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Objectives Imbalance of fluid and electrolyte homeostasis has been suggested to be associated with the neuropathological processes underlying bipolar disorder. However, longitudinal data regarding the association of bipolar episodes with fluid balance are still lacking. We hypothesized that mania may be associated with a relative fluid retention and hemodilution, and depression with a relative hemoconcentration. Methods Patients with bipolar disorder (n = 43) admitted to a mental health center, both with depressive and manic episodes, were retrospectively followed between 2005 and 2013. Fluid balance and electrolyte serum indices were compared between their manic and depressive episodes. We adjusted for physical and psychiatric comorbidities and for psychotropic treatment, using two-way analysis of variance with repeated measures. Results There was a significant reduction in serum fluid balance indices during mania compared to depression: mean hemoglobin concentration 13.9 ± 1.4 g/dL versus 14.5 ± 1.4 g/dL, paired t = −4.2, p

Background: Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt. Objectives: To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters. Method: The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression–impulsivity, mental pain, and communication difficulties. Results: The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p

Background Compulsory admission is practiced around the world with legislative variations. The legal status during compulsory hospitalization might be changed to consent or the patient might be discharged against medical advice (AMA), if he no longer poses a risk. Objective In the present study, we investigated the outcome of compulsory admitted patients who left the hospital after commitment period despite request by the treating psychiatrist to remain in the hospital (AMA) vs those who agreed to prolong their hospitalization. Results Of 320 patients with schizophrenia admitted involuntarily, 157 (49%) were discharged without converting to consent, and 163 (51%) agreed to stay in the hospital. There was no difference in baseline clinical and demographic characteristics and outcome measures (rate of readmission, legal status of next admission, and length of stay in the next admission) between the 2 groups. Conclusions Prolongation of length of stay in compulsorily psychiatrist-ordered schizophrenia patients did not affect their rate of rehospitalizations or the length of next admission compared with those who left the hospital immediately after the change in their legal status AMA.

Clozapine has superior efficacy for treating patients with schizophrenia. Its discontinuation could have detrimental consequences. We attempted to identify the clinical parameters that could predict clozapine discontinuation in patients diagnosed as having schizophrenia by conducting a retrospective analysis of all of those who started on clozapine treatment during their hospitalization in our institution between 2002 and 2008 (n=100). Demographic and clinical parameters were analyzed and compared between the 58 patients who continued and the 42 who discontinued clozapine treatment during a follow-up period of 8.1 years. Twenty of the latter patients (47.6%) discontinued clozapine because of nonadherence and 11 (26.2%) because of side effects. Thirty-three of them (78.6%) stopped taking clozapine during the first year of treatment. The duration of clozapine use correlated significantly with the time to readmission (P

Background/Aims: Previous studies have indicated that the validity and reliability of schizoaffective disorder (SAD) diagnosis according to the DSM-IV criteria are insufficient, and that the stability of the diagnosis is poor. However, no study has examined exclusively the diagnostic stability of SAD. The aims of this study were to examine the longitudinal stability of the diagnosis of SAD and SAD subtypes among a large sample of patients, and to examine demographic and clinical variables as predictors of diagnostic stability. Methods: A retrospective chart review of 123 inpatients who were admitted to Geha Mental Health Center between the years 2000 and 2005, and who had been diagnosed with SAD at some stage of their illness. We compared the group of patients whose diagnosis of SAD had remained stable and the group of patients whose diagnosis had changed. Results: The diagnostic stability for SAD was 73.1%. Diagnostic transitions were mainly from and towards schizophrenia. We found an association between the SAD bipolar subtype and higher rates of diagnostic stability. The time that had elapsed since SAD diagnosis was made was significantly shorter in the group of patients with stable diagnosis than in the group of patients whose diagnosis had changed (p = 0.037). Conclusions: The diagnostic stability of SAD might be higher than previously reported. Patients who are diagnosed with SAD manic subtype have a higher tendency to retain their diagnosis than patients with other SAD subtypes. The diagnostic changes are derived from manifestations of new symptoms in the course of the disease. Clarification of the current diagnostic criteria in order to enable a more precise utilization of the SAD subtype diagnoses is warranted. Study Limitations: (a) The study design was retrospective and further prospective studies are needed to establish our findings; (b) there is a misusage of the SAD subtype definitions, thus conclusions regarding polarity of SAD and stability of diagnosis are limited, and (c) the population studied was comprised of inpatients, therefore generalization to the outpatient population should be done with caution.

Glutamate disruption is thought to have a major role in schizophrenia brain processes, possibly involving NMDA hypofunction. The metabotropic glutamate receptors are distributed in brain regions related to schizophrenia and seem to affect glutamate release in a moderate way. Compounds modulating these receptors are being investigated in animal models of schizophrenia, in an attempt to discover new antipsychotics. This article reviews the current research data regarding the role of these receptors in schizophrenia animal models. It was found that more research was done on Group I and II metabotropic receptors while investigation of group III receptors is still trailing behind. Accumulating evidence shows that mGluR5 antagonists by themselves do not necessarily disrupt pre-pulse inhibition (PPI), but can exacerbate disruption of PPI caused by MK-801 and PCP, while positive modulation of this receptor has beneficial effects on these models of psychosis. Group II agonists are also showing beneficial effects in animal models. It seems that metabotropic glutamate receptor modulators could be developed into a novel treatment of schizophrenia by altering glutamate release, thus overcoming the putative NMDA hypofunction. Although the implications from these pre-clinical studies to human schizophrenia patients are premature, the data obtained with some compounds point to promising results for drug development. More studies, with agents active at other mGluRs in animal models and schizophrenia patients as well as with human subjects are needed in order to clarify the role of the metabotropic glutamate receptors in the pathophysiology and pharmacotherapy of schizophrenia.

The psychiatric clerkship is perceived as an intervention point in medical students' attitude toward psychiatry and career choice after graduation. The authors aim to assess the impact of the psychiatric clerkship in students from Israeli and U.S. origin on their attitude toward psychiatry.A modified Nielsen's questionnaire was administered at the start and end of the clerkship in two groups of students.There was no statistically significant difference in attitude scores between the start and endpoint of a clerkship on both the Israeli and the United States groups. Item analysis did not reveal significant impact of clerkship.The psychiatry clerkship does not change students' view on the attitude assessed in this study, regardless of their origin (Israeli or U.S.). Further research is needed in order to find more clerkship-dependent contributors to positive or negative attitudes toward psychiatry.

Background This study examined the role of mental pain, communication difficulties, and suicide history in predicting the medical severity of follow-up suicide attempts. Methods The cohort included 153 consecutive psychiatric in-patients who participated in earlier studies 1-9 years previously. Fifty-three had a history of a medically serious suicide attempt (MSSA), 64 had a history of a medically non-serious suicide attempt (MNSSA), and 36 had no history of suicide. A MSSA was defined as a suicide attempt that warranted hospitalization for at least 24 h and extensive medical treatment. Participants completed a battery of instruments measuring mental pain and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity. Results Fifty-three patients (35.5%) had attempted suicide: 15 (9.9%) a MSSA (including 5 fatalities) and 38 (25%) a MNSSA. The medical severity of the index attempt and level of hopelessness at the index attempt were significantly correlated with medical severity of the follow-up attempt. In younger patients, high levels of depression and self-disclosure predicted the medical severity of the follow-up attempt. In patients with relatively low hopelessness, the medical severity of the attempt increased with the level of self-disclosure. Limitations (i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA. Conclusions Patients who have made a suicide attempt should be assessed for medical severity of the attempt, hopelessness, and communication difficulties, which are important factors in follow-up attempts.

The purpose of this study was to investigate the efficacy of cyproheptadine, an antiserotonergic agent, in the treatment of neuroleptic-induced akathisia (NIA), as compared with propranolol, the current gold standard. In a double-blind trial, 30 patients with schizophrenia and NIA received either cyproheptadine 16 mg/day (N = 18) or propranolol 80 mg/day (N = 12) for 4 days, followed by 3 days without any anti-NIA treatment. The Barnes Akahisia Scale, Simpson-Angus Extrapyramidal Effects Rating Scale, and Brief Psychiatric Rating Scale were used to assess the severity of NIA, parkinsonism, and psychosis, respectively. In both groups, the severity of NIA decreased significantly over time (cyproheptadine, -46%; propranolol, -42%), with no significant intergroup difference. The NIA symptoms worsened significantly when cyproheptadine and propranolol were discontinued. We conclude that cyproheptadine 16 mg/day is as effective as propranolol for the treatment of acute NIA. The antiakathisic effect of cyproheptadine may be mostly attributable to its serotonin antagonistic activity.

Premorbid functioning may be associated with treatment response, but this is confounded by a lack of prospective longitudinal data and controls for medication compliance. This study tested the hypothesis that good premorbid functioning will be associated with better antipsychotic treatment response after controlling for drug adherence by using a long-acting injectable antipsychotic. This was a 6-month, open label, multicenter, phase IV trial in recent-onset schizophrenia treated with flexible doses of risperidone long-acting injectable (25-50 mg every 14 days). Premorbid functioning was assessed with the Premorbid Adjustment Scale (PAS)-Structured Interview; efficacy was evaluated with clinician-rated Positive and Negative Syndrome Scale, Clinical Global Impression scale of Severity of Illness, Clinical Global Impression scale of Change, Global Assessment of Functioning Scale, and trial participant completed SF-36. Analyses controlled for baseline scores and demo-graphics. With the use of a priori PAS scoring criteria, the participants' premorbid functioning was categorized as stable-good (n = 142), stable-poor (n = 116), and deteriorating (n = 36). At baseline, the stable-good group had the best functioning on most efficacy measures. All groups showed significant improvement on efficacy measures with treatment. Improvement was significantly higher for the stable-good group. The PAS global assessment of highest level of functioning scale (excellent, n = 75; good, n = 117; fair, n = 78; and poor, n = 31) showed a strong association with baseline functioning and improvement and had a significant linear association with meeting Remission in Schizophrenia Working Group symptom criteria at baseline (P = 0.003) and attained and sustained remission for 3 months during study (47.7%, 49.3%, 29.6%, and 22.2%; P = 0.006). Good premorbid functioning corresponds with better treatment response in recent-onset psychosis as captured on both clinician and patient-reported measures.

The authors aim to identify the most important factors for Israeli residents in determining their satisfaction with psychiatric training programs and to compare the findings with similar U.S. data. One hundred sixty Israeli psychiatric residents were asked to complete a 40-item questionnaire indicating the relative importance of these items in determining their satisfaction with training on a five-point Likert scale. A total of 100 residents from 15 programs completed the survey. The authors composed a list of the 10 most important items in determining Israeli residents’ satisfaction with psychiatric training. “Quality of supervision” and “respect of faculty for residents” were the most important items on this list. These items were ranked significantly higher than all the rest of the items. The authors identified some significant differences between subgroups of the Israeli residents, namely the Israeli and international medical graduates. The list of the most important items for Israeli residents was found to be very similar to published findings for U.S. residents. Program directors should consider this list of most important items in determining resident satisfaction, especially the domains of educational opportunities and educational ambiance, when attempting to improve training programs.

Schizophrenia is comprised of several debilitating symptoms. Antipsychotics offer an effective treatment for positive symptoms, while the negative signs and cognitive deficits are usually treatment-resistant. It was suggested that glutamate dysregulation may be involved in the neuropathology of schizophrenia, mainly through NMDA dysfunction. We hypothesized that addition of memantine, a weak non-selective NMDA receptor antagonist approved for dementia, to antipsychotics would improve the clinical status of un-remitted schizophrenia patients, notably the negative signs and cognitive deficits.Seven schizophrenia patients, were included in a six-week open-label study, with weekly increasing dosage (5, 10, 15, 20 mg) of memantine added to their on-going antipsychotic treatment.We found a significant improvement of the PANSS score (baseline 116.28+/-21.9 vs. 97.86+/-24.48 after six weeks, t=5.98, p0.001) with the most prominent improvement (21%) in negative signs sub-scale (baseline 40+/-6.38 vs. 31.71+/-7.76 after six weeks, t=5.87, p0.001). Cognitive status, measured with the Neurobehavioral Cognitive Examination (NCSE) and Clock Drawing Test (CDT) showed no improvement.Memantine addition to antipsychotic treatment, in schizophrenia patients might improve their clinical status, primarily the negative signs, but not their cognitive deficits. Further research is needed to replicate these observations.

To evaluate the reliability of using certain indicators derived from human figure drawings to distinguish between suicidal and nonsuicidal adolescents.Ninety consecutive admissions to an adolescent inpatient unit were assessed. Thirty-nine patients were admitted because of suicidal behavior and 51 for other reasons. All subjects were given the Human Figure Drawing (HFD) test. HFD was evaluated according to the method of Pfeffer and Richman, and the degree of suicidal behavior was rated by the Child Suicide Potential Scale.The internal reliability was satisfactory. HFD indicators correlated significantly with quantitative measures of suicidal behavior; of these indicators specifically, overall impression of the evaluator enabled the prediction of suicidal behavior and the distinction between suicidal and nonsuicidal inpatients (p.001). A group of graphic indicators derived from a discriminant analysis formed a function, which was able to identify 84.6% of the suicidal and 76.6% of the nonsuicidal adolescents correctly. Many of the items had a regressive quality.The HFD is an example of a simple projective test that may have empirical reliability. It may be useful for the assessment of severe suicidal behavior in adolescents.