Psychiatric referrals to the general hospital emergency department: are we being effective?

Introduction: General hospital emergency departments (GHEDs) are notoriously overcrowded. This is caused, in part, by ineffective referrals, that is to say referrals that do not require medical examination or other interventions in the context of a general hospital. This study aims to investigate the contribution of psychiatric referrals to this issue, to identify potential determinants of these referrals and offer means to reduce them. Materials and methods: Retrospective data were collected from psychiatric admission files within a GHED of a tertiary-care city hospital over a 1 year period. Two experienced clinicians separately reviewed each file to determine rationale of referrals according to predetermined criteria. Results: A total of 2,136 visits included a psychiatric examination, 900 (42.1%) were determined "effective," and 1,227 (57.4%) were deemed "potentially ineffective." The leading causes for potentially ineffective referrals to a GHED were psychiatric illness exacerbation (43.4%), and suicidal ideations (22%). Most referrals (66.9%) were initiated by the patient or their family, and not by a primary care physician or psychiatrist. Conclusion: More than half of the psychiatric referrals did not necessarily require the services of a general hospital, and may be more suitable for referral to a dedicated psychiatric facility. Ineffective referrals to the GHED pose a burden on general hospital resources, and may be less effective for the psychiatric patients. This calls for clear guidelines for the provision of optimal emergency treatment for mental-health patients.

Case report: Anorexia nervosa and unspecified restricting-type eating disorder in Jewish ultra-orthodox religious males, leading to severe physical and psychological morbidity.

Background: Young Jewish Ultra-Orthodox women usually show less disturbances in body image and eating in comparison to less religious communities. By contrast, problems with eating are highly unknown and unrecognized in Jewish Ultra-Orthodox males. Aim: To investigate whether in Ultra-Orthodox males, restricting-type AN (AN-R) with highly obsessional physical activity and unspecified restricting eating disorder (ED) in the context of obsessive-compulsive disorder (OCD) would lead to severe physical and emotional morbidity. Results: The study included two groups: the first, 3 adolescents with AN-R developing severely increased ritualized obsessional physical activity in addition to restricting eating, requiring inpatient treatment because of severe bradycardia. These youngsters ignored the severity of their obsessional physical activity, continuing with it in hospital despite their grave medical condition. One student began extensive training for triathlon, whereas another student, upon remitting from AN, developed severe muscle dysmorphia. These findings suggest that young Ultra-Orthodox males with AN may develop obsessional physical activity to increase their muscle mass rather than to lose weight Another four Jewish Ultra-Orthodox males developed malnutrition in the context of severe OCD, with no evidence of dieting or body-image disturbances. These individuals developed highly obsessional adherence to different Jewish religious rules, including prolonged praying, asceticism, and overvalued strict adherence to Jewish Kashrut rules of eating, leading in all cases to severe food restriction. They were highly unaware of their severe weight loss and required hospitalization because of severe physical disturbances associated with malnutrition. Moreover, most did not cooperate with their treatment, and their ED-related obsessionality was mostly resistant to psychopharmacotherapy. Conclusion: Owing to their highly ritualistic rigid way of life, combined with the need for excellency in studying, Jewish Ultra-Orthodox adolescent males with AN might be at a specific risk of developing severe physical disturbances if their illness is associated with highly perfectionistic obsessional physical activity. Second, Jewish Ultra-Orthodox religious males with OCD might be at a specific risk for severe undernutrition, as their rigid relentless observance of Jewish everyday laws might highly interfere with their eating.

Brain activation in individuals suffering from bulimia nervosa and control subjects during sweet and sour taste stimuli.

Introduction: Episodes of eating great quantities of extremely sweet and often aversive tasting food are a hallmark of bulimia nervosa. This unique eating pattern led researchers to seek and find differences in taste perception between patients and healthy control subjects. However, it is currently not known if these originate from central or peripheral impairment in the taste perception system. In this cross sectional study, we compare brain response to sweet and sour stimuli in 5 bulimic and 8 healthy women using functional magnetic resonance imaging (fMRI). Materials and methods: Sweet, sour and neutral (colorless and odorless) taste solutions were presented to subjects while undergoing fMRI scanning. Data were analyzed using a block design paradigm. Results: Between-group differences in brain activation in response to both sweet and sour tastes were found in 11 brain regions, including operculum, anterior cingulate cortex, midbrain, and cerebellum. These are all considered central to perception and processing of taste. Conclusion: Our data propose that sweet and sour tastes may have reward or aversion eliciting attributes in patients suffering from bulimia nervosa not found in healthy subjects, suggesting that alteration in taste processing may be a core dysfunction in bulimia nervosa (BN).

Virtual Online Home-Based Treatment During the COVID-19 Pandemic for Ultra-Orthodox Young Women With Eating Disorders.

Background: With the outbreak of the COVID-19 pandemic, the need arose to maintain treatment continuity for religious Jewish Ultra-Orthodox young women with eating disorders (EDs) previously hospitalized in the ED department at the Ultra-Orthodox "Mayanei Hayeshua" medical center in Israel. This need led to the development of home-based online treatment channels, previously unfamiliar, and unaccepted in this population. The implementation of this model had to take into consideration many of the difficulties inherent in the use of online treatment in Jewish Ultra-Orthodox mental health patients. Aims: We sought to investigate our online home-based treatment model implemented during the COVID-19 pandemic in previously hospitalized young Ultra-Orthodox women with EDs. Method: We briefly review the literature on: (1) The Jewish Israeli Ultra-Orthodox culture; (2) Young women in Ultra-Orthodox society; and (3) EDs in Jewish Israeli Ultra-Orthodox women. We then present the inpatient ED department for Ultra-Orthodox young women and describe the online treatment model adapted to this population during the COVID-19 pandemic. We highlight the difficulties, dilemmas, and advantages of our online model with the description of three patients. Findings: Online therapy can serve as a barrier to treatment in some cases, due to physical (lack of suitable online devices except phones), familial (over-crowded families), and religious circumstances, as well as because of the patients' reluctance to take part in this treatment. In other cases, virtual home-based treatment can lead to a positive change. This may be the case in patients who find the distancing online model suitable for them, and in parents who are committed to treatment, using their greater physical and emotional presence at home during the COVID-19 pandemic for the good if their ill-daughters. Discussion: This paper highlights the difficulties and possibilities inherent in a virtual home-based treatment during the COVID-19 pandemic for Ultra-Orthodox young women previously hospitalized because of an ED. This model can be effective for some patients and families if undertaken by a multidisciplinary team that is not only knowledgeable about the treatment of EDs and the use of online strategies but also knowledgeable and culturally sensitive to the specific needs and codes of Ultra-Orthodox populations.

Emotional regulation difficulties and premenstrual symptoms among Israeli students.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) reported to affect 3-8 % of women of reproductive age and resulting in marked emotional and occupational impairment. Despite its prevalence, the etiology of PMDD is largely unknown, and patients remain mostly undiagnosed and poorly treated. It has been suggested that PMDD is a manifestation of underlying depressive disorder which is associated with the inability to regulate emotions in an adaptive manner. Therefore, we hypothesized that women with PMDD would exhibit increased difficulty with emotional regulation. A total of 648 female Israeli college students were assessed by the Premenstrual Symptoms Screening Tool (PSST) and the Difficulties in Emotion Regulation Scale (DERS). Of these women, 166 (25.6 %) met the criteria for PMS. Sixty-four (9.9 %) suffered from PMDD. More emotion regulation deficits were observed in the PMDD and PMS groups compared to the control group. Furthermore, there were more emotional regulation deficits among the predominantly psychological and mixed symptom subtype compared to the predominantly physical symptom subtype group. This is the first study to report an association between emotional dysregulation and PMDD. These findings may lead to development of more individually tailored treatment protocols focused on improving emotional regulation techniques.