The Association Between Depression and Invasive and In-situ Cervical Tumors: A Large Population Based Cohort Study.

BACKGROUND: Depression has been shown to be associated with cervical tumors (CTs), an association mostly demonstrated in studies in which temporality could not have been ascertained. OBJECTIVES: To study the association between depression and CTs and the influence of co-morbidities of this association in a large cohort study. METHODS: A retrospective computer-based cohort study was conducted. The cohort included 357,450 female members of Maccabi Healthcare Services. The cohort was classified as depressed or non-depressed using the International Classification of Diseases 9/10 codes. For each subgroup, demographic characteristics, behavioral characteristics, co-morbidities, and CTs diagnosis were obtained. The burden of co-morbidities was defined as the sum of major co-morbidities. We used zero-inflated negative binomial regression analysis due to over-dispersion to estimate the relative risk (RR) for CTs with 95% confidence interval (95%CI). RESULTS: Depression was diagnosed in 15,789 women. Among this group, CTs were diagnosed in 1585 (10.0%). Among the 341,661 non-depressed, CTs were diagnosed in 4185 (1.2%). After adjustment to age and socioeconomic status, the association between depression and CTs was RR=9.2 (95%CI 8.7-9.9, P-value < 0.0001). The association between depression and CTs increased as the burden of clinical conditions increased (P-value < 0.0001). CONCLUSIONS: Women with depression are at a higher risk for CTs, especially among those who have several co-morbidities. Tighter gynecology surveillance is crucial among these women.

High variation between healthcare professionals in nutrition therapy plans of patients with feeding tubes admitted to a long-term rehabilitation center from an acute-care hospital.

BACKGROUND: Nutrition therapy plans (NTPs) in discharge summaries of tube-fed patients transferred from acute-care hospitals to rehabilitation centers are fundamental for continuity of care. This study examined the presence and quality of NTPs in discharge summaries of tube-fed patients. METHODS: This cross-sectional study was based on data retrieved from electronic medical records. The outcome measures were the presence of NTPs in discharge summaries, the presence of key elements of the NTPs, and the level of compatibility between multiple NTPs per discharge summary prepared by different health professionals. Descriptive statistics were used to assess the number of NTPs, the presence of key elements, and the degree of compatibility between NTPs for the same patient. RESULTS: A total of 100 discharge summaries of tube-fed patients admitted to a rehabilitation hospital during 2015-2017 were identified. The majority (91%) of discharge summaries included at least one NTP; 57 included more than one. Variance in the presence of key elements was observed in 165 NTPs prepared by physicians, nurses, and dietitians. Water amount and nutrition route were least reported by dietitians (6.3% and 9.4%, respectively), compared with physicians (77.6% and 81%) and nurses (77.3% and 62.7%). However, nutrition details were reported more frequently by dietitians (65.6%) than physicians (20.7%) and nurses (32%). Low compatibility was observed between dietitians and both nurses and physicians, in the range of 0%-26%. CONCLUSION: Large discrepancies were found between NTPs for the same patient prepared by dietitians, physicians, and/or nurses, and a portion of patients arrived without any NTP.

Epidemiology of treatment resistant depression among major depressive disorder patients in Israel.

INTRODUCTION: Major depressive disorder (MDD) is one of the most common mental disorders worldwide, estimated to affect 10-15% of the population per year. Treatment resistant depression (TRD) is estimated to affect a third of these patients who show difficulties in social and occupational function, decline of physical health, suicidal thoughts and increased health care utilization. We describe the prevalence of MDD, TRD and associated healthcare resource utilization in Maccabi Healthcare Services (MHS), a 2.5 million-member state-mandated health service in Israel. METHODS: All MHS members with an MDD diagnosis were identified within the years 2017-2018 and prevalence assessed by age, sex and TRD. To assess the incidence of MDD, members aged 18-65 years at the start of any MDD episode were identified between 1st January 2016 and 31st May 2018 with at least one systemic first-line antidepressant treatment within three months before or after the initial episode. Treatment patterns, time on first-line treatment, and healthcare resource utilization were compared by TRD. RESULTS: A total of 4960 eligible MDD patients were identified (median age = 51 years, 65% female), representing a period prevalence of 0.218%, and of those, a high proportion of patients received drug treatment (92%). Among incident MDD cases (n = 2553), 24.4% had TRD. Factors associated with TRD included increasing age and personality disorder. Median time on treatment was 3.7 months (longer for those without TRD than those with) and 81.9% of patients purchased more than one month's supply of therapy. In the year after index, patients with TRD had a significant increased number of visits to primary care physicians, psychiatrists, emergency room visits, general hospitalizations, and psychiatric hospitalizations. CONCLUSION: Our study shows that prevalence of MDD in Israel is low compared to other countries, however once diagnosed, patients' are likely to receive drug treatment. Among patients diagnosed with MDD, the proportion of TRD is similar to other countries, increases with age and is associated with increased healthcare utilization, therefore should be a focus of continued research for finding effective long term treatment options.

Comparison of Smoking Cessation Program Registration, Participation, Smoking Cessation Medication Utilization, and Abstinence Rates Between Smokers With and Without Schizophrenia, Schizo-affective Disorder, or Bipolar Disorder.

INTRODUCTION: People with serious mental illness (SMI) are three times more likely to smoke and be heavy smokers than smokers without SMI. Counseling combined with smoking cessation medication (SCM) is the recommended treatment. However, until 2017, SCM prescription for SMI smokers was discouraged (FDA black box warning). This study compared use of smoking cessation programs (SCP) and SCM between smokers with and without SMI. AIMS AND METHODS: Data regarding SCP and SCM use were extracted from the database of a large HMO that offers free Group and telephone SCP. SCP registration, participation, completion, and abstinence rates between July 2013 and December 2019 were compared between smokers with and without SMI, controlling for demographic and health variables. RESULTS: 48 000 smokers registered for a SCP during the study period. Smokers with SMI were 1.8 times more likely to register for a SCP than smokers without SMI. Smokers without SMI were, however, 1.2 times more likely to start the SCP, 1.5 times more likely to complete the SCP, and 1.6 times more likely to have quit by the end of the program. The strongest factors predicting abstinence were SCP completion and SCM use. Smokers with SMI were less likely to purchase SCM, although their purchase rate increased after the black box warning was lifted. CONCLUSIONS: Smoking cessation programs and SCM use should be encouraged in the SMI population. Providing support during the quit attempt and adapting SCP to the needs of smokers with SMI, combined with SCM prescription promotion, should improve abstinence. IMPLICATIONS: Smokers with serious mental illness (SMI) were more likely to seek professional help to quit smoking than non-SMI smokers, with over 30% achieving abstinence, discrediting healthcare professional beliefs that SMI smokers don't want to and cannot quit. Smoking cessation program (SCP) completion and smoking cessation medication (SCM) utilization were the strongest predictors of abstinence. SMI smokers were more likely to drop out of SCPs and less likely to use SCMs. Providing support during the quit attempt and adapting SCPs to the needs of smokers with SMI, combined with SCM prescription promotion, should improve abstinence.

Adherence to smoking cessation guidelines (5As) by psychiatrists and primary care physicians for persons with serious mental illness.

1) Compare the 5A (Ask-Advise-Assess-Assist-Arrange) practice rates between psychiatrists and primary care physicians (PCPs) regarding smoking cessation for PWSMI. 2) Compare the 5A practice rates reported by physicians with rates reported by PWSMI. 3) Identify which specialty is perceived as primarily responsible for smoking cessation promotion for PWSMI.Telephone surveys were carried out in a large health maintenance organization (HMO) among all psychiatrists, a random sample of PCPs, and HMO members with serious mental illness who had registered/participated in a smoking cessation program. Physicians were asked how frequently they carried out each 5A practice, along with questions regarding role responsibility and interaction between the two clinical specialties. PWSMI were asked to report about each 5A practice by both PCP and treating psychiatrist.Ask-Advise-Assess rates were higher than Assist-Arrange rates for both specialties. 83% of PCPs had satisfactory 5A practice scores compared to 46% of psychiatrists (X2=23.9, p < 0.001). With the exception of Ask rates, physician rates for each 5A component were higher than those reported by PWSMI. PCPs were more likely to see smoking cessation promotion as their responsibility and did not always confer with the psychiatrist regarding referral and SCM prescription.Interventions focusing on promoting Assist-Arrange practices and better integration between the specialties are required.

Comparison of Perceptions and Smoking Cessation Experiences Between Smokers With and Without Serious Mental Illness in a Large Health Maintenance Organization.

OBJECTIVE: Smoking prevalence is threefold higher among people with serious mental illness (PWSMI) than in the general population, yet smoking cessation rates for PWSMI are lower. Numerous reasons have been posited as to why tobacco use is higher and abstinence rates are lower among PWSMI. This study explores smoking cessation perceptions and experiences among PWSMI and people without serious mental illness (SMI). METHODS: Participants in this cross-sectional study were recruited from among members of a large health maintenance organization (HMO) in Israel who had registered for or commenced a smoking cessation program in 2015 through 2017. The sample comprised 208 PWSMI and a matched sample of people without SMI (N = 428). Telephone surveys were used to collect information about smoking status and smoking/cessation history, use of smoking cessation programs and aids (prescription medications, nicotine replacement therapy, electronic cigarettes), motivation and intention to quit, self-efficacy (to quit), smoking cessation outcome expectancies, physician support to quit, barriers and facilitators for those who had not quit, and reinforcements/challenges for those who had quit. RESULTS: Of those without SMI, 27% quit smoking compared to 20% of PWSMI (p = .051). Irrespective of mental health status, the most significant predictor of abstinence was the use of smoking cessation prescription medications. Family physicians were significantly less likely to inquire about motivation to quit, refer to smoking cessation programs, or prescribe smoking cessation medications for PWSMI than for people without SMI. Beyond these factors, no differences were noted between respondents with and without SMI regarding motivation to quit, intention to quit, and abstinence self-efficacy. PWSMI who had not quit were more likely to be concerned about how quitting might affect their functioning and how they would pass the time without cigarettes. CONCLUSIONS: PWSMI have similar levels of motivation and intention to quit smoking as those without SMI. However, they are disadvantaged by the reduced support received from their family physicians and lower cessation medication usage. Efforts to promote the implementation of smoking cessation treatment guidelines will help promote smoking abstinence among PWSMI.

The Impact of Smoking Cessation on Hospitalization and Psychiatric Medication Utilization among People with Serious Mental Illness.

Background: Despite the high prevalence of smoking amongst people with serious mental illness (SMI), referral rates to smoking cessation programs (SCPs) are low. Mental health workers reticence to refer to SCPs has been attributed, in part, to their belief that quitting will have a deleterious effect on their patients' mental health status. Objectives: This study's objective was to determine if participating in a smoking cessation program had an adverse effect on mental health status among people with SMI, measured here by a change in hospitalization occurrence or psychiatric medication utilization. People with SMI who had participated in at least one SCP session in a large health maintenance organization (n = 403) were compared to an age-gender-diagnosis matched sample of SMI smokers (1,209) who had never participated. Results: No change in psychiatric hospitalization occurrence pre- versus post-SCP participation was found among participants (Pre:7.2% vs. Post:5.2, p = 0.2) or nonparticipants (Pre:7.0% vs. Post:6.0%, p = 0.2). Mean defined daily dose (DDD) for anti-psychotic, mood stabilizer, anti-depressant and anxiolytic medications also did not change over time for participants and nonparticipants. However, participants who did not complete the SCP and didn't quit had a 0.35 higher mean DDD for anti-psychotic medications compared with participants who had completed the SCP or quit, and with nonparticipants (p = 0.006), and were the only group to exhibit an increase in mean antipsychotic DDD over time (Pre:1.42, Post:1.63). SCP participation was not associated with hospitalization occurrence or psychiatric medication utilization. Conclusions/Importance: Smoking cessation should be encouraged, with close monitoring during the quit process.

Mental pain, communication difficulties, and medically serious suicide attempts: a case-control study.

Medical severe suicide attempts (MSSA) are epidemiologically very similar to individuals who complete suicide. Thus the investigation of individuals who have made MSSAs may add to our understanding of the risk factors for completed suicide. The aim of this study was to assess the role of mental pain and communication difficulties in MSSA. A total of 336 subjects were divided into 4 groups: 78 meeting criteria for MSSA compared with116 subjects who made a medically non-serious suicide attempt (MNSSA), 47 psychiatric controls with no history of suicidal behavior, and 95 healthy controls. Mental pain variants (e.g., hopelessness), facets of communication difficulties (e.g., self-disclosure), as well as socio-demographic and clinical characteristics were assessed. The MSSA had significantly higher communication difficulties than the other 3 groups. Moreover, the interaction between mental pain and communication difficulties explained some of the variance in suicide lethality, above and beyond the contribution of each component alone. This report underlines the importance of mental pain for suicide attempts in general while difficulties in communication abilities play a critical role in differentiating MSSA from MNSSA. The co-existence of unbearable mental pain with difficulties in communication significantly enhances the risk for more lethal forms of suicidal behavior.

Ethical and Scientific Perspectives of Placebo-controlled Trials in Schizophrenia.

UNLABELLED: Clinical trials for development of new medications are essential in all fields of medicine. The requirement for a placebo arm in pharmaceutical trials presents ethical and clinical dilemmas that are especially complicated with regard to mentally ill persons whose free choice and ability to provide informed consent may be questionable. On the other hand, we do not believe that this predicament justifies unconditional rejection of placebo use in psychiatry, when the investigational drug may ultimately provide substantial benefit for some patients. At the same time it is the psychiatrist's responsibility to insure that investigators are adequately trained to conduct clinical trials and that stringent regulatory committees supervise the scientific, clinical and ethical aspects of the trials. KEYWORDS: Placebo-control; Schizophrenia; Medical ethics; Clinical trials.

Multi-modal weight control intervention for people with persistent mental disorders.

Obesity, a major problem worldwide, is more prevalent among people with schizophrenia. This study examined the effect of behavior intervention, nutritional information and physical exercise on the body mass index (BMI) and weight of people who were hospitalized with persistent DSM-IV schizophrenia and schizoaffective disorders. Fifty nine inpatients with a BMI greater than 25 participated, (28 intervention group; 31 control group). Significant reductions in BMI and weight were observed in the intervention group after 3 months and were maintained 1-year post study [F(1,52) = 6.1, p = .017) and F(1,52) = 3.7, P = .006, respectively]. If provided with adequate information and an appropriate framework, people with persistent schizophrenia can significantly reduce BMI and weight and maintain the loss.

[A long-acting second generation anti-psychotic--experience in Israel].

Schizophrenia is a chronic disease characterized by psychotic symptoms as well as negative symptoms such as affective flattening, social withdrawal and occupational dysfunction. Anti-psychotic medications reduce the risk of psychotic exacerbations and hospitalization. Poor compliance is common among patients with schizophrenia. Long-acting medications have such advantages as stabilizing drug levels and improving compliance. Second generation anti-psychotic medications were found to be more effective and tolerable compared to first generation drugs. These medications cause less extra-pyramidal symptoms, and compliance with them was shown to be better. Until recently there were only first generation long-acting anti-psychotics in use. Recently a new second generation long-acting anti-psychotic drug was introduced in Israel. We present our experience with a first schizophrenic patient treated with long-acting Risperidone (Risperdal Consta). The patient was treated in the past with several first generation anti-psychotics and suffered severe extra-pyramidal symptoms. His compliance with treatment was poor. Under treatment with oral Risperidone a considerable improvement was recorded, however compliance remained poor. Under treatment with long-acting Risperidone, Intramuscularly 25 Mg every two week, both positive and negative symptoms improved substantially, as well as compliance with treatment. The results of this case study encourage us to believe that many more patients will benefit from the advantages of both a second-generation anti-psychotic and a long-acting preparation.