Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries.

BACKGROUND: Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians' treatment choices for post-traumatic stress disorder (PTSD). METHODS: The case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148). RESULTS: About 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct "profiles" of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines. CONCLUSIONS: Clinicians' decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.

[PSYCHIATRY - AN ERA OF CHANGES AND TRANSFORMATIONS].

INTRODUCTION: In this issue of Harefuah, we present several aspects of mental health during hospitalization and rehabilitation and in the community. Most mental health care is now in the community. This issue begins with a study of sleep monitoring in the community aiming to predict the development of depression; and continues with an interesting characterization of seasonality in presentation to the emergency room, noting the importance of family and community connections as a protective factor. The relevance of early diagnosis and treatment of post-traumatic syndrome is discussed using a multidimensional approach to assessment. Since many individuals with mental disorders have experienced sexual trauma, it is of utmost importance to raise the issue during intake.

[KIDNEY TRANSPLANTION IN A MENTAL HEALTH PATIENT].

This journal has previously published articles on the issue of kidney transplantation in mentally ill patients. The current case report highlights the issue of kidney transplantation in a patient suffering from a psychotic disorder. The case study describes a patient who, although he does not comply with his psychopharmacological treatment, fully complies with all medications pertaining to his physical illness. The conclusion from this case study is that mentally ill patients are not a homogenous group and we need to discuss each case independently, with regard to the complexities of each patient.

Video Surveillance in Mental Health Facilities: Is it Ethical?

Video surveillance is a tool for managing safety and security within public spaces. In mental health facilities, the major benefit of video surveillance is that it enables 24 hour monitoring of patients, which has the potential to reduce violent and aggressive behavior. The major disadvantage is that such observation is by nature intrusive. It diminishes privacy, a factor of huge importance for psychiatric inpatients. Thus, an ongoing debate has developed following the increasing use of cameras in this setting. This article presents the experience of a medium-large academic state hospital that uses video surveillance, and explores the various ethical and administrative aspects of video surveillance in mental health facilities.

Maintenance electroconvulsive therapy for a neuroleptic-intolerant patient with disorganized schizophrenia.

Owing to unresolved questions concerning the efficacy and safety of electroconvulsive therapy (ECT) in the treatment of schizophrenia, and widespread negative attitudes toward ECT, maintenance ECT (mECT) is generally considered only as a last resort. Nevertheless, in some clinical situations, the advantages of mECT may outweigh the risks and associated concerns. We report the case of a patient suffering from disorganized schizophrenia who had life-threatening hematological side effects to treatment with antipsychotic agents. Long-term mECT was administered and the patient achieved remission with no notable side effects. He was able to maintain a peaceful daily routine and improved functioning. Considering the lack of controlled trials in this area, this case and other similar cases reported in the literature add support to a possible benefit of mECT in disorganized schizophrenia, particularly when pharmacotherapy is insufficient or contraindicated.

Testamentary capacity of the schizophrenic patient.

Testamentary capacity refers to an individual's capability to write his or her own will. Psychiatrists are required occasionally to give expert opinions regarding the testamentary capacity of individuals with a medical history or suspected diagnosis of a mental illness. This may stem from the patient/lawyer/ family initiative to explore the current capacity to testate in anticipation of a possible challenge, or may be sought when testamentary capacity of a deceased has been challenged. In this article we examine the medico-legal construct of testamentary capacity of the schizophrenic patient, and discuss the various clinical situations specific to schizophrenic patients, highlighting their impact on the medical opinion regarding testamentary capacity through examining the rulings of Israel's Supreme Court in a specific case where the testamentary capacity of a mentally ill individual who was challenged postmortem, and provide a workable framework for the physician to evaluate the capacity of a schizophrenic patient to write a will..

Voting of hospitalized and ambulatory patients with mental disorders in parliamentary elections.

The authors examined the voting rate among psychiatric inpatients and the voting rate of outpatients, in relation to the severity of their illness. On election day the number of inpatients that voted was recorded in one psychiatric hospital in Israel. For two weeks following the elections outpatients were asked if they voted: 100/271 (36.9%) inpatients and 131/181(72.4%) ambulatory patients voted; 53.8% of the inpatients and 4.7% of the ambulatory patients could not vote because they had no identity cards. Ambulatory patients with no prior hospitalizations had the highest voting rates. The most common reason for not voting among inpatients in Israel is lack of identity cards.

Culturally sensitive mental health care: a study of contemporary psychiatric treatment for ultra-orthodox Jews in Israel.

BACKGROUND: The literature describes psychiatric treatment of ultra-orthodox Jews as complex and challenging, in light of this community's unique characteristics and the ideological gap between ultra-orthodox patients and secular professionals. Recent data indicate that patient-centred culturally sensitive care contributes to the treatment outcomes among cultural minorities. AIMS: To examine the effect of the level of a physician's religiosity and cultural sensitivity, as perceived by ultra-orthodox Jewish psychiatric patients, as well as the treatment venue (i.e. the distance of the treatment facility from the patients' community) on treatment outcomes (working alliance, medical adherence and the patients' social adaptation). METHODS: The sample included 38 ultra-orthodox Jewish men and women receiving psychiatric treatment at the Lev Hasharon Mental Health Centre. The participants completed questionnaires about the physician's religiousness and cultural sensitivity, working alliance, medical adherence and social adaptation. RESULTS: Working alliance was positively related to the treatment location, meaning that patients were more committed and involved in the treatment when it took place in a facility distanced from their community. Working alliance was also correlated with medical adherence. Regression analysis revealed that the doctor's acquaintance with religion and cultural sensitivity predicted patients' reported social adaptation level. CONCLUSIONS: In contrary to common perceptions, ultra-orthodox patients are not necessarily reluctant to be treated by secular physicians. These patients prefer a discreet treatment far from their community's public eye. Their perception of a doctor who acknowledges and respects their religiosity positively affects the way that they perceive their social functioning. Culturally sensitive treatment enables patients to feel respected and acknowledged through their sociocultural affiliation, and not only through their disorder. It seems essential to train physicians about the importance of culturally sensitive treatment with this population.

Evaluation of the capacity of inpatients with chronic schizophrenia to provide informed consent for participation in clinical trials; use of the Hebrew version of the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR).

BACKGROUND: Patient protection requires the provision of informed consent for participation in medical research. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) is frequently used for screening the capacity of research subjects to consent to participate in research. OBJECTIVES: To evaluate the utility of the Hebrew translation of the MacCAT-CR for assessing the capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials. METHODS: We evaluated the translated MacCAT-CR by comparingthe capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials. The following standardized neurocognitive assessment tools were used: Addenbrooke's Cognitive Examination (ACE) and Frontal Assessment Battery (FAB), as well as the attending doctor's assessment. RESULTS: Twenty-one patients participated. Mean MacCAT-CR score was 12 +/- 10.57 (range 0-32), mean FAB score 9.9 +/- 4.77 (range 1-18), mean ACE 59.14 +/- 16.6 (range 27-86) and mean doctor's assessment 5.24 +/- 1.18 (range 3-7). CONCLUSIONS: The Hebrew version of the MacCAT-CR helped identify patients with the capacity to provide informed consent for participation in research. Patients with FAB scores > or = 12 tended to score higher on the Hebrew version of the MacCAT-CR, thus confirming the utility of the Hebrew version of the MacCAT-CR. During the screening process for clinical trials it may be practical to administer the concise FAB questionnaire, and then administer the MacCAT-CR only to those who scored > or = 12 on the FAB.

[Involuntary outpatient treatment].

Much has been written about involuntary outpatient treatment, both in Israel and abroad. Since the amendment of the law in Israel in 1991, there is an option for compulsory outpatient treatment that is Less confining than hospitalization. Research has noted its efficacy in avoiding exacerbation of the mental state, repeat hospitalizations and involvement in dangerous activities among patients with low compliance to treatment. In practice, there is no mechanism for implementation or enforcement. Thus, the main difficulty noted by Spinzy and Krieger, is the lack of tools to supervise involuntary outpatient treatment, thereby making it difficult to implement the law of involuntary outpatient treatment ordered by the regional psychiatrist. In addition, the court interpreted the law in a manner that prevents taking measures against the patient who does not comply with compulsory outpatient treatment unless his condition is so severe that it requires court ordered hospitalization. The issue becomes more problematic with court ordered compulsory outpatient treatment. In the United States there is Assisted Outpatient Treatment (AOT) in 42 states. The criteria include dangerousness to the environment, harm to self, or severe inability to care for one's self. AOT helps prevent hospitalizations and improves the outcome of treatment. According to "Kendra's Law" in the United States, the Court detaiLs the biological and psychosocial treatment programs in the court order recommendations: The recommendations include: create uniformity, determine a mechanism of action, assign skilled manpower to implement compulsory outpatient treatment, establish a plan for compulsory outpatient treatment, and create a legal mechanism to supervise patients in court ordered outpatient treatment. In conclusion, determining a mechanism for intervention, implementation and supervision of compulsory outpatient treatment is first and foremost in the best interest of: the patient, who does not want his condition to deteriorate to rehospitalization, the caregivers, for whom the mechanism will help provide medical care, and for society, which will be better protected.

Nonmedication smoking reduction program for inpatients with chronic schizophrenia: a randomized control design study.

People with schizophrenia are more likely to smoke, and to smoke more frequently, than those without schizophrenia. Furthermore, inpatients smoke even more frequently compared with those living in the community. In light of this, we implemented and assessed a smoking reduction intervention using a wide array of behavioral group techniques and methods in chronic hospitalized schizophrenic clients. Using a controlled design, we randomly assigned chronic schizophrenic clients to either a five-session smoking reduction intervention (n = 35) or a waiting list (WL; n = 18). We assessed self-reported smoking behavior, clinical status (Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression; Clinical Global Impression Scale for Psychosis), subjective quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire-abbreviated version), and weight before and 3 months after the intervention. The intervention successfully reduced the number of cigarettes smoked compared with nonintervention. No clinical worsening or weight gain was observed. Behavioral group-oriented smoking reduction interventions can significantly reduce smoking behavior in hospitalized chronic clients with schizophrenia.

Assessing the risk of violent behavior before issuing a license to carry a handgun.

Handguns are intended to be used for protection, but they can also be used as weapons of assault that may endanger others or inflict self-harm and facilitate suicide. Research has revealed a direct correlation between firearm availability and suicide risk. Gun control is intended to reduce violence through legislation that restricts ownership and use of firearms. How can we ensure that firearms will not reach the hands of individuals who may pose a danger to themselves or to others, without infringing on the rights of other citizens to carry guns for protection, which is in the public interest? The potential to commit a crime will materialize, depending on dynamic interactions among personality factors, environmental factors, and the individual's history of offending. We present illustrative cases involving various aspects of gun control and a description of instruments for the assessment of dangerousness that can facilitate the licensing process for carrying and using firearms.

Responsibility of the therapist for the patients' actions (Tarasoff Rules): position of the psychiatrists.

BACKGROUND AND AIMS: Patient confidentiality and the therapists responsibility to society may present a challenge in the therapeutic relationship between the psychiatrist and the patient. We examined the attitudes of Israeli psychiatrists concerning the duty to warn and protect according to the Tarasoff Rule. METHODS: Questionnaires to examine psychiatrists opinions concerning the implementation of the Tarasoff Rule in Israel were sent to senior psychiatrists involved in forensic psychiatry for anonymous completion. RESULTS: 108 (64%) questionnaires were returned. 61 (57%) replied that they encountered similar situations. CONCLUSIONS: Thorough understanding of the Tarasoff Rule, clarification of the patients potential dangerousness, and timely deliberation of the issues will assist the therapist. Investigation of the medical consensus of senior physicians, as performed in our study, is also a point of reference for formulating an opinion.

Management of the suicidal patient in the era of defensive medicine: focus on suicide risk assessment and boundaries of responsibility.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist's responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.

Security and psychiatry: the British experience and implications for forensic psychiatry services in Israel.

The courts have recently become increasingly involved in the administration of compulsory psychiatric services in Israel. Data reveal a gradual increase in the rate of court-ordered hospitalizations according to Section 15 of the Law for the Treatment of the Mentally Ill. This paper examines the implications of this trend, particularly the issues of security and safety in psychiatric hospitalization. We present highlights from extensive British experience, focusing on the implications on forensic psychiatry in Israel. We review the development of the hierarchy of security in the British psychiatric services, beginning in the early 1970s with the establishment of the Butler Committee that determined a hierarchy of three levels of security for the treatment of patients, culminating with the establishment of principles for the operation of medium security units in Britain (Read Committee, 1991). These developments were the basis for the forensic psychiatric services in Britain. We discuss the relevance of the British experience to the situation in Israel while examining the current status of mental health facilities in Israel. In our opinion, a safe and suitable environment is a necessary condition for a treatment setting. The establishment of medium security units or forensic psychiatry departments within a mental health facility will enable the concentration and classification of court-ordered admissions and will enable systemic flexibility and capacity for better treatment, commensurate with patient needs.

Ombudsman in a mental health centre.

The Israeli Ministry of Health attributes significance to the issue of patients' complaints in mental health settings. A Public Petition Commission was established in Lev Hasharon Mental Health Center, Netanya, Israel, in 1997 and includes representatives from the medical, nursing and social work sectors. We examined the ombudsman's activities in Lev Hasharon Mental Health Center - as a representative institution for mental health centres - in an effort to characterize those who sought the services of the ombudsman and the treatment of the petitions. We also evaluated treatment of the complaint across time, the satisfaction of the complainant and the factors that influenced satisfaction. The files of those who sought the services of the ombudsman prior to and during the six-month duration of the study were examined using a predetermined checklist, and those who approached the ombudsman were contacted and asked whether or not they were satisfied with the treatment of their petition/complaint, and what factors influenced their level of satisfaction. Though solutions were found for only 55% of the problems, 88% of the patients reported satisfaction with the treatment of their petitions and complaints. Beyond the resolution of complaints, the office of the ombudsman improves dialogue with patients and their families, continuously improves in-patient care and perhaps reduces future complaints.

Mentally ill persons who commit crimes: punishment or treatment?

In many countries, there continue to be conflicting opinions and mechanisms regarding the appropriateness of treatment and/or punishment for mentally ill individuals who commit crimes. The general population is concerned with public safety and often finds it difficult to accept the possibility that a mentally ill individual who commits a crime can be hospitalized and eventually discharged, sometimes after a relatively short time. In most countries the options of incarceration and hospitalization are available in concert. In some, incarceration occurs before hospitalization. In others, hospitalization is first, followed by a prison term. An additional option could be "treatment years." The court would determine the number of years of treatment required, according to the crime. This dilemma has no unequivocal solution. The goal is to reach a balance between the right of the patient to treatment and the responsibility of the courts to ensure public safety.

Dropout, early termination and detachment from a public psychiatric clinic.

BACKGROUND: Dropout from an outpatient clinic is the loss of a patient to scheduled follow-up. Due to movement of mental health care to the community, adherence to ambulatory care is crucial to maintain stability among individuals with mental disorders. We hypothesized that patients drop out from ambulatory psychiatric care when regardless of the therapist's evaluation, they feel that they have recovered, or because they are dissatisfied with treatment. The aim was to examine the phenomenon of premature termination of treatment in a public community-based ambulatory psychiatric clinic serving a catchment area with a population of 200,000. SUBJECTS AND METHODS: The study sample was drawn from patients who had at least one ambulatory therapy session during the previous five years, immediately or shortly following initial treatment and who were subsequently lost to follow-up. Participants completed a questionnaire that evaluated their satisfaction with treatment and described their reasons for early termination of treatment. RESULTS: The sample included eighty-two patients. Eighty percent of the responders (N=65) terminated therapy on their own, and twenty percent (N=17) decided to end treatment together with their therapists. DISCUSSION: Increased involvement of patients in treatment planning, duration and end of therapy, may improve attendance in ambulatory mental health care settings. CONCLUSIONS: Though dropouts generally reported satisfaction with the ambulatory service, some explained early termination of treatment as being due to dissatisfaction with the therapist, the type of treatment or because of therapist turnover. Others terminated treatment because they felt their problems were solved or their conditions had improved, though therapists had determined otherwise.