[WHEN MEDICATIONS ARE NOT ENOUGH - NEUROFEEDBACK AS A COMPLEMENTARY TREATMENT FOR POST-TRAUMATIC STRESS DISORDER - A CASE REPORT]

INTRODUCTION

Neurofeedback (NF) therapy is brain training using operant conditioning including real-time displays of brain activity to teach people how to regulate their brain function. We would like to present a treatment for a patient who experienced severe traumatic events on 7/10 including physical injury accompanied by difficulty sleeping for two months, nightmares, intrusive thoughts, difficulties in emotional regulation and difficulty in concentrating. Due to the complexity and difficulties in emotional regulation accompanied by severe sleep disturbances, it was decided to treat with medication in combination with neurofeedback. After several training sessions in addition to pharmaceutical treatment, significant relaxation was observed, there was an improvement in concentration and the patient was able to return to his work and normal social functioning. In addition, intrusive thoughts decreased in intensity and frequency.

Amygdala-derived-EEG-fMRI-pattern neurofeedback for the treatment of chronic post-traumatic stress disorder. A prospective, multicenter, multinational study evaluating clinical efficacy

We conducted a prospective, single arm, multisite, multinational, open label trial assessing the safety and efficacy of a novel amygdala derived neurofeedback treatment, designated Amygdala-Derived-EFP, for chronic PTSD. Participants, including veterans and civilians, underwent screening, training, 15 neurofeedback sessions over 8 weeks and; baseline, termination (8 weeks) and 3 month post treatment assessments with validated measures. The primary endpoint was more than 50 % of the participants demonstrating a Minimally Clinically Important Difference (MCID) defined as a 6-point reduction, on the Clinician Administered PTSD Scale (CAPS-5) total score at 3 months. Secondary measures included the PCL-5, ERQ, PHQ-9, and CGI. Statistical analyses were performed using SAS®V9.4. The primary endpoint was met, with a CAPS-5 MCID response rate of 66.7 %. The average reduction in CAPS-5 total scores at 3 month follow up was 13.5 points, more than twice the MCID. Changes from baseline in CAPS-5, PCL-5, PHQ-9 scores at 8 weeks and the 3 month follow-up demonstrated statistically significant improvements in response and; demonstrated effect sizes ranging from 0.46 to 1.07. Adverse events were mild and resolved after treatment. This study builds on prior research demonstrating similar outcomes using amygdala-derived neurofeedback. Positive attributes of this therapy include monitoring by non-physician personnel, affordability, accessibility, and tolerability.

Social Media Images Can Predict Suicide Risk Using Interpretable Large Language-Vision Models

Background: Suicide, a leading cause of death and a major public health concern, became an even more pressing matter since the emergence of social media two decades ago and, more recently, following the hardships that characterized the COVID-19 crisis. Contemporary studies therefore aim to predict signs of suicide risk from social media using highly advanced artificial intelligence (AI) methods. Indeed, these new AI-based studies managed to break a longstanding prediction ceiling in suicidology; however, they still have principal limitations that prevent their implementation in real-life settings. These include "black box" methodologies, inadequate outcome measures, and scarce research on non-verbal inputs, such as images (despite their popularity today).

Objective: This study aims to address these limitations and present an interpretable prediction model of clinically valid suicide risk from images.

Methods: The data were extracted from a larger dataset from May through June 2018 that was used to predict suicide risk from textual postings. Specifically, the extracted data included a total of 177,220 images that were uploaded by 841 Facebook users who completed a gold-standard suicide scale. The images were represented with CLIP (Contrastive Language-Image Pre-training), a state-of-the-art deep-learning algorithm, which was utilized, unconventionally, to extract predefined interpretable features (eg, "photo of sad people") that served as inputs to a simple logistic regression model.

Results: The results of this hybrid model that integrated theory-driven features with bottom-up methods indicated high prediction performance that surpassed common deep learning algorithms (area under the receiver operating characteristic curve [AUC] = 0.720, Cohen d = 0.82). Further analyses supported a theory-driven hypothesis that at-risk users would have images with increased negative emotions and decreased belongingness.

Conclusions: This study provides a first proof that publicly available images can be leveraged to predict validated suicide risk. It also provides simple and flexible strategies that could enhance the development of real-life monitoring tools for suicide.

[COPING WITH THE UNSEEN WOUNDS TO EVALUATE THE HANDICAPS CAUSED BY PTSD]

INTRODUCTION

Post-Traumatic Stress Disorder (PTSD) has been clinically known for over 3500 years, but due to political and financial reasons it was referred to by many names, to put the blame for its existence on the weakness of the victim instead of the abnormal hazards of war. Since it entered the DSM-3 as a specific illness entity (1980), the research and treatment methods grew tremendously, yet the way to diagnosis, understanding how the illness affects the victim, his family members and surrounding were left behind. Diagnosis of PTSD is largely based on the subjective reports of the victim. Talking about the trauma goes often in contradiction with the disorders' related feelings of avoidance, shame and guilt. On the other hand, the patient needs the recognition of his illness so that he can be compensated. These aspects lead to under- and over-diagnosis in many cases. Adding to the oddities of the illness in its diagnosis are the chronicity but wavy tendencies of the clinical picture (such as getting worse near the date of the trauma or when the terror rises) and the option of late onset PTSD etc.. One can understand the gaps between the suffering of the victims and the recognition of their handicap level.

[SLEEP MONITORING FOR PREDICTION OF MAJOR DEPRESSION RECURRENCE IN PATIENTS AT HIGH RISK - A PROSPECTIVE STUDY]

INTRODUCTION

Objective: To examine the feasibility of sleep monitoring using an innovative wearable technology, as a predictive tool for MDE (major depressive episode) recurrence in high risk patients.

Familial clustering of psychiatric disorders and low IQ

BACKGROUND

Although the ICD and DSM differentiate between different psychiatric disorders, these often share symptoms, risk factors, and treatments. This was a population-based, case-control, sibling study examining familial clustering of all psychiatric disorders and low IQ, using data from the Israel Draft-Board Registry on all Jewish adolescents assessed between 1998 and 2014.

METHODS

We identified all cases with autism spectrum disorder (ASD, N = 2128), severe intellectual disability (ID, N = 9572), attention-deficit hyperactive disorder (ADHD) (N = 3272), psychotic (N = 7902), mood (N = 9704), anxiety (N = 10 606), personality (N = 24 816), or substance/alcohol abuse (N = 791) disorders, and low IQ (⩾2 SDs below the population mean, N = 31 186). Non-CNS control disorders were adolescents with Type-1 diabetes (N = 2427), hernia (N = 29 558) or hematological malignancies (N = 931). Each case was matched with 10 age-matched controls selected at random from the Draft-Board Registry, with replacement, and for each case and matched controls, we ascertained all full siblings. The main outcome measure was the relative recurrence risk (RRR) of the sibling of a case having the same (within-disorder RRR) or a different (across-disorder RRR) disorder.

RESULTS

Within-disorder RRRs were increased for all diagnostic categories, ranging from 11.53 [95% confidence interval (CI): 9.23-14.40] for ASD to 2.93 (95% CI: 2.80-3.07) for personality disorders. The median across-disorder RRR between any pair of psychiatric disorders was 2.16 (95% CI: 1.45-2.43); the median RRR between low IQ and any psychiatric disorder was 1.37 (95% CI: 0.93-1.98). There was no consistent increase in across-disorder RRRs between the non-CNS disorders and psychiatric disorders and/or low IQ.

CONCLUSION

These large population-based study findings suggest shared etiologies among most psychiatric disorders, and low IQ.

Working in corona-designated departments in a fortified underground hospital: Concerns about corona and predictors of job burnout

Background

In August 2020 during Israel's second COVID-19 wave Rambam Medical Center opened the Sammy Ofer Fortified Underground Emergency Hospital. This was declared a regional Corona center in the north of Israel, receiving the most severe Corona patients from the region. Alongside the advanced inpatient capacity and technology within the underground facility, there was a severe shortage of trained medical and paramedical staff, as well as harsh working conditions. The current study examined the implications and effects of working in an underground facility on healthcare workers, focusing on emotion regulation tendencies and profession as predictors of job burnout.

Methods

Seventy-six healthcare workers, who had worked in the underground hospital for a minimum continuous period of 2 weeks during the peak of the COVID-19 pandemic, and a control group of 40 healthcare workers from northern Israel were asked to fill out an online survey administered via Qualtrics (total sample 116). The survey comprised six questionnaires: a demographic survey questionnaire; a COVID-19 concerns questionnaire; a psychological distress questionnaire (DASS, Depression Anxiety Stress Scale); trait worry (PSWQ; Penn State Worry Questionnaire); emotion regulation (ERQ, Emotion Regulation Questionnaire), and burnout (SMBM, Shirom - Melamed Burnout Measure).

Results

Independent-samples t-tests revealed no significant differences in psychological distress or burnout between Rambam Underground hospital workers and the control group. Conversely, COVID-19 concern scores were significantly different in the two groups, the Rambam hospital workers showing less concern (M = 2.9, SD = 0.73) than the control group (M = 3.47, SD = 0.76) [t ₍₁₁₄₎ = -3.974, p < 0.001]. Hierarchical linear regression analysis identified the significant predictors of burnout among healthcare workers. Participants' profession (physician), psychological distress (total DASS score), and a personality trait of worry were statistically significant predictors for job burnout (p = 0.028, p < 0.001, p = 0.023, respectively). Concerns about COVID-19 marginally predicted job burnout (p = 0.09). Group (underground vs. control) and emotion regulation tendencies did not predict burnout.

Conclusion

The two groups showed no significant differences in psychological distress nor in burnout. Being a physician, having an intrinsic trait of being overly worried and experiencing psychological distress were significant predictors for job burnout among healthcare workers, regardless of work environment (underground vs. control).

Personality disorders and cause-specific mortality: a nationwide study of 2 million adolescents

BACKGROUND

Personality disorders are prevalent in 6-10% of the population, but their risk for cause-specific mortality is unclear. The aim of the study was to assess the association between personality disorders diagnosed in late adolescence and all-cause as well as cause-specific (cardiovascular-related, external-related) mortality.

METHODS

We performed a longitudinal study on a historical prospective cohort based on nationwide screening prior to recruitment to the Israeli army. The study participants were 16-19-year-old persons who attended the army screening (medical and cognitive, including screening for psychiatric disorders) between 1967 and 2006. Participants were followed from 1967 till 2011.

RESULTS

The study included 2 051 606 subjects, of whom 1 229 252 (59.9%) were men and 822 354 (40.1%) were women, mean age 17.36 years. There were 55 508 (4.5%) men and 8237 (1.0%) women diagnosed with personality disorders. The adjusted hazard ratio (HRs) for coronary, stroke, cardiovascular, external-related causes and all-cause mortality among men with personality disorders were 1.34 (1.03-1.74), 1.82 (1.20-2.76), 1.45 (1.23-1.71), 1.41 (1.30-1.53) and 1.44 (1.36-1.51), respectively. The absolute rate difference for all-cause mortality was 56.07 and 13.19 per 10⁵ person-years among men and women, respectively. Among women with personality disorders, the adjusted HRs for external-related causes and all-cause mortality were 2.74 (1.87-4.00) and 2.01 (1.56-2.58). Associations were already evident within 10 years of follow-up.

CONCLUSIONS

Personality disorder in late adolescence is associated with increased risk of cardiovascular, external- and all-cause mortality. Increased cardiovascular mortality is evident before the age of 40 years and may point to the importance of lifestyle education already in youth.

Resting mononuclear cell NR3C1 and SKA2 expression levels predict blunted cortisol reactivity to combat training stress among elite army cadets exposed to childhood adversity

Childhood adversity (CA) may alter reactivity to stress throughout life, increasing risk for psychiatric and medical morbidity, yet long-term correlates of milder CA levels among high functioning healthy adolescents are less studied. The current study examined the prevalence and impact of CA exposure among a cohort of healthy motivated elite parachute unit volunteers, prospectively assessed at rest and at the height of an intensive combat-simulation exposure. We found significantly reduced gene expression levels in resting mononuclear cell nuclear receptor, subfamily 3, member 1 (NR3C1), and its transactivator spindle and kinetochore-associated protein 2 (SKA2), that predict blunted cortisol reactivity to combat-simulation stress among CA exposed adolescents. Long-term alterations in endocrine immune indices, subjective distress, and executive functions persist among healthy high functioning adolescents following milder CA exposure, and may promote resilience or vulnerability to later real-life combat exposure.

Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors

INTRODUCTION

Post-SSRI sexual-dysfunction (PSSD) is an iatrogenicsyndrome, the underlying neurobiological mechanisms of which areunclear. Symptom onset follows cessation of serotonergicantidepressants i.e. Selective Serotonin and Norepinephrine ReuptakeInhibitors (SSRI's, SNRI's), and Tricyclic antidepressants (TCA's). PSSDsymptoms include genital anesthesia, erectile dysfunction andorgasmic/ejaculatory anhedonia, and should be differentiated fromdepression-related sexual-dysfunction. Recently, accumulated data of numerous case-reports suggest additional non-sexual symptoms including, anhedonia, apathy, and blunted affect. PSSD gained official recognition after the European medical agency concluded that PSSD is a medical condition that persists after discontinuation of SSRI's and SNRI's.

OBJECTIVE

To review possible underlying neurobiological mechanisms ofthis syndrome, update information on the pathophysiology, present a listof potential risk-factors and discuss potential management options forPSSD.

METHODS

Extensive literature review on the main symptom-patterns ofthis disorder was undertaken using PubMed. It includes introductoryexplications of relevant neurobiology with the objective of generatinghypothesis.

RESULTS

Precipitating factors for PSSD include previous exposure to certain drugs, genetic predisposition, psychological stress or chemical stressful reaction to antidepressants along pre-existing medical conditions affecting neuroplasticity. Different theories have been proposed to explain the pathophysiology of PSSD: epigenetic gene expression, dopamine-serotonin interactions, serotonin neurotoxicity and hormonal changes. The diagnosis of PSSD is by excluding all other etiologies of sexual-dysfunction. Treatment is challenging, and many strategies have been suggested without definitive outcomes. We offerthe contours of a future neurobiological research agenda, and propose several underlying mechanisms for the various symptoms of PSSD which could be the foundation for a future treatment algorithm.

CONCLUSION

There is a need for well-designed neurobiological research in this domain, as well as in the prevalence, pathophysiology, and treatment of PSSD. Practitioners should be alert to the distinctive features of PSSD. Misdiagnosing this syndrome might lead to harmful Sexual Medicine Reviews. Peleg LC, Rabinovitch D, Lavie Y, et al. Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors. Sex Med Rev 2021;XX:XXX-XXX.

Machine learning-based diagnosis support system for differentiating between clinical anxiety and depression disorders

In light of the need for objective mechanism-based diagnostic tools, the current research describes a novel diagnostic support system aimed to differentiate between anxiety and depression disorders in a clinical sample. Eighty-six psychiatric patients with clinical anxiety and/or depression were recruited from a public hospital and assigned to one of the experimental groups: Depression, Anxiety, or Mixed. The control group included 25 participants with no psychiatric diagnosis. Participants performed a battery of six cognitive-behavioral tasks assessing biases of attention, expectancies, memory, interpretation and executive functions. Data were analyzed with a machine-learning (ML) random forest-based algorithm and cross-validation techniques. The model assigned participants to clinical groups based solely on their aggregated cognitive performance. By detecting each group's unique performance pattern and the specific measures contributing to the prediction, the ML algorithm predicted diagnosis classification in two models: (I) anxiety/depression/mixed vs. control (76.81% specificity, 69.66% sensitivity), and (II) anxiety group vs. depression group (80.50% and 66.46% success rates in classifying anxiety and depression, respectively). The findings demonstrate that the cognitive battery can be utilized as a support system for psychiatric diagnosis alongside the clinical interview. This implicit tool, which is not based on self-report, is expected to enable the clinician to achieve increased diagnostic specificity and precision. Further, this tool may increase the confidence of both clinician and patient in the diagnosis by equipping them with an objective assessment tool. Finally, the battery provides a profile of biased cognitions that characterizes the patient, which in turn enables more fine-tuned, individually-tailored therapy.

Sleep Monitoring Using WatchPAT Device to Predict Recurrence of Major Depression in Patients at High Risk for Major Depression Disorder Recurrence: A Case Report

Background: Major depressive disorders are strongly correlated with alterations in sleep pattern and architecture, including changes in the Rapid Eye Movement (REM) phase. However, it is still unknown whether sleep alterations precede other depression-related symptoms, particularly in patients with recurrent depressive episodes at relapse risk. Case Presentation: We initiated a study aimed at examining the value of ambulatory sleep monitoring using a WatchPAT device, in predicting recurrence of Major depression. Depression was assessed monthly with the Beck Depression Inventory version II (BDI-II). Here we present the case of a 63 years old woman, with a history of recurrent depressive episodes. AT the time of recruitment, she was asymptomatic, she experienced recurrence of Major depression 3 months into the study. We observed a significant reduction of the Rem Latency parameters 5 weeks prior to BDI-II score increase, reflecting major depressive episode recurrence. Conclusion: Though our results are preliminary, they suggest that ambulatory sleep monitoring can be used as a simple and accessible tool, predicting recurrence of Major Depressive episodes in patients at high risk, thus enabling early treatment intervention.

Trends in Psychiatric Emergency Department Visits in Northern Israel During the COVID-19 Outbreak

Background: During the spread of coronavirus disease (COVID-19), mandatory quarantines increased social isolation and anxiety, with inevitable consequences on mental health and health seeking behavior. We wished to estimate those trends. Methods: We examined all psychiatric visits to the emergency department (ED) during March, April 2020, compared to identical months in 2018, 2019. We evaluated both number and nature of referrals. Results: Throughout the years, psychiatric referrals comprised about 5% of the total number of ED visits. In March-April 2020, 30% decreases were observed in overall ED visits and in psychiatric referrals in the ED. Compared to 2018-2019, in 2020, the proportions of these diagnoses were higher: anxiety disorders (14.5 vs. 5.4%, p < 0.001), personality disorders (6.7 vs. 3.2%, p = 0.001), psychosis (9.5 vs. 6.7%, p = 0.049), post-traumatic stress disorder (3.2 vs. 1.5%, p = 0.023). Compared to 2018-2019, in 2020, proportions were lower for adjustment disorder (5.8 vs. 8.9%, p = 0.036) and for consultation regarding observation (11.7 vs. 31.6%, p < 0.001). Differences were not observed between 2018-2019 and 2020 in the proportions of other diagnoses including suicide and self-harm disorders. Referrals concerning suicide and self-harm in a rural hospital and community clinic were 30% lower in the COVID-19 lockdown than in the same months in 2018, 2019. Conclusion: Psychiatric ED visits decreased by the same proportion as overall visits to the ED, apparently driven by fears of COVID-19. Referrals relating suicidality and self-harm shown nominal decrease, but their proportioned share remained constant. Increased anxiety and delayed care may eventually lead to increased mental health needs.

Electronic Media Abstinence in Sabbath Observant Jews: A Comparison Between the Weekday and Sabbath

BACKGROUND

Dependence on technology and electronic media devices (EMDs) is a significant phenomenon of modern life with many people experiencing adverse symptoms during abstention. Orthodox Jews abstain from using all forms of EMDs for 25 consecutive hours every week on the Sabbath but do not appear to experience significant adverse reactions during this abstention.

OBJECTIVES

To better examine whether Sabbath observant Jews experience fewer and less severe adverse symptoms while abstaining from EMDs on the Sabbath compared to weekdays.

METHODS

Ten Sabbath observant Jews abstained from using all forms of EMDs for 25 hours on a Sabbath and again on a weekday. At the end of each 25-hour period participants completed a 12-item Likert-type scale self-assessment of 1-5, once as a report of their condition at 10:00 and again after 25 hours of abstaining. The authors compared the mean results of Sabbath and weekday using Wilcoxon signed ranks test. P ≤ 0.05 was considered significant.

RESULTS

Overall, discomfort on Sabbath was less than on weekdays. A statistically significant decrease on the Sabbath was found at both the 10:00 reporting time and after 25 hours in anxiety, restlessness, thoughts and plans of using devices, and overall difficulty to abstain. Significance was found for feelings of not knowing what to do with time (10:00) and moodiness and irritability, being drawn to devices, and cravings achieved significance (after 25 hours).

CONCLUSIONS

Sabbath observant Jews reported statistically significant less adverse reactions while abstaining from EMDs on the Sabbath compared to on a weekday.

Correlations between interpersonal and cognitive difficulties: Relationship to suicidal ideation in military suicide attempters

Background

Understanding suicidal ideation may help develop more effective suicide screening and intervention programs. The interpersonal and the cognitive-deficit theories seek to describe the factors leading to suicidal behavior. In the military setting it is common to find over- and under-reporting of suicidal ideation. This study sought to determine the relationship between these two models and determine to what degree their components can indirectly predict suicidal ideation.

Methods

Suicide attempters (n = 32) were compared with non-suicidal psychologically treated peers (n = 38) and controls (n = 33), matched for sex and age (mean 19.7 years). Pearson's analysis was used to quantify the relationship between the variables from the two models and hierarchal regression analysis was used to determine the explanation of suicidal ideation variance by these variables.

Results

Suicide attempters have more difficulties in problem-solving, negative emotion regulation and burdensomeness compared with their peers (P < .001). These variables are all closely correlated with each other and to suicide ideation (r > ± 0.5; P < .001). Prior suicide attempt, loneliness and burdensomeness together explain 65% (P < .001) of the variance in suicidal ideation.

Conclusions

Suicidal ideation is strongly correlated with components of interpersonal and cognitive difficulties. In addition to assessing current suicidal ideation, clinicians should assess past suicide attempt, loneliness and burdensomeness.

Changes in the dynamic network structure of PTSD symptoms pre-to-post combat

BACKGROUND

Combat exposure is associated with elevated risk for post-traumatic stress disorder (PTSD). Despite considerable research on PTSD symptom clustering, it remains unknown how symptoms of PTSD re-organize following combat. Network analysis provides a powerful tool to examine such changes.

METHODS

A network analysis approach was taken to examine how symptom networks change from pre- to post-combat using longitudinal prospective data from a cohort of infantry male soldiers (Mage = 18.8 years). PTSD symptoms measured using the PTSD Checklist (PCL) were assessed after 6 months of combat training but before deployment and again after 6 months of combat (Ns = 910 and 725 at pre-deployment and post-combat, respectively).

RESULTS

Stronger connectivity between PTSD symptoms was observed post-combat relative to pre-deployment (global strength values of the networks were 7.54 pre v. 7.92 post; S = .38, p < 0.05). Both the re-experiencing symptoms cluster (1.92 v. 2.12; S = .20, p < 0.03) and the avoidance symptoms cluster (2.61 v. 2.96; S = .35, p < 0.005) became more strongly inter-correlated post-combat. Centrality estimation analyses revealed that psychological reaction to triggers was central and linked the intrusion and avoidance sub-clusters at post-combat. The strength of associations between the arousal and reactivity symptoms cluster remained stable over time (1.85 v. 1.83; S = .02, p = .92).

CONCLUSIONS

Following combat, PTSD symptoms and particularly the re-experiencing and avoidance clusters become more strongly inter-correlated, indicating high centrality of trigger-reactivity symptoms.

An effective suicide prevention program in the Israeli Defense Forces: A cohort study

Objective

To evaluate the effectiveness of the IDF Suicide Prevention Program, implemented since 2006.

Design

Quasi-experimental (before and after) cohort study.

Participants

Two cohorts of IDF mandatory service soldiers: the first inducted prior to (1992–2005, n = 766,107) and the second subsequent to (2006–2012, n = 405,252) the launching of the intervention program.

Exposure

The IDF Suicide Prevention Program is a population-based program, incorporating: reducing weapon availability, de-stigmatizing help-seeking behavior, integrating mental health officers into service units, and training commanders and soldiers to recognize suicide risk factors and warning signs.

Main outcome measure

Suicide rate and time to suicide in cohorts before and after exposure to the Suicide Prevention Program.

Results

Trend analysis showed lower suicide rates in the cohort after intervention. The hazard ratio for the intervention effect on time to suicide was 0.44 (95% CI = 0.34–0.56, P < .001) among males. Lower risk was associated with: male gender; born in Israel; higher socio-economic status; higher intelligence score; and serving in a combat unit (HR = 0.43: 95% CI = 0.33–0.55).

Conclusions

There was a 57% decrease in the suicide rate following the administration of the IDF Suicide Prevention Program. The effect of the intervention appears to be related to use of a weapon, and being able to benefit from improved help-seeking and de-stigmatization. Future efforts should seek to extend the program's prevention reach to other demographic groups of soldiers. The success of the IDF program may inform suicide prevention in other military organizations and in the civilian sector.

Risk factors for suicide in the Israeli army between the years 1992–2012: A case-control study

Objective

Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army.

Methods

We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n = 462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n = 1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered.

Results

Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR = 6.703; P < 0.001), country of origin: Ethiopia (RR = 4.555; P = 0.014), low socioeconomic status (RR = 1.448; P = 0.016) and low adjustment difficulties (RR = 2.324; P < 0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR = 2.548; P = 0.027), low (RR = 1.657; P = 0.002), to average motivation to serve in a combat unit (RR = 1.322; P = 0.046) increased the risk for suicide.

Conclusions

IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers’ guidance regarding help seeking and de-stigmatizing suicide.

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.

Perceptions of belongingness and social support attenuate PTSD symptom severity among firefighters: A multistudy investigation

Firefighters experience high rates of posttraumatic stress disorder (PTSD). It is imperative to identify malleable factors that protect against the development of PTSD symptoms among this population. We examined whether perceptions of belongingness broadly (Study 1) and social support from supervisors, coworkers, and family/friends specifically (Study 2) are associated with lower PTSD symptom severity among firefighters. Study 1 included 840 U.S. firefighters (91.1% male); participants completed the Interpersonal Needs Questionnaire and PTSD Checklist-Civilian Version. Study 2 included 200 U.S. women firefighters exposed to a Criterion A traumatic event; participants completed the Generic Job Stress Questionnaire, Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders-5, and PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Linear regression analyses were conducted, adjusting for the number of years participants served as firefighters. Greater belongingness broadly (Study 1; b = -0.740, p < .001) as well as social support specifically (Study 2) from supervisors (b = -4.615, p < .001), coworkers (b = -4.465, p = .001), and family/friends (b = -3.206, p = .021) were associated with less severe PTSD symptoms. When all sources of social support were entered into a single model, only support from supervisors was significantly associated with lower overall PTSD symptom severity (b = -4.222, p = .004). Belongingness and social support may protect against the development of PTSD among firefighters. Supervisor social support may be particularly salubrious, suggesting that top-down mental wellness promotion within the fire service may be indicated to protect firefighters against PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Functioning of Young Adults With ADHD in the Military

Objective: To assess the functioning of young adults with ADHD in a military setting. Method: In all, 14,655 young adults with ADHD (mean age at first examination 17.8 ± 0.7) attending mandatory service in the Israeli military were compared with matched controls on several functioning domains. Results: Young adults with ADHD had more sessions with mental health care professionals, physician appointments, sick days, and disqualifications of professions than controls (p < .001). Young adults with ADHD were also less medically fit for combat service (odds ratio [OR] = 0.75, 95% confidence interval [CI] = [0.72, 0.79]), more medically unfit for military service in general (OR = 1.26, 95% CI = [1.13, 1.40]), and had higher rates of overweight and obesity (p < .001). In addition, they were more likely to be diagnosed with a personality disorder (OR = 1.29, 95% CI = [1.07, 1.53]) or with minor affective and anxiety disorders (OR = 1.33, 95% CI = [1.06, 1.67]) than matched controls. Conclusion: These results support a negative effect of ADHD on the functioning of young adults in a military setting.

Suicide ideation severity is associated with severe suicide attempts in a military setting

BACKGROUND

There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting.

METHODS

Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS).

RESULTS

Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall's tau-b correlation with bootstrap demonstrated stability of these correlations.

CONCLUSION

Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low.

[ISRAELI MILITARY PSYCHIATRY: CHALLENGES AND ACHIEVEMENTS]

In this article, we have attempted to summarize the achievements and the challenges of the mental health department (MHD) of the IDF Medical Core from the past four decades, since its initiation. We approach this wide scope question through the investigation of the MHD according to the perspective of its main fields of endeavor. These domains are widely arrayed. In this paper, we chose to focus on the following: the unique training of the mental health officers; the initial psychological screening of soldiers - from recruitment to discharge; the mental health treatment of soldiers and officers, and the life-time treatment of combat post traumatic (PTSD) patients; the development of combat PTSD diagnosis, treatment and prevention; the continuous prevention of soldiers' suicides; the prevention of psychiatric hospitalizations; and the participation of the MHD in research and in the development of new treatment modalities. In the writing of this paper we relied on the accumulative experience of the MHD and the historic perspective of the last four commanders of the Mental Health Department of the IDF.

Electrical fingerprint of the amygdala guides neurofeedback training for stress resilience

Real-time functional magnetic resonance imaging (rt-fMRI) has revived the translational perspective of neurofeedback (NF)¹. Particularly for stress management, targeting deeply located limbic areas involved in stress processing² has paved new paths for brain-guided interventions. However, the high cost and immobility of fMRI constitute a challenging drawback for the scalability (accessibility and cost-effectiveness) of the approach, particularly for clinical purposes³. The current study aimed to overcome the limited applicability of rt-fMRI by using an electroencephalography (EEG) model endowed with improved spatial resolution, derived from simultaneous EEG-fMRI, to target amygdala activity (termed amygdala electrical fingerprint (Amyg-EFP))^4-6. Healthy individuals (n = 180) undergoing a stressful military training programme were randomly assigned to six Amyg-EFP-NF sessions or one of two controls (control-EEG-NF or NoNF), taking place at the military training base. The results demonstrated specificity of NF learning to the targeted Amyg-EFP signal, which led to reduced alexithymia and faster emotional Stroop, indicating better stress coping following Amyg-EFP-NF relative to controls. Neural target engagement was demonstrated in a follow-up fMRI-NF, showing greater amygdala blood-oxygen-level-dependent downregulation and amygdala-ventromedial prefrontal cortex functional connectivity following Amyg-EFP-NF relative to NoNF. Together, these results demonstrate limbic specificity and efficacy of Amyg-EFP-NF during a stressful period, pointing to a scalable non-pharmacological yet neuroscience-based training to prevent stress-induced psychopathology.

A Population-Based Longitudinal Study of Symptoms and Signs Before the Onset of Psychosis

OBJECTIVE

The authors sought to characterize the symptoms of patients later hospitalized for psychotic disorders in primary mental health outpatient settings, and to investigate whether these symptoms can be used to predict later onset of psychotic illness.

METHOD

This was a population-based historical prospective cohort study using national registers of clinical psychiatric services. The sample (N=114,983) comprised 18- to 21-year-olds serving in the Israeli military and examined in military mental health outpatient clinics across 72 consecutive months.

RESULTS

Overall, 1,092 individuals (0.95%) not diagnosed with a psychotic disorder at the time of examination were hospitalized for nonaffective psychotic disorder up to 9 years after the index examination. A principal components analysis of symptoms presented at index examination found that a symptom cluster of thought disorder, perceptual abnormalities, poor orientation, and suicidality was associated with an increased risk for hospitalization for nonaffective psychotic disorder within 14 days after examination (hazard ratio=45.80, 95% CI=22.87-91.73), 15-111 days after examination, (hazard ratio=19.59, 95% CI=13.08-29.33), 112-365 days after examination (hazard ratio=4.94, 95% CI=2.59-9.40), and 1-3.5 years after examination (hazard ratio=3.42, 95% CI=2.21-5.28), but not for hospitalization 3.5 years or more after examination (hazard ratio=1.57, 95% CI=0.91-2.71). Despite the increased risk, the positive predictive values of this symptom cluster were low, ranging from 0.54% to 1.99%.

CONCLUSIONS

In 18- to 21-year-olds, the presence of psychotic symptoms was associated with later hospitalization for a nonaffective psychotic disorder. However, the low positive predictive values of symptoms elicited in primary mental health care settings suggest that symptoms alone are not useful in predicting later hospitalization for nonaffective psychotic disorder.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel

BACKGROUND

Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.

METHODS

Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques.

RESULTS

212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.

CONCLUSIONS

The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Treatment Seeking for Posttraumatic Stress in Israel Defense Forces Veterans Deployed in the 2006 Israel-Hezbollah War: A 7-Year Post-War Follow-Up

BACKGROUND

To determine the long-term prevalence of combat-related treatment seeking for PTSD in Israel Defense Force (IDF) veterans deployed to war.

METHODS

A seven-year surveillance records-based study determined the prevalence of treatment seeking and DSM-IV-TR diagnosis among treatment seeking IDF veterans in relation to the 2006 Israel-Hezbollah War. The whereabouts and combat exposure of veterans during the war was determined based on the IDF's Operations Directorate records.

RESULTS

Overall prevalence of psychological/psychiatric treatment seeking was 1.32%, and was significantly higher in soldiers deployed to high combat-exposure zones (2.19%), relative to low combat-exposure zones (0.24%), OR=9.20, CI=6.68-12.66, p<0.001. Treatment seeking did not differ between soldiers deployed in low combatexposure zones and soldiers deployed elsewhere than the war area (0.26%), OR=0.90, CI=0.65-1.24, p=0.45: 42% of care-seeking contacts occurred within the 3.5 months of the war's end. An additional 27.9% of all contacts occurred during the ensuing year, and decreased drastically in subsequent years. PTSD was more prevalent among treatment-seeking veterans deployed in high combatexposure zones relative to veterans who were deployed in low exposure zones or elsewhere.

CONCLUSIONS

Based on previous reports on postcombat PTSD prevalence using stratified samples, there appears to be a service-gap of anywhere between 3-11% between treatment seeking by IDF veterans following war deployment and the actual prevalence of PTSD and related symptoms in this soldier population. As in prior research, treatment seeking and PTSD strongly related to level of combat exposure.

Tracing the Neural Carryover Effects of Interpersonal Anger on Resting-State fMRI in Men and Their Relation to Traumatic Stress Symptoms in a Subsample of Soldiers

Uncontrolled anger may lead to aggression and is common in various clinical conditions, including post traumatic stress disorder. Emotion regulation strategies may vary with some more adaptive and efficient than others in reducing angry feelings. However, such feelings tend to linger after anger provocation, extending the challenge of coping with anger beyond provocation. Task-independent resting-state (rs) fMRI may be a particularly useful paradigm to reveal neural processes of spontaneous recovery from a preceding negative emotional experience. We aimed to trace the carryover effects of anger on endogenous neural dynamics by applying a data-driven examination of changes in functional connectivity (FC) during rs-fMRI between before and after an interpersonal anger induction (N = 44 men). Anger was induced based on unfair monetary offers in a previously validated decision-making task. We calculated a common measure of global FC (gFC) which captures the level of FC between each region and all other regions in the brain, and examined which brain regions manifested changes in this measure following anger. We next examined the changes in all functional connections of each individuated brain region with all other brain regions to reveal which connections underlie the differences found in the gFC analysis of the previous step. We subsequently examined the relation of the identified neural modulations in the aftermath of anger with state- and trait- like measures associated with anger, including brain structure, and in a subsample of designated infantry soldiers (N = 21), with levels of traumatic stress symptoms (TSS) measured 1 year later following combat-training. The analysis pipeline revealed an increase in right amygdala gFC in the aftermath of anger and specifically with the right inferior frontal gyrus (IFG).We found that the increase in FC between the right amygdala and right IFG following anger was positively associated with smaller right IFG volume, higher trait-anger level and among soldiers with more TSS. Moreover, higher levels of right amygdala gFC at baseline predicted less reported anger during the subsequent anger provocation. The results suggest that increased amygdala-IFG connectivity following anger is associated with maladaptive recovery, and relates to long-term development of stress symptomatology in a subsample of soldiers.

Neural indicators of interpersonal anger as cause and consequence of combat training stress symptoms

BACKGROUND

Angry outbursts are an important feature of various stress-related disorders, and commonly lead to aggression towards other people. Findings regarding interpersonal anger have linked the ventromedial prefrontal cortex (vmPFC) to anger regulation and the locus coeruleus (LC) to aggression. Both regions were previously associated with traumatic and chronic stress symptoms, yet it is unclear if their functionality represents a consequence of, or possibly also a cause for, stress symptoms. Here we investigated the relationship between the neural trajectory of these indicators of anger and the development and manifestation of stress symptoms.

METHOD

A total of 46 males (29 soldiers, 17 civilians) participated in a prospective functional magnetic resonance imaging experiment in which they played a modified interpersonal anger-provoking Ultimatum Game (UG) at two-points. Soldiers were tested at the beginning and end of combat training, while civilians were tested at the beginning and end of civil service. We assumed that combat training would induce chronic stress and result in increased stress symptoms.

RESULTS

Soldiers showed an increase in stress symptoms following combat training while civilians showed no such change following civil service. All participants were angered by the modified UG irrespective of time point. Higher post-combat training stress symptoms were associated with lower pre-combat training vmPFC activation and with higher activation increase in the LC between pre- and post-combat training.

CONCLUSIONS

Results suggest that during anger-provoking social interactions, flawed vmPFC functionality may serve as a causal risk factor for the development of stress symptoms, and heightened reactivity of the LC possibly reflects a consequence of stress-inducing combat training. These findings provide potential neural targets for therapeutic intervention and inoculation for stress-related psychopathological manifestations of anger.

Characteristics of pre-morbid functioning in male adolescents who later suffered from psychotic disorders: Case-controlled study

Background

Previous research has shown that people with psychotic disorders have impaired functioning prior to the onset of the illness. The main goal of the proposed study was to deepen understanding of the characteristics of pre-morbid impairment in persons later diagnosed with psychotic disorders.

Methods

We examined unique pre-morbid data from IDF archives, including narrative summaries of pre-induction interviews of 17-year old adolescents (168 male adolescents who were later hospitalized for psychotic disorders, and 168 matched control subjects). The data were analyzed using mixed-method analysis, combining qualitative and quantitative research methods.

Results

Between group comparisons revealed more adaptation difficulties, family problems and dealing with medical conditions in the group of future psychotic disorder patients, while suicidal thoughts and loss of a close person showed trends towards significance. Two factors characterized classification of outcome: adaptation difficulties and family problems. A “high-functioning” factor was significantly higher within the control group, while a “strange” factor was higher among the future psychosis patients. A “high-functioning” factor was identified as a protective factor.

Discussion

This study used narrative analysis of interview summaries of adolescents who underwent pre-induction assessments. The current study replicated previously published findings that were obtained as a result of retrospective investigations and comparing numeric scores, using unique pre-morbid data and in-depth qualitative analyses, combined with a quantitative one. The main strengths of the current study are the fact that the subjects were interviewed before the onset of psychosis, as well as the fact that the analyses of the data were performed blinded to outcome.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The contribution of the socio-demographic characteristics on suicidal ideation among Israeli soldiers

Background

Suicidal ideation is a risk factor for suicide attempt. The aim of the present study is to compare suicidal ideation of different groups with different distress.

Methods

100 soldiers, aged 18–21, divided into four research cohorts: soldiers who had carried out a suicide attempt (n = 40); soldiers with a psychiatric diagnosis (n = 20); soldiers having high severity adjustment difficulties (n = 20); and a control group of soldiers, having neither a history of mental health diagnosis, nor adjustment difficulties (n = 20). All completed the suicide ideation scale.

Results

Half of the attempters had a psychiatric diagnosis (depression or anxiety) on the day of their enlistment and 37.5 % of them had a specified personality disturbance. The attempters were characterized by previously-attempted suicide (p < .01). The lowest mean values (M = 1.95, SD = .67) were among the attempter (F = 3.173, df = 3, p = .02) in motivation for military service. The variable expressing low motivation for military service was the sole predictor of suicide ideation (p = .032).

Conclusions

Early diagnosis facilitated better monitoring by military mental health officers.

Accessible Neurobehavioral Anger-Related Markers for Vulnerability to Post-Traumatic Stress Symptoms in a Population of Male Soldiers

Identifying vulnerable individuals prone to develop post-traumatic stress symptoms (PTSS) is of paramount importance, especially in populations at high risk for stress exposure such as combat soldiers. While several neural and psychological risk factors are known, no post-traumatic stress disorder (PTSD) biomarker has yet progressed to clinical use. Here we present novel and clinically applicable anger-related neurobehavioral risk markers for military-related PTSS in a large cohort of Israeli soldiers. The psychological, electrophysiological and neural (Simultaneous recording of scalp electroencephalography [EEG] and functional magnetic resonance imaging [fMRI]) reaction to an anger-inducing film were measured prior to advanced military training and PTSS were recorded at 1-year follow-up. Limbic modulation was measured using a novel approach that monitors amygdala modulation using fMRI-inspired EEG, hereafter termed amygdala electrical fingerprint (amyg-EFP). Inter-subject correlation (ISC) analysis on fMRI data indicated that during movie viewing participants' brain activity was synchronized in limbic regions including the amygdala. Self-reported state-anger and amyg-EFP modulation successfully predicted PTSS levels. State-anger significantly accounted for 20% of the variance in PTSS, and amyg-EFP signal modulation significantly accounted for additional 15% of the variance. Our study was limited by the moderate PTSS levels and lack of systematic baseline symptoms assessment. These results suggest that pre-stress neurobehavioral measures of anger may predict risk for later PTSS, pointing to anger-related vulnerability factors that can be measured efficiently and at a low cost before stress exposure. Possible mechanisms underlying the association between the anger response and risk for PTSS are discussed.

Benefits of a Psychodynamic Group Therapy (PGT) Model for Treating Veterans With PTSD

OBJECTIVE

To examine the effectiveness of a treatment model of psychodynamic group therapy (PGT) for combat Veterans with posttraumatic stress disorder (PTSD).

METHOD

A total of 158 male Veterans with PTSD (mean age = 30.09 years) were assigned to 15 treatment groups of 7-13 patients each. PGT was a 1-year therapy, 1.5 hour, once-a-week sessions administered in the following stages: group building activities, differentiation of group members, intimacy building, and termination. Levels of PTSD and depression symptoms, functioning, and hope were assessed at pretreatment baseline, posttreatment, and 12-month follow-up.

RESULTS

Multilevel modeling analyses indicate that our group therapy is associated with reductions in PTSD and depressive symptoms at posttreatment, and that these effects were maintained at 12-month follow-up. The results also showed significantly improved patients' functioning by the end of therapy and at the 12-month follow-up point, and that the patients' hope level had increased.

CONCLUSION

The findings show that our model of psychodynamic group therapy is associated with mental improvements in Veterans with PTSD. However, further randomized controlled trials are recommended to establish the advantages of our therapeutic method compared to other modes of therapy.

Health and functioning of adolescents conceived by assisted reproductive technology

OBJECTIVE

To evaluate the general health, mental health, and cognitive ability of assisted reproductive technology (ART)-conceived adolescents.

DESIGN

A nested case-control study within a historic cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 253 ART-conceived adolescents born between 1982 and 1993 and 253 matched references according to birth year, gender, and the high-school they attended.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Medical and psychiatric diagnoses, and cognitive ability recorded at the military preinduction screening (ages 16-17 years) and doctor's appointments throughout the military service.

RESULT(S)

No differences were detected in general and mental health of ART adolescents or cognitive ability, compared with the reference group. Similar results were obtained after stratification for gender and singleton births. The ART adolescents had fewer cases of discharge from military service due to health reasons (4% vs. 8.3%). Follow-up during the military service revealed that male ART adolescents had significantly more doctor's appointments compared with the reference group (23.80 ± 15.59 vs. 19.95 ± 13.79).

CONCLUSION(S)

Our preliminary results provide reassurance that in the long-run health and functioning of ART-conceived adolescents is not compromised. Further studies with larger cohorts are needed to confirm these results.

The association between premorbid cognitive ability and social functioning and suicide among young men: A historical-prospective cohort study

Previous studies have found associations between low cognitive ability and later completed suicide. The aim of this study was to examine the association between cognitive ability and social functioning in adolescence, and later completed suicide in a large population-based longitudinal study. Data from the Israeli Draft Board Register for 634,655 Israeli male adolescents aged 16 and 17 was linked to a causes-of-death data registry, with a mean follow-up of 10.6 years for completed suicide. Our results show that in males without a psychiatric diagnosis, both low (adjusted HR=1.51, 95% CI: 1.19-1.92) and high (adjusted HR=1.36, 95% CI: 1.04-1.77) cognitive ability, and very poor (adjusted HR=2.30, 95% CI: 1.34-3.95) and poor (adjusted HR=1.64, 95% CI: 1.34-2.07) social functioning were associated with increased risk for later completed suicide; however positive predictive values were low (PPVs=0.09% and 0.10%, for low cognitive ability and very poor or poor social functioning, respectively). No association between cognitive ability or social functioning and risk for suicide was found in males with a psychiatric diagnosis. These data do not support the clinical utility of screening for such potential predictors.

Dissociation and acquired capability as facilitators of suicide ideation among soldiers

BACKGROUND

The phenomenon of suicide and suicidal behaviors during military service is universal, with a recent dramatic rise in some armies.

AIMS

The aim of this study was to shed light on the role of dissociation and habituation as facilitators of suicidal behavior, beyond other well-established risk factors of stress, such as depression and hopelessness.

METHOD

The study group included 167 soldiers, aged 18-21 years divided into three research groups: soldiers who made suicide attempts, soldiers who were psychologically treated, and a control group of soldiers having no history of mental health treatment. All subjects completed a suicide ideation scale and instruments measuring stress, mental pain, bodily dissociation, and habituation.

RESULTS

Suicide attempters had higher levels of subjective stress as well as depression and hopelessness compared with the psychologically treated and control groups. Using regression analysis, suicide facilitators of dissociation and habituation explained a significant proportion of the suicidal ideation variance, above and beyond the contribution of stress, depression, and hopelessness. A combined effect of stress and facilitating factors amplifies the level of suicidal ideation among soldiers.

CONCLUSION

Identifying psychological facilitators of suicide-like dissociation and habituation may contribute to understanding suicidal behavior in soldiers and assist in developing effective suicide-prevention initiatives in the military setting.

Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial

BACKGROUND

Efficacy of pre-trauma prevention for post-traumatic stress disorder (PTSD) has not yet been established in a randomized controlled trial. Attention bias modification training (ABMT), a computerized intervention, is thought to mitigate stress-related symptoms by targeting disruptions in threat monitoring. We examined the efficacy of ABMT delivered before combat in mitigating risk for PTSD following combat.

METHOD

We conducted a double-blind, four-arm randomized controlled trial of 719 infantry soldiers to compare the efficacy of eight sessions of ABMT (n = 179), four sessions of ABMT (n = 184), four sessions of attention control training (ACT; n = 180), or no-training control (n = 176). Outcome symptoms were measured at baseline, 6-month follow-up, 10 days following combat exposure, and 4 months following combat. Primary outcome was PTSD prevalence 4 months post-combat determined in a clinical interview using the Clinician-Administered PTSD Scale. Secondary outcomes were self-reported PTSD and depression symptoms, collected at all four assessments.

RESULTS

PTSD prevalence 4 months post-combat was 7.8% in the no-training control group, 6.7% with eight-session ABMT, 2.6% with four-session ABMT, and 5% with ACT. Four sessions of ABMT reduced risk for PTSD relative to the no-training condition (odds ratio 3.13, 95% confidence interval 1.01-9.22, p < 0.05, number needed to treat = 19.2). No other between-group differences were found. The results were consistent across a variety of analytic techniques and data imputation approaches.

CONCLUSIONS

Four sessions of ABMT, delivered prior to combat deployment, mitigated PTSD risk following combat exposure. Given its low cost and high scalability potential, and observed number needed to treat, research into larger-scale applications is warranted. The ClinicalTrials.gov identifier is NCT01723215.

Self-Perceived Emotional Distress and Diabetes Risk Among Young Men

INTRODUCTION

There are mixed data regarding the effect of emotional distress on diabetes risk, especially among young adults. This study assessed the effect of self-perceived emotional distress on diabetes incidence among young men.

METHODS

Incident diabetes during a mean follow-up of 6.3 (4.3) years was assessed among 32,586 men (mean age, 31.0 [5.6] years) of the Metabolic, Lifestyle, and Nutrition Assessment in Young Adults cohort with no history of diabetes between 1995 and 2011. Emotional distress was assessed by asking participants as part of a computerized questionnaire: Are you preoccupied by worries or concerns that affect your overall wellbeing? Time-dependent Cox models were applied. Data analysis took place between 2014 and 2015.

RESULTS

There were 723 cases of diabetes during 206,382 person-years. The presence of distress was associated with a 53% higher incidence of diabetes (95% CI=1.08, 2.18, p=0.017) after adjustment for age, BMI, fasting plasma glucose, family history of diabetes, triglyceride and high-density lipoprotein cholesterol levels, education, cognitive performance, white blood cell count, physical activity, and sleep quality. These results persisted when distress, BMI, physical activity, and smoking status were treated as time-dependent variables (hazard ratio=1.66, 95% CI=1.21, 2.17, p=0.002). An adjusted hazard ratio of 2.14 (95% CI=1.04, 4.47, p=0.041) for incident diabetes was observed among participants persistently reporting emotional distress compared with those persistently denying it.

CONCLUSIONS

Sustained emotional distress contributes to the development of diabetes among young and apparently healthy men in a time-dependent manner. These findings warrant awareness by primary caregivers when stratifying diabetes risk.

Developmental Trajectories of Impaired Community Functioning in Schizophrenia

IMPORTANCE

Community functioning is a core component of the functional deficits in schizophrenia, yet little systematic research on the origins of these functional deficits has been performed.

OBJECTIVES

To examine 3 key domains of community functioning--social activity, independent behavior, and functioning in school or work--before first hospitalization for schizophrenia and to determine whether these domains are familial.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based, prospective study that included a sibling-control comparison, data from the Israeli National Draft Board Registry were linked with data from the Israeli Psychiatric Hospitalization Case Registry. The merged file included data for all male adolescents who visited the draft board and were followed up for as much as 25.4 years from draft board assessment (through the end of 2010). The 3 functional domains for cases, their unaffected siblings, and controls were compared by time between assessment and time to hospitalization. Analyses were conducted from March 13, 2014, to October 19, 2014.

MAIN OUTCOMES AND MEASURES

The trajectories and familiality of 3 key components of community functioning--social activity, independent behavior, and functioning in school or work--in the years preceding hospitalization for schizophrenia.

RESULTS

Participants included 723,316 Israeli male adolescents who underwent a mandatory behavioral assessment to determine eligibility for military service. Linkage identified 3929 individuals hospitalized for schizophrenia. Data for 338,550 sibling pairs, 1659 hospitalized with schizophrenia, were similarly ascertained. Among those with schizophrenia, impairments in social activity (effect size [d], 0.55) and functioning in school or work (d = 0.37) were recognizable up to 15 years before hospitalization. Independent behavior seemed preserved until the few years before first admission. For social activity, differences between cases and controls were progressively greater for patients admitted closer to time of testing (F = 115.33, P < .001). Unaffected siblings had small impairments compared with controls in social activity (F = 28.25, P < .001) and functioning in school or work scales (F = 14.77, P < .001). Group familial (sibling) correlations were relatively high for social activity (r = 0.40; 95% CI, 0.39-0.41) and functioning in school or work (r = 0.50; 95% CI, 0.49-0.51) but nil for independent behavior (r = 0; 95% CI, -0.01 to -0.01). Impairments in siblings had no progressive increase and were unrelated to their affected sibling's time of illness onset (time trend: social activity: F = 5.463, P = .02; independent behavior: F = 0.908, P = .34; and functioning in school or work: F = 1.386, P = .24).

CONCLUSIONS AND RELEVANCE

Various components of impaired community functioning in schizophrenia followed different developmental trajectories. Our results indicate that impairments in social activity and functioning in school or work are familial.

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.

Cognitive Performance at Late Adolescence and the Risk for Impaired Fasting Glucose Among Young Adults

CONTEXT

Although dysglycemia is a risk factor for cognitive decline, it is unknown whether cognitive performance among young and apparently healthy adults affect the risk for impaired fasting glucose (IFG).

OBJECTIVE

This study aimed to characterize the relationship between cognitive function and the risk for IFG among young adults.

DESIGN AND SETTING

This was a retrospective cohort study utilizing data collected at pre-military recruitment assessments with information collected at the screening center of Israeli Army Medical Corps.

PARTICIPANTS

Normoglycemic adults (n = 17 348) (free of IFG and diabetes; mean age 31.0 ± 5.6 y; 87% men) of the Metabolic Lifestyle and Nutrition Assessment in Young Adults (MELANY) cohort with data regarding their General Intelligence Score (GIS), a comprehensive measure of cognitive function, at age 17 y.

INTERVENTIONS

Fasting plasma glucose was assessed every 3-5 y at scheduled visits. Cox proportional hazards models were applied.

MAIN OUTCOMES MEASURES

The main outcome of the study was incident IFG (≥ 100 mg/dL and <126 mg/dL) at scheduled visits.

RESULTS

During a median followup of 6.6 y, 1478 cases of IFG were recorded (1402 men). After adjustment for age and sex, participants in the lowest GIS category had a 1.9-fold greater risk for incident IFG compared with those in the highest GIS category. In multivariable analysis adjusted for age, sex, body mass index, fasting plasma glucose, family history of diabetes, country of origin, socioeconomic status, education, physical activity, smoking status, alcohol consumption, breakfast consumption, triglyceride level, white blood cell count, the risk for IFG was nearly doubled in the lowest GIS category compared with the highest GIS category (hazard ratio, 1.8; 95% confidence interval, 1.4-2.3; P < .001). These results persisted when GIS was treated as a continuous variable and when the model was adjusted also for body mass index at the end of followup.

CONCLUSIONS

This study demonstrates that lower cognitive function at late adolescence is independently associated with an elevated risk IFG in both men and women.

Threat-Related Attention Bias Variability and Posttraumatic Stress

OBJECTIVE

Threat monitoring facilitates survival by allowing one to efficiently and accurately detect potential threats. Traumatic events can disrupt healthy threat monitoring, inducing biased and unstable threat-related attention deployment. Recent research suggests that greater attention bias variability, that is, attention fluctuations alternating toward and away from threat, occurs in participants with PTSD relative to healthy comparison subjects who were either exposed or not exposed to traumatic events. The current study extends findings on attention bias variability in PTSD.

METHOD

Previous measurement of attention bias variability was refined by employing a moving average technique. Analyses were conducted across seven independent data sets; in each, data on attention bias variability were collected by using variants of the dot-probe task. Trauma-related and anxiety symptoms were evaluated across samples by using structured psychiatric interviews and widely used self-report questionnaires, as specified for each sample.

RESULTS

Analyses revealed consistent evidence of greater attention bias variability in patients with PTSD following various types of traumatic events than in healthy participants, participants with social anxiety disorder, and participants with acute stress disorder. Moreover, threat-related, and not positive, attention bias variability was correlated with PTSD severity.

CONCLUSIONS

These findings carry possibilities for using attention bias variability as a specific cognitive marker of PTSD and for tailoring protocols for attention bias modification for this disorder.

Risk factors for suicide attempt among Israeli Defense Forces soldiers: A retrospective case-control study

BACKGROUND

A major risk factor for suicide is suicide attempts. The aim of the present study was to assess risk factors for nonfatal suicide attempts. Methods The study's cohort consisted of 246,814 soldiers who were divided into two groups: soldiers who made a suicide attempt (n=2310; 0.9%) and a control group of soldiers who did not (n=244,504; 99.1%). Socio-demographic and personal characteristics as well as psychiatric diagnoses were compared. Results The strongest risk factors for suicide attempt were serving less than 12 months (RR=7.09) and a history of unauthorized absence from service (RR=5.68). Moderate risk factors were low socioeconomic status (RR=2.17), psychiatric diagnoses at induction (RR=1.94), non-Jewish religion (RR=1.92), low intellectual rating score (RR=1.84), serving in non-combat unit (RR=1.72) and being born in the former Soviet Union (RR=1.61). A weak association was found between male gender and suicide attempt (RR=1.36). Soldiers who met more frequently with a primary care physician (PCP) had a higher risk for suicide attempt, as opposed to a mental health professional (MHCP), where frequent meetings were found to be a protective factor (P<0.0001). The psychiatric diagnoses associated with a suicide attempt were a cluster B personality disorder (RR=3.00), eating disorders (RR=2.78), mood disorders (RR=2.71) and adjustment disorders (RR=2.26).

LIMITATIONS

Mild suicidal behavior constitutes a much larger proportion than among civilians and may have secondary gain thus distorting the suicidal behavior data.

CONCLUSIONS

Training primary care physicians as gatekeepers and improved monitoring, may reduce the rate of suicide attempts.

The impact of Herpes simplex virus type 1 on cognitive impairments in young, healthy individuals - A historical prospective study

Herpes simplex virus (HSV) is a highly prevalent neurotropic virus. Although on the whole, chronic, latent or persistent infection is considered to be relatively benign, HSV infections can cause cognitive impairment during and after acute encephalitis. Some studies have documented cognitive impairment in exposed persons that is untraceable to encephalitis. Most studies have focused on these impairments in the mentally ill, mostly among individuals with schizophrenia, and only recently have studies begun to examine the impact of HSV infection on the cognition of healthy individuals. Subjects were a representative, random sample of 612 soldiers before active duty in the Israeli military (Israeli defense force - IDF), 62.2% HSV positive (n=381) and 38.8% HSV negative (n=231). Cognitive functioning and language abilities were compared between these groups, controlling for years of education, immigration status, and gender. Compared to soldiers who were sero-negative, soldiers who were sero-positive for HSV had significantly lower IQ scores (IQ=97.96, SD=15.19 vs IQ=103.23, SD=14.23; p≤0.001, effect size (ES)=0.2), and significantly lower Hebrew language scores (ES=0.1, p≤0.01). The results remained significant after removing subjects with mild depression, anxiety or personality disorders. Although we could not control for socio-economic status directly, our findings indicate that infection with HSV-1 is associated with reduced cognitive functioning in healthy individuals. This finding adds to the growing number of studies in the schizophrenia literature and indicates that many research findings seemingly characteristic of schizophrenia are related to the association between HSV exposure and cognitive functioning in general, and are not illness specific.

A military suicide prevention program in the Israeli Defense Force: a review of an important military medical procedure

The phenomenon of suicide during military service is not unique to the Israeli military and other armies. Soldiers’ age––adolescence––is a known factor contributing to suicide, in light of psychological processes of identity formation and self-definition, the stresses of military service, and above all, the availability of weapons. The stigma of seeking help deters some soldiers from getting the assistance they need when they need it most, thus contributing to the higher suicide rate. In the previous decade the IDF initiated intensive and structured preventive procedures aimed at reducing suicide rate among soldiers. The IDF’s Suicide Prevention Program (SPP) was grounded in professional knowledge and backed by military policy changes, both critical to the implementation and change processes. The SPP includes thorough psycho-education and guidance, supervision, greater accessibility of mental health officers, and lower accessibility of nonessential weapons. The SPP has succeeded in reducing the suicide rate by almost 50 %.

The aim of this article is to review the background of the design of the IDF’s SPP and its major components, leading to the current success.