Impact of the mental health reform in Israel on health care and mortality among people with severe mental illness.

OBJECTIVE: Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI. METHOD: A case-control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded. RESULTS: Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform. CONCLUSIONS: Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.

Early adulthood psychiatric diagnoses and the subsequent risk of life-time incarceration: a cohort study.

BACKGROUND: The association between incarceration and psychiatric disorders has been noted. Yet, existing studies are cross-sectional or examine the risk of recidivism, which has limited the predictive validity of psychiatric disorders as a risk factor for incarceration. To overcome this limitation, this study used a prospective cohort to examine whether psychiatric diagnoses in early adulthood predicted incarceration throughout a 30-year follow-up. It tested the association between psychiatric diagnoses with future incarcerations, their number and durations, controlling for education and ethnic status. METHODS: This study merged data from three sources in Israel: a prospective 10-year birth cohort study of young adults aged 25-34, conducted in the 1980s (N = 4914) that included a psychiatric interview; data from the Prison Service, including the cause, number and duration of incarcerations; and from the Vital Statistics Registry on death records. RESULTS: Multivariate analysis showed that substance-use disorders, antisocial personality and lower levels of education predicted future incarceration, their number and maximum duration. The remainder diagnoses were not significantly associated with future incarceration. CONCLUSIONS: Results limited the prediction of future incarcerations to persons diagnosed with substance use and antisocial personality, and do not support an independent predictive association between additional psychiatric diagnoses and future incarceration.

Mental Health Care Gap: The Case of the Slovak Republic.

This study explored unmet mental health and social care needs in the Slovak Republic and their adverse human rights consequences. We estimated treatment gap for persons aged 15-64 years in year 2015 affected by depressive, anxiety, substance use and schizophrenic disorders by comparing local treated prevalence rates with population estimated rates for Europe. Two-thirds of people with depressive disorders and over 80% of those with anxiety disorders and alcohol dependence were not receiving treatment. There was no treatment gap for persons with schizophrenia. Fifty-one percent of those eligible for disability pension on the grounds of mental disorders failed to receive it. We discuss the implications of the estimated gaps in mental health and social care and consequent human rights violations that may result from the current system of mental health care in Slovakia.

Exposure to Genocide and the Risk of Dementia.

Competing hypotheses stating that past genocide exposure reduces (owing to resilience) versus increases (owing to vulnerabilities) the risk of dementia are yet to receive empirical support. This study tested these competing hypotheses. Registry data were extracted on 51,752 Israeli residents without dementia from September 2002 to January 2012; individuals were born between 1901 and 1945, alive on January 2012, and followed-up for the risk of dementia between January 2013 and October 2017. Groups were classified as exposed to the European Holocaust, based on government recognition, or unexposed. Hazard ratios (HRs) from Cox regression models were used to quantify the risk of dementia between the groups, adjusting for demographic and diagnostic covariates; additionally, 12 sensitivity analyses were computed. In total 10,780 participants (20.8%) were exposed to the Holocaust and 5,584 (10.8%) were diagnosed with dementia during follow-up. Dementia rates were 16.5% in the Holocaust-exposed group and 9.3% in the unexposed group. In the primary analysis, the estimated unadjusted HR of dementia for the exposed compared to the unexposed group was 1.77, 95% CI [1.67, 1.87], and the adjusted HR was 1.21, 95% CI [1.15, 1.28]. Sensitivity analyses significantly replicated the primary results with similar point estimates, adjusted HRs = 1.18-1.28, all ps < .001; all HRs had a small effect size. The current study results are consistent with the hypothesis that exposure to the extreme adversities of genocide heightens vulnerability to the risk of dementia in later life.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Exposición al Genocidio y el Riesgo de Demencia EXPOSICIÓN A GENOCIDIOS Y RIESGO DE DEMENCIA Existen hipótesis contradictorias que indican que la exposición pasada al genocidio, por un lado, reduce (debido a la resiliencia), y por otro, aumenta (debido a las vulnerabilidades) el riesgo de demencia, aún no han recibido apoyo empírico. Este estudio puso a prueba estas hipótesis en competencia. Los datos fueron tomados de un registro de 51,752 residentes israelíes, sin demencia, desde Septiembre del 2002 hasta Enero del 2012; los individuos nacieron entre 1901 y 1945, y se encontraban vivos a Enero del 2012, y con un seguimiento de riesgo de demencia entre Enero del 2013 y Octubre de 2017. Los grupos fueron clasificados como expuestos al Holocausto Europeo, basado en el reconocimiento del gobierno, o no expuestos. Se utilizaron cocientes de riesgos instantáneos (Hazard Ratio, HR en delante de acuerdo con su sigla en inglés) de modelos de regresión de Cox para cuantificar el riesgo de demencia entre los grupos, ajustándolo a las covariables demográficas y diagnósticas. Adicionalmente, se computaron 12 análisis de sensibilidad. Un total de 10,780 participantes (20.8%) fueron expuestos al Holocausto y 5,584 (10.8%) fueron diagnosticados con demencia durante el seguimiento. Las tasas de demencia fueron del 16.5% en el grupo expuesto al Holocausto y el 9.3% en el grupo no expuesto. En el análisis primario, el HR estimado no ajustado de demencia fue de 1.77, IC del 95% [1.67, 1.87], para el grupo expuesto en comparación con el grupo no expuesto, y el HR ajustada fue de 1.21, IC del 95% [1.15, 1.28]. Los análisis de sensibilidad replicaron significativamente los resultados primarios con estimaciones puntuales similares, HR ajustadas = 1.18-1.28, todos los ps <.001; todos los HR tuvieron un tamaño efecto pequeño. Los resultados del presente estudio son consistentes con la hipótesis de que la exposición a las adversidades extremas como el genocidio aumenta la vulnerabilidad para el riesgo de demencia en edad avanzada.

Using the capabilities approach to understand inequality in primary health-care services for people with severe mental illness.

BACKGROUND: Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning). METHODS: Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed. RESULTS: We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions. CONCLUSION: The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

Association of maternal exposure to terror attacks during pregnancy and the risk of schizophrenia in the offspring: A population-based study.

This study tested the hypothesis that maternal exposure to terror attacks during pregnancy is associated with the risk of schizophrenia in the offspring. A population-based study was conducted of Israeli children born between 1975 and 1995 and that were registered in the Ministry of Interior and followed up in the Ministry of Health from birth to 2015 for the risk of schizophrenia (N = 201,048). The association between maternal exposure to terror attacks during pregnancy and the risk of schizophrenia in the offspring was quantified with relative risks (RR) and their 95% confidence intervals (CI) fitting Cox regression models unadjusted and adjusted for confounders. Sensitivity analyses were performed to test the robustness of the results. The RR of schizophrenia in offspring of mothers exposed to terror attacks during pregnancy compared to offspring of mothers not exposed during pregnancy were estimated unadjusted (RR = 2.51, 95% CI, 1.33, 4.74) and adjusted (RR = 2.53, 95% CI, 1.63, 3.91). In the sensitivity analyses adjusted RRs were estimated using a sibling-based study design (2.85, 95% CI: 1.31-6.21) and propensity matching (2.45, 95% CI: 1.58-3.81). Maternal exposure to terror attacks during pregnancy was associated with an increased risk of schizophrenia in the offspring, possibly indicating a critical period of neurodevelopment that is sensitive to the stress of terror attacks and affected by epigenetic modifications.

A review of epidemiologic studies on suicide before, during, and after the Holocaust.

The available literature on the risk of suicides related to the Holocaust (1939-1945) and its aftermath differs in its time periods, in the countries investigated, and in the robustness of its sources. Reliable information seems to indicate that the risk of suicide for Jews in Nazi Germany and Austria during the pre-war period (1933-1939) was elevated, while information on suicide during the internment in the concentration camps is fraught with problems. The latter derives from the Nazis' decision to hide the statistics on the inmates' causes of death, and from the prevailing life conditions that impeded separation between self-inflicted death and murder. Reliable studies conducted in Israel among refugees who entered pre-state Israel, 1939-1945, and post-World War II survivors reaching Israel (1948 on), show a mixed picture: suicide rates among the former were higher than comparison groups, while the latter group shows evidence of resilience.

The Association Between Political Violence and the Connection Between Bullying and Suicidality Among Palestinian Youth.

We examined the association between protracted political violence and the connection between bullying and suicidality among Palestinian adolescents. Data were collected from a representative sample of Palestinian students (N = 5,713) from 100 schools in the West Bank and East Jerusalem who completed an in-class survey. Students who were victims of bullying or bully victims who were exposed to political violence were at higher risk for suicide attempts compared to students who were victims of bullying or bully victims but not exposed to political violence. Political violence moderated the association between bullying and suicide attempts after controlling for socio demographic and other mental health variables.

Double disparities in the health care for people with schizophrenia of an ethnic-national minority.

BACKGROUND: Studies have shown health care disparities among persons of minority status, including in countries with universal health care. Yet, a dearth of studies have addressed disparities resulting from the combined effect of two minority status groups: severe mental illness and ethnic-national sector filiation. This study aimed to compare the differential health care of Jewish- and Arab-Israelis with schizophrenia in a country with a universal health insurance. METHOD: This study builds on a large case-control epidemiological sample (N = 50,499) of Jewish- (92.9%) and Arab-Israelis (7.1%) service users with (n = 16,833) and without schizophrenia (n = 33,666). Health services records were collected in the years 2000-2009. Diabetes and cardiovascular disease (CVD) served as sentinel diseases. We compared annual number of LDL tests and visits to specialists in the entire sample, Hemoglobin-A1C test among people diagnosed with diabetes, and cardiac surgical interventions for those diagnosed with CVD. RESULTS: Service users with schizophrenia were less likely to meet identical indexes of care as their study counterparts: 95% of cholesterol tests (p < .001), and 92% visits to specialists (p < .001). These differences were greater among Arab- compared to Jewish-Israelis. Annual frequency of Hemoglobin-A1C test among people diagnosed with diabetes was lower (94%) in people with schizophrenia (p < 0.01), but no ethnic-national differences were identified. Among service users with CVD less surgical interventions were done in people with schizophrenia (70%) compared to their counterparts, with no ethnic-national disparities. CONCLUSIONS: In Israel, service users with schizophrenia fail to receive equitable levels of medical and cardiac surgical care for CVD and regular laboratory tests for diabetes. Although disparities in some health indicators were enhanced among Arab-Israelis, schizophrenia was a greater source of disparities than ethnic-national filiation.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

Holocaust exposure and subsequent suicide risk: a population-based study.

OBJECTIVES: To examine the association between the extent of genocide exposure and subsequent suicide risk among Holocaust survivors. METHODS: Persons born in Holocaust-exposed European countries during the years 1922-1945 that immigrated to Israel by 1965 were identified in the Population Registry (N = 209,429), and followed up for suicide (1950-2014). They were divided into three groups based on likely exposure to Nazi persecution: those who immigrated before (indirect; n = 20,229; 10%), during (partial direct; n = 17,189; 8%), and after (full direct; n = 172,061; 82%) World War II. Groups were contrasted for suicide risk, accounting for the extent of genocide in their respective countries of origin, high (>70%) or lower levels (<50%). Cox model survival analyses were computed examining calendar year at suicide. Sensitivity analyses were recomputed for two additional suicide-associated variables (age and years since immigration) for each exposure group. All analyses were adjusted for confounders. RESULTS: Survival analysis showed that compared to the indirect exposure group, the partial direct exposure group from countries with high genocide level had a statistically significant (P < .05) increased suicide risk for the main outcome (calendar year: HR 1.78, 95% CI 1.09, 2.90). This effect significantly (P < .05) replicated in two sensitivity analyses for countries with higher relative levels of genocide (age: HR 1.77, 95% CI 1.09, 2.89; years since immigration: HR 1.85, 95% CI 1.14, 3.02). The full direct exposure group was not at significant suicide risk compared to the indirect exposure group. Suicide associations for groups from countries with relative lower level of genocide were not statistically significant. DISCUSSION: This study partly converges with findings identifying Holocaust survivors (full direct exposure) as a resilient group. A tentative mechanism for higher vulnerability to suicide risk of the partial direct exposure group from countries with higher genocide exposure includes protracted guilt feelings, having directly witnessed atrocities and escaped death.

Health Care and Mortality among Persons with Severe Mental Illness.

OBJECTIVE: Reports show disparities in the health care of persons with severe mental illness (SMI), including in countries with universal health insurance. However, the moderating effect on disparities of specific mental health legislation is yet to be studied. The study aimed to investigate equality of health care for people with SMI in a country with a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities. METHOD: A case-control epidemiological study compared health services (laboratory tests, visits to specialists, and medications) provided to users with and without a history of schizophrenia and bipolar disorder ( N = 52,131) and with regard to a subgroup of users with diabetes ( n = 16,280). In addition, we examined the mortality rates of the study population. RESULTS: While service users with schizophrenia were somewhat less likely to meet the same indexes of care as controls, those with bipolar disorder did not differ from their counterparts. Yet, mortality risk among service users with schizophrenia and bipolar disorder was 2.4 and 1.7 times higher, respectively. Rates of services to persons with SMI and comorbid diabetes did not differ from their counterparts. CONCLUSIONS: In Israel, a country with a national health insurance and a rehabilitation law for persons with mental disabilities, service users with bipolar disorder receive equitable levels of general health care. For users with schizophrenia, the disparities exist in some of the health care measures but to a smaller extent than in other countries with universal health insurance. In contrast, mortality rates are elevated in persons with SMI.

Transgenerational effects of genocide exposure on the risk and course of schizophrenia: A population-based study.

BACKGROUND: Hypotheses about the sequel of parental genocide exposures on the offspring's risk and course of schizophrenia remain untested. AIMS: To test hypotheses related to the transgenerational transmission of parental genocide exposure on the risk and course of schizophrenia. METHODS: Data were extracted from the National Population Register on all offspring (N=51.233; born: 1948-1989) whose parents were born (1922 to 1945) in Nazi- dominated European nations. Both parents either immigrated before (indirect exposure: n=1627, 3.2%) or after (direct exposure: n=49.606, 96.8%) the Nazi era. Offspring subgroups were identified from the initial timing of parental exposure (e.g., likely in utero, combined in utero and postnatal, or postnatal). Schizophrenia disorders were ascertained (1950-2014) from the National Psychiatric Case Registry. Cox models were computed to compare the offspring groups with respect to the risk and the adverse course of schizophrenia, adjusting for confounders. RESULTS: The offspring rates on the risk and course of schizophrenia did not differ by parental affiliation to the direct and indirect exposure groups. Cox models showed that offspring subgroups with maternal Holocaust exposures in utero only (HR=1.74, 1.13, 2.66) and combined in utero and postnatal (HR=1.48, 1.05, 2.10); as well as paternal Holocaust exposures combined in utero and postnatal (HR=1.48, 1.08, 2.05), and early postnatal (aged 1-2; HR=1.49, 1.10, 2.00) had a significantly (P<0.05) higher psychiatric re-hospitalization rate than the indirect group. CONCLUSIONS: Transgenerational genocide exposure was unrelated to the risk of schizophrenia in the offspring, but was related to a course of deterioration during selected critical periods of early life.

Genocide Exposure and Subsequent Suicide Risk: A Population-Based Study.

The association between periods of genocide-related exposures and suicide risk remains unknown. Our study tests that association using a national population-based study design. The source population comprised of all persons born during1922-1945 in Nazi-occupied or dominated European nations, that immigrated to Israel by 1965, were identified in the Population Register (N = 220,665), and followed up for suicide to 2014, totaling 16,953,602 person-years. The population was disaggregated to compare a trauma gradient among groups that immigrated before (indirect, n = 20,612, 9%); during (partial direct, n = 17,037, 8%); or after (full direct, n = 183,016, 83%) exposure to the Nazi era. Also, the direct exposure groups were examined regarding pre- or post-natal exposure periods. Cox regression models were used to compute Hazard Ratios (HR) of suicide risk to compare the exposure groups, adjusting for confounding by gender, residential SES and history of psychiatric hospitalization. In the total population, only the partial direct exposure subgroup was at greater risk compared to the indirect exposure group (HR = 1.73, 95% CI, 1.10, 2.73; P < .05). That effect replicated in six sensitivity analyses. In addition, sensitivity analyses showed that exposure at ages 13 plus among females, and follow-up by years since immigration were associated with a greater risk; whereas in utero exposure among persons with no psychiatric hospitalization and early postnatal exposure among males were at a reduced risk. Tentative mechanisms impute biopsychosocial vulnerability and natural selection during early critical periods among males, and feelings of guilt and entrapment or defeat among females.

Psychological Factors Associated with Emotional Distress among Palestinian Arabs from East Jerusalem Accessing Psychiatric Care in Israel.

BACKGROUND: The Palestinian population residing in East Jerusalem is characterized by high rates of poverty and unemployment and is subject to discrimination in various forms, including infrastructure of mental health services. Little is known about the help seeking needs and practices of East Jerusalem residents. METHOD: We examined socio-demographic and clinical characteristics of a consecutive sample Palestinian residents from East Jerusalem (N=50) who accessed a specially assigned psychiatric clinic in Israel. In addition, we examined the psychological factors associated with emotional distress among these service-users upon entry to care. Participants completed a survey in Arabic that included a socio-demographic questionnaire and measures assessing emotional distress, perceived exposure to discrimination and social support, and mental health stigma. RESULTS: Participants reported high levels of emotional distress. Female gender, low socioeconomic status, higher perceived exposure to discrimination and higher perceived social support were associated with increased emotional distress. CONCLUSIONS: Findings add to the scarce body of knowledge on specific mental health characteristics of East Jerusalem Palestinian residents.

Demographic, Behavioral, and Psychiatric Risk Factors for Suicide.

BACKGROUND: There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias. AIMS: To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide. METHOD: We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years. RESULTS: Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ±â€†2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide. CONCLUSION: In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Primary mental health prevention themes in published research and academic programs in Israel.

BACKGROUND: The World Health Organization Comprehensive Mental Health Action Plan (CMHAP) 2013-2020 proposes the implementation of primary prevention strategies to reduce the mental health burden of disease. The extent to which Israeli academic programs and published research adhere to the principles spelled out by the CMHAP is unknown. OBJECTIVE: To investigate the presence of mental health primary prevention themes in published research and academic programs in Israel. METHODS: We searched for mental health primary prevention themes in: (1) three major journals of psychiatry and social sciences during the years 2001-2012; (2) university graduate programs in psychology, social work and medicine in leading universities for the academic year of 2011-2012; and (3) doctoral and master's theses approved in psychology and social work departments in five universities between the years 2007-2012. We used a liberal definition of primary prevention to guide the above identification of themes, including those related to theory, methods or research information of direct or indirect application in practice. RESULTS: Of the 934 articles published in the three journals, 7.2%, n = 67, addressed primary prevention. Of the 899 courses in the 19 graduate programs 5.2%, n = 47, elective courses addressed primary prevention. Of the 1960 approved doctoral and master's theses 6.2%, n = 123, addressed primary prevention. Only 11 (4.7%) articles, 5 (0.6%) courses, and 5 (0.3%) doctoral and master's theses addressed primary prevention directly. CONCLUSIONS: The psychiatric reform currently implemented in Israel and WHO CMHAP call for novel policies and course of action in all levels of prevention, including primary prevention. Yet, the latter is rarely a component of mental health education and research activities. The baseline we drew could serve to evaluate future progress in the field.

Suicides among persons with psychiatric hospitalizations.

BACKGROUND: Persons with severe mental disorders have higher suicide rates than the general population. Their risk profile needs to be fully explored to better guide suicide preventive efforts. Downsizing the number of beds in psychiatric hospitals and high bed turnover may also affect the suicide risk. OBJECTIVES: To investigate 1) Suicide rates among persons who were ever hospitalized in psychiatric facilities compared to the general population, 2) Associated sociodemographic and psychiatric factors, 3) Changes in rate over time, and 4) Timing of suicide deaths. METHODS: We linked the National Psychiatric Case Register (NPCR) with the national database on causes of death. Suicides in the years 1981-2009 were analyzed for the study group of Israelis aged 18 and over ever hospitalized (N= 158,800). ANALYSIS: Suicide rates were computed by age, gender, psychiatric diagnosis and year of death, as well as agestandardized rates and rate ratios (RR) for persons in the NPCR compared with those never hospitalized. The proportion of suicides committed by the ever hospitalized from all suicides in the population was calculated. Standardized mortality ratios (SMR) for suicide were computed for the ever hospitalized based on the total suicide rates of the population. A multivariate logistic model investigated risk factors associated with suicide in the ever-hospitalized population. RESULTS: The age-standardized suicide rate of Jews and Others with a psychiatric hospitalization was 17.6 times higher than that of the non-hospitalized (95% CI 16.7-18.6) and 29.7 times higher for Arabs (95% CI 23.4- 37.9). The rates were higher among females and younger persons. In the years 2007-2009, 30% of all suicides of Jews and Others were committed by persons who had been hospitalized in psychiatric facilities. The SMRs of Jews and Others, which increased at the beginning of the study period, fell steadily until 1995. In recent years they have been rising since 2000 and 2005 among females and males, respectively. One fifth (19%) of suicides of Jews and Others occurred before or on the discharge day, and another 6% and 7% within a week and between a week and a month after discharge, respectively. Logistic analysis showed significantly higher suicide risk for males, those who attempted suicide before hospitalization, persons under age 65 and Ethiopian immigrants. Suicide risk increased with number of hospitalizations. CONCLUSION: This study highlights the importance of suicide prevention interventions for persons both during their inpatient stay and who were expected to be followed up in community-based facilities.

Mental health stigma and attitudes to psychiatry among Bangladeshi medical students.

BACKGROUND: The shortage of specialized human resources in mental health in Bangladesh requires active recruitment of psychiatric residents. In addition, the involvement of positively inclined health personnel, for example, medical doctors, emerges as an immediate priority. AIM: To explore stigma among medical students toward persons with mental disorders (PMDs) and their attitudes toward psychiatry. METHOD: A cross-sectional study was conducted at Faridpur Medical College in Bangladesh before (First year) and following psychiatric rotation (Fifth year). Students (N = 200) filled anonymous questionnaires measuring stigma toward PMDs and attitudes to psychiatry. RESULTS: Upper medical school year (p = .028), older age (p = .005), mother's lower academic level (p = .043), upper and lower socioeconomic level affiliation (p = .008) and self-consultation for mental or neurological complaints (p = .032) were associated with increased stigma toward PMDs. More favorable attitudes toward psychiatry were found in upper medical school year (p = .073) and were significantly associated with female gender (p = .018) and middle socioeconomic level affiliation (p = .013). CONCLUSION: The relative improvement in attitudes toward psychiatry in the upper medical school year is overshadowed by the increased stigma toward PMDs. Specific anti-stigma program in the curriculum and strategies to improve the attitudes are required.

Predictors of mental health care stigma and its association with the therapeutic alliance during the initial intake session.

OBJECTIVE: We investigated the association between socio-demographic and clinical variables with mental health care stigma, and the impact of the latter on the quality of the therapeutic alliance measured at intake. METHOD: Consecutive clients (N = 236) filled questionnaires upon accessing services for a new episode of care. Immediately following the intake, a randomly selected sample of clients and their corresponding therapists (n = 102) completed the Working Alliance Inventory - Bond Scale. RESULTS: Lower mean years of education and higher emotional distress (both partial r = .17) were significantly associated with higher stigma. Higher care stigma negatively correlated with therapists' ratings of the therapeutic alliance during the intake (partial r = -.22), but not with those of clients. CONCLUSIONS: Care stigma is present among service-users and may affect outcomes of the intake.