A comparative study of Arab and Jewish patients admitted for psychiatric hospitalization in Jerusalem: the demographic, psychopathologic aspects, and the drug abuse comorbidity.

BACKGROUND: The influence of ethnicity on different aspects of psychiatric hospitalization is far from clear. THE AIM OF THE STUDY: The main aim of the study was to compare the Arab and the Jewish inpatients, at the time of admission, for the demographic factors, severity of psychotic, and affective psychopathology and comorbid drug abuse rate. POPULATION, METHOD, AND TOOLS: Among 250 consecutively admitted patients in the Jerusalem Mental Health Center-Kfar Shaul Hospital, 202 Jews and 42 Arabs (aged 18-65 years) were examined within 48 hours after admission. The psychiatric diagnoses were made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. For the differential measurement of psychopathologic severity, the following rating scales were used: 21-item Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale. Urine tests for Δ9-tetrahydrocannabinol (THC), cocaine, opiates, amphetamines, and methamphetamine were performed using the Sure Step TM kits (Applied Biotech, Inc, San Diego, CA, USA). The Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for drug abuse were applied based on self-report and results of urine analysis. RESULTS: The comparison of the 2 population showed that among the Arab inpatients, there were more males (81% vs 67.4%; P < .005). No significant difference in psychiatric diagnosis was observed. The overall severity of positive symptoms (PANSS positive) in Arab group was higher, but only slightly so (P = .05). No significant difference was observed for total rates of PANSS negative subscale. The rates of PANSS-general were also similar. The Arab patients were significantly less depressive according to 21-item Hamilton Depression Rating Scale (P = .032), and the total score of Hamilton Anxiety Rating Scale for the Jewish group was significantly higher (P = .001). No significant difference in general severity of manic symptoms for 2 groups was detected according to Young Mania Rating Scale. The rate of comorbid drug abuse for Jewish inpatients was borderline higher (P = .068). CONCLUSIONS: The issue of referral to psychiatric hospitalization could be culturally influenced; it may be the result of disparities in demographic, psychopathologic, and drug abuse comorbid presenting symptoms, which are demonstrated upon admission by patients of different ethnic origins.

[Phenomenology of malingering, dissimulation and aspiration].

Malingering is a voluntary production and presentation of false or grossly exaggerated physical or psychological symptoms in an attempt to achieve secondary gain which otherwise is difficult to reach. Dissimulation means concealment of genuine psychiatric or other medical symptoms in an attempt to present a picture of psychiatric or organic health. Secondary gain is prominent, yet, primary gain exists as well. Aspiration is a higher degree of dissimulation, whereby the person not only denies having symptoms but pretends to be much healthier than he actually is and even more than all the healthy people surrounding him. Aspiration is mostly driven by primary gain. Secondary gain strengthens the primary one by the positive feedback the individual receives in considering him to be healthy and strong, deserving appropriate social, professional and financial attitudes. The article discusses these three phenomenological concepts with their possible medico-legal aspects, illustrating each by clinical vignettes.

A comparative study of psychiatric inpatients in a general hospital and a psychiatric hospital in Israel: demographics, psychopathological aspects and drug abuse patterns.

BACKGROUND: Some specialists and policy makers advocate progression of the mental health reform in Israel by transferring beds from psychiatric to general hospitals. OBJECTIVES: To compare the demographic, diagnostic and psychopathological profiles of psychiatric inpatients hospitalized in psychiatric and general hospitals, as well as their patterns of drug abuse, and to estimate the preparedness of general hospitals for the possible expansion of their psychiatric services. METHODS: Between 2002 and 2006 a total of 250 patients were consecutively admitted to the Jerusalem Mental Health Center-Kfar Shaul Hospital and 220 to the psychiatric department of Sheba Medical Center, a general hospital in central Israel; the patients' ages ranged from 18 to 65. The two groups were compared for demographic features, psychiatric diagnoses and severity of psychopathology (utilizing PANSS, HAD-21, YMRS rating scales). Drug abuse was diagnosed by urine analyses and self-report. RESULTS: The patients in the psychiatric hospital were significantly younger, predominantly male, and more dependent on social security payments. In the general hospital, diagnoses of affective and anxiety disorders prevailed, while in the psychiatric hospital schizophrenic and other psychotic patients constituted the majority. The patients in the general hospital were decidedly more depressed; in the psychiatric hospital, notably higher rates of manic symptoms as well as positive, negative and general schizophrenic symptoms were reported. For the most abused substances (opiates, cannabis and methamphetamines) the rates in the psychiatric hospital were significantly higher. CONCLUSIONS: The differences between the two groups of inpatients were very pronounced, and therefore, the transferring of psychiatric beds to general hospitals could not be done without serious and profound organizational, educational and financial changes in the psychiatric services of general hospitals. Since each of the two inpatient systems has particular specializations and experience with the different subgroups of patients, they could coexist for a long time.

Bupropion as the treatment of choice in depression associated with Parkinson's disease and it's various treatments.

Parkinson disease (PD) is a chronic progressive degenerative disorder that affects over 6 million people worldwide. It is manifested by motor and psychiatric signs. The latter inflicts up to 88% of PD patients. With the prolongation of life expectancy, it is presumed that the prevalence of PD will further rise, together with comorbid depression. As a result, the need for an adequate therapeutic answer for compounded PD with depression is called for urgently. Several theories try to explain the trigger of depression in PD patients by impaired activity in dopamine, norepinephrine and serotonin systems. Various treatment to combat depressive symptoms in PD patients were proposed and are in use, with ambiguous results and disturbing side effects. These anti-depressive modalities include SSRI's, SNRI, TCA, NRI and ECT. Dopamine agonists showed some anti-depressant activity in several studies in depressive PD, but may cause side effects such as dizziness, somnolence, confusion and even hallucinations. The role of dopamine agonists in the treatment of depression is still being explored because of no sufficient number of controlled studies in this area. Our hypothesis is to suggest NDRI - Bupropion - as the first line of treatment in PD patients with depression, in PD induced depression and/or in depression triggered by one of the treatments given for PD. Dual norepinephrine and dopamine reuptake inhibition is associated with unique clinical profile that compounds together anti-depressant efficacy without serotonin associated side effects such as weight gain, sedation, sexual dysfunction. Bupropion, as mainly dopaminergic and noradrenergic anti-depressant can alleviate therapeutically depressive symptoms associated with PD. Clinical controlled studies on Bupropion use in PD depressed patients are required to support this hypothesis.

Cannabis abuse and severity of psychotic and affective disorders in Israeli psychiatric inpatients.

The influence of cannabis abuse on the severity of existing psychotic and affective symptoms is still unclear. Among 470 consecutively admitted psychotic or affective patients, 54 active (in the previous month) cannabis abusers were detected via urine tests (Sure Step TM kits; Applied Biotech Inc, San Diego, Calif) and Structured Clinical Interview for DSM-IV (SCID- IV) questionnaire. In 24 cases, substances other than cannabis were abused; 392 patients were nonabusers. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The following rating scales were used: Hamilton Depression Rating Scale (HAM-D-21), Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale (YMRS). Cannabis abusers (n = 54) were significantly younger and more frequently males than nonuser patients. In this group, there were more schizophrenic patients and fewer affective and anxiety patients (chi(2) = 11.76; P < .01). The double-diagnosed patients had more prominent psychotic symptoms than the nonusers (n = 392)-PANSS positive: 19.056 +/- 8.30 vs 16.128 +/- 8.031 (P < .02; t(446) = 2.510). The difference was statistically significant for hallucinatory behavior, excitement, grandiosity, and hostility. General PANSS scale rate of abusers was lower: 33.012 +/- 9.317 vs 37.3575 +/- 11.196 (P < .01; t = 2.727), especially for depression, anxiety, somatic concern, guilt feelings, tension, motor retardation, and volition disturbances. Rates of PANSS negative scale of abusers and nonusers were not significantly different (13.815 +/- 6.868 vs 14.983 +/- 6.446) except for lower rates of social withdrawal and stereotyped thinking for abusers. No significant difference in general level of manic symptoms (YMRS) between abusers and nonusers was observed (6.778 +/- 10.826 vs 4.910 +/- 7.754), but severity of thought/language disturbances and poor insight was found significantly higher in the abusers. Cannabis abusers are obviously less depressive (HAM-D): 5.944 +/- 10.291 vs 12.896 +/- 13.946 (P < .0005, t = 3.535). Such differences were observed in the high number of the subscales. Abusers' rates were higher (although not significantly) for paranoid symptoms and general somatic symptoms. Cannabis possibly produces some antidepressive and anxiolytic effect on psychotic and affective inpatients. The "price" of this effect is often an exacerbation of psychotic and some manic symptoms.

Substance abuse in hospitalized psychiatric patients.

BACKGROUND: The co-morbidity rate of illicit substance abuse and major mental problems in Israel is far from clear. OBJECTIVES: To investigate the extent of drug abuse in a sample of psychiatric patients hospitalized in a psychiatric hospital and in the psychiatric department of a general hospital in Israel, to compare demographic and other background factors in dual-diagnosis patients with those of abuse-free mental inpatients, and to examine the time correlation between drug abuse and the appearance of major mental problems. METHODS: Our data were derived from self-report and urine tests. The study population comprised 470 consecutively admitted patients--250 patients in the mental health center and 220 patients in the psychiatric department of the general hospital. RESULTS: The lifetime prevalence of drug abuse was 24%; cannabis abuse was found in 19.7%, opiates in 5.7%, cocaine in 2.7%, amphetamines in 3.4% and methamphetamine in 1.1%. Active abuse of drugs (during the last month) was registered in 17.3%, cannabis in 11.5%, opiates in 4.9%, amphetamine in 3.8%, cocaine in 1.3% and methamphetamine in 1.1%. We also found that 28.2% of active abusers used two or more substances. In 41.6% the drug abuse appeared prior to symptoms of the mental disorder; in 37.1% the duration of the mental disorders and the drug abuse was relatively similar, and in 21.3% of cases the duration of mental problems was longer than the duration of drug abuse. Dual-diagnosis patients were younger than non-abusers, more often male, unmarried, and of western origin. CONCLUSIONS: Substance abuse (especially cannabis) among hospitalized psychiatric patients in Israel is a growing problem.

[Non-urgent compulsory hospitalization].

The Israel Mental Health Law of 1991 gave authority to the regional psychiatrist to give orders of compulsory hospitalization - urgent and non-urgent. The non-urgent Hospitalization Order applies to conditions of non-immediate danger, in which potential for significant damage or harm to the patient or others is expected. Authority is granted to the District Psychiatric Committee as a body of appeal (before the Hospitalization Order is carried out) and as a tribunal to decide upon continuation after the first two weeks of hospitalization. This article aims to stress the main problems encountered by psychiatrists regarding management and treatment under the Non-Urgent Compulsory Hospitalization Order: 1) Postponing hospitalization or releasing a patient for 24 hours, in order to launch an appeal before receiving any treatment, may facilitate clinical deterioration. The ambiguous waiting period could enhance anxiety, acting out and dangerousness. 2) The article discusses clinical and legal aspects of compulsory hospitalization - both urgent and non-urgent. The diverse problematic issues will be elaborated through three clinical cases, and, when clinically indicated, proposals raised for possible solutions in converting an urgent compulsory order to a non-urgent compulsory order.

[Multisensory environmental intervention (snoezelen) as a preventive alternative to seclusion and restraint in closed psychiatric wards].

UNLABELLED: Seclusion and restraint, unfortunately, still remain a routine practice in closed psychiatric wards worldwide and in Israel. These practices often lead to distress, traumatized patients, and further increase the negative view and stigmatization of psychiatric treatment and, most especially, psychiatric hospitalization. Multisensory environmental intervention, Snoezelen, combines sensory integration theory with a client-oriented approach. Snoezelen treatment calms and relaxes agitative patients giving them a feeling of dignity, initiative and freedom of choice. The Snoezelen room is a high-tech, multisensory environment that includes music, light of fiber optic strands, calming image projections, vibrations of bubbles tubes, and soothing smells. After 30 to 40 minutes of exposure to Snoezelen, agitative patients in our closed ward reported substantial reduction of their distress level and, outwardly, appeared less agitated and displayed less aggressive and hostile behavior. Foremost, since the beginning of the multisensory environmental interventions in the closed wards, a statistically significant reduction in the number of restraints and seclusions has occurred in the closed male section in comparison to the closed female section, where snoezelen has not been administered (P < 0.05). IN CONCLUSION: Snoezelen is an innovative and preventative alternative to seclusion and restraint in closed psychiatric settings. It produces a calming effect on agitative patients, reduces the length of time and number of seclusions and restraints, and diminishes the stigma against psychiatric treatment and hospitalization.

[Legal involvement in psychiatric care].

In an amendment to the law regarding the treatment of the Mental Health patient in 1991, authority was given to the regional psychiatrists' committee to oversee compulsory orders for psychiatric hospitalization and compulsory orders for outpatient psychiatric treatment--and the extension of these orders. On 1st of June 2002 a pilot study was started in the Jerusalem region, in which mental health patients were to be represented by lawyers employed by the Ministry of Justice. The pilot study began as an initiative of the Ministry of Justice, in agreement with the Ministry of Health. We describe 3 cases which demonstrate that the procedure of legal representation lacks the necessary balance between medical and legal considerations. The decision of the regional psychiatrists' committee or the court is liable to worsen the patients' mental health status and even to accelerate aggression towards self or others. In rare cases a premature discharge based on legal considerations rather than medical evaluation may result in suicide, as demonstrated in one of the vignettes. The article discusses the unbalanced approach of legal versus medical consideration, preference of "liberty" over health and the "wish" of the patient rather than his well-being. The article considers the unbalanced approach of the legal system to appeals of therapists against the decision of the regional psychiatrists' committee, where prosecutors of the state decided an appeal of this kind over the staff treating the patient has no precedence. That was presented as justification that it should be rejected. A pilot study compared between patients discharged from compulsory hospitalization through regional psychiatrists' committee or court and patients discharged on a medical basis without legal interference. The study showed a shorter stay in the community in the first group (42%) compared to 75% stay in the community in the second group, after six months. We are of the opinion that the current provision of legal assistance is lacking the necessary balance between medical and legal considerations; the 'wish for freedom' as a default, although illogical, is within the new system of legal aid, and is more considerate and important than the 'best interests' of the patient and his health.

Comparison between two legal indications for compulsory outpatient treatment in Israel.

The aim of the present study was to compare the outcome of two legal indications for Compulsory Outpatient Treatment (COT) in Israel (a) as an alternative to compulsory hospitalization (CH) and (b) as a follow-up to CH. Demographic, clinical and legal measurements based on 326 COT orders issued in the Jerusalem and Southern district of Israel were compared according to the two legal provisions for COT contained in the Treatment of Mental Patients Law (1991). The COT order was found to be more effective when used as an alternative to CH (53.1%) than when it was used following CH (38.8%), p = 0.002. In the former case, there were fewer schizophrenic patients, fewer hospitalizations, fewer visits to psychiatric emergency services and longer remissions. Our results point to the influence of the legal indications on the efficacy of the COT order and help define the target population.