Flattening the COVID-19 Curve: The Unique Role of Emergency Medical Services in Containing a Global Pandemic

BACKGROUND

The potential excess flow of patients into emergency departments and community clinics for testing and examination during a pandemic poses a major issue. These additional patients may lead to the risk of viral transmission to other patients and medical teams. To contain the spread of coronavirus disease-2019 (COVID-19), the Israeli Ministry of Health initiated a plan spearheaded by Magen David Adom (MDA), Israel's national emergency medical services (EMS) organization.

OBJECTIVES

To describe outbreak containment actions initiated by MDA, including a COVID-19 tele-triage center and home testing by paramedics.

METHODS

Retrospective analysis was conducted of de-identified data from the call management and command and control systems during the first period of the COVID-19 outbreak in Israel (23 February 2020-15 March 2020).

RESULTS

During the study period, the total number of calls to the dispatch centers was 477,321 with a daily average of 21,696, compared to 6000-6500 during routine times. The total number of COVID-19 related calls was 334,230 (daily average 15,194). There were 28,454 calls (8.51% of all COVID-19 related calls, average 1293/day) transferred to the COVID-19 call center. Of the COVID-19 call center inquiries, 8390 resulted in the dispatch of a dedicated vehicle, including a paramedic wearing personal protective equipment, to collect samples for testing (daily average 381).

CONCLUSIONS

Maximizing EMS during a pandemic using phone triage, in addition to dispatching paramedics to perform home testing, may significantly distance infected patients from the public and health care system. These steps can further minimize the spread of disease.

[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.

The long-term health consequences of genocide: developing GESQUQ - a genocide studies checklist

Background

Genocide is an atrocity that seeks to destroy whole populations, leaving empty countries, empty spaces and empty memories, but also a large health burden among survivors is enormous. We propose a genocide reporting checklist to encourage consistent high quality in studies designed to provide robust and reliable data on the long term impact of genocide.

Methods

An interdisciplinary (Public Health, epidemiology, psychiatry, medicine, sociology, genocide studies) and international working committee of experts from Germany, Israel, the United States, and the United Kingdom used an iterative consensus process to develop a genocide studies checklist for studies of the long term health consequences.

Results

We created a list of eight domains (A Ethical approval, B External validity, C Misclassification, D Study design, E Confounder, F Data collection, G Withdrawal) with 1–3 specific items (total 17).

Conclusion

The genocide studies checklist is easy to use for authors, journal editors, peer reviewers, and others involved in documenting the health consequences of genocide.

Electronic supplementary material

The online version of this article (10.1186/s13031-019-0198-9) contains supplementary material, which is available to authorized users.

Holocaust Survival and the Long-term Risk of Cardiovascular Disease in the Elderly

BACKGROUND

Reports of longevity in Holocaust survivors (HS) conflict with excess prevalence of chronic diseases described among them. However, data on their long-term risk of cardiovascular diseases (CVD) are limited. Clinical data on large representative groups of HS who were exposed to severe persecution are also limited.

OBJECTIVES

To determine the prevalence of CVD and the risk factors in a large cohort of elderly HS compared to elderly individuals who were not exposed to the Holocaust (NHS).

METHODS

CVD prevalence rates and risk factors data from the computerized system of the central district of Clalit Health Services, the largest Israeli health maintenance organization (HMO) in Israel were evaluated in a retrospective observational study. The study was comprised of 4004 elderly HS who underwent direct severe persecution. They were randomly matched by identification numbers to 4004 elderly NHS.

RESULTS

HS were older than NHS and 51% of them were older than 85 years. The prevalence rate of ischemic heart disease (IHD) was significantly higher among HS. HS underwent significantly more cardiac interventions (20% vs. 15.7%, P < 0.05). HS status was an independent risk factor for increased IHD and for more coronary interventions.

CONCLUSIONS

Despite having a higher prevalence of CVD, a substantial number of HS live long lives. This finding may imply both unique resilience and ability to cope with chronic illness of the survivors as well as adjusted medical services for this population. These findings may help in planning the treatment of other mass trauma survivors.

Psychopathology of children of genocide survivors: a systematic review on the impact of genocide on their children`s psychopathology from five countries

Background

: The health consequences of genocides on children of survivors are increasingly discussed but conclusions have been conflicting.

Methods

We systematically reviewed studies from five electronic databases (EMBASE, PILOTS, PUBMED, PsycINFO, Web of Science), which used a quantitative study design and included: (i) exposure to the genocides of Armenians in Nazi Germany, Cambodia, Rwanda and Bosnia; (ii) mental health outcomes; (iii) validated instruments; (iv) statistical tests of associations. Study quality was appraised using a quality assessment tool for genocide studies. PRISMA reporting guidelines were followed.

Results

From 3352 retrieved records, 20 studies with a total of 4793 participants involving 2431 children of survivors and 2362 controls met the eligibility criteria. Studies were conducted in seven countries: Australia, Canada, Italy, Israel, Norway, Rwanda and the USAs over the past seven decades, using the Genocide Studies Quality Assessment Tool. Data from the high quality studies provide no consistent evidence that children of genocide survivors are more likely to have mental health problems than comparators who were not children of genocide survivors.

Conclusions

Methodological characteristics were associated with findings: studies investigating random samples of genocide survivors did not find an impact of genocides on health of children of survivors. Potential confounders (e.g. recent life events, poverty) need further investigation. Future studies of the impact of genocides on mental health should report using a standardized structure, such as the quality tool used here.

[Novel psychotherapeutic methods and the role of mental health centers in their implementation]

In this issue of Harefuah, Arbel et at. describe the implementation of mindfulness-based psychotherapy IMBP) in the Beer Sheba Mental HeaLth Center. MBP is an example of a form of complementary and alternative medical treatment, which became widespread and is now considered both safe and efficient. It includes mindful sitting practice, developing awareness, mindful movement, psycho-education, and often a cognitive component. MBP has a role in the treatment of minor and major mental disorders, and'may also alleviate stress and improve weLtl-being among therapists. In the Beer Sheba Center, MBP courses were offered to all staff members, and MBP group treatment was started in one of the wards. The promising results of MBP's implementation will be evaluated. This project emphasizes the pivotal role of mental health centers in the teaching of students and residents in mental health. This role must be considered while planning the future of these centers in the current reform of Israel's psychiatric services.

Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study

The use of firearms is a common means of suicide. We examined the effect of a policy change in the Israeli Defense Forces reducing adolescents' access to firearms on rates of suicide. Following the policy change, suicide rates decreased significantly by 40%. Most of this decrease was due to decrease in suicide using firearms over the weekend. There were no significant changes in rates of suicide during weekdays. Decreasing access to firearms significantly decreases rates of suicide among adolescents. The results of this study illustrate the ability of a relatively simple change in policy to have a major impact on suicide rates.

Factors influencing the willingness of volunteer paramedics to re-volunteer in a time of war

BACKGROUND

Professional volunteers play a crucial role in reinforcing emergency medical services in Israel. In order to encourage volunteers to return for additional shifts, the organization should provide conditions that will assure the return, particularly at a time of self-risk such as war. In 2009 Israeli emergency medical services (Magen David Adom) were required to increase preparedness in the southern part of the country due to missile attacks on civilian populations, while continuing their routine activities, i.e., responding promptly to emergency events. In order to perform these multiple functions, MDA stations in the towns under attack were strengthened with volunteers from other regions of the country. These volunteers, trained as paramedics, served in 24-48 hour shifts.

OBJECTIVES

To identify the factors influencing the willingness of volunteers to return.

METHODS

A questionnaire was used to assess the satisfaction of volunteers participating in the reinforcement with regard to their physical environment, job assignment and the actual activity they were involved in. Data were analyzed using SPSS statistical software.

RESULTS

During the 10 days of the study, 121 volunteers reinforced southern MDA stations and 99 (81%) of them responded to the questionnaire. We found that volunteers' willingness to return to do more shifts was affected by their welcome and reception at the station, their job assignment, and their training and preparation for performing the necessary tasks. The sleeping conditions and the number of events they participated in were also contributing factors.

CONCLUSIONS

Factors that contribute to the willingness of volunteers to re-volunteer should be taken into account by organizations that rely on them.

Hypnotherapy in the treatment of chronic combat-related PTSD patients suffering from insomnia: a randomized, zolpidem-controlled clinical trial

This study evaluated the benefits of add-on hypnotherapy in patients with chronic PTSD. Thirty-two PTSD patients treated by SSRI antidepressants and supportive psychotherapy were randomized to 2 groups: 15 patients in the first group received Zolpidem 10 mg nightly for 14 nights, and 17 patients in the hypnotherapy group were treated by symptom-oriented hypnotherapy, twice-a-week 1.5-hour sessions for 2 weeks. All patients completed the Stanford Hypnotic Susceptibility Scale, Form C, Beck Depression Inventory, Impact of Event Scale, and Visual Subjective Sleep Quality Questionnaire before and after treatment. There was a significant main effect of the hypnotherapy treatment with PTSD symptoms as measured by the Posttraumatic Disorder Scale. This effect was preserved at follow-up 1 month later. Additional benefits for the hypnotherapy group were decreases in intrusion and avoidance reactions and improvement in all sleep variables assessed.

Impaired reading comprehension and mathematical abilities in male adolescents with average or above general intellectual abilities are associated with comorbid and future psychopathology

Research indicates that persons with learning disorders often suffer from psychopathology. We assessed current and future psychopathology in male adolescents with discrete impairments in reading comprehension (IRC) or arithmetic abilities (IAA) but with average or above-average general intellectual abilities. Subjects were a population-based cohort of 174,994 male adolescents screened by the Israeli Draft Board with average or above-average intellectual abilities but with low scores (8.6th and 10th lowest percentile respectively) on reading or arithmetic tests. They were compared with adolescents who scored in the 10th percentile and above on these tests (comparison group). Relative to the comparison group, male adolescents with IRC, IAA, or IRC and IAA (0.69%), had poorer scores on most behavioral assessments and higher prevalence of current psychopathology: 4.2% (comparison group), 8.0% (IRC), 7.0% (IAA), and 9.8% (IRC and IAA). Adolescents with IRC were also at increased risk for later hospitalization for schizophrenia (hazard ratios = 1.8, 95% confidence interval: 1.3-2.6). Male adolescents with average and above-average general intellectual abilities but with IRC or IAA are more likely to have current and future psychopathology. Impairments in intellectual functioning and abnormal behaviors leading to mental illnesses may share common neurobiological substrates. The results support screening male adolescents with learning disorders for psychopathology.

Social and cognitive functioning, urbanicity and risk for schizophrenia

BACKGROUND

Previous work suggests that the association between urbanicity and schizophrenia may be greatest in those with pre-existing vulnerability.

AIMS

To test for synergism in risk of schizophrenia between population density and a combined exposure of poor premorbid social and cognitive functioning.

METHOD

For 371 603 adolescent males examined by the Israeli Draft Board on social and cognitive functioning, data on population density of place of residence and later hospitalisation for schizophrenia were obtained from population-based registries.

RESULTS

There was an interaction between population density (five levels) and poor premorbid social and cognitive functioning (interaction chi(2)=4.6, P=0.032). The adjusted increase in cumulative incidence associated with one unit change in population density was 0.10% in the vulnerable group (95% CI 0.019-0.18, P=0.015), nine times larger than that in the non-vulnerable group (0.011%, 95% CI 0.0017-0.020, P=0.021).

CONCLUSIONS

Risk of schizophrenia may increase when people with a genetic liability to the disorder, expressed as poor social and cognitive functioning, need to cope with city life.

Psychological guidelines for a medical team debriefing after a stressful event

Medical and rescue workers are at risk of developing mental syndromes including post-traumatic stress disorder after disasters and it is widely accepted that they should be offered a preventive intervention. The Israel Defense Force Medical Corps has developed psychological guidelines for the medical forces: a medical team debriefing after treating the injured as a preventive intervention for an event that may be experienced as stressful. The main purpose of the debriefing is to investigate the circumstances of the event, analyze the medical team's functioning, and draw the relevant conclusions and the manner of their implementation. The purpose of the guidelines is to enhance mental coping, possibly prevent stress reactions, and help in screening individuals in need of further professional intervention for stress reactions. These guidelines are suitable for similar interventions in other professional teams.

Advancing paternal age and autism

CONTEXT

Maternal and paternal ages are associated with neurodevelopmental disorders.

OBJECTIVE

To examine the relationship between advancing paternal age at birth of offspring and their risk of autism spectrum disorder (ASD).

DESIGN

Historical population-based cohort study.

SETTING

Identification of ASD cases from the Israeli draft board medical registry.

PARTICIPANTS

We conducted a study of Jewish persons born in Israel during 6 consecutive years. Virtually all men and about three quarters of women in this cohort underwent draft board assessment at age 17 years. Paternal age at birth was obtained for most of the cohort; maternal age was obtained for a smaller subset. We used the smaller subset (n = 132 271) with data on both paternal and maternal age for the primary analysis and the larger subset (n = 318 506) with data on paternal but not maternal age for sensitivity analyses.

MAIN OUTCOME MEASURES

Information on persons coded as having International Classification of Diseases, 10th Revision ASD was obtained from the registry. The registry identified 110 cases of ASD (incidence, 8.3 cases per 10 000 persons), mainly autism, in the smaller subset with complete parental age data.

RESULTS

There was a significant monotonic association between advancing paternal age and risk of ASD. Offspring of men 40 years or older were 5.75 times (95% confidence interval, 2.65-12.46; P<.001) more likely to have ASD compared with offspring of men younger than 30 years, after controlling for year of birth, socioeconomic status, and maternal age. Advancing maternal age showed no association with ASD after adjusting for paternal age. Sensitivity analyses indicated that these findings were not the result of bias due to missing data on maternal age.

CONCLUSIONS

Advanced paternal age was associated with increased risk of ASD. Possible biological mechanisms include de novo mutations associated with advancing age or alterations in genetic imprinting.

Increased use of mental health services related to isotretinoin treatment: a 5-year analysis

BACKGROUND

The association between exposure to Isotretinoin, the development of depression and suicide attempts is controversial.

OBJECTIVE

To retrospectively assess pattern of utilization of mental health services in the Israeli Defense Forces (IDF) during a 5-year period for all subjects exposed to Isotretinoin in comparison to a control group consisting of army conscripts suffering from psoriasis. All subjects were young adults (18 to 21 years old) in compulsory military service.

METHOD

Exposure to Isotretinoin mandates reporting and marking as a coded medical profile in the IDFs' computerized medical record of each conscript and soldier. Medical data, tracked by military medical profiles, were summarized from medical records of all subjects treated by Isotretinion during the years 1999-2003 and for the control group for the same period. Use of mental health services was the a-priori defined primary outcome measure.

RESULTS

During the study period 1419 subjects were exposed to Isotretinoin and 1102 suffered from psoriasis. Utilization of mental health services was highest for the index group wherein 17.2% (245/1419) of subjects were evaluated or treated compared to 12.5% in the control group (psoriasis). The inter-group differences were statistically significant; Chi-square=15.9 (df=2), p=0.0003.

CONCLUSIONS

We suggest that psychiatric evaluation be regularly undertaken prior to initiation of Isotretinion treatment in young adults at risk, as well as providing follow-up visits during and at completion of treatment.

Effects of season of birth on autism spectrum disorders: fact or fiction?

OBJECTIVE

This study attempted to examine the relationship between month and season of birth and risk for autism spectrum disorders.

METHOD

The cohort included all Jewish individuals born in Israel over 5 consecutive years (N=311,169) and assessed by the Israeli Draft Board as part of the mandatory assessment of eligibility for military service conducted at age 17. The outcome of autism spectrum disorders was ascertained from the Draft Board Medical Registry, which contains information about medical and psychiatric disorders for this population of adolescents.

RESULTS

There was no association between month or season of birth and the prevalence of autistic spectrum disorders.

CONCLUSIONS

The findings from this historical, population-based cohort study do not support an association between season of birth and autistic spectrum disorders.

Premorbid intra-individual variability in intellectual performance and risk for schizophrenia: a population-based study

BACKGROUND

Some, but not most, schizophrenia patients have below-average intelligence years before they manifest psychosis. However, it is not clear if those whose intelligence falls within-normal-range nevertheless have cognitive abnormalities. We examined the association between intra-individual variability in intellectual performance and risk for schizophrenia in individuals with normal IQ.

METHODS

555,326 adolescents, mandatory assessed by the Israeli Draft Board were followed up over 8 to 17 years for psychiatric hospitalization by means of the Israeli National Psychiatric Hospitalization Case Registry. Data were available on 4 intelligence sub-tests, and on behavioral and psychosocial variables. Variability was computed from the variance of the four intelligence tests' standardized scores.

RESULTS

There was a significant monotonic association between increased intra-individual variability in intellectual performance and risk of schizophrenia in individuals with within-normal-range IQ. Individuals with the highest variability were 3.8 times more likely to have schizophrenia [95%CI: 2.32-6.08; p < 0.0001] compared with individuals with the lowest variability. This association held after controlling for the effects of potential confounders.

CONCLUSIONS

Despite within-normal-range premorbid IQ, apparently healthy adolescents who will later on manifest schizophrenia, nevertheless have cognitive abnormalities such as increased variability across intellectual tasks, possibly related to frontal lobe abnormalities.

Premorbid intellectual functioning and risk of schizophrenia and spectrum disorders

Evidence from longitudinal studies indicates that lower IQ score in childhood and early adolescence increases risk of schizophrenia and schizophrenia spectrum disorders (SSD). This study investigated the association between premorbid IQ and risk of SSD in a population-based cohort of 17-year-old conscripts. Fifty four thousand males assessed by the Israeli Draft Board during two consecutive years were followed by means of the Israeli National Psychiatric Hospitalization Case Registry for up to 11 years. Tests of verbal and non-verbal reasoning, mathematical knowledge and instructions comprehension and several psychosocial variables were recorded by the Draft Board. Risk for SSD increased with decreasing IQ score. Only poorer non-verbal reasoning conferred a significant increased risk for SSD after taking into account general intellectual ability. IQ was not associated with age of onset. These results confirm the importance of low intellectual functioning as a risk factor for SSD. This is unlikely to be due to prodrome.

Elaboration on premorbid intellectual performance in schizophrenia: premorbid intellectual decline and risk for schizophrenia

CONTEXT

Consistent evidence indicates that some, but not most, patients with schizophrenia have below-average intelligence years before they manifest psychosis. However, it is not clear whether this below-average premorbid intelligence is stable or progressive.

OBJECTIVE

To examine whether increased risk for schizophrenia is associated with declining intellectual performance from childhood through adolescence.

DESIGN

Historical cohort study of an entire population using record linkage for psychiatric hospitalization during an 8- to 17-year follow-up period.

SETTING

Mandatory assessment by the draft board of Israeli conscripts.

PARTICIPANTS

Population-based cohort of 555 326 adolescents born in Israel. Data were available on 4 intelligence subtests as well as on reading and spelling abilities and on behavioral and psychosocial variables. A regression-based approach was used to assess the discrepancy between actual IQ at age 17 years and estimated IQ during childhood based on reading and spelling abilities.

MAIN OUTCOME MEASURES

Hospitalization for schizophrenia (as per the International Statistical Classification of Diseases, 10th Revision criteria).

RESULTS

Lower-than-expected IQ at age 17 years was associated with increased risk for later hospitalization for schizophrenia. Results were held after controlling for potential confounders. For 75% of patients with schizophrenia with low actual IQ (<85) at age 17 years and for 23% of patients with actual IQ within the normal range (> or =85), actual IQ was 10 or more points lower than expected. Lower-than-expected IQ was not associated with bipolar disorder or with depression or anxiety disorder.

CONCLUSIONS

Indirect evidence suggests that intellectual deterioration from childhood through adolescence is associated with increased risk for schizophrenia. Despite within-normal-range premorbid IQ scores, apparently healthy adolescents who will later manifest schizophrenia nevertheless have intellectual decline.

Paternal age and intelligence: implications for age-related genomic changes in male germ cells

BACKGROUND

A robust association between advancing paternal age and schizophrenia risk is reported, and genetic changes in the germ cells of older men are presumed to underlie the effect. If that is so, then the pathway may include effects on cognition, as those with premorbid schizophrenia are reported to have lower intelligence. There are also substantial genetic influences on intelligence, so de novo genetic events in male germ cells, which accompany advancing paternal age, may plausibly influence offspring intelligence.

OBJECTIVE

An association of paternal age with IQ in healthy adolescents may illuminate the mechanisms that link it to schizophrenia.

METHOD

We examined the association of paternal age and IQ scores using the Israeli Army Board data on 44 175 individuals from a richly described birth cohort, along with maternal age and other potential modifiers.

RESULTS

A significant inverted U-shaped relationship was observed between paternal age and IQ scores, which was independent from a similar association of IQ scores with maternal age. These relationships were not significantly attenuated by controlling for multiple possible confounding factors, including the other parent's age, parental education, social class, sex and birth order, birth weight and birth complications. Overall, parental age accounted for approximately 2% of the total variance in IQ scores, with later paternal age lowering non-verbal IQ scores more than verbal IQ scores.

CONCLUSION

We found independent effects of maternal and paternal age on offspring IQ scores. The paternal age effect may be explained by de novo mutations or abnormal methylation of paternally imprinted genes, whereas maternal age may affect fetal neurodevelopment through age-related alterations in the in-utero environment. The influence of late paternal age to modify non-verbal IQ may be related to the pathways that increase the risk for schizophrenia in the offspring of older fathers.

Increased risk of attempted suicide among aging holocaust survivors

OBJECTIVE

Suicide rates are higher in elderly persons than in those at other phase of the life-cycle. The majority of World War II (WWII) veterans and Holocaust survivors still define their war experiences as being the "most significant stressor" of their lives. Aging of survivors is frequently associated with depression, reactivation of traumatic syndromes, physical disorders, loss, and psychological distress, possibly increasing the risk of suicide. The aim of the present study was to investigate, among a large cohort of elderly Holocaust survivors, whether their WWII experiences confer an increased risk of suicidal behavior.

METHODS

All medical records of elderly patients admitted to a psychiatric hospital in Israel during a 5-year period were retrospectively evaluated. Suicidal patients were compared with patients who had not attempted suicide.

RESULTS

Of 921 eligible patients, 374 were Holocaust survivors; 135 (14.6%) had attempted suicide in the month before admission. Ninety Holocaust survivors (24%) had attempted suicide, versus 45 of the 502 patients (8.2%) with no WWII experience. The risk of attempted suicide among Holocaust survivors was significantly increased.

CONCLUSION

Although these findings are from a highly selected sample, we suggest that aging Holocaust survivors are at increased risk of attempting suicide. The growth of the elderly population, of whom many had had traumatic life experiences, emphasizes the need to implement preventive strategies so that suicidal risk may be contained.

Affective psychosis following Accutane (isotretinoin) treatment

Isotretinoin (Accutane) ranks in the top 10 of the US Food and Drug Administration's database of drugs associated with reports of depression and suicide attempts. However, this association is still controversial because up to 5.6% of patients with moderate acne may have pre-existing suicidal ideations, improvement of acne often reduces associated depression, and isotretinoin users are reportedly no more likely than those taking antibiotics for acne to have depression or commit suicide. We describe a series of cases of manic psychosis that developed in a 1-year period (2003) in association with isotretinoin treatment and resulted in suicidality and progression to long-standing psychosis. Cases were drawn from 500 soldiers who had been evaluated in a military specialists dermatology clinic for severe acne. Data were summarized from medical records of five severe acne patients treated by isotretinion during their compulsory military service. Data from their draft board examinations and service records, as well as repeated clinical assessments by certified psychiatrists at the Israel Defense Forces (IDF) Mental Health Department clinic, were evaluated. Five young adults developed manic psychosis within a mean of 7.6 months of exposure to isotretinoin. In three cases, this was accompanied by a suicide attempt, and in three cases, psychosis lasted for longer than 6 months. Either a personal history of obsessive-compulsive disorder, neurological insult or family history of a major psychiatric illness were present in all cases. The present case-series is suggestive of an increase in the likelihood of an association between exposure to isotretinion and manic psychosis. Associated risk factors were both family and personal history of psychiatric morbidity. Further studies are needed to establish our findings.

Cognitive performance of male adolescents is lower than controls across psychiatric disorders: a population-based study

OBJECTIVE

Psychiatric patients, as well as humans or experimental animals with brain lesions, often concurrently manifest behavioral deviations and subtle cognitive impairments. This study tested the hypothesis that as a group, adolescents suffering from psychiatric disorders score worse on cognitive tests compared with controls.

METHOD

As part of the assessment for eligibility to serve in the military, the entire, unselected population of 16-17-year old male Israelis undergo cognitive testing and screening for psychopathology by the Draft Board. We retrieved the cognitive test scores of 19 075 adolescents who were assigned any psychiatric diagnosis, and compared them with the scores of 243 507 adolescents without psychiatric diagnoses.

RESULTS

Mean test scores of cases were significantly poorer then controls for all diagnostic groups, except for eating disorders. Effect sizes ranged from 0.3 to 1.6.

CONCLUSION

As group, adolescent males with psychiatric disorders manifest at least subtle impairments in cognitive functioning.

Body mass index and future schizophrenia in Israeli male adolescents

BACKGROUND

Compared with the general population, individuals suffering from schizophrenia are more likely to be overweight, a finding attributed to the effect of antipsychotic medications, poor nutrition, and sedentary lifestyle. As evidence accumulates indicating that some aspects of the illness manifest before the onset of psychosis and establishment of the diagnosis, it has been suggested that increased weight, like other metabolic dysfunctions, might precede active illness.

METHOD

Data on height and weight of 203,257 male adolescents assessed by the Israeli Draft Board, and followed for 2-6 years for later hospitalization for schizophrenia using the Israeli National Psychiatric Hospitalization Case Registry, were analyzed.

RESULTS

From the entire cohort, 309 (0.15%) were later hospitalized for schizophrenia (ICD-10). After removing adolescents with evidence of illness before or within 1 year of the Draft Board assessment, 204 future schizophrenia patients were available for analysis. Compared with the rest of the cohort, future schizophrenia patients had lower body mass indexes (21.24 +/- 3.3 kg/m2 vs. 21.77 +/- 3.5 kg/m2; F = 4.682, df = 1, p = .03) and weighed slightly but significantly less (64.2 +/- 11.6 kg vs. 66.3 +/- 12.0 kg; F = 6.615, df = 1, p = .01). The mean height of the future patients did not differ significantly from the mean height of the remaining cohort (173.63 +/- 6.7 cm vs. 174.40 +/- 6.9 cm; F = 2.520, df = 1, p = .112). When reanalyzing the data, controlling for physical activity and socioeconomic status, the differences between the groups remained significant.

CONCLUSION

Before the onset of illness, future schizophrenia patients are not heavier compared with their peers. This implies that the increased weight of patients with schizophrenia is related to illness effects, including the effects of antipsychotic medication.

Suicidality and second generation antipsychotics in schizophrenia patients: a case-controlled retrospective study during a 5-year period

RATIONALE

Rates of attempted suicide for individuals with schizophrenia are approaching 30%. Attempted suicide is among the most potent predictors of subsequent suicide. Several studies suggest that suicide is more likely to occur in patients who are not being adequately treated or not being treated at all. An effort was made in the last decade to evaluate the antisuicide effects of pharmacological treatment in schizophrenia with emphasis on the role of the newer second-generation antipsychotics (SGA).

OBJECTIVE

The aim of the present study was to assess in a large cohort of schizophrenia patients the effects of exposure to SGA on suicidality of patients suffering from schizophrenia or schizoaffective disorder. The study is a retrospective case-controlled evaluation over a 5-year period undertaken in a large university affiliated tertiary care psychiatric hospital.

METHODS

Between January 1998 and December 2002, all records of admissions of schizophrenia or schizoaffective disorder patients (ICD-10) were assessed. Data as to age, gender, diagnosis, suicide attempt prior to admission, treatment with antipsychotic medication, dose and duration of treatment (mg daily, duration) with SGA was extracted from patients' files. All patients who had attempted suicide prior to admission were defined as the index group. The case-controlled group was comprised of the next admission of a patient suffering from schizophrenia (or schizoaffective disorder), matched for gender and age, who did not attempt suicide.

RESULTS

Records of 756 patients (4486 admissions for said period) were analyzed (56.6% male, mean age 39.1+/-13.5 years). Amongst 378 patients who attempted suicide (index group), 16.1% were exposed to SGA while 37% were exposed in the control group (P=0.0001). The protective effect (odds ratio) of treatment by SGA was 3.54 (95%CI: 2.4-5.3). Risperidone was more frequently prescribed in the control group (54.3%) and had a larger effect-size than olanzapine (3.16 versus 1.76), although not statistically significant. Clozapine was prescribed only to a few patients.

CONCLUSIONS

Schizophrenia patients exposed to both risperidone and olanzapine may gain protection from suicidality. The antisuicide effects seem to differ between SGAs. The long duration and large sample size support this finding, despite the retrospective nature of this study.

Higher rates of cigarette smoking in male adolescents before the onset of schizophrenia: a historical-prospective cohort study

OBJECTIVE

The prevalence of cigarette smoking among schizophrenia patients is significantly higher than in the general population; this may reflect self-medication of symptoms and/or adverse effects of neuroleptics. The authors examined the prevalence of cigarette smoking in apparently healthy adolescents later hospitalized for schizophrenia.

METHOD

Each year, a random sample of male Israeli military recruits, who have been screened and found not to be suffering from major psychopathology, complete a smoking questionnaire. Through the Israeli National Psychiatric Hospitalization Case Registry, 14,248 of these adolescents were followed to determine later psychiatric hospitalization.

RESULTS

Of the 14,248 adolescents assessed, 4,052 (28.4%) reported smoking at least one cigarette a day. Over a 4-16-year follow-up, the prevalence of schizophrenia in the entire cohort was 0.3% (N=44). Smokers were at greater risk for later schizophrenia; the adjusted relative risk was 1.94, and the 95% confidence interval (CI) was 1.05-3.58. The number of cigarettes smoked was significantly associated with the risk for schizophrenia. Compared to nonsmokers, adolescents who smoked 1-9 cigarettes/day were 1.38 times (95% CI=0.48-4.00) as likely to be hospitalized later for schizophrenia, and adolescents who smoked 10 cigarettes/day or more were 2.28 times (95% CI=1.19-4.34) as likely; the latter difference was statistically significant.

CONCLUSIONS

Taken together with the existing data on abnormalities in nicotinic transmission in patients and their relatives, this higher prevalence of smoking in future schizophrenia patients, before the onset of their illness, might indicate that impaired nicotinic neurotransmission is involved in the pathophysiology of schizophrenia.

COMT: a common susceptibility gene in bipolar disorder and schizophrenia

A variety of psychiatric illnesses, including schizophrenia and bipolar disorder, have been reported in patients with microdeletion on chromosome 22q11-a region which includes the catechol-O-methyltransferase (COMT) gene. The variety of psychiatric manifestations in patients with the 22q11 microdeletion and the role of COMT in the degradation of catecholamine neurotransmitters may thus suggest a general involvement of the COMT gene in psychiatric diseases. We have previously reported on a significant association between a COMT haplotype and schizophrenia. In this study, we attempt to test for association between bipolar disorder and the polymorphisms implicated in schizophrenia. The association between COMT and bipolar disorder was tested by examining the allele and haplotype found to be associated with schizophrenia. A significant association between bipolar disorder and COMT polymorphisms was found. The estimated relative risk is greater in women, a result consistent with our previous findings in schizophrenia. We suggest that polymorphisms in the COMT gene may influence susceptibility to both diseases--and probably also a wider range of behavioral traits.

Self-reported drug abuse in male adolescents with behavioral disturbances, and follow-up for future schizophrenia

BACKGROUND

The prevalence of illicit drug abuse in persons with schizophrenia is greater then in the general population and has been attributed to self-medication of the symptoms of the illness; however, limited data indicate that drug abuse is already prevalent before the manifestation of psychosis, consistent with the possibility that drug abuse might be associated with increased risk for schizophrenia.

METHODS

The Israeli Draft Board screens the entire, unselected population of 16- to 17-year-old male adolescents for behavioral or personality disturbances. In a cohort of 270,000 male adolescents screened, 50,413 adolescents were suspected of having behavioral or personality disturbances and were questioned about drug use and abuse. These adolescents were followed for hospitalization for schizophrenia using a national, population-based psychiatric hospitalization registry; 268 of 50,413 (.5%) were hospitalized for schizophrenia over the following 5-11 years.

RESULTS

The prevalence of self-reported drug abuse in adolescents later hospitalized for schizophrenia was 12.4%, compared with 5.9% prevalence of drug abuse in adolescents not later hospitalized; adjusted RR = 2.016, 95% confidence interval: 1.309-3.104.

CONCLUSIONS

In this cohort of male adolescents with behavior disturbances, these results further support the hypothesis that drug abuse may be associated with increased risk for future schizophrenia.

Attitudes towards malingering: a study among general practitioners and mental health officers in the military

OBJECTIVE

The authors assessed the attitudes of military physicians and mental health officers regarding the phenomenon of malingering.

METHOD

Questionnaires on attitudes regarding malingering and possible cues indicative of deception were sent to 115 general practitioners (GPs) and mental health officers (MHOs) in the Israel Defense Forces (IDF).

RESULTS

91 responses were received--a response rate of 80%. All the respondents claimed that they had seen cases of malingering. They estimated that every fourth soldier is malingering. GPs claimed that they had seen more cases of malingering as compared to MHOs. Those who estimated that malingering is very frequent in the military, also had higher estimates of malingering in their civil work. The most indicative clues of malingering among soldiers were inconsistency, flamboyant complaints, exaggeration of symptoms and accentuation of secondary gain.

CONCLUSIONS

Among IDF GPs and MHOs, there currently appears to be moderate consensus regarding the frequency of malingering and its characteristic signs. The study provides further support to the notion that malingering is an important clinical phenomenon. We believe that the issue merits further research and scrutiny.

Generalized cognitive impairment in male adolescents with schizotypal personality disorder

Schizotypal Personality Disorder (SPD) shares common genetic and biological substrates with schizophrenia, and patients with SPD have been reported to suffer both from specific cognitive impairments, and from a generalized cognitive dysfunction, similar to those found in schizophrenia. The aim of this cross-sectional, population-based study was to assess general cognitive functioning in adolescents with SPD. The Israeli Draft Board systematically assesses cognitive functioning and administers psychiatric screening in all 16-17-year-old males in the population. Of 341,511 males assessed, the cognitive test scores of adolescents with SPD (N = 326) were retrieved, and compared to the scores of adolescents diagnosed as suffering from schizophrenia (N = 901), and adolescents with no neurological or psychiatric diagnosis (controls, N = 293,820). Male adolescents with SPD or with schizophrenia scored lower on all measures compared to healthy individuals (effect sizes ranging from 0.6-0.88, all P < 0.001). The SPD patients scored significantly higher than the schizophrenia patients on the sub-tests of similarities and Ravens Progressive Matrices, tests that reflect abstract reasoning. On the sub-tests of arithmetic and instruction comprehension, tests that rely on concentration, SPD and schizophrenia patients' scores did not differ significantly from each other. These results might be interpreted to imply that a generalized cognitive impairment, in the presence of schizotypal personality traits and in the absence of psychosis, might be conceptualized as being the core of the schizotaxia syndrome. The greater impairment in abstract reasoning in the schizophrenia patients might be correlated with the psychotic symptoms that differentiate schizophrenia from SPD.

Clinical characteristics of adolescents later hospitalized for schizophrenia

Intellectual and behavioral abnormalities, non-psychotic psychiatric disorders, and drug abuse are sometimes present in adolescents who later develop schizophrenia. We followed a population-based cohort of adolescents with baseline assessments of intellectual and behavioral functioning, non-psychotic psychiatric disorders and drug abuse, and ascertained future hospitalization for schizophrenia. Results of the medical and mental health assessments on 16- to 17-year-old male adolescents screened by the Israeli Draft Board, were cross-linked with the National Psychiatric Hospitalization Case Registry, which contains data on all psychiatric hospitalizations in the country. Male adolescents who were later hospitalized for schizophrenia had significantly poorer test scores on all measures in comparison with adolescents not reported to the Psychiatric Registry, the magnitude of the differences was 0.3-0.5 standard deviation (SD). Adolescents (1.03%) of assigned a non-psychotic psychiatric diagnosis, compared to of the adolescents without any psychiatric diagnosis (0.23%), were later hospitalized for schizophrenia. Patients with schizophrenia (26.8%), compared to only 7.4% in the general population of adolescents, had been assigned a non-psychotic psychiatric diagnosis in adolescence (overall OR = 4.5, 95% CI = 3.6-5.6), ranging from OR = 21.5, (<2 >95% CI = 12.6-36.6) for schizophrenia-spectrum personality disorders to OR = 3.6 (<2 >95% CI = 2.1-6.2) for neurosis. The prevalence of self-reported drug abuse was higher in adolescents later hospitalized for schizophrenia (12.4%), compared to the prevalence of drug abuse in adolescents not later hospitalized (5.9%); adjusted RR = 2.033, 95% CI = 1.322-3.126. These results reflect the relatively common finding of impaired intellectual and behavioral functioning, the presence of non-psychotic psychiatric disorders, and drug abuse, in adolescents later hospitalized for schizophrenia, together with the relatively low power of these disorders in predicting schizophrenia.

A highly significant association between a COMT haplotype and schizophrenia

Several lines of evidence have placed the catechol-O-methyltransferase (COMT) gene in the limelight as a candidate gene for schizophrenia. One of these is its biochemical function in metabolism of catecholamine neurotransmitters; another is the microdeletion, on chromosome 22q11, that includes the COMT gene and causes velocardiofacial syndrome, a syndrome associated with a high rate of psychosis, particularly schizophrenia. The interest in the COMT gene as a candidate risk factor for schizophrenia has led to numerous linkage and association analyses. These, however, have failed to produce any conclusive result. Here we report an efficient approach to gene discovery. The approach consists of (i) a large sample size-to our knowledge, the present study is the largest case-control study performed to date in schizophrenia; (ii) the use of Ashkenazi Jews, a well defined homogeneous population; and (iii) a stepwise procedure in which several single nucleotide polymorphisms (SNPs) are scanned in DNA pools, followed by individual genotyping and haplotype analysis of the relevant SNPs. We found a highly significant association between schizophrenia and a COMT haplotype (P=9.5x10-8). The approach presented can be widely implemented for the genetic dissection of other common diseases.

Time zone change and major psychiatric morbidity: the results of a 6-year study in Jerusalem

Psychiatric morbidity among foreign tourists is usually connected to external factors such as unfamiliar surroundings, language problems, and special religious experiences, as well as biological factors such as dyschronism of circadian rhythms. Long-range flights through several time zones are typically followed by symptoms of jet lag such as fatigue, severe sleep schedule disturbance, impairment of cognitive functions, and even mild depression. Jet lag is generally attributed to a conflict between external time cues and internal biological rhythms. This study examined the possible association between jet lag and psychiatric morbidity among long-distance travelers hospitalized in the Jerusalem Mental Health Center, Kfar Shaul Hospital between 1993 and 1998. This was a prospective open-label study. Patients (n = 152) were divided into two groups based on the number of time zones crossed in the flight to Israel: group I, seven time zones or more (n = 81); and group II, three time zones or less (n = 71). The direction of flight was mainly eastbound. After controlling the two groups for demographic and religious background, past psychiatric history, and diagnosis on admission (P > 0.1, Fisher's exact test), the possible association between jet lag and psychotic or major affective disorder was evaluated according to the following criteria: (1) absence of major mental problems before the flight or good remission of an existing disorder 1 year or more before flight; and (2) the appearance of psychotic or major affective syndromes during the first 7 days after landing. The number of first psychotic/major affective episodes in both groups presumed as associated with jet lag was found similar (P =.5), whereas the number of relapses conjoint with jet lag in the seven or more time zone group was significantly higher (P =.04). The results suggest that the dyschronism of circadian rhythms and jet lag possibly play a role in the exacerbation of major psychiatric disorders.

The fitness of the mental patient to be a witness

The determination of whether a patient has criminal responsibility or is able to stand trial is routine psychiatric work. Cases in which we- psychiatrists- are asked to express our opinion on whether a patient can testify, however, are quite rare. We shall attempt to clarify some of the issues relating to the testimony of mentally ill patients through a case presentation. In this case, the Court agreed to consider our patient's testimony, only after receiving our expert opinion. We find that the Court's reversal of its original decision and its willingness to consider the testimony of a mental patient in the same trial in which he was initially found unable to stand trial, marks an important precedent. The question of the credibility of the mental patient as a witness has significance beyond this case concerning mental patients' rights in regard to the judicial system. We believe there is a need for further discussion between psychiatrists andjurists regarding the fitness of the mental patient to testify as a witness.

Psychiatric aspects of jet lag: review and hypothesis

Jet lag is a travel-induced circadian rhythm phenomenon that afflicts healthy individuals following long- distance flights through several time zones. The typical jet-lag manifestations - insomnia during local sleep time, day fatigue, reduced concentration, irritability, and exhaustion with mild depression - are attributed to transient desynchronization in the circadian rhythm until the internal biological clock is rephased to the new environmental conditions. There is strong evidence relating affective disorders with circadian rhythm abnormalities. Less convincing suggestions relate jet lag to psychosis. It can be hypothesized that in predisposed individuals jet lag may play a role in triggering exacerbation or even de novo affective disorders. Furthermore, we propose the possibility that psychosis and even schizophrenia can be elicited by jet lag. This outlook gains its support from case studies and some common underlying phase-advanced biological denominators involved in both jet lag sufferers and psychotic patients.

[Drug abuse among patients requiring psychiatric hospitalization]

We assessed the incidence of drug abuse among patients requiring psychiatric hospitalization, and characterized the population at risk. The data on drug abuse were obtained from self-reports and urine tests in 103 patients, aged 18-65, hospitalized in the Kfar Shaul Psychiatric Hospital (autumn 1998). There was close correspondence between the self-reports and the results obtained from urine tests. 1/3 admitted to having used illegal drugs and signs of drug abuse were found in about 1/4 of the urine tests. The most prevalent drugs were cannabis products (hashish and/or marijuana) and in 15 patients opiates. Drug users were younger than non-users. With regard to psychiatric symptomatology, fewer negative symptoms were recorded among cannabis abusers with schizophrenia, compared to schizophrenic patients with no history, past or present, of cannabis abuse. The present findings confirm the clinical impression that there has been an increase in drug abuse among mental patients, parallel to that found in society at large. Confirmatory surveys are necessary. Our findings clearly suggest that a change in attitude has occurred in Israel to what has been considered a marginal problem. Hospitalized mentally-ill patients, the younger in particular, should be considered at risk for drug abuse.

Adaptation of immigrant psychiatrists from the former Soviet Union in the Department of Mental Health of the Israel Defense Forces

Psychiatrists from the former Soviet Union serve in the Department of Mental Health of the Israel Defense Forces. The new immigrant psychiatrists confront a wide range of difficulties during the process of integration to the military system and adaptation to the specifically military aspects of psychiatry. These include unfamiliarity with the military system, cultural clashes with the different groups of soldiers representing the various subgroups of the absorbing society, the psychopathology of soldiers, which is different from that seen in civil psychiatry, and the change in focus in the military mental health service, which emphasizes the importance of evaluating ego strength. Arbitrarily, one can describe four stages of adaptation that the immigrant psychiatrist has to pass through before recruitment and during service until adaptation and integration in the new role take place. Individual and group supervision are the main means by which the assimilation process is eased. The military service smooth the acculturation process and has an important role in helping the immigrant's adaptation to Israeli society and in building his or her professional identity.

[Jet lag causing or exacerbating psychiatric disorders]

Desynchronization of circadian rhythmicity resulting from rapid travel through at least 4 time zones leads to symptoms of jet lag syndrome. The most commonly experienced symptoms in normal individuals are sleep disorders, difficulties with concentrating, irritability, mild depression, fatigue, and gastrointestinal disturbances. There is strong evidence relating affective disorders to circadian rhythm abnormalities, such as occur in jet lag. Less convincing suggestions relate jet lag to psychosis. We presume, relying on the literature and our accumulated experience, that in predisposed individuals jet lag may play a role in triggering exacerbation of, or de novo affective disorders, as well as, though less convincing, schizophreniform psychosis or even schizophrenia. An illustrative case vignette exemplifies the possible relationship between jet lag following eastbound flight and psychotic manifestations.

Clozapine and risperidone: combination/augmentation treatment of refractory schizophrenia: a preliminary observation

OBJECTIVE

Clozapine and risperidone were the first two antipsychotic drugs of a new class of agents for the pharmacotherapy of schizophrenia. It has been suggested that refractory schizophrenic patients who fail to respond to neither clozapine nor risperidone may respond to a combination/augmentation strategy of both medicaments.

METHOD

Three cases of individuals with unremittent schizophrenia treated via this combination are presented. Response was evaluated by clinical follow-up and PANSS rating scale.

RESULTS

Good clinical results with no noticeable adverse side effects, ascertained by a reduction from baseline scores of the Positive and Negative Syndrome Scale (PANSS) were obtained in all three patients.

CONCLUSION

The findings from this pilot study suggest this combination as a possible therapeutic approach for treating resistant schizophrenic patients.

First psychotic episodes among Israeli youth during military service

The military setting offers unique opportunities for the study of the epidemiology of first psychotic episodes among Israeli youth. The aim of the present study was to describe characteristics of first psychotic episodes among a cohort of Israeli soldiers. Ninety soldiers, 67 males and 23 females, who were hospitalized for a first psychotic episode were studied and compared with 90 soldiers hospitalized in psychiatric units during the same year who were not psychotic. The results include a high rate of schizophreniform psychoses and schizophrenia; no gender difference in the occurrence of psychoses; within-average mean ratings on the preinduction psychometric intelligence test; no history of substance abuse; and a remarkable occurrence of psychiatric hospitalizations, including first psychotic episodes, during the stressful beginning of military service, supporting the hypothesis that psychotic symptoms are likely to occur in a stressful situation among vulnerable individuals. Follow-up studies will indicate whether early detection and treatment may improve the outcome of the psychoses.

Jerusalem syndrome

BACKGROUND

Jerusalem's psychiatrists expect to encounter, as the millennium approaches, an ever-increasing number of tourists who, upon arriving in Jerusalem, may suffer psychotic decompensation.

AIMS

To describe the Jerusalem syndrome as a unique acute psychotic state.

METHOD

This analysis is based on accumulated clinical experience and phenomenological data consisting of cultural and religious perspectives.

RESULTS

Three main categories of the syndrome are identified and described, with special focus on the category pertaining to spontaneous manifestations, unconfounded by previous psychotic history or psychopathology.

CONCLUSIONS

The discrete form of the Jerusalem syndrome is related to religious excitement induced by proximity to the holy places of Jerusalem, and is indicated by seven characteristic sequential stages.

[Symptom severity among chronic schizophrenics in hospital and in the community]

We compared severity of symptoms of chronic schizophrenics in a psychiatric hospital with those treated in its outpatient clinics. The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitive performance, respectively, of 25 chronic schizophrenic inpatients matched for gender, age and education with 25 chronic schizophrenic outpatients. The Global Assessment Scale and the Clinical Global Impression Scale were used to test global functioning. Assessment included psychiatric and medical history and treatment and demographic characteristics. In-patients had significantly more positive, negative and general psychiatric symptoms. Their cognitive and general functioning were impaired. Most in-patients also had medical problems. Age of onset of schizophrenia among the in-patients was younger. Results show a marked difference in severity of symptoms and level of functioning between chronic schizophrenic in-patients and out-patients. These differences should be considered in the planning of discharge of chronic in-patients from psychiatric hospitals into the community.

Withdrawal from clozapine: the "rebound phenomenon"

Clozapine is an "atypical" antipsychotic agent for treating previously resistant schizophrenic patients. Its main advantages over "typical" neuroleptics are low incidence of extrapyramidal side effects and its capacity to induce therapeutic response in previously treated refractory patients. However, withdrawal from clozapine has been observed to lead to "atypical" clinical characteristics or a "rebound phenomenon," manifested in two interwoven clinical forms: (1) psychotic exacerbation, and (2) cholinergic rebound. The underlying pathophysiological mechanism of this phenomenon is postulated to be a result of cholinergic supersensitivity. In this paper, the "rebound phenomenon" will be discussed and exemplified by three case histories in which abrupt cessation of clozapine led to serious deterioration and psychotic exacerbation, and one case in which gradual titration from the drug was employed in order to preempt this hazardous occurrence.