Identification of Emotional Distress Among Asylum Seekers and Migrant Workers by Primary Care Physicians: A Brief Report.

BACKGROUND: Emotional distress (ED) is prevalent among immigrants. The open clinic of Physicians for Human Rights (PHR)-Israel provides free medical and psychiatric treatment to immigrants without access to the ambulatory health service. In 2010, the psychiatric records represented 1% of the total medical files (N=28,000) in the open clinic. OBJECTIVE: To compare service users' self-reported ED and its identification by general practitioners (GP) and to identify socio-demographic variables associated with ED. METHOD: A convenience sample (N=97) of the general medical service users completed the 12-item version of the General Health Questionnaire (GHQ-12). A score of 11 or above was considered a suspected mental disorder. The GPs' clinical assessment of ED was compared with the self-reported score. RESULTS: The sample's mean GHQ-12 score was higher than the threshold (M=12.7, SD=6.3, range 0-35). Fifty three percent (n=51) had a GHQ-12 score higher than 11, and 8% (n=8) were identified by the GPs as emotionally distressed and/or in need of psychiatric care. The mean score of the study sample was higher than that found in past studies regarding the Arab-Israeli general population (M=10.8, SD=0.35). Employment was the only socio-demographic variable significantly associated with ED. CONCLUSIONS: ED was high among immigrants, but under-diagnosed by GPs. Employment might serve as a protective factor for ED.

Examining the ethical boundaries of harm reduction: from addictions to general psychiatry.

Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidence based background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.

Using placebo medications in the clinical setting - an intellectual game or a possible reality?

Prior to the development of the pharmaceutical industry and the advocacy of evidence based medicine in the late 20th century, placebo treatments were commonly used by physicians. In current clinical practice, neither a physician's confidence in the efficacy of a specific treatment nor his personal ethical norms are any longer sufficient to initiate a given therapy. We will discuss whether placebo treatments can be ethically used in clinical practice as an alternative to standard therapy, and propose an innovative conceptualization of the factors involved in the exclusion of placebo treatments from the clinical setting. Patient-related ethical and interpersonal arguments and physician-related legal and ideological arguments concerning placebo usage are presented. We describe current use of placebo treatments in the healthcare system and suggest that placebo therapy thrives and that its therapeutic efficacy is widely acknowledged. There is currently "underground" use of placebo medication, open label placebo trials, and innovative approaches to informed consent to facilitate ethical prescription of placebo therapy. Finally, using the specific example of treatment for depression, we demonstrate how the arguments against placebo use might be undermined, to retrieve the legitimacy of placebo therapy.

Consenting not to be informed: a survey on the acceptability of placebo use in the treatment of depression.

The aim of this study was to investigate the opinions of healthy students regarding the acceptability of placebo treatment if they were to experience depression. A survey was conducted among 344 students in five academic centers in Israel. After a thorough explanation of the placebo effect, its efficacy and limitations in the treatment of depression, the study participants completed a 32-item self-report questionnaire. Seventy percent (n = 243) of the participants answered that they would agree to treatment with a placebo as a first-line treatment if they were to experience depression in the future. Eighty-eight percent (n = 297) of the subjects did not think that a physician who administered placebos was deceitful. Once aware of the possible benefits and limitations of placebo treatment, most of our study population was willing to accept placebo as a legitimate treatment of depression. Additional studies on the possible use of placebo as an effective, safe, and acceptable form of therapy are warranted.

Rebelliousness in patients suffering from schizophrenia-spectrum disorders--a possible predictor of attitudes towards medication.

The inclusive trait of rebelliousness has a proven role both in development and in the understanding of non-psychotic psychopathologies. The present study focused on evaluating rebelliousness levels and their possible correlation with the attitude towards medication among patients suffering from schizophrenia-spectrum disorders. Patient suffering from schizophrenia-spectrum disorders (n=75) and non-psychotic disorders (n=53) underwent a thorough clinical evaluation. The attitude towards medication was evaluated using the Drug Attitude Inventory (DAI-10), and levels of rebelliousness via the validated rebelliousness scale. Rebelliousness was also assessed in an additional control group (n=64). A significant negative correlation between levels of rebelliousness and the attitude towards medication was found uniquely in the schizophrenia group (r=-0.434, p<0.001). In a regression model rebelliousness levels were found to be the strongest predictor of the attitude towards medication ((ß=-0.434, p<0.01)) compared with other demographic variables such as drug abuse (ß=-0.256, p<0.05) and involuntary treatment (ß=0.236, p<0.05). The intriguing correlation between rebelliousness and drug attitude (as an indicator of adherence) should be further studied in additional longitudinal prospective studies.

Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel.

Prevalence of substance use and substance use disorders in Israel is similar to those in other developed countries. The aim of this study was to examine attitudes of physicians in Israel towards nicotine, alcohol and drug use and dependence. A national sample of physicians from different fields of medical specialty (n = 208, response rate 26%) responded to a 50-item questionnaire. Questions included general questions regarding substance use and addictions, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. The poor response rate in this survey dictates caution in interpretation the results. However, they suggest that among medical specialties, psychiatrists had higher levels of self-reported competency in treating addictions and lower rates of moralism towards addictions. Across substances, the highest rates of moralism and lowest ratings of treatment efficacy were directed towards individuals with alcohol dependence. Physicians generally reported experiencing lower levels of satisfaction and higher levels of aggression when treating individuals with alcohol or drug dependence compared with other patients. Physicians' attitudes towards addictions have a significant role in the care that clients with addictions receive. Medical education programs in Israel should devote provisions towards educating physicians about addictions.

Role of the self in schizophrenia: a multidimensional examination of short-term outcomes.

The manifestation, course, and prognosis of schizophrenia are extremely variable, raising an interest in the role of personality and self-concept in the illness' outcome. Building on voluminous research attesting to the fragility and instability of the self in schizophrenia, we examined the role of four self-concept aspects--self-esteem level, self-esteem instability, self-concept clarity, and the perception of the self as ill--in schizophrenia-spectrum disorders. Eighty-nine outpatients were assessed at baseline, and five days subsequently, regarding these self-concept aspects, symptoms, stress, and quality of life. Six weeks later, participants were again assessed using the baseline battery. Self-esteem instability predicted a decrease in quality of life over the study period. Self-concept clarity predicted an increase in quality of life and in positive symptoms, particularly under low stress. Depressive symptoms predicted a decrease in self-esteem levels and an increase in the perception of the self as ill. Thus, all four self-concept aspects were shown to be pertinent to the experience of schizophrenia, albeit in different ways. Special attention should be directed to self-concept clarity, which embeds both risk and resilience.

Does the Internet offer social opportunities for individuals with schizophrenia? A cross-sectional pilot study.

Web-browsing habits of 143 individuals with psychotic disorders were compared to individuals with non-psychotic disorders (n=118) and healthy volunteers (n=100). The psychotic group created social interactions via Internet use similarly to the control groups. Individuals with schizophrenia benefit from Internet use, as it bypasses some of their social difficulties.

Contributions of a relational psychoanalytic approach to dealing with the nonadherent psychiatric patient.

Nonadherence to medication is one of the great challenges facing any psychiatrist today. The main focus of this article is to illustrate the contributions of a relational psychoanalytic approach to dealing with the nonadherent psychiatric patient. Special emphasis is given to the importance of recognizing the therapist as an active subject and taking responsibility over the negative aspects of the therapist. A clinical vignette is presented, by which these points are illustrated and defined.

Internet-related psychosis−a sign of the times.

BACKGROUND: The psychopathological implications of the Internet are slowly being revealed as its use becomes increasingly common. This papers aim is to call attention to computer mediated communication (CMC), such as Facebook or chats, and alert to its possible relation to psychosis. DATA: We describe three individuals, with no prior major psychiatric disorder, who presented for psychiatric treatment, due to psychotic symptoms which appeared de novo while they were immersed in CMC. All three patients pointed to the contribution of specific CMC features to the gradual emergence of their psychotic symptoms. They described a 'hyperpersonal' relationship with a stranger, mistrust of the aims and identity of the other party, blurred self boundaries, misinterpretation of information, and undesirable personal exposure in cyberspace. The patients had little prior experience with computers or the Internet, and their vulnerability was intensified due to difficulties in deciphering the meaning of various elements of CMC and in managing its technical aspects. CONCLUSIONS: The cases we present support the assumption that unique features of CMC might contribute to the formation of psychotic experiences. The use of the Internet is vast, and, as such, we propose that medical staff members might consider routinely questioning patients about their use of it, especially CMC.

Relationship between ICD-10 psychosocial categories and psychiatric diagnosis in Israeli adolescents.

AIM: The study examined the relationship between psychosocial categories obtained by WHO-developed semistructured interviews (ICD-10 Axis V) and clinical Axis I psychiatric diagnoses in psychiatrically hospitalized adolescents. METHODS: The sample included 71 consecutive patients admitted to an adolescent unit and their mothers. Mothers completed a semi-structured interview derived from the criteria for each psychosocial category (Axis V), and the adolescents were diagnosed by experienced psychiatrists using the Schedule for Affective Disorders for School Age Children (K-SADS-P). RESULTS: Anorexia nervosa and conduct disorder were associated with a psychosocial category of 'abnormal qualities of upbringing,' and conduct disorder and schizophrenia were associated with a psychosocial category of 'events brought about by the child's own behavior.' CONCLUSIONS: The systematic assessment of psychosocial categories add specific information to the validity of the Axis I diagnosis.

Older paternal age strongly increases the morbidity for schizophrenia in sisters of affected females.

The effect of a family history of schizophrenia on the risk for this disorder in the offspring has rarely been examined in a prospective population cohort accounting for the sex of the proband and the first-degree relatives, and certainly not with respect to later paternal age. The influence of affected relatives on offspring risk of schizophrenia was estimated using Cox proportional hazards regression in models that accounted for sex, relation of affected first degree relatives and paternal age in the prospective population-based cohort of the Jerusalem Perinatal Schizophrenia Study. Of all first-degree relatives, an affected mother conferred the highest risk to male and female offspring among the cases with paternal age <35 years, however, female offspring of fathers ≥35 years with an affected sister had the highest risk (RR = 8.8; 95% CI = 3.9-19.8). The risk seen between sisters of older fathers was fourfold greater than the risk to sisters of affected females of younger fathers (RR = 2.2, 95% CI 0.7-6.7). The test for interaction was significant (P = 0.03). By contrast, the risk of schizophrenia to brothers of affected males was only doubled between older (RR = 3.3, 95% 1.6-6.6) and younger fathers (RR = 1.6, 95% CI 0.7-3.5). The most striking finding from this study was the very large increase in risk of schizophrenia to sisters of affected females born to older fathers. The authors speculate that the hypothesized paternally expressed genes on the X chromosome might play some role in these observations.

A double-blind, randomized study of minocycline for the treatment of negative and cognitive symptoms in early-phase schizophrenia.

BACKGROUND: Current antipsychotics have only a limited effect on 2 core aspects of schizophrenia: negative symptoms and cognitive deficits. Minocycline is a second-generation tetracycline that has a beneficial effect in various neurologic disorders. Recent findings in animal models and human case reports suggest its potential for the treatment of schizophrenia. These findings may be linked to the effect of minocycline on the glutamatergic system, through inhibition of nitric oxide synthase and blocking of nitric oxide-induced neurotoxicity. Other proposed mechanisms of action include effects of minocycline on the dopaminergic system and its inhibition of microglial activation. OBJECTIVE: To examine the efficacy of minocycline as an add-on treatment for alleviating negative and cognitive symptoms in early-phase schizophrenia. METHOD: A longitudinal double-blind, randomized, placebo-controlled design was used, and patients were followed for 6 months from August 2003 to March 2007. Seventy early-phase schizophrenia patients (according to DSM-IV) were recruited and 54 were randomly allocated in a 2:1 ratio to minocycline 200 mg/d. All patients had been initiated on treatment with an atypical antipsychotic < or = 14 days prior to study entry (risperidone, olanzapine, quetiapine, or clozapine; 200-600 mg/d chlorpromazine-equivalent doses). Clinical, cognitive, and functional assessments were conducted, with the Scale for the Assessment of Negative Symptoms (SANS) as the primary outcome measure. RESULTS: Minocycline was well tolerated, with few adverse events. It showed a beneficial effect on negative symptoms and general outcome (evident in SANS, Clinical Global Impressions scale). A similar pattern was found for cognitive functioning, mainly in executive functions (working memory, cognitive shifting, and cognitive planning). CONCLUSIONS: Minocycline treatment was associated with improvement in negative symptoms and executive functioning, both related to frontal-lobe activity. Overall, the findings support the beneficial effect of minocycline add-on therapy in early-phase schizophrenia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00733057.

Longitudinal associations between negative symptoms and social functioning in schizophrenia: the moderating role of employment status and setting.

While research has demonstrated strong relationships between negative symptoms and social difficulties in schizophrenia, little is known about the possible role of employment status and setting in this relationship. Seventy-seven participants with a diagnosis of schizophrenia spectrum disorder, who were either unemployed (n = 34), employed within a specialty mental health setting (n = 23), or employed within a community setting (n = 20) were assessed twice, six weeks apart, as to their negative symptoms and social functioning. Work in community settings generally predicted an increase in the levels of social functioning over time. However, individuals with high levels of negative symptoms who were employed in community settings evinced substantial decline in social functioning over time compared to unemployment or to employment in specialty mental health settings. These results are consistent with action models of psychopathology and encourage heightened sensitivity to individual symptomatic profiles in the course of vocational rehabilitation.

Enhancement of latent inhibition in patients with chronic schizophrenia.

OBJECTIVES: Latent inhibition (LI) refers to the retarding effects of inconsequential stimulus preexposure on subsequent conditioning to that stimulus, and reflects the organism's capacity to ignore irrelevant stimuli. LI is disrupted in schizophrenia patients, due to faster learning of the association between the conditioned stimulus (CS) and an unconditioned stimulus (US). It was recently proposed that LI has an additional pole of abnormality indicated by LI persistence. METHODS: Two experiments were performed to test this hypothesis. Both experiments applied a new within-subject, visual recognition LI procedure in which the association between a cue (CS) and the target (US) is acquired. In Exp 1 the task was applied to healthy volunteers (n=21). In Exp 2 chronic schizophrenia patients (n=19) were compared to control subjects (n=20). RESULTS: In Exp 1 the subjects showed LI in the initial trials of cue-target pairings, and an attenuation of the phenomenon at later trials. In Exp 2 control subjects showed a pattern of response comparable to the subjects of Exp 1, while the patients showed LI only on the later trials of the task. CONCLUSIONS: This result suggests that patients with chronic schizophrenia showed LI persistence. The possible advantages of the new LI paradigm are discussed.

Incidence of schizophrenia among second-generation immigrants in the jerusalem perinatal cohort.

OBJECTIVE: Increased incidence of schizophrenia is observed among some immigrant groups in Europe, with the offspring of immigrants, ie "second-generation" immigrants particularly vulnerable. Few contemporary studies have evaluated the risk of schizophrenia among second-generation immigrants in other parts of the world. METHODS: We studied the incidence of schizophrenia in relation to parental immigrant status in a population-based cohort of 88 829 offspring born in Jerusalem in 1964-1976. Parental countries of birth were obtained from birth certificates and grouped together as (1) Israel, (2) Other West Asia, (3) North Africa, and (4) Europe and industrialized countries. Cox proportional hazards methods were used in adjusting for sex, parents' ages, maternal education, social class, and birth order. RESULTS: Linkage with Israel's Psychiatric Registry identified 637 people admitted to psychiatric care facilities with schizophrenia-related diagnoses, before 1998. Incidence of schizophrenia was not increased among second-generation immigrants in this birth cohort, neither overall nor by specific group. CONCLUSIONS: The difference in risk of schizophrenia among second-generation immigrants in Europe and in this Israeli birth cohort suggests that the nature of the immigration experience may be relevant to risk, including reasons for migration, the nature of entry, and subsequent position in the host country for immigrants and their offspring. Minority status may be of importance as, in later studies, immigrants to Israel from Ethiopia had increased risk of schizophrenia.

Effect of socioeconomic status and parents' education at birth on risk of schizophrenia in offspring.

Although it is known that schizophrenia is associated with social class, controversy exists as to the nature of this association. The authors studied the incidence of schizophrenia in relation to social class at birth in a population-based cohort of 88,829 offspring born in Jerusalem in 1964-1976. They constructed a six-point scale to index social class, based on paternal occupation at the time of birth, with each of 108 occupations being ranked by mean education. Cox proportional hazards methods were used in adjusting for sex, parents' ages, duration of marriage and birth order. Linkage with Israel's Psychiatric Registry identified 637 people admitted to psychiatric care facilities with schizophrenia-related diagnoses, before 1998. There was no gradient of risk for schizophrenia associated with social class at birth; however, offspring of fathers in the lowest social class showed a modest increase in risk (adjusted Relative Risk = 1.4; 95% Confidence interval = 1.1-1.8, P = 0.002). These data suggest that in contrast to many other health outcomes, there is not a continuous gradient for increasing schizophrenia with decreasing social class of origin. Instead, a modest increase in risk for schizophrenia was observed only for those born at the bottom of the social ladder.

Points to ponder regarding contemporary psychiatric training in Israel.

In an era in which neuroscience is developing rapidly and different psychotherapeutic modalities are proliferating, psychiatric training encounters new difficulties. This article raises various issues that the authors feel are not adequately addressed in contemporary psychiatric residency programs in Israel. These include basic issues of doctor-patient relationship; different cultural trends such as the increase in popularity of CAM (complementary and alternative medicine), the increase in substance abuse, and the increasing popularity of different spiritual movements; transcultural aspects affecting the prevalence and understanding of different psychopathologies in various sectors of the population; ethical issues particular to psychiatric research; and the future psychiatrist's role as communicator and educator of GPs, mental health workers and the general public. In a time characterized by an abundance of models and theories in psychiatry, the authors stress the need to assist residents in integrating various theories and models into a comprehensive outlook regarding the psyche and psychiatric disorders. As mental hospitals vary greatly in their general psychiatric outlook, emphases, and competence of the senior staff in different fields and treatment modalities, the authors see programs for continuing medical education (CME) as the natural arena in which the issues mentioned in this paper should be addressed.

Tetrachloroethylene exposure and risk of schizophrenia: offspring of dry cleaners in a population birth cohort, preliminary findings.

Tetrachloroethylene is a solvent used in dry cleaning with reported neurotoxic effects. Using proportional hazard methods, we examined the relationship between parental occupation as a dry cleaner and risk for schizophrenia in a prospective population-based cohort of 88,829 offspring born in Jerusalem from 1964 through 1976, followed from birth to age 21-33 years. Of 144 offspring whose parents were dry cleaners, 4 developed schizophrenia. We observed an increased incidence of schizophrenia in offspring of parents who were dry cleaners (RR=3.4, 95% CI, 1.3-9.2, p=0.01). Tetrachloroethylene exposure warrants further investigation as a risk factor for schizophrenia.