Evaluation of compulsory ambulatory treatment in Israel.

The effectiveness of Israel's compulsory ambulatory treatment order was evaluated based on a one-year follow-up of the 326 orders served during the first four years of implementation. Demographic, epidemiological, clinical, and legal data were obtained from patient records. Success was defined as continuous treatment for the entire six-month period of compulsory ambulatory treatment, or as voluntary hospitalization during or after the compulsory treatment period. The compulsory ambulatory treatment order was found to be efficacious in 43.3 percent of the cases; in 32.5 percent it did not succeed in preventing compulsory hospitalization, and in the remaining cases (22.1 percent), success was partial.

Psychological distress among Ethiopian and Russian Jewish immigrants to Israel: a cross-cultural study.

A community survey was conducted examining the differences in levels of psychological distress and its symptomatology, comparing 110 Ethiopian-Jewish and 400 Russian-Jewish immigrants to Israel. Psychological distress was measured by the Talbieh Brief Distress Inventory. Russian immigrants were found to be more distressed than their Ethiopian counterparts and this between-group difference can be attributed to the greater relative number of females, older immigrants and those with longer duration of stay in Israel in the Russian sample. The highest levels of distress were observed for paranoid ideation in the Ethiopian sample and anxiety and hostility in the Russian sample. These symptoms were independent of gender and time since immigration. Russians with longer duration of stay demonstrated higher scores signifying adjustment difficulties than their Ethiopian counterparts. These results suggest that the differences in levels and symptom expression of psychological distress are determined, to a considerable extent, by demographic factors (sex, age) and the differing cultural backgrounds of the two immigrant groups.

Changing patterns of distress during the adjustment of recent immigrants: a 1-year follow-up study.

A sample of 419 recent immigrants from the former Soviet Union to Israel was assessed, with a 1-year follow-up of 199 of these subjects. The Immigration Related Stressors Scale, Talbieh Brief Distress Inventory and Multidimensional Scale of Perceived Social Support were employed to measure the level and sources of distress, as well as the sources of social support. Three major patterns of change in distress level were distinguished, and their 1-year prevalence rates were established. In total, 44% of the respondents demonstrated the 'normal' pattern, with a permanent low distress level, 33% displayed the 'positive' pattern, with either persistent moderate or decreasing distress, and 23% displayed the 'negative' pattern, with either persistent high or increasing distress. Among the immigrants who demonstrated the positive pattern of change in distress, rates of stressors such as 'anxiety about the future', 'uncertainty in the present', 'depressive state', 'insufficient knowledge of Hebrew' and 'malevolence of Israelis' decreased during the study period. In those who showed the negative pattern, rates of stressors such as 'personality characteristics' and 'lack of acceptance of the host culture/mentality' have increased. Immigrants who showed the normal and positive patterns had greater total social support than those who showed the negative pattern. The level of family support tended be higher among immigrants with the normal pattern, while support by friends tended to be greater among those with the positive pattern of change in distress.

Suicide ideation among recent immigrants: an epidemiological study.

This paper reports preliminary results of an epidemiological survey of suicide ideation among recent adult immigrants from the former Soviet Union to Israel. The study presents one-month prevalence rates of suicide ideation, and the relationship of suicide ideation with demographics, self-rated psychological distress, depression, emotional isolation and social support. Results show that the one-month prevalence rate of suicide ideation in the population is 16.9%. Suicide ideation was most frequent among socially and emotionally isolated immigrants with lower social support. The strongest predictor of suicide ideation for both sexes was level of psychological distress, whereas the severity of depression predicted suicide ideation only in females. The findings can be used as a point of departure for the development of suicide prevention programs.

[Compulsory, ambulatory psychiatric treatment].

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the southern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.

Electro-encephalography spectral analysis of heroin addicts compared with abstainers and normal controls.

UNLABELLED: Previous studies have shown that opiates slow the EEG and, in high doses, reduce the threshold of seizure activity. The present work looks at computerized EEG analyses (in the Fast Fourier Transform-FFT-method) of heroin addicts, recent abstainers and normal controls, with the aim of comparison and delineation of group characteristics. Examinations of 60 taped EEG recordings were performed: 20 subjects were current heroin users, 20 were recent abstainers and 20 were normal controls. Statistical analysis was performed for the relative frequency of wave bands. To amplify the known findings of slowing in heroin users, specific ratios were calculated: the alpha ratio (namely, the 8.0-9.5 Hz to 9.5-12.0 Hz ratio) and the delta to low alpha ratio. The specificity and sensitivity of the FFT method were evaluated through the use of discriminant analysis. The EEG was also recorded on conventional paper and evaluated by a neurologist. RESULTS: The addicts had a higher alpha ratio. The abstainers had a slowing of their alpha waves, a high incidence of delta waves and a delta to low alpha ratio that was relatively high. As a function of time from the beginning of abstinence, this ratio decreased. Abstainers for more than 80 days and controls had identical EEGs. The FFT method had 50% sensitivity for the addicts and 70% for the abstainers, while the specificity was 55%. In contrast, the neurologist's reading of the EEG had a very low sensitivity (25% for the addicts, 30% for the abstainers and 20% for the controls) and a 70% specificity.

Patterns of use and changes in diagnosis during first admission. National Case Register Study.

The goal of this study was to describe patterns of diagnosis and to explore the extent to which diagnosis changes during first-in-life psychiatric admissions. All 2,998 first admissions to Israeli psychiatric wards in 1989 were studied. Diagnosis did not change in at least 60% of the cases. Diagnoses in order of stability were: mental retardation (84%), substance abuse (82%), organic conditions (77.5%), neurotic (75%), schizophrenia (74%), personality disorders (73%), affective (68%), childhood (55%), paranoid (45%) and V-codes (22%). There was less change in diagnosis for patients over 45 (37.5%), than for patients aged 19-44 (43.2%) and 15-18 (57.8%). Diagnoses assigned at admission to first hospitalization are not likely to change during that hospitalization.

Psychological adjustment among Soviet immigrant physicians: distress and self-assessments of its sources.

The purpose of this study is to examine the psychological distress of Soviet immigrant physicians in Israel and their self-assessed sources of this distress. The subject of this study included 385 (152 men and 233 women) Soviet immigrant physicians who had participated in preparatory licensing courses. The investigation shows that women have higher scores of distress than men in Global Stress Index of the Brief Symptom Inventory and its subscales which reflect anxiety. A comparison of Global Stress Index of the subjects of this study with U.S. and British published non-patient norms shows a significantly higher distress level among the immigrant physicians. Most of the respondents evaluated their psychologic state before immigration to Israel as better (303 or 78.7%). These assessments are found to be directly dependent on the stress load of the respondents at the time of the interview. Perception of the sources of absorption difficulties and distress scores are also found to be in close dependence. The results of the multiple regression analysis indicate that both sex and distress are statistically significant predictors of immigrants' estimation of their difficulties. However, it is the level of distress that has the greatest influence on the assessments of the respondents.

Effects of immigration on the mentally ill--does it produce psychological distress?

This report explores psychological distress among immigrants seeking help from psychiatric outpatient clinics as compared with control nonpatient immigrants. Our hypothesis is that nonpsychotic mentally ill immigrants will react to acculturation by psychological distress similarly to healthy individuals. Three questionnaires were used in this survey: Demographic Psychosocial Inventory, Brief Symptom Inventory (BSI), and Psychiatric Epidemiology Research Interview-Demoralization Scale (PERI-D). They were completed by patient and control groups consisting of recent adult immigrants to Israel from the former Soviet Union. The patient group included 158 subjects seeking psychiatric help from outpatient clinics. Among them, 51 met ICD-10 criteria for neurotic, stress-related, and somatoform disorders; 41 for schizophrenia; 32 for mood disorders; 18 for organic illnesses; and 16 for personality disorders. The control group consisted of 222 immigrants with no previous psychiatric history, matched by gender and age to the patient group. Although all distress symptoms were significantly more severe in the patient group than in the control group, the BSI profile, showing a high level of depression, anxiety, interpersonal sensitivity, and obsessive-compulsive dimensions, was similar in both groups. The psychological distress level as measured by the PERI-D was 1.4 times higher in patients than in the control group. Within the patient group, the lowest distress level was found in patients suffering from organic disorders. No significant differences in the level of psychological distress were found among other diagnostic subgroups. The results suggest that mentally ill immigrants react to acculturation by a psychological distress syndrome similarly to nonpatient immigrants but more severely than nonpatient immigrants.

[Lithium-associated alopecia].

A 39-year-old woman who developed alopecia shortly after treatment with lithium carbonate was initiated is described. The alopecia resolved 2 months after lithium was discontinued. Though this side-effect is relatively rare, we suggest that patients getting lithium for short or long term treatment be monitored for it.

Changes in diagnosis in a 9-year national longitudinal sample.

Studied are changes in diagnosis in a random sample of 10% of all first admissions to psychiatric hospitals and psychiatric wards of general hospitals in Israel from 1983 to 1990 with follow-up evaluation to 1991. This included 4,570 hospitalizations of 2,220 patients. Data were extracted from the National Psychiatric Case Registry of the Ministry of Health. Almost 59% of the sample had one admission, 18% had two, 9% had three, and 14% had four or more. From the first admission to the last discharge (a mean of 2.15 years), 59.2% of the patients' diagnoses did not change. In 89.46% of the cases in which the diagnosis changed, the changes took place during the first admission. Diagnostic change differed between diagnostic groups. In descending order of stability in diagnosis from the first admission to the last discharge were neurotic and personality disorder (73.6%), mental retardation (73.5%), schizophrenia (73.0%), organic conditions (70.6%), affective disorders (66.2%), substance abuse (65.6%), childhood disorders (60%), paranoid disorder (43.6%), other nonorganic psychosis (30.3%), and V-codes (25.0%). The average level of diagnostic agreement between the first admission and the last discharge was a kappa of .52. The average length of stay for patients whose diagnosis became more severe was considerably longer than for patients whose diagnosis became less severe or did not change in level of severity. Older age was related to less change in diagnosis. For patients aged less than 18 years, diagnosis changed in 46.7% of the cases, for patients aged 19 to 44, 31.2%, and for patients older than 45, 27.8%.

The efficacy of naltrexone in preventing reabuse of heroin after detoxification.

The efficacy of Naltrexone in preventing reabuse of heroin among heroin addicts in Israel was studied in a double-blind, controlled design. Naltrexone (or placebo) treatment was given as part of a general treatment plan that continued for 12 weeks. Thirty-two addicts who successfully completed a detoxification program and met research criteria, were included in the study. Fifty milligrams of Naltrexone were taken orally three times a week (25 mg twice a week for the first 2 weeks). The follow-up procedure included an interview, urine tests, and screening for possible adverse effects. In addition, social and psychological parameters were evaluated. Fewer heroin-positive urine tests were found the Naltrexone group than in the placebo group. Throughout the entire study, the number of drug-free patients in the Naltrexone group was higher than in the placebo group. The Naltrexone group showed a significant improvement in most psychological parameters as compared with the placebo group. No differences were found in compliance or ratio of adverse effects between the Naltrexone and placebo groups. The concept "heroin abuse load" based on daily heroin consumption and duration of addiction enabled us to predict which addicts would complete the treatment program. The results suggest that heroin addicts in Israel may benefit from treatment with Naltrexone.

A look at court appointed psychiatric evaluations in Israel with special reference to criminal liability.

This article presents the data collected from 128 court appointed psychiatric evaluations (CAPEs) and their analysis. Issues addressed are: the link between type of criminal offence and mental disorder; rate of recidivism; efficacy of the early detection and follow-up systems; inherent psychiatric dilemmas; unacceptable lacuna in information recorded in the CAPEs; and the babel of legal and psychiatric terms. We advocate that a combined effort be made by the legal and psychiatric fraternities to create a uniform and standardized CAPE.

The criminal liability of the mental patient in Jewish law (Halacha).

The legal status of the mentally impaired has been dealt with in Halachic literature since the third century. This article presents four Halachic viewpoints regarding the exemption of the mentally ill patient from legal responsibility in tort and criminal law: lack of mental awareness; lack of free will; lack of judgment; categorial personal status. Halachic legislations with regard to the liability of the insane predate the criteria as applied by modern psychiatry. The similarities between the Halachic and contemporary medicolegal approaches are presented.

Who is to protect the rights of hospitalized mental patients?

The 1991 Treatment of Mentally Sick Persons Act contains a large section on the rights of hospitalized mental patients. However, mental patients are often ignorant of their rights, have difficulties gaining access to outside support and are hence unable to materialize their rights and protect them. Who is to protect their rights? The various individuals and groups which play a role in protecting the civil rights of mental patients are listed and discussed: patients themselves, family members, human rights organizations, legislators, courts, the state comptroller, the media and therapists. The introduction of another institution, non-existent in Israel, a 'patient advocate' (ombudsman) is suggested and discussed.

Report of the committee assigned to investigate the protection of hospitalized mental patients against sexual assault and abuse--a critical review.

On 7 March 1991 a special committee was nominated by the Deputy Minister of Health to investigate the protection of mental patients hospitalized in Israel against sexual assault and abuse. The committee reached the conclusion that '[t]here were cases of sexual assault and abuse' but avoided examining the frequency of such cases. The committee interpreted the Israeli criminal law to mean that no patient has the ability to give consent to sexual relations, thus every incident of sexual relations with a patient has to be considered to be rape, that is the total responsibility rests on hospital staff. The inevitable recommendation was to convert all the psychiatric wards in Israel to unisexual wards. This article contains a critical review of the report. The main arguments brought forward are: (a) Most psychiatric wards in Israel are open, a fact that makes separation meaningless. Since the mixing of the wards both sexual and aggressive behaviour has been significantly reduced. (b) Many, if not most inpatients are voluntary and if brought to court would be found to be responsible for their actions, including their competence to give consent for sexual relations. (c) Patients, like everybody else, adjust their behaviour to the expectancies of society. The message that they are irresponsible will have a detrimental effect on their behaviour. (d) It is the staff's duty to prevent patients who may later regret their sexual behaviour from having sexual relations. This can be done without separating the wards.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological adjustment and distress among Soviet immigrant physicians: demographic and background variables.

The goal of the present study was to examine the psychological distress of Soviet immigrant physicians in Israel and to identify risk and resilience factors in the psychological adjustment to immigration. This is a first report on a study conducted among 385 (152 men and 233 women) Soviet immigrant physicians who participated in preparatory licensing courses. The design of the study is described in detail and initial results are presented. These include demographic characteristics of the sample, background variables connected with motivation for immigration and reported absorption difficulties encountered in Israel. Family problems were found to be significantly correlated with depression: the highest rate of reported depression was found among single parents. Subjects who were examined during the second year after immigration reported depression more often than subjects who were in Israel less than a year. The findings suggest that motivational and family factors may enhance or mitigate the psychological distress experienced by immigrants.