Does Specializing in Family Medicine Improve the Detection and Diagnosis of Mental Health Problems?

BACKGROUND: Approximately half the patients seeking mental health (MH) treatment consult primary care practitioners (PCPs). Previous research indicates that patients often do not receive correct MH diagnoses or appropriate treatment from PCPs. The present study examines whether a specialization in family medicine compared to other or no PCP residency programs enhances physicians' ability to detect, diagnose and treat MH problems. METHODS: Face-to-face interviews with 49 physicans in eight clinics in Israel. Two case vignettes and questionnaires assess MH awareness and factors influencing treatment. RESULTS: Significantly more family practitioners (FPs) compared to others correctly diagnosed depression and anxiety vignettes were aware of patients' MH problems and prescribed psychotropic drugs. LIMITATIONS: Small sample size, indirect examination of PCPs' skills using vignettes and the absence of psychotherapy options. CONCLUSIONS: FPs are more likely than other PCPs to detect, diagnose and treat MH problems. To improve MH detection among a broad range of PCPs, an expanded MH curriculum should be encouraged. Additional MH training should be available for all PCPs.

Physicians' influence on primary care patients' reluctance to use mental health treatment.

OBJECTIVES: The study examined attitudes of primary care patients toward mental health treatment and whether ambivalent or negative attitudes change after patients receive recommendations from their primary care physicians to seek treatment from a mental health professional. METHODS: Data were collected in face-to-face interviews with 902 Jewish patients aged 25-75 in eight primary care clinics in Israel. Measures included validated mental health instruments and a vignette eliciting patients' readiness to consider treatment and potential influence of a physician's recommendation. RESULTS: Initially, almost half of patients were reluctant to consider specialized mental health treatment. The probability of having a more positive attitude after the physician's recommendation was significantly higher among patients with more severe clinical diagnoses. CONCLUSIONS: A major finding was the positive impact of primary care physicians' recommendations on reluctant patients. Encouraging physicians to discuss mental health issues would likely promote more positive attitudes and increase patients' willingness to access treatment.

Use of unconventional therapies by primary care patients--religious resources vs. complementary or alternative medicine services.

OBJECTIVES: The study examines the difference in characteristics between primary care patients who turn to "religious resources for medical purposes" (RRMP) and those who turn to "complementary or alternative medicine" (CAM) services to cope with a physical or mental health problem. DESIGN AND SETTING: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25-75. MAIN OUTCOME MEASURE: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of 'service use' was examined through logistic regression analysis. RESULTS: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. CONCLUSIONS: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies - RRMP and CAM - tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources.

Hospitalization of patients with schizophrenic and affective disorders in Israel in the aftermath of the structural and rehabilitation reforms.

BACKGROUND: In the last decade (2001-2010) the Ministry of Health implemented two major inter-related reforms: a 'structural reform' to reduce the number of psychiatric beds and the 'Rehabilitation of the Mentally Disabled in the Community Law', which allocated funds for a variety of residential and vocational programs in the community for these patients. The objective of the present paper was to examine the impact of the two reforms on the hospitalization of schizophrenic and affective disorder patients by tracking the patterns of their inpatient care during the last decade. METHODS: Data on all psychiatric admissions during the period 1990-2011 were extracted from the Israel Psychiatric Case Register to examine changes in the rate of admissions, length of hospitalizations, total inpatient days and tenure in the community. The analysis was done separately for first-in-life vs. all admissions and for patients with schizophrenia vs. patients with affective disorders. RESULTS: From 2006 onward, with no decrease in the number the beds, the number of inpatient days for first-in-life patients with schizophrenia decreased by 29%, their admission rates dropped by 22%, the proportion of short [< 30 days] first in life episodes went up, while the percentage of those whose first in life episode lasted more than one year went down from 2.5% to 0.5%. The parallel results for patients with affective disorders were much less significant. CONCLUSIONS: An increasing percentage of patients with schizophrenia are not admitted to psychiatric wards at all and an increasing percentage of those who are admitted are treated during a shorter episode. The change is probably due to the rehabilitation reform which enabled the structural reform (the reduction in beds) to be implemented effectively.

Trends in the use of rehabilitation services in the community by people with mental disabilities in Israel; the factors involved.

BACKGROUND: In 2001, the Rehabilitation of the Mentally Disabled Law was implemented, defining a basket of rehabilitation services to which people with mental disabilities are entitled. OBJECTIVES: To describe change over time in the characteristics of applicants to rehabilitation committees, types of referral agencies, and the proportion of those referred who were admitted. To identify factors affecting implementation of decisions to admit people with mental disabilities into different rehabilitation services and predictors of the length of time they remain in the services. METHODS: The study population consisted of all applicants to rehabilitation committees during 2001-2008. Rehabilitation services included hostels, supported housing, and vocational services. Data were extracted from Ministry of Health rehabilitation and psychiatric hospitalization case registers. Findings were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox regressions. RESULTS: There was a trend over time for more patients with shorter or no psychiatric hospitalization histories to be referred to rehabilitation services. Moreover, there was an increase in the proportion of referrals from the community, although the majority of referrals still came from psychiatric hospitals. Less than half of those recommended for a rehabilitation program were admitted and remained in a rehabilitation facility for one year or more. One factor predicting participants' longer stays in rehabilitation services after hospitalization was the proximity of the committees' decisions to the hospitalization. Another factor was the patient receiving vocational services while in residential care. CONCLUSION: Although over time the new law has resulted in a broader spectrum of people with mental disabilities receiving rehabilitation services, additional efforts are needed to enable them to remain in the system for a sufficient amount of time. Programs addressing specific needs should be developed accordingly.

Who gets mental health treatment from the GP? Results from the Israel National Epidemiological Mental Health Survey.

BACKGROUND: In view of the pending mental health (MH) reform, an increase in demand of MH services is expected. Primary care physicians will presumably be involved in meeting this expected increased demand. OBJECTIVES: To identify the preferable route of service use of populations with MH problems based on data from the Israel National Health Survey (INHS). METHODS: The sample was drawn from the INHS which assessed mental disorders as well as the existence of chronic physical diseases in the population and the use of services for MH problems (specialty and primary care). The examined variables were (i) the existence of any mood or anxiety disorder and its severity, (ii) suffering from a chronic physical disease, (iii) use of MH services and (iv) use of general health services for MH problems. RESULTS: Fifty-one per cent of all those treated for MH problems were treated in the MH specialty sector and 49% in the general sector. Among those who met the diagnostic Composite International Diagnostic Interview criteria of any mood or anxiety disorder, the percentages were 62% and 38%, respectively. Irrespective of diagnosis, the proportion of those using the services of the GP is significantly greater among people above the age 50 years than among younger people. CONCLUSIONS: People with emotional problems above the age of 50 years are more likely to prefer help for their problems from their GP regardless of the presence of any mental disorder or of a chronic medical disease.

Dropout from outpatient mental health care: results from the Israel National Health Survey.

OBJECTIVES: To examine the dropout rates from outpatient mental health treatment in the general medical and mental health sectors and to identify the predictors of dropout. METHOD: The study population was extracted from the Israel National Health Survey. The analysis was related to 12-month service utilization for mental health reasons. RESULTS: The total dropout rate from mental health treatment was 24%, but differed between sectors. The dropout rate from general medical care was 32, and 22% from mental health care. In the general medical care sector, 30% ended treatment within two visits, while only 10% did so in the mental health-care sector. Chronic health condition, but not severity of psychiatric disorder, predicted dropout in the mental health sector. DISCUSSION: The higher rate of early dropout in general medical care may be related to the brevity of general medical visits and/or the inexperience of primary care physicians, which limits the opportunity to develop patient-physician rapport. Providers of services will have to promote education programs for GPs and allocate proper time to psychiatric patients. LIMITATION: The sample, although based on a national representative cohort, was small and limited the number of independent variables that could be examined.

Predictors of early psychiatric rehospitalization: a national case register study.

BACKGROUND: Inconsistent results have been published on variables affecting readmission to psychiatric hospitals, in particular length of hospitalization before discharge. The objective of the present study was to develop a predictive model for 30 days readmission after discharge, as the latter is one of the performance indicators in the pending mental health reform in Israel. METHOD: The data were extracted from the Israeli national psychiatric case register. They concerned all patients discharged from psychiatric hospitals in Israel during a six month period (January 1,-June 30, 2004). A follow-up since the first discharge during this period (discharge from index hospitalization) until November 30, 2005 was performed for each patient. A Cox regression allowed constructing a multi factorial prediction model for readmission within 30 days from discharge. RESULTS: The readmission rate within 30 days was 13 percent. The variables predicting early readmission were age up to 45, history of prior hospitalization, short time between index and prior hospitalization and being discharged from a hospital in the Tel Aviv Center district. Length of hospitalization was not a predictor of early readmission, except for the very short ones (up to eight days) which predicted earlier readmission. CONCLUSION: The policy of shortening hospitalizations, which potentially could lead to premature discharge,was not found to be associated with early readmission,except for extremely short hospitalizations.

Post-discharge contact with mental health clinics and psychiatric readmission: a 6-month follow-up study.

BACKGROUND: Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization. OBJECTIVES: To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital. METHODS: Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model. RESULTS: Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare. CONCLUSIONS: The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.

Predictors of cumulative length of psychiatric inpatient stay over one year: a national case register study.

BACKGROUND: Prior studies have shown inconsistent results regarding predictors of length of stay (LOS) and of readmission in psychiatric hospitals. "Cumulative LOS" over a given period, which reflects both LOS and readmission, has not been examined so far in a systematic way. The Israel Psychiatric Case Register in Israel made it possible to examine predictors of Cumulative LOS in a nationwide, representative sample. METHOD: All hospitalization admissions during a six-month period in Israel were recorded and followed-up for one year. The variables predicting Cumulative LOS over one year were identified through a Cox regression. RESULTS: The median Cumulative LOS during one year was 43.0 days, and only 1.7% of the patients remained hospitalized for more than one year after admission. The variables significantly predicting longer Cumulative LOS were: Jewish ethnicity, a diagnosis of schizophrenia or other functional psychosis, prior hospitalization, compulsory admission and Northern and Jerusalem districts of hospitalization (which have a lower admission rate). LIMITATIONS: Lack of information on severity of pathology and type of treatment. CONCLUSION: Cumulative LOS, which reflects both the length of each inpatient episode and the rate of readmission, is affected not only by clinical factors,but also by the cultural background of the patient population and by administrative factors such as bed pressure.

Employment among persons with past and current mood and anxiety disorders in the Israel National Health Survey.

OBJECTIVE: The study examined associations between having a past or current mood or anxiety disorder and being employed in the past month and salary level. METHODS: The Israel National Health Survey used data from the National Population Register to compile a representative sample of noninstitutionalized residents aged 21 and older. Data for this study were from 4,859 persons interviewed in their homes between May 2003 and April 2004. Lifetime, past-year, and past-month DSM-IV mood and anxiety disorders were assessed with a revised version of the Composite International Diagnostic Interview. Respondents self-reported employment and salary information. Logistic regression was used to estimate associations. RESULTS: The employment rate was lowest-35%-among respondents with a past-month mood or anxiety disorder, compared with rates of 52% among those with a past-year disorder, 60% among those with a lifetime disorder who did not have a disorder in the past year, and 58% among those with no disorder. No significant differences in rates of employment were found between those who had never had a disorder and those who had a lifetime or past-year disorder. Age at onset of the disorder was related to earning above the average salary for the population of Israel: those with onset before age 25 had lower odds of being in the above-average group. CONCLUSIONS: The results indicate that employment was affected only during the acute phase of a disorder and that early onset had lasting effects in terms of job level and salary.

Estimating the changes in demand for public mental health services following changes in eligibility: analysis of national survey data.

BACKGROUND: Numerous national surveys have shown that the rate of use of mental health services in a population lags behind the prevalence rate of psychiatric disorder. The preparations to provide universal coverage in Israel require estimates of the utilization levels likely to be reached once mental health care becomes a legal right of each resident. AIMS: This paper aims to provide an estimate of the size of the population which not only will be eligible for specialty mental health care, but which will also demand ambulatory mental health specialty care from public providers METHODS: Data for this study were extracted from a national survey conducted during 2003-2004 in Israel as part of the WMH2000 initiative. Use and perceived need to use services among eligible respondents was used to estimate likely levels of demand. RESULTS: The estimates for future demands on public mental health clinics ranged between 1.2%--the size of the population that is eligible by law and is currently using public mental health services to 5.5%--the size of the eligible population that is currently using some type of service or perceives the need for care in mental health. DISCUSSION: The estimate of the expected use falls in the range of other universal access systems. CONCLUSIONS AND IMPLICATIONS FOR POLICY: The present study provides estimates that are much higher than the estimated size of the population currently using public mental health services, yet the upper limit of the range of estimates is close to those on which the new legislation is based.

Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care.

OBJECTIVE: Prevalence rates of mental health problems in primary care vary according to population and the type of measure used. This study examined the prevalence of a full range of mental health problems, including sub-threshold diagnoses, and the socio-demographic risk factors for psychiatric disorders among a population with low out-of-pocket expenditures for medical care. METHOD: Four validated mental health assessment instruments, including the CIDI-SF, were administered to a sample of 976 users of primary care in Israel between the ages of 25-75 in eight clinics throughout the country. Prevalence estimates were obtained for seven psychiatric diagnoses, two "other mental health disorders" (somatization and disordered eating) and five sub-threshold conditions. RESULTS: The most common types of morbidity were depression and disordered eating (20.6% and 15.0%, respectively), followed by somatization (11.8%) and general anxiety (11.2%). Among respondents, 31.1% had at least one psychiatric diagnosis, 24.3% had 'other mental disorders' and 15.5% had sub-threshold conditions. Panic attack, disordered eating and somatization, as well as a global measure of any psychiatric diagnosis were significantly more prevalent among women than men. Psychiatric diagnoses were also more common among those in the age group 45-64, with less education and insufficient income, the never married and separated/divorced and those not working. No significant differences were found between recent immigrants, veteran immigrants and Israeli-born, between Arab and Jewish Israelis or between secular or religious sectors of the population. CONCLUSIONS: This study establishes the prevalence of the most common disorders in primary care including PTSD, somatization and disordered eating behaviors. The additional of other mental disorders suggests that a more accurate picture of mental disorders in primary care requires an expanded assessment procedure.

Prevalence of mood and anxiety disorders in the community: results from the Israel National Health Survey.

OBJECTIVE: To estimate the 12-month and lifetime prevalence rates of mood and anxiety disorders in Israel and their socio-demographic correlates. METHOD: A representative sample of respondents extracted from the National Population Register of non-institutionalized residents, aged 21 or older, were interviewed at home between May, 2003, and April, 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview. RESULTS: Seventeen percent of the sampled adult population reported a lifetime occurrence of a mood or anxiety disorder, while nearly one in 10 (9.7%) reported a mood or anxiety disorder occurring during the previous 12 months. Mood disorders were twice as common as anxiety disorders. CONCLUSION: Contrary to expectations born out of Israel's unique life circumstances, the prevalence of mood or anxiety disorders fall within the range of other western countries. However, given the current age structure and the age of onset of these disorders, their total burden in the near future is likely to increase.

Twelve-month service utilization rates for mental health reasons: data from the Israel National Health Survey.

OBJECTIVE: To measure the 12-month utilization rates for mental health reasons in all types of services. METHOD: A representative sample extracted from the National Population Register of non-institutionalized residents aged 21 or older were interviewed at their homes between May 2003 and April 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview (WMH-CIDI). RESULTS: About 10% of the adult population receives some type of treatment for emotional or mental health problems within a single year. More than half of service consumers were not classified as suffering from mood or anxiety disorders. Of those diagnosed with mood or anxiety disorders in the past 12 months only about 50% used any type of service for mental health problems. CONCLUSION: There is only a partial overlap between those who utilize the services and those who meet the criteria for a clinical diagnosis of mental disorder.

Re-hospitalization of first-in-life admitted schizophrenic patients before and after rehabilitation legislation: a comparison of two national cohorts.

BACKGROUND: In line with the worldwide trend of deinstitutionalization and development of community facilities, a rehabilitation legislation was passed in Israel in 2000. Its aim was to establish an infrastructure for the chronic mentally ill. The objective of the present study was to evaluate the impact of this legislation on the re-hospitalization of schizophrenic patients. METHOD: Re-hospitalization rates within 3 years of discharge were compared for two cohorts of first-in-life hospitalized schizophrenics, those discharged in 1990-1991 and those discharged in 2000-2001, after the passing of the law. Possible confounding variables were controlled for by logistic regression analyses. The same analysis was done for patients with affective disorders who are not generally beneficiaries of this legislation. RESULTS: In 2000-2001, the re-hospitalization rate was significantly lower than in 1990-1991 for schizophrenic patients with an in-patient stay longer than 6 months (chronic patients) but not for short-stay schizophrenics or for affective patients. CONCLUSION: The study suggests that the expanding of the rehabilitation facilities in the community by legislation leads to increase in the survival in the community of schizophrenic patients.

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel.

BACKGROUND: The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals. METHODS: A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry. RESULTS: The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge. CONCLUSION: The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.

Reduction in inpatient length of stay and changes in mental health care in Israel over four decades: a national case register study.

BACKGROUND: The purpose of the present study was to investigate trends over the past 40 years in the accumulated length of hospital stay, and to consider how these trends might have been affected by changes in the provision of mental health care in Israel from 1960 to 1997. METHODS: The national psychiatric case register was used to follow four cohorts of all new admissions in 1960, 1970, 1980 and 1990 diagnosed with schizophrenia or affective disorders for the first seven years following the index admission. RESULTS: Most of the changes in length of stay occurred among patients with schizophrenia. The overall accumulated length of stay decreased by 50% between 1960 and 1980. The largest reduction was observed among long-stay patients with schizophrenia. Number of admissions did not change for the four cohorts. LIMITATIONS: The interpretation of the data remains speculative, as we are attempting to establish causality between parallel trends. CONCLUSIONS: The general trend in the findings of this study corresponds with changes that took place between 1970 and 1990 in the outpatient care for the mentally ill. These innovations facilitated the discharge of patients with chronic schizophrenia and altered the case mix of the newly admitted patients.

Neuroleptic Malignant Syndrome: Neuroleptic Rechallenge After Electroconvulsive Therapy.

The necessity of neuroleptic rechallenge in patients who have experienced neuroleptic malignant syndrome (NMS) has been discussed in recent articles. Electroconvulsive therapy (ECT) has been proposed as an alternative treatment to neuroleptics. In cases where ECT fails, neuroleptic rechallenge remains the only alternative. A case of NMS is reported with successful reintroduction of neuroleptics after an ECT course. Four prior rechallenges with neuroleptics before ECT had failed, and NMS recurred. ECT may change the reaction to neuroleptics.