Consenting not to be informed: a survey on the acceptability of placebo use in the treatment of depression.

The aim of this study was to investigate the opinions of healthy students regarding the acceptability of placebo treatment if they were to experience depression. A survey was conducted among 344 students in five academic centers in Israel. After a thorough explanation of the placebo effect, its efficacy and limitations in the treatment of depression, the study participants completed a 32-item self-report questionnaire. Seventy percent (n = 243) of the participants answered that they would agree to treatment with a placebo as a first-line treatment if they were to experience depression in the future. Eighty-eight percent (n = 297) of the subjects did not think that a physician who administered placebos was deceitful. Once aware of the possible benefits and limitations of placebo treatment, most of our study population was willing to accept placebo as a legitimate treatment of depression. Additional studies on the possible use of placebo as an effective, safe, and acceptable form of therapy are warranted.

Older paternal age strongly increases the morbidity for schizophrenia in sisters of affected females.

The effect of a family history of schizophrenia on the risk for this disorder in the offspring has rarely been examined in a prospective population cohort accounting for the sex of the proband and the first-degree relatives, and certainly not with respect to later paternal age. The influence of affected relatives on offspring risk of schizophrenia was estimated using Cox proportional hazards regression in models that accounted for sex, relation of affected first degree relatives and paternal age in the prospective population-based cohort of the Jerusalem Perinatal Schizophrenia Study. Of all first-degree relatives, an affected mother conferred the highest risk to male and female offspring among the cases with paternal age <35 years, however, female offspring of fathers ≥35 years with an affected sister had the highest risk (RR = 8.8; 95% CI = 3.9-19.8). The risk seen between sisters of older fathers was fourfold greater than the risk to sisters of affected females of younger fathers (RR = 2.2, 95% CI 0.7-6.7). The test for interaction was significant (P = 0.03). By contrast, the risk of schizophrenia to brothers of affected males was only doubled between older (RR = 3.3, 95% 1.6-6.6) and younger fathers (RR = 1.6, 95% CI 0.7-3.5). The most striking finding from this study was the very large increase in risk of schizophrenia to sisters of affected females born to older fathers. The authors speculate that the hypothesized paternally expressed genes on the X chromosome might play some role in these observations.

Incidence of schizophrenia among second-generation immigrants in the jerusalem perinatal cohort.

OBJECTIVE: Increased incidence of schizophrenia is observed among some immigrant groups in Europe, with the offspring of immigrants, ie "second-generation" immigrants particularly vulnerable. Few contemporary studies have evaluated the risk of schizophrenia among second-generation immigrants in other parts of the world. METHODS: We studied the incidence of schizophrenia in relation to parental immigrant status in a population-based cohort of 88 829 offspring born in Jerusalem in 1964-1976. Parental countries of birth were obtained from birth certificates and grouped together as (1) Israel, (2) Other West Asia, (3) North Africa, and (4) Europe and industrialized countries. Cox proportional hazards methods were used in adjusting for sex, parents' ages, maternal education, social class, and birth order. RESULTS: Linkage with Israel's Psychiatric Registry identified 637 people admitted to psychiatric care facilities with schizophrenia-related diagnoses, before 1998. Incidence of schizophrenia was not increased among second-generation immigrants in this birth cohort, neither overall nor by specific group. CONCLUSIONS: The difference in risk of schizophrenia among second-generation immigrants in Europe and in this Israeli birth cohort suggests that the nature of the immigration experience may be relevant to risk, including reasons for migration, the nature of entry, and subsequent position in the host country for immigrants and their offspring. Minority status may be of importance as, in later studies, immigrants to Israel from Ethiopia had increased risk of schizophrenia.

Effect of socioeconomic status and parents' education at birth on risk of schizophrenia in offspring.

Although it is known that schizophrenia is associated with social class, controversy exists as to the nature of this association. The authors studied the incidence of schizophrenia in relation to social class at birth in a population-based cohort of 88,829 offspring born in Jerusalem in 1964-1976. They constructed a six-point scale to index social class, based on paternal occupation at the time of birth, with each of 108 occupations being ranked by mean education. Cox proportional hazards methods were used in adjusting for sex, parents' ages, duration of marriage and birth order. Linkage with Israel's Psychiatric Registry identified 637 people admitted to psychiatric care facilities with schizophrenia-related diagnoses, before 1998. There was no gradient of risk for schizophrenia associated with social class at birth; however, offspring of fathers in the lowest social class showed a modest increase in risk (adjusted Relative Risk = 1.4; 95% Confidence interval = 1.1-1.8, P = 0.002). These data suggest that in contrast to many other health outcomes, there is not a continuous gradient for increasing schizophrenia with decreasing social class of origin. Instead, a modest increase in risk for schizophrenia was observed only for those born at the bottom of the social ladder.

Tetrachloroethylene exposure and risk of schizophrenia: offspring of dry cleaners in a population birth cohort, preliminary findings.

Tetrachloroethylene is a solvent used in dry cleaning with reported neurotoxic effects. Using proportional hazard methods, we examined the relationship between parental occupation as a dry cleaner and risk for schizophrenia in a prospective population-based cohort of 88,829 offspring born in Jerusalem from 1964 through 1976, followed from birth to age 21-33 years. Of 144 offspring whose parents were dry cleaners, 4 developed schizophrenia. We observed an increased incidence of schizophrenia in offspring of parents who were dry cleaners (RR=3.4, 95% CI, 1.3-9.2, p=0.01). Tetrachloroethylene exposure warrants further investigation as a risk factor for schizophrenia.

Points to ponder regarding contemporary psychiatric training in Israel.

In an era in which neuroscience is developing rapidly and different psychotherapeutic modalities are proliferating, psychiatric training encounters new difficulties. This article raises various issues that the authors feel are not adequately addressed in contemporary psychiatric residency programs in Israel. These include basic issues of doctor-patient relationship; different cultural trends such as the increase in popularity of CAM (complementary and alternative medicine), the increase in substance abuse, and the increasing popularity of different spiritual movements; transcultural aspects affecting the prevalence and understanding of different psychopathologies in various sectors of the population; ethical issues particular to psychiatric research; and the future psychiatrist's role as communicator and educator of GPs, mental health workers and the general public. In a time characterized by an abundance of models and theories in psychiatry, the authors stress the need to assist residents in integrating various theories and models into a comprehensive outlook regarding the psyche and psychiatric disorders. As mental hospitals vary greatly in their general psychiatric outlook, emphases, and competence of the senior staff in different fields and treatment modalities, the authors see programs for continuing medical education (CME) as the natural arena in which the issues mentioned in this paper should be addressed.

Maternal household crowding during pregnancy and the offspring's risk of schizophrenia.

BACKGROUND: Animal models of schizophrenia suggest a link between maternal crowding during pregnancy and increased risk of the offspring to develop physiological, developmental, and behavioral abnormalities that are comparable to those observed in schizophrenia. We tested the hypothesis that a similar link is present in humans. METHOD: We investigated whether prenatal exposure to household crowding was associated with the risk of schizophrenia in a sub-cohort of the Jerusalem Perinatal Study (JPS) consisting 11,015 individuals born between 1964 and 1976. During these years mothers participated in face to face interviews in early pregnancy. The prenatal and birth data, including the number of rooms and individuals living in the mothers' household, was cross-linked with the Israel Psychiatric Registry by ministry personnel. RESULTS: 104 schizophrenia cases were identified in the cohort. Offspring who, while in utero, their mother resided in a household with five or more individuals had RR of 1.47 (95% CI: 0.99-2.16, p=0.05) to develop schizophrenia, compared to those whose mother resided with four or fewer individuals. However, when adjusted for paternal age, the RR was reduced to 1.18 (95% CI: 0.76-1.84, p=0.46). The number of rooms in the household and the household crowding during pregnancy did not significantly impact the offspring's risk to develop schizophrenia. CONCLUSION: The link between maternal household crowding during pregnancy and the offspring's risk of schizophrenia was explained primarily by the impact of paternal age. The authors discuss the results in view of findings from animal and human studies.

Can we treat morbid obese children in a behavioral inpatient program?

Cognitive-Behavioral therapy (CBT) combined with a family -based intervention has proven as the most effective psychological approach for eating disorders in children and adolescents. The aim of the present paper is to present such a program in a population of severe morbid obese pediatric patients in an inpatient setting in our medical psychiatric unit specializing in the treatment of eating disorders. Our CBT program was developed according to the Cooper/Fairburn approach to the treatment of obesity. The program is organized in a series of treatment modules that include: 1. starting treatment: pre-admission phase; 2. establishing and maintaining weight loss; 3. encouraging acceptance, addressing realistic expectations to body weight, and addressing body image concerns; 4. long-term weight maintenance. Family intervention and physical activity were implemented throughout the program. The children enrolled in our program suffer from morbid obesity with life-threatening medical complications such as obstructive sleep apnea, intra-cranial pressure, and debilitating joint disease that required an aggressive, invasive approach. The aim of the program is not only to achieve a rapid weight reduction and avoiding invasive medical procedures, but also to minimize subsequent weight regain. Two patients representing the complexity of conducting the program are presented.

Clients' reasons for terminating psychotherapy: a quantitative and qualitative inquiry.

OBJECTIVE: To study private-practice clients' perspective on reasons for psychotherapy termination and how these are related to demographic and treatment variables and to satisfaction with therapy. DESIGN: Eighty-four persons who had been in extended private-practice psychotherapy which ended in the preceding three years participated in the study. Mean number of months in treatment was 27.70 (SD = 18.70). METHOD: Assessment included rating scales and open-ended questions assessing demographic variables, reasons for terminating therapy, and satisfaction with therapy. RESULTS: Quantitative results revealed that the most frequent reasons for termination were accomplishment of goals, circumstantial constraints and dissatisfaction with therapy, and that client satisfaction was positively related to positive reasons for termination. Qualitative results revealed two additional frequently mentioned reasons for termination: the client's need for independence and the client's involvement in new meaningful relationships. CONCLUSIONS: Findings suggest that psychotherapy termination may at times be required to facilitate the pursuit of personally meaningful goals.

Clients' feelings during termination of psychodynamically oriented psychotherapy.

Although the termination stage of psychotherapy is known to evoke powerful feelings, it has rarely been the subject of systematic investigation, and its relation to other aspects of therapy has not been evaluated. In the present study, we explored clients' feelings during termination of psychodynamically oriented psychotherapy and examined how these feelings are related to satisfaction with psychotherapy. Eighty-four persons who had been seen in private-practice psychodynamically oriented psychotherapy were assessed using open-ended questions and rating scales focusing on their feelings during termination. Results of the current study indicate that clients experience a wide range of feelings, many positive, during the termination phase of therapy. Factors that contributed to positive feelings were the experience of termination as a practice of independence, a reflection of positive aspects of the therapeutic relationship, and positive gains experienced in therapy. Loss of a meaningful relationship was the most frequently mentioned factor contributing to negative feelings during termination. Longer treatment was related positively to positive feelings toward termination and satisfaction with termination. The importance of incorporating the positive feelings about termination into the ending phase of therapy and its management are discussed.

Paternal age and intelligence: implications for age-related genomic changes in male germ cells.

BACKGROUND: A robust association between advancing paternal age and schizophrenia risk is reported, and genetic changes in the germ cells of older men are presumed to underlie the effect. If that is so, then the pathway may include effects on cognition, as those with premorbid schizophrenia are reported to have lower intelligence. There are also substantial genetic influences on intelligence, so de novo genetic events in male germ cells, which accompany advancing paternal age, may plausibly influence offspring intelligence. OBJECTIVE: An association of paternal age with IQ in healthy adolescents may illuminate the mechanisms that link it to schizophrenia. METHOD: We examined the association of paternal age and IQ scores using the Israeli Army Board data on 44 175 individuals from a richly described birth cohort, along with maternal age and other potential modifiers. RESULTS: A significant inverted U-shaped relationship was observed between paternal age and IQ scores, which was independent from a similar association of IQ scores with maternal age. These relationships were not significantly attenuated by controlling for multiple possible confounding factors, including the other parent's age, parental education, social class, sex and birth order, birth weight and birth complications. Overall, parental age accounted for approximately 2% of the total variance in IQ scores, with later paternal age lowering non-verbal IQ scores more than verbal IQ scores. CONCLUSION: We found independent effects of maternal and paternal age on offspring IQ scores. The paternal age effect may be explained by de novo mutations or abnormal methylation of paternally imprinted genes, whereas maternal age may affect fetal neurodevelopment through age-related alterations in the in-utero environment. The influence of late paternal age to modify non-verbal IQ may be related to the pathways that increase the risk for schizophrenia in the offspring of older fathers.

Reduced punishment in Israel in the case of murder: bridging the medico-legal gap.

The psychiatrist's assessment of criminal responsibility of an accused in court for an act of crime has always been a matter of great difficulty. In 1997, clause 300a was incorporated into the Penal Code of Israel, thereby permitting a more lenient punishment for murder than mandatory life imprisonment. The clause includes the definition of what is meant by "severe mental disorder" and "significantly restricted capacity" by the defendant to understand the criminal nature of his or her act and to refrain from committing it. Usage of the concepts "disorder" and "significantly restricted capacity" in addressing the issue of diminished responsibility of the mentally ill is new to the Israeli legal code. The emergence and evolvement of the above concepts are presented through a historical review of the Israeli encoded law concerning mental illness, analyzed from a psychiatric perspective.

Ethical dilemmas in psychotherapy: comparison between patients, therapists and laypersons.

BACKGROUND: The attitudes of patients towards ethical dilemmas in psychotherapy have been reported in only a few studies. AIMS OF THE STUDY: We investigated whether the attitudes of patients undergoing psychotherapy to confidentiality and boundaries are different from those of therapists and laypersons. METHODS: Clinical vignettes describing ethical dilemmas of confidentiality and boundaries were presented to 103 patients undergoing psychotherapy (patient group), 93 psychotherapists of different professional backgrounds (professional group), and 55 staff and students from the fields of law and the humanities (lay group). Patients were asked how they think therapists should act in the situations presented and therapists were asked how they should behave in such situations. RESULTS: In general, the patient group showed a greater tendency to view their therapists as breaching confidentiality than the professional and lay groups. Regarding boundaries, the majority of psychotherapists were against initiating any sexual relationship with current patients, former patients, students or supervisees, whereas both patients and laypersons showed a less stringent attitude; these differences were statistically significant. The vast majority of therapists (96.7%) disapproved of accepting money in advance compared to only 31.1% in the patients group and 54.4% of the lay group. Analysis of the patients group by gender did not reveal any significant relationships. CONCLUSIONS: (1) Patients have different ethical codes from therapists and laypersons regarding the issues of confidentiality. (2) Patients and lay persons are less strict than therapists regarding issues of boundaries.

Identification of Emotional Distress Among Asylum Seekers and Migrant Workers by Primary Care Physicians: A Brief Report.

BACKGROUND: Emotional distress (ED) is prevalent among immigrants. The open clinic of Physicians for Human Rights (PHR)-Israel provides free medical and psychiatric treatment to immigrants without access to the ambulatory health service. In 2010, the psychiatric records represented 1% of the total medical files (N=28,000) in the open clinic. OBJECTIVE: To compare service users' self-reported ED and its identification by general practitioners (GP) and to identify socio-demographic variables associated with ED. METHOD: A convenience sample (N=97) of the general medical service users completed the 12-item version of the General Health Questionnaire (GHQ-12). A score of 11 or above was considered a suspected mental disorder. The GPs' clinical assessment of ED was compared with the self-reported score. RESULTS: The sample's mean GHQ-12 score was higher than the threshold (M=12.7, SD=6.3, range 0-35). Fifty three percent (n=51) had a GHQ-12 score higher than 11, and 8% (n=8) were identified by the GPs as emotionally distressed and/or in need of psychiatric care. The mean score of the study sample was higher than that found in past studies regarding the Arab-Israeli general population (M=10.8, SD=0.35). Employment was the only socio-demographic variable significantly associated with ED. CONCLUSIONS: ED was high among immigrants, but under-diagnosed by GPs. Employment might serve as a protective factor for ED.

Differences in age of first hospitalization for schizophrenia among immigrants and nonimmigrants in a national case registry.

While previous studies have found an increased incidence of schizophrenia in some immigrant groups, differences in age of onset in these groups has not been examined. The purpose of this study was to compare age of first hospitalization of (1) native-born people versus immigrants, (2) immigrants from different countries of origin, and (3) first generation immigrants versus second generation immigrants; and to reexamine gender differences in age of first hospitalization. Data were extracted on all first hospital admissions nationally for the years 1978-1992 (n = 10,902) from the National Psychiatric Hospitalization Case Registry of the State of Israel Ministry of Health. Immigrants were older at time of first hospitalization than nonimmigrants, with considerable variations between different countries of origin. Second generation immigrants (i.e., born in Israel to immigrant parents) had ages of first hospitalization similar to people with native-born parents. Males had earlier ages at first hospitalization than females. The results suggest that immigration may have a delaying effect on age of first admission and support previous findings regarding gender difference in age of onset.

Physical recovery in anorexia nervosa: is this the sole purpose of a child and adolescent medical-psychiatric unit?

Patients with anorexia nervosa are discharged from inpatient medical psychiatric wards on achievement of their target weight ("physical recovery") or even earlier. However, recent studies have consistently revealed that a very high percentage relapse, usually within a year. We hypothesized that the more rapid pace of physical compared with psychological recovery in anorexia nervosa creates a gap or interim stage when inpatients are particularly vulnerable. This phase has its own identifiable characteristics and prognostic value. To counter this problem, we formulated a treatment model where patients in the "physical recovery" stage participate in a follow-up program within the inpatient unit itself concomitant with individual psychotherapy at the outpatient community service. The program helps to preserve the strong therapeutic alliance established during hospitalization and to maintain the patient's base of security against the loss of the "anorectic solution." The program provides a full range of services--inpatient, day-treatment and follow-up, adapting itself to the changing needs of the patient. It has been in effect in our unit for three years, and the rate of relapse has decreased dramatically. Further controlled studies are needed to confirm these findings.

Schizophrenia risk and paternal age: a potential role for de novo mutations in schizophrenia vulnerability genes.

How schizophrenia (SZ) is maintained at roughly 1% of the population despite diminished reproduction is one puzzle currently facing researchers. De novo mutations were first proposed over half a century ago as a source for new SZ genes. Current evidence linking advancing paternal age to SZ risk makes revisiting this hypothesis important. Advancing paternal age is the major source of new mutations in the human population. This article will examine potential mechanisms whereby parental age may impact new mutations, as well as review recent data supporting such a hypothesis.

Predictions made by psychiatrists and psychiatric nurses of violence by patients.

Studies have shown that it is difficult for psychiatrists to accurately predict which patients will be violent while hospitalized. The authors compared the predictions of 14 psychiatrists and nine psychiatric nurses who independently evaluated 308 patients consecutively admitted to a hospital in Israel and rated their likelihood of becoming violent. The psychiatrists and nurses also completed a general questionnaire about the criteria they used to predict violence. No significant differences were found in the accuracy of predictions between the two professional groups or in the criteria they used to predict violence. The total predictive value, or proportion of all cases predicted correctly, was 82 percent for the psychiatrists and 84 percent for the nurses. The predictions of the two groups coincided for 83 percent of the patients. The results suggest that psychiatrists and psychiatric nurses make similarly accurate predictions of violence and use similar criteria for making them.

Personality disorders as grounds for reduced sentence in murder cases.

Clause 300 A (A) of the Israel penal code stipulates that severe mental disorder may serve as grounds for reduced sentence in cases of murder. There is an unresolved debate in the forensic psychiatric field whether severe personality disorders are included in this category. We present a set of criteria for applying this clause to offenders with personality disorder and demonstrate through three cases how these criteria can be used. All three cases had the following basic characteristics: A. Established diagnosis of severe personality disorder on the basis of historical data from multiple sources and in accordance with the evidence presented to the court. B. Presentation of a coherent description of the content of the murder as it directly affected the offender's severe impairment, with a strong link between the pathology and the offender's reduced capacity to understand or avoid the act. C. Establishment of the significantly limiting impact of the personality disorder on the offender's capacity to avoid the act, as based on the evidence presented to the court. We conclude that guidelines for formulating the psychiatric assessment and court report are feasible and necessary in these cases. Further experience in this area is needed until definite conclusions can be reached. Further studies are needed to confirm the suitability of this method.

Attitude of general practitioners towards psychiatric consultation in primary care clinic.

Fifty general practitioners (GPs) were surveyed about their attitudes towards psychiatric liaison-consultation services. The questionnaire differentiated among GPs' attitudes towards the liason-consultation model and towards the various possible roles of the psychiatrist who visits the GP's practice. These attitudes were analyzed in relation to the level of post-graduate training of the GPs, and to their psychological sensitivity as measured by the PMI scale. GPs with specialist registration certificates in family medicine were more interested in working together with psychiatrists and rated themselves as more sensitive to psychological issues. The largest group (39%) among the GPs thought that the main task of the visiting psychiatrist is to advise them on psycho-social issues, while leaving clinical responsibility in their hands. Less frequent responses included: diagnosis and treatment within the primary care clinic (17%), facilitating referrals (15%), and update teaching of psychiatry (12%). The predominant attitude was consistent with the finding that 96% of the GPs thought that they had good abilities at recognizing patients in distress, and 92% rated their doctor-patient relationship skills as high.