IJP: Israel Journal of Psychiatry: Vol' 52, issue 3

israel journal of

psychiatry

Vol. 52 - Number 3 2015

ISSN: 0333-7308

3

An editor’s farewell and thanks DAVID GREENBERG

5

Editorial: Vision and appreciation: The passing of the baton Rael Strous

6

Cognition, symptoms and function in early schizophrenia Beata Hintz et al.

14

Emotional distress in asylum seekers and migrant workers Michal Dick et al.

20

Medical Clowning and Psychosis: A Case Report and Theoretical Review Alex Gruber et al.

24

Meaning in life and affect in firefighters Amit Shrira et al.

27

The Israeli-Polish Mental Health Association: Its History and Activities Jacek Bomba

33

Fate of Polish psychiatry under German occupation Friedrich Leidinger et al.

38

Early group intervention for reserve soldiers Yael Shoval-Zuckerman et al.

49

Psychiatric symptoms and quality of life in military personnel deployed abroad Taner Ă–znur et al.

55

Cardiovascular fitness and neurocognition in cardiac rehabilitation Yael Netz et al.

65

Aerobic exercise as augmentation therapy for depressive disorder Tal Shachar-Malach et al.

israel journal of

psychiatry

The Official Publication of the Israel Psychiatric Association

and related sciences

Vol. 52 - Number 3 2015

EDITORIALS

33 > The Fate of Polish Psychiatry under

3 > An editor’s farewell and thanks

Friedrich Leidinge and Andrzej Cechnicki

EDITOR

Rael Strous DEPUTY EDITORS

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

David Greenberg

BOOK REVIEWS EDITOR

CLINICAL FOCUS

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 Ilana Kremer ltzhak Levav Yuval Melamed 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

German Occupation in World War II

5 > Editorial: Vision and appreciation:

PSYCHIATRY AND THE MILITARY

Rael Strous

Intervention for Military Reserves Soldiers: The Role of the Repressive Coping Style

The passing of the baton

6 > Associations Between Cognitive

Function, Schizophrenic Symptoms, and Functional Outcome in Early-onset Schizophrenia With and Without a Familial Burden of Psychosis Beata Hintze and Alina Borkowska

14 > Identification of Emotional

Distress Among Asylum Seekers and Migrant Workers by Primary Care Physicians: A Brief Report Michal Dick and Ido Lurie

20 > Medical Clowning and Psychosis: A Case Report and Theoretical Review Alex Grube and Pesach Lichtenberg

24 > How Do Meaning in Life and

Positive Affect Relate to Adaptation to Stress? The Case of Firefighters Following the Mount Carmel Forest Fire Amit Shrira, Dov Shmotkin, Yuval Palgi, Yechiel Soffer, Yaira Hamama Raz, Patricia Tal-Katz, Menachem Ben-Ezra and Charles C. Benight

HISTORICAL PERSPECTIVE

27 > The Israeli-Polish Mental Health

Association: Its History and Activities Jacek Bomba

38 > The Effectiveness of Early Group

Yael Shoval-Zuckerman, Rachel Dekel, Zahava Solomonand Ofir Levi

49 > Psychiatric Symptoms and

Quality of Life in Military Personnel Deployed Abroad

Taner Öznur, Süleyman Akarsu, Murat Erdem, Murat Durusu, MD,4 Mehmet Toygar, Yavuz Poyrazoglu, Ümit Kaldirim, Mehmet Eryilmaz and Kamil Nahit Ozmenler

PSYCHIATRY AND EXERCISE

55 > Cardiovascular Fitness and

Neurocognitive Performance among Older Adults in the Maintenance Stage of Cardiac Rehabilitation Yael Netz, Tzvi Dwolatzky, Abid Khaskia and Ayelet Dunsky

65 > Effectiveness of Aerobic

Exercise as an Augmentation Therapy for Inpatients with Major Depressive Disorder: A Preliminary Randomized Controlled Trial

Tal Shachar-Malach, Rena Cooper Kazaz, Naama Constantini, Tzuri Lifschytz and Bernard Lerer

72 > Book Reviews Hebrew Section

74

> Abstracts

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

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Hands of Mercy Hands of therapist caring for the flower (patient) embracing with responsibility.

Hands are in gray symbolizing fatigue and endurance on the path to healing.

Flower overflows with life and vitality following dedicated and successful treatment. Message of thanks to therapists.

Photograph courtesy of “Master Art in Photography” program under direction of Alex Libak and Essie Tigner-Haus, Lev-Hasharon Hospital and Friend in Heart and Soul Foundation.

Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

DAVID GREENBERG

An editor’s farewell and thanks ‫חבל על דאבדין ולא משתכחין‬ A PITY FOR THOSE WHO HAVE DIED, BUT ARE NOT FORGOTTEN. (TALMUD SANHEDRIN 111A)

This beautiful Aramaic phrase, originally used as a rebuke to Moses, is now used to express some of our thoughts of those who have been important in our lives, and continue to remain alive for us after their passing. After 23 years as editor of the Israel Journal of Psychiatry (IJP), there are certain unforgettable people I would like to mention. The IJP, then known as the Israel Annals of Psychiatry and Related Disciplines, was founded by Heinz Zvi Winnik and first appeared in April 1963. Professor Winnik created a series of international contributing editors, who included Sir Aubrey Lewis in London (who published a paper in the journal in 1967 [1]), Henri Baruk in Paris (who published a paper on the history of French Psychiatry in the same issue), and Margaret Mead in New York.

Professor Winnik was the journal’s editor until his death aged 80 in 1982 (2). A year earlier Professor Eli Edelstein had joined him and was the editor during the transition to the Israel Journal of Psychiatry. In the course of 1992 I undertook to be its third editor and it is with great pleasure that I hand over the editorship to Professor Rael Strous as we close the journal’s 52nd volume and year of publishing.

The genie who stood at my right shoulder at the start of my editorship was the late Donald Cohen, the inexhaustible director of the Yale Child Study Center.

Donald was deeply committed to the success of the IJP, we planned the first issues over coffee together on Emek Refaim St. in Jerusalem, and his final and characteristically generous gesture was to honor the journal with the publication of the Sterling professorship Dean’s lecture he gave at Yale before he died, a posthumous contribution to the impact factor (3).

Today’s reader will find it hard to understand that in 1992 submissions were sent to me in triplicate by post, I removed the cover page and sent a copy by post to a potential reviewer with a cover letter. I recall that Donald donated a fax machine when they first appeared so that reviewers could submit their reviews with ease.

On assuming editorship, I contacted Mortimer Ostow, chairman of the journal’s American editorial 4

committee, a body of support created by Professor Winnik. Morty had published a paper in the first issue in 1963, in which he wrote: “It seems to me that the two most striking features which the Western Jew finds in Israel are its familiarity and its strangeness” (p. 33, 4). One of his last papers was published in the IJP in 2004 (5).

As I was born in the UK, my natural choice of journal was the British Journal of Psychiatry. The editor at that time was Hugh Freeman, who I admired for the way he introduced innovation. I wrote to him, and was surprised and delighted to receive a hand written reply (Hugh never adjusted to the word processor), inviting me to join him for lunch at the Oxford and Cambridge Club in Pall Mall. That meeting remains one of the special moments in my life, the austere and grand setting, in contrast with Hugh, initially very shy, but in fact so warm, who remained a friend and advisor concerning the IJP. My first act after becoming editor was to convene the editorial board. This took place in the evening in my home, and for 20 years, twice a year, we would meet there, sitting on settees, planning and discussing.

The Israel Psychiatric Association wisely approached leaders of Israeli Psychiatry who all gave of their time and contacts as board members. Each undertook to be guest editor of special issues in their areas of expertise, and drafted colleagues from Israel and abroad to join the cause. Without their active support, the journal may well have foundered. Instead, the IJP grew in size and quality. Scientific journals only began to have Impact Factors in 1975, and the IJP had its first score in the late 90s. Throughout the first decade of this century, it rose to 0.6-0.7 where it has remained, with the exception of 2012 when it was 1.36.

The IJP went online in 2005. In 2006, two deputy editors were appointed in recognition of the growing volume of work in evaluating manuscripts and planning issues. Since then, the number of those involved in guiding the IJP has grown substantially, with an impressive array of professional backgrounds represented on the board, and there are now seven deputy

editors, involved in processing all new submissions.

There are many moments that have been memorable during these last 23 years: the special issue on religion and mental health in 1994 was a forerunner of current interest, the issue on Arab society in 2005 was an achievement in our continuing troubled circumstances, and the bi-lingual issue in 2002 in which all the articles were written by mental health consumers was an early reflection of their growing important voice. In 2007 the complete Israel National Health Survey was published in the IJP and will remain an important epidemiological resource for years to come.

I smile to think of the delight of Aharon Arlazaroff and Roberto Mester et al. when we published along with their paper on pathological laughter a beautiful commentary by the late Oliver Sacks (6).

In 2010 we started putting a work of art by a consumer on the front page. In most cases I was in personal contact with the artist, and their pleasure on receiving the journal with their art work on its cover was a source of deep satisfaction.

Editing a journal requires a lot of time from many people. I am grateful to the Israel Psychiatric Association and the many chairmen who gave me their support over the years. I remain in awe of the many members of the editorial board who gave of their time, both driving to Jerusalem for meetings and in planning issues, all gratis. I am grateful to my hospital that did not blink at the flow of envelopes in the early years that left my office to reviewers and

authors, and the time I dedicated to the journal. Most, however, was done in the evenings, and I remain eternally grateful to my wife, Shari, for her patience and support and her advice.

I am delighted that Professor Rael Strous has agreed to be the fourth editor of the Israel Journal of Psychiatry. It is a special journal, with a responsibility of representing Israeli psychiatry while being a bridge to psychiatrists around the world with an interest in our endeavour. As a psychiatrist and teacher who has published in many areas of mental health, including ethics and the Holocaust, I feel I could not be placing the journal in better hands.

David Greenberg Herzog Hospital, Jerusalem davidg@mail.huji.ac.il

References 1. Lewis A. Problems presented by the ambiguous word “anxiety” as used in psychopathology. Isr Ann Psychiatry Relat Disc 1967;5:105-121.

2. New York Times. Obituaries. November 17, 1982. Heinrich Winnik, 80, of Israel, a pioneer of psychoanalysis.

3. Cohen DJ. Into life: Autism, Tourette’s syndrome and the community of clinical research. Isr J Psychiatry 2001;38:226-241.

4. Ostow M. Familiarity and strangeness. Isr Ann Psychiatry Relat Disc 1963;1:31-42.

5. Ostow M. Psychopharmacology and psychoanalysis. Isr J Psychiatry 2004;41:17-22.

6. Sacks O. Commentary on pathological laughter to the authors. Isr J Psychiatry 1998;35:189.

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

Editorial: Vision and appreciation: The passing of the baton QUALITY IS NOT AN ACT, IT IS A HABIT These words are not mine. They are those of Aristotle.

However I cannot think of nine better words to describe and sum up the retiring journal editor, Prof. David Greenberg. David is simply a quality act and this may be noted in all he does. He is a superb clinician, an outstanding academic, a sensitive administrator and above all, a wonderful person – simply a mensch. We have been only too fortunate to have had David at the helm of the journal for the past 23 years where after 91 issues the journal has substantially risen in quality and international prominence. In the past years the journal has reached on occasion an impact factor placing it as one of the foremost national psychiatry journals in the world. Much has changed in the field of psychiatry over the past two decades – spanning the decade of the brain with advancements in neuroscience, neuroimaging, pharmacotherapy, pharmacogenetics, CBT and more. These developments in the field demand a journal editor to maintain his finger on the pulse and be sensitive to changes in the direction of the field in order that the journal remains relevant and appropriate for the ever changing clinical and academic readers’ needs and interests. David had done a truly admirable job at this task, even considering the volunteer and ultimately thankless nature of the undertaking as well as the necessity to continue simultaneously a full time clinical and administrative position. David has attained this success of the journal with aplomb and is sincerely respected by his colleagues – both readers and the journal board – where he has carried himself with true dignity, utter professionalism and dedication to the goal with complete commitment and loyalty.

Fully recognizing the privilege and responsibility, it is with great awe and trepidation that I take now on the position of journal editor in place of David. Most importantly, I remain fully cognizant of the mammoth task of filling the immense shoes of those, including David of course, who have come before me. Editing a medical journal in the age of social media and “constant internet connection” does not come without its chal6

lenges. Maintaining a high quality level of academia as well as remaining relevant to readers who have a wide range of easily accessible competing online professional media does not come easy. However there is no place for Luddite complacency and we in the Israel Journal of Psychiatry and Related Sciences have to move with the times. The board and I commit to ensure that the journal remains readable, timely, relevant, economically viable, accessible, and meaningful. Several initiatives are being planned along these lines. This may also mean a move to a fully online format similar to many other journals today. However at no time will we sacrifice academic excellence and both local and international standards in the process. We have been around for the past 52 years and plan to be around for many more years to come linking academic advances within Israel with those fine developments outside the country. It is to the vision of those that have come before us, to which David has so profoundly contributed, that we express our sincere appreciation, enabling us to go where we may now. As Voltaire so aptly quipped, “appreciation is a wonderful thing: It makes what is excellent in others belong to us as well.” Thank you David.

Rael Strous Beer Yaakov Mental Health Center, Sackler Faculty of Medicine, Tel Aviv University raels@post.tau.ac.il

Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

Associations Between Cognitive Function, Schizophrenic Symptoms, and Functional Outcome in Early-onset Schizophrenia With and Without a Familial Burden of Psychosis Beata Hintze, PhD, 1 and Alina Borkowska, PhD2 1 2

Institute of Applied Psychology, Faculty of Applied Social Sciences, Maria Grzegorzewska Academy of Special Education, Warsaw, Poland.

Department of Clinical Neuropsychology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland

ABSTRACT Objective: The purpose of the present study was to assess the relationship between various domains of cognitive functions, the intensity of psychopathological symptoms, and the general functional outcome in adolescents with early-onset schizophrenia.

Method: 33 adolescents with early-onset schizophrenia (EOS) were investigated in their partial symptom remission period. The control group consisted of 30 healthy adolescents. Schizophrenia was diagnosed on the basis of ICD-10 criteria. Psychopathological symptoms were assessed with the use of the PANSS (Positive and Negative Symptoms Scale) scale. General functioning was evaluated with the use of the CGAS (Children’s Global Assessment Scale) scale.

Results: Significant dysfunctions of various aspects of working memory, executive functions, and verbal memory were found in the group of EOS adolescents, as compared to the control group. Working memory and executive function deficits were significantly more severe in patients with a greater intensity of negative schizophrenia symptoms. EOS patients with a familial burden of psychosis presented greater cognitive deficits than patients without such a burden.

Conclusions: These data suggest that visual working memory and verbal memory deficits with a higher intensity of negative and positive symptoms proved to be significant predictors of poor functioning. Limitations of the study are discussed.

Conflict of interest – The authors declare no conflicts of interest.

This study was sponsored by the Maria Grzegorzewska Academy for Special Education through a statutory grant to the author BW 01/09-III.

INTRODUCTION Schizophrenia is considered a severe psychiatric neurodevelopmental disorder with numerous structural and functional brain changes, mostly in the prefrontal cortex.

These abnormalities result in cognitive disturbances, especially with regard to working memory and executive functions, and are considered to be the core and enduring deficits in schizophrenia (1, 2). It has been found that cognitive dysfunctions are associated with a poor general functional outcome in patients with schizophrenia (3, 4).

Early-onset schizophrenia (EOS) is defined as schizophrenia with an onset before 18 years of age. A comparison of the course of illness in EOS and AOS (adult-onset schizophrenia) shows that early-onset schizophrenia is characterized by a higher rate of various developmental brain abnormalities and premorbid disturbances, a greater intensity of negative symptoms, worse performance in neuropsychological tests, and poorer functional outcome, also with regard to social skills (5-9). Furthermore, EOS patients exhibit numerous neurodevelopmental problems in childhood, especially psychomotor retardation (including delayed walking), worse visuospatial coordination, stereotyped movements, language and speech disorders, including delayed speech, and inferior psychosocial abilities, such as social isolation and withdrawal. These problems are usually associated with worse academic performance. Patients with early-onset schizophrenia, as compared to their healthy peers, perform lower on tests

Address for Correspondence: Beata Hintze, PhD, The Maria Grzegorzewska Academy of Special Education, ul. Szczesliwicka 40, 02-353 Warsaw, Poland. bhintze@aps.edu.pl

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BEATA HINTZ AND ALINA BORKOWSKA

measuring verbal, visual and working memory, attention and concentration, conceptual thinking, as well as visuospatial and visuomotor coordination. Their global level of intelligence tends to be lower compared to healthy individuals. Cognitive performance of EOS patients is usually 2-3 standard deviations (SD) below the results of average healthy subjects (10-14). Current research using the MATRICS test battery showed that adolescents with schizophrenia spectrum disorders present significantly lower abilities in most cognitive domains, except social cognition tasks, in comparison with healthy controls.

These differences are the greatest with regard to working memory as well as verbal and visual learning. Cognitive performance of patients ranges between 0.8 and 1.8 SD below the healthy population (15). However, studies among patients with first-episode psychosis showed that patients with EOS, as compared to adolescent patients with other (non-organic, non-affective) psychoses, may have more global IQ deficits when examined directly after the onset of illness (16).

Moreover, the results of some studies indicate worse cognitive functioning, especially with regard to visualmotor coordination and attention in schizophrenic patients with psychotic symptoms in first-degree relatives as compared to patients without a family history of psychosis (17).

Many studies reported the relationship between cognitive deficits and the intensity of negative symptoms to be the most predictive variable of functional outcome, including social skills, school or work performance, and independent living in adult-onset and chronic schizophrenia (18-21).

In the case of EOS patients, the results are not as conclusive. Some studies established an association between several cognitive deficits and worse general functional outcome, including social and daily living skills (22-25).

Other research indicates that positive and/or only negative symptoms as such are the crucial predictors of general functional outcome in EOS (9, 26-28). However, it is still unclear which particular cognitive dysfunctions might serve as good predictors of global functioning in EOS. Therefore, the aim of this study was to assess the relationship between chosen parameters of selected cognitive domains - working memory, executive functions, verbal memory and learning, and the intensity of symptoms (both positive and negative) as well as global functional outcome in patients with an early onset of schizophrenia.

The above mentioned cognitive domains are regarded as the most important deficits in EOS as well as in AOS

(1, 2, 6, 11). As to clinical symptoms, both positive and negative symptoms were described as more severe in EOS than in AOS patients (29).

We hypothesize that cognitive deficits, especially in various modalities of working memory and verbal memory, together with a higher intensity of psychopathological symptoms, both positive and negative, might be considered as significant predictors of poor global functioning of EOS patients in the remission period.

METHODS PARTICIPANTS PATIENT GROUP

The study examined 33 adolescent patients with earlyonset schizophrenia: 13 females and 20 males, aged 15-19 (mean 17.4 Âą 1.2 SD). The inclusion criteria comprised a diagnosis of EOS (according to ICD-10 criteria) in at least a partial remission of the illness with pharmacotherapy in outpatient clinics or rehabilitation centers. Thirty-six percent of adolescents with schizophrenia had a familial burden of psychosis, i.e., their first-degree relatives had been diagnosed with psychotic disorders. The exclusion criteria contained current or past psychoactive substance abuse, a diagnosis of mental retardation according to ICD-10 criteria, pervasive developmental disorders, and serious neurological or somatic disorders.

All patients were treated with second generation antipsychotics (olanzapine, risperidone, quetiapine, clozapine) administered in a stable standard daily dosage.

Sixteen patients were in monotherapy, and 17 received polytherapy (a combination of two atypical neuroleptics).

CONTROL GROUP

The control group consisted of 30 healthy adolescents whose age, sex and education (number of completed years of schooling) matched (one to one) the EOS patients.

There were 13 females and 17 males aged 15-19 (mean age 17.0 Âą1.3 SD). All the healthy adolescents were recruited from schools in the same area where the patients from the experimental group lived. The exclusion criteria for the control group were as follows: current or past psychoactive substance abuse, a diagnosis of mental retardation according to ICD-10 criteria, pervasive developmental disorders, serious neurological or somatic disorders, and positive family history of psychiatric illnesses (psychiatric disorders in first-degree relatives).

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COGNITION, SYMPTOMS AND FUNCTION IN EARLY SCHIZOPHRENIA

ETHICAL ISSUES

The study complied with the ethical standards laid down in the 1964 Helsinki Declaration. The design of the study was approved by the Ethics Committee of the Academy of Special Education in Warsaw. Participation in the investigation was voluntary. All adolescents (patients and control group members) and their parents or legal guardians signed an informed consent. All individuals taking part in the study were informed of their right to withdraw their consent at any time, without consequences.

PROCEDURE

The diagnosis of EOS and the evaluation of the intensity of psychopathological schizophrenia symptoms were carried out by psychiatrists before neuropsychological testing. Psychosocial functioning and neuropsychological assessment of each subject was conducted by the authors during one individual session, with breaks when needed.

The patients were tested in an outpatient clinic or in a rehabilitation center, while the controls were investigated at their schools or in the Academy of Special Education in Warsaw.

INSTRUMENTS

The assessment of schizophrenic symptoms (positive, negative, and general psychopathology) was conducted with the Polish validated version (30) of the Positive and Negative Symptoms Scale (PANSS) (31). Psychosocial functioning was evaluated with the Children’s Global Assessment Scale (CGAS) (32) translated into Polish with the author’s consent.

For the evaluation of selected cognitive domains a battery of neuropsychological tests was used. Executive functions and working memory were assessed with the Wisconsin Card Sorting Test (WCST) (the CV 4 test computer version by Heaton) (33). The following parameters were taken into account: percentage of perseverative and nonperseverative errors, percentage of total (perseverative and nonperseverative) errors, percentage of conceptual level responses, number of correctly completed categories, and number of cards needed to complete the first category. The N-back test was used for the evaluation of visual working memory (Coppola 1-back version). The measured parameters included the percentage of correct and incorrect responses and the mean reaction time (34). The Trail Making Test was also used – part A to assess psychomotor speed and part B to evaluate visuospatial working memory and the ability to shift strategies. The analyzed parameters included 8

the time of performance (in seconds) and the number of incorrect responses (35), according to the Polish validated version (36). Rey’s Auditory Verbal Learning Test (RAVLT) was used for the measurement of memory abilities. The following parameters were assessed: general number of words recalled in five repetitions (immediate memory) and the number of words recalled after a 20-minute delay period (delayed memory) (37), according to the Polish validated version (38).

Statistical calculations were performed with the use of STATISTICA 7 software. The Student’s t-test was used to evaluate the differences in means between the two groups.

For comparisons between schizophrenic patients with and without a familial burden of psychosis the Mann-Whitney U test was used (because the data did not meet the parametric analysis criteria). The correlation coefficients were computed using Pearson correlations between the results of neuropsychological tests, clinical data, and C-GAS scores.

To establish the predictive capacity of the cognitive and clinical variables on the functioning domains, a regression model was fitted using the forward stepwise method. Those variables which showed a significant correlation with the C-GAS score were included as potential predictors.

Significance was set at p<0.05.

RESULTS SAMPLE CHARACTERISTICS

The demographic and clinical characteristics of the sample are shown in Table 1. There were no significant differences in age and educational attainment (years of schooling) Table 1. Demographic and clinical characteristics of EOS patients and controls Demographic and clinical characteristics

EOS patients N=33

Controls N=30

Mean (SD)

Mean (SD) t-value

Age Education (years) Age at onset (years) Hospitalizations Length of illness (years) PANSS dimensions Positive Negative General Total C-GAS

17.4 (± 1.2) 9.7 (± 0.9) 15.3 (± 1.4) 2.5 (± 1.8) 2.0 (± 1.1)

17.0 (±1.3) 1.06 9.8 ( ±1.2) 0.30

Gender

N

Female Male Familial burden of psychosis

13 20 12

13.5 (± 4.4) 24.5 (± 8.3) 39 (± 12.2) 77 (± 21.9) 58.1 (± 8.9) % 40 60 36

N

%

13 17 0

43 57 0

BEATA HINTZ AND ALINA BORKOWSKA

Table 2. Results of neuropsychological tests in EOS patients and controls Neurocognitive tests

EOS patients N=33 Mean (SD)

Controls N=30 Mean (SD)

t-test p -level

WCST % perseverative errors % nonperseverative errors % total errors % conceptual level responses categories completed trials to complete 1st category

11.93 ( ±6.31) 11.34 (±6.19) 23.28 (± 10.70) 71.18 (±15.37) 5.59 ( ± 0.87) 15.31 (± 7.92)

7.46 (±1.65) 7.13 (±2.72) 14.60 (±3.17) 83.13 (±4.02) 6.00 (±0.00) 12.00 (± 1.87)

3.76 3.42 4.26 -4.12 -2.54 2.23

p<.001 p<.01 p<.0001 p<.001 p<.01 p <.05

N-back % number correct % number wrong reaction time (msec)

77.81 (±24.65) 22.18 (±24.65) 662.45 (±361.41)

99.46 (± 1.73) 0.53 (±1.73) 417 (±195.74)

-4.79 4.79 3.30

p<.0001 p<.0001 p<.001

TMT TMT A (sec) TMT B (sec)

35.90 (±11.82) 88.81 (±40.89)

17.60 (±3.15) 41.58 (±13.03)

8.21 6.04

p<.0001 p<.0001

RAVLT trials I-V recall after 20 min

45.43 (±8.88) 9.50 (±2.50)

56.66 (± 7.72) 13.03 (±1.92.)

-5.22 -6.13

p<.0001 p<.001

t Student test

between adolescents suffering from schizophrenia and their healthy peers. In the patient group, the majority of adolescents experienced the onset of schizophrenia at the age of 14-17 (91%). Only three individuals (9%) had a very early onset of schizophrenia (VEOS) at 12-13 years of age. Thirty-six percent of adolescents with schizophrenia had a familial burden of psychosis. Participants were receiving atypical antipsychotics. Twenty-one of them (63%) were able to return to regular school at the time of enrolment. Seven patients continued individualized education (21%), while five (16 %) remained absent from school on medical leave.

PERFORMANCE ON NEUROCOGNITIVE TESTS

longer performance time in parts A and B in TMT and more errors in part B. They also had significantly lower results in RAVLT, both in immediate and delayed recall, as compared to their healthy peers.

EOS patients with a familial burden of psychosis had poorer results on some neuropsychological tests as compared to patients without such a burden (Table 3).

They achieved a lower percentage of correct responses in the N-back test and had a longer performance time on the TMT B test, which indicates a greater level of set shifting and visual working memory disturbances. No significant differences between EOS patients with and without a family burden were observed in the PANSS (severity of positive, negative and general symptoms) and CGAS scores.

NEUROPSYCHOLOGICAL TESTS AND SYMPTOMS: GLOBAL FUNCTIONING

No correlations between the performance on neuropsychological tests and the intensity of positive symptoms on the PANSS scale were found, as shown in Table 4. A greater intensity of negative symptoms correlated with a lower performance on the WCST (higher percentage of perseverative errors) and in two parameters of the N-back test, as well as a longer time required to perform the TMT B test.

Global functional impairment measured by the CGAS scale was associated with worse results of neuropsychological tests. Patients with a greater impairment in CGAS (lower score) had a significantly higher percentage of perseverative errors and a lower percentage

Performance on neurocognitive tests is shown in Table 2. EOS adolescents performed significantly lower in all test parameters compared to Table 3. Neurocognitive test performance in EOS patients with and without healthy individuals. In the WCST, EOS familial burden of psychosis EOS patients without EOS patients with patients had a significantly higher perfamilial burden familial burden centage of total perseverative and nonN=21 N=12 Z-adjusted Mean (SD) p – level perseverative errors, a lower percentage Neurocognitive tests Mean (SD) of conceptual level responses, a lower per- N-back number correct 86.67 18.8 62.33 26.8 2.66 p<.01 centage of correctly completed categories, % % number wrong 18.8 590.62 26.8 788.17 p<.01 -1.83 and needed more cards to complete the reaction time (msec.) 13.33 342.1 37.67 374.3 -2.66 p=.06* first category.

TMT 34.63 73.33 38.33 115.91 -1.46 -2.61 EOS patients had a significantly lower TMT A (sec) TMT B (sec) 13.5 25.9 8.2 48.8 p=.14 p<.01 number of correct responses and a longer *tendency, Mann-Whitney U test reaction time in the N-back test, with a

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COGNITION, SYMPTOMS AND FUNCTION IN EARLY SCHIZOPHRENIA

Table 4. Correlations between neurocognitive tests performance and results in PANSS and CGAS in EOS patients Neurocognitive tests

PANSS Positive

PANSS Negative

PANSS General

CGAS

WCST % perseverative errors % nonperseverative errors % total errors % conceptual level responses categories completed trials to complete 1st category

-0.19 -0.16 -0.21 0.20 0.13 -0.23

0.38* 0.03 0.24 -0.25 -0.21 -0.07

0.02 0.02 0.03 -0.03 -0.07 -0.13

-0.40* -0.18 -0.34 0.35* 0.31 0.02

N-back % number correct % number wrong reaction time (msec)

-0.12 0.12 0.11

-0.47*** 0.47*** 0.34

-0.27* 0.27* 0.16

0.55** -0.55** -0.42*

TMT TMT A (sec) TMT B (sec)

0.05 0.24

0.33 0.53**

0.27 0.44*

-0.32 -0.60***

RAVLT trials I-V recall after 20 min

0.00 0.05

-0.22 -0.10

-0.25 -0.11

0.44* 0.33

*p<.05; **p<.01; ***p<.001 Pearson correlation

a significant contribution to the model (TMT B: t= -0.26, p=.794; WCST percentage of conceptual level responses: t=1. 35, p=.190; WCST percentage of perseverative errors: t=0.74, p=.465; N-back T: t=-0.048, p=.635). General psychopathology contributed to an increase of the predictive value of the model (general psychopathology: t=-0.082, p=.935). As TMT B results were highly correlated with the CGAS score (as shown in Table 4), it is probable that CGAS eliminates TMT B as a weaker predictor from this regression model. Table 5 shows the predictive value of cognitive abilities and clinical variables on functional impairment in EOS patients.

DISCUSSION The obtained results indicate that EOS, even in the period of a partial remission of psychotic symptoms, is associated with a specific pattern of cognitive dysfunctions and general functioning disturbances. In comparison with healthy individuals, EOS adolescents showed significantly poorer performance on all neurocognitive tests measuring working memory, executive functions, processing speed, verbal memory, and learning. Thereby our findings confirm the results of most other studies indicating greater neurocognitive deficits in patients with early-onset schizophrenia, not only in comparison with healthy controls but also with adult-onset schizophrenia patients (6, 15, 39, 40). Compared to their healthy peers, EOS patients had significantly lower scores in all parameters of the WCST: a higher percentage of perseverative errors indicating significant cognitive flexibility impairment and stereotyped reactions, a higher percentage of nonperseverative errors that might be connected with attentional dysfunctions, and a lower percentage of conceptual level responses indicating significant difficulties in logical concept formation and a reduced ability to apply new

of conceptual level responses. Likewise, they obtained poorer results in all parameters of the N-back test, needed more time to perform TMT B, and showed greater verbal memory disturbances in RAVLT (immediate recall trials).

The correlation between the CGAS score, the results of cognitive tests, and clinical variables was calculated to identify potential predictors for regression analysis (Table 5). Among the psychopathological symptoms in the PANSS scale, the most significant correlations with the CGAS score were found in relation to negative symptoms (Pearson’s r = - 0.62; p<.001), positive symptoms (Pearson’s r =-0.41; p<.05), and general psychopathology (Pearson’s r=- 0.55; p<.01). Further analysis was based on the forward stepwise method. The variables with significant correlations with CGAS scores were adopted as potential predictors in the relevant block: the PANSS negative, positive and general symptom scale score, parameters of the WCST (percentage of perseverative errors and percentage of conceptual level responses), and the results of the N-back test (all parameters), TMT part B, and RAVLT Table 5. The forward stepwise method regression analysis examining the (number of words recalled in five repeti- contribution of clinical variables and the results of neuropsychological tests tions). The N-back percentage of incorrect to predict the CGAS score in adolescents with EOS variable = B SE Beta SE Beta t-value p- value responses, the number of words in RAVLT Dependent CGAS score trials I-V, and the PANSS negative and posiN-back wrong -0.13 0.05 -0.36 0.13 -2.68 .013 tive symptom scores explained 63% of the RAVLT trials I-V (sum) 0.29 0.12 0.29 0.12 2.40 .024 -0.34 0.15 -0.32 0.14 -2.21 .036 variance of the total score in CGAS (adjusted PANSS Negative PANSS Positive -0.56 0.27 -0.26 0.12 -2.06 .049 R2=0.63; F(4)=12.96; p<.001). None of the other potential cognitive predictors made Adjusted R2=0. 63 F(4) =12.96, p=.00009 10

BEATA HINTZ AND ALINA BORKOWSKA

information to the current situation in order to change behavior. EOS patients also completed fewer categories in the WCST, which indicates a significantly decreased effectiveness of reasoning. Our findings correspond to other results that established a significant impairment of frontal functions measured with the WCST in patients with an early onset of schizophrenia (41, 42). In our study, EOS patients also presented lower performance on visual working memory tests compared to the results of the control group. In the N-back test, EOS patients achieved significantly poorer results with more incorrect responses and a longer mean reaction time. These findings indicate persistent impairment of visuospatial working memory and visuospatial processing. In various studies using the N-back test, it was found that the performance of adult schizophrenic patients was significantly poorer in comparison with healthy subjects. Patients committed more errors and had a longer reaction time, which was associated with abnormal functioning of the dorsolateral prefrontal cortex (43, 44). As recently established by Kyriakopoulos et al. (45), adolescents with EOS displayed reduced dorsolateral prefrontal and anterior cingulate cortex activity and reduced DLPFC connectivity within the working memory network.

In TMT, a significant decline of psychomotor speed was observed (TMT A) as well as reduced performance ability in visuospatial working memory and set shifting tasks (TMT B). These findings correspond with the results of other studies in which EOS adolescents had significantly longer reaction times compared to healthy controls (11, 46).

EOS adolescents with a familial burden of psychosis presented greater cognitive deficits (especially in complex visuospatial skills) compared to patients without such a burden. This result may suggest that more severe visual and visuospatial working memory and set shifting dysfunctions in patients with EOS may be associated with a hereditary predisposition to the illness and the coexistence of unfavorable factors in early CNS development, mainly associated with genetic conditions. Therefore, our data may support the neurodevelopmental concept of schizophrenia (47), especially in light of the recent study by Shenton, Whitford and Kubicki (48), which found subtle neurodegenerative changes in the frontal and parietal lobes of EOS patients with schizophrenia.

Moreover, Kumra and colleagues (49) established a relationship between the diminution of total cortical gray matter volume and a higher intensity of motor disorders and visual attention deficits in EOS patients. In the pre-

morbid period of EOS patients, a delayed early childhood development is observed with respect to motor functions as well as to visuomotor and spatial coordination. Some authors suspect that in certain patients cognitive deficits occur before the first episode of the illness and that they have a persistent character, while in other individuals with schizophrenia these disturbances may further develop in the course of the illness (50). This may, however, depend on the intensity of CNS dysfunctions, the familial burden of schizophrenia, and obstetric complications (51).

It should be noted that the results of this study did not establish associations between the performance on neuropsychological tests and the intensity of positive symptoms on the PANSS scale. However, a higher intensity of negative symptoms was found to correlate with poorer performance on working memory tests. These data correspond with the results of other studies concerning both EOS and AOS, which particularly identified a strong relationship between the negative symptoms of schizophrenia and cognitive deficits, especially in the scope of working memory impairment (52-54). This may support the hypothesis expressed by Crow that negative symptoms are associated mostly with neurocognitive dysfunctions and with greater prefrontal cortex disturbances (55).

Some authors emphasize that negative symptoms are more intense in AOS patients with more severe dysfunctions of premorbid psychosocial outcomes, a greater severity of the illness, and a deeper cognitive dysfunction (21, 56). It may be assumed that negative symptoms and frontal deficit symptoms are crucial to poorer general functioning outcome in EOS schizophrenia since EOS is the more severe form of the illness characterized by more serious clinical and functional outcomes (57).

The previous studies performed on EOS patients also showed that poor functioning in childhood, either negative or positive schizophrenic symptoms, as well as certain cognitive deficits without psychopathological symptoms, may serve as predictors of functional outcome, but these results were not confirmed by others (9, 25, 26, 28, 58).

The main conclusion of the present study is that deficits of visual working memory and verbal memory as well as a higher intensity of schizophrenia symptoms (both negative and positive) have been found to be significant predictors of poor global functioning of EOS patients.

A cross-sectional study of EOS adolescents showed that 63% of the total CGAS variance was predicted by the N-back percentage of incorrect responses, the RAVLT trials I-V (number of words), and the PANSS negative and positive symptoms score. Our results are particularly 11

COGNITION, SYMPTOMS AND FUNCTION IN EARLY SCHIZOPHRENIA

interesting in the light of the recent meta-analysis carried out by Ventura et al. (21), which showed an association between cognitive functions, negative symptoms, and functional outcome exclusively in AOS patients. The authors suggest that negative symptoms mediate the connectivity between cognition and general functioning.

However, EOS patients were not as extensively studied as AOS individuals. In this light, our study offers new findings demonstrating that in EOS patients the intensity of clinical symptoms (both positive and negative) together with cognitive dysfunctions (particularly visual and verbal memory) might be considered good predictors of functional outcome.

Impairment of cognitive domains, e.g., deficits in verbal memory, verbal fluency, working memory, or attention, may be associated with day-to-day functioning. However, it is not necessarily a predictor of how the patients will function in the future (22-24). The severity of executive dysfunctions may, in turn, contribute to impaired present and future social functioning of EOS patients. The study conducted by Puig and colleagues (58) established that several cognitive deficits and clinical symptoms could be associated with real-world daily living skills; however, only processing speed and executive functions were found to be independent predictors of performance in everyday skills. In their 15-year follow-up study of EOS patients, Röpcke and Eggers (27) observed that the time of schizophrenia onset and premorbid social adjustment are the best predictors of global psychopathological and psychosocial outcome.

These findings further emphasize the importance of neurocognitive functioning as a key area of vulnerability in the study of adolescents with schizophrenia. However, the significance of this study’s results is limited by the relatively small size of its samples. The use of the C-GAS scale as the only method determining psychosocial functioning seems to be insufficient for performing a full assessment of the investigated patients’ global functioning.

Therefore, studies using a longitudinal approach should be carried out in order to confirm the present findings.

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

Identification of Emotional Distress Among Asylum Seekers and Migrant Workers by Primary Care Physicians: A Brief Report Michal Dick, MD,1,2 Shmuel Fennig, MD,2,3 and Ido Lurie, MD2,3 1 Internal Medicine Department D, Rabin Medical Center, Beilinson, Petach Tikva, Israel 2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel 3 Outpatient Ambulatory Service, Shalvata Mental Health Center, Hod Hasharon, Israel

ABSTRACT Background: Emotional distress (ED) is prevalent among immigrants. The open clinic of Physicians for Human Rights (PHR)-Israel provides free medical and psychiatric treatment to immigrants without access to the ambulatory health service. In 2010, the psychiatric records represented 1% of the total medical files (N=28,000) in the open clinic.

Objective: To compare service users’ self-reported ED and its identification by general practitioners (GP) and to identify socio-demographic variables associated with ED. Method: A convenience sample (N=97) of the general medical service users completed the 12-item version of the General Health Questionnaire (GHQ-12). A score of 11 or above was considered a suspected mental disorder.

The GPs’ clinical assessment of ED was compared with the self-reported score.

Results: The sample’s mean GHQ-12 score was higher than the threshold (M=12.7, SD=6.3, range 0-35). Fifty three percent (n=51) had a GHQ-12 score higher than 11, and 8% (n=8) were identified by the GPs as emotionally distressed and/or in need of psychiatric care. The mean score of the study sample was higher than that found in past studies regarding the Arab-Israeli general population (M=10.8, SD=0.35). Employment was the only socio-demographic variable significantly associated with ED. Conclusions: ED was high among immigrants, but under-diagnosed by GPs. Employment might serve as a protective factor for ED.

Address for Correspondence:

14

INTRODUCTION Migration is an ever-increasing global phenomenon with public and individual emotional health implications (1). Immigrants are a heterogeneous group that includes, among others: migrant workers, refugees and asylum seekers (2). Reported rates of emotional distress (ED) and mental health problems vary in different studies and in different immigrant groups, but are usually higher than that found in the general population (3, 4). In contrast to the high level of reported ED, reports show low rates of mental health service utilization (5, 6). Although primary care practice was described as “de facto mental health care system” (7), there is a low detection rate of ED or psychiatric disorders as diagnosed by GPs in Israel (8, 9) and elsewhere (10, 11), and particularly among immigrant populations (12, 13). The restricted access to specialized psychiatric services emphasizes the important role of GPs who serve this population (13).

If left untreated, these health issues will affect the long-term health of immigrants (14).

Influenced by world trends and the geopolitical climate, Israel has faced waves of non-Jewish immigration, including of migrant workers (both documented and undocumented), mainly from Asia, and asylum seekers, mainly from East Africa (i.e., Sudan, Eritrea) (15, 16). The open clinic for migrant workers, refugees and asylum seekers was established in 1998 by Physicians for Human Rights (PHR)-Israel to deliver free health services to populations that are not eligible for mandatory national health insurance. The clinic provides primary health care and specialized services, including

Ido Lurie, MD, Shalvata Mental Health Center, Hod Hasharon, Israel.

ido.lurie@gmail.com

MICHAL DICK ET AL.

Table 1: Demographic characteristics of participants (N=97) N(%)/Average (SD) Sex

Male

50 (51.5%)

Female

47 (48.5%)

Unknown

10 (10.3%)

Working

71 (73.2%)

37.9 (SD=11)

Not working

22 (22.7%)

Asia

48 (49.5%)

Unknown

4 (4.1%)

Africa

39 (40.2%)

0-6

7 (7.2%)

Europe

8 (8.3%)

6-12

28 (28.9%)

America

2 (2.1%)

12 and above

45 (46.4%)

English

70 (72.2%)

Unknown

17 (17.5%)

Arabic

17 (17.5%)

Christianity

64 (66%)

Hebrew

5 (5.15%)

Islam

19 (19.6%)

Russian

5 (5.15%)

Buddhism

3 (3.1%)

Messianic Jews

1 (1%)

Atheism

1 (1%)

Unknown

9 (9.3%)

Age (years) Continent of origin

Questionnaire language

Duration period in Israel (years) Family status - partner

Partnerâ&#x20AC;&#x2122;s location

Family status - children

Childrenâ&#x20AC;&#x2122;s location

N(%)/Average (SD)

Employment

Years of education

Religion

5.04 (SD= 4.3) Married

47 (48.5%)

With partner

9 (9.3%)

Divorced/separated

8(8.2%)

No permit

39 (40.2%)

Widow/er

5 (5.2%)

Work permit

22 (22.7%)

Single

27 (27.8%)

Asylum seeking permit

0

In Israel

34 (35.1%)

Tourist Visa

13 (13.4%)

Not in Israel

16 (16.5%)

Other permit

7 (7.2%)

Unknown

6 (6.2%)

Missing data

16 (16.5%)

Yes

58 (59.8%)

No

33 (34%)

Unknown

6 (6.2%)

In Israel

19 (19.6%)

Some of the children are in Israel Not in Israel

Legal status

Legal status

When entering Israel

When participating in the research No permit

23 (23.7%)

Work permit

11 (11.3%)

Asylum seeking permit

35 (36.1%)

28 (28.9%)

Tourist Visa Other permit

0 24 (23.7%)

2 (2.1%)

Missing data

5 (5.2%)

15

EMOTIONAL DISTRESS IN ASYLUM SEEKERS AND MIGRANT WORKERS

Table 2: Pearson’s correlations between GHQ-12 scores and demographic variables Variable Sex - female Asia Europe +America Work visa upon arrival Tourist visa at arrival Current unknown visa Current work visa Current asylum/refugee visa Current other visa Have partner Partner In Israel Have children Children in Israel Employment Education Religion- Christian Islam Unknown Religiosity Less Religiosity Age Duration of stay in Israel

r 0.018

The study aimed to compare the service users’ selfreported ED and its identification by GPs and to identify socio-demographic variables associated with ED.

-0.134 0.205* -0.206* 0.150 -0.028 -0.031 0.089 -0.113 0.043 0.073 -0.078 0.114 -0.3** 0.028 -0.063 0.051 0.122 -0.153 -0.125 -0.141

* p<0.05, **p<0.01

psychiatric treatment (17). These services are provided by highly motivated medical personnel that work pro bono, from one to five times per month. Between 1998 and 2010, over 28,000 users attended the clinic, of whom 60% were examined by GPs. Of them, 350 were referred for psychiatric evaluation.

We investigated the possible discrepancy between ED in the clinic population and its identification by the GPs. Results of this study might contribute to better identification of ED among immigrants and appropriate treatment for this population.

16

OBJECTIVES

STUDY DESIGN The study was approved by the institutional review board (IRB) at Shalvata Mental Health Center, affiliated with Tel Aviv University.

We conducted a cross-sectional survey using a convenience sample (N=97) of the population visiting the primary care service in the open clinic between MarchAugust 2010. Inclusion criteria were: adults (age ≥ 18) and minimal language proficiency (reading and writing) in English, Arabic, Russian or Hebrew. Given the recruiting process, we could not document refusal rates.

Patients who were waiting to be examined by GPs were given information regarding the study and were asked to give informed consent to participate in the study. Oral informed consent was approved by the IRB, based on previous similar studies performed in complex study settings (18). Patients were interviewed for demographic data and they completed the 12 item- General Health Questionnaire (GHQ-12). Additional data (demographic and medical) were collected from the patients’ records.

The GHQ-12 is a widely accepted screening tool for ED (19) in primary care settings (20) and in culturally diverse clinics (21, 22). It assesses a person’s current (the last 30 days) status regarding symptoms in the spectrum of common emotional disorders (i.e., depression and anxiety) and problems with everyday functioning. Scores were calculated using Likert scoring method (ranging from 0-3) (23) with total score between 0-36. ED screening threshold was set to 11, as in previous studies (e.g., the World Health Organization study [(24). We also calculated the average GHQ-12 score, that may be used as a cut point in populations in which the threshold was not previously set (25). We used questionnaires in four languages: the original English version and translated versions in Russian, Arabic and Hebrew which were used in the World Mental Health Survey in Israel (26, 27).

The socio-demographic data collected included: sex, age, country of origin, family status, education, religious affiliation and religiosity, duration of stay in Israel, immigration status in Israel (migrant worker, asylum seeker) and employment.

For the GPs’ clinical impression, data were extracted

MICHAL DICK ET AL.

from the patients’ medical records in the clinic (by MD) including: past and current medical conditions, evidence of past or current ED or a diagnosis of a psychiatric disorder, and a current referral for psychiatric evaluation.

STATISTICAL ANALYSIS Data were collected, coded and analyzed using Excel and SPSS 17. The analyses included the estimation of Cronbach’s alpha as a reliability coefficient and descriptive statistics, Pearson correlations for unvaried analysis, one-way analysis of variance (ANOVA) for comparing association of independent variables scores, and a multivariable model using linear regression.

RESULTS The sample (N=97) demographic characteristics are shown in Table 1. The mean GHQ-12 score was 12.7 (SD=6.3, range 0-35). It showed good reliability (Cronbach’s alpha for the whole sample was 0.8).

Using the GHQ-12 with the threshold of 11 or the average score, 51 (52.6%) and 39 (40.2%) patients, respectively, had a score that indicated suspected ED. Eight patients (8.2%) were documented by the GP as having possible ED, of them six explicitly reported the problem. Patients who were identified by the GP as having current ED/psychiatric diagnosis (n=8, 8.2%) had a significantly higher GHQ-12 score compared to those without a GP’s identification or diagnosis (n=91) (M=18.9, SD=10.4, and M=12.3, SD=5.5 respectively, F=(2,94) 4.52, p=0.01). Five (5.2%) were referred for psychiatric evaluation.

Ten patients (10.3%) had previous documentation of ED/past psychiatric diagnosis in the GPs’ files. Those patients had a significantly higher GHQ-12 mean score than those without (M=17.1, SD=9.9, and M= 12.0, SD=5.6 respectively, F(2,94)=3.09, p=0.05).

Pearson’s correlations between questionnaires’ scores and demographic data showed weak to medium correlations (Table 2). Employment variables (i.e., working visa upon arrival (r=-0.21, p<0.05), current employment (r=-0.3, p<0.01)) showed a significant negative correlation with ED whereas America and Europe as continents of origin showed a significant positive correlation. Employment status was the only variable that had significant effect in a stepwise multivariate linear regression analysis (F=9.2(1,94) , R2 = 0.09, p=0.03).

The GHQ-12 mean score of the study sample was

higher than that found in past studies regarding the Arab-Israeli (M=10.8, SD=0.35) general population.

DISCUSSION In this study we sought to identify a possible discrepancy between self-reported ED (using the GHQ-12) of immigrant primary care users and its identification

by GPs. Our results indicate that the average score was higher than the threshold set for ED. However, the GPs detection rate of ED was relatively low (8%), and even fewer patients were referred for further psychiatric evaluation (5%). This finding is in accord with previous studies regarding the low identification rate of patients’ ED among non-psychiatric physicians (28-31), and in immigrants (12). Possible explanations include time restrictions, communication problems and detection skills (32) and inter-observer bias (i.e., variation among different observers) (20).

Dealing with immigrant populations, possible additional explanations include language barriers, cultural gaps (4) and a “nihilistic approach” by GPs, under the assumption that ED is a natural state for immigrants.

A possible conclusion from these results is the importance of cultural competence training, which may improve the attitudes and skills of health professionals, and may have positive effects on the quality of services delivered to immigrants (33, 34).

There are obvious methodological problems with comparing average GHQ-12 results from different studies.

However, the immigrants’ average GHQ-12 score was higher than the previously reported for the Israeli Arab general population (26) and for the Arab population in primary clinics (35), possibly reflecting the negative impact of the immigration process. The GHQ-12 score was similar to scores in refugees in other places (e.g., refugees from the Middle East in Sweden [(36)], and among older Somali refugees in Finland [(37)]).

Employment was the only socio-demographic factor that demonstrated a significant and consistent association with GHQ-12 scores. This is in line with previous reports showing that employment is a protective factor for ED among immigrants (4, 38). Employment can contribute to one’s sense of confidence and can answer both psychological and financial needs (39).

In contrast to our initial assumptions, other sociodemographic variables (e.g., legal status, sex, age and continent of origin) did not show consistent significant association with the GHQ-12 scores. This may be attrib17

EMOTIONAL DISTRESS IN ASYLUM SEEKERS AND MIGRANT WORKERS

uted to the relatively small sample size of such a heterogenic population that failed to achieve statistical power.

In addition, the affecting variables explained only some of the scores variance (9%). This fact together with the lack of correlations might demonstrate the impact of other unique factors influencing this population (40, 41) and the need further evaluation. One of these factors might be discrimination, previously found to have a major influence on ED in other immigrant populations (42).

LIMITATIONS The study has various methodological problems, including a relatively small sample size and use of non-random sampling process (a selection bias), which are common in immigrant health research (3).

Limitations regarding the GHQ-12 include high reliability that is attributed by some to a response bias for the negative or ambiguous items (e.g., the lack of differentiation in answering the question “felt constantly under strain” in persons with or without baseline emotional distress, accentuated by Likert scoring method) (43), being a screening tool with a relatively low positive predictive value (44, 45), and the existence and influence of cultural bias (46).

In addition, we used a threshold that was determined in previous studies using a two-phase model, with a second diagnostic stage that was not conducted in our study.

Threshold scores differ from one setting and population to another (24, 25). It is possible that a higher threshold would allow better identification.

Despite these limitations, our work is important for better characterizing migrants’ health needs and ED. The right to healthcare for immigrants was anchored in international treaties. However, immigrants are an excluded population and may lack resources and opportunities to benefit from suitable health care (13, 46). Identification of ED and its treatment are challenges that both health professionals and policy makers need to address. In the absence of such efforts, migrants’ capacity to contribute to host societies will be constrained. Similarly, employment may contribute both to immigrants as a protective factor and to the host society that can benefit from their integration into the work force and prevention of social exclusion.

References 1. World Health Organization. Health of migrants: The way forward - report of a global consultation. Madrid, Spain, 3-5 March 2010, World Health

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Organization, 2010. http://www.who.int/hac/events/3_5march2010/en/.

2. Pace P. Migration and the right to health. A Review of European Community Law and Council of Europe Instruments. International Organization of Migration. 2007. http://publications.iom.int/bookstore/ free/IML_12_EN.pdf 3. Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brahler E. Depression and anxiety in labor migrants and refugees – a systematic review and meta-analysis. Soc Sci Med 2009;69:246-257.

4. Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: General approach in primary care. CMAJ 2011;183:E959-67.

5. Kirmayer LJ, Weinfeld M, Burgos G, et al. Use of health care services for psychological distress by immigrants in an urban multicultural milieu.

Can J Psychiatry 2007;52:295-304.

6. Fenta H, Hyman I, Noh S. Mental health service utilization by Ethiopian immigrants and refugees in Toronto. J Nerv Ment Dis 2006;194:925-934.

7. Higgins ES. A review of unrecognized mental illness in primary care.

Prevalence, natural history, and efforts to change the course. Arch Fam Med 1994;3:908-917.

8. Shiber A, Maoz B, Antonovsky A, et al. Detection of emotional problems in the primary care clinic. Fam Pract 1990;7:195-200.

9. Taubman-Ben-Ari O, Rabinowitz J, Feldman D. Post-traumatic stress disorder in primary-care settings: Prevalence and physicians’ detection.

Psychol Med 2001;31:555-560.

10. Munk-Jørgensen P, Fink P, Brevik JI, et al. Psychiatric morbidity in primary public health care: A multicentre investigation. Part II. Hidden morbidity and choice of treatment. Acta Psychiatr Scand 1997;95:6-12.

11. Mitchell AJ, Rao S, Vaze A. International comparison of clinicians’ ability to identify depression in primary care: Meta-analysis and metaregression of predictors. Br J Gen Pract 201;61:e72-80.

12. Caplan S, Alvidrez J, Paris M, et al. Subjective versus objective: An exploratory analysis of Latino primary care patients with self-perceived depression who do not fulfill primary care evaluation of mental disorders patient health questionnaire criteria for depression. Prim Care Companion J Clin Psychiatry 2010;12(5). pii: PCC.09m00899. doi: 10.4088/PCC.09m00899blu.

13. Kaltman S, Pauk J, Alter CL. Meeting the mental health needs of lowincome immigrants in primary care: A community adaptation of an evidence-based model. Am J Orthopsychiatry 2011;81:543-551.

14. Tiong AC, Patel MS, Gardiner J, Ryan R, Linton KS, Walker KA, et al.

Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 2006;185:602-606.

15. Data regarding foreign workers in Israel- 2010- Population, Immigration and Border Authority in the Ministry of the Interior(PIBA). http://www. piba.gov.il/PublicationAndTender/ForeignWorkersStat/Documents/ summary2010.pdf.

16. Central Bureau of Statistics, State of Israel, press released data (in Hebrew). http://www.cbs.gov.il/reader/newhodaot/hodaa_template. html?hodaa=201120182 17. Lurie I. Psychiatric care in restricted conditions for work migrants, refugees and asylum seekers: Experience of the Open Clinic for Work Migrants and Refugees, Israel 2006. Isr J Psychiatry Relat Sci 2009;46:172-181.

18. de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet 2003;361:2128-2130.

19. Goldberg D, Williams P. A user’s guide to the General Health Questionnaire: NFER-Nelson, 1991.

20. Goldberg DP, Blackwell B. Psychiatric illness in general practice. A detailed study using a new method of case identification. Br Med J 1970;1:439-443.

21. Jacob KS, Bhugra D, Mann AH. The validation of the 12-item General Health Questionnaire among ethnic Indian women living in the United Kingdom. Psychol Med 1997;27:1215-1217.

22. Abubakar A, Fischer R. The factor structure of the 12-item General Health Questionnaire in a literate Kenyan population. Stress Health

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23. Banks MH, Clegg CW, Jackson PR, et al. The use of the General Health Questionnaire as an indicator of mental health in occupational studies.

J Occupational Psychol 1980;53:187-194.

24. Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997;27:191-197.

25. Goldberg DP, Oldehinkel T, Ormel J. Why GHQ threshold varies from one place to another. Psychol Med 1998;28:915-921.

26. Levav I, Al-Krenawi A, Ifrah A, et al. Common mental disorders among Arab-Israelis: Findings from the Israel National Health Survey. Isr J Psychiatry Relat Sci 2007;44:104-113.

27. Levinson D, Paltiel A, Nir M, Makovki T. The Israel National Health Survey: Issues and methods. Isr J Psychiatry Relat Sci 2007;44:85-93.

28. Nielsen AC, Iii, Williams TA. Depression in ambulatory medical patients: Prevalence by self-report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psychiatry 1980;37:999-1004.

29. McQuaid JR, Stein MB, Laffaye C, et al. Depression in a primary care clinic: The prevalence and impact of an unrecognized disorder. J Affect Disord 1999;55:1-10.

30. Vazquez-Barquero JL, Garcia J, Simon JA, et al. Mental health in primary care. An epidemiological study of morbidity and use of health resources.

Br J Psychiatry 1997;170:529-535.

31. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317-325.

32. Goldberg D. Epidemiology of mental disorders in primary care settings.

Epidemiol Rev 1995;17:182-190.

33. Beach MC, Price EG, Gary TL, et al. Cultural competence: A systematic review of health care provider educational interventions. Med Care 2005;43:356-373.

34. Beach M, Gary T, Price E, et al. Improving health care quality for racial/ ethnic minorities: A systematic review of the best evidence regarding provider and organization interventions. BMC Public Health 2006;6:104.

35. Lindencrona F, Ekblad S, Hauff E. Mental health of recently resettled

refugees from the Middle East in Sweden: The impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Soc Psychiatry Psychiatr Epidemiol 2008;43:121-31.

36. Molsa M, Punamaki RL, Saarni SI, et al. Mental and somatic health and pre- and post-migration factors among older Somali refugees in Finland. Transcult Psychiatry 2014;51:499-525.

37. Pernice R, Trlin A, Henderson A, North N, Skinner M. Employment status, duration of residence and mental health among skilled migrants to New Zealand: Results of a longitudinal study. Int J Soc Psychiatry 2009;55:272-287.

38. Nordenmark M, Strandh M. Towards a sociological understanding of mental well-being among the unemployed: The role of economic and psychosocial factors. Sociology1999;33:577-597.

39. Messias DK, Rubio M. Immigration and health. Annu Rev Nurs Res 2004;22:101-134.

40. Shidhaye R, Patel V. Association of socio-economic, gender and health factors with common mental disorders in women: A populationbased study of 5703 married rural women in India. Int J Epidemiol 2010;39:1510-1521.

41. Agudelo-Suarez AA, Ronda-Perez E, Gil-Gonzalez D, et al. The effect of perceived discrimination on the health of immigrant workers in Spain.

BMC Public Health 2011;11:652.

42. Hankins M. The reliability of the twelve-item general health questionnaire (GHQ-12) under realistic assumptions. BMC Public Health 2008;8:355.

43. Cano A, Sprafkin RP, Scaturo DJ, et al. Mental health screening in primary care: A comparison of 3 brief measures of psychological distress. Prim Care Companion J Clin Psychiatry 2001;3:206-210.

44. Makowska Z, Merecz D, Moscicka A, Kolasa W. The validity of general health questionnaires, GHQ-12 and GHQ-28, in mental health studies of working people. Int J Occup Med Environ Health 2002;15:353-362.

45. Lewis G, Araya RI. Is the General Health Questionnaire (12 item) a culturally biased measure of psychiatric disorder? Soc Psychiatry Psychiatr Epidemiol 1995;30:20-25.

46. World Health Organization (WHO). Ensuring access to health services and financial protection for migrants 2010. http://www.who.int/ healthsystems/topics/financing/healthreport/MigrationTBNo12.pdf.

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

Medical Clowning and Psychosis: A Case Report and Theoretical Review Alex Gruber, 1,2 Raz Levin, MSc,2,3 and Pesach Lichtenberg, MD2,3 1

Psychodramatist, Dream Doctors Project, Israel Herzog Memorial Hospital, Jerusalem, Israel 3 Faculty of Medicine of the Hebrew University of Jerusalem, Israel 2

ABSTRACT The medical clown has become an accepted therapeutic figure in non-psychiatric hospital departments in recent years. However, the potential role of the clown in psychiatry, especially for the treatment of psychosis, has not been investigated. We report here on the functioning of a medical clown in an inpatient psychiatric department. A program using psychodramatic group therapy techniques with the clown serving as moderator was developed.

We describe the case of one individual diagnosed with schizophrenia who in the course of four and a half months of group therapy led by the medical clown was able to adopt a succession of surprising roles. This process may have contributed to the patient’s remission. We discuss the special capacity of medical clowns to encourage communication and indulge in fantasy while returning to consensual reality. We suggest that this may have particular relevance in work with psychotic individuals.

Acknowledgements This project was funded by the Dream Doctors Project.

INTRODUCTION As disaffection has grown in recent years with the biomedical model of severe psychiatric illness and the limits of pharmacological interventions, new directions have been sought in research and treatment. Common to many of these efforts is encountering the sufferer as a person whose distress has meaning which may be grasped and Address for Correspondence:

20

form the basis of therapy.

A novel approach not yet evaluated in the treatment of psychosis is medical clowning. In general hospitals, medical clowns’ purpose is to minimize stress for patients and their families during hospitalization and treatment (1). Several randomized controlled trials (RCTs) indicate that the presence of a medical clown reduces anxiety in the presurgical period among hospitalized children (2-5) and their parents (6, 7). Medical clowns can alleviate the negative effects of hospitalization in children and enhance the well-being of hospitalized children, their parents and staff members (8). Humor therapy RCT by “elder clowns” in nursing houses did not reduce depression but significantly reduced agitation (9).

Medical clowns provide far more than a good laugh.

They can play the role of a lowly fool; by comparison, the hospitalized psychotic patient may feel empowered.

The clown can, as in psychodrama, show the patient how to maintain a distance from the role he is playing.

For the patient, this distance can provide a perspective from which to rethink his sick role as a powerless patient.

Finally, the clown invites the participant to adopt the role not only of family members and significant others (as is generally the case in psychodrama), but of any imagined fantastical figure he desires. In this manner, and by virtue of the makeup on his face and the red bulb on his nose, the clown allows the patient to stretch the boundaries of reality without fear of losing connection with it. This consideration in particular makes medical clowning an intervention worth evaluating in the treatment of psychotic patients.

In this brief case report we describe a group therapy intervention by a medical clown (AG) working in an inpatient psychiatric department. We focus on the therapeutic process of a specific patient with schizophrenia

Pesach Lichtenberg, MD, Herzog Hospital, POB 3900, Jerusalem 91035, Israel

licht@cc.huji.ac.il

ALEX GRUBER ET AL.

(B). To our knowledge, this is the first time in Israel, and perhaps elsewhere, that a medical clown became part of the treatment staff in such a setting.

THE THERAPEUTIC CLOWNING PROCEDURE AG, a medical clown who uses the professional name Professor Chimichurri, has developed the therapeutic program in which the treatment we report took place.

This program included one hour a week of group therapy with AG costumed as a clown. Each therapeutic session involved a psychodramatic therapeutic paradigm with three stages: introduction and warming up, role playing, and de-roling. In the first stage AG asks each participant his name and how he feels today, and then explains the session’s procedure to the participants. Afterwards, AG plays some recorded music and each group member makes a movement which the rest of the group repeats.

At the second stage, the role playing stage, AG ask each person in the group to choose a costume (hat or accessory) and to imagine himself as a fictional or real character whom they would like to meet (e.g., relatives, people they haven’t met for a long time, people whom they would like to meet either because they miss them or on account of unfinished business, etc.). The participant talks and behaves as the character and AG asks him why the character has appeared and encourages him to communicate with the group. Sometimes AG asks the individual to act again as himself in order to highlight the gap between their own vs. their character’s points of view. At the third stage, the de-roling and session summary, AG asks the group member to shed the character and to resume being himself. Afterwards, AG concludes the meeting while ascertaining that no one is confused.

The role of the group moderator in this therapy includes several components: maintaining a positive atmosphere conducive to the functioning of each individual in the group; facilitating patient participation in each phase of the therapy; clarifying what was taking place on the stage whenever necessary; and reflecting the emotional states of the participants. The moderator refrains from suggesting psychodynamic interpretations.

THE STORY OF B

B, a 28-year-old religiously observant single Jewish man with a DSM-IV diagnosis of schizophrenia, participated in the group therapy. B heard voices telling him that he was a pathetic, worthless individual. He was intermittently catatonic and always with blunted affect, limited speech, pas-

sivity and low self-confidence. Pharmacotherapy included in the past a wide range of antipsychotic medication, but for the duration of the treatment described here remained unchanged with quetiapine 600 mg daily. He did not function in individual psychotherapy. Nevertheless, he agreed to participate in group therapy with a medical clown.

Early in the treatment B chose to be a policeman. He was rigid, with minimal body movements and virtually no speech. Two weeks later, B chose to be “David the builder.” He made some sharp movements with a hammer that he took from the available accessories and seemed pleased with the character that he chose. By the next session, B chose to be “Barbapapa the policeman,” a fictional persona. He was happy and had a childish smile during the meeting. His next choice was to play a first grade teacher. He roamed all over the room. The therapist had a sense that B was becoming more enthusiastic in the group and starting to grasp its potential.

Subsequently, B adopted the role of a pantomimist. It seemed as if his body was freed while his speech remained mute, catatonic. Two weeks later, though stressed by an imminent meeting with the medical staff, B chose to be an energetic chef who baked cakes. Two weeks after that, B was the fictional singer “Kemari,” famous for his soul songs. B sang a popular song, to the applause of the group.

The next session was particularly dramatic. B became Simba the lion king. He entertained the group with tales of life in the jungle and declared that his duty was to protect other animals, a role he carried out symbolically.

He continued to expand his dramatic repertoire, and, at the next session, played a stand-up comedian who successfully aroused laughter among fellow patients, his audience. (We stress that outside the group he exhibited no signs of mania.)

At the following meeting, B’s choice of roles took a turn for the amusingly bizarre. He became an astronaut visiting aliens. AG asked B about life in outer space, and suggested that B teach the group the famous alien dance.

B surprised everybody by performing modern ballet movements, moving his hands and the rest of the body, while emitting eerie noises.

In the final meeting, B became Spiderman. He walked around the room by “launching” his cobweb with precise movements. He told the group about his relationship with Superman, whom he considered a dull figure. As Spiderman, he allowed himself to laugh at Superman, and demonstrated a cultivated sense of humor.

In the course of the meetings, over a span of four and a half months, B made great progress, as reflected 21

MEDICAL CLOWNING AND PSYCHOSIS: A CASE REPORT AND THEORETICAL REVIEW

in his greater social interactions and general functioning. Outside of the group as well, in outpatient follow up, B appeared more confident, and was able to join a sheltered workshop. He said that the voices no longer troubled him, though he was unwilling to discuss the matter further, and while he agreed that he felt better and had enjoyed the group therapy, he was unable to attribute his improvement to anything specific.

DISCUSSION We have presented here the group therapy of a patient diagnosed with schizophrenia who had serious impairment of functioning, suffered from hearing malicious voices, and exhibited significant negative symptoms. In the course of four and a half months of group therapy led by a medical clown, his well-being, subjectively reported and objectively assessed, improved significantly, and he became far less symptomatic. While psychopharmacology may have played a role, B seemed to have improved to an extent beyond what he had known for many years, during much of which he had been on medication. We therefore attribute much of the improvement to the therapeutic process. To understand how this might have happened, we will try to provide historical and conceptual background about clowning (see ref. 10, to which we are indebted).

In the course of our lives, we are called upon to play different roles within the social world. These roles are units of culture which provide a template by which a person interacts with others. People ordinarily comprise within themselves a dynamic variety of roles for different situations. A balance between these different roles is an important aspect of health (11, 12). Drama therapy is an attempt to broaden the variety of roles which a person can wield, and to help him cope as well with the roles of others.

The clown may perform a special function in this area.

A clown is considered to “lack an understanding of or respect for social norms and decorum” (13, p. 246). Either from miscomprehension or – like a Shakespearian court jester - out of deeper awareness of the situation and the daring to parody it, he acts in unacceptable ways. The medical clown, while exploiting these functions, makes special use of empathy and compassion in his work.

Yet the clown is a different kind of social role. Rather than developing in response to social interactions, the clown in his role is true to his own logic and understanding. This is a trait which can provide him with special empathy for a psychotic person. Similarly, the clown’s 22

ability to embrace contradiction, to be both lovable and ostracized, to be in constant motion while flouting any rules of logic, can make the psychotic person’s world more accessible (14).

Moreover, a person with psychosis sometimes appears to concretize his fantasies till they appear real to him, rather than the fruit of his imaginings. A clown, by the absurd role that he plays, is a sort of walking Winnicottian transitional space, presenting the possibility of embodying a role without being consumed by it. This too is a model with special significance for the treatment of psychosis (15).

Finally, a person who is in sufficient distress to be hospitalized may find himself stripped of personal identity, constrained to eat, sleep, and bathe with others, constricted to the role of a “mental patient,” and at the bottom of the social hierarchy. The clown’s intervention here can be twofold. First of all, as with psychodrama, the clown holds out the possibility of assuming roles of the person’s choosing beyond remaining solely a mental patient. Even more than in psychodrama, the possible roles one may choose with a clown are unlimited by reality testing. Secondly, the clown, playing a figure of derision, allows the patient to feel less inferior than he ordinarily would in dealings with the purportedly healthy, normative staff. This too differentiates psychiatric medical clowning from psychodrama.

We suggest that medical clowning with individuals suffering from psychosis may offer special advantages over other therapies, including psychodrama or drama therapy.

In particular, the clown, as a bizarre figure who flouts the boundaries of consensual reality, may be privileged with unique access into the world of the psychotic. But this strength may also present a danger by providing an unintended legitimacy of a psychotic reality.

A recent hi-tech innovation in therapy with psychotic patients bears a resemblance to what we are trying to accomplish with medical clowning. Leff and colleagues (16) used a computer-generated avatar to treat medication-resistant auditory hallucinations. The therapist communicates with the patient via a computer screen exhibiting a face chosen by the patient as appropriate to how the latter imagines the source of the voice, in a voice similar to the perceived auditory hallucination. As with our psychiatric medical clowning, the patient can learn to relate differently to the personified source of his psychotic distress. A potential advantage of medical clowning is that unlike avatar therapy, it need not be limited to hallucinatory symptoms but can deal with

ALEX GRUBER ET AL.

delusions as well. Further work will of course be necessary to show that this is so.

In the case of B, all of these components of therapeutic clowning came into play. B started therapy silent and passive. Even before hospitalization, the roles he adopted in his life were severely restricted, and became more so once admitted. He was deeply unsure of himself, acutely uncomfortable in dealing with staff, and unable or unwilling to participate in individual psychotherapy. He was particularly reticent with medical staff. Yet invited to join a therapy group by a man with stripes on his face, a round red nose, a garishly colored jacket, and shoes the size of his arms, B agreed.

In the course of therapy, he chose a succession of roles which would have been unavailable to him outside of the group. First he was a policeman, which might have been some sort of punitive introject, that allowed him to identify with the aggressor. Subsequently, his choice of figures became increasingly absurd, in a way that conventional psychodrama might not have allowed. As he discovered his voice, he went from a silent pantomimist to a singer and stand-up comedian. Empowered, he became the king of the jungle and a superhero. Though deroled at the end of each session, the benefits remained with him afterwards. He no longer conducted himself as some sort of lower caste figure in a psychiatric department hierarchy.

He was more active and comfortable being “himself ” with other people. He was able to enter a rehabilitation program. The voices appeared to continue, but caused less distress. He remained wary of medical personnel, further heightening the contrast in his comfortable connection with the medical clown.

Of course, this is only an anecdotal case report, with the attendant limitations. A case report is hardly enough to prove the value of a treatment modality. Selection bias is inherent to a case study: Of the various participants in the therapy, we chose to tell B’s story because he seemed to flourish in this modality of therapy. The story of the other patients would have been less dramatic. We also used no structured scale to quantify B’s progress. These shortcomings need to be overcome in subsequent studies.

One may claim that the progress in B’s condition derive from the elements of drama therapy in the group activity. Perhaps drama therapy would have been sufficient to produce the gains we saw. And medication may have affected symptomatology as well. Our impression remains that the surprising freedom exercised by B in the group, the joyful absurdity of his choices of roles that might have been inhibited by more conventional therapy, and the

empowerment and self-confidence which seemed to be beyond the symptomatic improvement one might hope to achieve pharmacologically, all point to the crucial benefit of the red-nosed therapist.

Corroboration of the special benefits of clown therapy with psychotic patients and in psychiatric wards will require wider experience and additional reports. A controlled study might usefully employ standard drama therapy for comparison. We hope that this promising therapeutic modality, new to psychiatry, will be further exploited and researched.

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12. Landy R. Role theory and the role method of drama therapy. In: Johnson D, Emunah R, editors. Current approaches in drama therapy. Springfield, Ill.: Charles C. Thomas, 2009.

13. Carp C. Clown therapy: The creation of a clown character as a treatment intervention. The Arts in Psychotherapy 1998; 25:245-255.

14. Handelman, D. The clown as a symbolic type. In: Models and mirrors: Towards anthropology of public events. New York: Cambridge University, 1990.

15. Winnicott DW. Playing and reality. London: Penguin, 1971.

16. Leff J, Williams G, Huckvale MA, Arbuthnot M, Leff AP. Computerassisted therapy for medication-resistant auditory hallucinations: Proofof-concept study. Br J Psychiatry 2013;202:428-433

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

How Do Meaning in Life and Positive Affect Relate to Adaptation to Stress? The Case of Firefighters Following the Mount Carmel Forest Fire Amit Shrira, PhD,1 Dov Shmotkin, PhD,2 Yuval Palgi, PhD,3 Yechiel Soffer, PhD,4 Yaira Hamama Raz, PhD,5 Patricia TalKatz, PhD,5 Menachem Ben-Ezra, PhD,5 and Charles C. Benight, PhD6 The Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat Gan, Israel Department of Psychology and the Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel 3 Department of Gerontology, University of Haifa. Haifa, Israel 4 Department of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel 5 School of Social Work, Ariel University 6 Department of Psychology, CU Trauma, Health, & Hazards Center, University of Colorado Springs, Colorado, U.S.A. 1

2

ABSTRACT Background: We examined how positive affect (PA) and meaning in life (MIL) conjointly regulate posttraumatic stress disorder (PTSD) symptoms and perceived coping self-efficacy. Hypotheses were guided by a recent holistic model, according to which PA and MIL should compensate for each other in relating to adaptation to high stress.

Method: The sample included 75 Israeli firefighters who took active part in extinguishing the 2010 Mount Carmel forest fire.

Results: PA and MIL helped to compensate for the other, demonstrating that when one of them was low, the other related to higher adaptation. That is, under low MIL, PA related to PTSD symptoms and coping self-efficacy, and under low PA, MIL related to PTSD symptoms and coping self-efficacy.

Limitation: The study design was cross-sectional and therefore precluded any causal inferences.

Conclusions: The findings lend additional support to the holistic model and help to understand how subjective well-being and MIL correlate with adaptation to stress.

Address for Correspondence: amit.shrira@biu.ac.il

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Subjective well-being (SWB) refers to the extent to which people perceive their lives as favorable in terms of satisfaction and happiness (1). MIL refers to the extent to which people perceive essential aspects of their lives as having significance and purpose (2). A recent holistic model (3-5) regards SWB and MIL as complementary systems interacting in order to facilitate coping with the hostile world scenario (HWS), one’s image of perceived actual or potential threats to one’s physical and mental integrity.

Whereas SWB can make the HWS more manageable by letting individuals evaluate their lives positively during negative conditions, MIL can make the HWS more interpretable by helping individuals make sense of what is happening.

Beyond their unique operations, the holistic model refers to how SWB and MIL conjointly operate in stressful situations (5). SWB and MIL are assumed to be more closely associated with each other as life adversity intensifies (6). This amplification mode may be explained by the increasing need, while facing adversity, to mobilize resources residing in the overlap between SWB and MIL. In addition, MIL and SWB may compensate for each other. That is, MIL is proposed to be utilized more when SWB is not providing adequate relief, and vice versa (4).

The current study aimed to examine the interaction

Amit Shrira, PhD, Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat Gan 52900, Israel.

AMIT SHRIRA ET AL.

of positive affect (PA), a major component of SWB, with MIL in relating to posttraumatic stress disorder (PTSD) symptoms and perceived coping self-efficacy among firefighters exposed to the 2010 Mount Carmel forest fire. Coping self-efficacy was assessed alongside PTSD symptoms, as it taps a more general belief regarding one’s ability to cope with the range of emotional reactions following extreme stress and manage on-going environmental demands (7).

Following the assumptions suggested by Shmotkin and Shrira (4, 5), we hypothesized that PA and MIL would compensate for each other. That is, under low MIL, PA would relate to adaptation (i.e., low PTSD symptoms and high coping self-efficacy), and under low PA, MIL would relate to adaptation (i.e., low PTSD symptoms and high coping self-efficacy).

METHOD PARTICIPANTS AND PROCEDURE

Seventy-five male firefighters who reported to take active part in extinguishing the 2010 Mount Carmel forest fire participated in the study, one month later in January, 2011. Mean age was 36.66 (SD = 7.80). Firefighters completed the questionnaires independently between shifts after signing an informed consent form. The study was approved by the Institutional Review Board in the School of Social Work at Ariel University.

MEASURES

PTSD symptoms over the past week were assessed by the 22-item Impact of Event Scale-Revised (IES-R; 8). PTSD symptoms score was the respondent’s sum of ratings (Cronbach’s α=.90).

Table 1. Descriptive Statistics and Correlations for the Study Variables M

SD

Range

1

1. PTSD symptoms

12.89

11.74

0-42

-

2. Coping self-efficacy

115.77

17.53

50-140

-.36**

-

3. Positive affect

4.19

0.60

2.33-5.00

-.17

.20

-

4. Meaning in life

5.78

0.99

2.50-7.00

-.24*

.17

.27*

Note. N = 75. PTSD = Posttraumatic stress disorder. * p < .05; ** p < .01.

2

3

Coping self-efficacy was assessed by the 20-item Firefighter Coping Self-Efficacy Scale (FFCSE; 9). Coping self-efficacy score was the respondent’s sum of ratings (Cronbach’s α=.89).

Positive affect (PA) was measured with the 6-item positive affect subscale from the Scale of Positive and Negative Experience (10). The PA score was the respondent’s mean rating (Cronbach’s α=.84).

Meaning in Life (MIL) was assessed by the 5-item “presence of meaning” subscale of the MIL Questionnaire (11). The MIL score was the respondent’s mean rating (Cronbach’s α=.70).

RESULTS Table 1 presents descriptive statistics and correlations for the study variables.

In order to examine the hypothesis, PTSD symptoms and coping self-efficacy were regressed in multiple hierarchical regressions on PA and MIL in Step 1 and on their interaction in Step 2. All continuous variables were Table 2. Hierarchical Regression Analyses Predicting PTSD symptoms and Coping Self-Efficacy PTSD symptoms B

SE

β

Coping self-efficacy B

SE

β

Step 1

(Δ R2 = .069)

Positive affect

-.11

.11

-.11

.17

.12

.17

Meaning in life

-.20

.11

-.20

.12

.12

.12

Step 2

(Δ R2 = .074*)

Positive affect X Meaning in life

.24

Complete model

(R2 = .144*)

.09

(Δ R2 = .056)

(Δ R2 = .051*) .27*

-.20

.10

-.23*

(R2 = .108*)

Note. N = 75. All variables were standardized. Only additional variables are shown in the results of Step 2. PTSD = Posttraumatic stress disorder. * p < .05; ** p < .01.

standardized and standardized values were multiplied to obtain interaction terms (12).

Table 2 presents the results for these hierarchical regression analyses. The analyses showed that PA and MIL did not predict PTSD symptoms or coping selfefficacy, but that the PA X MIL interaction was significant in both cases.

Figure 1 presents these interactions. The figure shows that there was no relationship between MIL and PTSD symptoms/coping self-efficacy when PA was high, but when PA was low, MIL was negatively correlated with 69

MEANING IN LIFE AND AFFECT IN FIREFIGHTERS

The cross-sectional design of the study precluded any causal inferences, and future longitudinal designs are needed in order to better understand (b) Coping self-efficacy (a) PTSD symptoms the mutual influences of PA, MIL, PTSD symptoms, and coping self-efficacy. Our relatively small and unique sample included people who were exposed to multiple adversities, and who reported relatively low levels of PTSD symptoms.

Future studies should try to replicate the findings in larger, more diverse samples, using additional measures of SWB. These limitations notwithstanding, the current study is the first which tested our model by referring to the conjoint operation of PA and MIL vis-à-vis PTSD symptoms and PTSD symptoms and positively correlated with copcoping self-efficacy. ing self-efficacy. Plotted differently, the figures showed that there was no relationship between PA and PTSD symptoms/coping self-efficacy when MIL was high, but References when MIL was low PA was negatively correlated with 1. Eid M, Larsen RJ, editors. The science of subjective well-being. New York: Guilford, 2008.

PTSD symptoms and positively correlated with coping 2. Steger MF. Meaning in life. In Snyder CR, Lopez SJ, editors. Oxford self-efficacy. handbook of positive psychology (2nd ed.). Oxford, UK: Oxford Figure 1. The interactions between meaning in life and positive affect in predicting posttraumatic stress disorder (PTSD) symptoms and coping self-efficacy (numbers represent standardized scores).

DISCUSSION This study examined how PA and MIL interactively relate to PTSD symptoms and coping self-efficacy among Israeli firefighters following a deadly fire. The findings showed that PA and MIL interactively compensated each other.

One of the components (either PA or MIL) relate to higher adaptation to stress (i.e., low PTSD symptoms and high coping self-efficacy) when the other component (either MIL or PA) was failing to preserve a favorable psychological environment (i.e., was low). That is, under low MIL, PA related to PTSD symptoms and coping self-efficacy, and under a low PA, MIL related to PTSD symptoms and coping self-efficacy.

The current findings join previous ones (6), and together they suggest that the conjoint application of SWB and MIL is particularly relevant to adaptation when the HWS looms (3-5). More specifically, these findings support the compensation assumption that was previously validated among those with high cumulative adversity (6). As the model predicts, when it is hard for them to rely on SWB, individuals can cope by reinstituting MIL (4). When MIL is gravely undermined by adversity, SWB can become more tightly associated with functioning (5). In sum, under high distress, SWB and MIL can compensate for each other.

70

University, 2009: pp. 679-687.

3. Shmotkin D. Happiness in face of adversity: Reformulating the dynamic and modular bases of subjective well-being. Rev Gen Psychol 2005; 9:291-325.

4. Shmotkin D, Shrira A. On the distinction between subjective wellbeing and meaning in life: Regulatory versus reconstructive functions in the face of a hostile world. In Wong PTP, editor. The human quest for meaning: theories, research, and applications (2nd ed.). New York: Routledge, 2012: pp. 143-164.

5. Shmotkin D, Shrira A. Subjective well-being and meaning in life in a hostile world: Proposing a configurative perspective. In Hicks JA, Routledge C, editors. The experience of meaning in life: Classical perspectives, emerging themes, and controversies. New York: Springer, 2013: pp. 77-86.

6. Shrira A, Palgi Y, Ben-Ezra M, Shmotkin D. How do subjective wellbeing and meaning in life interact in the hostile world? J Posit Psychol 2010; 6:273-285.

7. Benight CC, Bandura A. Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behav Res Ther 2004; 42:1129-1148.

8. Weiss DS, Marmar CR. The Impact of Event Scale–Revised. In Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford, 1997: pp. 399-411.

9. Lambert JE, Benight CC, Harrison E, Cieslak R. The firefighter coping self-efficacy scale: Measure development and validation. Anxiety Stress Coping 2012; 25:79-91.

10. Diener E, Wirtz D, Tov W, Kim-Prieto C, Choi DW, Oishi S, BiswasDiener R. New well-being measures: Short scales to assess flourishing and positive and negative feelings. Social Indic Res 2010; 97:143-156.

11. Steger MF, Frazier P, Oishi S, Kaler M. The meaning in life questionnaire: Assessing the presence of and search for meaning in life. J Couns Psychol 2006; 53:80-93.

12. Aiken, LS, West SG. Multiple regression: Testing and interpreting interactions. Newbury Park, Cal.: Sage, 1991

JACEK BOMBA

The Israeli-Polish Mental Health Association: Its History and Activities Jacek Bomba, MD, Professor of Psychiatry (Emeritus) The J.J. Haubenstock Foundation, Director The Jagiellonian University Collegium Medicum, Department of Psychiatry, Kraków, Poland

ABSTRACT The Israeli-Polish Mental Health Association (IPMHA) was founded in 2000. It is a unique organization as it is not only one of the many associations for mental health professionals but also a platform for people from distant countries who share an important and traumatic past. IPMHA members have been engaged in studies of consequences of massive trauma, intergenerational transmission of trauma and help for trauma survivors.

Keeping in mind the obligation of mental health professions to contribute to an enlightened and tolerant society, the IPMHA members have been trying to deal with “the past in the present,” investigating the roots of the harm caused by racial and ethnic hatred, anti-Semitism and other forms of social prejudice.

The IPMHA activities included symposia with discussions facilitated by the use of the dynamic group formula. Some of the materials presented in the meetings were published in Polish professional journals. This article reports on the activities of the IPMHA with special focus on the accompanying emotionally loaded problems.

Psychiatrists as well as other mental health professionals have been organizing themselves forming associations on national and international levels. Care for professional standards, continuous post-graduate training, exchange of thoughts and experience, promoting research in mental health can be found among declared goals of the associations. Some of international associations, such as the World Psychiatric Association, have a global character.

Address for Correspondence:

Many group professionals with a specific orientation, such as the World Federation of Societies of Biological Psychiatry, also aim for a global character. Membership in some of the associations is restricted to medical doctors or psychiatrists. Others, such as the International Association of Child and Adolescent Psychiatrists and Allied Professions, accept all mental health professionals. Significant changes in Europe in the late 80s and 90s resulted in an idea of “bridging West and East.” A good example of the bridging idea is a series of conferences organized by the American Psychiatric Association in Cracow (Poland), Prague (Czech Republic), Bratislava (Slovakia) and Budapest (Hungary) in cooperation with respective psychiatric societies in these countries (1).

However, conferences rarely provide an opportunity for long lasting collaborations. Such opportunities arise in multicenter international research programs. Nevertheless psychiatric research, as important as it is, forms only a part of mental health care, and only a small number of professionals are involved in it. One can presume this to be a reason for the founding of bi-national associations of professionals. An example is the Polish-German Association for Mental Health (Deutsch-Polnische Gesellschaft für Seelische Gesundheit e.V.) which is based on partnerships between psychiatric institutions in Germany and Poland.

Its main rationale has been promotion of community psychiatry in Poland and in eastern Germany after the reunification. Working together has been eased by the proximity of Germany and Poland.

FOUNDING OF THE ISRAELI-POLISH MENTAL HEALTH ASSOCIATION Israel and Poland are not neighboring states, and Hebrew is not a popular language among Poles as German is.

Jacek Bomba, MD, Kopernika 21 A, 31-501 Kraków, Poland.

jacek.bomba@uj.edu.pl

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THE ISRAELI-POLISH MENTAL HEALTH ASSOCIATION: ITS HISTORY AND ACTIVITIES

But, in spite of the geographical distance separating Israel and Poland, and language differences, the IsraeliPolish Mental Health Association (IPMHA) / PolskoIzraelskie Towarzystwo Zdrowia Psychicznego (PITZP) was founded and formally registered according to Polish law in 2001. The main form of the IPMHA activity has been organization of mental health care professionals meetings both in Israel and Poland. These events can be divided into three types. The most important have been binational symposia held alternatively in Israel and in Poland. The other type of conferences has been formed by a series of symposia commemorating Israeli, Cracow born, psychiatrist Hillel Klein. The third type of meetings have been symposia sponsored by IPMHA within the Israeli Psychiatric Association and the Polish Psychiatric Association congresses (2). Some of the lectures presented and discussed during these meetings were later published in peer-reviewed journals in Poland: the bimonthly Psychiatria Polska and quarterly Psychoterapia (both published in Polish), as well as quarterly Archives of Psychiatry and Psychotherapy, all of them official journals of the Polish Psychiatric Association, and in Dialog (published in Polish and German, and occasionally in English), an annual journal published by the German-Polish Mental Health Association.

The main purpose of this paper is to review the presence of the IPMHA activities, as well as their reception in Polish professional journals.

Mental health professionals, members of IPMHA, besides being active in various areas of clinical and community psychiatry, psychotherapy, family therapy, are all involved in studies on trauma and/or dealing with its consequences. They are specifically focused on the trauma of the Holocaust (3, 4).

The founding of the IPMHA had been preceded by an inspiring Israeli-Polish exchange. Maria Orwid, who for years had been involved in studies of the Holocaust survivors living in Poland (4), invited recognized Israeli students of the survivors’ problems: Haim Dasberg and Yosi Hadar. They both took part in the conference on post-traumatic syndrome which Orwid had organized in Cracow in 1998. Unfortunately the conference proceedings were not published. Nevertheless the meeting was so interesting that in 1999 the Jagiellonian University Department of Psychiatry, in cooperation with DeutschPolnische Gesellschaft für Seelische Gesundheit e.V. (DPGSG), organized a Polish-Israeli-German symposium, Myths and Taboo, and in 2000 Polish and German psy72

chiatrists attended the congress of the Israeli Psychiatric Association (IPA) and the congress symposium on fighting trauma and its consequences.

Haim Knobler, at the time the Secretary of the IPA, arranged a next symposium dedicated to the memory of the common past of Jews and Poles. The introductory lecture by Polish historian Marcin Kula appeared in print (5). Israeli and Polish mental health professionals were accompanied then by a significant group of German colleagues from DPGSG. On April 19, 2000, thirty Israeli and Polish participants in the Jerusalem symposium decided to create the IsraeliPolish Mental Health Association / Polsko-Izraelskie Towarzystwo Zdrowia Psychicznego (founding members are listed in Appendix 1). Ten of the founding members were born before 1945 and half of them were Holocaust survivors. A Temporary Board was appointed and the Association statutes were accepted (temporary board members are listed in Appendix 2). The preamble of the statutes summarizes the Association goals and tasks: “Having in mind the shared commitment of Polish and Israeli psychiatrists to the victims of the Holocaust, and having in mind a common wish to investigate the roots of the harm caused by racial and ethnic hatred, anti-Semitism and other forms of social prejudice, and having in mind the obligation of mental health professions to contribute to an enlightened and tolerant society, we hereby establish the Israeli-Polish Mental Health Association to further the above goals and to contribute to the improvement of mental health care in our two countries.”

THE IPMHA ACTIVITIES Among early activities, the IPMHA and DGSG cosponsored the plenary session of the 60th Congress of the Polish Psychiatric Association in Cracow, 2001.

The session commemorated the late co-founder of the IPMHA, Professor Adam Szymusik and focused on relations between totalitarian systems and psychiatry (6).

Maria Orwid spoke on Cracow’s Auschwitz Research Program. Maria Orwid and Adam Szymusik were members of the Program’s team directed by Antoni Kępiński.

Orwid, among others, discussed hypothetic reasons for not including the Jewishness of Auschwitz survivors among factors influencing the consequences of concentration camp trauma. According to Orwid, this exclusion in the late 1950s when the project was carried out could be best explained by an idea of the “conspiracy of silence”

JACEK BOMBA

(7). Henry Szor focused on the immense damage done to the survivors’ psyche, particularly in the area “beyond representation” (8, p. 167). He pointed out that in spite of great work done and immense achievements of clinical psychiatry and psychoanalysis to help survivors, and those to whom trauma was transmitted, the experience of trauma caused by totalitarianism, such as Shoah trauma, is inconceivable (8). Other lectures in the session were presented by: Jim Briley, a British psychiatrist and opponent of abuse of psychiatry by totalitarian regimes (9); Semyon Gluzman, an Ukrainian psychiatrist, himself victim of Soviet abuse of psychiatry and also opponent of political abuse of psychiatry (10, 11), and German psychiatrist Niels Pörksen (12). Their presentations concerned abuse of psychiatry by totalitarian political systems in the past and contemporary times.

TRAUMA OF THE HOLOCAUST Inevitably, the trauma of the Holocaust, its uniqueness and consequences became one of the main problems the IPMHA has been dealing with.

Martin Auerbach reported on enduring presence of the Holocaust consequences among Israeli users of mental health services (13). Organization and specificity of help for the Holocaust survivors and their descendants in Poland was reported by Maria Orwid and her co-workers (14). Haim Dasberg analyzed the dynamics in attitudes towards the Shoah consequences in Israeli psychiatry. In his opinion perception of the posttraumatic psychopathology in Survivors and its treatment has had a parallel evolution in mental health profession and in the Israeli community as a whole: from shock and shame, through focusing on grave psychopathologies, statistical assessment of anonymous non-patient survivors, to new narratives and “pan-European dialogues with the ‘Other.’” Consecutive stages involved sequence of defense mechanisms from perplexity, isolation to projective identification (15). Changes in psychiatrists’ approaches to the consequences of war trauma and in helping trauma survivors were studied in work of those Israeli and Polish mental health professionals who pioneered research and treatment of survivors of Nazi violence. Haim Knobler referred to works by his teacher of psychiatry, Cracow-born Survivor, the founder of Israeli psychiatry – Hillel Klein (16); Jacek Bomba reported studies of Antoni Kępiński (17), Krzysztof Gierowski and Adam Szymusik reported on Maria Einhorn-Susułowska (18). Some relevant papers by

Hillel Klein (19) and Antoni Kępiński (20-25) were published in Polish and English translations, respectively.

However, results of current research focused on the Holocaust trauma were also presented and discussed at the symposia (26-28).

Specificity of the Holocaust trauma has remained the most important focus of the IPMHA members. As quoted above, Haim Dasberg (15) emphasized relations between psychiatrists’ attitudes and the culture of which they are a part. He claimed that the Shoah is relevant for everybody independently of his/her, or his/her ancestors, position and role during the Shoah. Dasberg also pointed out that a neutral and objective attitude toward the Holocaust is impossible.

It is significant and meaningful for IPMHA members that the Jews were exterminated, and that the major part of the Holocaust was executed on Polish soil, in the presence of witnessing Poles. So, it is not unexpected that the debate covered relations between anti-Semitism and the Holocaust, between anti-Semitism and helping, indifference, hostile satisfaction, and last but not least, active participation of Poles in extermination of Jews.

Finally, it was the problem of roots and sources of antiSemitism that appeared especially important for the Polish IPMHA members.

All these problems have been topics at the symposia that the IPMHA has organized. Recognized scholars studying these problems have been invited to lecture.

Many of them represented fields other than psychiatric research of the Holocaust. They were historians (e.g., Marcin Kula, 5), philosophers (e.g., Michał Markowski, 29), poets (e.g., Maria Cechnicka, 30), as well as Israeli, German and Polish psychiatrists (31-35). Their texts, published mainly in Dialog, form only a small part of contributions presented at the symposia by psychiatrists, psychologists, psychotherapists, theologians, philosophers, anthropologists and historians. The lectures were concerned with understanding a genesis of human attitudes forming a background of the behavior which made the Final Solution possible. Namely, it was the problem of anti-Semitism.

GROUP DYNAMIC SEMINARS A very important part of the IPMHA work was carrying the debate on the problems presented in symposia lectures (these published, as well as those which were not published) in small groups, using group dynamics. The groups were composed of Israeli and Polish members.

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THE ISRAELI-POLISH MENTAL HEALTH ASSOCIATION: ITS HISTORY AND ACTIVITIES

At the beginning, German colleagues were invited. As the Israeli-Polish problems became very personal, the German colleagues were kindly asked to stand by. The groups were held in English, some in Polish, as some Israeli members are fluent in Polish. For the first years (the groups started in 2000) the number of groups grew.

Newcomers joined the group process. Ten years later, in 2009, the groups were organized for the last time. This form of work failed. A similar problem was described

by Volkan et al. (36). However, the significant difference between Volkan’s group and IPMHA groups was in moderation. Volkan was invited from outside to lead the group of German-Jewish/German psychotherapy professionals. Our groups were moderated by leaders – Israeli and Polish members of the IPMHA. Nevertheless, as in the experience described by Volkan, our goal was to employ methods we use in clinical practice to solve the problems of Polish-Jewish relations, in the significant context of the Shoah.

As mentioned above, the content of symposia lectures served as a starting point for exchanges of reflections, and personal history, aroused memory of facts and emotions.

In 2004, at the IPMHA symposium with the leading topic Guilt and Responsibility, Barbara Józefik, Bogdan de Barbaro and Krzysztof Szwajca presented their analysis of emotional and intellectual processes aroused in Polish psychotherapists taking part in the Israeli-Polish symposia (37, 38). They found that for many Polish participants the experience of the group process was seriously loaded emotionally, and even traumatic. They wrote: “Israeli colleagues… were talking in an emotional way about their experience of Poland and Polish heritage for them, about constructing their identity and the meaning of the Holocaust and anti-Semitism for this process. Polish participants were not prepared for such a personal process. ... The problem was in what each of them was to do. ... How to build the Jewish perspective into their thinking about their own country and nation up to present time” (37, pp. 74-75).

Polish, or rather Cracovian, therapists decided to meet more often informally to talk and prepare for the next Israeli- Polish meetings. “Participation in these meetings appeared to be ... more difficult than expected. ... The emotional load was expressed in questions, but also in silence. Suggestions which appeared one could interpret as defences” (37, p. 77). Barbaro, Józefik and Szwajca gave a description of the group debate: “... individual persons’ verbal expressions, however in the meeting time form 74

a polemic dialogue, are ... ‘external voicing’ fragments present within each of the participants. As in each of us are many voices: a voice demanding objective truth, and a voice looking for justification and purification, and a voice of defence fighting with any violation of the myth of the decent Pole. At the same time there are efforts to give atonement to the Other ...” (37, p. 78). In the authors’ opinion, the process started in this group disclosing “a dual view in a form of two perspectives: 1) explanatory, and at the same time deconstructive, and 2) ethical (37, p. 78). In their opinion “an explanatory perspective is justified only after taking responsibility for evident evil” (37, p. 79).

Several years later Bogdan de Barbaro, Barbara Józefik, Lucyna Drożdżowicz and Maria Orwid (39) discussed the goals of these group meetings and the possible causes of individual and group difficulties. They tried to find ways to prevent accumulation of these difficulties. Józefik and Szwajca (40), Barbaro and co-workers (41) stressed that such work, leading to deconstruction of the Polish myths, is necessary, although this is not easy.

Further events seem to indicate that continuation of the dynamic groups failed. Many members declare openly their need and readiness to meet in small groups.

Nevertheless, their organization encountered insurmountable obstacles.

One of these obstacles may be undiagnosed and unsolved traces of trauma inherited in our subconscious.

Another one, that we forgot, or did not believe, may be Haim Dasberg’s idea of an inability to come to neutral and objective attitudes toward the Holocaust.

Even if all authors quoted seem to include into their reasoning Dasberg’s opinion, one can feel overwhelmed.

On the other hand, there are indications that at least some of the dynamic groups’ participants experienced some gains. An example can be found in Moshe Landau’s article (42). Discussing his own work in the process, Landau is fully aware that a change “of ‘well known state of mind’ … for example: inner attitude towards the diaspora, towards survivors, toward Poland, etc., is difficult,” and following Bion he treats it as a “catastrophic change” (43, p. 89).

The group meetings, both yearly bi-national and monthly, became so draining that in 2005, at the small IPMH conference in Shalvata Mental Health Center in Hod Hasharon, the question was raised whether the IPMHA work had any meaning for contemporary mental health care. This is a significant question, and has no clear answer until now. Haim Knobler (3) said that the memory

JACEK BOMBA

of past traumas played an essential role in treatment of actual traumas and loss. Henry Szor (44) pointed out that “transgenerational transmission of trauma creates the necessity of lifelong elaboration, thinking - conscious and unconscious, a process composed of memory and fantasy, … crucial for a capacity to be alive in the threat of this, beyond the conceivable” (44, p. 177).

PROBLEM OF YOUTH A parallel debate concerned the theoretical background supporting an idea of using the dialogue for realization of the IPMHA goals, as expressed in its statutes. But not only. The IPMHA has been involved in a young people exchange, especially Israeli teenagers’ visits to Poland.

The IPMHA suggested that it would be purposeful to extend the visits program to include the Jewish cultural tradition in Poland and meetings with Polish adolescents.

The IPMHA sponsored such a model exchange. Andrzej Cechnicki and Haim Knobler have spoken and written about this (45).

TWICE FORGOTTEN MENTAL PATIENTS At the symposium held in 2004 at the Józef Babiński Psychiatric Hospital in Kobierzyn near Cracow the question of the fate of mentally ill Jewish patients of the hospital emerged. All patients of this institution were killed by Nazis in June 1942. The majority were transported to Auschwitz, and those who could not be transported were killed on the hospital grounds. They are commemorated in a monument erected in the hospital park. Their names were saved by one of the administration staff who had hidden the last list of the inpatients. It was also remembered that the Jewish inpatients had been previously, in September 1941, segregated and sent to the Jewish Psychiatric Hospital Zofiówka in Otwock (46, 47).

They perished together with all the Jews of Otwock. It was Anne Marie Ulman who found the document with the names of these patients in the Yad Vashem archives.

These names could be added to the already existing monument. In 2006, the IPMHA cosponsored, within the Annual Israeli Psychiatric Association Congress in Tel Aviv, a session on the extermination of mentally ill in the Third Reich.

In 2007, an extension of the Kobierzyn monument was unveiled. The extension has a form of two commemorative plaques and carries the names of the “twice forgotten patients.”

DISCUSSION Twelve years of the IPMHA activity has been relatively poorly reflected in professional publications, particularly in the main psychiatric journals. The majority of articles dealing with topics the Association had been working on have been published in journals concerned with psychotherapy. A close cooperation with the PolishGerman Association for Mental Health resulted in using its journal Dialog as a medium for presentation of a large number of papers.

Keeping in mind that the main problem the Association has been concerned with is past trauma and its consequences in present times, one should not be surprised that the post-conference papers have been published in psychotherapy and community psychiatry journals.

For the last half-century the problem of trauma has been extensively studied by mental health professionals.

It is extremely difficult to study the questions that remain unanswered because of the requirements of contemporary research standards. Nevertheless, trauma and coping with traumatic experience is a significant issue in the area of mental health: in prevention, treatment of disorders and psycho-social rehabilitation.

Another unanswered question is that of an influence of the Association activities on dealing with post-traumatic consequences of its members. Probably all of them experienced trauma of World War II and the Holocaust as survivors, witnesses, or offspring of survivors, or at least from treating PTSD patients. The fact of a fading need for continued work on the problem may be interpreted both as result of working through prolonged mourning and/or as a consequence of an inability to solve it. We can only hope the first interpretation refers to many of us.

References 1. Bomba J, de Barbaro B (eds.). Psychiatria amerykańska lat dziewięćdziesiątych. Kraków. Collegium Medicum UJ, 1995.

2. Bomba J, Knobler H. Polsko-Izraelskie Towarzystwo Zdrowia Psychicznego: jego historia i znaczenie. Psych Pol 2007; supl 3: 11-12.

3. Knobler HY. Cracow and Jerusalem – a reunion. Dialog 2006;14: 206-208.

4. Orwid M. Psychosocial perspective of Holocaut survivors. Dialog 2002; 11: 33-36.

5. Kula M. Stereotype: The self-perpetuating plague. Dialog 2002;11: 91-96.

6. XL Zjazd Naukowy Psychiatrów Polskich PTP: Integracja psychiatrii.

Psychiat Pol 2001; 35, supl. 3.

7. Orwid M. Kraków PTSD studies. Dialog 2002; 11: 171-172.

8. Szor H. Meeting the limits of representation. Psychotherapy with victims of the Nazi regime. Dialog 2002; 11: 164-167.

9. Birley J. Totalitarianism in psychiatry now. Psychiat Pol 2001; supl. 3: 22.

10. Gluzman S. Abuse of psychiatry in Ukraine. Psychiat Pol 2001; supl. 3: 68.

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THE ISRAELI-POLISH MENTAL HEALTH ASSOCIATION: ITS HISTORY AND ACTIVITIES 11. Gluzman S. Abuse of psychiatry in Ukraine. Dialog 2002, 11: 191-199.

12. Pörksen N. Healing or extermination. Dialog 2002; 11: 177-180.

13. Auerbach M. Past losses and old age - Holocaust survivors dealing with existential meanings of loss and death. Dialog 2002; 11: 65-68.

14. Orwid M, Biedka Ł, Domagalska-Kurdziel E, Kamińska M, Szwajca K. Holocaust survivors children (second generation) - Identity problems.

Dialog 2002; 11: 142-147.

15. Dasberg H. Myths and taboos among Isaeli first and second generation psychiatrist in regard to the Holocaust. Dialog 2002; 11: 21-27.

16. Knobler HY. The legacy of Hillel Klein - the late Krakow-born Iraeli psychoanalyst. Dialog 2002; 11: 71-72.

17. Bomba J. Heritage of Antoni Kępiński. Archives of Psychiatry and Psychotherapy 2009; 1-2: 69-72.

18. Gierowski JK, Szymusik A. Maria Einhorn-Susułowska: Founder of clinical psychology in Poland. Dialog 2002; 11: 78-84.

19. Klein H, Kogan I. Procesy identyfikacji i zaprzeczenie w cieniu nazizmu.

Psychoterapia 2007;4 (143): 17-25.

20. Kępiński A. Anus mundi (trans. J. Bomba). Archives of Psychiatry and Psychotherapy 2007; 4: 85-87.

21. Kępiński A, Orwid M. From psychopathology of Übermensch (trans. J. Bomba). Archives of Psychiatry and Psychotherapy 2007; 1&2: 73-80.

22. Kępiński A. The Auschwitz reflections (trans. J. Bomba). Archives of Psychiatry and Psychotherapy 2007; 3: 79-81.

23. Kępiński A. The nightmare (trans. J. Bomba). Archives of Psychiatry and Psychotherapy 2008; 1: 93-97.

24. Kępiński A. The ramp: Psychopathology of decision (trans. J. Bomba).

Archives of Psychiatry and Psychotherapy 2008; 3: 71-80.

25. Kępiński A. KZ-syndrome (trans. J. Bomba). Archives of Psychiatry and Psychotherapy 2008; 4: 77-84.

26. Prot-Klinger K. Potrzeba przebaczenia u ocalonych z Holocaustu na przykładzie Żydów z Rumunii. Dialog 2004; 13: 103-106.

27. Szwajca K, Bomba J. Problematyka drugiego pokolenia ocalonych z Holokcaustu w Polsce. Psych Pol 2007; 51, supl. 3: 162.

28. Prot K, Biedka Ł, Szwajca K, Bierzyński K, Domagalska E, Izdebski R. Psychotherapy of Holocaust survivors – group process analysis. Archives of Psychiatry and Psychotherapy 2011; 1: 21-33.

29. Markowski MP. Identity and deconstruction. Dialog 2002; 11:153-157.

30. Cechnicka M. The taboo of Jews among Poles. Dialog 2002; 11: 52-55.

31. Aleksandrowicz DR. Poland: Myth and reality in Israeli eyes. Dialog 2002; 11: 39-40.

32. Aleksandrowicz DR. Israeli identity: A mosaic of contradictions. Dialog 2002; 11: 133-136.

33. Leidinger F. Poles, Jews and Germans. Dialog 2002; 11: 117-128.

34. Seidel R. Myth and taboo: memory and forgetfulness. Dialog 2002; 11: 59-60.

35. Bomba J. Jewish taboo among Polish people. Dialog 2002; 11: 45-48.

36. Volkan V, Ast G, Greer WF, Jr. The Third Reich in the unconscious.

Transgenerational transmission and its consequences. New York, London:

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Brunner-Routledge, 2002.

37. Barbaro de B, Józefik B, Szwajca K. Problem żydowski? Refleksje nad procesem grupowym krakowskich psychoterapeutów. Psychoterapia 2004; 3: 73-79.

38. Barbaro B, Józefik B. Problem żydowski? Problem polski? Refleksje nad procesem grupowym krakowskich psychoterapeutów. Dialog 2004; 13: 112-115.

39. Barbaro B, Józefik B, Drożdżowicz L, Orwid M. Polsko-Izraelskie Towarzystwo Zdrowia Psychicznego: Dynamika i dylematy grupy polskiej. Psych Pol 2007; supl. 3: 32.

40. Józefik B, Szwajca K. Polish myths and their deconstruction in the Polish-Jewish relations. Archives of Psychiatry and Psychotherapy 2011; 13, 1: 35-41.

41. Barbaro B, Józefik B, Drożdżowicz L, Szwajca K. In the face of antiSemitism: thoughts of Polish psychotherapists. Archives of Psychiatry and Psychotherapy 2011; 13, 1: 55-60.

42. Landau M. Podróż z Tel Avivu do Krakowa: obecność przeszłości.

Dialog 2007; 15: 230-237.

43. Landau M. Smutek po utracie. Psychoterapia 2009, 4 (151): 87-89.

44. Szor H. When I think Lodz… life history as difficult memory. Dialog 2006; 14: 170-178.

45. Cechnicki A, Knobler H. Nasza młodzież – nasza przyszłość.

Psychoterapia 2009; 4 (151): 77-85.

46. Prot K, Biedka Ł. Zofiówka. The forgotten patients. Dialog 2006; 14:283285.

47. Przewłocka A. The forgotten patients. Invitation to the Polish-GermanIsraeli Symposium in Krakow June 2007. Dialog 2006; 14: 292- 294.

Appendix 1 Founding members: Jerzy Aleksandrowicz, Anna Bielańska, Kazimierz Bierzyński, Jacek Bomba, Andrzej Cechnicki, Jacek Dębiec, Ewa Domagalska, Igor Hanuszkiewicz, Maria Kamińska, Joanna Meder, Maria Orwid, Maria Pałuba, Adam Szymusik, Stanisława Szymusik, Krzysztof Szwajca, Dov Aleksandrowicz, Haim Dasberg, Peter Silfen, Meir Berger, Miriam Berger, Henry Szor, Zvi Zemishlany, Haim Knobler, Yoram Barak, Shmuel Fennig, Simona Naor, Ilona Mirecki, Zvi Fischel, Ilana Kremer, Martin Auerbach.

Appendix 2 The first temporary Board: president - Prof. Jacek Bomba, vice-president - Dr. Henry Szor, treasurers – Dr. Joanna Meder and Prof. Zvi Zemishlany, secretaries – Dr. Andrzej Cechnicki and Dr. Haim Knobler, board members: Dr. Yoram Barak, Dr. Shmuel Fennig, Dr. Maria Kamińska Dr. Ilana Kremer, Prof.

Maria Orwid Prof. Adam Szymusik; Review committee - Prof.

Jerzy Aleksandrowicz, Dr. Martin Auerbach, Dr Maria Pałuba.

Prof. Peter Silfen.

FRIEDRICH LEIDINGER AND ANDRZEJ CECHNICKI

The Fate of Polish Psychiatry under German Occupation in World War II Friedrich Leidinger, PhD, 1 and Andrzej Cechnicki, PhD 2 1 2

LVR Klinik Viersen, Viersen, Germany Department of Community Psychiatry, Collegium Medicum Jagiellonian University, Kraków, Poland

ABSTRACT Polish psychiatry was since its origin deeply influenced

by German (Austrian) and Russian psychiatry. As a larger part of the Polish territory had belonged to Germany or Austria before 1918, many institutions and staff in mental health had a German or Austrian history. During the occupation nearly all mental hospitals were taken over by the Germans, sometimes all the patients, sometimes part of them were murdered, and often the staff members were shot together with their patients.

Jews were separated from non-Jews and killed. Some institutions continued to work under German rule and with German directors. This paper will explore these issues from a historical and organizational perspective and address how Polish psychiatry attempted to survive during and after the war.

INTRODUCTION – THE FIRST FEW DAYS OF THE SECOND WORLD WAR “Day after day, trucks drove up to the institution. 60 patients were loaded on to each one. There were at least two vehicles. They were taken somewhere in the vicinity of Jeżewo and shot in the forest. (…) The liquidation took roughly five, six days. The remaining patients, of which there were between 350 and 370, were transported to Kocborowo, where they, too, were shot. I heard about this from a German who had a good relationship with the Poles. For a glass of vodka, he spoke a great deal about the details of an execution that he had witnessed.

He described how three patients at a time were led out Address for Correspondence:

of the truck and shot in the back of the head.

After that, the liquidation of the children’s barracks began. The children were excited at the chance to travel in a truck, but they, too, were shot. The children were murdered in the following manner. First they were all sent out into a field, and there they were shot at as if it were target practise” (1).

This episode took place during the first few days of the Second World War in a small village on the river Vistula between Warsaw and Danzig: soldiers from the SS division Wachsturmbann Kurt Eimann forced their way into the psychiatric hospital in Świecie (2). They took the medical director, Dr. Józef Bednarz, prisoner. The patients were divided into three groups: Jews, those unfit to work and those capable of working. On 10 September 1939, the transport of patients into the surrounding forests commenced. There, they were shot by the Volksdeutscher Selbstschutz under their leader Rost, a brewery owner from Bydgoszcz. Doctor Bednarz was executed together with his patients, once it was discovered that he had informed the families of the patients (3).

The institution Kocborowo, which was soon renamed Conradstein, had been occupied by the SS in the first days of September. On 22 September, the SS began removing the patients, purportedly transporting them to another hospital. In fact, the patients were escorted into the forest of Spengawsken and executed. Between the individual transports, the SS indulged in depraved revelry. Since they were almost constantly drunk, several patients were able to flee. In late autumn, 130 children from the institution branch Gniewo were transferred to Conradstein. The younger children were killed using phenol injections, while the older ones were shot along with the adults.

Under the new director Waldemar Schimansky, who from then on called himself Siemens (4), Conradstein began to take in new patients (2). In all the rooms, signs

Andrzej Cechnicki, PhD, 2/8 Sikorskiego Squ., 31-115 Cracow, Poland

acechnicki@interia.pl

33

FATE OF POLISH PSYCHIATRY UNDER GERMAN OCCUPATION

were displayed: “Only German may be spoken here.” The use of the Polish language was strictly forbidden. One doctor committed suicide after she failed the language test demanded by Schimansky/Siemens. Relatives were denied access. Starvation, typhus, tuberculosis and other deficiency illnesses led to a dramatic increase in the mortality rate. Siemens sold the bodies of those who perished in the institution to the Danzig anatomist Rudolf Maria Spanner, who was conducting experiments involving techniques for producing soap and other basic commodities from human bodies.

The more than 10,000 bodies of murdered civilians found in the mass graves of the Spengawsken forest included the 1,692 patients from the institution in Kocborowo who were shot between September 1939 and 21 January 1940 (5).

We will explore these issues from a historical and organizational perspective and address how Polish psychiatry attempted to survive during and after the war, in particular: • that mentally ill Polish patients were the first victims of the war, • that the technique of mass execution using poison gas, which played a central role in the extermination of the Jewish population in Eastern Europe, was first developed and tested on Polish psychiatric patients, • that the search for historical facts must be the basis for any international dialogue.

Right from the first day of the war, the Polish people quickly experienced the objectives of the German war first hand: the complete and permanent destruction of the Polish nation. In Hitler’s speeches, Poles were harangued as “racially alien” and “to be contained” in order to prevent the “contamination of German blood” (6). He ordered the indiscriminate suppression of any patriotic arousal in Poland, the liquidation of the leading classes of the population and for the Polish population to be removed from the areas surrounding German settlement, creating a “safety buffer zone” through “racial land clearance.”

THE FATE OF PSYCHIATRIC PATIENTS UNDER GERMAN OCCUPATION IN THE SECOND WORLD WAR Following the defeat of the Polish army, Danzig and the northern territories were incorporated into the German Reich as the “Reich District Danzig and West Prussia,” while the western Polish territories, including the cities Posen and Lodz, were incorporated as “Wartheland.”

34

Through entries in the “Volksliste,” mass displacement and mass murder, these previously majority Polish territories were to be completely “Germanized” (7); the southeast, under the designation “Generalgouvernement,” was administered as a colony and exploited for the military and economic interests of the Germans.

The German occupation of Poland can be divided into 4 chronological stages: • The September campaign from 1 September 1939 to 8 October 1939 and the Soviet invasion of Eastern Poland.

• 8 October 1939 to 22 June 1941: the division of Poland under German occupation into Danzig - West Prussia, Wartheland and the Generalgouvernement. The Polish territories east of the demarcation line came under Soviet occupation.

• 22 June 1941 to spring 1944: following the German attack on the Soviet Union, the eastern Polish territories were incorporated into the Generalgouvernement.

• Spring 1944 to spring 1945: retreat of the German armed forces and occupation of all Polish territories

by Soviet troops.

The Germans installed a complex system of terror consisting of harassment, raids, deportations, starvation, forced labor, theft and murder. Mass executions of prisoners of war and civilians, the “intelligentsia operation,” which by the end of 1940 had already taken the lives of 80,000 people (civil servants, officers, clerics, academics, teachers, intellectuals), the mobile gas chambers of the Sonderkommando Lange (1-4), the starvation camps for Jews, euphemistically termed “ghettos,” the Operation Reinhard, the “General Plan East” and the “SS Sonderlaboratorium Himmlerstadt” (8, 9). Poles were only allowed to live if they were of use to the Germans.

It is fairly clear that the killing in Wartheland was the result of central planning and organization. Alongside the large mental hospitals, smaller institutions and nursing homes were also affected. Troops from the SS Sonderkommando Lange transported the patients in trucks into a nearby forest and shot them for a bounty of 10 Reichsmark each. Patients who could not be transported were shot in their beds. Later some institutions were used for military purposes or as general hospitals, others continued taking in transports of mentally ill from Germany and of German resettlers. The total number of sick persons deported into occupied Poland is unknown (1-3).

From December 1939, the Sonderkommando Lange deployed a mobile gas chamber (2, 3). This consisted of a truck with the logo “Kaisers Kaffee-Geschäft,” the exhaust

FRIEDRICH LEIDINGER AND ANDRZEJ CECHNICKI

fumes of which or gas from storage bottles were piped into the cargo space. The development of this instrument of murder was overseen by the chemists Dr. Albert Widmann and August Becker, who had been involved in the preparation of Operation T4 since August 1939 (4).

The first execution using carbon monoxide gas most probably took place in November 1939 in a bunker of Fort VII in Posen (2, 3). Becker used the opportunity to observe the implementation of his idea. The first victims of murder by gas were 50 patients of the psychiatric institution Owińska (Treskau). Their bodies were taken to the forest at Oborniki. In the period up to November, approximately 400 patients from Owińska were murdered in Fort VII using gas. Subsequently, the trucks transported patients directly into the forest. There, they were loaded into the gas truck. Many of them resisted and were brutally forced into the truck. A medical sedation was often ordered before the “transfer.” Altogether, 1,000 patients from Owińska were murdered using gas. Before the operation, 100 ethnic German patients had been transferred to the institution at Dziekanka (2, 3).

The gas truck of the Special Commando Lange was later used at numerous other psychiatric institutions: • Dziekanka (Tiegenhof); November 1939 and January 1940: 1,043 patients; in June/July 1941: 158 patients.

Tiegenhof also played a role in a perfidious act on the part of the “T4” organization. A false death register was released in order to deceive relatives of the patients who had actually been murdered elsewhere, with bills being issued for the care of fictitious graves in the municipal graveyards (10).

• Kościan; January 1940: 297 women and 237 men (2, 3).

• Kochanówka near Lodz; March 1940 – summer 1941: approximately 2,200 patients; the head of the District Council Health Department, Herbert Grohmann, even ordered the recall of discharged patients (3, 4).

• Warta; the cost of the “evacuation” of 499 patients, which came to a total of 14,700 Reichsmark, was billed by the SS to the hospital. Director Renfranz also introduced electroconvulsive therapy (ECT), which was used more than 10,000 times by him and his (Polish) assistant doctor (2, 3, 11).

• Transition Camp Soldau; June 1940: 1,550 mental patients from various East Prussian institutions. There was a long dispute between authorities regarding the payment of the premium for this operation, which amounted to 15,500 Reichsmark (2, 3).

• Gostynin; 9 April 1941: 30 men and 29 women (2, 3).

In summer 1941 Arthur Nebe, leader of the SS

Einsatzgruppe B and responsible for the mass murders in Belarus, requested the support of Widmann (2, 3).

Nebe was informed about the “successful” work of the Sonderkommando Lange and operation T4. Under Widmann’s technical assistance, Nebe’s men murdered hundreds of patients of the psychiatric institutions Nowinki and Mogilew in late June/early July 1941 using carbon monoxide. The gas was provided from a truck engine.

Following this, Nebe ordered the SS Obersturmbannführer Walter Rauff to obtain such gas trucks (2, 3).

The Nazi civilian administration of Wartheland also had an extermination camp built in a forest near Chełmno (Kulmhof) in November 1941 (2, 3). The Sonderkommando Lange murdered at least 160,000 people in the period up to April 1943 in three gas trucks stationed there, including Poles and Jews from Wartheland, many Jews from the Ghetto Litzmannstadt, numerous patients from the psychiatric institution Kochanówka and other institutions.

In summer 1942, 92 members of T4 staff were placed under the command of the SS and police director in the district of Lublin, Odilo Globocnik, the coordinator of Operation Reinhard, the murder of the remaining Jewish population of the Generalgouvernement. For the extermination camps Bełżec, Majdanek, Treblinka and Sobibór, Globocnik made use not only of the T4 leadership personnel, but also of its killing technology.

In the course of the selections in the medical institutions of Wartheland, Jews were killed without exception; 160,000 people lived in the Ghetto Lodz (Litzmannstadt) at its outset. The director of administration Hans Biebow wanted to make the fullest possible use of its workforce.

He repeatedly appealed to the residents to bring their sick to one of the numerous hospitals newly erected in the ghetto. Altogether, the ghetto was equipped with more than 2,600 hospital beds. In a building adjoining the Jewish cemetery in the ghetto, a psychiatric hospital with 50 beds was opened. From March 1940, the Germans ordered a rapid series of “evacuation operations.” Since the patients resisted, they were given scopolamine injections beforehand. Selections were also carried out in other hospitals at short intervals, with patients being transported to the extermination camp Kulmhof (2, 3).

Jewish patients from various institutions of the Generalgouvernement were brought together in the Jewish medical institution Zofiówka in the Otwock Ghetto near Warsaw, where they died within a short time due to the horrendous living conditions (2, 3). In summer 1942, as part of the liquidation of the ghetto, most patients of Zofiówka were shot and an unknown number were 35

FATE OF POLISH PSYCHIATRY UNDER GERMAN OCCUPATION

taken to Treblinka and gassed. A few were able to flee to Warsaw in an ambulance where they slipped into the underground. The entire Jewish staff was murdered along with the patients.

In the Generalgouvernement, from 1940 to 1942, the supplies of essential goods flowing into the German Reich exceeded all expectations of the Germans (2, 3). According to the assessment of the director of the Generalgouvernement health administration Jost Walbaum in September 1941, the Polish population received “only 600 calories,” which is why they were so vulnerable to contagious disease (4); 40% of the population suffered from typhus. Walbaum was seriously concerned about the danger to the German armed forces and to the Reich.

The situation of the Jews in the ghettos was even worse, as was that of mental patients, “useless eaters” in terms of Nazi propaganda. Walbaum considered which solution would be better, shooting or slow starvation, although he believed that shooting had a deterrent effect (2, 3). Food supply was reduced once again through new regulations from Walbaum’s authority.

In some cases, the SS did not wait until all the patients had starved.

On 12 January 1940, the SS occupied the institution Chełm Lubelski (2, 3). The patients - 300 men, 124 women and 17 children – were taken into the courtyard in small groups and shot. Under the name Chelm II, the institution was used, similarly to Tiegenhof, for the covering up of the murder of patients as part of Operation T4 (10).

In 1940, 501 patients died in the institution Kobierzyn near Kraków (2, 3, 12). In September 1941, the last Jewish patients were deported to Zofiówka. On 23 June 1942, SS men loaded the remaining 535 Polish patients into a train. The director, Alex Kroll (12), told the staff that they were being transferred to the institution Drewnica, but in fact they were taken directly to the gas chambers of Auschwitz-Birkenau. Thirty bed-ridden patients were poisoned and buried in the institution’s cemetery. Kobierzyn was subsequently turned into a recreational retreat for the Hitler Youth.

Kroll’s efforts to keep the operation secret were marked by a bizarre mistake. In autumn 1942, a bill from the Eastern Rail was delivered to Kobierzyn for the transport of the patients to Auschwitz-Birkenau. The German cashier did not know what to do with this bill, and asked a former Polish administrative clerk for assistance. He advised her to send the bill on to Kroll. But the true destination of the transport thus became known.

In Kulparkow near Lemberg (Lwów) there were an 36

increasing number of deaths among the 2,000 patients under German command (2, 3). In August 1943, Dr. Max Rohde was reassigned from Galkhausen (Rhine Province) to Kulparkow (13). He stayed, according to his own account, until spring 1944. During this period, numerous patient transports arrived there from the Rhineland. The number of Rhineland patients who were deported to Kulparkow and presumably starved there is unknown.

In the institution Lubliniec (Lublinitz, Loben) Dr. Ernst Buchalik and Dr. Elisabeth Hecker established a Children’s Department in 1941. Of the 256 children “treated,“ 194 died (2, 3).

In the Hospital of the Merciful Brothers at the edge of the Old City of Warsaw following capitulation, the Germans took over the supervision of the hospital (2, 3). Despite the shortage of food, the staff continued to perform their duties for the patients and acted in the resistance movement. The underground university even held secret lectures for medical students. Persons from the directly adjacent ghetto with acute psychiatric crises continuously sought admittance to the hospital. For security reasons, they were soon transferred to institutions outside the city (2, 3).

THE FATE OF POLISH PSYCHIATRISTS UNDER GERMAN OCCUPATION IN THE SECOND WORLD WAR During the Warsaw Uprising after 1 August 1944 the Jan Boży psychiatric hospital came under bombardment from tanks and aircraft (2, 3). There were huge losses among patients and staff. On 2 September 1944, after the SS stormed the hospital, they arrested the roughly 50 people who could still walk, shot the bed-ridden wounded and set the ruins of the hospital on fire.

Despite the threat, many staff members of the psychiatric institutions remained with the patients and attempted to save at least some of them. More than half (51.1%) of all Polish psychiatrists, 138 people, did not survive the war (3). Doctors of Jewish descent had no chance, but non-Jewish psychiatrists were also systematically killed, either as victims of the intelligentsia operation or together with their patients during the special operations in the institutions. Many also disappeared or died under Soviet occupation, either in the course of deportation to the Soviet gulags or the executions of the NKWD (Katyń, Charków, Starobielsk). Some went underground and engaged in active resistance. It was not until the next book by Tadeusz Nasierowski et al. (3) that Polish readers, 70 years after the Second World War, got to know the fuller context of

FRIEDRICH LEIDINGER AND ANDRZEJ CECHNICKI

the extermination of Polish psychiatrists, describing facts known to some contemporary Polish psychiatrists, but not known to other researchers.

The German-Polish dialogue in the field of psychiatry has built bridges across historical abysses. It can only be successful as long as we are prepared to learn from our common history.

BRIDGES OVER HISTORICAL GAPS Since its origins in the 19th century, Polish psychiatry had a strong relationship with Germany; before 1939, many Polish psychiatrists had received an important part of their training from German-speaking institutions. After the end of the war, contacts between Polish and German psychiatry remained almost completely frozen for more than 40 years. There were isolated contacts between psychiatrists from the GDR and Poland, but these did not result in any more intensive exchanges.

In 1985, West German psychiatrists participated for the first time in an international congress in Krakow on the subject of “War, Occupation and Medicine” upon an invitation from Prof. Józef Bogusz. In 1987, a group of 27 West German psychiatrists travelled to Poland. They visited sites in the former German eastern territories and in occupied Poland where psychiatric patients from Germany and Poland had been murdered. Their 10-day trip concluded with the first German-Polish Symposium on Mental Health in Krakow.

In 1990, the German-Polish Society for Mental Health was founded in Münster by psychiatrists from Germany and Poland (14). The German-Polish dialogue in the field of psychiatry encompassed from the beginning all the professions involved in psychiatry, relatives, patients and the interested public. Driven by a curiosity for the hitherto unknown “other,” numerous partnerships between German and Polish clinics and other institutions of psychiatric care were established. The regular German-Polish symposia on current issues of mental health, human rights in the field of psychiatry and on the “taboos” of German-Polish relations, which take place alternately in Poland and Germany, draw several hundred participants every year.

Since 1998, the Polish-German dialogue has been extended to include a third partner: Israeli psychiatry.

Many Israeli psychiatrists are originally from Poland or have Polish ancestry. Relations between psychiatrists from the three countries have been further solidified in several joint conferences in Israel, Poland and Germany, as well as on joint trips to the Ukraine. The documentation of many years of joint efforts toward remembering is written down in trilingual annual volumes of Dialog from 2002 and 2006, titled “Myth and taboo” (15) and “Human fate in critical times” (16) (dedicated to Irena Sendler).

References 1. Gut A. Eutanazja – ukryte ludobójstwo pacjentów szpitali psychiatrycznych w Kraju Warty i na Pomorzu w latach 1939-1945.

(Euthanasia – the hidden genocide of the patients of psychiatric hospitals in Wartheland and in Pomerania in 1939-1945), 2009. http://www.ipn. gov.pl/portal/pl/2/730/Eutanazja_8211_ukryte_ludobojstwo_pacjentow_ szpitali_psychiatrycznych_w_Kraju_Wa.html (25.11.12) 2. Nasierowski, T. Zagłada osób z zaburzeniami psychicznymi w okupowanej Polsce. Początek ludobójstwa. (The extermination of the mentally ill in the occupied Poland. The beginning of genocide). Warszawa, Wydawnictwo Neriton, 2009.

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5. The Foundation Memorial to the Murdered Jews of Europe: Mass graves of Polish victims of Nazi crimes. Dokument im Internet: http://www. memorialmuseums.org/denkmaeler/view/923/Massengr%C3%A4berpolnischer-Opfer-der-nationalsozialistischen-Verbrechen (5.01.2013) 6. Broszat M. Zweihundert Jahre deutsche Polenpolitik (Two hundred years of German policy toward Poland). 2. Translation Berlin:TB Suhrkamp., 1973.

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8. Madajczyk C. Zamojszczyzna – Sonderlaboratorium SS. Zbiór dokumentów polskich i niemieckich z okresu okupacji hitlerowskiej.

(The Zamość region - Sonderlaboratorium SS. A collection of Polish and German documentation from the period of Nazi occupation). 2 Bände. Warsaw: Ludowa Spółdzielnia Wydawnictwo, 1977.

9. Halbersztadt J (1994): The Nazi Crimes in the Zamość Region. http://h-net. msu.edu/cgi-bin/logbrowse.pl?trx=vx&list=h-holocaust&month=9409& week=b&msg=ApqbBP3yPYXJ7TlmmKgJ1g&user=&pw= (05.01.2013) 10. Klee E. “Euthanasie“ im NS-Staat: die Vernichtung “lebensunwerten Lebens“ („Euthanasia“ in the Nazi state: extermination of “the life unworth living“). Frankfurt a.M: Fischer, 1983.

11. Renfranz HP. Weil der Vater das Sagen hatte als Herr über Leben und Tod: die Auseinandersetzung von Hans Peter Renfranz mit seinem Vater.

(Because father said so, as the master of life and death: conversations of Hans Peter Renfranz with his father). In: . Mainz: Landeszentrale für Politische Bildung Rheinland-Pfalz, 1996.

12. Szpytma M. Verbrechen an den Patienten der staatlichen Einrichtung für psychisch und nervlich Kranke in Kobierzyn. (The crime on patients of the State Hospital for Nervously and Mentally Ill in Kobierzyn). Dialog Nr. 12. Kraków/Muenster, 2002.

13. ALVR. Archiv des Landschaftsverbandes Rheinland. Rheinlad National Archives, 1968.

14. Leidinger F, Cechnicki A. Brückenschläge über geschichtliche Abgründe.

Zur Geschichte der Deutsch-Polnischen Gesellschaft für Seelische Gesundheit e.V. (Building bridges over historical gaps. A contribution to the history of the Polish-German Mental Health Association).

Sonderdruck der Zeitschrift Dialog, 1993.

15. Myth and taboo. Dialog Nr. 11. Kraków/Muenster, 2002.

16. Human fate in critical times. The publication dedicated to Irena Sendler.

Dialog Nr. 14. Kraków/Muenster, 2006.

37

YAEL SHOVAL-ZUCKERMAN ET AL.

The Effectiveness of Early Group Intervention for Military Reserves Soldiers: The Role of the Repressive Coping Style Yael Shoval-Zuckerman, MSW,1, 2 Rachel Dekel, PhD,2 Zahava Solomon, PhD,3 and Ofir Levi, PhD 1, 3, 4 Combat Stress Reaction Unit, Mental Health Division, Medical Corps, IDF, Ramat Gan, Israel School of Social Work, Bar-Ilan University, Ramat Gan, Israel 3 School of Social Work, Tel Aviv University, Ramat Aviv, Israel 4 School of Social Work, Ruppin Academic Center Emek Hefer, Israel 1

2

ABSTRACT This study had two aims: 1. To examine whether soldiers who participated in Early Group Intervention (EGI) would show less distress and better functioning and physical health than soldiers who did not participate in EGI, and 2. To examine the contribution of the intervention to participants with repressive coping style. The sample comprised 166 male reserve soldiers who fought in the Second Lebanon War. The intervention was conducted three months after the traumatic event, was based on military protocol, and took place over the course of one day. Data were collected at two points in time (four months apart). The findings indicated that after EGI, the intervention group experienced less post-traumatic distress than did the control group. In addition, four months after the intervention, the functioning and physical health of the intervention group was significantly better than that of the control group. Notably, the intensity of post-traumatic distress before the intervention was lower among repressors and low-anxious soldiers than among soldiers in the other two groups (high-anxious and defensive). No significant differences were found after the intervention with regard to the various styles of coping with post-traumatic distress. Future clinical implications of the findings are discussed.

INTRODUCTION The most widespread chronic psychiatric illness following soldiers’ participation in war is Post-traumatic Stress

Disorder (PTSD). It has been found that, cross-culturally, 13%-20% of soldiers who have fought in wars will develop PTSD during their lifetime (1, 2). PTSD is classified as an anxiety disorder and is typically defined by the coexistence of three clusters of symptoms: namely re-experiencing (intrusive thoughts and images), avoidance and hyperarousal symptoms. PTSD is frequently accompanied by functional difficulties in various domains such as work/ school, intimate relationships, and sexual functioning (3). In addition, veteran soldiers with PTSD have many physical health complaints, make intensive use of health services, and have a high rate of morbidity in comparison to veterans without PTSD (4-7).

In recent years, concerted efforts have been invested in developing psychological interventions to minimize both the risks of long-term psychological morbidity in general and PTSD in particular following exposure to combat. Some interventions have been conducted in the acute phase of combat situations, such as Front Line Treatment (8, 9) or psychological debriefing (10), which is the most commonly used crisis intervention.

Debriefing techniques are conducted mostly during the acute phase of combat situations rather than during subsequent phases when these techniques might be more suitable. In fact, therapy conducted during acute phases is controversial. There are those who claim that the mental reaction immediately after exposure to a traumatic event is natural, and that instead of direct intervention, professionals should simply “be with” the victims as soon as the combat situation ends, in order to help them “reconnect” with their natural strengths and regain their mental/emotional balance (11, 12).

Raphael (13) suggests performing the intervention only

Address for Correspondence: Mrs. Yael Shoval-Zuckerman, Combat Stress Reaction Unit, Mental Health Division, Medical Corps, IDF 4 Simtat Asaf Street, Ramat Hasharon 47275, Israel Yshovalzuckerman@gmail.com

49

EARLY GROUP INTERVENTION FOR RESERVE SOLDIERS

after a certain amount of time has passed, during which time the event can be digested and processed. A similar opinion is expressed by Mitchell (10), who emphasizes the need for psychological readiness for intervention; this readiness is enabled, according to him, only a significant time after the event has happened.

Although the term psychological debriefing has become controversial, researchers who have assessed the efficacy of this technique with military personnel (14) have found it to be effective with intact groups; this effectiveness may be due to the fact that intragroup processes are known to influence individual well-being and because group debriefing is consistent with the military tradition of after-action reviews (15). Other interventions, such as Cognitive Behavioral Therapy (16, 17) and Exposure Therapy (18), have been conducted in the second early phase (i.e., from one to six months following the traumatic event).

It is critical for intervention to be based on the most validated empirical findings. However, to date, noevidence-based consensus has been reached to support a clear set of recommendations for intervention in the acute and early phases that follow mass trauma (19).

Although many studies have found that acute and early intervention following combat are effective, there are only a few studies on the effect of interventions in subsequent phases (from one month to several months after combat) (6, 15). Moreover, critics of early interventions have argued that these interventions cannot be conducted among a wide variety of populations without taking into account the differential effect (20) brought about by interpersonal differences and differences in coping styles among potential participants.

The current study had two aims: The first was to examine the general efficacy of Early Group Intervention (EGI) – an intervention conducted three months after soldiers’ participation in a war. We sought to examine whether soldiers who took part in the EGI would show less distress after a traumatic incident, as well as more improvement in functioning and physical health, than the soldiers in the control group, who did not take part in the EGI or in any other intervention. Second, in an attempt to shed light on interpersonal differences, we examined the contribution that EGI made to soldiers, based on their coping styles.

REPRESSIVE COPING STYLE

A repressive coping style has been defined as the distancing of one’s self from anxiety-provoking threats through 50

diverting one’s attention away from the threat (21).

Other studies have suggested that the repressive coping style is an unconscious intra-psychic defense (22), and that substantial and persistent use of this defense mechanism turns it into a basic dimension of the personality (23) which is reflected in various cognitive and behavioral processes (24). The most widely used definition was introduced by Weinberger, Schwartz and Davidson (25), who conceptualized repressive coping as a specific combination of anxiety and defensiveness. Postulating four combinations of responses to threat, Weinberger defined repressors as individuals who express low anxiety and high defensiveness.

Recent research has suggested that the repressive coping style can be a pragmatic form of coping that helps people deal effectively with extremely aversive events (26). It has been suggested that in certain circumstances, repressing and avoiding thoughts, memories, and other cues related to the traumatic event may in fact be adaptive (27, 28).Ginzburg et al. (24) found that this coping style might promote both short- and long-term adjustment to traumatic events such as myocardial infarction. Similarly, Palyo and Beck (29) found that after motor vehicle accidents, repressors reported fewer post-traumatic symptoms, anxiety, depression, and health problems than did those who employed other coping styles.

The current study examined whether the efficacy of EGI would differ according to individuals’ coping styles.

In light of the knowledge we currently have, we hypothesized that soldiers who were characterized by a regressive coping style would have lower levels of distress following participation in combat than would non-repressors. In addition, we hypothesized that EGI would reduce posttraumatic distress among non-repressors, whereas no change or even a worsening of symptoms would be found among repressors. We assumed that EGI, which is based on the principles of debriefing, might expose repressors to threats and elicit a flood of thoughts and unpleasant memories that they would try to divert. Consistent with this view, it has been argued that interventions such as debriefing disrupt the natural process of recovery from trauma, especially for individuals who tend to use coping strategies such as repression and avoidance (30, 31).

THE CURRENT INTERVENTION

The EGI model (32) was formulated after targeting the special needs of the reserve soldiers, and in an attempt to help them process the separation from their fellow unit members and the return to their families and workplaces

YAEL SHOVAL-ZUCKERMAN ET AL.

after the war. In addition to providing an outlet for the articulation of thoughts and feelings, and to help foster the development of coping mechanisms, this intervention conveyed the expectation that participants would continue normative functioning in the future. This model could also be used to identify soldiers who need further treatment.

EGI is based on the assumption that the military group provides a significant support network and source of strength, enabling participants to overcome difficult situations. In our case, the existing connection among the soldiers provided social support that was crucial for the success of the intervention (12). The staff of the battalion and the professional workers from the Combat Reaction Unit held a preparatory meeting, which included familiarization with the EGI protocol, getting acquainted with the group mediators (an officer and a professional worker), coordination of the approach to the intervention, and the division of tasks during the intervention.

EGI emphasizes the transition from combat to home and recognizes that this transition is a critical socialpsychological task.

The intervention was based on a military stress debriefing protocol (33)(see Appendix 1) and was conducted by the Combat Reaction Unit of the Israel Defense Forces among soldiers who fought in the Second Lebanon War. It was held over the course of one day. The intervention consisted of three parts (see Figure 1): In the first part, the soldiers reviewed the sequence of events that occurred from the time of their release from army reserve duty until the present. In the second part, they articulated their thoughts and feelings at the present time (three months after the war). In this way, they were given an opportunity to relate to the losses they had experienced in the war, and they were able to express feelings of guilt and anger. In the third part of the intervention, the soldiers discussed their ability to continue functioning as individuals and as a group (a platoon). The discussion focused on the need to continue living, and the expectation that participation in the group would enable them to resume regular functioning. Common symptoms and difficulties in coping with daily living â&#x20AC;&#x201C; e.g., relating to spouses, family members or co-workers â&#x20AC;&#x201C; were discussed in the intervention.

Emphasis was placed on the strength of the group and the positive and functional coping mechanisms that the soldiers used. The intervention was conducted by a professional practitioner (mental health officer) and the commander of the relevant military unit.

Figure 1: Flowchart of Intervention

51

EARLY GROUP INTERVENTION FOR RESERVE SOLDIERS

METHOD PARTICIPANTS AND PROCEDURES

Participants in the study were 166 male reserve soldiers and officers in the Israel Defense Forces, who belonged to a battalion which sustained numerous casualties in the Second Lebanon War (2006). Data was collected in two stages.

Stage 1. The whole battalion was called for a oneday intervention during reserve duty (three months after the war). The intervention followed a structured protocol, and each group comprised an original organic unit. The intervention was facilitated by a professional worker (mental health officer) and a commander of the relevant military unit. Randomization was not feasible due to military constraints. A partial solution to the randomization problem was to form an internal control group consisting of soldiers who did not participate in the intervention for various reasons: (28% were studying, 25% were abroad, 23.5% had work obligations, 16% were unintentionally not invited, and 7.4% had injuries).

The soldiers who participated in the intervention completed the questionnaires before it started. The control group filled out questionnaires at home during the week following the intervention.

Stage 2. Four months after the intervention, the members of the battalion were called again for reserve duty. At that time, the members of the Combat Reaction Unit distributed a second questionnaire to the soldiers. Of those who filled out the questionnaires during this stage, 98 had participated in the intervention, and 68 had not (the control group). No participants in the study had dropped out between the two stages of data collection. No significant differences were found between the participants in the two research groups with regard to combat exposure except for proximity to fire: Both groups of soldiers reported high levels of exposure (Χ2=3.52, df=3,p=.32), such as exposure to injury and death (Χ2=.0.10, df=1, p=.75), evacuation of the wounded or dead (Χ2=0.34, df=1, p=.56), proximity to the range of fire (control=91.2%, intervention=98.0%, Χ2=4.03, df=1,p=.05), and risk of injury or death (Χ2=1.52, df=3,p=.68). In addition, no differences were found in background characteristics: 90% were born in Israel, 70% were single, 64.5% were employed, and 32% were students. Most of the participants were reserve soldiers (86.1% reserve soldiers, and 13.9% officers). A significant difference was found between the groups regarding years of education (M=14.37 SD=2.23 for the intervention group, and M=13.70, SD=1.77 for the control group, t=2.08, df=164, p=.04). Differences were also found in 52

the recent significant event (control=22.1%, intervention=10.2%, Χ2=4.41, df=1, p=.04), and these differences were controlled for during the data analysis.

MEASURES

1. Socio-demographic and military information (stages 1+2): This measure included information on the participants’ marital status, age, number of children, country of origin, year of immigration, education, occupational status, and military rank.

2. Combat exposure (stage 1): The measure was developed by Schwarzwald, Solomon, Weisenberg and Mikulincer(34)te> and consisted of six items that examined the soldiers’ exposure to combat: complexity of the battle, proximity to the range of fire, exposure to injury and death, evacuation of the wounded and dead , and risk of injury or death. A factor score was derived from a factor analysis (M=0, SD=1, percent variance explained=.51.5).

3. PTSD Inventory (stages 1+2): PTSD was measured by the PTSD Inventory, a self-report scale based on the DSM-IV (35). The scale consisted of 17 items that describe intrusive, avoidant and hyper-arousal symptoms.

Participants were asked to indicate how often they had experienced each symptom during the previous month on a scale ranging from 1 (not at all) to 4 (very often). The severity of PTSD was calculated as the mean severity of symptoms. The Cronbach’s alpha internal consistency of the questionnaire used in the current study was high (.93), and the scale was found to have high convergent validity compared with diagnoses made by experienced clinicians on the basis of structured clinical interviews (34).

4. Functioning: This dimension was measured on the basis of two questionnaires. Questionnaire stage 1.

This questionnaire consisted of one item relating to the participant’s level of functioning over the previous two weeks. Responses were based on a scale ranging from 0 (very bad) to 5 (very good). Questionnaire stage 2. This questionnaire assessed general psychological functioning over the previous two weeks using the Psychotherapy Outcome Assessment and Monitoring System-Trauma Version (POAMS-TV)(36). Responses were based on a 5-point Likert-type scale ranging from 0 (extreme distress or dissatisfaction) to 4 (optimal functioning or satisfaction). In this study, one score for functioning (e.g., work/ school performance/attendance) was calculated for the mean of the scores on the 10 items. The Cronbach’s alpha of the questionnaire used in this study was high (.90).

5. Self-rated health (stages 1+2): Based on a question-

YAEL SHOVAL-ZUCKERMAN ET AL.

naire developed by Benyamini and Idler (37), participants were asked to assess their current physical health on a scale comprised of three levels (1, 2, 3): bad, moderate, and good.

6. Repressive Coping Scale (stages 1+2): This selfreport measure consisted of 58 items, which combined two scales: Manifest Anxiety (Taylor Manifest Anxiety Scale)(38), and Defensiveness (the Marlow-Crowne Social Desirability Scale)(39). Participants were asked to indicate whether or not each item described them, on a dichotomous scale – 0 (no) 1 (yes). The repressive coping style was determined by the median scores on the two scales.

Participants with anxiety scores below the median and defensiveness scores above the median were classified as repressors. In addition, three categories of non-repressors were identified: low-anxious individuals (anxiety and defensiveness scores below the median); high-anxious individuals (anxiety score above the median, and defensiveness score below the median); and defensive individuals (anxiety and defensiveness scores both above the median).

The analyses reflected both the dichotomous distinction (repressors vs. non-repressors) and the four-category classification (repressors, low-anxious, high-anxious and defensive). The combination of anxiety and defensiveness as reflecting a repressive coping style has been validated in previous studies (24). The Cronbach’s alpha for the current sample was high, both for the Taylor Manifest Anxiety Scale (.85) and the Marlow-Crowne Social Desirability Scale (.78).

RESULTS DIFFERENCES IN LEVELS OF PTSD, PHYSICAL HEALTH, AND FUNCTIONING BEFORE AND AFTER THE INTERVENTION

To examine the hypothesis relating to the relationships between participation in the intervention and reduc-

tion of PTSD symptoms, ANCOVAs for PTSD, Physical Health, and Functioning were performed with repeated measures for each stage of data collection, with groups (intervention and control) as the independent variable and education, proximity to combat, and the significant event as covariates. The analysis revealed significant group and interaction effects.

The results of Bonferroni tests presented in Table 1 reveal that participants in the control group reported higher post-traumatic distress symptoms than did participants in the intervention group both before and after intervention. Contrary to the hypothesis, there was no improvement among soldiers in the intervention group.

However, while PTSD symptoms remained stable among participants in the intervention group, the symptoms increased among participants in the control group.

Physical Health. Significant differences were found between participants in the two groups with regard to self-assessed health: F(1, 161)=3.98, p<.05. Levels of physical health among participants in the control group were lower than among those in the intervention group (M=2.53, and M=2.70, respectively, with a lower score representing a greater negative change).

Functioning. Due to the use of different measures before and after the intervention, comparisons of the two groups were performed separately at each time point, and no significant change was found. Comparisons of the groups before the intervention revealed no significant differences – F(1, 161)=0.12, p>.05) – although the levels of functioning at that time were lower among participants in the intervention group than among participants in the control group (M=2.54, SD=1.12; and M= 2.60, SD=.88, respectively). After the intervention, the levels of functioning among participants in the intervention group were significantly better than among the participants in the control group (M=3.18, SD=0.53; and M=2.94,

Table 1: Means and Standard Deviations of Outcome Measures, by Group and Timing: controlling for education, proximity to combat, and significant event Intervention group (n=98)

Control group (n=68)

F values Ƞ2

Before

After

Before

After

F(1,161)

F(1,161)

F(1,161)

Group

Time

Group x Time

Means

1.52

1.47

1.63

1.77

5.97*

1.08

12.53**

SD

0.45

0.43

0.65

0.69

.03

.01

.07

Means

2.56

2.85

2.46

2.60

3.98*

0.00

2.27

SD

0.61

0.42

0.74

0.7

.02

.00

.01

Variable

Total PTSD Physical Health *p<.05. **p<.01.

53

EARLY GROUP INTERVENTION FOR RESERVE SOLDIERS

SD=0.77, respectively: F(1, 161)=5.52, p<.01).

THE ASSOCIATION BETWEEN COPING STYLE AND LEVELS OF DISTRESS

First, we examined whether there were differences between the two groups with regard to the distribution of different repressive styles. Table 2 presents the joint distribution of coping style and group. As can be seen in the table, the percentage of soldiers in each coping style category was similar for both groups, and no significant differences between the groups were found: X2(3)=.86, p>.05. In addition, Cohen’s Kappa was calculated to determine style consistency over time, revealing a high level of agreement over time (Kappa=.75, p<.001), while no difference in style between groups was observed.

In order to examine the hypothesis that after participation in combat, soldiers who have a repressive coping style will have lower levels of distress than non-repressors, a one-way ANOVA was conducted, with PTSD symptoms as the dependent variable and the four coping styles as the independent variable (F=18.07, df=3,162, p<.001). The Bonferroni post-hoc analysis supports this hypothesis: soldiers who were characterized by low anxiety or by being repressors reported lower levels of PTSD symptoms following combat than did soldiers who were characterized by high anxiety or defensiveness (see Table 3).

To examine the hypothesis that levels of PTSD would

decrease among non-repressive participants as a result of the intervention, whereas there would be no change or even an increase in the levels of PTSD symptoms among repressors, a two-way ANOVA was conducted in regard to change in the level of PTSD symptoms (preintervention level minus post-intervention level) x group and coping style. Only the group effect was found to be significant – F(1, 157)=14.96, p<.001 – a finding which fails to support this hypothesis, and replicates the first hypothesis. Moreover, there was no change in levels of PTSD among participants in the intervention group, whereas levels of PTSD increased among participants in the control group. Neither coping style nor interaction effects were significant: F (3, 157)=0.50, p>.05, and F(3, 157)=1.88, p>.05, respectively.

DISCUSSION The first aim of the research was to examine whether soldiers who had participated in EGI would show less post-traumatic stress than those who had not participated in the intervention. The findings indicated that after EGI participants in the control group experienced more posttraumatic stress than did the participants in the intervention group. However, contrary to the research hypothesis, there was no improvement in PTSD symptoms among the soldiers in the intervention group. Nevertheless, four months after the intervention, Table 2: Combined Distribution of Coping Style, by Group the levels of functioning and physiControl Intervention Total cal health among the participants Coping style Frequency % Frequency % Frequency % in the intervention group were Low-anxious 17 25.0 29 29.6 46 27.7 significantly better than among the Repressors 17 25.0 27 27.6 44 26.5 participants in the control group.

High-anxious 15 22.1 18 18.4 33 19.9 And four months after the intervention, the soldiers in the control Defensiveness 19 27.9 27 24.5 43 25.9 group assessed their own physical Total 68 100 98 100 166 100 health as worse than it had been a year earlier.

Table 3: Means, Standard Deviations, and F Values of Stress Indices The lack of improvement in (Prior to EGI) by Coping Style PTSD symptoms among participants 1 3 4 2 in the intervention group following Low Source of High Repressor Defensiveness EGI does not necessarily indicate anxious anxious F=(3,162) Ƞ2 differences that the intervention wasn’t effective.

N=46 N=33 N=44 N=43 Rather, this lack of improvement Total M 1.30 1.72 1.34 1.94 18.07 *** .25 1,3<2,4 might be attributed to the nature of PTSD the intervention, which focused on a discussion of responses to trauma.

SD 24.

53.

34.

69.

As such, the EGI may have raised *** p<.001 the participants’ awareness of their 54

YAEL SHOVAL-ZUCKERMAN ET AL.

symptoms and, paradoxically, inhibited future improvement (40, 41).

The findings also revealed that following the intervention, the participants in the control group experienced more post-traumatic distress than did the participants in the intervention group. They also had poorer functioning and more physical health problems than did the participants in the intervention group. As there was no random allocation, one cannot discount the possibility that there might have been differences between the two groups: for instance, those who did not take part in the intervention might have been more vulnerable to begin with. As suggested previously, it may be that soldiers with PTSD, who have a high awareness of their mental and physical problems, tend to assess their situation as more severe than soldiers without PTSD (42). This explanation is also consistent with the approach of researchers who argue that people who have experienced a traumatic event tend to develop hypochondria, and that somatic problems play a central role in their lives (43).

Two hypotheses regarding the repressive coping style were examined in this research. The research findings support the hypothesis that repressors will show higher levels of adaptation following traumatic events than will non-repressors. The repressors showed a lower intensity of post-traumatic distress, as did the participants in the low-anxious group versus the participants in the other two groups (high-anxious and defensive). These findings are consistent with the results of another study which revealed that among people who had been in a motor vehicle accident, there were no significant differences between repressors and low-anxious individuals with regard to levels of PTSD and depressive symptoms (29).

There are several explanations for the contribution of repressive coping to adaptive behavior: First, repressors are protected by their primary appraisal of stressful events (44), that is, by their perceptions and interpretations of threatening cues. Second, repressors seem to have exceptional control over what they pay attention to in the presence of threat, a process that may foster resilience in the face of trauma (45). They also recall fewer details of stressful experiences (46), and they remember fewer negative events (21). These findings suggest that repressors may be less prone to develop PTSD because they employ selective attention during and after a traumatic event, and thus perceive the event as less threatening than do non-repressors (47). Third, it has been argued that a major motive for repressive coping is maintaining a positive self-image (22). Various findings have indicated

that in comparison with non-repressors, repressors tend to ascribe fewer negative and more positive attributes to themselves (48).

The second hypothesis â&#x20AC;&#x201C; i.e., that the intervention would reduce post-traumatic distress among non-repressors whereas post-traumatic symptoms would remain unchanged or even worsen among repressors â&#x20AC;&#x201C; was not supported. This hypothesis derived from our assumption that EGI, which is based on the principles of debriefing, would expose repressors to threats that might cause a flood of thoughts and unpleasant memories that they would try to divert. However, no significant differences were found after the intervention with regard to the various styles of coping with post-traumatic distress.

Several possible explanations can be offered for this finding. As mentioned, various researchers have indicated that repressors have a more positive self-perception than non-repressors (49), and that they pride themselves on appearing self-controlled and unemotional (22).

Consistent with these arguments, it is possible that the EGI allowed the repressors in the present study to maintain their positive self-perception since behaviors that are generally perceived as failures were redefined in the intervention as reactions that are reasonable to expect following the return to civilian life (50).

Furthermore, EGI does not pose a threat to the selfimage of repressors. If they describe themselves as possessing effective coping skills, they receive encouragement from the group and from the facilitators. In that context, they are not exposed to threatening feelings from their peers or to feelings of failure and loss of control.

Consistent with the findings of Ginzburg et al. (24), in this study the repressive coping style was a protective factor, which contributed more to preventing mental health symptoms than it did to promoting mental health resilience and functioning.

LIMITATIONS OF THE RESEARCH

This study had several methodological limitations, as the intervention was designed to meet military needs (i.e., minimizing risks for long-term psychological problems and assisting soldiers in distress) and was not designed for systematic research. Rather, the research was planned after the intervention took place in order to address the gap between the need for intervention in the military and the lack of studies assessing its effectiveness.

The main limitation was that that there was no random allocation to research groups. Moreover, because the EGI was conducted by the military and aimed to mitigate 55

EARLY GROUP INTERVENTION FOR RESERVE SOLDIERS

distress among all soldiers, a random sample could not be attained. Nonetheless, no significant differences were found between the two groups in the main background variables, suggesting that in fact there was a basis for comparing the two groups.

Another limitation of this study was that the control group had significantly higher PTSD symptoms at Time 1 than did the intervention group, a drawback that might be related to the non-random allocation to the research groups.

The second stage of data collection occurred while the soldiers were in reserve duty. Perhaps the renewed contact with the army four months after the war influenced their feelings and reawakened memories and thoughts that biased their responses (i.e., reflecting more symptoms and higher intensity of distress). In addition, some changes were made in the questionnaires between the two stages of data collection due to logistical constraints. Other limitations include the lack of objective measures such as performance on military tasks and other observations.

IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE

To better understand the contribution of each component of EGI to preservation or improvement of behaviors among participants in an intervention, there is a need for additional long-term follow-up studies dealing with each of the specific aspects of the intervention method.

The clinical advantage of EGI is that it provides a basis for identifying soldiers with PTSD while they are doing reserve duty. Findings have revealed that at a later stage, when the soldiers are at home, they need to take initiative to continue treatment. As a result, those who are not proactive might not receive essential support. Furthermore, if the soldiers at risk are identified immediately following military service, treatment can be provided in closer temporal proximity to the traumatic event. Another significant advantage of the intervention for soldiers who remain in their organic unit relates to the informal interaction among the soldiers and their immediate commanders, who constitute a significant support system and a source of strength that helps them cope with the situation.

The finding that repressors showed a lower intensity of post-traumatic distress indicates that the repressive coping style is a mechanism that can facilitate adaptation after a traumatic event. Therefore, the clinical tendency to encourage all soldiers who have been exposed to a traumatic event to talk about their experience out of a concern that repression of the event might worsen their 56

condition was not supported in the present study. Finally, little is known about the development of repressive coping and the ability to change that style. Hence, especially in light of its protective function, it would be worthwhile to conduct further research on the role of the repressive style in the process of coping with traumatic events.

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42. Elhai JD, Kashdan TB, Snyder JJ, North TC, HeaneyCJ, Frueh BC. Symptom severity and lifetime and prospective health service use among military veterans evaluated for PTSD. Depress Anxiety 2007;24:178-184.

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EARLY GROUP INTERVENTION FOR RESERVE SOLDIERS

APPENDIX 1 - THE OPENING STAGE

Commander. 1. Goal of the intervention: “We went through harsh events (the commander should direct towards events experienced during the war) during the last reserve service, after which we returned to our life routine. In our session today we will try to clarify what our life routine looks like since we were discharged from reserve duty, with emphasis on the emotional processes that accompanied the process of our return to civilian life. It is important that each of you will express himself.

We on our part will enable each of you to do so. In this way we will learn how each person coped and is coping with the return to civilian life on the background of the war events we experienced and how we as a team need to cope in preparation for our next reserve duty.”

2. Framework: “The session is divided into three rounds. In the first round we will describe the sequence of events that each of us experienced since his discharge from reserve duty and will examine, at the facts level, how each of you copes with the routine of his civilian life with emphasis, as mentioned before, on the encounter with “civilianship” after being discharged from reserve duty – after the war. This second part will last about two hours. After a break we will convene for a second round that will last for about three hours, with a break in the middle, in which we will deal with our feelings from a distance of the time that has elapsed since the war events and since our discharge from reserve duty. During the third round we will summarize the discussion for about one hour and will discuss the future and the expected schedules. This entire day will be headed by (indicate name) – a therapist at the Combat Reaction Unit.”

3. Rules: “In order to create an atmosphere that will enable success of this session, I would like to ask you to make sure of the following: do not talk on your mobile phones because succession is important, and for mutual respect, do not enter and leave during the talk, allow each person to finish what he is saying, do not attack, do not criticize (it must be emphasized that this is not an operational debriefing), and finally, it is very important that each of you will speak. If anyone has difficulty with this, he should at least describe his position and role during the event that took place in the war.”

Therapist. 4. Rationale: “‘The early group intervention’ is intended to prevent the development of effects that belong to what we call the post-traumatic stress disorder, which I will detail right away. This disorder may develop among soldiers who, like you, experienced combat events in which soldiers were killed and injured.

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We know from studies and from reports of professionals who experienced such models of talks that the talk within a group of people who know each other well and who experienced the event together is very helpful for emotional alleviation and for preventing post-trauma.

This talk is supposed to take place at a distance of about three months from the previous talk you had, the ‘team talk after the event’ during the last two days of your reserve duty, because it is believed that it is possible to prevent the development or exacerbation of effects that belong to the post-traumatic stress disorder during the first three months after exposure to an event. This talk, of ‘early group intervention,’ is actually a continuation of the previous talk in which you participated, and comprises another opportunity for all of you to describe your experiences and emotions and to learn how each of you is coping with civilian life on the background of the event which you experienced during the war. It is also supposed to increase the cohesion, sharing and mutual care among you and will help us, the therapists and the commanders, identify and suggest, to those for whom these talks were not helpful, to receive individual therapy at the Combat Reaction Unit.”

5. Psycho-education: “Chronic post-trauma develops, according to the research literature, over three months and is characterized by three groups of symptoms: ‘avoidance’ of thoughts about the event or contact in reality with things that are reminiscent of the event, for example: contact with the army or watching news that broadcasts pictures from a war, ‘hyperarousal’ which is expressed in alertness on a background of the tension created by the feeling that another harsh event can happen, which sometimes leads to panic from noises reminiscent of the sound of explosives, and ‘intrusiveness,’ which is expressed in nightmares and unceasing dreams and thoughts about the event. All three of these symptoms eventually impair functioning, since if one does not sleep well because of dreams and nightmares one becomes tense during the day, the level of attention decreases and the ability to function well at work, as a parent or as a partner, is impaired. Furthermore, think about the fact that when a person who was exposed to a traumatic event is busy avoiding thinking about the event or coming into contact with things that are taking place in reality that are reminiscent of that event during his waking hours, this increases his difficulty to function even more. We would like to prevent all of this or at least reduce the intensity of the symptoms among those who are already suffering from them, and as I mentioned already, the ‘window of

YAEL SHOVAL-ZUCKERMAN ET AL.

opportunity’ for prevention is within this range of time, i.e., in the early months after exposure.

It is important for me to indicate that even if symptoms characteristic of post-trauma have developed among some of the people sitting here, and even if after the session today some of the symptoms will remain, there are still things that can be done. First of all you must remember that people who experienced such a harsh event react to the event at the emotional level. We know from studies that not less than 80% of the people who are exposed suffer from at least one symptom of a stress reaction, which is the first stage of post-trauma, but the symptoms usually disappear. How? By talking with friends, partners, family, etc. Thus, they recover without any help from a professional by spontaneous talk. What is done here is something more structured, but is based on the idea that one must talk about things, because ‘talk’ apparently helps. Of course, your belief that it is possible to feel better and that it is possible to again function well as a team is also very important. Finally, it is important to stress that if there is no improvement among someone who already suffers from symptoms, he can come to us at the CRU for individual help. Such help is supposed, in the end, to help reduce the intensity of the symptoms and improve the quality of functioning.”

APPENDIX 2 - SECOND STAGE

Second Round Therapist. Explanation of the different losses (friends, relatives, worldview, self-trust, confidence, trust in commanders, trust in operational ability, loss of motivation)

as a result of exposure to traumatic events.

Commander. “Based on what (should mention the name of the therapist with whom he is working) described, it is important that we talk about each of our losses. What did each of us lose during this event?”

After each participant referred to this question, the therapist should ask: “What are the emotions that accompany the loss?” (The therapist should focus the talk on anger and guilt by reflection, confrontation, leading questions, etc.)

APPENDIX 3 - SECOND STAGE

Third Round Commander. “Based on the talk today, what things do you think need to be taken from here for the future at the personal level and at the team level?”

Therapist. Stressing the positive forms of coping (for example: reflection of the component of sharing and receiving support from the partner).

Commander. “I would now like to ask each of you to indicate at least one thing that he received from the group today and what his message is to the group.” After the discussion the commander summarizes the intervention according to the following points: (1) Summarize the session up to this point (major and positive components that were prominent around the return to functioning after the discharge, prominent feelings and prominent recommendations for future coping). (2) Speak about the moral and ethical (comradeship) commitment “to go on.” (3) Speak about the importance of “to go on” for the individual and for the team.

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)

Psychiatric Symptoms and Quality of Life in Military Personnel Deployed Abroad Taner Öznur, MD,1 Süleyman Akarsu, MD,2 Murat Erdem, MD,3 Murat Durusu, MD,4 Mehmet Toygar, MD,5 Yavuz Poyrazoglu, MD,6 Ümit Kaldirim, MD,4 Mehmet Eryilmaz, MD,4 and Kamil Nahit Ozmenler, MD1 Gülhane Military Medical Academy, Dept. of Psychiatry, Dept. of Military Psychology and Combat Psychiatry, Ankara, Turkey Aksaz Military Hospital, Dept. of Psychiatry, Marmaris, Muğla, Turkey 3 Gülhane Military Medical Academy, Dept. of Psychiatry, Ankara, Turkey 4 Gülhane Military Medical Academy, Dept. of Emergency, Ankara, Turkey 5 Gülhane Military Medical Academy, Dept. of Forensic Medicine, Ankara, Turkey 6 Mevki Military Hospital, Dept. of General Surgery, Elazığ, Turkey 1

2

ABSTRACT Background: Military personnel deployed abroad could be exposed to more risk factors that adversely affect quality of life. In this study, we examined psychiatric symptoms and quality of life in Turkish Armed Forces deployed to Afghanistan.

Method: A total of 289 Turkish military personnel working in Afghanistan enrolled in this study. They completed two surveys containing questions about socio-demographic characteristics. Data were collected and analyzed from 258 of the participants.

Results: The general symptom scores (GSI) were above 1 in 20.8% (n=54) of the participants. The lowest SF-36 scores by the sub-groups were mental health (59.14 ± 18.56) and vitality (59.25 ± 21.17). The highest score was in the

physical function subscale (84.42 ± 19.53). All Quality of Life Questionnaire Short Form (SF-36)subscale scores were lower in the GSI above 1 group than the GSI below 1 group.

In the GSI above 1 group: education level and depression affected SF-36 physical functioning; paranoid ideation and somatization affected SF-36 role limitations due to physical health; age and somatization affected SF-36 pain; age affected SF-36 general health; phobic anxiety affected SF-36 vitality; age, tenure of occupation, tenure abroad; and phobic anxiety affected SF-36 mental health.

Conclusions: The negative effects of psychiatric symptoms on the quality of life were similar to those in the general population and in specific disease groups. These results should be considered when evaluating the mental health of military personnel deployed abroad.

I have obtained permission from all persons named in the acknowledgement. No financial support from any company or institution has been received and the authors do not have any commercial relationship. This manuscript has not been published elsewhere or submitted for publication elsewhere.

INTRODUCTION Performing tasks abroad is challenging for military personnel because of certain conditions, like limited resources, increased risk of illness, life-threatening situations, separation from the family, different climate, different cultural. These extreme conditions strain military personnel involved in multinational forces equipped for Address for Correspondence: drakarsus@hotmail.com

60

different purposes. Besides separation from familiar family, social and occupational environments, personnel are faced with the process of physically and psychologically adapting to performing a task in a new environment.

The absence of a private and sexual life, the difficulty of ensuring hygienic conditions, and a variety of challenging weather conditions and geographic features are significant difficulties that interfere with this process.

Süleyman Akarsu, MD, Aksaz Military Hospital, Dept. of Psychiatry, Marmaris, Muğla, Turkey.

TANER ÖZNUR ET AL.

Additionally, occupational challenges are another source of stress (1). The emergence of psychiatric symptoms associated with this process adversely affects the quality of life of the individual.

The World Health Organization defines quality of life as “perception of the conditions of people within the entirety of their culture and values in connection with objectives, expectations, standards and concerns.” Quality of life can also be defined as “a concept that reflects the individual reactions to the diseases, physical, psychological, social effects of daily life and affecting the level of personal satisfaction that can be achieved in the context of life” (2). Many factors have an effect on health-related quality of life. Biological and physiological variables, functional status, and general health perception have been included in this concept by Wilson and Cleary (3). Yıldırım has discussed individuals’ physical, functional and emotional satisfaction levels in the context of social health-related quality of life (4). Studies have revealed an intermediate or advanced relationship between the health-related quality of life and feeling disabled, which is dependent on a person’s age, income, type of chronic disease, and use of health care services (5). Mental health is an important part of health-related quality of life. Individuals who have a psychiatric disorder have a lower quality of life score compared to those who do not (6). Similar quality of life scores have been reported in patients with major depression and in patients with physical illness (7).

According to the other international task groups (e.g., civil society aid organizations), military personnel deployed abroad could be exposed to more risk factors related to the properties of “being a soldier,” such as wearing uniforms and carrying weapons. Studies evaluating the psychiatric symptoms and quality of life of the military personnel deployed abroad are often performed after the end of the task and in the post-traumatic stress disorder (PTSD) samples. In the studies researching soldiers involved in the Vietnam, Afghanistan and Iraq wars, the association between PTSD and impaired quality of life was determined (8, 9).

In this study, our aim was to identify psychiatric symptoms and how these symptoms affect the quality of life in the military personnel deployed to a foreign country to maintain international peace.

METHODS Military personnel who served at least three months with the International Security Assistance Force (ISAF), and

who voluntarily agreed to participate, were enrolled in the study. ISAF has been serving in Afghanistan and its staff changes every six months. ISAF consists of ranking personnel and soldiers. Their duties focus on humanitarian purposes. There are no casualties.

The Brief Symptom Inventory (BSI), Quality of Life Questionnaire Short Form (SF-36) and a data form containing questions about socio-demographic characteristics such as age, marital status, rank, tenure of occupation, and tenure abroad were administered to the participants. Of the 289 participants, 258 filled out the forms properly and the data from these 258 were evaluated. Ethical approval was obtained from the university hospital research ethics committee from the hospital where the study was conducted. Written consent was obtained from all participants after being informed about the research.

MATERIALS THE BRIEF SYMPTOM INVENTORY

The BSI is a 53 item Likert-type scale derived from the acronym Symptom Check List-90 and is used for scanning for a wide variety of psychological symptoms (10).

A Turkish adaptation and a reliability and validity study were made by Sahin et al. (11). Items are rated using values between 0–4. This scale consists of nine subscales, three global indices, and additional ingredients.

The subscales are somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.

The global indices are called the general symptom index, the sum of signs index, and the symptom severity index.

In this study, general symptom index (GSI) scores were used for the overall assessment of psychopathology.

QUALITY OF LIFE QUESTIONNAIRE-SHORT FORM

The SF-36 is a self-administered, generic measure of health status, containing 36 items. A Turkish reliability and validity study was made Kocyigit et al. (12). Scores are transformed to a scale of 0–100, where higher scores represent higher function. Using content analysis, the items are assigned to eight subscales: physical functioning, role limitations due to physical health, pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. The most obvious advantage of the scale is that it measures physical function and related skills. A limitation of this 61

PSYCHIATRIC SYMPTOMS AND QUALITY OF LIFE IN MILITARY PERSONNEL DEPLOYED ABROAD

questionnaire is that it did not to include questions to assess sexual function.

STATISTICAL ANALYSIS

RESULTS The GSI scores were above in 20.8% (n=54) of the participants. A comparison of age, education level, marital status, rank, tenure of occupation, and tenure abroad in the participants whose GSI was above 1 to those with a GSI under 1 is shown in Table 1. There are no differences Table 1: Comparison of two groups according to age, tenure of occupation, tenure abroad, education level, marital status and rank Variable

GSI<1 (n=205) GSI >1 (n=54)

Z/X2, p

Age

25.42 ± 6.12

24.63±5.24

0.87, 0.38

Tenure of occupation (years)

1.77 ± 1.14

1.75±0.89

0.12, 0.90

Tenure abroad (months)

3.38 ± 1.00

3.48±0.99

0.56, 0.58

Education level (years)

11.22 ± 0.68

11.15±0.76

0.62, 0.53

47(22.9) 158(77.1)

11(20.4) 43(79.6)

0.16, 0.69

20(9.8) 34(16.6) 151(73.7)

2(3.7) 8(14.8) 44(81.5)

2.27, 0.32

Rank Officer-Petty officer Expert lance corporal Private-Ranker

GSI: General Symptom Index. Z: Mann-Whitney U test value.

X2:Chi-square test value.

62

GSI<1 (n=205) GSI >1 (n=54) (Mean ± sd) (Mean ± sd)

Z

p

Physical functioning

87.29 ± 17.89

73.52 ± 21.69

5.23

< 0.001

Role limitations due to physical health

70.73 ± 33.07

50.00 ± 34.00

4.06

< 0.001

Pain

69.38 ± 24.90

46.85 ± 21.78

5.68

< 0.001

General health perception

69.46 ± 17.87

45.19 ± 22.73

6.79

< 0.001

Vitality

63.98 ± 19.02

41.30 ± 19.33

6.62

< 0.001

Social functioning

72.56 ± 24.98

45.85 ± 26.41

6.17

< 0.001

49.39 ± 31.67

4.65

< 0.001

39.11 ± 14.30

8.58

< 0.001

SF-36 Subscale

The data are presented in the form of numbers and percentages for categorical variables and in the form of mean plus or minus standard deviation for continuous variables. Because the parametric conditions were not met, the Mann-Whitney U test was used when comparing the participants whose GSI was above 1 with those whose GSI was under 1.

A backward linear regression analysis was done to determine the effect of the BSI subscales, and the age, education level, tenure of occupation, and tenure abroad of each participant, on the SF-36 subscale scores. We evaluated all eight subscales of the SF-36 as dependent variables. We evaluated the nine subscales of the BSI, as well as age, education level, tenure of occupation and tenure abroad, as independent variables. The refined models results are presented. A p-value of 0.05 was considered statistically significant.

Marital status (n, %) Married Single

Table 2: Comparison of SF-36 subscale scores in the participants whose BSI general symptom index above 1 or under 1

Role limitations due to emotional 71.49 ± 30.18 problems Mental health

64.41 ± 15.76

GSI: General Symptom Index. Z: Mann Whitney U test value.

SF-36 subscale scores of the group with GSI score below 1 found to be higher than the group with GSI score above 1 (p< 0.001).

between these two groups with regard to these features.

A comparison of the SF-36 subscale scores in the participants whose GSI was above 1 to those with a GSI below 1 is shown in Table 2. All of the SF-36 subscale scores were lower in the GSI above 1 group than of those in the GSI below 1 group. Factors affecting the SF-36 subscale scores of the GSI above 1 group are shown in Table 3. In the group having psychopathology (GSI above 1), BSI depression subscale score was found to have a positive effect on the SF-36 physical functioning subscale score, but education level was found to have a negative effect. The BSI paranoid ideation subscale score had a positive effect on the SF-36 role limitations due to physical health subscale score, but the somatization subscale score had a negative effect. The BSI somatization subscale score had a negative effect on the SF-36 pain subscale score, and the BSI phobic anxiety subscale score had a negative effect on the SF-36 vitality and mental health subscale scores.

On the other hand, the age of participants was found to have a negative effect on the SF-36 pain, general health, and mental health subscale scores in the GSI above 1 group. Also, tenure of occupation had a positive effect on the SF-36 mental health subscale score, but tenure abroad had a negative effect.

The BSI anxiety, obsessive compulsive, hostility, interpersonal sensitivity, and psychoticism subscale scores had no effect on quality of life in the GSI above 1 group.

TANER ÖZNUR ET AL.

DISCUSSION Psychological morbidity was determined in 20.8% of the study sample. This ratio is similar to the general population (9–26%) (13–23). In a prior study, the total percentage of depression, generalized anxiety, PTSD and alcohol abuse was found to be 24.5% in U.S. soldiers who served in Afghanistan (24). This result indicates that personnel had substantially adapted to the task even though they were in service abroad. Despite the many difficulties brought about by performing a task abroad, this study’s detection of a similar rate of psychological morbidity to that in the general population indicates that personnel had substantially adapted to the task and that coping attitudes, with moral and motivational factors, were sufficient to manage the challenges.

In this study, the lowest SF-36 scores by the subgroups were mental health (59.14 ± 18.56) and vitality (59.25 ± 21.17). The highest score was in the physical function subscale (84.42 ± 19.53). Similar to our findings, the quality of life for U.S. soldiers who participated in the Iraq and Afghanistan wars was found to be impaired for those with psychiatric diagnosis, especially for PTSD (1). The results of other studies, Table 3: Factors affecting the SF-36 subscale scores of the GSI above 1 group Beta

t

p

%95 Confidence Interval

Education level

-0.48

-2.88

0.009

-11.50- (-1.85)

Depression

0.38

2.27

0.034

0.64–14.53

Physical functioning

Role limitations due to physical health Somatization

-0.42

-2.47

0.022

-43.97- (-3.80)

Paranoid ideation

0.68

3.97

0.001

16.49–52.76

Age

-0.42

-2.31

0.031

-2.91-(-0.15)

Somatization

-0.39

-2.17

0.041

-24.97-(-0.55)

-0.52

-2.82

0.01

-3.58- (-0.55)

-0.47

-2.49

0.021

-26.89-(-2.45)

Age

-1.32

-2.92

0.009

-4.97-(-0.82)

Tenure of Occupation

1.25

2.78

0.012

3.82–27.17

Tenure Abroad

-0.69

-3.06

0.006

-13.37-(2.51)

Phobic Anxiety

-0.50

-2.24

0.037

-22.63-(-0.76)

Pain

General Health Perception Age Vitality Phobic Anxiety Mental Health

not involving soldiers, were similar (25–27).

These results show that personnel serving abroad, with high levels of psychiatric symptoms, had an adversely affected quality of life. The multiple linear regression analysis showed that one or more psychiatric symptom clusters affected some aspects of quality of life. It was noteworthy that most of symptom groups (except for paranoid ideation and depression) had a negative effect on the quality of life.

Educational level had a negative effect, but BSI depression subscale score had a positive effect on the SF-36 physical functioning subscale score. This result suggests that low educational level adversely affected the physical functionality in tasks abroad. Also, in GSI above 1 group, the presence of subthreshold depressive symptoms had a positive effect on physical functionality. Contrary to this finding, depressive disorders (major depression, minor depression, etc.) were found to be associated with deterioration in physical functioning in the Cuijpers et al. study (28). Age, financial status and moral motivation for tasks were evaluated to prevent the reduction in the level of physical functioning in our study.

The BSI somatization subscale score had a negative effect on the SF-36 role limitations due to physical health subscale score, but the BSI paranoid ideation subscale score had a positive effect. This relationship suggests that high levels of somatization may cause role limitations and physical problems. In a similar study, somatization was found to cause role limitations and great deterioration in business life and social activities (29).

The positive effect of paranoid ideation on role limitations due to physical health was considered to be associated with the shortness of the task period of the sampling group and the presence of occupational and financial motivational factors. Similar to this result, individuals who have paranoid ideation characteristic of paranoid personality disorder have been found to not lose function in the fields of physical health and role limitations (30).

Age and the BSI somatization subscale score had a negative effect on the SF-36 pain subscale score in the group with possible psychopathology. Physical pain increased with an increase in age, and this was considered a negative impact on quality of life. Contrary to this finding, Sun et al. determined that the physical dimension of quality of life, including physical pain, negatively correlated with age (31).

A negative correlation has been found between age and physical pain in a population-based study (32). This difference seems to be associated with the low-mean 63

PSYCHIATRIC SYMPTOMS AND QUALITY OF LIFE IN MILITARY PERSONNEL DEPLOYED ABROAD

age of the sample. The mean age of participants with a GSI above 1 was 24.63±5.24 in our study and the mean ages in the other studies were 73.2 ± 5.8 and 47 ± 13, respectively (31, 32). The finding that the negative effect of the somatization on physical pain in the GSI above 1 group in our study is compatible with the results of the study (33) indicating the negative effect of the somatization on physical dimension of quality of life, including physical pain.

Age had a negative effect on the SF-36 general health subscale score in the GSI above 1 group in our study. This finding is consistent with the findings of Sun et al. that general health perception in male participants decreases with the age (31).

Phobic anxiety had a negative effect on the SF-36 vitality subscale score in the GSI above 1 group. This finding suggests that the phobic thoughts level of participants reduce energy (vitality) levels. In other studies, vitality has been found to be negatively affected by the panic-agoraphobia levels in the patients with social phobia (34), dental fears (35), and rheumatoid arthritis (36).

The finding of a negative effect of age on mental health does not coincide with the finding of McAndrew et al. that young age is associated with poorer mental health function (37). On the other hand, Sun et al. found that age has a negative effect on a mental component summary score that contains the mental health subscale score (31).

The negative effect of tenure abroad on the mental health is considered to be associated with the lack of family and social support systems and the burden created by the challenging task conditions. In a related study, the deployment length was found to influence psychological health levels of male soldiers in a peacekeeping deployment (38).

The negative effect of phobic anxiety on mental health was detected in the participants. Mental health has been shown to be negatively affected in patients with social phobia (34). In relation to phobic anxiety, psychological well-being has been found to be negatively affected in patients with dental fear (35). Also, panic-agoraphobic symptoms have been found to adversely affect the mental health of patients with rheumatoid arthritis (36).

The positive effect of tenure of occupation on mental health suggests the positive influence of the experience of dealing with occupational challenges. Occupational experience had been shown to increase familiarity and competence in dealing with occupational challenges in studies carried out in different occupational groups (39, 40).

64

CONCLUSION In this study, the negative effects of the psychiatric symptoms on quality of life in many areas was determined to be similar to the general population and to specific disease groups, although not to evaluation axis I psychiatric diagnoses such as PTSD was a limitation.

Another limitation of this study is absence of a control group. This is a cross-sectional study. A follow up study is needed that includes a control group. Also, there is a need for further research examining the interpretation of psychological problems and coping styles in relation to the cultural structure of participants.

The literature shows that studies of international military tasks were conducted after soldiers return to their country (37, 41, 42). We believe that the assessment of psychiatric symptoms associated with deployment and quality of life while the task is not yet finished is a better methodology, one that would give more accurate results. This study demonstrates the effects of psychiatric symptoms arising in the soldiers during deployment on quality of life. Rigorous planning and implementation of training before the task in order to prevent the occurrence of psychiatric symptoms is considered necessary.

Conflict of interest The authors declared that they have no conflict of interest.

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16. Lahelma E, Martikainen P, Rahkonen O, Roos E, Saastamoinen P. Occupational class inequalities across key domains of health: Results from the Helsinki Health Study. Eur J Public Health 2005; 15:504-510.

17. Niedhammer I, Chastang JF, David S, Barouhiel L, Barrandon G. Psychosocial work environment and mental health: Job-strain and effort-reward imbalance models in a context of major organizational changes. Int J Occup Environ Health 2006; 12:111-119.

18. Rona RJ, Hooper R, Greenberg N, Jones M, Wessely S. Medical downgrading, self-perception of health and psychological symptoms in the British Armed Forces. Occup Environ Med 2006; 63:250-254.

19. Cheng TA, Williams P. The design and development of a screening questionnaire (CHQ) for use in community studies of mental disorders in Taiwan. Psychol Med 1986; 16:415-422.

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22. Yang TZ, Huang L, Wu ZY. The application of Chinese Health Questionnaire for mental disorder screening in community settings in mainland China. Zhonghua Liu Xing Bing Xue Za Zhi 2003; 24:769773 (in Chinese).

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24. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL.Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

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27. Ormel J, Von Korff M, Ustun B, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures: Results from the WHO collaborative study on psychological problems in general health care.

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31. Sun W, Aodeng S, Tanimoto Y, Watanabe M, Han J, Wang B, Yu L, Kono K.Quality of life (QOL) of the community-dwelling elderly and associated factors: A population-based study in urban areas of China.

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32. Wang R, Wu C, Zhao Y, Yan X, Ma X, Wu M, Liu W, Gu Z, Zhao J, He J. Health related quality of life measured by SF-36: A population-based study in Shanghai, China. BMC Public Health 2008; 8:292.

33. Vu J, Kushnir V, Cassell B, Gyawali CP, Sayuk GS. The impact of psychiatric and extraintestinal comorbidity on quality of life and bowel symptom burden in functional GI disorders. Neurogastroenterol Motil 2014; 26:1323-1332.

34. Wittchen HU, Fuetsch M, Sonntag H, Müller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia. Findings from a controlled study. Eur Psychiatry 2000; 15:46-58.

35. Mehrstedt M, Tönnies S, Eisentraut I. Dental fears, health status, and quality of life. Anesth Prog 2004; 51:90-94.

36. Piccinni A, Maser JD, Bazzichi L, Rucci P, Vivarelli L, Del Debbio A, Catena M, Bombardieri S, Dell’Osso L. Clinical significance of lifetime mood and panic-agoraphobic spectrum symptoms on quality of life of patients with rheumatoid arthritis. Compr Psychiatry 2006; 47:201-208.

37. McAndrew LM, D’Andrea E, Lu SE, Abbi B, Yan GW, Engel C, Quigley KS. What pre-deployment and early post-deployment factors predict health function after combat deployment?: A prospective longitudinal study of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) soldiers. Health Qual Life Outcomes 2013; 11:73.

38. Adler AB, Huffman AH, Bliese PD, Castro CA. The impact of deployment length and experience on the well-being of male and female soldiers. J Occup Health Psychol 2005; 10:121-137.

39. Al Juhani AM, Kishk NA. Job satisfaction among primary health care physicians and nurses in Al-Madinah Al-Munawwarah. J Egypt Public Health Assoc 2006; 81:165-180.

40. Campbell SL, Fowles ER, Weber BJ. Organizational structure and job satisfaction in public health nursing. Public Health Nurs 2004; 21:564571.

41. Steenkamp MM, Boasso AM, Nash WP, Litz BT. Does mental health stigma change across the deployment cycle? Mil Med 2014; 179:14491452.

42. Welsh MM, Federinko SP, Burnett DG, Gackstetter GD, Boyko EJ, Seelig AD, Wells TS, Hooper TI. Deployment-related depression screening, 2001-2008: comparing clinical versus research surveys. Am J Prev Med 2014; 47:531-540.

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YAEL NETZ ET AL.

Cardiovascular Fitness and Neurocognitive Performance among Older Adults in the Maintenance Stage of Cardiac Rehabilitation Yael Netz, PhD,1 Tzvi Dwolatzky, MD, PhD, 2,3 Abid Khaskia, MD,4 and Ayelet Dunsky, PhD1 The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Israel Department of Geriatrics and Memory Clinic, Mental Health Center, Beer Sheva, Israel 3 Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel 4 Cardiac Rehabilitation, Meir Medical Center, Israel 1

2

ABSTRACT Background: Cardiovascular fitness is associated with cognition in advanced age. Cardiovascular disease (CVD) is a risk factor for cognitive decline beyond the normal aging process, thus we investigated this association in CVD patients.

Method: Patients in phase III of cardiac rehabilitation were divided into high and low cardiovascular fitness groups based on their predicted peak VO2. Cognition was assessed by a battery of neuropsychological tests examining memory, attention, visual spatial function, executive function and global cognitive score.

Results: The two groups were similar on reported physical activity and on the Mini-Mental State Examination (MMSE). However, the high fitness group had significantly higher scores than the lower fitness group on attention and on the global cognitive score, and marginally significant scores on executive functioning.

Limitation: Due to the small sample size no differentiation was made among the various CVD conditions.

Conclusion: Higher cardiovascular fitness of CVD patients is associated with superior cognition – predominantly in attention and executive functioning.

INTRODUCTION There is solid evidence on the association between cardiovascular fitness and cognitive performance in Address for Correspondence: Israel neyael@wincol.ac.il

relatively healthy older adults (1). In a previous study we were able to demonstrate an association between multidomain cognitive function and cardiovascular fitness in healthy participants aged 77.54 (+5.28) years – older than those previously studied (2). In that study participants performed a graded maximal exercise test, and based on their peak VO2 scores were divided into a low-fitness and a high-fitness group. Their cognitive status was then assessed by means of a computerized neuropsychological battery. Although the two groups were very similar in terms of demographic, physical and clinical characteristics, the moderately-fit group achieved significantly better scores on a global cognitive score, and a significant correlation was found between peak VO2 and attention, executive function, and the global cognitive score. In the present study we explored this association in older cardiac patients.

Cardiovascular disease (CVD) has long been known as a risk factor for cognitive decline above and beyond the normal aging process (3), ranging from minimal difficulties in memory, psychomotor speed and executive function (4-6), to dementia (6, 7). Impaired cognitive function is observed in persons with CVD even in the absence of major cardiac events (7).

Several mechanisms have been proposed as contributing to cognitive dysfunction in CVD patients. In addition to reduced cerebral blood flow (8) that is also attributed to old age in general, impaired cardiovascular reactivity to the autonomic nervous system signaling indicated by reduced heart rate recovery (9), elevated total plasma homocysteine and loss of cerebral grey matter (10), as well as poor cardiovascular fitness (11), all have been proposed as contributing to cognitive deterioration,

Yael Netz, PhD, The Wingate College of Physical Education and Sport Sciences, Wingate Institute 4290200,

55

CARDIOVASCULAR FITNESS AND NEUROCOGNITION IN CARDIAC REHABILITATION

specifically in CVD. In spite of the increased risk of cognitive decline beyond the normal aging process that occurs in CVD, there are relatively few studies exploring the association between cardiovascular fitness and cognitive performance in older adults with CVD. Three of them (11-13) reported on exercise intervention, albeit without a control group, in CVD patients with mixed clinical backgrounds (e.g., myocardial infarction, coronary artery disease, heart failure, cardiac surgery, etc.), assessing cognition and fitness before and after 12 weeks. All three studies reported on improvements in fitness as well as in attention and/or psychomotor abilities or executive functioning.

Other studies found an association between cardiovascular fitness and executive functioning (14), executive function and language (9) and psychomotor processing speed and complex attention (15). Studies focusing specifically on heart failure patients reported an association between aerobic endurance and executive function and language (16), and between cardiovascular fitness and executive function, attention and memory (17). All five studies also reported an association between cardiovascular fitness and general mental status (assessed by the Mini Mental State Examination – MMSE; 18).

Interestingly, the majority of the above-mentioned studies were conducted fairly close to the CVD event or to the condition diagnosis, during phase II of a cardiac rehabilitation program. The mean age of participants in all five studies did not go beyond 68, and in most of them the mean age was even younger than that. To the best of our knowledge, no studies have explored the relationship between cardiovascular fitness and cognition in phase III – the maintenance stage of cardiac rehabilitation. It is well evidenced that people live longer today, including people who are chronically ill (19). For example, the prevalence of chronic heart failure is estimated to be 10% among those over the age of 75, rising to 15-20% among the population over the age of 80 (20). Given that cognitive functioning of CVD patients may deteriorate beyond the normal aging process (3), and that increased cardiovascular fitness may attenuate this deterioration (13), studying the relationship between fitness, cognition and aging may be more crucial in CVD patients than in healthy older adults.

Our study aims to extend the knowledge of the association between cardiovascular fitness and cognitive function among CVD patients enrolled in a cardiac rehabilitation center, in three aspects: 1. We extended the study of this association to stage III – the maintenance stage of 56

cardiac rehabilitation; 2. Participants were older (mean age 72.9) than those previously reported on; and 3. We used a novel adaptation of traditional neuropsychological tests, providing an overall measure of cognitive function as well as an evaluation of specific cognitive domains.

In this study we followed the same concept used in our previous study, conducted on older adults with no cardiovascular disease (see 2). Participants were divided into two fitness groups, and were compared first on demographic and clinical characteristics and then on the cognitive scores. Our previous study reported that the two fitness groups of older adults with no CVD did not differ demographically or clinically. Furthermore, they did not differ in terms of general mental status (assessed by the MMSE). However, they did differ on more specific neurocognitive measurements as assessed by the multidomain neuropsychological battery.

METHODS PARTICIPANTS

CVD patients aged 60 and over, who had participated in a cardiac rehabilitation program for at least nine months, were recruited from two cardiac rehabilitation centers: Wingate College Center (n=24) and Meir Medical Center (n=25). Individuals with a history of myocardial infarction, coronary artery bypass, hypertension, atrial fibrillation, diabetes, heart failure, ischemic heart disease, percutaneous transluminal coronary angioplasty, open heart surgery, or valve repair or replacement were eligible to participate. Exclusion criteria included current signs of dementia indicated by a score of below 24 on the MMSE (18), and/or a history of significant neurological (e.g., stroke) or psychiatric (e.g., schizophrenia, bipolar disorder) problems, to prevent confounding explanations for cognitive functioning. Individuals who were unable to use a computer (due to difficulties in vision or motor function) and smokers were also excluded.

Figure 1 describes the procedure for participation in the study. At the center located at Wingate College, a relatively small center, all eligible patients – 24 out of 44 registered patients – signed the informed consent and completed the tests. At Meir Center, out of 160 eligible patients 35 were willing to participate and signed the informed consent. Seven withdrew consent later, without providing any explanation, and three could not find suitable time and thus did not complete the tests. Thus, 49 individuals – 24 from the Wingate Center and 25

YAEL NETZ ET AL.

Figure 1. Selection of participants Meir Medical Center

Wingate Center

400 registered members

44 registered members

160 met criteria

7 withdrew consent 3 couldn’t find suitable time for completing the tests

20 did not meet criteria

24 participants signed informed consent and completed the tests

35 signed informed consent 25 participants completed the tests

from Meir Center – with an average age of 72.9 (±7.57), participated in the study.

Participants visited the cardiac rehabilitation center on a regular basis two or three times a week. Their routine in the center included a customized exercise plan developed for each patient. The individualized plan generally consisted of 30 to 60 minutes of treadmill walking, 15 minutes of stationary cycle, and between 6 to 8 exercises (lasting 15 to 20 minutes) for developing muscle strength and endurance in the main muscle groups of abdominals, legs and arms.

The study was approved by the Ethics Committee of the Meir Medical Center (Kfar Saba, Israel), and it conforms to the provisions of the Declaration of Helsinki.

All participants provided written informed consent for participation in the study, including their permission to use information from their files.

CLINICAL ASSESSMENT

Demographic information, including exercise routine (minutes per week) in the cardiac rehabilitation center and at home, was collected via a face-to-face interview.

Medical history and health details were obtained from the participants’ files. The MMSE (18) was used as a preliminary tool for cognitive screening, the 15-item Geriatric Depression Scale (GDS; 21) was utilized for detecting depression, and the Lawton and Brody Scale (22) was administered for assessing functional status for instrumental activities (IADL). For the purpose of the study, a score of 0-2 on the GDS was considered to be no depression, and >3 partial depression. A score of 1 on

the Lawton IADL was considered high functioning, and >1 below normal functioning. Medications were coded according to therapeutic categories (e.g., antihypertensives, anticoagulants, lipid lowering).

ASSESSMENT OF CARDIOVASCULAR FITNESS

Participants performed a graded, progressive, maximal exercise test on a motorized treadmill (Woodway, Germany) for assessing their estimated peak VO2 and maximal heart rate (HRmax). Estimated peak VO2 provides a reasonably accurate reflection of an individual’s fitness at a reduced risk (23), and thus is widely used in older adults in general (24) as well as in CVD patients (9, 11, 13). The method of testing was identical to that used in our previous study (see 2). For the duration of the test the electrocardiogram (ECG), heart rate (HR), blood pressure, and rating of perceived exertion were monitored continuously, using a 12-lead ECG, a sphygmomanometer, and the Borg scale (25), respectively. Participants with abnormal cardiac signs or symptoms were excluded from the study. The test commenced with 2-5 minutes of practice and adaptation. Based on the modified Balke protocol (23), an initial speed of 3.2 km/hr with a gradient of zero was determined. The gradient was increased by 2.5% every 2 minutes until a symptom appeared (e.g., dizziness, breathlessness, changes in ECG, etc.), limited max was reached, or until the subject reached exhaustion.

The test lasted 6-13 minutes (mean 9.75±1.6).

Prediction of peak VO2: Peak VO2 was estimated from the last stage of the graded maximal treadmill exercise challenge. The following equation was used to estimate peak VO2 for each subject: VO2 (ml*kg-1*min-1) = 0.1 (final speed) + 1.8 (final speed) (final fractional grade) + 3.5 ml*kg-1*min-1 (23).

COMPUTERIZED BATTERY OF NEUROCOGNITIVE TESTS Computerized cognitive tests were performed using the NeuroTrax (NeuroTrax Cognitive Assessment System, Modiin, Israel), which provides an overall measure of cognitive function as well as an evaluation of specific cognitive domains. It consists of software that resides on a local testing computer and serves as the platform for interactive cognitive tests (26). The battery, which is simple to use and requires no previous computer experience, is comprised of the following tests: Go-NoGo Response Inhibition, Verbal Memory, Stroop Interference, Nonverbal Memory, Catch Game and Visual Spatial Orientation. The scoring procedure has been described 57

CARDIOVASCULAR FITNESS AND NEUROCOGNITION IN CARDIAC REHABILITATION

in detail elsewhere (e.g., 26). Briefly, scores for Table 1. Age and gender distribution within the low and high fitness groups the Go-NoGo and Stroop include accuracy based on median scores and reaction time (RT); in order to capture Age range Low fitness High fitness Median value of predicted performance both in terms of accuracy and RT, (N) (N) peak VO2 (ml*kg-1*min-1) a performance index is computed as (accuracy/ 60-69.9 RT) x 100. Scores for Memory (Verbal and men 6 9 31.85 Nonverbal) include accuracy of four repetiwomen 2 2 21.18 tions, mean accuracy of the four repetitions, 70-79.9 and delayed memory accuracy. Scores for men 9 8 25.20 Catch Game include time of first move, first women 2 2 18.03 move response time standard deviation, aver80+ age number of direction changes per trial, and a men 4 5 23.10 total score – summed accuracy across sublevels Total=23 Total=26 weighted by difficulty (range 0-1000). Scores for Visual Spatial Orientation were calculated as total accuracy. prior to the cognitive evaluation. As participants in both To permit summarizing the performance in each outcenters routinely undergo the cardiac evaluation every come parameter across different types of scores (e.g., six months, we used the data from their last evaluation accuracy, RT), each score was normalized and applied to prior to the cognitive evaluation. The time between the a standard score scale (mean, 100; SD, 15) in an age- and cardiac and cognitive evaluations was therefore no more education-specific fashion. Normalized scores were averthan six months. aged to produce four summary subtests, each indexing a different cognitive domain, as follows: Memory – mean DATA ANALYSIS accuracies for learning and delayed recognition phases of the Verbal and Nonverbal Memory tests; Attention – Following the concept used in our previous study (see mean RT for the Go-NoGo test and the no interference 2), we divided the participants into two fitness groups, (meaning) phase of the Stroop test and mean standard and compared them first on demographic and clinical deviation of RT for the Go-NoGo test; Visual-spatial – characteristics and then on the cognitive scores. The two mean accuracy for the Visual-Spatial processing test; fitness groups were created as follows: participants were Executive function – performance indices for the Stroop first divided into three age groups: 60-69.9 (N=19, 15 test and Go-NoGo test and mean weighted accuracy for men), 70-79.9 (N=21, 17 men) and 80+ (N=9, all men), Catch Game. These cognitive domains, and a Global and we then used the median value for differentiating Cognitive Score computed as the average of these cognibetween high and low fitness for each age and gender tive domains, provided a measure of cognitive function group separately. We did not use the official American (2, 26).

College of Sports Medicine (23) age and gender norms of peak VO2 (which are based on percentile values for each age decade) for two reasons: 1. No norms were provided PROCEDURE for age 80 and above; and 2. Had we chosen the 50th Participants in both cardiac rehabilitation centers were percentile as a cutoff point for the other two age groups invited to take part in the study. Possible candidates were (60-69.9 and 70-79.9), we would have had only a small interviewed by trained research assistants, were provided number of people in the high fitness group. with general demographic and medical data, and received Table 1 presents the age and gender distribution within an outline of the proposed study. Those who expressed the fitness groups and the median values for each group. an interest in participating in the study provided written If a person had a peak VO2 score identical to the median informed consent following a detailed explanation of the value, we placed him or her in the group where the next study. Participants completed the cardiac and cognitive person had a score similar to his or her score. For example, evaluation on separate occasions, each in his/her rehaif a man in the 70-79.9 age group had a score of 25.20 bilitation center (at Wingate College Center or at Meir ml*kg-1*min-1 (the median value for this group), the next Medical Center). The clinical assessment was performed person in the high fitness group had a score of 28.00 and 58

YAEL NETZ ET AL.

Table 2. Demographic, physical, and clinical characteristics of the low and high fitness (predicted peak VO2) groups Variables

Low fitness, (N=23)

High fitness, (N=26)

Age, mean years (SD)

73.71 (8.00)

72.17 (7.28)

175.47 (6.12) 153.00 (2.16)

173.68 (7.05) 160.50 (3.32)*

86.61 (9.16) 67.50 (12.16)

81.05 (10.67) 74.75 (14.48)

Men Women

28.21 (3.45) 28.90 (5.54)

26.80 (2.51) 28.96 (5.69)

Education, mean years (SD)

14.83 (2.84)

14.81(2.65)

284.43 (230.21)

368.77 (272.48)

3

1

17 6 28.26 (1.57)

15 11 28.85 (1.22)

15 8

19 7

14 7 96.22 (82.76)

23† 3 85.88 (65.50)

22 18 18 14

22 23 23 14

10 11 18 8 12 4 2

14 11 12† 3 7 2 3

Height, mean cm (SD) Men Women Weight, mean kg (SD) Men Women BMI, mean (SD)

Physical activity per week, mean min. (SD) Handedness, left-handed (N) Computer experience (N) Frequently Seldom MMSE, mean score (SD) Geriatric Depression Scale (N) No depression (score 0-2) Partial depression (score 3-7)˟ Lawton (IADL) (N) Normal (score 1) Below normal (score >1) Months since cardiac event (SD) Medication Groups (N)** Antihypertensives Anticoagulants Lipid lowering Other Heart Disease Groups (N)** Myocardial infarction Coronary artery bypass Hypertension Atrial fibrillation Diabetes Heart failure Ischemic heart disease Percutaneous transluminal Coronary angioplasty

1

Open heart surgery Valve repair or replacement

1 1

the next person in the low fitness group had a score of 24.85, then we placed the person with the median value in the low fitness group. Among the men in the 60-69.9 age group, there were two with a score of 31.85 ml*kg-1*min-1 (identical to the median value), which was closer to the high fitness group. Both men were therefore placed in the high fitness group.

RESULTS Demographic, physical and clinical characteristics of the two groups are presented in Table 2. No differences were found on these variables except for height differences among the women. The two groups had similar clinical characteristics in terms of cardiovascular diseases, medications and the time since the cardiac event. However, a significantly (Fisher’s Exact Test) greater number of participants in the low-fitness group were more limited in IADL (p=0.04), and suffered more from hypertension (p=0.04), than those in the highly fit group.

Table 3 presents the detailed scores of the neuropsychological tests for the two fitness groups. In terms of absolute values, the higher cardiovascular fitness group demonstrated better scores on virtually all the parameters, in terms of both accuracy and RT, than the low-fitness group. Although in most cases differences were not significant, the pattern of scores consistently favored the high fitness group.

The cognitive domains scores for the two groups are demonstrated in Figure 2. A clear pattern for better scores in the highly fit compared to the low-fitness group was present for all scores. Significantly betFigure 2. Cognitive domain scores of the two fitness groups normalized (mean 100; SD 15) in an ageand education-specific fashion 110 105 100

1 0 1

BMI = Body Mass Index, MMSE= Mini-Mental State Examination IADL= Instrumental Activities of Daily Living * t test p<0.05 ˟ One person in the low fitness group had a score of 11 † Fisher’s Exact Test p<0.05 ** Participants may belong to more than one group

95

105.96 (16.79)

103.80 (9.28)

94.20 (14.23)

96.92 (13.36)

*

95.14 (17.58)

101.56 (10.61)

98.20 (19.10)

♦ 94.94 (13.93)

*

102.07 (8.66)

95.62 (12.80)

90 85 80

Memory

Low Fitness

Attention High Fitness

Visual Spatial p<0.05

Executive Global Function Cognitive Score p=0.06

59

CARDIOVASCULAR FITNESS AND NEUROCOGNITION IN CARDIAC REHABILITATION

Table 3. Detailed scores of the neurocognitive tests for the low and high fitness (predicted peak VO2) groups* Neurocognitive test

Outcome parameter

Low fitness, (N=23)

High fitness, (N=26)

t-test p value

Go-NoGo

Accuracy

92.78 (17.57)

99.31 (8.35)

0.11

Reaction time

96.62 (21.30)

105.38 (11.19)

0.09

Performance Index

95.39 (17.79)

103.14 (12.60)

0.08

Accuracy, 1st repetition

90.17 (17.15)

94.63 (14.15)

0.32

Accuracy, 2nd repetition

92.45 (16.11)

97.01 (15.30)

0.32

Accuracy, 3rd repetition

93.40 (16.32)

94.14 (18.63)

0.88

Accuracy, 4th repetition

92.46 (16.37)

96.49 (17.60)

0.41

Accuracy, all repetitions

91.05(16.72)

94.83 (16.82)

0.43

Delayed verbal memory

90.62 (18.03)

95.76 (16.85)

0.31

Accuracy

98.20 (16.99)

100.47 (10.12)

0.57

Reaction time

96.02 (19.85)

105.22 (9.82)

0.06

Performance Index

99.38 (19.51)

104.40 (14.76)

0.32

93.38 (22.26)

97.97 (13.77)

0.39

Reaction time

94.23 (23.03)

105.53 (12.02)

0.05

Performance Index

95.38 (18.00)

104.19 (12.55)

0.05

Accuracy

92.77 (15.20)

95.14 (17.52)

0.62

Reaction time

97.36 (14.53)

96.97 (18.22)

0.94

Performance Index

94.65 (15.83)

97.28 (16.64)

0.58

Accuracy, 1st repetition

96.30 (15.82)

97.43 (17.22)

0.81

Accuracy, 2nd repetition

98.24 (14.00)

100.15 (15.66)

0.66

Accuracy, 3rd repetition

96.43 (15.92)

98.61(14.67)

0.62

Accuracy, 4th repetition

97.11 (15.92)

97.15 (15.75)

0.99

Accuracy, all repetitions

96.73 (14.95)

98.08 (16.16)

0.76

Non Verbal Memory (cont’d)

Delayed non-verbal memory

100.17 (15.92)

99.03 (16.36)

0.81

Catch Game

Time to make first move

98.99 (20.31)

105.88 (16.82)

0.20

First move response time SD

99.53 (18.01)

102.70 (15.26)

0.51

Average number of direction changes per trial

99.43 (19.04)

101.06 (15.96)

0.75

Total score

96.84 (18.27)

104.35 (17.44)

0.15

Total accuracy

98.20 (19.10)

105.96 (15.92)

0.14

Verbal Memory

Stroop Test No interference letter color

Stroop Test (cont’d)

No interference word meaning (choice reaction time test)

Interference color vs meaning

Non Verbal Memory

Visual Spatial Orientation

Accuracy

*NOTE: Scores have been normalized and applied to a standard score scale (mean, 100; SD, 15) in an age - and education-specific fashion.

ter scores for the high VO2 group were observed for Attention (Cohen’s d=0.61) and the Global Cognitive Score (d=0.58), and were marginally significant (p=0.06; d=0.53) for Executive Function. Pearson correlations assessing the relationship between the scores on each cognitive domain and the predicted peak VO2 scores were significant for Attention (r=0.35, p=0.01), Executive Function (r=0.32, p=0.02) and the Global Cognitive Score (r=0.30, p=0.03).

Pearson correlations between the cognitive domains and amount of physical activity per week were nonsignificant (range: -0.25 to 0.11). Pearson correlation between the amount of physical activity per week and 60

the predicted peak VO2 scores was also non-significant (r=0.08; p=0.59).

Since the predicted peak VO2 groups differed with regard to the Lawton IADL and hypertension, t-tests were performed for assessing differences in the Global Cognitive Score between normal and below-normal Lawton scores, and between participants suffering from hypertension and those not suffering from hypertension. No differences on the Global Cognitive scores were detected between participants having normal and below normal Lawton IADL (t47=1.23, p=0.2), or between participants suffering or not suffering from hypertension (t47=0.91, p=0.37).

YAEL NETZ ET AL.

DISCUSSION CVD is a risk factor for cognitive decline above and beyond the normal aging process (3), however there are relatively few studies exploring the association between cardiovascular fitness and cognitive performance in CVD patients. The present study extends the evident relationship between cardiovascular fitness and cognitive functioning in advanced age (1, 2) to older CVD patients participating in cardiac rehabilitation programs.

Our findings indicate that higher cardiovascular fitness is associated with enhanced cognitive functioning, in particular with attention and executive functioning.

While these results support previous studies reporting such a relationship fairly close to the CVD event or to the condition diagnosis (phase II of the cardiac rehabilitation program) (9, 14, 15), the present study is innovative in examining this relationship in the maintenance stage (phase III) of cardiac rehabilitation â&#x20AC;&#x201C; an average of 90 months after the condition diagnosis, as well as in ages older than previously reported, when the CVD patients have been exposed to the aging process for a longer period of time.

Although participants visited the cardiac rehabilitation center on a permanent basis â&#x20AC;&#x201C; two to three times a week, and maintained a routine of physical activity, their cardiac fitness relative to their age norms (23) was low. The two fitness groups were quite similar in all demographic and clinical aspects, including in reported physical activity, but differed in cognitive functioning. This finding supports our previous study suggesting that physical fitness and not physical activity is related to cognition (2). The methodological limitation of a self-report measurement may explain these findings. Staying in the cardiac rehabilitation center 90 minutes or more twice or three times a week does not necessarily mean being active all that time. The visits to the center also involve social interactions, including chatting, drinking coffee, etc. Yet the participants tended to report all this time as physical activity.

Another explanation may be that one of the pathophysiological mechanisms associated with CVD may contribute to the observed cognitive deterioration or to the reduced cardiovascular fitness in this population.

For example, CVD is associated with elevated plasma homocysteine and loss of cerebral gray matter volume (10), which may not be related to physical activity; alternatively, a greater amount of physical activity is needed to increase cardiovascular fitness as well as to alter this

mechanism. A previous nine-year longitudinal study (27) showed that walking at least 72 blocks (roughly 6-9 miles) per week was necessary to detect increased gray matter volume of the frontal, occipital, entorhinal and hippocampal regions, and that greater gray matter volume reduced the risk for cognitive impairment twofold.

It is questionable whether CVD patients are able and/ or allowed to perform such a large amount of physical activity. The lack of an association between physical activity and physical fitness (peak VO2) may therefore be attributed either to a tendency to exaggerate the amount of reported physical activity, or to the inability to perform physical activity effectively due to the CVD limitations.

Intervention studies reporting improved cardiovascular fitness and cognitive functioning in CVD patients following a 12-week cardiac rehabilitation program were conducted fairly close to the condition diagnosed, and applied aerobic activity as well as educational intervention (11, 13). These studies, however, were performed without a control group, and it is possible that improvements immediately after the cardiac event may have been observed even without the intervention.

One interesting explanation for the relationship between limited gains in cardiovascular fitness and poor cognitive functioning is that patients with poorer cognitive functioning may derive reduced benefit from cardiac rehabilitation (12). Based on this hypothesis, it is suggested that cardiac rehabilitation programs consider screening patients at baseline for low cognitive functioning to help identify those patients at greater risk for poor outcome.

A meaningful finding of the present study is that the two fitness groups had similar scores on the general cognitive test â&#x20AC;&#x201C; the MMSE. Although this test usually serves as a screening tool for differentiating between normal and cognitively impaired individuals, it is rather limited in its ability to detect subtle or specific scores.

Apparently, both groups were functioning within the normal cognitive scores, although the more specific cognitive variations were revealed in the distinctive cognitive tests of the NeuroTrax battery. These more sensitive tests showed distinctive differences on attention and executive functioning between the two fitness groups.

In that sense our study does not corroborate previous studies that indicated an association between the MMSE and physical fitness in addition to other more sensitive cognitive measures (e.g., 9, 14-17). On the other hand, while we studied CVD patients in phase III of cardiac rehabilitation, these studies examined CVD patients in 61

CARDIOVASCULAR FITNESS AND NEUROCOGNITION IN CARDIAC REHABILITATION

phase II. It is possible that close to the traumatic cardiac event people deteriorate cognitively below their normal cognitive functioning, but recuperate after a while. For example, patients with acute transient ischemic attack and minor stroke experienced cognitive deficits which gradually improved after 7, 30 and 90 days (28). Another example is the temporary cognitive decline demonstrated in women following the death of their partner (29). It is likely that maintaining or improving cardiovascular fitness in CVD patients may further delay cognitive deterioration and prevent cognitive impairment. The finding that CVD is a risk factor for dementia (6, 7) may support this idea, but interventional, well-controlled studies are needed to confirm this cause-effect relationship.

The pattern of cognitive differences observed in the present study are comparable to that found in our previous study assessing two fitness groups of residents of a sheltered housing facility with a mean age of 77 years (see 2). In both studies we found a significant difference in the Global Cognitive Score, which is based on the collective results of all cognitive domains tested. While the differences in the individual tests comprising the Mindstreams battery did not reach significance in most cases, the trend for better cognitive scores in the highfitness compared to the low-fitness groups was clear (the direction of scores was consistently in favor of the high VO2). This was demonstrated in almost all cognitive measures, reflecting both accuracy and RT (Table 3) and indices of cognitive domains (Figure 2).

The present study is also in line with our previous study demonstrating significant group differences on Attention. These differences and the association between fitness and attention conform to the findings of a review reporting on the effects of increased cardiorespiratory fitness, particularly on cognitive speed (Attention in the Mindstreams was evaluated by means of a combination of choice RT measurements) and on auditory and visual attention (30). In the present study marginally significant differences were also observed in Executive Functioning.

These differences and the relationship between fitness and executive functions are in line with another review (1), and with other studies emphasizing the beneficial effect of exercise and fitness predominantly on executive functions (e.g., 31).

It should be noted that the classification of cognitive functions is not uniform in the literature. Although there is agreement that executive function refers to the ability to plan and perform goal-directed activities (32), and that it involves planning, scheduling, working memory, 62

interference control and task coordination, it has also been proposed that executive function is closely linked to the ability to focus on a given task necessitating attention (32). The variability in classifying cognitive tasks into categories has been demonstrated in the two aforementioned reviews examining the same type of studies and/ or cognitive tasks (i.e., 1, 30). The methodology used in these reviews was not uniform, in that they compared different population groups evaluated by the use of various cognitive tasks. Our study, therefore, has the clear advantage of using a uniform computerized battery assessing multiple cognitive domains within a specific population. Furthermore, to the best of our knowledge, it is the first time a uniform multidomain battery for assessing cognitive capacity has been used in CVD patients in relation to their cardiovascular fitness. On the other hand, CVD patients are a diverse group in terms of the various CVD conditions, and no attempt was made in the present study to differentiate among these conditions. It is recommended that the findings be extended to more narrowly-defined CVD patient samples.

It may be argued that the estimated (predicted) peak VO2 is not as precise as the measured VO2. Furthermore, the error in estimating exercise capacity from prediction equations is more significant in advanced-age adults with chronic diseases than in young individuals (23). On the other hand, while this error may result in the spurious elevation of the estimated peak VO2 (33), the estimated scores in the present study were quite low and it is questionable whether the real scores were much lower than these. It is unnecessary to point out the risk involved in a maximal stress test (HRmax) measuring the real peak VO2 in CVD patients, just as it is in older adults in general. On the other hand estimated peak VO2 provides a reasonably accurate reflection of an individualâ&#x20AC;&#x2122;s fitness (23), and thus is widely used in older adults in general (24) as well as in CVD patients in particular (9, 11, 13).

The present study, like our previous study conducted on relatively healthy older adults (2), suffers from the limitation of being based on only a small group of people who were willing to participate in the study. On the other hand, it may be concluded in both studies that higher cardiovascular fitness is associated with superior global cognitive functioning among these volunteers. This trend should be examined in a larger number of individuals â&#x20AC;&#x201C; in healthy people as well as CVD patients.

The main unresolved issue derived from our current study is the cause-effect relationship. Future wellcontrolled studies are needed for examining whether

YAEL NETZ ET AL.

an increased physical activity level and/or the increased aerobic fitness of CVD patients in stage III of rehabilitation may improve cognitive functioning level. Future studies should also inquire whether, in light of the CVD limitations, it is possible to increase physical activity and/or cardiovascular fitness in the first place. More studies are also needed to explore whether potential mechanisms, for example the autonomous nervous system, may mediate both cardiovascular functioning and cognition independently of cardiovascular fitness. It is also recommended that other potential mechanisms mediating between cognitive training and cardiovascular functioning, such as improved integrity of white matter pathways or a better-functioning autonomic nervous system, be studied.

In summary, the current study extends the knowledge on the association between cardiovascular fitness and cognitive function among CVD patients enrolled in a cardiac rehabilitation center, in three aspects: these patients were in stage III – the maintenance stage of cardiac rehabilitation, they were older than previously reported, and a novel adaptation of traditional neuropsychological tests was used, providing an overall measure of cognitive function as well as an evaluation of specific cognitive domains. The findings clearly indicate that higher cardiovascular fitness is associated with better global cognitive functioning, specifically with enhanced attention and executive functioning. Further studies are recommended to clarify possible mechanisms for these findings, to examine a cause-effect relationship, and to extend the findings to more narrowly-defined CVD patient samples.

Conflict of Interest None.

Description of each author’s contribution YN developed the concept and designed the study, supervised the data collection and the statistical analyses and wrote the manuscript. TD contributed to the concept and the design of the study, contributed to the interpretation of the data and revised the manuscript. AK obtained Ethics Committee approval, performed medical evaluations of the participants, coordinated the collection of the data at Meir Medical Center, and revised the manuscript. AD contributed to the concept and design of the study, supervised the data collection, contributed to the interpretation of the data, and critically revised the manuscript.

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2. Netz Y, Dwolatzky T, Zinker Y, Argov E, Agmon R. Aerobic fitness and multidomain cognitive function in advanced age. Int Psychogeriatr

2011;23:114-124.

3. Okonkwo OC, Cohen RA, Gunstad J, Tremont G, Alosco ML, Poppas A. Longitudinal trajectories of cognitive decline among older adults with cardiovascular disease. Cerebrovasc Dis 2010;30:362-373.

4. Almeida OP, Garrido GJ, Beer C, Lautenschlager NT, Arnolda L, Flicker L. Cognitive and brain changes associated with ischaemic heart disease and heart failure. Eur Heart J 2012; 33:1769-1776.

5. Rafnsson SB, Deary IJ, Smith FB, Whiteman MC, Fowkes FGR. Cardiovascular diseases and decline in cognitive function in an elderly community population: The Edinburgh Artery Study. Psychosomatic Med 2007; 69:425-434.

6. Vogels RLC, Scheltens P, Schroeder-Tanka JM, Weinstein HC. Cognitive impairment in heart failure: A systematic review of the literature. Eur J Heart Fail 2007; 9:440-449.

7. Duron E, Hanon O. Vascular risk factors, cognitive decline, and dementia.

Vasc Health Risk Manag 2008;4:363-381.

8. Dai W, Lopez OL, Carmichael OT, Becker JT, Kuller LH, Gach HM. Abnormal regional cerebral blood flow in cognitively normal elderly subjects with hypertension. Stroke 2008; 3:349-354.

9. Keary TA, Galioto R, Hughes J, Waechter D, Spitznagel MB, Rosneck J, et al. Reduced heart rate recovery is associated with poorer cognitive function in older adults with cardiovascular disease. Cardiovasc Psychiatry Neurol 2012;2012:392-490.

10. Ford AH, Garrido GJ, Beer C, et al. Homocysteine, grey matter and cognitive function in adults with cardiovascular disease. Plos One 2012; 7:e33345.

11. Gunstad J, Macgregor KL, Paul RH, et al. Cardiac rehabilitation improves cognitive performance in older adults with cardiovascular disease. J Cardiopulm Rehabil. 2005;25:173-176.

12. Kakos LS, Szabo AJ, Gunstad J, et al. Reduced executive functioning is associated with poorer outcome in cardiac rehabilitation. Prev Cardiol 2010;13:100-103.

13. Stanek KM, Gunstad J, Spitznagel MB, et al. Improvements in cognitive function following cardiac rehabilitation for older adults with cardiovascular disease. Int J Neurosci 2011;121:86-93.

14. Swardfager W, Herrmann N, Marzolini S, et al. Cardiopulmonary fitness is associated with cognitive performance in patients with coronary artery disease. J Am Geriatr Soc 2010;58:1519-1525.

15. Swardfager W, Herrmann N, Marzolini S, et al. Brain derived neurotrophic factor, cardiopulmonary fitness and cognition in patients with coronary artery disease. Brain Behav Immun 2011;25:1264-1271.

16. Alosco ML, Spitznagel MB, Raz N, et al. The 2-minute step test is independently associated with cognitive function in older adults with heart failure. Aging Clin Exp Res 2012; 24:468-474.

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23. American College of Sports Medicine (ACSM). ACSM’s guidelines for exercise testing and prescription. Baltimore, Md.: Lippincott Williams and Wilkins, 2010.

24. Bauermeister S, Bunce D. Aerobic fitness and intraindividual reaction time variability in middle and old age. J Gerontol B Psychol Sci Soc Sci.

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CARDIOVASCULAR FITNESS AND NEUROCOGNITION IN CARDIAC REHABILITATION 2014; 28. pii: gbu152. [Epub ahead of print] 25. Borg G. Psychophysical studies of effort and exertion: some historical theoretical and empirical aspects. In Borg G, Ottoson D, editors. The perception of exertion in physical work. London: Macmillan, 1986: pp. 3-12.

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TAL SHACHAR-MALACH ET AL.

Effectiveness of Aerobic Exercise as an Augmentation Therapy for Inpatients with Major Depressive Disorder: A Preliminary Randomized Controlled Trial Tal Shachar-Malach, MD,1,3 Rena Cooper Kazaz, MD,1 Naama Constantini, MD,2 Tzuri Lifschytz, PhD,1 and Bernard Lerer, MD1 Department of Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Sport Medicine Center, Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 3 Department of Psychiatry, Herzog Hospital, Jerusalem, Israel 1

2

ABSTRACT Background: Physical exercise has been shown to reduce depressive symptoms when used in combination with antidepressant medication. We report a randomized controlled trial of aerobic exercise compared to stretching as an augmentation strategy for hospitalized patients with major depression.

Methods: Male or female patients, 18-80 years, diagnosed with a Major Depressive Episode, were randomly assigned to three weeks of augmentation therapy with aerobic (n=6) or stretching exercise (n=6). Depression was rated, at several time points using the 21-item Hamilton Depression Scale (HAM-D), Beck Depression Inventory (BDI) and other scales.

Results: According to the HAM-D, there were four (out of six) responders in the aerobic group, two of whom achieved remission, and none in the stretching group.

According to the BDI, there were two responders in the aerobic group who were also remitters and none in the stretching group.

Conclusions: The results of this small study suggest that aerobic exercise significantly improves treatment outcome when added to antidepressant medication.

However, due to the small sample size the results must be regarded as preliminary and further studies are needed to confirm the findings.

None of the authors have conflict of interest to declare.

Funding for the research was from internal sources.

Address for Correspondence:

INTRODUCTION Major depressive disorder (MDD) is a common and important cause of morbidity and mortality worldwide.

In western countries the yearly incidence of depression is estimated to be 3-5% and the lifetime prevalence is 17% (1). The most frequently used first line agents for the pharmacological treatment of MDD are specific serotonin reuptake inhibitors (SSRIs). Successful treatment with SSRIs may require up to eight weeks (2, 3). In the first stage of the STAR*D trial in which patients suffering from MDD were treated with the specific serotonin reuptake inhibitor, citalopram, the self-reported remission rate was 32.9% and the observer rated Hamilton Depression scale (HAM-D) remission rate was 27.5% (4). These findings, from the largest prospective study to date, confirm that even with optimal dosage and duration of treatment more than 60% of depressed patients will remain significantly symptomatic and will need some additional treatment. The options available to optimize antidepressant treatment include: a) substitution of a different antidepressant; b) augmentation strategies with lithium, triiodothyronine or another antidepressant; and, c) electroconvulsive therapy (5). There is a need to search for new treatments that will enhance the efficacy of these available options, or even replace them in some cases.

The last decade has witnessed a significant growth of interest in Complementary and Alternative Medicine (CAM) worldwide. Depression is one of the 10 most frequent indications for using CAM (6). The reasons for using CAM in depression include lower incidence of adverse effects, decreased likelihood of negative interactive treatment effects, a holistic approach to the indi-

Tal Shachar-Malach, MD, Herzog Hospital, Jerusalem 91035, Israel

â&#x20AC;&#x2020; talmal@ekmd.huji.ac.il

65

AEROBIC EXERCISE AS AUGMENTATION THERAPY FOR DEPRESSIVE DISORDER

vidualâ&#x20AC;&#x2122;s problems and dissatisfaction with conventional reduction in depression scores in patients who were in healthcare. In a previous review of the evidence base of the exercise group than those who were not, as well as an increase in maximum oxygen uptake that was related various complementary and alternative therapies for to improvement in depression (16). depression, exercise was found to have Grade 1 evidence In the present study, we evaluated the effect of a shortsupport from a meta-analysis of 14 randomized controlled term aerobic exercise program as an adjuvant treatment in trials (7), though this evidence was inconclusive (8). A patients with MDD undergoing standard antidepressant recent Cochrane systematic review found a moderate, medication therapy, as compared to the effect of stretching non-significant effect of exercise (9). exercise. Most studies have examined the effect of exercise There are several types of exercise: aerobic exercise in non-hospitalized depressed patients. The current study such as brisk walking, running or cycling, which aims was specifically designed to evaluate aerobic exercise as to improve cardio-respiratory fitness; strength (resisan augmentation treatment for inpatients with MDD. tance) exercise such as weightlifting, which improves muscle and bone strength, and flexibility exercise such as stretching, which is designed to improve range of METHODS motion. Both aerobic and strength training have been shown to improve depression in randomized controlled studies. Two published randomized controlled trials, CLINICAL METHODS comparing aerobic training versus no treatment (10) This was an observer-blinded, randomized controlled trial and anaerobic strength training versus standard general (ClinicalTrials.gov Identifier: NCT00464048). It involved practitioner treatment (11), suggest that training has a patients with a Major Depressive Episode (MDE) in the positive effect on patients diagnosed with depression. context of Major Depressive Disorder (MDD) admitted Furthermore, the studies found an association between to the Department of Psychiatry, Hadassah - Hebrew exercise amount and reduction of symptoms in patients University Medical Center. Inclusion criteria were (1) with depression. However, meta- analyses could not male or female; (2) diagnosis of MDE in the context of determine the effects of exercise on depression because MDD according to DSM-IV criteria, without psychotic of a lack of good quality research on clinical populations features; (3) age 18-80 years;4( ) a score >14 on the (7, 12). The authors found that most of the studies involved non-clinical populations, Figure 1: Study Design were without blinded outcome assessment, lacked intent-to-treat analyses and had short Assessment for eligibility Medical evaluation: medical follow up. history, physical exam.

Exercise has also been shown to reduce Psychiatric Evaluation-SCID, depressive symptoms when used in comATHF, HAM-D, CGI, BDI, VAS Informed consent bination with other medical treatments for depression. A recent study comparing Preliminary patient exclusion high dose and low dose exercise, given as an augmentation to antidepressant treatment Randomization therapy in non-hospitalized patients, found that high exercise dose led to better results Aerobic exercise group Stretching exercise group (13). Another trial in psychiatrically hospiPre- activity GXT 4 sessions per week talized depressed patients compared aerobic 4 sessions per week for 3 weeks for 3 weeks Weekly Blind Assessments: Weekly Blind Assessments: exercise to stretching exercise and found HAM-D ,CGI, BDI, VAS HAM-D, CGI, BDI, VAS a significantly greater effect in the aerobic exercise group (14). A significant effect of aerobic exercise was also found in a mixed Follow-up assessment HAM-D, CGI, BDI, VAS group or depressed in- and outpatients in an open label study (15). Of note is an inpatient SCID = Structured Clinical Interview for Diagnosis. ATHF = antidepressant treatment history study in which addition of aerobic exercise form. GXT = Graded Exercise Testing. BDI = Beck Depression Inventory (BDI). HAM-D = Hamilton Depression Scale. VAS = Visual Analog Scale. CGI = Clinical Global Impressions Scale. to the treatment regimen resulted in greater 66

TAL SHACHAR-MALACH ET AL.

Hamilton Depression Scale (21 items, HAM-D) with item 1 (depressed mood) >2; (4) physical capability to perform aerobic exercise or stretching exercise; (5) competent and willing to give written informed consent. Exclusion criteria were (1) current, significant physical illness or any physical impairment that precluded exercise training or an abnormal exercise test; (2) current psychotic features; (3) current treatment with electroconvulsive therapy.

The study design is shown in Figure 1. Screening evaluation was conducted by a psychiatrist to diagnose MDD and to rule out any physical disorders. MDD was diagnosed by Structured Clinical Interview for Diagnosis (SCID), Hebrew Version (17) on the basis of DSM-IV criteria. To ensure there were no contraindications for participation in an exercise program, an extensive medical history was obtained and a full medical examination, resting ECG and blood pressure measurement were performed. All patients in the study received antidepressant medication according to usual clinical practice and the medication remained stable during the course of the trial.

The patients were randomly assigned to three weeks of augmentation therapy with either: 1) aerobic exercise (index group); or, 2) stretching exercise (control group), by the use of a computer program to generate a random sequence. Randomization was stratified according to response to antidepressant treatment evaluated by the Antidepressant Treatment History Form [ATHF] (18) (cutoff 3 points and higher which means they were given adequate dose for adequate duration of time during the current episode) and gender. The rationale for stratification was to achieve balanced assignment to the two treatment groups with regard to these two variables. Both gender (19) and resistance to antidepressant therapy have been shown to predict response to antidepressant treatment (20).

Patients assigned to the aerobic exercise group underwent graded exercise testing (GET) on a treadmill, using the Bruce protocol to screen for abnormal blood pressure and ECG responses, assess physical fitness and prescribe the intensity of the exercise program. In accordance with the recommendations of the Centers for Disease Control and the American College of Sports Medicine (21), aerobic exercise training consisted of four sessions per week of 30 minutes walking on a treadmill with a moderate intensity corresponding to a heart rate of 60-80% of the maximal estimated heart rate. The training was performed individually; during training, the patient was supervised by study personnel, and heart rate was continuously monitored to evaluate training

intensity. Patients assigned to the stretching exercise group performed a very low intensity activity consisting of four sessions per week of 30 minutes light stretching exercises. Instructions were given to the patients how to perform the exercises and they carried out the program individually supervised by study personnel. The length of both exercise programs was 21 days involving a total of 12 sessions.

Severity of depression was rated using the Hamilton Depression Scale (HAM-D 21 items), Clinical Global Impression Scale (CGI) (observer-rated) and Beck Depression Inventory (BDI) and Visual Analog Scale (self-rated). Patients were evaluated at five points in the study: week 0, week 1, week 2, week 3, and one week after conclusion of the study. All patients were rated by the same investigator who did not work on the inpatient unit, was unaware of the participant’s group assignment and had no contact with the participants other than for the purpose of rating. The statistician who performed the data analysis was also blind to treatment allocation.

Adverse effects were assessed at the beginning of the study and at the end of every week of the exercise program using a checklist.

The study was approved by the Internal Review Board (Helsinki Committee) of Hadassah – Hebrew University Medical Center. All patients gave written informed consent. It was not possible to blind patients to the intervention; therefore patients were told that the aim of the study was to compare the effects of two different types of exercise on mood.

STATISTICAL ANALYSIS

Univariate differences between groups were analyzed using the Student t test or chi square. One way ANOVA with repeated measures was used to examine effects over time followed by Neuman Keuls post hoc tests. Intent to treat analysis was performed with last observation carried forward. The primary outcome criterion for the study was response to exercise intervention defined as > 50% reduction in pretreatment HAM-D score at the end of the follow-up period. Secondary outcome criteria were >50% reduction in pretreatment BDI score at the end of the follow-up period, remission rates defined as final HAM-D total ≤6 or a final BDI total < 9.4 and rating scale scores in the two groups compared over the entire treatment period from baseline to the post-treatment assessment. We also compared length of hospitalization of both groups defined as the number of days between the beginning of training and discharge from hospital.

67

AEROBIC EXERCISE AS AUGMENTATION THERAPY FOR DEPRESSIVE DISORDER

Table 1: Comparison of the background and demographic characteristics of the treatment groups at the beginning of research; df=10, N=6 for each exercise group (aerobic, stretching).

Aerobic

Stretching

Variable

Mean

Std.Dev.

Mean

Std.Dev.

P value

Age

33.17

13.41

53.50

18.78

0.06

Gender

Female 66.6%

Female 83.3%

0.51

History of depression in family

Positive 67%

Positive 33%

0.25

Years of schooling

13.00

1.67

9.33

6.19

0.19

Number of depressive episodes

4.17

3.54

3.50

2.93

0.75

Duration of current depressive episode

40.33

20.02

20.20

16.29

0.10

Antidepressant Treatment History Form (ATHF) score

10.00

5.55

5.33

1.75

0.08

Hamilton Depression Scale (HAM-D)

29.00

5.06

27.50

7.66

0.70

Beck Depression Inventory (BDI)

28.33

6.28

35.33

5.28

0.06

Clinical Global Impressions Scale (CGI)

4.33

0.52

4.50

0.55

0.60

Visual Analog Scale (VAS)

17.00

19.29

12.33

13.16

0.63

RESULTS Of 69 patients with MDE in the context of MDD admitted to the Department of Psychiatry during the research period (June 2009 - August 2011), 28 fulfilled the inclusion criteria for this study. Of these 15 agreed to participate and were recruited. Three patients dropped out before starting the exercise program (two changed their minds and one had an abnormal exercise test). There were no dropouts during the course of the study from baseline to the post-treatment assessment.

The groups were compared on the following parameters: age, gender, presence of depression in the family, years of schooling, number of depressive episodes (including current episode), duration of current episode, antidepressant treatment history form (ATHF) score, and initial scores on the four depression rating scales. There were no significant differences (p<.05) in background and demographic characteristics between the stretching and the aerobic exercise groups at the beginning of the research, although there was a trend for the stretching group to be older and slightly more depressed according

to the BDI (p=.06). On the other hand the aerobic group tended to greater resistance to antidepressant treatment as indicated by the ATHF (p=.08) (Table 1).

Differences in response and remission rates between the two exercise groups were examined according to the HAM-D and BDI final total scores. The results are shown in Table 2. In the aerobic exercise group there were four responders according to the primary outcome criterion, >50% reduction in pretreatment HAM-D score at the end of the follow-up period, corresponding to a 66.6% response rate, as compared to no responders in the stretching group (x2=6.0; p=0.014). Two responders in the stretching group also achieved remission with final HAM-D scores ≤6 (33.3%) (p>0.1). On the BDI there were two responders in the aerobic exercise group who also achieved remission with BDI scores < 9.4 and no responders in the stretching group (p>0.1).

For each depression scale a one way repeated measures ANOVA was performed from baseline to post-treatment assessment. Repeated measures ANOVA of HAM-D scores yielded no significant exercise effect (F[1,10]=0.42, p=0.52), a significant time effect (F[4,40]=13.2,

Table 2: Response and remission rates in the two exercise groups (Response defined as > 50% reduction in pretreatment HAM-D or BDI scores. Remission defined as HAM-D final score ≤6, or BDI final scores ≤ 9.4). BDI= Beck Depression Inventory.

HAM-D= Hamilton Depression Scale.

Rating Scale

Exercise Program

No. Subjects

No. Responders

% Responders

HAM-D

Aerobic

6

4

66.66

Stretching

6

0

0

BDI

Aerobic

6

2

33.33

Stretching

6

0

0

68

X2 square P-value P<0.05* P<0.5

No. Remitters

% Remitters

2

33.33

0

0

2

33.33

0

0

X2 square P-value P>0.1 P>0.1

TAL SHACHAR-MALACH ET AL.

Figure 2: Effect of aerobic and stretching exercise on HAM-D score from baseline to one week after completion of the study. (HAM-D, Hamilton Depression Scale, BL – baseline, Wk – Week, Post – one week post completion of the study).

Figure 3: Effect of aerobic and stretching exercise on BDI score from baseline to one week after completion of the study (BDI - Beck Depression Inventory, BL – baseline, Wk – Week, Post – one week post completion of the study). A symbol denotes a significant (P<0.05) difference in depression scores between exercise groups at particular time point. A star denotes p value of p<0.05, a rectangle denotes p value of p<0.01 and a triangle denotes a p value of p<0.001.

p=5.71462E-07) and no interaction (F[4,40]1.6, p=0.19) (Figure 2). For BDI scores there was a significant exercise effect (F [1, 10] =10.44, p=0.008), a significant time effect (F[4,40]=10.6, p=5.98577E-06) but no interaction (F[4,40]=1.1, p=0.38). Neuman Keuls post hoc tests showed BDI scores were significantly lower among the aerobic group than the stretching exercise group at alltime points: after one week (p=0.02), two weeks (P=0.001) and three weeks (p=0.003) of treatment and one week following the study (p=0.0002) (Figure 3). For CGI scores there was a significant exercise effect (F[1,10]=7, p=0.02), a significant time effect (F[4,40]=8.5, p=4.36289E-05) and a significant interaction (F[4,40]=2.62, p=0.04). Post hoc Neuman Keuls tests showed that the aerobic group CGI scores were significantly lower than the stretching group scores after three weeks of treatment (T4, p=0.03) and one week following the study (p=0.0004) (Figure 4). For VAS scores there was a significant exercise effect (F[1,10]=6.16, p=0.03), a significant time effect (F[4,40]=15.4, p=1.05903E-07), but no interaction (F[4,40]=1.8, p=0.14). Neuman Keuls post hoc tests showed that the VAS scores of the aerobic exercise group were significantly higher than those of the stretching exercise group after two weeks of treatment (T3, p=0.04), after four weeks (T4, p=0.02) and one week after conclusion of the study (T3, p=0.0006 (Figure 5).

Mean duration of hospitalization, measured as the number of days between the beginning of training and discharge

from hospital, was shorter in the aerobic group than the stretching group (38.83+25.36 days versus 61.16+52.4 days ) but the difference was not statistically significant (p=0.38).

ADVERSE EFFECTS

No adverse effects were reported by the participants in either exercise group.

DISCUSSION In this study, we evaluated the effect of a short-term aerobic exercise program as an adjuvant treatment for hospitalized patients with major depression as compared to the effect of stretching exercise. Both groups showed improvement over time on the four depression scales used in the study. Improvement in the aerobic group was significantly greater than in the stretching group on three of the four scales (CGI, BDI and VAS). We found that response and remission rates were significantly higher in the aerobic group on HAM-D and BDI scales. Response to exercise intervention, defined as > 50% reduction in pretreatment HAM-D score at the end of the follow-up period, was the primary outcome criterion of the study.

No significant difference was found in the duration of hospitalization between the two groups.

The results of our study are in accordance with previous trials indicating a positive effect of aerobic exercise as an augmentation treatment for depression. Our findings 69

AEROBIC EXERCISE AS AUGMENTATION THERAPY FOR DEPRESSIVE DISORDER

Figure 4: Effect of aerobic and stretching exercise on CGI score from baseline to one week after completion of the study (CGI - Clinical Global Depression Scale, BL – baseline, Wk – Week, Post – one week post completion of the study).

A symbol denotes a significant (P<0.05) difference in depression scores between exercise groups at particular time point. A star denotes p value of p<0.05 and a triangle denotes a p value of p<0.001.

Figure 5: Effect of aerobic and stretching exercise on VAS score from baseline to one week after completion of the study (VAS - Visual Analog Scale, BL – baseline, Wk – Week, Post – one week post completion of the study). A symbol denotes a significant (P<0.05) difference in depression scores between exercise groups at particular time point. A star denotes p value of p<0.05 and a triangle denotes a p value of p<0.001.

resemble those of four previously published studies.

Knubben et al. (14) showed a positive effect of short term aerobic exercise lasting only 10 days among hospitalized depressive patients. The uncontrolled study of Dimeo et al. (15) showed a significant effect after only 12 days.

The duration of exercise in our study was longer, three weeks, and included a one week follow up. In contrast, the study of Martinsen et al. (16), which was also positive, lasted nine weeks. Studies in outpatients tend to be longer, the majority lasting 8-12 weeks. Trivedi et al.

(13) found a positive effect of aerobic training among depressed outpatients, while Krogh et al. did not (22). A meta-analysis by Krogh et al. (12) suggested a short-term effect of exercise on depression, but this effect does not seem to last in the longer term beyond cessation of the exercise program. This meta-analysis mainly included trials performed outside clinical settings, only half of which were blinded. Our study is unique in that it is a blinded trial performed among hospitalized patients suffering from severe depression. The improvement was on all four depression scales indicating that exercise improves both objective and subjective depression parameters.

We planned to recruit a total of 40 patients for this study in order to detect a difference significant at p<0.05 with a power of 80%, based on effect size observed in the previous controlled study of Knubben et al. (14) and using the program Power and Precision (Release 3.1, 2007). The number of patients actually recruited was

much smaller than this. Out of 28 patients who fulfilled the inclusion criteria, only 15 agreed to participate in the study. However, all 12 patients who started the exercise program completed it. We calculated the power of our recruited sample to detect a significant effect using our primary outcome variable, 50% reduction in HAM-D score from baseline. On this basis our sample had 74% power to detect a significant effect of aerobic exercise at p<0.05 two tailed. The small number of patients who agreed to take part is most likely related to the low level of motivation for participation in programs of this type among patients suffering from depression. The fact that despite this small sample size significant results were obtained suggests a strong effect of the aerobic treatment.

Treatment-resistant depression (TRD) has several definitions. One of these definitions refers to inadequate response to at least one antidepressant trial of adequate dose and duration (23). The cutoff for definition of resistant depression in our study was above two according to the ATHF (18); all the patients were resistant except one. Our results show that aerobic exercise augments the effect of standard antidepressant pharmacotherapy and improves depression even in resistant depressive inpatients. However, because of the small sample size in our study the results must be regarded as preliminary and consideration of aerobic exercise as part of the regular treatment plan in patients with resistant depression requires replication in further clinical trials.

70

TAL SHACHAR-MALACH ET AL.

REFERENCES 1. Blazer DG, Kessler RC, McGonagle KA, et al. The prevalence and distribution of major depression in a national community sample. Am J Psychiatry 1994; 7:979-986.

2. Trivedi MH, Greer TL, Grannemann BD, et al. Exercise as an augmentation strategy for treatment of major depression. J Psychiatr Pract 2006; 12:205- 213.

3. Karasu TB, Gelenberg A, Merriam A, et al. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry 2000;157: 1-45.

4. Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. Am J Psychiatry 2006; 163:28-40.

5. Joffe RT, Levitt AJ. Antidepressant failure: Augmentation or substitution?

J Psychiatry Neurosci 1995; 20:7-9.

6. Kessler RC, Soukup J, Davis RB, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United State.

Am J Psychiatry 2001; 158:289-294.

7. Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001; 322:763-767.

8. Thachil AF, Mohan R, Bhugra D. The evidence base of complementary and alternative therapies in depression. J Affect Disord 2007; 97:23-35.

9. Mead GE, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Syst Rev 2008; (4): CD004366.

10. Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: Efficacy and dose response. Am J Prev Med 2005; 28:1-8.

11. Singh NA, Stavrinos TM, Scarbek Y, et al. A randomized controlled trial of high versus low intensity weight training versus general practitioner care for clinical depression in older adults. J Gerontol A Biol Sci Med Sci 2005; 60:768-776.

12. Krogh J, Nordentoft M, Stern J AC, et al. The effect of exercise in clinically depressed adults: Systematic review and meta- analysis of randomized Controlled Trials. J Clin Psychiatry 2011; 72:529-538.

13. Trivedi MH, Greer TL, Church TS, et al. Exercise as an augmentation treatment for nonremitted major depressive disorder: A randomized, parallel dose comparsion. J Clin Psychiatry 2011; 72:677-684.

14. Knubben K, Reischies FM, Adli M, et al. A randomized, controlled study on the effects of a short- term endurance training programme in patients with major depression. Br J Sports Med 2007; 41:29-33.

15. Dimeo F, Baucer M, Varahram I, et al. Benefits from aerobic exercise in patients with major depression: A pilot study. Br J Sports Med 2001; 35:114-117.

16. Martinsen EW, Medhus A, Sandvik L. Effects of aerobic exercise on depression: A controlled study. Br Med J (Clin Res Ed) 1985; 291(6488):109.

17. Shalev AY, Abramovitz M, Kaplan DeNour A. Structured Clinical Interview for DSM-IV (SCID-IV) Hebrew Version. Jerusalem, June, 1996.

18. Oquendo MA, Baca- Garcia E, Kartachov A, et al. A computer algorithm for calculating the adequacy of anti-depressant treatment in unipolar and bipolar depression. J Clin Psychiatry 2003; 64:825-833.

19. Kornstein SG, Schneider RK. Clinical features of treatment- resistant depression. J Clin Psychiatry 2001; 62:18-25.

20. Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry 2001; 62:10-7.

21. Pate RR. Physical activity and health: Dose-response issues. Res Q Exer Sport 1995; 66:313-317.

22. Krogh J, Saltin B, Gluud C, et al. The DEMO trial: A randomized, parallel-group, observer-blinded clinical trial of strength versus aerobic versus relaxation training for patients with mild to moderate depression.

J Clin Psychiatry 2009; 70:790-800.

23. Fava M. Diagnosis and definition of treatment-resistant depression.

Biol Psychiatry 2003; 53:649-659.

71

BOOK REVIEWS

Violence and Mental Health: Its Manifold Faces Jutta Lindert & Itzhak Levav, Editors ISBN 978-94-017-8998-1 ISBN 978-94-017-8999-8 (eBook) DOI 10.1007/978-94-017-8999-8 New York, London: Springer Dordrecht Heidelberg

L

indert and Levav open their comprehensive text with the following sentence: “Violence is omnipresent in societies, communities, institutions, families, interpersonal relationships, and it is even acted against oneself.” In a sense this dry understatement reflects the chilling facts that most of us try so hard to ignore: violence is omnipresent in human lives.

There have been numerous texts published focusing on violence. A Pubmed literature search reveals that over 38,000 studies were published in the last decade focusing on violence. This would suggest that more publications may be redundant. Not so with this amazing feat of clarity, expertise and interest.

Since the beginning of the 21st century the increasing awareness of the impact of violence on health had been formally recognized by clinicians, researchers and global organizations. In 2003 the World Health Assembly declared violence as a leading worldwide public health problem that requires creative and sustained interventions.

The first section deals with common issues of violence and mental health. It reviews the psychological factors associated with using and sustaining violence in protracted conflicts, the transgenerational impact of violence, the association of violence with depression and anxiety. Violence directed against oneself is scrutinized next. The opening chapter is followed by the thorough examination of violence in families. Among others, violence and abuse of women and the elderly are highlighted.

Social violence in institutions and communities such as bullying in schools, violence against the person in mental institutions and the industry of trafficking of humans are presented and discussed. Logically this is complemented by a chapter focusing on terrorism, political oppression, war and genocide.

The book closes with a positive note by introducing the readers to the reconciliation project in South Africa after the apartheid era and youth violence prevention projects worldwide.

I choose to “borrow” from the authors of chapter 17 (focusing on the apartheid) the closing sentences 72

of this review. The two contrasting master narratives about South Africa affect contemporary mental health practice differentially. The first of these is the “miracle” narrative – the story that South Africa was saved from an apocalyptic conflagration at the 11th hour. The second narrative is that the problems of South Africa are so deep-rooted, so embedded in a long and continuing history of corruption and greed that the problems are intractable. Each narrative has an impact on the way mental health is practiced. Perhaps the most painful lesson, though, for mental health professionals in South Africa from the apartheid period to today is that when there is a clear enemy (the apartheid state), it is far easier to know where one stands on issues of violence and mental health. Progressive mental health workers at the time were absolutely clear that an important part of the solution to the problem would be the fall of apartheid and the advent of democracy. In the times since, it is just as clear that violence and abuse is unacceptable.

How one works for appropriate, sustainable and meaningful change is much less clear.

Yoram Barak, Bat Yam

Fads & Fallacies in Psychiatry Joel Paris RCPsych Publications, 2013 ISBN 978-1-909726-06-2 Price: £15

“

Aspects of mental illness are still a mystery,” writes Prof. Joel Paris, a full professor at McGill University and the legendary editor of the Canadian Journal of Psychiatry. This is the beginning of a brief but fabulous journey into his slim – 124 pages – volume on the fads and fallacies of our profession.

The book takes off after an introduction in which the famous quote “psychiatry has gone from being brainless to being mindless” (Eisenberg, 1986) is discussed in three sections. Part I describes fads in medicine and psychiatry in general. Part II focuses on effects, while Part III describes the antidotes to fads. The book concludes with a reference list and an index.

Joel Paris, whom I do not know personally, is a very courageous man and with a keen nose for blood. He slaughters the “holy cows” of psychiatry with a sure and smooth swing of his literary sickle. In order not to write

BOOK REVIEWS

any “spoilers” I shall only mention Paris’s description of the rise and fall of Cameron (president of the APA and founder of the WPA) who came up with the brilliant idea of “de-patterning” that involved massive doses of ECT (up to 100 treatments) in order to “remove” memories and close down dysfunctional brain circuits to be replaced by new and healthier patterns. This took an even more sinister twist in 1977 when it was revealed that the CIA provided funds for this project.

This book is highly recommended for physicians and psychiatrist who have a healthy portion of cynicism and curiosity underlying their basic personality. This book is to be hidden from journalists or TV personalities or we may never live down the shame they will bring to our professional doorstep.

Yoram Barak, Bat Yam

Essentials of Physical Health in Psychiatry I. Cormac & D. Gray, Editors Paperback, 496 pages, 35£ RCPsych Publications, U.K. ISBN: 978-1-908020-40-6

T

his colorful, hefty, tempting volume was sent to me by the marketing officer of the Royal College of Psychiatrists, London, U.K. I usually read through the books I review and then grimace at the selling “points” emphasized by the publishers. The present book is a different story (excuse the pun). The publishers start off by stating: “As a psychiatrist you may be the only

medically qualified person caring for your patient.”

Indeed, even with the accessible general medical services in Israel this rang true. I have been looking into the diagnosis of cancer in chronic users of tertiary psychiatric centers in Israel and can testify that psychiatrists are often the only physician a patient will meet with or consult for decades. So, the book challenges us: “Someone taking antipsychotic medication complains of chest pain – what action do you need to take? Your patient with bipolar disorder also has poorly controlled asthma – what do you do? Your elderly patient suffering from dementia shows signs of respiratory distress after a fall – is a transfer to the emergency department the best course of action?”

The book has four sections: the first covers improving physical health, the second medical specialties, the third psychiatric specialties and physical health and the fourth covers medical emergencies and injuries. Within the various sections each chapter opens with a brief introduction and then moves to describe physical symptoms and signs. Each chapter ends with a useful summary and a list of learning points. The photos and illustrations are an “extra” that adds to the books’ appeal.

The book was co-edited by “a psychiatrist and a physician” says the marketing officer. I was quite convinced that psychiatrists are physicians. This is no mere Freudian slip – it embodies the need for all psychiatrists to connect with the basics of physical medicine. This book provides an attractive read on the way to address the “gap” between psychiatrists and physicians.

Yoram Barak, Bat Yam

73

‫מחקר מבוקר לבדיקת מועילות של פעילות גופנית‬ ‫כאוגמנטציה לטיפול נוגד דיכאון בתרופות בקרב‬ ‫מאושפזים הסובלים מדיכאון‬ ‫ט‪ .‬שחר‪-‬מלאך‪ ,‬ר‪ .‬קופר‪-‬קזאז‪ ,‬נ‪ .‬קונסטנטיני‪ ,‬צ‪ .‬ליפשיץ וב‪ .‬לרר‪.‬‬ ‫‪ ,‬ירושלים‬

‫רקע‪ :‬מחקרים הראו כי פעילות גופנית יכולה לשפר‬ ‫תסמיני דיכאון כאשר היא משולבת עם טיפול נוגד דיכאון‬ ‫בתרופות‪ .‬מחקר מבוקר זה השווה בין פעילות גופנית‬ ‫אירובית לבין מתיחות‪ ,‬הניתנות כאוגמנטציה לטיפול נוגד‬ ‫דיכאון בתרופות בקרב חולי דיכאון מאושפזים‪.‬‬ ‫שיטות‪ :‬המחקר כלל מטופלים בני ‪ 75–20‬הסובלים‬ ‫מאפיזודה של דיכאון מג’ורי שאושפזו במחלקה‬ ‫הפסיכיאטרית‪ .‬המטופלים חולקו אקראית לשתי קבוצות‬ ‫של פעילות שנמשכה שלושה שבועות‪ .‬קבוצה אחת ביצעה‬

‫פעילות אירובית וקבוצה שנייה ביצעה פעילות של מתיחות‪.‬‬ ‫החולים עברו הערכה של מדדי הדיכאון על סמך מילוי‬ ‫השאלון על שם המילטון (‪,)Hamilton Depression Scale‬‬ ‫השאלון על שם בק (‪ )Beck Depression Inventory‬ושאלונים‬ ‫נוספים‪.‬‬ ‫תוצאות‪ :‬לפי מדד המילטון‪ ,‬בקבוצת הפעילות האירובית‬ ‫ארבעה מששת הנבדקים הגיבו לטיפול‪ ,‬ואצל שניים מהם‬ ‫נראתה נסיגה של הדיכאון‪ ,‬לעומת אפס נבדקים בקבוצת‬ ‫המתיחות‪ .‬לפי מדד בק‪ ,‬בקבוצת הפעילות האירובית‬ ‫שני נבדקים הגיבו לטיפול וגם השיגו נסיגה‪ ,‬לעומת אפס‬ ‫נבדקים בקבוצת המתיחות‪.‬‬ ‫מסקנות‪ :‬תוצאות מחקר קטן זה תומכות בכך שלפעילות‬ ‫גופנית אירובית המבוצעת כאוגמנטציה לטיפול נוגד דיכאון‬ ‫בתרופות בקרב חולי דיכאון מאושפזים‪ ,‬יש השפעה חיובית‪.‬‬ ‫נדרשים מחקרים נוספים כדי לתמוך בממצאים אלו‪.‬‬

‫‪74‬‬

‫בתפקוד ובמצב הבריאות כשלושה וכשישה חודשים‬ ‫לאחר המלחמה‪ ,‬בהשוואה לחיילי קבוצת ביקורת שלא‬ ‫השתתפו בהתערבות‪ .‬המטרה השנייה הייתה לבחון אם‬ ‫“התערבות קבוצתית מוקדמת” מועילה לחיילים בעלי‬ ‫סגנון התמודדות רפרסיבי‪.‬‬ ‫במחקר השתתפו ‪ 166‬חיילים מגדוד מילואים אשר ביצע‬ ‫משימות צבאיות שונות במהלך מלחמת לבנון השנייה‪.‬‬ ‫החיילים השתתפו בהתערבות כשלושה חודשים לאחר‬ ‫המלחמה‪ .‬ההתערבות נמשכה יום והתבססה על שיחה‬ ‫מובנית (על בסיס התערבות מסוג תשאול)‪ .‬השאלונים‬ ‫מולאו לפני ההתערבות וכארבעה חודשים אחריה‪.‬‬ ‫בהתאם להשערת המחקר נמצא כי לאחר “ההתערבות‬ ‫הקבוצתית המוקדמת” חיילי קבוצת הניסוי סבלו פחות‬ ‫ממצוקה פוסט טראומטית מחיילי קבוצת הביקורת‪.‬‬ ‫עוד נמצא כי ארבעה חודשים לאחר ההתערבות‪ ,‬התפקוד‬ ‫ומצב הבריאות של חיילי קבוצת הניסוי היה טוב יותר‬ ‫במידה ניכרת בהשוואה לחיילי קבוצת הביקורת‪.‬‬ ‫רמת המצוקה הפוסט‪-‬טראומטית של בעלי סגנון‬ ‫התמודדות רפרסיבי ובעלי סגנון התמודדות של חרדה‪-‬‬ ‫נמוכה לפני ההתערבות‪ ,‬הייתה נמוכה ביחס לחיילים בעלי‬ ‫סגנונות התמודדות אחרים (חרדה‪-‬גבוהה והגנתיים)‪ .‬כמו‬ ‫כן‪ ,‬לא נמצאו הבדלים מובהקים בין סגנונות ההתמודדות‬ ‫במקרים של מצוקה פוסט‪-‬טראומטית לאחר ההתערבות‪.‬‬ ‫ההשלכות הקליניות העתידיות של המחקר נדונות‪.‬‬

‫תסמינים פסיכיאטרים ואיכות חיים בקרב אנשי‬ ‫צבא המשרתים בחו”ל‬ ‫ט‪ .‬אוזנור‪ ,‬ס אקרסו‪ ,‬מ ארדם‪ ,‬מ דורוסו‪ ,‬מ טויגר‪ ,‬י פורוזגלו‪ ,‬א‬ ‫קלדירים‪ ,‬מ אלירימז‪ ,‬ק אוזמנלר‪ ,‬טורקיה‬

‫רקע‪ :‬אנשי צבא המשרתים בחו”ל עלולים להיחשף לגורמי‬ ‫סיכון רבים שמשפיעים על איכות החיים שלהם‪ .‬במחקר‬ ‫זה בדקנו תסמינים פסיכיאטריים ואיכות חיים בקרב אנשי‬ ‫צבא טורקיה המשרתים באפגניסטן‪.‬‬ ‫שיטה‪ 289 :‬אנשי צבא המשרתים באפגניסטן גויסו למחקר‪.‬‬ ‫הם השלימו שני סקרים שכללו שאלות לבירור מאפיינים‬ ‫סוציו‪-‬דמוגרפיים‪ .‬נתוניהם של ‪ 258‬משתתפים נאספו ונותחו‪.‬‬ ‫תוצאות‪ :‬הציונים של הסימפטומים הכלליים (‪ )GSI‬היו‬ ‫מעל ‪ 1‬אצל ‪ 20.8%‬מהמשתתפים (‪ 54‬משתתפים)‪ .‬הציונים‬ ‫הנמוכים ביותר בשאלון איכות החיים המקוצר (‪)SF-36‬‬ ‫בתת‪-‬הקבוצות היו בריאות הנפש (‪ )18.56 ± 59.14‬וחיוניות‬ ‫(‪ .)21.17 ± 59.25‬הציון הגבוה ביותר היה בתת‪-‬סולם של‬ ‫תפקוד פיזי (‪ .)19.53 ± 84.42‬כל ציוני תת‪-‬הקבוצות בשאלון‬ ‫‪ SF-36‬היו נמוכים יותר בקבוצה שבה ה‪ GSI-‬היה גבוה‬ ‫מ‪ 1-‬בהשוואה לקבוצה שבה הוא היה נמוך מ‪ .1-‬בקבוצה‬ ‫שבה ה‪ GSI-‬היה מעל ‪ 1‬רמת ההשכלה ודיכאון השפיעו על‬ ‫‪75‬‬

‫תפקוד פיזי ב ‪ ;SF-36‬מחשבות פרנואידיות וסומטיזציה‬ ‫השפיעו על ‪ SF-36‬מגבלות תפקיד עקב בריאות פיזית; גיל‬ ‫וסומטיזציה השפיעו על ‪ SF-36‬כאב; גיל השפיע על ‪SF-36‬‬ ‫בריאות כללית; חרדת ופוביה השפיעו על ‪ SF-36‬חיוניות;‬ ‫גיל‪ ,‬קביעות במקצוע וותק בחו”ל; וחרדה פובית השפיעה‬ ‫על בריאות הנפש של ‪.SF-36‬‬ ‫מסקנות‪ :‬ההשפעות השליליות של תסמינים פסיכיאטריים‬ ‫על איכות החיים באוכלוסייה הכללית ובקבוצות מחלה‬ ‫ספציפיות היו דומות‪ .‬התוצאות הללו צריכות להילקח‬ ‫בחשבון כאשר בוחנים את בריאות הנפש של אנשי צבא‬ ‫המשרתים בחו”ל‪.‬‬

‫כושר לב‪-‬ריאות ותפקוד קוגניטיבי בקרב מבוגרים‬ ‫המשתתפים בתכנית שיקום לב ונמצאים בשלב‬ ‫התחזוקה‬ ‫י‪ .‬נץ‪ ,‬צ‪ .‬דבולצקי‪ ,‬ע‪ .‬חזקייה וא‪ .‬דונסקי‪ ,‬מכון וינגייט‬

‫העיר שבה נערך המחקר‪ :‬המכללה האקדמית בווינגייט‬ ‫(המכון לשיקום לב) ליד נתניה וכפר סבא (המכון לשיקום‬ ‫לב במרכז הרפואי מאיר)‬ ‫תקציר‬ ‫הקדמה‪ :‬הקשר בין כושר לב‪-‬ריאות לתפקוד קוגניטיבי‬ ‫בגיל מבוגר מוכר ומתועד היטב‪ .‬ידוע כי מחלת לב היא‬ ‫גורם סיכון לירידה ביכולת הקוגניטיבית‪ ,‬נוסף על הירידה‬ ‫ביכולות אלו הקשורה לגיל‪ ,‬ומטרת מחקר זה הייתה לבדוק‬ ‫קשר זה בקרב חולי לב‪.‬‬ ‫שיטה‪ :‬חולי לב המשתתפים בתכנית שיקום לב ונמצאים‬ ‫בשלב התחזוקה (שלב ‪ )III‬חולקו לשתי זרועות על בסיס‬ ‫צריכת חמצן מקסימלית חזויה – בעלי כושר גבוה ובעלי‬ ‫כושר נמוך‪ .‬התפקוד הקוגניטיבי של המשתתפים נמדד על‬ ‫ידי מערכת של תפקודים נוירופסיכולוגיים הכוללים זיכרון‪,‬‬ ‫קשב‪ ,‬כושר חזותי‪-‬מרחבי‪ ,‬תפקודים ניהוליים וציון גלובלי‬ ‫שנקבע על פי ממוצע כל התפקודים‪.‬‬ ‫תוצאות‪ :‬בעלי הכושר הגבוה והנמוך דיווחו על דפוסי‬ ‫פעילות גופנית דומים ואף השיגו תוצאות דומות במבחן‬ ‫מנטלי בסיסי (‪.)Mini-Mental State Examination – MMSE‬‬ ‫עם זאת‪ ,‬בתפקודים הנוירופסיכולוגיים נמצאו הבדלים‬ ‫מובהקים בקשב ובציון הגלובלי לטובת קבוצת הכושר‬ ‫הגבוה‪ .‬הבדל גבולי לטובת קבוצה זו נמצא גם בתפקודים‬ ‫הניהוליים‪.‬‬ ‫מגבלות המחקר‪ :‬לאור מספר הנבדקים הקטן יחסית‪ ,‬לא‬ ‫ניתן היה להתייחס לסוג מחלת הלב כמשתנה מתערב‪.‬‬ ‫מסקנה‪ :‬יש קשר בין כושר לב‪-‬ריאות לתפקוד שכלי בקרב‬ ‫חולי לב המשתתפים בתכנית שיקום ונמצאים בשלב‬ ‫התחזוקה‪ .‬קשר זה זוהה בעיקר ביכולות הקשב ובמידה‬ ‫מסוימת אף בתפקודים הניהוליים‪.‬‬

‫הליצן פיתח גישה שבמסגרתה נעשה שימוש בטכניקות של‬ ‫טיפול קבוצתי בפסיכודרמה‪ ,‬והליצן משמש כמנחה‪ .‬אנו‬ ‫מתארים מקרה של מטופל שאובחן כסובל מסכיזופרניה‬ ‫אשר במהלך ארבעה וחצי חודשי טיפול קבוצתי בהנחיית‬ ‫הליצן הרפואי היה מסוגל לאמץ בצורה המשכית תפקידים‬ ‫מפתיעים‪ .‬ייתכן שתהליך זה תרם לנסיגת מחלתו של‬ ‫המטופל‪ .‬אנו דנים ביכולת של ליצנים רפואיים לעודד‬ ‫תקשורת ולהיענות לפנטזיה כאשר חוזרים למציאות‬ ‫המוסכמת‪ .‬אנו מציעים את האפשרות שטיפול כזה יהיה‬ ‫רלוונטי במיוחד לעבודה עם מטופלים פסיכוטיים‪.‬‬

‫כיצד תחושת משמעות בחיים ורגשות חיוביים‬ ‫קשורים להסתגלות ללחץ? מקרה הכבאים‬ ‫שהשתתפו בכיבוי השריפה ביערות הכרמל‬ ‫ע‪ .‬שרירא‪ ,‬ד‪ .‬שמוטקין‪ ,‬י‪ .‬פלגי‪ ,‬י‪ .‬סופר‪ ,‬י‪ .‬חממה‪-‬רז‪ ,‬פ‪ .‬טל‪-‬כץ‪,‬‬ ‫מ‪ .‬בן‪-‬עזרא וצ‪ .‬ס‪ .‬בנייט‪ ,‬חיפה‬

‫רקע‪ :‬במחקר זה בדקנו כיצד רגשות חיוביים ותחושת‬ ‫משמעות בחיים מווסתים יחדיו סימפטומים של הפרעה‬ ‫פוסט‪-‬טראומטית ותפיסת התמודדות המתאפיינת‬ ‫במסוגלות‪-‬עצמית‪ .‬השערות המחקר התבססו על מודל‬ ‫הוליסטי‪ ,‬שלפיו רגשות חיוביים ותחושת משמעות בחיים‬ ‫משלימים זה את זה בהקשר של הסתגלות ללחץ גבוה‪.‬‬ ‫שיטה‪ :‬המדגם כלל ‪ 75‬כבאים ישראלים שלקחו חלק פעיל‬ ‫בכיבוי השריפה ביערות הכרמל בשנת ‪.2010‬‬ ‫תוצאות‪ :‬רגשות חיוביים ותחושת משמעות פיצו זה על‬ ‫זה‪ ,‬כך שכאשר נראתה רמה נמוכה של אחד המשתנים‪,‬‬ ‫המשתנה השני היה קשור להסתגלות טובה‪ .‬כלומר‪,‬‬ ‫כאשר תחושת המשמעות בחיים הייתה ירודה‪ ,‬רגשות‬ ‫חיוביים היו קשורים לפחות סימפטומים של הפרעה‬ ‫פוסט‪-‬טראומטית וליותר תפיסת התמודדות המתאפיינת‬ ‫במסוגלות‪-‬עצמית‪ ,‬וכאשר הרגשות החיוביים היו נמוכים‪,‬‬ ‫תחושת משמעות בחיים הייתה קשורה לסימפטומים של‬ ‫הפרעה פוסט‪-‬טראומטית ולתפיסת התמודדות המתאפיינת‬ ‫במסוגלות‪-‬עצמית‪.‬‬ ‫מגבלות‪ :‬מערך המחקר הרוחבי לא אפשר הסקה לגבי‬ ‫סיבתיות‪.‬‬ ‫מסקנות‪ :‬הממצאים תומכים במודל ההוליסטי ועוזרים‬ ‫להבין כיצד רווחה סובייקטיבית ותחושת משמעות בחיים‬ ‫קשורות להסתגלות ללחץ‪.‬‬

‫איגוד בריאות הנפש הישראלי‪-‬פולני (‪ )IPMHA‬נוסד בשנת‬ ‫‪ .2000‬זהו ארגון ייחודי היות שהוא אינו אחת מהעמותות‬ ‫הרבות לאנשי מקצוע בתחום בריאות נפש‪ ,‬אלא הוא‬ ‫במה לאנשים ממדינות שונות שחולקים עבר חשוב‬ ‫וטראומטי‪ .‬חברי ה‪ IPMHA-‬חוקרים את ההשלכות של‬ ‫טראומה מסיבית‪ ,‬העברה בין‪-‬דורית של טראומה ועזרה‬ ‫לניצולי טראומה‪ .‬תוך התחשבות בחובת מקצועות בריאות‬ ‫הנפש לתרום לחברה נאורה וסובלנית‪ ,‬חברי ה‪IPMHA-‬‬ ‫משתדלים להתמודד עם “העבר בהווה”‪ ,‬וחוקרים את‬ ‫השורשים של הנזקים שנגרמו על ידי שנאה גזענית‬ ‫ואתנית‪ ,‬אנטישמיות וצורות אחרות של דעות קדומות‬ ‫חברתיות‪.‬‬ ‫פעילויות ה‪ IMPHA-‬כוללות סימפוזיונים ודיונים בשיטת‬ ‫הקבוצה הדינמית‪ .‬חלק מהחומרים שהוצגו בפגישות‬ ‫האיגוד פורסמו בכתבי עת מקצועיים בפולין‪ .‬במאמר זה‬ ‫מדווח על פעילויות ה‪ IMPHA-‬תוך שימת דגש על הבעיות‬ ‫הרגשיות הטעונות המתלוות‪.‬‬

‫גורל הפסיכיאטרים הפולנים תחת הכיבוש הגרמני‬ ‫במלחמת העולם השנייה‬ ‫פ‪.‬ךיידינגר וא‪ .‬צ’צ’ניקי‪ ,‬קרקוב‬

‫מראשיתה הושפעה עמוקות הפסיכיאטריה בפולין‬ ‫מהפסיכיאטריה בגרמניה (אוסטריה) ומהפסיכיאטריה‬ ‫ברוסיה‪ .‬היות שחלק גדול משטחה של פולין השתייך‬ ‫לגרמניה או לאוסטריה לפני שנת ‪ ,1918‬למוסדות רבים‬ ‫לבריאות הנפש הייתה היסטוריה גרמנית או אוסטרית‪.‬‬ ‫בתקופת הכיבוש במלחמת העולם השנייה הועברו כמעט‬ ‫כל בתי החולים הפסיכיאטריים לידי הגרמנים‪ ,‬ולעתים כל‬ ‫החולים או חלק מהם נרצחו‪ .‬לעתים קרובות נורו אנשי‬ ‫הצוות יחד עם מטופליהם‪ .‬יהודים הופרדו מלא יהודים‬ ‫ונרצחו‪ .‬מוסדות מסוימים המשיכו לעבוד תחת שלטון‬ ‫גרמני והנהלה גרמנית‪ .‬מאמר זה חוקר את הנושאים‬ ‫הללו מנקודת מבט היסטורית וארגונית וכולל התייחסות‬ ‫לניסיונות הפסיכיאטרים הפולנים לשרוד במהלך המלחמה‬ ‫ואחריה‪.‬‬

‫מועילות התערבות קבוצתית מוקדמת לחיילי‬ ‫מילואים‪ :‬תרומת סגנון ההתמודדות הרפרסיבי‬ ‫י‪ .‬שובל‪-‬צוקרמן‪ ,‬ר‪ .‬דקל‪ ,‬ז‪ .‬סולומון וא‪ .‬לוי‪ ,‬תל אביב‬

‫איגוד בריאות הנפש הישראלי‪-‬פולני (‪– )IPMHA‬‬ ‫היסטוריה ופעילויות‬ ‫ז’‪ .‬בומבה‪ ,‬קראקוב‪ ,‬פולין‬

‫למחקר זה היו שתי מטרות‪ :‬המטרה הראשונה של‬ ‫המחקר הייתה לבדוק אם חיילים שהשתתפו ב”התערבות‬ ‫קבוצתית מוקדמת” הנשענת על יסודות התשאול‪ ,‬סובלים‬ ‫פחות ממצוק פוסט‪-‬טראומטית‪ ,‬ואם נראה אצלם שיפור‬ ‫‪76‬‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫הקשר בין תפקוד קוגניטיבי‪ ,‬תסמיני סכיזופרניה‬ ‫ותפקודים ניהוליים בקרב הלוקים בסכיזופרניה של‬ ‫הילדות במקרים שבהם יש תורשה של פסיכוזה‬ ‫ובמקרים שבהם אין תורשה כזו‬ ‫ב‪ .‬הינץ וע‪ .‬בורקוסקה‪ ,‬ורשה‬

‫מטרה‪ :‬מטרת המחקר הייתה לבחון את הקשר בין תחומים‬ ‫שונים של תפקודים קוגניטיביים‪ ,‬עוצמת סימפטומים‬ ‫פסיכופתלוגיים‪ ,‬ורמת התפקוד הכללי בקרב מתבגרים‬ ‫הלוקים בסכיזופרניה של הילדות‪.‬‬ ‫שיטה‪ 33 :‬מתבגרים הלוקים בסכיזופרניה של הילדות‬ ‫נבדקו בתקופה של נסיגה חלקית של המחלה‪ .‬קבוצת‬ ‫הביקורת כללה ‪ 30‬מתבגרים בריאים‪ .‬סכיזופרניה‬ ‫אובחנה לפי הקריטריונים של ה‪ .ICD-10-‬סימפטומים‬ ‫פסיכופתלוגיים הוערכו באמצעות הסולם להערכת סימנים‬ ‫חיוביים וסימנים שליליים (‪ )PANSS‬והתפקוד הכללי הוערך‬ ‫באמצעות הסולם להערכה גלובלית של ילדים (‪.)CGAD‬‬ ‫תוצאות‪ :‬הפרעות תפקוד משמעותיות בהיבטים שונים של‬ ‫זיכרון עבודה‪ ,‬תפקודים ניהוליים וזיכרון מילולי נמצאו‬ ‫יותר בקבוצת המתבגרים הלוקים בסכיזופרניה של הילדות‬ ‫בהשוואה לקבוצת הביקורת‪ .‬הפגיעות בזיכרון העבודה‬ ‫ובתפקודים הניהוליים היו חמורות יותר באופן משמעותי‬ ‫בקרב חולים שנמצאה אצלם רמה גבוהה יותר של סימנים‬ ‫שליליים של סכיזופרניה‪ .‬בקרב חולי סכיזופרניה של‬ ‫הילדות שהייתה להם גם תורשה משפחתית של פסיכוזה‪,‬‬ ‫נראו ליקויים קוגניטיביים חמורים יותר בהשוואה לחולים‬ ‫ללא תורשה משפחתית‪.‬‬ ‫מסקנות‪ :‬הנתונים הללו מצביעים על כך שפגיעות בזיכרון‬ ‫העבודה הוויזואלי ובזיכרון המילולי וכן סימנים שליליים‬ ‫וחיוביים חזקים בסולם ‪ PANSS‬הם מנבאים משמעותיים‬ ‫לתפקוד לקוי‬

‫מצוקה רגשית בקרב מבקשי מקלט ומהגרי עבודה‬ ‫– זיהויה על ידי רופאי משפחה‬ ‫מ‪ .‬דיק‪ ,‬ש‪ .‬פניג וע‪ .‬לוריא‪ ,‬תל אביב‪-‬יפו‬

‫תקציר‬ ‫רקע‪ :‬מצוקה רגשית (‪ )Emotional distress, ED‬היא תופעה‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,52‬מס' ‪2015 ,3‬‬

‫נפוצה בקרב מהגרים‪ .‬המרפאה הפתוחה של ארגון רופאים‬ ‫לזכויות אדם (רל”א) בישראל מספקת טיפול רפואי‬ ‫ופסיכיאטרי למהגרים חסרי נגישות לשירותי בריאות‬ ‫אמבולטוריים‪ .‬בשנת ‪ 2010‬היו התיקים הפסיכיאטריים‬ ‫אחוז אחד מסך כל התיקים הרפואיים (‪ 28,000‬תיקים)‬ ‫במרפאה‪.‬‬ ‫מטרה‪ :‬השוואה בין הדיווח העצמי על מצוקה רגשית בקרב‬ ‫הפונים לשירות הרפואה הכללי במרפאה לבין זיהויה על‬ ‫ידי רופאי המשפחה‪ ,‬וכן זיהוי משתנים סוציו‪-‬דמוגרפיים‬ ‫הקשורים למצוקה רגשית‪.‬‬ ‫שיטה‪ :‬נבדק מדגם נוחות (‪ 97‬משתתפים) של הפונים‬ ‫לשירות הרפואה הכללי במרפאה‪ .‬הנבדקים מילאו שאלון‬ ‫של ‪ 12‬שאלות (‪.)General Health Questionnaire, GHQ-12‬‬ ‫מטופל שהציון שלו בשאלון הוא של ‪ 11‬ומעלה חשוד‬ ‫כסובל מהפרעה נפשית‪ .‬ההערכה הקלינית של רופא‬ ‫המשפחה לגבי מצוקה נפשית הושוותה לציון הדיווח‬ ‫העצמי‪.‬‬ ‫תוצאות‪ :‬ציון ה‪ GHQ-12-‬הממוצע של המדגם היה גבוה‬ ‫מציון הסף (‪.)M=12.7, SD=6.3, range 0-35‬‬ ‫‪ 53‬אחוזים (‪ )n=51‬קיבלו ציון ‪ GHQ-12‬גבוה מ‪ 11-‬ו‪8%-‬‬ ‫(‪ 8‬מטופלים) זוהו על ידי רופאי המשפחה כסובלים‬ ‫ממצוקה רגשית או ככאלה הזקוקים לטיפול פסיכיאטרי‪.‬‬ ‫הציון הממוצע של מדגם המחקר היה גבוה מזה של‬ ‫מחקרים קודמים באוכלוסייה הערבית‪-‬ישראלית הכללית‬ ‫(‪ .)M=10.8, SD=0.35‬תעסוקה הייתה המשתנה הסוציו‪-‬‬ ‫דמוגרפי היחיד שנמצא קשר מובהק בינו לבין מצוקה‬ ‫רגשית‪.‬‬ ‫מסקנות‪ :‬רמת המצוקה הרגשית הייתה גבוהה בקרב‬ ‫מהגרים‪ ,‬והיה אבחון חסר שלה על ידי רופאי משפחה‪.‬‬ ‫תעסוקה עשויה להיות גורם המגן מפני מצוקה רגשית‪.‬‬

‫ליצנות רפואית ופסיכוזה‪ :‬הצגת מקרה וסקירה‬ ‫תיאורטית‬ ‫א גרובר‪ ,‬ר‪ .‬לוין ופ‪ .‬ליכטנברג‪ ,‬ירושלים‬

‫תקציר‪ :‬בשנים האחרונות הפכה הליצנות הרפואית‬ ‫לטיפול מקובל במחלקות לא פסיכיאטריות בבתי החולים‪.‬‬ ‫הפוטנציאל הטמון בתפקיד הליצן בפסיכיאטריה‪ ,‬בייחוד‬ ‫לטיפול בפסיכוזה‪ ,‬לא נחקר עדיין‪ .‬אנו מדווחים כאן על‬ ‫עבודתו של ליצן רפואי במחלקה פסיכיאטרית סגורה‪.‬‬