201004_psychiatry

‫ה‬ ‫א‬ ‫ם‬ ‫ה‬ ‫יי‬ ‫ת‬ ‫רו‬ ‫צ‬ ‫ה‬ ‫ש‬ ‫ה‬ ‫מ‬ ‫טו‬ ?‫פלות שלך ירגישו כך כל יום‬

israel journal of

psychiatry

Vol. 47 - Number 4 2010

ISSN: 0333-7308

244

The Israel Survey of Mental Health among Adolescents

Volume 47, Number 4, 2010 Israel Journal of Psychiatry and Related Sciences

Ivonne Mansbach-Kleinfeld, Daphna Levinson, Ilana Farbstein, Alan Apter, Itzhak Levav, Rasim Kanaaneh, Nechama Stein, Rachel Erhard, Hava Palti, Razek Khwaled, and Alexander M. Ponizovsky

254

Postpartum Depression Saralee Glasser

260

Guardianship Appointment

Yuval Melamed, Lili Yaron-Melamed and Jeremia Heinik

269

Health-related quality of life two years after injury due to terrorism

Maya Tuchner, Zeev Meiner, Shula Parush, and Adina Hartman-Maeir

276

Combat Exposure, Posttraumatic Stress Symptoms and Risk-Taking Behavior in Veterans of the Second Lebanon War Vlad Svetlicky, Zahava Solomon, Rami Benbenishty, Ofir Levi, and Gadi Lubin

284

Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals

Ehud Bodner, Amiram Sarel, Omri Gilat, and Iulian Iancu

L.IL.WH.03.2010.0004

291 YAZ - oral contraceptive tablets. Composition: 24 light pink film-coated tablets: contains 0.020 mg ethinylestradiol and 3 mg drospirenon; and 4 white placebo film-coated tablets. Indications: Oral contraception, Treatment of moderate acne vulgaris in women who seek oral contraception, Treatment of symptoms of PMDD in women who have chosen oral contraceptives as their method of birth control. Contraindications: COCs should not be used in the presence of any of the conditions listed below: Venous thrombosis present or in history, Arterial thrombosis present or in history, or prodromal conditions, CVA present or in history, The presence of a severe or multiple risk factor(s) for arterial thrombosis: diabetes mellitus with vascular symptoms, severe hypertension, severe dyslipoproteinemia.

Hereditary or acquired predisposition for venous or arterial thrombosis, Pancreatitis or a history thereof if associated with severe hypertriglyceridemia, Presence or history of severe hepatic disease as long as liver function values have not returned to normal, Severe renal insufficiency or acute renal failure, Presence or history of liver tumours, Known or suspected sex-steroid influenced malignancies, Undiagnosed vaginal bleeding, History of migraine with focal neurological symptoms, Known or suspected pregnancy, Hypersensitivity to the active substances or to any of the excipients. Undesirable effects: Common: Emotional lability, Headache, Nausea, Breast pain, Metrorrhagia, Amenorrhea.

Uncommon: Depression, Libido decreased, Nervousness, Somnolence, Dizziness, Paresthesia, Migraine, Varicose vein, Hypertension, Abdominal pain, Vomiting, Dyspepsia, Flatulence, Gastritis, Diarrhea, Acne, Pruritus, Rash, Back pain, Pain in extremity, Muscle cramps, Vaginal candidiasis, Pelvic pain, Breast enlargement, Fibrocystic breast, Uterine/Vaginal bleeding, Genital discharge, Hot flushes, Vaginitis, Menstrual disorder, Dysmenorrhea, Hypomenorrhea, Menorrhagia, Vaginal dryness, Papanicolaou smear suspicious, Asthenia, Sweating increased, Edema, Weight increase. Rare: candidiasis, Anemia, Thrombocythemia, Allergic reaction, Endocrine disorder, Increased appetite, Anorexia, Hyperkalemia, Hyponatremia, Anorgasmia, Insomnia, Vertigo, Tremor, Conjunctivitis, Dry eye, Eye disorder, Tachycardia, Phlebitis, Vascular disorder, Epistaxis, Syncope, Abdomen enlarged, Gastrointestinal disorder, Gastrointestinal fullness, Hiatus hernia, Oral candidiasis, Constipation, Dry mouth, Biliary pain, Cholecystitis, Chloasma, Eczema, Aopecia, Dermatitis acneiform, Dry skin, Erythema nodosum, Hypertrichosis, Skin disorder, Skin striae, Contact dermatitis, Photosensitive dermatitis, Skin nodule, Dyspareunia, Vulvovaginitis, ostcoital bleeding, Withdrawal bleeding, Breast cyst, Breast hyperplasia, Breast neoplasm, Cervical polyp, Endometrial atrophy, Ovarian cyst, Uterine enlargement, Malaise, Weight decrease.

For full product information see completet prescribing information. Approved 11/09

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‫לראשונה בישראל‬ ‫גלולה למניעת הריון‬ :‫ התויות רפואיות‬3 ‫בעלת‬ ‫• מניעת הריון‬ ‫• טיפול באקנה בינוני‬ ‫• טיפול בתופעות טרום ויסתיות חמורות‬

Self-estimation of performance time versus actual performance time in older adults with suspected mild cognitive impairment Jeremia Heinik and Liat Ayalon

297

Male genital self-mutilation as a psychotic Solution

Erol Ozan, Erdem Deveci, Meltem Oral, Esra Yazıcı and İsmet Kırpınar

304

Predictors of Cumulative Length of Psychiatric Inpatient Stay Yaacov Lerner and Nelly Zilber

308

Diagnosing ADHD in Israeli Adults Freedom like never before

Ada H. Zohar and Hani Konfortes

israel journal of

psychiatry and related sciences EDitor

David Greenberg DEPUTY EDITORS

David Roe Rael Strous Gil Zalsman

Book reviews editor

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Zvi Zemishlany International Advisory Board

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Margarete Mitscherlich-Nielsen Peter Neubauer Phyllis Palgi Leo Rangell Melvin Sabshin Robert Wallerstein Myrna Weissman

242 > Editorial: The Alliance of Mental Health and Education Regarding the Needs for Services for the Young Itzhak Levav, Ivonne Mansbach-Kleinfeld, Anneke Ifrah, Rachel Erhard, Cendrine Bursztein, Daphna Levinson, Ilana Farbstein Ziev, and Alan Apter

244 > The Israel Survey of

Mental Health among Adolescents: Aims and Methods

Ivonne Mansbach-Kleinfeld, Daphna Levinson, Ilana Farbstein, Alan Apter, Itzhak Levav, Rasim Kanaaneh, Nechama Stein, Rachel Erhard, Hava Palti, Razek Khwaled, and Alexander M. Ponizovsky

254 > Postpartum Depression: A Chronicle of Health Policy Development Saralee Glasser

260 > Guardianship Appointment: Current Status in Israel Yuval Melamed, Lili Yaron-Melamed and Jeremia Heinik

269 > Health-related quality

of life two years after injury due to terrorism

Maya Tuchner, Zeev Meiner, Shula Parush, and Adina Hartman-Maeir

276 > Combat Exposure, Posttraumatic Stress Symptoms and Risk-Taking Behavior in Veterans of the Second Lebanon War

Vlad Svetlicky, Zahava Solomon, Rami Benbenishty, Ofir Levi, and Gadi Lubin

The Official Publication of the Israel Psychiatric Association Vol. 47 - Number 4 2010

284 > The Relationship between Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals: The Israeli Case

Ehud Bodner, Amiram Sarel, Omri Gilat, and Iulian Iancu

291 > Self-estimation of performance time versus actual performance time in older adults with suspected mild cognitive impairment: a clinical perspective Jeremia Heinik and Liat Ayalon

297 > Male genital self-mutilation as a psychotic Solution Erol Ozan, Erdem Deveci, Meltem Oral, Esra Yazıcı and İsmet Kırpınar

304 > Predictors of Cumulative Length of Psychiatric Inpatient Stay Over One Year: A National Case Register Study Yaacov Lerner and Nelly Zilber

308 > Diagnosing ADHD in Israeli Adults: The Psychometric Properties of the Adult ADHD Self Report Scale (ASRS) in Hebrew Ada H. Zohar and Hani Konfortes

Hebrew Section

316 > News and Notes 319 > Abstracts

Assistant Editor

Joan Hooper

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Of the picture: "The picture is bombastic, happy and brilliant. I have painted a beautiful girl, alluring, full of joy and life. She is a figure from my imagination taken from the Middle Ages, an exotic historic period. My art, producing works of beauty, is an important part of my self-recovery."

Isr J Psychiatry Relat Sci - Vol 47 - No.3 (2010)

Editorial: The Alliance of Mental Health and Education Regarding the Needs for Services for the Young Following a diagnosis of the global mental health situation and an analysis of the evidence-based data, the World Health Organization (WHO) has recommended ten strategies to address the deficiencies found in a number of areas in the field of mental health. The depth and extent of the application of those strategies vary according to the level of development of each country (1).

However, for both developing and developed nations, WHO has wisely recommended the use of an inter-sectoral approach. This is, simply, because the challenge of both providing an equitable answer to the mental health needs of those requiring care and improving services and programs is far too great for the health sector to tackle alone. One alliance which is essential for all levels of mental health action – promotion, and primary, secondary and tertiary prevention – is the mental healtheducation partnership, particularly for the population of children and adolescents, who spend many hours of the day and many months of the year in school.

Today, no one holds the mistaken notion that psychiatric disorders among the young are rare or have little impact, particularly with regard to education. For example, children with conduct disorders have been shown to generate additional health and education costs between the ages of 10 and 27 (2). The special burden on the educational system has been shown very persuasively in a study conducted in Finland on children aged 8: those with a psychiatric disorder were found to be three times more likely to receive extra tutoring or special education than children free of disorders (3).

Previous studies have shown that untreated early disorders may lead to a poor educational track and, subsequently, to a poor work career (4, 5).

The Israel Survey on Mental Health among Adolescents (ISMEHA), a recent community-based study and the first ever to be conducted in Israel on psychiatric disorders in adolescents aged 14 to 17 (N=957), has found a prevalence rate of internalizing disorders (e.g., anxiety, depression, obsessive compulsive disorder) of: girls, 11.6%; boys, 4.8%; and for both genders, 8.1%. For externalizing disorders (e.g., conduct disorders) the respective rates were: 3.0%, 6.6%, and 4.8% (6).

242

Translating these rates into population figures implies that nearly 33,000 young Israelis in this age group are affected. Studies focusing on substance use have shown that in 2005, 9.9% of high school students – girls, 7.6% and boys, 12.1% – admitted having used illicit drugs in the preceding year (7).

The above rates need to be gauged against the specialized psychiatric resources available today. By 2008, 34.9% of the total population of Israel was less than 18 years of age (8). However, while the rate of psychiatrists in the adult population (aged 18 and over) was 23.8 per 100,000, the respective rate of child and adolescent psychiatrists in the same year was only 8.8 per 100,000 children and youth aged 0-17. Obviously, with our current human resources in the health sector we are far from being able to provide the necessary services for the youth requiring mental health care. This situation is shared by European (9) and most other countries in the world (10).

The above considerations with regard to the role of education in mental health care have been confirmed empirically in Israel, at least with reference to the age group of 14-17 years. The ISMEHA reported that while 4% of mothers of adolescents consulted a mental health specialist and 4% consulted a primary care practitioner or pediatrician about emotional or behavioral concerns regarding the adolescent, a greater proportion – 8% of mothers and 22% of adolescents – consulted a member of the educational system, usually the school counselor or the classroom teacher, for the same concerns (11).

The reasons for their help-seeking choices are clear, namely, availability, easy access and little or no stigma.

Thus, two questions arise: First, are the educational staff (school health nurse, guidance counselors, teachers and principals) well prepared to assist the pupils and parents who seek mental health assistance? Second, do the community-based services provide the educational staff with the training and consultation support that they require? As far as we know, no local studies have been conducted thus far; therefore the answers still elude us.

A good example of collaboration between both sectors is the Saving and Empowering Young Lives in

Itzhak Levav ET AL.

Europe (SEYLE) program (coordinated by Dr. Danuta Wasserman at the Karolinska Institute in Stockholm), that includes Israel. This is a health promoting program for adolescents linked to the educational system, which is currently being assessed in Israel (http://www.seyle. org). Its main objectives are to lead adolescents to better health through decreased risk-taking and reduction of suicidal behaviors; to evaluate outcomes of different preventive programs; and to recommend effective, culturally-adjusted models for promoting the health of adolescents in different countries and communities.

The program targets students’ awareness of healthy/ unhealthy behaviors and students’ self-efficacy in reducing unhealthy behaviors. Additionally, it attempts to empower mental health professionals in the identification of students at risk, and teachers in the identification and referral of students in need of mental health facilities. Clearly, it is important to follow-up the outcomes of this joint health-education project.

The current limited alliance between the health and educational systems must be extended. The agenda includes advocacy: Costello et al. (12) showed that healthy public policies translate into a reduction of the prevalence of disorders among the young. Therefore, it is incumbent upon both sectors to jointly advocate for social policies seeking to reduce the impact of socio-economic inequalities among the young and their families.

In conclusion, the alliance can take place if the community-based mental health system provides what the education sector requires in order to better fulfill its duties with reference to the mental health needs of the students and, conversely, if the educational sector recognizes and relies on its counterpart through an open and continuous dialogue in order to provide collaboratively what the students and their parents expect. The latter is even more relevant to sectors (e.g., the ultra-orthodox, the Arab-Israelis) that because of cultural or other reasons (13) do not regard the formal mental health services as their preferred source of psychiatric care.

editors. Advances in clinical psychology. New York: Plenum, 1998.

5. Kessler R, CL Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I. Educational attainment. Am J Psychiatry 1995; 152: 1026-1032.

6. Farbstein I, Mansbach-Kleinfeld I, Levinson D, Goodman R, Levav I, Vograft I, Kanaaneh R, Ponizovsky AM, Brent DA, Apter A. Prevalence and correlates of mental disorders in Israeli adolescents: Results from a national mental health survey. J Child Psychol Psychiatry 2010; 51: 630-639.

7. Anti-Drug Authority (Israel). The use of psychoactive substances among Israeli residents, 2005 (www.Antidrugs.org. il).

8. Central Bureau of Statistics: Israel in Figures. Jerusalem: Central Bureau of Statistics, 2009 (www.gov.il).

9. Levav I, Jacobsson L, Tsiantis J, Kolaitis G, Ponizovsky A. Psychiatric services and training for children and adolescents in Europe: Results of a country survey. Eur Child Adolesc Psychiatry 2004; 13: 395-399.

10. World Health Organization htpp://who.int/mental_health/resources/ Child_ado_atlas, pdf. ; 2005 11. Mansbach-Kleinfeld I, Farbstein I, Levinson D, Apter A, Erhard R, Palti H, Geraisy N, Brent DA, Ponizovsky AM, Levav I. Service use for mental disorders and unmet need: Results from the Israel Survey on Mental Health among Adolescents. Psychiatr Serv 2010; 61: 241-249.

12. Costello EJ, Compton SN, Keeler G. Relationships between poverty and psychopathology: A natural experiment. JAMA 2003; 290: 2023-2029.

13. Al-Krenawi A. The epidemiology of mental health disorder among Arabs in Israel. In Levav I, editor. Psychiatric and behavioral disorders in Israel. Jerusalem: Gefen, 2009.

Itzhak Levav, Ministry of Health, Jerusalem

Ivonne Mansbach-Kleinfeld Ministry of Health, Jerusalem

Anneke Ifrah, Center for Disease Control, Tel Hashomer Hospital, Ramat Gan

Rachel Erhard, Tel Aviv University, Tel Aviv

Cendrine Bursztein Schneider Hospital, Petach Tivka

Daphna Levinson Ministry of Health, Jerusalem

Ilana Farbstein Ziev Hospital, Sefad

Alan Apter SchneiderHospital, Petach Tikva

References 1. World Health Organization. World Health Report. New understanding, New hopes. Geneva: World Health Organization, 2001.

2. Knapp MRJ, Almond S, Percudani M. Costs of schizophrenia. In Maj M, Sartorius N, editors. Evidence and experience in psychiatry (Vol. I).

London: Wiley, 1999.

3. Kumpulainen K, Rasanen E, F. Hentonnen, I, Puura K, Moilanen I, Piha J, Tamminen T, Almqvist. Psychiatric disorders, performance level at school and special education at early elementary school age. Eur Child Adolesc Psychiatry 1999; 8: S 48-S54.

4. Maughan B, Rutter M. Continuities and discontinuities in antisocial behavior from childhood to adult life. In Ollendick TH, Prinz RK,

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

The Israel Survey of Mental Health among Adolescents: Aims and Methods Ivonne Mansbach-Kleinfeld, PhD, MPH,1 Daphna Levinson, PhD,1 Ilana Farbstein, MD,2 Alan Apter, MD,3 Itzhak Levav, MD, MSc,1 Rasim Kanaaneh, MD,2 Nechama Stein, MA,4 Rachel Erhard, PhD,5 Hava Palti, MD, MPPH,6 Razek Khwaled, MA,1 and Alexander M. Ponizovsky, MD, PhD1 1

Mental Health Services, Ministry of Health, Jerusalem, Israel Department of Child and Adolescent Psychiatry, Ziv Hospital, Safed, Israel 3 Department of Child and Adolescent Psychiatry, Schneider Center for Children in Israel, Petach Tikvah, Israel 4 Department of Health Information, Ministry of Health, Jerusalem, Israel 5 School of Education, University of Tel Aviv, Israel 6 Hadassah and Hebrew University, Braun School of Public Health and Community Medicine, Jerusalem 2

Conflict of Interest: None of the authors has any financial or intellectual proprietary relationships relevant here.

ABSTRACT Objective: The Israel Survey of Mental Health among Adolescents (ISMEHA) aimed to ascertain the prevalence of selected mental disorders and patterns of comorbidity; service utilization and unmet needs; health and sociodemographic covariates; and risk and protective factors.

This paper reviews the methods used and discusses the strengths and limitations of the survey.

Method: The ISMEHA was a cross-sectional survey that included 957 Israeli adolescents, representative of the adolescent population aged 14-17 years. The Strengths and Difficulties Questionnaire, Hebrew version (SDQ-H), the Development and Well-Being Assessment (DAWBA) inventory, services utilization, health status and sociodemographic questions were administered to adolescents and their mothers at the respondents’ homes between January 2004 and March 2005.

Results: The overall response rate was 68.2%, and it varied by gender and type of locality. Among boys, 71.3% responded, as compared to 65.2% among girls.

The response rate among adolescents living in a Jewish or mixed city was 62.5% as compared to 89.6% among adolescents living in an exclusively Arab-populated city.

Conclusions: The ISMEHA allows the creation of a unique and comprehensive database informing on the

prevalence, burden, services utilization and unmet needs of adolescents with psychiatric disorders.

These data will enable policymakers to more rationally plan services and prevention programs for the target population.

Introduction The resources allotted for mental health care and the types of services offered vary across countries (1, 2).

Different reasons may be imputed, among them, the uncertainty of policymakers regarding the kind of services that need to be delivered, for whom and by whom (3). In an era of restricted resources, the local agencies responsible for providing mental health services for children and adolescents follow the world trend (1, 4-7), namely, to rely on epidemiological data for rational policy and planning of programs and services.

Because of the limited data available on mental health problems among adolescents in Israel (8-13), the Mental Health Services at the Ministry of Health, along with the Ministry of Education, the Ziv Hospital in Safed and the Schneider Medical Center for Children in Israel, initiated a national project entitled the “Israel Survey of Mental Health among Adolescents” (ISMEHA). This

Address for Correspondence: Ivonne Mansbach-Kleinfeld, PhD, MPH, Mental Health Services, Ministry of Health, 2 Ben Tabai St., POB 1176, Jerusalem 91010, Israel. ivonne.mansbach@moh.health.gov.il

244

Ivonne Mansbach-Kleinfeld ET AL.

project was carried out between 2004 and 2005 and its main goals were to assess the mental health needs of adolescents living in the community and their careseeking practices. The study yields information on both the adolescents and their mothers that can assist decision-makers to prioritize and prepare evidence-based options for services and programs for this population.

Table 1 shows the methods used by major European and American community studies and their results (14-22), and includes major findings of the ISMEHA. Our study is comparable to the B-CAMHS in design and instruments used and to the Puerto Rico survey and the MECA study insofar as population interviewed (adult caretaker/mother and child dyads). Our study differs from the Great Smoky Mountain Study, which was a longitudinal study and included three distinct age groups, and from the BCS which, although it used the same instruments as the ISMEHA, included a younger age group and sampled for children attending schools.

Two national community surveys carried out in Israel have dealt with specific problems and behaviors but have not used epidemiological instruments to assess prevalence of mental disorders among adolescents (9, 23). A national representative study of prevalence of mental disorders in the adult population of Israel, the first of its kind, has recently been published (24).

The specific aims of the study were: to estimate the prevalence of behavioral, emotional and mental disorders among adolescents according to the International Classification of Diseases, Tenth Edition (ICD-10) (25) and the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) (26), and the patterns of comorbidity; to identify help-seeking patterns in the adolescents and their mothers; to assess the extent of unmet needs; to ascertain health and social covariates; and to identify protective and risk factors for mental disorders. This paper reports on the methods used in the ISMEHA, the results of the fieldwork, and reviews the strengths and limitations of the study.

Methods The survey population. This nationwide, cross-sectional study included a representative sample of 14-17-yearold adolescents living in the community, in urban settings with more than 2,000 inhabitants and meeting the status of legal residents according to the National Population Register (NPR). Initially we sampled 13 to 15 year olds so that by time of interview they would

be 14 to 16 years of age. However, due to field work constraints, not all the data collection was carried out within schedule and therefore the age of the group shifted upwards. Not included in the survey population were: adolescents residing in small rural settings, such as kibbutzim or other collective settings (comprising 7.3% of the population in this age group) and small or unrecognized Bedouin villages (1.7% in this age group); adolescents who study in the Arab sector in Jerusalem (2.8% in this age group), and Jewish ultra-orthodox (Haredi) adolescents. The last group was excluded before data collection began due to low response rates achieved in the pilot stage (4%), despite the active efforts made to adjust the survey’s methods to their specific requests (see below). Children of migrant workers, a very small percentage of the population in this age group, were not included in the study as most are not registered and do not meet the status of legal residents in Israel.

The sampling frame. The sample was based on the National Population Register prepared for the Ministry of Education. The file, updated to August 2002, included the names of all residents born in Israel or abroad between July 1, 1987 and June 30, 1990; and demographic data such as home address, school of attendance, country of birth, and year of immigration, if relevant. New immigrants arriving in the country after August 2002 were not included in the sample. Deceased adolescents were removed from the sampling frame and migrants were partially removed (see Table 2). The number of adolescents in this age group in the sampling frame (including Jewish ultra-orthodox adolescents) was 317,604.

Sample size and sampling probability. Based on reported prevalence of mental disorders among adolescents of between 12% and 20% (16, 19, 27, 28), a sample size of 1,000 adolescents (without Jewish ultra-orthodox adolescents) was calculated to enable the identification of “any mental disorder� with adequate statistical power. Given an expected response rate of 2/3, an initial sample size of about 1,500 adolescents was chosen. The average sampling fraction was 1/212. However, calculations were made according to a sampling fraction of 1/190 and therefore the final sample was not 1,500 but 1,670, a little larger than originally planned.

Sampling Method. To increase the cost-efficiency of the study, we sampled localities with a minimum of 30 adolescents in this age group in the sample. All the urban settlements were distributed into sampling strata as follows: 245

THE ISRAEL SURVEY OF MENTAL HEALTH AMONG ADOLESCENTS: AIMS AND METHODS

Table 1: Review of major community studies of prevalence of mental disorders in children and adolescents in Europe and the American Continent

Country

Study

Year

Study design

Sampling frame

Sample size

Instruments

Taxonomy

Age group

Prevalence of Any Disorder (%)

Europe and Israel Norway

Bergen Child Study (BCS) (Heiervang et al., 2007)

20022003

Crosssectional

All children attending grades 2 to 4 in Bergen schools

9,155 in 1st phase; 1,001 in 2nd phase

SDQ (screening) DAWBA (2nd phase)

DSM-IV ICD-10

8 - 10

7%

Great Britain

B-CAMHS (Meltzer et al., 2003)

1999

Crosssectional

475 postal sectors from Child Benefit Register

10,438 parent child dyads

DAWBA SDQ GHQ-12

DSM-IV ICD-10

5 - 15

9.5% and 2.1% NOS

Holland

National Sample of Dutch Adolescents (Verhulst et al., 1997)

1993

Crosssectional

All 4-18 yearolds of Dutch nationality, living in the Netherlands

780 parent-child dyads

YSR, CBCL & TRF (screening) DISC & CGAS (2nd phase)

DSM-III-R DISC

13-18

7.9% -21.8%*

Israel

ISMEHA (Farbstein et al., 2009)

20042005

Crosssectional

All residents of Israel born between 7.1.1987 and 6..30.1990.

957 parentadolescent dyads

SDQ DAWBA Use of services and demography questions

DSM-IV ICD-10

14- 17

11.7%

American Continent Southeast Brazil

Child and Adolescent Psychiatric Disorders (FleitlichBilyk & Goodman, 2004)

20002001

Crosssectional

All school children in Municipality of Taubate

1,251 school children and mothers

SDQ DAWBA Risk Factors Measure

DSM-IV

7 - 14

12.7%

Puerto Rico

Rates of Child and Adolescent Disorders (Canino et al., 2004)

2000

Crosssectional

US Bureau of the 1990 Population and Housing Census

1,886 parent-child dyads

DISC-IV PIC-GAS

DSM-IV

4 - 17

6.9% -16.4% *

Southeast USA

Great Smoky Mountain Study of Youth (Costello et al., 1996)

19932000

Longitudinal

All public school districts in 11 counties

1,420 youth - adult caretaker dyads

CAPA CBCL

DSM-III-R

9, 11, 13

12% -15%

USA

National Health Interview Survey (Halfon et al., 1999)

19921994

Crosssectional

US Bureau of Census for the NCHS - households

99,513 parents of noninstitutionalized minors

Direct questions to parents: is the child limited, to what degree, in what activities

ICD-9

4 - 17

2.1% suffer form disabling mental health condition

USA

MECA (Lahey et al., 1996; Shaffer et al., 1996)

19911992

Crosssectional

Probability household samples in 4 geographic areas

1,285 youth - adult caretaker

DISC - 2.3 SURF PPVT-R

DSM-III-R CGAS

9 - 17

5.4% to 50.6% *

USA

National Comorbidity Survey (Kessler & Walters, 1998)

19901992

Crosssectional

US household population

1,769 adolescents and young adults

CIDI 1.0

DSM-III-R

15-24

Lifetime prevalence of MD = 15.3% and of mD = 9.9%.

30/day prevalence of MD=5.8% and of mD 2.1%.

* depending on measure of impairment

246

Ivonne Mansbach-Kleinfeld ET AL.

1. Cities were ordered according to size of the adolescent population 13-15 years of age.

2. The three largest Israeli cities (Jerusalem, Tel Aviv and Haifa) plus another eight large cities were included in the sample with certainty. The adolescents in those cities were chosen through systematic random sampling and they were sampled in one-step.

3. In all the other urban settlements the sampling was made in two-steps. The cities were distributed into strata according to the two main types of locality (whether they were Jewish/mixed or mainly Arabpopulated cities) and by six geographical regions (Jerusalem District, Tel Aviv District, Haifa District, Northern District, Central District and Southern District) and ordered within each stratum according to size. Size referred specifically to the estimated number of 13 to 15 year olds in the sampling frame in each city.

4. The urban settlements in the sample were chosen through systematic random sampling with a probability proportional to size so that the final sample in each stratum represented all the adolescents in that stratum.

5. All adolescents within each of the sampled localities were ordered according to age, gender and geographic distribution within the city, in an attempt to represent all socio-economic groups. The adolescents in that city were sampled by a systematic random sampling method. The sampling probability within each city was calculated so that the final sampling fraction would be the same for the total sample.

Instruments The survey used two measures: the Strengths and Difficulties Questionnaire (SDQ) (29), the Development and Well-Being Assessment Inventory (DAWBA) (30), and services utilization questions and health status and socio-demographic questions.

The Strengths and Difficulties Questionnaire The SDQ is a screening diagnostic instrument designed for evaluating social, emotional and behavioral functioning in children and adolescents aged 4-17 years (30-32). It includes five subscales: four of them refer to difficulties and one to the adolescents’ strengths. Its 25 items cover four clinical domains, namely, hyperactivity-inattention, emotional symptoms, peer-relationship problems and conduct problems, and one distinct pro-

social behavior domain. Each item/statement is rated on a 3-point scale as 0 (not true), 1 (somewhat true), or 2 (certainly true). The questionnaire is multi-informant, i.e., can be administered to adults (parents, caretakers and teachers), and also includes a self-report version for adolescents aged 11-17. In addition to the clinical domains, the SDQ is supplemented with an impact module that asks the respondents to assess whether the adolescent in question has a problem, its chronicity, and whether this results in emotional distress, social impairment or burden to the family. The psychometric properties of the SDQ, tested in different cultural contexts and in clinical and community settings, are satisfactory (3339). Its internal reliability-consistency (mean Cronbach alpha) was 0.73; for retest stability after 4 to 6 months, the mean was 0.62 and for cross-informant correlation the mean was 0.34 (36).

The SDQ has been used internationally and translated into more than 60 languages. We used the Arabic and Russian versions of the instrument readily available at http://www.sdqinfo.com/, while the Hebrew version was developed especially for this study by the team members (DL, IM-K, IL). The Hebrew translation took into account cultural aspects of the questions, colloquialism and idioms. Two bilingual researchers were in charge of back-translating the Hebrew version into English. The back-translation was compared to the original questionnaire and sent to the SDQ’s author, whose comments were discussed by both translators and a third bilingual staff member was consulted about the few discrepancies that emerged. Lastly, a pilot test was conducted on 15 subjects recruited for the study, after which a final decision on the exact wording was made. The questionnaire took from 5 to 10 minutes to complete.

The Development and Well-Being Assessment Inventory The DAWBA is a package of questionnaires, interviews and rating techniques that generates ICD-10 and DSM-IV psychiatric diagnoses for children aged 5 to 17 years (30). The specific disorders include: separation anxiety, specific phobias, social phobia, panic attacks and agoraphobia, post-traumatic stress, compulsions and obsessions, generalized anxiety, depression, and less common problems such as tic disorder. In addition, information is obtained concerning deliberate selfharm, hyperactivity and awkward/troublesome behaviors, and on the burden and impact of these symptoms on the respondent’s family.

247

THE ISRAEL SURVEY OF MENTAL HEALTH AMONG ADOLESCENTS: AIMS AND METHODS

The DAWBA is a multi-informant instrument, constructed for its administration in private homes and combines some of the best features of structured and semi-structured measures. When definite symptoms are identified by the structured questions, interviewers use open-ended questions and supplementary prompts to get parents or the adolescent himself to describe the problem in their own words (14). On the basis of the comments of both mothers and adolescents recorded by the interviewers, a team of psychiatrists confirmed or rejected the preliminary computerized diagnoses and a final diagnosis for each adolescent was thus obtained.

The Hebrew translation was performed by the same procedure as described above for the SDQ. Services Utilization These questions assess parental attitudes and practices regarding the needs of the adolescent experiencing emotional and behavioral problems. They include items on lifetime and past 12 months use of services for mental and physical disorders. As well, they ask about the use of psychotropic medication and referral to specialists by school or other agents in the community. The self-report version inquires about the adolescent’s contacts with school-based counseling sources and contact with other service providers in the community, without any attempt to evaluate the effectiveness of the services received.

Health Status and Sociodemographic Questions These questions record the socio-demographic characteristics of the family and the adolescent, probe health status and health problems as well as daily life experiences, school performance and extracurricular activities. Risk and protective factors for psychopathology, such as family and social life, school performance, smoking, drinking, drug use and sexual harassment, were included.

Survey Procedures

Survey mode. The survey used a face-to-face interview mode and was carried out at the respondents’ homes between January 2004 and March 2005. Two trained interviewers interviewed the mother and adolescent simultaneously and independently. The mother was specifically targeted, as opposed to “any adult caretaker,” because we assumed she is more frequently at home, more accessible and more aware of the health services used by the family members. As in other studies (20), 248

we selected the mother as the adult respondent, unless she had not lived with the child for the six months preceding the interview.

A survey firm, Public Opinion & Marketing Research of Israel (PORI), employed interviewers and supervised the fieldwork, together with the staff of the Ministry of Health. The face-to-face mode was particularly important given the sensitive questions asked and the length of the interview. On average the mothers' interview took between 50 and 90 minutes and the adolescents' interview between 45 and 75 minutes, depending on the history of disorders of the adolescent.

The interviews were carried out in Hebrew (n = 570), Arabic (n =300) and Russian (n = 87) according to the preference of respondents. Russian was used only for immigrant mothers, as it was assumed that all adolescents who have been in the country for at least one year had adequate Hebrew knowledge.

Training of interviewers. The 104 lay interviewers who participated in the data collection, mostly women, were college students and experienced survey interviewers. They were trained in small groups in an 8-hour training session during which they went over the interview schedule, reviewed the questionnaires and were instructed regarding particular aspects of the different questions. After they completed the first three interviews, they went through the questionnaires with the fieldwork supervisor and reviewed any errors or omissions in each of the completed questionnaires.

Confidentiality and ethics. All interviewers signed a form promising to respect the confidentiality of the information they received. All identifying information, except for the identity code, was stored separately from the questionnaire. Confidentiality could be infringed only for cases in which the adolescent reported sexual abuse or explicit suicidal intentions, cases that the law mandates should be conveyed to the appropriate authorities. The Helsinki Ethics Committee of the Schneider Medical Center for Children in Israel approved the study.

Data collection. Efforts were made to confirm the address and telephone number of families of all the adolescents included. An introductory letter explaining the objectives, the randomization method and confidentiality of the data and providing a phone number for possible queries was sent to each pre-designated target family. A week later, the interviewer arranged an interview date by phone and on the assigned date two interviewers made a home visit. They asked the mother

Ivonne Mansbach-Kleinfeld ET AL.

to sign a consent form and informed both the mother and adolescent about their right to stop the interview at any time. After the interview was completed, both mother and adolescent were asked for their consent to approach a schoolteacher of their choice. If both mother and adolescent signed the consent form, then it was mailed to the teacher, along with the teacher’s version of the DAWBA, and a letter of explanation signed by a high officer of the Ministry of Education and a prestamped envelope with a return address.

Response rates. Table 2 shows response rates by gender and population groups. Overall response rate was 68.2%: 14.8% of the subjects were not located and 17.0% refused to participate in the study. Among the located subjects response rate approached 80%. Response rates varied by population group, with higher rates among boys and inhabitants from Arab localities.

After the feasibility stage showed that only 4% of the Jewish ultra-Orthodox families would be willing to participate, it was decided not to include this group in the study. The 245 Jewish ultra-Orthodox adolescents and their families were identified by the name of the school they were attending and their home address, as they attend a separate educational system and live in specific neighborhoods, and thus it was possible to exclude them from the sample.

but signed and consented that their child participates, and 50 adolescent who refused, although their mothers answered the questionnaire. In these cases, we based our diagnoses on single source of information. Thus, we have 957 cases with at least a single informant, 885 cases with, at least, two informants (adolescent and mother), and 169 cases with three informants (adolescent, mother and teacher).

“Refusals.” When the introductory letter did not return, the family was contacted in order to convince both mother and adolescent to participate. If the family refused, a second letter signed by the Mental Health Advisor to the Minister of Health (IL) was sent, appealing to them to contribute to the public good. If they still refused, the survey coordinator again tried to convince them to participate. Only after the third refusal were they classified as “Refusals” (N=238).

“Not located.” If the introductory letter was returned by the mail, the interviewer visited the address to corroborate that the family had moved and to try to find out from neighbors the new address. If the interviewer could not obtain information from the neighbors, the school principal was approached and, with the help of an official letter from the Ministry of Education, was requested to help us find the adolescent's address and home telephone. If the child had left the school and the school authorities did not have any information, we approached the Ministry of Interior and tried to find out the new address of the family. If we failed, the case was considered “Not located” (N = 207).

Inflation Method and Response Rates. The sample was weighted back to the total population to compensate for

Defining “Respondents,” “Refusals” and “Not contacted” “Respondents.” The subjects were classified as respondents if the interviews to mother and adolescent were performed and completed as described. There were 22 mothers who refused to answer the questionnaire Table 2: Fieldwork results by gender and population groups Total population

Gender

Type of locality

Male

Female

Jewish/mixed localities

Arab localities

N

%

N

%

N

%

N

%

N

%

Gross sample

1,670

100.0

854

100.0

816

100.0

1,370

100.0

300

100.0

Excluded:

268

16.0

139

16.3

130

15.9

267

19.5

1

0.3

a) Ultra-Orthodox Jews

245

14.7

132

15.5

114

14.0

245

17.9

0

0.0

b) Abroad 1 year+

23

1.3

7

0.8

16

1.9

22

1.6

1

0.3

Net sample

1,402

100.0

715

100.0

686

100.0

1103

100.0

299

100.0

Not located

207

14.8

102

14.3

105

15.3

195

17.7

12

4.0

Refusals

238

17.0

116

16.2

121

17.6

219

19.9

19

6.4

Respondents

957

68.2

497

69.5

460

67.1

689

62.5

268

89.6

Of located: Respondents

957

80.1

497

81.1

460

79.2

689

75.9

268

93.4

249

THE ISRAEL SURVEY OF MENTAL HEALTH AMONG ADOLESCENTS: AIMS AND METHODS

unequal selection probabilities resulting from clustering effects and non-response. The weights were adjusted to make weighted sample totals conform to known population totals taken from reliable Central Bureau of Statistics (CBS) sources, after Jewish ultra-Orthodox adolescents were removed.

The weighted groups were chosen according to gender, age and population groups. The categories were gender (male and female), age (14, 15, 16, 17 years) and population group (Jews and others born in Israel; Jews and others born abroad; Muslim and Christian Arabs; and Druze). The inflation method for each group of individuals was determined according to the known characteristics of the respondents and non-respondents in the given group. Response status was assigned according to the following categories: a) respondent; b) left the country; c) refused to answer; d) ultra-Orthodox; e) not located. Jewish ultra-Orthodox youth were excluded from the population, as explained above, as well as those who left the country. Respondents and refusals were included in the study population and those not contacted were proportionally divided into refusals and those who should not have been included in the study population from the start.

Table 3 presents response rates according to population group and size of city. There were higher response rates among Druze, Muslim and Christian respondents than among Jewish respondents. There were higher response rates among adolescents living in mid-sized urban localities than among those living in larger cities.

Quality control procedures. Data quality was controlled in a number of ways in order to increase the reliability and validity of the survey information. Parents had to sign an informed consent form, as well as their consent to interview their child’s teacher and, therefore, we could corroborate that the interview had indeed taken place. A few parents refused to sign the form out of fear that this would obligate them to something later on but agreed to carry out the interview. These parents were contacted again to make sure they had agreed to be interviewed. All questionnaires were reviewed upon reception by the field coordinator and missing data that could be provided by the interviewers were retrieved as soon as possible.

Results of the Fieldwork. Table 4 presents the sociodemographic characteristics of the survey participants.

The proportion of boys was slightly higher than that of girls. Over 85% of adolescents lived in a household with married parents, and 14% lived with their divorced or 250

single mother. The majority of respondents, 77%, lived in families with three or more children. Approximately 40% of the respondents’ mothers had 13 years or more of education. Nearly 1/4 of the respondents’ fathers did not work in paid employment: 1/3 of them had a physical or a mental disability; 1/3 were not looking for work because they were pensioners or still studying, or in prison; and 1/3 were unemployed and did not find work.

Most respondents (80%) were living in a Jewish or mixed Jewish-Arab city and 20% in exclusively Arab locations.

Over 81% of the adolescents were born in Israel.

Discussion The ISMEHA is the first general population survey on mental disorders and use of services in adolescence ever carried out in Israel. It used a structured psychiatric interview that allows the establishment of prevalence estimates in the non-institutionalized population in the community, and enables international comparisons.

This study also overcomes one of the main problems that hamper studies on children’s and adolescents’ use of services by studying the different service sectors available to families and adolescents rather than concentrating on services provided by one single sector (usually the specialty of mental health or the education sector).

Additionally, ISMEHA brings benefits to the research community: for example, the approved Hebrew version of the SDQ we developed has been posted at the public open website of the SDQ created by Goodman Table 3.

Response rates (%) by population group and city size Characteristic

%

Population group Jews and others born in Israel

65.0

Jews and others born out of Israel

55.0

Arab Muslims and Christians

86.0

Druze

93.0

City size Jerusalem (732,100)

60.0

Tel Aviv (384,600)

57.0

Haifa (267,000)

46.0

Other large cities (100,000-200,000)

60.0

Jewish-mixed mid-size urban localities (<100,000)

66.0

Arab urban localities (<70,000)

89.6

Ivonne Mansbach-Kleinfeld ET AL.

(www.sdqinfo.com) and Hebrew-speaking researchers are freely accessing and using it. In addition, the database developed in this project, which belongs to the Ministry of Health of Israel, will be placed in the public domain and open access to this data base will enrich knowledge on adolescent mental health and will stimulate further research.

The overall response rate obtained is an acceptable rate for community studies that draw their samples from the National Population Registry (39-41). A householdbased survey would probably yield a higher response rate but a bias would be emerging because of parentsâ&#x20AC;&#x2122; tendency to choose the â&#x20AC;&#x153;healthiestâ&#x20AC;? child to be interviewed. The results of this study can be generalized to the general population and provide essential information for policy and for planning programs and services.

Study limitations The main limitation is that the survey covers a reduced age group. Although initially we targeted the 5-17 years of age group, limited resources forced us to narrow the age band. The rationale for choosing the 14-17 age group was that psychiatric disorders are diagnosed more reliably as age increases. Older adolescents also provide independent information that parents may not be aware of and then the two sources of information may be combined to provide a better estimate of mental disorder. An additional argument for choosing the older end of the spectrum was that retrospective information that might shed light on the development of the disorder and attempts to care for it could be obtained. The upper age limit was determined by the fact that after adolescents become 17, many (both genders) join the Israel Defense Forces (IDF) and are not eligible for interviewing by civilian sources.

We have insufficient knowledge regarding whether the two sub-populations not included in the study (i.e., Jewish ultra-Orthodox and Arab residents of East Jerusalem) have higher rates of mental disorders, but we know that they have different patterns and lower rates of use of psychiatric services (42-44), and therefore an assessment of these particular populations is definitely needed. One of these groups, the ultra-Orthodox Jewish population, follows the most theologically conservative form of Orthodox Judaism and comprised 17.8% of the population among adolescents between 14 and 17 years of age at the time the sample was drawn (2002).

Children and adolescents attend schools where girls and boys study separately and live in more or less seg-

regated neighborhoods in several cities. Children are not allowed to watch TV or films, to read secular newspapers or use the web and thus parents and teachers have strong control over the information to which they are exposed. A survey that attempts to assess the ultraOrthodox community in Israel has to be planned, from its conception, together with the religious leaders of the community in order to secure their approval of the content of the subjects to be dealt with. In order to include all sub-cultures, a national survey might consider a basis of common core questions and additional differential supplements for the different cultural groups.

Differential non-response rates must be discussed.

Although the response rate was satisfactory, rates substantially varied across the study subgroups. The compliance of the new immigrants was lowest (55%), whereas that of the Israeli-Arabs was highest (90%), with the mainstream Jewish population around the Table 4. Socio-demographic characteristics of the ISMEHA sample (raw numbers and weighted proportions) Characteristic

N

%

Boys

497

51.2

Girls

460

48.8

Married

813

85.6

Single/divorced/widowed

122

14.4

23

3.0

Gender

Marital status of parents

Number of children in family 1 2

151

19.7

3

230

25.9

4-6

401

40.1

7-16

132

11.3

299

27.3

Maternal years of schooling 0-11 12

277

32.8

13 and over

325

39.9

Employment status of father Employed

661

77.0

Unemployed

214

23.0

Type of locality Jewish or mixed city

689

80.1

Arab city

268

19.9

Country of origin Israel

826

81.5

Other

131

18.5

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THE ISRAEL SURVEY OF MENTAL HEALTH AMONG ADOLESCENTS: AIMS AND METHODS

62% rate. Based on research on the determinants of non-response (45), there is some reason to believe that these non-respondents had higher rates of psychiatric disorder than respondents, although this must be corroborated for the adolescent population.

Finally, there was a low teachers’ response rate. The original design took into account the three-informant format: the parent, the teacher and the adolescent.

Teachers’ participation was conditional to the written consent signed by both mother and adolescent. If consent was given, a letter with the name of the teacher was sent to the school, but often families provided only the first name of the teacher or the wrong school address. Due to budgetary restrictions the follow-up of the teachers’ compliance was not carried out efficiently enough.

Despite these limitations, the ISMEHA enables the creation of a unique and comprehensive database informing on the prevalence, services utilization and unmet needs of adolescents with mental and behavioral disorders in Israel.

Acknowledgements This survey was supported by the Israel National Institute for Health Policy and Health Services Research, the Association for Planning and Development of Services for Children and Youth at Risk and their Families (ASHALIM), the Englander Center for Children and Youth of the Brookdale Institute in Jerusalem and the Rotter Foundation of the Maccabi Health Services. We also acknowledge the important contribution of Robert Goodman, Jane Costello and David Brent in the planning of this project and the help of Olga Goralik in the Russian translation of the Assessment of Services Utilization questionnaires.

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List of reviewers for Israel Journal of Psychiatry, 2010 The Editors would like to thank the following for their contribution as reviewers of manuscripts during 2010.

Henry Abramowich

Milka Donchin

Malcolm Lader

Michael Ritsner

Eitan Abramowitz

Jacques Eisenberg

Alon Lazar

David Roe

Alean Al-Krenawi

Naomi Fineberg

Dori Laub

Shlomo Romi

Paul Appelbaum

Gilad Gal

Vladimir Lerner

Ariel Rosler

Alan Apter

Gary Ginsberg

Pesach Lichtenberg

Isaac Schechter

Yoram Barak

Saralee Glasser

Laura McCray

Gaby Shefler

Haim Belmaker

Daphne Gofrit

Jacob Margolin

Leo Sher

Dorit Ben Shalom

Howard Goldstein

Yuval Melamed

Sharon Shiovitz-Ezra

Yoram Bilu

Harvey Gordon

Shlomo Mendlovic

Susan Stuebner

Avi Bleich

Jon Grant

Kim Mueser

Amir Tal

Maya Bleich

David Guay

Tali Nachshoni

Anne-Marie Ulman

Yuval Bloch

Zinoviy Gutkovich

Yuval Neria

Abraham Weizman

Jed Boardman

Talma Hendler

Nurit Nirel

Nomi Werbeloff

Ehud Bodner

Jonathan Huppert

Magne Nylenna

Perla Werner

Mayer Brezis

Iulian Iancu

Tamar Peleg

Eliezer Witztum

Danny Brom

Moshe Kalian

Alberto Pertusa

Marc Woodbury-Smith

Mark Bubow

Yoav Kohn

Alexander Ponizovsky

Gil Zalsman

Michael Conn

Harvey Kranzler

Michael Poyurovsky

Zvi Zemishlany

Rena Cooper

Max Lachman

Martin Rabey

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Postpartum Depression: A Chronicle of Health Policy Development Saralee Glasser, MA Unit for Mental Health Epidemiology & Research on the Psychosocial Aspects of Illness, Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Ramat Gan, Israel

ABSTRACT The current report presents an example of the path taken from identification of a public health problem at the primary health service level, to conducting research documenting the scope of the problem and nature of the risk factors, disseminating the findings, and fostering development and application of relevant policy. The example presented is the case of postpartum depression, an issue with bio-psycho-social implications.

Public health nurses identified the problem, prompting epidemiological research. The findings encouraged the Ministry of Health (MOH) to conduct a pilot program for screening and early intervention among pregnant and postpartum women reporting depressive symptoms.

Based on the results of the pilot program, the MOH is expanding the program to all Mother-Child Health (MCH) clinics. Israel᾿s largest Health Maintenance Organization has followed suit and is including this program in its own clinics. This Israeli experience may serve as an instructive example of a locally identified problem evolving into a national policy.

Introduction Epidemiological research should serve as a basis for identifying and addressing public health issues, health promotion, disease prevention and clinical practice (1).

However, the results of such research often take years to find their way to fruition in the field. The road from research to application is even more difficult when it must cross the conceptual border that many consider

to divide physical from emotional health. The current report presents the developments leading to such change in the case of postpartum depression (PPD).

PPD, a condition with bio-psycho-social implications and consequences, may be the most common complication of childbirth (2, 3), with prevalence estimated at 10-20% (cf. 3-5). Findings in this range have been reported in Israel (6) as well as in many countries and cultures, including Dubai (7), England (8, 9) Sweden (10, 11), Malta (12), New Zealand’s Pacific Islands (13), China (14), and Portugal (15). Goldbort (16) conducted a transcultural analysis of PPD research, concluding that it is a universal experience, although labeled variously in different cultures.

PPD can have serious consequences for the mother, infant and family (17-23), placing it within the realm of public health concerns (24). Despite the prevalence of PPD and the frequency of contacts between women and health personnel during pregnancy and postpartum, most cases are not identified, diagnosed or treated (10, 25-29).

Thus, the potentially negative influences on the mother, on the infant’s physical, emotional, and cognitive development, and on the entire family, are often unattended.

The prevalence, severity and consequences of PPD make early identification and intervention a high-priority case for action (24), with programs for this purpose reported in many countries. For example, in the U.S. Georgiopoulos et al. (30) found that routine screening for PPD at the sixthweek postpartum visit was associated with increased diagnosis, while in the U.K. MacArthur et al. (31) found that midwifery-led care resulted in improved maternal mental health at four months postpartum. In Sweden, Wickberg and Hwang (32) found that counseling visits by public health nurses were very effective in reducing depressive symptoms among women screened for PPD. Each of these

Address for Corrsepondence: Saralee Glasser, Unit for Mental Health Epidemiology & Research on the Psychosocial Aspects of Illness, Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel saraleeg@gertner.health.gov.il

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Saralee Glasser

studies had somewhat different foci and methodology, but shared many aspects of approach and purpose. Differences were usually not conceptual, but due to the effort to facilitate implementation in existing health care frameworks.

As will be seen, the Israeli program presented here has much in common with these efforts.

While awareness of the problem of PPD has heightened over the past few decades, strategies for identification and treatment of cases have generally been developed on a local basis. The Israeli experience in this area may be instructive as an example of a locally identified problem evolving into a national policy. The purpose of this report is to describe an example of the steps taken from identification of a public health problem in the field (in this case PPD), to conducting research documenting the scope of the problem and nature of the risk factors, to disseminating the findings, and fostering development and application of relevant public health policy.

I. From Practice…

During 1983-1984 a developmental psychologist (SG) was employed by the Health Services Research Unit1 (HSRU), on behalf of a special intervention program (33) at three Mother-Child Health (MCH, Tipat Chalav) clinics covering service for a small city (pop. approx. 20,000).

Noting her presence in the clinics, the nursing staff often requested that she meet with women who seemed to be suffering what might be PPD, saying: “she hasn’t ‘returned’ to herself ”; “she isn’t relating to the baby,” etc.

The nurses were disturbed by these cases and felt lacking in skills or resources to deal with them. The psychologist would meet these new mothers for short-term counseling and/or referral to mental health clinics. When the psychologist moved on to other projects in the HSRU, she was contacted repeatedly by the same nurses, requesting advice on these suspected “PPD” cases.

II. …to Research…

In response to these requests, the late Vita Barell (then Head of the HSRU), stressing the Unit’s policy role as a Ministry of Health (MOH) research unit, suggested planning an epidemiological study to document the scope of the problem and investigate possible solutions.

The literature was searched for similar Israeli studies on this topic, but none was found. Thus a prospective study of PPD was conducted.

The Health Services Research Unit is currently known as The Unit for Mental Health Epidemiogy and Research on the Psychosocial Aspects of Illness, Gertner Institute for Epidemiology and Health Policy Research.

1

The research aimed to: (a) document the prevalence of PPD in a community cohort; (b) identify PPD risk factors; and (c) ascertain the feasibility of PPD screening in the primary health clinic using the Edinburgh Postnatal Depression Scale (EPDS) (34).

The study’s main findings were: 1. A rate of 22.6% of PPD symptoms, as determined by a >10 cutoff score on the EPDS (6).

2. Psycho-social risk factors, as recorded during pregnancy, were the main predictors of PPD. These included poor marital satisfaction, lack of social support, depression symptoms during pregnancy, and previous emotional problems (35).

3. The EPDS was found acceptable by both MCH patients and staff.

From 1998 to 2000 peer-reviewed articles were published based on this research (6, 35) and the Hebrew EPDS translation was published in Harefuah, the Israel Medical Association’s Hebrew-language journal (36), to raise awareness of the issue among local professionals and encourage utilization of the same translation, making findings more readily comparable and facilitating accumulation of knowledge. This translation was subsequently validated (37) and incorporated in a book about the use of the EPDS (38).

III. Networking…

In addition to publication of the findings, the research was presented at local, national and international professional conferences, as well as professional meetings and academic seminars. Graduate students in psychiatry, psychology, nursing and social work were referred to the Unit for mentoring of theses or doctoral work, further increasing awareness and expanding knowledge about PPD in Israel among a growing group of professionals.

Special emphasis was placed on communicating the research findings and disseminating other relevant literature about PPD and intervention programs to key persons at the MOH and the Knesset (Israel’s Parliament). Two sessions dedicated to PPD information and policy were held by the Knesset’s Sub-Committee on Women’s Health serving to further increase awareness and encourage policymakers to take a stand promoting early identification and intervention with women at-risk, as well as inclusion of the topic in medical schools’ curricula (39, 40).

It is important to note that in addition to the empirical findings in an Israeli cohort, the case for a PPD screening program was strengthened by other research find255

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ings regarding prevalence of PPD, risk factors, and the value of screening for signs of depression in primary care clinics, which generally recommended similar programs (cf. 27, 28, 30). Further, legislative activity, particularly in the U.S. Congress, urged such screening in recognition of PPD as a major public health concern (41). As this information was published or disseminated (via internet, etc.), our team made it a point to forward relevant findings and recommendations to Israeli policymakers, keeping them “in the loop,” and maintaining awareness and interest in the issue. While there is no “hard proof ” that these activities were the impetus of change, they may have contributed to focusing attention on the issue and fostering the changes that occurred.

IV. Policy Development…

In May 1999, the directors of MOH Mother, Child and Adolescent Health Service and Public Health Nursing Department decided to institute screening for PPD and PPD-risk in the national network of MCH clinics. It was determined that: (a) this policy decision would first be implemented as a pilot program in selected clinics; (b) nurses would screen with the EPDS at about 32 weeks pregnancy and six weeks postpartum; (c) clinical guidelines would be prepared for screening and intervention; (d) nurses in these clinics would be trained in the use of the EPDS, the clinical guidelines and content of intervention; (e) a Mental Health Coordinating Nurse would be available to serve as advisor to both nurses and mothers participating; (f) the head of the MOH Mental Health Service would be included in this effort, to facilitate referrals to mental health clinics when necessary; and (g) the pilot program would be monitored and evaluated. During 2001 the pilot program was conducted at clinics in five cities. The evaluation report was presented to the MOH in May 2002, and the recommendation to continue and expand the program was adopted.

At the same time an information brochure on postpartum emotional difficulties was prepared as well, and submitted to the MOH Printing Office, but was not published. However, several services photocopied the draft of the brochure and distributed it in local clinics.

V. Translating Policy into Practice

Ministry of Health: Although the screening and intervention program continued in some MCH clinics that participated in the pilot program, the MOH was then unable to train more nurses due to more pressing issues. However in response to consistent 256

positive feedback from those pursuing the program, in October 2003 the Public Health Nursing Service undertook expansion. Several training courses were subsequently conducted and the program has been implemented in about 175 MCH clinics throughout the country. Furthermore, a six-hour unit of study about PPD (theory, screening, supportive intervention) was instituted in MOH continuing education courses for accreditation of public health nurses and has been offered regularly since 2004.

Health Maintenance Organizations (HMO): Parallel to MOH activity, Clalit HMO instituted a similar PPD screening and supportive intervention by nurses country-wide, supported by Program Coordinators and/or social workers. Our Unit served as consultant for planning nurses’ training and EPDS data collection methods. Clalit Health Services insures 55% of the Israeli population, (42) and by May, 2005, about 160 Clalit clinics were participating in the program. Israel’s three remaining HMOs have also expressed interest, but not yet implemented the program.

The PPD Brochure: In September, 2006, the MOH published and distributed to all Ministry MCH clinics the informational brochure on PPD entitled: “What you should know about Postpartum Depression: Information for women who are pregnant or after delivery.” The brochure is in Hebrew and an Arabic version is being prepared. Plans include distribution to additional sites, such as hospital maternity departments. The brochure can be requested in quantity by individuals or organizations free of charge. In addition, the MOH is currently preparing information regarding PPD for its website.

Conclusion As recently as December 2006, Wisner et al.’s editorial in JAMA described PPD as “A Major Public Health Problem,” and called for screening to be implemented no later that 12 weeks postpartum, noting the EPDS as a useful instrument for this purpose (24). Considering the legal and ethical aspects of pediatric providers screening for PPD among mothers of children in their care, Chaudron (43) concludes that the benefits of such a process outweigh the risks, on condition that caregivers be educated to implement and respond appropriately. It is, however, vital that mental health services are involved in provision of training, support and treatment to programs such as these.

Similar PPD screening and intervention programs in primary care settings throughout the world have reported

Saralee Glasser

favorable results, with nurses/midwives generally the service providers (cf. 30, 31, 44-47) and back-up by mental health services. An analysis of PPD prevention research from the Cochrane Pregnancy and Childbirth Group trials register (48) noted that a “… promising intervention appears to be the provision of intensive postpartum support provided by public health nurses or midwives” (p. 1), and that although prevention programs begun prenatally were not found by them to be more effective than those begun postnatally, identifying “at-risk” mothers assisted in prevention of PPD. Further, studies have found routine EPDS screening acceptable to most women and health professionals (49, 50). In a recent study of women before, during and after pregnancy, Dietz et al. (51) found that among those identified with depression there was a high degree of willingness to obtain treatment, thus providing support for a program of routine screening, …“which could uncover undetected depression and, with appropriate treatment, mitigate the devastating effects of this disease on the mother, infant and other siblings” (p.1520). Goldbort’s transcultural analysis (16) led to the recommendation to screen and/or teach all women about depressive disorders prenatally and postnatally, to “open up dialogue and communication…giving them permission to express their feelings, to ask for help…to decrease the stigma…” (p. 126).

The constellation of health policy hierarchy is different in every country; however there is usually a “top of the pyramid.” If policy is mandated from that peak, be it the legislature or the executive branch, the likelihood increases that the largest number of citizens will benefit. The MOTHERS Act was introduced in the U.S. Senate (52) to ensure education, screening and services relating to PPD, and in October, 2007 the House of Representatives passed the Melanie Blocker Stokes Postpartum Depression Research and Care Act by a vote of 382-3 (53). In addition, several states have mandated such activities. (54) In February 2007, the U.K.’s National Institute for Health and Clinical Excellence published guidelines for antenatal and postpartum mental health, which although non-binding, provide detailed recommendations for care of women during these periods of life, and are likely to set standards for such care (55). In Australia the National Post-Natal Depression Research Program (56), conducted from 2001 to 2005, reported favorable results and is developing a national action plan to turn the research into policy and practice. The Scottish Intercollegiate Guideline Network has recommended depression screening during pregnancy and postpartum as part of their detailed and comprehensive approach to

dealing with PPD (57), and Lee et al. (14) recommended universal PPD screening for early detection in women in China, although no steps to this effect have been reported.

An Icelandic national study (58) employing web-based courses in diagnosis and intervention with distressed postpartum women found the use of internet successful in training nurses, and in turn reducing the rates of PPD. This model could be important in rural areas and in countries with dispersed populations. These steps serve to increase the exposure and public awareness of the issue of PPD, generating in themselves a positive atmosphere for influencing policy. In sum, considering the experience in many countries, Almond (59) has concluded that from a global perspective, PPD is clearly a public health problem, and recommends further research and encourages routine assessment of all women in the postpartum period.

The Israeli experience with PPD is a clear example of the cycle in which problem identification at the community level led to research, and research findings led back to application in the community. This is a mutually beneficial transaction, which can contribute to fostering evidence-based public health policy (60). The time-line for this “chronicle” may seem long; however, from publication of the first research findings in 1998, to actual implementation – 2002 when the results of the pilot screening study were endorsed by the MOH, and 2003 when implementation by the Clalit HMO began – it was relatively short for such a widespread shift in viewing and dealing with PPD as a public health issue.

To our knowledge this is the first instance in Israel in which a screening program has been instituted for a mental health problem within the primary health system, and it is hoped that this bodes well for a future more holistic approach to public health. As Gordis (1) stated: “Indeed, one of the major sources of excitement in epidemiology is the direct applicability of its findings to the alleviation of problems of human health” (p. 247).

Acknowledgements The author would like to thank Dr. Raz Gross, Mr. Giora Kaplan and Dr. Elizabeth Langner for their comments and suggestions regarding this manuscript.

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39. Protocol No 10 of the Knesset Subcommittee for Women’s Health, Education and Sport, May 27, 2002: 2002 [cited 2008 July 15] Available from: URL: http:// www.knesset.gov.il/protocols/data/html/maamad/2002-05-27.html 40. Protocol No. 127 of the Meeting of the Knesset Committee on the Status of Women, Oct. 20, 2004. 2004 [cited 2008 July 15]; Available from: URL: http:// www.knesset.gov.il/protocols/data/html/maamad/2004-10-20.html 41. Office of Legislative Policy and Analysis. Legislative updates: Melanie BlockerStokes postpartum depression research and care act; Available from: URL:http:// olpa.od.nih.gov/legislation/108/pendinglegislation/postpartum.asp 42. Ministry of Health. Health in Israel: 2005 – Selected Data. Jerusalem; Sept.

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52. GovTrack.US. S.1375: Mom’s Opportunity to Access Health, Education, Research, and Support for Postpartum Depression Act. 2007 [cited 2008 July 15]; Available from: URL:http://www.govtrack.us/congress/billtext.xpd?bill=s110-1375 53. Office of Congressman Bobby Rush. Rep. Rush’s Postpartum Depression Bill receives overwhelming support as it passes the House. 2004 [cited 2008 July 15]; Available from: URL: http://www.house.gov/apps/list/pres/i101_rush/PPSD.html 54. Murdock, S. Postpartum depression legislation in the United States: A brief history. 2008 [cited 2008 July 15]; Available from: URL:http://postpartum.net/ resources/healthcare-pros/legislation-history/ 55. National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: Clinical management and service guidance. 2007 [cited 2008 July 15]; Available from: URL: http://www.nice.org.uk/guidance/CG45

56. Beyondblue: The National Depression Initiative – about the PND program [cited 2008 July 15]; Available from: URL:http://www.beyondblue.org.au 57. Scottish Intercollegiate Guidelines Network. Guideline 60: postnatal depression and puerperal psychosis. 2002 [cited 2008 July 15]; Available from: URL:http:// www.sign.ac.uk/guidelines/fulltext/60/index.html 58. Ingadóttir E, Thome M. Evaluation of a web-based course for community nurses on postpartum emotional distress. Scand J Caring Sci 2006;20:86-92.

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Yuval Melamed et al.

Guardianship Appointment: Current Status in Israel Yuval Melamed, MD, MHA, 1,2 Lili Yaron-Melamed, MSW, 3,4 and Jeremia Heinik, MD 2,5 1

Lev Hasharon Mental Health Center, Netanya, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3 Mental Health Center, Jaffa, Israel 4 Bob Shappell School of Social Work, Tel Aviv University, Tel Aviv, Israel 5 Margoletz Psychogeriatric Center, Ichilov Hospital, Tel Aviv, Israel 2

ABSTRACT The appointment of a guardian is an important complex process that significantly infringes upon the individual’s liberty and autonomy; however it is a necessary paternalistic intervention when called for. The law does not provide precise criteria for the appointment of a guardian, though physicians have tried to determine criteria for the initiation of the process. The authors present a review of the various aspects of the assessment of the need for guardianship and the appointment process for guardians for adults in Israel. The medical document that will ultimately determine the need for the appointment of a guardian for an elderly person should be the product of a comprehensive medical, psychiatric and cognitive evaluation and an accurate evaluation of competence.

Introduction The appointment of a guardian is an important, complex process that significantly infringes upon the individual’s liberty and autonomy; however, it is a necessary paternalistic intervention when called for. Autonomy and liberty are the building blocks of society (1), and any breach of these principles should be avoided and, when unavoidable, should be proportional (2). On the other hand, non-appointment of a guardian when necessary is social neglect that may leave those in need unprotected and at economic and physical risk. The process of appointment (3) is based on the Capacity and Address for Correspondence: ymelamed@post.tau.ac.il

Guardianship Law from1962 (4), that basically has had no major amendments, though there have been updates as described in the following sections.

The law does not provide precise criteria for the appointment of a guardian (5), though physicians have tried to establish guidelines (6). In some instances alternative solutions for guardian appointment are sufficient. The Court determines the need for a guardian based on expert medical opinions (7, 8). Guardian appointment for adults generally involves the mentally ill (9) and the elderly (10).

The authors present a review of the various aspects of guardian appointment for adults in Israel.

Legal rulings Amendments to the Capacity and Guardianship Law 1962 Throughout the years, the Law has been updated.

A. 1970 – guidelines for the appointment of a guardian were determined, including the obligation for accounting, and financial reporting by the guardian (amendments 5732, 5752). The names of legally incompetent persons must be recorded in a central registry that can be accessed by the general public, and is located near the Jerusalem District Court.

B. 1988 – Salary for guardians. Previously, the Court determined a monthly wage for legally appointed public guardians (e.g., attorneys, public agencies who are paid for their services) not greater than eight percent of the National Insurance pension, when the protected person was hospitalized and four percent when the protected person was not hospitalized. Today the fee for professional services is higher. This situation leaves less money for the protected person, especially

Dr. Yuval Melamed, Deputy Director, Lev Hasharon Mental Health Center, POB 90000,Netanya 42100, Israel

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when hospitalized. Friends and relatives who serve as guardians generally do not require payment.

C. 2000 – Methods for the investment of the protected person’s funds. These amendments determine the obligation to invest the protected person’s money in solid risk free investments, or in alternative courtapproved programs. Any investment over 25 times the National Insurance pension requires court approval.

Related Laws These laws allow for an alternative solution for the protection of the patient, or an immediate action until the appointment of a guardian is arranged.

A. Agency Law 1965 (11).

Agency is power of attorney of an agent or an emissary to perform a legal action vis-à-vis a third party in the name of or in place of the sender. Any legal action can be the subject of the errand, except for an action that by definition or according to law must be performed in person, e.g., voting.

It should be noted that power of attorney is an appropriate legal act when the sender may supervise implementation. Power of attorney is appropriate for a person who physically cannot perform a specific activity.

However, if the individual is unable to supervise the agent due to mental status or other serious illness, implementation of power of attorney is inappropriate.

When a guardian is appointed, the Court becomes the supervising authority together with the supervisor of guardianship in the Ministry of Justice. These officials must verify that the guardian acts in the best interests of the protected person. In the case of power of attorney, the capacity of the individual who appoints the power of attorney is not evaluated.

B. Pension recipients The National Insurance Law, Chapter 14 - benefits, general instructions, Section 4, designated benefit, paragraph 304, appointment of recipient of the benefit.

The National Insurance Institute is authorized to appoint a recipient for a person who is entitled to receive benefits. Notice must be given to the person entitled to receive the benefit prior to the appointment of the recipient. This section enables disbursement of a pension to a person who is incapable of managing his/ her affairs but does not have a guardian.

This is a potential solution, when necessary to protect income, but is limited specifically to the receipt 261

of pension funds, or to a temporary condition where it is necessary to protect an individual for whom the need to appoint a guardian has not yet been clarified.

The pensioner need not express his/her consent, and must only be informed. This process is supervised by the patient’s social worker, and may continue as long as the patient does not oppose. If the patient objects, payment will be made directly to him/her.

C. Law for the Defense of Protected Persons, 1966 (12) A protected person is an individual who because of disability, mental deficiency or old age is incapable of caring for himself/herself (Section 1, Law for the Defense of Protected Persons).

The Law for the Defense of Protected Persons grants authority to the social welfare clerk to manage the affairs of a person in immediate need, even when not appointed as a guardian. Implementation of the law is performed under the auspices and supervision of the Court.

D. Penal Code 1977 – Injury to minors and the helpless (13) Helpless – a person who because of his age, illness or physical or mental disability, mental deficiency, or any other reason, is incapable of caring for his/ her daily needs, health or safety (Law of the Helpless, 1977, amendment 21). The law protects the helpless by requiring bystanders to report injuries inflicted on helpless individuals to the authorities, and by requiring those responsible for helpless individuals to care for them.

E. Law for the Treatment of Mentally Ill 5751-1991(14) Section 40 of the law: Urgent actions of the Administrator General If the Head of Mental Health Services (in the Ministry of Health) is notified that a patient who is incapable of managing his/her affairs and has no guardian, and has assets requiring immediate legal action, the Administrator General will be informed.

F. The law allows performance of urgent economic actions by the Administrator General. When necessary the Head of Mental Health Services is notified using a structured legal form, in which the necessary details are submitted. This option enables performance of urgent economic activities for a hospitalized patient for whom a legal guardian has not yet been appointed. For example, if the parent of a hospitalized patient dies, there is an immediate need to deal with the inheritance. This intervention is urgent and necessary, because these may potentially be the patient’s main assets that provide for his care.

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Directives of the Health Administration 31/99 Petition to the Court for the appointment of a guardian for one’s person, or to approve a medical procedure (15) In 1999 the Health Administration distributed a directive to facilitate an organized and efficient process, coordinated among the responsible authorities, to petition the courts for appointment of a guardian. The department of social services in each hospital is the responsible and coordinating body, and the department head is responsible for preparation of the medical material. The directive presents the procedure for the appointment of a family relative or other person to care for the patient, when the petitioner is a close relative or an interested party. This is the first document to delineate the need for an expert medical opinion: 1. The patient’s insight and capacity to give informed consent is questionable.

2. One of the following conditions: a. Mental illness, or mental impairment b. Dementia c. Mental deficiency d. Other mental or physical conditions e. The patient cannot provide consent for essential medical treatment. This directive determines what type of medical specialist can provide the required expert opinion: psychiatrist, geriatrician, psychogeriatrician, neurologist. The detailed directive describes the methods of referral and the documents required.

Appointment of a guardian of the Person and/or the issue and setting of long-term hospitalization

In 2006 an additional directive of the Ministry of Health was published that deals with the procedure of guardian appointment for a patient for routine or other medical care (but not for “emergency situations” and urgent conditions). A guardian is also required to arrange institutional care or other treatments for which the patient, owing to physical or mental conditions, is incapable of providing consent independently. This directive deals with disabled patients, infirm persons who cannot carry out daily living activities, and all long-term institutionalized patients. The details of the regulations are similar to those in the directive from 1999, and the specialists consulted are psychiatrists, geriatricians, neurologists, or specialists in family medicine and internal medicine. It is recommended

that the specialty of the physician should correlate with the patient’s illness, and that the physician who provides the expert opinion has been caring for the patient across time.

• This directive also determines that the court is authorized to appoint a guardian for any individual who needs one, even if s/he is not an Israeli resident or citizen.

• Concerning patients hospitalized in a hospital or in a nursing home, the patient cannot be charged for preparation of the document.

• The directive presents a semi-structured physician’s document that relates to cognitive status, behavioral impairment, insight and classification of the degree of deficiency.

The Guardians’ Legal Obligations

A. Guardian for the legally incompetent The law defines the role of the guardian for a person who is legally incompetent: obligation to fulfill his needs; train him/her to work; protect his/her assets – manage and develop them; determine his/her place of residence; and is authorized to represent him/her.

B. Obligation to submit an inventory to the Administrator General Within thirty days of his/her appointment, the guardian must prepare a verified account of the assets of the protected person, including debits and credits.

C. Obligation to manage accounts The guardian is obligated to invest the protected person’s assets in solid investments.

D. Obligation to report to the Administrator General The guardian must report to the Administrator General at least once a year concerning his activities.

This issue is not sufficiently organized. Day-to-day experience reveals that not all guardians actually file financial reports. On the other hand, we have not encountered instances where the Administrator General enforced sanctions against a guardian who did not file a report.

It should be noted that there is a supervisor of guardians for assets in the Ministry of Justice, to whom complaints concerning the functioning of a guardian may be filed.

E. Real estate transactions Sale of land, residence, extension of lease, require prior approval of the court.

These are some of the guidelines that every Guardian of Person receives in writing from the Administrator 262

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General when appointed to the role of guardian.

It should be noted that the court approves the purchase of an apartment for a protected person, even if in order to do so s/he must use savings funds, in order to secure financial security and independence in the future (Family Court Tel Aviv 4797 Protected Person vs Administrator General) (16).

Guardianship for the person

There are no similar guidelines for guardianship for the person, though it would be beneficial if such guidelines would determine the obligations of the guardian concerning basic treatment for the individual, e.g., issues of health, housing, clothing, nutrition, etc. The guardian of the person has the authority to sign in the name of the protected person, or instead of him/her, for consent to medical treatment including surgery, etc., to sign on all documents for admitting the protected person into various facilities such as: hospitals, hostels, etc., in order to move him/her from one treatment setting to another and all issues related to the (physical) care of the protected person.

Cooperation may be necessary between the guardian of the person and the guardian of assets, for example in order to cover the expenses of medical treatment.

In extreme cases, when the protected person opposes medical treatment and, according to the expert psychiatric opinion, s/he is capable of expressing an opinion (the patient’s opinion must be considered and may not be ignored), the guardian must petition the court for instructions on how to proceed (Ministry of Labor and Welfare – Personal Communication).

The Guardian’s Obligations – According to Regulations

In the directive from the Ministry of Labor and Welfare additional obligations of the guardian are detailed. For example, concerning a protected person in the community – the guardian is required to visit the protected person on a weekly basis, and maintain regular contact, provide assistance in utilization of his/her rights and make arrangements for paying his/her bills and maintenance of his/her home (from the funds of the protected person), etc.

Concerning the hospitalized protected person – the guardian must visit and maintain regular contact with the protected person, and his/her caregivers and family members. The guardian must also provide needs that the institution does not provide: clothing, sweets, 263

cigarettes, newspapers (from the funds of the protected person), etc.

Guardian’s Legal Status

Status of the guardian in psychiatric hospitalizations As a rule the consent of the guardian must be acquired prior to admission of a protected person to psychiatric hospitalization; however, that does not mean that the protected person may not be admitted without consent.

The final decision is according to clinical and medical considerations. If hospitalization is called for, and the protected person agrees, it is voluntary hospitalization, even if the guardian theoretically opposes the hospitalization. It is difficult to imagine such a situation in practice. If the protected person objects to hospitalization, s/he may be admitted only if there is due cause according to the Law for the Treatment of the Mentally Ill. A protected person may not be admitted against his will solely based on the consent of the guardian, since the Law for the Treatment of the Mentally Ill does not include an option of “involuntary admission by a guardian” (Legal Office, personal communication).

Discharge or moving a patient to a different hospital In the event of discharge, the guardian must consent. If the guardian does not consent to discharge, the patient may not be released, and section 31 of the Law for the Treatment of the Mentally Ill, which deals with ways to discharge a patient when the patient or a family members opposes discharge, must be implemented. This is similar to moving a patient to a different institution, but here the authority is given to the head of mental health services to move patients from one institution to another even without the consent of the patient (and in our case, the guardian).

Legal status of the protected person

In principle, if a guardian is appointed for an individual, but that individual is not declared legally incompetent, or other limitations on his legal competence have not been determined, the protected person is formally still fit to fulfill his/her legal rights and responsibilities, unless at a given time his/her medical condition does not allow him/her to do so (e.g., psychotic exacerbation, catatonic state).

Thus, the waiver of confidentiality signed by the patient must be honored, even if that patient has a guardian.

However, it would be appropriate to notify the guardian of the request (Attorney General’s Office, Personal Communication).

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The right to legal representation

Every citizen has the right to legal representation, even if s/he is a protected person or legally incompetent.

Legal aid may be the only venue one has to approach the court in the event that s/he feels that s/he has suffered an injustice and that the guardian is not dealing with the matter.

Provision of medical information for future protected persons

A designated guardian must provide consent prior to appointment. Public agencies generally request information concerning future appointments, and actually request medical and social welfare information concerning the person for whom the guardian is to be appointed.

The agencies must be informed if there is a conflict of interest with another protected person under the care of the same guardian, and whether the protected person has assets, housing, etc. In effect there is disclosure of personal information concerning the protected person, usually without his consent, especially if the appointment of the guardian is without his knowledge.

The process is problematic â&#x20AC;&#x201C; without the consent of the public agency the appointment process cannot begin. The agency stipulates its consent on the receipt of medical and sociological information that the person being discussed may not have consented to reveal.

Though there might be viable solutions to the problem, it remains problematic. It may be appropriate to petition the Court to approve disclosure of the above mentioned information, although considering the already long appointment process, this would only extend the procedure. Legal agencies need to address this issue.

Special medical treatment

The consent process for electro-convulsive therapy (ECT) is complex and requires the consent of the patient and his/her family. In rare cases, compulsory ECT treatment may be required (17). What is the status of the guardian in such a situation? Since ECT is an intervention that is comparable to surgery (including general anesthetic), the consent of the guardian is required. We encountered situations where the guardian is a public agency that does not want to become involved in the consent process. According to this legal interpretation, ECT is part of the medical treatment, and once the agency consented to hospitalization, it agreed to treatment and does not want to be involved in every procedure, just as it does not need to be consulted

for various pharmacological treatments. In the cases we encountered, the treatment was administered with the consent of the patient and family, as long as the guardian did not oppose.

Medical Research

Performance of medical research on human participants is a complex issue. The need for and benefits of research to promote medical knowledge is clear, yet there may be disadvantages for the individual patient.

In the case of a psychiatric patient, the question arises as to whether or not the potential participant has the capacity to provide informed consent for participation in medical research (18).

The proposed Law for Clinical Trials in Human Subjects, 2007 (19), allows for the inclusion of a protected person in the trial if the guardian consents.

In practice, many guardians oppose participation in research because of the associated negative connotations. There have been cases where guardians agreed to participation of protected persons in pharmaceutical trials on the condition that the trial drug is guaranteed to prove beneficial and to improve the condition of the protected person (Foundation for the Care of Protected Persons, Personal communication). However, by nature of medical research, the outcomes cannot be known prior to the study.

However, excluding this population from medical research is not advisable, as studies performed without this population will not represent the entire population of patients.

Organ donation

Can a protected person donate an organ to a family member when the guardian provides consent? This is a difficult issue that is discussed only on extremely rare occasions. In one case (20), the court allowed a mother to decide that her mentally retarded daughter could donate bone marrow to her younger sister, because the Court was impressed that the mentally retarded sister understood the process and wanted to participate, and the procedure did not pose a serious risk.

In another case (21), the Court ruled that a son who was legally incompetent due to mental retardation could donate a kidney to his father, who was his guardian, with whom he lived, and who took care of him devotedly, thus avoiding his institutionalization. However, the Supreme Court did not approve since the law does not allow removal of an organ from one person in order 264

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to cure another without the informed consent of the donor, and the donor was legally incompetent and could not provide consent.

Stay of exit order

Any person can exit or enter the country (according to the laws and regulations) unless a stay of exit order was issued by the court. The family of a person with mental illness may become concerned if the patient desires to leave the country, for reasons arising out of his illness: paranoia, sense of danger, believing that abroad he will feel better or get well. Though the family is genuinely concerned about the patient’s ability to care for himself they cannot prevent him from leaving the county, even if there is a guardian, unless the guardian petitions the court to take out a stay of exit order. In this event the case will be deliberated in Family Court, and the patient’s view will also be heard.

The Supreme Court determined (20) that once a person is classified as a protected person, the court can act to protect his interests, including initiating a stay of exit order.

The ability of a patient to manage his affairs

Determination of whether or not a patient is able to manage his affairs is a complex issue (5). In every psychiatric hospital admission and discharge the admitting/ discharging physician relates to this issue and must note whether or not the patient is able to manage his affairs.

During hospitalization, there is also reference to this issue. According to the Law for the Treatment of the Mentally Ill, the caregiver must report if there is any change in the patient’s capacity to manage his affairs, e.g., when there is an exacerbation of the patient’s condition, including lack of capacity, and the patient concurrently performs a damaging financial transaction. The appointment of a guardian is a slow process and this type of parallel report could be a real time testimony that may bear weight when the issue is deliberated in court. When the discharging physician determines that the patient no longer has the capacity to manage his affairs, the appointment of a guardian, or the beginning of the actual appointment process should be initiated.

When evaluating the patient’s capacity to manage his financial and personal affairs, the physician should relate to specific criteria: the criteria for financial capacity should include whether or not the patient is aware of the extent of his property, income, expenses, and whether or not he demonstrates the ability to make logi265

cal decisions concerning these issues. The criteria for personal capacity [physical wellbeing] should include whether or not the patient can independently take care of his personal needs and care for himself in terms of: nutrition, housing, clothing, general security and a safe living environment.

The expert opinion should specifically relate to the issues of guardianship for physical wellbeing and/or property and should include the following: 1. The patient’s diagnosis 2. Degree of cognitive impairment 3. Degree of functional impairment Request to declare a protected person legally incompetent

Though in the past the Court often declared protected persons “legally incompetent” (pisul din) , today the court tends to appoint a guardian without declaring legal incompetence. Thus, the protected person retains his legal rights. The question arises as to how a guardian can protect an individual who has the legal rights to open a bank account, to perform economic transactions, etc. It is possible that though an individual has a guardian, he may be a spendthrift and exhaust his funds.

However, experience teaches us that the protected person generally obeys the guardian. In practice, the guardian controls the protected person’s major transactions: gives instructions to the bank, records warning notes in the land registry office concerning the person’s property (thus preventing the possibility of the sudden sale of the property) and acts as a go-between with the caregiving agencies. However, it is possible for the protected person to cause personal or financial harm despite the fact that he has a guardian. For example, a patient who owns an apartment may take in a boarder, to increase his income and avoid loneliness. The boarder may not be an appropriate companion and may cause more harm than good. During a manic state he may go on a shopping spree and purchase superfluous, unnecessary items, creating a serious debt, for example by buying a new car, etc. These transactions are not cancelled based on the fact that they were performed by a protected person. If the seller made the sale in good faith, there is little chance that the transaction may be cancelled. The guardian has legal standing and can attempt to cancel the transaction by contacting the seller and offering to return the merchandise. Alternatively, he can approach the court and plea to cancel the transaction, which may be a more complicated option.

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The Law of Contracts (General Section) 5723, 1973 (22), does not explicitly address the question concerning the validity of a legal transaction performed by a mentally incompetent person prior to the declaration of his legal incompetence.

Although Section 18 of the law determines that if a contract is drawn up, taking advantage of the mental/ intellectual distress of the other party, it may be declared invalid, if the conditions are unreasonably inferior to the accepted standards.

In any case, a contract drawn up by a person who was not competent to do so is not inherently void, though the contract may be declared invalid (23, 24). Thus, in this type of case, there is room to ask the court to declare legal incompetence in addition to the appointment of a guardian.

Guardian appointment for the elderly

The elderly population is heterogeneous demographically, socially, economically and medically (25). The needs and the condition of the “young” elderly (in their late sixties) are essentially different from those of the “old” elderly (in their eighties), and certainly from those in their nineties. The older the population, the greater the incidence of cognitive and mental symptoms and syndromes, physical illnesses, medications consumed, sensorial impairment (visual and auditory), and functional decline (25). These potential impairments contribute to the suspicion that the elderly may be “naturally” incompetent. However, the vast majority of the elderly in Israel live in the community, and only 4.1% are in institutions (25) and guardians were appointed for only about 3% (rough estimate) (26).

Thus, as long as an elderly person has not been declared legally incompetent, it is obligatory to relate to him/her as legally competent, for all intents and purposes (27).

When appointing a guardian for an elderly person, three groups can be clinically discerned. The first group includes elderly persons for whom guardians were appointed when they were younger. Sometimes, the guardian himself (whether a parent or another family member) gets older and is no longer competent to serve as a guardian. The second group includes elderly persons whose mental illness emerged or who were diagnosed with mental illness at old age. The treatment of both groups is similar to that of a younger person with mental illness, with regard to guardian appointment, though there is one reservation. Multiplicity of

illnesses and medications taken during old age contribute to a greater incidence of psychiatric syndromes with a clinical picture of “functional” mental disorders (for example organic delusional syndrome or hallucinations, DSM-IV). The clinical picture in these cases may be reversible or transient or may significantly improve with appropriate diagnosis or treatment. If the clinician deems that the clinical picture is reversible, he must clearly state that, and put a time limit on his medicolegal conclusions, and recommend an additional evaluation after a given period of time.

However, our third group consists of elderly patients with different levels of cognitive decline, beginning with mild cognitive impairment and up to advanced stages of dementia. The main issue concerning those patients is the appointment of a guardian for their assets. Demographic changes (for example an aging society where the elderly have a disproportionately higher portion of the property and wealth), with a higher incidence of cognitive decline and dementia among them, and increasing complexity of the modern family structures, all contribute to the fact that the capacities of the elderly to manage their financial affairs and to perform legal activities with financial significance (testamentary capacity, or to give gifts) are questioned more frequently (28).

A person can prepare himself for old age and pension, security and nursing care but generally does not expect or plan the time when, if ever, he will become incompetent. Even if power of attorney was previously granted, it becomes void the moment incompetence is declared, and a guardian is appointed (4).

The appointment of a guardian for an elderly person with cognitive decline but no psychiatric history is a delicate issue and generally involves family members. Due to the insidious beginning, slow progression and relatively delayed clinical diagnosis of most dementias in the elderly, it may take a while for family members to understand that a seemingly respected family figure is no longer competent. The need for a guardian often becomes apparent in a situation that is complicated and emotionally-charged both for the protected person and the family: the need for surgery, relocation to a home for the elderly, financial entanglement, or suspected exploitation.

Throughout the process repressed tensions of family members might be fueled and hidden conflicts may emerge. The appointment of a guardian is sometimes the cause for family disputes, undue influence, exploitation within the family, receipt of gifts, and preoccupation with a future inheritance (29). Nevertheless this 266

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process is generally executed satisfactorily by most families (30).

At present there are neither administrative directives from the Ministry of Health nor clinical guidelines relevant to the Israeli population, concerning how clinicians are to assess competency of elderly subjects with cognitive impairment to take care of their assets, when the question of guardianship arises. This issue was dealt with elsewhere (8, 10), practical and clinical recommendations were drawn, and consequently is not discussed here in depth.

However, several additional points need to be emphasized: A. In order to be able to assess the competence of the patient to manage his assets, the physician might need access to relevant information concerning the patient’s financial matters. This information is generally lacking. This difficulty can be overcome by providing the doctor with a social welfare report before s/he writes the medical certificate, or by providing the doctor with an anamnesis from a reliable source concerning the patient’s financial affairs. B. Certain families request the appointment of a guardian for property, usually a family member, in a too early stage of cognitive decline, when the protected person is still able to manage his affairs either with or without some assistance. This step is evidently conceived as a precautionary measure (e.g., the subject lives in his/her apartment, though with a foreign worker, and the children live far away and fear presumed exploitation). A comprehensive evaluation of competence for this purpose with regular follow-ups constitute the best means to avoid a premature preparation of a medical certificate, and on the other hand would make sure that the medical certificate would be written at the appropriate time. C. Even when some families are convinced of the need to appoint a guardian they are reluctant to have the protected person taken to court to express his opinion regarding the nomination of a guardian and thus involve him in the legal process and subjected to embarrassing situations. The law requires that the patient appear in court: “The court must hear the opinion of the protected person before the appointment if he is capable of understanding and his opinion can be clarified” (4). In practice, the issue is partially in the hands of the physician, who is asked to note in his report whether the patient is competent to express an opinion. Once the clinician finds the protected person unable to express his opinion on this matter, s/he would not usually be called to the court. Clinically, it implies the need to examine whether the protected person is 267

able to understand the concept of guardianship and if s/ he can express her opinion concerning nomination of a guardian to her assets and the identity of the guardian.

The patient’s opinion should be solid and consistent. The protected person is sometimes found by the physician incompetent to manage her affairs but competent to express an insightful and balanced opinion concerning the appointment of a guardian. This should be clearly indicated in the report.

The medical certificate that will determine the need for the appointment of a guardian for an elderly person should be the product of a comprehensive medical, psychiatric and cognitive evaluation and an accurate evaluation of competence (8, 10).

Conclusion Based on our extensive experience in this field, we present a review of related issues that may assist professionals involved in the guardian appointment process.

Though the law is over 40 years old, the issue remains relevant and more information is needed for physicians and the general public.

References 1. Basic Law: Human Dignity and Liberty Passed by the Knesset on 12 Adar 5752 (17th March 1992) and amended on 21 Adar, 5754 (9th March, 1994). Amended law published in Sefer Ha-Chukkim No. 1454 of the 27th Adar 5754 (10th March, 1994), p. 90; the Bill and an Explanatory Note were published in Hatza’ot Chok No. 2250 of 5754, p. 289. http://www.knesset.gov.il/laws/special/eng/basic3_eng.htm Accessed 24 August 2008.

2. Jerusalem District Court, 815/05 Anonymous vs. Attorney General.

3. Melamed Y, Shnit D, Kimchi R, Elizur A. Guardianship nomination: Rethinking the decision making process.. Harefuah 1999;137:503-506 (Hebrew).

4. Legal Capacity and Guardianship Law 1962, 16 Laws of the State of Israel. Passed by the Knesset on the 7th Av, 5722 (7th August, 1962) and published in Sefer Ha-Chukkim No. 380 of the 17th Av, 5722 (17th August, 1962), p. 120; the Bill and an Explanatory Note were published in Hatza’ot Chok No. 456 of 5721, p. 170.

5. Melamed Y, Zamir O, Doron A, Gelbard Y, Bleich A. Decision-making concerning guardianship – who is the “person that no longer has the capacity to make decisions regarding personal matters”? Harefuah 2008;147:394-397, 479 (Hebrew).

6. Doron I. Law in the Service of the Elderly. http://research.haifa. ac.il/~doronfam/guardianship.html. Accessed 28 August, 2008.

7. Melamed Y, Doron I, Shnitt D. Guardianship of people with mental disorders. Soc Sci Med 2007;65:1118-1123.

8. Heinik J, Solomesh A. How do physicians actually write guardianship certificates for elderly patients? Harefuah 2001;140:827-830, 895, 894 (Hebrew).

9. Melamed Y, Kimchi R, Barak Y. Guardianship for the severely mentally ill. Med Law 2000;19:321-326.

10. Heinik J, Hess JP. Clinical and practical aspects of the medical certificate as to the question of guardianship. Harefuah 1992;122:386-389 (Hebrew).

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11. Agency Law 1965, Book of Laws no. 462, July 23, 1965, p. 220.

12. Law for the Defense of Protected Persons, 1996.

13. Penal Code 1977 - Injury to minors and the helpless.

14. Law for the Treatment of Mentally Ill Persons 5751-1991.

15. Law of the “Helpless” (subsection e’1 of the Penal Law, is also called Amendment 21 of the Penal Law, 5737-1977, Laws, Volume 27, p.

14901.

16. Family Court Tel Aviv 4797 Protected Person vs Administrator General.

17. Melamed Y, Altmark D, Alfici S, Or E, Zipris P, Bzura G, Bleich A. What is the role of compulsory ECT therapy today? Harefuah 2004;143:254257, 320, 319 (Hebrew).

18. Melamed Y, Davidson M, Bleich A. Placebo-controlled trials in schizophrenia. Harefuah 2004;143:236-240, 244 (Hebrew).

19. Proposed law for Medical Research in Human Subjects 5758-2007, Listings of Proposed Laws, 321, 1 Av 5757, 16/7/2007, pp. 786-824.

20. Supreme Court 3458/07 ‫ בע”מ‬Anonymous vs Social Welfare Department (26/82).

21. 661(2) ‫ ר"ע‬698/86 ‫פ"ד מ"ב‬

22. Law of Contracts (General Section) 5723, 1973.

23. Chen D. Legal competency of the mentally impaired. Med Law 1993; 12: 40-43 (Hebrew).

24. Supreme Court, 8163/05 ‫ע”א‬. Insurance Company vs. Anonymous.

25. Brodsky G, Davies M. Demography and epidemiology of aging and the elderly population. In: Rosen A, editor. Age and aging in Israel, Jerusalem, Israel: JDC-Eshel, 2003: pp. 289-342.

26. Doron I. Aging in the shadow of the law: The case of elder guardianship in Israel. J Aging Soc Policy 2004;16:59-77.

27. Doron I. Law and geriatrics: An Israeli perspective on future challenges.

Med Law 2003;22:285-300.

28. Shulman KI, Cohen CA, Hull I. Psychiatric issues in retrospective challenges of testamentary capacity. Int J Geriatr Psychiatry 2005;20:63-69.

29. Peisah C, Finkel S, Shulman K, Melding P, Luxenberg J, Heinik J, Jacoby R, Reisberg B, Stoppe G, Barker A, Firmino H, Bennett H, for the International Psychogeriatric Association Task Force on Wills and Undue Influence. The wills of older people: Risk factors for undue influence. Int Psychogeriatr 2009; 21: 7-15.

30. Schindler M. When and how a guardian should be appointed to protect elderly persons who are exposed to abuse. Society and Welfare Quarterly for Social Work 2007; 27:315-338.

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Health-related quality of life two years after injury due to terrorism Maya Tuchner, MSc,1,2 Zeev Meiner, MD,2 Shula Parush, PhD,1 and Adina Hartman-Maeir, PhD1 1

School of Occupational Therapy, Hadassah and Hebrew University of Jerusalem, Jerusalem, Israel Rehabilitation Department, Hadassah Mount Scopus University Hospital, Jerusalem, Israel

2

ABSTRACT Background: During the past few decades, terrorist acts have been an unfortunate reality worldwide.

There is a striking paucity of research investigating the multitude of long-term outcomes after severe physical injury due to terrorist attacks, a unique subgroup of trauma patients. The purpose of this study was to provide a profile of the long-term health-related quality of life (HR-QOL) after injury due to terrorist attacks and to explore the relationships between Post Traumatic Stress Disorder (PTSD), occupational status and injury severity with HR-QOL Methods: We included 35 survivors of terrorist attacks living in the community, two years on average after the injury, mean age at follow-up = 32.1 (±13.8), mean Injury Severity Score (ISS) = 27 (±14.2). The subjects were recruited from consecutive admissions to a rehabilitation department in a tertiary care center between September 2000 - June 2004. Most of the subjects suffered multiple trauma. The main outcome measures were the Short-Form Health Survey (SF-36), Post Traumatic Diagnostic Scale and return to work rates.

Results: The mean scores on 6/8 of the SF-36 subscales were significantly lower among the survivors compared to normative population norms. Post Traumatic Stress Disorder (PTSD) was found in 39% of the sample and 43% did not resume their main occupation two years after the injury. Multivariate analysis of variance of PTSD and occupational status (returned vs. did not return to work) on quality of life scores revealed significant main effects for both PTSD (p=. 000) and occupational status (p=. 005) with no interaction

effect (p=. 476). No significant correlations were found between injury severity and the SF-36 scores.

Conclusions: This study demonstrated the long-term impact of injury due to terrorism. Results showed independent effects of PTSD and occupational status on health related quality of life, two years after injury.

These findings suggest that this group may benefit from intervention focusing on their emotional and occupational status in order to improve their quality of life.

INTRODUCTION During the past few decades, terrorist acts have been an unfortunate reality worldwide. From September 2000 to January 2006, 7,633 individuals have been injured in terrorist attacks in Israel (1) and unfortunately many more worldwide, posing a serious challenge for acute care and rehabilitation services. Definitions of terrorism are usually complex and controversial. However, in order to promote international consensus concerning these atrocities the United Nations (UN) proposed using the definition of the League of Nations Convention from 1937: “All criminal acts directed against a State and intended or calculated to create a state of terror in the minds of particular persons or a group of persons or the general public” (2). Terrorist activities are characterized as the use of increasingly dramatic, violent, and high-profile attacks in furtherance of political/social objectives, such as hijackings, hostage takings, kidnappings, car bombings, and, frequently, suicide bombings. The victims and locations of terrorist attacks often are carefully selected for their shock value, such as shopping centers, bus and train stations, and restaurants and nightclubs (3).

Address for Correspondence: Maya Tuchner, MSc, School of Occupational Therapy, Faculty of Medicine Hadassah and Hebrew University Mount Scopus, POB 24026, Jerusalem 91240, Israel. mayat@hadassah.org.il

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Maya Tuchner ET al.

Current research on the health related issues of this population has focused on the unique characteristics of the victims of terrorist attacks mainly during the acute stage after injury. It has been shown that terrorist attacks worldwide (4) and especially in Israel (5-9), Spain (10, 11) and Australia (12), most of them bombings, inflicted injury of a distinctly different pattern than other causes of trauma. Patients hospitalized after bombing incidents were typically younger, suffered from increased injury severity with more body regions involved compared to non-terrorrelated trauma patients. Furthermore, enhanced use of intensive care, prolonged hospital stay, more surgical interventions and increased hospital mortality were also characteristics of these patients (5-9). The remainder of the studies conducted on the effects of injury due to terrorism has focused on the emotional consequences, especially Post Traumatic Stress Disorder (PTSD) (13-15). Studies found that in direct survivors, the frequency of PTSD that was found in the aftermath of the attacks was 39% (13, 14) and 25% to 31% 2.6 years on average after the attack (14, 15). In sum, the outcome literature on trauma due to terrorism is limited primarily to the injury pattern in the acute phase and to the emotional consequences of the trauma.

However, several follow-up outcome studies have been performed among broadly defined injury-related trauma populations, mainly caused by motor vehicle accidents, work injuries and crime assault, on levels of functioning, disability and quality of life (16-21). Taken together, the results of these studies point to a complex pattern of injury among survivors, involving physical (e.g., chronic pain), emotional (e.g., PTSD) and functional disabilities (e.g., employment and instrumental activities of daily living), and decreased quality of life in the long term after the trauma. There is a lack of studies relating to broader outcomes of return to work and Health-Related Quality of Life (HR-QOL) in survivors of injury due to terrorist attacks, which have been proposed as important outcome measures in trauma victims (17). HR-QOL represents a subjective person-centered measure of well-being in relation to multiple domains that are affected by health status (such as physical and emotional status) (22). Thus, the aim of this study was to provide a profile of the longterm health-related outcomes of injury due to terrorist attacks. Specifically the objectives were to describe the domains of HR-QOL, the presence of PTSD and occupational status of survivors of terrorist attacks residing

in the community two years on average after the injury.

A secondary objective was to explore the relationships between PTSD, occupational status and injury severity with HR-QOL. Given the recent rise in terror attacks worldwide, such research may be helpful in meeting the long-term health-related needs of these individuals.

METHODS Participants

The 35 subjects of this study were recruited from consecutive admissions to the rehabilitation department of Hadassah Hospital, Mount Scopus, Jerusalem, between September 2000 and June 2004. The study was approved by the Helsinki Committee of the hospital. The study inclusion criteria were: subjects suffering injuries due to terrorist attacks, were civilians at the time of the injury, were at least one year post injury, were currently residing in Jerusalem, and were at least 17 years old at follow-up. Seventy-four subjects met the above inclusion criteria, of these, one died, three foreign workers returned to their countries, four could not be located, 16 were living outside Jerusalem, two were living abroad and two were immigrants who did not have sufficient knowledge of Hebrew to be interviewed. Explanatory letters with informed consent (specifying that data collection would include gathering information from the hospital medical records and home interview) were sent to the 46 individuals who were eligible for follow-up.

Thirty-five subjects (76% of those eligible) gave their informed consent to participate in the study. The followup questionnaires were collected through interviews conducted by an experienced occupational therapist in the subjectsâ&#x20AC;&#x2122; homes.

Demographic and injury variables of the sample are presented in Table 1. The majority of the subjects were young (mean age at follow up was 32.1y Âą13.8) and had completed high school education. Most of the subjects suffered Multiple-Trauma (MT) and the average ISS at the time of injury was 27, indicating an overall high severity of injury in this sample. Concerning the mechanism of injury, all the subjects were injured as a result of a suicide bombing. The settings of the attacks were buses (10), restaurants and indoor cafes (11), semi-confined spaces (3) and open spaces such as bus stops and shopping centers (11). The mean time since injury was two (SD=1.1) years, and the mean time since discharge from rehabilitation (inpatient or outpatient) was 20 months (SD= 10.31, range 5 to 39).

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Health-related quality of life two years after injury due to terrorism

Table 1. Demographics and Injury Variables Variable

Mean (SD)

Range

Age at follow-up

32.15 (13.8)

14-74

Time since injury (years)

2 (1.1)

1-3.5

Years of education

Gender

Family status

Type of injury

ISS score

13.2 (3.4)

0-20

N

%

Men

17

48.6%

Women

18

51.4%

Single

21

60%

Married

12

34%

Divorced

1

3%

Widow

1

3%

Multiple Trauma (MT)

25

71.4%

Traumatic Brain Injury (TBI)

6

17.1%

Spinal Cord Injury (SCI)

4

11.4%

1-8 (Mild injury)

2

6.8%

9-15 (Moderate injury)

5

17.2%

16-24 (Severe injury)

5

17.2%

> 25 (Very severe injury)

17

58.6%

Abbreviations. ISS: Injury Severity Score; SD: Standard Deviation

Measures

Medical Outcome Study 36-Item Short-Form Health Survey. The Medical Outcome Study 36-Item ShortForm Health Survey (SF-36) (23-25) is a generic measure of HR-QOL that has been extensively validated and used by researchers to study a variety of disease states.

This measure consists of 36 items that encompass eight areas of health: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health. Results are presented on a scale of 0 to100; higher scores reflect better health status. A total score and two aggregate scores are calculated from the measure: the physical component summary score (PCS) (which is the mean score of four scales: physical functioning, role physical, bodily pain, general health) and the mental component summary score (MCS) (which is the mean score of four scales: vitality, social functioning, role emotional and mental health.). The SF-36 Hebrew version was used in the current study. The psychometric properties of this version were evaluated based on a sample of the adult population of Israel (26). Reliability scores (Cronbach’s 271

alpha) ranged from 0.76 to 0.93. The analysis also showed that the SF-36 scales are able to discriminate among population groups known to have different levels of health and thus can serve as valid indicators of health status in Israel.

Post Traumatic Diagnostic Scale. The PDS (27) is a widely used, psychometrically reliable and valid selfreport measure of PTSD. The PDS yields a diagnosis according to DSM-IV criteria. It probes the 17 symptoms of PTSD (5 reexperiencing, 7 avoidance and 5 hyperarousal) from the DSM-IV. For each item participants rate, on a 4-point scale, the degree to which each symptom has bothered them in the past month (0 = not at all; 3 = five or more times a week/ almost always). To obtain a PTSD diagnosis from the PDS, the DSM-IV diagnostic procedure for PTSD is followed: at least 1 reexperiencing symptom, at least 3 avoidance symptoms and at least 2 arousal symptoms must be endorsed with a score of 1 or above. The PDS has been shown to have high internal consistency (α = .92) and good test-retest reliability (r = .74). Agreement between PTSD diagnosis obtained from the PDS and structured clinical interview for PTSD was 82%, sensitivity of the PDS was .89 and its specificity was .75 (27, 28).

Injury Severity Score. The injury severity score (ISS) (29) is used to quantify the severity of injury and allows comparison of severity among dissimilar types of injury and therefore was chosen to quantify the diverse effects of injury due to terrorism. The injury severity score is calculated by using the sum of squares of the injury severity, as measured by the Abbreviated Injury Scale (AIS) (30), of the three most severely injured body regions. The ISS ranges from 0 to 75 and can be categorized into four levels of injury severity: 1 to 8 – mild, 9 to 15 - moderate, 16 to 24 - severe and above 24 very severe. Numerous studies have used the ISS to measure injury severity among different types of injury confirming the validity of this measure and extending its potential usefulness (6, 7, 16-18, 21, 31-34). In the current sample the ISS was rated at the time of injury by trauma physicians in the emergency room and for the purpose of this study was obtained retroactively from the medical charts.

Return to work. Information regarding this variable was obtained through a question about whether the subjects returned to their major occupation (i.e., work, study), changed their main occupation as a consequence of the injury or did not resume any main occupation.

All the questionnaires were administered in Hebrew.

Maya Tuchner ET al.

Data Analysis

Statistical analyses were performed using SPSS version 12.0 software. The data were normally distributed on all the outcome variables (Kolmogorov-Smirnov p > .05). Hence all the variables were analyzed with parametric statistics. One sample t-test was conducted to compare SF-36 scores of the current sample with Israeli norms. Multiple analysis of variance (MANOVA) was performed in order to examine the effects of PTSD, occupational status, and initial ISS with SF-36 summary scores (MCS, PCS and Total).

RESULTS According to the PDS, 39% of the survivors were diagnosed as having PTSD. Regarding return to work, 43% of the sample did not resume their major occupation. Of the survivors who resumed their productivity role (57%), 17% changed their occupation after their injury in line with normal developments (e.g., from student to worker, from soldier to student); and only one participant changed her occupation due to her injury (to a less demanding position). It is worth noting that no significant relationship was found between PTSD and occupational status (Chisquare= 0.008, p=. 930).

Health-Related QOL

Table 2. SF-36 Scale Scores: Comparisons Between Survivors and Normative Population in Israel

SF-36 subscales

Survivors (N=35) Mean (SD)

Normative population in Israel (N=2,030) Mean (SD)

T

P

Physical Functioning

66.9 (25.7)

77.3 (26.6)

-2.3

.03

Role Physical

64.3 (41.9)

71.3 (40.8)

-.94

.35

Bodily Pain

55.8 (28.5)

71.6 (29.8)

-3.1

.00

General Health

58.5 (17.9)

62.9 (23.8)

-1.4

.17

Vitality

49.2 (20.1)

56.9 (22.8)

-2.1

.03

Social Functioning

71.2 (29.3)

81.8 (26.8)

-2.1

.04

Role Emotional

52.5 (52.7)

81.1 (35.7)

-3.1

.00

Mental Health

59.3 (15.3)

67.1 (21.7)

-2.2

.03

The published norms (26) include only the scale scores of the SF-36 therefore no comparison was possible with the summary scores

*

cant correlations were found between the severity of PTSD symptoms with the SF-36 total score (r= -.555; p<. 000) and the MCS (r=-.636; p=. 000); whereas the correlation with the PCS was lower and non-significant (r=-. 295). The effect of PTSD diagnoses (with/without PTSD) and occupational status (resumed/did not resume major occupation) on HR-QOL was examined with MANOVA on the SF-36 summary scores (see Table 3). The analysis revealed overall significant main effects on the SF-36 summary scores for both PTSD (Wilks᾿ Lambda F (31, 1) = 8.65, p = .000) and occupational status (Wilks᾿ Lambda F (31, 1) = 5.29. p = .005) with no interaction effect of PTSD * occupational status (Wilks᾿ lambda F (31, 1) =. 856, p=. 476). Examination of the effects of these variables on the individual summary scores of the SF-36 showed that the subjects without

The results of the summary scores of the SF-36 revealed that the mean total score was 59.6 (SD=15.5), the mean PCS was 58.9 (SD=16.5) and the mean MCS was 58.1 (SD=17.9). The results of the SF-36 subscales were compared with published norms for the general Israeli population (N = 2,030) (26) and are presented in Table 2. The survivors obtained lower than normative scores on all SF-36 subscales, with the largest notable difference on “bodily pain” and Table 3. Descriptives and Multiple Analysis of Variance of PTSD and Occupational Status on SF-36 Summary Scores “role emotional” scales. The differences Without With Returned to Did not between the groups were statistically PTSD PTSD occupation return significant on all scales except for “role (n=20)a (n=13)a (n=20) (n=15) Mean (SD) Mean (SD) F (p)b Mean (SD) Mean (SD) physical” and “general health” scales.

Relationships with health-related QOL

The correlations between the ISS and the SF-36 summary scores were found to be low and non-significant (r=. 269 with the PCS; r=. 189 with the MCS; and .327 with the total SF-36 score; all not statistically significant). However, moderate signifi-

F (p)b

PCS

62.4 (15.3)

53.5 (17.5)

1.8 (.19)

59.8 (17.8)

57.5 (14.8)

.07 (.78)

MCS

66.3 (11.7)

45.6 (16.9)

26.3 (.00)

64.1 (15.4)

49 (16.1)

14.8 (.00)

Total

65.8 (11.9)

50.46 (15.7)

10.8 (.00)

63.5 (15.9)

54.1 (12.9)

4.2 (.04)

Abbreviations. PCS: Physical Component Summary Score; MCS: Mental Component Summary Score a 2 participants did not complete the PDS questionnaire b Multivariate analyses results for PTSD (Wilks' Lambda F (31, 1) = 8.65, p = .000) and for occupational status (Wilks' Lambda F (31, 1) = 5.29. p = .005).

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Health-related quality of life two years after injury due to terrorism

PTSD achieved significantly higher mean scores on the MCS and the SF-36 total score than those with PTSD. In addition, the subjects who returned to their main occupation achieved significantly higher mean scores on the MCS than those who did not. Regarding demographics and HR-QOL, the correlation between age and the SF-36 total score was low and non significant (r=.056), and there were no significant differences between men and women on these scores (p>.10).

The mean scores of the interaction demonstrated the lowest SF-36 scores for the group with PTSD, those who did not resume their major occupation and the highest scores for the group without PTSD, those who resumed their occupation (Table 4).

Table 4. SF-36 Means of the Interaction Between PTSD and Occupational Status PTSD Diagnosis a

Occupational Status b

n (%)

SF-36 PCS Mean (SD)

-

+ + -

12 (36%) 8 (24%) 8 (24%) 5 (15%)

64.58 (15.94) 59.25 (14.65) 52.57 (19.29) 54.8 (16.46)

+

SF-36 MCS Mean (SD) +

+ + -

12 (36%) 8 (24%) 8 (24%) 5 (15%)

71 (12.31) 59.37 (6.75) 53.87 (14.44) 32.4 (11.8) SF-36 Total score Mean (SD)

+

+ + -

12 (36%) 8 (24%) 8 (24%) 5 (15%)

71 (12.31) 59.37 (6.75) 53.87 (14.4) 32.4 (11.8)

Abbreviations. PCS: Physical Component Summary Score; MCS: Mental Component Summary Score a PTSD + : diagnoses of PTSD; PTSD- : no diagnosis of PTSD b Occupational status + : resumed major occupation; Occupational status- : did not resume major occupation

DISCUSSION The results of the study demonstrated the long-term impact of injury due to terrorism. Despite the fact that all subjects were at least one year post injury and several months after discharge from rehabilitation, a considerable number of survivors were living in the community with emotional and occupational consequences of their injury that were found to have a detrimental effect on their current quality of life.

The impact of the injury due to terrorist attacks was clearly demonstrated by significantly lower SF-36 scores 273

of the survivors compared with those of the normative population. The largest differences between the groups were found on the “bodily pain” and “emotional status” scales of the SF-36, which may shed light on two major HR-QOL issues concerning this population: chronic pain and emotional status. Similarly, the mean scores of the two final components (mental and physical health) of the SF-36 were almost identical, indicating the involvement of both physical and mental health in the quality of life of this group of survivors, on average two years after their injury. To our knowledge, there are no other studies of HR-QOL in direct survivors of terrorist attacks who were physically injured, yet a comparison is warranted with the population suffering multiple trauma due to causes other than terrorist attacks. Several studies on survivors of multiple trauma conducted at a similar time post onset also demonstrated the significant reduction in HR- QOL (as measured by the SF-36) in relation to the normative population in both physical and mental health components (17, 32, 35, 36). A comparison of the SF-36 scores of this sample with those presented by Michaels et al. (19) which investigated HR-QOL in 126 subjects one year after multiple trauma, revealed that the current sample of survivors of terrorist attacks obtained lower scores in “bodily pain,” “role emotional,” and “mental health” scales. The comparison between groups affected by different causes of trauma needs to be further examined, although it may point to possible unique consequences of injury due to terrorist attacks as opposed to other types of traumatic injuries.

The results of the current study contribute to the growing body of research pertaining to PTSD among survivors of terrorist attacks revealing a considerable prevalence and chronicity of emotional sequelae of terrorist attacks (13-15). The diagnosis of PTSD in these studies was determined by the DSM criteria; however the studies differ in their use of clinical interview or self-report questionnaires. Verger et al. (15) studied 196 survivors of the 1995-1996 bombings in France and found PTSD in 31% of the sample, 2.6 years on average after the terrorist attack. Jehel et al. (14) found PTSD in 39% of their sample, comprising 32 victims of a bomb attack in a Paris subway, six months after the attack; however, a small decrease was found in the frequency of PTSD (25%), 32 months after the attack. The frequency of PTSD that was found in the current study (39%) was identical to that found by Shalev and Freedman (13) in a different sample of 39 survivors of terrorist

Maya Tuchner ET al.

attacks (also in Jerusalem), at an earlier time point (four months post trauma). One could hypothesize that the similar percentages of PTSD that were found in both studies, despite the fact that they were not conducted at the same time point after the attack, may be due to the different measures of PTSD and hence a reduction in frequency over time was not found. An alternative explanation may lie in the sample characteristics, as the current sample was selected from survivors who suffered severe physical injuries that required physical rehabilitation, whereas the other Israeli sample was not.

The incidence of PTSD in survivors with physical injuries has been shown to be higher than in survivors of the same trauma without physical injuries (37), and may explain the high frequency of PTSD at this time point.

The implications of the presence of PTSD on the daily life of survivors were shown by the significant main effect that was found for PTSD on the SF-36. This finding is in line with previous studies, which documented the relationship of PTSD with decreased quality of life as measured by the SF-36 in trauma survivors (38-41).

Although the sample consisted of young people, previously employed or in a student role, only 57% of the sample resumed their major occupation. These findings are within the wide range (53-90%) of returnto-work rates after major trauma that were reported in the literature (16, 20-22, 32, 34, 42). The significantly lower SF-36 scores found in our study, of subjects who did not return to their major occupation compared to those who did, are in line with the results of Nandi et al. (43). They investigated the long-term consequences of the September 11 attacks in the United States and found that persons unemployed in the aftermath of a disaster may be at risk for poor mental health in the long-term. It is important to note that both PTSD and occupational status had independent main effects on HR-QOL. A substantial percentage of the survivors were dealing with PTSD, loss of occupational role, or both. The Table of Interactions (Table 4) demonstrated the cumulative effect of these important outcomes, showing, as expected, that individuals with PTSD who did not return to their major occupation had the lowest QOL scores.

Regarding injury severity, the mean ISS of the survivors of trauma due to terrorism at the time of the injury was very high, yet did not significantly effect long-term HR-QOL in this group. This result could be explained by the time interval between ISS and the outcomes measured in this study, and is in line with several other

studies involving survivors of multiple trauma injury that did not find a significant relationship between initial injury severity and long-term outcomes (32, 33, 44, 45). However, a number of studies did show a positive significant relationship between these variables (16-18, 20, 21, 34). This issue requires further investigation in studies of trauma survivors, in order to understand the relationship between initial injury severity and longterm outcomes.

This study is unique in both the population studied and the scope of outcomes examined, therefore promoting an understanding of the long-term HR-QOL of trauma due to terrorism.

This study has several limitations: the small sample size and the fact that the sample was recruited from one rehabilitation center in Jerusalem may limit the generalization of the findings. In addition, despite the comparison to previous outcome studies on multiple trauma, the absence of a comparison group in this study (suffering multiple trauma not due to terrorism, e.g., due to road accidents) may limit the ability to reach conclusions regarding the unique characteristics of trauma due to terrorism as opposed to other types of trauma.

CONCLUSIONS The study demonstrated the negative impact of injury due to terrorist attacks on long-term health related quality of life (HR-QOL). The results of the MANOVA analysis suggest that interventions to address PTSD and occupational status in survivors of terrorism should be further studied with respect to their impact on longterm HR-QOL. Because terrorism is a worldwide problem, further studies representing other regions and including comparison groups are recommended in order to fully understand the health related implications of injuries due to terrorism attacks.

Acknowledgements The authors would like to thank the survivors of terrorism attacks for participating in the study and sharing their experience.

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Isr J Psychiatry Relat Sci - Vol. 47 - No 4 (2010)

Vlad Svetlicky et al.

Combat Exposure, Posttraumatic Stress Symptoms and Risk-Taking Behavior in Veterans of the Second Lebanon War Vlad Svetlicky, MSW,1 Zahava Solomon, PhD,2 Rami Benbenishty, PhD,3 Ofir Levi, PhD,1 and Gadi Lubin, MD1 1

Department of Mental Health, Israel Defense Forces Medical Corps, Ramat Gan, Israel Shappel School of Social Work and Adler Research Center, Tel Aviv University, Tel Aviv, Israel 3 Paul Baerwald School of Social Work, Hebrew University of Jerusalem, Jerusalem, Israel 2

ABSTRACT Prior research has revealed heightened risk-taking behavior among veterans with posttraumatic stress disorder (PTSD). This study examined whether the risktaking behavior is a direct outcome of the traumatic exposure or whether this relationship is mediated by posttraumatic stress symptoms. The sample was comprised of 180 traumatized Israeli reserve soldiers, who sought treatment in the wake of the Second Lebanon War. Combat exposure was indirectly associated with risk-taking behavior primarily through its relationship with posttraumatic stress symptoms.

Results of the multivariate analyses depict the implication of posttraumatic stress symptoms in risktaking behavior, and the role of self-medication and of aggression in traumatized veterans.

Introduction Studies of war veterans consistently show that exposure to combat stress is a risk factor for a wide array of psychiatric disorders, most notably posttraumatic stress disorder (PTSD) (1, 2). According to DSM-IV (3), this syndrome is characterized by posttraumatic stress symptoms including repeated re-experiencing of the traumatic event (unwanted intrusion of trauma-related material into conscious thoughts, mental images, and dreams), numbing of responsiveness to or reduced involvement with the external world (trauma-related avoidance responses),

and a variety of autonomic, affective, and cognitive signs of hyperarousal. Some researchers (4) postulate that the DSM-IV definition of the diagnostic boundary between the presence and the absence of PTSD is not optimal in that many individuals without PTSD are exhibiting part of the symptoms described below. In any case, the experiences of these symptoms are a life-altering and complex psychological condition estimated to affect combat veterans with or without diagnosis of PTSD (1). There is ample evidence that the development of combat-induced posttraumatic symptoms is related to problems maintaining professional, interpersonal and familial relationships.

Posttraumatic stress symptoms (PTSS) have also been associated with low self-esteem, with distrust of people (5), with higher incidence of psychological problems, and with poorer employment performance (6). With regard to interpersonal relationships, chronic PTSS have been associated with poor family functioning (7), attachment problems (5), higher incidences of chronic nonpsychiatric medical conditions (8), marital dysfunction (9), social dysfunction (10), and unfit parenting (11, 12). In a previous study of veterans of the First Lebanon War (13), PTSS were found to correlate with a wide range of general psychiatric symptoms, as measured by the SCL-90.

Moreover, clinical observations and empirical studies suggest that PTSS are associated with an increased tendency for risk-taking behaviors (RTB) (14-16) such as health-risk behaviors (17), substance abuse (14, 18), aggressive and violent behaviors (16, 19), reckless driving (15), and inappropriate behavior at oneâ&#x20AC;&#x2122;s work or study environment (i.e., occupational misbehavior) (20). Although the review points to substantial evidence of RTB resulting from PTSS, a great deal remains to be

Address for Correspondence: Zahava Solomon , Shappel School of Social Work and Adler Research Center, Tel Aviv University, Ramat Aviv 39040, Israel â&#x20AC;&#x2020; sidalv@013.net

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learned about the interrelationships between combat exposure, PTSS and RTB. Previous research that investigated this issue revealed inconsistent results. For the most part, studies suggested that both intensive combat exposure and PTSS were associated with post military RTB, and that PTSS plays a mediatory role in the relationship between war-zone traumatic exposure and RTB. Lasko et al. (21) assessed aggression, hostility and anger in Vietnam combat veterans with and without chronic PTSD and concluded that these behaviors were more appropriately regarded as part of PTSS, rather than as a direct consequence of military combat. In a similar vein, Taft et al. (22) reported that combat exposure was indirectly associated with aggression primarily through its relationship with PTSS. A study of a civilian sample (23) examined whether exposure to traumatic events increases the risk for nicotine dependence or for alcohol or other drug use disorders, independent of PTSS. The findings of this research supported the hypothesis that exposure to traumatic events per se did not increase the risk for substance abuse disorders. This conclusion is also consistent with the findings of a review of the research literature on PTSD and substance abuse comorbidity among combat veterans (18). Similar conclusions were drawn from studies that examined health-risk behaviors among war veterans with PTSD (17, 24, 25). Fontana and Rosenheck (26) investigated the role of war zone trauma and PTSD in the etiology of antisocial behavior in a large sample of male Vietnam War veterans. Their study found that PTSD played a mediatory role for the effects of war-zone traumatic exposure on post military antisocial behavior.

Another group of studies, however, is at variance with the above mentioned conclusions, and suggests that the RTB is related to the level of exposure to traumatic events. For example, Kramer et al. (27) found that suicidal behaviors were observed in Vietnam veterans who did not display trauma-related symptoms or other psychiatric problems. Similarly a study that investigated interpersonal violence in Vietnam veterans with PTSD (28) reported that combat exposure was positively linked with interpersonal violence independent of PTSD. As demonstrated by the studies described earlier, the extent and nature of RTB in combat induced PTSD remains insufficiently investigated at this time. It is still unclear whether RTB is a direct outcome of the traumatic exposure or whether this relationship is mediated by PTSD. Due to the elevated risk of mortality among traumatized veterans (29) further research is needed on the 277

subject of RTB among war veterans. Although in recent years much has been learned about the long-term impact of combat trauma on Israeli veterans, little of the existing research has examined co-existence of risk-taking behaviors and PTSD. Moreover, the few Israeli studies that were conducted focused only on substance abuse and revealed inconsistent results. Skodol et al. (30) found increased rates of drug and alcohol use among Israeli veterans with PTSD. These findings were at odds with those of previous clinical studies of small samples of Israeli combat veterans (31, 32). More recently, reports by the Israel Anti-Drug Authority show increased usage of drug and alcohol in recent years in Israel (33). Given the rise in mortality among PTSD veterans, substance abuse in Israel and increased exposure of Israeli soldiers to combat violence, investigating the risk-taking behavior among traumatized veterans is a highly relevant, important and timely issue.

The primary aim of the current study is to assess the RTB prevalence among Israeli reserve soldiers with and without PTSD. Another aim is to investigate the interrelationship among combat exposure, PTSS and RTB. Method Participants and Procedure

Our sampling pool consisted of all male combat reserve soldiers who sought treatment in the IDF Combat Reaction Unit between August 2007 and June 2008 in the wake of the Second Lebanon War. The group consisted of 274 individuals. Data collection started six months after the battles were over and lasted for four months.

At the time of the data collection 28 (10%) soldiers were unreachable due to various reasons, 61 (22.1%) refused to participate, and the therapists of 5 (1.8%) soldiers recommended against including them in the study due to their mental instability. Eventually, 180 (65.7%) veterans completed the questionnaires; 121 of the questionnaires were administered by the first author (V.S.), and the rest (n=59) were administered by trained and experienced therapists working in the IDF Combat Reaction Unit. The purpose of the study was explained to the participants, they were assured confidentiality, and it was made clear and emphasized to them that participation in the study is voluntary.

Measures Sociodemographic and military information. Data on sociodemographic and military variables were collected via a questionnaire, completed by the subjects, inquiring

Vlad Svetlicky et al.

about their military and civilian background including age, father’s country of origin, education, family status, children, occupational status, military rank, and type of military service.

Combat exposure. A self-report questionnaire consisting of 18 items was used in this study. The questionnaire was initially devised by Dekel et al. (6) to assess the level of exposure to battlefield stressors in soldiers of the Yom Kippur War. A factor analysis with varimax rotation revealed four factors that explained 64.1% of the variance.

Factor 1 consisted of seven items relating to exposure to injuries and death (e.g., “I saw a lot of dead soldiers”).

Factor 2 consisted of four items describing experiencing life-threatening situations (e.g., “I found myself in a situation where I was not sure whether I’d come out alive”).

Factor 3 consisted of four items describing injury to the enemy (e.g., “I killed enemy soldiers”). Factor 4 consisted of three items describing dysfunction in one’s army (e.g., “I was in a situation where support did not arrive when required”). The internal consistency reliability estimate for the four factors ranged from .69 to .92. Previous studies indicate similar internal consistency reliability, from .76 to .91 (6).

Life functioning. The impact of the war on veterans’ daily functioning was assessed by the Life Functioning Scale, derived from the Psychotherapy Outcome Assessment and Monitoring System-Trauma Version (POAMS-TV; 34). Respondents were asked to rate each of 11 areas related to their daily life (e.g., work, social relationships and physical health) on a 5-point Likerttype scale (0, “barely functioning” to 4, “functioning very well”). The internal consistency reliability estimate for Life Functioning Scale was .90.

Posttraumatic stress symptoms (PTSS). The PTSD Inventory (35), a self-report scale, was used to assess posttraumatic stress symptoms. The questionnaire consists of statements tapping DSM-IV (3) symptom criteria. Subjects were asked to indicate on a 4-point scale ranging from “never” to “very often” the frequency with which they had experienced the described symptom during the preceding month. The average rate of the reported symptoms reflected the general rate of PTSS severity. The internal consistency reliability estimate for this Inventory was .94. The scale was also found to have good psychometric properties, including high convergent validity compared with clinical interviews based on the SCID (36). Since we used here both PTSD and PTSS, following the DSM-IV definition, the PTSD assessment was made when no less than the following

symptoms were present: at least one intrusive symptom, three avoidant symptoms, two arousal symptoms, and functional impairment in at least one daily life field as measured by the Life Functioning Scale (criterion F).

PTSS, however, reflects only the symptom criteria.

Risk-taking behavior. The Cognitive Appraisal of Risky Events questionnaire (CARE; 37) was used to assess frequency of involvement in 30 hazardous behaviors.

Subjects were asked to indicate, on a 5-point scale ranging from “not at all” to “very frequently,” the frequency with which they had experienced the described behavior within the preceding six months. Our initial factor analysis with varimax rotation resulted in eight factors with low reliability. The removal of three items describing dangerous sport activities resulted in seven factors that explained 66.4% of the variance. Factor 1 consisted of five items relating to occupational misbehavior (e.g., “Truancy from class or absence from work”; “Procrastinating on tasks or assignments”). Factor 2 consisted of six items describing severe violence (e.g., “Punching or hitting someone with a fist”). Factor 3 consisted of four items describing substance abuse (e.g., “Mixing drugs and alcohol”). Factor 4 consisted of three items describing risky sexual activities (e.g., “Sex without protection against sexually transmitted diseases”). Factor 5 consisted of three items describing reckless driving (e.g., “Driving after drinking alcohol”).

Factor 6 consisted of three items describing engagement in dangerous sport activities (e.g., “Rock or mountain climbing”). Factor 7 consisted of two items describing aggressiveness (e.g., “Getting into a fight or argument”).

The internal consistency reliability estimate for the seven factors ranged from .69 to .83.

Data analysis

Data analyses were comprised of several steps. In addition to descriptive statistics the bivariate relationships between each of the dependent and independent variables were examined. Furthermore, hierarchical regression analyses were conducted to assess the independent and cumulative contribution of each of the predictors (i.e., sociodemographic variables, war exposure and posttraumatic stress symptoms) to the independent variable, namely, severity of the risk taking behavior.

Results Sociodemographic and military characteristics

The participants’ mean age was 29.95 years (SD=5.82; range= 20 to 54 years). Most of the 180 men were 278

Combat Trauma and Risk-Taking Behavior

Israeli-born (82.8%; N=149) and had a high school education (69.4%; N = 125). Slightly more than half (55.6%; N=100) were not married and only 35% (N=61) had children. The majority of participants (70%; N=126) were employed at the time of the study. Approximately half the participants (46.7%; N=84) were infantry soldiers and only 8.9% (N=16) were officers.

Risk-Taking Behaviors

The majority of the respondents (84%; N=152) reported “frequent” or “very frequent” participation in at least one type of RTB during the previous six months. Sixtyeight veterans (37.6%) reported “frequent” or “very frequent” occupational misbehavior, 45 (24.8%) reported “frequent” or “very frequent” aggressive behavior, 10 (5.7%) were involved in “frequent” or “very frequent” severely violent behavior, 22 (12.1%) reported “frequent” or “very frequent” substance abuse, 19 (10.3%) reported “frequent” or “very frequent” reckless driving, 23 (12.8%) reported “frequent” or “very frequent” risky sexual activities, and 5 (2.6%) reported “frequently” or “very frequently” engaging in dangerous sports. The last two types of RTB, risky sexual activities and dangerous sports were not significantly correlated with other study variables and are thus not reported in further analyses.

PTSD

Seventy-one percent (N=128) of participants met the full criteria for PTSD. Results show that 17 (9%) participants experienced occasional intrusive symptoms during the preceding month, while 162 (90%) experienced them “often” or “very often,” in the same period; 33 (18%) participants experienced occasional avoidant symptoms in the preceding month, while 133 (74%) experienced them “often” or “very often”; 26 (14%) participants experienced occasional numbing symptoms in that period, while 151 (84%) reported experiencing them “often” or “very often”; 16 (9%) participants experienced occasional arousal symptoms during the preceding month, while 157 (87%) experienced them “often” or “very often.” Table 1 presents the means and Standard Deviations of the PTSS and symptom cluster severity.

Sociodemographic characteristics and Risk-Taking Behavior

A series of analyses were conducted to determine if there were RTB group differences with regard to sociodemographic characteristics. Analyses of variance (ANOVAs) provided RTB mean score comparisons across the follow279

Table 1. Means and std. deviations of PTSS and symptom clusters severity PTSS

Intrusion

Avoidance

Numbing

Arousal

Mean

2.6

2.7

2.4

2.3

2.8

SD

0.7

0.8

0.8

0.7

0.8

Sliding scale from 1-“never” to 4-“very often”

ing variables: age, education, family status, occupational status, having children, and type of military service. Results of the ANOVAs revealed significant group differences.

Violent behavior was significantly associated with age (F(3,176)=3.67; p<0.05), (1,171)=8.94; p<0.01), occupational status (F(3,174)=4.19; p<0.01), and type of military service (F(3,177)=3.61; p<0.01). Substance abuse was significantly associated with age (F(3,174)=5.83; p<0.001), family status (F(2,177)=11.07; p<0.001), parenthood (t(174)=3.71; p<0.001), occupational status (F(3,172)=3,10; p<0.05), and type of military service (F(3,175)=6.08; p<0.001). No association was found between sociodemographic characteristics and other types of RTB. Finally, younger, single and childless participants exhibited a higher tendency to participate in risk-taking behaviors.

Combat Exposure and Risk-Taking Behavior

An examination of combat exposure revealed that, on a scale of 4 slightly less than half the participants (43.5%; N=78) reported “intermediary” and “high” levels of exposure to injuries and death. Significantly more than half (70.4%; N=127) reported “intermediary” and “high” levels of exposure to life-threatening situations.

Only 11.2% (N=20) of participants reported “intermediary” and “high” levels of exposure to enemy casualties. One third of participants (29.6%; N=53) reported “intermediary” and “high” levels of exposure to their own army’s malfunctioning.

Pearson correlation between combat exposure and risktaking behaviors revealed significant but weak correlations (Table 2). Generally, findings suggest that more intense battle exposure is associated with a higher tendency to participate in risk-taking behaviors. More intense exposure to enemy casualties had the strongest association with higher tendency to participate in risk-taking behaviors like substance abuse (r=0.25; p<0.01) and reckless driving (r=0.17; p<0.05). More intense exposure to dysfunction in one’s army had the strongest association with higher tendency to participate in RTB such as occupational misbehavior (r=0.25; p<0.01), severe violence (r=0.24; p<0.01), and aggressive behavior (r=0.26; p<0.01).

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Table 2. Pearson correlation between RTB factors and Combat Exposure situations Aggressive behavior

Reckless driving

Substance abuse

Severe violence

Occuptnl misbhvr

General index of the RTB

0.25**

0.19*

0.26**

0.19**

0.26**

0.32**

General index of the Combat Exposure

0.17*

0.13

0.22**

0.17*

0.16*

0.22**

Injuries and death

0.10

0.16*

0.12

0.05

0.20**

0.18*

Life-threatening situations

0.12

0.17

0.25

0.15

0.08

0.22

Enemy casualties

0.26**

0.15*

0.19**

0.24**

0.25**

0.29**

*

**

*

**

Dysfunction in oneâ&#x20AC;&#x2122;s army

* p<0.05, ** p<0.01, *** p<0.001

Table 3. Means and standard deviations of RTB according to PTSD appearance PTSD (N=128)

Non PTSD (N=52)

N

M

SD

N

M

SD

General index of the RTB

127

2.02

0.53

53

1.43

0.33

t(178)=-7.45***

Occuptnl misbhvr

126

3.25

1.01

53

2.08

0.83

t(177)=-7.45***

Severe violence

127

1.57

0.65

53

1.12

0.32

t(178)=-4.85***

Substance abuse

125

1.85

0.97

53

1.31

0.52

t(176)=-3.85***

Reckless driving

125

1.79

0.82

53

1.28

0.46

t(176)=-4.19***

Aggressive behavior

120

2.58

1.09

51

1.67

0.85

t(169)=-5.34***

*** p<0.001

PTSD and Risk-Taking Behavior

We used independent tests to compare RTB between subjects with and without PTSD. The findings revealed significant differences (Table 3). Generally, the findings suggest that participants who were diagnosed with PTSD reported a higher tendency for RTB than veterans without PTSD. Means of occupational misbehavior (t(177)=-7.45; p<0.001), severe violence (t(178)=-4.85; p<0.001), substance abuse (t(176)=-3.85; p<0.001), reckless driving (t(176)=-4.19; p<0.001), and aggressive behavior (t(169)=-5.34; p<0.001) among participants who have PTSD were higher. The prevalence of RTB beyond moderate frequencies among PTSD veterans showed that 58.7% of participants reported occupational misbehavior, 27.5% of participants reported aggressive behavior, 12.8% of participants reported substance abuse, 8.2% of participants reported reckless driving, and 3.1 % reported severe violence.

Pearson correlation between PTSS and risk-taking behaviors revealed strongly significant and strong associations (Table 4). Generally, findings suggest that more severe PTSS is associated with higher tendency to engage in RTB. More severe intrusive symptoms had the strongest association with a higher tendency to participate in risk-taking behaviors like severe violence (r=0.45;

p<0.01) and aggressive behavior (r=0.41; p<0.01). More severe arousal symptoms had the strongest association with a higher tendency to participate in RTB like occupational misbehavior (r=0.55; p<0.01), and aggressive behavior (r=0.52; p<0.01). More severe avoidant symptoms had the strongest association with higher tendency to participate in RTB like occupational misbehavior (r=0.38; p<0.01). More severe numbing symptoms had the strongest association with higher tendency to participate in RTB like occupational misbehavior (r=0.53; p<0.01), and severe violence (r=0.46; p<0.01).

Predicting Risk-Taking Behavior

To investigate whether the relation of combat exposure to RTB was mediated by PTSS, we employed hierarchical multiple regression analysis with RTB as the dependent variable. Sociodemographic characteristics (i.e., yes/no academic degree, yes/no children, not married/ others, married/others, self employed/others, employed/ others, unemployed/others) were entered first, followed by combat exposure events (i.e., life-threatening situations, dysfunction in oneâ&#x20AC;&#x2122;s army, enemy casualties, injuries and death), and PTSS (i.e., intrusion, arousal, avoidance, numbing). Results of this analysis are presented in Table 5.

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Combat Trauma and Risk-Taking Behavior

Table 4. Pearson correlation between RBT factors and PTSS Numbing

Avoidant

Arousal

Intrusion

General index of PTSS

0.54**

0.35**

0.60**

0.45**

0.59**

General index of the RTB

0.53

0.38

0.55

0.39

0.54

Occuptnl misbhvr

0.46**

0.27**

0.45**

0.45**

0.48*

Severe violence

**

0.30

0.20

0.23

0.18

0.27

Substance abuse

0.30**

0.16*

0.33**

0.25**

0.31**

Reckless driving

0.41

0.30

0.52

0.41

0.48

Aggressive behavior

**

**

*

**

**

**

**

**

**

**

**

**

**

**

**

p<0.05, ** p<0.01, *** p<0.001

Multiple regression analysis demonstrated additive effects for sociodemographic characteristics, level of combat exposure, and PTSS (r2=0.43), F(15,162)=7.36; p<0.001. The most important contribution was made by PTSS and explained 24% of the variance. Less but still significant contributions were found to come from sociodemographic characteristics (11%) and combat exposure intensity (8%). RTB was significantly associated with level of arousal and numbing symptoms, level of exposure to Table 5. Regression coefficients, R2 and R2 Change values for sociodemographic variables, Combat Exposure and PTSS predicting for RTB Standardized beta Predictor Variable

Step 1

Step 2

Step 3

Academic degree (yes/no)

0.13

0.11

0.03

Children (yes/no)

0.06

0.06

-0.02

Family status (not married/others)

0.27

0.17

0.20

Family status (married/others)

0.07

0.04

0.04

Occupation status (self employed/others)

-0.12

-0.17

-0.16*

Occupation status (employed/others)

-0.22*

-0.23*

-0.21*

Occupation status (unemployed/others)

-0.05

-0.05

-0.19*

Step 1. Sociodemographic characteristics

Step 2. Combat Exposure Life-threatening situations

0.03

-0.04

Dysfunction in one’s army

0.18*

0.06

Enemy casualties

0.12

0.07

Injuries and death

0.07

0.03

Step 3. PTSS Intrusion

0.05

Arousal

0.32**

Avoidant

-0.05

Numbing

0.27**

R2 Change

0.11**

0.08**

0.24***

R

0.11

0.19

0.43

2

* p<0.05, ** p<0.01, *** p<0.001

281

dysfunction in one’s army, and occupational status. When PTSS was statistically controlled for the contribution of combat exposure to RTB was nullified.

Discussion The first purpose of the current research was to assess the prevalence of risk-taking behaviors among Israeli reserve soldiers with and without PTSD. The results show that the majority of combat veterans (84%) reported a significant engagement in at least one type of RTB during the six months preceding the study. The PTSD veterans scored significantly higher than the non-PTSD subjects on all measures of RTB. It also seems that younger veterans were at a higher risk for RTB. These findings are consistent with earlier studies that suggest that RTB disturbance may be an especially prevalent problem in helpseeking combat veterans with PTSD (14-16, 38).

The second and main aim of this study was to examine the inter-relationship among the level of combat exposure, posttraumatic stress symptoms, and risktaking behavior. More specifically, the independent and cumulative contributions of combat exposure and posttraumatic stress symptoms to risk-taking behavior were assessed. Results revealed a significant contribution of PTSS to RTB. Furthermore, PTSS promoted the relationship between combat exposure and RTB. These findings are consistent with previous studies (16-18, 21-25) and confirm the conclusion that more severe PTSS is associated with higher tendency for RTB regardless of level of combat exposure.

Several possible explanations for the relationship between RTB and PTSS are suggested. First, RTB may serve as a maladaptive attempt to temporarily relieve posttraumatic stress symptoms. For instance, the ’’Selfmedication’’ and ’’Tension reduction’’ models outlined

by Khantzian (39) postulate that PTSD develops first and alcohol addiction or abuse are reinforced sec-

Vlad Svetlicky et al.

ondarily in order to reduce tension (e.g., 17). In other words, veterans use RTB as a destructive coping strategy to temporarily reduce or numb the negative effect the posttraumatic stress symptoms.

According to Herman (40), there are several reasons that may cause trauma survivors to engage in risky behaviors after exposure. These behaviors, as aforementioned, may be the trauma survivorsâ&#x20AC;&#x2122; attempts to regulate their internal emotional state. For example, traumatized individuals who are unable to dissociate effectively from their painful experiences may try to produce similar numbing effects by resorting to alcohol and drug use. Trauma survivors may also use alcohol or drugs to control the hyperarousal and intrusive symptoms associated with PTSD. In addition, risky behaviors may be a result of the psychopathology caused by the exposure to trauma. For example, a war veteran who is dissociating may fail to adequately respond to danger signals or may misinterpret dangerous situations and thus increase his risk for further victimization. Finally, due to guilt, shame or shattered self-esteem, trauma survivors may feel undeserving of safety, care or protection and, therefore, do not seek out protection.

Another perspective is related to Berkowitzâ&#x20AC;&#x2122;s (41) cognitive-neoassociationistic model. This model postulates that the experience of a dysphoric effect is likely to activate associative networks of anger-related feelings, thoughts, memories and aggressive inclinations, making aggressive behavior more likely. According to Berkowitz (41, 42) and other aggression theorists (43), bodily reactions and higher order cognitive processing influence the expression of aggression. When people do not feel well, they are more likely to experience feelings of anger and hostility which, in turn, may arouse memories, and aggressive inclinations, all of which increase the tendency for risky behaviors. Attribution processes and prior learning play an important role in most conceptualizations of aggression and may be particularly significant for combat veterans suffering from posttraumatic stress symptoms. The suggestion is that the anger-related thoughts and hostile attributions of these individuals are likely to be heightened due to prior experiences of trauma, fear and life-threatening situations, and a hypersensitivity to potential threats in the environment (44). In other words, traumatized war veterans are likely to be aggressive and display maladaptive and inadequate behaviors.

Findings of the present study may have important clinical implications. Theoretical models interpreted in light of these findings suggest that the identification and treatment of dysphoric symptomatology should

also be incorporated into high-risk behavior management interventions for combat veterans, experiencing symptoms of PTSD. This study has several limitations that should be noted.

First, the sample used was of reserve soldiers who sought treatment in an IDF Combat Reaction Unit between August 2007 and June 2008 in the wake of the Second Lebanon War and may not be representative of the larger veteran population. This study should be replicated in a cohort of regular service soldiers and veterans of other wars. The study data are based on memories of events that occurred several months in the past and are based on self-report. Therefore the findings should be interpreted with caution. Memories of combat experiences may have changed with the passing of time and may be variously affected by posttraumatic stress symptoms and negative affect (45). Participants seeking compensation may have exaggerated their reports of combat exposure, psychopathology and negative affect, and/or aggression, inflating the observed associations (46). Unfortunately, it is impossible to determine from our data whether any demographic factors have changed after the war. Hence, we adopted the assumption that these factors were left unchanged. Nevertheless, this study limitation should be taken into account when interpreting the results of this study. Finally, the help-seeking status of participants may also limit the ability to generalize from the current findings to the larger population of veterans not seeking care or compensation.

Further research is needed to examine a broader array of variables (e.g., cognitive and information-processing systems, social support, coping patterns, and more) that co-exist with PTSS and PTSD but may represent different emotional experiences, in order to enhance our understanding of the full associative network leading to risk-taking behavior among military veterans.

Despite these limitations, this study contributes to better understanding of risk-taking behavior in this population. Findings indicated that PTSS largely account for the effect of combat exposure on risk-taking behavior. Further research in this area and better understanding of the disorder may serve to mitigate the severe interpersonal and health consequences associated with such maladaptive behavior.

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Ehud Bodner ET AL.

The Relationship between Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals: The Israeli Case Ehud Bodner, PhD,1 Amiram Sarel, MD,2 Omri Gilat, PhD,3 and Iulian Iancu, MD2 1

The Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat Gan, Israel Rehovot Community Mental Health Center and the Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel 3 Department of Psychology, University of Kansas, Lawrence, Kansas, U.S.A. 2

Introduction

ABSTRACT Background: According to the current standard of practice in modern medicine, medical decision-making is often forced to comply with stipulations of the insurance provider. In the field of psychiatry, there has been a trend of shortened psychiatric hospitalizations which some have suggested may be due to pressures related to insurance coverage. In Israel, soldiers have comprehensive medical coverage provided by the military, and this coverage includes full payment for psychiatric hospitalizations. In contrast, Israeli civilians are insured by the government according to a global payment system. In this study, we aimed to examine differences between these two groups in terms of length of stay (LOS) in psychiatric hospitals.

Methods: Data on psychiatric admissions of soldiers (aged 18-21) spanning the past 30 years was obtained from the military database (N=2,106). Corresponding data was collected on first psychiatric hospitalizations of a cohort of matched civilians (N=6556). The mean LOS of the two groups was compared.

Results: Civilians had a significantly longer LOS than soldiers. Moreover, LOS decreased between the seventies and the nineties for both groups, and the decrease was observed for all diagnoses regardless of disease severity.

Discussion: We conclude that in the managed care era, economic considerations may at times take precedence over psychiatric ones, irrespective of the degree of severity of illness. The parallel process is manifested in a general trend towards deinstitutionalization in the United States, Canada and Europe.

Address for Correspondence: E-mail: iulian1@bezeqint.net

The term “managed care” is often used in the medical literature to describe how cost-effectiveness considerations influence all levels of decision-making processes in medical settings (1-4), including assignment of resources (e.g., drugs, medical procedures) and medical services (e.g., counseling, waiting lists), as well as conditions of the hospitalization per se (patients per room, LOS) (5). It is argued that financial factors may create a conflict of interests in the service-provider-patient relationship (6). Over the last two decades, two new factors have been introduced into the service-providerpatient relationship in Western countries: the organization (the government or the employer) and the insurer (4-9). This has led to a situation in which the service provider, who in the past was committed only to the patient, is now also committed to the insurer, who pays for the treatment. When the patient’s interest (optimal medical treatment) is incongruent with the interest of the insurer (maximum profit and minimum cost), the service provider is forced to find a compromise position (6, 10, 11). Thus in the current environment of financial stress, hospitalizations may in some cases tend to be shorter irrespective of the patient’s best interest.

This delicate situation, plaguing medicine in general, becomes more complex in the field of psychiatry, which suffers from problems of subjective diagnostic criteria and high rates of comorbid mental illness (1215). Service providers (e.g., hospitals) may be interested in diminishing costs and remaining profitable, whereas insurers (e.g., governments) may wish to cut their expenses. This may be one of the reasons for the

Dr. Iulian Iancu, Yavne Community Mental Health Center, 4 Dekel St., Yavne 81540, Israel

284

The Relationship between Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals: The Israeli Case

significant decline in mean LOS and quality of psychiatric admissions across the United States (1, 16-18).

Psychiatrists are under constant pressure from hospitals that refuse to hospitalize chronic psychiatric patients who usually have poor quality medical insurance (19, 20). The hospitals, in turn, are under pressure from insurance companies which are interested in decreasing the LOS. In cases where the insurer paid hospitals a fixed global fee in advance for a given period, hospitals preferred patients who were likely to be hospitalized for shorter periods over patients who required a prolonged period of hospitalization (9). When a fee-for-service system (payment given per days of hospitalization) was compared to a global payment strategies (fixed fee paid in advance), hospitals tended to establish stricter criteria for discharge and to extend the LOS (2, 5, 7, 8).

In Israel, the government has a global contract with hospitals. The government, which is both the insurer and service provider, does not pay per hospitalization and exerts less control over LOS, as the conflict of interests between insurer and service provider does not exist. This is true for civilians, but not for soldiers.

Soldiers are insured by the Israeli Defense Forces (IDF), which pays the government for the treatment in a feefor-service system (i.e., payment is given per days of hospitalization). Thus, despite other potential influences, a comparison of the LOS of Israeli civilian and military inpatients may shed some light on the influence of medical insurance on LOS. A previous inquiry into the effect that management considerations have on LOS of psychiatric admissions over a five-year period (2000-2004) found a decrease in both parameters, which was mainly evident in general hospitals (21). The researchers, however, did not examine the effect of the type of insurer and their inquiry was limited to five years only.

In the present study, we examined the influence of the type of insurer and the period of hospitalization on LOS, and we compared civilian and military patients over three decades. The hypotheses of the study were as follows: (1) LOS of soldiers will be shorter than that of matched civilians due to the different insurance policies of the Israeli Government and the IDF; (2) since during the 1970s the number of beds in psychiatric hospitals decreased and subsequent budgets were infused into the outpatient service, longer hospitalizations will be found in this period as compared to later periods; (3) as clinical guidelines are more precise and the social dysfunction is more prominent for severe 285

disorders (e.g., schizophrenia, mood disorders) (22), the insurer (military/government) would only have an influence on the LOS in the less severe diagnoses (e.g., neurotic disorders).

Method Israelis (aged 18-21) who were admitted for a first psychiatric hospitalization in one of three given periods (1974-1976, 1984-1986, 1994-1996) during the course of their obligatory military service were selected as the study group. (We restricted the sample only to the obligatory service period due to the fact that the military does not finance the hospitalization of reserve duty soldiers and the LOS for career service soldiers is affected by confounds that could not be controlled for in this study.) A matched sample of civilians who did not serve in the IDF and had a first psychiatric hospitilization in one of the same periods was selected as the control group. Data were obtained from the IDF database and the National Psychiatric Hospitalization Case Registry (which includes all psychiatric admissions in Israel as well as the discharge ICD-10 diagnoses given by a certified psychiatrist). Specifically, a simple frequency matching on age (18-21 years), first admission and period of hospitalization was used, followed by tests of differences on place of residence and place of birth (socio-demographic variables) and on psychiatric diagnosis, self-competence, type of hospital admittance, type of hospital discharge, suicide attempts, substance use and hospital type (psychiatric variables). Type of hospital admittance was as follows: regular admission, night admission or day admission. Type of hospital discharge included regular discharge, discharge by a psychiatric committee, discharge against medical advice, etc. Preliminary statistical analyses revealed no differences between the two groups on these variables. However, it should be noted that as service in the IDF is compulsory, it is reasonable to assume that the civilian sample included subjects who were rejected from the military due to medical or psychiatric illness. In addition, the male to female ratio was not equal in the military and civilian samples.

Data analysis: A study design of 2 X 3 X 5 was constructed. The first factor was the insurer (military/government), the second was the hospitalization period (1974-1976, 1984-1986 or 1994-1996), and the third was the ICD-10 diagnosis, with five levels (schizophrenia

Ehud Bodner ET AL.

and delusional disorders, affective disorders, neurotic disorders, personality disorders and Z codes). We examined our hypotheses, by a three-way analysis of variance with insurer type, period and diagnosis as independent variables and LOS as the dependent variable.

Results Overall, the sample consisted of 8,662 subjects between the ages of 18-21: 2,106 soldiers (1,691 males and 415 women) and 6,556 civilians (3,701 males and 2,855 women). The three-way analysis of variance yielded a significant main effect for insurer type (F= (1, 8632)

= 8.68, p< .01), indicating, as predicted, that the LOS for soldiers (M=49.43, SD=101.78) was shorter than the LOS for civilians (M=87.33, SD=272.46).

In addition, a significant main effect was found for hospitalization period F= (2, 8632) = 3.006, p< .05. A scheffe post-hoc analysis revealed a significant trend indicating that during the years 1974-1976 (M=90.99 days, SD=334.28) subjects were hospitalized for a longer LOS when compared to the years 1984-1986 (M=74.00, SD=178.43) and 1994-1996 (M=65.69, SD=130.66).

In addition, a significant difference was found between types of diagnoses F= (4, 8632) = 17.809,

Table 1: LOS (mean and S.D. in days) insured by the Military by decade of hospitalization and diagnosis Decade of hospitalization

Diagnosis

N

Mean

Std. Deviation

1974-1976

Schizophrenia and delusional disorders

350

113.07

203.65

Mood Disorders

65

44.83

54.89

Neurotic Disorders

123

39.88

50.27

Personality Disorders

317

29.94

70.05

Other causes for referrals

182

41.86

56.18

Sum

1037

62.20

133.59

Schizophrenia and delusional disorders

177

74.32

67.77

Mood Disorders

45

49.76

48.47

Neurotic Disorders

107

30.28

34.58

Personality Disorders

189

24.68

38.52

Other causes for referrals

86

8.94

15.18

Sum

604

39.85

52.90

Schizophrenia and delusional disorders

122

54.73

74.82

Mood Disorders

61

46.10

30.18

Neurotic Disorders

143

21.87

29.65

Personality Disorders

73

33.25

63.76

Other causes for referrals

66

7.33

9.99

Sum

465

33.39

52.63

Schizophrenia and delusional disorders

649

91.54

158.80

Mood Disorders

171

46.58

45.47

Neurotic Disorders

373

30.22

39.53

Personality Disorders

579

28.64

60.67

Other causes for referrals

334

25.56

45.56

Sum

2106

49.43

101.78

1984-1986

1994-1996

Total sum

286

The Relationship between Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals: The Israeli Case

Table 2: LOS (Mean and SDs, in days) insured by the Government by decade of hospitalization and diagnosis Decade of hospitalization

Diagnosis

N

Mean

Std. Deviation

1974-1976

Schizophrenia and delusional disorders

1379

137.70

505.38

Mood Disorders

196

55.07

77.84

Neurotic Disorders

293

54.99

70.82

Personality Disorders

298

55.94

97.51

Other causes for referrals

229

62.43

103.23

Sum

2395

103.45

389.76

Schizophrenia and delusional disorders

972

113.81

254.63

Mood Disorders

185

59.64

95.83

Neurotic Disorders

182

47.79

84.16

Personality Disorders

401

72.79

150.35

Other causes for referrals

164

12.00

27.05

Sum

1904

84.83

201.42

Schizophrenia and delusional disorders

1230

91.84

157.45

Mood Disorders

343

51.19

80.50

Neurotic Disorders

265

50.44

100.58

Personality Disorders

300

56.65

155.83

Other causes for referrals

119

20.05

83.32

Sum

2257

72.34

140.58

Schizophrenia and delusional disorders

3581

115.47

353.26

Mood Disorders

724

54.40

83.96

Neurotic Disorders

740

51.59

85.67

Personality Disorders

999

62.92

138.67

Other causes for referrals

512

36.43

84.54

Sum

6556

87.33

272.46

1984-1986

1994-1996

Total sum

p< .001. Scheffe post-hoc tests revealed that patients who were diagnosed as suffering from schizophrenia and delusional disorders were hospitalized for longer periods (M=111.79, SD=331.03) than patients diagnosed as suffering from affective disorders (M=52.91, SD=78.12), neurotic disorder (M=44.43, SD=74.17), personality disorders (M=50.34, SD=117.44) and Z codes (M=32.53, SD=71.86).

Finally, a comparison between the two types of insurers (military / government) on each type of diagnosis revealed that the LOS of soliders was significantly shorter than that of civilians for the following diagnoses: (1) schizophrenia and delu287

sional disorders, t(2319)=4.29, p<.001, (M=57.85, SD=79.46 vs. M=85.66, SD=137.77 ); (2) mood disorders t(898)=2.99, p<.01, (M=36.71, SD=28.32 vs. M=47.44, SD=72.74 ); and (3) neurotic disorders, t(719)=5.85, p<.0001, (M=18.60, SD=26.66 vs.

M=43.45, SD=84.74 ).

Discussion The main purpose of the current study was to examine the influence of differences in type of insurance on the care of psychiatric inpatients, focusing specifically on LOS. The first hypothesis was that compared to civilian

Ehud Bodner ET AL.

Table 3: Total Means and SDs of LOS in Days by Decade of Hospitalization and Diagnosis Decade of hospitalization

Diagnosis

N

Mean

Std. Deviation

1974-1976

Schizophrenia and delusional disorders

1729

132.72

460.60

Mood Disorders

261

52.52

72.84

Neurotic Disorders

416

50.52

65.72

Personality Disorders

615

42.54

85.40

Other causes for referrals

411

53.32

86.16

Total

3432

90.99

334.28

Schizophrenia and delusional disorders

1149

107.73

236.11

Mood Disorders

230

57.71

88.58

Neurotic Disorders

289

41.30

70.45

Personality Disorders

590

57.38

127.79

Other causes for referrals

250

10.95

23.66

Total

2508

74.00

178.43

Schizophrenia and delusional disorders

1352

88.49

152.21

Mood Disorders

404

50.42

75.09

Neurotic Disorders

408

40.42

83.99

Personality Disorders

373

52.07

142.80

Other causes for referrals

185

15.51

67.26

Total

2722

65.69

130.66

Schizophrenia and delusional disorders

4230

111.79

331.03

Mood Disorders

895

52.91

78.12

Neurotic Disorders

1113

44.43

74.17

Personality Disorders

1578

50.34

117.44

Other causes for referrals

846

32.53

71.86

Total

8662

78.12

242.83

1984-1986

1994-1996

Total sum

Fig. 1: Means of LOS in days as a function of the decade of hospitalization and the type of insurer 120 100

103.45

Means of LOS

84.83 80 60

72.34

62.2 39.85

40 20 0

33.39 Civilians Military 74-76

84-86 Decade of Hospitalization

94-96

matched controls, soldiers would be hospitalized for shorter time periods. This hypothesis was confirmed. It seems that despite the tendency of hospitals to extend the LOS of hospitalizations in order to increase their income, when the insurer monitors the length of hospitalizations, the LOS is shortened (7, 9).

Another intention of the study was to examine the ongoing process of de-institutionalization that characterizes much of the Western world (21, 23). This process reflects an approach which favors the transfer of psychiatric treatment from a hospital setting to a community service setting. Our hypothesis was that since the major shift in funding the hospitals took place in the 1970s, this period should be different than subsequent periods regarding the mean LOS. This hypothesis was also con288

The Relationship between Type of Insurance, Time Period and Length of Stay in Psychiatric Hospitals: The Israeli Case

firmed: the mean LOS for both groups was significantly shorter during the 1980s and the ’90s.

The third hypothesis was that the type of insurer (military/government) would disproportionately influence the length of psychiatric hospitalizations for the less severe psychiatric diagnoses (neurotic disorders) as compared to more debilitating disorders such as schizophrenia and psychotic major depression (22). In order to examine this assumption, a comparison of the LOS between the two types of insurers was conducted for both mild and severe diagnoses. The results indicated that the mean LOS was shorter for soldiers compared to civilians for both the less severe psychiatric diagnoses (neurotic disorders), as well as for the more severe diagnoses (schizophrenia, delusional disorders and mood disorders). Therefore, we conclude that financial considerations affect LOS even for the severe psychiatric diagnoses.

The mean LOS in Israel is considerably higher that that reported in the U.S. (where a 10-day average was reported nationwide) (24), and also higher than in the U.K. (25) and Germany (26), where LOS of 15 and 34 days respectively was reported, whereas one U.S. study (27) found a mean LOS of 35.4 days (alas not of first admissions). In Canada the mean average LOS was reported to be 35 days (28), a considerable decrease from the 1994-1995 average (66 days). This reduced LOS might result from continuous pressures for deinstitutionalization and budget savings which are especially strong in the U.S., and appear to be less powerful in Canada, Europe and in Israel. The high standard deviations in our study reflect the inclusion of mild cases (z diagnoses and neurotic disorders) and the trend in the last decades for very long hospitalizations for severe psychopathology (mainly among the civilians).

However, despite the high standard deviations, our data were significant. One should not forget however that our mean LOS is based only on subjects who were admitted for the first time, which usually tends to be longer (26), whereas the mean LOS reported in other countries (24-28) was not limited to first admissions.

Although there are significant differences between the mean LOS in Israel and in other countries (especially the U.S.), there exists a common trend toward shorter admissions worldwide due to financial pressures. Therefore, it is possible that the U.S. case is the “end case” scenario of the Israeli, Canadian and the European one. Of course, ideally, reduced LOS should be complemented by excellent ambulatory services, and we recommend that public health officials should 289

assess the presence and efficacy of outpatient services.

In addition, since in the U.S. different insurance programs exist, it might be interesting to compare these programs, and see their impact on LOS with the same methodology used in the current study.

A methodological limitation of this study refers to the fact that our control group (non-military Israeli citizens) included individuals who were found unfit for military service. Although no significant differences were found between the study group (Israeli soldiers) and the control group on either socio-demographic or psychiatric variables, we cannot rule out the possibility that the civilian group was more mentally disturbed in a way that simple matching would not predict. Therefore, it is possible that selection bias impacted on the results of our study in terms of differences in LOS between the study group and the control group. It is possible that soldiers may have been more motivated to shorten the length of their hospitalization in comparison to the control group, for the soldiers may have felt an obligation to return to military service. Finally, the different male/ female ratio in the military and civilian sample might have caused a bias, because women are more compliant and have longer LOS (29).

Finally, the findings of the current study complement the extensive literature exploring the influence of financial policies and insurer type on professional decisions in the medical field in general (7, 9), and in the psychiatric area in particular (30, 31). One possible conclusion from our findings is that standardized criteria for psychiatric discharge are needed in order to protect psychiatric patients from the restrictions to care imposed by the insurance provider. The results of this study also highlight the need to integrate rehabilitative and functional criteria in the considerations for admission and discharge of psychiatric patients. Such steps may help to balance patients’ rights for proper medical treatment on the one hand and financial considerations on the other.

Acknowledgements The work was financed by Israel National Institute for the Study of Medical Services and Medical Policy.

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Self-estimation of performance time versus actual performance time in older adults with suspected mild cognitive impairment: a clinical perspective Jeremia Heinik, MD,1 and Liat Ayalon, PhD2 1

Margoletz Psychogeriatric Center, Ichilov Hospital, Tel Aviv, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel School of Social Work, Bar-Ilan University, Ramat Gan, Israel

2

ABSTRACT Background: Estimation of the passage of time has received marginal attention in contemporaneous psychiatric assessment and diagnosis. There is disagreement regarding the ability of older adults with dementia, particularly of the Alzheimerâ&#x20AC;&#x2122;s type, to estimate time passage, and there is lack of data concerning the ability of older adults in the early stages of cognitive impairment to estimate the passage of time.

Objective: We investigated the hypothesis that individuals with mild dementia perform worse compared to those with no cognitive impairment, and that those with mild cognitive impairment (MCI) assume an intermediate position in terms of their ability to accurately estimate time passage. Another objective was to study demographic and clinical (cognitive, functional, psychiatric) predictors of self-estimation of performance time versus actual performance time.

Method: In the context of a comprehensive psychogeriatric evaluation, three performance time measures were established: actual performance time, subjective estimation of performance time, and accuracy of estimation of performance time.

Results: 102 consecutive persons with suspected MCI were assessed. Final cognitive diagnoses were: dementia 49 (48%), MCI 36 (35%), no cognitive impairment (NCI) 17 (17%). Whereas there were significant group differences (dementia, MCI, NCI) on all cognitive measures and on functional impairment, there were no significant group differences on the three time measures. With the exception of age, estimation

of performance time was not associated with any of the other demographic and clinical variables.

Conclusion: Self-estimation of performance time versus actual performance time was not found impaired either in the dementia group or in the MCI group when compared to participants without cognitive impairment.

Introduction Descriptive psychopathology makes an important distinction between chronological, clock time (objective, quantifiable) and personal time (subjective) (1). Both might be affected in psychiatric disorders, such as psychoses (2, 3), depression (4) and organic conditions (1).

Altered chronological clock time may involve disorientation to time of day, day of the week, month and year, as well as the inability to evaluate correctly the passage or the duration of time. Whereas disorientation to time constitutes a cardinal feature of psychiatric examination, estimation of the passage of time has received marginal attention in contemporaneous psychiatric assessment and diagnosis.

Time perception is considered an unclear cognitive construct (5), for which several mechanisms are potentially responsible (6-9). It is thought that the ability to estimate the passage of time is related to cognitive processes and to the interaction between cognitive and biological mechanisms (10). Memory and attentional-

Address for Correspondence: Jeremia Heinik, MD, Margoletz Psychogeriatric Center, Ichilov Hospital, 6 Weizmann Street, Tel Aviv, Israel 64239 â&#x20AC;&#x2020;heinik@post.tau.ac.il

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Jeremia Heinik and Liat Ayalon

executive function seem to be crucial determinants (5). Impairments in time estimation have been found in different types of pathology such as dementia of the Alzheimer’s type (5, 10-12), amnesic patients (11), frontal-damaged and alcoholic Korsakoff (13) and brain damaged patients (14). As for dementia, whereas most studies reported impaired time estimation in individuals with Alzheimer’s disease (5, 10-12), Levy and Dreier (15) showed that temporal skills, such as intuitive time (i.e., the ability to estimate time interval duration) and socialized time may be relatively preserved in patients with possible Alzheimer’s disease. Hence, there is no consensus regarding the level of impairment in time estimation associated with the presence of dementia.

To evaluate respondents’ assessment of the passage of time, study designs have adopted sophisticated time estimation tasks (e.g., using computerized devices), covering very short (seconds) intervals, and conducted in experimental settings. Their applicability to clinical, real life situations is not clear. In addition, individuals with dementia recruited for these studies were mild to moderate cases of cognitive impairment with a mean Mini-Mental State Examination (MMSE) (16) score of 22.63 (10), 15 (15), 15 to 24 and 7 to 15 in mild to moderate dementia, respectfully (12). Control groups in most studies consisted of healthy participants (5, 10). In only one study (15) the comparison group consisted of psychiatric patients who had MMSE scores in the normal range, thus mimicking a clinical situation.

One group that could provide meaningful information about the ability of older adults with cognitive impairments to assess the passage of time is the group of individuals with mild cognitive impairment (MCI).

MCI is used to describe a group of older adults who have cognitive impairments, often involving memory, not of sufficient severity to warrant the diagnosis of dementia (17). It is a commonly encountered condition in geriatric practice (18). MCI patients have been shown to perform intermediately between individuals with normal cognitive functioning and individuals with dementia on a large scale of cognitive tasks (17, 19). To date, the ability of individuals with MCI to evaluate the passage of time has not been evaluated.

The present study aims to investigate differences in self-estimation of performance time versus actual performance time in three groups of individuals that vary in terms of their cognitive functioning: mild dementia, MCI and NCI. All individuals were referred for evaluation of suspected MCI in the context of an outpatient

psycho-geriatric setting. We hypothesized that individuals with mild dementia perform worse compared to those with NCI, and that those diagnosed with MCI assume an intermediate position. Another objective was to study demographic and clinical predictors of self-estimation of performance time versus actual performance time.

Methods About 70% of the new referrals to our outpatient psychogeriatric service include patients with various degrees of cognitive impairment. The remaining are individuals with functional psychiatric disturbances, mainly those with depression or anxiety disorders, treatable on an ambulatory basis. Combinations of cognitive and noncognitive psychiatric disorders evidently commonly occur. Each new referral with cognitive complaints undergoes a comprehensive multidisciplinary assessment process (geriatric psychiatrist, geriatrician, social worker, nurse). Fully and semi-structured formats to register information pertinent to each specific field are used. Family members/information providers are encouraged to accompany the patient at each evaluative stage. The psychiatrist is always the first to evaluate the person. The structured part of the psychiatrists’ cognitive examination consists of the Mini-Mental State Examination (MMSE) (16) and the Clock Drawing Test-Modified and Integrated Approach (CDT-MIA) (20). Instrumental Activities of Daily Living (IADL) are scored with the Lawton and Brody scale (21). Laboratory investigations, including imaging studies, are recommended to exclude potentially treatable causes for cognitive impairment and physical causes for emotional disorders. For those referrals with early stages of cognitive impairment an MCI clinic was established, where subjects with a working diagnosis of suspected MCI (that is, judged clinically at the first encounter as not demented however not cognitively normal), and considered cooperative enough to undertake further assessment, and in which demographics (schooling, fluency in language) and sensory/motor conditions are favorable, are offered a more comprehensive cognitive and psychiatric evaluation. It has been our experience that final cognitive diagnoses in this heterogeneous clinic population result either in confirmed MCI, mild dementia or NCI, which is in accordance with other clinics reports (e.g., 22).

The cognitive states of participants with suspected MCI are further evaluated, within 4 to 6 weeks from 292

Self-estimation of performance time versus actual performance time in older adults

the first psychiatric interview, with the Kingston Standardized Cognitive Assessment-Revised (KSCA-R) (23) and the Cambridge Cognitive-ExaminationRevised (CAMCOG-R) (24). CAMCOG-R protocol may serve to generate an MMSE score and its clock drawing task to obtain a score along with CDT-MIA procedure. Psychiatric diagnoses are obtained with a modified version of CAMDEX-R, the Cambridge examination for mental disorders of the elderly-revised (24) as described elsewhere (25).

DSM-IV operational criteria are used for cognitive and psychiatric diagnoses (25, 26). MCI diagnosis is established according to Winblad et al. (27) criteria operationalized in the following order: a. not demented according to DSM-IV criteria; b. self and/or informant report of cognitive decline; c. impairment on objective cognitive tasks (defined as CAMCOG-R total score below the 25th percentile compared to normative values by age-group, sex and educational level (28); d. preserved basic activities of daily living/ minimal impairment in instrumental functions.

In order to study self-estimation of performance time we took advantage of the fact that both KSCA-R and CAMCOG-R query the correct time of day, and CAMCOG-R includes a “passage of time” evaluation, that is, participants’ estimation of the actual duration of interview (minutes) from the beginning of Section A to the end of Section B (CAMCOG-R). KSCA-R was administered at the beginning of the interview (duration of administration time is 15 to 20 minutes [23]), followed by the CAMCOG-R (duration of administration time is 25 to 30 minutes [24]). KSCA-R asks for the exact time of day early in the questionnaire (item 9) whereas CAMCOG-R queries the exact time and time passage estimation at the end of the questionnaire (items 204 to 206). In parallel to participants’ response, the examiner registers the exact hour and minute. The assessment is conducted in a room without clocks or calendars, and looking at a personal time piece during the assessment is not permitted. The same investigator, a trained geropsychiatrist (JH), performed all cognitive assessments.

For the purpose of the present study we examined the medical files of all subjects fully evaluated at the MCI clinic during the period December 2004 to June 2006. For each participant the following data were registered: demographic (age, gender, years of education), cognitive and psychiatric diagnoses/features, scores on the MMSE (of the second interview), the CDT-MIA (of the second interview), the CAMCOG-R total, the 293

KSCA-R total, the Lawton and Brody IADL scale, and the number of psychotropic medications taken by each subject. Three performance time measures were established: actual performance time (objectively verified), subjective estimation of performance time, and accuracy of estimation of performance time. The last was expressed in absolute value, that is, the absolute differences between actual performance time and estimated performance time (higher scores on this variable represent greater inaccuracy). The study protocol was approved by the local Helsinki committee.

Analysis. We first conducted descriptive analyses, evaluating group (dementia, MCI, NCI), differences on demographic (age, sex, education), cognitive (MMSE, CDTMIA, CAMCOG-R, KSCA-R), functional (IADL) and psychiatric status (the presence of psychiatric diagnosis/ features, of depressive disorders/features, number of psychiatric medication taken). Next, we evaluated group differences on actual performance time, estimated performance time, and absolute accuracy of estimation of performance time, conducting three separate One Way Analysis of Variance (ANOVAs), with the time measures as outcome variables and cognitive diagnosis (dementia, MCI, NCI) as the independent variable. Finally, three separate regression models were constructed with actual performance time, estimated performance time and accuracy of estimation of performance time, as the dependent variables, and the demographic and clinical variables as predictors. In an additional sensitivity analysis, we evaluated the presence of depressive disorder/features diagnosis instead of the more general presence or absence of a psychiatric diagnosis/features in order to see whether a formal diagnosis of depression was related to the outcome variables. We did not evaluate other psychiatric diagnoses (e.g., anxiety disorders) separately because of the limited sample size.

Results A total of 102 consecutive persons with suspected MCI completed the entire assessment. Final cognitive diagnoses were: dementia – 49 individuals (48%; of which 63% with Alzheimer’s type, 8% with vascular dementia, 10% with mixed type, 19% with other type dementia), MCI – 36 individuals (35%) and no cognitive impairment (NCI) – 17 individuals (17%). Psychiatric diagnoses and predominant features were found in 54 individuals (52.9%) of the sample: 22 (44.9%) in the dementia group, 22 (61.1%) in MCI, and 10 (58.8%) in NCI. Dementia

Jeremia Heinik and Liat Ayalon

with depressive features prevailed (63.6%) in the dementia group followed by dementia with behavioral disturbances (22.7%) and with delusions (13.6%). In the MCI group, mixed anxiety-depressive disorder (27.2%), major depressive disorder (22.7%) and minor depressive disorder (22.7%) were the prevailing psychiatric diagnoses.

The other psychiatric diagnoses in this group were: dysthymic disorder (9%), bipolar disorder (4.5%), post-traumatic stress disorder (4.5%), anxiety disorder not otherwise specified (4.5%) and adjustment disorder (4.5%).

In the NCI group, adjustment disorders prevailed (50%) followed by major depressive disorder (30%). The other psychiatric diagnoses in this group were: post-traumatic stress disorder (10%), generalized anxiety disorder (10%), and anxiety disorder not otherwise specified (10%) (one person had two psychiatric diagnoses).

Table 1 shows that there were significant group differences (dementia, MCI, NCI) in age, all cognitive measures used, and functional impairment. However, no between-group differences were observed in gender, years of education, the presence of psychiatric diagnosis/features, presence of depressive disorders/features or number of psychotropic medications taken.

There were no significant between-group differences on actual performance time, estimated performance

time, and accuracy of estimation of performance time in absolute values across the cognitive diagnoses.

None of the variables evaluated in the present study predicted actual performance time (R^2=.06, p=.90) or estimated performance time (R^2=.07, p=.82).

With regard to absolute accuracy of estimation time, age was the only significant predictor, with higher age being associated with poorer accuracy (B= .927, SE =.27, p=.005) (R^2=.18, p=.13). Similar findings were obtained in a sensitivity analysis that evaluated depressive disorders/features diagnoses only (instead of overall psychiatric diagnoses) as a potential covariate of the various outcome variables.

Discussion We investigated self-estimation of performance time versus actual performance time in individuals with dementia, MCI and NCI seen at a specialized outpatient setting. Whereas on all cognitive and functional measures evaluated in the present study, the MCI group demonstrated intermediate performance between individuals with dementia and individuals with normal cognitive functioning, the time measures showed no variability across the three cognitive groups studied. Self-

Table 1. Demographic, Clinical and Time Measure Characteristics of the Sample Dementia (n=49)

MCI (n=36)

NCI (n=17)

P value

Age

77.45(6.29)

75.28(6.44)

72.71(4.59)

.02

Male (%)

23(46.9)

19(52.8)

7(41.2)

.71

Years of education

11.35(3.43)

12.03(3.00)

13.59(3.28)

.06

MMSE (range 0-30)

24.81(1.79)

27.56(1.71)

28.12(1.36)

<.001

CDT-MIA total (range 0-33)

20.07(4.47)

24.52(2.99)

27.50(2.53)

<.001

CAMCOG-R total (range 0-105)

76.31(7.95)

86.25(5.37)

93.41(5.03)

<.001

KSCA-R total (range 0-125)

87.24(8.03)

98.82(5.47)

105.62(5.51)

<.001

IADL scale (range 0-8)

5.44(1.89)

6.39(1.88)

7.06(1.24)

.003

Presence of psychiatric diagnosis/features (%)

22(44.9)

22(61.1)

10(58.8)

.29

Presence of depressive disorder/features (%)

14(28.6)

19(52.8)

8(47.1)

.06

Number of psychotropic medications

.71(.81)

1.13(1.04)

.76(.90)

.09

Actual performance time (minutes)

43.95(6.72)

43.72(13.04)

39.33(5.02)

.23

Estimation of performance time (minutes)

42.00(15.96)

40.00(18.24)

46.66(16.67)

.45

Accuracy of estimation in absolute value (minutes)

12.75(8.74)

14.33(16.82)

11.60(13.57)

.76

MCI – mild cognitive impairment; NCI-no cognitive impairment; MMSE – Mini-Mental State Examination; CDT-MIA – Clock Drawing Test Modified and Integrated Approach; CAMCOG-R – Cambridge Cognitive Examination-Revised; KSCA-R – Kingston Standardized Cognitive AssessmentRevised; IADL – Instrumental Activities of Daily Living

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Self-estimation of performance time versus actual performance time in older adults

estimation of performance time versus actual performance time (in absolute values) was not impaired in the dementia group or in the MCI group when compared to participants with normal cognitive functioning. Hence, estimation of performance time is largely preserved even among those with mild dementia. Furthermore, estimation of performance time is not associated with other demographic, psychiatric or functional variables, with the exception of age. These findings are in accordance with Grewal (12), that individuals with mild dementia of the Alzheimer’s type (DAT) did not show significant loss of awareness of time relative to individuals with moderate DAT. Findings also are consistent with Levy and Dreier (15) who found no significant differences between individuals with possible Alzheimer’s disease and individuals with normal cognitive functioning in the estimation of the passage of time.

There have been conflicting reports about the influence of depression and other pathologic emotions on the accuracy of judgement of time intervals. While some authors reported a detrimental effect of psychiatric diagnosis (29, 30), others found no evidence for the effect of psychiatric diagnosis on the estimation of the passage of time (15, 31). Our findings concur with the latter and demonstrate that there was no difference in estimation of performance time in individuals with psychiatric diagnosis versus individuals with no psychiatric diagnosis. This tendency was maintained even when only subjects with depressive disorders/features, considered to more specifically influence estimation of performance time (29, 30), were examined.

We hypothesize that estimation of performance time in early stages of cognitive impairment such as MCI and mild dementia depends less on the cognitive domains that are known to be impaired in these syndromes, such as memory and executive function, and more on other domains, such as time judgement, internal clock or the automatic processes of socialized and intuitive time, which are relatively spared at the early stages of cognitive impairment (6-9, 15).

This study does not go without limitations. First, the number of participants in the total sample and in each diagnostic group was relatively small, consisting of those who completed the entire evaluation. Hence, a larger sample is needed to affirm negative results. Second, the NCI control group was composed of psycho-geriatric clinic referrals with cognitive complaints. This is not a healthy control group. We may assume that among some participants subjective cognitive complaints, 295

labeled “subjective cognitive impairment” (32), may be a harbinger of dementia (32, 33). In addition, 52.9% of the sample received a psychiatric diagnosis, mostly depression, that although mild (25) might still influence time estimation if studied with rating scales designed specifically to quantify the severity of depression, rather than relying solely on a formal diagnosis. Third, the etiology of dementia in our sample is heterogeneous. It is possible that dementia etiology is related to estimation of performance time. For example, individuals with vascular dementia (“arteriosclerotic” dementia, MultiInfarct Dementia) are notoriously claimed to have a relatively preserved personality and judgement compared with individuals with Alzheimer’s disease (34). Hence, further research examining groups of homogenous dementia etiology is warranted.

Nevertheless, the present finding demonstrates that time estimation cannot be used to distinguish individuals with normal cognitive functioning from individuals with MCI or individuals with mild dementia. Findings also suggest that the ability to estimate the passage of time is largely preserved even in those individuals with mild dementia. These preserved temporal skills can be used by caregivers and clinicians therapeutically to enhance feelings of competence among patients (15).

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Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Male genital self-mutilation as a psychotic Solution Erol Ozan, MD, Erdem Deveci, MD, Meltem Oral, LCSW, Esra Yazıcı, MD, and İsmet Kırpınar, MD Ataturk University, School of Medicine, Department of Psychiatry, Erzurum, Turkey

ABSTRACT Background: Male genital self-mutilation (GSM) is a rare, but serious phenomenon. Some of the risk factors for this act are: presence of religious delusions, command hallucinations, low self-esteem and feelings of guilt associated with sexual offences. Other risk factors include failures in the male role, problems in the early developmental period, such as experiencing difficulties in male identification and persistence of incestuous desires; depression and having a history of GSM. The eponym Klingsor Syndrome, which involves the presence of religious delusions, is proposed for GSM. Data section: Four male GSM cases are presented: Case 1 and Case 2 were diagnosed with schizophrenia, Case 3 with schizophrenia and depressive disorder, not otherwise specified, and Case 4 with bipolar depression with psychotic features.

Discussion: All definite and probable motives and cultural aspects for their GSM are discussed.

Atonement is proposed as a new concept in formulating religiously themed psychotic male GSM.

Introduction Behaviors that involve damaging the body tissues without intending suicide are defined as self-mutilation (1, 2). Most common types of self-mutilation are damaging the skin, the eyes or the genitals (1). It is proposed as a fast self-aid action, providing temporary relief from inner tension and confusion (3), depersonalization, feelings of guilt, negative feelings of being rejected, hallucinations and preoccupation with sexual matters (4).

Even if the patient attains temporary relief after the self-

mutilation behavior, pain is said not to be perceived.

Although patients suffering from a psychotic disorder, especially schizophrenia, show more tolerance to pain than healthy people, the sense of pain is known not to have completely disappeared (5).

Bizarre acts aiming to wound oneself, like genital self-mutilation (GSM), are generally related to psychosis (6-8). GSM is usually carried out in a state of clear consciousness, often after a period of planning. It is seen more frequently in males than females (9). Male GSM was recorded in Greek mythology: the God Eshmun castrated himself to evade the erotic advances of the Goddess Astronae; therefore auto castration came to be known as the Eshmun Complex (10). Greilsheimer and Groves (6) identified three groups of men at risk for GSM: 1) patients suffering from a psychotic disorder, 2) transsexuals and patients with personality disorder, 3) those under socio-cultural influence, including patients suffering from schizophrenia with religious delusions and those who consider themselves failures in the male role.

Considerable overlap among these three groups complicates the identification of individual potential patients.

The major psychotic motivations for GSM include delusions often religious and command hallucinations that are seen in paranoid schizophrenia and affective psychosis (11-14). Other predisposing factors of GSM include severe deprivation in childhood, pathological feelings of guilt associated with aberrant sexual conduct and conflicts, suicide attempts or other self-destructive behaviors in the history, social withdrawal and being depressed (5, 9, 15, 16). However, the motives for GSM are usually mixed (7, 8). It is estimated that <10% of self-mutilators intend to kill themselves (17). A general belief is that amputation of the penis is fatal (7), and GSM among the Chinese is suggested to be considered a suicidal attempt (18).

Address for Correspondence: Erol Ozan, Assistant Professor, MD, Ataturk University School of Medicine, Department of Psychiatry, 25240 Erzurum, Turkey erolozan@gmail.com

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Blacker and Wong (19) identified six risk factors for male GSM: 1) absence of a competent male figure for identification during the early developmental period, 2) over-controlling mothers who encouraged their sons’ masochistic behaviors, 3) pathological feminine behaviors of the male child, 4) repudiation of body image (especially the penis), 5) unresolved sexual conflicts, 6) anxiety and feelings of guilt often relieved by GSM. Psychoanalytically, self-mutilating behaviors are explained as persistence of infantile sexuality patterns and castration anxiety as a result of unresolved Oedipal conflicts (20), or as self-punishment, focal suicide and aggression directed to oneself (21). The clinical application of these factors to a potential or actual patient is cumbersome due to the fact that the same factors can exist in those who do not resort to GSM. These predictors help only to identify the patients at risk retrospectively (12).

The term Klingsor Syndrome has been suggested for GSM associated with religious delusions (22). The name Klingsor was based on a fictitious character in Wagner’s opera, Parsifal: Klingsor was a magician who wanted to be accepted as a Knight of the Grail, a religious brotherhood. He castrated himself because of his inability to remain chaste in order to be accepted into this brotherhood (5). Schweitzer (9) has suggested expanding the definition of this syndrome to include GSM resulting from all delusional syndromes.

During GSM, varying amounts of tissues get amputated. The most severe is the total amputation of the penis, scrotum and testes (23, 24), which occurs in <10% of the GSM cases (17). A review of 110 male GSM cases revealed that guilt feelings associated with sexual conflicts were the most significant factor leading to selfmutilation in a state of psychosis. The GSM acts of these cases were also related to psychotic religious experiences that were often the direct motives. Self-mutilators with sexual conflicts and guilt feelings were more likely to injure themselves more severely than those without (16). Erdur et al. (25) reported on a male patient suffering from schizophrenia, who mutilated his tongue two years after the GSM. In both acts, the patient had used local anesthesia.

While most patients show no interest in their amputated parts and dispose of them immediately, some patients who have sought help are reported to have preserved the amputated organs (6). A few of the patients, who did not want the amputated parts retrieved or reattached flushed them away or ritually burned them

(10). Complications from GSM vary with the extent of the injury inflicted. A common complication is hemorrhage, which may be fatal (13).

Psychotic and non-psychotic GSM is well recognized in males but not in females, even though the incidence of self-mutilating behavior has been estimated to be higher in females. A possible explanation is that castration is more dramatic than cutting and therefore tends to be more frequently reported. Although most reported cases of female GSM involve self-induced abortions or insertion of a foreign object into the body, one report describes a female who masturbated with a pair of scissors. It has also been suggested that female habitual self-mutilators may have a higher incidence of GSM. Female GSM may present as unexplained vaginal bleeding. Although self-mutilation is reported to be common in personality disorders, the use of sharp objects inserted into the vagina may suggest a more severe psychopathology (26).

Case 1 A 26-year-old male patient, who amputated his penis after self-administered local anesthesia, is presented.

The patient was taken unconscious to hospital due to hemorrhage. After receiving a blood transfusion and uretro-cutaneous anastomosis, he was transferred to the psychiatry clinic. Positive symptoms remitted with clozapine 250 mg/day treatment. After remission, the patient began insisting on a penile prosthesis.

The patient’s parents were reported to have divorced when he was 10 months old. He complained about his father’s apathy and unloving behavior and his mother’s extreme protective and watchful behavior during his childhood and adolescence. His adult circle consisted of very religious people. When the patient was 20 persecutory, referential, bizarre and grandiose delusions appeared. The delusions consisted of a religious theme where the patient thought that he was Jesus Christ and his mental energy covered the cosmos. The patient indicated that other people’s energies got inside his body and caused distress. The patient also had visual hallucinations which he described as colorful light rings around women and he interpreted these light rings as his own sperm. He believed his sperms died when the light rings disappeared by exploding. He explained his distress as “I was fighting to keep my sperm alive.” He saw light rays coming down from the sky to the earth and believed that girls would come via these rays and 298

MALE GENITAL SELF-MUTILATION AS A PSYCHOTIC SOLUTION

would have sex with him, and they would together float into space. His symptoms subsided with prescribed drugs, but he was apparently noncompliant with his medication. The patient reported that a few years later his anxiety gradually intensified, and guilt and sinful delusions reappeared. He believed that he was the Antichrist this time and had auditory hallucinations such as “the Antichrist entered the mosque.” He believed that the devil deceived him, he attributed a partner to God, and so committed a great sin, and due to this sin, God punished him with intense anxiety. He started to recite the “azan” (the Islamic call to prayer) aloud in the house. Fearing that he had lost his faith, he entered a mosque by breaking a window and performed the ritual prayers in his bloody clothes. He was taken to a psychiatric hospital by the police, but after being discharged he was again non-compliant with his medication. He concluded that if he shed his “dirty blood,” his sins would be forgiven. He reported going to the Red Crescent (equivalent to the Red Cross) to donate his blood, but he was refused because of aspirin use. He then tried to cut his abdominal skin to shed his blood, but was not able to bear the pain. After several attempts to shed his blood, the patient then reported buying prilocaine 20 mg/ml flacon and an injector. Under the influence of intense guilt and delusions of sin and command hallucinations like “Shed blood, get rid of the dirt and the sins,” he reported injecting Prilocaine under the skin of his penis and cutting his penis off using a razor blade. He said he wrapped the amputated tissue in a handkerchief. The patient described his final act in his own words as “after that, I buried it somewhere by wrapping a shroud around it.”

Case 2 A 29-year-old male patient, who had amputated one of his testicles with a knife and had thrown it into the toilet, is presented. He was taken to an emergency room immediately and then referred to an inpatient urology clinic. After completion of treatment in urology, he was referred to the psychiatry clinic, where he was diagnosed with schizophrenia and treated with haloperidol.

The patient had been reportedly socially withdrawn, introverted and shy during his childhood and adolescent years. He had become increasingly interested in religion and magic in early adulthood. He reported having pre-psychotic experiences like déjà vu and jamais vu. His success in medical school decreased gradually 299

and he started failing his classes. He reported falling in love with a girl when he was 28. He proposed to the girl but was rejected. Meanwhile, he was thrown out of medical school and returned to his family. He became socially withdrawn and was constantly dreaming about the girl he had fallen in love with. After a long prodromal period, religious delusions and hallucinations appeared. The patient believed that the Devil caused him to have sexual dreams about the girl he loved, and he heard voices such as “you are the devil.” He mentioned feeling guilty and sinful, and thought that God would punish him. He concluded that his sexual organs and desires were the only reason for being thrown out of medical school and rejected by the girl he loved. He believed if he could rid himself of his genitals, he would rid himself of his sins too. Six months after the beginning of his delusions and hallucinations, he took a knife and went to the bathroom where he skinned his scrotum, separated and cut off one of his testicles, despite the pain it caused, and threw it into the toilet.

Case 3 A 55-year-old married male patient, who had surgery in a urology clinic after cutting his penis off with a knife, is presented. He was then referred to inpatient psychiatry where he was diagnosed with paranoid schizophrenia and depressive disorder not otherwise specified. The patient was treated with haloperidol and an SSRI. Apparently, when the patient was 37, he had started experiencing delusions of jealousy and thought insertion. The patient reported that a very powerful creature inserted a thought into his mind that his wife and his closest friend were having an affair. He then began to follow his wife even at night. Because of his jealous delusions, he moved to another city with his family.

He received no treatment while his jealous delusions, talking to self and angry behavior continued. Over the last six years, the patient started having depressed feelings with guilt and delusions of sin. He reported feeling intense grief, unwillingness, incapability, and had insomnia and loss of appetite as well. He complained that no one loved him; everyone appeared to be an enemy and that he felt worthless and God would send him to hell because of his sins. He reported that he had sold a few of his cars and had given all the money to the poor for the purpose of atonement. The patient said that the same powerful creature ordered him to donate his eyes, and for this purpose he went to the hospital. But

Erol Ozan et al.

he was told that this was not possible. The patient also indicated that he ran away from his home five times, sometimes returned on his own and sometimes was brought back by the police. In the last two years, the patient reported having erectile dysfunction as well.

He said he started sleeping apart from his wife. He was taken to a psychiatrist but was non-compliant with the antidepressant and antipsychotic medication prescribed.

The patient indicated that 20 days prior to his GSM he was preoccupied with the thought of cutting his penis off. He said that this thought was put into his mind by the same powerful creature. Two weeks before the GSM, the patient said he had left home without informing anyone, aiming at performing a pilgrimage. He said he traveled through many other distant cities on foot. He then decided to use the bathroom of a hospital to cut his penis off. He said he preferred a hospital bathroom to perform this act where help would be more available if bleeding would not stop. Despite the pain, he said he cut off his penis and threw it into the toilet and flushed it away. During the first psychiatric interview with him, he said that the same powerful creature was now ordering him to cut his arm off.

Case 4 A 38-year-old male patient, who was treated in the emergency room and referred to a urology clinic after GSM, is presented. The consultant psychiatrist ordered lithium 900 mg/day, sertraline 50 mg/day and risperidone 3 mg/ day. He was fully remitted at the first month; he was still in remission four months later.

The patient was a devout person during the premorbid period. When he was 31 years old, he had his first psychotic depressive episode. He was treated in an inpatient psychiatry clinic and within one month he was fully remitted. After discharge, he was apparently non-compliant with his medications. At the end of six months of full remission, the patient had his first manic episode. During the manic episode, he started using obscene words to women and touching them inappropriately. After being treated as an inpatient for one month, manic symptoms fully remitted. Full remission continued for almost 2.5 years despite the patient’s non-compliance with medication. The second manic episode occurred when the patient was 34 years old. He was treated with haloperidol and biperiden, and again was fully remitted within one month. However, the patient was non-compliant with his medications again. After almost two years of full remis-

sion, his third manic episode occurred at age 36. Full remission was achieved again within one month, with haloperidol and biperidene treatment. The patient said he used no medication and was symptom-free for 2.5 years.

Nevertheless, after the 2.5 year period, the patient started having depressive feelings along with mood congruent psychotic symptoms which then led to the GSM. Because of the patient’s conduct during his manic episode, such as inappropriate sexual advances towards women, his feelings of guilt and sin rose to a delusional level. The patient also had command hallucinations, like “you burned the Holy Qur’an; you are sinful, you will go to hell; butcher your children, amputate your penis.”

He left home secretly early one morning, taking a razor blade and went to the countryside. Despite the intense pain, he said he amputated 2/3 of the distal part of his penis. He then reported throwing away the amputated tissue. Immediately after the GSM, he cut an edge of his tongue. When he was asked why he cut his tongue, the patient indicated that he was criticized several times by other people but he couldn’t talk or defend himself and he thought his tongue was useless, and so he cut it.

He was found by his wife and taken to hospital. After the first intervention, he was hospitalized in the urology clinic. During the first psychiatric interview, he said he was afraid that he might butcher his children if he went back home.

Discussion In all of the cases, intense guilt and delusions of sin were definite motives (9, 16) which match well with Klingsor Syndrome (9, 22). Cases 1 and 4 also had command hallucinations (1, 14). All cases were preoccupied with sexual matters (3, 4). Case 1 had visual hallucinations and bizarre delusions with a sexual theme. Case 2 considered his sexual desires sinful and aimed at getting rid of them (9). In Case 3, because of his erectile dysfunction and failure in the male role (6, 21), he felt guilty and also had delusions of sin. Case 4 had guilt and delusions of sin associated with his aberrant sexual conduct (15). We may say that GSM transiently saved these patients from the negative feelings that were brought about by preoccupation with sexual matters (4).

In all of the cases, it is obvious that none of the patients intended suicide (1, 2). Case 1 had repeated self harming behaviors (8) aiming only at shedding his “dirty blood.” The patient wanted to donate his blood and then tried shedding his “dirty blood” by cutting 300

MALE GENITAL SELF-MUTILATION AS A PSYCHOTIC SOLUTION

his skin. Finally, for the same purpose, he sacrificed his penis. Furthermore, he administered local anesthesia before his act (25). This supports the information that the sense of pain does not disappear completely in patients suffering from schizophrenia (5). The GSM act might have rapidly but temporarily saved him from the feelings of guilt and delusions of sin, and being preoccupied with sexual matters (3, 4). Likewise, Case 2 considered his sexual organs and desires to be the only reason for the loss of his educational rights and the girl he loved. He sacrificed only one of his testicles meticulously which shows that he had no intent to commit suicide. The GSM act might have rapidly but temporarily allowed him to get rid of the negative feelings of being rejected by the girl he loved and constantly dealing with sexual matters (4). Case 3 had preferred the hospital for his GSM, planning to receive urgent intervention in case of excessive bleeding. He also was a patient at risk for repeated self-harm (8). He had delusions of thought insertion, ordering him to cut off his arm. Case 4 had auditory hallucinations commanding him to butcher his children and to amputate his penis. Just after the GSM act, the patient also cut his tongue.

The motives for GSM are multi-factorial (7, 8). Aside from the major motives, we can offer some probable motives that might have contributed to the GSM act.

Early developmental problems and a premorbid lifestyle, like being a devout person, may be mentioned.

Case 1 had a close relationship with his mother and had no competent male figure for identification during his childhood (14, 19, 21). He might have failed in repressing incestuous desires. Thus, guilt feelings and belief that he deserved punishment might have intensified in this patient. Also, an over-controlling mother might have prompted him to engage in masochistic behavior (19). In addition, identification with a devout adult circle during his childhood might have strengthened the guilt and sinful beliefs in the patient and therefore caused him to seek punishment (9, 14, 21). The guilt and sinful beliefs might have turned into delusions and hallucinations during the psychotic attack which might have directed the patient to perform GSM (21). Case 2 was socially withdrawn during GSM (5). In Case 3, the major motive for GSM was the patient’s thought that he had failed in his male role (6) which caused shame and guilt feelings (27). Delusions of thought insertion also seemed to have contributed to the GSM act.

Patients’ attitudes concerning their amputated parts show that none of them could return to reality, even 301

after the action. Cases 2, 3 and 4 showed no interest in the amputated organs and flushed them away. Case 1 stated that he enshrouded and buried his amputated organ; instead of saving the amputated tissue, he buried it according to his religious rituals (10).

It appears that the phenomenon of genital self-mutilation endorsed by religious beliefs is not specific to Islam.

Zislin et al. (28) also discusses GSM in the context of religious belief: the Jerusalem Syndrome. This syndrome is a well-defined example, named for a group of mental phenomena involving the presence of religiously themed obsessive ideas, delusions or other psychosis-like experiences triggered by, or leading to, a visit to the city of Jerusalem. It is not endemic to one single religion or denomination, but has affected Jews and Christians of many different backgrounds. The best known, although not the most prevalent manifestation of the Jerusalem Syndrome, is the phenomenon whereby a person who seems previously balanced and devoid of any signs of psychopathology becomes psychotic after arriving in Jerusalem. The psychosis is characterized by an intense religious theme and typically resolves to full recovery after a few weeks, or after being removed from the area (29).

We propose that GSM in the cases mentioned above were performed for “atonement” for perceived sins. In the Encyclopaedia Britannica (30), atonement is defined as “the process by which a person removes obstacles to his reconciliation with God. It is a recurring theme in the history of religion and theology. Rituals of expiation and satisfaction appear in most religions, whether primitive or developed, as the means by which the religious person reestablishes or strengthens his relation to the holy or divine. Atonement is often attached to sacrifice, both of which often connect ritual cleanliness with moral purity and religious acceptability.”

In Christianity, the Scriptures emphasize the shedding of blood and shaming and mutilation of the body in order to avoid or atone for sin (31).

“According to the law almost everything is purified by the blood, and without the shedding of blood there is no forgiveness.” (Hebrews 9:22) “If your hand or foot is your undoing, cut it off and throw it from you! Better to enter life maimed or crippled than be thrown with two hands or two feet into the endless fire. If your eye is your downfall, gouge it out and cast it from you! Better to enter life with one eye than be thrown with both into Gehenna.” (Matthew 18:7-9) However, in Islam and Judaism, physical suffering and mutilation does not appear to be the primary means of

Erol Ozan et al.

atonement. In Islam, depending on the sin, atonement can range from repentance and compensation of the sin if possible, feeding the poor, freeing slaves to even stoning to death or cutting off hands. Acknowledging one’s wrongdoing, apologizing, and repenting in front of the wronged person and in front of God can make possible forgiveness from the wronged person and also from God. Muslims are encouraged to forgive because God is the most forgiving. Similar to Islam, Judaism also teaches atonement between individual persons. If a person harms another but personally apologizes and tries to rectify the wrong done, then the wronged person is religiously required to grant forgiveness for atonement (32). We can suggest that in Anatolia, the concept of atonement might have been influenced more by the ancient Christian and Roman cultures that existed in the area than by the Islamic culture. This may be why the behaviors of the cases mentioned above, such as shedding blood and selfmutilation, are more similar to the Christian concept of atonement than the Islamic concept.

The concept of atonement is not specific only to religion. In most societies, punishment such as beating, amputation of limbs and tongues, castration, etc., can also be a means to achieve atonement. The discipline of children still involves physical punishment in many societies. There is also the notion that through punishment atonement can be achieved. A person who is physically punished in childhood learns that one must physically suffer in order to atone for wrongdoings.

The idea that wrongdoing deserves and can be atoned through physical punishment is highly significant for the understanding of self-injury among individuals in emotional distress (31).

Although physical suffering and mutilation does not seem to be the primary means of atonement in Islam, in a state of active psychosis, the perception of atonement seems to exceed cultural boundaries. In Case 1, hallucinations and delusions ordered the patient to shed his “dirty blood” in order to be forgiven. The patient sacrificed his penis to shed his blood. In Case 2, the patient’s sexual desires led to guilt and delusions of sin. In Case 3, the patient sold his property and donated the proceeds to the poor and the inserted thoughts directed him to donate his eye for transplantation. In Case 4, auditory hallucinations commanding the patient to butcher his children resemble the historical roots of ritual sacrifice.

All of these acts appear with the aim of strengthening the patient’s relation to the holy. With failure in the male role being the major motive, atonement might be

another important motive for this patient’s GSM act. We can assume that, as a psychotic solution, the patients sacrificed their genitals or donated their belongings in order to atone for their sins and to feel purified.

Auto castration may be a psychotic solution. Patients having problems with the early developmental period as mentioned above and with a self-mutilation history as well as experiencing religious delusions, command hallucinations to self-mutilate and who are non-compliant with treatment are at greater risk for GSM. Therefore, they need special attention and may need to be hospitalized. It is suggested that the examining psychiatrist needs to be aware of the cultural background of the patient (33). Investigating probable plans for sacrifice related to atonement might be helpful in predicting and preventing self-mutilation acts, especially GSM. Psychotropic medication must be the first line intervention in both treating the active psychotic episode and in preventing recurrences. An important contributing and motivating factor for male GSM appears to be sexual dysfunction, so clinicians may prefer medications causing fewer sexual side effects. Furthermore, during the remission period, cognitive and behavioral techniques may be helpful for replacing thoughts of sacrifice with harmless alternatives for atonement.

Note All four patients gave a written informed consent for the publication of the manuscript under hidden identities.

References 1. Feldman MD. The challenge of self-mutilation: A review. Compr Psychiatry 1988; 29: 252-269.

2. Dallam SJ. The identification and management of self-mutilating patients in primary care. Nurse Pract 1997; 22: 159-165.

3. Cavanaugh RM. Self-mutilation as a manifestation of sexual abuse in adolescent girls. J Pediatr Adolesc Gynecol 2002; 15: 97-100.

4. Favazza AR. The coming age of self-mutilation. J Nerv Ment Dis 1998; 186:259-268.

5. Siddiquee RA, Deshpande S. A case of genital self-mutilation in a patient with psychosis. German J Psychiatry 2007; 10: 25-28.

6. Greilsheimer H, Groves JE. Male genital self-mutilation. Arch Gen Psychiatry 1979; 36: 441-446.

7. Conacher GN, Villeneuve D, Kane G. Penile self mutilation presenting as rational attempted suicide. Can J Psychiatry 1991; 36: 682-685.

8. Aboseif S, Gomez R, McAninch JW. Genital self mutilation. J Urology 1993; 150: 1143.

9. Schweitzer I. Genital self-mutilation and Klingsor Syndrome. Aust N Z J Psychiatry 1990; 24: 566-569.

10. Kushner AW. Two cases of auto-castration due to religious delusions. Br J Med Psychol 1967; 40: 293-298.

11. Hall DC, Lawson BZ, Wilson LG. Command hallucinations and selfamputation of the penis and hand during a first psychotic break. J Clin

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Psychiatry 1981; 42: 322-324.

12. Waugh AC. Auto castration and biblical delusions in schizophrenia. Br J Psychiatry 1986; 149: 656-658.

13. Koops E, Puschel K. Self-mutilation and autophagia. Arch Fur Kriminologie 1990; 186: 29-36.

14. Martin T, Gattaz WF. Psychiatric aspects of male genital self mutilation.

Psychopathology 1991; 24: 170-178.

15. Shimizu A, Mizuta I. Male genital self-mutilation: A case report. Br J Med Psychol 1995; 68: 187-189.

16. Nakaya M. On background factors of male genital self-mutilation.

Psychopathology 1996; 29: 242-248.

17. Romilly CS, Isaac MT. Male genital self-mutilation. Br J Hosp Med 1996; 55: 427-431.

18. Yang JGH, Bullard MJ. Failed suicide or successful male genital selfamputation? Letter. Am J Psychiatry 1993; 150: 350-351.

19. Blacker KH, Wong N. Four cases of auto castration. Arch Gen Psychiatry 1963; 8: 169-176.

20. Beilin LM, Grueneberg J. Genital self-mutilations by mental patients. J Urol 1948; 59: 635-641.

21. Sudarshan CY, Rao KN, Santosh SV. Genital self-mutilation in depression: A case report. Indian J Psychiatry 2002; 44: 297-300.

22. Ames D. Auto castration and biblical delusions in schizophrenia. Br J Psychiatry 1986; 150: 407.

23. Kenyon HR, Hyman RM. Total auto emasculation. Report of three

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cases. JAMA 1953; 151: 207-210.

24. Abbou CC, Servant M, Bonnet F, Chopin D, Alasseur F, Grellet M and Auvert J. Reimplantation of the penis and both testicles after complete auto castration. Review of the literature about a case (authorâ&#x20AC;&#x2122;s transl.).

Chirurgie 1979; 105:354-357.

25. Erdur B, Turkcuer I, Herken H. An unusual form of self-mutilation: Tongue amputation with local anesthesia. Letter. Am J Emerg Med 2006; 24:625-628.

26. Alao AO, Yolles JC, Huslander W. Female genital self-mutilation.

Psychiatry Serv 1999; 50: 971.

27. GĂśssler R, Vesely C, Friedrich MH. Auto castration of a young schizophrenic man. Psychiatry Prax 2007; 29:214-217.

28. Zislin J, Katz G, Strauss Z, Teitelbaum A, Durst R. Male genital selfmutilation in the context of religious belief: The Jerusalem Syndrome.

Transcultural Psychiatry 2002; 39: 257-264.

29. Bar-el Y, Durst R, Katz G, Zislin J, Strauss Z, Knobler HY. Jerusalem Syndrome. Br J Psychiatry 2000; 176, 86-90.

30. Encyclopedia Britannica: http://www.britannica.com/EBchecked/ topic/41872/atonement 31. Babiker G, Arnold L. The language of injury: Comprehending selfmutilation. British Psychological Society Books, 1997: p. 26.

32. New World Encyclopedia: http://www.newworldencyclopedia.org/ entry/Atonement 33. Greenberg D, Witztum E, Buchbinder JT. Mysticism and psychosis: The fate of Ben Zoma. Br J Med Psychol 1992; 65: 223-225.

Isr J Psychiatry Relat Sci - Vol 47 - No.4 (2010)

Yaacov Lerner and Nelly Zilber

Predictors of Cumulative Length of Psychiatric Inpatient Stay Over One Year: A National Case Register Study Yaacov Lerner, MD, and Nelly Zilber, D ès Sc The Falk Institute for Mental Health Studies, Jerusalem, Israel

Introduction

ABSTRACT 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 sixmonth period in Israel were recorded and followedup 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

Address for Correspondence:

During the last decades, deinstitutionalization has led to impressive changes in the use of psychiatric services all over the western world (1). Length of stay (LOS) in psychiatric hospitals has decreased dramatically (2), but some authors have claimed that readmission occurs consequently earlier (2-5). Other studies have not confirmed such a relationship (6-9). Anyhow, no definitive conclusion can be reached, since most studies are based on samples restricted to data of one hospital (5-9), or one insurance company (2-3). One study used a large population-based data set (4), but, even in this study, admissiondata could be linked, for each individual patient, only to one hospital. Patients, however, can be hospitalized in several hospitals and even in several districts. Moreover, it is uncertain whether the above-mentioned findings can be generalized across different districts or hospitals, as both patient population and service-related variables may differ between them. In addition, insurers, administrators and policy makers are interested not only in the predictors of the length of each hospitalization or of readmission rates, but also, more importantly, in the predictors of the cumulative inpatient stay in a given year (10).

The Israel Psychiatric Case Register, which includes both demographic and cumulative clinical and administrative information on all patients admitted to a psychiatric hospital in Israel since 1950 (11), makes it possible to aggregate all episodes of inpatient care for each patient in a nation-wide sample and thus to measure the total length of inpatient stay over a given period of time (“Cumulative LOS”). Moreover, it is important to note that, in Israel, the government is the sole insurer of psychiatric care. Hospitals receive prospective financing

Falk Institute, Kfar Shaul Hospital, Givat Shaul, Jerusalem 91060, Israel

falk1@012.net.il

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Predictors of Cumulative Length of Psychiatric Inpatient Stay Over One Year: A National Case Register Study

based on the number of beds and, thus, there are no insurance constraints on the length of stay.

The objective of the present study was to develop a prediction model for Cumulative LOS over one year.

We assume that after controlling for clinical and demographic variables, and given identical health insurance coverage (universal health coverage), differences among districts of hospitalization could be attributed to differences in the policy of the hospitals and to differences in cultural and demographic characteristics of the population.

Material and Methods Database

A data file (without any identifying information on patients) was extracted from the Israel National Case Register of Psychiatric Hospitalizations. It consisted of all patients with at least one admission to a psychiatric hospital in Israel, during a six-month period (January 1, - June 30, 2004). A one-year follow-up was performed for each patient since this first admission during the sixmonth sample period. Clinical and administrative data were extracted from the Israel National Psychiatric Case Register for all hospitalization episodes. All patients who died during the follow-up period were excluded.

Study variables

The dependent variable concerning hospitalization was the Cumulative LOS during one year from date of admission for each patient. The independent variables were: demographic data (gender, age, ethnic group), clinical data (ICD-10 diagnosis, existence of prior hospitalization, legal status at admission â&#x20AC;&#x201C; compulsory vs. voluntary) and district of hospitalization. The six districts differ in particular in their population characteristics. In 2005, the proportion of the Arabic population in the Northern district was 52%, in the Haifa district 24%, in the Jerusalem district 29%, compared to 8% in the Center, 1% in the Tel Aviv district and 13% in the Southern district (12). The Center and Tel Aviv districts were combined in the analysis, as hospitals in these two districts admit patients from both districts and they are also similar in their demographic breakdown.

The ICD-10 diagnoses were recoded into five diagnostic groups according to the main diagnosis: Disorders due to alcohol and drug abuse (F10-F19), schizophrenia and other functional psychoses (F20-F29), organic mental disorders (F00-F09), mood disorders (F30-F39) and neurotic and personality disorders (F40-F48 and 305

F60-F69). Only 1.3% of the cases did not belong to any of these categories and were not included in the analysis. Comorbidity was not considered because only the main diagnosis is recorded in the Case Register.

Data analysis

A survival (Kaplan-Meier) analysis of the outcome variable, Cumulative LOS, was performed for each patient.

Since the studied variable revealed a decaying exponential rather than a normal distribution (data available on request), this analysis was preferred to ANOVA procedures which assume that the dependent variable is normally distributed (cf. Stevens et al., 13). In addition, survival analysis has the advantage of including censored data. A Cox regression allowed constructing a multi-factorial prediction model for Cumulative LOS over one year. The independent variables related to the first episode of the follow-up. Data analyses were carried out using SPSS/PC version 14.0.

Results A total of 6,985 admitted patients were included in the study. About 58% were males, 84% were Jews; 63% of the patients were diagnosed as suffering from schizophrenia or other psychosis and 16% from an affective disorder; for 27% of the patients, the index admission was the first-inlife. The distribution of the patients by Cumulative LOS was the following: up to 30 days: 40%; 31-60 days: 22%; 61-90 days: 12%; 91-180 days: 16%; and > 180 days: 10%.

The median Cumulative LOS over one year was 43.0 days (95% CI: 41.5-44.5) and only 1.7% of the patients accumulated more than one year in hospital (Fig. 1). In Table 1, the results of the Cox regression for Cumulative LOS are given. The variables significantly predicting longer Cumulative LOS were: Jewish ethnicity, a diagnosis of schizophrenia or other functional psychosis, prior hospitalization, compulsory admission and hospitalization in the Northern and Jerusalem districts.

Discussion The main strength of the present study is an analysis based on cumulative national data from the Israel Psychiatric Case Register, which enables the measure of cumulative length of stay in hospital for the individual patients, with non-biased nationwide data.

Notwithstanding a study limitation (lack of information about individual patientsâ&#x20AC;&#x2122; clinical characteristics other

Yaacov Lerner and Nelly Zilber

Cumulative Proportion of Patients

Figure 1: Survival Function of Cumulative Length of Stay in Hospital (Cumulative LOS)

Table 1. Cox Regression Results for Predictor Variables of Cumulative LOS

1.0

N

Exp(B)

95% CI

Sig.

0.9

Age

0.73

Up to 65 years

5890

1.00

0.6

66 years or more

671

1.02

0.93-1.11

0.5

Gender

0.37

0.4

Male

3735

1.00

0.3

Female

2826

1.02

0.97-1.08

Ethnic Group

0.00

Jewish

5566

1.00

Arab

695

1.31

1.20-1.42

0.00

Unknown

300

1.07

0.95-1.21

0.26

Diagnosis

0.00

Schizophrenia or other psychosis

4153

1.00

Organic Disorder

304

1.33

1.18-1.50

0.00

Affective Disorder

1070

1.35

1.25-1.45

0.00

Neurotic and Personality Disorder

792

1.65

1.52-1.79

0.00

Drugs and Alcohol

238

1.70

1.48-1.94

0.00

Prior hospitalization

0.00

Yes

4848

1.00

0.8 0.7

0.2 0.1 00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Cumulative Time in Hospital (Days) * Proportion of patients for whom the cumulative length of stay in hospital is greater than the corresponding x.

than diagnosis, such as severity of pathology and type of treatment), the analysis provides relevant data for policymaking and service delivery decisions.

Lengthy Cumulative LOS was found to be associated with both prior hospitalization and diagnosis of psychosis - consistent with other studies (13, 14) - and with compulsory hospitalization, as reported also by Blais et al. (15). It was also associated with elderly age and Jewish ethnicity. The finding that Arabs cumulate shorter periods of hospitalization may be attributed to the structure of the typically larger Arab family (16), consisting of many members, with strong ties between them (17). Such families might be more ready than Jewish families to accept back home and support the psychiatric patient, who can therefore be released earlier. Moreover, Arabs have been reported to have lower rates of psychiatric admissions than Jews (2.65/1000 vs. 3.50 among males, 1.02 vs. 2.51 among females) (18). This is probably due to culture-related negative attitudes towards psychiatric hospitalization (19).

Lengthy Cumulative LOS was also found to be associated with hospitalization in the Northern and Jerusalem districts of Israel. This lengthy Cumulative LOS could be related to the lower admission rates in these two districts: 3.9 and 3.8/1000 adult population respectively vs. 4.7 in the Haifa districts, 4.6 in the combined Tel Aviv and Center districts and 4.4 in the Southern district (Internal report of the Mental Health Services, Department of Information and Evaluation, Ministry of Health, Israel, 2006). The fact that the admission rates in the Northern and Jerusalem districts are lower can be explained by their higher concentration of Arabs (12).

No

1713

1.43

1.35-1.52

Legal Status at Admission

0.00

Compulsory Admission

1551

1.00

Voluntary Admission

5010

1.12

1.05-1.19

Hospital District

0.00

North District

685

1.00

Haifa District

1236

1.17

1.06-1.28

0.00

Jerusalem District

694

1.04

0.93-1.15

0.52

Tel Aviv and Center District

3166

1.21

1.11-1.32

0.00

South District

780

1.55

1.39-1.72

0.00

Total

6561

Values of Exp(B) greater than 1 indicate increased incidence of what can be called “discharge” (if the cumulative stay in hospital is considered as one continuous hospitalization), i.e., shorter cumulative stay than in the reference group.

Since the bed ratio is similar for all districts (except the South, with a lower bed ratio), a lower admission rate enables hospital staff to keep patients longer in hospital.

This can explain the fact that the cumulative stay is the longest in the Northern and Jerusalem districts in spite 306

Predictors of Cumulative Length of Psychiatric Inpatient Stay Over One Year: A National Case Register Study

of the higher proportion of Arabs in the population.

Similar findings were reported by Harman et al. (20), who concluded that “unlike health services for other conditions, the variation in LOS for inpatient psychiatric treatment of depression or schizophrenia is quite dependent upon hospitals.” In view of the impending Reform of Psychiatric Services, which will make services more dependent on financial constraints, a further study implying a clinical follow-up of the patients is needed in order to examine how to balance between financial constraints and the true needs of the patients.

Conclusion Cumulative LOS of psychiatric patients, 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.

References 1. Fakhoury W, Priebe S. The process of deinstitutionalization: An international overview. Curr Opin Psychiatry 2002;15:187-192.

2. Figueroa R, Harman J, Engberg J. Use of claims data to examine the impact of length of inpatient psychiatric stay on readmission rate.

Psychiatr Serv 2004;55:560-565.

3. Wickizer TM, Lessler D. Do treatment restrictions imposed by utilization management increase the likelihood of readmission for psychiatric patients? Med Care 1998;36:844-850.

4. Heggestad T. Operating conditions of psychiatric hospitals and early readmission – effects of high patient turnover. Acta Psychiatr Scand 2001;103:196-202.

5. Heeren O, Dixon L, Gavirneni S, Regenold WT. The association between decreasing length of stay and readmission rate on a psychogeriatric unit.

Psychiatr Serv 2002;55:76-79.

307

6. Lieberman PB, Witala ST, Elliott B, McCormick S, Goyette SB. Decreasing length of stay: are there effects on outcomes of psychiatric hospitalization? Am J Psychiatry 1998;155:905-909.

7. Moran PW, Doerfler LA, Scherz J, Lish JD. Rehospitalization of psychiatric patients in a managed care environment. Ment Health Serv Res 2000;2:191-199.

8. Hodgson RE, Lewis M, Boardman AP. Prediction of readmission to acute psychiatric units. Soc Psychiatry Psychiatr Epidemiol 2001;36:304-309.

9. Thompson EE, Neighbors HW, Munday C, Trierweiler S. Length of stay, referral aftercare, and rehospitalization among psychiatric inpatients.

Psychiatr Serv 2003;54:1271-1276.

10. Kolbasovsky A, Reich L, Futterman R. Predicting future hospital utilization for mental health conditions. J Behav Health Serv Res 2007; 34:34-42.

11. Lichtenberg P, Kaplan Z, Grinshpoon A, Feldman D, Nahon D. The goals and limitations of Israel’s psychiatric case register. Psychiatr Serv 1999;50:1043-1048 12. Statistical Abstract of Israel 2005 No. 56. Central Bureau of Statistics.

Jerusalem, 2005.

13. Stevens A, Hammer K, Buchkremer G. A statistical model for length of psychiatric in-patient treatment and an analysis of contributing factors.

Acta Psychiatr Scand 2001;103:203-211.

14. Huntley DA, Cho DW, Christman J, Csernansky JG. Predicting length of stay in an acute psychiatric hospital. Psychiatr Serv 1998;49:10491053.

15. Blais MA, Matthews J, Lipkis-Orlando R, Lechner E, Jacobo M, Lincoln R, Gulliver C, Herman JB, Goodman AF. Predicting length of stay on an acute care medical psychiatric inpatient stay. Adm Policy Ment Health 2003;31:15-29.

16. Israel Central Bureau of Statistics, 2004: The Arab population of Israel, 2003.

17. Al-Haj M.. The Arab society in Israel. Soc Welfare 1994;14:249-264 (Hebrew).

18. Mental Health in Israel. Statistical Annual 2004. Ministry of Health, Israel.

19. Shurka E. Attitudes of Israeli Arabs towards the mentally ill. Int J Soc Psychiatry 1983;2:101-110.

20. Harman JS, Cuffel BJ, Kelleher KJ. Profiling hospitals for length of stay for treatment of psychiatric disorders. J Behav Health Serv Res 2004; 31:66-74.

Isr J Psychiatry Relat Sci - Vol 47 - No.2 (2010)

Ada H. Zohar and Hani Konfortes

Diagnosing ADHD in Israeli Adults: The Psychometric Properties of the Adult ADHD Self Report Scale (ASRS) in Hebrew Ada H. Zohar, PhD,1 and Hani Konfortes, MA2 1

Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel Support Center for Students with Learning Disabilities, Ruppin Academic Center, Emek Hefer, Israel.

2

ABSTRACT This paper argues for the importance of diagnosing ADHD in adults, while acknowledging the many attendant difficulties. The paper presents results from two studies implementing the Adult ADHD Self Report Screen (ASRS) in Hebrew. The Hebrew version of the ASRS as approved by the World Health Organization is appended to this paper. The first of the two studies used a paper and pencil version of the ASRS (ASRS_PP) and the second used a computer administered version (ASRS_C). A subset of the participants in the two studies was given both versions. The Hebrew ASRS had excellent test-retest reliability. It had good internal consistency in both forms. Support for the validity of the Hebrew ASRS is given by the significantly higher scores of adults with ADHD versus those without, on both versions of the ASRS and on all of its subscales. The sensitivity of the raw sum of all 18 items was significantly higher than that of the 6-item screen suggested by the authors of the ASRS. The sensitivity and specificity of the ASRS in Hebrew should be further examined in future studies including clinically referred participants. The benefit of using the ASRS as part of the diagnostic process for adult ADHD is discussed.

Introduction Attention deficit hyperactive disorder (ADHD) is a common childhood disorder that can be found in 3-5% of school children, in most cultures as in Israel (1). It can be diagnosed if an individual has serious attention probAddress for Correspondence: â&#x20AC;&#x2020; adaz@ruppin.ac.il

lems, serious hyperactivity and impulsivity, or both. At least some of the symptoms must appear before the age of seven to satisfy the DSM IV diagnosis (2). Many more boys than girls are affected with ADHD, and in particular the hyperactivity component of the diagnosis is more common among boys.

There is substantial genetic influence on ADHD, so that the risk for a sibling of an affected child is 15%, three times the population prevalence, and the risk for children of adults with childhood onset ADHD is 57%, twelve times the population prevalence (3, 4). These results can be interpreted to mean that ADHD that persists into adolescence and adulthood is more genetically influenced than remitting childhood ADHD (5). This odds ratio might be construed as additional motivation to diagnose ADHD in adults, as it confers substantial risk on offspring, who might profit from timely diagnosis and treatment, unlike their parent.

The diagnosis of ADHD in adults is both important and difficult. By definition, at least some of the symptoms need to be present before the age of seven, in order to diagnose the disorder (2). Clinicians to whom children are brought, and who are the first to diagnose ADHD in the child, often note that at least one of the parents who brings in the child meets criteria for ADHD or would have met criteria in childhood had there been a professional available to observe and diagnose the disorder.

On the other hand, the diagnosis of ADHD requires two sources of report (such as parent and teacher) and significant functional impairment or distress. In adults who have already built their life around the undiagnosed and untreated impairment, having made life choices that reflect their limitations, this criterion is much harder to establish (4).

A.H. Zohar, Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer 40250, Israel.

308

DIAGNOSING ADHD IN ISRAELI ADULTS

In a recent epidemiological study of adult ADHD (6) a probability sample of households was ascertained in ten countries, the United States, Mexico, Colombia, Belgium, the Netherlands, France, Germany, Spain, Italy and Lebanon. All adults above 18 and under 44 years of age were interviewed by trained lay interviewers using a semi-structured interview schedule. An overall prevalence estimate of 3.4% was found. The most common comorbid conditions in descending order were substance use, mood disorders and anxiety disorders. The most common configuration was three or more co-morbid conditions. With the exception of specific phobia, the temporal order of onset was first ADHD, and then the co-morbid conditions. Substantial dysfunction was associated with ADHD in this study, affecting mobility, cognitive function, and the number of days per month when the adult with ADHD was able to function in his social and occupational capacities.

While semi-structured interviews are the golden standard for psychiatric diagnosis, they are time consuming and expensive, and are not feasible for screening large populations. Several self-assessment instruments have been suggested to bridge this gap. A partial list includes: the Connorážżs Adult ADHD Rating Scales (7); the Brown ADD Scale (8), and the Wender Utah Rating Scale (9).

These self-assessments were originally intended for clinical use, but were also extensively used in research.

They showed good screening qualities against diagnostic interviews, in clinical settings. These screening scales were based on the research into adult ADHD of the 1980s (8) and 90s (7, 9). However, as longitudinal and epidemiological information on adult ADHD accrued, it was important to devise a friendly and simple screener that incorporated this additional information. In particular, the measure of hyperactivity or impulsivity in adults needed revision, as they are the most likely to be modified over maturation.

Recently, a group of researchers in the United States in conjunction with the World Health Organization (WHO) developed a self-report scale for the screening of ADHD in adults (ASRS-v1.1; 10). The scale they propose is a short, 18-item scale which relates directly to the DSM IV TR diagnostic criteria (2). Part A of the scale is a 6-item screen, and the second part is the remaining 12 items. Gaining a score of 4 or more on Part A is a strong indication of adult ADHD (10). The ASRS can be used by a clinician, as in the WHO version appended to the current paper. It can also be used as a self-assessment (11) without loss of sensitivity or specificity.

309

The goals of the current study were to present the self-report ASRS-v1.1 in Hebrew, in a paper and pencil form as well as in a computer administered form, and to test its validity against clinical diagnosis in college students. The self-report rather than the clinician administered form was used. The inference behind using the self-administered form is that it will provide a conservative, lower bound estimate, of the psychometric properties of the ASRS, with the clinician administered version expected to outperform it.

Methods Instruments

The ASRS-v1.1 was translated into Hebrew by translation back translation comparison and correction. The Hebrew translation of the ASRS-v1.1 and the scoring information are appended to this paper. The current Hebrew version of the ASRS-v1.1 has been approved by the WHO as the official Hebrew version (12, 13).

In addition, the items of the Hebrew ASRS-v1.1 were adapted for computer presentation. The order of presentation, the wording of the items, and the response categories remained the same. However, the computer presents each item separately on the computer screen. A new item appears only when the participant has responded to the previous item. Thus there were two modes of presentation of the Hebrew ASRS-v1.1 in the current study, paper and pencil (ASRS_PP) and computer screen (ASRS_C).

The self-report version can be used in any setting, and thus is the more generalizable. Kessler et al. found it to be no less sensitive or specific than the clinician administered version (11). However, it is reasonable to suppose that the clinician administered version will outperform it psychometrically, especially if there is an established relationship of trust between the clinician and the patient being screened.

Procedure

The research protocol was approved by the ethics committee of the Department of Behavioral Sciences at Ruppin Academic Center, and by the General Director of the college. The study goals were presented to the participants as studying cognitive and emotional function of young adults. Informed consent forms were obtained from all participants. Participants also agreed to have their file at the Learning Disorders Center reviewed by the researchers. Confidentiality was promised and ensured by entering the data without any identifying information.

Ada H. Zohar and Hani Konfortes

The ASRS in both modes was presented after other psychological measures were presented, and was not the last scale presented in either mode. For the subset of participants who completed both the ASRS_PP and the ASRS_C, the order of presentation was randomized, about half (N=29) completed the ASRS_PP first, and the other half (N=26) completed the ASRS_C first.

Participants

All participants were college student volunteers. Most were first year volunteers, who were completing their requirement of participating in research as part of their Introduction to Psychology class. In addition, students were ascertained through the learning-disorder support center of Ruppin College, enriching the sample for individuals who had previously been clinically diagnosed with ADHD. All participants were told that the study was concerned with the cognitive and emotional function of young adults, without mention of ADHD. The ASRS_PP was administered to 120 participants, with a mean age of 24.9, ranging from 21 to 35 years of age. Of this sample, 20 participants, or 16.7%, had a current clinical diagnosis of ADHD. The ASRS_C was administered to 72 participants, with a mean age of 24.8, and a range of 21 to 34. Of these 23 participants, or 31.9%, had a current clinical diagnosis of ADHD. A subset of each group, 55 participants in all, completed both the ASRS_PP and the ASRS_C. The demographics of this subset were similar to those of the two original samples, and 8 out of 55 or 12% had previously been diagnosed with ADHD by a clinician.

Clinical Diagnosis of ADHD

The learning-disorder support center of Ruppin College has a two-tier process. The students who apply to the center come with a diagnosis of learning disorders or ADHD given by a relevant professional, a neurologist, psychiatrist, clinical psychologist, or neuropsychologist. An MA level educational psychologist (HK) conducts a file review, as well as a face-to-face interview to assess current status and current severity of symptoms. All the participants ascertained through the College support center were judged to currently meet criteria for ADHD. In addition all participants, who were volunteer college students and who were not ascertained through the learning disorder center, were asked about childhood onset conditions, including ADHD. Five participants reported that they had been diagnosed with ADHD in the past, and were interviewed

by AHZ, a senior clinical psychologist, to assess their current status. The semi-structured interview developed for

the International Gilles de la Tourette Syndrome Linkage Group (14) was used for determining the diagnosis of these individuals. This interview takes into account the individual's developmental history as well as operationalizing the DSM IV TR criteria for ADHD. Four of these five individuals met criteria for current ADHD and were thus added to the "clinical diagnosis of ADHDâ&#x20AC;? group.

Results Reliability of the Hebrew ASRS-v1.1 was tested in two ways. Test-retest reliability was assessed by calculating the Pearson correlation between the same items presented in the ASRS_PP and the ASRS_C, as well as the correlation of the unweighted sum of responses in the ASRS_PP and the ASRS_C, in the subset of participants who were administered both forms of the ASRS. The correlations are presented in Table 1, and are all highly significant. The lowest correlation is 0.60 and the highest is 0.90. Thus there is very high test-retest reliability, even though the Table 1: Test â&#x20AC;&#x201C;Retest Reliability; Pearson Correlation Between Written Items of the ASRS_PP and Items Presented Singly on a Computer Screen in the ASRS_C (N=55) Item number

Pearson correlation

1.

0.82

2

0.67

3

0.62

4

0.60

5

0.63

6

0.80

7

0.76

8

0.81

9

0.63

10

0.77

11

0.85

12

0.77

13

0.90

14

0.80

15

0.81

16

0.71

17

0.82

18

0.77

Total score (unweighted sum of the 18 responses)

0.89

310

DIAGNOSING ADHD IN ISRAELI ADULTS

scales were presented in two quite different modes.

Reliability as a measure of internal consistency was assessed for the two scales and for the whole measures of the ASRS_PP and the ASRS_C by means of Cronbach᾿s lower bound estimate of reliability, and these results are summarized in Table 2 below. All reliability estimates are between 0.79 and 0.89, i.e., the Hebrew ASRS-v1.1 is highly consistent both in the ASRS_PP and in the ASRS_C modes. The ASRS_PP is slightly more reliable than the ASRS_C. The validity of the ASRS was assessed by comparing the scores of the participants with and without an independent clinician᾿s diagnosis of ADHD, for the scales and the entire ASRS, for the unweighted responses as well as for symptom count, which is the number of items endorsed in the 6-item screen. For ease of reading, the results are shown in two tables: the ASRS_PP validity is shown in Table 3a, and for the ASRS_C in Table 3b. Group differences were tested by means of t-test. All mean scores of participants with ADHD were significantly higher than those of participants without ADHD, at the p=0.05 level, for all the ASRS variables in both versions of the test.

Comparing Table 3a and 3b demonstrates that the group differences in the ASRS_C are larger and more significant than in the ASRS_PP. This is due mainly to the participants with ADHD scoring higher on the ASRS_C than in the ASRS_PP. There are virtually no differences in the reports of the participants without ADHD in the ASRS_PP and the ASRS_C. In their analysis of the diagnostic properties of the ASRS, Kessler et al. (10) found that the Part A, 6-item screen, scored dichotomously resulted in the optimal sensitivity and specificity. In the following analysis we present the properties of the Part A screen, as well as those of the complete unweighted, 18-item score. The two data sets, that of the ASRS_PP and that of the ASRS_C, are presented side by side in Table 4 with the resulting sensitivity and specificity values. The 6-item screen has over 70% specificity in both presentation modes, but is Table 2: Scale Reliabilities for Written ASRS, and Computer Presented ASRS (N=55) ASRS_PP

ASRS_C

Complete scale

0.89

0.85

Nine inattention items

0.82

0.79

Nine hyperactivity and impulsivity items

0.88

0.81

311

low on sensitivity, 40% on the ASRS_PP and 52% on the ASRS_C. Since a screening test should err in the direction of high sensitivity, even if the price is lower specificity (15) the unweighted full scale outperforms the 6-item screen. In the full scale option, the sensitivity of the ASRS_C is 73.9% and of the ASRS_PP 62.7%; there is a price in specificity, the ASRS_PP has a specificity of 68% while the ASRS_C has a specificity of 62.7%.

Discussion The results of this study should be viewed in light of its limitations. The participants were all college students.

Sampling from college students potentially restricts the severity and dysfunction of ADHD, as well as the range of co-morbid conditions prevalent in adults with ADHD (6). This range restriction of ADHD severity potentially makes it more difficult for the screening process to detect ADHD, and therefore might also be Table 3a: Validity of ASRS – Scores of ASRS_PP in Participants with and without a Clinical Diagnosis of Current ADHD Groups

Mean (SD)

t-value

p

Total ASRS

ADHD (N=20) No-ADHD (N=100)

52.9 (7.5) 47.7 (5.3) -2.98

0.005

6-item screen

ADHD (N=20) No-ADHD (N=100)

3.1 (1.4) 2.1 (1.5)

-2.84

0.008

Hyperactivity

ADHD (N=20) No-ADHD (N=100)

25.0 (1.9) 22.8 (1.9)

-2.02

0.052

Inattention

ADHD (N=20) No-ADHD (N=100)

27.9 (2.3) 24.9 (1.8) -2.68

0.012

Table 3b: Validity of ASRS – Scores of ASRS_C in Participants with and without a Clinical Diagnosis of Current ADHD Groups

Mean (SD)

t-value

P

Total ASRS

ADHD (N=23) No-ADHD (N=49)

57.9 (8.9) 47.3 (5.3)

-4.16

0.000

6-item screen

ADHD (N=23) No-ADHD (N=49)

3.6 (1.6) 2.3 (1.6)

-3.27

0.002

Hyperactivity

ADHD (N=23) No-ADHD (N=49)

27.4 (5.3) 22.7 (2.3)

-3.35

0.001

Inattention

ADHD (N=23) No-ADHD (N=49)

30.5 (3.7) 24.6 (3.1)

-3.99

0.000

Ada H. Zohar and Hani Konfortes

Table 4: Sensitivity and Specificity of the Hebrew ASRS-v1.1 ASRS_PP

1 2

ASRS_C

Screen 3/41

Full scale 50/512

Screen 3/41

Full scale 50/512

Sensitivity

40%

65%

52%

73.9%

Specificity

78.4%

68%

73.5%

62.7%

Participants with ADHD N=20, participants without ADHD N=100.

Participants with ADHD N=23, participants without ADHD N=49.

viewed as making the psychometric assessment of the instrument more conservative.

Another limitation of sampling college students is that it restricts the range of IQ. Adults with all the symptoms of ADHD and lower IQ may have more difficulty in identifying and communicating their difficulties. This is a more serious limitation of the current sampling scheme.

In addition the version of the ASRS used in the current study was the self report. Kessler et al. (11) demonstrated for the English ASRS that the self-report performs just as well as the clinicianâ&#x20AC;&#x201C;administered version (10). It is the belief of the current researchers that the psychometric properties of the self-report provide lower bound estimates relative to the clinician administered version. This is a reasonable empirical hypothesis which, however, needs verification in future research.

The results of the current study show that the Hebrew ASRS-v1.1 has excellent reliability in both its forms, paper and pencil and computer administration. Item reliability was extremely high, as was the scale consistency in both the ASRS_PP and the ASRS_C. There is support for the validity of both the ASRS_PP and the ASRS_C. Participants with ADHD rated themselves higher on the ASRS_C than on the ASRS_PP, while there were virtually identical scores for non-ADHD participants in the two presentation modes. In the paper and pencil presentation all the items are presented on one page, so that the participants are aware of all their responses and can adjust them. Interestingly, this did not affect the responses of the participants without ADHD whose answers in both modes were indistinguishable, but it had a measurable effect on those with ADHD, who, when given the control afforded by comparison, reported their symptoms as less frequent and less severe, but in the single item presentation of the ASRS_C scored higher.

This might also explain why the ASRS_C was slightly more sensitive than the ASRS_PP. However, both versions showed consistent and significant discriminant

validity for the complete ASRS as for its subscales.

It should be noted that the ASRS_C showed slightly lower reliability estimates than the ASRS_PP. The lower reliability of computer administered tests versus the pencil and paper mode has been noted by others (16).

Gamliel and Peer (16) interpreted this difference in reliability estimates as an inflation in the paper and pencil mode due to a conscious effort on the part of participants to be consistent, made possible by the simultaneous presentation of the items in the paper and pencil mode. This comparison is impossible to accomplish in the computer administration. In the current study, although reliability is lower in the ASRS_C it is still robust, as all reliability estimates are around 0.80.

While in the English version the Part A 6-item screen with dichotomized scoring of the items provided the best specificity and sensitivity for the diagnosis of adult ADHD, this is not true for the Hebrew ASRS-v1.1 in either presentation forms. In particular the Part A screen provides low sensitivity. If there is a tradeoff between sensitivity and specificity, a screen should be set to err in the opposite direction, providing higher sensitivity and lower specificity (15). The current study supports the conclusion that the best practice of the Hebrew ASRS-v1.1 is to present the complete scale and to score it using the full range of the response categories.

As argued in the introduction, there are excellent reasons to diagnose adults with ADHD, and to do so accurately. It is hoped that the Hebrew ASRS_v1.1 will prove a useful addition to the screening process and aid correct diagnosis. It is suggested that the Hebrew ASRS-v1.1 be adopted as a standardized and psychometrically sound measure by clinicians, testing centers in academic centers, and by researchers who wish to study adult ADHD. References 1. Zohar AH, Ratzoni G, Pauls DL, Apter A, Bleich A, Kron S, Rappaport M, Weizman A, Cohen DJ. An epidemiological study of obsessive-compulsive disorder and related disorders in Israeli adolescents. J Am Acad Child Adolesc Psychiatry 1992;31:1057-1061.

2. American Psychiatric Association. The diagnostic statistical manual of mental disorders, 4th ed. Washington, DC: APA, 2000.

3. Biederman J, Faraone S, Milberger S, Curtis S, Chen L, Marrs A, Ouellette C, Moore P, Spencer T. Predictors of persistence and remission of ADHD into adolescence: Results from a four-year prospective follow up study. J Am Acad Child Adolesc Psychiatry 1996;35:343-351.

4. Faraone SV, Biederman J, Feighner JA, Monuteaux MC. Assessing symptoms of attention deficit hyperactivity disorder in children and adults: Which is more valid? J Consult Clin Psychol 2000;17:830-842.

5. Biederman J, Faraone SV, Taylor A, Sienna M, Williamson S, Fine C. Diagnostic continuity between child and adolescent ADHD: Findings from a longitudinal clinical sample. J Am Acad Child Adolsc Psychiatry 1998;37: 305-313.

312

DIAGNOSING ADHD IN ISRAELI ADULTS

6. Fayyad J, de Graaf R, Kessler J, Alonso M, Angermeyer K, Demyttenaere G, de Girolamo G, Haro JM, Karam EG, Lara C, Lepine J-P, Ormel J, Posada-Villa J, Zaslavsky AM, Jin R. Cross-national prevalence and correlates of adult ADHD. Br J Psychiatry 2007; 198: 402-409.

7. Connors CK, Erhart D, Sparrow E. Connorážżs adult ADHD rating scales, technical manual. New York: Multi-Health Systems, 1999.

8. Brown TE, Gammon GD. The Brown attention-activation disorder scale: Protocol for clinical use. New Haven, Conn.: Yale University, 1991.

9. Ward MF, Wender PH, Reimherr FW. The Wender Utah rating scale: An aid in the retrospective diagnosis of childhood ADHD. Am J Psychiatry; 1993;150: 885-890.

10. Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun B, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychol Med 2005;35:245-256.

11. Kessler RC, Adler LA, Gruber MJ, Sarawate A, Spencer T, Van Brunt DL. Validity

313

of the WHO Adult ADHD self-report scale screener in a representative sample of health plan members. Int J Methods Psychiatr Res 2007; 16: 52-65.

12. Zohar AH, Gonen Y, Yemini S. The World Health Organization Official Hebrew version of the ASRS-v1.1 six-item-screen. 2007: http://www.who.int/research/ en/ from March, 2007.

13. Zohar AH, Gonen Y, Yemini S. The World Health Organization Official Hebrew version of the ASRS-v1.1 eighteen-item-screen. 2007. http://www.who.int/ research/en/ from March, 2007.

14. Zohar AH, Ebstein RP, Pauls DL. TPQ profiles of patients with OCD and GTS and their first degree relatives. World J Bio Psychiatry 2005; 6: 151.

15. Kraemer HC. Evaluating medical tests: Objective and quantitative guidelines.

Newbury Park, Cal.: Sage, 1992.

16. Gamliel E, Peer E. The effect of response bias on internal reliability of questionnaires. Presented at the 114th Annual Convention of the American Psychological Association at New Orleans, Louisiana, August, 2006. http://www. apa.org/divisions/div5/program2006.rtf, pp. 8, July, 2007.

‫‪Ada H. Zohar and Hani Konfortes‬‬

‫רשימת הסימפטומים על פי סולם דיווח–עצמי של ‪ ADHD‬אצל מבוגרים (‪)ASRS-vl.l‬‬ ‫שם‪:‬‬

‫תאריך היום‪:‬‬

‫ענה על השאלות שלמטה ודרג את עצמך בכל אחד מהקריטריונים המוצגים‪ ,‬על–ידי שימוש‬ ‫בסולם המופיעה בצד השמאלי של דף זה‪ .‬כאשר אתה עונה על כל שאלה‪ ,‬הקף את המספר‬ ‫בתא המתאר בצורה הטובה ביותר את האופן בו הרגשת וניהלת את עצמך בששת החודשים‬ ‫האחרונים‪ .‬בבקשה העבר את הרשימה המלאה למטפל הבריאותי שלך‪ ,‬על–מנת שתדונו בכך‬ ‫במהלך הפגישה היום‪.‬‬

‫אף‬ ‫פעם‬ ‫לא‬

‫לעיתים‬ ‫לעיתים‬ ‫לעיתים‬ ‫תכופות‬ ‫לפעמים‬ ‫תכופות‬ ‫רחוקות‬ ‫מאוד‬

‫חלק א'‬ ‫‪.1‬‬ ‫‪.2‬‬ ‫‪.3‬‬ ‫‪.4‬‬ ‫‪.5‬‬ ‫‪.6‬‬

‫באיזו תכיפות את‪/‬ה מתקשה להשלים את הפרטים הקטנים של פרויקט‪ ,‬מהרגע בו‬ ‫החלקים המאתגרים הסתיימו?‬ ‫באיזו תכיפות את‪/‬ה מתקשה ליצור סדר בדברים‪ ,‬כאשר את‪/‬ה מבצע‪/‬ת משימה‬ ‫המצריכה ארגון?‬ ‫באיזו תכיפות את‪/‬ה מתקשה בזכירת פגישות או התחייבויות?‬ ‫כאשר מוטלת עלייך משימה המצריכה חשיבה מרובה‪ ,‬באיזו תכיפות את‪/‬ה נמנע‪/‬ת או‬ ‫דוחה את התחלתה?‬ ‫באיזו תכיפות את‪/‬ה מתפתל‪/‬ת או מניע‪/‬ה בקוצר–רוח את ידייך או רגלייך‪ ,‬כאשר עליך‬ ‫לשבת במקומך למשך זמן ארוך?‬ ‫באיזו תכיפות את‪/‬ה מרגיש‪/‬ה פעיל‪/‬ה יתר על המידה או מרגיש‪/‬ה צורך לעשות דברים‪,‬‬ ‫כאילו את‪/‬ה פועל‪/‬ת על–ידי מנוע?‬

‫‪1‬‬

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‫חלק ב'‬ ‫באיזו תכיפות את‪/‬ה מבצע שגיאות הנובעות מרשלנות‪ ,‬כאשר עלייך לעבוד על‬ ‫פרויקט משעמם או מסובך?‬ ‫באיזו תכיפות את‪/‬ה מתקשה בשמירה על ריכוז‪ ,‬כאשר את‪/‬ה מבצע‪/‬ת עבודה‬ ‫משעממת או עבודה החוזרת על עצמה?‬ ‫באיזו תכיפות את‪/‬ה מתקשה להתרכז במה שאנשים אומרים לך‪ ,‬אפילו כאשר הם‬ ‫מדברים אלייך באופן ישיר?‬

‫‪1‬‬

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‫‪.17‬‬

‫באיזו תכיפות את‪/‬ה מתקשה לחכות לתורך בסיטואציות בהן נדרשת המתנה?‬

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‫‪.18‬‬

‫באיזו תכיפות את‪/‬ה מפריע‪/‬ה לאחרים כאשר הם עסוקים?‬

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‫‪.7‬‬ ‫‪.8‬‬ ‫‪.9‬‬ ‫‪.10‬‬ ‫‪.11‬‬ ‫‪.12‬‬ ‫‪.13‬‬ ‫‪.14‬‬ ‫‪.15‬‬ ‫‪.16‬‬

‫באיזו תכיפות את‪/‬ה מאבד‪/‬ת חפצים או מתקשה במציאתם‪ ,‬בעבודה או בבית?‬ ‫באיזו תכיפות דעתך מוסחת על–ידי פעילות או רעש בסביבתך?‬ ‫באיזו תכיפות את‪/‬ה קם‪/‬ה ממושבך במהלך פגישה או בכל סיטואציה אחרת‪ ,‬בה‬ ‫מצופה ממך להישאר במקומך?‬ ‫באיזו תכיפות את‪/‬ה מרגיש‪/‬ה חסר‪/‬ת–מנוחה או קצר‪/‬ת–רוח?‬ ‫באיזו תכיפות את‪/‬ה מתקשה להירגע ולהשתחרר כאשר יש לך זמן לעצמך?‬ ‫באיזו תכיפות את‪/‬ה מוצא‪/‬ת את עצמך מדבר‪/‬ת יותר מידי כאשר את‪/‬ה בסיטואציה‬ ‫חברתית?‬ ‫כאשר את‪/‬ה במהלך שיחה‪ ,‬באיזו תכיפות את‪/‬ה מוצא‪/‬ת את עצמך מסיים‪/‬ת‬ ‫משפטים של האנשים עימם את‪/‬ה מדבר‪/‬ת‪ ,‬לפני שהם מסיימים אותם בעצמם?‬

‫הערה‪ :‬בגרסה האנגלית של ארגון הבריאות העולמי נמצא כי אם בחלק א' השיב הנבדק תשובה מוצללת על לפחות ‪ 4‬פריטים זוהי אינדיקציה‬ ‫טובה להמשך בירור ולהיתכנות של ‪ .ADHD‬לפי מחקר על הגרסה העברית נראה כי סכום הציונים הגולמיים על כל ‪ 18‬הפריטים (חלק א וחלק ב‬ ‫ביחד) היא האינדיקציה הטובה ביותר להמשך בירור של ‪ ,ADHD‬ובפרט אם הסכום הוא ‪ 51‬ומעלה‪.‬‬ ‫‪314‬‬

‫‪DIAGNOSING ADHD IN ISRAELI ADULTS‬‬

‫הנחיות לרשימת סימפטומים על פי סולם דיווח־עצמי‬ ‫של ‪ ADHD‬אצל מבוגרים (‪)ASRS-vl.l‬‬ ‫השאלות בעמוד הבא מיועדות לעורר דיאלוג בינך‬ ‫לבין הפציינטים שלך‪ ,‬וכן לעזור לאשר אם הם סובלים‬ ‫מהתסמינים של הפרעת קשב‪ ,‬ריכוז והיפר–אקטיביות‬ ‫(‪.)ADHD‬‬ ‫תיאור‪ :‬רשימת הסימפטומים הינה כלי המורכב‬ ‫משמונה–עשר הקריטריונים של ה–‪ .DSM-IV-TR‬שש מתוך‬ ‫שמונה–עשרה השאלות נמצאו כמנבאות הטובות ביותר‬ ‫של קביעות סימפטומים ב–‪ .ADHD‬שש השאלות הללו‬ ‫הינן הבסיס למיון על–פי ה–‪ ,ASRS-vl.l‬והן גם חלק א'‬ ‫ברשימת סימפטומים‪ .‬חלק ב' מרשימת הסימפטומים‬ ‫כולל את שתיים–עשרה השאלות הנותרות‪.‬‬ ‫הנחיות‪ :‬בקש מהפציינט להשיב על השאלות בחלקים‬ ‫א' ו–ב' מרשימת הסימפטומים‪ ,‬על–ידי הקפת המספר‬ ‫בתא‪ ,‬המייצג בצורה האמיתית ביותר את שכיחות‬ ‫ההתרחשות של כל אחד מהסימפטומים‪.‬‬ ‫רשום את הניקוד של חלק א'‪ .‬במידה וארבעה סימונים‬ ‫או יותר מופיעים בתאים המוצללים בחלק ב' של‬ ‫השאלון‪ ,‬אז לפציינט ישנם סימפטומים עקביים מאוד‬ ‫של ‪ ADHD‬אצל מבוגרים וראויה חקירה נוספת‪.‬‬ ‫שכיחות התוצאות בחלק ב' תספק רמזים נוספים ותוכל‬ ‫לשרת כאמצעי–בדיקה נוסף לסימפטומים של הפציינט‪.‬‬ ‫שים לב במיוחד לסימונים המופיעים בתאים המוצללים‪.‬‬ ‫שאלות מסוימות הן יותר רגישות לתשובות המבוססות‬ ‫על תכיפות‪ .‬אין‪ ‬תוצאה כוללת או סבירות אבחונית בכל‬

‫הנוגע לשתיים עשרה השאלות‪ .‬נמצא כי שש השאלות‬ ‫בחלק ב' הינן המנבאות הטובות ביותר של ההפרעה‬ ‫והינן הטובות ביותר לשימוש כאמצעי–סינון‪.‬‬ ‫בצע סקירה של כלל רשימת הסימפטומים יחד עם‬ ‫הפציינט ובצע הערכה של רמת הליקוי בשילוב עם‬ ‫הסימפטום‪.‬‬ ‫קח בחשבון את מסגרות העבודה‪ /‬בית הספר‪,‬‬ ‫המשפחה והחברה‪.‬‬ ‫שכיחות הסימפטום בדרך–כלל קשורה עם חומרת‬ ‫הסימפטום‪ ,‬לכן‪ ,‬רשימת הסימפטומים יכולה גם‬ ‫היא לסייע בהערכת הליקויים‪ .‬אם למטופליך ישנם‬ ‫סימפטומים תכופים‪ ,‬אתה עשוי להיות מעוניין בכך שהם‬ ‫יתארו כיצד בעיות אלה משפיעות על היכולת לעבוד‪,‬‬ ‫לטפל בדברים בבית‪ ,‬או להסתדר בחברת אנשים‪ ,‬כמו‬ ‫בן–זוגם או אחרים משמעותיים‪.‬‬ ‫היסטוריה‪:‬‬ ‫הערך את נוכחות הסימפטומים הללו או סימפטומים‬ ‫דומים בילדות‪ .‬מבוגרים בעלי ‪ ADHD‬צריכים שלא להיות‬ ‫מאובחנים רשמית (כסובלים מההפרעה) בילדותם‪.‬‬ ‫בהערכת ההיסטוריה של הפציינט‪ ,‬חפש ראיות של‬ ‫הופעה מוקדמת ובעיות ארוכות–טווח הקשורות בקשב‬ ‫או בשליטה–עצמית‪ .‬ישנם סימפטומים משמעותיים‬ ‫אשר אמורים היו להיות נוכחים בילדות‪ ,‬אך לא דרושים‬ ‫לכך כל הסימפטומים‪.‬‬

‫ערכו של הסינון עבור מבוגרים עם ‪:ADHD‬‬ ‫המחקר מציע כי סימפטומים של ‪ ADHD‬יכולים להימשך‬ ‫במהלך הבגרות‪ ,‬עם יכולת השפעה משמעותית על‬ ‫יחסים‪ ,‬קריירה ואפילו על ביטחונם האישי של מטופלייך‪,‬‬ ‫אשר עשויים לסבול מכך‪ .‬מכיוון שלעיתים קרובות‬ ‫הפרעה זו אינה מובנת כהלכה‪ ,‬אנשים רבים הסובלים‬ ‫ממנה לא מקבלים טיפול הולם וכתוצאה מכך‪ ,‬הם‬ ‫עשויים לא לממש את הפוטנציאל המלא שלהם לעולם‪.‬‬ ‫חלק מהבעיה הינו הקושי באבחון‪ ,‬במיוחד אצל מבוגרים‪.‬‬ ‫רשימת הסימפטומים על פי סולם דיווח–עצמי של‬ ‫‪ ADHD‬אצל מבוגרים (‪ ,)ASRS-vl.l‬פותחה בשיתוף עם‬ ‫ארגון הבריאות העולמי (‪)World Health Organization - WHO‬‬ ‫ובשיתוף עם קבוצת–עבודה על ‪ ADHD‬אצל מבוגרים‪,‬‬ ‫אשר כללה צוות של פסיכיאטרים וחוקרים‪:‬‬ ‫* ‪Lenard Adler, MD‬‬

‫פרופסור עמית לפסיכיאטריה ונוירולוגיה‬ ‫בית–הספר לרפואה‪ ,‬אוניברסיטת ניו–יורק‪.‬‬

‫* ‪Ronald C. Kessler, PHD‬‬

‫פרופסור‪ ,‬המחלקה למדיניות הטיפול הבריאותי‬ ‫בית–הספר לרפואה‪ ,‬הרווארד‪.‬‬ ‫* ‪Thomas Spencer, MD‬‬

‫פרופסור עמית לפסיכיאטריה‬ ‫בית–הספר לרפואה‪ ,‬הרווארד‪.‬‬ ‫כמטפל בריאותי‪ ,‬אתה יכול להשתמש ב–‪ASRS-vl.l‬‬ ‫כאמצעי–עזר לסינון הפרעת ‪ ADHD‬אצל פציינטים‬ ‫מבוגרים‪ .‬הסתכלות פנימה על–ידי כלי–סינון זה‪,‬‬ ‫עשוי להעלות את הצורך בהסתכלות מעמיקה יותר‬ ‫על–ידי ראיון קליני‪ .‬השאלות ב–‪ ASRS-vl.l‬עוקבות אחר‬ ‫הקריטריונים של ה–‪ DSM-lV‬ופונות להצגת הסימפטומים‬ ‫של ‪ ADHD‬אצל מבוגרים‪ .‬תוכנו של השאלון גם משקף‬ ‫את החשיבות שנותן ה–‪ DSM-lV‬לסימפטומים‪ ,‬לליקויים‬ ‫ולהיסטוריה ‪ -‬לאבחון מדויק ונכון‪.‬‬ ‫* מילוי השאלון לוקח חמש דקות (לערך) והוא יכול לספק מידע קריטי‪,‬‬ ‫אשר יתווסף לתהליך האבחון‪.‬‬

‫‪315‬‬

‫דיווח ועד האיגוד הפסיכיאטרי‬ ‫לאספה הכללית ‪ -‬ירושלים‬ ‫‪ 25‬בנובמבר ‪2010‬‬

‫‪1 .1‬אוישו הוועדות השונות‪ ,‬המשקיפים ונציגי המתמחים‬ ‫באיגוד‪.‬‬ ‫‪2 .2‬גובש נייר עמדה בנושא האובדנות‪.‬‬ ‫‪3 .3‬העיתון ‪ IJP‬הועבר להוצאה לאור של עיתון הרפואה‪.‬‬ ‫‪4 .4‬ועדת הסניורים והיו"ר נבחרו על ידי ‪ 125‬גמלאי האיגוד‪.‬‬ ‫‪5 .5‬אתר האינטרנט שודרג ועבר להיות אינטראקטיבי ובמה‬ ‫להתייעצות‪.‬‬ ‫‪6 .6‬פורום המתמחים באיגוד אושר‪.‬‬ ‫‪7 .7‬ועדת הטכנולוגיות גיבשה הצעה לסל התרופות במשותף‬ ‫עם המועצה הלאומית לברה"נ‪.‬‬ ‫‪8 .8‬הועברה הצעה למסלול התמחות משולב של פסיכיאטריה‬ ‫של המבוגר ושל ילדים ונוער למועצה המדעית בהר"י‪.‬‬ ‫‪9 .9‬אומצה החלטת הר"י שלא לקדם הגדרת תפקיד לעוזר‬ ‫רופא‪.‬‬ ‫‪1010‬גובשו הבקשות לשינוי הצעת החוק להעברת האחריות על‬ ‫בריאות הנפש לקופות החולים‪.‬‬ ‫‪1111‬אומצו עקרונות ההתערבות לטיפול בפוסט־טראומה של‬ ‫הקונסורציום הלאומי ומשרד הביטחון‪.‬‬ ‫‪1212‬גובשה ההצעה לתחום העיסוק‪ ,‬היעדים והרישום בסילבוס‬ ‫של פסיכותרפיה‪.‬‬ ‫‪1313‬ועדת ההתמחות בהר"י הכירה במחלקות לטיפול יום‬ ‫בקהילה כמוכרות להתמחות בחלק האשפוז‪ .‬הועבר לאישור‬ ‫נשיאות המועצה המדעית בהר"י‪.‬‬ ‫‪1414‬נמשך הניסיון לאשר את הפסיכיאטריה כמקצוע המאפשר‬ ‫חוו"ד נגד המדינה‪ ,‬אותרו ‪ 647‬פסיכיאטרים מתוך ‪950‬‬ ‫בשירות המדינה‪.‬‬

‫‪1515‬הועברו דרישות האיגוד לארגון הרופאים לקראת דיוני השכר‪.‬‬ ‫‪1616‬הועברה ההתנגדות לדיווח למכון לבטיחות בדרכים על‬ ‫המשתמשים בריטלין ללא הפרעה בנהיגה‪.‬‬ ‫‪1717‬הועברו הדרישות לתוספות כ"א רופאים להר"י ולמשרד‬ ‫הבריאות לקראת הדיונים מול האוצר‪ ,‬לאור השינוי והצורך‬ ‫בהתאמות לתמהיל החולים‪.‬‬

‫משולחנו של ועד האיגוד‬ ‫הפסיכיאטרי‬ ‫‪ 10‬בינואר ‪2010‬‬

‫‪1 .1‬הוצג סקר ‪ ECT‬ארצי והמלצות;‬ ‫• יש לפתח שירותי ‪ ECT‬אמבולטורי בפריסה ארצית‪ .‬יגובש‬ ‫כתב הסכמה לטיפול‪.‬‬ ‫• תוצע תוכנית הכשרה ארצית לרופאים ולאחיות‪ .‬יוגדר‬ ‫הצוות המקצועי הנדרש‪.‬‬ ‫‪2 .2‬יתוקן הרישום בסילבוס בנושא‪ :‬ההכשרה וההסמכה לעיסוק‬ ‫בפסיכותרפיה‪ ,‬הערכת המסוכנות אצל עברייני מין‪.‬‬ ‫‪3 .3‬לכנס התלת–יומי במאי ‪ 2012‬נבחרו‪:‬‬ ‫• יו"ר הועדה המארגנת ‪ -‬ד"ר נמרוד גריסרו‪.‬‬ ‫• יו"ר הועדה המקצועית ‪ -‬פרופ' אבי בלייך‪.‬‬ ‫‪4 .4‬הנושא המרכזי לכנס יידון בישיבת הוועד הבאה‪.‬‬ ‫‪5 .5‬ימי העיון והכנסים‪ ,‬על הנושאים‪ ,‬התאריך ומיקום הכנסים‬ ‫בסניפים‪ ,‬יתואמו עם מזכיר האיגוד‪.‬‬ ‫‪6 .6‬הכנס בנושא "חלוקת האחריות והשירותים בפסיכיאטריה‬ ‫ברפורמה בשיתוף נציגי איגוד רופאי המשפחה" יתקיים‬ ‫ב–‪ .13-15.1.11‬ישיבת האיגוד הבאה תתקיים במהלך הכנס‪.‬‬ ‫‪7 .7‬יימשך איתור המועמדים לאות מפעל חיים בפסיכיאטריה‪.‬‬

‫איגוד הפסיכיאטריה בישראל‪ :‬ההסתדרות הרפואית ‪ -‬המועצה המדעית ‪Israeli Psychiatric Association -‬‬ ‫יו"ר‪ :‬פרופ' זאב קפלן ‪President: Prof. Z. Kaplan /‬‬ ‫‪Zeev.kaplan@pbsh.health.gov.il‬‬ ‫מזכיר‪ :‬ד"ר נמרוד גריסרו ‪President: Dr. N. Grisaru /‬‬ ‫‪grisarun@gmail.com‬‬ ‫גזבר‪ :‬ד"ר בוריס נמץ ‪Treasurer: Dr. B. Nemets /‬‬ ‫‪nemetz@bgu.ac.il‬‬ ‫יו"ר נבחר‪ :‬פרופ' משה קוטלר ‪Elected President: Prof. M. Kotler /‬‬ ‫‪Moshe.kotler@beerness.health.gov.il‬‬

‫יו"ר יוצא ואחראי קשרי חו"ל‪ :‬פרופ' אבי בלייך ‪/‬‬

‫‪President Emeritus and Foreign Affairs: Prof. A. Bleich‬‬ ‫‪ableich@lev-hasharon.co.il lean@bgu.ac.il‬‬

‫‪316‬‬

‫המרכז לבריאות הנפש באר שבע‬

‫‪Beer-Sheva Mental Health Center‬‬

‫ טל'‪ ;08-6401606 :‬פקס‪08-6401621 :‬‬ ‫ רח' הצדיק מירושלים ‪ ,2‬באר שבע‪ ,‬ת"ד ‪ 4600‬‬ ‫ ‪Hazadik from Jerusalem St. P.O. Box 4600‬‬ ‫ ‪www.psychiatry.org.il‬‬

‫מסקנות‪ :‬הערכה עצמית של זמן ביצוע לעומת זמן ביצוע‬ ‫ממשי לא נמצאה פגומה בקבוצה של חולי דמנציה או בקבוצת‬ ‫חולי ‪ MCI‬בהשוואה לנבדקים ללא ליקוי קוגניטיבי‪.‬‬ ‫פגיעה עצמית גניטלית כפתרון פסיכוטי‬ ‫א' אוזן‪ ,‬א' דבצ'י‪ ,‬מ' אורל‪ ,‬א' אורל‪ ,‬א' יאזיסי‪ ,‬א' קירפינאר‪,‬‬ ‫טורקיה‬

‫פגיעה עצמית גניטלית היא נדירה‪ ,‬אבל בעלת תוצאות קשות‪.‬‬ ‫ידועים כמה גורמי סיכון להופעתה‪ .‬בין אלו מחשבות שווא‬ ‫דתיות‪ ,‬הלוצינציות פוקדניות‪ ,‬ערך עצמי ירוד ותחושות‬ ‫אשמה‪ .‬המאמר סוקר מצבים של פגיעה עצמית גניטלית על‬ ‫רקע מחשבות שווא דתיות (סינדרום ע"ש קלינגסור)‪ .‬במאמר‬ ‫מוצגים ארבעה סיפורי מקרה‪ ,‬ולאחריהם דיון המתרכז במניעים‬ ‫ובאספקטים התרבותיים הקשורים לתופעה נדירה וחמורה זו‪.‬‬ ‫מנבאים של משך אשפוז מצטבר אצל‬ ‫מאושפזים פסיכיאטריים לאורך שנה‪ :‬מדגם‬ ‫ארצי מקובץ האשפוזים הפסיכיאטריים‬ ‫י' לרנר‪ ,‬נ' זילבר‪ ,‬ירושלים‬

‫רקע‪ :‬במחקרים קודמים הובאו תוצאות לא עקביות ביחס‬ ‫למנבאים של משך אשפוז פסיכיאטרי ושל חזרה לאשפוז‬ ‫שכזה‪ .‬משך אשפוז מצטבר לאורך זמן‪ ,‬המשקף גם את משך‬ ‫האשפוז וגם את החזרות לאשפוז‪ ,‬לא נבדק בצורה סיסטמטית‪.‬‬ ‫קובץ האשפוזים הפסיכיאטריים בישראל מאפשר לבדוק את‬ ‫המנבאים לאשפוז מצטבר במדגם ארצי מייצג‪.‬‬ ‫שיטות‪ :‬כל הקבלות לאשפוז פסיכיאטרי בישראל במשך‬ ‫שישה חודשים נרשמו‪ ,‬ונעשה מעקב אחריהן במשך שנה‪.‬‬ ‫המשתנים המנבאים אשפוז מצטבר למשך שנה‪ ,‬אותרו בעזרת‬ ‫רגרסיה מסוג ‪.COX‬‬ ‫תוצאות‪ :‬האשפוז המצטבר החציוני במשך שנה היה ‪ 43‬יום‪,‬‬ ‫ורק ‪ 1.7%‬מן המתאשפזים נשארו באשפוז יותר משנה רצופה‬ ‫מיום הקבלה‪ .‬המשתנים שניבאו באופן משמעותי אשפוז מצטבר‬ ‫ארוך יותר היו‪ :‬מוצא יהודי‪ ,‬אבחנה של סכיזופרניה או פסיכוזה‬ ‫אחרת‪ ,‬אשפוז קודם‪ ,‬אשפוז בכפייה ומחוז האשפוז (שיעורי‬

‫הקבלות לאשפוז יותר נמוכים במחוז צפון ובמחוז ירושלים)‪.‬‬ ‫מגבלות‪ :‬חוסר אינפורמציה על החומרה של הפסיכופתולוגיה‬ ‫וסוג הטיפול‪.‬‬ ‫מסקנות‪ :‬משך אשפוז מצטבר לאורך זמן (המשקף בו–זמנית‬ ‫את משך כל אשפוז ואת שיעור החזרה לאשפוז) מושפע גם על‬ ‫ידי גורמים תרבותיים וקליניים‪ ,‬וגם על ידי גורמים מנהליים‬ ‫כמו לחץ מיטות‪.‬‬ ‫האבחון של ‪ ADHD‬במבוגרים בישראל‪ :‬התכונות‬ ‫הפסיכומטריות של השאלון לדיווח עצמי של‬ ‫מבוגרים עם ‪ )ADHD) ASRS‬בעברית‬ ‫ע"ח זוהר‪ ,‬ח' קונפורטס‪ ,‬עמק חפר‬

‫המאמר טוען לחשיבות האבחון של ‪ ADHD‬במבוגרים‪ ,‬למרות‬ ‫הקשיים הרבים המלווים את האבחון‪ .‬במאמר מוצגות תוצאות‬ ‫של שני מחקרים‪ ,‬ששניהם התבצעו בהשתתפות סטודנטים‪,‬‬ ‫והשתמשו ב–‪ ASRS‬בעברית‪ .‬הגרסה העברית של ה–‪ ,ASRS‬כפי‬ ‫שאושררה על ידי ארגון הבריאות העולמי‪ ,‬מצורפת כנספח‬ ‫למאמר‪ .‬במחקר הראשון הועבר ה–‪ ASRS‬בגרסת עיפרון ונייר‪,‬‬ ‫ובמחקר השני בגרסה ממוחשבת‪ .‬חלק מהמשתתפים ענו על‬ ‫שתי הגרסאות‪ .‬מהימנות מבחן חוזר של ה–‪ ASRS‬היא גבוהה‬ ‫מאוד‪ ,‬הן ברמת הפריט והן ברמת תת–הסולמות והמבחן‬ ‫בכללותו‪ .‬מהימנות במונחי עקביות פנימית נמצאה גם היא‬ ‫גבוהה בשתי הגרסאות‪ .‬התקפות של ה–‪ ASRS‬בעברית נבדקה‬ ‫בהשוואת ציוני ה–‪ ASRS‬של קבוצת משתתפים שאובחנה‬ ‫קלינית כמתמודדת עם ‪ ADHD‬בהווה‪ ,‬לעומת קבוצה של‬ ‫משתתפים ללא ‪ ADHD‬בהווה‪ .‬מבוגרים המתמודדים עם‬ ‫‪ ADHD‬קיבלו ציונים גבוהים באופן מובהק ב–‪ ASRS‬כולו‪,‬‬ ‫וכן בשני תת–הסולמות שלו בשתי הגרסאות‪ .‬מחברי ה–‪ASRS‬‬ ‫באנגלית מצאו שסכום ‪ 6‬פריטים בציינון דיכוטומי נותנים‬ ‫רגישות וספציפיות אופטימליים‪ .‬בגרסה העברית‪ ,‬סכום כל ‪18‬‬ ‫הפריטים בציוניהם הגולמיים נתן רגישות וספציפיות גבוהות‬ ‫יותר‪ .‬יש לבדוק את תכונות הסינון של ה–‪ ASRS‬בעברית גם‬ ‫בשימוש בפונים למרכזים קליניים‪ .‬נדונה התועלת של השימוש‬ ‫ב–‪ ASRS‬כחלק מהתהליך האבחוני של ‪ ADHD‬במבוגרים‪.‬‬

‫‪317‬‬

‫תסמונת פוסט–טראומטית (‪ )PDS‬ושיעורי חזרה לעבודה‪.‬‬ ‫תוצאות‪ :‬הממוצע ב–‪ 6‬מתוך ‪ 8‬סולמות ב–‪ SF-36‬היה נמוך‬ ‫יותר בקרב נפגעי הטרור לעומת הנורמות באוכלוסייה הכללית‪.‬‬ ‫תסמונת פוסט–טראומטית נמצאה בקרב ‪ 39%‬מהמדגם ו–‪43%‬‬ ‫לא חזרו לעיסוקם הקודם כשנתיים בממוצע לאחר הפגיעה‪.‬‬ ‫בניתוח שונות של תסמונת פוסט–טראומטית וסטטוס עיסוקי‬ ‫(חזר‪/‬לא חזר לעבודה או ללימודים) עם איכות חיים נמצאו‬ ‫השפעות עיקריות לתסמונת פוסט–טראומטית (‪)p=.000‬‬ ‫וסטטוס עיסוקי (‪ ,)p=.005‬ללא השפעת אינטראקציה (‪.)p=.476‬‬ ‫לא נמצא קשר מובהק בין חומרת הפגיעה לבין ‪.SF-36‬‬ ‫מסקנות‪ :‬מחקר זה בחן את ההשלכות ארוכות הטווח של‬ ‫פגיעת טרור‪ .‬נמצאו השפעות בלתי–תלויות לתסמונת פוסט–‬ ‫טראומטית וסטטוס עיסוקי על איכות חיים כשנתיים לאחר‬ ‫הפגיעה‪ .‬קבוצה זו עשויה להפיק תועלת מהתערבות הממוקדת‬ ‫במצבם הנפשי והעיסוקי על מנת לשפר את איכות חייהם‪.‬‬ ‫חשיפה לקרב‪ ,‬סימפטומים פוסט־טראומטיים‬ ‫והתנהגות נוטלת סיכונים בקרב ותיקי‬ ‫מלחמת לבנון השנייה‬ ‫ו‪ .‬סבטליצקי‪ ,‬ז‪ .‬סולומון‪ ,‬ר‪ .‬בנבנישתי‪ ,‬א‪ .‬לוי‪ ,‬ג‪ .‬לובין‪ ,‬צה"ל‬

‫הספרות המקצועית הדנה בוותיקי מלחמות הסובלים מהפרעת‬ ‫דחק פוסט–טראומטית מורה על נטייה גבוהה להתנהגות‬ ‫נוטלת סיכונים באוכלוסייה זו‪ .‬המחקר הנוכחי בוחן האם‬ ‫התנהגות נוטלת סיכונים הינה פועל יוצא של חשיפה לאירוע‬ ‫טראומטי או מאידך‪ ,‬הקשר ביניהם אינו ישיר ומתקיים בתיווך‬ ‫של הסימפטומים הפוסט–טראומטיים‪ .‬מדגם המחקר כולל ‪180‬‬ ‫חיילי מילואים ישראלים שהופנו לטיפול ביחידה לתגובות קרב‬ ‫בעקבות השתתפותם במלחמת לבנון השנייה‪ .‬נמצא כי חשיפה‬ ‫לקרב קשורה באופן בלתי–ישיר עם התנהגות נוטלת סיכונים‪,‬‬ ‫בעיקר דרך הסימפטומים הפוסט–טראומטיים‪ .‬תוצאות הרגרסיה‬ ‫ההיררכית הורו על משקלם המשמעותי של הסימפטומים‬ ‫הפוסט–טראומטיים בניבוי התנהגות נוטל סיכונים‪ .‬תיאוריות‬ ‫של טיפול עצמי ושל אגרסיביות הוצעו לצורך הדיון בממצאים‪.‬‬ ‫הקשר בין סוג הביטוח‪ ,‬תקופת‬ ‫האשפוז ואורך האשפוז בבתי חולים‬ ‫פסיכיאטריים‪ :‬המקרה הישראלי‬ ‫א' בודנר‪ ,‬ע' שראל‪ ,‬ע' גילת‪ ,‬י' יאנקו‪ ,‬רחובות‬

‫רקע‪ :‬על פי אמות המידה הנוכחיות ברפואה מודרנית‪ ,‬קבלת‬ ‫החלטות רפואית נאלצת לעתים קרובות לציית לתנאים‬ ‫שנקבעים על ידי ספק הביטוח‪ .‬בתחום הפסיכיאטרי קיימת‬ ‫נטייה לקיצור האשפוזים הפסיכיאטריים אשר נובעת‪ ,‬לפי‬ ‫חלק מהדעות‪ ,‬עקב לחצים הקשורים לכיסוי הביטוחי‪ .‬לחיילי‬ ‫צה"ל יש ביטוח רפואי מקיף שמספק הצבא‪ ,‬וביטוח זה כולל‬ ‫תשלום מלא עבור אשפוזים פסיכיאטריים‪ .‬לעומת זאת‪,‬‬ ‫אזרחים ישראלים מבוטחים על ידי הממשלה על פי שיטת‬ ‫תשלום גלובלית‪ .‬מחקר זה כוון לבחון את ההבדלים בין שתי‬ ‫‪318‬‬

‫קבוצות אלו‪ ,‬במונחים של אורך האשפוז (א"א) בבתי חולים‬ ‫פסיכיאטריים‪.‬‬ ‫שיטות‪ :‬נתונים לגבי קבלות פסיכיאטריות של חיילים‬ ‫(גילאי ‪ ,)21-18‬המשתרעים על פני ‪ 30‬השנים שעברו‪ ,‬הושגו‬ ‫מתוך קובץ הנתונים של הצבא (‪ .)n=2,106‬נתונים תואמים‬ ‫נאספו לגבי אשפוזים פסיכיאטריים ראשונים של קבוצת‬ ‫אזרחים תואמת (‪ .)n=6,556‬נעשתה השוואה של ממוצע א"א‬ ‫בין הקבוצות‪.‬‬ ‫תוצאות‪ :‬אורך האשפוזים של אזרחים היה משמעותית ארוך‬ ‫יותר מאשר אורך האשפוז של חיילים‪ .‬יתר על כן‪ ,‬אורך האשפוז‬ ‫בשתי הקבוצות פחת בין שנות השבעים לבין שנות התשעים‪,‬‬ ‫והירידה נצפתה לגבי כל האבחנות‪ ,‬ללא קשר לחומרתן‪.‬‬ ‫דיון‪ :‬אנו מסיקים כי בעידן תקופת הביטוח הרפואי‪,‬‬ ‫שיקולים כלכליים מקבלים לעתים זכות קדימה על פני שיקולים‬ ‫פסיכיאטריים‪ ,‬ללא קשר לדרגת החומרה של המחלה‪ .‬התהליך‬ ‫המקביל נראה בנטייה הכללית לדה–מיסוד בארצות הברית‪,‬‬ ‫בקנדה ובאירופה‪.‬‬ ‫הערכה עצמית של זמן ביצוע לעומת זמן ביצוע‬ ‫ממשי בקרב קשישים עם חשד לליקוי קוגניטיבי‬ ‫מתון (‪ :)Mild Cognitive Impairment‬היבט קליני‬ ‫י' הייניק‪ ,‬ל' אילון‪ ,‬תל אביב‬

‫רקע‪ :‬הערכת מעבר הזמן זכתה לתשומת לב גבולית באבחון‬ ‫הפסיכיאטרי בן זמננו‪ .‬קיימת אי–הסכמה לגבי יכולתם של‬ ‫קשישים עם דמנציה‪ ,‬במיוחד מסוג אלצהיימר‪ ,‬להעריך את‬ ‫מעבר הזמן‪ .‬חסרים נתונים על אודות יכולתם של קשישים‬ ‫להעריך את מעבר הזמן בשלבים המוקדמים של הפגיעה‬ ‫הקוגניטיבית‪.‬‬ ‫מטרה‪ :‬בדקנו את ההשערה ולפיה אנשים עם דמנציה‬ ‫מתונה מתפקדים גרוע יותר מאשר אנשים ללא ליקויים‬ ‫קוגניטיביים‪ ,‬ואנשים עם ליקויים קוגניטיביים מתונים (‪)MCI‬‬ ‫ממוקמים באמצע מבחינת יכולתם לדייק בהערכת מעבר הזמן‬ ‫ביחס לאנשים עם דמנציה או אנשים עם תפקוד קוגניטיבי‬ ‫תקין‪ .‬מטרה נוספת הייתה לבחון את המנבאים (הקוגניטיביים‪,‬‬ ‫התפקודיים והפסיכיאטריים) להערכה עצמית של זמן ביצוע‬ ‫לעומת זמן הביצוע הממשי‪.‬‬ ‫שיטה‪ :‬במסגרת הערכה פסיכו–גריאטרית מקיפה‪,‬‬ ‫נקבעו שלושה מדדים לזמן ביצוע‪ :‬זמן ביצוע ממשי‪ ,‬הערכה‬ ‫סובייקטיבית של זמן ביצוע‪ ,‬ודיוק ההערכה לזמן ביצוע‪.‬‬ ‫תוצאות‪ :‬הוערכו ‪ 102‬אנשים (בדיקות עוקבות) עם חשד‬ ‫ל–‪ .MCI‬האבחנות הקוגניטיביות הסופיות היו‪ :‬דמנציה ‪49 -‬‬ ‫(‪ ,MCI - 36 (35% ,)48%‬ללא ליקוי קוגניטיבי (‪NCI] - 17‬‬ ‫‪ .)[17%‬אף על פי שהיו הבדלים משמעותיים בין הקבוצות‬ ‫(דמנציה‪ )MCI, NCI ,‬בכל המדדים הקוגניטיביים והתפקודיים‪,‬‬ ‫לא היו הבדלים משמעותיים בין הקבוצות בכל הקשור לשלושת‬ ‫המדדים של זמן הביצוע‪ .‬פרט לגיל‪ ,‬לא נמצא כל קשר בין הערכת‬ ‫זמן ביצוע למשתנים דמוגרפיים או למשתנים קליניים אחרים‪.‬‬

‫)‪Isr J Psychiatry Relat Sci - Vol. 47 - No 4 (2010‬‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫סקר על בריאות הנפש בקרב‬ ‫בני נוער בישראל‪ :‬מטרות ושיטות‬ ‫א' מנסבך־קליינפלד‪ ,‬ד' לוינסון‪ ,‬א' אפטר‪ ,‬י' לבב‪ ,‬ר' כנאענה‪ ,‬נ'‬ ‫שטיין‪ ,‬ר' ארהרד‪ ,‬ח' פלטי‪ ,‬ר' חואלד‪ ,‬א' פוניזובסקי‪ ,‬ירושלים‬

‫מטרות‪ :‬הסקר על בריאות הנפש בקרב בני נוער בישראל נועד‬ ‫לאמוד את שכיחות ההפרעות הנפשיות‪ ,‬דפוסי הקו–מורבידיות‬ ‫והיקף הפנייה לטיפול‪ .‬כמו כן‪ ,‬הסקר עוסק בנושאים של‬ ‫בריאות כללית ורקע סוציו–אקונומי ובקשר שלהם לשכיחות‬ ‫ההפרעות הנפשיות‪ .‬המאמר הנוכחי מתמקד בתיאור השיטה‪.‬‬ ‫שיטה‪ :‬ראיונות אישיים עם מדגם מייצג של ‪ 957‬בני נוער‬ ‫בגילאי ‪ ,17-14‬וראיונות נפרדים עם האמהות של אותם‬ ‫בני נוער‪ ,‬נערכו במהלך השנים ‪ 2005-2004‬בבתי הנסקרים‪.‬‬ ‫הראיונות התבססו על השאלונים לאבחון הפרעות נפשיות‬ ‫‪ SDQ-H‬ו–‪ ,DAWBA‬בתוספת שאלות בנושאים של בריאות‬ ‫כללית ופנייה לטיפול‪.‬‬ ‫תוצאות‪ :‬אחוז ההיענות הכולל היה ‪ .68.2%‬אחוז ההיענות‬ ‫היה גבוה יותר בקרב בנים (‪ )71.3%‬בהשוואה לבנות (‪,)65.2%‬‬ ‫ובקרב המתגוררים ביישובים ערביים (‪ )89.6%‬בהשוואה‬ ‫למתגוררים ביישובים יהודיים או מעורבים (‪.)62.5%‬‬ ‫סיכום‪ :‬הסקר על בריאות הנפש בקרב בני נוער בישראל‬ ‫תרם מאגר מידע ארצי ראשוני המאפשר לחקור את שכיחות‬ ‫ההפרעות הנפשיות בקרב הנוער ולמפות את הגורמים הקשורים‬ ‫בהן‪ .‬מאגר זה הוא צעד ראשון בתכנון פעילות מניעה וטיפול‬ ‫בהפרעות נפשיות בקרב הנוער בישראל‪.‬‬ ‫דיכאון לאחר לידה‪ :‬מהלכים‬ ‫בפיתוח מדיניות בריאות‬ ‫ש' גלסר‪ ,‬רמת גן‬

‫המאמר הנוכחי מציג דוגמה של הדרך שהובילה מזיהוי בעיה‬ ‫בבריאות הציבור ברמת שירות בריאות ראשוני‪ ,‬לחקר הנושא‬ ‫כדי לאמוד את היקף הבעיה וגורמי הסיכון‪ ,‬דרך הפצת‬ ‫הממצאים‪ ,‬ועד לפיתוח ויישום מדיניות מתאימה‪ .‬הדוגמה‬ ‫המובאת כאן הינה דיכאון לאחר לידה‪ ,‬נושא ביו–פסיכו–סוציאלי‬ ‫שיש לו השלכות שליליות על היולדת‪ ,‬התינוק והמשפחה כולה‪.‬‬ ‫במקרה זה‪ ,‬זיהוי הבעיה על ידי אחיות בריאות הציבור הוביל‬ ‫לביצוע מחקר אפידמיולוגי‪ .‬ממצאי המחקר עודדו את משרד‬ ‫הבריאות לבצע תוכנית חלוץ (פיילוט) לאיתור על ידי סינון‬ ‫והתערבות מקודמים בקרב נשים הרות ויולדות המדווחות על‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,47‬מס' ‪2010 ,4‬‬

‫סממני דיכאון‪ .‬בהתבסס על ממצאי תוכנית החלוץ‪ ,‬החליט‬ ‫משרד הבריאות להרחיב את התוכנית לתחנות "טיפת חלב"‬ ‫ברחבי הארץ‪ .‬נוסף על כך‪ ,‬יחידות לימוד בנושא "דיכאון‬ ‫לאחר הלידה‪ ,‬איתור והתערבות" נכללו בקורסים על–בסיסיים‬ ‫להכשרת אחיות בריאות הציבור‪ .‬כמו כן‪ ,‬שירותי בריאות‬ ‫כללית אימצו את התוכנית ומקדמים אותה במרפאות לבריאות‬ ‫האישה ולבריאות הילד ברחבי הארץ‪ .‬ניסיון ישראלי זה יכול‬ ‫להוות דוגמה של בעיה שאותרה ברמה המקומית שהתפתחה‬ ‫למדיניות ארצית‪.‬‬ ‫מינוי אפוטרופוס‪ :‬מצב נוכחי בישראל‬ ‫י' מלמד‪ ,‬ל' ירון־מלמד‪ ,‬י' הייניק‪ ,‬נתניה‬

‫מינוי אפוטרופוס הינו תהליך חשוב ומורכב אשר פוגע‬ ‫משמעותית בעצמאותו של אדם ובחירותו מחד גיסא‪ ,‬אך‬ ‫מאידך גיסא מספק התערבות פטרנליסטית הכרחית כאשר‬ ‫הוא נחוץ‪ .‬החוק אינו מספק קריטריונים מדויקים למינוי‬ ‫אפוטרופוס‪ .‬רופאים ניסו לקבוע קריטריונים הנחוצים כדי‬ ‫להתחיל בתהליך‪ .‬המחברים מציגים סקירה של היבטים שונים‬ ‫של הערכת הצורך באפוטרופסות ותהליך מינוי אפוטרופוס‬ ‫לאנשים מבוגרים בישראל‪ .‬המסמך הרפואי שבסופו של דבר‬ ‫יקבע את הצורך למינוי אפוטרופוס לקשיש צריך להיות תוצר‬ ‫של הערכה רפואית וקוגניטיבית מקיפה‪ ,‬וכן הערכה מדויקת‬ ‫ככל האפשר של כשירות‪.‬‬ ‫איכות חיים הקשורה בבריאות‬ ‫כשנתיים לאחר פגיעת טרור‬ ‫מ' טוכנר‪ ,‬ז' מינר‪ ,‬ש' פרוש‪ ,‬ע' הרטמן־מאיר‪ ,‬ירושלים‬

‫רקע‪ :‬בשנים האחרונות הפכו אירועי טרור למציאות קשה‬ ‫ברחבי העולם‪ .‬קיים מחסור בולט בספרות בנוגע להשלכות‬ ‫ארוכות הטווח של פגיעה פיזית כתוצאה מטרור‪ ,‬תת–קבוצה‬ ‫ייחודית של נפגעי טראומה‪ .‬מטרת המחקר הנוכחי הינה לתאר‬ ‫את איכות החיים הקשורה בבריאות בטווח הארוך לאחר פגיעת‬ ‫טרור ולבחון את הקשרים בין תסמונת פוסט–טראומטית‪,‬‬ ‫סטטוס עיסוקי וחומרת הפגיעה לבין איכות החיים‪.‬‬ ‫שיטה‪ :‬המחקר כלל ‪ 35‬נפגעי טרור החיים בקהילה‪ ,‬שנתיים‬ ‫בממוצע לאחר הפגיעה‪ ,‬גיל ממוצע במעקב ‪ 32.1±13.8‬שנים‬ ‫שסבלו מפגיעה פיזית קשה מאד עם ממוצע חומרת פגיעה‬ ‫(‪ .)ISS=27±14.2‬כל הנבדקים טופלו במחלקת שיקום בבית חולים‬ ‫כללי בתקופה שבין ספטמבר ‪ 2000‬ליוני ‪ .2004‬רוב הנבדקים‬ ‫סבלו מפגיעה רב–מערכתית‪ .‬מדדי התוצאה העיקריים היו‬ ‫שאלון לאיכות חיים הקשורה בבריאות (‪ ,)SF-36‬שאלון לאבחון‬ ‫‪319‬‬