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To examine changes in service utilisation before, during and after the 2006 Lebanon War – a 34-day military conflict in northern Israel and Lebanon – among three groups: general population, people ‘at risk’ for depression or anxiety and severely mentally ill individuals. Given that exposure to traumatic events is a pathogenic factor known to cause and exacerbate psychiatric distress and disorder, we hypothesised that healthcare service utilisation would increase in populations exposed to war, especially among more vulnerable populations such as those with mental illness.
A nested case–control design was used to examine changes in health care utilisation and use of psychiatric medication as recorded by the databases of Maccabi Healthcare Services (MHS), one of Israel's largest health maintenance organisations (HMOs). Purchases of benzodiazepines, antidepressants and antipsychotic medications were identified from all the medications purchased in pharmacies by MHS members during 2006. Drug consumption data were expressed as defined daily doses (DDDs), summing all DDDs per person per month. Similarly, number of visits to general practitioners (GPs), psychiatrists and Emergency Rooms (ERs) were summed per person per month. Three-way repeated measures ANOVA was used, including the variables time (12 months), region (north/other) and study group.
During the war there was a decline in GP visits among people from the general population and people ‘at risk’ for depression/anxiety who resided in northern Israel that was not paralleled among controls. Similarly, in all three study groups, there was a decline in the number of psychiatrist visits during the war among people from northern Israel which did not occur to the same extent in the control group. There were no changes in ER visits or use of psychiatric medication that could be attributed to the war.
There is less utilisation of community services at times of war among exposed populations, and there is neither evident compensation in use of emergency services, nor any compensation after the war. This may suggest that if there is an efficient medical and mental health infrastructure, people with or without psychiatric risk factors can tolerate a few weeks of a mass stress event, with no need to expand medical service utilisation. However, service utilisation at times of war may be confounded by other variables and may not serve as a direct measure of increased stress.
Previous studies have found that patients with schizophrenia are more likely to be violent than the general population. The aim of this study was to investigate the association between schizophrenia and violent crime in the Israeli population.
Using the Israeli Psychiatric Hospitalization Case Registry we identified 3187 patients with a discharge diagnosis of schizophrenia. For each proband we identified parents and siblings, and gender- and age-matched controls for patients, parents and siblings. Information on violent crimes was obtained from police records.
Patients with schizophrenia were at increased risk for violent crimes compared with controls [odds ratio (OR) 4.3, 95% confidence interval (CI) 3.8–4.9], especially women (OR 9.9, 95% CI 6.2–15.7). Risk for violent crimes was higher among patients with co-morbid substance misuse than in patients without such co-morbidity (OR 5.1, 95% CI 4.2–6.3).
The results of this study suggest that increased risk of violence is part of the clinical picture of schizophrenia and needs to be recognized as a legitimate, essential, aspect of clinical management.
The base rate of transition from subthreshold psychotic experiences (the exposure) to clinical psychotic disorder (the outcome) in unselected, representative and non-help-seeking population-based samples is unknown.
A systematic review and meta-analysis was conducted of representative, longitudinal population-based cohorts with baseline assessment of subthreshold psychotic experiences and follow-up assessment of psychotic and non-psychotic clinical outcomes.
Six cohorts were identified with a 3–24-year follow-up of baseline subthreshold self-reported psychotic experiences. The yearly risk of conversion to a clinical psychotic outcome in exposed individuals (0.56%) was 3.5 times higher than for individuals without psychotic experiences (0.16%) and there was meta-analytic evidence of dose–response with severity/persistence of psychotic experiences. Individual studies also suggest a role for motivational impairment and social dysfunction. The evidence for conversion to non-psychotic outcome was weaker, although findings were similar in direction.
Subthreshold self-reported psychotic experiences in epidemiological non-help-seeking samples index psychometric risk for psychotic disorder, with strong modifier effects of severity/persistence. These data can serve as the population reference for selected and variable samples of help-seeking individuals at ultra-high risk, for whom much higher transition rates have been indicated.
Being a small and culturally different minority, or having a different appearance, has been invoked to account for the increased prevalence of psychotic disorders among immigrants. The majority of the Jewish Israeli population are first- or second-generation immigrants from Europe, North Africa or Asia, and during the late 1980s and 1990s, 885 000 persons immigrated to Israel from the former Soviet Union and 43 000 immigrated from Ethiopia. These Ethiopian immigrants came from a very different culture compared to the rest of the population, and have a distinct appearance. To further understand the association between immigration and schizophrenia, we compared risk for later schizophrenia between adolescents who immigrated from Ethiopia with risk among the other immigrant groups, and with native-born Israelis.
Of 661 792 adolescents consecutively screened by the Israeli Draft Board, 557 154 were native-born Israelis and 104 638 were immigrants. Hospitalization for schizophrenia was ascertained using a National Psychiatric Hospitalization Case Registry. All analyses controlled for socio-economic status (SES).
Risk for schizophrenia was increased among both first- [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.18–2.22] and second-generation immigrants [HR 1.41, 95% CI 1.01–1.95 (one immigrant parent) and HR 1.49, 95% CI 1.11–2.0 (two immigrant parents)]. When risk for schizophrenia was calculated for each immigrant group separately, immigrants from Ethiopia were at highest risk of later schizophrenia (HR 2.95, 95% CI 1.88–4.65).
This comparison between diverse groups of immigrants supports the notion that immigrants who differ in culture and appearance from the host population are at increased risk for schizophrenia.
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