Smell Function in Schizophrenia During Acute Psychosis and Correlation with Clinical Symptomatology and Length of Hospitalization.

BACKGROUND: While several studies have noted smell impairment in schizophrenia, it is unclear whether this impairment extends to acute psychosis and whether it is associated with more severe illness as expressed in extended hospitalization. OBJECTIVES: To evaluate the olfactory function of patients in an acute psychotic state and correlate it with clinical symptomatology and length of hospitalization. METHODS: Olfactory function was assessed in 20 patients with schizophrenia in their first week of hospital admission for acute psychosis compared with matched controls. Olfaction was evaluated via three stages: threshold, discrimination, and identification of different odors utilizing the Sniffin' Sticks test battery. RESULTS: Schizophrenia patients scored significantly lower on total smell score, discrimination, and identification abilities. A significant association was observed between hospitalization duration and total smell score and smell discrimination. No significant associations between smell and clinical symptomatology were observed. CONCLUSIONS: Study observations confirm impaired sense of smell in schizophrenia patients and suggest that smell impairment may be a potential marker of more serious illness as expressed in longer hospital stay.

'Witness in White' medical ethics learning tours on medicine during the Nazi era.

During the Nazi era, physicians provided expertise and a veneer of legitimacy enabling crimes against humanity. In a creative educational initiative to address current ethical dilemmas in clinical medicine, we conduct ethics learning missions bringing senior physicians to relevant Nazi era sites in either Germany or Poland. The tours share a core curriculum contextualising history and medical ethics, with variations in emphasis. Tours to Germany provide an understanding of the theoretical origins of the ethical violations and crimes of Nazi physicians. Tours to Poland address the magnitude of the Nazi physician's atrocities as well as displays of heroism by Jewish and righteous among the nations' physicians. Exemplary as well as shameful physician behaviour is analysed from an ethical perspective. A combination of unique educational methodologies maximises learning and personal growth, enabling participants to examine ethically complex clinical situations with extrapolation to modern-day medical practice. Learning is designed with relevance to contemporary medical ethics dilemmas such as beginning and end-of-life issues, providing tenets from which participants can develop as more ethical and informed physicians. Participant feedback confirms efficacy and worth of these growth-promoting ethics learning tours which should be expanded to other international groups and settings (see online film Witness in White Berlin 2019 available at https://www.youtube.com/watch?v=75VUZvo3Bec).

Role of Religion in Psychotic Illness in the Israeli Ultra-Orthodox Jewish Population: Patient Beliefs and Expectations.

ABSTRACT: This study aims to describe the role that religion and belief may play in members of the Israeli ultra-Orthodox Jewish population hospitalized in the Mayanei Hayeshua Medical Center and diagnosed with a psychotic disorder. Religion was judged essential by the patients in the management of their illness. Forty percent of the patients perceive their illness as their destiny, 26.7% as an "affliction of love," and 33.3% as resulting from their sins. Sixty percent of patients explained that faith is a source of hope in their life, with 76.7% indicating that collective religious practices help them face their illness. Ninety percent expressed no conflict between consulting a psychiatrist and their religious beliefs. Collective religious practices were correlated with higher treatment credibility. The use of religious coping methods was correlated with lower anxiety and tension among women. Higher conflict between religion and consulting a psychiatrist was correlated with lower treatment credibility among men.

Anxiety Reactions and Coping Modalities with the COVID-19 Pandemic: A Cross-Sectional Study Comparing a Population of Religious Patients with Mental Illness and their Health Caregivers.

This study evaluates the nature and intensity of anxiety, interpretations of the COVID-19 pandemic and coping modalities of hospitalized patients with mental illness compared with their caregivers. One hundred and fifty-one subjects were evaluated with a specially designed questionnaire. Psychiatric inpatients reported more anxiety and more negative feelings than staff members and healthy subjects, but inpatients felt protected by the hospital and Ministry of Health (MoH) measures. Despite this anxiety, inpatients reported a lower compliance with MoH instructions than staff and healthy subjects and gave more fatalistic interpretations to the pandemic. Haredi study participants reported less anxiety, more optimism and had a higher sense of control regarding the pandemic compared to non-religious participants.

Psychiatry and COVID-19: putting our best foot forward.

COVID-19 presents new challenges for psychiatry as clinical management, ethical dilemmas and administrative complications need to be addressed. The psychiatrist should protect the needs and rights of the mentally ill while maximising population health and ensuring solidarity, reciprocity and community well-being for all.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

["WITNESS IN WHITE" SEMINAR TOURS ON MEDICINE AND PHYSICIANS IN THE HOLOCAUST].

INTRODUCTION: The Holocaust represents a seminal event in the annals of medicine. For the first time in history, doctors played a prominent role in the extreme abuse of medical rights, violation of medical obligation to patients, infringement of patient autonomy, forced and unnecessary invasive and damaging procedures for political purposes and the ultimate injustice of involuntary euthanasia. Physicians provided the legitimacy, know-how and momentum that allowed these processes to take place in a symbiotic relationship with the political establishment during the Nazi era. It is critical that modern day physicians be aware of what transpired during this period. For that purpose, we describe a multiyear program bringing Israeli physicians on a learning mission to relevant sites of medical involvement and complicity in Nazi era crimes. These guided educational tours, under the auspices of the Israel Medical Association, originally took place in Poland and more recently, alternately visit Germany and Poland. At all sites, background information on medical practice during the Nazi era is provided, as well as ethical discussions on the merits (positive) or demerits (negative) of physicians who played a role at those particular locations. In addition to site visits, background discussions and lectures are provided to achieve a more comprehensive, deeper and more profound understanding of the issues. Emphasis is placed on learning from examples with relevance to modern day medicine, thus providing the principles from which participants can grow to become more ethical, principled and sensitive physicians as well as individuals. The tour includes formal and emotional ceremonies when relevant at extermination sites where physicians were directly involved, as well as focus groups allowing and encouraging emotional expression and catharsis. The critical role of personal growth during the tour is emphasized with both pre-tour and post-tour meetings providing buffering on both ends. Participants and staff, as well as documented feedback over the years, attest to the utility and profound value of these learning and growth-oriented medical missions.

Ethical lessons learned and to be learned from mass casualty events by terrorism.

PURPOSE OF REVIEW: The world has seen a major upturn in international terror awareness. Medicine has had to respond. In addition to the unique physical and mental injuries caused by terror which require special clinical attention, so too terror represents a challenge for medicine from an ethics perspective. RECENT FINDINGS: Several responses in the literature over the past few years have attempted to reflect where the battlefront of ethical dilemmas falls. These include issues of resource allocation, triage, bioterror, the therapeutic relationship with terrorists, dual loyalty, and challenges in the role in the promotion of virtuous behavior as a physician under difficult conditions. SUMMARY: Although many challenges exist, physicians need to be prepared for ethical response to terror. With their associated unique status, providing legitimacy and specialized ability in the management and approach to terror situations, physicians are held to a higher standard and need to rise to the occasion. This is required in order to promote ethical behavior under trying conditions and ethical sensitivity of the medical profession by means of being attuned to the reality around.

[TREATMENT ISSUES IN PSYCHIATRY IN THE MANAGEMENT OF THE HAREDI SUBPOPULATION].

INTRODUCTION: In recent years, the importance of cultural sensitivity and the adaptation of mental health services to diverse populations has been growing. Simultaneously, awareness of psychiatric illnesses and treatment is increasing, even among the Haredi (ultra-orthodox) population in Israel, with specialized services developing. Many studies have emphasized the central role of religion and belief in the coping styles of those with mental illness and their healing processes. These characteristics are especially evident among the Haredi population, where religion is present in behavior, in thought, both within the individual and in the community, and throughout life. In the encounter between a religious Haredi patient and the professional, many issues arise regarding religion and the patient's socio-cultural affiliation. Being familiar with this world, including unique concepts and sensitivity to these issues, can promote treatment that is provided to ultra-orthodox individuals with mental-illness in a manner that is culturally sensitive. These issues include specific expressions and manifestations of psychiatric illness in the religious Haredi patient, and issues related to the specific Haredi community to which the patient belongs. Discussions in the literature and halakhic rulings are divided into issues concerning the patient, religious law observance by the patient with mental-illness, issues regarding treatment coercion, pregnancy, and issues relating to therapy, such as "privacy" and "life and death" dilemmas. Unique expressions of psychiatric disorders in the Haredi patient may be noted in eating disorders, psychosis and OCD, both in clinical terms and in prognosis and disease processes. Factors related to society and the ultra-orthodox community to which the psychiatric patient belongs include issues of stigma and secrecy that are maintained by the community in relation to mental illness; interference by non-professional individuals involved in treatment; as well as the distinctiveness of treatment and rehabilitation adapted to the Haredi population and finally cultural sensitivity to the needs of the religiously observant patient (such as avoiding desecration of Shabbat, rehabilitation in unique areas such as Torah study, etc.).

Exercise, Dehydroepiandrosterone (DHEA), and Mood Change: A Rationale for the "Runners High"?

BACKGROUND: Although exercise has been shown to improve mood and well-being, the precise mechanism remains unknown. Neurosteroids are important neuroactive molecules with demonstrated involvement in several neurophysiological and disease processes. Previous research has noted neurosteroid changes in dehydroepiandrosterone (DHEA) levels following exercise. OBJECTIVES: To determine whether changes in DHEA levels are associated with mood improvement after exercise and whether there are any differences in the effects on younger and older individuals. METHODS: Individuals ≤ 50 years of age or > 65 years of age were recruited for study participation. Before and after 30 minutes of a standardized cycling regimen, each patient provided a blood sample and completed a questionnaire on mood and well-being. RESULTS: Findings confirmed a significant increase in DHEA levels post-exercise. A decrease in negative factors (fatigue, tension, depression, anger) and an increase in positive mood factors were noted. No difference in change of measures was noted between younger and older subjects. A positive correlation was noted between mood change and DHEA blood-level changes in older subjects. Among older males, DHEA appeared to be associated with mood change after exercise. CONCLUSIONS: While preliminary, findings indicate a possible association between mood improvement following exercise and DHEA blood level changes. Understanding the biological mechanisms of exercise-induced mood changes is critical to utilizing exercise as a treatment for mood disorders.

Second thoughts about who is first: the medical triage of violent perpetrators and their victims.

Extreme intentional and deliberate violence against innocent people, including acts of terror and school shootings, poses various ethical challenges, some related to the practice of medicine. We discuss a dilemma relating to deliberate violence, in this case the aftermath of a terror attack, in which there are multiple injured individuals, including the terror perpetrator. Normally, the priority of medical treatment is determined based on need. However, in the case of a terror attack, there is reason to question this. Should the perpetrator of extreme violence receive medical treatment on the scene before the victims if he or she is designated as the most seriously injured? Or rather, should victims receive medical care priority if they are also in some life-threatening danger, although not at the same level of severity as the perpetrator? We present two opposing approaches: the conventional 'no-exceptions' approach, which gives priority to the terrorist, and the justice-oriented 'victim first' approach, which gives priority to the victims. Invoking concepts of retributive justice, distributive justice and corrective justice, this latter approach suggests that 'value-neutrality' can lead to injustice. Perpetrators of terror-like violence should be treated as an act of humanism and good ethical medical practice. However, in clear and obvious terror-like situations, to treat the perpetrators of violence before their victims may be unjust. Thus, in some specific situations, the 'victim first' approach may be considered a legitimate alternative triage policy.

Sex Differences in Psychiatric Hospitalizations of Individuals With Psychotic Disorders.

We aimed to evaluate the association between sex and hospitalization characteristics in psychotic disorders. We identified all acute hospitalizations, between 2010 and 2013, for psychotic disorders in patients younger than 45 and older than 55 years (n = 5411) in the hospital's database. In addition, we identified patients who were prescribed with intramuscular risperidone (n = 280) or clozapine (n = 192) at discharge. The results showed that women younger than 45 years had lower proportions of hospitalizations (33.52% vs. 66.47%) and involuntary hospitalizations (33.85% vs. 45.55%) than did men in the same age group. Women older than 55 years had higher proportions of hospitalizations (57.22% vs. 42.77%) and similar proportion of involuntary hospitalizations. Women younger than 45 years were prescribed similar doses of intramuscular risperidone and lower doses of clozapine (345.8 vs. 380.2 mg) and women older than 55 years were prescribed higher doses of intramuscular risperidone (44.8 vs. 34.4 mg/2 weeks) and clozapine (164.32 vs. 154.5 mg) than were men in the same age group. Women in the reproductive years have better hospitalization characteristics than do men on these measures.

Assessing the Need for Hospitalization in Order to Conduct a Psychiatric Evaluation as part of Criminal Law Procedure.

BACKGROUND: In criminal law, psychiatrists are consulted regarding the "insanity defense" and the defendant's competency to stand trial. Court-ordered hospital admissions for such evaluations are on the increase, creating a major burden on the health system. OBJECTIVES: To assess, in a hospital setting, whether hospitalization of the defendant is necessary for conducting a psychiatric evaluation. METHODS: A 6 month prospective observational study exploring the phenomenon was conducted at the Beer Yaakov Mental Health Center. The psychiatrist was asked both at the initiation and at the end of the assessment process whether the subject was competent to stand trial and responsible for his/her actions and if hospitalization was necessary in order to conduct the evaluation. RESULTS: During the study period there were 112 admissions with a court request for a psychiatric evaluation. In 73 of the cases (65.2%) the evaluating psychiatrist believed there was no need for hospitalization. This assessment did not change by the end of the hospitalization in all cases. Employment and alcohol use were the only factors associated with a lower need for hospitalization (OR 0.24, 95% CI 0.07-0.77, and OR 0.34, 95% CI 0.13-0.90, respectively). CONCLUSIONS: In the majority of cases, based on the evaluating psychiatrist's responses, the evaluation could have been conducted without need for hospitalization. The findings indicate that an outpatient unit designated to write court-requested psychiatric evaluations could significantly reduce the rates of hospital admissions for this purpose.

Attitudes towards euthanasia and assisted suicide: a comparison between psychiatrists and other physicians.

Euthanasia and physician assisted-suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician-assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.

Study of recovery model implementation in psychiatric hospitals: Clients and multidisciplinary staff perspective.

The recovery model guides mental health services. However, the delivery of recovery-oriented services in inpatient settings is still a challenge. Factors affecting recovery model implementation can be classified into three types: the hospital environment, the inpatient and the service provider. This study aims to quantitatively evaluate the impact of environment, inpatient and service provider factors on recovery model implementation in hospitals. Forty-five service providers and 42 inpatients from three types of wards (acute locked, acute open and daycare) of two hospitals participated in this cross-sectional study. We assessed inpatient cognition, functional capacity and illness severity. In addition, we retrieved information on service providers' professional status and evaluated the recovery model knowledge and attitudes. Implementation of the recovery model was measured using the Recovery Self-Assessment, both the inpatient and service provider versions. Differences were found between the three types of wards in recovery orientation as reported by service providers ( χ 2 2  = 15.3, P < 0.001), but not by inpatients ( χ 2 2  = 2.34, P > 0.05). Providers' internalized knowledge and attitudes toward recovery, inpatients' functional capacity and age of illness onset were associated with recovery implementation (0.31 < r < 0.48, P < 0.05). The findings confirm quantitatively the multilevel nature of factors that affect the implementation of the recovery model in psychiatric hospitals. The inpatients' perspective should be incorporated into the service development process. Based on the study results, the reduction in the restrictive features of the wards' environment is recommended. Promotion of the recovery model implementation in the hospital setting requires the expansion of staff's internal positive attitudes toward recovery.

Postmortem brain donation and organ transplantation in schizophrenia: what about patient consent?

In patients with schizophrenia, consent postmortem for organ donation for transplantation and research is usually obtained from relatives. By means of a questionnaire, the authors investigate whether patients with schizophrenia would agree to family members making such decisions for them as well as compare decisions regarding postmortem organ transplantation and brain donation between patients and significant family members. Study results indicate while most patients would not agree to transplantation or brain donation for research, a proportion would agree. Among patients who declined organ donation for transplantation or brain research, almost half of family members would have agreed to brain donation for research and over 40% to organ transplantation. Male relatives are more likely to agree to organ donation from their deceased relatives for both transplantation and research. The authors argue that it is important to respect autonomy and interests of research subjects even if mentally ill and even if no longer living. Consent may be assisted by appropriate educational interventions prior to patient death.

Exposure to antidepressant medications and suicide attempts in adult depressed inpatients.

The effects of antidepressant medication on suicide risk remain unclear. This study explores any association between antidepressant medication and suicide attempts leading to hospitalization in adult depressed patients.The medical records of 103 patients admitted after a suicide attempt were examined and compared with those of a matched control group of depressed patients (n = 103) admitted without suicide attempts as well as a patient group with and without suicide attempts on separate hospitalizations (n = 25). No significant difference in antidepressant medication exposure before hospitalization was found between groups. Selective serotonin reuptake inhibitor exposure was higher in patients with suicide attempts, albeit nonsignificant, but was identical in patients admitted on two occasions with and without suicide attempts. The most common method for suicide attempt was drug overdose (52.4%). Patients in the group with suicide attempts had significantly more past suicide attempts. Study results do not confirm any relationship between antidepressants and suicide attempts. Close monitoring of depressed patients is advised especially in early treatment.

Postpartum post-traumatic stress disorder symptoms: the uninvited birth companion.

BACKGROUND: While many are familiar with postpartum depression, the phenomenon of postpartum post-traumatic stress disorder (PTSD) is less well known and investigated. OBJECTIVES: To assess the prevalence of postpartum PTSD in a cohort of women in Israel and examine factors affecting its development. METHODS: Eighty-nine women completed several ratings immediately post-delivery and after a month. Factors examined related to the pregnancy, childbirth expectations, and delivery. Rating scales comprised evaluations of attachment, personality, PTSD, and demographic variables. RESULTS: The prevalence of post-partum PTSD was 3.4% (complete PTSD), 7.9% nearly complete PTSD, and 25.9% significant partial disorder. Women who developed PTSD symptoms had a higher prevalence of "traumatic" previous childbirth, with subsequent depression and anxiety. They also reported more medical complications and "mental crises" during pregnancy as well as anticipating more childbirth pain and fear. Instrumental or cesarean deliveries were not associated with PTSD. Most of the women who developed PTSD symptoms delivered vaginally, but received fewer analgesics with stronger reported pain. Women with PTSD reported more discomfort with the undressed state, stronger feelings of danger, and higher rates of not wanting additional children. CONCLUSIONS: The study results indicate the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations and increased awareness of the disorder. The importance of addressing anticipatory concerns of pain prior to delivery as well as respecting dignity and minimizing the undressed state during childbirth should not be underestimated. A short questionnaire following childbirth may enable rapid identification of symptoms relevant to PTSD.

Ethical Issues in Medical Rehabilitation: The Dilemma of Who to Admit.

ABSTRACT: Ethical allocation of scare medical resources is a ubiquitous challenge in many, if not all, medical specialties. The field of physical medicine and rehabilitation is no exception and presents its own unique dilemmas. We report on a small inpatient rehabilitation unit at a large university medical center with a large catchment area representing a vast range of socioeconomic classes. The decision of whom to admit is a constant challenge. We review the existing literature regarding ethical considerations in rehabilitation department admission criteria and attempt to analyze criteria used to admit patients to a general physical medicine and rehabilitation ward. Finally, we discuss our medical center approach to the ethical dilemma of admission priority. A systemic search was conducted in six sources (PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS, Embase). Searches were limited to English language articles with no date restriction, reflecting all available data. A reviewer applied the inclusion criteria to identify relevant articles.This review highlights a number of important ethical issues in evaluation and selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation. Further high-quality empirical studies and reviews of ethical admission practice with regard to rehabilitation acceptance are required.