Forty-two chronic SC users, 39 natural cannabis users, and 47 non-using control participants, without history of mental disorder, or current substance use diagnosis (mean age 26± 4.47 years; 23 females, 105 males), completed the Big-Five Factor Inventory (BFI), the Schizotypal Personality Questionnaire-Brief (SPQ-B), substance use history, rating scales of depression and anxiety, and a demographic questionnaire. RESULTS: On the BFI, SC users scored higher than natural cannabis users and non-users on neuroticism, but lower on agreeableness and extraversion, and endorsed greater schizotypal symptoms on the SPQ-B. In addition, SC users had lower scores on conscientiousness than non-users, and natural cannabis users were more extroverted than non-users. Higher openness and lower conscientiousness predicted schizotypy for both SC and natural cannabis users. Finally, greater neuroticism predicted schizotypy for natural cannabis users, and introversion predicted schizotypy for non-users. CONCLUSIONS: These results show that chronic SC users differ from natural cannabis users and non-users on dimensions of specific personality traits and schizotypy that may indicate psychotic proneness.

Community emergency psychiatric service in Israel: a one-year experience.

BACKGROUND: In 2005 the Forensic Psychiatry Department of Mental Health Services at the Ministry of Health launched a pilot project: the Community Emergency Psychiatric Service (CEPS). The purpose was to offer community-based emergency response to acute psychiatric conditions during after-hours periods, including Saturdays and holidays. The project was implemented in the Tel Aviv, Central and Southern districts. METHOD: Advertisements were posted in mass circulating newspapers announcing the launching of the new program for the general public in the participating districts. The public was invited to call the hotline of the medical emergency service, Magen David Adom (MDA), in the event of psychiatric distress or emergency. MDA personnel were instructed to give the callers a telephone number of an on-call psychiatrist. The Ministry of Health engaged a pool of seven licensed psychiatrists to be available on-call one per shift. The psychiatrists offered crisis intervention over the phone or house visits when necessary. RESULTS: Data were obtained from the Tel Aviv, Central and Southern Districts. The results show that there were 1,472 calls between May 2005 and June 2006. In 198 cases (13.5%) clients were referred for treatment and follow-up to local outpatient clinics, while in 116 of the cases (7.8%) a home visit by the on-call psychiatrist was carried out, resulting in 50 voluntary and 16 involuntary hospitalizations. An examination of records of calls received by the on-call psychiatrists (N=97) during August 2006 suggests that most callers fit the following profile: female, ranging in age 19-35, unmarried, with diagnosis of schizophrenia, with no previous psychiatric hospitalizations, and presenting no danger to herself or others. CONCLUSIONS: A limited response team, comprised of one on-call psychiatrist per shift, can provide a viable service for psychiatric emergencies in a population center of approximately 2.7 million. The findings also suggest that such a service may increase the number of referrals to outpatient clinics in the community as well as the number of voluntary and involuntary hospitalizations after working hours. The potential contribution of such a project to improving accessibility to outpatient psychiatric care and to reinforcing continuity of care among in- and out-patient facilities needs further investigation as is the important question of cost-effectiveness.

[Outpatient commitment under court order in psychiatry].

Outpatient commitment under court order is a controversial issue among mental health professionals in different countries. This kind of outpatient involuntary treatment is provided for mental patients suspected to have committed a crime endangering society while in a severe psychotic state. Despite their dangerousness, the Israeli Mental Health Law of 1991 provides outpatient commitment under court order as an alternative to inpatient commitment. This legal provision raises several concerns and important ethical questions. A major dilemma is the question of whether this legal tool is efficacious in stabilizing the mental condition of criminal mental patients in order to prevent the perpetuation of violent crimes in an open setting such as outpatient clinics. Other major concerns are: (a) who bears the responsibility for the implementation of the enforcement? (b) how the enforcement might be implemented? This paper discusses this complex issue and presents some possible solutions aimed at improving the practical use of this important component of the comprehensive modern system of care for mental patients.

Synthetic Cathinone and Cannabinoid Designer Drugs Pose a Major Risk for Public Health.

As part of an increasing worldwide use of designer drugs, recent use of compounds containing cathinones and synthetic cannabinoids is especially prevalent. Here, we reviewed current literature on the prevalence, epidemiology, bio-behavioral effects, and detection of these compounds. Gender differences and clinical effects will also be examined. Chronic use of synthetic cathinone compounds can have major effects on the central nervous system and can induce acute psychosis, hypomania, paranoid ideation, and delusions, similar to the effects of other better-known amphetamine-type stimulants. Synthetic cannabinoid products have effects that are somewhat similar to those of natural cannabis but more potent and long-lasting than THC. Some of these compounds are potent and dangerous, having been linked to psychosis, mania, and suicidal ideation. Novel compounds are developed rapidly and new screening techniques are needed to detect them as well as a rigorous regulation and legislation reinforcement to prevent their distribution and use. Given the rapid increase in the use of synthetic cathinones and cannabinoid designer drugs, their potential for dependence and abuse, and harmful medical and psychiatric effects, there is a need for research and education in the areas of prevention and treatment.