Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients.

BACKGROUND: Assessment of risk of violent behavior in forensic psychiatric practice is a complex and responsible clinical task and the use of a valid instrument can make the expert's work more effective. The Historical Clinical and Risk Management scale 20 (HCR-20) is a widely accepted measure of the risk of violence, sexual and criminal behavior. The aim of this study was to validate the HCR-20 in Israeli psychiatric inpatient settings. METHOD: In a prospective design, data were collected on 150 male patients aged 15-65, diagnosed with ICD-10 schizophrenia, who were hospitalized in three wards: an acute psychiatric ward (n=50), a high security ward (n=50), and an open ward (n=50). The HCR-20, as the predictor measure, and the Positive and Negative Syndrome Scale, as a concurrent measure, werecompleted at baseline, and the Violence Assessment Scale, as the outcome measure, was completed at 6-, 12- and 18-month follow-up points. RESULTS: Internal consistency reliability was good for the total HCR-20 scale, satisfactory for the H-subscale, but low for the C- and R-subscales. Concurrent validity was good for the C-subscale, and discriminative validity was reasonable for the C- and H-subscales. The total scale as well as the Historical and Clinical subscales predicted the risk of physical as well as physical/sexual violent behavior at both 6- and 18-month follow-up points. CONCLUSIONS: Appropriate psychometric properties of the HCR-20 suggest that it can serve as a useful measure of the risk of violent behavior in psychiatric settings in Israel. Further research is necessary to confirm norms and cut-off scores, using a larger representative sample.

Psychiatric hospitalization by court observation order in Israel: a ten year follow up study.

OBJECTIVES: To explore the proportion of defendants hospitalized by court observation order (COO) who were diagnosed as having a psychiatric disorder during: 1) the COO period, or 2) a 10-year follow-up period. METHODS: Data on all adult defendants, who underwent psychiatric hospitalization by COO between 1991 and 1995, were extracted from the National Psychiatric Case Registry of the Israel Ministry of Health, and rehospitalizations over the next ten years were identified. ANO VA and Wilcoxon signed-rank test were used for comparing the diagnosed and undiagnosed defendant cohorts. RESULTS: Only 17% of defendants hospitalized by COO received a psychiatric diagnosis (N=316), while the remaining referred defendants (N=1,532) were not diagnosed as suffering from any psychiatric disorder. Although 56% of the initially undiagnosed group (N=863) were rehospitalized and received a psychiatric diagnosis during the next ten years, 36% of the original cohort never received a diagnosis subsequent to hospitalization (N=556). Significant median differences in inpatient days associated with a follow-up diagnosis of psychotic disorder were found between the diagnosed and undiagnosed defendant cohorts (z=4.89, p less than .001). CONCLUSIONS: The high rate of diagnosis of defendants who were undiagnosed at the index hospitalization suggests that the COO is ineffective and tends to discharge without diagnosis defendants who are later found to be psychotic. Therefore, an independent examination of the accuracy of the forensic psychiatric evaluation (FPE) process is called for, to determine whether actual disorders are being missed. There should be a professional and public debate on the unnecessary use of court-ordered hospitalizations and ways of their prevention.

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

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

Community emergency psychiatric service in Israel: a one-year experience.

BACKGROUND: In 2005 the Forensic Psychiatry Department of Mental Health Services at the Ministry of Health launched a pilot project: the Community Emergency Psychiatric Service (CEPS). The purpose was to offer community-based emergency response to acute psychiatric conditions during after-hours periods, including Saturdays and holidays. The project was implemented in the Tel Aviv, Central and Southern districts. METHOD: Advertisements were posted in mass circulating newspapers announcing the launching of the new program for the general public in the participating districts. The public was invited to call the hotline of the medical emergency service, Magen David Adom (MDA), in the event of psychiatric distress or emergency. MDA personnel were instructed to give the callers a telephone number of an on-call psychiatrist. The Ministry of Health engaged a pool of seven licensed psychiatrists to be available on-call one per shift. The psychiatrists offered crisis intervention over the phone or house visits when necessary. RESULTS: Data were obtained from the Tel Aviv, Central and Southern Districts. The results show that there were 1,472 calls between May 2005 and June 2006. In 198 cases (13.5%) clients were referred for treatment and follow-up to local outpatient clinics, while in 116 of the cases (7.8%) a home visit by the on-call psychiatrist was carried out, resulting in 50 voluntary and 16 involuntary hospitalizations. An examination of records of calls received by the on-call psychiatrists (N=97) during August 2006 suggests that most callers fit the following profile: female, ranging in age 19-35, unmarried, with diagnosis of schizophrenia, with no previous psychiatric hospitalizations, and presenting no danger to herself or others. CONCLUSIONS: A limited response team, comprised of one on-call psychiatrist per shift, can provide a viable service for psychiatric emergencies in a population center of approximately 2.7 million. The findings also suggest that such a service may increase the number of referrals to outpatient clinics in the community as well as the number of voluntary and involuntary hospitalizations after working hours. The potential contribution of such a project to improving accessibility to outpatient psychiatric care and to reinforcing continuity of care among in- and out-patient facilities needs further investigation as is the important question of cost-effectiveness.

[Outpatient commitment under court order in psychiatry].

Outpatient commitment under court order is a controversial issue among mental health professionals in different countries. This kind of outpatient involuntary treatment is provided for mental patients suspected to have committed a crime endangering society while in a severe psychotic state. Despite their dangerousness, the Israeli Mental Health Law of 1991 provides outpatient commitment under court order as an alternative to inpatient commitment. This legal provision raises several concerns and important ethical questions. A major dilemma is the question of whether this legal tool is efficacious in stabilizing the mental condition of criminal mental patients in order to prevent the perpetuation of violent crimes in an open setting such as outpatient clinics. Other major concerns are: (a) who bears the responsibility for the implementation of the enforcement? (b) how the enforcement might be implemented? This paper discusses this complex issue and presents some possible solutions aimed at improving the practical use of this important component of the comprehensive modern system of care for mental patients.

Trends in involuntary psychiatric hospitalization in Israel 1991-2000.

BACKGROUND: Though information about involuntary psychiatric hospitalizations (IPH) is crucial for the planning of Israel's National Mental Health Care Policy, very few studies have been carried out to date on this subject. AIMS: To identify trends in first IPH to all inpatient psychiatric settings in Israel. METHOD: The sample included all admissions of adults (18 years and older) over the ten-year period, 1991-2000, according to the registration of such admissions in the National Psychiatric Case Registry. RESULTS: A 2.4-fold increase was found in first IPH over the decade studied. The typical profile of the involuntarily admitted patient was that of a native-born Jewish male, aged 18-24 or 65 and older, single, with less than 8 years of education, and with a diagnosis of schizophrenia or delusional psychosis. CONCLUSIONS: These findings suggest the need for improving the interfaces between hospital and community services, and for preparing specific guidelines to extend the use of involuntary ambulatory treatment orders. Further study is needed to explore the respective roles of involuntary inpatient and outpatient treatment.

Rehospitalizations among psychiatric patients whose first admission was involuntary: a 10-year follow-up.

OBJECTIVES: To examine the characteristics of patients whose first admission to Israel's psychiatric units was involuntary, and to identify a specific profile of the patients at increased risk for future readmissions. Our hypothesis was that when the first admission of a patient was involuntary, the number and duration of future hospitalizations would be greater. METHOD: We used information extracted from the National Psychiatric Case Registry on all patients admitted for the first time during 1991 (N=2150) and on their follow-up over the next ten years. Chi-square statistics were used to test for significance differences in demographic and clinic variables between patients hospitalized voluntarily and those hospitalized involuntarily. Multiple regression analysis was performed to identify a specific profile of risk of recidivism during a ten-year period (1991-2000). RESULTS: Compared with patients admitted voluntarily, those who were admitted involuntarily had a significantly greater number and duration of rehospitalizations. They were more likely be diagnosed as suffering from schizophrenia while the voluntarily admitted patients were more likely be diagnosed as having an affective disorder. Risk factors for the number of readmissions included: young age, legal status (involuntary) of the first admission, as well as period of residence in the country. Risk factors affecting the duration of readmissions were single/widowed status, native born and a suicide attempt in the two months prior to the first admission. CONCLUSIONS: Two distinct profiles for the number ofreadmissions and inpatient days were identified. A diagnosis of schizophrenia and selected demographic variables were better at predicting risk of recidivism than the involuntary legal status of the first admission.

[Complaints in mental health services in Israel: a one year-study].

Despite the growing awareness of mental patients of their rights, the number of complaints is still under-represented for different reasons including the patients' fear that they will be 'punished' because of their complaints or their lack of knowledge concerning the correct procedure and the appropriate address for issuing their complaint. This article presents the summary of one year's work (year 2001), on the complaints and letters we received at the Forensic Psychiatry Unit, Mental Health Services, Ministry of Health, from the general public, mental health patients, their families or Advocacy Agencies concerning mental patients' rights. We analyzed the complaints according to the topic, the process and the results of our interventions. The data collected on the complaints show that most of the complainants were the patients themselves, especially males and adults. Most of the complaints dealt with the patients' dissatisfaction with the type of treatment received, in that it did not match their expectations. Fifty percent of the complaints involved treatment received at psychiatric hospitals and 34% of the complaints were related to out-patient treatment. Sixty-five percent of complainants wrote a single complaint during the year 2001. Our intervention and reply to the complainants was completed within a month in 66% of the cases. We conclude suggesting different ways to improve this important service.