A 10-year comparison of short versus long-term court-ordered psychiatric hospitalization: a follow-up study.

BACKGROUND: The Israel Mental Health Act of 1991 stipulates a process for court-ordered involuntary psychiatric hospitalization. As in many Western countries, this process is initiated when an individual is deemed "not criminally responsible by reason of mental disorder (NCR-MD)" or "incompetent to stand trial (IST)." A patient thus hospitalized may be discharged by the district psychiatric committee (DPC). The decision rendered by the DPC is guided by an amendment to the Mental Health Act that states that the length of the hospitalization should be in accordance with the maximum time of incarceration associated with the alleged crime. Little empirical research has been devoted to the psychiatric, medical, and social outcome of short versus long-term hospitalization under court order. METHODS: In our study we examined the outcomes of court-ordered criminal commitments over a 10-year period (2005-2015) at the Jerusalem Mental Health Center with a catchment area of 1.5 million. We found 136 cases (between the ages of 18 and 60) of criminal commitments during that period and used the average length of hospitalization, 205 days, as a cutoff point between short and long stays. We compared the outcomes of short and long hospitalizations of discharged patients using a follow-up phone survey (at least 7 years post-discharge) and data extracted from the Israel National Register to include recidivism, patient satisfaction and trust in the system, readmission, and demise. RESULTS: We found no statistically significant difference between short-term and long-term hospitalizations for reducing instances of re-hospitalization (p = 0.889) and recidivism (p = 0.54), although there was a slight trend toward short-term hospitalization vis-à-vis reduced recidivism. We did not find a statistical difference in mortality or incidents of suicide between the two groups, but the absolute numbers are higher than expected in both of them. Moreover, our survey showed that short-term hospitalization inspired more trust in the legal process (conduct of the DPC), in pharmacological treatment satisfaction, and in understanding the NCR-MD as a step toward avoiding future hospitalization and that it resulted in a higher level of patient satisfaction. CONCLUSIONS: The results we present show that as far as recidivism and readmission are concerned, there is no evidence to suggest that there is an advantage to long-term hospitalization. Although there may be unmeasured variables not investigated in the present study that might have contributed to the discrepancy between long- and short-term hospitalization, we believe that longer hospitalizations may not serve the intended treatment purpose. Additionally, the high cost of long-term hospitalization and overcrowded wards are obviously major practical drawbacks. The impact of the clinical outcomes should be reflected in medico-legal legislation and in court-ordered hospitalization in particular.

Patients behind the front lines: the exchange of mentally-ill patients in the 1948 Arab-Israeli War.

The British Mandate in Palestine ended abruptly in 1948. The British departure engendered a complex situation which affected all areas of life, and the country's health system was no exception. Gradual transition of the infrastructure was almost impossible owing to the ineffectiveness of the committee appointed by the United Nations. The situation was further complicated by the outbreak of the Arab-Israeli War. We relate for the first time the story of 75 Jewish patients who were left in a former British mental hospital in Bethlehem - deep behind the front lines. Despite the hostilities, there were complex negotiations about relocating those patients. This episode sheds light on the Jewish and Arab relationship as it pertained to mental institutions during and immediately after the British Mandate.

[THE EFFICACY OF THE DECISIONS OF TREATING PHYSICIANS VS. DISTRICT PSYCHIATRIC COMMITTEES IN REGARD TO THE DISCHARGE OF COMMITTED PSYCHIATRIC PATIENTS: A REGIONAL STUDY].

BACKGROUND: The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized can be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. This study attempts to compare the variance between the TP and the DPC decisions in different geographical regions in Israel. METHODS: We examined the outcomes of decisions made by the DPC using readmission data - an internationally recognized indicator of the quality of hospital care - and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were taken from the Israel National Register. We also collected information regarding all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in fewer than 30 days, involuntary civil readmission in fewer than 180 days, and involuntary readmission under court order in less than 1 year. RESULTS: The re-hospitalization pattern was compared in the two groups of patients discharged from psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the success rates of the various regional DPCs and the hospital TP groups, with the TP average (74.5% national success rate) success significantly better than the DPC groups (66.7% national success rate). Moreover, the variance between the decisions made in the different geographical regions in the two groups was also statistically significant (σ2 variance was 80.4 and 27.1 for the DPC and TP groups, respectively). CONCLUSIONS: The results we present indicate that the variance of decision "failure" (readmission) and "success" across the various geographical regions was found to be significantly better in the TP group than in the DPC group. We consider it likely that whereas TPs discharge IPH patients in accordance with well-accepted clinical approaches, the DPC's decisions are based on interpretations of the law (regarding, e.g., the patient posing a physical threat) and on the DPC's understanding of what is meant by the patient's "best interests." We suggest introducing more formal psychiatric training for the legal staff of the DPCs and building a structured and standardized method for reviewing the patient. Moreover, we propose using "soft paternalism" as an approach, which would justify limitations on individual liberties for the benefit of persons being restricted, provided that they are unable to make a choice that would be consistent with their own interests. This is often an appropriate and perhaps a more practical approach, one that the DPC could adopt in place of the present conservative approach, which requires a specific standard of "proof" of major illness to qualify as insanity requiring hospitalization.

The long-term health consequences of genocide: developing GESQUQ - a genocide studies checklist.

BACKGROUND: Genocide is an atrocity that seeks to destroy whole populations, leaving empty countries, empty spaces and empty memories, but also a large health burden among survivors is enormous. We propose a genocide reporting checklist to encourage consistent high quality in studies designed to provide robust and reliable data on the long term impact of genocide. METHODS: An interdisciplinary (Public Health, epidemiology, psychiatry, medicine, sociology, genocide studies) and international working committee of experts from Germany, Israel, the United States, and the United Kingdom used an iterative consensus process to develop a genocide studies checklist for studies of the long term health consequences. RESULTS: We created a list of eight domains (A Ethical approval, B External validity, C Misclassification, D Study design, E Confounder, F Data collection, G Withdrawal) with 1-3 specific items (total 17). CONCLUSION: The genocide studies checklist is easy to use for authors, journal editors, peer reviewers, and others involved in documenting the health consequences of genocide.

A comparison of decisions to discharge committed psychiatric patients between treating physicians and district psychiatric committees: an outcome study.

BACKGROUND: The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized may be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. Although much has been written about the ethical issues of restricting patients' rights and limiting their freedom, far less attention has been devoted to the psychiatric, medical, and social outcome of legal patient discharge against the doctor's recommendation. METHODS: In our study we examined the outcomes of the decisions made by the DPC using readmission data, an internationally recognized indicator of the quality of hospital care, and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were extracted from the Israel national register. We also collected all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in less than 30 days, involuntary civil readmission in less than 180 days, and involuntary readmission under court order in less than 1 year. RESULTS: The rehospitalization pattern was compared in the two groups of patients discharged from their psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the DPC and the TP group for each of the time frames, with the DPC group returning to IPH much more frequently than the TP group. Using cross-sectional comparison with logistic regression adjusted for age, gender, diagnosis and length of hospitalization, we found the probability of a decision failure in the TP group was significantly less with an OR of 0.7 (95% CI .586-.863), representing a 30% adjusted decrease in the probability for failure in the TP group. CONCLUSIONS: The results we present show that the probability of decision "failure" (readmission) was found to be significantly higher in the DPC group than in the TP group. It is often assumed that IPH patients will fare better at home in their communities than in a protracted hospitalization. This is frequently the rationale for early discharge by the DPC (30.1 days vs. 75.9 DPC and TP groups, respectively). Our results demonstrate that this rationale may well be a faulty generalization.

Psychopathology of children of genocide survivors: a systematic review on the impact of genocide on their children`s psychopathology from five countries.

Background: : The health consequences of genocides on children of survivors are increasingly discussed but conclusions have been conflicting. Methods: We systematically reviewed studies from five electronic databases (EMBASE, PILOTS, PUBMED, PsycINFO, Web of Science), which used a quantitative study design and included: (i) exposure to the genocides of Armenians in Nazi Germany, Cambodia, Rwanda and Bosnia; (ii) mental health outcomes; (iii) validated instruments; (iv) statistical tests of associations. Study quality was appraised using a quality assessment tool for genocide studies. PRISMA reporting guidelines were followed. Results: From 3352 retrieved records, 20 studies with a total of 4793 participants involving 2431 children of survivors and 2362 controls met the eligibility criteria. Studies were conducted in seven countries: Australia, Canada, Italy, Israel, Norway, Rwanda and the USAs over the past seven decades, using the Genocide Studies Quality Assessment Tool. Data from the high quality studies provide no consistent evidence that children of genocide survivors are more likely to have mental health problems than comparators who were not children of genocide survivors. Conclusions: Methodological characteristics were associated with findings: studies investigating random samples of genocide survivors did not find an impact of genocides on health of children of survivors. Potential confounders (e.g. recent life events, poverty) need further investigation. Future studies of the impact of genocides on mental health should report using a standardized structure, such as the quality tool used here.

Cannabis and Alcohol Abuse Among First Psychotic Episode Inpatients.

BACKGROUND: Psychoactive substance abuse, which includes abuse of alcohol and street drugs, is common among first-episode psychosis patients, but the prevalence of cannabis abuse is particularly high. However, there have been very few reported studies concerning the occurrence of psychoactive substance abuse among first-episode psychotic individuals using standard toxicological testing. We study the prevalence of cannabis and alcohol abuse among first-psychoticepisode inpatients as well as compare the demographic, diagnostic, and psychopathological profiles of substance abusers versus nonusers. METHODS: Subjects were recruited from the Jerusalem Mental Health Center between 2012 and 2014. Ninety-one consecutively admitted psychiatric patients diagnosed using the DSM-IV criteria with a first psychotic episode due to schizophrenia, schizophreniform disorder, bipolar disorder, brief psychotic episode, and psychosis NOS disorder entered the study. The diagnoses of schizophrenia (all types), psychosis NOS disorder, brief psychotic episode, and schizophreniform disorder were categorized as "only psychosis" and those of bipolar disorder manic episode with psychotic features (congruent and incongruent) and severe depression with psychotic features were categorized as "predominantly affective symptoms." Urine tests for tetrahydrocannabinol (THC) were performed during the first 48 hours of admission, and likewise self-report questionnaires were administered. Alcohol abuse and dependence were diagnosed by self-report. RESULTS: Of the 91 subjects in the study, 49 (53.8%) did not abuse any illegal psychoactive substance. Twenty patients (22%) abused only cannabis; 14 (15.4%) abused cannabis and another psychoactive substance; 54 (59.3%) of the subjects reported no alcohol abuse; 33 (36.3%) reported occasional drinking (between two and ten times a month); and 4 (4.4%) reported continuous repeated drinking (more than ten times a month). There was no correlation between the demographic characteristics and the abuse of cannabis. Two-thirds of the "predominantly affective symptoms" subjects were positive for THC, whereas only a third of the "only psychosis" subjects screened positive for THC. CONCLUSIONS: The percentage of cannabis and alcohol abuse in the study population is much higher than one would expect to see in the general Israeli population (according to the Knesset Research Department 7.6-10.2% of the adult Israeli population abuse cannabis). Different patterns of cannabis abuse among "predominantly affective" and "psychotic only" patients may lend credence to the preferential use of a specific substance per diagnosis.

Attitudes among medical and law students toward decision-making in regard to involuntary psychiatric hospitalization.

BACKGROUND: The management of individuals with mental illnesses sometimes requires involuntary hospitalization. The Israel Mental Health Act requires that cases of involuntary psychiatric hospitalization (IPH) be periodically reviewed by the district psychiatric committee. The discussion in the committee often leads to debate regarding the need for an IPH potentially depriving the patient of his freedom. Little is known about the way in which the psychiatrists and attorneys on these committees arrive at their decisions. The present study was designed to examine the views of future doctors and attorneys concerning cases of possible IPH to determine whether their decisions would be influenced by their respective professional educational backgrounds. METHODS: After compiling demographic data, we asked 170 students from each of the two disciplines what their decision would be in two hypothetical cases that dealt with the question of a prolongation of a psychiatric hospitalization. Questionnaires examining social distance and possible stigmatizing views concerning psychiatric patients were also distributed and collected. RESULTS: The response rates for the medical and law students were, respectively, 90% and 85%. We found no differences between the medical and law students regarding their views on prolongation of a psychiatric hospitalization. This was consistent regardless of whether the hospitalization was against the patient's will or according to his wish and against the treating physicians' advice. We also found that the medical and law students had similar general views regarding psychiatric patients, but that the latter evidenced greater social distance than the former. CONCLUSIONS: Academic background and socialization were not found to influence the decisions of students regarding IPH. Educational programs and exposure to psychiatric patients during law studies are proposed to lessen psychiatric stigma and promote better understanding between members of the two disciplines.

[Novel psychotherapeutic methods and the role of mental health centers in their implementation].

In this issue of Harefuah, Arbel et at. describe the implementation of mindfulness-based psychotherapy IMBP) in the Beer Sheba Mental HeaLth Center. MBP is an example of a form of complementary and alternative medical treatment, which became widespread and is now considered both safe and efficient. It includes mindful sitting practice, developing awareness, mindful movement, psycho-education, and often a cognitive component. MBP has a role in the treatment of minor and major mental disorders, and'may also alleviate stress and improve weLtl-being among therapists. In the Beer Sheba Center, MBP courses were offered to all staff members, and MBP group treatment was started in one of the wards. The promising results of MBP's implementation will be evaluated. This project emphasizes the pivotal role of mental health centers in the teaching of students and residents in mental health. This role must be considered while planning the future of these centers in the current reform of Israel's psychiatric services.

The effect of integration of non-cognitive parameters on medical students' characteristics and their intended career choices.

BACKGROUND: A new approach for assessing non-cognitive attributes in medical school candidates was developed and implemented at the Hebrew University Medical School. The non-cognitive tests included a biographical questionnaire, a questionnaire raising theoretical dilemmas and multiple mini-interviews. OBJECTIVES: To evaluate the effects of the change in the admission process on students' demographics and future career choices. METHODS: A questionnaire including questions on students' background and future residency preferences was administered to first-year students accepted to medical school by the new admission system. Results were compared with previous information collected from students admitted through the old admission process. RESULTS: Students accepted by the new process were significantly older (22.49 vs. 21.54, P < 0.001), and more had attended other academic studies before medical school, considered other professions besides medicine, and majored in humanities combined with sciences in high school. Significantly more students from small communities were admitted by the new system. Differences were found in preferences for future residencies; compared with the old admission process (N = 41), students admitted by the new system (N = 85) had a more positive attitude towards a career in obstetrics/gynecology (41% vs. 22%, P < 0.001) and hematology/oncology (11.7% vs. 4.8%, P < 0.001), while the popularity of surgery and pediatrics had decreased (34.5% vs. 61%, P < 0.001 and 68.7% vs. 82.5%, P < 0.001 respectively). CONCLUSIONS: Assessment of non-cognitive parameters as part of the admission criteria to medical school was associated with an older and more heterogenic group of students and different preferences for future residency. Whether these preferences in first-year students persist through medical school is a question for further research.

Is it time to use checklists in mental health care auditing?

A key strategy for improving the quality of mental health care is the design and implementation of a mechanism for on-site inspection and clinical auditing. We discuss the use of checklists in auditing providing an objective, comprehensive system for recording and analyzing multi-disciplinary, clinical auditing in mental health services. We believe such an approach can identify potential risks and allow for better decision making.

Relative perceptions of the needs of inpatients with schizophrenia and schizoaffective disorders.

BACKGROUND: Although there is a consensus that mental health services should be provided on the basis of need, the concept of client needs differs substantially among professionals, patients and involved family members. The aim of the present study was to identify the needs of patients repeatedly hospitalized with schizophrenia and schizoaffective disorders and to compare them with the needs rated by their nursing staff and relatives. METHOD: Using the Camber well Assessment of Need (CAN), we surveyed 52 consecutive voluntarily re-admitted inpatients aged 18- 65 fulfilling the ICD-10 criteria for schizophrenia and schizoaffective disorders. Analysis of variance and post-hoc t-test single comparisons were performed to examine the between-groups differences in the number of unmet needs rated by patients, clinical staff and family members. RESULTS: Significant differences in the perceptions of the patients and staff occurred in only 6 of the 22 CAN domains, with the patients rating higher the needs for "information on condition and treatment" and "benefits," and the staff member rating higher the patients' needs for "intimate relationships,"; "safety for others," "self-care" and "daytime activities." The analogical differences occurred between the patients and their relatives in the same need areas. CONCLUSIONS: Comparing the needs assessments from different perspectives provides a powerful means of patient evaluation and is potentially valuable information for care planning.

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.

Changes in stability of first-admission psychiatric diagnoses over 14 years, based on cross-sectional data at three time points.

BACKGROUND: Stability of diagnoses over time is an important criterion of reliability of any diagnostic system. AIMS: To compare the stability of diagnoses among hospitalized psychiatric patients over 14 years, based on cross-sectional data at three time points. METHOD: Diagnoses extracted from the National Psychiatric Case Register concerning psychiatric patients first admitted during 1989 (n=2996) were compared to those who were admitted during 1996 (n=3021) and 2003 (n=4041). Stability of diagnostic categories was measured by positive predictive value of admission diagnosis at discharge from hospital. RESULTS: There was no significant difference in diagnostic stability for most diagnostic categories between 1989 and 1996 patient cohorts. However, over the seven following years (cohort 2003) the diagnostic stability had been substantially increased: by 19% for affective disorders, by 18% for childhood disorders, by 17% for organic conditions, by 14% for neurotic disorders, by 12% for both schizophrenia and drug and alcohol dependence. CONCLUSIONS: In long-term perspective, reliability of most diagnostic categories of mental disorders has clearly improved.

The attitudes of Israeli medical students toward residency in psychiatry.

OBJECTIVE: The authors analyze attitudes toward psychiatry residency of Israeli medical students in preclinical years, compared with similar U.S. data. METHODS: A 23-item questionnaire was administered anonymously to 181 Israeli medical students in their preclinical years and was completed by 70% of the students present. RESULTS: Psychiatry was ranked most attractive as far as intellectual challenge was considered and least attractive when the degree to which it draws upon all aspects of medical training was considered. Our study shows that 32.8% of the Israeli medical students in the preclinical years consider residency in psychiatry, compared to 7.7% in the U.S. and 15.9% in Australia, using the same questionnaire and methodology. CONCLUSIONS: The population of students interested in family medicine and neurology, as well as those interested in the humanities, should be the source of psychiatry residents, and their faith in the psychiatric paradigm should be strengthened.

The making of a psychiatrist: an Israeli perspective.

When medical school educators - polished veteran doctors - review data on their students' attitudes towards residencies, they remember their own long days in the anatomy dissection room. They recall treating their first teenage patient and comforting a patient seeking solace while succumbing to a fatal illness. They think about why they made their important career choice. Thus the glory days of medical school become a defining and shaping experience for physicians, similar to boot camp for veteran paratroopers.

Prisons and the human rights of persons with mental disorders.

PURPOSE OF REVIEW: This paper deals with issues of human rights related to persons suffering from a mental disorder in the prison system. In particular, I consider whether the rights afforded prisoners with mental disorders in various international conventions and resolutions are being implemented in legislation and case law. RECENT FINDINGS: There have been advances in recent years in the Western world, particularly in the USA and the UK, with regard to prisoners' rights. In the UK, there is now a partnership of responsibility between the National Health Service and the Prison Service so that these organizations would become jointly responsible for delivering health care to prisoners. In the USA, the Prison Rape Elimination Act of 2003 and the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 go a long way in ensuring the basic rights of the imprisoned individual. SUMMARY: The large number of mentally ill inmates necessitates a continuous safeguarding of the rights of these individuals. It is now widely acknowledged that prisoners should be entitled to expect the same standard of health care as that provided to persons with unrestricted freedom, and have similar access to psychiatric beds. Further research is needed to see whether the improvement in their rights also improves their mental health and the long-term outcome of their illness.

Patient rights and law: tobacco smoking in psychiatric wards and the Israeli Prevention of Smoking Act.

In August 2001, the Israeli Ministry of Health issued its Limitation of Smoking in Public Places Order, categorically forbidding smoking in hospitals. This forced the mental health system to cope with the issue of smoking inside psychiatric hospitals. The main problem was smoking by compulsorily hospitalized psychiatric patients in closed wards. An attempt by a psychiatric hospital to implement the tobacco smoking restraint instruction by banning the sale of cigarettes inside the hospital led to the development of a black market and cases of patient exploitation in return for cigarettes. This article surveys the literature dealing with smoking among psychiatric patients, the role of smoking in patients and the moral dilemmas of taking steps to prevent smoking in psychiatric hospitals. It addresses the need for public discussion on professional caregivers' dilemmas between their commitment to uphold the law and their duty to act as advocates for their patients' rights and welfare.