Sensitivity of ICD-10 diagnosis of psychotic disorders in the Israeli National Hospitalization Registry compared with RDC diagnoses based on SADS-L

Assessing the validity of a self-reported clinical diagnosis of schizophrenia

Background

Diagnoses in psychiatric research can be derived from various sources. This study assesses the validity of a self-reported clinical diagnosis of schizophrenia.

Methods

The study included 3,029 clinically ascertained participants with schizophrenia or psychotic disorders diagnosed by self-report and/or research interview and 1,453 UK Biobank participants with self-report and/or medical record diagnosis of schizophrenia or schizoaffective disorder depressed-type (SA-D). We assessed positive predictive values (PPV) of self-reported clinical diagnoses against research interview and medical record diagnoses. We compared polygenic risk scores (PRS) and phenotypes across diagnostic groups, and compared the variance explained by schizophrenia PRS to samples in the Psychiatric Genomics Consortium (PGC).

Results

In the clinically ascertained sample, the PPV of self-reported schizophrenia to a research diagnosis of schizophrenia was 0.70, which increased to 0.81 when benchmarked against schizophrenia or SA-D. In UK Biobank, the PPV of self-reported schizophrenia to a medical record diagnosis was 0.74. Compared to self-report participants, those with a research diagnosis were younger and more likely to have a high school qualification (clinically ascertained sample) and those with a medical record diagnosis were less likely to be employed or have a high school qualification (UK Biobank). Schizophrenia PRS did not differ between participants that had a diagnosis from self-report, research diagnosis or medical record diagnosis. Polygenic liability r2, for all diagnosis definitions, fell within the distribution of PGC schizophrenia cohorts.

Conclusions

Self-report measures of schizophrenia are justified in research to maximise sample size and representativeness, although within sample validation of diagnoses is recommended.

Gender differences in quality of life and the course of schizophrenia: national study

BACKGROUND

Evidence from various sources suggests that females with schizophrenia tend to report lower quality of life than males with schizophrenia despite having a less severe course of the disorder. However, studies have not examined this directly.

AIMS

To examine gender differences in the association between quality of life and the risk of subsequent psychiatric hospital admissions in a national sample with schizophrenia.

METHOD

The sample consisted of 989 (60.90%) males and 635 (39.10%) females with an ICD-10 diagnosis of schizophrenia. Quality of life was assessed and scored using the Manchester Short Assessment of Quality of Life. The course of schizophrenia was assessed from the number of psychiatric hospital admissions. Participants completed the quality of life assessment and were then followed up for 18-months for subsequent psychiatric admissions. Hazard ratios (HR) from Cox proportional hazards regression models were estimated unadjusted and adjusted for covariates (age at schizophrenia onset and birth year). Analyses were computed for males and females separately, as well as for the entire cohort.

RESULTS

A subsample of 93 males and 55 females was admitted to a psychiatric hospital during follow-up. Higher quality of life scores were significantly (P < 0.05) associated with a reduced risk of subsequent admissions among males (unadjusted: HR = 0.96, 95% CI 0.93-0.99; adjusted HR = 0.96, 95% CI 0.93-0.99) but not among females (unadjusted: HR = 0.97, 95% CI 0.93-1.02; adjusted HR = 0.97, 95% CI 0.93-1.02).

CONCLUSIONS

Quality of life in schizophrenia is a gender-specific construct and should be considered as such in clinical practice and future research.

COVID-19 and severe mental illness in Israel: testing, infection, hospitalization, mortality and vaccination rates in a countrywide study

Previous studies on psychiatric patients infected with COVID-19 have reported a more severe course of disease and higher rates of mortality compared with the general population. This cohort study linked Israeli national databases including all individuals ever hospitalized for a psychiatric disorder (cases), and COVID-19 testing, infection, hospitalization, mortality, and vaccinations, between March 1^st 2020 and March 31^st 2021. Cases were 125,273 individuals aged 18 and above ever hospitalized in a psychiatric facility (ICD-10 F10-F69 or F90-F99), compared to the total population, n = 6,143,802. Compared with the total population, cases were less likely to be tested for COVID-19, 51.2% (95% CI: 50.8-51.7) vs 62.3% (95% CI 62.2-62.4) and had lower rates of confirmed COVID infection, 5.9% (95% CI: 5.8-6.1) vs 8.9% (95% CI: 8.9-8.9). Among those infected, risks for COVID-19 hospitalization, COVID-19 attributed mortality and all-cause mortality were higher for cases than the total population, adjusted odds ratios were 2.10; (95% CI: 1.96-2.25), 1.76; (95% CI: 1.54-2.01) and 2.02; (95% CI: 1.80-2.28), respectively. These risks were even higher for cases with non-affective psychotic disorders and bipolar disorder. Age adjusted rates of vaccination were lower in cases, 60.4% (95% CI: 59.9-60.8) vs 74.9% (95% CI: 74.8-75.0) in the total population, and particularly low for cases with non-affective psychotic disorders, 56.9% (95% CI: 56.3-57.6). This study highlights the need to increase testing for COVID-19 in individuals ever hospitalized for a psychiatric disorder, closely monitor those found positive, and to reach out to encourage vaccination.

Age of onset group characteristics in forensic patients with schizophrenia

This study aims to empirically identify age of onset groups and their clinical and background characteristics in forensic patients with schizophrenia. Hospital charts were reviewed of all 138 forensic patients with schizophrenia admitted to Geha Psychiatric Hospital that serves a catchment area of approximately 500,000 people, from 2000 to 2009 inclusive. Admixture analysis empirically identified early- (M = 19.99, SD = 3.31) and late-onset groups (M = 36.13, SD = 9.25). Early-onset was associated with more suicide attempts, violence before the age of 15, and early conduct problems, whereas late-onset was associated with a greater likelihood of violence after the age of 18 and marriage (P < 0.01). The current findings provide clinicians with a unique direction for risk assessment and indicate differences in violence between early- and late-onset schizophrenia, particularly co-occurrence of harmful behavioral phenotypes.

Understanding the association between advanced paternal age and schizophrenia and bipolar disorder

BACKGROUND

Previous studies reported an association between advanced paternal age at birth and increased risk for schizophrenia and bipolar disorder. While some hypothesize that this association is caused by de-novo mutations in paternal spermatozoa, others cite factors associated with psycho-social characteristics of fathers who have children at a late age. This study aims to test these hypotheses.

METHODS

A historical-prospective, population-based cohort study, performed by linking the Israeli Draft Board Registry and the Israeli National Psychiatric Hospitalization Registry (N = 916 439; 4488 with schizophrenia, 883 with bipolar disorder). Odds ratios (OR) and two-sided 95% confidence intervals (CI) were calculated by logistic regression models, using paternal age as predictor and risk for later hospitalizations for schizophrenia or bipolar disorder as outcome measure. Models were first fitted unadjusted, then adjusted for paternal age at birth of the first child.

RESULTS

In the unadjusted model, offspring of fathers aged 45 and above at birth had increased risk of schizophrenia (OR = 1.71, 95% CI 1.49-1.99) and bipolar disorder (OR = 1.63, 95% CI 1.16-2.24). However, taking into account paternal age at birth of first child, advanced paternal age was no longer associated with increased risk of schizophrenia (OR = 0.60, 95% CI 0.48-0.79) or bipolar disorder (OR = 1.03, 95% CI 0.56-1.90).

CONCLUSIONS

Controlling for paternal age at birth of the first offspring, advanced paternal age does not predict increased risk for schizophrenia or bipolar disorder. These data indicate that the association between advanced paternal age and having an offspring with schizophrenia and bipolar disorder is likely due to psychos-social factors, or common genetic variation associated with delayed initial fatherhood.

The role of substance use and adult sexual assault severity in the course of schizophrenia: An epidemiological catchment study of sexual assault victims

BACKGROUND

Childhood trauma increases the risk of schizophrenia, yet the role of adult sexual assault in the course of schizophrenia is unknown. This study aims to examine the associations between substance use and sexual assault severity characteristics with the course of schizophrenia among adult sexual assault victims using an epidemiologic study design.

METHODS

Sexual assault data on all individuals received from 2000 to 2010 (N = 2147) at the Center for Care of Sexual Assault Victims at Wolfson Medical Center, the largest medical center for sexual assault victims in the country, were merged with the Israel National Psychiatric Case Registry, that consisted of lifetime psychiatric hospitalizations of schizophrenia (birth to 6 years post-assault). The associations between substance use and adult sexual assault severity characteristics with hospitalizations were quantified using recurrent events Cox modeling.

RESULTS

Schizophrenia with sexual assault survivors occurred in 117 persons. Cox modeling showed that recurrent psychiatric hospitalizations were associated with younger age, sexual assault at older age, previous diagnosis of psychosis, and drug use shortly before or during the assault. Other assault characteristics (number of assailants, means of subdual, penetration type, perpetrator violence, physical injury of the victim) and immediacy of seeking help had a null association with the course of psychiatric hospitalization. These results replicated in two sensitivity analyses.

CONCLUSIONS

Substance use among victims of sexual assault was associated with an exacerbated course of schizophrenia, pointing to a possibly modifiable risk factor that should be targeted in prevention, assessment, treatment formulation and implementation.

The association between comorbid psychiatric diagnoses and hospitalization-related factors among individuals with schizophrenia

BACKGROUND

Though schizophrenia is associated with substantial psychiatric comorbidity, data pertaining to multiple comorbid psychiatric disorders among individuals with schizophrenia is missing. Furthermore, despite abundant research indicating that the course of schizophrenia is characterized by relapses, often leading to psychiatric emergency room visits and consequent hospitalizations, data regarding the association between different comorbid psychiatric diagnoses among schizophrenia patients, and these hospitalization-related factors is lacking. The aim of this study was to describe the number and types of comorbid psychiatric diagnoses of inpatients diagnosed with schizophrenia, and to explore whether these are associated with hospitalization-related factors.

METHODS

Registry data from the years 1997-2017 was analyzed from a large psychiatric hospital database. We compared the annual mean number of psychiatric emergency room visits and hospitalizations, as well as mean length of hospitalizations, among individuals with schizophrenia and no additional psychiatric diagnosis, to those with one or more comorbid psychiatric diagnoses. Furthermore, we compared these hospitalization-related based on the different types of the comorbid diagnoses.

RESULTS

Among inpatient individuals with schizophrenia, the greater the number of comorbid psychiatric diagnoses, the higher the increase in number of emergency room visits and hospitalizations, as well as in the mean length of hospitalizations. Furthermore, all comorbid psychiatric disorders explored were found to be associated with an increase in the mentioned hospital-related factors. Such diagnoses include substance use disorders, bipolar, personality and depressive disorders, which were the most common disorders associated with schizophrenia.

CONCLUSIONS

Comorbid psychiatric disorders among inpatients with schizophrenia are associated with greater utilization of hospital-related services. These comorbid disorders should be addressed in the assessment and treatment of patients suffering from schizophrenia.

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.

Suicide Risk Among Holocaust Survivors Following Psychiatric Hospitalizations: A Historic Cohort Study

The association between Holocaust experience, suicide, and psychiatric hospitalization has not been unequivocally established. The aim of this study was to determine the risk of suicide among 3 Jewish groups with past or current psychiatric hospitalizations: Holocaust survivors (HS), survivors of pre-Holocaust persecution (early HS), and a comparison group of similar European background who did not experience Holocaust persecution. In a retrospective cohort study based on the Israel National Psychiatric Case Register (NPCR) and the database of causes of death, all suicides in the years 1981-2009 were found for HS (n = 16,406), early HS (n = 1,212) and a comparison group (n = 4,286). Age adjusted suicide rates were calculated for the 3 groups and a logistic regression model was built to assess the suicide risk, controlling for demographic and clinical variables. The number of completed suicides in the study period was: HS-233 (1.4%), early HS-34 (2.8%), and the comparison group-64 (1.5%). Age adjusted rates were 106.7 (95% CI 93.0-120.5) per 100,000 person-years for HS, 231.0 (95% CI 157.0-327.9) for early HS and 150.7 (95% CI 113.2-196.6) for comparisons. The regression models showed significantly higher risk for the early HS versus comparisons (multivariate model adjusted OR = 1.68, 95% CI 1.09-2.60), but not for the HS versus comparisons. These results may indicate higher resilience among the survivors of maximal adversity compared to others who experienced lesser persecution.

Quality of life disparities between persons with schizophrenia and their professional caregivers: Network analysis in a National Cohort

BACKGROUND

Disparities between mental health patients and their professional caregivers in quality of life appraisals have been identified, however, the structure that such disparities assume is unknown.

AIMS

To examine the network structure of quality of life appraisals and disparities using network analysis.

METHODS

Participants were 1639 persons with schizophrenia using psychiatric rehabilitation services and their primary professional caregivers (N=582). Quality of life for persons with schizophrenia was measured based on an abbreviated version of the Manchester Short Assessment of Quality of Life. Appraisals were made self-reported and by professional caregivers. Disparities scores between the aforementioned were computed. Network analysis was performed on all quality of life appraisals. Sensitivity analyses were conducted.

RESULTS

The self-appraised network significantly (p<0.05) differed by network strength compared to the caregiver-appraised network. Self-appraised network communities (clusters of quality of life items) were health conditions and socioeconomic system, whereas caregiver-appraised network communities were social activities, and combined socioeconomic and health conditions. Strength centrality was highest for self-appraised social status and for caregiver-appraised residential status (Z=1.63, Z=1.12, respectively). The disparity scores network clustered into two communities: social relations and combined financial and health conditions. The most central appraisal disparities were in social status.

CONCLUSIONS

Quality of life differed when self-appraised by persons with schizophrenia compared to when appraised by their professional caregivers, yet the salient role of social relations was shared. The latter may be an initial focus of discussion by persons with schizophrenia and their caregivers.

Age of onset and quality of life among males and females with schizophrenia: A national study

Background:

Age of onset is considered central to understanding the course of schizophrenia, yet little is known regarding its association with quality of life in general, and specifically among males and females.

Aims:

To examine the association between the age of schizophrenia onset and quality of life, in general, and among males and females, using data from a national sample and competing statistical models.

Methods:

Participants with a diagnosis of schizophrenia (N = 1624) completed the Manchester Short Assessment of Quality of Life (MSA-QoL) and were rated on a parallel measure by their professional caregivers (N = 578). Multiple regression analysis models were computed for self-appraised quality of life, and mixed models with random intercepts were used for caregivers. Six competing models were tested for parsimony for each rating source. Three models without adjustment and three models adjusted for confounding variables. Sensitivity analyses were conducted for males and females separately.

Results:

Age of onset was statistically significantly (P <.05) negatively associated with self-appraised and caregiver-appraised quality of life on aggregate and among females. Among males, a significant (P <.01) quadratic effect of onset age on self-appraised quality of life demonstrated a negative association up to onset age of 36.67 years, after which the association was positive.

Conclusions

An earlier age of onset is associated with a better quality of life in schizophrenia which is tentatively explained by social decline. Specific trends in psychiatric symptom severity may account for this association among females while social advantages may account for the particular results found among males.

Risk of hospitalization for psychiatric disorders among siblings and parents of probands with psychotic or affective disorders: A population-based study

Relatives of people diagnosed with psychotic and affective disorders have a higher risk of developing psychiatric disorders compared to the general population. This study examined the risk of hospitalization for psychiatric disorders among siblings and parents of patients affected with major psychiatric disorders. In this large population-based case-control study, 17,895 siblings and parents of 7671 hospitalized subjects with a diagnosis of narrowly defined schizophrenia (SZ), broadly defined SZ, schizoaffective disorder (SAD), bipolar disorder (BD) or unipolar depression (UD) were identified from the Israeli Psychiatric Hospitalization Registry and compared to 71,580 age and gender-matched controls from the Israeli Population Registry. Results indicated that siblings of people diagnosed with broadly defined SZ had a significantly higher risk of hospitalization for broadly (OR=11.06, 95% CI=7.93-15.41) and narrowly defined SZ (OR=10.59, 95% CI=6.8-16.33), SAD (OR=9.69, 95% CI=4.76-19.73), BD (OR=7.46, 95% CI=21.8-25.52), UD (OR=2.84, 95% CI=1.01-8.00), and other psychiatric disorders (OR=1.85, 95% CI=1.16-2.93), compared to controls. Siblings of patients with BD had a significantly higher risk of hospitalization for broadly defined SZ (OR=2.92, 95% CI=1.11-7.71) and for other psychiatric disorders (OR=6.67, 95% CI=2.17-20.50), compared to controls. Parents of probands with SZ were at significantly increased risk for all disorders examined, except for UD and ¨other psychiatric disorders¨, which was not significant in parents of probands with BD. This large, population-based study provides evidence for common genetic risk across different psychiatric disorders.

Posttraumatic growth among people with serious mental illness, psychosis and posttraumatic stress symptoms

Recent research has shown high rates of exposure to trauma among people with serious mental illness (SMI). In addition, studies suggest that psychosis and mental illness-related experiences can be extremely traumatic. While some individuals develop posttraumatic symptomatology related to these experiences, some appear to experience posttraumatic growth (PTG). Little is known, however, about PTG as a possible outcome among people who experienced psychosis as well as posttraumatic stress symptoms (PTSS). For further understanding of the relationship between PTSS and PTG among people with SMI who experienced psychosis, 121 participants were recruited from community mental health rehabilitation centers and administered trauma and psychiatric questionnaires. Results revealed that while high levels of traumatic exposure were common, most participants experienced some level of PTG which was contingent upon meaning making and coping self-efficacy. In addition, posttraumatic avoidance symptoms were found to be a major obstacle to PTG. The range of effect sizes for significant results ranged from η²=0.037 to η²=0.144. These findings provide preliminary evidence for the potential role of meaning making and coping self-efficacy as mediators of PTG in clinical, highly traumatized populations of people with SMI and psychosis. Implications of these findings for future research and clinical practice are discussed.

Double disparities in the health care for people with schizophrenia of an ethnic-national minority

BACKGROUND

Studies have shown health care disparities among persons of minority status, including in countries with universal health care. Yet, a dearth of studies have addressed disparities resulting from the combined effect of two minority status groups: severe mental illness and ethnic-national sector filiation. This study aimed to compare the differential health care of Jewish- and Arab-Israelis with schizophrenia in a country with a universal health insurance.

METHOD

This study builds on a large case-control epidemiological sample (N = 50,499) of Jewish- (92.9%) and Arab-Israelis (7.1%) service users with (n = 16,833) and without schizophrenia (n = 33,666). Health services records were collected in the years 2000-2009. Diabetes and cardiovascular disease (CVD) served as sentinel diseases. We compared annual number of LDL tests and visits to specialists in the entire sample, Hemoglobin-A1C test among people diagnosed with diabetes, and cardiac surgical interventions for those diagnosed with CVD.

RESULTS

Service users with schizophrenia were less likely to meet identical indexes of care as their study counterparts: 95% of cholesterol tests (p < .001), and 92% visits to specialists (p < .001). These differences were greater among Arab- compared to Jewish-Israelis. Annual frequency of Hemoglobin-A1C test among people diagnosed with diabetes was lower (94%) in people with schizophrenia (p < 0.01), but no ethnic-national differences were identified. Among service users with CVD less surgical interventions were done in people with schizophrenia (70%) compared to their counterparts, with no ethnic-national disparities.

CONCLUSIONS

In Israel, service users with schizophrenia fail to receive equitable levels of medical and cardiac surgical care for CVD and regular laboratory tests for diabetes. Although disparities in some health indicators were enhanced among Arab-Israelis, schizophrenia was a greater source of disparities than ethnic-national filiation.

A population-based study of premorbid scholastic achievement among patients with psychiatric disorders

Population-based studies of premorbid cognitive functioning in schizophrenia have found verbal deficits and low IQ scores. It remains unclear, however, whether premorbid deficits are specific to schizophrenia, compared with other psychiatric disorders. Moreover, studies using school-based measures are few and their results inconsistent. This study assesses the eighth-grade (ages 13-14; n=11, 418) scholastic performance of adults with psychiatric disorders (n=194, 1.7, particularly with schizophrenia (n=86, 0.8%), comparing the results with those of their normative peers. The researchers examined report cards of eighth-graders at state secular schools in Jerusalem over a ten-year period (1978-1988), applying ANOVA and logistic regression models to evaluate associations between school performance and subsequent psychiatric hospitalization. The findings indicated that participants hospitalized with varied psychiatric disorders had lower grades in mathematics, gym, handcraft and academic core subjects, with significantly lower overall scores. Amended logistic regression models indicate that reduced performance (in mathematics, gym, handcraft and overall scores) was correlated with an increasing likelihood of hospitalization for the psychiatric disorders group and the subgroup with schizophrenia-related ailments. These results imply that eighth-grade school performance in core subjects is poorer among persons later hospitalized with psychiatric disorders than that of their classmates.

Health Care and Mortality among Persons with Severe Mental Illness

OBJECTIVE

Reports show disparities in the health care of persons with severe mental illness (SMI), including in countries with universal health insurance. However, the moderating effect on disparities of specific mental health legislation is yet to be studied. The study aimed to investigate equality of health care for people with SMI in a country with a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities.

METHOD

A case-control epidemiological study compared health services (laboratory tests, visits to specialists, and medications) provided to users with and without a history of schizophrenia and bipolar disorder ( N = 52,131) and with regard to a subgroup of users with diabetes ( n = 16,280). In addition, we examined the mortality rates of the study population.

RESULTS

While service users with schizophrenia were somewhat less likely to meet the same indexes of care as controls, those with bipolar disorder did not differ from their counterparts. Yet, mortality risk among service users with schizophrenia and bipolar disorder was 2.4 and 1.7 times higher, respectively. Rates of services to persons with SMI and comorbid diabetes did not differ from their counterparts.

CONCLUSIONS

In Israel, a country with a national health insurance and a rehabilitation law for persons with mental disabilities, service users with bipolar disorder receive equitable levels of general health care. For users with schizophrenia, the disparities exist in some of the health care measures but to a smaller extent than in other countries with universal health insurance. In contrast, mortality rates are elevated in persons with SMI.

Health care disparities among persons with comorbid schizophrenia and cardiovascular disease: a case-control epidemiological study

AIMS

Studies showed health care disparities among persons with comorbid schizophrenia and cardiovascular disease (CVD), including in countries with universal health care. However, the potential positive effect of specific mental health legislation has not been reported. This study aimed to investigate the health care of persons with comorbid schizophrenia and CVD in a country with both a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities.

METHOD

This study builds on a large case-control epidemiological sample (N = 52 189) of service users. Within the sample we identified a sub-group of persons with CVD diagnoses (n = 8208) and compared service users with and without schizophrenia on drug utilisation, laboratory tests, visits to specialists and surgical interventions.

RESULTS

Service users with schizophrenia were less likely to meet similar indexes of care as their counterparts: 91% cholesterol tests (p < 0.001), 60% stress tests (p < 0.001), 93% visits to specialists (p = 0.001), 93% drug utilisation (p < 0.001) and 55% CVD surgical interventions (odds ratio 0.55, 95% confidence intervals 0.49-0.61).

CONCLUSIONS

In Israel, a country with a national health insurance and a rehabilitation law specific for persons with mental disabilities, service users with schizophrenia still fail to receive equitable levels of health care for CVD. However, the disparities appear to be smaller than in other countries with universal health insurance.

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.

Demographic, Behavioral, and Psychiatric Risk Factors for Suicide

Abstract. Background: There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias. Aims: To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide. Method: We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years. Results: Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ± 2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide. Conclusion: In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Exposure to genocide and the risk of schizophrenia: a population-based study

BACKGROUND

No evidence exists on the association between genocide and the incidence of schizophrenia. This study aims to identify critical periods of exposure to genocide on the risk of schizophrenia.

METHOD

This population-based study comprised of all subjects born in European nations where the Holocaust occurred from 1928 to 1945, who immigrated to Israel by 1965 and were indexed in the Population Register (N = 113 932). Subjects were followed for schizophrenia disorder in the National Psychiatric Case Registry from 1950 to 2014. The population was disaggregated to compare groups that immigrated before (indirect exposure: n = 8886, 7.8%) or after (direct exposure: n = 105 046, 92.2%) the Nazi or fascist era of persecutions began. The latter group was further disaggregated to examine likely initial prenatal or postnatal genocide exposures. Cox regression modelling was computed to compare the risk of schizophrenia between the groups, adjusting for confounders.

RESULTS

The likely direct group was at a statistically (p < 0.05) greater risk of schizophrenia (hazard ratio = 1.27, 95% confidence interval 1.06-1.51) than the indirect group. Also, the likely combined in utero and postnatal, and late postnatal (over age 2 years) exposure subgroups were statistically at greater risk of schizophrenia than the indirect group (p < 0.05). The likely in utero only and early postnatal (up to age 2 years) exposure subgroups compared with the indirect exposure group did not significantly differ. These results were replicated across three sensitivity analyses.

CONCLUSIONS

This study showed that genocide exposure elevated the risk of schizophrenia, and identified in utero and postnatal (combined) and late postnatal (age over 2 years) exposures as critical periods of risk.

A Nation-Wide Study on the Percentage of Schizophrenia and Bipolar Disorder Patients Who Earn Minimum Wage or Above

OBJECTIVE

Although it is undisputable that patients with severe mental illness have impaired ability to work, the extent of this is unclear. This is a nation-wide, cross-sectional survey of patients who have been hospitalized with severe mental illness earning minimum wage or above.

METHOD

Data from the Israeli Psychiatric Hospitalization Case Registry were linked with nation-wide data from the National Insurance Institute (the equivalent of US Social Security) on personal income. Hospitalization data were obtained on all consecutive admissions to any psychiatric hospital in the country between 1990-2008 with a diagnosis of schizophrenia, other nonaffective psychotic disorders, or bipolar disorder (N = 35 673). Earning minimum wage or more was defined as earning at least 1000 USD/month, which was equivalent to minimum wage in Israel in December 2010.

RESULTS

The percentages of patients with only 1 admission who were earning minimum wage or above in December 2010 were as follows: 10.6% of patients with a diagnosis of schizophrenia; 21.6% of patients with a diagnosis of nonaffective psychotic disorders; and 24.2% of patients with bipolar disorder. The percentages of patients with multiple admissions who were earning minimum wage or above were as follows: 5.8% of patients with schizophrenia; 11.2% of patients with nonaffective psychotic disorders; and 19.9% of patients with bipolar disorder.

CONCLUSIONS

Despite potential confounders, the results indicate that patients with schizophrenia, nonaffective psychotic disorders, or bipolar disorder have a poor employment outcome, even if they have only been admitted once. These results emphasize the importance of improving interventions to re-integrate these individuals into the work force.

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.

Posttraumatic Growth in Psychosis

OBJECTIVE

Recent research has shown high rates of exposure to trauma among people with serious mental illness (SMI). In addition, studies suggest that psychosis and mental illness-related experiences can be extremely traumatic. While some individuals develop full blown PTSD related to these experiences, it has been noted that some may also experience posttraumatic growth (PTG). However, few studies have examined PTG as a possible outcome in people who have experienced psychosis.

METHOD

To further understand the relationships between psychosis and PTG, 121 participants were recruited from community mental health rehabilitation centers and administered trauma and psychiatric questionnaires.

RESULTS

High levels of traumatic exposure were found in the sample. Regarding our main focus of study, we observed that people who endured psychosis can experience PTG, and that PTG is mediated by meaning making and coping self-efficacy (CSE) appraisal. Psychotic symptoms were found to be a major obstacle to meaning making, CSE, and PTG, whereas negative symptoms were found to be significantly related to PTG when mediated by meaning making and CSE.

CONCLUSION

The current research provides preliminary evidence for potential role of meaning making and CSE as mediators of PTG in the clinical, highly traumatized population of people with SMI who have experienced psychosis. This may have both research as well as clinical practice relevance for the field of psychiatric rehabilitation.

A population-based longitudinal study of suicide risk in male schizophrenia patients: Proximity to hospital discharge and the moderating effect of premorbid IQ

Suicide is a major cause of death in schizophrenia. Identifying factors which increase the risk of suicide among schizophrenia patients might help focus prevention efforts. This study examined risk of suicide in male schizophrenia patients using population-based data, examining the timing of suicide in relation to the last hospital discharge, and the effect of premorbid IQ on risk of suicide. Data on 930,000 male adolescents from the Israeli military draft board were linked with data from the Israeli Psychiatric Hospitalization Case Registry and vital statistics from the Israeli Ministry of Health. The relationship between premorbid IQ and risk for suicide was examined among 2881 males hospitalized with schizophrenia and compared to a control group of 566,726 males from the same cohort, who were not hospitalized for a psychiatric disorder, using survival analysis methods. Over a mean follow-up period of 9.9 years (SD=5.8, range: 0-22 years), 77/3806 males with schizophrenia died by suicide (a suicide rate of 204.4 per 100,000 person-years). Approximately 48% of the suicides occurred within a year of discharge from the last hospital admission for schizophrenia. Risk of suicide was higher in male schizophrenia patients with high premorbid IQ (HR=4.45, 95% CI=1.37-14.43) compared to those with normal premorbid IQ. These data indicate that male schizophrenia patients with high premorbid IQ are at particularly high risk of suicide, and the time of peak risk is during the first year after the last hospitalization discharge.

The association between negative symptoms, psychotic experiences and later schizophrenia: a population-based longitudinal study

BACKGROUND

Psychotic experiences are common in the general population, and predict later psychotic illness. Much less is known about negative symptoms in the general population.

METHOD

This study utilized a sample of 4,914 Israel-born individuals aged 25-34 years who were screened for psychopathology in the 1980's. Though not designed to specifically assess negative symptoms, data were available on 9 self-report items representing avolition and social withdrawal, and on 5 interviewer-rated items assessing speech deficits, flat affect and poor hygiene. Psychotic experiences were assessed using the False Beliefs and Perceptions subscale of the Psychiatric Epidemiology Research Interview. Psychiatric hospitalization was ascertained 24 years later using a nation-wide psychiatric hospitalization registry.

RESULTS

After removing subjects with diagnosable psychotic disorders at baseline, 20.2% had at least one negative symptom. Negative symptoms were associated with increased risk of later schizophrenia only in the presence of strong (frequent) psychotic experiences (OR = 13.0, 9% CI: 2.1-79.4).

CONCLUSIONS

Negative symptoms are common in the general population, though the majority of people with negative symptoms do not manifest a clinically diagnosed psychiatric disorder. Negative symptoms and psychotic experiences critically depend on each other's co-occurrence in increasing risk for later schizophrenia.

Schizophrenia and violent crime: a population-based study

BACKGROUND

Previous studies have found that patients with schizophrenia are more likely to be violent than the general population. The aim of this study was to investigate the association between schizophrenia and violent crime in the Israeli population.

METHOD

Using the Israeli Psychiatric Hospitalization Case Registry we identified 3187 patients with a discharge diagnosis of schizophrenia. For each proband we identified parents and siblings, and gender- and age-matched controls for patients, parents and siblings. Information on violent crimes was obtained from police records.

RESULTS

Patients with schizophrenia were at increased risk for violent crimes compared with controls [odds ratio (OR) 4.3, 95% confidence interval (CI) 3.8-4.9], especially women (OR 9.9, 95% CI 6.2-15.7). Risk for violent crimes was higher among patients with co-morbid substance misuse than in patients without such co-morbidity (OR 5.1, 95% CI 4.2-6.3).

CONCLUSIONS

The results of this study suggest that increased risk of violence is part of the clinical picture of schizophrenia and needs to be recognized as a legitimate, essential, aspect of clinical management.

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.

Longitudinal association between epilepsy and schizophrenia: a population-based study

A large number of studies have reported an association between epilepsy and major psychiatric conditions. This study investigated the association between epilepsy and later schizophrenia, utilizing a historical-prospective, population-based design. Of the 861,062 17-year-old male adolescents consecutively screened by the Israeli Draft Board and found free of major mental illness, 0.06% suffered from severe, treatment-refractory epilepsy, 0.25% had treated, controlled epilepsy, and 0.16% had a history of seizures which had abated 5 or more years prior to screening. Hospitalization for schizophrenia was ascertained through the Israeli National Psychiatric Hospitalization Case Registry, with an average follow-up of 9.6±1.0years (range: 1.0-10.0years). Risk of hospitalization was calculated using Cox regression analyses, compared to socioeconomic-adjusted risk of hospitalization in the general population of male adolescents. Among adolescents whose epilepsy was nonresponsive to medication, the adjusted risk of hospitalization was significantly increased for schizophrenia (HR=3.89, 95% CI=1.75-89.67). Male adolescents with successfully treated epilepsy were not at increased risk for schizophrenia. Male adolescents with severe, treatment-refractory epilepsy are at increased risk of later schizophrenia. Future studies attempting to understand the biology of this association might focus on this subset of patients, and these patients should be monitored for the appearance of psychosis.

Prenatal stress and affective disorders in a population birth cohort

OBJECTIVES

Pregnant women exposed to an acute traumatic event are thought to produce offspring with an increased incidence of affective disorders. It is not known whether there are specific times in pregnancy which confer increased vulnerability, or if psychosocial stress alone can increase the incidence of affective disorders in offspring. We examined the relationship of the timing of an acute psychosocial threat during pregnancy to the incidence of affective disorders in offspring using data from a large birth cohort.

METHODS

Using data on 90079 offspring born in Jerusalem in 1964-1976 and linked to Israel's psychiatric registry, we constructed proportional hazards models to evaluate the link between gestational age during the Arab-Israeli war of June 1967 and incidence of mood disorders.

RESULTS

Those in their first trimester of fetal development during the war were more likely to be admitted to hospitals for any mood disorders [relative risk (RR) = 3.01, 95% confidence interval (CI): 1.68-5.39, p = 0.0002]; for bipolar disorder the risk was doubled (RR = 2.44, 95% CI: 0.996-5.99, p = 0.054) and for all 'other' mood disorders the risk was tripled (RR = 3.61, 95% CI: 1.68-7.80, p = 0.001). Mood disorders were also increased in offspring whose mothers had been in the third month of pregnancy in June of 1967 (RR = 5.54, 95% CI: 2.73-11.24, p < 0.0001).

CONCLUSIONS

A time-limited exposure to a severe threat during early gestation may be associated with an increased incidence of affective disorders in offspring. The third month of fetal development was a moment of special vulnerability.

Diagnosis of schizophrenia: consistency across information sources and stability of the condition

BACKGROUND

The Social Security Administration is considering whether schizophrenia may warrant inclusion in their new "Compassionate Allowance" process, which aims to identify diseases and other medical conditions that almost always qualify for Social Security disability benefits simply on the basis of their confirmed presence. This paper examines the reliability and validity of schizophrenia diagnosis, how a valid diagnosis is established, and the stability of the diagnosis over time. A companion paper summarizes evidence on the empirical association between schizophrenia and disability, thus leading to this paper that evaluates how valid clinical diagnoses of schizophrenia are.

METHODS

Literature review and synthesis, based on a workplan developed in an expert meeting convened by the National Institute of Mental Health and the Social Security Administration.

FINDINGS

At least since the introduction of the 3rd edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III) in 1980, diagnoses of schizophrenia made by mental health specialists are valid, reliable, and stable over time, across community as well as academic practice settings, and across different assessment methods. These analyses are particularly valid during the time-frame relevant to social security awards: at least 2 years after the initial stages of illness. We could not find studies that have evaluated the validity or reliability of schizophrenia diagnoses made exclusively by primary care providers (vs. mental health professionals).

DISCUSSION

In the post-DSM-III era, schizophrenia diagnosis-using modern diagnostic criteria-is valid and reliable when performed by doctoral-level mental health specialists (i.e., psychiatrists and psychologists), in community as well as academic settings.

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.

Real-world premorbid functioning in schizophrenia and affective disorders during the early teenage years: a population-based study of school grades and teacher ratings

BACKGROUND

Population-based studies of cognitive and behavioral premorbid functioning in psychotic disorders generally focus on late adolescence in schizophrenia and most are based on IQ test scores.

AIMS

To examine differences in school grades at the ages of 13-14 between persons hospitalized during adulthood for schizophrenia or affective disorders and their peers.

METHODS

Ten years of school report data were ascertained on 8th grade children (n=21,448) in the city of Jerusalem (1978-1988). During adulthood cases with schizophrenia (n=194, 0.9%) or an affective disorder (n=41, 0.19%) were identified based on psychiatric hospitalizations in the National Psychiatric Hospitalization Case Registry of the State of Israel. School assessments of academic performance, nonacademic topics, and teacher ratings of classroom behavior were compared between peers without illness and cases, and their association with illness was examined.

RESULTS

Children subsequently hospitalized with schizophrenia had significantly lower nonacademic performance (ES=.20, p=.007) and teacher ratings on behavior (ES=.18, p=.02) than controls and numerically lower teacher behavior ratings than people subsequently hospitalized for an affective disorder (ES=.25, p=.19). Cox regression modeling showed that poorer nonacademic and lower behavioral ratings were significantly associated with earlier age of onset of schizophrenia.

CONCLUSIONS

Premorbid behavior and nonacademic deficits are evident in early adolescence among persons subsequently hospitalized with schizophrenia and different from those hospitalized with affective disorders. This suggests that these ratings may have diagnostic specificity between schizophrenia and affective disorders.

Catatonic schizophrenia: a cohort prospective study

BACKGROUND

In the 20th century, catatonia was usually deemed a subtype of schizophrenia. Recently, the nature and classification of catatonia are being reconsidered. This study is the first to describe catatonia using prospectively collected data and to examine how catatonic schizophrenia differs from, or resembles, other types of schizophrenia.

METHODS

Data were analyzed in a cohort of 90,079 offspring followed from birth till ages 29-41 years. Proportional hazards models were used, calculating time to first psychiatric hospital admission, to compare risk factors for catatonic schizophrenia vs "other schizophrenia."

RESULTS

Of 568 cases of schizophrenia, 43 (7.6%) had catatonic schizophrenia. The sexes were equally at risk for catatonic schizophrenia in contrast to other schizophrenia, for which the incidence was higher in males (1.70, 1.42-2.03, P < .0001). Advancing paternal age had no influence on the risk of catatonic schizophrenia in contrast to other schizophrenia, in which the risk to offspring of fathers age 35+ was 1.27 (1.03-1.57, P = .03) compared with those of younger fathers. Those with catatonic schizophrenia were somewhat more likely to have older mothers (aged 35+) (relative risk = 2.14, 0.85-5.54) while maternal age was not related to other schizophrenia. Both were equally affected by parental history of schizophrenia. Patients with catatonia were significantly more likely to attempt suicide (P = .006).

CONCLUSION

Patients with catatonic schizophrenia show a somewhat different profile of risk factors from those with other types of schizophrenia in this cohort and are more likely to attempt suicide. This lends some support to the hypothesis that catatonic schizophrenia may have a distinct etiology.

Do psychiatric registries include all persons with schizophrenia in the general population? A population-based longitudinal study

BACKGROUND

Psychiatric hospitalization registries are utilized to investigate the incidence and prevalence of schizophrenia for both research and administrative purposes. The assumption behind this is that most individuals with schizophrenia will be hospitalized at least once in their life-time.

METHOD

In an epidemiological survey conducted in the 1980s, a population-based sample (n = 4914) of Israel-born individuals then aged 25-34 were screened in the community, and 29 (0.6%) were subsequently diagnosed by psychiatrists using SADS/RDC criteria. Twenty four years later we linked data from the epidemiological survey with the Israeli National Psychiatric Hospitalization Registry.

RESULTS

Twenty seven of the 29 individuals (93%) diagnosed with schizophrenia in the survey were identified in the hospitalization registry with the same diagnosis. Fifty-two (1.0%) participants not diagnosed during the survey with schizophrenia were identified in the psychiatric hospitalization registry 24 years later with schizophrenia. The majority of them were diagnosed with other psychiatric disorders in the survey. If all diagnoses of schizophrenia are accepted at face value, the lifetime prevalence rate would be 1.8% for this cohort.

CONCLUSION

The overwhelming majority of individuals diagnosed with schizophrenia at ages 25-34 in an epidemiological survey were present in the Psychiatric Hospitalization Registry. However, the assessment of life-time rates of schizophrenia at these ages is problematic because some future cases are asymptomatic, others have premorbid non-psychotic disorders, while in others it is difficult to differentiate between affective disorders and schizophrenia. Availability of psychiatric services and hospitalization policy must be considered when generalizing these findings to other countries.

Elaboration on the association between immigration and schizophrenia: a population-based national study disaggregating annual trends, country of origin and sex over 15 years

PURPOSE

Generally, immigrant status and male sex are separately documented to increase the risk of schizophrenia; although population-based risk trends by sex and immigration over time have not been examined. This study aims to examine the extent to which immigration acts as a risk factor for schizophrenia, delineated by origin, sex and year, using national population-based data over 15 years.

METHOD

Data on all first psychiatric admissions from 1978 to 1992 (n = 10,892) from the National Psychiatric Hospitalization Case Registry of the State of Israel were merged with aggregate national data from the Israeli Central Bureau of Statistics.

RESULTS

Compared to native-born Israelis, people who migrated prior to the age of 15 (n = 2,335) were at a greater risk of schizophrenia (n = 8,557; RR = 1.6, 95% CI = 1.53; 1.68), particularly those from Far Eastern (RR = 2.43, 95% CI = 1.91; 3.1) and Caribbean and South American (RR = 1.94, 95% CI = 1.51; 2.51) countries. Aggregate risk was higher among female than male immigrants and over the 15-year study immigration-related risk declined across the sexes.

CONCLUSION

The current findings replicate past research showing that immigrants, particularly from a social minority, as suggested by the social defeat-hypothesis, are at an increased risk of schizophrenia, and extend past findings to show that risk at least in Israel has decreased with time irrespective of sex.

Childhood exposure to ionizing radiation to the head and risk of schizophrenia

While the association between exposure to ionizing radiation and cancer is well established, its association with schizophrenia is unclear. The aim of our study was to assess risk of schizophrenia after childhood exposure to ionizing radiation to the head (mean dose: 1.5 Gy). The study population included an exposed group of 10,834 individuals irradiated during childhood for treatment of tinea capitis in the 1950s and two unexposed comparison groups of 5392 siblings and 10,834 subjects derived from the National Population Registry individually matched to the exposed group by age, sex (when possible), country of birth, and year of immigration to Israel. These groups were followed for a median 46 years for diagnosis of schizophrenia updated to December 2002. The Cox proportional hazards model stratified by matched sets was used to compare the risk of schizophrenia between the groups. Based on 1,217,531 person-years of follow-up, 451 cases were identified. No statistically significant association was found between radiation exposure and schizophrenia for the total group (hazard ratio per 1 Gy to the brain: 1.05, 95% confidence interval: 0.93-1.18) or within subgroups of sex, dose categories or latent period. When comparing a subgroup of subjects irradiated under 5 years of age with the matched unexposed group, the estimated hazard ratio reached 1.18 (95% confidence interval: 0.96-1.44; P = 0.1). The results of our analysis do not support an association between exposure to ionizing radiation and risk of schizophrenia. More research on possible effects of early exposure to ionizing radiation on schizophrenia specifically and brain tissue in general is needed.

The relationship between risk of hospitalization for schizophrenia, SES, and cognitive functioning

Although most studies find low socioeconomic status (SES) to be associated with prevalence of schizophrenia, incidence studies do not generally support this, and some even report an inverse association. The objective of the current historical prospective study was to examine the relationship between SES, cognitive functioning, and risk of hospitalization for schizophrenia in a population-based sample of Israeli adolescents. Subjects were 811 487 adolescents, assessed by the Israeli military draft board for socio-demographic factors and cognitive functioning. Data on later hospitalization for schizophrenia were obtained from a population-based hospitalization registry. Findings indicated that when simply examining SES and schizophrenia, lower SES was associated with greater risk of hospitalization for schizophrenia (Hazard Ratio [HR] = 1.193, 95% CI = 1.091-1.303). When dividing the cohort into low, average, and high cognitive functioning, SES did not influence the risk for schizophrenia among individuals with high and average cognitive functioning, whereas among individuals with low cognitive functioning, high SES was found to slightly increase the risk for schizophrenia (HR = 1.21, 95% CI = 1.03-1.42). One possible explanation for this finding might be that among individuals from low socioeconomic backgrounds, low IQ may reflect decreased opportunities related to SES, whereas among individuals from high SES backgrounds, low IQ might reflect risk for later psychopathology.

Trajectories of the course of schizophrenia: from progressive deterioration to amelioration over three decades

BACKGROUND

The extent of heterogeneity in the long-term course of schizophrenia is unclear.

AIMS

To examine the course of schizophrenia in a population-based cohort.

METHODS

This study included all Israeli individuals born in 1970-1988, of North African or European origin (N=2290), entered in the National Psychiatric Hospitalization Case Registry with a last discharge diagnosis of schizophrenia (1978-2004) and followed to 2009. Linked socio-demographic information was extracted from the Population Registry. Based on the number of hospitalized days at each age, trajectory groups were empirically derived, plotted and compared on psychiatric hospitalization measures of the course of illness, social factors and family stressors.

RESULTS

Trajectory analysis identified four course groups. Group I (57%) assumed a prototypical course, had an average first hospitalization age of 20, deteriorated until 23 and then ameliorated. Group II (15.5%) assumed an early-onset protracted course, had an average first hospitalization age of 17.1, and deteriorated until 21. Group III (15%) assumed a late-onset with longest deterioration period course, had an average first hospitalization age of 22.7, and deteriorated until 29. Group IV (12%) assumed an early-onset refractory illness course, had an average first hospitalization age of 18, and had the longest hospitalization period. Groups significantly differed on hospitalization (i.e., onset), social (i.e., socioeconomic and ethnic status) and familial factors (i.e., parental death). Despite group differences all deteriorated and then ameliorated on average by the age of 23.

CONCLUSIONS

The course of schizophrenia was heterogeneous, yet evolved from deterioration to assume a course consistent with amelioration.

Age, sex and first treatment of schizophrenia in a population cohort

OBJECTIVE

Schizophrenia affects men more than women, but this may not be true at all ages. This study examines the incidence of first hospitalization for treatment of schizophrenia in each sex over different ages.

METHODS

We compared the incidence of first admission for treatment in a cohort of 46,388 males and 43,680 females followed from birth until ages 29-41, using life tables and proportional hazards methods.

RESULTS

Life table estimates of cumulative incidence by age 40 were 1.44% in males and 0.86% in females. For over all ages the relative risk (RR) in males was 1.6 (95% confidence limits=1.4-1.8) compared with females. Before age 17 there was no significant difference between the sexes (RR=0.86, 0.56-1.3). Excess risk in males was observed only from age 17 (RR=1.7, 1.4-1.9). There was no evidence of the incidence in females catching up with that in males, during the 30s.

CONCLUSION

In this population, there was a significant change, over age, in the relative incidence of first hospitalization for schizophrenia between the sexes; the excess incidence in males first developed at age 17.

CNS infection in childhood does not confer risk for later schizophrenia: a case-control study

OBJECTIVE

The hypothesized role of CNS infection during childhood in increasing later risk of brain malfunction manifested as schizophrenia has been supported by some but not other studies. We sought to contribute to this debate by linking data on persons who had been hospitalized for meningitis as children, with a National Psychiatric Hospitalization Registry.

METHOD

Data were gathered on 3599 persons who had been hospitalized for a CNS infection before the age of 16, and 6371 controls who had been hospitalized as children for gastroenteritis. Both groups were followed for later hospitalization for schizophrenia between 1970 and 2007 using the Israeli National Psychiatric Hospitalization Case Registry. Data were analyzed using Cox regression analyses.

RESULTS

The mean age of the subjects at hospitalization for a CNS infection was 3.4 ± 3.6 years, mean age of the subjects at follow up was 29.3 ± 6.0 years. Compared to controls, hospitalization for any CNS infection during childhood was not associated with an increased risk of later hospitalization for schizophrenia, adjusted HR = 0.81, 95% CI: 0.5-1.32.

CONCLUSIONS

Overall there was no significant association between childhood CNS infection and schizophrenia. These data do not support the presence of an infectious etiology of schizophrenia.

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.

Suicide attempts at the time of first admission and during early course schizophrenia: a population based study

This article examined suicide attempt rates at first psychiatric hospitalization and risk factors for subsequent suicide attempts over the early course of schizophrenia in national population-based data. Data were extracted from the National Psychiatric Hospitalization Case Registry of the State of Israel that contains all first psychiatric admissions with schizophrenia 1989-1992 and were followed up to 1996 (N=2293). Attempted suicide rates were: 8.5% (n=196) at the time of first psychiatric hospitalization and 6.6% (n=151) over the follow-up period of 4 to 7 years. Of those with a suicide attempt at first admission, 31.6% (n=62) made a subsequent suicide attempt during the follow-up period (OR=10.44, 95% CIs=7.22 to 15.09). Risk profiles were derived using recursive partitioning to predict sub-groups at risk of a subsequent suicide attempt. Those characterized by an attempt at the time of first admission were college educated, female and not married (45.9% (17/37), OR=13.46, 95% CIs=6.89 to 26.3). The risk profiles together correctly classified 90.7% (137/151) of subsequent suicide attempts. Suicide attempts at first admission and premorbid years of education have long-term prognostic utility and risk profiles are available.

Time-to-pregnancy and risk of schizophrenia

Schizophrenia has been linked to advanced paternal age, but the explanation is unknown. We questioned whether the incidence of schizophrenia would be related to male reproductive capacity, as reflected in the time taken to conceive. We measured the incidence of schizophrenia in relation to time to conception in a sub-group of 12,269 in the Jerusalem cohort whose mothers, interviewed post-partum, reported that the pregnancy had been intended. Compared with those conceived in less than 3 months, the unadjusted relative risks (RR) of schizophrenia associated with conception-waits of 3-5, 6-11 and 12+ months were 1.10 (95% confidence interval, 0.62-1.94), 1.41 (0.79-2.52) and 1.88 (1.05-3.37) with p for trend=0.035. This trend was attenuated somewhat by adjusting for paternal age, and was observed more strongly in offspring of fathers aged 30+ (p=.010). These findings suggest that factors associated with fecundability, either male or female, may contribute to the risk of schizophrenia.

Depression and post-traumatic stress disorder among Haitian immigrant students: implications for access to mental health services and educational programming

BACKGROUND

Previous studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use, high risk sexual behavior, and delinquency, with very little information available on "internalizing" symptoms, such as depression and anxiety. Analyzing stressors and "internalizing" symptoms offers a more balanced picture of the type of social and mental health services that may be needed for this population. The present study aims to: 1) estimate the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant students; and 2) examine factors associated with depression and PTSD to identify potential areas of intervention that may enhance psychosocial health outcomes among immigrant youth from Haiti in the U.S.

METHODS

A stratified random sample of Haitian immigrant students enrolled in Boston public high schools was selected for participation; 84% agreed to be interviewed with a standardized questionnaire. Diagnosis of depression and PTSD was ascertained using the best estimate diagnosis method.

RESULTS

The prevalence estimates of depression and PTSD were 14.0% and 11.6%; 7.9% suffered from comorbid PTSD and depression. Multivariate logistic regression demonstrated factors most strongly associated with depression (history of father's death, self-report of schoolwork not going well, not spending time with friends) and PTSD (concern for physical safety, having many arguments with parents, history of physical abuse, and lack of safety of neighborhood).

CONCLUSIONS

A significant level of depression and PTSD was observed. Stressors subsequent to immigration, such as living in an unsafe neighborhood and concern for physical safety, were associated with an increased risk of PTSD and should be considered when developing programs to assist this population. Reducing exposure to these stressors and enhancing access to social support and appropriate school-based and mental health services may improve educational attainment and psychosocial health outcomes among Haitian immigrant youth.

A population-based examination of the role of years of education, age of onset, and sex on the course of schizophrenia

This article examines how premorbid years of education and age of onset relate to the course of schizophrenia in a population-based cohort. All first and subsequent cases who were hospitalized with schizophrenia (1988-92, followed up until 1996) and completed their formal education at least 1 year before hospitalization (n=2135) were extracted from the Israeli National Psychiatric Hospitalization Registry. Results, based on hierarchical moderated regression models showed that age of onset predicted the course with greater consistency and magnitude than years of education. Years of education predicted the age of first hospitalization among males. Years of education and age of first hospitalization significantly interacted to predict the length of first stay and average number of days hospitalized over the course for males. The interaction showed that for males less education predicted poorer hospitalization outcomes if an earlier onset occurred. Together, the results suggest that less educated, early onset males are at higher risk of a poorer course.

Schizophrenia and birthplace of paternal and maternal grandfather in the Jerusalem perinatal cohort prospective study

Some forms of epigenetic abnormalities transmitted to offspring are manifested in differences in disease incidence that depend on parent-of-origin. To explore whether such phenomena might operate in schizophrenia spectrum disorders, we estimated the relative incidence of these conditions in relation to parent-of-origin by considering the two grandfathers' countries of birth. In a prospective cohort of 88,829 offspring, born in Jerusalem in 1964-76 we identified 637 cases through Israel's psychiatric registry. Relative risks (RR) were estimated for paternal and maternal grandfathers' countries of birth using proportional hazards methods, controlling for parents' ages, low social class and duration of marriage. After adjusting for multiple observations, we found no significant differences between descendants of maternal or paternal grandfathers born in Iraq, Iran, Turkey, Syria, Yemen, Morocco, Algeria, Tunisia, Libya/Egypt, Poland, USSR, Czechoslovakia, Germany or the USA. Those with paternal grandfathers from Romania (RR=1.9, 95% CI=1.3-2.8) or Hungary (1.6, 1.0-2.6) showed an increased incidence; however, those with maternal grandfathers from these countries experienced reduced incidence (RR=0.5, 0.3-0.8 and 0.4, 0.2-0.8). In post-hoc analyses we found that results were similar whether the comparison groups were restricted to descendants of other Europeans or included those from Western Asia and North Africa; and effects of paternal grandfathers from Romania/Hungary were more pronounced in females, while effects of maternal grandfathers from these countries were similar in males and females. These post-hoc "hypothesis-generating" findings lead one to question whether some families with ancestors in Romania or Hungary might carry a variant or mutation at a parentally imprinted locus that is altering susceptibility to schizophrenia. Such a locus, if it exists, might involve the X chromosome.

Increased number of offspring in first degree relatives of psychotic individuals: a partial explanation for the persistence of psychotic illnesses

OBJECTIVE

As patients with psychotic illness have fewer offspring than controls, the persistence of psychotic illness is puzzling. We hypothesized that unaffected first-degree relatives of patients have more offspring than controls.

METHOD

Probands were 4904, individuals with non-affective psychotic disorders identified from a hospitalization registry. Unaffected first degree relatives and matched controls were identified from the Israeli Population Registry. The number of offspring of unaffected parents, biological siblings and controls was ascertained.

RESULTS

Unaffected parents of psychotic patients had more offspring/person than controls; 4.5 +/- 2.7 vs. 3.4 +/- 2.2, P = 0.000. Unaffected parents from familial psychosis families (more than one affected family member) had 1.83 more offspring than controls; unaffected parents from non-familial psychosis families had 0.97 more offspring than controls (both P < 0.001).

CONCLUSION

These findings might imply that genes which increase susceptibility for schizophrenia may be associated with increased number of offspring, perhaps supplying a partial explanation for the persistence of psychosis.

Pathways to functional outcomes in schizophrenia: the role of premorbid functioning, negative symptoms and intelligence

BACKGROUND

Social and intellectual premorbid functioning are generally estimated retrospectively, and related to clinical or hospitalization outcomes in schizophrenia. Yet the relationship between premorbid functioning assessed prior to psychiatric hospitalization and postmorbid functional outcomes has not been examined.

OBJECTIVES

To test competing models of the relationship between (a) functional outcomes with (b) premorbid functioning assessed on nationally administered tests prior to psychiatric hospitalization, postmorbid intellectual functioning and symptomatology using a historical prospective design.

METHODS

Ninety one inpatient and outpatient males with schizophrenia or schizoaffective disorder, aged 19 to 35, were examined using the Positive and Negative Syndrome Scale, the WAIS-III and Strauss and Carpenter social and occupational functional outcome scale. Premorbid intelligence and social functioning data were obtained from national standardized tests administered during high school prior to first hospitalization for schizophrenia.

RESULTS

Path modeling showed that premorbid intelligence and behavioral functioning directly predicted postmorbid IQ and negative symptoms, and indirectly predicted postmorbid social and occupational functioning via negative symptoms. Item level analysis indicated that better social and occupational outcomes occurred in a group with few negative symptoms.

CONCLUSIONS

Premorbid functioning, postmorbid IQ and negative symptoms are related, yet the relationship between premorbid functioning and postmorbid functional outcomes appears to be mediated by postmorbid negative symptoms.