Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel.

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

RESUMEN: La prevención del VIH/VHC entre las personas que se inyectan drogas (PWID) es de vital importancia para la salud pública. Nuestro objetivo fue evaluar el impacto de COVID-19 y las medidas de respuesta asociadas en los servicios de prevención del VIH/VHC y el estado socioeconómico de las PWID en sitios de alto riesgo de VIH. Se contactó con sitios con brotes recientes (2011­2019) de VIH entre PWID en Europa, América del Norte e Israel, que habían sido previamente identificados, a principios de mayo de 2020. De los 17 sitios invitados a participar, 13 aceptaron. Se prepararon informes cualitativos semiestructurados del sitio que cubrían los datos de marzo a mayo de 2020, analizados/codificados y confirmados con un cuestionario estructurado, en el que todos los sitios respondieron explícitamente a los 103 asuntos reportados en los informes cualitativos. El tratamiento de mantenimiento con opiáceos, los programas de agujas/jeringas y el tratamiento antirretroviral/tratamiento de la hepatitis C continuaron, pero con importantes reducciones y cambios operativos. Se reportaron aumentos en las sobredosis, dificultades generalizadas con las necesidades alimentarias y de higiene, interrupciones en el suministro de medicamentos y aumento de personas sin hogar. Los programas de servicios reformaron rápidamente las políticas restrictivas de prestación de servicios, establecidas desde hace mucho tiempo y políticamente arraigadas. Las futuras medidas de control de epidemias deben incluir la mitigación de los efectos secundarios negativos en la prestación de servicios y los determinantes socioeconómicos en las PWID.

Differential Effect of Community Rehabilitation Reform on Hospitalizations of Patients with Chronic Psychotic Disorders With and Without Substance Use Disorder, Israel, 1991-2016.

The co-occurrence of schizophrenia and substance use disorder (SUD) is clinically challenging and increasingly prevalent. This study compares trends in hospitalization characteristics of chronic psychotic patients with and without SUD in Israel, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000. The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorders, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of group (patients with and without co-occurring disorders (COD)), time-period (Period1: 1991-2000, Period2: 2001-2009, Period3: 2010-2016) and age, on hospitalization measures-average length of stay (LOS), annual number of hospitalizations and hospitalization days. Among non-COD patients hospitalized in all three periods, LOS declined by half from 133.3 days in Period1 to 63.2 in Period3, and the annual number of hospitalizations increased slightly from 0.45 to 0.56. Among COD patients, LOS declined moderately from 82.7 days to 58.3 days, while annual hospitalizations increased dramatically from 0.56 to 0.82. The annual average number of hospitalization days/capita declined from 49.7 in Period1 to 26.3 in Period3 among non-COD patients, yet remained virtually unchanged among COD patients-39.6 and 37.4 in the two periods, respectively. Since introduction of the law, a significant improvement in hospitalization characteristics of chronic psychotic non-COD patients has been noted, whereas the situation worsened somewhat for COD patients. Community rehabilitation services for COD patients in Israel have yet to develop as a suitable alternative to hospitalization, and additional rehabilitation services are urgently needed.

Psychiatric Hospitalizations of Chronic Psychotic Disorder Patients With and Without Dual Diagnosis, Israel, 1963-2016.

Objective: A significant proportion of patients with severe mental illness also experience substance use disorder. For these dual diagnosis (DD) patients, treatment is more complicated and prognosis is worse. Despite the introduction of the Community Rehabilitation of Persons With Mental Health Disability Law in 2000 and ongoing national mental health reforms, psychiatric services in Israel are not meeting the needs of an increasing number of DD patients. This study examines, for the first time in Israel, the prevalence of DD and patterns of psychiatric hospitalizations of chronic psychotic disorder patients with and without substance use disorder. Methods: The National Psychiatric Case Registry provided data on 18,684 persons with schizophrenia/schizoaffective disorders, aged 18-65, with a psychiatric hospitalization during the period 1963-2016 (with at least one hospitalization in 2010-15). Patients were considered as having DD if their substance use disorder was indicated in at least two, or 20%, of hospitalizations. Regression modeling predicted hospitalization measures (number of hospitalizations, total days hospitalized, length of stay). Results were also analyzed by legal status of admission (voluntary or involuntary; psychiatrist-ordered and court-ordered). Results: One-third of patients with chronic psychotic disorder met DD criteria, with a threefold higher rate among males (37.1%) than females (12.8%). Particularly high rates of DD (nearly 50%) were noted among male immigrants from Ethiopia. Compared with non-substance use disorder patients, DD patients had a significantly younger mean age at first hospitalization and shorter average length of stay per hospitalization but a greater number of hospitalizations and total hospital days (p < .0001 for all comparisons). The associations between DD status and hospitalization characteristics remained significant even after accounting for the effects of confounding factors. Hospitalization characteristics were also associated significantly with sex, population group, age, age at first hospitalization, and country of origin. The rate of court-ordered observation or hospitalization was threefold higher in the DD group. Conclusions: These findings, which broadly align with other countries, reflect a scarcity of outpatient services for DD patients with schizophrenia/schizoaffective disorder and substance use disorder. To achieve long-term mental health improvements, an expansion of community-based integrative treatment and rehabilitation services is needed in Israel.

The effects of synthetic cannabinoids (SCs) on brain structure and function.

There is an increasing use of "Novel Psychoactive Substances" containing synthetic cannabinoids worldwide. Synthetic cannabinoids (SC) are highly addictive and cause severe adverse effects. The purpose of our study was to assess whether chronic use of SC alters brain volume and function. Fifteen SC chronic users and 15 healthy control participants undertook an MRI scan to assess brain volume and function while performing a working memory N-back task and a response-inhibition Go-No-Go task. SC users showed impaired performance on the N-back task but not on the Go-No-Go task. They also showed reduced total gray matter volume compared with control participants, as well as reduced gray matter volume in several cortical regions including the middle frontal gyrus, frontal orbital gyrus, inferior frontal gyrus, insula, anterior cingulate cortex and the precuneus. Moreover, SC users showed diminished brain activations in the precuneus, cuneus, lingual gyrus, hippocampus and cerebellum while performing the N-back task. No differences were found in brain activation while performing the response-inhibition task. This is the first study showing overall reduced grey matter volume and specific reduced grey matter volumes in chronic SC users. Furthermore, this study showed for the first time impairment in the neural brain mechanisms responsible for working memory in SC users. Our results of reduced grey matter density and diminished activation during a working memory task in SC users, may suggest vulnerability of the frontal-parietal network in chronic SC users.

The effects of synthetic cannabinoids on executive function.

BACKGROUND AND AIMS: There is a growing use of novel psychoactive substances (NPSs) including synthetic cannabinoids. Synthetic cannabinoid products have effects similar to those of natural cannabis but the new synthetic cannabinoids are more potent and dangerous and their use has resulted in various adverse effects. The purpose of the study was to assess whether persistent use of synthetic cannabinoids is associating with impairments of executive function in chronic users. METHODS: A total of 38 synthetic cannabinoids users, 43 recreational cannabis users, and 41 non-user subjects were studied in two centers in Hungary and Israel. Computerized cognitive function tests, the classical Stroop word-color task, n-back task, and a free-recall memory task were used. RESULTS: Synthetic cannabinoid users performed significantly worse than both recreational and non-cannabis users on the n-back task (less accuracy), the Stroop task (overall slow responses and less accuracy), and the long-term memory task (less word recall). Additionally, they have also shown higher ratings of depression and anxiety compared with both recreational and non-users groups. DISCUSSION: This study showed impairment of executive function in synthetic cannabinoid users compared with recreational users of cannabis and non-users. This may have major implications for our understanding of the long-term consequences of synthetic cannabinoid based drugs.

Monitoring long-term court order psychiatric hospitalization: a pilot project in Israel.

BACKGROUND: In Israel, the rules of compulsory psychiatric hospitalization, including hospitalization under a court order, are set out in the Israel Mental Health Act, 1991 (MHA). The MHA does not specifically define the time limits of hospitalization by Court Order, though every patient, by law has to be brought before the Regional Psychiatric Board (RPB) once every six months for reevaluation. The Supreme Court recently addressed this issue and suggested that by having no specific time span, the way lies open for infringement of individual rights (Criminal Appeals 3854\02). Consequently the Supreme Court suggested that some court committed patients should be moved from the criminal to the civil track which inflicts less severe infringement of the mentally ill patient's rights. This ruling generated rethinking at the ministerial level aimed at improving the monitoring of the care of long-term psychiatric hospitalization in criminal cases. The Ministry of Health initiated a project designed to study this issue. OBJECTIVES: The main objective of this project, which is described below, is to monitor the type and incidence of forensic mental patients hospitalized in Israel for more than 10 years, and to propose alternatives to replace this untenable situation. METHODS: All the 12 psychiatric hospitals in Israel which hospitalize forensic patients were sent written requests for data on criminal patients hospitalized under court orders, including demographic data, diagnosis and type of offense. We identified in all 65 such patients. The data received were compared with the National Psychiatric Register databank of the Ministry of Health and divided in subgroups according to diagnosis, type of offence, demographic variables and length of hospitalization. RESULTS: Most of the subjects of the sample (89%) suffered from psychotic disorder mainly schizophrenia of the paranoid type. 95.5% were male. The most prominent type of offense was assault against family members (37%), which is in keeping with statistics reported in the relevant literature. The profile of the typical patient of this sample is: male, aged 45-65, unmarried, with 8 years of education and suffering from paranoid schizophrenia. DISCUSSION: No correlation between type and severity of offense and length of involuntary forensic hospitalization was found. We suggest some possible alternatives to improve the current handling of the group of long term hospitalized forensic patients. We also feel that a further study should be carried out on forensic patients hospitalized for a period of five to ten years.

[Lithium-associated alopecia].

A 39-year-old woman who developed alopecia shortly after treatment with lithium carbonate was initiated is described. The alopecia resolved 2 months after lithium was discontinued. Though this side-effect is relatively rare, we suggest that patients getting lithium for short or long term treatment be monitored for it.

[Medication group for noncompliant patients in a psychiatric day unit--experiences during a one year period].

A group of noncompliant psychiatric patients was treated on a weekly basis over a 6-month period; 13 started but 3 dropped out. Results indicated greater feeling of security with medication; increased desire to maintain follow-up treatment in the outpatient clinic; greater likelihood of patients accepting their illness; and strong desire to discuss medication-related topics with staff. Our medication group appears to offer a convenient and organized method for addressing issues of psychiatric medication, especially for chronic patients, which we recommend to clinicians in other medical disciplines.

[Risk versus confidentiality: the therapist's responsibility for his psychiatric patient's acts].

In this article we deal with the responsibility and liability of the therapist for aggressive and criminal acts perpetuated by his psychiatric patient against third parties. This issue has been the object of controversial discussion among professionals in the legal and medical field since the famous case of Tarasoff (this psychiatric patient killed his former girlfriend after he informed his therapist of his intention to harm her. The therapist was sued because he did not warn nor protect the potential victim and did not prevent the criminal act). We describe the situation in the U.S. before Tarasoff and the implications of the decision of the Supreme Court of California in 1974-76 which dealt with this case and broadened the therapist's responsibility towards third parties. We also analyze the actual legal situation in Israel on this issue, its disadvantages and shortcomings. We suggest some proposals for improvement, together with some operational measures to cope with this complex issue including a thorough evaluation of the patient's clinical state, identification of the potential victim, warning and involvement of the relevant authorities, and hospitalization if needed.

[Attention deficit hyperactivity disorder, facilitating alcohol and drug abuse in an adult].

Attention-deficit hyperactivity disorder (ADHD) has been considered a mental and behavioral disorder of childhood and adolescence. It is being increasingly recognized in adults, who may have psychiatric co-morbidity with secondary depression, or a tendency to drug and alcohol abuse. We describe a 32-year-old woman known for years as suffering from borderline personality disorder and drug dependence (including hashish, marijuana, LSD and "ecstasy") and alcohol abuse that did not respond to treatment. Only when correctly diagnosed as ADHD and appropriately treated with the psychotropic stimulant, methylphenidate (Ritalin), was there significant improvement. She succeeded academically, which had not been possible previously, the craving for drugs diminished and a drug-free state was reached. Although administration of psychostimulants to drug abusers is controversial, as they are addictive, in cases of ADHD they have promoted drug abstinence.

Serum melatonin levels in schizophrenic and schizoaffective hospitalized patients.

Conflicting results on changes of the diurnal melatonin rhythms of patients with affective disorders have been reported in the literature. The heterogeneous data may derive from the great discrepancy in the diagnostic criteria of different authors. A study of 12 schizoaffective and chronic schizophrenic psychotic patients found a constant pattern of an obliterated nocturnal melatonin rise only in the latter group. The presence or absence of the nocturnal melatonin rise was determined in drug-free hospitalized patients and remained unchanged despite 2 months of drug treatment including large doses of neuroleptics. This finding, when confirmed in a larger number of patients, could possibly serve as a marker for the type of mental disorder, drug to be applied and response expected.

The late effects of Nazi persecution among elderly Holocaust survivors.

Eighty-six survivors of the Holocaust from a nonclinical population were interviewed to examine the recent mental state, coping and adjustment of elderly Holocaust survivors. Most of the interviewees suffered after the war and are still suffering from the results of persecution. Death camp survivors suffer more than survivors who were subjected to other forms of Nazi persecution. Despite the mental suffering, Holocaust survivors succeeded to cope and to adjust. They are successful at work and in society. They managed to raise warm families. They behaved and still behave as if fulfilling a testament to those who perished.

[Late effects of massive psychic trauma. Holocaust survivors 50 years later]. / Effetti tardivi del trauma psichico massivo. I sopravvissuti all'Olocausto 50 anni dopo.

The authors report the results of a study aimed at examining the present mental state, adjustment and lifestyle of a non-clinical sample of Holocaust survivors aged 60 and over. Most the interviewees have suffered since the war from various psychic symptoms, the so-called "survivor syndrome". Concentration camp survivors form a special group whose level of suffering appears greater and more severe than other survivors. In spite of continuous mental suffering Holocaust survivors have succeeded in adjusting well. They hold top positions at work, are socially successful and have stable family nuclei. They behave as if they need to fulfil the expectations of all those who perished in the Holocaust. Only 4 subjects reported a latency period before the appearance of symptoms.