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.

The Effect of Community-Based Mental Health Rehabilitation Services for Schizophrenia: a Retrospective Cohort Study.

Deliberative efforts are constantly made to provide community-based mental health rehabilitation services to people with mental health disabilities nationwide. In this study we aimed to assess the effectiveness of rehabilitation services in Israel by assessing the impact of utilization of rehabilitation services on hospitalization rates among a cohort of patients diagnosed with schizophrenia. Data derived from the Clalit Health Services were crossed with the Ministry of Health rehabilitation and psychiatric hospitalization case registries. Patients utilizing rehabilitation services were assessed for rates and durations of hospitalizations before and after the utilization of the rehabilitation services, and were compared to patients who did not use these services (n = 185). Mixed-model analyses of covariance (ANCOVA) were conducted to assess changes in rates and durations of hospitalizations at the beginning and end of the cohort period. Patients who used rehabilitation services showed higher rates and durations of hospitalizations prior to utilization of rehabilitation services, as well as higher decreases in number and duration of hospitalizations after utilizing their rights to rehabilitation services, as compared to patients who did not receive these services. Schizophrenia patients tend to show a decreasing trend in number and duration of hospitalizations over time. Nonetheless, the utilization of rehabilitation services offers larger gains in hospitalization prevention, primarily to schizophrenia patients who experience high rates and durations of hospitalizations at the beginning of illness. These findings provide additional support for the necessity of rehabilitation services, primarily for patients with severe onset.

When Can We Predict the Outcome of an Electroconvulsive Therapy Course in Adolescents?: A Retrospective Study.

OBJECTIVE: There is a dearth of up-to-date literature regarding electroconvulsive therapy (ECT) in adolescents, and the question of when to pronounce course failure has not been properly addressed. The current study aims to evaluate trajectories of clinical status throughout ECT courses in adolescent patients. METHODS: We retrieved detailed data of 36 patients who received ECT in our treatment center. Clinical records were retrospectively assessed and evaluated every 6 ECT sessions to quantify Clinical Global Impressions-Improvement (CGI-I) scores. RESULTS: The mean number of sessions per course was 24.4 ± 14.2. The mean CGI-I score at the conclusion of the ECT courses was 2.47 ± 1.19. At the end of the acute treatment stage, 26 patients (72.2%) were much or very much improved, based on CGI-I scores. Only 5 patients exhibited a significant response after 6 sessions or fewer, whereas 21 patients (56.6%) improved after 12 sessions. Pearson correlations between CGI-I scores throughout the course of ECT showed no significant correlation between CGI-I scores after 6 sessions and the final CGI-I scores. However, a significant correlation was found between CGI-I scores after 12 sessions and the final CGI-I score. CONCLUSIONS: An improvement in the clinical status of adolescents treated by ECT might occur only after a substantial number of sessions. An early lack of response does not necessarily predict a failed ECT course.

COVID-19 Morbidity Among Individuals with Autistic Spectrum Disorder: A Matched Controlled Population-Based Study.

In this study we aimed to assess whether individuals with ASD are prone to higher infection rates, or to severe COVID-19 illness. Individuals with ASD and age- and gender-matched controlled counterparts (total n = 32,812) were assessed for COVID-19 infection rates and hospitalizations. Results indicated higher infection rates among individuals with ASD, with the largest effect among individuals aged 40-60 (OR = 2.05, 95%CI 1.33-3.15, p < .001), as well as higher odds for hospitalizations, evident primarily in men (OR = 2.40, 95%CI 1.14-5.02, p = 0.02) but not women. Medical and environmental risk factors may associate ASD with higher infection and morbidity rates. Healthcare policy providers should consider proactive steps to protect this population from the associated risks.

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.

Anxiety in Patients with Neovascular Age-related Macular Degeneration.

PURPOSE: The main objective of the study is to investigate the prevalence of anxiety in patients with neovascular age-related macular degeneration (nAMD). METHODS: A retrospective cross-sectional study of 3 304 nAMD patients and 16 515 age- and gender-matched controls. The proportions of patients with anxiety were compared between the groups using univariate analyses and a multivariate logistic regression model. Proportion of anxiety in patients with nAMD was compared with the proportion of anxiety in controls, matched for age and gender. Data was obtained from the largest health maintenance organization in Israel (Clalit Health Services) with 4 200 000 members. RESULTS: The mean age of patients was 79.7 years; 54.8% were females; Anxiety was more common in patients with nAMD (13.2%) compared to the control group (10.2%) (OR 1.3; 95%CI 1.2-1.5). Multivariate logistic regression analysis revealed a significant association between anxiety and nAMD (OR 1.3; 95% CI: 1.2-1.5), adjusted for age, gender, and socio-economic status. CONCLUSION: Our study demonstrated that anxiety is more common in patients with nAMD compared to a control group. Physicians treating patients with nAMD should be aware of this association, in order to provide appropriate care for the anxiety associated with nAMD.

COVID-19 Booster Vaccination Among Individuals With Schizophrenia in Israel.

Importance: Individuals with schizophrenia are at higher risk for severe COVID-19 illness and mortality. Previous reports have demonstrated vaccination gaps among this high-risk population; however, it is unclear whether these gaps have continued to manifest with the booster dose. Objective: To assess gaps in first, second, and booster vaccinations among individuals with schizophrenia. Design, Setting, and Participants: This was a matched, controlled, retrospective cohort study conducted in November 2021, and included follow-up data from March 2020, to November 2021. The study used the databases of Clalit Health Services, the largest health care management organization in Israel. Individuals with a diagnosis of schizophrenia at the onset of the pandemic and matched controls were included in the analysis. Main Outcomes and Measures: Rates of first, second, and booster vaccinations and time to reach vaccination. Results: The study included 34 797 individuals (mean [SD] age, 50.8 [16.4] years; 20 851 men [59.9%]) with schizophrenia and 34 797 matched controls (mean [SD] age, 50.7 [16.4] years; 20 851 men [59.9]) for a total of 69 594 individuals. A total of 6845 of 33 045 individuals (20.7%) with schizophrenia were completely unvaccinated, compared with 4986 of 34 366 (14.5%) in the control group (odds ratio [OR], 0.65; 95% CI, 0.62-0.67, P < .001). Once vaccinated, no significant differences were observed in the uptake of the second vaccine. Gaps emerged again with the booster vaccine, with 18 469 individuals (74.7%) with schizophrenia completing the booster, compared with 21 563 (77.9%) in the control group (OR, 0.83; 95% CI, 0.80-0.87, P < .001). Kaplan-Meier analyses indicated significant differences in time to reach vaccination, although gaps were lower compared with those reported in the first vaccination (log-rank test, 601.99 days; P < .001 for the first vaccination, compared with log-rank test, 81.48 days, P < .001 for the booster). Multivariate Cox regression analyses indicated that gaps in the first and booster vaccine were sustained even after controlling for demographic and clinical variables (first vaccine: hazard ratio [HR], 0.80; 95% CI, 0.78-0.81; P < .001 and booster: HR, 0.88; 95% CI, 0.87-0.90; P < .001) but were not significant for the second vaccine. Conclusions and Relevance: Results of this cohort study of Israeli adults found lower rates of COVID-19 vaccination among individuals with schizophrenia compared with a control group without schizophrenia, especially during the vaccine initiation phase. Countries worldwide should adopt strategies to mitigate the persistence of vaccination gaps to improve health care for this vulnerable population.

COVID-19 vaccination among individuals with autism spectrum disorder: A population-based study.

BACKGROUND: Individuals with autistic spectrum disorder (ASD) are more susceptible to COVID-19 morbidity and should therefore be prioritized for vaccination. Although individuals with neurodevelopmental disabilities are given some priority in Israel, it is unclear to what extent individuals with ASD are being vaccinated relative to that of the general population. This study was aimed to assess vaccination prevalence among individuals with ASD. METHOD: Individuals with ASD, and age- and sex-matched controls (total n = 11,080), were assessed for prevalence of COVID-19 vaccination by February 2021, approximately a month and a half after the national vaccination distribution plan was launched in Israel. Data were obtained from the database of Clalit Health Services (CHS), the largest healthcare organization in Israel. RESULTS: Individuals with ASD were more likely to be vaccinated for COVID-19 (OR = 2.55, 95 %CI 2.35-2.75, p < .001) across both sexes, but only in the 16-20 (OR = 2.04, 95 %CI 1.79-2.32, p < .001) and 21-40 (OR = 3.95, 95 %CI 3.52-4.43, p < .001) age groups. After adjusting for chronic illnesses, ASD remained significant in predicting the uptake of COVID-19 vaccination. CONCLUSIONS: Efforts to prioritize ASD patients may improve vaccination prevalence among individuals with ASD, especially among younger individuals. Healthcare providers worldwide should therefore consider prioritization policies so as to increase vaccination rates among this vulnerable population.

The co-occurrence of autistic spectrum disorder and schizophrenia: A nationwide population-based study.

Although the co-occurrence of autistic spectrum disorder (ASD) and schizophrenia have been previously reported, the scope and magnitude of this comorbidity across large samples have not been sufficiently established. This study was aimed to assess the co-occurrence between schizophrenia and ASD in a large dataset, and to examine its predominance across different age and sex groups. Schizophrenia patients and age and sex frequency controls (n = 49,334) were assessed for the prevalence of autism spectrum disorder. The sample was stratified by age and sex, and co-occurrence was assessed using univariate and multivariate logistic regressions. Results indicated that schizophrenia was associated with ASD (OR = 7.01, 95%CI 2.98-16.43, p < .0001) across all age groups aside from 50 to 70 years. This association was significant among male participants (OR = 11.69, 95%CI 3.59-38.01, p < .0001) but not among female participants (OR = 2.33, 95%CI 0.60-9.03, p = .21). These findings indicate a large overlap between schizophrenia and ASD, and point to the need to expand the understanding of the potential mediating mechanisms of this co-occurrence.

COVID-19 Prevalence and Mortality Among Schizophrenia Patients: A Large-Scale Retrospective Cohort Study.

OBJECTIVE: Individuals with schizophrenia may be at an increased risk for COVID-19 morbidity due to the disease characteristics. In this study, we aimed to explore the odds of significant COVID-19 morbidity and mortality among schizophrenia patients while controlling for potential sociodemographic and medical confounders. METHODS: Schizophrenia patients and age-and-sex matched controls (total n = 51 078) were assessed for frequency of COVID-19 positivity, hospitalizations, and mortality. The odds for COVID-19-associated hospitalization and mortality were calculated using logistic regression models, while controlling for age, sex, marital status, sector, socioeconomic status, diabetes, ischemic heart disease, hypertension, hyperlipidemia, obesity, smoking, and chronic obstructive pulmonary disease. RESULTS: Individuals with schizophrenia were less likely to test positive for COVID-19; however, they were twice as likely to be hospitalized for COVID-19 (OR 2.15 95% CI 1.63-2.82, P < .0001), even after controlling for sociodemographic and clinical risk factors (OR 1.88 95% CI 1.39-2.55, P < .0001). Furthermore, they were 3 times more likely to experience COVID-19 mortality (OR 3.27 95% CI 1.39-7.68, P < .0001), compared to controls. CONCLUSIONS: We found evidence of associations between schizophrenia and increased COVID-19 morbidity and mortality compared to controls regardless of sociodemographic and medical factors. As these patients present with a combination of potential risk factors for mortality, efforts should be made to minimize the effects of the pandemic on this vulnerable population.

Blood transcriptional response to treatment-resistant depression during electroconvulsive therapy.

Selective serotonin reuptake inhibitors (SSRIs) are currently the first-line antidepressant drug treatment for major depressive disorder (MDD). Treatment-resistant depression (TRD), defined as failure to achieve remission despite adequate treatment, affects ~30% of persons with MDD. The current recommended treatment for TRD is electroconvulsive therapy (ECT), while ketamine is an experimentally suggested treatment. This study aimed to elucidate the transcriptional differences in peripheral blood mononuclear cells (PBMC) between individuals with TRD and a control group without a psychiatric illness; and between patients with TRD, treated with either standard antidepressant drugs alone, or in combination with ECT or ketamine. Additionally, PBMC transcriptomics were compared between treatment responders, following completion of their treatment protocols. Total RNA was extracted from PBMC of the TRD group at two time points, and RNA and miRNA expression were profiled. Multiple mRNAs and miRNAs were found to be modified, with two protein coding genes, FKBP5 and ITGA2B, which are up- and downregulated, respectively; and several miRNAs have shown changes following successful ECT treatment. Further analysis demonstrated the direct functional regulation of ITGA2B by miR-24-3p. Our findings suggest that PBMC expression levels of FKBP5, ITGA2B, and miR-24-3p should be further explored as tentative ECT response biomarkers.

Open-Label placebo for the treatment of unipolar depression: Results from a randomized controlled trial.

BACKGROUND: The response to placebo is robust in studies of various antidepressant treatments. The strong placebo response, combined with the absence of side-effects, has prompted suggestions to use the ethically sound open-label placebo (OLP) as a treatment for depression. The aim of the present study was to assess the efficacy of OLP as an adjunct to treatment as usual (TAU) in the setting of a randomized controlled trial for the treatment of unipolar depression. METHODS: Thirty-eight patients (age: 50 ± 17.1; 73.7% females) were randomized to either eight-week OLP treatment (n = 18) or four weeks of TAU followed by four weeks of OLP (n = 20). Clinical and socio-demographic measures were assessed at baseline, after four weeks, and at the end of the trial. Response to treatment was determined using the QIDS SR-16. RESULTS: There was an overall decrease in depression levels over time, F(2,35) = 3.98, p = .028. A significant group x time interaction was found only among non-geriatric patients (<65years) with an early onset of depression (<50years), F(2,22) = 3.89, p = .036. Post-hoc tests indicated a significant decrease during the first four weeks, but only in the OLP group, t(11) = 2.29, p = .043. LIMITATIONS: Small sample size and the use of a self-report questionnaire to assess depressive symptoms. CONCLUSIONS: Our findings support the possibility that OLP is an effective treatment for the relatively young population of depressed patients. Additional studies are warranted to explore the use of OLP in clinical practice.

Chronic kidney disease in adults with schizophrenia: A nationwide population-based study.

OBJECTIVE: Several studies have recently reported an association between chronic kidney disease (CKD) and schizophrenia, yet this association has not been sufficiently established. The aim of this study was to examine the association between schizophrenia and CKD in a large dataset, as well as to assess the level of accessibility of these patients to common treatments for CKD. METHOD: Patients diagnosed with schizophrenia (n = 27,516) and an equal number of age and sex frequency-matched controls were included in this nationwide population-based study. Logistic regressions and ROC curves were employed to assess the association between schizophrenia and CKD and the level of fit of the models. RESULTS: Schizophrenia was associated with CKD, after controlling for demographic, behavioral, and medical risk factors (OR = 1.62, CI 1.45-1.82, p < .0001). After adjusting for demographic and behavioral risk factors, CKD patients without schizophrenia were more likely to receive dialysis (OR = 1.70, 95% CI 1.18-2.44, p < .01) and kidney transplantation (OR = 5.43, 95% CI 2.84-10.38, p < .001) as compared to CKD patients with schizophrenia. CONCLUSION: As CKD affects survival, quality of life, and medical and familial burden, additional thought should be given to detection of CKD, as well as to accessibility to treatment, among patients with schizophrenia.

Increased risk of smoking-related illnesses in schizophrenia patients: A nationwide cohort study.

BACKGROUND: Schizophrenia patients smoke at three times the rate of the general population, and are more susceptible to smoking-related illnesses. The goal of the current study was to evaluate the cumulative probability of chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD) following first documentation of smoking among schizophrenia patients as compared to smoking healthy controls. METHODS: A nationally representative cohort study was designed to assess the odds and cumulative probability of COPD and IHD among individuals with schizophrenia (n = 10,502) and a matched-sample of smoking healthy controls (n = 10,502). Hierarchical logistic regressions and Kaplan-Meier regression models were used to compare odds and cumulative probabilities across the two groups. RESULTS: After adjusting for clinical and demographic factors, smoking schizophrenia patients had a higher probability of receiving a diagnosis of COPD than smoking healthy controls (OR 2.14, 95%CI 1.51-3.01, p < 0.001). The probability of having COPD increased more rapidly in smoking schizophrenia patients, yet the opposite trajectory prevailed for IHD, showing a decreased cumulative probability in smoking schizophrenia patients compared to smoking healthy controls. DISCUSSION: Schizophrenia has a unique contribution to the facilitation of COPD, which extends beyond the effect of smoking, or other clinical and demographic risk factors. Differential smoking patterns could potentially account for this effect. The differential pattern of IHD should be subjected to further research, as our results might indicate that schizophrenia patients are underdiagnosed with IHD, and may be even less diagnosed as a function of time and chronicity.

Suggestibility as a predictor of response to antidepressants: A preliminary prospective trial.

BACKGROUND: The growing awareness that so many do not respond adequately to antidepressant (AD) pharmacotherapy has sparked research seeking to characterize those who do. While the pharmacological mechanisms of AD treatment have been extensively evaluated, much remains unknown about the placebo component of the response to medication. This study examined the association between suggestibility levels and response to ADs amongst depressed patients. METHODS: Twenty unipolar depression outpatients, recruited before starting AD monotherapy, received clear, standardized instructions that the therapeutic effects of AD, though not side effects, would require 2-4 weeks. At baseline (T1), 1 week (T2), and 1 month (T3), participants were evaluated for depressive symptoms, using the Hamilton Rating Scale for Depression-17 items (HAM-D); for anxiety by the Hamilton Rating Scale for Anxiety (HAM-A); for side effects by the Antidepressant Side Effect Checklist (ASEC); and for suggestibility, using the Multidimensional Iowa Suggestibility Scale (MISS). RESULTS: High levels of baseline suggestibility were associated with less improvement in depression level and more side-effects during the first week. In accordance with our hypothesis the more suggestible patients improved more between T2 and T3. No significant correlations were found between baseline suggestibility levels and change in anxiety. LIMITATIONS: Small sample size and a self-report questionnaire assessing suggestibility were limitations. CONCLUSION: This study offers a potentially new and clinically useful approach to understanding and predicting who will respond to AD treatment. Suggestibility seems to play a role, presumably by shaping expectation, in response to AD treatment. We hope that this avenue will be further explored.