Acute Stress Disorder Symptoms Predict All-Cause Mortality Among Myocardial Infarction Patients: a 15-Year Longitudinal Study.

BACKGROUND: Studies have recognized myocardial infarction (MI) as a risk for acute stress disorder (ASD), manifested in dissociative, intrusive, avoidant, and hyperarousal symptoms during hospitalization. PURPOSE: This study examined the prognostic role of ASD symptoms in predicting all-cause mortality in MI patients over a period of 15 years. METHODS: One hundred and ninety-three MI patients filled out questionnaires assessing ASD symptoms during hospitalization. Risk factors and cardiac prognostic measures were collected from patients' hospital records. All-cause mortality was longitudinally assessed, with an endpoint of 15 years after the MI. RESULTS: Of the participants, 21.8 % died during the follow-up period. The decedents had reported higher levels of ASD symptoms during hospitalization than had the survivors, but this effect became nonsignificant when adjusting for age, sex, education, left ventricular ejection fraction, and depression. A series of analyses conducted on each of the ASD symptom clusters separately indicated that-after adjusting for age, sex, education, left ventricular ejection fraction, and depression-dissociative symptoms significantly predicted all-cause mortality, indicating that the higher the level of in-hospital dissociative symptoms, the shorter the MI patients' survival time. CONCLUSION: These findings suggest that in-hospital dissociative symptoms should be considered in the risk stratification of MI patients.

Nonmedication smoking reduction program for inpatients with chronic schizophrenia: a randomized control design study.

People with schizophrenia are more likely to smoke, and to smoke more frequently, than those without schizophrenia. Furthermore, inpatients smoke even more frequently compared with those living in the community. In light of this, we implemented and assessed a smoking reduction intervention using a wide array of behavioral group techniques and methods in chronic hospitalized schizophrenic clients. Using a controlled design, we randomly assigned chronic schizophrenic clients to either a five-session smoking reduction intervention (n = 35) or a waiting list (WL; n = 18). We assessed self-reported smoking behavior, clinical status (Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression; Clinical Global Impression Scale for Psychosis), subjective quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire-abbreviated version), and weight before and 3 months after the intervention. The intervention successfully reduced the number of cigarettes smoked compared with nonintervention. No clinical worsening or weight gain was observed. Behavioral group-oriented smoking reduction interventions can significantly reduce smoking behavior in hospitalized chronic clients with schizophrenia.

Management of the suicidal patient in the era of defensive medicine: focus on suicide risk assessment and boundaries of responsibility.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist's responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.

Psychosocial remission in schizophrenia: developing a clinician-rated scale.

BACKGROUND: There is a growing awareness of the importance of psychosocial factors incorporated in treatment goals in schizophrenic patients. Remission, both symptomatic and psychosocial, is now an achievable goal in a substantial proportion of patients. Thus, the development of handy tools to quantify outcomes is called for. OBJECTIVE: To develop a brief, clinician-rated scale for the assessment of psychosocial remission in schizophrenia (the Psychosocial Remission in Schizophrenia [PSRS] Scale). The scale is to match the quantification of symptomatic remission as delineated by the American Psychiatric Association task force. METHOD: A "bank" of 124 questions pertaining to psychosocial remission was derived from published scales reflecting 2 domains: quality of life and activities of daily living. Psychiatrists, residents, psychiatric nurses, and community nurses were presented with the questions. All were asked to choose the 8 items they considered as reflecting the essence of psychosocial remission. Interrater reliability of the final scale version was assessed among psychiatrists. RESULTS: The questions' bank was reviewed by 429 mental health professionals. The 4 items found to be most frequently sanctioned in the quality-of-life domain were (a) familial relations (endorsed by 78% of participants), (b) understanding and self-awareness (46%), (c) energy (58%), and (d) interest in everyday life (38%). The 4 items sanctioned in the instrumental activities of daily living domain were (a) self-care (86%), (b) activism (65%), (c) responsibility for medications (54%), and (d) use of community services (32%). Interrater reliability among 70 psychiatrists ranged from 0.67 to 0.83. CONCLUSION: The PSRS is an 8-item scale quantifying psychosocial remission in schizophrenia in a manner that complements symptomatic assessment of remission. The PSRS may be useful for both research and clinical evaluation.

Security and psychiatry: the British experience and implications for forensic psychiatry services in Israel.

The courts have recently become increasingly involved in the administration of compulsory psychiatric services in Israel. Data reveal a gradual increase in the rate of court-ordered hospitalizations according to Section 15 of the Law for the Treatment of the Mentally Ill. This paper examines the implications of this trend, particularly the issues of security and safety in psychiatric hospitalization. We present highlights from extensive British experience, focusing on the implications on forensic psychiatry in Israel. We review the development of the hierarchy of security in the British psychiatric services, beginning in the early 1970s with the establishment of the Butler Committee that determined a hierarchy of three levels of security for the treatment of patients, culminating with the establishment of principles for the operation of medium security units in Britain (Read Committee, 1991). These developments were the basis for the forensic psychiatric services in Britain. We discuss the relevance of the British experience to the situation in Israel while examining the current status of mental health facilities in Israel. In our opinion, a safe and suitable environment is a necessary condition for a treatment setting. The establishment of medium security units or forensic psychiatry departments within a mental health facility will enable the concentration and classification of court-ordered admissions and will enable systemic flexibility and capacity for better treatment, commensurate with patient needs.

Effect of antiviral amantadine treatment on elderly chronic schizophrenia patients.

BACKGROUND: In compliance with public health measures initiated by the Israel Ministry of Health following an outbreak of influenza, amantadine was administered to all patients in the psychogeriatric department of Lev Hasharon Mental Health Center to reduce transmission and illness severity in this susceptible population. OBJECTIVES: To evaluate the potential beneficial effects of amantadine on elderly hospitalized patients with persistent schizophrenia. METHODS: We conducted a retrospective case review of the treatment effects of amantadine on the mental, cognitive and clinical states of elderly chronic schizophrenic patients who received concomitant amantadine treatment and were routinely evaluated with the Positive and Negative Syndrome Scale, the Mini Mental State Examination, and Sandoz Clinical Assessment Geriatric Scale. RESULTS: No significant differences before and after amantadine treatment were noted. CONCLUSION: Amantadine did not influence the mental, cognitive and clinical states of elderly schizophrenia patients and thus can be considered as an anti-influenza preventive measure for this population, when indicated.

Revolving-door patients in a public psychiatric hospital in Israel: cross sectional study.

AIM. To study social, demographic, clinical, and forensic profiles of frequently re-hospitalized (revolving-door) psychiatric patients. METHODS. The study included all patients (n=183) who were admitted to our hospital 3 or more times during a 2-year period from 1999 through 2000. We compared these patients to 2 control groups of patients who were admitted to our hospital in the same period. For comparison of forensic data, we compared them with all non revolving-door patients (n=1056) registered in the computerized hospital database and for comparison of medical and clinical data we compared them with a random sample of non revolving-door patients (n=98). The sample was sufficiently large to yield high statistical power (above 98%). We collected data on the legal status of the hospitalizations (voluntary or involuntary) and social, demographic, clinical, and forensic information from the forensic and medical records of revolving-door and non revolving-door patients. RESULTS. In the period 1999-2000, 183 revolving-door patients accounted for 771 (37.8%, 4.2 admissions per patient) and 1056 non revolving-door patients accounted for 1264 (62.5%, 1.2 admissions per patient) of the 2035 admissions to our hospital. Involuntary hospitalizations accounted for 23.9% of revolving-door and 76.0% of non revolving-door admissions. Revolving-door patients had significantly shorter mean interval between hospitalizations, showed less violence, and were usually discharged contrary to medical advice. We found no differences in sex, marital status, age, ethnicity, diagnoses, illegal drug and alcohol use, or previous suicide-attempts between the groups. CONCLUSIONS. Revolving-door patients are not necessarily hospitalized for longer time periods and do not have more involuntarily admissions. The main difference between revolving-door and non revolving-door patients is greater self-management of the hospitalization process by shortening the time between voluntary re-admission and discharge against medical advice.

The psychological toll of the Intifada: symptoms of distress and coping in Israeli soldiers.

BACKGROUND: Detrimental effects of military service among the civilian Palestinian population have been reported in soldiers. OBJECTIVES: To examine the frequency and type of stressors encountered by soldiers in close contact with the CPP and its relationship with post-traumatic symptomatology. We also investigated coping methods and the preferred types of professional help. METHODS: Using random digit dialing methodology we conducted a phone survey of veteran soldiers, men (n=167) and women (n=59) in close contact with the CPP; the comparison group comprised male veteran soldiers with no CPP exposure (n=74). We used focus groups to develop context-related measures to assess exposure to violent incidents, coping modes and preferred modes of professional assistance. We included measures of traumatic exposure, post-traumatic stress symptoms and post-traumatic stress disorder. RESULTS: Soldiers who served among the CPP had greater exposure to traumatic events and to civilian-related violent incidents (more than half as victims, and a third as perpetrators); and 17.4% perceived their behavior as degrading civilians. Primary traumatic exposure, perceived health problems and avoidance coping were found to be risk factors for PTS and PTSD. Involvement in incidents that may have degraded Palestinian civilians predicted PTS. CONCLUSIONS: Friction with the CPP in itself does not constitute a risk factor for psychopathology among soldiers. However, contact with this population entails more exposure to traumatic events, which may cause PTS and PTSD. Furthermore, a relative minority of soldiers may be involved in situations that may degrade civilians, which is a risk factor for PTS. To avoid violent and sometimes degrading behaviors, appropriate psycho-educational and behavioral preparation should be provided.

Multi-modal weight control intervention for people with persistent mental disorders.

Obesity, a major problem worldwide, is more prevalent among people with schizophrenia. This study examined the effect of behavior intervention, nutritional information and physical exercise on the body mass index (BMI) and weight of people who were hospitalized with persistent DSM-IV schizophrenia and schizoaffective disorders. Fifty nine inpatients with a BMI greater than 25 participated, (28 intervention group; 31 control group). Significant reductions in BMI and weight were observed in the intervention group after 3 months and were maintained 1-year post study [F(1,52) = 6.1, p = .017) and F(1,52) = 3.7, P = .006, respectively]. If provided with adequate information and an appropriate framework, people with persistent schizophrenia can significantly reduce BMI and weight and maintain the loss.

Fatal and non-fatal suicidal behavior in Israeli adolescent males.

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18-21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.

The civil liability for damages of the criminally insane.

As a rule, mentally ill patients are held to be responsible for their acts just like everyone else. Notwithstanding, the law in Israel contains special rules which distinguish individuals with mental illness from other people. The instructions laid out in article 34h of the Israeli Penal Law empower the court to release a defendant from criminal responsibility. To do this the following criteria must be met: (a) the defendant was mentally ill, (b) he/she was in a psychotic state at the time he/she performed the felony, (c) his/her mental illness deprived him/her of his/her abilities in at least one of the two following areas: 1] he/she could not understand what he/she was doing, or the forbidden nature of the act; 2] he/she was incapable of preventing him/herself from carrying it out. In the case presented, a mentally ill individual was charged with the murder of his child and with an attempt to murder another child. The court ruled him to be legally insane and therefore non-punishable. He was later sued by the other child's parents for damages on the grounds of the assault tort. The issue in question was how does the fact that the defendant was ruled legally insane while committing the wrong doing affect the legal ruling of the defendant's liability especially regarding the tort of assault? The Magistrate's Court ruled that the Israeli Tort Law did not determine exemption from responsibility for the mentally ill. Liability for damages will be imposed upon an individual whenever the prerequisites to define a tort are met, even if the mental requisite is an outcome of one's mentally ill state. The District Court determined that an individual who intended to inflict harm is guilty of assault, even though the intent was an outcome of his mental state. Lack of volition due to one's inability to refrain from action does not constitute a defense for assault. In this case liability for damages was imposed on the defendant. The Court related to the issue of justice according to which an innocent person's damages should not remain uncompensated, and the assailant was required to pay damages to the victim.

[Decision-making concerning guardianship--who is the "person that no longer has the capacity to make decisions regarding personal matters"?].

Appointment of a guardian is a complicated and important process, when necessary. It is a paternalistic intervention in the life of an individual, which aims to protect those who require that protection. Appointment of a guardian significantly impedes the rights and autonomy of the individual and should therefore remain a last resort. Alternatively, not appointing a guardian for one who needs protection could potentially expose that person to financial or physical harm, exploitation and neglect. The law allows for appointment of a guardian for a person that no longer has the capacity to make decisions regarding some or all of his/her personal matters. The law and the ruling have not defined who is considered a person that no longer has the capacity to make decisions. The criteria for financial capacity should include whether or not the patient knows the extent of his property, his income, expenses, and demonstrates ability to make logical decisions concerning these issues? The criteria for personal capacity [physical wellbeing] should include whether or not the patient can independently take care of his personal needs and care for himself in terms of: nutrition, housing, clothing, general security, and a safe living environment? We suggest that the expert opinion should specifically relate to the issues of guardianship for physical wellbeing and/or property and should provide the following: 1) Reason: What is the disorder/diagnosis that the patient suffers from? 2) Cognitive impairment: What cognitive impairment results from the patient's illness? 3) Functional impairment: What functional impairments resulting from illness affect the life of the patient?

Foreign objects in the vagina of a mentally ill woman: case series.

OBJECTIVE: Reports of the insertion of foreign objects to the vagina by psychiatric patients are scant. We present two such cases. METHODS: Case I resulted from psychotic content and auditory command hallucinations. Case II -- the patient, in a manic state used her vagina as a hiding place for keys she stole from a staff member. RESULTS: Both cases required gynecological intervention. CONCLUSIONS: Medical cooperation between psychiatrists and gynecologists was necessary in order to achieve improvement in both the physical and mental conditions of the patients and in order to plan programs for continued care.

Clozapine-induced eosinophilia and switch to quetiapine in a patient with chronic schizophrenia with suicidal tendencies.

Clozapine has proven effective in reducing morbidity and suicidality in chronic non-remitting patients with schizophrenia. Occasionally, despite good therapeutic response, clozapine must be stopped due to dangerous side effects such as agranulocytosis. Drug-induced eosinophilia is a non-dose-dependent side effect of clozapine. In cases of mild increments of eosinophils and if the patient is asymptomatic, there is no need to make an immediate decision. However, if the increment is severe and producing symptoms, withdrawing the probable causative drug is warranted. There is a possible association between eosinophilia and myocarditis, a life-threatening condition. The efficacy of corticosteroid therapy in the treatment of eosinophilia has not been clearly established. We present a case report where switching from clozapine to quetiapine maintained the improvement in clinical status, after remittance of eosinophilia.

Psychiatric inpatient and staff attitudes regarding smoking reduction.

AIMS: We assessed the interest of psychiatric inpatients and the staff in a smoking reduction program. METHODS: Inpatients, nurses, social workers and psychologists at a university-affiliated psychiatric hospital completed questionnaires addressing attitudes towards smoking and the desire to reduce smoking. RESULTS: 52% of the inpatients (N = 160) and 37.3% of the staff members (N = 41) reported that they smoked. Mean number of cigarettes for patients was 21.4 cigarettes per day for men, and 18.8 for women; 74 patients (46.2% of the smokers) and 96 staff members (88% of the smokers) expressed interest in participating in a smoking reduction program. No correlation was found between the rate of smoking among the staff and the rate of smoking of the patients in any given department. CONCLUSIONS: Psychiatric inpatients and their caregivers who smoke are interested in reducing the number of cigarettes that they smoke. Further study regarding the initiation of therapeutic smoking reduction programs in inpatient settings is warranted.

Mental health and resiliency following 44 months of terrorism: a survey of an Israeli national representative sample.

BACKGROUND: Israeli citizens have been exposed to intense and ongoing terrorism since September 2000. We previously studied the mental health impact of terrorism on the Israeli population (Bleich et al., 2002), however the long-term impact of ongoing terrorism has not yet been examined. The present study evaluated the psychological sequelae of 44 months of terrorism in Israel, and sought to identify factors that may contribute to vulnerability and resilience. METHODS: This was a telephone survey using strata sampling of 828 households, which reached a representative sample of 702 adult Israeli residents (84.8% contact rate). In total, 501 people (60.5%) agreed to participate. The methodology was similar to that of our previous study. Exposure to terrorism and other traumatic events, number of traumatic stress-related symptoms (TSRS), percentage of respondents with symptom criteria for post-traumatic stress disorder (PTSD), traumatic stress (TS) resiliency and feelings of depression, anxiety, optimism, sense of safety, and help-seeking were the main outcome measures. RESULTS: In total, 56 participants (11.2%) were directly exposed to a terrorist incident, and 101 (20.2%) had family members or friends exposed. Respondents reported a mean +/- SD of 5.0 +/- 4.5 TSRS; 45 (9%) met symptom criteria for PTSD; and 72 (14.4%) were TS-resilient. There were 147 participants (29.5%) who felt depressed, 50 (10.4%) felt anxious, and almost half (235; 47%) felt life-threatening danger; 48 (9.7%) felt the need for professional help. Women and people of Arab ethnicity had more TSRS, more PTSD, and less TS resiliency. Injury following a life-threatening experience, a major stressful life event, and a major loss of income were associated with PTSD. Immigrant status, lower education, low sense of safety, low sense of social support, high societal distress, and injury following life-threatening experiences were associated with TSRS. TSRS did not increase with exposure severity. This study revealed less depression and functional impairment, similar rates of PTSD, increased help-seeking and poorer TSRS and TS resiliency than our initial study, 2 years previously. DISCUSSION: The response of people in Israel to 4 years of terrorism is heterogeneous. Vulnerability factors change over time; Arab ethnicity, immigrant status and less education, not found to be risk factors in our previous study, were found in the present study to contribute to trauma-related distress. Prior experience of highly stressful events increases vulnerability to adverse psychological effects of terror.

[Ethical considerations of psychiatric treatment in chronic post traumatic stress following multiple casualty attacks].

Israeli society has been repeatedly exposed to traumatic stress following terrorist attacks with multiple casualties. Individuals who are subjected to these incidents experience various mental reactions, including traumatism, fear, loss and bereavement. Unfortunately, evidence based medical knowledge is lacking regarding natural methods for dealing with incidents that may precipitate traumatic stress, ways of identifying people who are more likely to develop post traumatic symptoms, or suggestions on early interventions that may avert the onset of these symptoms. Ethical problems may arise, especially in situations involving mass traumatic stress, when there are insufficient therapeutic resources. In such cases, the issues of whether to intervene, who to treat, and how, will often be influenced by conflicting personal and social interests. Another concern involves the principle of autonomy - the individual's right to decide whether he/she wants treatment. Should "latent" victims be identified in the community and referred to therapy? Diverse ethical issues emerge in situations of traumatic stress, and may potentially evoke dilemmas among health policy makers and among the therapists who work in the field. This type of discussion may enhance the understanding, help formulate key principles and assist in making reasonable and appropriate decisions when dealing with such difficult and complex situations.

[Pharmacotherapy in schizophrenia--comparison of second generation antipsychotic agents].

Schizophrenia is a severely limiting chronic illness. The disease is characterized by periods of psychoses, remission, and sometimes even recovery. Effective pharmacotherapy for schizophrenia began with the development of antipsychotic neuroleptics in the 1950's, followed by the second generation of antipsychotic agents developed in the 1990's. Across time, treatment with some of these preparations revealed extrapyramidal and other side effects, including metabolic phenomenon, such as: an increase in the incidence of diabetes, and weight gain. When choosing the appropriate medication from among the second generation of antipsychotic agents, the following aspects should be considered; cost, efficacy, unique advantages, employment rehabilitation, relapse and metabolic side effects. Therapeutic algorithms and recommended guidelines are helpful when planning treatment strategies. Information regarding prior beneficial treatments, cost, and the patient's quality of life should be considered. Today, when patients' rights, economic and legal aspects are emphasized, the physician must take into account multiple factors when choosing the most appropriate treatment for the patient.

[Psychiatric patients, dialysis, kidney transplant: case report and discussion].

Psychiatric patients' coping capacity with various life situations is limited due to their mental illness. This difficulty is even more pronounced when dealing with severe physical conditions such as kidney failure, the need for dialysis and kidney transplant. In the past, similar to patients who suffered from additional physical conditions, patients with major psychiatric disorders, long-term psychotic illness such as schizophrenia, were not considered candidates for dialysis treatment. Although these attitudes have changed, there is still concern that psychiatric patients would find it difficult to cooperate with the long-term treatment required following kidney transplant, and that lack of careful adherence to medication regimens could lead to rejection of the implant. This article describes five mentally ill individuals who suffer from terminal kidney failure, and illustrates the dilemma associated with dialysis and kidney transplant in psychiatric patients. Close cooperation between the psychiatric staff and the nephrology team can lead to the hoped for outcomes.

Maintenance electroconvulsive therapy for a neuroleptic-intolerant patient with disorganized schizophrenia.

Owing to unresolved questions concerning the efficacy and safety of electroconvulsive therapy (ECT) in the treatment of schizophrenia, and widespread negative attitudes toward ECT, maintenance ECT (mECT) is generally considered only as a last resort. Nevertheless, in some clinical situations, the advantages of mECT may outweigh the risks and associated concerns. We report the case of a patient suffering from disorganized schizophrenia who had life-threatening hematological side effects to treatment with antipsychotic agents. Long-term mECT was administered and the patient achieved remission with no notable side effects. He was able to maintain a peaceful daily routine and improved functioning. Considering the lack of controlled trials in this area, this case and other similar cases reported in the literature add support to a possible benefit of mECT in disorganized schizophrenia, particularly when pharmacotherapy is insufficient or contraindicated.