Psy 2 15 low by MEDIC

israel journal of

psychiatry

Vol. 52 - Number 2 2015

ISSN: 0333-7308

Editorial: Contemporary Psychosocial Interventions for Psychosis Bitya Friedman and Pesach Lichtenberg

Academic-Industry Partnerships in Alcohol and Gambling Dan J. Stein

Depression, Risk Factors for Insulin Resistance and Diabetes Incidence in a Large U.S. Sample James E. Gangwisch et al.

Psychopathology and its Early Impact on Parenting Behaviors in Mothers Miri Keren and Sam Tyano

100

Severe Internalizing and Disruptive Disorders from Preschool into Adolescence Sara Spitzer et al.

107

Dual Evaluation/Intervention Program for Morbidly Obese Adolescents Silvana Fennig et al.

114

Dental Health and the Type of Antipsychotic Treatment Alexander Grinshpoon et al.

119

Psychiatric Disorders and Dental Health in Jerusalem Rena Cooper-Kazaz et al.

121

HCR-20 Scale for Assessing Risk of Violent Behavior David Ivgi et al.

129

Negative and Positive Automatic thoughts in Social Anxiety Disorder Iulian Iancu et al.

137

Voluntary Departure of Family Physicians from their Workplace Yuval Shorer et al.

israel journal of

psychiatry

The Official Publication of the Israel Psychiatric Association Vol. 52 - Number 2 2015

and related sciences EDitor

David Greenberg

78 > Editorial: Contemporary Psychosocial Interventions for Psychosis

DEPUTY EDITORS

Bitya Friedman and Pesach Lichtenberg

Doron Gothelf Yoav Kohn Ivonne Mansbach Ora Nakash Shaul Lev-Ran David Roe Rael Strous Book reviews editor

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Omer Bonne Elliot Gershon Talma Hendler Ehud Klein Shlomo Mendlovic Ronnen Segman Eliezer Witztum Gil Zalsman Zvi Zemishlany International Advisory Board

Paul Appelbaum Dinesh Bhugra Yoram Bilu Boris Birmaher Aaron Bodenheimer Stephen Deutsch Carl Eisdorfer Michael First Helen Herrman Julian Leff Ellen Liebenluft John Mann Phyllis Palgi Soumitra Pathare Daniel Pine Bruce Pollock Dan Stein Robert Wallerstein Myrna Weissman Associate editor

Rena Kurs

Assistant Editor

Joan Hooper

Marketing: MediaFarm Group +972-77-3219970 23 Zamenhoff st. Tel Aviv 64373, Israel amir@mediafarm.co.il www.mediafarm.co.il

81 > Academic-Industry Partnerships in Alcohol and Gambling: a Continuum of Benefits and Harms

Dan J. Stein

85 > Differential Associations Between Depression, Risk Factors for Insulin Resistance and Diabetes Incidence in a Large U.S. Sample James E. Gangwisch, Raz Gross and Dolores Malaspina

92 > Psychopathology and its Early Impact on Parenting Behaviors in Mothers: The Interface between Adult and Infant Psychiatry

Miri Keren and Sam Tyano

100 > The Outcome of Severe

Internalizing and Disruptive Disorders from Preschool into Adolescence: A Follow-up Study

Sara Spitzer, Ornit Freudenstein, Miriam Peskin, Sam Tyano, Assaf Shrira, Tova Pearlson, Aviad Eilam, Gil Zalsman, Tamar Green and Doron Gothelf

114 > Dental Health and the Type of Antipsychotic Treatment in Inpatients with Schizophrenia

Alexander Grinshpoon, Shlomo P. Zusman, Abraham Weizman and Alexander M. Ponizovsky

119 > Severity of Psychiatric Disorders and Dental Health Among Psychiatric Outpatients in Jerusalem, Israel

Rena Cooper-Kazaz, Dan H. Levy, Avraham Zini and Harold D. Sgan-Cohen

121 > Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients David Ivgi, Arie Bauer, Razek Khawaled, Paola Rosca, Joshua M. Weiss and Alexander M. Ponizovsky

129 > Negative and Positive Automatic thoughts in Social Anxiety Disorder Iulian Iancu, Ehud Bodner, Samia Joubran, Yelena Lupinsky and Damian Barenboim

137 > Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook

Yuval Shorer, Aya Biderman, Stanley Rabin, Aharon Karni, Ayelet Levi and Andre Matalon

145 > Book Reviews

107 > Feasibility of a Dual Evaluation/ Intervention Program for Morbidly Obese Adolescents Silvana Fennig, Anat Brunstein-Klomek, Ariel Sasson, Irit Halifa Kurtzman and Arie Hadas

Hebrew Section

148

> Abstracts

Life Vera Novitsky This drawing was inspired by the poem, “Memory,” by the Russian poet Nikolai Gumilev: “Snakes shed their skins and their souls grow mellow. We do it differently, we change souls, not bodies.” I have drawn myself at different moments in my life: as a bespectacled child with a book, as a pretty young girl, as a mother with a saucepan in my hand, and what awaits me as a calm older woman. All these women are so different, but they are me, on one tree of life.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Editorial: Contemporary Psychosocial Interventions for Psychosis The attitude of society and professionals toward psychosis has undergone major changes over the past century. The first significant “paradigm shift” in this field rejected psychotherapeutic approaches which were common in the middle of the last century and promoted instead the medicalization of psychosis, which came to be viewed as a brain disorder. The second revolution, with the advent of antipsychotics, came in the form of de-institutionalization. It enabled a shift away from the asylums and sharply reduced the number of psychiatric hospital beds. However, the effect of this second paradigm shift has plateaued (1). Extraordinary developments in neurobiological research have not been translated into major progress in the understanding and treatment of psychosis. Disenchantment with the possibly oversold potential of neuroscience for unlocking the mysteries of mental illness has fostered a search for non-biological alternatives. A growing awareness of the potential harm resulting from the long term use of antipsychotic medication – including the specter of widespread brain atrophy (2) and increased mortality (3) – has been a further source of concern and a prod for creative solutions. Accordingly, numerous projects and treatment programs featuring psychosocial interventions have been implemented. This has been particularly prominent in the treatment of early psychosis, with the hope of altering the trajectory of the illness by reducing relapse and enhancing functioning. Disappointingly, a comprehensive Cochrane review from 2012 (4) failed to distinguish specific programs or types of treatment as superior to others. The reason may have been methodological, and the reviewers conclude that there is a need for more extensive research. Perhaps what is needed now in addition to continued research is a change of perspective. The Recovery movement (5) offers one such possibility. The Recovery model focuses on the individual’s strengths rather than disabilities, and encourages the person diagnosed with a psychotic disorder to seek a sense of meaning and purpose despite the limitations caused by his illness, with the aim of learning to lead a satisfying life and to contribute to society. Inspired by this model, an increasing number of professionals and service-users have stopped referring to psy78

chosis simply as a medical disease. Instead, they choose to address the person in the throes of psychosis as suffering from a crisis, understandable in the context of his subjective experience and personal history. With this approach, the therapeutic goals are not defined as providing symptomatic relief and facilitating speedy functional rehabilitation. Rather, therapy strives to maintain social contact with the person and to jointly understand the meaning and the context of the psychotic experience. We will briefly discuss two models consistent with these changes of approach, which have been gaining traction in recent years. Open Dialogue An innovative psychosocial approach which has been developed in an attempt to intervene at the early stages of severe mental crises is the Finnish Open Dialogue (OD) program (6-8). A key element of the OD program is the provision of integrated community-based care involving the patient’s social network from the start. A crisis intervention team - including two or three trained professionals such as a psychiatrist, social worker or nurse - is assembled within 24 hours of first contact. The team then strives to engage the psychotic person and members of her family and support system as equal partners in the therapeutic process. A series of network meetings are conducted, daily at first, less frequently as the condition stabilizes, though the team remains the treatment address for years afterwards, providing invaluable continuity of care. The strength of OD is that in the course of the repeated dialogical sessions, the behavior of the psychotic individual whose condition spurred the family to seek care comes to be seen by all participants, family and professionals alike, as emerging from the context of family communication. By “dialogical” is meant that all voices are given a hearing without any prejudgment: the family, the apparently psychotic individual, even her psychotic voices, are heard and validated. Communication is completely transparent; in a characteristic move, one therapist might turn to another and reflect aloud about her attempt to understand the meaning of what has been said. Needless to say

Bitya Friedman and Pesach Lichtenberg

the psychotic individual is present and hears everything: the rule is “nothing about me without me.” All decisions are taken consensually, including the administration of medication. Over several such meetings, apparently aberrant expressions may reveal their meaning and become accessible, coherent communication for all participants. Practitioners of OD have made impressive claims of success in preventing hospitalization and improving long term psychosocial adaptation in the catchment area of Western Lapland, where it is an integral part of the public mental health care system (8, 9). Though the definitive study has yet to be done, OD is being adapted to various locales around the world, and has produced early stirrings of interest here in Israel. Community alternatives to acute inpatient care Deinstitutionalization has stalled at the doors of the inpatient ward, where conditions are still too often characterized by overcrowding of patients, a dreary physical environment, staff overtaxed and under-trained, and the use of medication as the mainstay of treatment. An alternative is the community homes for the treatment of the acutely psychiatrically ill which have been established in several places in the world (10). Many of these homes draw their inspiration from R.D. Laing’s early work with psychotic individuals and from the Soteria homes initially founded in the 1970s by Lauren Mosher, then the psychiatrist in charge of schizophrenia research at the National Institute of Mental Health. Mosher developed an “interpersonal phenomenology” which stressed a non-judgmental “being with” the patient as he goes through a psychotic crisis (11). These homes are generally characterized by a lack of hierarchy, a de-emphasis of the distinction between mentally ill and normal, a reclaiming of the psychotic experience within the realm of human experience, and the continual striving to maintain contact with the psychotic individual. In keeping with these principles, the number of residents is limited to under ten, meals are shared, the house is jointly maintained, a homey atmosphere is fostered, formal psychotherapy is not necessarily offered, staff is chosen more for ability to establish contact with individuals in psychotic states than on the basis of professional credentials, and shifts are as long as 48 hours in order to promote continuity of care. Several research studies have been undertaken, some of them randomized, which overall suggest that the short term clinical outcome is as good as in conventional inpatient settings, the sense of self-stigma is greatly lessened,

lower doses of medication are prescribed, and long-term psychosocial adjustment may be enhanced (12). The effort to establish Soteria in Israel has received official approval from the Ministry of Health and a Soteria-inspired treatment residence is expected to be set up as a pilot in the Jerusalem area in the near future. Conclusion Some have referred to the shift from psychological to pharmacological modes of understanding and treating mental disorders as a switch from a “brainless” to a “mindless” psychiatry (13). The sobering awareness of the limitations of focusing too exclusively on the brain has resulted in a renewed interest in psychological and social theories of psychosis. However, were the pendulum to return to a “brainless” psychiatry, we would lose the rich insights that the neurosciences have to offer and which may yet advance the practice of psychiatry. Fortunately, historical pendulums don’t usually work that way. More likely, a richer and more comprehensive understanding of the brain will ideally encompass not only the parenchyma within the skull, but all that it perceives in space and remembers in time, and the effects that environment can have upon the person, for better or worse. Perhaps the time has come to let go of the debate about whether best to adopt biological or psychosocial approaches to mental illness. Many similar dichotomies which once exercised mental health professionals, like nature/nurture, or mind/body, are being gradually integrated into more complex, nuanced modes of understanding. While some have enthusiastically advocated that psychiatry be replaced by clinical neuroscience (14), the recent innovations in psychosocial interventions for psychosis suggest that the irreducibly subjective phenomena of the mind will continue to demand our clinical attention and to inform our therapeutic efforts. Bitya Friedman bitbit50@walla.com

Pesach Lichtenberg Herzog Hospital and the Hebrew University of Jerusalem, Israel

References 1. McGlashan TH. Treatment timing vs. treatment type in first-episode psychosis: A paradigm shift in strategy and effectiveness. Schizophr Bull 2012;38:902–903. 2. Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term antipsychotic treatment and brain volumes: A longitudinal study of

Editorial: Contemporary Psychosocial Interventions for Psychosis

first-episode schizophrenia. Arch Gen Psychiatry 2011;68:128-137 3. Weinmann S, Read J, Aderhold V. Influence of antipsychotics on mortality in schizophrenia: Systematic review. Schizophr Res 2009; 113:1–11. 4. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.:CD004718. DOI: 10.1002/14651858.CD004718.pub3. 5. Slade M. Personal recovery and mental illness: A guide for mental health professionals. Cambridge, UK: Cambridge University Press, 2009. 6. Olson M, Seikkula J, Ziedonis, D. The key elements of dialogic practice in open dialogue. Worcester, Mass.: University of Massachusetts Medical School, 2014. 7. Seikkula J. and Olson M. The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process 2003;42: 403–418. 8. Seikkula J, Aaltonen J, Alakare B, Haarakanga K, Keranen J, Lehtinen K. Five-year experience of first-episode nonaffective psychosis in open-

dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research 2006;16:214-228. 9. Seikkula J, Alakare B, Aaltonen J. The comprehensive open-dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis 2011;1–13. 10. Lichtenberg P. The residential care alternative for the acutely psychotic patient. Psychiatr Q 2011;82:329-341. 11. Mosher L, Hendrix V, Fort DC. Soteria: Through madness to deliverance. Philadelphia: Xlibris, 2004. 12. Calton T, Ferriter M, Huband N, Spandler H. A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia. Schizophr Bull 2008;34:181-192. 13. Eisenbery L. mindlessness and brainlessness in psychiatry. Br J psychiatry 1986;148:497-508. 14. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA 2005;294:2221-2224.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Dan J. Stein

Academic-Industry Partnerships in Alcohol and Gambling: a Continuum of Benefits and Harms Dan J. Stein, MD, PhD Dept. of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa

There are many reasons why collaboration between academic institutions and private industry should be encouraged. At the same time, such collaborations raise the potential for profound conflicts of interest. Furthermore, there may be different kinds of issues in different kinds of industry, as is reflected in the metaphors we employ to think about them. The pharmaceutical industry is at times viewed as a “good” industry that can go wrong, while the tobacco industry is analogously viewed as a “bad” industry that can do little right. The alcohol and gambling industries may be particularly useful to think through insofar as they arguably require a continuum of benefits and harms to be acknowledged. I consider a number of initiatives by the alcohol and gambling industry in South Africa, and argue that there are real opportunities for delineating and developing more robust models of academic-industry collaboration, which ensure that public health is maximized in that country and elsewhere.

At the same time, academic-industry collaborations raise the potential for conflicts of interest. Certainly, in the case of psychiatry, conflicts of interest have received increasingly critical attention (2, 3). There may be strong incentives for academic clinicians to accept funding for research from particular companies, for example, in exchange for presenting biased views of a particular pharmaceutical product. Examination of particular cases of collaboration of academic psychiatrists with industry indicates that increasing public health and private profit can at times be mutually exclusive (4). In this paper we focus on academic relationships with the alcohol and gambling industries specifically. We argue that these are particularly useful industries “with which to think” (5), insofar as they do not fit easily into the typical categories of “good” and “bad” industries, but rather fall on a continuum of benefits and harms. Work with these industries therefore relies on, and calls for, the delineation and development of more robust models of academicindustry collaboration to ensure that public health is maximized. We compare two exemplars of academic-industry collaborations in South Africa in order to help consider optimal ways forwards in this contentious area.

Academic institutions and academic clinicians have a mandate to teach and to do research. Private industry has a mandate to produce products and to make a profit. Despite these differences, there are many reasons for academia and industry to collaborate. Indeed, the Bayh-Dole Act in the United States encouraged universities to patent inventions that resulted from publically funded research and to issue licenses to private companies, and other countries have subsequently adopted similar legislation (1). The underlying assumption of such collaboration in the clinical sphere is that maximizing public health and private profit are not incommensurable goals.

Idealizations of Industry Human categories often involve typical and atypical examplars (6). For example, robins and sparrows are typical birds, while ostriches and owls are atypical ones. Where exemplars are atypical, humans may experience more difficulties in thinking efficiently and clearly; we are slower, for example, to classify owls and ostriches than we are to classify robins and sparrows (7). Here I want to put forwards an idealization of a typically “good” industry, and of a typically “bad” industry. I will argue that the alcohol and gambling industries are atypical, insofar as they have elements of both “good” and bad.” While it is perhaps

Abstract

Address for Correspondence: Cape Town 7925, South Africa

Prof. Dan Stein, Dept. of Psychiatry, Groote Schuur Hospital J2, University of Cape Town, Anzio Rd., Observatory, dan.stein@uct.ac.za

Academic-Industry Partnerships in Alcohol and Gambling: a Continuum of Benefits and Harms

therefore harder to think clearly about these industries, it is important to do so. The typically “good” industry is one which works hard for the benefit of mankind. The better the products of such an industry for health, the more profitable are the component businesses. The role of the academic clinician is to share his or her knowledge and expertise, so that the industry moves quickly to make more profits. There is therefore a strong case for collaboration between academia and industry, and indeed such collaboration is prized. The pharmaceutical industry is seen by many as just that kind of industry, with academic clinicians valuing collaborative opportunities. However, there are times that industry acts in a way that is contrary to patient interests (e.g., ignoring negative trials or important adverse effects). Academics then attempt to impose additional regulatory measures, e.g., transparent reporting of conflicts of interest, public availability of trial databases. Kopelman et al (8) identified 285 reviews from 10 high-impact journals in psychiatry and 2 in general medicine. Disclosures were reliably coded as biotechnology/pharmaceutical/other material interests, nonprofit/government, communication companies, or other. The authors in both types of journals frequently reported industry ties. However, the reviews in the psychiatric journals were significantly less likely to include industry-related disclosures (32% of the reviews; 18% of the authors). Some industries are viewed as essentially “bad” or “evil.” Thus the industry works only for profits at the expense of mankind. The worse the products of such an industry for health, the more profitable are the component businesses. The academic clinician can have no collaborative role here, he or she must insist that the industry limit production. The tobacco industry is viewed in this light, with academic clinicians viewing tobacco sponsorships of any kind (e.g., at sports events) as “dirty money,” and insisting that any scientific work is mediated by government in order to ensure that there is no direct collaboration. This “non-association model” (9) holds that while government may need to maintain some relationships with industry (e.g., to monitor standards and comply with regulations), engagement of health academics with the industry must be indirect. The alcohol and the gambling industry are arguably “atypical,” in that there are seemingly both “good” and “bad” components. On the one hand, these industries are associated with many benefits, including employment, leisure, tax revenues, etc. On the other hand, alcohol and gambling are both associated with significant problems 82

for certain individuals, and indeed for society as a whole. Partnerships with these industries therefore run several kinds of risks, including unacceptable kinds of conflict, failure to recognize differences in power, inappropriate government-industry alliances, fragmentation of the health sector, and silencing of dissent (9). The precise health outcomes of industry products may depend on the nature of the models that government and academia develop for working with the industry, and the extent of harm reduction which results. Two Industries in South Africa The alcohol industry in South Africa is enormously successful from the perspective of its shareholders. South African Breweries is one of the biggest breweries in the world. Wine farms in the Western Cape are an important part of the national economy, contributing to local employment and to foreign tourism. At the same time, alcohol-related problems are immensely costly to individuals and to the country as a whole, resulting as they do in a broad range of problems, including the world’s highest rates of fetal alcohol syndrome, as well as very high rates of alcohol-associated interpersonal violence and motor vehicle collisions. Current calculations indicate that the alcohol industry is very costly for the country’s economy. To date, the extent of interaction between academic clinicians and the alcohol industry is not particularly well documented. One exception is industry funding of the Foundation for Alcohol Related Research (FARR), which has focused on research on fetal alcohol syndrome. For those who value alcohol-academia collaboration, this would be an exemplar of how industry funds can be used to highlight an alcohol-related problem, and to help to think through the most appropriate interventions. For those who are more sceptical, this exemplar instantiates the view that industry only provides funding for certain kinds of issue, and fails to address many key research and policy questions (10-15). The gambling industry in South Africa has only been legalized in recent years. During apartheid, gambling was permitted in some of the so-called “homelands.” However, with the advent of democracy, gambling was allowed throughout the country. Once again, this is associated with a range of positive effects, including local employment, as well as negative outcomes, including pathological gambling. With this in mind, industry funds were used to establish a National Responsible Gambling Foundation, which provided education on gambling, did research on the scope

Dan J. Stein

of gambling in the country, and offered free treatment to those suffering from pathological gambling (16). A good deal of the NRGF work has been undertaken in collaboration with academia. For example, research on prevalence of pathological gambling was done by researchers based at the University of Cape Town. More recently the NRGF funded a Fellowship in Addiction Psychiatry at the University (in the interests of rigorous disclosure, it is important to emphasize that I helped negotiate this post, and have helped mentor the research on gambling done by this Fellow). While industry is arguably interested more in profit maximization than harm reduction, the model instantiated by the NRGF allows for at least some harm reduction, and academic clinicians have contributed to this effort (17). A Way Forward Academic clinicians, including those working in psychiatry, find themselves facing a broad range of potential conflicts of interest, both financial and non-financial (2). In the case of the pharmaceutical industry such conflicts of interest have been well documented, and a range of standard practices have emerged in order to help ensure optimal outcomes (e.g., disclosure by clinicians of their interests, disclosure by industry of negative trials) (18). Similarly, in the case of the tobacco industry, stringent rules have emerged to help ensure that academics do not help contribute to smoking-related harms (15). In the case of the alcohol industry, there is a growing sense that this industry has unfairly dictated the rules of academia-industry relationships, so that the potential benefits of such collaboration are far from realized (19). Thus, for example, the industry has focused its attention on particular kinds of research and policy, at the expense of addressing more effective ways of reducing harm (20). There is a real opportunity for industry to make larger and more robust contributions to improving the health of those who suffer from alcohol dependence, and so to help mitigate the enormous harm associated with alcohol. The South African experience confirms this view of the alcohol industry, and also offers an alternative exemplar of academic collaboration with the gambling industry. The NRGF, despite being funded by industry, has been able to provide some useful services, and to undertake some useful research (16). While the gambling industry is clearly committed to greater sales of its product (and so to more gamblers), corporate social responsibility also demands attention to harm reduction (21). It is important

to note, however, that such collaborations are dynamic; they entail a continuum of moral jeopardy (22), and at particular time points unmanageable conflicts of interest may emerge (23). Much further work is needed to determine how best to facilitate academic-industry collaborations in the areas of alcohol and gambling so that public health is maximized. Good models of such collaboration remain to be fully delineated and developed; these might arguably provide space for these industries to remain profitable, but also make a real and substantive contribution to mitigating addiction-related harms. Given the negative impacts of alcohol and gambling on individuals and on societies, it is incumbent on both industry and academia to produce and implement such models and to optimize public health (24-26). Such models need to spell out appropriate governance mechanisms, including establishing clear walls between marketing interests and research prioritization, and oversight of financial transactions, in order to avoid conflict of interests. Conclusion There are a range of opinions about the nature of philosophy, including bioethics (27). The approach taken here is unlikely to be one that will appeal to all. Nevertheless, the argument that philosophy in general, and ethics in particular, proceeds by delineating and adjudicating different metaphors is arguably consistent with data from the cognitive-affective neurosciences that emphasize the importance of metaphoric processes to thinking about categories, and our moral decision-making in relation such categories (28-30). While the specific exemplars of relationships between the alcohol and gambling industry noted here are drawn from the South African context, the argument is one which is intended to apply more broadly. When discussing relationships between academics clinicians and industry, it may be instructive to consider typical examples of “good” and “bad” industries. In the former case, the industry is generally thought to be focused on products that improve patient outcomes, and provided that certain measures are in place (e.g., transparency about relationships, availability of all data), collaborative models are supported. In the latter case the industry is generally thought to be focused on products that are harmful to individual and public health, and therefore a non-association model is needed (with no direct contact, and any association only occurring via a government agency). In practice, however, it would seem that many industries 83

Academic-Industry Partnerships in Alcohol and Gambling: a Continuum of Benefits and Harms

have aspects of both “good” and “bad,” as exemplified by the alcohol and gambling industries. Instead of conceptualizing funding as simply “clean” or “dirty,” we need a more complex model which emphasizes a continuum of jeopardy (22). It would seem useful to try to optimize ways of relating to industry that maximize patient and societal outcomes; while partnership models run important risks, given the potential conflicts of interest that arise, the non-association models that have been developed for “bad” industries are unlikely to encourage efficient collaboration. Thus there is a need for models which allow a sustainable and effective “third way,” acknowledging that many industries entail a continuum of benefits and harms, where all parties agree on the goal of maximizing health outcomes and/or reducing harms, and where there are structures and processes which monitor this goal and ensure that it is reached. Acknowledgements Prof. Stein is supported by the Medical Research Council of South Africa.

References 1. Sampat BN. Lessons from Bayh-Dole. Nature 2010;468: 755–756. 2. Maj M. Financial and non-financial conflicts of interests in psychiatry. Eur Arch Psychiatry Clin Neurosci 2010;260:S147–51. 3. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med 2010;85:68–73. 4. Insel TR. Psychiatrists’ relationships with pharmaceutical companies: Part of the problem or part of the solution? JAMA 2010;303:1192–3. 5. Papert S. Mindstorms: Children, computers and powerful ideas. New York: Harper Collins, 1980. 6. Lakoff G. Women, fire, and dangerous things: What categories reveal about the mind. Chicago, Ill.: University of Chicago, 1987. 7. Rosch E. Principles of categorization. E. Rosch & B. B. Lloyd, editors. Cognition and Categorization. Hillsdale, N.J.: Lawrence Erlbaum, 1978: pp. 27-48. 8. Kopelman AM, Gorelick DA, Appelbaum PS. Disclosures of conflicts of interest in psychiatric review articles. J Nerv Ment Dis 2013;201: 84–87. 9. Adams PJ, Buetow S, Rossen F. Vested interests in addiction research and policy poisonous partnerships: Health sector buy-in to arrangements with government and addictive consumption industries. Addiction 2010;105: 585–590. 10. Munro G. An addiction agency’s collaboration with the drinks industry: Moo Joose as a case study. Addiction 2004;99:1370–1374. 11. Babor TF. Alcohol research and the alcoholic beverage industry: Issues, concerns and conflicts of interest. Addiction 2009;104;S34–47.

12. Bakke Ø, Endal D. Vested interests in addiction research and policy alcohol policies out of context: Drinks industry supplanting government role in alcohol policies in sub-Saharan Africa. Addiction 2010;105:22–28. 13. Miller PG, de Groot F, McKenzie S, Droste N. Vested interests in addiction research and policy. Alcohol industry use of social aspect public relations organizations against preventative health measures. Addiction 2011;106: 1560–1567. 14. Jernigan DH. Global alcohol producers, science, and policy: The case of the International Center for Alcohol Policies. Am J Public Health 2012;102: 80–89. 15. Casswell S. Vested interests in addiction research and policy. Why do we not see the corporate interests of the alcohol industry as clearly as we see those of the tobacco industry? Addiction 2013;108: 680–685. 16. Collins P, Stein DJ, Pretorius A, Sinclair H, Ross D, Barr G, et al. Addressing problem gambling: South Africa’s National Responsible Gambling Programme. S Afr Med J 2011;101: 722–723. 17. Pasche SC, Sinclair H, Collins P, Pretorius A, Grant JE, Stein DJ. The effectiveness of a cognitive-behavioral intervention for pathological gambling: A country-wide study. Ann Clin Psychiatry 2013;25: 250–256. 18. Appelbaum PS, Gold A. Psychiatrists’ relationships with industry: The principal-agent problem. Harv Rev Psychiatry 2010;18: 255–265. 19. Babor TF, Robaina K . Public health, academic medicine, and the alcohol industry’s corporate social responsibility activities. Am J Public Health 2013;103:206–214. 20. Adams PJ. Addiction industry studies: Understanding how proconsumption influences block effective interventions. Am J Public Health 2013;103: e35–38. 21. Hancock L, Schellinck T, Schrans T. Gambling and corporate social responsibility (CSR): Re-defining industry and state roles on duty of care, host responsibility and risk management. Policy Soc 2008; 27:55-68. 22. Adams PJ . Assessing whether to receive funding support from tobacco, alcohol, gambling and other dangerous consumption industries. Addiction 2007;102: 1027–1033. 23. Adams PJ, Rossen. A tale of missed opportunities: Pursuit of a public health approach to gambling in New Zealand. Addiction 2012;107:1051– 1056. 24. Adams PJ, Raeburn J, de Silva K. A question of balance: prioritizing public health responses to harm from gambling. Addiction 2009;104: 688–691. 25. Livingstone C, Adams PJ . Harm promotion: Observations on the symbiosis between government and private industries in Australasia for the development of highly accessible gambling markets. Addiction 2011;106: 3–8. 26. Litten RZ, Ryan M, Falk D, Fertig J. Alcohol medications development: Advantages and caveats of government/academia collaborating with the pharmaceutical industry. Alcohol Clin Exp Res 2014; 38:1196-1199. 27. Overgaard S, Gilbert P, Burwood S. An introduction to metaphilosophy. Cambrige: Cambridge University, 2013. 28. Johnson M. Moral imagination: Implications of cognitive science for ethics. Chicago: University of Chicago, 1994. 29. Varela F. Ethical know-how: Action, wisdom, and cognition. Stanford: Stanford Universityr, 1999. 30. Lakoff G, Johnson M. Philosophy in the flesh: The embodied mind and its challenge to western thought. New York: Basic Books, 1999.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

James E. Gangwisch et al.

Differential Associations Between Depression, Risk Factors for Insulin Resistance and Diabetes Incidence in a Large U.S. Sample James E. Gangwisch, PhD,1 Raz Gross, MD,2 and Dolores Malaspina, MD1,3 1

Columbia University, College of Physicians and Surgeons, Department of Psychiatry, New York, New York, U.S.A. Columbia University, Mailman School of Public Health, Department of Epidemiology, and College of Physicians and Surgeons, Department of Psychiatry, New York, New York, U.S.A. 3 New York University, School of Medicine, Department of Psychiatry, New York, New York, U.S.A. 2

Abstract Background: Depression frequently co-occurs with diabetes. The associations between risk factors for insulin resistance and depression and diabetes can help determine the relative importance of factors that contribute toward the comorbidity. Method: Analyses of the NHANES I (n = 10,025) to examine the cross-sectional relationships between depression and risk factors for insulin resistance at baseline using logistic regression and to explore the longitudinal relationships between risk factors for insulin resistance and diabetes incidence using Cox proportional hazards modeling. Results: Many risk factors for insulin resistance were associated with depression and diabetes incidence. Depression was cross-sectionally associated with diabetes, but did not increase the risk for diabetes incidence. These counterintuitive results can be explained primarily by the differing relationships between risk factors for insulin resistance, depression, and diabetes. Limitations: Lack of repeated measures of depression. Conclusions: Lack of physical activity, hypertension, and inadequate sleep were the risk factors for insulin resistance with the highest associations with both depression and diabetes incidence.

INTRODUCTION Major depression is a heterogeneous disorder, yet up to 50% of those diagnosed with it have been found to have insulin resistance (1, 2). There are three primary explanations for the comorbidity between these two disorders. The first is that many behaviors or symptoms associated with depression are established risk factors for insulin resistance. Weight changes, appetite disturbances, and the over-consumption of sweets (3) are connected with depression. Depression is linked with fatigue, psychomotor retardation, lower physical fitness levels (4), and engagement in less physical activity (5). Depressed individuals often suffer from insomnia resulting in inadequate and disrupted sleep, which have been shown to compromise insulin sensitivity (6). Depression is often associated with early life stress and a history of chronic emotional stress (7) which have been shown to impair the bodyâ&#x20AC;&#x2122;s glucocorticoid negative feedback system to limit the production of cortisol (8, 9). About 50% of depressed individuals have been found to hypersecrete cortisol (10), an insulin antagonist (11). Depressed individuals have been found to be more likely to over consume alcohol (12) and to smoke cigarettes (13), which can compromise insulin sensitivity (14, 15). Various biological mechanisms by which insulin resistance could cause or exacerbate depressed mood represent a second explanation for the comorbidity between depression and insulin resistance (16). One mechanism is by diminishing insulinâ&#x20AC;&#x2122;s effects on catecholamines. Insulin promotes central catecholaminergic activity (17), perhaps by suppressing the reuptake of norepinephrine, prolonging its residence in the synaptic cleft (18). Another

Address for Correspondence: James Gangwisch, PhD, Assistant Professor, Columbia University, College of Physicians and Surgeons, Department of Psychiatry, 1051 Riverside Drive, Unit 4, New York, NY 10032, U.S.A. â&#x20AC;&#x2020; jeg64@columbia.edu

Depression, Insulin Resistance, and Diabetes

mechanism is through the impairment of insulinâ&#x20AC;&#x2122;s ability to promote brain serotonin synthesis. Tryptophan, a precursor for serotonin, competes with the other large neutral amino acids for the same transport system that moves them across the blood-brain barrier (19). Insulin stimulates the uptake of the competing large neutral amino acids, but not tryptophan, into muscle tissue increasing the ratio of tryptophan to the other large neutral amino acids in plasma. Tryptophan is then allowed access to the transport system to cross the blood brain barrier to contribute toward the synthesis of serotonin (20). A third explanation for the comorbidity between depression and insulin resistance is that they share some common antecedent such as prenatal exposure to stress or inadequate nutrition. Theories of prenatal programming, imprinting, and gene expression posit that the experience of stress or inadequate nutrition by the mother during pregnancy results in biochemical signals to the fetus that induce adaptations designed to optimize the potential for survival of the offspring under conditions of stress or malnutrition after birth (21). The adaptations from prenatal exposure to malnutrition can be maladaptive if food is abundantly available after birth leading to insulin resistance, obesity, and diabetes (22). Prenatal exposure to stress and resultant elevated glucocorticoids have been theorized to program a hyperactive hypothalamic-pituitary-adrenal axis (HPA) in the offspring (23). A hyperactive HPA axis would be adaptive for facing a stressful environment, but chronic stressors and an increased stress response can lead to depression and insulin resistance through chronically elevated glucocorticoids such as cortisol (24). There are few population based studies on the association between insulin resistance and depression in subjects without diabetes and their findings are contradictory, fueling the debate over the nature and direction of causality between these two disorders. Insulin resistance in subjects without diabetes was found to be negatively associated with depression in one study (25) and with suicide in another study (26), leading the authors to assert that insulin resistance could be protective against depression and suicide. Another cross-sectional study with subjects without diabetes showed insulin resistance to be positively associated with depression (27) while a prospective study found no relationship at all between insulin resistance and depression (28). Insulin resistance and the resultant increased load on the pancreas can lead to type 2 diabetes over time by compromising beta cell function. If depression is associated with insulin resistance then it would be expected that depression 86

of sufficient severity and duration would increase the risk of developing diabetes over time. Strong cross-sectional associations have been found between depression and diabetes with those suffering from diabetes being two to three times more likely to suffer from depression than those in the general population. However, these cross-sectional associations could be partially attributed to the psychosocial adjustments required to cope with a chronic medical condition and to the overlap of symptoms of diabetes and depression such as fatigue and changes in appetite and weight. Results from prospective population-based studies can help shed light on the contributions of these competing explanations on the comorbidity of depression and diabetes. By excluding subjects with known diabetes at baseline from analyses, the observed associations between depression and the onset of type 2 diabetes are unlikely to have resulted from stress associated with being diagnosed with a chronic medical condition or from the overlap of symptoms of diabetes and depression. Results from prospective population-based studies have varied though from no relationship between depression and diabetes incidence (29) to a strong relationship (30) making it difficult to disentangle these competing explanations for the comorbidity between depression and diabetes. In 2002 William Eaton (31) suggested that large-scale epidemiologic studies such as the NHANES be used to study the comorbidity between depression and diabetes by identifying, measuring, and prioritizing the mechanisms presumed to be responsible for the relationship. The NHANES I provides a unique opportunity to explore these issues because it has a large sample size, a longitudinal design, and includes measures for depression, many known risk factors for insulin resistance, diabetes, and incidence cases of diabetes over the follow-up period. The relationship between depression and diabetes has already been explored previously in the NHANES (32, 33). The primary goal of our study is to explore the differential associations between the risk factors for insulin resistance and depression at baseline and the diagnosis of diabetes over follow-up to help clarify their relative importance in the comorbidity between the two illnesses. SUBJECT METHODS Subjects

Subjects for this study were participants in the Epidemiologic Follow-up Studies of the first National Health and Nutrition Examination Survey (NHANES I) (34). The survey included a probability sample of the civilian non-institutionalized

James E. Gangwisch et al.

population of the United States between 1971 and 1975. The NHANES I Epidemiologic Follow-up Study conducted between 1982 and 1984 attempted to trace and interview NHANES I subjects, or their proxies, who were aged 25 to 74 years at baseline (n = 14,407). Eighty-five percent of all eligible subjects were successfully re-contacted (n = 12,220). Individuals who were deceased (n = 1,697) or who failed to answer any of the Center for Epidemiologic Studies Depression Scale (CES-D) questions (n = 498) were excluded from the analyses, yielding a total final sample size of 10,025. All study participants gave informed consent and the data do not include information that could be used to identify participants to protect confidentiality. The study was approved by the Ethics Committee of Columbia University and the study conforms to the provisions of the Declaration of Helsinki. The NHANES I includes weights to account for the complex sampling design and to allow approximations of the U.S. population. We conducted non-weighted analyses using SAS Software (35) for three reasons. First, our objective was not to provide national estimates, but to look at the associations between risk factors for insulin resistance, depression, and the incidence of diabetes. Second, our studyâ&#x20AC;&#x2122;s baseline measures were taken from the 1982 to 1984 Follow-up to the NHANES I, so the weights created for baseline measures taken from the 1971 to 1974 NHANES I did not account for subjects who were lost to follow-up between the two waves. Third, there have been differences of opinion regarding the appropriateness of using the sample weights in the NHANES (36). Measures Depression

Our measure of depression came from the CES-D which was administered to subjects at the time of the 1982-1984 NHANES I Follow-up. The standard cutoff score for the presence of depressive symptoms in the CES-D is 16 out of a total possible score of 60 (37), so we defined the presence of depression as a score of 16 or above. Incidence of Diabetes

Incident cases of diabetes over the 8 to 10 year follow-up period were determined by cause of death, by self report of having been diagnosed by a physician, or by hospital diagnosis at the times of the 1986, 1987, or 1992 follow-up surveys. We presumed that the incident cases of diabetes were predominantly of the type 2 variety since they were diagnosed later in life.

Risk Factors for Insulin Resistance

We examined ten risk factors for insulin resistance, including body mass index (BMI) greater than 25, physical inactivity, inadequate sleep (< 6 Hours Per Night), elevated stress, alcohol consumption greater than 2 drinks per day, hypertension, high serum cholesterol, cigarette smoking, age greater than 45 years, and non-Caucasian ethnicity. The risk factors were dichotomized between their presence and absence. We considered subjects physically inactive if they reported getting little or no exercise in things they did for recreation and if they reported being quite inactive in non-recreational activities. To determine whether subjects had elevated stress, we created a scale ranging from 2 to 18 that was based upon the subjectâ&#x20AC;&#x2122;s responses to three questions taken from the 10-item version of the General Well-Being Schedule (34). These three questions assessed whether over the last month they had been under strain, stress, or pressure, whether they had been anxious, worried, or upset, and how relaxed or tense they had been. Subjects were considered to have had elevated stress if they had a score on this scale greater than 12. Subjects were considered to have been hypertensive if they reported ever having been told by a doctor that they had hypertension or high blood pressure or if their measured systolic pressure was greater than 140 or their diastolic pressure was greater than 90. The control variables used in the study were gender, income, and education. Statistical Analyses Cross-Sectional

We used logistic regression models to examine the crosssectional relationships between depression and the risk factors for insulin resistance while controlling for gender, income, and education. We added together the number of risk factors for insulin resistance that were present to create an insulin resistance risk factor index. In one set of logistic models we included the index as the main independent variable while in another set of logistic models we included risk factors for insulin resistance separately to determine their individual influences. Missing values, which for most variables represented less than 5% of the total sample size, were imputed using mean and mode substitution. Longitudinal

We used Cox proportional hazards models to examine the effect of depression and the risk factors for insulin resistance upon the risk for being diagnosed with diabetes over the 8 to 10 year follow-up period. We excluded from these 87

Depression, Insulin Resistance, and Diabetes

analyses subjects who had been diagnosed with diabetes at or before baseline (n = 807). The time duration to diagnosis was determined from the baseline date to the first report of diabetes. We included the insulin resistance risk factor index as the main independent variable in one set of Cox proportional hazards models while we included the risk factors for insulin resistance separately to determine their individual influences in another set of models.

1.49-1.63). These results remained stable after controlling for gender, income, and education (OR = 1.52, 95% CI 1.45-1.59). Only 6% of the subjects who had no risk factors for insulin resistance were depressed while 73% of subjects who had seven or more risk factors were depressed. Table 1 shows the results from the logistic regression models that included the risk factors for insulin resistance separately. Subjects who were physically inactive, got inadequate sleep,

RESULTS

Table 1. Cross-Sectional Logistic Regression Analysis â&#x20AC;&#x201C; Odds of Suffering from Depression by Risk Factors For Insulin Resistance at Baseline (1982-1984).

Cross-Sectional

Before excluding subjects with diabetes from the baseline sample, there were 1,726 (17%) subjects who suffered from depression. Depressed subjects were 89% (Unadjusted OR = 1.89, 95% CI 1.61-2.23) more likely than non-depressed subjects to suffer from diabetes at baseline. This association was attenuated after adjusting for the risk factors for insulin resistance, gender, income, and education (Adjusted OR = 1.30, 95% CI 1.07-1.58). Subjects with diabetes at baseline (n = 807) were excluded from the other analyses so we could see the associations between the risk factors for insulin resistance and depression at baseline and then explore the effects of depression and the risk factors upon incidence cases of diabetes over the follow-up period. In Figure 1 we can see that as subjects had more risk factors for insulin resistance, their likelihood of being depressed progressively increased. As the number of risk factors for insulin resistance increased by one, the odds of suffering from depression increased by 56% (OR = 1.56, 95% CI Figure 1. The percentage of subjects who suffered from depression at baseline and who were diagnosed with diabetes over the follow-up period by the number of risk factors for insulin resistance present at baseline.

percentage of subjects

depression at baseline

Model 2

Odds Ratio

95% Confidence Interval

Odds Ratio

95% Confidence Interval

Lean (BMI <= 25)

1.00

Overweight (BMI > 25)

0.85

0.73, 0.99

0.91

0.78, 1.06

At least Moderate Activity

1.00

Very Inactive

2.86

2.29, 3.58

2.68

2.14, 3.35

â&#x2030;Ľ 6 Hours of Sleep Per Night

1.00

< 6 Hours of Sleep Per Night

2.47

1.99, 3.06

2.30

1.85, 2.86

Low/Moderate Stress

1.00

High Stress

11.83

9.95, 14.06

12.28

10.15, 14.85

<= 2 Drinks Per Day

1.00

> 2 Drinks Per Day

0.69

0.52, 0.93

0.96

0.71, 1.28

Non-Hypertensive

1.00

Hypertensive

1.32

1.12, 1.56

1.22

1.03, 1.45

Total Cholesterol < 240

1.00

Total Cholesterol => 240

1.11

0.83, 1.49

1.13

0.84, 1.53

Non-Smoker

1.00

Smoker

1.27

1.08, 1.50

1.26

1.08, 1.48

Age <= 45

1.00

Age > 45

1.25

1.06, 1.48

1.07

0.90, 1.28

Caucasian Ethnicity

1.00

Non-Caucasian Ethnicity

1.36

1.08, 1.71

1.16

0.93, 1.45

Risk Factors For Insulin Resistance Body Mass Index (kg/m2)

Physical Activity

Hours of Sleep Per Night

Stress

Consumption of Alcohol

Hypertension

Cholesterol

Cigarette Smoking

Age

diagnosed with diabetes over the follow-up period number of risk factors for insulin resistance present at baseline

Model 1

Non-Caucasian Ethnicity

Model 1 Unadjusted. Model 2 Adjusted for Gender, Income, and Education.

James E. Gangwisch et al.

had high stress, were hypertensive, and who were cigarette smokers were all significantly more likely to suffer from depression. The risk factor with the highest association with depression was high stress, with subjects with high stress being over twelve times more likely to suffer from depression. Having high cholesterol, being over the age of 45, and being of non-Caucasian ethnicity were associated with an elevated, yet not statistically significant, likelihood of suffering from depression. Being overweight and consuming more than two alcoholic beverages per day were actually associated with a reduced, yet statistically insignificant, likelihood of suffering from depression. Longitudinal

There were 446 incidence cases of diabetes over the follow-up period. The presence of depression at baseline had a weak and statistically insignificant relationship with the incidence of diabetes over the follow-up period (HR = 1.22, 95% CI 0.96-1.55) in the unadjusted model. The hazards ratio fell below 1.0 after the risk factors for insulin resistance were included in the Cox model (HR = 0.98, 95% CI 0.75-1.28). Figure 1 shows that as subjects had more risk factors for insulin resistance at baseline, their likelihood of being diagnosed with diabetes over the follow-up period increased up to the presence of five risk factors and then leveled off. The odds of being diagnosed with diabetes at some time over the follow-up period increased by 54% (HR = 1.54, 95% CI 1.44-1.64) for each additional risk factor for insulin resistance present at baseline. These results were somewhat attenuated after controlling for gender, income, and education (HR = 1.49, 95% CI 1.39-1.59). The results from the Cox models with the risk factors for insulin resistance included separately are shown in Table 2. Being overweight, physically inactive, hypertensive, over the age of 45, and of non-Caucasian ethnicity were associated with a significantly increased risk for being diagnosed with diabetes over the follow-up period. Getting inadequate sleep and being a cigarette smoker were associated with an elevated, yet not statistically significant, likelihood of being diagnosed with diabetes over the follow-up period. Consuming more than two alcoholic beverages per day and having high cholesterol were actually associated with a reduced, yet statistically insignificant, likelihood of being diagnosed with diabetes over the follow-up period. DISCUSSION Depression was associated with diabetes cross sectionally at baseline. Possible explanations for the strong cross-sec-

Table 2. Longitudinal Cox Proportional Hazards Modeling Analysis â&#x20AC;&#x201C; Hazards Ratio of Being Diagnosed with Diabetes Over the Follow-up Period by the Presence of Depression and Risk Factors for Insulin Resistance at Baseline Model 1 Risk Factors For Insulin Resistance

Model 2

95% 95% Hazards Confidence Hazards Confidence Ratio Interval Ratio Interval

Depression Non-Depressed (CES-D < 16)

1.00

Depressed (CES-D => 16) 0.98

1.00

0.75, 1.28

0.94

0.72, 1.25

Body Mass Index (kg/m2) Lean (BMI <= 25)

1.00

Overweight (BMI > 25)

3.58

2.78, 4.61

3.56

2.76, 4.59

At least Moderate Activity

1.00

Very Inactive

1.56

1.21, 2.01

1.54

1.19, 1.99

â&#x2030;Ľ 6 Hours of Sleep Per Night

1.00

< 6 Hours of Sleep Per Night

1.29

0.97, 1.72

1.26

0.95, 1.68

Low/Moderate Stress

1.00

High Stress

1.01

0.71, 1.43

1.02

0.72, 1.45

<= 2 Drinks Per Day

1.00

> 2 Drinks Per Day

0.63

0.42, 0.97

0.65

0.42, 1.00

Non-Hypertensive

1.00

Hypertensive

1.78

1.45, 2.20

1.72

1.39, 2.12

1.00

0.57, 1.29

0.86

0.57, 1.30

Physical Activity

Hours of Sleep Per Night

Stress

Consumption of Alcohol

Hypertension

Cholesterol Total Cholesterol < 240

Total Cholesterol => 240 0.86 Cigarette Smoking Non-Smoker

1.00

Smoker

1.16

0.93, 1.44

1.15

0.92, 1.43

Age <= 45

1.00

Age > 45

1.69

1.32, 2.18

1.60

1.24, 2.07

Caucasian Ethnicity

1.00

Non-Caucasian Ethnicity

1.59

1.28, 1.99

1.52

1.21, 1.90

Age

Non-Caucasian Ethnicity

Model 1 Unadjusted. Model 2 Adjusted for Gender, Income, and Education.

Depression, Insulin Resistance, and Diabetes

tional association found between depression and diabetes at baseline include the relationship between depression and many of the risk factors for insulin resistance, various neurobiological mechanisms, prenatal programming, and the stress associated with being diagnosed with a chronic medical condition. Among subjects who had not been diagnosed with diabetes at baseline, significant positive cross-sectional relationships were found between five of the risk factors for insulin resistance and depression, while elevated, yet not statistically significant, relationships were found between three of the risk factors for insulin resistance and depression. As subjects possessed more risk factors for insulin resistance their likelihood of suffering from depression increased. Five of the risk factors for insulin resistance were associated with a significantly increased risk for diabetes incidence over the follow-up period while two of the risk factors were associated with an elevated, yet not statistically significant, risk for diabetes incidence. As subjects had more risk factors for insulin resistance their chances of being diagnosed with diabetes over the follow-up period increased. Given the fact that depression was correlated with many of the risk factors for insulin resistance at baseline, one would presume that the presence of depression at baseline would result in a significantly increased risk for the incidence of diabetes over the follow-up period, but this was not the case. These counterintuitive results can be explained primarily by the differing relationships between the risk factors for insulin resistance and depression at baseline and the incidence of diabetes over the follow-up period. Lack of physical activity, hypertension, and inadequate sleep were the risk factors for insulin resistance that had the highest associations with both depression at baseline and the diagnosis of diabetes over the follow-up period. Being overweight was negatively associated with depression (OR = 0.92, 95% CI 0.81-1.05) while it had the strongest association of all of the risk factors for insulin resistance with the incidence of diabetes (HR = 3.56, 95% CI 2.764.59). High stress was highly associated with depression but not at all associated with the incidence of diabetes over the follow-up period. Having high cholesterol was weakly associated with depression at baseline and was actually negatively associated with the diagnosis of diabetes over the follow-up period. Another factor likely to have contributed toward these findings is the fact that the NHANES dataset did not include repeated measures of depression over the follow-up period and therefore the presence of depression at baseline may not have reflected the presence of a 90

chronic mood state that could have contributed toward the development of diabetes over the follow-up period. Glucose control is of primary importance in the treatment of insulin resistance and type II diabetes. The primary behavioral interventions to control blood glucose levels have included dietary and exercise regimens. More recently it has been suggested that getting adequate sleep could also help manage blood glucose levels and improve insulin sensitivity (38). Compliance with these behavioral interventions can be particularly difficult for patients with appetite disturbance, fatigue, sleep disruption, and lack of motivation associated with depression. Individuals who suffer from both diabetes and depression have been found to have significantly poorer blood glucose regulation (39). Poor blood glucose regulation could exacerbate depressed mood by increasing the likelihood of suffering from complications of diabetes and by increasing the pervasiveness of hypoglycemic reactions. When blood sugar levels drop to a point where brain glucose supplies are jeopardized, counter-regulatory hormones such as epinephrine and cortisol are secreted that can induce symptoms of anxiety, confusion, sadness, irritability, and weakness (40, 41). Individuals suffering from depression have been found to have higher cortisol responses to hypoglycemia (42). Given the potential physical and mental health implications, it would be advantageous for health and mental health professionals to bolster their efforts to encourage and motivate their patients who suffer from either diabetes or depression to eat a healthy diet and get adequate amounts of exercise and sleep. Financial Support Dr. Gangwisch was supported by National Research Service Awards (NRSA) 2 T32 MH 14623 and 5 T32 MH 013043 by the National Institute of Mental Health to Columbia Universityâ&#x20AC;&#x2122;s Mental Health Services Research Training Program and Psychiatric Epidemiology Research Training Program. Drs. Gangwisch, Gross, and Malaspina have no financial conflicts of interest to report.

Acknowledgements We are grateful to Doctors William W. Eaton, Edward J. Mullen, Sharon B. Schwartz, and Myrna M. Weissman for helpful comments for this manuscript.

References 1. Okamura F, Tashiro A, Utumi A, Imai T, Suchi T, Tamura D, Sato Y, Suzuki S, Hongo M. Insulin resistance in patients with depression and its changes during the clinical course of depression: Minimal model analysis. Metabolism 2000;49:1255-1260. 2. Winokur A, Maislin G, Phillips JL. Insulin resistance after oral glucose tolerance testing in patients with major depression. Am J Psychiaty 1988;145: 325-330. 3. Christensen L, Somers S. Comparison of nutrient intake among depressed and nondepressed individuals. Int J Eat Disorder 196; 20:105-109.

James E. Gangwisch et al.

4. Martinson EW, Strand J, Paulsson G, Kaggestad J. Physical fitness level in patients with anxiety and depressive disorders. Int J Sports Med 1989;10:58-61. 5. Steptoe A, Wardle J, Fuller R, Holte A, Justo J, Sanderman R, Wichstrom L. Leisure-time physical exercise: Prevalence, attitudinal correlates, and behavioral correlates among young Europeans from 21 countries. Prev Med 1997; 26: 845-854. 6. Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 1999; 354:1435-1439. 7. Dohrenwend BP.The role of adversity and stress in psychophathology: Some evidence and its implications for theory and research. J Health Soc Behav 2000; 41: 1-19. 8. Van Cauter E, Leproult R, Kupfer DJ. Effects of gender and age on the levels of circadian rhythmicity of plasma cortisol. J Clin Endocr Metab 1996; 81: 2468-2473. 9. Halbreich U, Asnis GM, Zumoff B, Nathan RS, Shindledecker R. Effects of age and sex on cortisol secretion in depressive and normals. Psychiaty Res 1984;13: 221-229. 10. Gold PW, Goodwin FK, Chrousos GP. Clinical and biomedical manifestations of depression: Relationship to the neurobiology of stress (Parts I and II). New Engl J Med 1988; 319: 348-420. 11. Holmang A, Bjorntorp P. The effects of cortisol on insulin sensitivity in muscle. Acta Physiol Scand 1992;144:425-431. 12. Nunes EV, Levin FR. Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. JAMA 2004; 291:1887-1896. 13. Paperwalla KN, Levin TT, Weiner J, Saravay SM. Smoking and depression. Med Clin N Am 2004; 88: 1483-1494. 14. Bell RA, Mayer-Davis EJ, Martin MA, D’Agostino RB, Haffner SM. Associations between alcohol consumption and insulin sensitivity and cardiovascular disease risk factors: The Insulin Resistance and Atherosclerosis Study. Diabetes Care 2000; 23: 1630-1636. 15. Frati AC, Iniestra F, Raul Ariza C. Acute effect of cigarette smoking on glucose tolerance and other cardiovascular risk factors. Diabetes Care 1996; 19:112-118. 16. McCarty MF. Enhancing central and peripheral insulin activity as a strategy for the treatment of endogenous depression – an adjuvant role for chromium picolinate? Med Hypotheses 1994; 43:247-252. 17. Sauter A, Goldstein M, Engel J, Ueta K. Effect of insulin on central catecholamines. Brain Res 1983; 260: 330-333. 18. Raizada MK, Shemer J, Judkins JH, Clarke DW. Insulin receptors in the brain: Structural and physiological characterization. Neurochem Res 1988; 13: 297-303. 19. Oldendorf LA, Szabo J. Amino acid assignment to one of three bloodbrain barrier amino acid carriers. Am J Physiology 1976; 230: 94-98. 20. Wurtman RJ, Hefti F, Melamed E. Precursor control of neurotransmitter synthesis. Pharmacol Rev 1981; 32: 315-335. 21. Hales CN, Barker DJP. Type 2 (non-insulin-dependent) diabetes mellitus: The thrifty phenotype hypothesis. Diabetologia 1992; 35: 595-601. 22. Seckl JR. Physiologic programming of the fetus. Clin Perinat 1998; 25: 939-962. 23. Maccari S, Darnaudery M, Morley-Fletcher S, Zuena AR, Cinque C, Van Reeth O. Pernatal stress and long-term consequences: Implications of glucocorticoid hormones. Neurosci Biobehav R 2003; 27: 119-127. 24. Holsboer F Psychiatric implications of altered limbic-hypothalamicpituitary adrenocortical activity. Euro Arch Psychiatry Neurol Sci 1989; 238:302-322.

25. Lawlor DA, Smith GD, Ebrahim S. Association of insulin resistance with depression: Cross sectional findings from the British women’s heart and health study. BMJ 2003; 327: 1383-1384. 26. Golomb BA, Tenkanen L, Alikoski T, Niskanen T, Manninen V, Huttunen M, Mednick SA. Insulin sensitivity markers – Predictors of accidents and suicides in Helsinki Heart Study screenees. J Clin Epidemiol 2002; 55: 767-773. 27. Timonen M, Laakso M, Jokelainen J, Rajala U, Meyer-Rochow VB, Keinanen-Kiukaanniemi S. Insulin resistance and depression: Cross sectional study. BMJ 2005;330: 17-18. 28. Lawlor DA, Ben-Shlomo Y, Ebrahim S, Smith GD, Stansfeld SA, Yarnell JWG, Gallacher JEJ. Insulin resistance and depressive symptoms in middle aged men: Findings from the Caerphilly prospective cohort study. BMJ 2005; 330: 705-706. 29. Kumari M, Head J, Marmot M. Prospective study of social and other risk factors for incidence of type 2 diabetes in the Whitehall II Study. Arch Intern Med 2004; 164: 1873-1880. 30. Palinkas LA, Lee PP, Barrett-Connor E.A prospective study of type 2 diabetes and depressive symptoms in the elderly: the Rancho Bernardo Study. Diabetic Med 2004; 21: 1185-1191. 31. Eaton W. Epidemiologic evidence on the comorbidity of depression and diabetes. J Psychosom Res 2002; 53: 903-906. 32. Saydah SH, Brancati FL, Golden SH, Fradkin J, Harris MI. Depressive symptoms and the risk of type 2 diabetes mellitus in a US sample. Diabetes Metab Res Rev 2003; 19: 202-208. 33. Carnethon MR, Kinder LS, Fair JM, Stafford RS, Fortmann SP. Symptoms of depression as a risk factor for incidence diabetes: Findings from the National Health and Nutrition Examination Epidemiologic Follow-up Study, 1971-1992. Am J Epidemiol 2003; 158: 416-423. 34. Miller H. Plan and operation of the health and nutrition examination survey, United States, 1971-1973. U.S. Public Health Service, Vital and Health Statistics, Series 1, Nos. 10a and 10b. U.S. Government Printing Office, Washington, DC, 1973. 35. SAS Institute Inc. The SAS System for Windows, Version 9.0, Cary, NC. 36. Ingram DD, Makuc DM. Statistical issues in analyzing the NHANES I Epidemiologic Followup Study. Vital & Health Statistics – Series 2: Data Evaluation and Methods Research 1994; 121: 1-30. 37. Radloff LS, Locke BZ. The community mental health assessment survey and the CES-D scale. In: Weissman MM, Myers JK, Ross CE, eds. Community surveys of psychiatric disorders. New Brunswick, N.J.: Rutgers University Press 1986; pp. 177-189. 38. Van Cauter E, Speigel K. Sleep as a mediator of the relationship between socioeconomic status and health: A hypothesis. Ann NY Acad Sci 1999; 896:254-261. 39. Gross R, Olfson M, Gameroff MJ, Carasquillo O, Shea S, Feder A, Lantigua R, Fuentes M, Weissman MM. Depression and glycemic control in Hispanic primary care patients with diabetes. J Gen Intern Med 2005; 20: 460-466. 40. Taylor LA, Rachman SJ.The effects of blood sugar level changes on cognitive function, affective state, and somatic symptoms. J Behav Med 1982;11:279-291. 41. Hale F, Margen S, Rabak D. Postprandial hypoglycemia and “psychological” symptoms. Biol Psychiatry 1982; 17: 125-130. 42. Kathol, RG, Gehris TL, Carroll BT, Samuelson SD, Pitts AF, Meller WH, Carter JL. Blunted ACTH response to hypoglycemic stress in depressed patients but not in patients with schizophrenia. J Psychiatr Res 1992; 26:2, 103-116.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Psychopathology and its Early Impact on Parenting Behaviors in Mothers: The Interface between Adult and Infant Psychiatry Miri Keren, MD,1,2 and Sam Tyano, MD2 1

Geha Mental Health Center, Petach Tikva, Israel Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel

Abstract Parenting is, in its essence, the domain where adult mental health and infant’s mental and physical health meet in a complex and dynamic interplay. Becoming a parent is a developmental challenge in itself, and often exacerbates an existing mental illness, and in turn, maladaptive parenting impinges on the early parent-infant relationship, and on the infant’s socio-emotional development and later functioning. The capacity for mentalization is brought as a bridging concept between adult and infant psychiatry. A few clinical vignettes illustrate the dynamic interplay between very young children’s vulnerabilities and needs and their parents’ strengths and weaknesses, leading to a complex interaction and often to symptoms in both child and parent. In the light of the compelling data about the impact of parental psychopathology on parenting behaviors and children outcomes, there is an imperative need for a working alliance and on-going communication between child and adult psychiatrists.

Introduction Parenting is, in its essence, the domain where adult mental health along with infant’s mental and physical health meet in a complex and dynamic interplay, and therefore an intrapsychic reorganization needs to take place. This reorganization has been conceptualized by Stern under the name of “Maternal Constellation.” This includes four hierarchical capacities: The most basic theme relates to the mother’s capacity to ensure her baby’s survival, then comes her capacity to become engaged with her baby, Address for Correspondence:

followed by her capacity to create a supporting network around the baby. The most sophisticated level of this psychic reorganization is the need to integrate her new identity as being-a-mother to her existing identities of being a daughter-of, a partner-of, a professional-in (1). This deep, intrapsychic process may be a challenge for mentally vulnerable women. Indeed, becoming a parent often exacerbates an existing mental illness, and in turn, maladaptive parenting impinges on the early parent-infant relationship, as well as on the infant’s socio-emotional development and later functioning. In spite of this quite obvious, intrinsic, interplay between adult and infant/child psychiatry, fragmentation of the disciplines is still very common: Adult psychiatrists treat individuals with no specific focus on their parental-self. In this paper we aim to show the imperative need for a working alliance and on-going communication between child and adult psychiatrists. We will use some clinical vignettes to illustrate the dynamic interplay between very young children’s vulnerabilities and needs and their parents’ strength and weaknesses, leading to a complex interaction and often to symptoms in both child and parent. The Capacity of Mentalization as a Bridging Concept between Adult and Infant Psychiatry, and as a Goal of Mother-Infant Psychotherapeutic Treatments

Mentalization (2) has been conceptualized as “an innate social-cognitive evolutionary adaptation implemented by a specialized and pre-wired mindreading mechanism that seems active and functional at least as early as 12 months of age in humans” (p. 59). Mentalization is crucially needed for adaptive interpersonal functioning (what is named as “social intelligence”) in a highly sophisticated social world. Reflective Functioning (3) is the construct, or the operation of mentalization. Mentalization and reflective functioning

Miri Keren, MD, Geha Infant Mental Health Unit, POB 102, Petach Tikva 49100, Israel

ofkeren@zahav.net.il

Miri Keren and Sam Tyano

involve cognitive components, these mainly being the acquisition of a Theory of Mind (4) as well as affective components such as empathy. These two develop from the earliest affect regulating attachment relationships between infant and caregiver. Dysfunctional and traumatic early attachment relationships due to neglect, abuse, dissociative, highly intrusive and grossly unpredictable patterns of parental responses have long-term detrimental and disruptive effects on the child’s later capacity to use his/ her innate competence for mentalization. This presents a difficulty in adequately dealing with the challenges embedded in intimate relationships, leading to the development of personality disorders, especially borderline personality disorders (BPD) (5-10). One of the main mediating factors in the trans-generational transmission of personality disorders is the impairment in the parent’s capacity for mentalization and reflective functioning (11). Maladaptive self and caregiver-child relationship representations have been studied in a sample of 30 children aged 4-7 whose mothers had a diagnosis of BPD, as compared with 30 normative dyads (12). Their narratives included stories with more parent-child role reversal, more fear of abandonment, and more negative mother-child and father-child relationship expectations, more shameful representations of the self, poorer emotion regulation with confused boundaries between fantasy and reality and less narrative coherence. Maternal identity disturbance and self-harm were the most potent predictors of these maladaptive self and caregiver-child relationship representations among the children of BPD mothers. The quality of the family environment has a major role in the development of mentalization: the frequency of perspective taking in caregiver-child verbal interactions (13), the amount of role play in the family, and the degree of family verbalization of conflicting emotions (14) have been found as correlates of mentalization capacity in parents as well as in the child. In light of this relatively new knowledge, promoting parental reflective mentalization, i.e., facilitating the attribution of emotional motives to the child’s behavior, has become a major therapeutic aim of parent-infant psychotherapies (15), as we will try to show in a few clinical vignettes below. Transition to Parenthood as a Major Stressful Life-event in the Young Adult’s Life

Winnicott introduced the concept of “Primary Maternal Preoccupation” (16), defining the phenomena as “almost an illness” that a mother must experience and recover from, in order to create the environment that can meet the physical and emotional needs of the infant.

It is useful in understanding normal and abnormal reactions to parenthood and is about a special state of heightened sensitivity, similar to a dissociative state that heightens the mother’s ability to anticipate the infant’s needs and to learn its unique signals. This unique obsessive-like psychological state also takes place in fathers though less intensively than in mothers (17). Emotionally vulnerable mothers may have difficulty in tolerating such a level of intense preoccupation and may react with either too much preoccupation or too little. Both situations are detrimental to the infant and the mother: Too much preoccupation does not leave space for other family members’ needs nor does it leave room for other caretakers and disrupts the infant’s growing separated self. Furthermore, extreme preoccupation in a mentally impaired mother often includes distortions in perceptions of her infant and puts him/her at risk for psychopathology in the future. Too little maternal preoccupation, as seen in post-partum depression, psychosis, severe narcissistic personality disorders, when the mother’s needs come first, may lead to deprivation and even to maltreatment. The concepts of motherhood constellation and primary maternal preoccupation are useful in our understanding of prenatal and postnatal clinical situations. Pregnancy and the year after giving birth are indeed a time when a woman is most at risk of increased mental symptomatology by either triggering a latent vulnerability or exacerbating an existing psychopathology (18, 19). Approximately 1-6% of women experience post-partum post-traumatic stress disorder following childbirth (20). Most often this illness is caused by a real or perceived trauma during delivery or post-partum. Past traumatic events, such as sexual abuse, have been related to the development of post-partum PTSD shortly after delivery. The presence of post-traumatic symptoms, such as dissociation, numbing, and re-experiencing have a negative impact on the mother’s capacity to enter the maternal preoccupation and constellation states. Women with obsessive compulsive personality disorder often find the transition to parenthood an overwhelming challenge. The Adult and Child Psychiatrists’ Roles

Parental psychopathology, regardless of the specific diagnosis, impinges on the child’s socio-emotional development through the impact of associated presence of impaired parenting behaviors (21). Hence the adult psychiatrist needs to ask explicit questions about parental behaviors that are induced by their patient’s illness. Relevant questions would be; “What do you think your child sees when you are very upset, very sad? “What do you do when you feel the urge to do your rituals while your child calls for your attention?” 93

Psychopathology and its Early Impact on Parenting Behaviors in Mothers

“Does it happen to you sometimes that you take your child with you when you’re elated and do a lot of shopping?” “Has your child witnessed you under the influence of drugs?” The child psychiatrist needs to observe how these behaviors specifically interfere early and directly with the child’s developmental tasks and needs, such as regulation of behaviors and affects, basic sense of security, balanced autonomy and dependency and the development of a positive view of self and others. Family functioning has been found to be the most powerful mediator of parental mental illness impact on the child (22). The clinical implication of this finding is that there is a need for the adult psychiatrist to inquire about the family functioning at his/her individual patient’s home. A reasonably good level of family functioning buffers the potentially adverse impact of the parent’s symptoms on the infant (23). In addition to the impact of the parent’s symptoms, repeated hospitalizations are especially difficult for offspring between 6 months and 5 years. A short clinical vignette will illustrate the advantage of on-going communication between adult and child psychiatrists: A 27-year-old new mother developed a manic episode two weeks after giving birth, and was hospitalized at an Adult Psychiatric Day Ward. Her husband and her mother took care of the baby. When baby was three months old it became obvious that the mother’s recovery would be slow. The adult psychiatrist, who had heard about our Infant Mental Health Unit, became concerned with the mother’s feelings of estrangement from her baby and referred her to us. She was surprised that we asked the husband to come together with his wife and baby: “He is fine with the baby, she’s the problem,” the adult psychiatrist said. Indeed, the father took good care of the baby but he had also been on anti-depressant medications for many years and he disclosed his fear of breaking down too. His interaction with the baby was very anxious and overprotective. The mother’s interaction was anxious and underinvolved. As opposed to the impression the adult psychiatrist had it turned out that this couples’ functioning was very fragile. Hence an alternate triadic (mother, father, baby) and dyadic (mother, baby) psychotherapy plan was put in place, in parallel with the mother’s individual treatment at the Adult ward. On-going communication between the adult and the child psychiatrists conveyed a feeling of security to the couple. The Impact of Specific Psychopathologies on Parenting

In this paper, we address only maternal psychopathologies, simply because the literature on the specific impact 94

of fathers’ psychopathology on parenting behaviors is unfortunately extremely sparse. • Maternal depression and parenting As described above the transition to motherhood is already a challenging normative task. Furthermore, post-partum depression makes this task very challenging. Some parenting behaviors such as hostility are detrimental for all ages, but sadness is especially problematic for young children (24). Post-partum depression impacts on the infant’s development through genetic transmission as well as through the impact of the conditions correlated with the mother’s depression; such as disturbed family life, marital conflict, past maternal interpersonal experiences and through its impact on the quality of the early mother-infant relationship (touch, gaze, affect). Mothers with depressed mood touch their infants more negatively and talk to them in a way that is less well adjusted to their infant’s developmental needs. Compared to normal infants, infants of depressed mothers were more drowsy, more passive, more distressed and fussy, tended to look at mothers less and engaged in self-centered activity. Most bothering is the finding that these infants’ reactions to their depressed mothers generalize to non-depressed strangers and elicit depressed-like behavior in non-depressed adults (24, 25). Three different patterns of depressed mothers’ interactions with their infant with decreasing order of impact have been identified (26): Disengaged and apathetic, Engaged, but angry and intrusive, and Engaged and positive. The disengaged type may lead to neglect and is characterized by a much diminished primary maternal preoccupation. The engaged but angry and intrusive type may be accompanied with verbal, and more rarely, physical aggression towards the infant. It should be noted that the third type is easier to treat in terms of the mother-infant relationship, though the mother’s depression may still be severe. In addition a complex interplay between the maternal depression and the infant’s characteristics, such as gender and temperament, has been observed (27). Depressed mothers have a more conflicted relationship with their girls than with their boys and older girls of depressed mothers have more disruptive and acting out behaviors than boys. Difficult temperament children of depressed mothers are more at risk for later problems than those of healthy mothers. The long-term impact of maternal depression on offspring is rather worrying; 65% of infants with depressed mothers had insecure attachment classifications at one year of age (27). Cognitive and developmental deficits, negative self-image, conduct disorder, and affective disturbances, have all been observed among children who grow up with depressed

Miri Keren and Sam Tyano

mothers (25-28). Moreover, the quality of the mother-child interaction and the child’s behavioral problems did not improve in parallel to the remission of maternal depression (21). In turn, the children’s difficulties make them more difficult to handle by the mother, which in a vicious circle, impact negatively on her self-esteem. To summarize the dynamic interplay between maternal depression and parenting the infant, it is the consistency and pervasiveness of messages across interrelated contexts of the family relationship, the maternal specific behaviors related to her depression and the characteristics of her interaction with the child that increase the child’s vulnerability. Radke-Yarrow’s 15 year longitudinal study (28) has shown that there is no universal outcome of children’s early exposure to maternal depression. Each case is the result of the interplay between vulnerability and resilience factors in child and parents, overall growing up as a child of a depressed parent is costly: Many have serious and multiple diagnoses, not only depression. A few stay “untouched.” Prevention of such gloomy outcomes requires the joint work of the adult’s psychiatrist, who is in charge of the mother’s treatment, and the child psychiatrist who assesses the impact of the mother’s depressive symptoms on the mother-infant relationship and on the infant’s current functioning. The therapeutic aim of enhancing maternal reflective functioning should be a joint goal as well. In sum, it is not enough to treat the mother’s depressive symptomatology. We must also address, as early as possible, the maladaptive mother-infant interactive patterns, the specific mother’s “depressive” attitudes conveyed to child, the other parent’s functioning and the proximal support system. Clinical vignette: H., 32 years old, and her 3-month-old baby boy, were referred to our (MK) Infant Mental Health Unit with suspected post-partum depression. Baby’s birth was complicated with hemorrhagic enterocolitis from an unknown origin, which had necessitated a 2-month hospitalization. During the hospitalization, the mother’s sadness was interpreted as an adequate response to the baby’s medical condition; therefore the medical staff did not send her for a psychiatric consultation. Still, her husband was very concerned because of past history of post-partum depression following her first pregnancy, and asked their family doctor to refer them to us. Their older daughter developed into a very dependent child, with poor peer relationships, and both parents were aware of the link between their daughter’s difficulties and the mother’s long lasting depression. During the triadic (mother-baby-father) assessment ses-

sion, the mother was sitting passively, remote and detached, while the father was busy with baby as if he was in the state of primary maternal (paternal) preoccupation. Baby already exhibited gaze avoidance towards his mother. The mother admitted having aggressive impulses towards the baby and was afraid of staying alone with him. Her own mother came and stayed with her while her husband was at work. On the one hand, this arrangement was safe for the baby. On the other hand, it reinforced the mother’s avoidant position towards him and worsened her ambivalent relationship with her dominant and intrusive own mother. We installed a treatment plan that first included mother-father-baby psychotherapy. Antidepressant medication for the mother was administered by the adult psychiatrist. As we observed an improvement in her depression but a pervasive lack of enjoyment at being with her infant, a joint meeting with her psychiatrist led to the decision of adding an individual psychotherapy. This was aimed at making the process of entry into the motherhood constellation, that is finding a balance between her identities and needs as a woman and as a mother, and working through her complex relationship with her own mother. The triadic psychotherapy focused on the lack of co-parenting due to the mother’s self-exclusion, the father’s anger at her lack of interest in their baby, and the baby’s preference for his father. A significant improvement in the mother-infant interaction on the behavioral level was achieved, but it took more than a year until we could observe a significant change in the mother’s balanced perception of her infant and mentalization capacities. It is beyond the scope of this paper to describe the psychotherapeutic process in detail, but for example, we encouraged the mother to accept the interpretation of baby’s gaze avoidance as a way of telling her “it is difficult for me to look at you when you look sad and angry,” instead of her perception of the baby as “simply preferring her husband.” This case illustrates the need for a comprehensive, joint work of adult and child clinicians, while keeping in mind the common gap between the improvement of the mother’s clinical depression and her actual relationship with her baby and husband. • Maternal Obsessive Compulsive Disorder and Parenting Surprisingly, little attention has been given to the impact of parental OCD on the quality of parenting. In our clinical experience we have come to realize that the entry into parenthood often exacerbates an already existing OCD and parenting makes it worse, up to the point of evoking aggressive feelings towards the baby who is perceived as preventing the mother from performing her rituals. In one of the few studies we found (29), an incidence of 4% among 95

Psychopathology and its Early Impact on Parenting Behaviors in Mothers

302 women who developed post-partum OCD (PPOCD) at 6 weeks was reported. Interestingly, the PPOCD women had significantly more frequent aggressive obsessions and less severe other obsessive-compulsive symptoms than the OCD patients without post-partum onset. A more recent study (29) of 400 post-partum women reported an incidence of 2.3% of PPOCD and 9% of OCD in general. Similarly to the first study, aggression and contamination were the most common obsessions, together with a cleaning/washing and checking compulsions; 38.9% also had comorbid depression. Previous psychiatry history, somatic disease or complications at delivery are risk factors for developing PPOCD (30). In spite of these very significant clinical data, the literature about the psycho-social development of the children of mothers with OCD is practically non-existent. From our clinical experience at a community infant mental health unit in the last 5 years we have had some 15 cases of infants born to mothers with OCD. None of them have developed childhood OCD, at least in their first 4 years of life, but all of them have exhibited oppositional behavioral traits, mixed with anxious features, as illustrated in the following vignette. Clinical vignette: S., two years old, was referred to us by her pediatrician because of temper tantrums, sleep problems and overeating. She was the first child of a couple in their thirties. The mother suffered from OCD since her early twenties but was never treated. She did have psychotherapy for her difficulty with engaging in intimate relationships with men. When she was pregnant she became obsessed with the doubt of being able to love her future baby. Right after birth she felt she did not love her “enough” and handed over the baby’s care to her husband. She returned to work while he stayed at home, until he was obliged to go back to work when baby was 12 months old. S. entered day care and became a difficult toddler with intense temper tantrums, oppositional and aggressive behavior towards her mother and relentless requests for food at home as well as at the day care. A very tense, angry and rejecting mother-child relationship was observed: The mother said, in the child’s and father’s presence, “what can I do, I simply don’t love her!” The father was baffled and remained speechless and S. said, “I want food.” The therapist (MK) tried to make the link between S.’s request for food and her distress at hearing what the mother just said. The mother dismissed this interpretation by saying “she did not understand what I just said, she’s too young.” The mother perceived her daughter as a persecutory object, as taking care of S. was at the expense of performing her compulsive cleaning. Dyadic mother-child psychotherapy was put in place, while trying to help the 96

mother to develop the capacity to link her child’s behaviors to underlying feelings of being unloved and rejected, namely what is meant by parental reflective functioning. In parallel, we had to convince the mother to get CBT and medications for her own OCD. We referred her to the adult psychiatrist at our hospital. At first she did not comply and we had to let her know that we would need to report her for emotional abuse. Close monitoring of the case together with the adult psychiatrist brought significant overall improvement after one year of weekly triadic meetings. The father’s presence at the therapy sessions was needed because he tended to over-identify with S. and was not able to give her reasonable boundaries when needed. This case illustrates, beyond the need for close cooperation between child and adult psychiatrists, the extent to which entry into motherhood may exacerbate, but also motivate for treatment, mothers with long lasting undiagnosed OCD. • Maternal Borderline Personality Disorder and Parenting Mothers with BPD have been shown as being more intrusively insensitive to their infants during the Still Face procedure (31, 32) and their infants reacted with increased looking away and dazed looks. As we have mentioned above in the paragraph about mentalization, Borderline Personality Disorder (BPD) is linked with a severe distortion in attachment representations, mentalization, self and emotion regulation, all of which have the potential to impair the mother-infant relationship and the child’s later development. Hobson et al. (33) have compared the mother-infant interaction characteristics of 13 borderline mothers with 15 depressed mothers and 31 healthy mothers. They found a higher proportion (85%) of disrupted affective communication among mothers with BPD compared with the two control groups and the presence of frightened-frightening behaviors differentiated it from the group of depressed mothers. More specifically, infants of mothers with BPD were significantly less available for positive engagement, less organized and positive in their emotional state, and tended to be disorganized in their pattern of attachment with their mothers. Borderline mothers exhibited intrusive insensitive behavior during play interaction. The mothers’ disrupted affective communication and frightened/frightening response to their infant’s attachment needs predict significant behavioral and interpersonal problems in their children at kindergarten and school (9). A recent prospective controlled study (34) showed the impact of combined personality disorder

Miri Keren and Sam Tyano

and depression on the infant’s cognitive and emotional development at 18 months of age: Dysregulated behavior, impaired cognitive scores and high levels of internalizing behavior were the main negative outcomes. Clinical vignette: S., a two-month-old baby girl and her mother, A., were referred to our Infant Mental Health unit by a community nurse. She was worried because of the baby’s persistent crying while the mother looked tense, sad and at a loss. The community nurse referred them with the suspected diagnosis of post-partum depression and described S.’s parents as “hard-to-reach” and distrustful. The referred mother did not show up at the clinic. A home visit was set up by therapist (MK). While entering the one-room apartment she was struck by the chaotic atmosphere: mess was all around, baby was crying, the mother was unsuccessfully trying to breast-feed her. She was so overwhelmed that she did not greet the therapist and straight away said: “Even breast-feeding does not calm her, I’m really bad at it, she knows it.” The crudeness of this projection was striking. Standard questions about the course of pregnancy and delivery triggered tears and the mother talked for two and a half hours. At first, asking about the baby’s name revealed the mother’s pathological grief over her only sister’s death in a car accident, 10 years before. Following a dream about her late sister saying “I can’t wait anymore,” A. felt she had to “get pregnant and have a girl like her sister,” in spite of her inner feeling she was not ready for motherhood. Baby’s name was identical to her late “little aunt’s,” except for one letter. A. linked her lack of readiness for motherhood to her own very traumatic attachment experiences. She grew up with a drug-addicted and sexually promiscuous mother. Her father left home when she was about two years old and ignored her and she experienced emotional and sexual abuse by her stepfather. This led to her placement in a boarding school, while her younger and only sister stayed at home. She continued to have negative experiences with adult caregivers at the boarding school and grew up into a very lonely and angry adolescent. The relationship with her sister was very ambivalent, mixed with feelings of responsibility and anger towards her. On the day of the car accident, A. was 15 years old and her sister was 9. They were both in the back of the car, having a fight, and the accident happened while A.’s sister was trying to reconcile and A. refused. A. developed a very pathological grief reaction, and at the time of the referral, she still would go almost every day to her sister’s grave. During the following sessions maternal pathological projections on the infant were identified: S. was born in order to continue A.’s late sister’s existence (a “replacement” child) and her cry reminded A. of her sister’s clingy behavior. As a result, A. developed a maladaptive reaction to S.’s normative cry: She

would either gratify the child at once, or she would become harsh and rejecting. S. reacted with alternating oppositionality and overcompliance. It became evident how A.’s projections on S. impinged on her ability to be a consistent protective figure for her child. Following a session where she talked about the car accident and her guilt feelings, a frightening “missed” accident happened to S.: A. “forgot” to tie the baby in her stroller. Also, her ability to place boundaries for the infant was very poor, because saying “No” to S. reminded her of saying “No” to her sister just before the car accident. An additional distorted parenting behavior was around sleep habits: S. would sleep with her mother because, in A.’s perception, “nights are dangerous to sleep alone” (A. unconsciously perceived her husband as potentially harmful to her and to her child). S.’s father had a less dramatic childhood history, but his attachment experiences were very negative with a history of physical abuse by his mother and a helpless father. Unlike his wife, he had absolutely no insight about his own problematic parenting behaviors. The marital relationship became very tense, and ended in separation. This clinical case illustrates how very early traumatic attachment experiences and early sexual abuse lead to a basic and pervasive lack of trust and unstable close relationships, transmitted from one generation to another, and how entry into parenthood triggers distorted projections on the infant who, with his/her own constitutional characteristics, becomes a dysfunctional infant. Early detection of these high risk families is crucial, if one wishes to prevent the development of personality disorders from childhood into adulthood. Borderline personality patients represent a significant proportion of the population treated at psychiatric outpatient clinics. Early detection and joint treatment of these high risk parent-infant dyads can/ should therefore be relatively easily achieved, provided the adult psychiatrist has an awareness of the potential impact of BPD on parenting. Such awareness could lead him/her to ask the patient questions about the mother’s parenting experience, getting an idea about her capacity to handle frustration and regulation of negative affects, while facing the expected difficult moments with her infant/toddler. • Maternal Psychotic Disorders and Parenting The challenging task of parenting that involves the provision of a safe environment for the infant, attendance to physical needs, appropriate age-related stimulation, and the establishment of an attuned and secure relationship, can be very much affected by a new-onset postnatal psychosis, as well as by long-standing illness such as schizophrenia, bipolar illness and substance abuse induced-psychosis. The 97

Psychopathology and its Early Impact on Parenting Behaviors in Mothers

way these severe mental disorders impact parenting determines the extent to which the parent’s symptoms impact her parenting behavior. For instance, a psychotic mother who perceives her baby as a dangerous, ill-intentioned creature, may become dangerous to him/her, or may withdraw from caregiving tasks. Furthermore, some mothers with a psychotic disorder are so preoccupied with psychotic thoughts that they behave in a disorganized way and are unable to take care of the baby in a safe manner. In these situations, the main therapeutic challenge is to ensure the baby’s physical and emotional safety and in parallel, to try to keep some continuity of contact between the mother and the baby, so that if and when she feels better and comes back home, both she and the infant will not be strangers one to the other. Mother-infant psychotherapeutic treatment may become possible as soon as mothers become able to perceive their infant in a non-psychotic way. Fathers may have a special role in these situations, as the caregiver who can make a narrative of the mother’s absence for the infant, such as “Mummy is too sick to take care of you, but she loves you and will be back with the doctor’s help.” It is therefore of paramount importance to support the father, and to see him with the infant, while the mother is at the hospital. Clinical vignette: A 29-year-old pregnant woman became acutely psychotic during her first pregnancy. Her first hospitalization was at the age of 15, and she was diagnosed with schizophrenia. The pregnancy was from an unknown man she met once while she was wandering around. She was hospitalized at the adult closed ward, when she was 28 weeks pregnant. One of her delusions was that a hedgehog was growing in her belly. She was put on antipsychotic medications, but at the time of delivery she was still psychotic. The adult psychiatrist reported her to the Child Protection services. Her own mother became the baby’s guardian. The grandmother tried to bring the baby for short visits to his mother but the mother insisted the baby was not hers. When baby boy was 6 months old, the mother was discharged from the adult ward in partial remission and came to live with her mother. The adult psychiatrist referred her to us to assess the mother’s potential capacity to become attached to her baby. During the assessment dyadic session we witnessed a difficult interaction where the mother held her baby in a very awkward manner, baby would look away and the mother said, “you see, he does not look at me because he is not mine.” The therapist tried to offer her an alternative explanation such as “Look, he does not know yet, but he will…let’s give both of you a chance to get to know each other…” The mother agreed to give it a chance and we started weekly therapeutic sessions sometimes 98

together with the grandmother at their home, sometimes at the clinic with the mother and the baby alone. Our focus was on interactional guidance as the mother’s ego strengths were too fragile to go into any psychodynamic exploration of her projections onto her son. Her capacity for mentalization remained very low throughout the treatment with concrete and self-centered thinking, but she became able to take part to some extent in the daily caregiving tasks. Her physical and emotional availability to her boy was still partial and unpredictable. At the age of one year and a half the child called her “Mummy” and would interact with her playfully but his secure attachment was towards the grandmother. When he was two years old the mother tragically died from a heart attack. This case is an additional example of the advantages of joint on-going collaboration between adult and child psychiatrists even in severe cases of parental psychopathology. When the mother is actively psychotic and has delusions directly related to the baby as it was in this case much clinical work cannot be done. However, as soon as her psychiatric status improves it is worth trying to assist in the development of a significant relationship between the child and the mother even if the mother is not the child’s primary caregiver. This enables the child to develop a maternal representation of “I have a Mummy, she’s sick but she tries to be with me,” as opposed to “I have a Mummy but she does not love me and therefore she does not take care of me.” Conclusions This paper deals with the interface between adult and child psychiatry with the main aim to increase adult psychiatrists’ awareness of the effect of psychiatric diagnoses on parenting behaviors and early referral of infants at risk to child psychiatrists. We have reviewed the impact of some diagnoses, such as depression, obsessive-compulsive disorder, borderline personality disorder, and psychosis, on parenting behaviors and offspring’s development and wellbeing. Introductory notions of entry into motherhood constellation, primary maternal preoccupation, parental reflective functioning, and mentalization have been reviewed as they represent core concepts with which both child and adult psychiatrists need to be familiar. Among them, the concept of mentalization as one’s capacity to attribute emotional meanings to his/ her own and others’ behaviors is of paramount importance for understanding adult and child mental health, as well as a therapeutic tool. In recently developed parent-infant psychotherapeutic schemes the therapist’s direct aim is to develop and/or to correct the parental reflective functioning

Miri Keren and Sam Tyano

by reflecting together on the possible emotional meanings of the baby’s interactive behaviors. A better understanding of the infant’s behaviors may then be transferred into more adaptive parental behavioral and verbal interactions with the child. We have tried through short clinical vignettes to illustrate joint adult and child psychiatrist pharmacotherapeutical and psychotherapeutic work, as well as the clinical presentations of the impact of maternal psychopathology on the infant’s functioning. Early detection of parents and infants at risk should be achieved by adult as well as child psychiatrists. This requires knowing the potential impact of parental psychopathology on parenting behaviors and asking adult patients about their parental functioning. Beyond the referral and the assessment phase the collaboration needs to continue throughout the different phases of the treatment. Indeed, very often these cases of maternal psychopathology require long-lasting professional accompaniment on the individual parent’s level as well as on the parent-infant relationship one. There is an urgent need for controlled studies of the impact of paternal psychopathologies on parenting and on the child’s development. References 1. Stern D. The motherhood constellation. New York: Guilford, 1995. 2. Gergely G, Unoka Z. The development of the unreflective self. In Busch FN, editor. Mentalization. Theoretical considerations, research findings and clinical implications. New York, London: The Analytic Press, Taylor and Francis Group, 2008: pp. 57-102. 3. Fonagy P, Gergely G, Jurist E, Target M. Affect regulation, mentalization and the development of the self. New York: Other Press, 2002. 4. Leslie AM, Friedman O, German TP. Core mechanisms in “theory of mind.” Trends Cogn Sci 2004; 8: 528-532. 5. Bateman AW, Fonagy P. Psychotherapeutic treatment of personality disorder. Br J Psychiatry 2000; 117:138-143. 6. Bateman AW, Fonagy P. The development of an attachment-based treatment program for borderline personality disorder. Bull Menninger Clin 2003, 67:187-211. 7. Bateman AW, Fonagy P. Mentalizing and borderline personality disorder. J Mental Health 2007;16: 83-101. 8. Lyons-Ruth K, Yellin C, Melnick S, Atwood G. Expanding the concept of unresolved mental states: Hostile/helpless states of mind on the Adult Attachment Interview are associated with disrupted motherinfant communication and infant disorganization. Dev Psychopathol 2005;17: 1-23. 9. Sroufe LA, Egeland B, Carlson E, Collins WA. The development of the person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford, 2005. 10. Fonagy P, Bateman AW. The development of borderline personality disorder -a mentalizing model. J Pers Disord 2008; 22:4-21. doi: 10.1521/ pedi.2008.22.1.4 11. Fonagy P, Target M. Attachment and reflective function: Their role in self-organization. Dev Psychopathol 1997; 9:679-700. 12. Macfie J, Swan SA. Representations of the caregiver–child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder. Dev

Psychopathol 2009;21 : 993-1011. 13. De Rosnay M, Hughes C. Conversation and theory of mind: Do children talk their way to socio-cognitive understanding? Br J Dev Psychol 2006; 24: 7-37. 14. Cutting AL, Dunn J. Theory of mind, emotion understanding, language, and family background: Individual differences and interrelations. Child Dev 1999;70: 853-865. 15. Keren M, Hopp D, Tyano S. Won’t it heal with time? Mental health in the first three years of life. Tel Aviv: Modan, 2013. 16. Winnicott DW. Primary maternal preoccupation. In Collected papers, through pediatrics to psychoanalysis. London: Tavistock Publications 1958: pp. 300-305. 17. Leckman J, Feldman R, Swain JE, Eicher V, Thompson N, Mayes LC. Primary parental preoccupation: Circuits, genes, and the crucial role of the environment. J Neural Transmission 2004;111: 753-771. 18. Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Mortensen PB. New parents and mental disorders: A population-based register study. JAMA 2006; 296:2582-2589. 19. Munk-Olsen T, Laursen TM, Mendelson T, Pedersen CB, Mors O, Mortensen PB. Risks and predictors of readmission for a mental disorder during the postpartum period.Munk-Olsen T, Laursen TM, Mendelson T, Pedersen CB, Mors O, Mortensen PB. J Arch Gen Psychiatry 2009; 66:189-195. 20. Reynolds JL. Post-traumatic stress disorder after childbirth: The phenomenon of traumatic birth. Can Med Assoc J 1997;156:831-835 21. Rutter M, Quinton D. Parental psychiatric disorder: Effects on children. Psychol Med 1984; 14:853-880. 22. Dickstein S[PubMed], Hayden, LC, Schiller M, Seifer R, Sameroff AJ, Keitner G, Miller I, Rasmussen S, Matzko M. Levels of family assessment II: Family functioning and parental psychopathology. J Fam Psychol 1998;12:23-40. 23. Sameroff AJ, Fiese B. Models of development and developmental risk. In Zeanah CH, Jr., editor. Handbook of infant mental health. New York: Guilford, 2000: pp. 3-19. 24. Field T. Infants of depressed mothers. Infant Behav Dev 1995;18:1-13. 25. Murray L, Cooper P. Post partum depression and child development. New York: Guilford, 1997. 26. Cohn JF, Campbell SA, Matias R, Hopkins J. Face-to-face interactions of postpartum depressed and nondepressed mother-infant pairs at 2 months. Dev Psychol 1990;26: 15-23. 27. Radke-Yarrow M, Cummings E, Kuczynski L, Chapman M. Patterns of attachment in two and three year olds in normal families and families with parental depression. Child Dev 1985; 56: 884-893. 28. Radke-Yarrow M, Nottelmann E, Martinez P, Fox MB, Belmont B. Young children of affectively ill parents: A longitudinal study of psychosocial development . J Am Acad Child Adolesc Psychiatry 1992;31: 68-77. 29. Uguz F, Akman C, Kaya N, Cilli AS. Postpartum-onset obsessivecompulsive disorder: Incidence, clinical features, and related factors. J Clin Psychiatry 2007;68:132-138. 30. Zambaldi CF, Cantilino A, Montenegro AC, et al. Postpartum obsessive compulsive disorder: Prevalence and clinical characteristics. Comprehensive Psychiatry 2009;50:503-509. 31. Tronick E, Als H, Adamson L, Wise S, Brazelton TB. The infants’ response to entrapment between contradictory messages in face to face interactions. J Am Acad Child Adolesc Psychiatry 1978; 17: 1-13. 32. Crandell LE, Patrick MP, Hobson RP. “Still Face” interaction between mothers with BPD and their two-months old infants. Br J Psychiat ry2003;183:239-247. 33. Hobson RP , Patrick MPH, Crandell L, Hobson JA, Bronfman E, Lyons R K . How mothers with borderline personality disorder relate to their one-year-old infant. Br J Psychiatry 2009; 195: 325-330 34. Conroy S, Marks MN, Schacht R, Davies HA, Moran P. The impact of maternal depression and personality disorder on early infant care. Soc Psychiatry Psychiatr Epidemiol 2010;45:285-292.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

The Outcome of Severe Internalizing and Disruptive Disorders from Preschool into Adolescence: A Follow-up Study Sara Spitzer, MD,1 Ornit Freudenstein, PhD,1 Miriam Peskin, MD,1,2 Sam Tyano, MD,1 Assaf Shrira, BA,1 Tova Pearlson, MA,1 Aviad Eilam, PhD,1 Gil Zalsman, MD,1,2 Tamar Green, MD,2,3 and Doron Gothelf, MD2,4 1

Division of Child and Adolescent Psychiatry, Geha Mental Health Center, Petah Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3 The Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry, Stanford University, California, U.S.A. 4 The Child Psychiatry Department, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel 2

Abstract Purpose: In this study we aimed to examine the outcome of children’s severe psychiatric disorders from preschool into later childhood and adolescence. Method: Forty preschool children (28 boys and 12 girls) treated in a tertiary referral mental health center, evaluated at admission and 5.5 ± 1.2 years thereafter. Results: Seven (58.3%) children diagnosed with internalizing disorders at baseline were free of any psychiatric diagnosis at follow-up (p=0.02). Conversely, only one child (8.3%) diagnosed with comorbid disruptive-internalizing disorders at baseline was free of any psychiatric disorder at follow-up (p=1.0). Seven (43.7%) children diagnosed with disruptive disorders at baseline were free of psychiatric diagnoses at follow-up (p=0.02). Limitations: The small sample size and naturalistic nature of the study. Conclusion: The trajectories of severe psychiatric disorders at preschool years are similar to those reported in community samples and differ according to the baseline diagnosis. Children with internalizing disorders show a much better recovery rate than those with comorbid disruptive and internalizing disorders.

INTRODUCTION Discovering the course of severe mental disorders during preschool years is critical to clinicians treating young children with severe early-onset psychiatric disorders as well as to the families of children with early-onset mental disorders. We used a historical prospective methodology in order to evaluate the consequence of children with severe psychiatric disorders from the preschool age into later childhood and early adolescence. Various psychiatric disorders, e.g., conduct problems, hyperactivity-impulsivity and inattention, and anxiety disorders start during the preschool years (1-6). With the exception of autism, data about the trajectories of severe childhood psychiatric disorders in preschoolers referred for treatment are scant, especially for earlyonset disorders (7, 8). Epidemiological and longitudinal studies in children and adolescents showed that the point prevalence of serious emotional disturbances, i.e., psychiatric morbidity causing significant impairment, is ~12%, similar to the rates reported for adults (9, 10). The interpretation of the above-mentioned stability of rates of psychiatric morbidity along development could be that psychiatric disorders begin early in life and continue into adulthood. This seems to be the case for at least some psychiatric disorders, such as conduct disorder (11). In addition, psychiatric disorders in childhood generally, and with few exceptions, exhibit homotypic continuity, whereas earlier disorders, such as depression, predict later depression (12). Altogether, these data suggest that we should continually monitor psychiatric morbidity

Address for Correspondence: Prof. Doron Gothelf, MD, The Child Psychiatry Department, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer 5262000, Israel gothelf@post.tau.ac.il

100

Sara Spitzer et al.

among our preschool sample of children who had been identified as having severe psychiatric morbidity. The epidemiology of psychiatric disorders in preschool children was examined less extensively than in school-aged children (8, 13). In a comprehensive review of epidemiological studies, the authors (8) reported the following rates: attention deficit hyperactivity disorder (ADHD) 2.0%5.7%, oppositional defiant disorder (ODD) 4.0%-16.8%, conduct disorder (CD) 0%-4.6%, depression 0%-2.1% and any anxiety disorder 9.4%. Studies of samples recruited from mental health clinics report that preschoolers, referred for psychiatric treatment, tend to suffer from comorbid disorders, more severe symptoms, and greater impairment than children from community samples (8). In a previous study (14), we retrospectively assessed the outcome of 28 children treated in a therapeutic nursery at a mental health center of a tertiary mental health center. The assessment was conducted during hospitalization, and it was based on a clinical psychiatric examination without the use of any structured psychiatric tools. We found that 64% of the children significantly improved during hospitalization. That study (14), however, was limited by a small sample size, a relatively short-term follow-up, and the lack of any structured psychiatric assessment. A classification of behavioral problems into internalizing and externalizing problems was first suggested by Achenbach (15), who later developed the child behavior checklist (CBCL). The CBCL divides behavioral symptoms into internalizing and externalizing symptoms in a standardized format (16). In longitudinal and follow-up studies of psychiatric disorders during preschool age the internalizing (anxiety and mood disorders) vs. externalizing (disruptive) (ADHD, ODD and CD) distinction is especially useful as it represents the most consistent empirically identified classification of psychopathology across ages, including the early preschool years (17). Of note, the distinction between internalizing and externalizing disorders has changed throughout the years, and it is currently less clear-cut. For example, in the recent edition of the Diagnostic and Statistical Manual DSM-5, a new entity was defined as â&#x20AC;&#x153;severe disruptive mood dysregulation,â&#x20AC;? which is composed of a mixture of internalizing (e.g., sad mood) and externalizing (i.e., angry outbursts) symptoms (18). The aim of the present study was to follow the longterm developmental trajectories of psychopathology in children who suffer from severe psychiatric morbidity during preschool age. We hypothesized that the recovery rate would be low in all types of psychopathology. We further hypothesized that the recovery rate in preschool-

ers with comorbid disruptive and internalizing disorders would be lower than in preschoolers with either disruptive or internalizing disorders alone. Our last aim was to identify predictors for the persistence of psychiatric morbidity over time in our sample. Based on the findings of our previous study of a different sample, we assumed that low socioeconomic status (SES), female gender, the presence of family problems, and treatment with psychiatric medications would predict the presence of continued psychiatric morbidity at follow-up (14). METHOD Participants

Between 2003 and 2005 we conducted a follow-up psychiatric evaluation of children who were admitted to a tertiary referral mental health center in Israel from November 1995 to December 2001. The program receives referrals of children from the central regions of Israel and is the only hospital day program for preschoolers in Israel. Participants were preschool age children aged 3 to 6 years with a variety of severe emotional and/or behavior problems. The treatment center is located in central Israel and serves the local population. The therapeutic work in the program varies from ambulatory treatment to a combination of community nursery and therapeutic nursery school to full-board day nursery schooling as previously described (14). The therapeutic program is custom tailored for every child and family. It consists of individual play therapy, parental counselling, dyadic therapy, family therapy, parent-child movement groups, music therapy, art therapy, occupational therapy, speech therapy, pet therapy, parental or sibling support groups, pharmacological treatments, and educational interventions. A research coordinator contacted parents of all participants by telephone and explained to them the nature of the psychiatric follow-up. We excluded participants who had, at baseline, autistic spectrum disorder, mental retardation, a medical condition as their primary diagnosis (including cerebral palsy, severe sensory impairment, or poorly controlled epilepsy), or did not fulfill any DSM-IV axis I diagnosis. We decided to exclude these participants due to the small number of subjects in each of these groups and because in this study we wanted to focus only on children with severe internalizing or disruptive disorders, who constitute the largest group by far in the treatment program. Parents of 129 children who were being treated in the preschool program between 1995 to 2001 were contacted 101

The Outcome of Severe Internalizing and Disruptive Disorders from Preschool into Adolescence

and 60 (46.5%) agreed to participate in the follow-up assessment. Twenty of those were excluded, based on the exclusion criteria mentioned in the Methods section. Consequently, 40 children - 28 boys and 12 girls - were included in the analysis. The mean age at admission was 5.7 ± 0.6 years. The mean duration of treatment in the mental health center unit was 14.6 ± 9.0 months. The mean age at follow-up was 10.7 ± 1.1 years. Time elapsed from baseline to follow-up was 5.5 ± 1.2 years and ranged from 3.4 years to 7.7 years. Assessment

Baseline Psychiatric Diagnoses – All children underwent a psychiatric evaluation based on the DSM-IV criteria, by a senior child psychiatrist. The psychiatric diagnoses were the product of a comprehensive DSM-IV based clinical evaluation of the child and his/her family by skilled senior child psychiatrists (19). Subjects were evaluated for current Axis I psychiatric disorders at intake by using all case-history information and a diagnostic interview with the parent and child. At follow-up we used the Hebrew version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime Version (K-SADS-PL)(20) - a semi-structured interview that is designed to evaluate current and lifetime disorders (ADHD, mood, psychotic, anxiety and disruptive behavior disorders) in children and adolescents aged 7 to 18. A trained clinician who was blind to the diagnoses given at the preschool period administered the interview. Socioeconomic status was assessed by the Hollingshead Factor Index of Social Status (21). Raw scores range from 8 (lowest socioeconomic status) to 66 (highest socioeconomic status). In homes with two parent incomes, the scores were averaged to obtain a single score per family. The children’s medical records were reviewed as well and the following information was coded: 1. The presence of family functioning problems was determined based on indications of one or more of the following common potential problems as retrieved from the medical records: divorce or separation of parents, physical or sexual abuse of the child by a family member, or the child living outside the house because of parental inability to provide care; 2. Psychiatric medications at baseline were recorded from the child’s hospital chart and at follow-up the parents were asked about treatment received by the child at that time. The study was approved by the Geha Mental Health Center Review Board (Petah Tikva, Israel). The children’s parents or guardians gave written consent to the 102

participation in the study after its nature was explained to them in detail. Statistical Analysis

The significance of differences in gender and psychiatric medications among the three diagnostic groups was analyzed with chi-square tests. The significance of differences in age and SES was analyzed using ANOVA analysis of variance. McNemar test was used to analyze the stability of the psychiatric diagnoses between baseline and follow-up. A binary logistic regression was conducted to determine the potential contribution of each of the predictive factors to the persistence of psychiatric morbidity at follow-up. RESULTS Psychiatric Diagnoses

We divided psychiatric diagnoses into three groups: 1. Disruptive disorders (n = 16) including oppositional defiant disorder (n = 12), conduct disorder (n = 4) and ADHD (any type) (n = 13). 2. Internalizing disorders (n = 12) including anxiety disorders (specific phobia [n = 2], separation anxiety disorder [n = 5], anxiety disorder not otherwise specified [n = 1], social phobia [n = 3], posttraumatic stress disorder [n = 1], generalized anxiety disorder [n = 1], obsessive compulsive disorder [n = 1]), depressive disorders (depressive disorder not otherwise specified [n = 3] and reactive attachment disorder, inhibited type [n = 1]). 3. Disruptive-internalizing disorders (n = 12) including oppositional defiant disorder (n = 7), conduct disorder (n = 3), ADHD (any type) (n = 4) and anxiety disorders (specific phobia [n = 5], separation anxiety disorder [n = 1], anxiety disorder not otherwise specified [n = 5], social phobia [n = 1], panic disorder with or without agoraphobia [n = 1], posttraumatic stress disorder [n = 1] and depressive disorder not otherwise specified [n = 2]). The frequency of those psychiatric disorder groups in the study cohort at baseline and follow-up are presented in Table 1. As expected, more comorbid disorders were observed in the disruptive-internalizing disorder group than in the disruptive and internalizing disorder groups (p = .02) (Table 1). The distribution of demographic and clinical characteristics of the 40 preschool children at baseline is also presented in Table 1. As can be seen, the three groups were similar in age at baseline and mean years at follow-

Sara Spitzer et al.

Internalizing Disorders (n = 12) Mean (SD)

DisruptiveInternalizing Disorders (n = 12) Group Mean (SD) Differences

Age at baseline 5.3 (0.7)

5.0 (0.5)

5.2 (0.6)

F = 0.61 ; p = .55

Age at follow-up

10.5 (0.9)

10.7 (1.3)

10.8 (1.1)

F = 0.28; p = .75

∆age

5.3 (0.9)

5.7 (1.4)

5.7 (1.2)

F = 0.63 ; p = .54

Comorbid Disorders

1.8 (0.4)

1.5 (0.5)

2.0 (0.7)

χ² = 11.37; p = .02

SES at baseline

39.4 (10.7)

44.0 (15.6)

43.2(13.6)

F = 0.45; p = .65

Males/ Females at baseline

13/3

5/7

10/2

χ² = 6.57; p = .04

Family functioning problems at baseline

4 (25%)

2 (15.4%)

7 (58.3%)

χ² = 5.43; p = .07

Family functioning problems at follow-up

1 (6.3%)

Disruptive Disorders (n = 16) Mean (SD)

Figure 1. The distribution of psychiatric disorders in the study cohort at baseline and at follow-up evaluations 70% Psychiatric Disorders at Follow-up

Table 1. Demographic and Clinical Characteristics of Preschool Children with Severe Psychiatric Morbidity

50% 40% 30% 20% 10% 0%

1 (8.3%)

4 (33.3%)

χ² = 4.54; p = .10

Medications at baseline Any Stimulants Antipsychotics Mood stabilizers

11 (68.8%) 1 (8.3%) 8 (50.0%) 1 (8.3%) 2 (12.5%) 0

6 (50.0%) 6 (50.0%) 0

χ² = 10.29;p < .01 χ² = 6.22; p = .05 χ² = 3.16; p = .21

1 (6.3%)

χ² = 1.54; p = .46

Medications at follow-upa Any Stimulants Antipsychotics Mood stabilizers

7 (77.8%) 6 (66.7%) 1 (11.1%)

1 (20.0%) 1 (20.0%) 0

4 (36.4%) 3 (30.0%) 1 (10.0%)

χ² = 7.13; p = .07 χ² = 10.76; p = .01 χ² = 0.63; p = .89

χ² = 1.71; p = .56

Disruptive disorders at follow-up (n=9), internalizing disorders at followup (n=5) and disruptive-internalizing disorders at follow-up (n=11).

No diagnosis Disruptive disorders Internalizing disorders Disruptive-Internalizing disorders

60%

Disruptive disorders (n=16)

Internalizing disorders (n=12)

Disruptiveinternalizing disorders (n=12)

Psychiatric Disorders at Baseline

who continued to suffer from psychiatric disorders, 4 (80.0%) maintained the internalizing disorder at followup. Seven (43.7%) of 16 children diagnosed with disruptive disorders were free of symptoms at follow-up (p = .02, Figure 1). Seven out of 9 children (77.8%) with baseline diagnosis of disruptive disorders who continued to suffer from psychiatric disorders still had disruptive disorders at follow-up. Only 1 of 12 children (8.3%) diagnosed with disruptive-internalizing disorders at baseline was free of any psychiatric disorder at follow-up (p = 1.0, Figure 1). Of the 11 children with disruptive-internalizing disorders who continued to suffer from a psychiatric disorders at follow-up 4 (33.3%) had solely internalizing disorders, 3 (25.0%) had only disruptive disorders and 4 (33.3%) had disruptive-internalizing disorders.

up (~5 years), and in SES status (Table 1). As expected, the proportion of males in the disruptive disorders and disruptive-internalizing disorders groups was higher than in the internalizing disorders group (χ² = 6.57; p = .037). No differences between groups were found at baseline in therapeutic setting (day care vs. ambulatory) (χ² = 3.91; p = .141). Stability of Psychiatric Diagnoses

The McNemar test revealed that 7 of the 12 children (58.3%) in the internalizing disorders group at baseline were free of any psychiatric diagnosis at follow-up (p = .02, Figure 1). Of the 5 children with internalizing disorders

Predictors for the Persistence of Psychiatric Morbidity

To assess potential predictors for the persistence of psychiatric morbidity at follow-up we performed a binary logistic regression. Of the following potential predictors at baseline-age, gender, family problems and psychiatric medications, only treatment with a psychiatric medication approached significance (B = 1.33, p = .08) as predicting the persistence of psychiatric morbidity at follow-up. Psychiatric Medications

At baseline, significantly more children with disruptive disorders and disruptive-internalizing disorders were receiving medications (68.8% and 50.0%, respectively) as compared to children with internalizing disorders 103

The Outcome of Severe Internalizing and Disruptive Disorders from Preschool into Adolescence

(8.3%) χ² = 10.29; p < .01. The same trend was found at follow-up , i.e., more children with disruptive disorders and disruptive-internalizing disorders (77.8% and 36.4%) were on a psychiatric medication regime than children with internalizing disorders (20.0%) (χ² = 7.13; p = .07). The medications most commonly used at baseline χ² = 6.22; p < .05 and at follow-up χ² = 10.76; p = .01 in the disruptive disorders and disruptive-internalizing disorders groups were stimulants (see Table 1). DISCUSSION In this study we investigated the developmental course of psychopathology in children who suffer from severe psychiatric disorders during the preschool years. Contrary to expectations, we found a relatively favorable prognosis for preschool children with internalizing or externalizing disorders. After intensive multidisciplinary treatment 58.3% of children with internalizing disorders were found at follow-up to be free of any psychiatric disorder. Of the preschoolers with baseline disruptive disorders, 43.8% were free from psychiatric disorder at follow-up. The worst prognosis was detected in children who suffered from both internalizing and externalizing disorders, i.e., only 8.3% of these children were free of psychiatric disorders at follow-up (Figure 1). The high rates of recovery from psychiatric morbidity found in our current study for preschoolers with internalizing or externalizing disorders is in line with epidemiological studies on children showing that the cumulative prevalence of psychiatric disorders is much higher than their point prevalence (22). For example, the cumulative prevalence of DSM-IV psychiatric disorders by young adulthood in the Great Smoky Mountains study is 61%, while their point prevalence is only 13% (22). The discrepancy between cumulative and point prevalence indicates that psychiatric morbidity is transient in many children. Epidemiological studies on community preschoolers followed longitudinally found a recovery rate of ~50% (12, 23-25), which is very similar to the recovery rate found in our clinical sample. As noted earlier, there are only few reports on the continuity of psychiatric disorders in community samples and none in clinically referred severely disturbed inpatient preschoolers. The fact that even these severely ill preschool inpatients had high recovery rates similar to the less severe community sample preschoolers is a novel finding of our study. We found that preschoolers who suffered from both internalizing and disruptive disorder had a poor 104

prognosis with most of them (~92%) continuing to suffer from psychiatric disorders at follow-up. Most children in the disruptive-internalizing disorders group had ODD/ CD (with or without ADHD) and comorbid internalizing disorders at baseline. Longitudinal studies from both community and clinical samples show that similar to our findings, children with internalizing disorders and comorbid ODD tend to be on a chronic course (26). Children in the disruptive-internalizing disorders group were diagnosed at follow-up with combinations of all three types of disorders (internalizing, disruptive and disruptive-internalizing disorders). The diverse developmental psychopathological pathways in this group could reflect, in our view, the rather vague boundaries between internalizing and disruptive disorders in younger children. For example, irritability, the hallmark of oppositional behavior is also a common symptom of depression in preschool children (25). We observed a high level of continuity in the group of preschoolers with internalizing disorders. Similar high continuity rates were reported in a study that evaluated the continuity levels of internalizing disorders in preschoolers between the age of 3 to 6 years (27). We found high stability of diagnosis in the disruptive disorders as well. Similarly to our observation, significant stability of ADHD and ODD in the preschool years has been previously shown in preschoolers (27, 28). Stability was higher when the baseline diagnosis was ODD or family history of disruptive disorders and stressful life events (28). Significantly more children with disruptive disorders and disruptive-internalizing disorders were treated with psychiatric medications than children with internalizing disorders. As expected, stimulants were the most commonly used medication. The use of stimulants for ADHD in preschool age population has been shown to be both effective and safe, albeit associated with higher rates of adverse events than in school-age children (29). Zuvekas et al. (30) examined the utilization of stimulants among U.S. children and found that they are seldom used (0.1% from 2004 onwards) in children under age 6. The very high rate of use in our sample for children with disruptive disorders or disruptive and internalizing disorders at both time points (Table 1) reflect, most probably, the severity of our cohort’s psychopathology. Within the internalizing disorders group, significantly lower rates of medications were used at both time points (p=0.01 for T1 and p=0.04 for T2). Previous reports showing moderate effectiveness of selective serotonin reuptake inhibitor (SSRI) medications in the treatment of anxiety disorders in children (31) and

Sara Spitzer et al.

even lower effectiveness in treatment of depression (32), and the lack of data on effectiveness of SSRI medications in preschoolers probably led to the low usage of SSRIs in our study population. The present studyâ&#x20AC;&#x2122;s limitations include the relatively small sample size, the naturalistic nature of the study, and the fact that psychiatric evaluation at baseline was based solely on the DSM-IV criteria with no structural assessment tools. The K-SADS was used only at followup evaluations. Psychometrically validated structured interviews might have yielded more accurate and valid data. In addition, the small sample size limited our ability to detect risk factors for psychopathology at follow-up. Each child in our study received different combinations of treatments based on many factors, including his/her psychiatric and developmental challenges, the parental challenges and his/her preference for a specific mode of communication (e.g., pets, music or art). Because of the above-mentioned naturalistic nature of our study, we could not control for the different psychosocial treatments that were included in the analysis. CONCLUSION Our results demonstrate that the trajectories of children with severe psychiatric disorders during preschool years differ significantly and are dependent on the baseline diagnosis. Preschoolers with internalizing disorders at baseline had a relatively favorable prognosis, preschoolers with disruptive disorders had intermediate prognosis and preschoolers with disruptive-internalizing disorders had bad prognoses. Further studies are needed to determine specific risk and protective factors that affect the prognosis of preschoolers who suffer from severe psychiatric disorders. Contributors Sara Spitzer, Ornit Freudenstein, Miriam Peskin and Doron Gothelf designed the study and wrote the protocol; Sara Spitzer, Ornit Freudenstion, Miriam Peskin, Assaf Shrira, Tova Pearlson and Aviad Eilam participated in data collection; Gil Zalsman and Sam Tyano contributed to the concept and to the editing of the manuscript; Sara Spitzer, Ornit Freudenstein, Tamar Green and Doron Gothelf conducted the analyses and wrote the first draft of the manuscript; Miriam Peskin, Tamar Green and Doron Gothelf prepared the final draft for submission.

Acknowledgements We express our gratitude to the participants and their families for making this study possible. The authors thank Anne Lise and Peter Madsen and the people of the Evangelical Church of Denmark for their generous support of this research. Funding for Tamar Green was provided by the Gazit Globe Postdoctoral

Fellowship Award - a fellowship for advanced researchers. The study sponsors were not involved in any phase of this study including: design, data collection, analysis and interpretation, writing of the report or decision on submission for publication.

References 1. Belden AC, Gaffrey MS, Luby JL. Relational aggression in children with preschool-onset psychiatric disorders. J Am Acad Child Adolesc Psychiatry 2012;51:889-901. 2. Boylan K, Vaillancourt T, Szatmari P. Linking oppositional behaviour trajectories to the development of depressive symptoms in childhood. Child Psychiatry Hum Dev 2012;43:484-497. 3. Coskun M, Zoroglu S, Ozturk M. Phenomenology, psychiatric comorbidity and family history in referred preschool children with obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health 2012;6:36. 4. Galera C, Cote SM, Bouvard MP, Pingault JB, Melchior M, Michel G, et al. Early risk factors for hyperactivity-impulsivity and inattention trajectories from age 17 months to 8 years. Arch Gen Psychiatry 2011;68:1267-1275. 5. Oliver BR, Barker ED, Mandy WP, Skuse DH, Maughan B. Social cognition and conduct problems: A developmental approach. J Am Acad Child Adolesc Psychiatry 2011;50:385-394. 6. Reef J, Diamantopoulou S, van Meurs I, Verhulst FC, van der Ende J. Developmental trajectories of child to adolescent externalizing behavior and adult DSM-IV disorder: Results of a 24-year longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2011;46:1233-1241. 7. Wals M, Verhulst F. Child and adolescent antecedents of adult mood disorders. Curr Opin Psychiatry 2005;18:15-19. 8. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. J Child Psychol Psychiatry 2006;47:313-337. 9. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60:837-844. 10. Costello EJ, Mustillo S, G. K, Angold A. Prevalence of psychiatric disorders in childhood and adolescence. In: Lubotsky. LB, Petrila J, Hennessy K, editors. Mental Health Services: A Public Health Perspective. New York: Oxford University, 2004: pp. 111-128. 11. Rowe R, Costello EJ, Angold A, Copeland WE, Maughan B. Developmental pathways in oppositional defiant disorder and conduct disorder. J Abnorm Psychol 2010;119:726. 12. Costello EJ, Copeland W, Angold A. Trends in psychopathology across the adolescent years: What changes when children become adolescents, and when adolescents become adults? J Child Psychol Psychiatry 2011;52:1015-1025. 13. Lavigne JV, Lebailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol 2009;38:315-328. 14. Gothelf D, Gertner S, Mimouni-Bloch A, Freudenstein O, Yirmiya N, Weitz R, et al. Follow-up of preschool children with severe emotional and behavioral symptoms. Isr J Psychiatry Relat Sci 2006;43:16-20. 15. Achenbach TM. The classification of childrenâ&#x20AC;&#x2122;s psychiatric symptoms: A factor analytic study. Psychological Monographs 1966;80:1-37. 16. Achenbach TM. Manual for the child behavior checklist. Burlington, Vermont: University of Vermont Department of Psychiatry, 1991. 17. Kim J, Cicchetti D. Longitudinal trajectories of self-system processes and depressive symptoms among maltreated and nonmaltreated children. Child Development 2006;77:624-639. 18. Association AP. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, D.C.: American Psychiatric Association, 2013: pp. 156-160. 19. Association AP. Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, D.C.: American Psychiatric Association, 1994.

105

The Outcome of Severe Internalizing and Disruptive Disorders from Preschool into Adolescence

20. Shanee N, Apter A, Weizman A. Psychometric properties of the K-SADSPL in an Israeli adolescent clinical population. Isr J Psychiatry Relat Sci 1997;34:179-186. 21. Hollingshead AB. Four Factor Index of Social Status. New Haven, Conn.: Yale University Department of Sociology, 1975. 22. Copeland W, Shanahan L, Costello EJ, Angold A. Cumulative prevalence of psychiatric disorders by young adulthood: A prospective cohort analysis from the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry 2011;50:252-261. 23. Beyer T, Postert C, Muller JM, Furniss T. Prognosis and continuity of child mental health problems from preschool to primary school: Results of a four-year longitudinal study. Child Psychiatry Hum Dev 2012;43:533-543. 24. Law EC, Sideridis GD, Prock LA, Sheridan MA. Attention-deficit/ hyperactivity disorder in young children: Predictors of diagnostic stability. Pediatrics 2014;133:659-667. 25. Luby JL, Heffelfinger AK, Mrakotsky C, Brown KM, Hessler MJ, Wallis JM, et al. The clinical picture of depression in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42:340-348. 26. Boylan K, Vaillancourt T, Boyle M, Szatmari P. Comorbidity of

106

internalizing disorders in children with oppositional defiant disorder. Eur Child Adolesc Psychiatry 2007;16:484-494. 27. Bufferd SJ, Dougherty LR, Carlson GA, Rose S, Klein DN. Psychiatric disorders in preschoolers: Continuity from ages 3 to 6. Am J Psychiatry 2012;169:1157-1164. 28. Tandon M, Si X, Luby J. Preschool onset attention-deficit/hyperactivity disorder: Course and predictors of stability over 24 months. J Child Adolesc Psychopharmacol 2011;21:321-330. 29. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry 2006;45:1284-1293. 30. Zuvekas S, Vitiello B, Norquist G. Recent trends in stimulant medication use among U.S. children. Am J Psychiatry 2006;163:579-585. 31. Kodish I, Rockhill C, Ryan S, Varley C. Pharmacotherapy for anxiety disorders in children and adolescents. Pediatric Clinics of North America 2011;58:55-72, x. 32. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: Systematic review of published versus unpublished data. Lancet 2004;363:1341-1345.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Silvana Fennig et al.

Feasibility of a Dual Evaluation/Intervention Program for Morbidly Obese Adolescents Silvana Fennig, MD,1,2 Anat Brunstein-Klomek, MD,1,3 Ariel Sasson, MD,1,3 Irit Halifa Kurtzman, MSc, RD,1 and Arie Hadas, MD1 1

Crisis Intervention Unit, Feinberg Child Study Center, Schneider Childrenâ&#x20AC;&#x2122;s Medical Center of Israel, Petach Tikva, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel 3 School of Psychology, IDC, Herzliya, Israel 2

Abstract Background: In the absence of evidence-based guidelines for screening adolescent candidates for bariatric surgery, or improving their adherence to preoperative recommendations, we designed a dual-phase multidisciplinary program aiming for observation-based preoperative assessment/ intervention, as well as for post-operative/ conservative follow up. Methods: This study focused on the preoperative 3-month phase. Fifteen morbidly obese adolescents attending the eating disorders unit of a pediatric hospital underwent the program protocol consisting of medical examinations/ tests, psychological measures, self-monitoring, tailored diet, physical activity schedule, individual and group cognitive behavior-oriented therapy, and psycho educational parent training. Results: All patients completed the preoperative phase. Most of them (70%) followed the structured diet with a significant reduction in BMI. The patients complied with self-monitoring, and body dissatisfaction score improved. Parental participation in therapy was poor. Four patients with low adherence were found ineligible for surgery. Conclusions: The findings support the feasibility of our dual screening/intervention protocol. Measures to improve parental participation are warranted.

Introduction In 1998, the Maternal and Child Health Bureau convened a committee of pediatric obesity experts to formulate recommendations for the evaluation and treatment of childhood obesity (1). In a 2007 revision of these guidelines, the committee emphasized that accurate and appropriate assessment is needed in order to individually tailor treatment programs for patients (2, 3). However, similarly to the state of affairs for adults, a consensus regarding the optimal approach for assessment is still lacking (4). Obesity assessment needs to account for the many factors that complicate adolescent obesity, such as ethics, development, and the need for chronic care (5, 6), as well as the pros and cons of the various available treatment modalities, on a case-by-case basis with a lifetime perspective. When bariatric surgery is included as a treatment option for morbidly obese adolescents, the initial assessment serves as the basis for qualifying candidates for surgery and predicting the short- and long-term outcome. In 1991, a Consensus Panel from the National Institutes of Health advocated that surgeons work with a multidisciplinary team or use a multidisciplinary approach to optimize patient care (7). However, a recent survey reported that surgeons vary greatly in their conception of what multidisciplinary teams constitute (8), and even the minimum criteria of a multidisciplinary evaluation are often unmet. Furthermore, the mental health professionals who conduct the preoperative psychosocial assessment of candidates for bariatric surgery are hindered by the lack of evidence-based guidelines. Although various authors have described their evaluation techniques or provided suggestions (9), there is no available standard of practice (10, 11). Additionally, the available instruments, i.e., unstructured

Address for Correspondence: Silvana Fennig, MD, Crisis Intervention Unit, Feinberg Child Study Center, Schneider Childrenâ&#x20AC;&#x2122;s Medical Center, Petach Tikva 49202, Israel â&#x20AC;&#x2020; Silvanafen@gmail.com

107

Feasibility of a Dual Evaluation/Intervention Program for Morbidly Obese Adolescents

interviews and patient or parent self-report scales, limit the validity of the assessment. Walfish et al. (11) noted that 85% of clinicians evaluate adult obese patients with an unstructured interview combined with an assortment of psychological tests, and the other 15% employ an unstructured interview alone. The most frequently used psychological tests are the Minnesota Multiphasic Personality Inventory 2, the Beck Depression Inventory 2 (BDI-2), and the Millon Behavioral Medicine Diagnostic. Millon et al. (12) attempted to establish norms for the Behavior Medicine Diagnostic, but further analyses revealed that the reliability of 16 of the instrument’s 32 subscales was inadequate for the assessment of candidates for bariatric surgery. Some providers also include other questionnaires (13, 14), but these are also self-reports. Recently, Eisenmann (15) found that most of the inconsistencies in assessments occurred in the psychological domain. The aim of the present study was to examine the feasibility of a dual assessment/intervention program for morbidly obese adolescents. The program simultaneously evaluates the adolescents and includes interventions preparing them and their families for either bariatric surgery or conservative psychosocial/behavioral treatment. The program is based on a structured protocol, but, at the same time, allows the team flexibility in addressing the specific needs of individual patients and families. In addition to using standard methods, the multidisciplinary team evaluates the patients’ coping strategies and psychological variables in “real time,” while the patients cope with the restrictions and demands imposed by the program. This helps the team identify risks, strengths and resiliency factors that can influence the course and outcome of treatment. The program protocol is divided into a 3-month pre-surgical assessment/intervention phase, and a 6-month maintenance phase (post-surgical or conservative). The present study focuses on the feasibility of the initial 3-month phase. Method Setting and Participants

The study was conducted in an open inpatient psychiatric unit that specializes in the management of eating disorders, somatoform disorders, and other conditions of organic-psychiatric comorbidity. The unit’s staff includes a psychiatrist, nurses, dieticians, psychotherapists, art therapists, teachers and psychology students, who work as “social mentors.” Located within a general children’s hospital in Israel, the unit has access to various consultants, including endocrinologists, pediatricians and pediatric 108

surgeons. A detailed description of the unit can be found elsewhere (16). The program described in this article was developed especially within the unit to meet the needs of morbidly obese adolescents. The study protocol was approved by the hospital’s Institutional Review Board. The study group consisted of 15 adolescents diagnosed with morbid obesity (BMI ≥ 40, or BMI ≥ 35 with obesity-related medical complications). The subjects were referred to the program from other pediatric units in the hospital or by community pediatricians. Eligibility criteria matched the Israel Ministry of Health recommendations for bariatric surgery in children and adolescents (17), and included Body Mass Index (BMI; weight (kg) / height (m2)) >40 with serious physical complications amenable to improvement by weight reduction, or BMI >50 with less severe medical complications and previous failures to lose weight. Additional criteria for subsequent surgery included: multidisciplinary assessment, pre-surgical preparation, consent for post-surgical medical, nutritional and psychological follow-up at our unit, cognitive ability to understand the consequences of the surgical procedure, and the presence of a supportive family environment. Exclusion criteria from the program included diseaserelated etiology for obesity (e.g., Prader Willi Syndrome, brain tumor), drug induced etiology for obesity, mental retardation (or inability for another reason to understand or cooperate with the program requirements), psychiatric diagnosis of a severe mental disorder, and severe medical or psychiatric complication that requires acute intervention outside the scope of the program. Subjects whose parents or caretakers could not adhere to the program requirements were excluded as well. The clinical investigator (S.F.) provided oral and written explanations of the nature and purpose of the study to parents and participants. Prior to enrollment, parents signed a consent form, and subjects approved participation orally. Description of the Program Treatment Principles

The treatment protocol is based upon four principles. 1. Diet and physical activity. Patients are expected to eat three balanced meals per day (breakfast, lunch, dinner), and three snacks (total daily intake 1400-1600 calories), as prescribed by the National Institute for Food, and to drink up to 1.5 L of water. The goal of this diet is a moderate weight loss. Patients are encouraged to decrease sedentary activities (e.g., TV watching or computer

Silvana Fennig et al.

games) during and after school hours and to adhere to individually-tailored physical activity program. Participants and parents alike receive psycho education in regard to weight loss and weight maintenance skills. 2. Family life-style changes. Parents meet for a weekly parents guidance meeting and participate in a bi-weekly parent group. The psychotherapeutic interventions are based on the work of Cooper et al. (18). To increase parents’ capacity to encourage their child to adopt new skills and cooperate with the program, parents receive psycho education. This is focused on themes such as regular family meals, healthy foods, reduction of sedentary activities and parental modeling. 3. Educational functioning. An educational curriculum is formulated for each patient by a special education teacher. Patients gradually move from a closed hospital environment to a regular community and school functioning. 4. Intensive cognitive behavioral therapy (CBT) (18). Therapy has been adapted for adolescents. Initially, patients participate in eight CBT sessions, held twice weekly over four weeks. Sessions aim to introduce and implement a structured schedule of weighing, regular meals and self-monitoring, with the goal of encouraging patients to accept life-style changes and moderate weight loss. Psycho education is introduced aiming to clear up misconceptions regarding weight loss and weight-loss maintenance. In sessions, patients’ self-monitoring charts are reviewed by patients and therapists and difficulties are discussed. As the program progresses, CBT is more directed at helping patients to conceptualize the factors and processes that may keep them from losing weight and increase their capacity and skills to control and manage weight loss. Another important aspect concerns identifying and changing patients’ self-evaluation of their body-shape and weight and their eating habits. Behavioral interventions include exposure to relevant food cues. Patients are also encouraged to increase their involvement in social, academic and familial domains. Addressing interpersonal problems, such as solving conflicts with others, is also an important aspect of the program. Assessment and Treatment Protocol

Patients are assessed at three time points throughout the program. Pre-admission assessment (T0). The pre-admission assessment is conducted one month prior to the inpatient phase. After patients and parents receive a detailed description of the program, patients go through a detailed clinical evalu-

ation. Their weight, height, BMI, developmental history and medical complications are assessed and reviewed. A battery of questionnaires and measures of psychopathology is completed by patients and parents. Patients are asked to go through medical tests. Two weeks after the above evaluation, patients and parents meet with a dietician who trains them in performing self-monitoring of food intake. Admission assessment (T1). One month after the preadmission assessment, patients are admitted to the unit. At that time, they undergo a physical examination consisting of measurement of weight and height, vital signs and an electrocardiogram. T0 medical tests are reviewed for possible diagnoses of sleep apnea, type 2 diabetes, hyperinsulinemia, hypertension, dyslipidemia or polycystic ovary syndrome. The self-monitoring data are collected as well. Patients are admitted for four weeks during which they are placed on a moderate restricted-calorie diet. During the inpatient phase each patient goes through individual behavioral and cognitive therapy performed side by side with intensive psycho educational training for parents. Each patient performs a physical exercise plan. Medical complications are closely monitored. Following the month of inpatient treatment are eight weeks of twice weekly day treatment program. This phase is geared to help patients continue moderate weight loss until a goal of a 5%-15% weight loss is achieved. Besides visiting the unit, patients continue their school and home routines. Follow-up assessment (T2). Follow-up assessment is performed three months after program enrollment. At this phase, a multidisciplinary team (endocrinologists, surgeons, dieticians and psychosocial staff) review the medical and psychosocial findings in order to formulate a treatment plan. This may consist of continuing the conservative program at the unit or at the community, or undergoing bariatric surgery. The full program includes an additional three-month post-intervention maintenance phase, designed according to the type of treatment selected (conservative vs. surgery). This phase is not described in the present study. Instruments

Life Habits Questionnaire. This 11-item semi-structured interview was developed especially for this study, in order to evaluate daily personal and family eating habits and physical activities. It is administered by the unit nurse or dietitian in the form of a semi-structured interview. Cooperation with Treatment Questionnaire. This sixitem therapist-rated questionnaire was developed especially for this study, in order to evaluate the patients’ overall 109

Feasibility of a Dual Evaluation/Intervention Program for Morbidly Obese Adolescents

cooperation with the treatment, including aspects such as performing self-monitoring in and out of the unit, adherence to dietary regimen, and degree of parental cooperation in parental guidance sessions, and in monitoring their child’s food intake, eating habits, and daily activities. Each item is rated on a scale from 0 (not at all) to 4 (always). Beck Depression Inventory (BDI-IA) (19). The BDI-IA was used to assess cognitive, behavioral, affective and somatic components of depression in the program participants. Loss of libido was not assessed. The instrument consists of 21 items rated on a scale from 0 (not present) to 3 (severe). The total score can range from 0 (no depression) to 63. The BDI-IA has been applied in more than 200 studies, including some with adolescent samples (20, 21), and has accumulated considerable evidence for its reliability and validity. For example, in a meta-analysis (22), its estimated internal consistency in psychiatric samples was found to be high (α=0.86). Eating Disorder Inventory (EDI-2) (23). The EDI-2 is a self-report measure of symptoms frequently related to anorexia nervosa or bulimia nervosa. Each of the instrument’s 11 subscales covers a different psychological and behavioral dimension of these disorders. For the present study, we used five subscales: Bulimia, Body Dissatisfaction, Interpersonal Distrust, Impulse Regulation, and Social Insecurity. Responses are rated on a 6-point scale from “never” to “always.” The EDI-2 has been used widely, including in Israeli samples (23, 24). Eating Disorder Examination – Questionnaire version 6.0 (EDE-Q) (25). The EDE-Q is a self-report version of the well-established investigator-based EDE interview (26). It is composed of four subscales: Weight Concern, Shape Concern, Eating Concern, and Dietary Restraint. The frequency of diagnostic behaviors such as binge eating and self-induced vomiting is assessed as well. Each item is rated on a 7-point scale; higher scores reflect greater symptom severity and/or frequency. The mean value of the four subscale scores is calculated to determine the global score. In the present study, we used only the first three subscales. The EDE-Q has been found to have good validity and reliability.

Results The study group consisted of 15 patients (10 females and 5 males) aged 8 to 17 years. Fourteen were Jewish and one was Muslim. Six patients (40%) were first-born children. Four patients (27%) had obese fathers, five (33%) had obese mothers, and six (40%) had obese siblings. Other characteristics of the sample are shown in Table 1. One additional candidate declined participation during the preadmission phase. There was no statistically significant difference in BMI between this candidate and the rest of the participants. Another participant, a boy who was attending boarding school, dropped out of the study after six weeks due to difficulties transporting to and from the hospital. His BMI was not different from the mean BMI of the participants. Mean age at the onset of the program was 14.47 years (SD 2.61). Weight-related psychosocial distress was reported by the patients to begin at a mean age of 4.60 years (SD 4.88). All patients had tried at least one weight reduction diet in the past, with a mean of 3.64 diets (SD 2.92). Mean age for Table 1. Demographic characteristics of 15 morbidly obese adolescents participating in a dual assessment/intervention program

Statistical Analysis

One-way analysis of variance with repeated measures was used to analyze changes over time. The least significant difference (LSD) post hoc test was performed on variables that showed significant differences over time. Statistical analyses were performed with the SPSS, version 18. 110

Characteristics

N (%)

Gender (female)

10 (66)

Religiosity (Jews, n=14) Secular Traditional Orthodox Ultraorthodox

6 (44) 3 (21) 3 (21) 2 (14)

Socioeconomic status of family Medium – high Medium Medium – low

3 (20) 8 (53) 4 (27)

Parental overweight1 Neither parent One parent Both parents

4 (27) 4 (27) 7 (46)

Father’s weight Normal Overweight Obese

7 (46) 4 (27) 4 (27)

Mother’s weight Normal weight Overweight Obese

5 (33) 5 (33) 5 (33)

Siblings weight2 Normal Overweight Obese

9 (60) 0 (0) 6 (40)

Overweight = BMI between 25-30; Obese = BMI > 30. Data includes all siblings, younger and older.

Silvana Fennig et al.

trying the first diet was 9 years (SD 3.13). Ten patients (66%) had been in psychotherapy at some point prior to admission. The ideal weight stipulated by the patients at onset of the program was 65.28 kg (SD 15.97). It is noteworthy that patients answered this question regardless of their actual BMI. Furthermore, in order to attain this weight, patients had to lose, on average, 42% of their admission weight. The most frequent medical complications were fatty liver (100%) and obstructive sleep apnea (30%), followed by acanthosis nigricans, hyperinsulinemia and diabetes. Psychiatric comorbidities included depression/dysthymia (70%), attention deficit hyperactivity disorder (30%), and generalized anxiety disorder (20%), followed by oppositional defiant disorder and developmental disorder. Table 2 presents maximum, minimum and mean values of patients’ weight and BMI at three assessment points (T0, T1, and T2). Both weight and BMI decreased significantly over time. A significant reduction was noted from T0 to T2 (p<.001), as well as from T1 to T2 (p<.001). No significant difference was found between T0 to T1. Mean BMI loss was 0.54 (SD 1.12) m2/kg. between T0-T1 and 3.14 (SD 2.05) m2/kg between T1-T2. Table 3 presents EDI-2 and EDE-Q subscales scores . On the EDI-2, bodydissatisfaction scores showed a near significant change (p=.06). No significant difference was found on any of the other subscales. From patients’ self-report on admission it was clear that none ate according to a structured menu and none selfTable 2. Weight and BMI in 15 morbidly obese adolescents at pre-admission (T0), admission (T1) and 3-months’ follow-up (T2) T0

Weight Mean (SD)

113.45a (21.56)

112.25b (21.09)

104.12ab (20.47)

Maximum

150

144.7

142.25

Minimum

73.95

72.95

63.35

BMI Mean (SD)

45.32a (10.95)

44.79b (10.27)

41.64ab (9.43)

Maximum

76.53

72.45

69.23

Minimum

32.3

31.66

29.92

EBMI* Mean (SD)

22.00a (11.72)

21.47b (11.00)

18.32ab (10.3)

Maximum

7.3

6.76

5.02

Minimum

58.63

54.55

51.33

Significant difference of p<.001 between T0 and T2 Significant difference of p<.001 between T1 and T2 *The EBMI is calculated from the 85th percentile for age and sex a

Table 3. Means (SD) of EDI-2 and EDE-Q in 15 morbidly obese adolescents at pre-admission (T0), admission (T1), and at a 3-months’ follow-up (T2) Time Points

Time Points Parameter

monitored their eating habits. The majority of the patients (86%) did not engage in physical activity. Moreover, none of the parents monitored or supervised their child’s eating behavior. Based on the observation by the multidisciplinary program team at T2, as well as the monitoring records of participants and parents, it was found that 70% of the patients ate at this time point according to their prescribed diet. Moreover, about 60% were self-monitoring their eating behavior and physical activity, and 80% engaged in physical activity. In addition, 70% of the parents were supervising their child’s eating behavior. Parental attendance in guidance sessions increased with time, but remained low overall. Between T1 and T2, 50% of the parents failed to attend any of the guidance sessions and 20% attended only occasionally. Four of the 15 patients were found ineligible for bariatric surgery because of unsatisfactory cooperation with the program. Specifically, these four patients failed to eat according to their prescribed diet, did not self-monitor, failed to attend scheduled meetings, and did not adhere to medical recommendations. Furthermore, in general their parents were not supportive of the program’s principles and were only marginally involved in their child’s treatment plan. These patients were referred to community settings for continuation of treatment with specific treatment recommendations. Five participants underwent bariatric surgery (“sleeve surgery”). Six patients continued with conservative follow up.

Instrument

Bulimia

5.07 (3.83)

4.36 (4.43)

3.35 (4.94)

.50

Body dissatisfaction 23.36 (5.30)

20.21 (7.49)

19.71 (7.71)

.06

Distrust

5.00 (3.01)

5.50 (4.07)

4.71 (3.07)

.74

Impulse

4.78 (4.06)

4.43 (4.25)

6.64 (7.04)

.18

Insecurity

5.07 (4.35)

3.85 (3.46)

6.38 (4.55)

.13

Total

43.00 (12.93)

38.07 (15.06)

41.28 (18.63)

.46

EDI-2

EDE-Q Eating concern

1.96 (1.65)

1.80 (1.83)

2.33 (2.56)

.54

Weight concern

3.86 (1.41)

3.21 (1.49)

3.93 (1.97)

.29

Shape concern

4.01 (1.39)

3.48 (1.56)

3.95(2.11)

.49

Total

3.28 (1.39)

2.83 (1.51)

3.40 (1.86)

.34

BDI

13.57 (8.48)

11.00 (9.63)

12.79 (11.29)

.47

EDI-Eating Disorder Inventory, EDE-Eating Disorder Examination, BDI-Beck’s Depression Inventory

111

Feasibility of a Dual Evaluation/Intervention Program for Morbidly Obese Adolescents

Discussion The present study supports the feasibility of a preoperative program of comprehensive “real time” assessment combined with psychosocial/nutritional intervention for morbidly obese adolescents. The findings reported pertain to the initial evaluation/preparation phase. The program was designed as an alternative to the standard methods of assessment which are based only on retrospective or subjective information. The characteristics of our sample are similar to those described in related studies in terms of demographics (27), level of depression (28), and physiological and psychological comorbidities (29). The program was found to be effective in reducing BMI. The lack of a significant change in BMI between T0 (preadmission) and T1 (admission) may indicate that standard monitoring and psycho education are insufficient to create change. In contrast, the significant weight loss between T0 and T2 (3-month follow-up) and between T1 and T2 may indicate that the assessment/ intervention program has an impact and can make important change in regard to the weight of morbidly obese adolescents. The short duration of the assessment/intervention is based on Stice et al.’s (30) suggestion that shorter interventions produce a significantly larger effect than longer ones. Moreover, the finding regarding a significant weight loss following this 3-month assessment/intervention phase is consistent with the findings of Murphy et al. (31) and Braet (32) wherein the magnitude of weight change achieved early in treatment was found to be a good predictor of treatment outcome. The importance of this initial assessment/ intervention phase may be true for both surgical and psychosocial interventions. Our analysis revealed that the body dissatisfaction was reduced during the program. Other features of disordered eating were also reduced, but these changes were not statistically significant and therefore should be interpreted with caution. Other features of eating disorders even increased, but these changes as well were not statistically significant. For example, eating concern and weight concern as measured by the EDE-Q showed near significant increases from T1 to T2, which might indicate a greater focus on eating habits and weight management following program participation. Most patients adhered to the program. Most improved their eating habits, and regularly monitored their eating behavior and physical conditions (e.g., behavioral factors related to postsurgical outcome) (32, 33). In addition, most 112

parents began monitoring and supervising their child’s food intake and sedentary behaviors. Studies suggest that parental monitoring may reflect commitment to child’s weight loss and may be critical to successful weight control (33). However, in our study, parental involvement was found to be relatively poor, at least in terms of attendance in parental guidance sessions. Approximately one half of the parents did not attend the sessions at all. Further research is needed in order to address parental barriers to effective participation and factors that may reinforce parental commitment and active participation (34-36). Besides the standard data collection from the adolescent patients and their families, the present study included collection of observational data for each individual patient. These data may best indicate the patient’s ability to cooperate with the strict pre- and post-operative regimen, as well as the family’s ability to function as an effective support system. The finding regarding the four patients who were referred back to the community seems to indicate that the observational assessment/intervention provides important comprehensive psychosocial data that may improve postoperative outcome. Furthermore, the assessment/intervention itself, with its emphasis on self-monitoring, exercise, structured diet and familial support, may prepare the patient and family to deal with long-term conservative treatment. This conclusion is similar to that of Zeller and Modi (37) who concluded that therapists must take into account the contribution of psychosocial status to adolescents’ ability to achieve weight change and weight maintenance. In patients referred for bariatric surgery, our assessment/intervention protocol can also serve as a preparatory program for postoperative weight control (32, 36). Several limitations of the study should be considered when interpreteting its findings. First, this is only a pilot feasibility study conducted with a small sample. Second, the medical complications were systematically assessed only at onset of the program but not at the end of the assessment/ intervention. Further studies that will include all the phases of the intervention are in planning. The benefits of the entire protocol will be evaluated in a randomized controlled efficacy trial. References 1. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics 1998;102:E29. 2. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity:

Silvana Fennig et al.

Summary report. Pediatrics 2007;120:164-192. 3. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120/suppl 4:192-227. 4. Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki J. How do mental health professionals evaluate candidates for bariatric surgery? Surgery results. Obes Surg 2006;16:567-573. 5. Braet C, Tanghe A, De Bode P, Franckx H, Van Winckel M. Inpatient treatment of obese children: A multicomponent programme without stringent calorie restriction. Eur J Pediatr 2003;162:391-396. 6. Inge TH, Zeller MH, Lawson ML, Daniels SR. A critical appraisal of evidence supporting a bariatric surgical approach to weight management for adolescents. J Pediatr 2005;147:10-19. 7. NIH Consensus 1991. http://consensus.nih.gov/1991/1991gisurgeryo besity084html.htm. Accessed: January 2012. 8. Santry HP, Marshall HC, Kathleen AC, John CA, Diane SL. The use of multidisciplinary teams to evaluate bariatric surgery patients: Results from a national survey in the USA. Obes Surg 2006;16:59-66. 9. Pfeil M. Weight loss surgery for morbid obese adolescents. J Child Health Care 2011;15:287-298. 10. Walfish S, Vance D, Fabricatore AN. Psychological evaluation of bariatric surgery applicants: Procedures and reasons for delay or denial of surgery. Obes Surg 2007;17:1578-1583. 11. Walfish S, Wise D, Streiner D. Limitations of the Millon behavioral medicine diagnostic (MBMD) with bariatric surgical candidates. Obes Surg 2008;18: 1318-1322. 12. Millon T, Antoni M, Millon C, Minor S, Grossman G (editors). MBMD Manual Supplement: Bariatric Report. NCS Pearson: Minneapolis, 2007. 13. DecaluwĂŠ V, Braet C. Assessment of eating disorder psychopathology in obese children and adolescents: Interview versus self-report questionnaire. Behav Res Ther 2004;42:799-811. 14. Reas DL, Grilo CM, Masheb RM. Reliability of the Eating Disorder Examination-Questionnaire in patients with binge eating disorder. Behav Res Ther 2006;44:43-51. 15. Eisenmann JC. Assessment of obese children and adolescents: As survey of pediatric obesity management programs. Pediatrics 2011;128:S51-S58. 16. Fennig S, Fennig S. Intensive therapy for severe pediatric morbid obesity. Pediatr Endocrinol Rev 2006;3:590-595. 17. Israel Ministry of Health. Eligibility Criteria for Adolescent Bariatric Surgery. http://www.health.gov.il/hozer/mr32_2009.pdf, Accessed June 10, 2012. 18. Cooper Z, Fairburn CG, Hawker DM. Cognitive-behavioral treatment of obesity: A clinicianâ&#x20AC;&#x2122;s guide. New York: Guilford, 2003. 19. Beck AT, Steer RA (editors). Manual for the Beck Depression Inventory. San Antonio: Psychological Corporation, 1993.

20. Strober M, Green J, Carlson G. Utility of the Beck Depression Inventory with psychiatrically hospitalized adolescents. J Consult Clin Psychol 1981;49: 482-483. 21. Teri L. The use of the Beck Depression Inventory with adolescents. J Abnorm Child Psychol 1982;10:277-284. 22. Beck AT, Steer RA, Garbin MG. Psychometric properties of the beck depression inventory: Twenty-five years of evaluation. Clin Psychol Rev 1988;88:77-100. 23. Garner DM, Olmsted MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983;2:15-34. 24. Niv N, Kaplan Z, Mitrani E, Shiang J. Validity study of the EDI-2 in Israeli population. Isr J Psych Relat Sci 1998;35:287-292. 25. Fairburn CG, Beglin SJ. The assessment of eating disorders: Interview or self-report questionnaire? Int J Eat Disord 1994;16:363-370. 26. Fairburn CG, Cooper Z. The eating disorders examination. In C. G. Fairburn CG, Wilson GT, editors. Binge eating: Nature, assessment and treatment. 12th edn. New York: Guilford, 1993: pp. 317-360. 27. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292:1724-1737. 28. Fabricatore AN, Wadden TA, Higginbotham AJ, et al. Intentional weight loss and changes in symptoms of depression: A systematic review and meta-analysis. Int J Obes 2011;35:1363-1376. 29. Sarwer DB, Dilks RJ. Overview of the psychological and behavioral aspects of bariatric surgery, bariatric times. http://bariatrictimes. com/2011/02/11/overview-of-the-psychological-and-behavioral-aspectsof-bariatric-surgery/. Accessed: March 2012. 30. Stice E, Shaw H, Marti CN. A meta-analytic of obesity prevention programs for children and adolescents: The skinny on interventions that work. Psychol Bull 2006;132:667-691. 31. Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral therapy for eating disorder. Psychiatr Clin North Am 2010;33:611-627. 32. Braet C. Patient characteristics as predictors of weight loss after an obesity treatment for children. Obesity 2006;14:148-155. 33. Germann NJ, Kirschenbaum SD, Risch HB. Child and parental selfmonitoring as determinants of success in the treatment of morbid obesity in low-income minority children. J Pediatr Psychol 2007;32:111-121. 34. Ingelfinger RJ. Bariatric surgery in adolescents. N Engl J Med 2011;365: 1365-1367. 35. Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity. Obes Res 1998;12:357-361. 36. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998; 67:1130-1135. 37. Zeller MH, Modi CA. Predictors of health-related quality of life in obese youth. Obesity 2006;14:122-130.

113

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Dental Health and the Type of Antipsychotic Treatment in Inpatients with Schizophrenia Alexander Grinshpoon, MD, PhD, MHA,1 Shlomo P. Zusman, MD,2 Abraham Weizman, MD,3 and Alexander M. Ponizovsky, MD, PhD4 1

Sha’ar Menashe Mental Health Center, Hadera, Israel, and Bruce Rappoport Faculty of Medicine, Technion, Haifa, Israel Division of Dental Health, Ministry of Health, Jerusalem, Israel 3 Geha Mental Health Center, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 4 Research Unit, Mental Health Services, Ministry of Health, Jerusalem, Israel 2

Abstract Aim:This study examined the association between dental conditions in hospitalized patients with ICD-10 schizophrenia and type of antipsychotic treatment. Based on the literature suggesting that atypical antipsychotics are thought to be more tolerable than typical antipsychotics, we hypothesized that hospitalized patients with schizophrenia treated with atypicals would have better dental health than those treated with typicals alone or with a combination of both (combined group). Methods: A representative sample of 348 patients (69% males), aged 51.4 (SD=14.5, range 31-58) years, was assessed on the standardized criteria of the Decayed, Missing and Filled Teeth (DMFT) index and component scores. Data on medication were extracted from patients’ electronic medical records. Results: Patients treated with typicals had significantly higher DMFT index scores than those who received atypicals (23.5±9.9 vs. 19.0±10.5; p<0.05), and higher Missing (20.2±11.6 vs. 13.5±11.2; p<0.01) and lower Filled (1.0±2.4 vs. 2.1±3.9; p<0.05) teeth component scores. No between-group differences in Decayed component scores were found (2.3±3.4 and 3.4±5.0, respectively; p>0.05). The combined treatment group was situated in between the typicals and atypicals groups on all measures. Conclusions: The results suggest that patients with schizophrenia maintained on atypicals have better dental health than patients treated with typicals or with

a combination of both. From an oral health perspective, monotherapy with atypicals is superior to both typical and atypical/typical treatments. Although the choice between typical and atypical antipsychotic agents is based mainly on clinical psychiatric efficacy, the benefit of atypicals with regard to dental health should be taken into consideration in clinician’s decision making.

Introduction In recent years, there has been increasing interest in dental health among patients with schizophrenia and other severe mental illnesses. This is probably related to an interest in improving the physical health, integration in the community, quality of life and more tolerable and safe pharmacological treatment for this population. Psychiatric patients are exposed to a particularly high risk of dental diseases because of both patient-related and service-related factors, most of which are modifiable. Patient-related risk factors include heavy smoking (1, 2), neglecting oral hygiene (3-5), avoidant behavior (6), having a carbohydrate-rich diet (7, 8), and abusing alcohol and drugs (9). Service-related factors include lack of suitable dental clinics (10), lack of funds designated for dental services, poor accessibility to dental services (11), and insufficient concern of psychiatrists (12). An important, but understudied factor, is the impact of psychotropic medications that can cause dry mouth (5, 13, 14), or other side-effects that contribute to oral health problems (2, 15, 16).

Address for Correspondence: Alexander M. Ponizovsky, MD, PhD, Mental Health Services, Ministry of Health 39, Yirmiyahu St., POB 1176, Jerusalem 9446724, Israel alexander.ponizovsky@moh.health.gov.il

114

Alexander Grinshpoon et al.

Dental health and antipsychotic drugs

Typical antipsychotics (typicals or first-generation antipsychotics) and atypical antipsychotics (atypicals or second-generation antipsychotics) are used for treating various psychiatric disorders. Although both groups of antipsychotics block brain dopamine receptors and have comparable efficacy, atypicals differ from typicals in that they have a safer profile of neurological side-effects. They are less likely to cause extrapyramidal symptoms, such as Parkinsonism expressed by muscular rigidity, and involuntary and intentional tremors (17). Such impairments have a negative effect on fine motor movements and, consequently, on the patient’s ability to effectively brush his/her teeth and perform oral hygiene activities (2). Both types of antipsychotics can cause tardive dyskinesia, but atypicals compared to typicals are less likely to do so (3.9% versus 5.5%) (18). This para-functional activity of the oral, chewing and tongue musculature can have a negative effect on teeth and occlusion (19). Both typicals and atypicals have anticholinergic side-effects, including xerostomia (dry mouth). Saliva has a major role in preventing dental caries; therefore xerostomia is a major risk factor of dental caries. Patients with dry mouth drink carbonated drinks more frequently, which further increase the risk for caries (20). However, a systematic review and meta-analysis of the relevant literature did not find differences in dry mouth between typicals and atypicals over medium- and long-term (21). The prominent side-effect of atypicals is the metabolic syndrome that manifests with significant weight gain, dyslipidemia and diabetes mellitus (22). All listed side-effects of antipsychotics are considered risk factors for poor dental health (2). The aim of this cross-sectional study was to examine the association between dental conditions in long-stay hospitalized patients with schizophrenia and type of antipsychotic medication they received. Based on the literature suggesting that atypicals are thought to be more tolerable than typicals (17, 18, 22), we hypothesized that hospitalized patients with schizophrenia treated with atypicals could have better dental health than those treated with typicals alone or with a combination of both types of antipsychotics. Methods Sample

Fourteen psychiatric institutions (six government-owned and eight private), providing care for 98% of all chronic psychiatric inpatients in Israel were included in the present study. The study protocol was approved by the

Ministry of Health (MoH) Institutional Review Board. Of all patients hospitalized for more than one year on July 1, 2005 (n=1,997), a sample of approximately 20% of the patients was randomly chosen for dental examination. Randomization used Israeli citizens’ unique 9-digit identity codes (ICs). Only inpatients whose ICs ended with the randomly selected digits (“5” and “7”) participated in the survey (n=348). Demographics (age and gender), information on the clinical diagnosis according to the International Classification of Diseases, 10th edition (ICD-10) (23) mental disorder category and history of psychiatric hospitalizations were extracted from National Psychiatric Hospitalization Registry of the MoH (24). The sample consisted of 241 men (69%) and 107 women (31%) diagnosed with schizophrenia according to ICD-10 criteria. The mean age of patients was 51.4± 14.5 years (range 31-58). The mean age at onset of the disorder, as measured by age of first psychiatric hospitalization, was 25.5±9.4 years (range 14-29) and duration of the disorder was 28.0±13.4 (range 5–24). The mean number of psychiatric hospitalizations was 10.2±12.2 and cumulative length of hospital stay was 67.2±86.9 months. Antipsychotic medication groups

Data on medication were extracted from patients’ electronic medical records. All patients (n=348) were divided into three groups according to type of antipsychotic medication which they received from the onset of their illness to time of the dental examination: only typicals (n=163), only atypicals (n=40) and a combined group that received a combination of both (n=145). Patients in the typicals and combined groups were treated continuously for at least 60.2±41.0 and 63.1±45.4 months, respectively, whereas the mean duration of drug administration in the atypicals group was 48.2±38.0 months. The observed periods of antipsychotic medication were limited by approximately five years, because atypicals were introduced in Israel during the year 2000. The typicals included haloperidol (n=28, 25.0±20.6 mg/ day), levomepromazine (n=25, 125.0±120.0 mg/day), perphenazine (n=24, 40.0±51.0 mg/day), zuclopenthixol (n=18, 36.0±16.0 mg/day), haloperidol decanoate (n=20, 6.7±3.8 mg/day), fluphenazine decanoate (n=19, 1.8±0.9 mg/day), zuclopenthixol decanoate (n=29, 10.0±7.5mg/ day). Most of the patients treated with typicals received adjunctive anticholinergic agents for extrapyramidal side effects, whereas most of the patients treated with atypicals did not need this addition. The atypicals were clozapine (n=7, 300.0±95.0 mg/day), olanzapine (n=22, 18.0±5.0 115

Dental Health and the Type of Antipsychotic Treatment in Inpatients with Schizophrenia

Table 1. DMFT Index and component scores comparisons in patients with schizophrenia treated with typical versus atypical versus combined antipsychotic drugs Antipsychotic drug group

ANOVA (df=2,347)

Dental status

Typicals (n=163)

Atypicals (n=40)

Combined (n=145)

F-value

Tukey HSD posthoc comparisons

Decayed

2.3±3.4

3.4±5.0

2.7±4.3

1.26

T=A=C

Missing

20.2±11.6

13.5±11.2

17.2±12.4

5.84

p<0.01

T>A<C

Filled

1.0±2.4

2.1±3.9

1.5±2.9

2.98

p<0.05

T<A=C

DMFT Index

23.5±9.9

19.0±10.5

21.5±10.1

3.75

p<0.05

T>A=C

mg/day) and risperidone (n=11, 4.5±1.5 mg/day). We did not find any differences between these groups in the use of adjunctive antidepressants, anxiolytics or mood stabilizers, which possess significant anticholinergic properties (data not shown). Dental status assessment

According to the MoH protocol based on the National Health Insurance Law [Israel], 1994 (25), each hospitalized psychiatric patient is entitled to an annual dental check-up. For this study, this examination was performed by two dentists who were calibrated prior to the study to an experienced examiner who serves as the “national standard” [coefficient of agreement (kappa) between the examiners was 0.88]. The dental examination was carried out with a mirror and a periodontal probe (Community Periodontal Index Treatment Needs) (26), with the patient sitting in front of a window, under natural light. Patients in closed wards who were not mobile and elderly bedridden patients were examined in the wards. Patients were checked for the state of their teeth and restorations, soft and hard tissues according to the WHO Oral survey methods, 4rd edition, which details criteria for the examination (26). The DMFT index, which represents overall dental status and past caries experience, i.e., number of Decayed (D), Missing (M) or Filled (F) Teeth (T) in the permanent dentition, was calculated for each patient. The DMFT index score (DMFT) is a sum of its three components (26) and ranges from 0 (if the patient is caries-free) to a maximum of 28 (if all teeth are affected). It should be kept in mind that because the DMFT index is done without X-ray imaging, it might underestimate the prevalence of dental caries (27). Data analysis

All analyses were performed using the SPSS-14.0 for Windows (SPSS Inc., Chicago, IL). DMFT data are presented as mean score and SD. Differences in patients’ characteristics, categorical and continuous variables, 116

were analyzed with Chi-square test and ANOVA, respectively. We tested our hypotheses about differences in DMFT index and component scores between the typicals, atypicals and combined medication groups using oneway ANOVA with Tukey HSD post-hoc comparisons. Potential confounding effect of gender on between-group differences was tested with paired t-tests. The level of statistical significance was set at p<0.05. Results The typicals group was somewhat older (51.3±15.1 years) than the atypicals (49.0±12.2 years) and combined (48.9±13.9 years) groups, although these differences did not reach statistical significance (F=1.45; df=2,346; p=0.15). Likewise, significantly more female patients were in the typicals group (n=57, 35%) relative to the atypicals (n=9, 22.5%) and combined (n=41, 28.3%) groups (Chi-square=17.5, df=1, p<0.05). To test our hypothesis, DMFT scores were compared across the study groups (Table 1). ANOVA results showed that the patients treated with typicals had significantly higher DMFT index scores (23.5±9.9 vs. 19.0±10.5; p<0.05), as well as higher Missing (20.2±11.6 vs. 13.5±11.2; p<0.01) and lower Filled (1.0±2.4 vs. 2.1±3.9; p<0.05) teeth component scores than those treated with atypical antipsychotics. No between-group differences in Decayed component scores were found (2.3±3.4 and 3.4±5.0, respectively; p>0.05). The patients treated with typicals did not differ significantly from those in the combined group in all DMFT scores, except for a higher mean number of missing permanent teeth (p<0.05). There were no statistically significant differences in all DMFT scores between patients in the atypicals group and those in the combined antipsychotic group. To test a potential confounding effect of gender on dental status of patients treated with the different types of antipsychotics, we compared DMFT index and component scores between men and women within each treated group

Alexander Grinshpoon et al.

using paired t-tests. No gender differences in DMFT scores were found within each antipsychotic medication group (data not shown). Discussion This study examined the association between type of antipsychotic medication and dental status among long-stay schizophrenia inpatients. As hypothesized, patients treated with atypicals had better dental health than patients treated with typicals. The overall decay level in the group treated with atypicals, as measured by the DMFT index, was significantly lower compared to the group treated with typicals, indicating that patients maintained on atypicals have significantly more treated (filled) teeth and significantly fewer extracted (missing) teeth. The results of the combined treatment group (typicals along with atypicals) fell in between the atypicals and typicals groups on all measures. How could the findings be explained?

Due to the cross-sectional correlational design of our study, most explanations for our findings are rather speculative. Theoretically, after caries begins to develop and cause pain, there are two principal strategies of behavior for the sufferer: immediate seeking of professional dental care or treatment avoidant behavior, such as taking analgesics to lower pain, an approach that results in treatment delay. The first strategy is reflected in an increase in the DMFT Filled teeth component, whereas the second strategy leads to progressing caries with decay and subsequent loss of the tooth reflected in the DMFT Missing teeth component. Since the atypicals have fewer neurological side-effects (including less dyskinesia) compared with typicals, adherence to the former is better (28). Better adherence is associated with more stable remission and better judgment that contribute to the patientsâ&#x20AC;&#x2122; adherence to oral hygiene practices and seeking adequate dental treatment in a timely manner, leading eventually to more dental repairs and fewer extractions. Notably, the group that received combined treatment scored between the groups treated with only typicals or only atypicals in all dental parameters except for the number of extracted teeth which was significantly higher in the group treated with only typical antipsychotics. This finding suggests that compared with the typicals group, patients treated with a combination of typicals and atypicals might be more cooperative with dental care and dentists should avoid extraction of the decayed teeth in that group when restorations are possible.

Our results suggest that the better dental status of the patients treated with atypicals might be related to changes in health-seeking behaviors in terms of dental care, perhaps because of better insight of these patients and more awareness of their dental health needs, better oral hygiene practices or owing to better cooperation with their dentists, or a combination of these factors. It is suggested that atypicals, relative to typicals, are to some extent more effective in reducing negative symptoms (29-31). Such negative symptoms may play a role in the poor oral health of mentally ill patients (32), likely due to social withdrawal that might reduce help-seeking behavior. Adjunctive anticholinergic agents for extrapyramidal side effects that cause dry mouth might be responsible for the poorer dental status of patients treated with typicals compared to those taking atypicals. However, there were no differences in the Decayed teeth component between the groups. Finally, age-sex differences, most commonly cited as risk factors for dental health (33-35), could account for the obtained findings, if these factors were not controlled for in our study. Limitations

The findings of this study should be regarded as preliminary in view of the following limitations. First, our outcome measure (DMFT) reflects past and present caries activity and the way they were treated. Recent medication regimen does not influence past activity but this limitation is common to both groups, which differed only by the type of medication participants currently received. The crosssectional design of our study precludes establishing causality for the current association. Future longitudinal studies could confirm our findings and determine the causal relationship between types of long-term antipsychotic treatment and dental status in schizophrenia patients. factors such as socioeconomic status (32), health habits (34), self-care and oral care (2), and diet (7) were not assessed in this study, although these factors seem irrelevant for a study on the impact of drug treatment on dental health. Nonetheless, independent of type of antipsychotic treatment, preventive dental care, including oral hygiene, healthy diet, fluoride utilization, etc., should be recommended and monitored by the hospital staff among psychiatric inpatients. Clinical implications

A recent systematic review and meta-analysis of comparative effectiveness of typicals versus atypicals for treating adults with schizophrenia concluded that the strength of 117

Dental Health and the Type of Antipsychotic Treatment in Inpatients with Schizophrenia

evidence for advantages of typicals versus atypicals, as well as their comparative safety for major medical events is low or insufficient (22). Our findings demonstrate a possible benefit of atypicals over typicals at least with regard to the Missing teeth component of dental health. This benefit was less notable in the group treated with a combination of both medications. Hence, from the dental health perspective, the popular practice among clinicians to combine atypicals with typicals for enhancing treatment effectiveness should be avoided or at least minimized. In conclusion, the results suggest that schizophrenia patients maintained on atypicals have better dental health than patients treated with typicals or with a combination of both. From the oral health perspective treatment with atypical antipsychotics only is superior to treatment with typicals and a combination of atypicals and typicals. Although the choice between typicals and atypicals is based mainly on their psychiatric efficacy, the benefit of atypicals with regard to dental health should be taken into consideration in clinical decision making. Acknowledgements Dr. A.M. Ponizovsky was supported in part by the Ministry of Immigrant Absorption.

References 1. Dalack GW, Healy DJ, Meador-Woodruff JH. Nicotine dependence in schizophrenia: Clinical phenomena and laboratory findings. Am J Psychiatry 1998;155: 1490-1501. 2. Tani H, Uchida H, Suzuki T, et al. Dental conditions in inpatients with schizophrenia: A large-scale multi-site survey. BMC Oral Health 2012; 12:32. 3. Lewis S, Jagger RG, Treasure E. The oral health of psychiatric in-patients in South Wales. Spec Care Dentist 2001;21:182-186. 4. McCreadie RG, Stevens H, Henderson J, et al. The dental health of people with schizophrenia. Acta Psychiatr Scand 2004;110:306-310. 5. Kisely S, Quek LH, Pais J, et al. Advanced dental disease in people with severe mental illness: Systematic review and meta-analysis. Br J Psychiatry 2011;199:187-193. 6. Edward KL, Felstead B, Mahoney AM. Hospitalized mental health patients and oral health. J Psychiatr Ment Health Nurs 2012;19:419-425. 7. Henderson DC, Borba CP, Daley TB, et al. Dietary intake profile of patients with schizophrenia. Ann Clin Psychiatry 2006; 18:99-105. 8. Kebede B, Kemal T, Abera S. Oral health status of patients with mental disorders in Southwest Ethiopia. PLoS ONE 2012; 7: e39142. 9. Drake RE, Mercer-McFadden C, Mueser KT, et al. Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophr Bull 1998; 24:589-608. 10. Ponizovsky AM, Zusman SP, Dekel D, et al. Effect of implementing dental services in Israeli psychiatric hospitals on the oral and dental health of inpatients. Psychiatr Serv 2009; 60:799-803. 11. Almomani F, Brown C, Williams KB. The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatr Rehabil J 2006;29:274-281. 12. Ramon T, Grinshpoon A, Zusman SP, et al. Oral health and treatment needs of institutionalized chronic psychiatric patients in Israel. Eur Psychiatry 2003;18:101-105.

118

13. Sjögren R, Nordström G. Oral health status of psychiatric patients. J Clin Nurs 2000 9:632-638. 14. Pajukoski H, Meurman JH, Halonen P, et al. Prevalence of subjective dry mouth and burning mouth in hospitalized elderly patients and outpatients in relation to saliva, medication, and systemic diseases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:641-649. 15. Jovanovic S, Milovanovic SD, Gajic I, et al. Oral health status of psychiatric in-patients in Serbia and implications for their dental care. Croat Med J 2010;51:443-450. 16. Kossioni AE, Kossionis GE, Polychronopoulou A. Oral health status of elderly hospitalised psychiatric patients. Gerodontology 2012;29:272-283. 17. Culpepper L. A roadmap to key pharmacologic principles in using antipsychotics. Prim Care Comp J Ass Med Psychiatry 2007;9:444–454. 18. Dorsey ER, Rabbani A, Gallagher SA, et al. Impact of FDA black box advisory on antipsychotic medication use. Arch Intern Med 2011;170: 96–103. 19. Bassett A, Remick RA, Blasberg B. Tardive dyskinesia: An unrecognised cause of orofacial pain. Oral Surg Oral Med Oral Pathol 1986;61:570–572. 20. Nielsen J, Munk-Jørgensen P, Skadhede S, Correll CU. Determinants of poor dental care in patients with schizophrenia: A historical, prospective database study. J Clin Psychiatry 2011;72:140-143. 21. Ozbilen M, Adams CE, Marley J. Anticholinergic effects of oral antipsychotic drugs of typicals versus atypicals over medium- and long-term: Systematic review and meta-analysis. Curr Med Chem 2012;19:5214-5218. 22. Hartling L, Abou-Setta AM, Dursun S, et al. Antipsychotics in adults with schizophrenia: Comparative effectiveness of first-generation versus second-generation medications: A systematic review and meta-analysis. Ann Intern Med 2012;157:498-511. 23. World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: WHO, 1993. 24. Lichtenberg P, Kaplan Z, Grinshpoon A, et al. The goals and limitations of Israel’s psychiatric case register. Psychiatr Serv 1999;50:1043-1048. 25. National Health Insurance Law [Israel], 1994. Published Book of Laws Act of No. 1469 dated 26.06.1994, pp. 156 (Prop. Act of No. 2249, p 230). Available at: http://www.nevo.co.il/law_html/law01/036_001. htm [Hebrew] 26. World Health Organization. Oral Health Surveys: Basic Methods. Washington, DC, 1987. 27. Yehuda Z, Bechor R. Hidden occlusal caries—challenge for the dentist. NY St Dent J 2008;74:46-50. 28. Dolder CR, Lacro JP, Dunn LB, Jeste DV. Antipsychotic medication adherence: Is there a difference between typical and atypical agents? Am J Psychiatry 2002; 159:103-108. 29. Müller-Spahn F. Current use of atypical antipsychotics. Eur Psychiatry 2002;17; :377s-384s. 30. Nasrallah HA, Lasser R. Improving patient outcomes in schizophrenia: Achieving remission. J Psychopharmacol 2006;20:57-61. 31. Murphy BP, Chung YC, Park TW, McGorry PD. Pharmacological treatment of primary negative symptoms in schizophrenia: A systematic review. Schizophr Res 2006;88:5-25. Epub 2006 Aug. 23. 32. Azodo CC, Ezeja EB, Omoaregba JO, et al. Oral health of psychiatric patients: The nurse’s perspective. Int J Dent Hyg 2012;10:245-249. 33. Chu Kuan-Yu, Yang Nan-Ping, Chou Pesus, et al. Factors associated with dental caries among institutionalized residents with schizophrenia in Taiwan: A cross-sectional study. BMC Public Health 2010;10: 482. 34. Zusman SP, Ponizovsky AM, Dekel D, et al. An assessment of the dental health of chronic institutionalized patients with psychiatric disease in Israel. Spec Care Dentist 2010;30:18-22. 35. Velasco-Ortega E, Segura-Egea JJ, Córdoba-Arenas S, et al. A comparison of the dental status and treatment needs of older adults with and without chronic mental illness in Sevilla, Spain. Med Oral Patol Oral Cir Bucal 2013;18:e71-75.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Rena Cooper-Kazaz et al.

Severity of Psychiatric Disorders and Dental Health Among Psychiatric Outpatients in Jerusalem, Israel Rena Cooper-Kazaz, MD,1 Dan H. Levy, DMD,2 Avraham Zini, PhD, DMD, MPH,2 and Harold D. Sgan-Cohen, DMD, MPH2 1

Talbiah Psychiatric Clinic, Clalit Heath Services, The Hebrew University, Faculty of Medicine, Jerusalem, Israel Department of Community Dentistry, The Hebrew Universityâ&#x20AC;&#x201C;Hadassah, Faculty of Dental Medicine, Jerusalem, Israel

Brief Communication The association between severity of psychiatric disorder and dental disease has not been adequately studied. The aim of the present study was to examine the level of dental caries morbidity and the association with Severe Mental Illness (SMI) and mild/moderate psychiatric disorders. The population sample included patients aged 30 to 50, treated at the Hadassah psychiatric outpatient clinic, after giving written informed consent. Exclusion criteria included eating disorders which are recognized as being associated with several dental pathologies. The term SMI, frequently used in the literature (1), refers to psychiatric patients suffering from a significant mental disorder and implies a greater burden of illness and dysfunction. The SMI group in this study included patients suffering from schizophrenia, bipolar disorder, resistant depression and chronic post-traumatic stress disorder (PTSD). The mild/ moderate illness group consisted of all other psychiatric disorders on Axis I or II according to DSM IV-TR (2). The following clinical variables were included:

1. Dental caries was recorded according to the DMFT index, as recommended by the World Health Organization (WHO) (3) which assesses past and present dental caries experience by recording the number of untreated decayed (D), treated filled (F= restored) and missing (M) teeth due to dental caries. 2. Potential Dry Mouth effect of medications was determined using the Drymouth.info website that ranks each xerogenic (mouth drying) drug on a 1-3 scale: 1. Drug affects 1% of users; 2. Drug affects 1-10% of users; 3. Drug affects more than 10% of users (4). The study protocol was approved by the Hadassah Hospital Human Ethics (Helsinki) IRB Committee. Patients were approached by their therapist, treating psychiatrist or Address for Correspondence: â&#x20AC;&#x2020; crena1966@gmail.com

by the head of the clinic (RCK). After providing written consent, participants were interviewed and examined by a single dental examiner (DHL). Of 128 patients in the sample, 42 refused to participate and in four cases the therapists requested that the patient not be enrolled, leaving 80 examinees: 47 patients were diagnosed with mild/moderate mental illness (58.8%) and 33 patients with SMI (41.2%). Among the SMI group the average number of untreated teeth with caries was 0.91 teeth, as compared to 0.13 teeth among the mild/ moderate patients (p=0.033). We found that the overall effect of drugs on dry mouth in SMI patients is three-fold higher than in the mild/moderate group (average scores of 6.55 vs. 2.02 respectively, ANOVA, p<0.001). The main limitation of this study was its methodology. In order to overcome the limited number of available out-patients of one clinic, we defined psychiatric disorder severity by employing a dichotomous division of SMI and mild/moderate sub-groups. Including patients from other clinics and creating a larger study population could potentially have led to more robust analyses and conclusions. An alternative range of severity of the psychiatric disorder might have assisted in revealing potential differences. Another alternative methodology could have been to compare a population of psychiatric patients with a comparable group of people or patients without psychiatric disorders. This latter approach is not simple, as efforts have to be invested in order to optimize similarity and comparability, but should be considered in future research. Another methodological flaw was in the high refusal rate (about one third), which we encountered. This could have caused a selection bias. Low response rates are a common problem in community surveys but cannot be ignored and efforts have to be invested to accommodate this potential study weakness. The Israeli National Health Insurance Law (5) states that SMI patients are entitled to a dental rehabilitation basket

Rena Cooper-Kazaz, MD, Clalit Health Services, Jerusalem, 17 Dâ&#x20AC;&#x2122;Israeli St., Jerusalem 92222 Israel

119

Severity of Psychiatric Disorders and Dental Health Among Psychiatric Outpatients in Jerusalem, Israel

that includes restorative dental care. There is therefore little reason that this population should be undertreated. Oral and dental health levels are strongly associated with quality of life and should not be disregarded. The implementation of the mental health component of the law, with respect to dental care, needs to be further investigated. We suggest assessing awareness of the need for dental rehabilitation among patients, caregivers, general doctors, psychiatrists and mental health care providers along with assessing the actual dental treatment which patients are receiving.

120

References 1. Fagiolini A, Goracci A. The effects of undertreated chronic medical illness in patients with severe mental disorders. J Clin Psychiatry. 2009;70:22-29. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition-text revision, 2000. 3. World Health Organization. World Health Organization: Oral Health Surveys â&#x20AC;&#x201C; Basic Methods, 4th Edition. Geneva, 1997. 4. http://drymouth.info/consumer/SearchForDrugs.asp. 5. Dental health (8.9) mental health (65.001) regulation, 2004. http://www.old.health.gov.il/download/forms/a2745_shen8-9.pdf (Hebrew).

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

David Ivgi et al.

Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients David Ivgi, MD,1 Arie Bauer, MD, LLB,1 Razek Khawaled, RN,1 Paola Rosca, MD, MPP,2 Joshua M. Weiss, PhD,3 and Alexander M. Ponizovsky, MD, PhD4 1

Department of Forensic Psychiatry, Mental Health Services, Ministry of Health, Jerusalem, Israel Department for the Treatment of Substance Abuse, Ministry of Health, Jerusalem, Israel 3 Israel Prison Service, Ashkelon Academic College, Ashkelon, Israel 4 Research Unit, Mental Health Services, Ministry of Health, Jerusalem, Israel 2

Abstract Background: Assessment of risk of violent behavior in forensic psychiatric practice is a complex and responsible clinical task and the use of a valid instrument can make the expert’s work more effective. The Historical Clinical and Risk Management scale 20 (HCR-20) is a widely accepted measure of the risk of violence, sexual and criminal behavior. The aim of this study was to validate the HCR-20 in Israeli psychiatric inpatient settings. Method: In a prospective design, data were collected on 150 male patients aged 15-65, diagnosed with ICD-10 schizophrenia, who were hospitalized in three wards: an acute psychiatric ward (n=50), a high security ward (n=50), and an open ward (n=50). The HCR-20, as the predictor measure, and the Positive and Negative Syndrome Scale, as a concurrent measure, were completed at baseline, and the Violence Assessment Scale, as the outcome measure, was completed at 6-, 12- and 18-month follow-up points. Results: Internal consistency reliability was good for the total HCR-20 scale, satisfactory for the H-subscale, but low for the C- and R-subscales. Concurrent validity was good for the C-subscale, and discriminative validity was reasonable for the C- and H-subscales. The total scale as well as the Historical and Clinical subscales predicted the risk of physical as well as physical/sexual violent behavior at both 6- and 18-month follow-up points. Conclusions: Appropriate psychometric properties of the HCR-20 suggest that it can serve as a useful measure

of the risk of violent behavior in psychiatric settings in Israel. Further research is necessary to confirm norms and cut-off scores, using a larger representative sample.

Introduction In recent decades, there is increased focus on the dangerousness of patients with severe mental illness (SMI) (1, 2). Reportedly, the risk of committing a violent crime among individuals with SMI is 4 to 6 times higher than in the general population (3-5). In the light of the reports, a need for a standardized instrument assessing violence risk as an adjunct to clinical examination among people with SMI for routine use by clinicians and law enforcement officers becomes essential (6). According to the amendment number 4 to the Law for the Treatment of the Mentally Ill (7), in Israel involuntarily hospitalized patients with SMI should regularly be represented before Regional Psychiatric Boards by the State’s Attorney’s office (Criminal Defense Division) or by the Civil Legal Aid. Following the implementation of the amendment to the law, it became necessary to assess the risk of violent behavior and provide expert opinions including risk assessment in order to provide the tribunals with appropriate tools to examine the legality of compulsory hospitalization (8), the need to extend these hospitalizations or discharge patients while protecting the public interests, without infringing on patients’ rights. Traditionally, assessment is a process based on the subjective judgment, intuition and clinical experience

Address for Correspondence: Alexander M. Ponizovsky, MD, PhD, Mental Health Services, Ministry of Health, 39 Yirmiyahu St., POB 1176, Jerusalem 9446724, Israel alexander.ponizovsky@moh.health.gov.il, alexpon8@gmail.com

121

Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients

of the professional. Thus, its results may vary according to the personality of the professionals performing the assessment, and the validity of the assessment is related to the level of accuracy of the assessor. In various countries, such as the United Kingdom and United States, Canada and Germany, the assessment of violence risk in individuals with SMI, integrating clinical judgments and actuarial evaluations has been conducted with the use of the Historical Clinical Risk Management Scale-20 (HCR20) (9, 10). The use of HCR-20 offers an opportunity to more objectively measure the risk of violent behavior in psychiatric and forensic populations and compare various assessments of dangerousness risk in time, minimizing a potential error. The risk management subscale allows evaluating the impact of therapeutic interventions on the patient dangerous behavior and in case of a lack of effect to change the treatment approach accordingly. Despite a great need for a tool assessing violence risk in Israel, to date there is no validated actuarial instrument for this purpose. Consequently, this study aims to examine the psychometric properties and utility of the HCR-20 in individuals with SMI across diverse psychiatric and forensic settings in Israel. Implementation of the HCR-20, an internationally accepted and widely used instrument, could enable quick and reliable evaluation lending support both to the clinical decisions of the hospital staff and of the Regional Psychiatric Boards and Courts. Routine use of the HCR-20 could both reduce the risk that patients would remain compulsorily hospitalized without sufficient grounds, and alternately, that patients at risk of violent behavior would be prematurely discharged. Methods Patients

The study sample included 150 male patients aged 18-65 with an ICD-10 diagnosis of schizophrenia. Patients with dual diagnosis, organic disorders or severe chronic illnesses were not enrolled. All patients were hospitalized in three Mental Health Centers (MHC): the Lev Ha-Sharon MHC (Group 1, n=50), the Sha’ar Menashe MHC (Group 2, n=50), and the Maban MHC (Group 3, n=50). The groups were chosen thus to test criterion validity of the HCR-20 and differed by legal status of the baseline admission: Group 1 patients were hospitalized voluntarily in an acute ward; Group 2 patients were hospitalized involuntarily in a high security ward either by Court Observation Order (n=46) or by District Psychiatrist’s Order (n=4); and Group 3 patients were hospitalized voluntarily in an open ward. 122

For the total sample, the mean age was 37.2±10.7 years. The majority of patients were never married (n=111, 74%) and Jewish (n=125, 83%); 73 patients (49%) were Israelborn, 23 patients (15%) immigrated to Israel from the former Soviet Union, 13 patients (9%) from Ethiopia, and 41 patients (27%) from other countries. Only 30% (45 patients) served in the Israel Defense Forces. The mean number of psychiatric hospitalizations was 10.5±10.3 (median = 7) and mean duration of the current hospitalization was 21.7±43.7 months (median = 4 months). The groups did not differ in the mean number of psychiatric admissions (χ2=1.66, df=2, p>0.05), but Group 1 and 2 had a significantly longer duration of the current hospitalization than Group 3 (F=58.8, df=2, p<0.001). Instruments The HCR-20

The HCR-20 (9, 10) is a 20 item broad-band violence risk assessment instrument with potential applicability to a variety of settings. The conceptual scheme of the HCR-20 aligns risk markers into past, present, and future (see Appendix). Its 10 Historical factors obviously concern the past (e.g., previous violence, young age at first violent incident, etc.), the 5 Clinical items are meant to reflect current, dynamic (changeable) correlates of violence (e.g., lack of insight, impulsivity, active symptoms of SMI, etc.). The future is recognized in the 5 Risk Management items, which focus on situational post-assessment factors that may either aggravate or mitigate risk (e.g., plans lack feasibility, lack of personal support, stress, etc.). Scores on the whole scale are calculated, as well as scores on each of three subscales: 0=rating for absence of an item, 1=for possible presence of the item, and 2=for definite evidence for this item. This study was designed to explore the reliability and discriminant, concurrent and predictive validity of the HCR-20 for use in the mental health (forensic psychiatry) service system in Israel. Positive and Negative Syndromes Scale

We used the PANSS (11) to measure participants’ current levels of symptomatology. It is a 30-item scale with 7 positive-symptom items, 7 negative-symptom items, and 16 general psychopathology symptom items. Each item is scored on a 7-point severity scale, resulting in a range of possible scores from 30 to 210. The positive- and negativesymptom item groups are often reported separately, with a possible range of 7 to 49. A patient with schizophrenia entering a clinical trial typically scores 91. The PANSS

David Ivgi et al.

has sound psychometric properties, and its Positive and Negative scales are very sensitive to changes (12). For our sample, the internal consistency of the PANSS, as measured by the Cronbach’s alpha coefficient, was 0.92 for the PANSS total scale, and ranged from 0.82 for the general psychopathology dimension to 0.92 for the negative syndrome dimension. The severity of psychopathology, as measured by PANSS scores, was 11.7 (SD=10.7) for positive symptoms, 15.0 (SD=10.6) for negative symptoms, 23.2 (SD=14.6) for general psychopathology symptoms and 49.9 (SD=31.5) for the PANSS as a whole. Violence Assessment Scale (VAS)

We used the VAS (13, 14) as an outcome measure for the severity of violent behavior. It is a 0-100 point scale, analogous to the DSM-IV, GAF (15), with 10 anchor points that contain descriptions of overt violence toward others. The descriptions encompass physical or sexual assault (e.g., murder, rape, stabbing, punching, molesting, etc.) as well as threatening behavior (e.g., raising a fist, pointing a weapon, chasing or stalking, verbal threats, etc.) and damage to property (e.g., setting fire, breaking, slamming things). The VAS also contains severity indications such as degree of damage and use of weapons which are embedded in the scale where appropriate. The VAS was previously validated with the Mac-Arthur Community Violence Instrument (3) with Kappa of within-rater and between-scale agreement of .52–.89. We used the cut-off score of 30 to dichotomize violent behavior into two severity categories: mild or no physical violence versus moderate /severe physical violence. In addition, the detailed personnel records of physical and sexual violent behaviors for each case during the entire follow-up period were used as an additional dichotomous outcome measure (presence vs. absence). Demographic information

Standard sociodemographic characteristics included age, family status, years of education, and military service in the IDF. Procedure The Institutional Review Board in each participating MHC approved the study protocol and all patients signed informed consent forms. Only three patients refused to participate in the study, and they did not differ from the participants in their sociodemographic and clinical variables. At baseline, the HCR-20 was rated on the base of a detailed case file including data available in the MHC ward

by a trained criminologist. The PANSS also was rated at baseline for each case by a trained psychiatrist. The VAS was rated at 6, 12 and 18 month follow-up points by raters blinded to the HCR-20 initial ratings. The detailed personnel records of violent behaviors for each case during the follow-up period were analyzed as an outcome measure, independent of the VAS outcome ratings. Statistical analysis

All analyses were conducted using the 20 release of IBMSPSS Statistics. Scores of missing items (within the number allowed) were calculated as the mean score of the remaining items. Internal consistency reliability was calculated using the raw Cronbach alpha coefficient with 95% Confidence Intervals (CI). Concurrent validity was assessed by comparing scores on the HCR-20 with PANSS total and dimension scores using the Pearson product-moment correlation coefficient. Discriminant validity was assessed by comparing patient HCR-20 scores across the three groups (patient from acute, high security and open wards), computed by analysis of variance with GLM procedures, using Sidak’s post-hoc single comparison option. Predictive validity, based on the assumption that patient HCR-20 scores at baseline will predict episodes of violent behavior during 6, 12 and 18 month follow-up periods, was assessed by comparing HCR-20 scores using t-test analysis for pooled patient groups. Receiver Operating Characteristics (ROC) analyses (16) were used to examine the predictive validity of the HCR-20 score for dichotomous outcome measures. ROCs also offer the advantage of plotting the trade-off between sensitivity (true positive rate) and 1-specificity (false positive rate). The Area under the curve (AUC) statistics ranges from 0 (perfect negative prediction) to 1 (perfect positive prediction) with 0.50 representing a chance level of prediction. ROC AUC statistics of 0.76 approximate to Cohen’s d of 1 which is considered a large effect size (17, 18). Distributions of raw scores were used to determine the cut-off scores to identify patients as belonging to the high and low risk groups. A P-value of 0.05 was considered significant for all analyses, unless otherwise specified. Results Internal Consistency

Good internal consistency was demonstrated for the total HCR-20 scores for all wards [Cronbach’s α= 0.81, 95% Confidence Interval (CI) 0.76-0.85]. The values were satisfactory for the Historical (H)-subscale [α=0.75, CI 0.68-0.80]; however for both the Clinical (C)- and Risk 123

Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients

Table 1. Discriminant validity of the total HCR-20 scale and its subscales by study groups Clinical ward Acute

High security

Open

Total

ANOVA

HCR-20

Mean

F (2,147)

Historical

11.6

3.1

13.9

4.2

12.4

4.3

12.6

4.0

4.617

0.011

Clinical

5.7

2.3

5.8

2.0

5.0

2.3

5.5

2.2

1.92

0.15

Risk management

6.4

1.8

6.1

2.4

6.6

1.8

6.4

2.0

0.9

0.409

Total

23.7

5.6

25.8

7.5

24.0

7.0

24.5

6.8

1.465

0.234

management (R)- subscales the values were low [α=0.56, CI 0.43-0.66 and α=0.47, CI 0.32-0.59], suggesting great caution in interpreting these subscales within these samples.

Table 2. Concurrent validity of the total HCR-20 scale and subscales with criteria measure (Pearson correlations with PANSS dimension scores at baseline) PANSS dimension

HCR-20 mean scores

Table 1 presents HCR-20 total and subscale mean scores and SD across all study settings. For the entire sample, the mean total HCR-20 score was 24.5 (SD 6.8), the H-subscale score was 12.6 (SD 4.0), the C-subscale score was 5.5 (SD 2.2) and the R-subscale score was 6.4 (SD 2.0). Patients in the high security ward scored significantly higher on the HCR-20 H-subscale than patients in the acute ward (F2,147 = 4.62, p=0.011), whereas no significant differences were found between the former and patients from the open ward. The total HCR-20 scale score, as well as the C- and R- subscale scores did not differ significantly across the wards.

HCR-20 subscale

General Total Positive Negative psychopathology score

Historical

0.071

-0.158

-0.002

-0.055

Clinical

.540**

.193*

.416**

.413**

Risk management

0.092

-0.124

-0.075

-0.025

Total score

.246**

-0.068

0.113

0.095

*P< 0.05,** P< 0.01

relations with all PANSS dimensions, and the HCR-20 total score positively correlated with PANSS Positive subscale score (r=.25, p<0.01). These correlations suggest that the HCR-20 C-subscale may measure positive and general psychopathology symptoms consistent with the PANSS.

Concurrent Validity

Concurrent validity was assessed by correlating scores on the HCR-20 with measures of psychopathology already in use in Israel (PANSS). Significant positive correlations were found between the HCR-20 C-subscale scores and PANSS Positive (r=0.54, p<0.01), Negative (r=0.19, p<0.05) and General Psychopathology (r=0.42, p<0.01) dimension scores and PANSS total score (r=0.41, p<0.01), as well (Table 2). The H- and R-subscale scores showed no significant cor-

Predictive validity

Compared to patients with mild violent behavior (VAS score ≤30; n=115), those with moderate/severe violent behavior according to VAS (VAS score =31-100; n=34) had the significantly highest baseline HCR-20 total and H- , C-, and -R subscale scores at Time 1 and Time 3, except for R-subscale at Time 3 (Table 3). Similar differences were found in comparison to the baseline HCR-20 total and

Table 3. Predictive validity of the HCR scale and subscales by VAS mild (score <30) versus severe (score 31-100) violence at three time points VAS

Time 1

VAS

Time 2

VAS

Time 3

HCR dimension

<30

31-100

t-value (df=147) P

<30

31-100

t-value (df=145) P

<30

31-100

t-value (df=143) P

History

12.3(4.0)

14(3.8)

-2.169

0.03

12.4(4.0)

14(4.1)

-1.791

0.075

12.4(4.0)

14.4(3.6)

-2.26

0.025

Clinical

5.2(2.2)

6.5(2.1)

-3.12

0.002

5.3(2.1)

6.4(2.4)

-2.285

0.024

5.3(2.2)

6.7(1.5)

-2.916

0.004

Risk management

6.2(2.1)

6.9(1.7)

-1.828

0.07

6.3(2.0)

6.5(2.2)

-0.406

0.685

6.3(2.1)

6.9(1.5)

-1.301

0.2

Total score

23.7(6.7)

27.4(6.1)

-2.874

0.005

24.1(6.6)

26.8(7.3)

-1.919

0.057

23.9(6.9) 28(5.4)

-2.671

0.008

115

121

VAS=the Violence Assessment Scale Time 1=6-month follow-up; Time 2=12-month follow-up; Time 3=18-month follow-up

124

122

David Ivgi et al.

subscale scores between patients with the presence and absence of physical violence during the same follow-up periods (Table 4). No significant differences between the groups in all baseline HCR-20 scores were noted at Time 2, except for the C-subscale score. The findings suggest that the total HCR-20 scale as well as the H-, C- and R-subscales may predict episodes of severe/moderate physical violence in both short- and long-term.

AUC, with values varying between 0 and 1 (Table 5). The HCR-20 total score was a reasonable predictor for Time 1 and Time 3 VAS outcomes (AUC 0.65 and 0.66, respectively) as well as for physical (AUC 0.76 and 0.69, respectively) and physical/sexual violence outcomes (AUC 0.73 and 0.69, respectively). Analysis of the subscale scores showed that the C and H subscales were better than chance predictors, compared with the R subscale (Figure 1a and b).

Discriminant validity

Cut-off scores

We compared patients of the high risk group and those of the low risk group according to the VAS scores (VAS score>30 and <30, respectively) as well as those with the presence/ absence of physical and physical/sexual violence episodes over the three follow-up periods, using ROC analysis, where sensitivity and specificity are combined and provide an

A cut-off score of 12 for the total HCR-20 was determined for all patients in the study. According to the cut-off score, the sensitivity (i.e., classifying a patient at high risk of violent behavior correctly) for the total HCR-20 would be 0.59 and specificity (i.e., classifying a patient at low risk of violent behavior correctly) was 0.60. This cut-off score allowed to

Table 4. Predictive validity of the HCR by presence/absence of physical violence at three time points Physical violence HCR dimension

Absent

Present

Time 1 t-value df=148

Physical violence Absent

Present

Time 2 t-value df=146

Physical violence Absent

Present

Time 3 t-value df=144

History

12 (3.9)

15.4(3.0) -4.26

0.00004 12.6(4.1)

13.5(3.8)

-0.968

0.33

12.5(4.0) 14.6(3.6) -2.128

0.035

Clinical

5.2 (2.2)

7 (1.8)

-4.249

0.00004 5.4(2.2)

6.3(2.0)

-1.901

0.06

5.3(2.2)

0.006

7.1(1.7)

-2.203

0.029

6.2(1.9)

0.318

0.75

0.00001 24.3(6.9) 26(5.8)

-1.087

0.28

128

Risk management

6.2 (2.0)

Total score

23.4(6.6) 29.6(5.1) -4.655

Number of cases defined

121

6.4(2.0) 125

6.8(1.1)

-2.797

6.3(2.1)

7.1(1.6)

-1.635

24(6.8)

28.6(5.1) -2.658

0.1 0.009

Time 1=6-month follow-up; Time 2=12-month follow-up; Time 3=18-month follow-up

Table 5. HCR-20 subscale and total score as a predictor of the outcome measure Outcome measure VAS <30 vs. 31-100

Physical violence Presence vs. Absence

Physical and sexual violence Presence vs. Absence

HCR subscale

Time 1

Time 2

Time 3

Time 1

Time 2

Time 3

Time 1

Time 2

Time 3

Historical

0.61

0.64

0.74

0.57

0.65

0.7

0.58

0.65

95% CI

.50 - .72

.48 - .73

.52 - .76

.65 -.83

.44 - .70

.51 - .79

.60 - .80

.46 - .71

95% CI

0.053

0.08

0.04

0.0001

0.3

0.04

0.001

0.2

0.04

Clinical

0.67

0.65

0.67

0.75

0.62

0.7

0.73

0.64

0.7

95% CI

.57 - .77

.53 - .77

.57 - .78

.65 - .84

.50 - .75

.60 - 80

.64 - .83

.52 - .76

.60- .80

0.003

0.015

0.007

0.0001

0.06

0.007

0.0001

0.03

0.01

Risk management

0.59

0.52

0.57

0.62

0.46

0.6

0.63

0.48

0.6

95% CI

.48 - .69

.38 - .65

.46 - .68

.51 - 73

.33 - .59

.47 - .62

.52 - .73

.35 - .61

.47- .72

0.12

0.8

0.31

0.05

0.55

0.18

0.03

0.8

0.18

Total scale

0.65

0.61

0.66

0.76

0.57

0.69

0.73

0.59

0.69

95% CI

.54 - .75

.48 - .74

.55 -.77

.67 - 85

.45 - .69

.57 - .81

.64 - .83

.47 - .71

.57 - .81

P-value

0.009

0.08

0.014

0.0001

0.29

0.012

0.0001

0.17

0.012

Number of cases defined

Time 1=6-month follow-up; Time 2=12-month follow-up; Time 3=18-month follow-up

125

Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients

Figure 1 a. Area under curve for the HCR-20 total and subscale score as a predictor of the VAS 6-month outcome

Figure 1 b. Area under curve for the HCR-20 total and subscale score as a predictor of the VAS 18-month outcome

ROC Curve

1.0

0.8

0.6 Sensitvity

Sensitvity

0.8

0.4 Source of the Curve total h total c total r total Reference line

0.2

0.0

0.2

0.4

0.6

0.8

0.6

0.4 Source of the Curve total h total c total r total Reference line

0.2

1.0

1- Specificity

identify correctly 20 of 34 patients as belonging to the low risk group and 46 of 115 patients as belonging to the high/ moderate risk group according to the VAS definitions. Discussion The results of this study demonstrate reasonable psychometric properties for the HCR-20 instrument that promise its feasibility as a valid and reliable tool for use in Israelâ&#x20AC;&#x2122;s institutional patient samples for ongoing clinical, forensic and research purposes. Reliability was confirmed for the total HCR-20 instrument and for its H-subscale by good and satisfactory internal consistency was demonstrated across all inpatient settings under this study. Unfortunately, the C- and R- subscales showed low internal consistency, suggesting great caution in interpreting these subscales with these samples. Studies in other countries (19, 20) also reported more favorable results for the total HCR-20 and for the H-subscale and lower values for the C- and R-subscales. Concurrent validity was confirmed for the HCR-20 C-subscale by its significant positive correlations with the criterion measures - PANSS Positive, Negative and General Psychopathology domain scores and with PANSS total score. However, the HCR-20 H- and R-subscales did not correlate 126

ROC Curve

1.0

0.0

0.2

0.4

0.6

0.8

1.0

1- Specificity

with any PANSS scores. These results can be easily explained by the fact that the PANSS as a diagnostic instrument attempts to detect the presence of a current condition (as it makes the HCR-20 C-subscale), whereas the HCR-20 H-subscale obviously concerns the past (previous violence episodes) and the R-subscale attempts to predict the likelihood of a future outcome. In addition, out of the HCR-20 subscales, only the H-subscale discriminated patients involuntarily hospitalized in the high security ward from patients voluntarily hospitalized in the other two wards. In other HCR-20 validity studies, violence was strongly associated with higher positive and general symptom scores and higher total PANSS scores (2, 5, 21). A recent study (22), which examined factors related to moves from higher to lower levels of therapeutic security in forensic settings, indicated that, among others, HCR-20 dynamic (C- and R-subscales combined) and PANSS general symptom scores predicted subsequent positive moves, i.e., were associated with one another. Predictive validity was evidenced for the total HCR-20 instrument and for the subscales by comparing baseline rates with outcome levels of violence (mild vs. moderate/ severe, assessed by the VAS scores) and type of violence (verbal vs. physical, according to the staff records) over the follow-up periods. We found that the total HCR-20 and subscale base rates predicted the levels and type of

David Ivgi et al.

violence observed at a 6-month and 18-month follow-up points, but only the C-subscale predicted the violence levels at a 12-month follow-up. We compared the accuracy of actuarial predictions of inpatient violence using a cut-off score of 12 on the HCR-20 versus the VAS levels and staff ’s violence records. The ROC AUC analyses confirmed discriminant validity for the total HCR-20 and H- and C-subscales for the 6- and 18-month follow-up times. The total score ROC AUC curves ranged from 0.57 to 0.76 for the total instrument which are similar to many previous studies in both civil and forensic psychiatric settings (20, 23-26). Consistent with some previous studies (27, 28), we found that the accuracy of actuarial predictions of inpatient violence was somewhat less for the R-subscale, compared with H- and C-subscales. A possible explanation is that the items of criminal history, substance use problems and current psychotic symptoms (H- and C-subscales) are more structured and more associated with risk of violence in individuals diagnosed with psychosis than risk management items, on which actuarial prediction of the future violence is based. Out of the latter factors, only psychotic patients non-adherent with psychological therapies and psychotropic medication were associated with a risk of violence (5). Limitations of this study include a relatively small sample size and a focus on a male inpatient cohort with Jewish majority. Taking into consideration gender and ethnic differences in certain scores of some HCR-20 items (29-31), the study results cannot be generalized to women and groups with a greater representation of non-Jewish minorities. Another limitation is the absence of test-retest reliability investigation. Hence, further validation of the tool with a larger inpatient samples including female and more nonJewish patients and test-retest is warranted. Larger sample sizes are needed in particular in order to further establish cut-off scores for more accurate violence predictions. In conclusion, this study has demonstrated satisfactory psychometric properties of the HCR-20, suggesting that it can serve as a useful measure of violence risk in diverse clinical forensic and research settings in Israel. However, the conclusions of the recent systematic review and metaanalysis study on the use of risk assessment instruments for predicting violence (4, p. 12) certainly refer to our validity study too: “The current level of evidence is not sufficiently strong for definitive decisions on sentencing, parole, and release or discharge to be made solely using these tools. The extent to which these instruments improve clinical outcomes and reduce offending needs further research.” We conclude suggesting the use of this tool as an important add-on to a thorough clinical structured assessment.

Acknowledgements Dr. A.M. Ponizovsky was supported in part by the Ministry of Immigrant Absorption. We wish to thank M. Shait, Y. Drori and R. Ben-Dor for their assistance in data collection, Ms. B. Adler for her statistical assistance and Drs. A. Grinshpoon, M. Birger and Y. Melamed for their help at different stages of the study.

References 1. Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M. Mental disorder and crime. Arch Gen Psychiatry 1996; 53:489-496. 2. Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: Systematic review and meta-analysis. PLoS Med 2009; 6: 1–14. 3. Appelbaum PS, Robbins PC, Monahan J. Violence and delusions: Data from the MacArthur Violence Risk Assessment Study. Am J Psychiatry 2000; 157:566-572. 4. Fazel S, Singh JP, Doll H, Grann M. Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: Systematic review and meta-analysis. BMJ 2012; 345:e4692. 5. Witt K, van Dorn R, Fazel S. Risk factors for violence in psychosis: Systematic review and meta-regression analysis of 110 studies. PLoS ONE 2013; 8: e55942. 6. Singh JP, Serper M, Reinharth J, Fazel S. Structured assessment of violence risk in schizophrenia and other psychiatric disorders: A systematic review of the validity, reliability, and item content of 10 available instruments. Schizophr Bull 2011;37:899-912. 7. The Law for the Treatment of the Mentally Ill, the State of Israel, 2004. 8. Bauer A, Khawaled R, Rosca P, Ponizovsky AM. Legal representation is associated with psychiatric readmissions. Open Law J 2008;1:6-10. 9. Webster CD, Eaves D, Douglas KS, Wintrup A. The HCR-20 scheme: The assessment of dangerousness and risk. Burnaby, BC, Canada: Mental Health, Law, and Policy Institute, and Forensic Psychiatric Services Commission of British Columbia, 1995. 10. Webster CD, Douglas KS, Eaves SD, Hart SD. Assessing risk of violence to others. In C. D. Webster & M. A. Jackson (Eds.), Impulsivity: Theory, assessment, and treatment. New York: Guilford, 1997: pp. 251-277. 11. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-276. 12. Santor DA, Ascher-Svanum H, Lindenmayer JP, Obenchain RL. Item response analysis of the Positive and Negative Syndrome Scale. BMC Psychiatry 2007;7:66. 13. Alia-Klein N. Violence assessment scale (VAS): A study of validity and reliability and suggestions for future use. Paper presented at International Congress of Schizophrenia Research, Whistler, British Columbia, May, 2001. 14. Alia-Klein N, O’Rourke TM, Goldstein RZ, Malaspina D. Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggress Behav 2007; 33:86-96. 15. Jones SH, Thornicroft G, Coffey M, Dunn G. A brief mental health outcome scale reliability and validity of the global assessment of functioning (GAF). Br J Psychiatry 1995; 166:654-659. 16. Cope R, Ward M. What happens to special hospital patients admitted to medium security? J Forens Psychiatry Psychol 1993, 4:14-24. 17. Mossman D. Assessing predictions of violence: Being accurate about accuracy. J Consult Clin Psychol 1994, 62:789-792. 18. Ogloff J, Lemphers A, Dwyer C. Dual diagnosis in an Australian forensic psychiatric hospital: Prevalence and implications for services. Behav Sci Law 2004; 22:543-562. 19. Belfrage H. Implementing the HCR-20 scheme for risk assessment in a forensic psychiatric hospital: Integrating research and clinical practice. J Forensic Psychiatry 1998; 9:328-338. 20. Ross DJ, Hart SD, Webster CD. Aggression in psychiatric patients: Using the HCR-20 to assess risk for violence in hospital and in the

127

Validation of the HCR-20 Scale for Assessing Risk of Violent Behavior in Israeli Psychiatric Inpatients

community. In HCR-20 violence risk assessment schema: Overview and annotated bibliography, 2008. Available at: http://kdouglas.wordpress. com/. Retrieved on 10.10.2013. 21. Douglas KS, Guy LS, Reeves KA, Weir J. HCR-20 Violence risk assessment schema: Overview and annotated bibliography, 2008. Available at: http:// kdouglas.wordpress.com/. Retrieved on 10.10.2013. 22. Davoren M, O’Dwyer S, Abidin Z, Naughton L, Gibbons O, Doyle E, McDonnell K, Monks S, Kennedy HG. Prospective in-patient cohort study of moves between levels of therapeutic security: The DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20. BMC Psychiatry 2012;12:80. 23. Grann M, Belfrage H, Tengström A. Actuarial assessment of risk for violence: Predictive validity of the VRAG and the historical part of the HCR-20. Crim Justice Behav 2000; 27: 97-114. 24. McNiel D, Gregory A, Lam J, Binder R, Sullivan G. Utility of decision support tools for assessing acute risk of violence. J Cons Clin Psychol 2003; 71:945-953. 25. Dolan M, Fullam R, Logan C, Davies G. The Violence Risk Scale Second Edition (VRS-2) as a predictor of institutional violence in a British forensic inpatient sample. Psychiatry Res 2008;158:55-65. 26. Allen C, Howells K. The implementation and evaluation of a structured professional judgment risk assessment tool within a high secure forensic hospital. Paper presented at the annual conference of the International Association of Forensic Mental Health Services, Vienna, Austria, 2008. 27. Gray NS, Hill C, McGleish A, Timmons D, Mac-Culloch MJ, Snowden RJ. Prediction of violence and self-harm in mentally disordered offenders: A prospective study of the efficacy of the HCR-20, PCL-R, and psychiatric symptomatology. J Cons Clin Psychol 2003; 71: 443-451. 28. Lindsay WR, Hogue TE, Taylor JL, Steptoe L, Mooney P, O’Brien G, Johnston S, Smith AH. Risk assessment in offenders with intellectual disability: A comparison across three levels of security. Int J Offender Ther Comp Criminol 2008; 52:90-111. 29. Strand S, Belfrage H. Comparison of HCR-20 scores in violent mentally disordered men and women: Gender differences and similarities. Psychol Crime Law 2001, 7:71-79. 30. Fujii DE, Tokioka AB, Lichton AI, Hishinuma E. Ethnic differences in prediction of violence risk with the HCR-20 among psychiatric inpatients. Psychiatr Serv 2005: 56:711-716. 31. Dolan M, Blattner R. The utility of the Historical Clinical Risk-20 Scale as a predictor of outcomes in decisions to transfer patients from high to lower levels of security – a UK perspective. BMC Psychiatry 2010;10:76.

128

Appendix

Items

Items in the HCR-20 Risk Assessment Scheme Sub-Scales

Historical Scale Previous Violence

Young Age at First Violent Incident

Relationship Instability

Employment Problems

Substance Use Problems

Major Mental Illness

Psychopathy

Early Maladjustment

Personality Disorder

Prior Supervision Failure

H10

Clinical Scale Lack of Insight

Negative Attitudes

Active Symptoms of Major Mental Illness

Impulsivity

Unresponsive to Treatment

Risk Management Scale Plans Lack Feasibility

Exposure to Destabilizers

Lack of Personal Support

Noncompliance with Remediation Attempts

Stress

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Iulian Iancu et al.

Negative and Positive Automatic thoughts in Social Anxiety Disorder Iulian Iancu, MD,1 Ehud Bodner, PhD,2 Samia Joubran, MEd,3 Yelena Lupinsky, MD,1 and Damian Barenboim, MA1 1

Yavne Mental Health Clinic, Sackler School of Medicine, Tel Aviv University Israel The Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat Gan, Israel 3 Department of Psychology and Center for Psychobiological Research, The Yezreel Valley College, Israel 2

Introduction

Abstract Background: Social Anxiety Disorder (SAD) is characterized by fear and avoidance in social situations where one is exposed to scrutiny by others. It is possible that automatic thoughts either cause the disorder or maintain it, and thus their examination is warranted. Method: 30 SAD subjects diagnosed with the MiniInternational Neuropsychiatric Interview (MINI) and 30 healthy controls were administered the Liebowitz Social Anxiety Scale (LSAS), the Automatic Thoughts Questionnaires (ATQ–Negative and ATQ–Positive), the Sheehan Disability Scale (SDS) and the Beck Depression Inventory (BDI). It was hypothesized that the SAD subjects would display more depression and disability, more negative automatic thoughts and fewer positive automatic thoughts than the healthy controls, and that the automatic thoughts will predict the severity of SAD. Results: SAD patients had higher scores of depression and disability, higher scores on the ATQ–Negative questionnaire and lower scores on the ATQ–Positive questionnaire. The scores of the LSAS subscales were predicted by the scores of the ATQ-Positive and the BDI questionnaires. Limitations: Moderate sample size and limits of the questionnaires used in the study. Conclusions: Automatic thoughts may be an important area of research with larger samples. Further studies should be carried out in order to examine if strengthening positive thinking and ablation of negative thinking can reduce SAD symptoms during cognitive behavioral treatment.

Address for Correspondence:

Social Anxiety Disorder (SAD) is a common condition characterized by fear and avoidance of situations where scrutiny by other people is possible and might lead to social embarrassment (1-3). The condition causes disability and is accompanied frequently by comorbid mental disorders, such as depression and substance abuse (1). It is possible that cognitive factors might play a part in the etiology or maintenance of the disorder. SAD subjects display thoughts and beliefs that are dysfunctional and cause anxiety and avoidance. The socially anxious person experiences the environment as threatening and dangerous (4-7). SAD persons claim to see the point of view of the other person and to believe that others’ gazes indicate criticism and rejection. Their mental image is usually negative; they believe that they are failing and that the results of their behavior will be disastrous. These thoughts strengthen their negative feelings, creating a vicious circle. On another vein, socially anxious persons lack the positive bias (healthy protective optimism) of non-anxious persons. There is an association between SAD and low positive affect. Also, socially anxious individuals more easily forget socially positive words than do non-anxious individuals (8). Moreover, there is evidence of a diminished attentional allocation for socially positive information in SAD (9). Furthermore, the SAD subject tends to discount positive social information and fails to accept others’ positive reactions at face value (10). Numerous studies evaluated the pathological cognitions characteristic of individuals with SAD (11-14).Turner and associates (11) discussed the importance of building a tool to assess pathological cognitions in SAD and constructed the Social Thoughts and Beliefs Scale (STABS), which showed good psychometric abilities. Boden et al.

Iulian Iancu, MD, Yavne Mental Health Clinic, 4 Dekel St., Yavne 81540, Israel

iulian1@bezeqint.net

129

Negative and Positive Automatic thoughts in Social Anxiety Disorder

(12) examined maladaptive beliefs of 47 individuals with SAD receiving CBT. They reported that these beliefs were associated with social anxiety at baseline and at treatment completion, were reduced and accounted for reductions in social anxiety after CBT. Koerner et al. (13) assessed beliefs of SAD patients following CBT in 77 adults with SAD and used the STABS. A positive change in the belief that others are more socially competent emerged as a significant unique predictor of social anxiety symptoms at post-treatment. Calvete, Orue and Hankin (14) evaluated 1,052 adolescents with measures of early maladaptive schemas, socially anxious automatic thoughts and social anxiety symptoms. The subjects were a non-clinical group of students with a mean age of 13.4 years. The study’s findings were consistent with hierarchical cognitive models of social anxiety given that deeper schemas predict more surface-level thoughts; however these more surface-level thoughts also contributed to perpetuating schemas. Thus, a bidirectional longitudinal relationship among schemas and automatic thoughts was found. Maladaptive cognitions in SAD subjects may exist at various levels: negative automatic thoughts, maladaptive thinking patterns (cognitive distortions), core beliefs and schemas. Beliefs are central to one’s identity, are negatively biased, inaccurate and rigid (12), whereas automatic thoughts are less stable and on the surface (15). Automatic thoughts represent “what just ran through [the] mind” and can be defined as spontaneous, evaluative cognitions about oneself, the future and the world (see 15). While the identification of negative automatic thoughts is rather easy, the scrutiny of core beliefs and schemas is more complex and therefore more difficult to examine. Nevertheless, as will be later described, in comparison to the above-mentioned studies in SAD patients on core beliefs and schemas, much less has been written on the role of positive and negative automatic thoughts in SAD. We believe that identifying automatic thoughts is important (15), as they might provide a first step in the elucidation of maladaptive cognitions in SAD. The better understanding of automatic thoughts in SAD patients may lead patients and clinicians to the identification of thinking distortions and also core beliefs. In this study, we aimed to evaluate the bias in cognition in SAD subjects, as regards negative and positive automatic thoughts. Negative automatic thoughts in SAD have received little attention. Positive automatic thoughts are a new area of research in psychology (“positive psychology”) and have not been the main focus of research, either in depression or in SAD. In depression, several studies have 130

shown that the score of the ATQ (16), and not an anxiety tool (the Beck Anxiety Inventory), predicted the BDI score (17). This study supported the cognitive content specificity theory, which suggests that particular cognitive content can be automatically activated and associated with specific psychological disorders (18). In another study on 200 community children and 160 adolescents with anxiety, depression or conduct disorder, automatic thoughts about loss or failure were the best predictor of anxiety (19). Despite their centrality, very few studies examined automatic thoughts in SAD subjects. Stopa and Clark (20) outlined six different categories of automatic thoughts that were self-reported by a small sample of 12 individuals with SAD. They used a thought checklist generated by the researchers and a “think aloud” activity, and measured the frequency of thoughts, as well as belief ratings for each of the thoughts. The thoughts were categorized as (1) self evaluative thoughts, (2) thoughts about the evaluation of others, (3) evaluative thoughts about the other person with whom they are interacting, (4) thoughts about coping strategies and behavioral plans, (5) thoughts of avoidance, and (6) any other thoughts that were not categorized. SAD participants had more negative self-evaluative thoughts than anxious or non-patient controls. Stopa and Clark (20) suggested that persons with SAD might react to social situations by running through a routine of negative thoughts without attending to the actual circumstances. In another study, Hope et al. (21) analyzed the semantic content of automatic thoughts reported in group cognitive behavior therapy (CBT) for 55 SAD subjects and found that the most common thoughts were related to poor social performance, negative labels by others, and anticipation of negative outcomes in feared situations. In another study, Mortberg et al. (22) examined selffocused attention and negative automatic thoughts in 29 patients with SAD receiving individual cognitive therapy. They used the 22-item Social Cognitions Questionnaire (23) for the examination of negative automatic thoughts. Both self-focused attention and negative social phobiarelated automatic thoughts changed in line with the overall outcome and were significantly reduced over the course of the treatment (22). The alteration from self-focused to externally focused attention mediated improvements in social anxiety one week later, whereas the change in frequency of, or belief in, negative automatic thoughts did not predict social anxiety one week later. This study will focus on the role of automatic thoughts in SAD patients, and evaluate their cognitive bias toward more negative and less positive automatic thoughts. This

Iulian Iancu et al.

is contrary to other studies that assessed both thoughts and beliefs (11-13).To the best of our knowledge, no studies have administered the ATQ in SAD subjects. A number of measures of automatic thoughts have been developed (24), but the most widely used is the Automatic Thought Questionnaire (ATQ) by Hollon and Kendall (16). Based on its good psychometric qualities, the ATQ might identify subjects with elevated anxiety (24) and be related to other measures of anxiety and depression, in ways which may increase our understanding of the role of automatic thoughts in SAD subjects. Study questions and hypotheses:

1. Do SAD subjects display more negative automatic thoughts and fewer positive automatic thoughts, as well as more social fear, social avoidance, disability, and depression, as compared to healthy controls? Based on the possible role of negative automatic thoughts in SAD patients (20) and the prevalence of depression and disability among SAD patients (1), we hypothesized they do. 2. Can the level of automatic self-reported negative and positive thoughts (i.e., scores on the ATQ-Negative and ATQ-Positive) predict the severity of reported fear and avoidance on the LSAS? In line with previous studies regarding the association between negative automatic thoughts and SAD (20-22), we hypothesized that the ATQ-Negative score will be positively correlated with fear and avoidance, and predict higher fear and higher avoidance in SAD individuals. In accordance with previous studies regarding the relationship between low positive affect, low recall of socially positive words, diminished attentional allocation for socially positive information, and a tendency among SAD subjects to discount positive social information and not to accept others’ positive reactions at face value (8-10), we hypothesized that the ATQ-Positive score will be negatively correlated with fear and avoidance and predict lower fear and avoidance among SAD. Materials and Methods Participants

The sample included 60 participants, 20 males and 40 females, average age 38.10 ± 13.57 years, range: 19 to72 years. The SAD participants were recruited consecutively during their first visit at a community mental health clinic and were all treatment seekers. Screening interviews were carried out by the first author. Out of 35 participants who agreed to be interviewed, 30 were selected. The remaining

five subjects had difficulty in Hebrew, the language in which the therapy was conducted. Thirty healthy controls were recruited from the technical and administrative staff of our institution (a large mental health hospital). These subjects had no psychiatric diagnosis and were not in treatment. Inclusion criteria were: MINIdiagnosed social anxiety disorder (25), no current alcohol or drug abuse, no health conditions characterized by body disfigurement or stuttering and Parkinson’s disease, and no active psychiatric disorder (e.g., schizophrenia, major depressive disorder, OCD, etc.). Exclusion criteria included severe cognitive impairment and psychotic symptoms secondary to acute intoxication or withdrawal from alcohol or other substances. The patient sample had in the past, but not during the time of the study, various conditions such as major depression (16%), bipolar disorder (3%), specific phobia (10%) and obsessive compulsive disorder (3%). Axis II diagnoses were not examined in this study. Seven participants in the social anxiety group took psychotropic medications (1 venlafaxine, 1 paroxetine, 2 sertraline, 1 citalopram, 1 escitalopram and 1 calmanervin). There were no significant differences in the distribution of age, education, gender, income level, family status, country of origin, and number of children between the groups (p> 0.05). Measures

Automatic Thoughts Questionnaire–Negative (ATQ-N). The ATQ-N (16) consists of 30 items which measure the frequency with which an individual experiences negative automatic thoughts over a 1-week period. It includes items such as “I’m not OK,” “No one understands me.” Respondents are required to rate their answers on a 5-point scale, ranging from 1 (not at all) to 5 (all the time). This scale has been reported to have excellent reliability (split-half and coefficient alpha were 0.97 and 0.96, respectively) (16) and was found to correlate significantly with other related measures. The Hebrew version of the questionnaire is reported to have reasonable internal consistency of α=0.80 (26). This inventory was included in order to measure differences in the extent of automatic negative thoughts between SAD and healthy controls. In the current study, it demonstrated a very high alpha reliability coefficient of 0.98. Automatic Thoughts Questionnaire–Positive (ATQ-P). The ATQ-P (27) was developed to measure the frequency of positive self thoughts over a 1-week period. It consists of 30 items on a 5-point scale, ranging from 1 (not at all) to 5 (all the time). It includes items such as “I will 131

Negative and Positive Automatic thoughts in Social Anxiety Disorder

succeed,” “It is fun to be with me.” Its internal reliability is very high (coefficient alphas reported as high as .95, (see 28)), and demonstrates adequate convergent and discriminate validity (29). The Hebrew version of the questionnaire is reported having reasonable internal consistency of α=0.78 (26). This inventory was included in order to measure differences in the extent of automatic positive thoughts between SAD and healthy controls. In the current study, it demonstrated a very high alpha reliability coefficient of 0.98. The Beck Depression Inventory (BDI): This scale was developed by Beck et al. (30) in 1961 to measure depression, and is still in clinical and experimental use (31). Due to the comorbidity of depression among SAD patients (1), this inventory was included in order to measure differences in the extent of depressive symptoms between SAD and healthy controls as well as the association between the BDI score and the scores of the Liebowitz Social Anxiety Scale (32). The questionnaire includes 21 items referring to emotional, cognitive, behavioral, and physical aspects of symptoms and attitudes consistent with depression. Answers are scored on a scale ranging from 0 = nonexistent to 3 = very serious. The Hebrew version of the questionnaire is reported to have reasonable internal consistency of α=0.76 (31). In the current study it demonstrated a high alpha reliability coefficient of 0.91. Liebowitz Social Anxiety Scale (LSAS) (32): It includes two subscales which measure social fear and social avoidance. The scale consists of 24 items that refer to performances in social settings (e.g. “participating in a small group”) and to social interactions (e.g. “going to a party”). Respondents are asked to rate both their level of anxiety when they experience the situation (0= “none” to 3= “severe”) and the frequency of their avoidance of the situation (0= “never” to 3= “usually [67-100%]”). The LSAS is used for screening SAD in research settings. It has very good internal consistency (Chronbach’s α ranging from 0.81 to 0.92), and good convergent validity (33). It was translated to Hebrew and demonstrated strong testretest reliability, internal consistency, and discriminant validity (34). Participants with mild SAD score 30-40, whereas those with moderate to severe SAD score 50-80. In the current study, the average scores for participants diagnosed by the psychiatrists as suffering from SAD were mild (33.60± 12.39 for social fear and 30.19± 12.46 for social avoidance), and differed significantly for social fear (t(58)=10.32, p < 0.001), and for social avoidance (t(58)=7.63, p < 0.001) from the average scores of the healthy controls (6.83± 6.59 for social fear and 7.13± 132

9.17 for social avoidance). In the present study, the alpha reliability coefficients were very high (0.95 for both social fear and social avoidance). Sheehan Disability Scale (SDS) (35). This scale measures functional deficiencies in three inter-related life domains (work or school, social life and family life), and is widely used by researchers and clinicians. The respondent is asked to rate on a 10-point visual analog scale, the extent to which his or her social and leisure activities are impaired by his or her symptoms. The three items are summed into one score, ranging from 0 (unimpaired) to 30 (highly impaired). The scale demonstrated reasonable sensitivity (83%) and specificity (69%). In the current study, it demonstrated a very high alpha reliability coefficient of 0.93. Background data. Age, gender, years of education, country of birth, family status, income level, medical conditions and medications, number of children and number of friends (the last two were regarded as measures that may reflect interpersonal functioning). Procedure

The study was approved by the Institutional Review Board. The questionnaires were administered individually in the clinic by the first author as a part of the intake procedure. The participants were asked to participate and if they agreed, they signed informed consent forms and were provided with the research instrument and filled out the questionnaire in the presence of the first author. Completed questionnaires were then placed together with other completed questionnaires in order to ensure anonymity. Data analysis

To examine hypothesis 1, the SAD group and the healthy control group were compared by series of Univariate Analyses of Variance (ANOVAs) in which gender also served as an independent variable, and the following variables as dependent variables: the BDI score, the ATQ-N and ATQ-P score, the social fear and social avoidance scores, and the various disability measures (SDS scales and number of children and friends). In order to examine hypothesis 2, Pearson correlations were computed between the ATQ-N and ATQ-P score and the social fear and social avoidance scores. Two separate stepwise regression analyses were conducted to examine the relative contribution of a set of predictor (independent) variables to the variance of the social anxiety subscales’ scores. Participants’ sociodemographic variables (gender, age and number of friends), medical background (chronic disease), automatic thoughts

Iulian Iancu et al.

(the ATQ-N and the ATQ-P scores), and BDI score served as predictors in these analyses. The LSAS scores (fear and avoidance) were the predictive (dependent) variables in the analyses. Results Hypothesis 1: SAD subjects will display more depression, more negative and less positive automatic thoughts, and more social fear, social avoidance and disability. As demonstrated in Table 1, the ANOVAS revealed main effects for group so that in comparison to the healthy control group, the social anxiety group reported significantly more depression, more negative automatic thoughts, less positive automatic thoughts, and more social fear and social avoidance (p< 0.001). Univariate Analyses of Variance (ANOVAS) conducted on the SDS score, and on two measures of interpersonal functioning (number of friends and children) by group (SAD/controls) and by gender, revealed as expected a Table 1. ANOVAs results regarding the various dependent measures by groups Scores

Group

η²

ATQ-N

Social Anxiety

74.70

25.72

27.86

0.001

0.33

Healthy Controls

44.13

16.98

Social Anxiety

83.30

ATQ-P

BDI

LSAS Fear

LSAS Avoidance

SDS

Number of Friends

21.10

Healthy Controls

118.20

22.16

Social Anxiety

11.08

9.86

Healthy Controls

2.41

3.36

Social Anxiety

34.00

12.39

Healthy Controls

8.20

6.59

Social Anxiety

29.90

12.46

Healthy Controls

8.33

9.17

Social Anxiety

14.47

6.02

Healthy Controls

0.83

1.15

Social Anxiety

3.07

2.83

Healthy Controls

9.14

6.70

main effect of group for the SDS score, a main effect for the number of friends, but not for the number of children. Therefore, hypothesis 1 was mostly confirmed. No main effects and no interaction effect of group gender were found regarding the ATQ measures. No main effects of gender were found on the SDS score, and number of friends and children (p> 0.05). No interaction effects of group gender were found on the SDS score and number of friends (p> 0.05). Hypothesis 2: The ATQ-N will be positively correlated with fear and avoidance, and also predict higher fear and higher avoidance among SAD individuals, whereas the ATQ-P will be negatively correlated with fear and avoidance and also predict lower fear and avoidance among SAD individuals. As demonstrated in Table 2, the ATQ-N score was positively correlated with the BDI and LSAS fear and avoidance scores, whereas the ATQ-P was negatively correlated with these three scores. Two separates stepwise regression analyses were conducted to examine the second hypothesis. Table 3 summarizes the results of the two regression analyses and shows a pattern where the ATQ-P score and Table 2. Correlations’ matrix of the ATQ-N, ATQ-P, and the LSAS subscales in the study groups

ATQ-N 42.96

17.98

0.001

0.43

0.25

53.38

0.001

ATQ-P

LSAS Fear

LSAS Avoidance

-.786

.457

.429

.000

.013

.018

-.485

-.444

.008

.014

.925

Significance ATQ-P Fear LSAS Avoidance LSAS

95.53

Correlation

ATQ-N

Correlation

-.786

Significance

.000

Correlation

.457

-.485

Significance

.013

.008

Correlation

.429

-.444

.925

Significance

.018

.014

.000

.000 1

0.64

0.49

Table 3. The relative contribution of depression and positive automatic thoughts to social fear and avoidance using stepwise regression analysis B

Significant predictors for the fear score of social anxiety 125.65

23.73

0.001

0.69

0.30

ATQ-P score

-0.28

0.06

-0.47

4.79

0.001

BDI score

0.78

0.18

0.43

4.32

0.001

0.62

Significant predictors for the avoidance score of social anxiety BDI score

1.25

0.16

0.72

7.75

0.001

ATQ-P score

0.23 -

0.06

0.40-

4.08

0.001

0.61

133

Negative and Positive Automatic thoughts in Social Anxiety Disorder

the BDI score contributed significantly to the explained variance of the two LSAS subscales. The ATQ-P score contributed more to the social fear score than the BDI, whereas the BDI contributed more to the social avoidance score than the ATQ-P. The ATQ-P score and the BDI score explained 62% of the variance of social fear (F(2,55)=47.43, p<0.001). The ATQ-P accounted for 50% of the variance (p<0.001), and BDI score added 12% (p<0.001). The remaining predictors (including the ATQ-N) did not reach significance. The BDI score and the ATQ-P score explained 61% of the variance of social avoidance (F(2,56)=46.61, p<0.001). The BDI score accounted for 50% (p<.001), and the ATQ-P score added 11% (p<.001). The remaining predictors (including the ATQ-N) did not reach significance. The β coefficients for ATQ-P scores in the regression analyses were negative indicating that the more frequent the positive automatic thoughts, the lower the extent of social fear and avoidance. The β coefficients for the BDI were positive, indicating that the higher the depression score, the higher the extent of social fear and avoidance. Therefore, hypothesis 2 was partially confirmed, mostly for the ATQ-P. Discussion In line with hypothesis 1, the SAD group displayed more depression, more negative and less positive automatic thoughts, more social fear and social avoidance and disability as compared to healthy controls. These findings on the clinical and social consequences of SAD are in accordance with the results of other studies on SAD (1, 36). In accordance with hypothesis 2, the negative ATQ score was positively correlated with the LSAS scores and the positive ATQ score was negatively correlated with the LSAS scores. However, in partial accordance with hypothesis 2, only the positive ATQ score predicted lower fear and avoidance among SAD individuals. Moreover, the ATQ-P score contributed more to the prediction of social fear than the BDI score, whereas the BDI score contributed more to the prediction of the social avoidance score than the ATQ-P score. Our findings on the clinical and social consequences of being afflicted with SAD are in accordance with other studies on SAD (1, 36). In addition, most of our findings on the automatic thoughts are in accordance with the theoretical framework proposed for SAD (16). As a significant portion of SAD patients do not respond to pharmacotherapy (1), we need to know more about developmental and maintaining factors of SAD, and also on effective components of treatment. One factor which 134

is presumed to play a critical part in the onset and maintenance of SAD is cognition. Anxious cognition could be measured by automatic thoughts evaluation, although the literature is limited in this area. Our findings regarding the higher score of negative automatic thoughts in the SAD group as compared with the healthy control group are in accordance with the abovementioned cognitive theoretical framework proposed for SAD (21) and support the literature which is scant in this area. Muris et al. (37) studied the efficacy of CBT in anxious children (n=45; 22 with severe SAD, 18 with separation anxiety disorder and 27 with generalized anxiety disorder). The authors reported a decrease of the score on Children’s Automatic Thoughts Scale (CATS), which measures negative automatic thoughts. They found that a reduction of anxiety disorders symptoms was significantly associated with a decrease in negative automatic thoughts and that the children felt more capable of controlling their anxiety. The researchers concluded that a reduction of anxiety symptoms after a CBT intervention in these young patients may be mediated by a lessening of negative automatic thoughts. Foa and colleagues (38) compared 15 patients in their thirties, who suffered from generalized SAD and 15 non-anxious controls over a 14 weeks period. At pretreatment, the SAD subjects had higher scores on negative cognitions. The group of patients received CBT with combined exposure, cognitive restructuring and social skills training. The intensiveness of negative cognitions associated with social contexts and non-social contexts for the two groups was assessed prior to treatment and following treatment. Again, the researchers found that the reduction in the extent of negative cognitions associated with social contexts (i.e., cost estimates for social events) mediated improvement in SAD in this case of adult patients. These two studies are in line with our finding regarding the higher score of negative automatic thoughts among the SAD group, but contradict our lack of findings regarding the predictive value of negative cognitions for the intensity of SAD. Moreover, the prediction of the LSAS scores by positive automatic thoughts and not by negative automatic thoughts is intriguing and might suggest that the “positive” bias in our subjects was greater than the negative one, and this should be reexamined in future studies, on a larger sample of SAD patients. While our study shows differences between the study groups on positive and negative automatic thoughts, there are several models that assess this theoretical issue. Ryff ’s cognitive model of psychological well-being puts an emphasis on countering negative thoughts and increas-

Iulian Iancu et al.

ing positive ones (39). This form of therapy, described as Well-being therapy, is structured, directive, and based on an educational approach (40). It emphasizes the development of a capacity to sustain attention to aspects of daily experience or emotions that are positive and pleasurable. Well-being therapy was successfully implemented in patients who suffer from generalized anxiety disorder (41) or from depression (42). In this form of therapy, the therapist reinforces and encourages pleasurable activities for a certain time each day, and counters the tendency of patients to focus exclusively on circumstances associated with lower levels of hedonia. In line with our findings regarding the relationship between automatic negative and positive thoughts and the severity of SAD, such interventions which are directed to decrease negative thoughts and increase positive ones, may be also beneficial for patients with SAD. Well-being therapy has been validated in a number of randomized controlled trials (43). Flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one’s self, a sense of continued growth and development, the belief that life is meaningful, the possession of quality relations with others, the capacity to manage effectively one’s life, and a sense of self-determination and autonomy. Additional perspectives in the area include the Statesof-Mind (SOM) model (44), which maintains that the balance of positive and negative thoughts is essential for psychological well-being. A ratio of 0.62 between positive and negative thoughts is considered optimal or healthy. A ratio less than 0.31 is related to depression or anxiety. A final additional model is the “power of non-negative thinking” that states that anxious children may benefit more from a reduction of negative thoughts than from an increase in positive thoughts (45). It is also worth mentioning that the ATQ-P score had a more dominant role than the BDI score in the prediction of social fear, whereas the BDI score explained the variance of the social avoidance score more than the ATQ-P score. Is fear derived by lack of positive self-statements and avoidance constitutes rather a depressive derivate? We speculate that the absence of positive thinking might create fear , but it is mainly the depressive counterpart that predicts avoidance (low initiative and drive, or even learned helplessness)(46).The latter link is supported by the results of a recent study which demonstrated that the depression score was a predictor of the LSAS avoidance subscale score (47). Our study has not shown differences across gender, which is not in line with the findings of Xu and associates

(48), who reported that women with lifetime SAD had more lifetime social fears and internalizing disorders and were more likely to have received pharmacological treatment for SAD. This lack of gender differences may be due to the small sample size. Our study has several limitations. The moderate number of patients included in the study is a limitation, although we nevertheless found significant differences between the study groups. Second, we tried to ensure that the controls were healthy; however it is unclear whether they are representative of the general population. Third, the ATQ-N measures general (negative) affect and not anxiety and/or depression separately, so it is difficult to examine content specificity. The items of the ATQ-P and the ATQ-N do not refer specifically to social contexts, which according to Foa et al. (38) and Hope et al. (21) pose a different kind of threat on the individual than in other anxiety disorders (poor social performance, negative labels by others, and the anticipation of negative outcomes in feared situations). It is improbable the ATQ will differentiate between patients with various anxiety disorders, whereas the STABS did show this ability (11). The use of the STABS which is more specific to SAD would have been more straightforward, although as explained above, in contrast to the ATQ, the STABS does not differentiate between thoughts and beliefs. A final limitation is that the study’s methodology does not allow us to speak about causality between the various constructs examined in this study. Taking in consideration all the above, the results of our study justify the further elucidation of the role of automatic thoughts in distress and dysfunction in SAD. In conclusion, further research should examine whether indeed the strengthening of positive thinking and the ablation of negative thinking is crucial in the treatment of SAD. The identification of negative thoughts is the first step in their eradication and elements of positive psychology can assist in adopting a less anxious-prone view of life. Research is warranted on the question of the preferred sequential order of tackling specific automatic thoughts in CBT and whether some automatic thoughts change more in CBT. References 1. Stein MB, Stein DJ. Social anxiety disorder. Lancet 2008;371: 1115-1125. 2. Rodebaugh TL. Hiding the self and social anxiety. The core extrusion schema measure. Cogn Ther Res 2009; 33:90-109. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5thed. Washington, D.C.: American Psychiatric Association, 2013. 4. Coles ME, Turk CI, Heimberg RG, Fresco DM. Effects of varying levels of anxiety within social situation: Relationship to memory perspective and attributions in social anxiety disorder. Behav Cogn Psychother

135

Negative and Positive Automatic thoughts in Social Anxiety Disorder

1998; 26:3-12. 5. Foa EB, Kozak MJ. Emotional progressing of fear: Exposure to corrective information. Psychol Bull 1986; 99:20-35. 6. Heinrichs N, Hofman SG. Information processing in social phobia: A critical Review. Clin Psychol Rev 2001; 21, 751-770. 7. Rapee RM, Heimberg RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther 1997;35:741-756. 8. Liang CW, Hsu WY, Hung FC, Wang WT, Lin CH. Absence of a positive bias in social anxiety: The application of a directed forgetting paradigm. J Behav Ther Exp Psychiatry 2011; 42:204-210. 9. Taylor CT, Bomyea J, Amir N. Attentional bias away from positive social information mediates the link between social anxiety and anxiety vulnerability to a social stressor. J Anxiety Disord 2010;24:403-408. 10. Vassilopoulos SP, Banerjee R. Social interaction anxiety and the discounting of positive interpersonal events. Behav Cogn Psychother 2010; 38:597-609. 11. Turner SM, Johnson MR, Beidel DC, Heiser NA, Lydiard RB. The Social Thoughts and Beliefs Scale: A new inventory for assessing cognitions in social phobia. Psychol Assess 2003;15:384-391. 12. Boden MT, John OP, Goldin PR, Werner K, Heimberg RG, Gross JJ. The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder. Behav Res Ther 2012;50:287-291. 13. Koerner N, Antony MM, Young L, McCabe RE. Changes in beliefs about the social competence of self and others, following cognitive-behavioral treatment. Cog Ther Res 2013; 37:256-265. 14. Calvete E, Orue I, Hankin BL. Early maladaptive schemas and social anxiety in adolescents: The mediating role of anxious automatic thoughts. J Anxiety Disord 2013; 27:278-288. 15. Donnelly R, Renk K, Sims VK, McGuire J. The relationship between parents’ and children’s automatic thoughts in a college student sample. Child Psychiatry Hum Dev 2011;42:197-218. 16. Hollon SD, Kendall PC. Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cog Ther Res 1980; 383-395. 17. Lamberton A, Oei TP. A test of the cognitive content specificity hypothesis in depression and anxiety. J Behav Ther Exp Psychiatry 2008;39:23-31. 18. Beck AT. Cognitive therapy and the emotional disorders. New York: New American Library, 1976. 19. Schniering CA, Rapee RM. The relationship between automatic thoughts and negative emotions in children and adolescents: A test of the cognitive content-specificity hypothesis. J Abnorm Psychol 2004; 133:464-470. 20. Stopa L, Clark DM. Cognitive processes in social phobia. Behav Res Ther 1993; 31, 255-267. 21. Hope DA, Burns JA, Hayes SA, Herbert JD, Warner MD. Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder. Cog Ther Res 2010; 4:1-12. 22. Mörtberg E, Hoffart A, Boecking B, Clark DM. Shifting the focus of one’s attention mediates improvement in cognitive therapy for social anxiety disorder. Behav Cogn Psychother 2013;28: 1-11. 23. Wells A, Stopa L, Clark DM. The social cognitions questionnaire. Unpublished, 1993. 24. Glass CR, Arnkoff DB. Questionnaire methods of cognitive self-statement assessment. J Consult Clin Psychol 1997;65:911-927. 25. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59:22-33.

136

26. Besser A, Flett GL, Hewitt PL, Guez J. Perfectionism, and cognitions, affect, self-esteem and physiological reactions in a performance situation. J Rat-Emo Cognitive-Behav Ther 2008; 26: 206-228. 27. Ingram RE,Wisnicki KS. Assessment of positive automatic cognition. J Consult Clin Psychol 1988; 56:898-902. 28. Burgess E, Haaga DAF. The Positive Automatic Thoughts Questionnaire (ATQ-P) and the Automatic Thoughts Questionnaire–Revised (ATQ-RP): Equivalent measures of positive thinking. Cog Ther Res 1994; 18: 15-23. 29. Ingram RE, Kendall PC, Siegle G, Guarino J, McLaughlin SC. Psychometric properties of the Positive Automatic Thoughts Questionnaire. Psychol Assess 1995; 7: 495-507. 30. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory of measuring depression. Arch Gen Psychiatry 1961; 4: 561-571. 31. Landau G, York AS. Keeping and disclosing a secret among people with HIV in Israel. Health Soc Work 2004; 29: 116-127. 32. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1987;22:141-173. 33. Heimberg RG, Horner KJ, Juster HR, et al. Psychometric properties of the Liebowitz Social Anxiety Scale. Psychol Med 1999;29:199-212. 34. Levin JB, Marom S, Gur S, Wechter D, Hermesh H. Psychometric properties and the three proposed subscales of a self-report version of the Liebowitz Social Anxiety Scale translated into Hebrew. Depress Anxiety 2002;16:143-151. 35. Sheehan DV. Sheehan Disability Scale. Handbook of psychiatric measures. Washington DC: American Psychiatric Association, 2000. 36. Fehm L, Pelissolo A, Furmark T, Wittchen HU. Size and burden of social phobia in Europe. Eur Neuropsychopharmacol 2005;15:453-462. 37. Muris P, Mayer B, den Adel M, Roos T, van Wamelen J. Predictors of change following cognitive-behavioral treatment of children with anxiety problems: A preliminary investigation on negative automatic thoughts and anxiety control. Child Psychiatry Hum Dev 2009; 40:139-151. 38. Foa EB, Franklin ME, Perry KJ, Herbert JD. Cognitive biases in generalized social phobia. J Abnorm Psychol 1996;105:433-439. 39. Ryff CD. In the eye of the beholder: Views of psychological well-being among middle-aged and older adults. Psychol Aging 1989;4:195-201. 40. Fava GA, Ruini C. Development and characteristics of a well-being enhancing psychotherapeutic strategy: Well-being therapy. J Behav Ther Exp Psychiatry 2003;34:45-63. 41. Ruini C, Fava GA. Well-being therapy for generalized anxiety disorder. J Clin Psychol 2009;65:510-519. 42. Moeenizadeh M, Salagame KKK. The impact of Weltbeing therapy on symptoms of depression. Int J Psychol Study 2010;2:223-230. 43. Fava GA, Tomba E. Increasing psychological well-being and resilience by psychotherapeutic methods. J Pers 2009; 77:1903-1934. 44. Schwartz RM, Garamoni GL. Cognitive balance and psychopathology: Evaluation of an information processing model of positive and negative states of mind. Clin Psychol Rev 1989; 9: 271-294. 45. Kendall PC, Chansky TE. Considering cognition in anxiety-disordered children. J AnxDisord 1991; 5: 167-185. 46. Abramson LY, Seligman ME, Teasdale DJ. Learned helplessness in humans: Critique and reformulation. J Abnor Psychol 1978, 87: 49-74. 47. Dalbudak E, Evren C, Aldemir S, Coskun KS, Yıldırım FG, Ugurlu H. Alexithymia and personality in relation to social anxiety among university students. Psychiatry Res 2013;209:167-172 48. Xu Y, Schneier F, Heimberg RG, Princisvalle K, Liebowitz MR, Wang S, Blanco C. Gender differences in social anxiety disorder: Results from the national epidemiologic sample on alcohol and related conditions. J Anxiety Disord 2012; 26:12-19.

Isr J Psychiatry Relat Sci - Vol. 52 - No 2 (2015)

Yuval Shorer et al.

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook Yuval Shorer, MD,1 Aya Biderman, MD,2 Stanley Rabin, PhD,1 Aharon Karni, MD,3 Ayelet Levi, MD,2 and Andre Matalon, MD4 1

Soroka University Medical Center, Psychiatric Department, and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel 2 Clalit Health Service, Southern District, Beer Sheba, and the Family Medicine Department, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel. 3 Clalit Health Services, Jerusalem District, Israel 4 Clalit Health Services, Dan-Petach Tikva District and the Family Medicine Department, Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel

Abstract Objectives: The objective of this study was to highlight and assess the important topic of the voluntary departure of the physician from his/her clinic. We used the topic of the voluntary departure of a family physician from the clinic as an example. The physician’s leaving challenges the personal credo regarding the continuity of care, which is a basic concept in Family Medicine, and other professions, too: Psychiatrists are also devoted to long-term doctor-patient care. Leaving a place of work is a significant life event that can be accompanied by stress and even a crisis for the doctor, patients, and staff. Methods: In this article, we will present four stories, of four family physicians who voluntarily left their practices, written from a reflective point of view, either before or after the actual departure. The stories will be analyzed in a qualitative way, and the central themes and narratives will be defined. Results: The personal departure stories revealed important personal and systemic themes that emerge from and influence the departure process. Among the themes were: practical and emotional work circumstances; leaving as a grief process; and reactions of patients, staff, and management. Conclusion: Qualitative analysis revealed that the voluntary departure of the family physician has complex personal and systemic implications. Practical implications: The combination of Balint group discussions and written reflections can help the physician better cope with the departure and also help patients and staff deal with the separation process.

Introduction Separations are an unavoidable fact of life. The personal and family cycle of life comprises a series of separations and changes. Some separations are anticipated in advance and others are sudden and unforeseen. Either a one-way “cutoff” separation or a separation process that is conscious and mutually forged is a universal human dilemma. A one-way cutoff is described by Bowen (1) as a rift that occurs between one person and the rest of the family because of a difficulty in separating normally from the family. According to Erikson’s psychosocial stages of development (2), a person’s life is described as a series of anticipated goals, whose attainment involves the person’s coping with conflicts vis-à-vis the social network. For instance, moving from one workplace to another may be expressed in conflicts between daring to leave a protected and a secure workplace and, on the other hand, stagnation and inactivity because of the fear of change. During the process of professional transfer, the need to safeguard one’s privacy might conflict with the ability to intimately confide in colleagues about the uncertainty of separation. Levinson et al. in their book Seasons of a Man’s Life (3) describe the stages of the cycle of life of a mature man as being shaped mainly by the social, physical world, with work and family at its center. These expected and normal stages, which include both periods of stability and periods of change, might also result in taking the initiative to make a change in work/workplace. Holmes and Rahe (4) created a scale whereby they graded various life events and their impact on the danger of developing illness - either mental or physical. Being dismissed

Address for Correspondence: Yuval Shorer, MD, Psychiatric Department, Soroka Medical Center, Clalit Health Services, and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba 8110101,POB 151, Israel yuvalshorer@gmail.com

137

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook

and leaving a workplace are quite high on the scale, 47 and 45, on a scale of 0-100 (with 100 as most stressful). They contend that every life event, whether it is desirable or not, can cause stress. Even a desired separation, such as a promotion in work, can be accompanied by stress and even a crisis situation, and therefore must be addressed. Coping with the departure of a caregiver from his patient is an important topic in the work of mentalhealth professionals related to their coping with the end of psychotherapeutic care. In family practice, the main issue of separation of a physician from his patient is due to illness or death. In our view, there is not enough awareness among doctors of the implications of the separation process when they voluntarily leave their position of work. A survey of physicians conducted in England between 1991–2001 found a 33% increase in the number of doctors planning to resign from direct care of patients (5). In another survey done in 2002 among 1,939 family physicians or general practitioners in the U.S.A., it was found that 27% forecast a clear chance of leaving their work in a span of two years from the time of the survey (6). Family practitioners, more than other doctors, are entrusted with continuity of care (7, 8) as well as integrative care: the care of patients belonging to a system of family, work and social environment. Some family practitioners chose this specialty because of the subconscious fantasy of the so-called constant availability of the doctor to his patient. These aspects can, in our opinion, give rise to a difficulty in separating from patients when the physician voluntarily leaves his clinic. While it is important to note that articles and personal stories have been described in the literature about physicians retiring from work (9-11), little has been published about the voluntary leaving of physicians from work. The physician must be aware of the fact that the difficulties created by his voluntary leaving may cause a parallel process in his patients and their families, as well as for other staff members and partners in his workplace. In the analysis of the contents of letters from patients to their doctors who were retiring (12), it was found that patients responded in an emotional way to the separation process from their doctor whom they described as a “friend,” as a “family friend,” who “cares,” or was “always available.” Phillips and Green (13), two family doctors, described their community’s reflections about their colleague physician, the “personal doctor” in the community, who leaves his community and his patients (and their shared practice) after 33 years, because of cancer. The authors, the remaining partners, conclude 138

by asking: “when we go, we know there will be friends, patients and stories to celebrate. We wonder: when those pictures are chosen to show us at our best, what will we be holding on to?” Denning (14) wrote about “doctors suddenly leaving the practice” from the business-systems’ perspective. Here, the following questions may arise: What were the reasons for leaving? How should the managers respond? Who will replace him? Do we need to replace him? Will the next physician be a new recruit, fresh from training or someone from the community? He concludes by stating from the business’ viewpoint: “We all hope that key physicians never leave, but when they do, even when it’s without warning, don’t let the upset of the moment cloud your judgment.” Materials and Methods In order to demonstrate the complexity of separation of physicians, we present four stories of family physicians voluntarily leaving their clinics, and then analyze the significant subjects, the emotional process, and the systemic overall aspects of their leaving. In our presentation, these separation stories were discussed in Balint groups and some of them were written as personal reflective stories. The stories were qualitatively analyzed and themes and central subjects that arose through the stories were defined. Through them, we attempt to define the central problems that should be brought to the awareness of the physician and the system about the separation process. Story A

A recess in the first stages of professional specialization, along with an expanding of the family nest - a chance for retrospection (female, 37, 10 years medical experience). I left kibbutz infirmaries, and family clinics, which are characterized by the personal interconnections between the staff and the patients. I worked for three years in three clinics like this; in one of them I was part of the staff that established it. During this period of work, there was much coping and emotional and professional stress which arose from the work itself, from the involvement in the small communities and from the personal challenge I faced in connecting my own family life (at the stage of increasing the family nest) in a demanding job. I was very happy when the opportunity presented itself for me to take a family trip away from my country for two years due to an offer of work abroad accepted by my life partner.

Yuval Shorer et al.

Truthfully, I nearly “skipped” the separation process. I was totally immersed in my work, concentrating on the work itself. I notified my superiors and the staff of nurses in each clinic of my impending departure. But aside from that I didn’t plan and didn’t touch on the subject from any angle. From my standpoint, the best coping method for those remaining months before leaving was to “work as if there is no tomorrow.” Then I attended a Balint meeting of fellow physicians, which, from my point of view, was a dramatic turning point. The meeting took place about a month before my planned departure. In the Balint group, I talked about my coping with the continued care of a family in my practice who had just lost a son. From the story that I related, the group moderators honed the subject of the emotional connection with the family as possibly being connected to my own separation from the clinic. At first I did not think that I needed any emotional processing for my impending separation, since the stopping of work was for a happy reason, and was desired. During the course of the process of change I discovered that the human connection that was established with the patients and staff during my work was very significant and precious to me, and it was not easy to separate from all of this. I defined for myself that it was important for me to separate and summarize my leaving for the staff, “to change shifts” in an orderly way with the physician who was going to replace me. I also realized that in some way it was important to separate from the patients as well, or at least some of them, in a way that would provide a solution for me to separate from my relationship with them and plan for the future. As a first step I wrote a letter which I asked to be published in the weekly news bulletin of the kibbutz - and a slightly different letter for each clinic. Most of the patients were surprised at first, some expressed disappointment, and some even felt hurt at my initiating a one-way decision to end the connection between us. Many expressed fears relating to the future of the clinic and the doctor who would replace me. It is worthwhile noting that there were a number of patients who were happy for me and expressed interest in my personal plans and those of my family, and wished me success. At the same time, I met with the physician designated to replace me and we carried out a general briefing about the clinics. In each clinic, I decided, together with the nurses, which patients it would be important for me to invite for a farewell chat and summary. I became aware that each nurse, each patient, and each community clinic has its own personal style of separating and its own particular

needs in ending a connection. One of the kibbutzim held a number of “farewell events”; in another the farewell was more personal, and in the third, the women of the kibbutz gathered in the clinic, for a thank-you meeting. Story B

Separation in a stage of personal, professional and social assimilation – the price of advancement and pangs of separation (male, 57, 25 years medical experience). I have been a specialist in family medicine for the last 25 years, during which time I have been transferred to several different clinics. My last separation from patients was eight years ago, when I left a position as a family practitioner in a moshav (a rural settlement in Israel) to head the Department of Family Medicine. I worked in the moshav for seven years with a very poor population, whose health and life habits were dictated by a culture and tradition very far removed from the Western culture in which I grew up. This work satisfied my curiosity to learn about new and different cultures, to become flexible and to relax my Western standpoint, and gave me great satisfaction and a very special feeling. I was of the opinion that only a senior doctor, who knows himself and has vast professional experience, can cope with a population such as this one, and address their needs. Because I myself was an immigrant, having moved from one culture to another, the self-confidence I acquired in personal psychoanalysis and my prior experience in connections with patients, and perhaps also because of the length of my professional experience, I felt a feeling of control in my ability to handle things that I had not felt in previous positions. The termination of my work at the moshav was planned because I was promoted in my work ,and I was also privileged to have an expert in family medicine replace me in the clinic, a fact which without a doubt contributed to my ability to separate and feel less of a “traitor” to the people I had cared for over a period of many years. The doctor sat with me for two weeks and the community was invited, via a personal letter, to come and take leave of me and to receive the new doctor. In the letter, I described my valuable work in the community and the sadness that I felt in leaving the clinic. While the presence of the replacing doctor in the room often disrupted the feeling of intimacy from previous visits, it did not prevent patients from expressing their appreciation of me and their sorrow at my leaving. Only a few did not come to say goodbye. Some brought gifts, others sent me letters, and some presented me with poems which they wrote. Some sent me wine which they themselves made. Without a doubt they missed me, as I 139

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook

missed them. I also discussed my feelings in my regular Balint group. Despite the transfer to a position which is considered a step up on the social-professional ladder and despite the feeling of release from the emotional burden of working in such a demanding environment, the day after I finished working there I began to feel a sense of emptiness and loss. In my work with these patients I had a continued sense of doing a “good deed.” I always felt needed and alert, despite a few moments of friction, of frustration and pain. Work in a poor community fulfilled in me a socialist wish for a more equal society, and a better one. This is the place where I was really needed and the place that gave me a sense that I understood their culture and my place, a place that gave me the sense of being chosen to do my work, which gave me much fulfillment. Looking back, today I am thankful to my patients and the nurses I intimately worked with, together aiming at a mutual significant goal. I am thankful too for the opportunity given to me to grow and develop, to remember, to hurt and to feel pride and happiness. Story C

Leaving a management position from a stage of acceptance, and returning to patients (female, 57, 30 years medical experience). I began working in a teaching clinic for interns, medical and nursing students, as an expert in family medicine, and I was the director of the clinic for 25 years. In recent years, I felt that the demands of the management had increased, without providing sufficient support. Half a year ago, I reached the conclusion that it was time to extricate myself from this position and to return to being a “regular” doctor. From the management’s standpoint, the necessary steps were taken to find me a replacement, and I was offered a position in a different clinic in a new neighborhood. Leaving the clinic involved separating from the staff, my colleagues, the doctors, and my many patients, many of whom I had “raised” since their infancy. The staff often expressed their warm feelings towards me, feeling that I was in many ways a “mother figure” for them, and therefore was very saddened by my proposed departure. About six weeks before my departure, I asked the management to send a personal letter to my patients, in my name. The letter was sent out by the marketing department, and thus it soon became clear to me that the institutional motives did not coincide with the personal separation process, as I saw it. 140

The timing of the letter was very important - the letter arrived about two weeks before I left, and the reactions were, for the most part of astonishment “Why you?” and “Why now?”, “Don’t you want to care for us anymore?” My response was very clear “I’m tired of managing…” I asked the management for two weeks of training time with the new doctor, to transfer the tasks to him and for him to get to know the patients. I studied the list of my patients, and together with the nurse, we decided which patients to invite for a visit, which patients to speak to on the phone, and which patients we thought would be satisfied only to receive the letter sent to them. Together with the new physician, we conducted house calls to most of the home-bound patients. These visits were for the most part emotional; I received gifts, emotional letters, plants and flowers. Some of my patients chose to move with me to the new clinic. I have now been working for a few months in the new clinic. The tremendous burden of managing the clinic has been lifted from me; I feel great relief, as well as physical and emotional well-being. The new clinic has absorbed new patients and families. The experience of receiving a new patient again had been unfamiliar to me, for a long time. To “begin at the beginning” is an interesting and challenging experience. After many years of treating the same patient population, this is a refreshing change. Separating from the staff was also laden with emotion: friends from the past were invited to the farewell ceremony, many expressed their feelings by wishes, poems and music. A video presentation was presented, a beautiful album was prepared, a picture for my wall in my new clinic was given, and not a few tears were shed! I felt that I accomplished the separation well, from the standpoint of the staff, from standpoint of the patients and from my own standpoint. Story D

Leaving a clinic for refreshment and preventing exhaustion, and its impact on a special caring connection (male, 62, 36 years medical experience). For 20 years I had worked in a rural clinic, with much satisfaction. However, recently the enjoyment from work lessened, influenced by changes in the clinic and conflicts with management. I wanted a new start, and when an opportunity presented itself, I chose to pursue it. I advertised my date of departure and began conducting farewell meetings with my patients, some of them planned and some spontaneous. There were some patients

Yuval Shorer et al.

who didn’t react to the departure, and there were those who transferred to another physician, as if by coincidence. However, I realized that for some of them I had become much more significant than I had intended, significant to the point of dependence. One of these was M., whom I had treated for her illnesses and their complications. The connection between us deepened even more as a result of the care I gave to her daughter and her two parents, one after the other, for serious illnesses which eventually led to their deaths. M. heard about my impending departure accidentally, and immediately phoned me, expressing hurt and disbelief. As a result we met a few times. M. did not allow time during these meetings for a discussion about the impending separation. She refused to accept it. Our connection was strong and I was irreplaceable for her and, as she said, she would not survive without me. She thought even of moving close to my new clinic either by selling her house or moving close to me in order to become a patient at the new clinic where I was going to be working, a very unrealistic idea in her situation. In addition M. wrote letters to the management of the HMO asking them to convince me to remain. M. was dear to me as a patient and as a person but it was difficult to cope with this dependency which had developed because of these special circumstances, and to which I had unwittingly contributed. I raised the difficulties of the separation in a Balint group. The group raised associations and emotions so that I was able to realize my need to change and therefore separate from M. and even to strive to get her good wishes for my impending success. As a result of the meeting in the group and after sharing feelings via e-mail with partners in the group, I wrote a letter to M., in which I described our relationship and how I saw the entire process. I described how I found her house when I first came to meet her daughter who was sick with cancer. I described the entire difficult process of caring for her daughter, until she asked for my support at the end of her loved one’s young life. I wrote about her parents’ home and the connection between us during the final years of their lives. I described to her how special her family was to me, and the care I provided for them all. I related to the process that she was undergoing and the difficulties she faced in order to provide quality of life to her loved ones and the death that they sought. I wrote about our mutual partnership in this. At our next meeting I read her the letter. This time too

she reacted with an unwillingness to accept my decision. After I left, M. and I met a few more times and talked on the telephone. I did not hear any change in her willingness to separate from me by her words, but essentially, our telephone connection began to fade more and more. Two years after my departure, the conversations between us became very sporadic and infrequent, and centered on her daughter’s and granddaughter’s health. Now, with time and distance between us, I understand how significant the connection with M. was for me but also how threatening it became. In the Balint group I had the opportunity not only to work through the separation process and to plan it for the good of the patient, but also to formulate for myself a new contract of connection for my new professional chapter, which will probably be the last one before retirement. Results Analysis of the Themes and Narratives:

1. Background of the work, the clinic, and description of the patient population: All of the authors began their stories with a description of their workplace and the patients they cared for, as a place of professional learning. Here we see the expression of a family practitioner as someone who is involved in the life of the community and in the lives of his/her patients and their families, over a long period of time. The stories described clinics - rural, kibbutz and city - at higher or lower socioeconomic levels, and also the general characteristics of each clinic. The doctors primarily described the clinic as a “professional home” in which they created something new for themselves, both from a professional and from a personal viewpoint: “this work satisfied my curiosity to learn new cultures” or “a sense of being chosen to do my work,” or: “separation from staff, colleagues and patients I had ‘raised’ since their infancy.” They underwent a sort of cultural immersion in a new land as immigrants: “because I myself was an immigrant … I felt control in my ability to handle things,” or a first experience in combining, family and work in my life: “involvement in the small communities and the personal challenge in connecting my own family life in a demanding job.” Two of the stories (A, B) took place quite early on in the professional career of the physician and the two others (C, D) further along in the doctors’ careers. Stories A, D were written during the separation process and stories B, C were written from a later perspective, after the separation. 141

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook

2. Motives for leaving: Motives can be varied: family needs during the personal life cycle, burnout and professional development. According to the stories, it appears that the motive of career development or the motive of a family need were experienced as less ambivalent, and, as a result, were less conflicting for the leaving physician. This was expressed in story C by the doctor’s expectation of more considerate support by the organization’s management, for example, in sending a farewell letter in advance to facilitate a more appropriate separation process: “I asked the management to send a personal letter to my patients in my name ... the letter was sent out by the marketing department…. It soon became clear to me that the institutional motives did not coincide with the personal separation as I saw it.” 3. Emotions of physicians before and after their leaving: The doctors showed ambivalent feelings. On the one hand, they experienced release from emotional and physical burdens, from professional exhaustion: “Recently the enjoyment from work lessened…. I wanted a new start” or “I felt that the demands of the management increased without providing sufficient support…it was time to extricate myself ” … “or happiness at being promoted or a family experience like a prolonged trip abroad”: “there was much emotional and professional stress ….I was happy when the opportunity presented to take a family trip for two years.” On the other hand, some expressed feelings of denial and “doing instead of feeling”: “I nearly skipped the separation process … I was immersed in work.… I worked as if there is no tomorrow.” Emotions described after the leaving included emptiness and sadness: “I began to feel a sense of emptiness and loss” or feeling of relief: “I feel great relief as well as physical and emotional well-being.” The physician separated from patients and families that he had accompanied for many years in health, crises and death, and also in various life events: “leaving the clinic involved separating from … patients, many of whom I had ‘raised’ since their infancy.” In story A, the leaving of the doctor coincided with a tragic event in a family she was treating. This led the doctor to discover and confront her own difficulties in the separation. The feelings that accompanied the separation resembled the feelings accompanying a process of grief as described by Kubler-Ross (15). Coping was accompanied by feelings of sadness, anger, bargaining and negotiation, and acceptance and making inner peace. Some of the physicians expressed 142

their grief for the lost world of the clinic they left: “M. was dear to me … it was difficult to cope with this dependency because of these special circumstances … now with time and distance I understand how significant the connection was … but also how threatening it became.” 4. Separation from staff and management: Involving and updating the management about a voluntary departure, and a request to find a different position left the physician feeling that there was a gap between the perception of the managerial response to her leaving and the expectations of the physician in the leaving process: “from the management standpoint, the necessary steps were to find me a replacement” or: “I asked the management to send a personal letter in my name … the letter was sent by the marketing department … the institutional motives didn’t coincide with the personal process.” Involvement of the replacement physician in the separation process helped to serve as a “shock absorber” for the physician himself as well as for his patients: “an expert in family medicine replaced me … contributed to my ability to separate and feel less of a traitor.” But despite that, in the background remained the question, “Will the new doctor succeed in adequately filling my place with the patients? … his presence in the room disrupted the feeling of intimacy from previous visits.” To some of the staff members, it was difficult to separate, and they expressed ambivalent emotions; some of them tried to prevent the departure, but when they understood the reasons for it, the separation was made easier. Participation of the staff in the conversations with the patients was important. 5. Separation from the point of view of patients and families: Ambivalence was expressed in the emotional and actual reactions of the patients. Some patients were happy for the doctor’s decision and wrote farewell letters or brought presents. Others wondered about the motives for leaving and others expressed feelings of sadness and anger and protest. In story D, the anger and denial were similar to the recurrence of a grief reaction in the family with which the doctor was involved in the past. There were also expressions of denial and indifference: “some didn’t react and some asked to be transferred to another doctor as if by coincidence.” The physician also noticed the differences in types of farewell ceremonies in various communities: some were more public, others more personal. 6. The leaving process reflection as a “life review” (16): The stories described in our cases represent a sort of professional life review, and the separation offers the physician an

Yuval Shorer et al.

opportunity to reflect, examine and evaluate a significant period in his/her professional life: “work in poor community fulfilled in me a socialist wish for a more equal society…. This is a place where I was really needed … a place that gave me the sense of being chosen … which gave me much fulfillment” or “the experience of receiving new patients again which was unfamiliar to me, to ‘begin at the beginning’ is a challenging experience … a refreshing change” or “ now with time and distance … and in my Balint group I was able to formulate for myself a new contract of connection for my new professional chapter in my life, which will be the last one before retirement.” Discussion Although this article describes stories of family physicians, it might relate to the voluntary departure from a place of work by any physician or other caregiver. The article presented and highlighted the complex process of family physicians voluntarily leaving their clinics. Smith et al. (17) wrote about using role-playing exercises and physicians’ scripts to teach termination skills for residency training in family practice. In their evaluation of the teaching methods, they found that the residents value termination instructions, prefer participative approaches, and report greater sensitivity to the feelings and issues evoked by termination. Reflective writing and the development of reflective abilities were found to be essential for professional competency. Reflective writing helps to promote feedback in the physician’s training, improve the accuracy of diagnosis, create empathy and enrich the quality of life for the doctor (18). We chose to highlight the issue of the voluntary departure from work, through reflective writing and Balint group reflections. The separation takes place in the context of an individual within his professional establishment - his staff and management system. Analogies that arose from the personal stories heightened the parallel process of separation that takes place in a family (19). A family member who separates from the family structure expects that they will send him graciously “from the nest” and give him their blessing. When a physician leaves his work, sometimes because of conflicting emotions or lack of awareness of the management system, he expects a positive expression of goodbye from the management. But since leaving sometimes involves conflict, this happy goodbye is not always possible. In our cases, neither the needs of the physician

nor those of his patients and staff are met due to lack of proper tools -such as time to organize, or the opportunity to write farewell letters in a way that will transform the separation into a more conscious and thought-out process for the patients and the physician. The emotional and practical aspects of voluntary departure are similar in part to a grief process and involve the physician, patients and their families, staff and management. The process also depends on the degree of ambivalence about the reason for leaving. Those at the managerial level should also be aware of the complexity of the process for the benefit of the patients and families. It must be remembered that in addition to the leaving and the crisis that accompanies many cases, this is also an opportunity to develop personally and professionally. Wald and Reis (18) contend that there is a need to evaluate the effectiveness of reflective writing at various stages of the professional cycle of a family physician. Our paper illustrates the importance of reflection as an emotional and practical tool in dealing with the leaving process. This was described previously by Smith et al. (17), and the sharing of the leaving process in Balint groups was described by Shorer et al. (20). Writing “farewell letters” from the caregiver to the patient, as a part of a therapeutic process, was originally suggested by White and Epston (21), pioneers of the narrative therapy approach. It should be pointed out that in case D, it was shown that reflective participation in a Balint group led to reflective writing afterward. Matalon and Rabin in their book Behind the Consultation (22) demonstrated correspondence between two clinicians, a family physician, and a clinical psychologist. Formulating a letter and writing a story to be read by another person is often a very helpful process for the writer. Doctors and psychotherapists often need a person, or a group meeting like a Balint group, to whom they can talk spontaneously about what happened with a patient, while they are still preoccupied with that story. When writing a story-asletter, we usually try to relate experiences, thoughts, emotions and fears clearly, in a comprehensible manner. Every story has its order of subjects and content, an internal coherence. This does not always follow common logic, and often develops according to a private, subjective logic. “It is not good that man should be alone” (Gen. 2, 18) - the need for a mate was clear even in the Garden of Eden, and is doubly clear here on Earth, where family physicians and psychotherapists work very much alone, coping with their often painful emotions and compassion fatigue. This reflective sharing can be seen as another 143

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook

tool for doctors facing similar situations, helping them discover creativity and enthusiasm in their work and preventing burnout (23). References 1. Bowen M. Family therapy in clinical practice. New York: Jason Aronson, 1978. 2. Erikson E. Childhood and society (2nd ed). New York: W. W. Norton, 1963. 3. Levinson D J, Darrow C N, Klein E B. Seasons of a manâ&#x20AC;&#x2122;s life. New York: Random House, 1978. 4. Holmes T, Rahe R. The social readjustment rating scale. J Psychosom Res 1967; 11: 213-218. 5. Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. Brit Med J 2003; 326:22. 6. Pathman D E, Konrad T R ,Williams E S, Scheckler W E, Linzer M, Douglas J . Physician job satisfaction, dissatisfaction and turnover. J Fam Pract 2002; 51: 593. 7. Stokes T, Tarrant C, Mainous I A G, Schers H, Freeman G, Baker R. Continuity of care: Is the personal doctor still important? A survey of general practitioners and family physicians in England and Wales, the United States and the Netherlands. Ann Fam Med 2005; 3: 353-359. 8. Saultz J W, Albedaiwi W. Inter personal continuity of care and patient satisfaction: A critical review. Ann Fam Med 2004; 2:445-451. 9. Pereira A G, Kleinman K P, Pearson S D. Leaving the practice: Effects of primary care physician departure on patient care. Arch Int Med 2003; 163:2733-2736. 10. Weisman A. The physician in retirement: Transition and opportunity.

144

Psychiatry 1996; 59: 298-307 11. Grossman E R. Withdrawing from practice. The Lancet 1992; 340: 776-777. 12. Merenstein B, Merenstein J. Patient reflections: Saying good bye to a retiring family doctor. J Am Board Fam Med 2008; 21: 461-465. 13. Phillips WR, Green LA. A public celebration of a personal doctor. Ann Fam Med 2010;8:362-365. 14. Denning J J. When a doctor suddenly leaves the practice. Business of Medicine, 6. 2013; http://www.medscape.com/viewarticle/804919_2. 15. Kubler-Ross E. On death and dying. New York: Macmillan, 1969. 16. Butler R. The life review: An interpretation of reminiscence in the aged. Psychiatry 1963; 26: 65-76. 17. Smith M F, Nathan R G, Mitnick N C. Prescriptions for saying goodbye: Teaching termination to family practice residents. Fam Med 1991; 23:469-470. 18. Wald HS, Reis SP. Beyond the margins: Reflective writing and development of reflective capacity in medical education. J Gen Intern Med 2010; 25:746-749. 19. Carter B, McGoldrick M. The changing family life cycle: A framework for family therapy. Boston: Allyn and Bacon, 2nd ed., 1989: pp. 3-25. 20. Shorer Y, Biderman A, Levy A, Rabin S, Karni A, Maoz B, Matalon A. Family physicians leaving their clinic--the Balint group as an opportunity to say good-bye. Ann Fam Med 201;9: 549-551. 21. White M, Epston D. Narrative means to therapeutic ends. New York: Norton, 1990. 22. Matalon A, Rabin S. Behind the consultation â&#x20AC;&#x201C; reflective stories from clinical practice. UK: Radcliffe, 2007. 23. Rabin S, Maoz B, Shorer Y, Matalon A. Rekindling the spirit: Creativity, passion and the prevention of burnout in the medical profession. Tel Aviv: Ramot ed., Tel Aviv University, Israel (in Hebrew).

Book Reviews

ADHD in Adults Craig B.H. Surman, editor Springer, New York: Humana Press ISBN 978-1-62703-248-3 (eBook)

“

This volume is the collective work of professionals specializing in ADHD,” starts the editor of this important work in his introduction. Indeed this is reflected in the clinical and research wisdom demonstrated by the authors of the various chapters. The book is composed of 11 chapters followed by an extensive appendix rich in items for clinicians or items that may be given to clients. The first four chapters focus on assessment and treatment planning for adults with ADHD. Chapters 5 and 6 detail the pharmacological treatment with stimulant and non-stimulant drugs available. Chapter 7 is of immense importance focusing on psychosocial treatment. The chapter focusing on psychosocial treatment is accompanied by a demonstrative case report that makes it lively and instructive. These chapters focusing on treatment are extensive, detailing clinical use as well as indications, recommendations for specific sub-populations and the management of side effects. Switching strategies are described as well as the rationale for the use of non-stimulants. The closing four chapters each tackles a specialized subgroup of clients of services such as those suffering from comorbidities and ADHD in families. Each chapter is followed by an extensive reference list. This is a useful guide for the diagnosis and treatment of ADHD in adults. The book is clearly written for the clinician who has a firm grounding in adult psychiatry. Those of us who treat adults with ADHD will enjoy the insights and clinical acumen offered by the authors of the various chapters. The volume reads as a collection of articles and although it may “feel” strange to some readers it allows focusing on one or two chapters of interest. I recommend this volume as a primer for psy-

chiatrists and neurologists interested in working with adult ADHD. Yoram Barak, Bat Yam

Prevention and Management of Violence Guidance for Mental Healthcare Professionals M. Khwaja & D. Beer RCPsych Publications ISBN 978-1-908020-95-6 Price: £20

his slim and elegant soft cover book is misleading. I started out by feeling “what can they teach me? I have seen it all…” It is a treasure and a book every psychiatrist needs on his desk or in the ward. Every chapter is well thought out and every recommendation well-grounded in evidence and clinical lore. There are 13 chapters, an appendix (organizations that victims of crime can contact) and an index contained in 127 pages. Legislation, Safeguarding vulnerable individuals, Post-incident management and Liaison with the police are described side by side with Risk assessment, Use of medication and ECT as well as Clinical governance. These chapters are complemented by chapters focusing on specific populations and settings such as older adults, prison inmates and more. The chapters are brief, precise and insightful. Each is complemented by a short list of relevant references. The book is an easy read and can easily be put into a “powerpoint” presentation format for use in teaching medical and para-medical staff. The book is highly indorsed with the only reservation being that some of the data and recommendations are “country specific.” It is of note that this guidance is official policy recommended by the Royal College of Psychiatrists. Yoram Barak, Bat Yam

145

‫הטיפול בתרופות על יובש הפה (לפי סקלת ‪.)Drymouth.info‬‬ ‫בקבוצת ‪ SMI‬נמצאה רמת עששת לא מטופלת ממוצעת של‬ ‫‪ 0.91‬שיניים לעומת ‪ 0.13‬שיניים בקבוצת התחלואה הקלה‪/‬‬ ‫בינונית (‪ .)p=0.033‬נמצא כי השפעת הטיפול בתרופות על יובש‬ ‫הפה הייתה גבוהה פי ‪ 3‬בקבוצת ‪ SMI‬לעומת קבוצת התחלואה‬ ‫הקלה‪/‬בינונית (‪ .)p<0.001‬נמצאה מגמה המצביעה על קשר בין‬ ‫חומרת התחלואה הפסיכיאטרית לבין התחלואה הדנטלית‪.‬‬ ‫למרות כמה מגבלות במתודולוגיה של המחקר‪ ,‬שתוארו במאמר‪,‬‬ ‫אפשר להסיק כי יש להעלות את מודעות המטפלים והמטופלים‬ ‫לאפשרויות שמציע חוק שיקום נכי נפש בקהילה בהקשר של‬ ‫קידום בריאות הפה והשיניים באוכלוסייה זו‪.‬‬ ‫תיקוף של סולם ‪ 20-HCR‬להערכת הסיכון להתנהגות‬ ‫אלימה בקרב מאושפזים פסיכיאטריים בישראל‬

‫ד‪ .‬איבגי ‪ ,‬א‪ .‬באואר‪ ,‬ר‪ .‬חואלד‪ ,‬פ‪ .‬רושקה‪ ,‬מ‪ .‬וייס וא‪.‬מ‪.‬‬ ‫פוניזובסקי‪ ,‬ירושלים‬

‫רקע‪ :‬הערכה של הסיכון להתנהגות אלימה בפרקטיקה של פסיכיאטריה‬ ‫משפטית היא משימה מסובכת המחייבת אחריות‪ ,‬והשימוש בכלי‬ ‫מהימן יכול להפוך את עבודתו של המומחה ליעילה יותר‪.‬‬ ‫ה–‪ 20-HCR‬התקבל באופן רחב ככלי מדיד של הסיכון‬ ‫להתנהגות אלימה‪ ,‬מינית ופלילית‪ .‬מטרת מחקר זה היא לתקף‬ ‫את ה–‪ 20-HCR‬במערכות אשפוז פסיכיאטרי בישראל‪.‬‬ ‫שיטות‪ :‬איסוף פרוספקטיבי של נתונים של ‪ 150‬מטופלים‬ ‫ממין זכר בני ‪ 65-15‬אשר אובחנו באמצעות ‪ ICD 10‬כחולים‬ ‫בסכיזופרניה ואשר מאושפזים בשלוש מחלקות שונות‪:‬‬ ‫מחלקה פסיכיאטרית חריפה (‪ 50‬משתתפים)‪ ,‬מחלקה‬ ‫פסיכיאטרית עם ביטחון מרבי (גבוה) (‪ 50‬משתתפים) ומחלקה‬ ‫פתוחה (‪ 50‬משתתפים)‪ .‬ה–‪ 20-HCR‬ככלי מנבא וה–‪ PANSS‬ככלי‬ ‫מקביל נבדקו בתחילה בבדיקת בסיס‪ ,‬וה–‪ VAS‬נבדק בעת המעקב‬ ‫אחרי חולים אלו לאחר ‪ 6‬חודשים ולאחר ‪ 18‬חודשים‪.‬‬ ‫תוצאות‪ :‬המהימנות הפנימית הייתה טובה עבור ‪20-HCR‬‬ ‫בכללותה‪ ,‬מספקת עבור ‪( H‬היסטורי)‪ ,‬אך נמוכה עבור תת‬ ‫הסולמות ‪( C‬קליני) ו–‪( R‬הערכה)‪.‬‬ ‫התקפות התחרותית הייתה טובה עבור תת סקלה ‪ C‬ותקפות‬ ‫הבידול הייתה סבירה עבור תת הסולמות ‪ C‬ו–‪ .H‬הסולם הכולל‪,‬‬ ‫כמו זה ההיסטורי והקליני‪ ,‬ניבא את הסיכון להתנהגות תוקפנית‪/‬‬ ‫מינית בתקופת המעקב‪ ,‬לאחר ‪ 6‬חודשים ו–‪ 18‬חודשים‪.‬‬ ‫מסקנות‪ :‬תכונות ה–‪ HCR-20‬יכולות לשמש ככלי יעיל‬ ‫למדידת הסיכון להתנהגות תוקפנית במערכות פסיכיאטריה‬ ‫בישראל‪ .‬מחקר נוסף נחוץ לאישור נקודות החיתוך של‬ ‫ההתנהגות האלימה תוך כדי שימוש במדגם גדול יותר של חולים‪.‬‬

‫אנשים אחרים‪ .‬נראה שמחשבות אוטומטיות גורמות להפרעה‬ ‫או משמרות אותה‪ ,‬ולכן יש הצדקה לבחון את המידה שבה הן‬ ‫משפיעות על הפרעה זו‪.‬‬ ‫שיטה‪ 30 :‬נבדקים שאובחנו כלוקים בהפרעת חרדה חברתית‬ ‫על פי ריאיון ‪( MINI‬קבוצת הניסוי) ו–‪ 30‬נבדקים בריאים‬ ‫(קבוצת הביקורת) מילאו כמה שאלונים‪ :‬סולם ליבוביץ לחרדה‬ ‫חברתית‪ ,‬שאלון המחשבות האוטומטיות‪ ,‬סולם שיהאן לפגימה‬ ‫ושאלון בק להערכת דיכאון‪ .‬שוער כי נבדקי קבוצת הניסוי יביעו‬ ‫במידה רבה יותר תחושת דיכאון‪ ,‬פגימה ומחשבות אוטומטיות‬ ‫שליליות‪ ,‬ויביעו פחות מחשבות אוטומטיות חיוביות בהשוואה‬ ‫לנבדקים מקבוצת הביקורת‪ .‬מכאן שהמחשבות האוטומטיות‬ ‫ינבאו את החומרה של הפרעת החרדה החברתית‪.‬‬ ‫תוצאות‪ :‬בקרב נבדקי קבוצת הניסוי נמצאו ציונים גבוהים‬ ‫בשאלון הדיכאון‪ ,‬בסולם הפגימה ובשאלון המחשבות‬ ‫האוטומטיות השליליות וציון נמוך בשאלון המחשבות‬ ‫האוטומטיות החיוביות‪ .‬הציונים בתת הסולמות של סולם‬ ‫ליבוביץ לחרדה חברתית נובאו על ידי הציונים בשאלון‬ ‫המחשבות האוטומטיות החיוביות ובשאלון להערכת דיכאון‪.‬‬ ‫מגבלות‪ :‬מדגם בגודל בינוני ומגבלות של השאלונים שהועברו‬ ‫במחקר‪.‬‬ ‫מסקנות‪ :‬מחשבות אוטומטיות הן תחום חשוב למחקר ויש‬ ‫צורך במדגמים גדולים יותר ובמחקרי המשך כדי לבחון אם חיזוק‬ ‫החשיבה החיובית והקטנת החשיבה השלילית יכולים להפחית‬ ‫תסמינים של הפרעת חרדה חברתית במהלך טיפול קוגניטיבי–‬ ‫התנהגותי‪.‬‬ ‫עזיבה יזומה של רופא המשפחה את‬ ‫המרפאה‪ :‬מבט רפלקטיבי‬

‫י‪ .‬שורר‪ ,‬א‪ .‬בידרמן‪ ,‬ס‪ .‬רבין‪ ,‬א‪ .‬קרני‪ ,‬א‪ .‬לוי וא‪ .‬מטלון‪ ,‬באר שבע‬

‫התמודדות המטפל עם עזיבתו המתוכננת את הטיפול היא נושא‬ ‫חשוב בבריאות הנפש והיא חלק מההתמודדות עם פרידה בסיום‬ ‫הקשר הטיפולי‪ .‬עזיבה מרצון של רופא המשפחה את המרפאה‬ ‫מאתגרת את ה"אני מאמין" המקצועי של הרופא בדבר המשכיות‬ ‫הטיפול‪ .‬חלק מרופאי המשפחה בחרו התמחות זו בשל הפנטזיה‬ ‫הלא תמיד מודעת של זמינות מתמדת של הרופא לטובת החולה‪,‬‬ ‫ולכן עזיבה מרצון של המרפאה יוצרת אצלם קושי‪ .‬במאמר‬ ‫מוצגים ארבעה סיפורי פרידה של רופאי משפחה בשלבים‬ ‫שונים של הקריירה המקצועית‪ .‬סיפורי הפרידה נחקרים מבחינה‬ ‫איכותנית‪ ,‬ומזוהים נרטיבים אישיים ומערכתיים וכן נושאים‬ ‫מרכזיים שעלו מסיפורי הפרידה‪ .‬נוסף על כך מוצגות מסקנות‬ ‫מעשיות הנובעות מהמחקר האיכותני לגבי תהליך עזיבה רצונית‬ ‫של המרפאה‪.‬‬

‫מחשבות אוטומטיות חיוביות ושליליות‬ ‫בהפרעת חרדה חברתית‬

‫י‪ .‬יאנקו‪ ,‬א‪ .‬בודנר‪ ,‬ס‪ .‬ג'ובראן‪ ,‬י‪ .‬לופינסקי וד‪ .‬ברנבוים‪ ,‬יבנה‬

‫רקע תיאורטי‪ :‬הפרעת חרדה חברתית מאופיינת בפחד‬ ‫ובהימנעות ממצבים חברתיים שבהם האדם נחשף לביקורת מצד‬ ‫‪146‬‬

‫שיטה‪ 40 :‬ילדים בגיל הגן (‪ 28‬בנים ו–‪ 12‬בנות) אשר טופלו במרכז‬ ‫לבריאות נפש שלישוני‪ ,‬עברו הערכה בעת הקבלה ולאחר ‪ 5.5‬שנים‬ ‫(‪ 1.2 ±‬שנים)‪.‬‬ ‫תוצאות‪ :‬שבעה מהילדים (‪ )58.3%‬שאובחנו כסובלים מהפרעות‬ ‫מופנמות בגיל הגן לא סבלו מאבחנה פסיכיאטרית כלשהי בזמן‬ ‫המעקב (‪ .)p=0.02‬נבדק אחד בלבד (‪ )8.3%‬מאלו שאובחנו כסובלים‬ ‫משילוב של הפרעות מופנמות והפרעות מוחצנות בגיל הגן לא סבל‬ ‫מהפרעה פסיכיאטרית כלשהי בבדיקת המעקב (‪ .)p=1.0‬שבעה‬ ‫ילדים (‪ )43.7%‬אשר אובחנו כסובלים מהפרעות מוחצנות בגיל הגן‬ ‫לא סבלו מאבחנה פסיכיאטרית כלשהי בבדיקת המעקב (‪.)p=0.02‬‬ ‫מגבלות המחקר‪ :‬גודל המדגם הקטן והיות המחקר נטורליסטי‪.‬‬ ‫מסקנות‪ :‬ההתפתחות של הפרעות פסיכיאטריות חמורות‬ ‫מתקופת גיל הגן ועד לגיל החביון המאוחר וגיל ההתבגרות‬ ‫המוקדם דומה לזו המתוארת בקרב ילדים הסובלים מהפרעות‬ ‫פסיכיאטריות במדגמים בקהילה‪ ,‬אך משתנה בהתאם לאבחנה‬ ‫הניתנת לילד בתקופת גיל הגן‪ .‬אצל ילדים הסובלים מהפרעות‬ ‫מופנמות נראה שיעור החלמה טוב הרבה יותר מזה של ילדים‬ ‫הסובלים משילוב של הפרעות מופנמות ומוחצנות‪.‬‬ ‫היתכנות של תוכנית הערכה והתערבות‬ ‫למתבגרים עם השמנת יתר חולנית‬

‫ס‪ .‬פניג‪ ,‬ע‪ .‬ברונשטיין קלומק‪ ,‬א‪ .‬ששון‪ ,‬א‪ .‬קורץ חליפה וא‪ .‬הדס‪,‬‬ ‫פתח תקווה‬

‫רקע‪ :‬אין כיום קווים מנחים מבוססי ראיות להערכה של‬ ‫מתבגרים המועמדים לניתוח בריאטרי ולשיפור הדבקות שלהם‬ ‫בהמלצות לשינוי הרגלי חיים לפני הניתוח ואחריו‪ .‬לפיכך‬ ‫נבנתה תכנית רב–מקצועית דו–שלבית‪ ,‬הכוללת שלב של הערכה‬ ‫והתערבות לפני הניתוח וכן שלב של מעקב לאחר הניתוח‪.‬‬ ‫שיטות‪ :‬המחקר התמקד בשלב לפני הניתוח‪ ,‬שנמשך שלושה‬ ‫חודשים‪ .‬הנבדקים היו ‪ 15‬מתבגרים ומתבגרות הסובלים‬ ‫מהשמנת יתר חולנית‪ .‬התכנית התקיימה במסגרת מחלקה‬ ‫המתמחה בהפרעות אכילה בבית חולים כללי‪ ,‬וכללה פרוטוקול‬ ‫טיפול רב–מקצועי ומובנה‪ ,‬שבין מרכיביו בדיקות רפואיות‪,‬‬ ‫מדדים פסיכולוגיים‪ ,‬טכניקות ניטור עצמי‪ ,‬דיאטה מותאמת‬ ‫אישית‪ ,‬תכנית פעילות גופנית וטיפול התנהגותי קוגניטיבי פרטני‬ ‫וקבוצתי‪ .‬בד בבד עם הטיפול שקיבלו המתבגרים‪ ,‬עברו הוריהם‬ ‫הדרכה והתערבויות פסיכו–חינוכיות‪.‬‬ ‫תוצאות‪ :‬כל הנבדקים השלימו את השלב שלפני הניתוח‪.‬‬ ‫רובם (‪ )70%‬שמרו על דיאטה מובנית‪ ,‬וחלה ירידה מובהקת ב–‬ ‫‪ BMI‬שלהם‪ .‬הנבדקים ביצעו ניטור עצמי ונמצא שיפור בשביעות‬ ‫הרצון שלהם מגופם‪ .‬השתתפות ההורים בטיפול הייתה מעטה‪.‬‬ ‫ארבעה נבדקים התקשו לדבוק בפרוטוקול הטיפול ובהתאם לכך‬ ‫נמצאו לא מתאימים לניתוח‪.‬‬ ‫מסקנות‪ :‬הממצאים תומכים בכך שפרוטוקול הערכה‬ ‫והתערבות לפני ניתוח למתבגרים המועמדים לניתוח בריאטרי‬ ‫הוא אפשרי‪ .‬נחוצות התערבויות נוספות לשיפור מעורבות‬ ‫ההורים בתהליך ההערכה וההכנה לניתוח‪.‬‬ ‫‪147‬‬

‫בריאות השיניים וסוג הטיפול האנטי־פסיכוטי‪:‬‬ ‫מחקר בקרב חולי סכיזופרניה מאושפזים‬

‫א‪ .‬גרינשפון‪ ,‬ש‪.‬פ‪ .‬זוסמן‪ ,‬א‪ .‬ויצמן וא‪.‬מ‪ .‬פוניזובסקי‪ ,‬ירושלים‬

‫מטרות‪ :‬מחקר זה בדק את הקשר בין מצב השיניים של חולי‬ ‫סכיזופרניה מאושפזים לבין סוג הטיפול האנטי–פסיכוטי שהם‬ ‫מקבלים‪ .‬על פי הספרות תכשירים אנטי–פסיכוטיים אטיפיים‬ ‫נחשבים נסבלים יותר מתכשירים אנטי–פסיכוטיים טיפיים‪.‬‬ ‫השערתנו הייתה שבקרב חולי סכיזופרניה המטופלים בתכשירים‬ ‫אטיפיים‪ ,‬בריאות השיניים תהיה טובה יותר מאשר בקרב חולים‬ ‫המטופלים בתכשירים טיפוסיים בלבד או המטופלים בשילוב של‬ ‫שני הסוגים (קבוצה משולבת)‪.‬‬ ‫שיטות‪ :‬בריאות השיניים בקרב מדגם מייצג של ‪ 348‬חולים‬ ‫(‪ 69%‬גברים)‪ ,‬בגיל ממוצע של ‪ 51.4‬שנים (סטיית תקן ‪,14.5‬‬ ‫טווח גילים ‪ 31-58‬שנים) נבדקה באמצעות מדד ‪:DMFT‬‬ ‫שיניים שנמצאה בהן עששת‪ ,‬שיניים חסרות ושיניים משוחזרות‪.‬‬ ‫נתונים על הטיפול בתרופות התקבלו מהרשומות הרפואיות‬ ‫האלקטרוניות של החולים‪.‬‬ ‫תוצאות‪ :‬בקרב חולים שטופלו בתכשירים טיפיים היה מדד ה–‬ ‫‪ DMFT‬גבוה יותר מאשר בקרב חולים שטופלו בתכשירים אטיפיים‪:‬‬ ‫‪ 23.5±9.9‬לעומת ‪ .)p<0.05( 19.0±10.5‬מרכיב ‪( M‬שיניים חסרות) היה‬ ‫‪ 20.2±11.6‬לעומת ‪ ,)p<0.01( 13.5±11.2‬ומרכיב ‪( F‬שחזורים) היה נמוך‬ ‫יותר ‪ 1.0±2.4 -‬לעומת ‪ .)p<0.05( 2.1±3.9‬לא נמצאו הבדלים בין הקבוצות‬ ‫במרכיב ה–‪( D‬שיניים שנמצאה בהן עששת לא מטופלת) (‪2.3±3.4‬‬ ‫ו–‪ ,3.4±5.0‬בהתאמה; ‪ .)p>0.05‬המדדים בקבוצה של טיפול משולב היו‬ ‫בטווח שבין ‪ 2‬קבוצות הטיפול‪ ,‬האטיפי והטיפי‪ ,‬בכל המרכיבים‪.‬‬ ‫מסקנות‪ :‬התוצאות מצביעות על כך שלחולי סכיזופרניה‬ ‫המטופלים בתכשירים אטיפיים יש שיניים בריאות יותר מאלו‬ ‫של חולים המטופלים בתכשירים טיפיים או בשילוב של שני סוגי‬ ‫התכשירים האנטי–פסיכוטיים‪ .‬מבחינת בריאות הפה‪ ,‬מונותרפיה‬ ‫בתכשירים אטיפיים עדיפה על פני טיפול בתכשירים טיפיים‬ ‫או טיפול משולב‪ .‬אמנם בחירת הטיפול המתאים נעשית בעיקר‬ ‫על פי יעילות פסיכיאטרית קלינית‪ ,‬אך יש להביא בחשבון את‬ ‫היתרון של תכשירים אטיפיים בהקשר של בריאות הפה בעת‬ ‫קבלת החלטה לגבי הטיפול המתאים למטופל‪.‬‬ ‫חומרת ההפרעה הפסיכיאטרית והבריאות‬ ‫הדנטלית‪ ,‬ממצאים בקרב מטופלים‬ ‫פסיכיאטריים אמבולטורים בירושלים‬

‫ר‪ .‬קופר־קזאז‪ ,‬ד‪.‬ה‪ .‬לוי‪ ,‬א‪ .‬זיני‪ ,‬ה‪ .‬סגן‪-‬כהן‪ ,‬ירושלים‬

‫מטרת המחקר הייתה לבחון את הקשר בין חומרת התחלואה‬ ‫הפסיכיאטרית לבין התחלואה הדנטלית‪ 80 .‬חולים פסיכיאטרים‬ ‫המטופלים במרפאה אמבולטורית‪ ,‬בטווח גילים של ‪,30-50‬‬ ‫חולקו לשתי קבוצות לפי חומרת מצבם ‪ -‬תחלואת נפש קשה‬ ‫(‪ )SMI - Serious Mental Illness‬ותחלואה קלה‪/‬בינונית [‪33‬‬ ‫(‪ ,)58.8%( 47 ,)41.2%‬בהתאמה]‪ .‬נרשם מדד עששת לפי ‪DMFT‬‬ ‫(‪ )Decayed, Missing, Filled Teeth‬וכן פוטנציאל השפעת‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫שיתוף פעולה בין האקדמיה לתעשייה בתחום‬ ‫האלכוהול וההימורים‪ :‬יתרונות ונזקים‬ ‫ד‪ .‬שטיין‪ ,‬קייפטאון‪ ,‬דרום אפריקה‬

‫יש סיבות רבות לעודד שיתוף פעולה בין מוסדות אקדמיים‬ ‫לתעשייה פרטית‪ .‬עם זאת‪ ,‬שיתוף פעולה מסוג זה מעלה את‬ ‫הפוטנציאל לניגודי אינטרסים ניכרים‪ .‬יתר על כן‪ ,‬ייתכן שיש‬ ‫סוגים שונים של בעיות בסוגי תעשייה שונים‪ ,‬כפי שמשתקף‬ ‫במטאפורות שבהן אנו משתמשים כאשר אנו מתייחסים אליהן‪.‬‬ ‫תעשיית התרופות נתפסת לעתים כתעשייה "חיובית" שעלולים‬ ‫לחול שיבושים בפעילותה‪ ,‬ואילו תעשיית הטבק נתפסת‬ ‫כתעשייה "רעה" שכמעט אינה מסוגלת לעשות טוב‪ .‬כדאי‬ ‫במיוחד לחשוב על תעשיות האלכוהול וההימורים היות שניתן‬ ‫לטעון שיש להכיר ברצף של יתרונות ונזקים הטמונים בהן‪.‬‬ ‫במאמר אני מתייחס לכמה יוזמות של תעשיית האלכוהול‬ ‫וההימורים בדרום אפריקה‪ ,‬וטוען כי יש הזדמנויות אמתיות‬ ‫להתוויה ולפיתוח של מודלים חזקים יותר של שיתוף פעולה בין‬ ‫האקדמיה לתעשייה‪ ,‬אשר יבטיחו מיטוב של בריאות הציבור‬ ‫במדינה זו ובמקומות אחרים‪.‬‬ ‫יחסים דיפרנציאליים בין דיכאון לגורמי סיכון‬ ‫לעמידות לטיפול באינסולין ולשכיחות מחלת‬ ‫הסוכרת במדגם רחב היקף בארצות הברית‬ ‫ג'‪ .‬גנגוויש‪ ,‬ר‪ .‬גרוס וד‪ .‬מלספינה‪ ,‬ניו יורק‪ ,‬ארה״ב‬

‫רקע‪ :‬דיכאון ומחלת הסוכרת מופיעים יחד לעתים קרובות‪.‬‬ ‫הקשר בין גורמי הסיכון לעמידות לטיפול באינסולין לדיכאון‬ ‫ולסוכרת עשוי לקבוע את החשיבות היחסית של הגורמים אשר‬ ‫תורמים לתחלואה הנלווית לדיכאון‪.‬‬ ‫שיטה‪ :‬ניתוח הסולם ‪NHANES I‬נ(‪ 10,025‬משתתפים) לצורך‬ ‫בדיקת היחסים בחתך רוחבי בין דיכאון לגורמי סיכון עבור‬ ‫עמידות לטיפול באינסולין בתחילת המחקר באמצעות רגרסיה‬ ‫לוגיסטית‪ ,‬ובחינת יחסי הגומלין ארוכי הטווח בין גורמי סיכון‬ ‫לעמידות לטיפול באינסולין ושכיחות מחלת הסוכרת באמצעות‬ ‫מודלים של סיכונים יחסיים של קוקס (‪Cox proportional‬‬ ‫‪.)hazards modeling‬‬ ‫תוצאות‪ :‬נמצא קשר בין גורמי סיכון רבים לעמידות‬ ‫לאינסולין‪ ,‬לדיכאון ולשכיחות של סוכרת‪ .‬בחתך רוחבי נמצא‬ ‫קשר בין דיכאון לסוכרת‪ ,‬אך הוא לא העלה את הסיכון לשכיחות‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,52‬מס' ‪2015 ,2‬‬

‫של סוכרת‪ .‬אפשר להסביר את התוצאות המנוגדות הללו בעיקר‬ ‫באמצעות מערכות יחסים שונות בין גורמי סיכון לעמידות‬ ‫לאינסולין‪ ,‬לדיכאון ולסוכרת‪.‬‬ ‫מגבלות‪ :‬העדר מדידות חוזרות של דיכאון‪.‬‬ ‫מסקנות‪ :‬העדר פעילות גופנית‪ ,‬יתר לחץ דם ושינה בלתי‬ ‫מספקת היו גורמי הסיכון לעמידות לטיפול באינסולין שהיו להם‬ ‫הקשרים החזקים ביותר הן לדיכאון והן לשכיחות של סוכרת‪.‬‬ ‫פסיכופתולוגיה והשפעתה המוקדמת על התנהגות‬ ‫האם‪ :‬נקודת מפגש בין פסיכיאטריה של המבוגר‬ ‫לפסיכיאטריה של התינוק (מלידה עד גיל ‪ 3‬שנים)‬ ‫מ‪ .‬קרן‪ ,‬א‪ .‬אלפנדארי וש‪ .‬טיאנו‪ ,‬פתח תקווה‬

‫מעצם הגדרתה הורות היא תחום שבו בריאות הנפש של המבוגר‬ ‫ובריאותו הגופנית והנפשית של התינוק נפגשות במשחק‬ ‫יחסי גומלין מורכב ודינמי‪ .‬הפיכתו של הפרט להורה היא‬ ‫אתגר התפתחותי‪ ,‬אשר עלול להחמיר פסיכופתולוגיה קיימת‬ ‫ולהשפיע על התנהגותו כהורה‪ .‬התנהגות לא הולמת של ההורה‬ ‫עלולה להוביל להפרעה בקשר בין ההורה לתינוק‪ ,‬והפרעה‬ ‫זו תתבטא בתסמינים אצל התינוק (מלידה עד גיל ‪ 3‬שנים)‬ ‫ותשפיע על תפקודו הרגשי–חברתי בשלב מאוחר יותר‪ .‬המושג‬ ‫של יכולת "מנטליזציה" מוצג במאמר כאחד הגורמים המרכזיים‬ ‫המגשרים בין הפסיכיאטריה של המבוגר לפסיכיאטריה של‬ ‫התינוק‪ .‬לאור ממצאים איתנים במחקרים אשר בדקו את‬ ‫השפעת הפסיכופתולוגיה של האם על התנהגויותיה כהורה ועל‬ ‫התפתחות הצאצאים שלה‪ ,‬עולה צורך דחוף בשיתוף פעולה‬ ‫ובתקשורת רציפה בין הפסיכיאטרים למבוגרים לפסיכיאטרים‬ ‫לילדים‪ .‬לצערנו הספרות המקצועית בנושא ההשפעה של‬ ‫פסיכופתולוגיה של אבות על הילדים לוקה מאוד בחסר‪ ,‬ולכן לא‬ ‫התייחסנו אליה במאמר זה‪ .‬כמה תיאורי מקרי קצרים מדגימים‬ ‫את יחסי הגומלין בין תפקוד האם המושפע מפסיכופתולוגיה‬ ‫לבין תגובותיהם של ילדים צעירים מאוד‪ ,‬וכן את שיתוף הפעולה‬ ‫בין פסיכיאטרים למבוגרים לאלה של ילדים‪.‬‬ ‫התפתחות הפרעות מופנמות ומוחצנות חמורות‬ ‫מגיל הגן ועד לגיל ההתבגרות‪ :‬מחקר מעקב‬

‫ש‪ .‬שפיצר‪ ,‬א‪ .‬פרוידנשטיין‪ ,‬מ‪ .‬פסקין‪ ,‬ש‪ .‬טיאנו‪ ,‬א‪ .‬שרירא‪,‬‬ ‫ט‪ .‬פרלסון‪ ,‬א‪ .‬עילם‪ ,‬ג‪ .‬זלצמן‪ ,‬ת‪ .‬גרין* וד‪ .‬גוטהלף*‪ ,‬פתח תקווה‬ ‫*שני הכותבים תרמו באופן שווה לעבודה זו‪.‬‬

‫מטרה‪ :‬במחקר זה הערכנו את ההתקדמות של הפרעות‬ ‫פסיכיאטריות חמורות בקרב ילדים מגיל הגן ועד לגיל החביון‬ ‫וההתבגרות המוקדם‪.‬‬ ‫‪148‬‬