Effect of implementation of mental health services within primary care on GP detection and treatment of mental disorders in Israel

BACKGROUND

Psychiatric morbidity is frequent in primary care, but a substantial proportion of these psychiatric problems appear to be neither recognized nor adequately treated by GPs. There exists a number of models of introduction of mental health services (MHS) into primary care, but little data are available on their effect on GPs' detection or management of mental disorders. The study aimed to measure the effect of referring patients to a psychiatrist within primary care (Shifted OutPatient model-SOP) or consultation of psychiatrists by the GPs (Psychiatric Community Consultation Liaison-PCCL) on the detection and treatment of mental disorders by GPs.

METHODS

In six primary care clinics in Israel (three "SOP clinics" and three "PCCL clinics"), GP detection of mental disorders and treatment of GP-detected cases were evaluated before and after provision of 1-year MHS, according to GP questionnaires on a sample of primary care consecutive attenders whose psychological distress was determined according to the GHQ12 and psychiatric disorders according to the Composite International Diagnostic Interview.

RESULTS

After model implementation, a significant reduction in detection of mental disorders was found in SOP clinics, while no significant change was found in PCCL clinics. No significant change in detection of distress was found in any clinic. An increase in referrals to MHS for GP-diagnosed depression and anxiety cases, a reduction in GP counselling for GP-detected cases and those with diagnosed anxiety, an increased prescription of antidepressants and a reduced prescription of antipsychotics were found in SOP clinics. In PCCL clinics, no significant changes in GP management were observed except an increase in referral of GP-diagnosed depression cases to MHS.

CONCLUSIONS

MHS models did not improve GP detection of mental disorders or distress, but possibly improved referral case mix. The SOP model might have a deskilling influence on GPs, resulting from less involvement in treatment, with decrease of detection and counselling. This should be taken into consideration when planning to increase referrals to a psychiatrist within primary care settings. Lack of positive effect of the PCCL model might be overcome by more intensive programs incorporating educational components.

Effects of individual differences, society, and culture on youth-rated problems and strengths in 38 societies

BACKGROUND

Clinicians increasingly serve youths from societal/cultural backgrounds different from their own. This raises questions about how to interpret what such youths report. Rescorla et al. (2019, European Child & Adolescent Psychiatry, 28, 1107) found that much more variance in 72,493 parents' ratings of their offspring's mental health problems was accounted for by individual differences than by societal or cultural differences. Although parents' reports are essential for clinical assessment of their offspring, they reflect parents' perceptions of the offspring. Consequently, clinical assessment also requires self-reports from the offspring themselves. To test effects of individual differences, society, and culture on youths' self-ratings of their problems and strengths, we analyzed Youth Self-Report (YSR) scores for 39,849 11-17 year olds in 38 societies.

METHODS

Indigenous researchers obtained YSR self-ratings from population samples of youths in 38 societies representing 10 culture cluster identified in the Global Leadership and Organizational Behavioral Effectiveness study. Hierarchical linear modeling of scores on 17 problem scales and one strengths scale estimated the percent of variance accounted for by individual differences (including measurement error), society, and culture cluster. ANOVAs tested age and gender effects.

RESULTS

Averaged across the 17 problem scales, individual differences accounted for 92.5% of variance, societal differences 6.0%, and cultural differences 1.5%. For strengths, individual differences accounted for 83.4% of variance, societal differences 10.1%, and cultural differences 6.5%. Age and gender had very small effects.

CONCLUSIONS

Like parents' ratings, youths' self-ratings of problems were affected much more by individual differences than societal/cultural differences. Most variance in self-rated strengths also reflected individual differences, but societal/cultural effects were larger than for problems, suggesting greater influence of social desirability. The clinical significance of individual differences in youths' self-reports should thus not be minimized by societal/cultural differences, which-while important-can be taken into account with appropriate norms, as can gender and age differences.

Suicide rates and risk factors for suicide among Israeli immigrants from Ethiopia (1985-2017)

BACKGROUND

Suicide rates among Ethiopian immigrants to Israel (EI) are relatively high. This study sought to identify suicide-risk factors in this population in order to suggest some potentially preventive measures to mental health policymakers who are struggling to prevent suicide among EI.

METHOD

Nationwide age-adjusted suicide rates were calculated for EI, Former Soviet Union immigrants (FSUI) and Israeli-born (IB) Jews by age, gender, and year of death and, for EI, by marital status and immigration period in the years 1985-2017 (1990-2017 for FSUI).

RESULTS

Age-adjusted suicide rates for the period 1990-2017 confirmed the significantly higher rate among EI--3.1 times higher than for FSUI and 4.1 times higher than for IB. Similar rates were obtained for both genders, within each age group, and in all study years. Comparable male/female rate ratios were found among EI and IB (3.3, 3.6, respectively). Over the years of the study, only among the Ethiopian immigrants were there large fluctuations in suicide rates: a decrease (1992-2001), followed by an increase (2001-2006), and then a progressive decrease (from 2006). The secular changes differed greatly according to age. Among females, these fluctuations were smaller, the decrease began earlier and was greater, and the subsequent increase was much smaller. Marriage was found to be less protective for Ethiopian immigrants than for the other surveyed populations.

CONCLUSIONS

The considerable gap between the EI's and FSUI's suicide rates highlights the critical role of immigrants' integration difficulties. These difficulties among EI lead to ongoing conflict within the family, which may explain why marriage is less protective for EI. Nevertheless, progressive integration is occurring as indicated by the decline in suicide rates since 2006. The fluctuations in EI suicide rates over time seem to be associated with modifications in social welfare allowances, which are crucial for EI of low socioeconomic status. Groups at risk, particularly EI men facing socioeconomic challenges and EI with considerable family conflict, typically identified by HMOs and welfare services, should be screened for suicide risk, and those identified as at risk referred to tailored workshops sensitive to Ethiopian culture.

Does Specializing in Family Medicine Improve the Detection and Diagnosis of Mental Health Problems?

BACKGROUND

Approximately half the patients seeking mental health (MH) treatment consult primary care practitioners (PCPs). Previous research indicates that patients often do not receive correct MH diagnoses or appropriate treatment from PCPs. The present study examines whether a specialization in family medicine compared to other or no PCP residency programs enhances physicians' ability to detect, diagnose and treat MH problems.

METHODS

Face-to-face interviews with 49 physicans in eight clinics in Israel. Two case vignettes and questionnaires assess MH awareness and factors influencing treatment.

RESULTS

Significantly more family practitioners (FPs) compared to others correctly diagnosed depression and anxiety vignettes were aware of patients' MH problems and prescribed psychotropic drugs.

LIMITATIONS

Small sample size, indirect examination of PCPs' skills using vignettes and the absence of psychotherapy options.

CONCLUSIONS

FPs are more likely than other PCPs to detect, diagnose and treat MH problems. To improve MH detection among a broad range of PCPs, an expanded MH curriculum should be encouraged. Additional MH training should be available for all PCPs.

Physicians' influence on primary care patients' reluctance to use mental health treatment

OBJECTIVES

The study examined attitudes of primary care patients toward mental health treatment and whether ambivalent or negative attitudes change after patients receive recommendations from their primary care physicians to seek treatment from a mental health professional.

METHODS

Data were collected in face-to-face interviews with 902 Jewish patients aged 25-75 in eight primary care clinics in Israel. Measures included validated mental health instruments and a vignette eliciting patients' readiness to consider treatment and potential influence of a physician's recommendation.

RESULTS

Initially, almost half of patients were reluctant to consider specialized mental health treatment. The probability of having a more positive attitude after the physician's recommendation was significantly higher among patients with more severe clinical diagnoses.

CONCLUSIONS

A major finding was the positive impact of primary care physicians' recommendations on reluctant patients. Encouraging physicians to discuss mental health issues would likely promote more positive attitudes and increase patients' willingness to access treatment.

Mental disorders in primary care in Israel: prevalence and risk factors

OBJECTIVE

Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders.

METHOD

Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI).

RESULTS

A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders.

CONCLUSIONS

High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.

Trends in the use of rehabilitation services in the community by people with mental disabilities in Israel; the factors involved

Background

In 2001, the Rehabilitation of the Mentally Disabled Law was implemented, defining a basket of rehabilitation services to which people with mental disabilities are entitled.

Objectives

To describe change over time in the characteristics of applicants to rehabilitation committees, types of referral agencies, and the proportion of those referred who were admitted. To identify factors affecting implementation of decisions to admit people with mental disabilities into different rehabilitation services and predictors of the length of time they remain in the services.

Methods

The study population consisted of all applicants to rehabilitation committees during 2001-2008. Rehabilitation services included hostels, supported housing, and vocational services. Data were extracted from Ministry of Health rehabilitation and psychiatric hospitalization case registers. Findings were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox regressions.

Results

There was a trend over time for more patients with shorter or no psychiatric hospitalization histories to be referred to rehabilitation services. Moreover, there was an increase in the proportion of referrals from the community, although the majority of referrals still came from psychiatric hospitals. Less than half of those recommended for a rehabilitation program were admitted and remained in a rehabilitation facility for one year or more. One factor predicting participants' longer stays in rehabilitation services after hospitalization was the proximity of the committees' decisions to the hospitalization. Another factor was the patient receiving vocational services while in residential care.

Conclusion

Although over time the new law has resulted in a broader spectrum of people with mental disabilities receiving rehabilitation services, additional efforts are needed to enable them to remain in the system for a sufficient amount of time. Programs addressing specific needs should be developed accordingly.

Utilization patterns of ambulatory psychiatric services by Ethiopian immigrants in Israel

BACKGROUND

Ethiopian immigrants in Israel (EI) have limited familiarity with western psychiatric care and, reciprocally, their culture is hardly known by mental health professionals.

OBJECTIVE

to compare utilization patterns of ambulatory psychiatric services in Israel by EI and other population groups.

METHODS

EI, former Soviet Union immigrants and Israel-born users of the 64 psychiatric governmental clinics and of the nationwide psychiatric rehabilitation services were compared on demographic and clinical data. Data were obtained from the Ministry of Health for the years 1997-2003.

RESULTS

Among the EI cared in psychiatric clinics, there was a greater proportion of users with psychotic disorders; a lesser proportion was referred by self, family or friends; a greater proportion was prescribed psychotropic medications; and a lesser proportion received individual psychotherapy. EI used more protected housing facilities and less social and leisure services.

DISCUSSION

Patterns of utilization of both types of services were found to be different among EI, suggesting a need to develop culturally-sensitive programs for both the Ethiopian immigrants and the mental health professionals.

[Impairment status and related predictors for adults hospitalized as children in a psychiatric ward in Israel]

BACKGROUND

The few studies that exist on long term outcome of psychiatric hospitalization of children show poor prognosis.

OBJECTIVES

To study the level of functioning of adults who were hospitalized as children in a psychiatric ward in Israel and to identify prognosis predictors.

METHODS

The study population consisted of all 1654 people who had been hospitalized in a psychiatric hospital in Israel and whose age at the time of the study was 21 years and above. For each subject, demographic and clinical data were extracted from a national case registry and data on disability benefits were retrieved from another file in the Ministry of Health.

RESULTS

Only 8% of the study subjects were married, 8.3% died (3.5 times more in men compared to the general population), and 21% received disability benefits. More than half of the people who were hospitalized as children were rehospitalized during the follow-up (43% as adults). Younger age at first hospitalization was associated with a longer cumulative duration of hospitalization, while an older age was associated with a greater number of hospitalizations and a higher rate of eligibility for disability benefits. Diagnosis at first hospitalization was associated with all measures of functioning in adulthood. Diagnosis of an "organic" or severe psychiatric disorder was associated with poor prognosis. Longer duration of first hospitalization was associated with a higher rate of death and eligibility for disability benefits.

CONCLUSIONS

This study shows poor prognosis for adults who were hospitalized in child psychiatry wards and calls for long-term prospective and controlled studies.

Predictors of early psychiatric rehospitalization: a national case register study

BACKGROUND

Inconsistent results have been published on variables affecting readmission to psychiatric hospitals, in particular length of hospitalization before discharge. The objective of the present study was to develop a predictive model for 30 days readmission after discharge, as the latter is one of the performance indicators in the pending mental health reform in Israel.

METHOD

The data were extracted from the Israeli national psychiatric case register. They concerned all patients discharged from psychiatric hospitals in Israel during a six month period (January 1,-June 30, 2004). A follow-up since the first discharge during this period (discharge from index hospitalization) until November 30, 2005 was performed for each patient. A Cox regression allowed constructing a multi factorial prediction model for readmission within 30 days from discharge.

RESULTS

The readmission rate within 30 days was 13 percent. The variables predicting early readmission were age up to 45, history of prior hospitalization, short time between index and prior hospitalization and being discharged from a hospital in the Tel Aviv Center district. Length of hospitalization was not a predictor of early readmission, except for the very short ones (up to eight days) which predicted earlier readmission.

CONCLUSION

The policy of shortening hospitalizations, which potentially could lead to premature discharge,was not found to be associated with early readmission,except for extremely short hospitalizations.

Post-discharge contact with mental health clinics and psychiatric readmission: a 6-month follow-up study

BACKGROUND

Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization.

OBJECTIVES

To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital.

METHODS

Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model.

RESULTS

Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare.

CONCLUSIONS

The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.

Predictors of cumulative length of psychiatric inpatient stay over one year: a national case register study

BACKGROUND

Prior studies have shown inconsistent results regarding predictors of length of stay (LOS) and of readmission in psychiatric hospitals. “Cumulative LOS” over a given period, which reflects both LOS and readmission, has not been examined so far in a systematic way. The Israel Psychiatric Case Register in Israel made it possible to examine predictors of Cumulative LOS in a nationwide, representative sample.

METHOD

All hospitalization admissions during a six-month period in Israel were recorded and followed-up for one year. The variables predicting Cumulative LOS over one year were identified through a Cox regression.

RESULTS

The median Cumulative LOS during one year was 43.0 days, and only 1.7% of the patients remained hospitalized for more than one year after admission. The variables significantly predicting longer Cumulative LOS were: Jewish ethnicity, a diagnosis of schizophrenia or other functional psychosis, prior hospitalization, compulsory admission and Northern and Jerusalem districts of hospitalization (which have a lower admission rate).

LIMITATIONS

Lack of information on severity of pathology and type of treatment.

CONCLUSION

Cumulative LOS, which reflects both the length of each inpatient episode and the rate of readmission, is affected not only by clinical factors,but also by the cultural background of the patient population and by administrative factors such as bed pressure.

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

OBJECTIVE

This study compared the prevalence and patterns of psychiatric hospitalization for persons who immigrated to Israel from Ethiopia and the Former Soviet Union (FSU) and the Israel-born population.

METHODS

Data were extracted from the Israel Psychiatric Case Register for six population groups: Operation Moses 1980s immigrants, who emigrated from Ethiopia, January 1, 1980-August 31, 1985 (178 had at least one psychiatric hospitalization within five years of immigration); Operation Moses immigrants in the 1990s, the same group ten years later (194 were hospitalized ten to 14 years after immigration); Operation Solomon 1990s immigrants, who emigrated from Ethiopia in 1990-1991 (184 had at least one hospitalization within five years of immigration); FSU 1990s immigrants, who emigrated from the FSU in 1990-1991 (2,082 had at least one hospitalization within five years of immigration); Israel born 1980s (10,120 had at least one psychiatric hospitalization between January 1, 1980, and August 31, 1985); and Israel born 1990s (11,241 had at least one psychiatric hospitalization in 1990-1994).

RESULTS

Operation Moses 1980s immigrants differed from the other groups; they had higher rates of hospitalization, less severe diagnoses, and shorter lengths of stay, compared with Israel born 1980s. Ten years later, this group's rates of hospitalization were lower and similar to those of non-Ethiopian populations, and the individuals in this group were more likely to have a diagnosis of schizophrenia or other psychosis, compared with the other groups. The hospitalization pattern for Operation Solomon 1990s immigrants fell between that of Operation Moses 1980s immigrants and Operation Moses immigrants in the 1990s. For immigrants from the FSU, the hospitalization rate was similar to that of Israel born 1990s and Operation Moses immigrants in the 1990s and much lower than that of Operation Solomon 1990s immigrants.

CONCLUSIONS

Marked sociocultural differences between immigrants and the host society and the understanding of these differences by mental health professionals may influence rates and patterns of psychiatric hospitalization more than the immigration experience itself.

Estimating the changes in demand for public mental health services following changes in eligibility: analysis of national survey data

BACKGROUND

Numerous national surveys have shown that the rate of use of mental health services in a population lags behind the prevalence rate of psychiatric disorder. The preparations to provide universal coverage in Israel require estimates of the utilization levels likely to be reached once mental health care becomes a legal right of each resident.

AIMS

This paper aims to provide an estimate of the size of the population which not only will be eligible for specialty mental health care, but which will also demand ambulatory mental health specialty care from public providers

METHODS

Data for this study were extracted from a national survey conducted during 2003-2004 in Israel as part of the WMH2000 initiative. Use and perceived need to use services among eligible respondents was used to estimate likely levels of demand.

RESULTS

The estimates for future demands on public mental health clinics ranged between 1.2%--the size of the population that is eligible by law and is currently using public mental health services to 5.5%--the size of the eligible population that is currently using some type of service or perceives the need for care in mental health.

DISCUSSION

The estimate of the expected use falls in the range of other universal access systems. CONCLUSIONS AND IMPLICATIONS FOR POLICY: The present study provides estimates that are much higher than the estimated size of the population currently using public mental health services, yet the upper limit of the range of estimates is close to those on which the new legislation is based.

Adapting the SRQ for Ethiopian populations: a culturally-sensitive psychiatric screening instrument

The objective of the study was to develop a culturally sensitive psychiatric screening instrument valid for Ethiopians in Ethiopia and Israel. The study sample was composed of 356 Amharic-speaking Ethiopians from Ethiopia and Israel, aged 18-55, divided into three groups: i) general population; ii) people in non-psychiatric treatment; iii) people in psychiatric treatment. They were interviewed with the Self-Reporting Questionnaire (SRQ), modified to include 10 culturally specific items, and the Brief Psychiatric Research Scale (BPRS) as a criterion of psychopathology. Physicians also completed an encounter form about the presence of mental health symptoms in participants. To make the questions more culturespecific, the translation of 12 items on the SRQ was changed. The content, construct, and criterion validity of each question were also examined, leading to the deletion of five items. The validity of the revised instrument (SRQ-F) was superior to that of the original instrument (SRQ). This study demonstrates the need for psychiatric screening instruments to be adapted to different cultures by incorporating meaningful translations and adding culturally specific items.

The generalizability of the Youth Self-Report syndrome structure in 23 societies

As a basis for theories of psychopathology, clinical psychology and related disciplines need sound taxonomies that are generalizable across diverse populations. To test the generalizability of a statistically derived 8-syndrome taxonomic model for youth psychopathology, confirmatory factor analyses (CFAs) were performed on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) completed by 30,243 youths 11-18 years old from 23 societies. The 8-syndrome taxonomic model met criteria for good fit to the data from each society. This was consistent with findings for the parent-completed Child Behavior Checklist (Achenbach & Rescorla, 2001) and the teacher-completed Teacher's Report Form (Achenbach & Rescorla, 2001) from many societies. Separate CFAs by gender and age group supported the 8-syndrome model for boys and girls and for younger and older youths within individual societies. The findings provide initial support for the taxonomic generalizability of the 8-syndrome model across very diverse societies, both genders, and 2 age groups.

Testing the 8-syndrome structure of the child behavior checklist in 30 societies

There is a growing need for multicultural collaboration in child mental health services, training, and research. To facilitate such collaboration, this study tested the 8-syndrome structure of the Child Behavior Checklist (CBCL) in 30 societies. Parents' CBCL ratings of 58,051 6- to 18-year-olds were subjected to confirmatory factor analyses, which were conducted separately for each society. Societies represented Asia; Africa; Australia; the Caribbean; Eastern, Western, Southern, and Northern Europe; the Middle East; and North America. Fit indices strongly supported the correlated 8-syndrome structure in each of 30 societies. The results support use of the syndromes in diverse societies.

Re-hospitalization of first-in-life admitted schizophrenic patients before and after rehabilitation legislation: a comparison of two national cohorts

BACKGROUND

In line with the worldwide trend of deinstitutionalization and development of community facilities, a rehabilitation legislation was passed in Israel in 2000. Its aim was to establish an infrastructure for the chronic mentally ill. The objective of the present study was to evaluate the impact of this legislation on the re-hospitalization of schizophrenic patients.

METHOD

Re-hospitalization rates within 3 years of discharge were compared for two cohorts of first-in-life hospitalized schizophrenics, those discharged in 1990-1991 and those discharged in 2000-2001, after the passing of the law. Possible confounding variables were controlled for by logistic regression analyses. The same analysis was done for patients with affective disorders who are not generally beneficiaries of this legislation.

RESULTS

In 2000-2001, the re-hospitalization rate was significantly lower than in 1990-1991 for schizophrenic patients with an in-patient stay longer than 6 months (chronic patients) but not for short-stay schizophrenics or for affective patients.

CONCLUSION

The study suggests that the expanding of the rehabilitation facilities in the community by legislation leads to increase in the survival in the community of schizophrenic patients.

Epidemiological comparisons of problems and positive qualities reported by adolescents in 24 countries

In this study, the authors compared ratings of behavioral and emotional problems and positive qualities on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) by adolescents in general population samples from 24 countries (N = 27,206). For problem scales, country effect sizes (ESs) ranged from 3% to 9%, whereas those for gender and age ranged from less than 1% to 2%. Scores were significantly higher for girls than for boys on Internalizing Problems and significantly higher for boys than for girls on Externalizing Problems. Bicountry correlations for mean problem item scores averaged .69. For Total Problems, 17 of 24 countries scored within one standard deviation of the overall mean of 35.3. In the 19 countries for which parent ratings were also available, the mean of 20.5 for parent ratings was far lower than the self-report mean of 34.0 in the same 19 countries (d = 2.5). Results indicate considerable consistency across 24 countries in adolescents' self-reported problems but less consistency for positive qualities.

Prevalence of mood and anxiety disorders in the community: results from the Israel National Health Survey

OBJECTIVE

To estimate the 12-month and lifetime prevalence rates of mood and anxiety disorders in Israel and their socio-demographic correlates.

METHOD

A representative sample of respondents extracted from the National Population Register of non-institutionalized residents, aged 21 or older, were interviewed at home between May, 2003, and April, 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview.

RESULTS

Seventeen percent of the sampled adult population reported a lifetime occurrence of a mood or anxiety disorder, while nearly one in 10 (9.7%) reported a mood or anxiety disorder occurring during the previous 12 months. Mood disorders were twice as common as anxiety disorders.

CONCLUSION

Contrary to expectations born out of Israel's unique life circumstances, the prevalence of mood or anxiety disorders fall within the range of other western countries. However, given the current age structure and the age of onset of these disorders, their total burden in the near future is likely to increase.

Twelve-month service utilization rates for mental health reasons: data from the Israel National Health Survey

OBJECTIVE

To measure the 12-month utilization rates for mental health reasons in all types of services.

METHOD

A representative sample extracted from the National Population Register of non-institutionalized residents aged 21 or older were interviewed at their homes between May 2003 and April 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview (WMH-CIDI).

RESULTS

About 10% of the adult population receives some type of treatment for emotional or mental health problems within a single year. More than half of service consumers were not classified as suffering from mood or anxiety disorders. Of those diagnosed with mood or anxiety disorders in the past 12 months only about 50% used any type of service for mental health problems.

CONCLUSION

There is only a partial overlap between those who utilize the services and those who meet the criteria for a clinical diagnosis of mental disorder.

Multiple sclerosis frequency in Israel's diverse populations

BACKGROUND

Israel has served for almost half a century as a site for epidemiologic studies of multiple sclerosis (MS). Its small geographic size, well-equipped, accessible, and subsidized health facilities, trained physicians, detailed census data, and a National MS Register, maintained since 1960, offer advantages for accurate determinations of MS frequency in its diverse populations.

METHOD

The authors calculated age-specific prevalence of MS in Israeli-born Jewish inhabitants, immigrant Jews from Europe/America and from North Africa/Asia, Israeli-born Christian and Moslem Arabs, Druze, and Bedouins.

RESULTS

Prevalence rate of MS per 10(5) population on June 30, 2000, for each of these groups in the order listed was 61.6, 53.7, and 27.9 for the Jewish groups and 35.3, 14.7, 10.9, and 17.3 for the non-Jewish groups. Three tiers in MS prevalence were apparent. The highest rates were in Israeli-born Jews and in Jewish immigrants from Europe/America (significantly higher in the former than the latter). Jewish immigrants from African/Asian countries and Christian Arabs had intermediate MS rates (significantly lower than in the first two groups but not significantly different from each other). Moslem Arabs, Druze, and Bedouins had the lowest rates of MS (significantly lower than in the intermediate group but not significantly different from each other).

CONCLUSION

Diverse ethnic groups living in the same geographic area may have significantly different frequencies of MS.

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel

BACKGROUND

The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals.

METHODS

A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry.

RESULTS

The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge.

CONCLUSION

The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.

Immigrants from the former Soviet Union, 5 years post-immigration to Israel: adaptation and risk factors for psychological distress

BACKGROUND

Studies about the effect of time on the degree of psychological distress among immigrants have reported conflicting findings. We investigated this issue in Israel, which supports actively the absorption of immigrants, and also looked for risk and protective factors for psychological distress 5 years post-immigration.

METHOD

A nationwide sample of 600 subjects who emigrated from the former Soviet Union to Israel in 1990 were interviewed in 1995, with the demoralization subscale of the Psychiatric Epidemiologic Research Interview (PERI-D) for psychological distress, and with a series of questions regarding sociodemographic characteristics, personal assets and their absorption experience. The results were compared with those obtained in a previous study for a sample of the same cohort of immigrants in their first year post-immigration. A multivariate analysis was carried out to examine the relation between the PERI score and the different independent variables.

RESULTS

Although, 5 years after immigration, a favorable change in objective parameters of absorption was found, no decrease in psychological distress was observed. The main risk factors remaining significantly associated with psychological distress in the final model were: adverse life events, lack of perceived social support, poor family functioning, external locus of control, poor physical health status, non-identification with host society and, to a lesser degree, poor material conditions.

CONCLUSION

Psychological readjustment apparently takes longer than other processes of adaptation. Several years after immigration, social and psychological factors have a more important role for the well-being of immigrants than their material conditions.

Comparisons of problems reported by youths from seven countries

OBJECTIVE

This study compared ratings for self-reported behavioral and emotional problems in adolescents from seven countries.

METHOD

Youth Self-Report scores were analyzed for 7,137 adolescents ages 11-18 years from general population samples from Australia, China, Israel, Jamaica, the Netherlands, Turkey, and the United States.

RESULTS

Comparisons of problems scores yielded small to medium effect sizes for cross-cultural variations. Youths from China and Jamaica had the highest and youths from Israel and Turkey had the lowest mean total problems scores. With cross-cultural consistency, girls scored higher for internalizing and lower for externalizing than boys. Cross-cultural correlations were high among the mean item scores.

CONCLUSIONS

Empirically based assessment provided a robust method for assessing and comparing adolescents' self-reported problems. Self-reports thus supplemented empirically based assessments of parent-reported problems and offered a cost-effective way of identifying problems for which adolescents from diverse cultural backgrounds may need help.

Prevalence of myotonic dystrophy in Israeli Jewish communities: inter-community variation and founder premutations

In a comprehensive epidemiological survey among Jews living in Israel, the average prevalence of myotonic dystrophy (DM) was 15.7/10(5) (1 case in 6369) with intercommunity variations; the Ashkenazi Jews had the lowest rate, 5.7/10(5) (1 case in 17544) as compared to the rate in the Sephardim/Oriental Jews 20/10(5) (1 case in 5000) and the in the Yemenite Jews 47.3/10(5) (1 case in 2114). The rate of unrelated DM-sibships per 10(6) people of each community was used as an estimate of the transition rate from stable to unstable DMPK-(CTG)(n) alleles assuming that each transition is a beginning of a new DM sibship. This study indicated that the difference in the incidence of DM is a result of higher mutation rate in the non-Ashkenazi Jews (>50/10(6)) as compared to the rate in the Ashkenazi Jews (16.3/10(6)). The intragenic haplotype of the DM alleles was the same as that of the DM in many populations all over the world. However, two DM closely linked markers D19S207 and D19S112 were in linkage disequilibrium with the DM mutation in patients of Yemenite and Moroccan (the largest subgroup in the Sephardim Jews) extractions and not in the Ashkenazi patients. This observation indicated a common ancestral origin for the DM premutation in patients of the same ethnic origin. We concluded that the difference in the prevalence of DM among the Jewish communities is a consequence of founder premutations in the non-Ashkenazi Jewish communities.

Epidemiology of dementia in Ashkelon: the influence of education

A population study aimed at evaluating the influence of education on the prevalence of dementia was carried out in Ashkelon, a rural city in Israel. The whole population aged over 75 years was screened, with a very low refusal rate. Altogether, 1501 people were examined, using DSM III-R criteria for dementia. The prevalence of dementia increased with age and was higher among females and immigrants to Israel from Africa and Asia. The most significant correlation was with a low level of education, which completely explained the ethnic differences and partially the female predominance in the frequency of dementia. Our study confirms that schooling appears to be an important protective factor against the development of dementia.

The frequency of multiple sclerosis in jewish and arab populations in greater jerusalem

A comparison of the incidence rate (IR) and the prevalence rate (PR) of multiple sclerosis (MS) in subgroups of the same ethnic origin, but born and living in different geographical areas, may delineate the relationship between environmental and genetic risk factors for MS. Previous epidemiological studies of MS in Israel did not include the Arab population and used diagnostic criteria that did not include MRI findings. Therefore, we studied the age-adjusted IR and PR of MS in a more recent sample in different population groups, including Arabs, of Greater Jerusalem. We found that the PR of MS in Israeli Jews is higher than previously described. Furthermore, the PR was significantly lower among immigrant Jews from Asia/Africa (A/A) than among native-born Jews of Asian/African origin (I-A/A). Since these groups have similar genetic susceptibilities to MS, the higher PR in the latter is probably due to environmental factors. Our study does not support the effect of latitude on the risk of developing MS since no difference in the PR was found between immigrant Jews from Europe/America (E/A) and native-born Jews of European/American origin (I-E/A). Among Arabs, the PR was similar to that among A/A. Therefore, we hypothesized similarity in environmental etiologic factors for MS between the countries of origin of A/A immigrants and of Arabs communities in Greater Jerusalem. The IR of I-E/A was higher than that of I-A/A and Arabs, although this difference did not reach statistical significance.

Effect of transfer of long-stay psychiatric inpatients from hospital to hospital

BACKGROUND

Chronic psychiatric patients hospitalized in institutions about to be closed are not always fit to be transferred to community-based facilities. The purpose of our study was to investigate how the mental health of a group of such patients was affected by their being transferred to another hospital.

METHODS

202 patients were evaluated prior to transfer and six months after the transfer, by means of the Clinical Global Impression (CGI), the World Health Organization (WHO) Disability Scale and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE).

RESULTS

On the CGI, half the patients showed evidence of improvement while only 4% seemed to deteriorate. For the NOSIE and WHO Disability Scale, improvement of scores was similarly more common than deterioration. Factors that correlated with improvement included male sex, younger age, and a shorter hospital stay.

LIMITATIONS

This is a naturalistic study of the effects of transfer which does not include a control group.

CONCLUSION

Institutional transfer of psychiatric patients can be carried out without harm to the patient's welfare, and may even be beneficial.

[Development of a culturally sensitive psychiatric screening instrument for detecting emotional problems among Ethiopian immigrants in Israel]

BACKGROUND

Studies have demonstrated that a large percentage of patients in primary care clinics suffer from emotional problems. Many of the patients who suffer from these problems are not diagnosed properly, and do not receive appropriate treatment by the medical staff. The problem is especially severe for patients who immigrated to Israel from Ethiopia. This is mainly due to the difference between the medical belief system familiar to the Ethiopian immigrants and that of the non-Ethiopian doctors. It is also the result of the use of culturally typical idioms of distress by the Ethiopians that are not clearly understood by the doctors. The WHO developed the SRQ--Self-Reporting Questionnaire, a psychiatric screening instrument to assess populations in developing countries. Although this instrument has been widely used both in developing and developed countries, it has been found to be problematic in certain cultures. The difficulties stem partly from differences between the spontaneous idioms of distress used by the interviewees, for example the Ethiopians, and the idioms of distress that appear in the SRQ.

OBJECTIVE

The goal of this research was to develop a psychiatric screening instrument, based on the SRQ, which would be valid and culturally sensitive to Ethiopian immigrants in Israel.

METHODS

The sample included 161 immigrants from Ethiopia, aged 18-55 years, who were born in the Gondar region. The interviewees were divided into three groups according to their "level of treatment": healthy individuals from the general population, who were sampled, mainly using the "quota sampling" method, in those cities where a high percentage of Ethiopian immigrants reside; consecutive patients in primary care clinics and in specialist clinics in the same cities; and consecutive patients in care in psychiatric clinics throughout the country. The research instruments included an expanded version of the SRQ (the SRQ-E) and the expanded version of the BPRS--Brief Psychiatric Rating Scale. The validity of each question of the SRQ-E was examined in order to create a new psychiatric screening questionnaire that is both valid and parsimonious. The internal consistency and the construct and criterion validity of this new screening questionnaire were then examined. The sensitivity and specificity of the instrument for detecting psychopathology were assessed.

RESULTS

The new screening instrument was determined to be valid: a score of 7 distinguishes between those with and without psychopathology, with a sensitivity and a specificity of 87%.

Depression and anxiety disorders among Jews from the former Soviet Union five years after their immigration to Israel

BACKGROUND

Epidemiological studies have shown that the prevalence rates of major depression and anxiety are lower in the elderly than in younger adults. In a recent survey, we found, among immigrants, that the association of age with psychological distress was the reverse.

OBJECTIVE

The objective of the present study was to examine, among immigrants, whether the relationship of age with clinically diagnosed depression and anxiety disorders is also reversed. This was done by assessing the age-specific incidence and prevalence of depression and anxiety among immigrants from the former Soviet Union to Israel five years after their immigration.

METHODS

A stratified subsample was chosen from a larger random sample of immigrants from the Former Soviet Union who arrived in Israel in 1990. We selected the subsample to include an over-representation of those with a high level of distress in order to increase the probability of finding people suffering from psychopathology. The subjects were interviewed with a diagnostic instrument, the CIDI-S, an abbreviated version of the CIDI. Prevalence and incidence rates of depression and anxiety were calculated separately for two age groups (those below age 65 and those aged 65 and above).

RESULTS

Before immigration, incidence rates were lower among the elderly than among younger adults, a finding consistent with the literature. However, after immigration, the reverse was found, with higher prevalence and incidence rates among elderly immigrants.

CONCLUSION

The data suggest that immigration contributes to an increase of psychopathology which is particularly pronounced among the elderly.

Creutzfeldt-Jakob disease profile in patients homozygous for the PRNP E200K mutation

We identified 70 Creutzfeldt-Jakob disease patients with the previously described E200K mutation in the prion protein gene. The purpose of this study was to define the clinical features of E200K homozygous patients (n = 5), compared with heterozygotes. We found a statistically significant younger age at disease onset for the homozygous patients, although the average age at onset in this group was still in midlife. Disease features were not statistically different in the two groups. Possible explanations are discussed.

Syndrome dimensions of the child behavior checklist and the teacher report form: a critical empirical evaluation

The construct representation of the cross-informant model of the Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF) was evaluated using confirmatory factor analysis. Samples were collected in seven different countries. The results are based on 13,226 parent ratings and 8893 teacher ratings. The adequacy of fit for the cross-informant model was established on the basis of three approaches: conventional rules of fit, simulation, and comparison with other models. The results indicated that the cross-informant model fits these data poorly. These results were consistent across countries, informants, and both clinical and population samples. Since inadequate empirical support for the cross-informant syndromes and their differentiation was found, the construct validity of these syndrome dimensions is questioned.

A statistical method for quantitative evaluation of the progression of chronic diseases: the mean score graph (MSG)

We present a quantitative method of evaluation of the clinical course of chronic disease with long-term progressive deterioration. The method takes into account information on all patients, whatever their duration of follow-up. We present the 'mean score graph' as a descriptive device which is an extension of a survival graph. The description of progression of idiopathic torsion dystonia, comparing progression in males and females, is used as an example of the application. A test for group comparison is described.

Environmental risk factors for subacute sclerosing panencephalitis (SSPE)

In Israel, SSPE has been shown to be much more frequent among Sephardic Jews and Arabs than among Ashkenazic Jews. In the present study, we tried to explore environmental factors that may be of etiological importance and explain these differences in prevalence. The study is a case-control one, which includes 95 patients and 2 groups of controls, with 95 people in each. The general population controls were group-matched to the case group by sex, age, and ethnic origin. The family controls consisted of the sibling closest in age to each patient. A statistically significant positive correlation was found between risk of SSPE and early measles infection, large family, overcrowding in the home, older age of the mother, higher birth order, fewer years of schooling of the parents, fewer cultural activities, and rural place of birth. All these factors are interpreted as contributing to a higher risk of early measles infections, which thus may well be the main risk factor for SSPE.

The natural history of degenerative ataxia: a retrospective study in 466 patients

The aim of the present study was (i) to compare disease progression and survival in different types of degenerative ataxia, and (ii) to identify variables that may modify the rate of disease progression. We included patients suffering from Friedreich's ataxia (FRDA, n = 83), early onset cerebellar ataxia (EOCA, n = 30), autosomal dominant cerebellar ataxia (ADCA) type I (ADCA-I, n = 273), ADCA-III (n = 13) and multiple system atrophy (MSA, n = 67). Molecular genetic testing allowed us to assign 202 ADCA-I patients to one of the following subgroups: spinocerebellar ataxia type I (SCAI, n = 36), SCA2 (n = 56) and SCA3 (n = 110). To assess disease progression we defined the following disease stages: stage 0 = no gait difficulties; stage 1 = disease onset, as defined by onset of gait difficulties; stage 2 = loss of independent gait; stage 3 = confinement to wheelchair; stage 4 = death. Disease progression was most rapid in MSA, intermediate in FRDA, ADCA-I and ADCA-III and slowest in EOCA. The rate of progression was similar in SCA1, SCA2 and SCA3. The CAG repeat length was a significant risk factor for faster progression in SCA2 and SCA3, but not in SCA1. In FRDA, the time until confinement to wheelchair was shorter in patients with earlier disease onset, suggesting that patients with long GAA repeats and early disease onset have a poor prognosis. Female gender increased the risk of becoming dependent on walking aids or a wheelchair, but it did not influence survival in FRDA, SCA3 and MSA. In SCA2, female gender was associated with shortened survival. In MSA, later age of onset increased the risk of rapid progression and death.

Risk factors for multiple sclerosis: a case-control study in Israel

This case-control study was aimed at identifying environmental risk factors for multiple-sclerosis (MS). Ninety-three Israeli-born MS patients identified in country-wide studies and 94 age- and sex-matched controls were interviewed. The questionnaire covered a large span of factors at ages 0, 10 and onset of the disease, with particular emphasis on socioeconomic status (SES) and sanitary conditions (SAN). A significantly larger percentage of patients reported frequent respiratory educational levels than controls. The SES and SAN at age 10 were also systematically higher among patients, but significance was reached only when the frequencies of conditions indicating extremely low values of SES or SAN were compared. It is possible that the protective effect of low SES or SAN on risk of MS can be detected only when living conditions are well below average, as is frequent in developing countries.

Psychological distress among recent immigrants from the former Soviet Union to Israel, II. The effects of the Gulf War

The psychological effects of the Gulf War were studied on a group of Israeli civilians particularly at risk, viz. recent immigrants from the former Soviet Union. A quasi-experimental design was used. A sample of immigrants who had already been screened for psychological distress just before the war were reassessed after the war with the same instrument (PERI demoralization questionnaire). Various parameters related to the war period were also assessed. Psychological symptoms during the war were significantly associated with pre-war level of distress and with actual physical harm from the missiles, but not with exposure to danger (proximity of residence to areas hit by missiles). Correlates of behaviour in the face of life-threatening danger during the war (change of residence and help-seeking behaviour) were also identified. Overall the level of post-war psychological distress was not found to be higher than pre-war levels. This was explained by the immigrants' feelings of shared fate, belonging and sense of cohesion, which characterize the general Israeli population during war time.

Psychological distress among recent immigrants from the former Soviet Union to Israel, I. Correlates of level of distress

In most migrations some selection takes place either by the absorbing country and/or the individuals who emigrate. Israel has an open-door policy for immigrants and the recent large wave of immigrants from the former Soviet Union was made up of entire families rather than individuals. This provided an opportunity to examine the issue of migration and psychological distress more directly. A nationwide sample of 600 immigrants who arrived during the preceding year were interviewed in December 1990. Their psychological distress was measured by the PERI Demoralization questionnaire. For both genders, the mean demoralization score of the immigrant sample was found to be significantly higher than that reported for the Israeli-born population (after controlling for education). The factors that were found to be correlated with the level of distress were mostly individual characteristics of the immigrants (e.g. profession, religiousness, former residence in the Chernobyl region, previous contact with the health profession because of psychological problems). Increased distress was also significantly related to perceived lack of social support in Israel, which may in fact be partly determined by personality traits.

Brief report: circadian melatonin, thyroid-stimulating hormone, prolactin, and cortisol levels in serum of young adults with autism

An abnormal circadian pattern of melatonin was found in a group of young adults with an extreme autism syndrome. Although not out of phase, the serum melatonin levels differed from normal in amplitude and mesor. Marginal changes in diurnal rhythms of serum TSH and possibly prolactin were also recorded. Subjects with seizures tended to have an abnormal pattern of melatonin correlated with EEG changes. In others, a parallel was evidenced between thyroid function and impairment in verbal communication. There appears to be a tendency for various types of neuroendocrinological abnormalities in autistics, and melatonin, as well as possibly TSH and perhaps prolactin, could serve as biochemical variables of the biological parameters of the disease.