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.

Intranasal oxytocin as an adjunct treatment among patients with severe major depression with and without comorbid borderline personality disorder.

INTRODUCTION: Results of studies concerning a possible beneficial effect of Intranasal-Oxytocin (IN-OT) as an add-on treatment for patients with major depression (MDD) have been inconsistent. One possible explanation to account for the difference in the effect of IN-OT is comorbid borderline personality disorder (BPD). This randomized controlled study was aimed to explore the differential effect of IN-OT administration among depressive patients with or without comorbid borderline personality disorder. METHODS: A secondary analysis was conducted on a specific subset of patients who participated in an RCT evaluating the impact of IN-OT as add-on treatment for patients with severe mental illness. Patients treated in inpatient settings (N = 58) were randomized and double-blindly allocated to receive twice daily IN-OT (32 IU) or placebo for a period of four weeks. The effect of IN-OT on therapy process and outcome was examined among patients with (n = 35) and without (n = 23) comorbid BPD. RESULTS: An interaction effect between diagnosis and group was observed on the Outcome Questionnaire-45 (B = 8.93, p = .007). Further analysis revealed that patients without BPD demonstrated significantly greater improvements following OT administration (B = -8.32, p = .001), whereas patients with BPD did not show significant improvement (B = 0.61, p = .76). The interactive pattern was also observed in the Hopkins Symptom Checklist (B = 0.25, p = .02), where patients without BPD demonstrated significantly larger improvements following OT administration (B = -0.29, p = .0009) as compared to placebo, while patients with BPD demonstrated no significant improvement (B = -0.04, p = .55). We did not find a harmful effect of IN-OT administration among patients with MDD and comorbid BPD. CONCLUSIONS: Patients with MDD and comorbid BPD benefit less from IN-OT administration as compared to depressed patients without BPD. Future studies should aim to identify patients who are more likely to benefit from IN-OT administration.

Oxytocin as a transdiagnostic biomarker of well-being in severe mental illness during the Covid-19 pandemic.

Individuals with severe mental illness (SMI) have been found to suffer a greater decline in psychological well-being compared to the general population in times of stress. The present study aimed to examine clinical and endocrine resilience factors of psychological well-being in SMI patients during the Covid-19 pandemic. METHODS: After Covid-19 crisis outburst in Israel 112 participants, 69 outpatients, and 43 inpatients and day treatment patients were recruited. Outpatients signed an online informed consent and filled in questionnaires regarding their level of mental health symptoms (OQ-45), fear of Covid-19 (FCV), and psychological well-being (PWB). Inpatients answered the same questionnaires and in addition, went through a positive social interaction paradigm while providing three saliva samples to measure their s-IgA and oxytocin (OT) levels. RESULTS: A strong negative correlation was found in the whole sample between reported mental health symptoms, fear of Covid-19, and well-being. Hierarchical regression did not find additional contribution of the fear of the pandemic in predicting well-being beyond the impact of symptomatology. For inpatients (N = 39) only, hierarchical regression found that oxytocin, but not s-IgA could explain 5% of the variance of well-being (R2 = 0.05) in individuals with SMI regardless of their mental health symptoms (R2 = 0.46) and their marital status (R2 = 0.21). CONCLUSIONS: OT is suggested as a possible independent biological resilience factor of well-being in times of major stress among SMI patients. It is still unknown whether OT is a mediator that contributes to well-being or a biological marker that indicates the degree of beneficial social interactions.

The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial.

OBJECTIVES: The effects of oxytocin (OT) administration on psychotherapeutic processes have thus far been elusive. This study explored the effect of OT administration on patient-therapist congruence of the working alliance. METHOD: Inpatients with mental disorders (N = 87) participating in a randomized controlled trial received OT (n = 44) or placebo (n = 43) intranasally twice a day, for four weeks. Patients and therapists rated the alliance after each session. RESULTS: Oxytocin significantly moderated the level of agreement (b = -0.56, SE = 0.25, t = -2.30, p = 0.02), such that patients receiving OT demonstrated lower discrepancy (b = -0.73, p < 0.001) than did those receiving placebo (b = -1.30, p < 0.001). On the other hand, the mutual covariance of patient-therapist ratings across sessions was positive and significant for patients receiving placebo (b = 0.26, p = 0.01) but not for patients in the OT group (b = -0.06, p = .56). CONCLUSION: Oxytocin can reduce discrepancies of patient-therapist perceptions of the alliance, although additional studies are needed to explore OT's effect on alliance development over time. As alliance congruence is associated with therapy outcomes, such intervention may lead to enhancement of therapeutic gains.

[SEASONALITY, HOLIDAYS AND THE DEMAND FOR URGENT PSYCHIATRIC CARE IN ISRAEL].

INTRODUCTION: The demand for urgent psychiatric services provided in emergency departments demonstrates high variability throughout the year. Seasonality and holidays may influence this demand. While these two phenomena are widely documented for mental healthcare, the unique climate and Israeli population, which is mostly Jewish, raises doubts regarding the relevance of prior results.

Hospitalisation outcomes for patients with severe mental illness treated by female vs. male psychiatry residents.

OBJECTIVE: Recent literature suggests that female physicians provide higher quality of care compared to their male counterparts across a variety of physical medical conditions. We examine whether a similar phenomenon is observed for psychiatry residents treating hospitalised psychiatric patients. METHODS: We analysed 300 hospitalised patient records from Shalvata Mental Healthcare Centre (Hod Hasharon, Israel). Resident-patient sex matchings were compared. RESULTS: No significant differences were observed in terms of residents' age and patients' age, medical condition and hospitalisation history. Male and female patients treated by female residents presented shorter hospitalisations (58 and 54 days compared to 67 and 66 days, respectively, p < .05), longer time to next hospitalisation (269 and 179 days compared to 179 and 123 days, respectively, p < .01), lower 30-day readmission rate (37% and 35% compared to 10% and 19%, respectively, p < .05), higher levels of family involvement during hospitalisation (2.6 and 2.7 points compared to 2.1 and 1.9 points, respectively, p < .01) and higher chances of obtaining rehabilitation services (39% and 34% vs. 23% and 17%, respectively, p < .05). CONCLUSIONS: Hospitalised patients treated by female psychiatry residents are associated with better hospitalisation outcomes compared to those cared for by male residents. KEY POINTSBoth male and female patients treated by female residents presented better hospitalisation outcomes.These hospitalisation outcomes include shorter hospitalisation periods, longer time to next hospitalisation, lower 30-day remission rate, significantly higher levels of family involvement and higher chances of obtaining rehabilitation services.Further work is needed in order to investigate the sources and reasons for the identified differences.

A double-edged hormone: The moderating role of personality and attachment on oxytocin's treatment facilitation effect.

BACKGROUND: Studies exploring the potential augmenting effect of oxytocin for patients with mental disorders have thus far reported mixed effects. However, oxytocin's effect may differ across patients with different interpersonal characteristics. This study aimed to examine the moderating role of attachment and personality traits on the effect of oxytocin administration on the therapeutic working alliance and symptomatic change, among hospitalized patients with severe mental illness. METHODS: Patients (N = 87) were randomly assigned to receive oxytocin or placebo, as an add-on to psychotherapy for a period of four weeks, in two inpatient units. Therapeutic alliance and symptomatic change were measured weekly, and personality and attachment were assessed at pre- and post-intervention. RESULTS: Oxytocin administration was significantly associated with improvement of depression (B=2.12, SE=0.82, t = 2.56, p = .012), and suicidal ideation (B=0.03, SE=0.01, t = 2.44, p = .016) for patients low in openness and extraversion, respectively. Nonetheless, oxytocin administration was also significantly associated with a deterioration in the working alliance for patients high in extraversion (B=-0.11, SE=0.04, t = -2.73, p = .007), low in neuroticism (B=0.08, SE=0.03, t = 2.01, p = .047) and low in agreeableness (B=0.11, SE=0.04, t = 2.76, p = .007). CONCLUSIONS: Oxytocin may act as a double-edged sword when it comes to its effect on treatment process and outcome. Future studies should focus on routes to characterize patients who might benefit the most from such augmentation. CLINICAL TRIAL REGISTRATION: Pre-registration in clinicaltrials.com: NCT03566069; Israel Ministry of Health: MOH_2017-12-05_002003.

Intranasal Oxytocin as Add-On Treatment for Inpatients with Severe Mental Illness: A Randomized Clinical Trial.

INTRODUCTION: In recent years, several studies were conducted to explore the potential augmenting effect of oxytocin for the treatment of individuals with severe mental illness. Nonetheless, studies exploring its effects in routine inpatient settings using high-quality randomized controlled trials are scarce. The current study assessed the effect of oxytocin administration on treatment process and outcome among psychiatric inpatients, while employing a rigorous experimental methodology. METHODS: A double-blind, placebo-controlled, randomized trial was conducted at a public psychiatric hospital in Israel. Patients (N = 87, 71.3% female participants) were administered intranasal oxytocin/placebo twice daily for 4 weeks, as add-on to usual care. Patients were assessed for severity of anxiety and depression symptoms and their working alliance with their therapist after each therapy session, and treatment outcome was assessed weekly. Multilevel modeling was performed to assess the linear change from pre- to post-treatment. RESULTS: Patients receiving OT demonstrated significantly larger symptomatic improvements (B = -0.01, t [437] = -2.36, p = 0.01). Larger gains were also observed for depression (B = -0.14, p < 0.001 in the OT group, B = -0.06, p = 0.02 in the placebo group) and general distress (B = -0.57, p < 0.001 in the OT group, B = -0.29, p = 0.02 in the placebo group). No significant effect was observed for anxiety, the working alliance, or attachment. DISCUSSION: Oxytocin has the potential to improve treatment outcome among inpatients. Nonetheless, additional controlled research is needed to further assess its effects on therapy process, as well as to account for therapeutic, pharmacological, and neuronal intervening factors.

The Impact of a Continuity-of-Care Model From Hospitalization to Outpatient Clinic for Patients With Severe Mental Illness.

The authors sought to assess the impact of a continuity-of-care model on quality-of-care measures among hospitalized patients with severe mental illness in Israel. A "continuity-of-care physician" provided psychiatric care to patients during hospitalization and outpatient care after discharge. In the year after the model's implementation, emergency department visits significantly decreased by 32% and rehospitalization rates of patients discharged within 30 and 90 days decreased by 40% and 29%, respectively. The yearly rate of compulsory admissions decreased from 35% to 25%, and the proportion of patients who entered rehabilitation significantly increased (from 9% to 13%). This model shows promise for improving quality of care of patients with severe mental illness admitted to acute psychiatric wards.

Buffering effect of in-patient psychiatric care on the link between fear of covid-19 and mental health consequences.

BACKGROUND& AIMES: Psychiatric admissions during the covid-19 pandemic were limited, overlooking their possible benefit. This study focused on assessing the effect of the fear of covid on the mental health and well-being of inpatients as opposed to outpatients. METHODS: During the first lockdown, forty-four inpatients and day care patients (inpatient group) and 74 outpatients (outpatient group) were recruited after an informed consent procedure. Fear of the infection was assessed using the Fear of COVID-19 (FCV-19S); severity of mental health symptomatology was evaluated with the outcome questionnaire-45 (OQ-45); wellbeing was assessed with the Psychological well-being scale (PWB). OUTCOMES: There was no difference between the inpatient group and outpatient group in their fear of COVID-19 levels.FCV-19 predicted changes in the outpatient OQ total score (B â€‹= â€‹2.21, p â€‹< 0.001), OQ interpersonal relation subscale (B â€‹= â€‹0.34, p â€‹= 0.01), PWB total score (B â€‹= â€‹-0.05, p â€‹< 0.001), PWB environmental mastery subscale (B â€‹= â€‹-0.07, p â€‹< 0.001) and PWB positive relation subscale (B â€‹= â€‹-0.05, p â€‹< 0.001), but not in the inpatient group. CONCLUSIONS: Mental health and wellbeing of the outpatient group, which had less therapeutic contact than the inpatient group, correlated with the fear of covid, supporting the hypothesis that intensive psychiatric therapy had a protective effect on the mental health consequences of "fear of covid".

Case Report: Oxytocin and Its Association With Psychotherapy Process and Outcome.

The potential of Oxytocin (OT) as a facilitator of psychotherapy has been previously acknowledged, nonetheless, randomized controlled trials thus far have not yielded conclusive results. One approach suggested to clarify empirical inconsistencies is to refine the study hypotheses and data collection process by utilizing an in-depth idiographic exploration of the investigated phenomena. In this case illustration we provide an in-depth analysis comparing two patients hospitalized in a closed psychiatric ward with depression and undergoing psychotherapy twice a week. These two patients were randomly allocated to receive either OT or placebo, twice a day for a period of 4 weeks. Both patients completed longitudinal assessments of process and outcome measures, and therapists' clinical notes were extracted and reviewed. Reliable clinical change was calculated for all outcome and process measures. The results indicated that the patient receiving OT showed significant improvement in interpersonal distress, as well as in anxiety and depression symptoms, while the placebo patient showed no significant change during the study period. Furthermore, while both patients showed no significant changes in the therapeutic alliance ratings, the therapist of the OT patient regularly reported positive changes in alliance in the medical notes, while no such report was observed in the placebo patient. These results suggest that changes produced by OT administration may be more noticeable by the therapist. Implications for future studies aimed at assessing the effect of OT on psychotherapy process and outcome are discussed.

Emotion perception and theory of mind in adolescents with major depression.

BACKGROUND: The research of theory of mind (ToM) and emotion perception (EP) in adolescents with major depressive disorder (MDD) is scarce, and no study to date has investigated the association between EP and long-term outcomes of adolescents with MDD. The aim of the current study was to evaluate ToM and EP in adolescents with MDD, as compared to healthy controls (HCs). In addition, we aimed to assess the association between impairment in ToM and EP, depressive symptom severity, and long-term outcome in the MDD group. METHODS: We compared the performance of 14 adolescents with MDD and 25 HC in the Facial Expression Recognition Task (FERT) and the Interpersonal Perception Task. We followed up with the MDD group 2 years later to assess the level of their depressive symptoms using the Children's Depression Rating Scale-Revised (CDRS-R). RESULTS: No differences were found between adolescents with MDD and HC in the ToM and FERT tasks. Also, within the MDD group, there was no association between the severity of depressive symptoms and task performance. In the MDD group, there was a significant correlation between lower levels of accuracy in the FERT during the index depressive episode and lower CDRS-R scores on follow-up 2 years later (r2 = 0.35, p = 0.021). CONCLUSIONS: EP impairments in adolescents with MDD might predict worse long-term outcome. Further research is needed to verify our findings and to assess for a possible neurobiological underpinning for the state and trait impairments in EP in adolescents with MDD.

Attitudes of patients with severe mental illness towards COVID-19 vaccinations: A preliminary report from a public psychiatric hospital.

BACKGROUND: As patients with severe mental illness are at increased risk for COVID-19 mortality, the issue of willingness to be vaccinated is of extreme importance. METHODS: During February 2021 Shalvata Mental Health hospital provided Covid-19 vaccines to its patients. Fifty one patients suffering from severe mental illness, out of 196 patients hospitalized in closed, open or day wards during that period, signed the informed consent and were assessed for their clinical condition (OQ-45), fear of Covid-19 (FCV-19S) and approach to the vaccine (C19-VHS). All patients who were not vaccinated in February 2021 (baseline) were re-approached a month later to assess whether they had gotten vaccinated since. RESULTS: Patients who were not vaccinated at baseline had an oppositional approach to the vaccine, and did not significantly differ in their fear of Covid-19 levels or in levels of clinical severity (t(49) = 2.51, p = 0.02) from those who were vaccinated. From the 29 patients who were not vaccinated at baseline approach to the vaccine was a good predictor to getting vaccinated after one month (79% positive predictive value). CONCLUSIONS: The majority of patients suffering from a severe mental illness are willing to get vaccinated, and their decision of whether or not to get vaccinated is based on their viewpoint on the vaccine rather than being an outcome of their level of distress (OQ-45). It is important to allow vaccine accessibility to hospitalized patients, to consider their opinions and to provide useful information to lower vaccine hesitancy and improve vaccination rates.

The association between symptom severity and theory of mind impairment in children with attention deficit/hyperactivity disorder.

The aim was to investigate the correlation between ADHD symptom severity and impairments in "theory of mind" (ToM) and empathy, and the improvement in these functions following the administration of methylphenidate (MPH). Fifty children aged 6-12 years with ADHD participated in the study. Symptom severity was assessed using the Swanson, Nolan and Pelham Questionnaire-IV (SNAP-IV). ToM performance was assessed using the "ToM test" and the "Faux-Pas Recognition Test". A significant negative correlation was found between the SNAP-IV Conners index, the oppositional and deportment subscales, and ToM test scores. MPH administration improved ToM scores in a magnitude that was negatively correlated with baseline performance. Additionally, Children with more severe behavioral problems showed greater improvement in ToM following administration of MPH. We conclude that severity of ADHD symptoms, most notably behavioral symptoms, is correlated with deficits in ToM. Administration of MPH improves ToM performance, with the greatest improvement occurring in children with more severe behavioral symptoms.

Lack of association between severity of ADHD symptoms and salivary oxytocin levels.

Impairments in the reactivity of Oxytocin (OT) system were associated with interpersonal difficulties in children with ADHD. The current study aimed to explore the correlation between symptoms severity and salivary OT levels at different time-points in children with ADHD. Symptoms severity was assessed in 50 children with ADHD (28 males, mean age 9.42 ± 1.65) using the Swanson, Nolan and Pelham Questionnaire-IV (SNAP-IV) and the Strengths and Difficulties Questionnaire (SDQ). Salivary OT levels were measured at baseline, as well as 15 min after positive social interaction. There was no statistical correlation between severity of ADHD and salivary OT levels in each of the time points. We conclude that impairments in the reactivity of the OT system in children with ADHD, associated with interpersonal impairments, might be a distinct aspect of the clinical picture, differentiated from the levels of inattentive, hyperactive/impulsive or behavioral symptoms.

High-gamma oscillations as neurocorrelates of ADHD: A MEG crossover placebo-controlled study.

Attention Deficit Hyperactive Disorder (ADHD) is a common neurobehavioral disorder with a significant and pervasive impact on patients' lives. Identifying neurophysiological correlates of ADHD is important for understanding its underlying mechanisms, as well as for improving clinical accuracy beyond cognitive and emotional factors. The present study focuses on finding a diagnostic stable neural correlate based on evaluating MEG resting state frequency bands. Twenty-two ADHD patients and 23 controls adults were blindly randomized to two methylphenidate/placebo evaluation days. On each evaluation day state anxiety was assessed, a 2N-back executive function task was performed, and resting state MEG brain activity was recorded at three timepoints. A frequency-based cluster analysis yielded higher high-gamma power for ADHD over posterior sensors and lower high-gamma power for ADHD over frontal-central sensors. These results were shown to be stable over three measurements, unaffected by methylphenidate treatment, and linked to cognitive accuracy and state anxiety. Furthermore, the differential high-gamma activity evidenced substantial ADHD diagnostic efficacy, comparable to the cognitive and emotional factors. These results indicate that resting state high-gamma activity is a promising, stable, valid and diagnostically-relevant neurocorrelate of ADHD. Due to the evolving understanding both in the cellular and network level of high-gamma oscillations, focusing future studies on this frequency band bears the potential for a better understanding of ADHD, thus advancing the specificity of the evaluation of the disorder and developing new tools for therapy.

Correction: The effect of methylphenidate on social cognition and oxytocin in children with attention deficit hyperactivity disorder.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The effect of methylphenidate on social cognition and oxytocin in children with attention deficit hyperactivity disorder.

The current study aimed to explore the possible effect of stimulants on oxytocin (OT), a neuropeptide which regulates social behavior, as a mediator of the pro-social effect of methylphenidate (MPH) in children with attention deficit hyperactivity disorder (ADHD) compared to healthy controls (HCs). Utilizing a double-blind placebo-controlled design, we compared the performance of 50 children with ADHD and 40 HCs in "theory of mind" (ToM) tasks and examined the effect of a single dose of MPH/placebo on ToM and salivary OT levels in children with ADHD at baseline and following an interpersonal interaction. Children with ADHD displayed significantly poorer ToM performance; however, following MPH administration, their performance normalized and differences between children with ADHD and HC were no longer found. Salivary OT levels at baseline did not differ between children with ADHD and HCs. However, after a parent-child interaction, OT levels were significantly higher in the HC group compared to children with ADHD. Administration of MPH attenuated this difference such that after parent-child interaction differences in OT levels between children with ADHD and HC were no longer found. In the ADHD group, OT levels decreased from administration of placebo to the parent-child interaction. However, the administration of MPH to children with ADHD was associated with an increase in OT levels after the parent-child interaction. We conclude that OT might play a role as a mediator of social deficits in children with ADHD and that the reactivity of the OT system to social interaction in children with ADHD might be impaired. Stimulants may improve ToM and social functions in children with ADHD via its impact on the OT system. PRS: OT and Social Cognition in Children with ADHD: Impact of MPH.

Initial Evaluation of Pain Intensity Among Depressed Patients as a Possible Mediator Between Depression and Pain Complaints.

Pain complaints are frequently described by depressed patients, and are mostly attributed to abnormal pain perception and modulation. The present study aimed to assess whether a unique pain processing profile differentiates depressed patients from healthy controls. Participants were 25 patients suffering from a moderate-severe unipolar depressive episode and 25 age and sex-matched healthy controls. Thermal stimuli were used to assess sensory threshold and pain threshold. Pain-60 temperature (temperature that induces pain ratings of 60 out of 100) was the first noxious stimuli to be administered during the experimental session. Central pain inhibition was assessed via conditioned pain modulation (CPM) and the degree of central nervous system excitability was assessed via mechanical temporal summation. Depressed patients reported higher levels of pain compared with healthy controls, and a significantly higher perceived pain during the last month. Additionally, they displayed significantly lower pain-60 temperature values compared with healthy controls (p = 0.01). Otherwise, no significant group differences were found in measures of pain perception and modulation. Our results suggest that the initial evaluation of pain intensity among depressed patients, as validated by pain-60 temperature values, is increased compared with healthy controls, and might be the mediator between depression and pain complaints. Possibly, depressed patients' negative bias in the processing of pain is similar to their processing pattern of facial expression or future events. Further studies are necessary in order to establish the mechanisms underlying the excessive pain complaints reported by patients with unipolar depression.