Long-term efficacy of a continuity-of-care treatment model for patients with severe mental illness who transition from in-patient to out-patient services.

BACKGROUND: Despite its significance, ensuring continuity of care demands substantial resources, which might not be readily accessible in many public healthcare systems. Studies indicate that continuity of care remains uncertain in numerous healthcare systems. AIMS: This study aimed to assess the effectiveness of a continuity-of-care model for patients with severe mental illness (SMI), providing seamless treatment from discharge from a closed ward to subsequent psychiatric, psychological and rehabilitation services. METHOD: Data from patients discharged before (1 January to 31 December 2018) and after (1 June 2021 to 31 May 2022) full implementation of the model were analysed and compared in terms of average duration of hospital stay, emergency department visits within 90 days of discharge, readmission rate within a year post-discharge and initiation of rehabilitation process. RESULTS: In the post-implementation period (n = 482), the average admission time significantly decreased from 30.51 ± 29.72 to 26.77 ± 27.89 days, compared with the pre-implementation period (n = 403) (P = 0.029). Emergency department visits within 90 days following discharge decreased from 38.70 to 26.35% of discharged patients (P < 0.001). The rate of readmission decreased from 50.9 to 44.0% (P = 0.041) for one readmission and from 28.3 to 22.0% (P = 0.032) for two readmissions in the year following discharge. Additionally, the proportion of patients entering formal rehabilitation increased from 7.94 to 12.03% (P = 0.044). CONCLUSIONS: This study highlights the effectiveness of a continuity-of-care model spearheaded by senior psychiatrists and involving paramedical personnel. These findings underscore the significant potential of the model to substantially enhance mental health services and outcomes. Moreover, they emphasise its relevance for patients, clinicians and policy makers.

Not All Days Were Created Equal-Better Day Orientation Following the Weekend on Mini-Mental State Examination (MMSE).

OBJECTIVE: The aim of this study was to test whether patients are better oriented to the day on the first working day following the weekend (in Israel-Sunday), compared with other weekdays, on the Mini-Mental Score Examination (MMSE). METHODS: All MMSE scores from November 2016 until December 2022 in our mental health center's computerized system were collected. The proportion of correct answers to orientation to the day was compared between weekdays. RESULTS: The cohort consisted of 2049 MMSEs taken by 1376 patients [average age 80.3 (SD=9.3), 56.4% female]. The difference between the proportion of correct and incorrect answers was statistically significant between the days, of which Sundays showed a larger difference (53.4%) compared with the other days (χ 2 =20.77, P <0.001, Cramer V =0.104). A statistically significant odds ratio (OR) for providing a correct response was found for Sundays (OR=1.55, P =0.001) and, to a lesser extent, on Thursdays (OR=1.29, P =0.01). The difference between Sundays and other weekdays disappears as the total MMSE decreases. CONCLUSION: Day orientation on the MMSE may be better on the first day following the weekend, especially in early cognitive decline. CLINICAL IMPLICATIONS: The weekday in which the MMSE is performed may influence its results.

Peripartum dissociation, sense of control, postpartum posttraumatic stress disorder and emotional adjustment to motherhood in adult survivors of childhood maltreatment.

Survivors of childhood maltreatment (CM) may experience difficulties in the peripartum period and in adjustment to motherhood. In this study we examined a model wherein CM is associated with maternal self-efficacy and maternal bonding three months postpartum, through mediation of peripartum dissociation and reduced sense of control during childbirth and postpartum-posttraumatic-stress disorder (P-PTSD). Women were recruited in a maternity ward within 48 h of childbirth (T1, N = 440), and contacted three-months postpartum (T2, N = 295). Participants completed self-report questionnaires: peripartum dissociation, sense of control (T1), and CM, P-PTSD, postpartum-depression, maternal self-efficacy and bonding (T2). Obstetrical data were collected from medical files. Structural equation modeling was conducted to test the hypothesized model, controlling for mode of delivery and postpartum-depression. Reported CM included child emotional neglect (CEN; 23.5%), child emotional abuse (CEA; 16.3%), child sexual abuse (CSA; 12.9%) and child physical abuse (CPA; 7.1%). CM was positively associated with peripartum dissociation and P-PTSD (p < .001). Peripartum dissociation was positively associated with P-PTSD (p < .001). P-PTSD was negatively associated with maternal self-efficacy (p < .001) and maternal bonding (p < .001). Association between CM and maternal self-efficacy and bonding was serially mediated by peripartum dissociation and P-PTSD, but not by sense of control. Findings remained significant after controlling for mode of delivery and postpartum-depression. CM is a risk factor for adjustment to motherhood, owing to its effects on peripartum dissociation and P-PTSD. Implementation of a trauma-informed approach in obstetric care and recognition of peripartum dissociative reactions are warranted.

Proximity to COVID-19 patients and role-specific mental health outcomes of healthcare professionals.

BACKGROUND: Healthcare professionals (HCPs) experience extreme hardships and challenges during the time of COVID-19, due to their professional roles. At the same time, HCPs may experience a feeling of importance as contributing members of the community, which could enhance their well-being alongside COVID-19-work-related stressors. AIMS: This cross-sectional study examined the relationship between HCPs' proximity to COVID-19 patients and role-specific fears of COVID-19 and sense of emotional, social and psychological well-being. METHODS: Participants (N = 1,378) included: HCPs who treated COVID-19 patients (frontliners, n = 188), HCPs that did not work directly with COVID-19 patients (secondliners, n = 524), and a group of non-HCPs who served as the comparison group (n = 666). Participants completed the Depression and Anxiety Stress Scale-21; Fear of COVID-19 Scale; Fear of COVID-19 Familial Infection Scale; and the Mental Health Continuum Short-Form. RESULTS: Results indicate that the comparison group reported higher levels of fear of COVID-19 compared to secondliners, while frontliners reported the highest levels of fear of infecting their families. Frontliners and secondliners HCPs reported significantly higher levels of social and psychological well-being compared to the non-HCP group. CONCLUSIONS: This study indicates that there are role-specific mental health outcomes related to HCP's proximity to COVID-19 patients.

Patterns of psychiatric hospitalizations among migrant workers and asylum-seekers in Israel: a single hospital archive study, 2005-2011.

Aim: Migrants have increased risk for psychiatric hospitalizations. Over the last decades Israel has become a destination for migration of migrant workers and asylum-seekers.Methods: The current retrospective study retrieved socio-demographic, clinical and migration-related chart data for 117 migrants admitted to a major Israeli psychiatric hospital between 2005-2011, to delineate characteristics and risk-factors for psychiatric hospitalizations. Multivariate logistic regression analyses were performed to predict re-hospitalization.Results: Of the study sample, 61% were single men, 20% had been exposed to trauma, 15% had prior psychiatric hospitalizations and 24% had attempted suicide. Approximately, 76% were involuntarily hospitalized and diagnosed with psychosis. None were diagnosed with PTSD. Approximately, 20% were re-hospitalized. Factors significantly associated with re-hospitalization were male gender (OR = 15.2, 95%, CI 1.8-126.9, p = 0.012), prior psychiatric hospitalization (OR = 15.4, 95% CI 2.1-111.9, p < 0.01), being single (OR = 5.96, 95% CI1.14-31.07, p = 0.03) and traumatic exposure (OR = 4.75, 95% CI: 1.17-19.36, p= 0.03). Shorter duration in Israel, unemployment, asylum-seekers, no temporary-visa and use of restraints were more prevalent among those re-hospitalized.Conclusion: Identification of migrants at risk and trauma-informed, culturally relevant services can reduce hospitalizations.

[THE ASSOCIATION BETWEEN EXPOSURE TO TRAUMA AND MENTAL ILLNESS AMONG WORK MIGRANTS AND ASYLUM SEEKERS IN ISRAEL: A SURVEY AT THE OPEN CLINIC, PHYSICIANS FOR HUMAN RIGHTS, 2012-2013].

INTRODUCTION: In 2012, 183,896 work migrants and 47,704 asylum-seekers and work-migrants arrived in Israel. These populations are at high-risk for depression, anxiety and posttraumatic stress disorder (PTSD). The Open Clinic of Physicians for Human Rights (PHR) delivers free medical and mental health services to these individuals. AIMS: To evaluate exposure to traumatic events, and compare the prevalence and risk for PTSD, depression and anxiety symptoms between work-migrants and asylum-seekers. METHODS: An analytical cross-sectional study of adults visiting the Open Clinic was conducted. Participants completed self-report questionnaires including information on demographics and exposure to traumas, depression, anxiety and PTSD. Statistical models were constructed to predict outcome variables of PTSD, depression and anxiety as dichotomist variables using a logistic regression, and association odds ratio (OR) and confidence interval (CI) on 95% level. RESULTS: There were 241 participants; 165 asylum-seekers, 76 work-migrants. Work-migrants were exposed to more traumatic events. A total of 17-31% met PTSD criteria. Significantly more asylum-seekers met PTSD criteria. A total of 43%-50% met criteria for depression and/or anxiety, with no between-group differences. Significant association was found between immigration status and PTSD risk. Exposure to traumatic events was significantly associated with the prediction of PTSD, depression and anxiety. DISCUSSION: Exposure to traumatic events was high among the Open Clinic service users, specifically work-migrants. Prevalence and risk for post-traumatic symptoms were significantly higher among asylum-seekers. It is important to conduct further research, in order to characterize risk and resilience factors in this excluded population, and to plan language and culture-competent mental health services.

Posttraumatic Stress Disorder and Cancer Risk: A Nested Case-Control Study.

Data regarding cancer risk for individuals who were exposed to traumatic and stressful life events are conflicting. We sought to evaluate the association between posttraumatic stress disorder (PTSD) and the risk of the four most common solid tumors: lung, breast, prostate, and colorectal cancers. We conducted four nested case-control studies using a large UK population-based database. Cases were defined as individuals with any medical code for the specific malignancy. For every case, we used incidence-density sampling to match four controls by age, sex, practice site, and both duration and calendar time of follow-up. Exposure of interest was any diagnosis of PTSD prior to cancer diagnosis. The odds ratios (ORs) and 95% confidence intervals (CIs) for cancer risk associated with PTSD were estimated using multivariable conditional logistic regression and were adjusted for smoking status, obesity, and antidepressant use. The study population included four case groups according to cancer type. There were 19,143 cases with lung cancer (74,473 matched controls), 22,163 cases with colorectal cancer (86,538 matched controls), 31,352 cases with breast cancer (123,285 matched controls), and 27,212 cases with prostate cancer (105,940 matched controls). There was no statistically significant association between PTSD and cancer risk among any of the cancer types: lung, OR = 0.73, 95% CI [0.43, 1.23]; breast, OR = 0.73, 95% CI [0.52, 1.01]; prostate, OR = 1.24, 95% CI [0.87, 1.77]; and colorectal, OR = 1.05, 95% CI [0.68, 1.62]. Our findings indicated that participants in our study with PTSD were not at increased risk of lung, breast, prostate, and colorectal cancers.

Adult and Adolescent Patient Evaluations of Electroconvulsive Therapy in Comparison to Other Therapeutic Modalities.

OBJECTIVES: There is an increasing awareness of the importance of patients' subjective evaluations of therapy. Regarding electroconvulsive therapy (ECT), the results are conflicting. We hypothesized that making a comparison between patients' satisfaction with ECT and other forms of psychiatric therapies would capture personal experience as opposed to opinion about the treatment modalities. We compared adult responses to adolescent responses. METHODS: Four unmatched patient groups were recruited (N = 98) and were divided as follows: (a) patients treated with ECT as adolescents (n = 13), (b) patients treated with ECT as adults (n = 25), (c) patients hospitalized as adolescents but not treated with ECT (n = 30), and (d) patients hospitalized as adults but not treated with ECT (n = 30). All patients were interviewed using similar questions related to their satisfaction regarding the treatment modalities they experienced, including psychotherapy, pharmacotherapy, hospitalization and ECT, and years after being treated. RESULTS: Adults and adolescents viewed ECT as a legitimate and effective form of treatment (70%). Patients who were treated with ECT had a more positive attitude toward this treatment compared with patients who had not been treated with ECT. In comparison to other treatment modalities, ECT was considered by both adolescents and adults as the least effective form of therapy. Psychotherapy was considered the most effective, specifically among adolescents. CONCLUSIONS: Comparing patients' satisfaction in regard to different therapeutic modalities can potentially help clarify discrepancies in patient reports on satisfaction with ECT. Patients' satisfaction with ECT, just like their clinical response to ECT, is more dichotomous than with other forms of therapy.

Sleep Disorders Among Holocaust Survivors: A Review of Selected Publications.

After World War II, traumatic after effects often caused persistent sleep disorders for Holocaust survivors (HSs). This is a review of studies reporting on sleep disturbances and nightmares (as primary or secondary outcomes) among HSs between 1939 and 2015, conducted in various countries and contexts (clinical settings, pension claims, community surveys, sleep laboratories). Most studies revealed various sleep disturbances among HSs. Some studies found those disturbances in the absence of clinical disorders. Both men and women reported similar frequencies of sleep disturbances, although posttraumatic stress disorder and depression were more frequent in women. Sleep laboratory studies provided the single most direct and detailed sources of information. Findings included a) long-standing changes in sleep architecture, for example, decreased rapid eye movement (REM) sleep, and b) contrasting patterns of dreaming and recall among better versus poorly adjusted survivors. These results are of importance to both HSs and their families and for medical and mental health professionals.

Medical condition and care of undocumented migrants in ambulatory clinics in Tel Aviv, Israel: assessing unmet needs.

BACKGROUND: Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. METHODS: This cross-sectional study included a random sample of 610 UM aged 18-64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. RESULTS: MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. CONCLUSIONS: The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.

The association between acculturation patterns and mental health symptoms among Eritrean and Sudanese asylum seekers in Israel.

Past research has documented the role acculturation plays in the process of adjustment to new cultures among migrants. Yet little attention has been paid thus far to the role of acculturation in the context of forced migration. In this study we examined the association between acculturation patterns and mental health symptoms among a convenience sample of Eritrean and Sudanese asylum seekers (n = 118) who accessed health services at the Physicians for Human Rights Open-Clinic in Israel. Participants completed measures on sociodemographic information as well as detention history, mental health symptoms, exposure to traumatic events, and acculturation pattern, in their native language upon accessing services. Consistent with our predictions, findings showed that acculturation predicted depressive symptoms among asylum seekers beyond the effect of history of detention and reports of experiences of traumatic events. Assimilated compared with integrated asylum seekers reported higher depressive symptoms. Findings draw attention to the paradox of assimilation, and the mental health risks it poses among those wishing to integrate into the new culture at the expanse of their original culture. Asylum seekers may be particularly vulnerable to the risks of assimilation in the restrictive policies that characterize many industrial countries in recent years.

Mental Health Outcomes of Arab and Jewish Populations in Israel a Month after the Mass Trauma Events of October 7, 2023: A Cross-Sectional Survey of a Representative Sample.

On October 7, 2023, a war erupted in Israel following a mass terror attack including mass shootings, violent events, civilian abductions, and numerous fatalities, ranking as the third most deadliest terror attack. This cross-sectional, population-based study evaluated the impact on the mental health and utilization of mental health services in the Arab and Jewish populations. Conducted through a virtual platform, the study compared demographic factors, exposure to war-related events, anxiety, and post-traumatic stress symptoms among 517 participants in a representative sample of the adult population in Israel (79.1% Jewish, 20.9% Arab). Jews reported higher exposure to war-related events, but a majority expressed a lack of interest in mental help. In contrast, more Arabs desired mental help but faced barriers like stigma and scarce resources. Arabs showed a greater preference for group therapy and medical treatment. Trust in official bodies was consistently higher among Jews. Both populations exhibited similar levels (12-15.4%) of probable post-traumatic stress disorder (PTSD). This study equips clinicians, researchers and policymakers with real-time insights into improving mental health support for the culturally diverse needs of Jewish and Arab communities following exposure to mass trauma.

Internalizing symptoms impede adolescents' ability to transition from in-person to online mental health services during the 2019 coronavirus disease pandemic.

INTRODUCTION: Online mental health services were previously found to be effective in many studies. However, this method was not generally used in Israel. By the end of 2019, the coronavirus disease 2019 pandemic erupted, forcing mental health services to transition to online meetings to maintain the standard of care. In this cross-sectional study, we investigated the attitudes of adolescent patients toward this involuntary new mode of care. METHODS: Forty-four adolescents (mean age 14.62 ± 2.12 years, 54.5% females) and 40 of their primary caregivers completed a battery of questionnaires that included the telemedicine satisfaction questionnaire, session evaluation questionnaire, working alliance inventory, and pediatric symptom checklist. RESULTS: Both adolescents and their caregivers reported a reasonable experience with the online medium and a feeling that the meetings were overall powerful, helpful, and comfortable as demonstrated by medium to high scores on the telemedicine satisfaction questionnaire and session evaluation questionnaire questionnaires. A therapeutic alliance was generally maintained according to working alliance inventory scores. However, working alliance inventory scores were negatively correlated with higher levels of internalizing symptoms and parental stress. DISCUSSION: Our findings point to the possibility that anxious/depressed adolescents will have greater difficulties re-establishing therapeutic alliance when transitioned from in-person to online meetings. This may be due to the introduction of an "invisible" third party to the therapeutic setting-the computer. Psychologists and psychiatrists should be aware of these difficulties and respond adequately to maintain the standard of care.

Dropout from Mental Health Treatment Among Asylum-Seekers in Israel: A Retrospective Chart Study.

Dropout from psychiatric treatment and psychotherapy is common among asylum-seekers, even though they are at increased risk of emotional distress and psychiatric disorders. We aimed to define the associations between demographic and clinical variables and dropout among asylum-seekers in Israel. In this retrospective chart review we initially examined 271 files from Gesher (Bridge, in Hebrew), a government psychiatric clinic for asylum-seekers. All cases were considered eligible provided data were sufficient and asylum-seeker status could be ascertained. Of the 101 files included in the analysis, comparisons between patients who dropped out and patients who continued treatment were made, and logistic regression for dropout risk was conducted. In the study sample, 27 patients (26.7%) dropped out of treatment. Diagnosis of psychotic spectrum disorder and shorter time in Israel were significantly associated with dropout. Parenthood was significantly associated with dropout for men, but not for women. Defining factors associated with dropout and adherence to therapy for asylum-seekers may help improve ambulatory mental health services and the outcomes of treatment for this population.

Obstetric outcome and emotional reactions to childbirth in women with dyspareunia: A cross-sectional study.

OBJECTIVE: To assess obstetrical outcomes, perceptions of childbirth experience and emotional adjustment, in women with dyspareunia. STUDY DESIGN: In this cross-sectional study, 440 women were recruited within 48 h postpartum in the maternity ward of a large medical center, during the period of April 2018- August 2020. Self-report questionnaires were administered which addressed demographic and reproductive background, dyspareunia, perceptions of control during labor (Labor Agentry Scale), perceived professional support (Intrapartum Care Scale), and maternal adjustment, implicated in perinatal dissociation (Peritraumatic Dissociative Experiences Questionnaire), acute stress disorder (ASD) symptoms (Stanford Acute Stress Reaction Questionnaire), bonding (Mother-to-Infant Bonding Scale), anticipated maternal self-efficacy (Maternal Self-Efficacy Scale) and well-being (Positive and Negative Affect Schedule, Edinburgh Postnatal Depression Scale). Obstetrical information was retrieved from clinical files and included pregnancy complications, week and mode of delivery, nature of labor onset, analgesia during delivery, birthweight, perineal tears. RESULTS: The dyspareunia group included 71 women (18.3%) and the comparison group 317 (81.7%). Demographic data were similar among groups. No difference was observed in nature of labor onset, type of analgesia, route of delivery, perineal tears. More participants with dyspareunia had premature delivery versus comparisons (14.1% vs 5.6%, p = 0.02). Women with dyspareunia reported lower levels of control (p = 0.01) and perceived support during childbirth (p < 0.001), higher levels of perinatal dissociation (p < 0.001) ASD symptoms (p < 0.001), depression (p = 0.02), negative affect (p < 0.001), and reported lower levels of maternal bonding (p < 0.001) and anticipated maternal self-efficacy (p = 0.01). CONCLUSION: Dyspareunia was associated with more premature deliveries, parameters of emotional distress during childbirth and poorer maternal adjustment following childbirth. Perinatal caregivers should be cognizant of such cognitive and emotional reactions in women with dyspareunia, so as to assess for a history of dyspareunia in pregnant women and provide adequate support during pregnancy and delivery.

Comprehension and companionship in the emergency department as predictors of treatment adherence.

OBJECTIVE: Lack of adherence to recommended treatment poses major clinical and economic challenges for psychiatry, and requires further examination. In this pilot study, we aimed to prospectively investigate the association between the level of understanding of psychiatric emergency department (ED) discharge recommendations and the presence of a companion with short-term treatment adherence. METHOD: Sixty subjects were evaluated twice: upon ED discharge and a month later. Instruments included a structured questionnaire based on the MacArthur Competence Assessment Tool for Treatment, Mini Mental State Examination, and corroboration of data with the computerized hospital medical file. In order to control for the possibility that evaluation of the understanding of recommendations might positively influence adherence, the 60 subjects were randomly assigned into 50 who were interviewed with the full survey tool and 10 who were not asked questions about their understanding of treatment and/or follow-up recommendations. RESULTS: Understanding of discharge recommendations and the presence of a companion enhanced adherence. CONCLUSIONS: This preliminary study suggests that ensuring patients' understanding of treatment recommendations and encouraging the company of patients are achievable, practical strategies that may improve adherence and thereby promote better outcomes.

Psychiatrists' awareness of the cost of medication, rates of social disability pension, and their attitudes regarding knowledge of treatment costs.

BACKGROUND: Medication is a significant component of the cost of mental health care. Studies from different countries indicate that physicians are often not aware of medication costs, despite the impact of such knowledge on treatment plans. The purpose of this study was to examine Israeli psychiatrists' knowledge regarding the cost of medication and rates of disability pension, and the impact of these factors on treatment decisions. METHODS: Cross-sectional study. A questionnaire was distributed by e-mail to psychiatry specialists and residents, including: (a) socio-demographic and professional information; (b) knowledge regarding rates of National Insurance disability pension and medications' costs; (c) attitudes regarding relevance of knowledge of treatment costs. Correlations between socio-demographic variables and knowledge regarding treatment costs and attitudes were examined. RESULTS: Of the 175 psychiatrists who completed the questionnaire, 55% were men. The level of knowledge regarding cost of psychotropic medication and disability pension rates was low. Sixty-eight percent rated economic considerations as important or very important, yet 75% were informed of medication prices by their patients, and 57% by pharmaceutical companies. Doctors who worked in regions other than the center of the state were more aware of the economic aspects of treatment. Physicians who reported easy access to information regarding drug prices were less likely to err in estimating the price of medications. CONCLUSIONS: Psychiatrists in Israel are not sufficiently informed of the costs of psychotropic medications, despite their awareness of the relevance of affordability to treatment compliance. Awareness of economic issues relating to treatment should be included in residency programs, and access to relevant information of medication cost and disability pensions should be more accessible to physicians both on national and local levels, by the government and health maintenance ogranizations (HMOs).

Mental health professionals' awareness of the parental functioning of persons with severe mental disorders: a retrospective chart study.

BACKGROUND: The proportion of persons with severe mental illness (SMI) who are parents has increased in recent decades. Children of parents with SMI are at increased risk for medical, behavioral, emotional, developmental, academic, and social problems. They also have an increased risk for injuries, accidents, and mortality, addictions, and various psychiatric disorders compared to children of parents with no such diagnoses. We aimed to examine the extent to which mental health professionals (MHPs) who treat adult patients with SMI in ambulatory settings are aware of these individuals' functioning in three parenting domains: parental functioning, familial support system and children's conditions. We also compared psychiatrists' awareness with that of psychologists and social workers. METHODS: In this retrospective practice-oriented study, we reviewed 80 clinical files of individuals diagnosed with schizophrenia, affective disorder or personality disorder treated in a mental health outpatient clinic, using the Awareness of Family's Mental Health Checklist (AFMHC) developed for this study. Thus, awareness was determined on the basis of what was recorded in the patient file. RESULTS: Almost half of the MHPs were unaware to their patients' parental functioning as only 44% of files contained records relating to this issue. Awareness to other domains was even lower: 24% of files contained information on patient's support system and 12% had information about their children's mental and/or physical health. No statistically significant differences between psychiatrists and other MHPs were found with regards to awareness to the various domains. Positive correlations were found among MHP's for awareness in the three domains. CONCLUSION: Lack of awareness among MHPs to their patients' parental functioning is not specific to a certain profession and may be attributed to patients (e.g., reluctance to disclose relevant information) or to MHPs (e.g., lack of training). Awareness of family and parental functioning by MHPs working with persons with SMI should be part of a standard procedure, integrated into policy and training.

Suicide Among Holocaust Survivors: A National Registry Study.

Previous findings regarding European Holocaust survivors' suicide risk are conflicting. North African survivors' suicide risk was not previously studied. In this study, we aimed to determine suicide risk among European and North African Holocaust survivors. The study was based on the Israeli population census from 1972, followed until 2015 for suicide. European survivors were grouped into survivors of severe Nazi persecution (HS) and early HS. North African survivors were grouped into those from Algeria, Libya and Tunisia who were likely to have suffered more severe persecution (group 1) and those from Morocco who apparently suffered less persecution (group 2). Comparison groups were chosen according to similar ethnic origins who were not under Nazi control. Age standardized suicide rates, Standard Mortality Ratios (SMR) were calculated. Cox regression analysis was used to assess suicide risk. The age adjusted suicide rates (per 100,000) among Europeans were: HS 17.8 (95%CI 16.9-18.6), early HS 28.6 (95%CI 24.9-32.2), comparison group 20.3 (95%CI 18.5-22.1). Among North Africans: group 1, 6.9 (95%CI 5.6-8.2), group 2, 4.8 (95%CI 4.0-5.5), comparison group, 8.5 (95% CI 6.4-11.0). The SMRs with European comparisons were 0.88 (95%CI 0.84-0.92) for HS and 1.41 (95%CI 1.20-1.65) for early HS. SMRs with North African comparisons were 0.81 (95%CI 0.67-0.97) for group 1 and 0.57 (95%CI 0.48-0.66) for group 2. Cox regression models showed significantly higher suicide risk for European early HS vs comparisons (Hazard Ratio (HR) = 1.31, 95% CI 1.12-1.52), and lower risk for HS (0.89, 95%CI 0.80-0.98). North African group 2 had significantly lower HR (0.58, 95%CI 0.43-0.79). To conclude, higher resilience was found among European survivors of severe adversity, compared to those who suffered lesser persecution. No elevated risk was found among North African survivors.