Involuntary psychiatric hospitalizations in Israel 2001-2018 and risk for immigrants from different countries.

Since 2000, the Israeli mental health system has undergone a reduction in hospital beds, initiation of community-based rehabilitation, and transfer of governmental services to health maintenance organizations. This study examined trends, predictors and outcomes of involuntary psychiatric hospitalizations (IPH), in particular for immigrants. All first psychiatric hospitalizations of adults, 2001-2018, in the National Psychiatric Case Registry were used. Involuntary and voluntary hospitalizations were analyzed by demographic and clinical characteristics, and age-adjusted rates calculated over time. Multivariate logistic regression models were used to investigate IPH predictors and first IPH as a risk factor for one-year suicide after last discharge, and a Cox multivariate regression model to examine its risk for all-cause mortality. Among 73,904 persons in the study, age-adjusted rates of IPH were higher between 2011 and 2015 and then decreased slightly until 2018. Ethiopian immigrants had the highest risk for IPH, immigrants from the former Soviet Union a lower risk, and that of Arabs was not significantly different, from non-immigrant Jews. IPH was not significantly associated with one-year suicide or all-cause mortality. These findings demonstrate the vulnerability of Ethiopian immigrants, typical of disadvantaged immigrants having a cultural gap with the host country and highlight the importance of expanding community mental health services.

Association of maternal exposure to terror attacks during pregnancy and the risk of schizophrenia in the offspring: A population-based study.

This study tested the hypothesis that maternal exposure to terror attacks during pregnancy is associated with the risk of schizophrenia in the offspring. A population-based study was conducted of Israeli children born between 1975 and 1995 and that were registered in the Ministry of Interior and followed up in the Ministry of Health from birth to 2015 for the risk of schizophrenia (N = 201,048). The association between maternal exposure to terror attacks during pregnancy and the risk of schizophrenia in the offspring was quantified with relative risks (RR) and their 95% confidence intervals (CI) fitting Cox regression models unadjusted and adjusted for confounders. Sensitivity analyses were performed to test the robustness of the results. The RR of schizophrenia in offspring of mothers exposed to terror attacks during pregnancy compared to offspring of mothers not exposed during pregnancy were estimated unadjusted (RR = 2.51, 95% CI, 1.33, 4.74) and adjusted (RR = 2.53, 95% CI, 1.63, 3.91). In the sensitivity analyses adjusted RRs were estimated using a sibling-based study design (2.85, 95% CI: 1.31-6.21) and propensity matching (2.45, 95% CI: 1.58-3.81). Maternal exposure to terror attacks during pregnancy was associated with an increased risk of schizophrenia in the offspring, possibly indicating a critical period of neurodevelopment that is sensitive to the stress of terror attacks and affected by epigenetic modifications.

Transgenerational effects of genocide exposure on the risk and course of schizophrenia: A population-based study.

BACKGROUND: Hypotheses about the sequel of parental genocide exposures on the offspring's risk and course of schizophrenia remain untested. AIMS: To test hypotheses related to the transgenerational transmission of parental genocide exposure on the risk and course of schizophrenia. METHODS: Data were extracted from the National Population Register on all offspring (N=51.233; born: 1948-1989) whose parents were born (1922 to 1945) in Nazi- dominated European nations. Both parents either immigrated before (indirect exposure: n=1627, 3.2%) or after (direct exposure: n=49.606, 96.8%) the Nazi era. Offspring subgroups were identified from the initial timing of parental exposure (e.g., likely in utero, combined in utero and postnatal, or postnatal). Schizophrenia disorders were ascertained (1950-2014) from the National Psychiatric Case Registry. Cox models were computed to compare the offspring groups with respect to the risk and the adverse course of schizophrenia, adjusting for confounders. RESULTS: The offspring rates on the risk and course of schizophrenia did not differ by parental affiliation to the direct and indirect exposure groups. Cox models showed that offspring subgroups with maternal Holocaust exposures in utero only (HR=1.74, 1.13, 2.66) and combined in utero and postnatal (HR=1.48, 1.05, 2.10); as well as paternal Holocaust exposures combined in utero and postnatal (HR=1.48, 1.08, 2.05), and early postnatal (aged 1-2; HR=1.49, 1.10, 2.00) had a significantly (P<0.05) higher psychiatric re-hospitalization rate than the indirect group. CONCLUSIONS: Transgenerational genocide exposure was unrelated to the risk of schizophrenia in the offspring, but was related to a course of deterioration during selected critical periods of early life.

Has deinstitutionalization affected inpatient suicide? Psychiatric inpatient suicide rates between 1990 and 2013 in Israel.

OBJECTIVE: To examine variations in rates of inpatient suicide and clinical risk factors for this phenomenon. METHOD: The National Israeli Psychiatric Hospitalization Case Registry was used to study inpatient suicide. Clinical risk factors for inpatient suicide were examined in a nested case control design. RESULTS: Between 1990 and 2013 there were 326 inpatient suicides, at an average of one inpatient suicide per 1614 admissions. A significant decline in rates of suicide per admission over time (p<0.001) was associated with a reduced number of beds (p<0.001) and a decline in nationwide suicide rates (p=0.001). Clinical risk factors for inpatient suicide were: affective disorders (OR=5.95), schizoaffective disorder (OR=5.27), schizophrenia (OR=3.82), previous suicide attempts (OR=2.59), involuntary hospitalization (OR=1.67), and more previous hospitalizations (OR=1.16,). A multivariate model with sensitivity of 27.3% and specificity of 95.3% for inpatient suicide, showed a positive predictive value of 0.4%. CONCLUSIONS: The absolute number and rates of inpatient suicide per admission have decreased over time, probably due to the decreased number of beds lowering total time at risk. Patients with affective and psychotic disorders and with previous suicide attempts have the greatest risk of inpatient suicide. However, clinical characteristics do not enable identification of patients who are at risk for suicide.

Genocide Exposure and Subsequent Suicide Risk: A Population-Based Study.

The association between periods of genocide-related exposures and suicide risk remains unknown. Our study tests that association using a national population-based study design. The source population comprised of all persons born during1922-1945 in Nazi-occupied or dominated European nations, that immigrated to Israel by 1965, were identified in the Population Register (N = 220,665), and followed up for suicide to 2014, totaling 16,953,602 person-years. The population was disaggregated to compare a trauma gradient among groups that immigrated before (indirect, n = 20,612, 9%); during (partial direct, n = 17,037, 8%); or after (full direct, n = 183,016, 83%) exposure to the Nazi era. Also, the direct exposure groups were examined regarding pre- or post-natal exposure periods. Cox regression models were used to compute Hazard Ratios (HR) of suicide risk to compare the exposure groups, adjusting for confounding by gender, residential SES and history of psychiatric hospitalization. In the total population, only the partial direct exposure subgroup was at greater risk compared to the indirect exposure group (HR = 1.73, 95% CI, 1.10, 2.73; P < .05). That effect replicated in six sensitivity analyses. In addition, sensitivity analyses showed that exposure at ages 13 plus among females, and follow-up by years since immigration were associated with a greater risk; whereas in utero exposure among persons with no psychiatric hospitalization and early postnatal exposure among males were at a reduced risk. Tentative mechanisms impute biopsychosocial vulnerability and natural selection during early critical periods among males, and feelings of guilt and entrapment or defeat among females.

Suicides among persons with psychiatric hospitalizations.

BACKGROUND: Persons with severe mental disorders have higher suicide rates than the general population. Their risk profile needs to be fully explored to better guide suicide preventive efforts. Downsizing the number of beds in psychiatric hospitals and high bed turnover may also affect the suicide risk. OBJECTIVES: To investigate 1) Suicide rates among persons who were ever hospitalized in psychiatric facilities compared to the general population, 2) Associated sociodemographic and psychiatric factors, 3) Changes in rate over time, and 4) Timing of suicide deaths. METHODS: We linked the National Psychiatric Case Register (NPCR) with the national database on causes of death. Suicides in the years 1981-2009 were analyzed for the study group of Israelis aged 18 and over ever hospitalized (N= 158,800). ANALYSIS: Suicide rates were computed by age, gender, psychiatric diagnosis and year of death, as well as agestandardized rates and rate ratios (RR) for persons in the NPCR compared with those never hospitalized. The proportion of suicides committed by the ever hospitalized from all suicides in the population was calculated. Standardized mortality ratios (SMR) for suicide were computed for the ever hospitalized based on the total suicide rates of the population. A multivariate logistic model investigated risk factors associated with suicide in the ever-hospitalized population. RESULTS: The age-standardized suicide rate of Jews and Others with a psychiatric hospitalization was 17.6 times higher than that of the non-hospitalized (95% CI 16.7-18.6) and 29.7 times higher for Arabs (95% CI 23.4- 37.9). The rates were higher among females and younger persons. In the years 2007-2009, 30% of all suicides of Jews and Others were committed by persons who had been hospitalized in psychiatric facilities. The SMRs of Jews and Others, which increased at the beginning of the study period, fell steadily until 1995. In recent years they have been rising since 2000 and 2005 among females and males, respectively. One fifth (19%) of suicides of Jews and Others occurred before or on the discharge day, and another 6% and 7% within a week and between a week and a month after discharge, respectively. Logistic analysis showed significantly higher suicide risk for males, those who attempted suicide before hospitalization, persons under age 65 and Ethiopian immigrants. Suicide risk increased with number of hospitalizations. CONCLUSION: This study highlights the importance of suicide prevention interventions for persons both during their inpatient stay and who were expected to be followed up in community-based facilities.

The effects of pre-natal-, early-life- and indirectly-initiated exposures to maximum adversities on the course of schizophrenia.

BACKGROUND: The effects of pre-natal-, early-life- and indirectly-initiated exposures to protracted maximum adversity on the course of schizophrenia are unknown. AIMS: To compare the aforementioned Holocaust directly exposed subgroups with an indirectly exposed subgroup on the course of schizophrenia. METHOD: The study population were: Israeli Jews in-uterus or born in Nazi-occupied or dominated European nations by the end of the persecution of the Jews, who were alive in 1950, and who had a last discharge diagnosis of schizophrenia in the Israel National Psychiatric Case Registry by 2013 (N=4933). The population was disaggregated into subgroups who (1) migrated after WWII and who had (1a) pre-natal (n=584, 11.8%) and (1b) early-life (n=3709, 75.2%) initiated exposures to the maximum adversities of the Holocaust, and (2) indirectly exposed individuals to the Holocaust who migrated before the Nazi-era persecution begun (n=640, 13%). Recurrent event survival analyses were computed to examine the psychiatric re-hospitalization risk of the study subgroups, unadjusted and adjusted for age of onset of the disorder and sex. RESULTS: The pre-natal initiated exposure subgroup had a significantly (p<0.05) greater risk of psychiatric re-hospitalizations for schizophrenia than the other subgroups (unadjusted: HR=3.39, 95% CI 2.95, 3.90; adjusted: HR=2.28, 2.00, 2.60). This result replicated in sensitivity analyses for: Poland-born individuals, the years 1922 and 1935; and followed at least 10 years and to the year 2000. CONCLUSIONS: Pre-natal initiated exposure to the maximal adversity of the holocaust constitutes a consistent risk factor for a worse course of schizophrenia, a possible byproduct of neurodevelopment disruptions induced by maternal stress and/or famine and/or infections.

Suicide attempts in a national population of twins concordant for psychoses.

Psychotic disorders are associated with an increased risk of suicide attempts, the etiology of which remains unknown across diagnoses. Thus it is relevant to understand how genetic and environmental factors contribute to the liability of suicide attempts in psychosis. The current study aims to examine the role of genetic and environmental factors in suicide attempts across psychotic disorders in twins concordant for psychosis. The study population consisted of all twin pairs in the Israeli National Psychiatric Case Registry hospitalized with a last discharge diagnosis of a psychotic disorder. Twin pairs (N=116) were born between 1900 and 1993 and hospitalized from 1964 to 2001. Competing genetic models were examined to decompose the variance in suicide attempts into: the individual-specific environment (unique), shared-family environment, and genetic effects. Across schizophrenia, psychosis and non-affective psychosis comparison of genetic models showed a model combining shared-family and unique environmental effects were superior to competing genetic models. Modeling estimates for attempted suicide were: in non-affective psychosis 60% to the shared-family and 40% to the unique environment; in schizophrenia 60% to the shared-family and 40% to the unique environment; and in psychosis 66% to the shared-family and 34% to the unique environment. Across psychosis, schizophrenia and non-affective psychosis vulnerability toward suicide attempts consists predominantly of substantial individual and familial environmental elements.

Cancer in parents of persons with schizophrenia: is there a genetic protection?

A reduced risk for cancer has been noted among persons with schizophrenia as well as their first degree relatives. One explanation for these findings suggests that genes associated with schizophrenia confer reduced cancer susceptibility. Given the well documented genetic factor in schizophrenia it could thus be expected that cancer incidence rates should be lower in persons with schizophrenia with a known family history of schizophrenia compared to persons with sporadic schizophrenia, as well as their first degree relatives. This study investigated the risk for cancer among the biological parents of persons with schizophrenia accounting for the familial aggregation. Linkage was conducted between national population, psychiatric and cancer databases. Standardized incidence rates for all cancer sites were calculated by comparing the parents' rates with those of the general population. In addition, the association between familial aggregation of schizophrenia and risk for cancer was calculated among the parents. A reduced cancer risk was found among the parents compared to the general population (SIR 0.8, 95% CI 0.8-0.9). However, no evidence of decreased risk was associated with familial schizophrenia. Thus, no association between familial aggregation and cancer incidents was found with regard to most cancer sites. Moreover, a small, but not statistically significant increased risk of colon cancer was associated with familial aggregation scores among the parents (OR 1.2, 95% CI 1.0-1.5). These findings undermine the support to the genetic explanation for the reduced risk for cancer in schizophrenia among patients and their biological parents.

The mortality risk among persons with psychiatric hospitalizations.

BACKGROUND: Persons affected by severe mental disorders have a higher mortality risk than the general population. OBJECTIVES: To investigate the overall mortality and selected natural and external causes of death by age, gender and mental health-related variables among persons who were ever admitted to psychiatric inpatient services. METHODS: This cohort study compared the mortality risk among Israeli Jews aged 18 and over who were ever hospitalized in psychiatric facilities until 2006, as recorded in the Psychiatric Case Register (PCR), with never- hospitalized subjects. The national database on causes of death was linked to the PCR. ANALYSIS: Mortality rates were computed by age, gender and psychiatric diagnosis, while proportions of deaths were computed by time from discharge. Rates were also analyzed by time-periods of date of death to check for possible association with mental health policy decisions. Age-adjusted and age-specific mortality rates and rate ratios (RR) were computed for persons in the PCR compared with those never hospitalized. RESULTS: The age-adjusted mortality rate of hospitalized psychiatric persons was double that of the nonhospitalized, RR = 1.98 (95% CI 1.96-2.00). The rate was higher in both genders and for persons of all age groups, particularly for the young. The highest RRs were found for external causes of death, in particular suicide (RR = 16.34, 95% CI 15.49-17.24). Natural causes also showed higher risk, except for malignancies (RR = 1.13, 95% CI 1.10- 1.16). The risk for death was highest for persons admitted for substance abuse, while it was almost equal for those diagnosed with either schizophrenic or affective disorders. The rate ratios were not observed to change as a result of policy decisions, e.g., dehospitalization and the introduction of the atypical antipsychotics. A third of all deaths and 62% of suicides occurred before discharge or within a year from discharge. CONCLUSIONS: This study highlights the importance for advancing programs of both preventative and curative medical care among persons who had psychiatric inpatient care.

Patterns of psychiatric hospitalization among ethiopian and former soviet union immigrants and persons born in Israel.

OBJECTIVE: This study compared the prevalence and patterns of psychiatric hospitalization for persons who immigrated to Israel from Ethiopia and the Former Soviet Union (FSU) and the Israel-born population. METHODS: Data were extracted from the Israel Psychiatric Case Register for six population groups: Operation Moses 1980s immigrants, who emigrated from Ethiopia, January 1, 1980-August 31, 1985 (178 had at least one psychiatric hospitalization within five years of immigration); Operation Moses immigrants in the 1990s, the same group ten years later (194 were hospitalized ten to 14 years after immigration); Operation Solomon 1990s immigrants, who emigrated from Ethiopia in 1990-1991 (184 had at least one hospitalization within five years of immigration); FSU 1990s immigrants, who emigrated from the FSU in 1990-1991 (2,082 had at least one hospitalization within five years of immigration); Israel born 1980s (10,120 had at least one psychiatric hospitalization between January 1, 1980, and August 31, 1985); and Israel born 1990s (11,241 had at least one psychiatric hospitalization in 1990-1994). RESULTS: Operation Moses 1980s immigrants differed from the other groups; they had higher rates of hospitalization, less severe diagnoses, and shorter lengths of stay, compared with Israel born 1980s. Ten years later, this group's rates of hospitalization were lower and similar to those of non-Ethiopian populations, and the individuals in this group were more likely to have a diagnosis of schizophrenia or other psychosis, compared with the other groups. The hospitalization pattern for Operation Solomon 1990s immigrants fell between that of Operation Moses 1980s immigrants and Operation Moses immigrants in the 1990s. For immigrants from the FSU, the hospitalization rate was similar to that of Israel born 1990s and Operation Moses immigrants in the 1990s and much lower than that of Operation Solomon 1990s immigrants. CONCLUSIONS: Marked sociocultural differences between immigrants and the host society and the understanding of these differences by mental health professionals may influence rates and patterns of psychiatric hospitalization more than the immigration experience itself.

The risk for cancer among patients with schizoaffective disorders.

BACKGROUND: Several epidemiological studies explored the risk for cancer among both persons with schizophrenia and their first-degree relatives, and among patients with bipolar disorder. No studies have yet explored the risk among persons with schizoaffective disorders. METHOD: Linkage analysis was conducted based on the psychiatric and the cancer national databases. Standardized incidence ratios (SIR) for aggregated cancer sites were calculated by comparing the incidence rates among patients in the psychiatric case register with schizoaffective disorders with the incidence rates in the Jewish-Israeli general population. RESULTS: No significant alteration in cancer risk was found for both genders: males, SIR=1.11, 95% CI (0.48-1.73) and females, SIR=1.38, 95% CI (0.96-1.80). LIMITATIONS: Our sample was derived from patients with a history of psychiatric hospitalization. Putative factors such as diet, smoking and medications were not investigated. CONCLUSIONS: Our study showed no significant increase in the risk for cancer in schizoaffective disorders. Those results appear to be positioned between the schizophrenia findings that show a lower risk for cancer and the bipolar disorder findings that show an increased risk.

Enhanced cancer risk among patients with bipolar disorder.

BACKGROUND: In contrast to numerous epidemiological studies that explored the risk for cancer among persons with schizophrenic psychoses, analogous studies conducted on people with bipolar disorder are rarer, despite some commonalities in biological, treatment-related variables and unhealthy lifestyles. This study investigates the risk for cancer among psychiatric inpatients diagnosed with bipolar disorder. METHODS: Linkage analysis was conducted based on the psychiatric and the cancer national databases. Standardized incidence ratios (SIR) for both aggregated sites and for breast cancer were calculated by comparing the incidence rates among hospitalized patients with bipolar disorder with the incidence rates in the Jewish-Israeli general population. RESULTS: An enhanced cancer risk was found for bipolar disorder in both genders: men, SIR 1.59 (95% CI 1.01-2.17); women, SIR 1.75 (95% CI 1.31-2.18). The risk for breast cancer was higher, but not significantly, than in the general female population, SIR 1.70 (95% CI 0.99-2.41). LIMITATIONS: Our sample was derived from psychiatric inpatients, thus it is likely that the bipolar disorder cases had greater severity. Putative factors such as diet, smoking and medications were not investigated. CONCLUSIONS: Our study showed an enhanced risk for cancer among patients with bipolar disorder. Clinicians might note this risk for timely diagnosis and treatment.

The impact of human rights advocacy, mental health legislation and psychiatric reform on the epidemiology of involuntary psychiatric hospitalizations.

Several years ago, the Ministry of Health published a report on the epidemiology of involuntary psychiatric hospitalizations. Many developments (advances in human rights advocacy, mental health legislation and the nascent Psychiatric Reform) have occurred in the mental health field in Israel since 1990 when the earlier report was released. Those favorable developments in mental health care were thought to have the capacity to modify the admission rates. We explored several parameters to check the hospitalization patterns (eg, by demographic factors, diagnosis) and found no substantial modifications. The case for an analytic study was clearly established.