Exposure to genocide and the risk of schizophrenia: a population-based study.

BACKGROUND: No evidence exists on the association between genocide and the incidence of schizophrenia. This study aims to identify critical periods of exposure to genocide on the risk of schizophrenia. METHOD: This population-based study comprised of all subjects born in European nations where the Holocaust occurred from 1928 to 1945, who immigrated to Israel by 1965 and were indexed in the Population Register (N = 113 932). Subjects were followed for schizophrenia disorder in the National Psychiatric Case Registry from 1950 to 2014. The population was disaggregated to compare groups that immigrated before (indirect exposure: n = 8886, 7.8%) or after (direct exposure: n = 105 046, 92.2%) the Nazi or fascist era of persecutions began. The latter group was further disaggregated to examine likely initial prenatal or postnatal genocide exposures. Cox regression modelling was computed to compare the risk of schizophrenia between the groups, adjusting for confounders. RESULTS: The likely direct group was at a statistically (p < 0.05) greater risk of schizophrenia (hazard ratio = 1.27, 95% confidence interval 1.06-1.51) than the indirect group. Also, the likely combined in utero and postnatal, and late postnatal (over age 2 years) exposure subgroups were statistically at greater risk of schizophrenia than the indirect group (p < 0.05). The likely in utero only and early postnatal (up to age 2 years) exposure subgroups compared with the indirect exposure group did not significantly differ. These results were replicated across three sensitivity analyses. CONCLUSIONS: This study showed that genocide exposure elevated the risk of schizophrenia, and identified in utero and postnatal (combined) and late postnatal (age over 2 years) exposures as critical periods of risk.

Religiosity as a protective factor against suicidal behaviour.

OBJECTIVE: Data suggest that adherence to religious beliefs is associated with lower rates of suicide. A number of mediating factors have been hypothesized to explain this association, including enhanced social support, less substance abuse, and lower rates of psychopathology. METHOD: We utilized data from a two-phase population-based, epidemiological study of mental disorders among young Jewish Israel born in a 10-year birth-cohort conducted in the 1980s. This study included data on religiosity and suicidal behaviour. Twenty-five years thereafter, mortality data were obtained from a national vital statistics registry. RESULTS: Rates of suicidal ideation were similar among secular, partially observant, and religious subjects (9.4%, 6.7%, and 6.2%, respectively; adjusted OR for linear trend: 0.80, 95% CI: 0.58-1.09). Rates of suicide attempts were significantly lower among religious subjects (2.4%, 2.5%, and 0.4% for secular, partially observant, and religious, respectively; adjusted OR for linear trend: 0.62, 95% CI: 0.43-0.88). Of the 4914 subjects, eight died by suicide: Seven of them were secular and one was partially observant (χ(2) = 2.52, P = 0.09). There were no differences in social functioning or rates of psychopathology among the study groups. CONCLUSION: Religiosity has a protective effect against suicide attempts, which is independent of social functioning, psychopathology, and substance use.

Completed suicide and suicide attempts in the Arab population in Israel.

Completed suicide and suicide attempts among four Arab groups defined by religious affiliation in Israel: Bedouins, Muslims (other than Bedouin), Christians and Druze were investigated using national databases of suicide (1999-2011), and suicide attempts (2004-2012). Age specific and age-adjusted rates and ratio of suicides to suicidal behavior were calculated, and compared with the total Israeli population rates. Age-adjusted suicide rates were lowest among the non-Bedouin Muslims, 2.5, followed in ascending order by Bedouins, 3.2, and Christian Arabs, 3.3 per 100,000 population, respectively. The highest rate was found among the Druze, 8.7, per 100,000 population, particularly for young males. The rates among the Arab groups were lower than for the total Israeli population, 7.9 per 100,000 population, except for the Druze. The pattern of suicide rates by gender, higher for males than females, was similar in all groups. The rates among the Arab Israelis were highest for the 15-24 year old age group, while in the total population the rates increased with age. Age-adjusted suicide attempt rates were higher amongst non-Bedouin Muslims, 84.8 per 100,000 population, followed by the Bedouin, 72.4; Druze. 64.9; and lowest among Christian Arabs, 58.6, all per 100,000 population. In the total Israeli population, the rate was even higher, 89.8 per 100,000 population. Suicide attempt rates were higher for women in all groups, except among the Druze. Rates were higher in most groups for ages 15-24. In this age group, the rates for female Muslims and Bedouins and for male Druze were higher than among the total population. Arab elderly had low rates of both suicide and suicide attempts. The ratio of suicides to suicide attempts increased with age for all groups, except for the Christian Arabs. It was markedly higher for the Druze, compared to 7.3 % for the total population for ages 15 and over. Findings highlight the importance of investigating the differential distribution of suicidal behavior by specific ethno-religious groups.

Psychiatrists' knowledge, training and attitudes regarding the care of individuals with intellectual disability.

BACKGROUND: Psychiatrists are responsible for providing proper care for people with intellectual disability who have psychiatric disorders. This study examined psychiatrists' perceptions of their own training, knowledge and therapeutic skills, as well as their attitudes towards this population. METHODS: Questionnaires were distributed to 679 psychiatrists working within the public sector in Israel. RESULTS: Completed questionnaires were returned from 256 psychiatrists (38% response rate). Most (90%) participants reported having had limited training in the diagnosis and treatment of people with intellectual disabilities, while between 34% and 72% reported having inadequate knowledge in specific areas. CONCLUSION: The findings of limited training and self-perceived inadequate knowledge are at least partially explained by the service model, wherein people with intellectual disabilities are cared for by general mental health services. The identified inadequacies could be overcome through the implementation of a model in which specially trained psychiatrists are deployed within generic services.

Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean.

BACKGROUND: Studies suggest a paucity of and lack of prioritisation in mental health research from low- and middle-income (LAMI) countries. AIMS: To investigate research priorities in mental health among researchers and other stakeholders in LAMI countries. METHOD: We used a two-stage design that included identification, through literature searches and snowball technique, of researchers and stakeholders in 114 countries of Africa, Asia, Latin America and the Caribbean; and a mail survey on priorities in research. RESULTS: The study identified broad agreement between researchers and stakeholders and across regions regarding research priorities. Epidemiology (burden and risk factors), health systems and social science ranked highest for type of research. Depression/anxiety, substance use disorders and psychoses; and children and adolescents, women, and people exposed to violence/trauma were prioritised among the disorders and population groups respectively. Important criteria for prioritising research were burden of disease, social justice, and availability of funds. Stakeholder groups differed in the importance they gave to the personal interest of researchers as a criterion for prioritising research. Researchers' and stakeholders' priorities were consistent with burden of disease estimates, however suicide was underprioritised compared with its burden. Researchers' and stakeholders' priorities were also largely congruent with the researchers' projects. CONCLUSIONS: The results of this first ever conducted survey of researchers and stakeholders regarding research priorities in mental health suggest that it should be possible to develop consensus at regional and international levels regarding the research agenda that is necessary to support health system objectives in LAMI countries.

Socioeconomic status and psychiatric disorders: the causation-selection issue.

Are inverse relations between psychiatric disorders and socioeconomic status due more to social causation (adversity and stress) or social selection (downward mobility of genetically predisposed)? This classical epidemiological issue is tested by focusing on ethnic status in relation to socioeconomic status. Ethnic status cannot be an effect of disorder because it is present at birth whereas socioeconomic status depends on educational and occupational attainment. A birth cohort sample of 4914 young, Israel-born adults of European and North African background was selected from the country's population register, screened, and diagnosed by psychiatrists. Results indicate that social selection may be more important for schizophrenia and that social causation may be more important for depression in women and for antisocial personality and substance use disorders in men.

Challenges to reduce the '10/90 gap': mental health research in Latin American and Caribbean countries.

OBJECTIVE: To analyze the status of mental health research in 30 Latin American and Caribbean countries (LAC). METHOD: Medline and PsycInfo databases were searched to identify the LAC authors. Their publications were classified according to the topic, type of research and target population studied. Scientific indicators of these countries were assessed in other two different databases: Essential Scientific Information and Atlas of Science Project, both from Institute for Scientific Information. RESULTS: Indexed-publications were concentrated in six countries: Argentina, Brazil, Chile, Colombia, Mexico and Venezuela. Most studies dealt with the burdensome mental disorders but neglected important topics such as violence and other mental health priorities. CONCLUSION: Mental health research is mostly concentrated in a few LAC countries, but these countries would contribute to reduce the research gap, if they provide research training to their neighbors and engage in bi- or multi-lateral research collaboration on common region priorities.

Care gap: a comprehensive measure to quantify unmet needs in mental health.

AIM: Treatment gap refers to the percentage of individuals who require treatment in a country or a defined community but do not receive it due to various reasons. There is widespread acceptance of 'treatment gap' as a measure of unmet needs in mental health. However, the term 'treatment' carries a medical connotation and implies biomedical treatment (or lack of it) of mental illness and is often interpreted by policymakers, planners and researchers, as well as by non-professional stakeholders as exclusively referring to curative clinical psychiatric interventions. This common interpretation results in the exclusion of a range of effective psychosocial interventions available today. Treatment gap also does not include physical health services for persons with mental illness, a major concern due to the relative frequent yet highly unattended physical comorbidity and early mortality of persons with severe mental illness. METHODS & RESULTS: We, therefore, propose a more comprehensive measure of unmet needs.

Information for mental health systems: an instrument for policy-making and system service quality.

AIMS: Information is crucial in mental healthcare, yet it remains undervalued by stakeholders. Its absence undermines rationality in planning, makes it difficult to monitor service quality improvement, impedes accountability and human rights monitoring. For international organizations (e.g., WHO, OECD), information is indispensable for achieving better outcomes in mental health policies, services and programs. This article reviews the importance of developing system level information with reference to inputs, processes and outputs, analyzes available tools for collecting and summarizing information, highlights the various goals of information gathering, discusses implementation issues and charts the way forward. METHODS: Relevant publications and research were consulted, including WHO studies that purport to promote the use of information systems to upgrade mental health care in high- and low-middle income countries. RESULTS: Studies have shown that once information has been collected by relevant systems and analyzed through indicator schemes, it can be put to many uses. Monitoring mental health services, represents a first step in using information. In addition, studies have noted that information is a prime resource in many other areas such as evaluation of quality of care against evidence based standards of care. Services data may support health services research where it is possible to link mental health data with other health and non-health databases. Information systems are required to carefully monitor involuntary admissions, restrain and seclusion, to reduce human rights violations in care facilities. Information has been also found useful for policy makers, to monitor the implementation of policies, to evaluate their impact, to rationally allocate funding and to create new financing models. CONCLUSIONS: Despite its manifold applications, Information systems currently face many problems such as incomplete recording, poor data quality, lack of timely reporting and feedback, and limited application of information. Corrective action is needed to upgrade data collection in outpatient facilities, to improve data quality, to establish clear rules and norms, to access adequate information technology equipment and to train health care personnel in data collection. Moreover, it is necessary to shift from mere administrative data collection to analysis, dissemination and use by relevant stakeholders and to develop a "culture of information" to dismantle the culture of intuition and mere tradition. Clinical directors, mental health managers, patient and family representatives, as well as politicians should be educated to operate with information and not just intuition.

Health care disparities among persons with comorbid schizophrenia and cardiovascular disease: a case-control epidemiological study.

AIMS: Studies showed health care disparities among persons with comorbid schizophrenia and cardiovascular disease (CVD), including in countries with universal health care. However, the potential positive effect of specific mental health legislation has not been reported. This study aimed to investigate the health care of persons with comorbid schizophrenia and CVD in a country with both a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities. METHOD: This study builds on a large case-control epidemiological sample (N = 52 189) of service users. Within the sample we identified a sub-group of persons with CVD diagnoses (n = 8208) and compared service users with and without schizophrenia on drug utilisation, laboratory tests, visits to specialists and surgical interventions. RESULTS: Service users with schizophrenia were less likely to meet similar indexes of care as their counterparts: 91% cholesterol tests (p < 0.001), 60% stress tests (p < 0.001), 93% visits to specialists (p = 0.001), 93% drug utilisation (p < 0.001) and 55% CVD surgical interventions (odds ratio 0.55, 95% confidence intervals 0.49-0.61). CONCLUSIONS: In Israel, a country with a national health insurance and a rehabilitation law specific for persons with mental disabilities, service users with schizophrenia still fail to receive equitable levels of health care for CVD. However, the disparities appear to be smaller than in other countries with universal health insurance.

Social functioning of psychiatric patients in contrast with community cases in the general population.

Most cases in epidemiologic surveys of community populations have never been treated by mental health professionals. We studied how community cases and patients may be similar or different with respect to their social functioning in such areas as work, marriage, and parenting. There are grounds for two contrasting hypotheses: the universal hypothesis (disorder is accompanied by disability independently of treatment status) and the patient-specific hypothesis (disorder is accompanied by disability only for cases who become patients). We investigated these hypotheses using data from symptom scales and social functioning scales that are part of the Psychiatric Epidemiology Research interview. The sample consisted of 205 adults from the general population and 204 psychiatric patients from Jerusalem. The results provided some support for each hypothesis depending on the types of symptoms and functioning and disorder involved; however, the relationship between symptoms and social functioning in patients as well as cases from the community was weaker than had been supposed.

Minor depression in a cohort of young adults in Israel.

BACKGROUND: A diagnosis of minor depression was considered for DSM-IV. Mild depression is thought to be common in primary care settings and the community, but studies of the validity of minor depression as a separate diagnostic category are few. METHODS: Minor depression as defined by Research Diagnostic Criteria was assessed by psychiatrists using a modified Schedule for Affective Disorders and Schizophrenia-Lifetime version in a cohort of 5200 young adults in Israel. Subjects with year-prevalent minor depression were compared with subjects with major depression or generalized anxiety disorder and with controls on aspects of psychopathologic condition, psychosocial functioning, help-seeking behaviors, and demographic correlates. RESULTS: Symptomatically, minor depression appeared to be a mild version of major depression. Minor depression was associated with good teenage and general social functioning, but also with absence from work, separation or divorce, recent impairment in overall functioning, and help-seeking. CONCLUSIONS: The results lend support for including minor depression or expanding severity modifiers in future classifications to better capture the phenomenon of subthreshold depression.

Psychiatric combat reactions during the Yom Kippur War.

The authors explore the stress of war by reporting some selected epidemiological aspects of the psychiatric combat reactions among Israeli troops during a period of intensive hostilities in the Yom Kippur War of 1973. They examined the distribution of these casualties according to intensity of fire, age, rank, sociopsychological grading, and military assignment and measured treatment outcome at the end of the war and 18 months later.

Vulnerability of Jews to affective disorders.

OBJECTIVE: Psychiatric literature over the past 100 years suggests that Jews are at higher risk for affective disorders than numbers of other religious groups. To examine these claims, the authors analyzed data from the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study. In addition, the relationships among gender, alcoholism, and major depression were investigated. METHOD: The period prevalence and lifetime rates of DSM-III major depression among Jews, Catholics, Protestants, individuals in other religious groups, and individuals with no religious affiliation were examined in the Los Angeles and New Haven, Conn., ECA data. Logistic regression with covariates for site, gender, marital status, and socioeconomic status was used to estimate odds ratios and 95% confidence intervals. The calculated rates, based on the combined data from ECA study waves 1 and 2 for the white population, were weighted according to the 1980 U.S. population census. Female-to-male rate ratios and rates of alcohol abuse/dependence were also obtained. RESULTS: While no differences were found among females, Jewish males had significantly higher rates of major depression than Catholics, Protestants, and all non-Jews combined. Jews had a 1:1 female-to-male ratio for major depression, in contrast to the other religious groups, which approached the universal 2:1 ratio. Rates of alcohol abuse/dependence were inversely related to rates of major depression. CONCLUSIONS: The results support only in part the earlier reports that Jews have higher rates of depression. The equal gender distribution of major depression among Jews may be associated with the lower rate of alcoholism among Jewish males.

Two shortened versions of the Cornell Medical Index--a new test of their validity.

Two shortened versions of the Cornell Medical Index (CMI) were tested for concurrent validity using two reference groups. Sensitivity, specificity and relative liability were computed and found to be of relatively low value. The usefulness of the questionnaires for screening the emotionally disturbed was found to be affected by respondents' sociodemographic characteristics such as age and sex and, in particular, educational level and ethnicity.

Epidemiology of youth suicide in Israel.

OBJECTIVE: This study examined sociodemographic correlates and temporal trends in suicide among young Jews, Moslem Arabs, Druzes, and Christian Arabs in Israel. METHOD: The average yearly rates (1975 through 1989) for suicide and undertermined causes of death were calculated for children, adolescents, and subjects of army age. Rates were examined by gender, national/religious affiliation, and place of residence for all groups and, in addition, by ethnic origin among the jews. Logistic regression was used to ascertain the statistical differences. Temporal changes were examined by plotting the rates over the 15-year period and fitting a regression line. RESULTS: Among the young, differences by gender, national/religious, and ethnic origin did not consistently follow the pattern found in adults. Male Jews and Druzes of army age, facing a period of enhanced stress and availability of weapons, showed increased risk for suicide. Temporal trends for suicide differed from the worldwide pattern of increasing risk; these changes, however, were not homogeneous across all groups. CONCLUSIONS: The suicide rates among the youth in Israel, as in adults, are among the lowest in the world. Army service may be a period of enhanced risk, justifying preventive action. The almost worldwide trend of increasing suicide among the young is only partially present.

The primary medical care practitioner's attitudes toward psychiatry. An Israeli study.

General practitioners are important to the delivery of mental health care because they perform three important functions, as an identifier, as a referral agent and as a caregiver. This study investigates the importance of the attitudes G.P.s hold on their performance of two of these functions, screening and referring. Relying on items developed in previous investigations, four measures of attitudinal dimensions are developed using factor analysis: Belief in Psychogenesis, Psychiatric Fatalism, Referral Reluctance and G.P. as Caregiver. These attitude dimensions are then related to the functions of screening and referral. Three major findings emerge from the results. First, the attitudinal dimensions uncovered are empirically distinct, suggesting that no single pro-to-anti psychiatry is present. Second, attitudes play a role in the screening of cases. A G.P. is more likely to identify cases if he believes in the psychogenesis of physical disorders, and is not concerned that identification and referral will lead to negative consequences for the patient. Third and finally, attitudes do not play a strong role in the referral of cases once they have been identified as such. The findings are presented and interpreted by referring to the sensitive position G.P.s occupy between the public and the psychiatrist.

The restructuring of psychiatric care in Latin America: a new policy for mental health services.

This article discusses the epidemiologic and programmatic bases for action as well as the political, historical and technical background for "The Initiative for Restructuring of Psychiatric Care in Latin America." It discusses also the broad implications of this health policy, the modus operandi of its implementation and monitoring, and the chief obstacles that it has encountered. Lastly, it briefly sketches the results obtained thus far.

Nongenetic familial transmission of psychiatric disorders? Evidence from children of Holocaust survivors.

There is considerable evidence that psychiatric disorders aggregate in families, a phenomenon for which both genetic and nongenetic explanations have been proposed. However, since genetic and social inheritance usually co-occur, it is difficult to separate out their effects. In this paper, we argue that examining the rates of disorder among children of Holocaust survivors provides a special situation where genetic and nongenetic factors in familial transmission can be separated, and where specific nongenetic mechanisms can be tested. We specify competing hypotheses, and test their viability using data from an epidemiological study of psychiatric disorders conducted in Israel. We find no evidence of higher symptom scale scores or higher rates of current psychiatric disorders for the children of Holocaust survivors. However, they did have higher rates of past disorders.

The epidemiology of suicide in Israel: international and intranational comparisons.

A comparison of overall rates of completed suicide is made between Israel and selected European and North American countries. Rates for Israel are generally lower. A second comparison is made among different national-religious groups in Israel. Rates are higher for Jews than for the Muslim minority. An explanation is attempted for both sets of findings.