Routine Drug Screening for Patients in the Emergency Department of a State Psychiatric Hospital: A Naturalistic Cohort Study.

OBJECTIVE: This study investigates the proportion of drug users among patients with mental disorders who attended the emergency department of one major psychiatric hospital in Northern Israel, the most frequent psychiatric diagnoses associated with drug use, and the impact of confirmed drug use on hospital admission. We hypothesized that the proportion of individuals with positive urine drug test results presenting at the psychiatric emergency department during the study period would be 20% to 30%. METHODS: An unselected cohort of 2,019 adult patients who visited the emergency department of Sha'ar Menashe Mental Health Center, a university-affiliated government facility, was evaluated and underwent routine urine drug testing between April 2012 and February 2014. Clinical, demographic, and urine drug test data were collected from medical records and statistically analyzed, comparing diagnostic evaluation at admission and after discharge from either the emergency department or the hospital. Univariate and logistic regression analyses were used to identify the possible variables associated with drug use in this sample. RESULTS: Urine drug test results showed that 194 of the 2,019 subjects (9.6%) had used a psychoactive substance before attending the emergency department. Among patients with positive urine drug test results, the majority (77.8%) used cannabis, 25.8% used opiates, 24.7% used ecstasy, and 5.2% used cocaine. Differences in the prevalence of positive urine drug test results between admitted and nonadmitted patients did not reach a statistically significant level. The frequency of positive urine drug test results across lifetime International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) diagnoses was 27.2% for substance-related disorders, 4.8% for psychotic disorders, 4.2% for mood disorders, 11.0% for personality disorders, and 11.5% for nonpsychotic disorders. Both univariate and logistic regression analyses revealed that younger age (18-40), male sex, fewer years of education, single marital status, and ICD-10 diagnosis of substance-related, personality, and nonpsychotic disorders were indicators of higher likelihood of positive urine drug test findings. CONCLUSIONS: Results suggest that routine urine toxicology screening is not necessary in the psychiatric emergency department as an adjunct to a thorough psychiatric clinical examination. However, urine drug tests should be performed when the clinical evaluation cannot determine whether the mental disorder is the result of illicit drug use or clearly non-drug-related.

Voting rights for psychiatric patients: compromise of the integrity of elections, or empowerment and integration into the community?

BACKGROUND: Participation of the mentally-ill in elections promotes integration into the community. In many countries, individuals with compromised mental incompetence who have legal guardians are denied the right to vote. In Israel, mental health consumers are eligible to vote. We evaluated the capacity of psychiatric inpatients with and without legal guardians to understand the nature and effect of voting. METHODS: Fifty-six inpatients with/without legal guardians were recruited to the study. Participants completed the Competency AssessmentTool for Voting (CAT-V), Brief Psychiatric Rating Scale and the Mini-Mental State Exam. RESULTS: Cluster analysis determined voting capacity using CAT-V as a continuous variable. Subjects who scored >1.6 on the CAT-V (59%) had high capacity to vote. Subjects without guardians revealed significantly higher capacity to vote. Voting capacity positively correlated with cognitive state and negatively correlated with severity of illness. Among patients with legal guardians those who scored >1.6 on the CAT-V maintained the capacity to vote. CONCLUSIONS: The right to vote is an important basic right for individuals coping with mental disorders.However, it is important to evaluate the capacity to understand the voting process among individuals with mental disorders who have legal guardians. Thus, the integrity of the elections would be preserved by eliminating the risk of undue influence or manipulation of individuals who lack the capacity to understand the nature and meaning of voting, while preserving the right to vote for those with the capacity to do so, whether or not they have guardians.

Internalization of stigma and self-esteem as it affects the capacity for intimacy among patients with schizophrenia.

The study examines the relationship between internalization of stigma, self-esteem, and the ability of people diagnosed with schizophrenia to form intimate attachments with loved ones. The study included sixty patients with schizophrenia, ages 18-60, men and women. After providing informed consent, all participants completed four questionnaires: Demographics Questionnaire, Self-Esteem Scale, Internalized Stigma of Mental Illness Scale and the Intimacy Attitude Scale-Revised. Internalization of social stigma was found to be a statistically significant core factor that affects self-esteem and the ability to create intimacy among patients with schizophrenia. There was statistically significantly less internalization of stigma of mental illness among hospitalized patients than among individuals with schizophrenia who live in the community.

Evaluation of the capacity of inpatients with chronic schizophrenia to provide informed consent for participation in clinical trials; use of the Hebrew version of the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR).

BACKGROUND: Patient protection requires the provision of informed consent for participation in medical research. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) is frequently used for screening the capacity of research subjects to consent to participate in research. OBJECTIVES: To evaluate the utility of the Hebrew translation of the MacCAT-CR for assessing the capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials. METHODS: We evaluated the translated MacCAT-CR by comparingthe capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials. The following standardized neurocognitive assessment tools were used: Addenbrooke's Cognitive Examination (ACE) and Frontal Assessment Battery (FAB), as well as the attending doctor's assessment. RESULTS: Twenty-one patients participated. Mean MacCAT-CR score was 12 +/- 10.57 (range 0-32), mean FAB score 9.9 +/- 4.77 (range 1-18), mean ACE 59.14 +/- 16.6 (range 27-86) and mean doctor's assessment 5.24 +/- 1.18 (range 3-7). CONCLUSIONS: The Hebrew version of the MacCAT-CR helped identify patients with the capacity to provide informed consent for participation in research. Patients with FAB scores > or = 12 tended to score higher on the Hebrew version of the MacCAT-CR, thus confirming the utility of the Hebrew version of the MacCAT-CR. During the screening process for clinical trials it may be practical to administer the concise FAB questionnaire, and then administer the MacCAT-CR only to those who scored > or = 12 on the FAB.

Effect of antiviral amantadine treatment on elderly chronic schizophrenia patients.

BACKGROUND: In compliance with public health measures initiated by the Israel Ministry of Health following an outbreak of influenza, amantadine was administered to all patients in the psychogeriatric department of Lev Hasharon Mental Health Center to reduce transmission and illness severity in this susceptible population. OBJECTIVES: To evaluate the potential beneficial effects of amantadine on elderly hospitalized patients with persistent schizophrenia. METHODS: We conducted a retrospective case review of the treatment effects of amantadine on the mental, cognitive and clinical states of elderly chronic schizophrenic patients who received concomitant amantadine treatment and were routinely evaluated with the Positive and Negative Syndrome Scale, the Mini Mental State Examination, and Sandoz Clinical Assessment Geriatric Scale. RESULTS: No significant differences before and after amantadine treatment were noted. CONCLUSION: Amantadine did not influence the mental, cognitive and clinical states of elderly schizophrenia patients and thus can be considered as an anti-influenza preventive measure for this population, when indicated.

Revolving-door patients in a public psychiatric hospital in Israel: cross sectional study.

AIM. To study social, demographic, clinical, and forensic profiles of frequently re-hospitalized (revolving-door) psychiatric patients. METHODS. The study included all patients (n=183) who were admitted to our hospital 3 or more times during a 2-year period from 1999 through 2000. We compared these patients to 2 control groups of patients who were admitted to our hospital in the same period. For comparison of forensic data, we compared them with all non revolving-door patients (n=1056) registered in the computerized hospital database and for comparison of medical and clinical data we compared them with a random sample of non revolving-door patients (n=98). The sample was sufficiently large to yield high statistical power (above 98%). We collected data on the legal status of the hospitalizations (voluntary or involuntary) and social, demographic, clinical, and forensic information from the forensic and medical records of revolving-door and non revolving-door patients. RESULTS. In the period 1999-2000, 183 revolving-door patients accounted for 771 (37.8%, 4.2 admissions per patient) and 1056 non revolving-door patients accounted for 1264 (62.5%, 1.2 admissions per patient) of the 2035 admissions to our hospital. Involuntary hospitalizations accounted for 23.9% of revolving-door and 76.0% of non revolving-door admissions. Revolving-door patients had significantly shorter mean interval between hospitalizations, showed less violence, and were usually discharged contrary to medical advice. We found no differences in sex, marital status, age, ethnicity, diagnoses, illegal drug and alcohol use, or previous suicide-attempts between the groups. CONCLUSIONS. Revolving-door patients are not necessarily hospitalized for longer time periods and do not have more involuntarily admissions. The main difference between revolving-door and non revolving-door patients is greater self-management of the hospitalization process by shortening the time between voluntary re-admission and discharge against medical advice.

Insight into obsessive-compulsive symptoms and awareness of illness in adolescent schizophrenia patients with and without OCD.

A substantial proportion of adolescent schizophrenia patients also has obsessive-compulsive disorder (OCD). As the reliability of OCD identification in schizophrenia has been challenged, we evaluated insight into OCD symptoms and awareness of schizophrenia, using the Brown Assessment of Beliefs Scale and the Scale to Assess Unawareness of Mental Disorder respectively, in 22 adolescent inpatients who met DSM-IV criteria for both schizophrenia and OCD. Awareness of illness was also assessed in a comparison group of 22 non-OCD adolescent schizophrenia patients. Nineteen (86.3%) schizo-obsessive patients exhibited good or fair insight into OCD, while only 3 patients revealed lack of insight. Roughly 30% of patients in the two schizophrenia groups with and without OCD exhibited unawareness of schizophrenia, indicating that the presence of OCD does not substantially modify global awareness of illness. The effect size of the correlation between insight into OCD and awareness of schizophrenia in the schizo-obsessive group was small and not statistically significant. Our findings support the notion that OCD in adolescent schizophrenia patients represent an identifiable dimension of psychopathology independent of core schizophrenia symptoms. Early identification of this potentially treatable syndrome is imperative for appropriate diagnosis and treatment of this unique subset of schizophrenia patients.

Professional integration and re-education for immigrant psychiatrists: a personal perspective "docendo distimus".

To be a good psychiatrist, aside from being knowledgeable, one must acknowledge and be constantly aware of the importance of ethnic customs and cultural differences. Psychiatrists who emigrated from the former Soviet Union to Israel, who were raised and educated in totalitarian systems, must develop the flexibility necessary to disengage from preconceptions and learn to flourish in a democratic society. The acculturation process is mutual, and native Israelis need to acquaint themselves with all aspects of Russian history and culture, in order to bond with their immigrant colleagues. At the same time, ethnic sensitivity and sincere involvement in all aspects of Israeli culture are crucial for the immigrant's development of a sense of security in the psychiatric profession and for developing the rapport necessary for treating native Israelis.

Awareness of illness and insight into obsessive-compulsive symptoms in schizophrenia patients with obsessive-compulsive disorder.

Obsessive-compulsive symptoms (OCS) have been revealed in a substantial proportion of schizophrenia patients. We sought to evaluate insight into OCS in schizo-obsessive patients. We evaluated insight into OCS and awareness of schizophrenia, using the Brown Assessment of Beliefs Scale (BABS) and the Scale to Assess Unawareness of Mental Disorder (SUMD), respectively. Fifty-seven inpatients that met DSM-IV criteria for both schizophrenia and OCD were recruited. To determine a possible modifying effect of OCS on the awareness of schizophrenia, we included a comparison group of non-OCD schizophrenia patients (N = 80). Nine (15.8%) schizo-obsessive patients revealed lack of insight into OCS, whereas a majority (48 patients, 84.2%) exhibited good or fair insight. In the schizo-obsessive group, insight into OCS positively correlated with awareness of schizophrenia but not with awareness of delusions. Roughly 40% of the schizo-obsessive and non-OCD schizophrenia patients revealed unawareness of schizophrenia. Our findings indicate that OCS in schizophrenia represent an identifiable dimension of psychopathology independent of core schizophrenia symptoms.

Israeli psychiatric inpatients go to the polls.

In 1996, mobile polls were introduced in Israel, enabling physically and emotionally ill inpatients to vote. We surveyed the rate of participation of inpatients at Lev-Hasharon Mental Health Center in parliamentary elections, their feelings regarding voting, and the nature of their vote, compared with the general population. One hundred eighteen of 306 (38.6%) patients voted compared with 63.8% of the general population. Forty-nine more patients (16%) wanted to vote but were unable to for technical reasons. More patients voted in the open than the closed wards (chi=14.5; df=1; p=.001). Most patients reported positive subjective feelings, a sense of responsibility (39%), belonging to the general community (28%), and pride (22%) after voting. Psychiatric inpatients voted similarly to the general population, though their percentage of voters was significantly lower. This discrepancy can be accounted for by lack of concern and ineligibility due to lack of identification documents that may reflect fundamental illness-related problems.

Neurocognitive deterioration in elderly chronic schizophrenia patients with and without PTSD.

Neurocognitive deficits are associated with chronic schizophrenia and aging. We investigated whether elderly chronic schizophrenia inpatients who also suffer from posttraumatic stress disorder (PTSD) have more severe cognitive impairment than elderly schizophrenia inpatients that do not. Fourteen schizophrenia inpatients that are Holocaust survivors and suffer from PTSD (survivor group) were compared with schizophrenia inpatients not exposed to the holocaust and without PTSD (comparison group) using neurocognitive assessments and psychiatric evaluation instruments. The survivors performed significantly worse on measures of processing speed and visual scanning, recognition memory, and general mental status, than the comparison group. Though nonsignificantly, the comparison group revealed better performance on tests that measured visuospatial perception, visuospatial planning and strategies, organizational and constructional skills. The survivor group displayed a greater severity of antipsychotic-induced side effects that were not associated with differences in cognitive performance. Comorbid PTSD may contribute to the severity of neurocognitive impairment in elderly chronic schizophrenia patients.

The effect of humorous movies on inpatients with chronic schizophrenia.

We assessed the impact of humorous movies on psychopathology, anxiety, depression, anger, social functioning, insight, and therapeutic alliance in schizophrenia inpatients. Twenty-nine psychiatric inpatients in open wards participated in the study. The study group viewed humorous and the control group viewed neutral movies daily for 3 months. Participants were assessed before and after viewing movies with the Positive and Negative Symptom Scale, Calgary Depression Scale, the State-Trait Anxiety Inventory, the State-Trait Anger Expression Inventory-2, the Multinomah Community Ability Scale, the Insight and Treatment Attitude Questionnaire, and the Working Alliance Inventory. Reduced levels of psychopathology, anger, anxiety, and depression symptoms and an improvement in social competence were revealed in the study group. No changes were observed in treatment insight or working alliance. Video films are a practical and cost-efficient means of entertainment that seem to have a positive effect on patient morale, mood, and mental status.

Coping patterns as a valid presentation of the diversity of coping responses in schizophrenia patients.

This study aimed to identify coping patterns used by schizophrenia inpatients in comparison with those used by healthy individuals, and to explore their association with selected clinical and psychosocial variables. The Coping Inventory for Stressful Situations (CISS) was used to assess coping strategies among 237 inpatients who met DSM-IV criteria for schizophrenia and 175 healthy individuals. Severity of psychopathology and distress, insight into illness, feelings of self-efficacy and self-esteem (self-construct variables), social support, and quality of life were also examined. Factor analysis, analysis of covariance and correlations were used to examine the relationships between the parameters of interest. Using dimensional measures, we found that emotion-oriented coping style and emotional distress were significantly higher in the schizophrenia group, whereas the task-oriented coping style, self-efficacy, perceived social support and satisfaction with quality of life were lower compared with controls. When eight CISS coping patterns were defined, the results revealed that patients used emotion coping patterns 5.5 times more frequently, and task and task-avoidance coping patterns significantly less often than healthy subjects. Coping patterns have different associations with current levels of dysphoric mood and emotional distress, self-construct variables, and satisfaction with quality of life. Thus, the identified coping patterns may be an additional useful presentation of the diversity of coping strategies used by schizophrenia patients. Coping patterns may be considered an important source of knowledge for patients who struggle with the illness and for mental health professionals who work with schizophrenia patients.

Cost effectiveness, safety, and satisfaction with video telepsychiatry versus face-to-face care in ambulatory settings.

Videoconference telepsychiatry provides an alternative for the psychiatric treatment of mental health patients who reside in remote communities. The objective of this study was to compare institutional ambulatory and hospitalization costs, treatment adherence, patient and physician satisfaction, and treatment safety between mental healthcare via videoconferencing and care provided in person. Data collected for 1 year of telepsychiatry treatment was compared to that of the preceding year and a matched comparison group. Twenty-nine patients from Or Akiva and 20 patients from Reut Hostel in Hadera who met the inclusion criteria agreed to participate; 24 and 15 patients, respectively, completed the study. Forty-two matched patients, who continued face-to-face interviews, comprised the comparison group. Drop-out patients and those who did not consent to telepsychiatry treatment were not involved. During the year of telepsychiatry treatment, patients and physicians were satisfied and treatment was safe. However, 1 hour of telepsychiatry treatment was more expensive than face-to-face care, and a tendency of increased hospitalizations was noted. Adherence ratios before and during telepsychiatry treatment were similar, but were twice as high versus the comparison group. The limited sample size precludes the drawing of definite conclusions, and further studies involving a larger study population and longer duration of investigation is warranted.

Validity of an abbreviated quality of life enjoyment and satisfaction questionnaire (Q-LES-Q-18) for schizophrenia, schizoaffective, and mood disorder patients.

We sought to identify a core subset of Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) items that maintains the validity and psychometric properties of the basic version. A parsimonious subset of items from the Q-LES-Q that can accurately predict the basic Q-LES-Q domain mean scores was sought and evaluated in 339 inpatients meeting DSM-IV criteria for schizophrenia, schizoaffective, and mood disorders. Three additional data sets were used for validation. Assessments included Q-LES-Q, Quality of Life Scale, Lancashire Quality of Life Profile, rating scales for psychopathology, medication side effects, and self-reported emotional distress, self-esteem, self-efficacy, and social support. We found that 18-items predicted basic Q-LES-Q domains (physical health, subjective feelings, leisure time activities, social relationships) and general index scores with high accuracy. Q-LES-Q-18 showed high reliability, validity, and stability of test-retest ratings. Thus, Q-LES-Q-18, a brief, self-administered questionnaire may aid in monitoring quality of life outcomes of schizophrenia, schizoaffective, and mood disorder patients.

Condensed version of the Quality of Life Scale for schizophrenia for use in outcome studies.

The Quality of Life Scale (QLS(21)) is widely used in clinical trials involving schizophrenia patients. This study aimed to identify a core subset of QLS(21) items that maintains the validity and psychometric properties of the complete version. A parsimonious subset of items from the QLS(21) that can accurately predict the total scale score was sought and evaluated in 133 schizophrenia patients, using the heuristic algorithm for a regression model. Two additional data sets were used for model validation: a subset of 124 patients who participated in the model construction and who completed the QLS(21) 1 year later as well as a new sample of 40 inpatients. Patients were examined with the Positive and Negative Syndrome Scale (PANSS), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Talbieh Brief Distress Inventory (TBDI), the Extrapyramidal Symptom Rating Scale (ESRS) and the Global Assessment of Functioning Scale (GAF). Using only five QLS items (social initiatives, adequacy, acquaintances, motivation, and time utilization; QLS(5)) as predictors, the correlation was 0.9805 between the predicted and true QLS totals. Two validation samples confirmed this finding. Additional analyses indicate that the QLS(5) exhibited similar performance to the QLS(21) regarding construct validity, test-retest reliability and responsiveness to changes over time. Thus, the five-item condensed Quality of Life Scale for schizophrenia maintains the validity of the full QLS, and has the advantage of shorter administration time. Utilization of the revised QLS(5) in routine care and clinical trials may potentially facilitate evaluation of treatment outcomes in schizophrenia.

Quality of life and temperament factors in schizophrenia: comparative study of patients, their siblings and controls.

This study aimed to determine which temperament factors are associated with quality of life (QOL) in schizophrenia based on a triplet design comparing patients with their non-affected siblings and healthy control subjects. Forty-seven DSM-IV clinically stable schizophrenia outpatients, 47 non-affected siblings, and 56 non-patients matched for gender and age were evaluated using the Tridimensional Personality Questionnaire and the Quality of Life Enjoyment and Life Satisfaction Questionaire. As expected, schizophrenia patients reported significantly poorer QOL in most specific domains and in general. They also revealed significantly higher scores on harm avoidance and scored lower on reward dependence, than both their siblings and controls. Tridimensional Personality Questionnaire temperament factors revealed no differences between the controls and the siblings. When differences between patients, their siblings and controls were adjusted for gender, age at examination, and education, ANOVA demonstrated that temperament factors contributed to poor satisfaction with physical health, social relationships and subjective feelings in schizophrenia patients. Harm avoidance was associated with general QOL independent of severity of psychopathology. Thus, this study suggests that temperament factors that are not necessarily part of the deterioration process of the illness are associated with the quality of life of schizophrenia patients. These and other non-illness related factors should be considered when evaluating quality of life outcomes in intervention studies.

Quality of life outcomes of risperidone, olanzapine, and typical antipsychotics among schizophrenia patients treated in routine clinical practice: a naturalistic comparative study.

Findings in previous studies investigating the beneficial effect of risperidone and olanzapine versus typical antipsychotics on quality of life (QOL) are controversial since they did not adjust for various factors contributing to QOL. To test this assumption in a naturalistic cross-sectional design, we evaluated general and domain-specific QOL scores for baseline data of schizophrenia outpatients stabilized on atypical (N = 78, risperidone or olanzapine) and typical (N = 55) agents. Self-report and observer-rated QOL outcomes of both risperidone and olanzapine with typical antipsychotic therapy were compared across demographic, illness-related, and treatment-related factors using analysis of variance, multivariate analysis of variance, and correlation analysis. No significant differences were found in QOL outcomes of risperidone-treated and olanzapine-treated patients. Both self-report and rater-observed QOL measures indicated superiority of atypical over typical antipsychotic agents after adjusting for daily doses, duration of treatment, subjective tolerability, and adjuvant antidepressants. Lower daily doses and longer antipsychotic treatment were associated with better QOL. Self-report and observer-rated QOL scores correlated positively (r = 0.64, P < 0.001). Gender, marital status, age, education, living arrangement and employment status, age of onset, illness duration, symptom severity, emotional distress, subtypes of schizophrenia, and side effects did not affect QOL outcomes in either group. Risperidone and olanzapine revealed an advantage over typical agents in terms of QOL. Findings suggest that when calculating the beneficial effects of atypical antipsychotic therapy on QOL outcomes, daily doses, duration of treatment, and subjective tolerability may be intervening variables and should be adjusted accordingly to clearly appreciate benefits of atypical antipsychotics.

Perceived quality of life in schizophrenia: relationships to sleep quality.

We examined the relationship between perceived quality of life (QOL) and subjective quality of sleep among schizophrenia patients, and its relation to symptom severity, side effects and emotional distress. One hundred and forty five schizophrenia patients were comprehensively evaluated with standardized measures of symptom severity, adverse effects, emotional distress, QOL, and sleep quality (the Pittsburgh Sleep Quality Index, PSQI). Partial correlation and multiple regression analyses were performed. Poor sleepers reported lower mean scores on all QOL domains, they were more depressed and distressed, and had more adverse effects to medications with concomitant distress than good sleepers. The negative relationship between complaints of poor sleep quality and QOL measures remained significant when the confounding effect of depression, side effects, and distress was partialled from the correlation matrix. Daytime dysfunction (a component of the PSQI) accounted for 12.6% of the variance in QOL index scores. Thus, poor QOL reported by schizophrenia patients is substantially associated with poor sleep quality. This association appears both independently and synergistically with depression, distress and side effects of medications.