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Background Familial hypercholesterolemia (FH) is an under-diagnosed condition. Aim We applied standard laboratory criteria across a large longitudinal electronic medical record database to describe cross-sectional population with possible FH. Methods A cross-sectional study of Clalit Health Services members. Subjects who met the General Population MED-PED laboratory criteria, excluding: age <10 years, documentation of thyroid, liver, biliary or autoimmune diseases, a history of chronic kidney disease stage 3 or greater, the presence of urine protein >300 mg/l, HDL-C>80 mg/dl, active malignancy or pregnancy at the time of testing were considered possible FH. Demographic and clinical characteristics are described at time of diagnosis and at a single index date following diagnosis to estimate the burden on the healthcare system. The patient population is also compared to the general population. Results The study cohort included 12 494 subjects with out of over 4.5 million members of Clalit Health Services. The estimated prevalence of FH in Israel was found to be 1:285. These patients are notably positive for, and have a family history of, cardiovascular disease and risk factors. For most of them the LDL-C levels are not controlled, and only a quarter of them are medically treated. Conclusions By using the modified MED-PED criteria in a large electronic database, patients with possible FH can be identified enabling early intervention and treatment. [ABSTRACT FROM AUTHOR]

Presents a cross cultural study which compared the difference in levels of psychological distress experienced by Russian Jewish and Ethiopian Jewish immigrants in Israel. Link between immigration and psychological reaction; Common features which the Russians and Ethiopians in Israel share; Difference between the two groups; What the results of the study suggest.

Introduction: Lipoprotein(a) [Lp(a)] is composed of 2 major protein components, a low-density lipoprotein (LDL) cholesterol-like particle containing apolipoprotein B (apo B) that is covalently bound to apolipoprotein(a). Its level is predominantly genetically determined, and it is estimated that 20% to 25% of the population have Lp(a) levels that are associated with increased cardiovascular risk. Elevated Lp(a) is related to increased vascular inflammation, calcification, atherogenesis and thrombosis, and is considered an independent and potentially causal risk factor for atherosclerotic cardiovascular diseases and calcified aortic valve stenosis. Recent data demonstrate that Lp(a) testing has the potential to reclassify patients' risk and improve cardiovascular risk prediction, and therefore could inform clinical decision-making regarding risk management. Statins and ezetimibe are ineffective in lowering Lp(a) levels, whereas proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have a modest effect on Lp(a) reduction. Nevertheless, RNA interference-based therapies with potent Lp(a)-lowering effects are in advanced stages of development, and clinical trials are underway to confirm their benefit in reducing cardiovascular events. This scientific consensus document was developed by a committee that consisted of representatives from the Israeli Society for the Research, Prevention and Treatment of Atherosclerosis, and the Israeli Society for Clinical Laboratory Sciences, in order to create uniformity in Lp(a) measurement methods, indications for testing and reporting of the results, aiming to improve the diagnosis and management of elevated Lp(a) in clinical practice.

Context: A germline mutation can be identified in up to 10% of patients with primary hyperparathyroidism (PHPT). In 2017, a high frequency of the GCM2 [(NM&#95; 004752.4) c.1181A> C; p.Tyr394Ser; rs142287570] variant was reported in PHPT Ashkenazi Jews (AJ)., Objective: To evaluate the presence of the GCM2 p.Tyr394Ser variant in Israeli patients addressed for genetic evaluation to characterize their phenotype and clinical management., Method: Patients with PHPT who underwent addressed for genetic screening for suspected familial hypocalciuric hypercalcemia (FHH), a family history of isolated hyperparathyroidism (FIHP), or failed parathyroidectomy with persistent PHPT were recruited. Those with normal initial selected gene sequencing or hyperparathyroid genetic panel completed the GCM2 p.Tyr394Ser variant sequencing. The prevalence of this variant was evaluated using our local genomic database., Results: A total of 42 single individuals from unrelated kindreds were evaluated. A disease-causing mutation was found in 11 (26.1%) patients: 10 were diagnosed with FHH (eight CASR and two AP2S1 mutations), and one patient had a CKN2B mutation. In 28 of the remaining patients, the GCM2 p.Tyr394Ser variant was positive in three (10.7%), and all were AJ. Within AJ (15/28, 53.5%), the rate of the p.Tyr394Ser variant was 3/15 (20%), and of those, two had a history of familial isolated hyperparathyroidism. Multi-glandular parathyroid adenoma/hyperplasia was also observed in two of these patients. No clinical or laboratory findings could discriminate patients with the GCM2 p.Tyr394Ser variant from those with FHH. Cinacalcet normalized the calcium levels in one patient. The prevalence of the GCM2 p.Tyr394Ser variant in 15,407 tests in our local genomic database was 0.98%., Conclusion: In contrast to previous observations, the GCM2 p.Tyr394Ser variant-associated phenotype may be mild in AJ with FIHP, sometimes mimicking FHH. Because surgery may be curative, surgeons should be aware of the possibility of multiple gland diseases in these patients. The clinical spectrum and clinical utility of screening for this variant warrant further investigation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Szalat, Shpitzen, Pollack, Mazeh, Durst and Meiner.)

Introduction: Despite the impressive decline in mortality from atherosclerotic cardiovascular diseases (ASCVD), these diseases still account for a large proportion of the overall morbidity and mortality worldwide. A vast amount of research has demonstrated the key role played by circulating lipoproteins, and especially low-density lipoprotein (LDL), in the etiology of atherosclerosis, and numerous studies have proven the efficacy of interventions that lower the atherogenic lipoproteins in reducing morbidity and mortality from ASCVD. While previous guidelines placed an emphasis on the use HMG-CoA reductase inhibitors (statins) for the treatment of dyslipidemia, recent studies have shown that other LDL cholesterol lowering drugs, including ezetimibe and the PCSK9 inhibitors, can provide additional benefit when used in combination with (and in certain cases instead of) statins. These studies have also shown that blood LDL cholesterol levels lower than previously recommended targets provide additional benefit, without evidence of a threshold beyond which the benefit ceases and without excess adverse effects. The updated guidelines were formulated by a committee that consisted of representatives from the Israeli Society for the Research, Prevention and Treatment of Atherosclerosis, the Israel Society of Internal Medicine, the Israeli Heart Association, the Israeli Neurology Association and the Israel Association of Family Medicine. They provide recommendations for revised risk stratification of patients, novel target goals, and the use of evidence-based treatment and follow-up strategies with reference to specific patient sub-groups.

Background: Familial hypercholesterolemia (FH) is an under-diagnosed condition., Aim: We applied standard laboratory criteria across a large longitudinal electronic medical record database to describe cross-sectional population with possible FH., Methods: A cross-sectional study of Clalit Health Services members. Subjects who met the General Population MED-PED laboratory criteria, excluding: age <10 years, documentation of thyroid, liver, biliary or autoimmune diseases, a history of chronic kidney disease stage 3 or greater, the presence of urine protein >300 mg/l, HDL-C>80 mg/dl, active malignancy or pregnancy at the time of testing were considered possible FH. Demographic and clinical characteristics are described at time of diagnosis and at a single index date following diagnosis to estimate the burden on the healthcare system. The patient population is also compared to the general population., Results: The study cohort included 12 494 subjects with out of over 4.5 million members of Clalit Health Services. The estimated prevalence of FH in Israel was found to be 1:285. These patients are notably positive for, and have a family history of, cardiovascular disease and risk factors. For most of them the LDL-C levels are not controlled, and only a quarter of them are medically treated., Conclusions: By using the modified MED-PED criteria in a large electronic database, patients with possible FH can be identified enabling early intervention and treatment., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The influence of ethnicity on different aspects of psychiatric hospitalization is far from clear., The Aim of the Study: The main aim of the study was to compare the Arab and the Jewish inpatients, at the time of admission, for the demographic factors, severity of psychotic, and affective psychopathology and comorbid drug abuse rate. POPULATION, METHOD, AND TOOLS: Among 250 consecutively admitted patients in the Jerusalem Mental Health Center-Kfar Shaul Hospital, 202 Jews and 42 Arabs (aged 18-65 years) were examined within 48 hours after admission. The psychiatric diagnoses were made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. For the differential measurement of psychopathologic severity, the following rating scales were used: 21-item Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale. Urine tests for Δ9-tetrahydrocannabinol (THC), cocaine, opiates, amphetamines, and methamphetamine were performed using the Sure Step TM kits (Applied Biotech, Inc, San Diego, CA, USA). The Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for drug abuse were applied based on self-report and results of urine analysis., Results: The comparison of the 2 population showed that among the Arab inpatients, there were more males (81% vs 67.4%; P < .005). No significant difference in psychiatric diagnosis was observed. The overall severity of positive symptoms (PANSS positive) in Arab group was higher, but only slightly so (P = .05). No significant difference was observed for total rates of PANSS negative subscale. The rates of PANSS-general were also similar. The Arab patients were significantly less depressive according to 21-item Hamilton Depression Rating Scale (P = .032), and the total score of Hamilton Anxiety Rating Scale for the Jewish group was significantly higher (P = .001). No significant difference in general severity of manic symptoms for 2 groups was detected according to Young Mania Rating Scale. The rate of comorbid drug abuse for Jewish inpatients was borderline higher (P = .068)., Conclusions: The issue of referral to psychiatric hospitalization could be culturally influenced; it may be the result of disparities in demographic, psychopathologic, and drug abuse comorbid presenting symptoms, which are demonstrated upon admission by patients of different ethnic origins., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The influence of cannabis abuse on the severity of existing psychotic and affective symptoms is still unclear. Among 470 consecutively admitted psychotic or affective patients, 54 active (in the previous month) cannabis abusers were detected via urine tests (Sure Step TM kits; Applied Biotech Inc, San Diego, Calif) and Structured Clinical Interview for DSM-IV (SCID- IV) questionnaire. In 24 cases, substances other than cannabis were abused; 392 patients were nonabusers. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The following rating scales were used: Hamilton Depression Rating Scale (HAM-D-21), Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale (YMRS). Cannabis abusers (n = 54) were significantly younger and more frequently males than nonuser patients. In this group, there were more schizophrenic patients and fewer affective and anxiety patients (chi(2) = 11.76; P < .01). The double-diagnosed patients had more prominent psychotic symptoms than the nonusers (n = 392)-PANSS positive: 19.056 +/- 8.30 vs 16.128 +/- 8.031 (P < .02; t(446) = 2.510). The difference was statistically significant for hallucinatory behavior, excitement, grandiosity, and hostility. General PANSS scale rate of abusers was lower: 33.012 +/- 9.317 vs 37.3575 +/- 11.196 (P < .01; t = 2.727), especially for depression, anxiety, somatic concern, guilt feelings, tension, motor retardation, and volition disturbances. Rates of PANSS negative scale of abusers and nonusers were not significantly different (13.815 +/- 6.868 vs 14.983 +/- 6.446) except for lower rates of social withdrawal and stereotyped thinking for abusers. No significant difference in general level of manic symptoms (YMRS) between abusers and nonusers was observed (6.778 +/- 10.826 vs 4.910 +/- 7.754), but severity of thought/language disturbances and poor insight was found significantly higher in the abusers. Cannabis abusers are obviously less depressive (HAM-D): 5.944 +/- 10.291 vs 12.896 +/- 13.946 (P < .0005, t = 3.535). Such differences were observed in the high number of the subscales. Abusers' rates were higher (although not significantly) for paranoid symptoms and general somatic symptoms. Cannabis possibly produces some antidepressive and anxiolytic effect on psychotic and affective inpatients. The "price" of this effect is often an exacerbation of psychotic and some manic symptoms.

Background: The co-morbidity rate of illicit substance abuse and major mental problems in Israel is far from clear., Objectives: To investigate the extent of drug abuse in a sample of psychiatric patients hospitalized in a psychiatric hospital and in the psychiatric department of a general hospital in Israel, to compare demographic and other background factors in dual-diagnosis patients with those of abuse-free mental inpatients, and to examine the time correlation between drug abuse and the appearance of major mental problems., Methods: Our data were derived from self-report and urine tests. The study population comprised 470 consecutively admitted patients--250 patients in the mental health center and 220 patients in the psychiatric department of the general hospital., Results: The lifetime prevalence of drug abuse was 24%; cannabis abuse was found in 19.7%, opiates in 5.7%, cocaine in 2.7%, amphetamines in 3.4% and methamphetamine in 1.1%. Active abuse of drugs (during the last month) was registered in 17.3%, cannabis in 11.5%, opiates in 4.9%, amphetamine in 3.8%, cocaine in 1.3% and methamphetamine in 1.1%. We also found that 28.2% of active abusers used two or more substances. In 41.6% the drug abuse appeared prior to symptoms of the mental disorder; in 37.1% the duration of the mental disorders and the drug abuse was relatively similar, and in 21.3% of cases the duration of mental problems was longer than the duration of drug abuse. Dual-diagnosis patients were younger than non-abusers, more often male, unmarried, and of western origin., Conclusions: Substance abuse (especially cannabis) among hospitalized psychiatric patients in Israel is a growing problem.

The Israel Mental Health Law of 1991 gave authority to the regional psychiatrist to give orders of compulsory hospitalization - urgent and non-urgent. The non-urgent Hospitalization Order applies to conditions of non-immediate danger, in which potential for significant damage or harm to the patient or others is expected. Authority is granted to the District Psychiatric Committee as a body of appeal (before the Hospitalization Order is carried out) and as a tribunal to decide upon continuation after the first two weeks of hospitalization. This article aims to stress the main problems encountered by psychiatrists regarding management and treatment under the Non-Urgent Compulsory Hospitalization Order: 1) Postponing hospitalization or releasing a patient for 24 hours, in order to launch an appeal before receiving any treatment, may facilitate clinical deterioration. The ambiguous waiting period could enhance anxiety, acting out and dangerousness. 2) The article discusses clinical and legal aspects of compulsory hospitalization - both urgent and non-urgent. The diverse problematic issues will be elaborated through three clinical cases, and, when clinically indicated, proposals raised for possible solutions in converting an urgent compulsory order to a non-urgent compulsory order.

Background and Aim: Hypercholesterolaemia is a major risk factor for atherosclerosis. Cholesterol is modulated by genetic and environmental factors. An important regulatory pathway is controlled by the sterol-regulatory element-binding proteins (SREBPs) and the SREBP cleavage-activating protein (SCAP). Both SREBP-2 and SCAP are candidates to contribute to the development of atherosclerosis. We investigated the possible effects of the variability of proteins involved in this regulatory pathway on plasma lipids among familial hypercholesterolaemia patients., Methods and Results: Single nucleotide polymorphisms (SNPs) in the genes encoding SREBP-2 and SCAP causing amino acid changes at positions 595 (595G/A) and 796 (796I/V), respectively, were genotyped in 801 FH individuals originating from Israel, The Netherlands, and Switzerland. A linear regression model to examine the associations between SREBP-2 and SCAP isoforms and lipid and lipoprotein levels was used. In females, homozygosity either for the SREBP-2-595A or for the SCAP-796I isoform was associated with higher LDL-cholesterol plasma concentrations (14.7 mg/dl and 20.3 mg/dl, respectively). Surprisingly, heterozygosity for the combination SREBP-2-595A/SCAP-796I was associated with a decrease of 30.28 mg/dl in LDL-C (p-value for gene-gene interaction=0.09). No such effect was observed among FH males. Subgroup analysis considering the most frequent (N>/=24) LDL receptor mutations (del191-2, ins313+1-2, C660X, E207K, S285L) revealed further gene-dosage- and gender-dependent effects of the SCAP mutations on LDL-cholesterol concentrations (p=0.0345). These effects were, however, not present when less frequent LDL receptor mutations were investigated., Conclusions: These results suggest a possible gene-gene interaction between the genes encoding SREBP-2 and SCAP that modulate plasma lipids in a strictly gender-specific fashion. Further investigation is needed to confirm this effect. A study in a larger FH group or in non-FH hypercholesterolaemic subjects may further define the role of this regulatory mechanism in determining plasma lipid concentration.

In an amendment to the law regarding the treatment of the Mental Health patient in 1991, authority was given to the regional psychiatrists' committee to oversee compulsory orders for psychiatric hospitalization and compulsory orders for outpatient psychiatric treatment--and the extension of these orders. On 1st of June 2002 a pilot study was started in the Jerusalem region, in which mental health patients were to be represented by lawyers employed by the Ministry of Justice. The pilot study began as an initiative of the Ministry of Justice, in agreement with the Ministry of Health. We describe 3 cases which demonstrate that the procedure of legal representation lacks the necessary balance between medical and legal considerations. The decision of the regional psychiatrists' committee or the court is liable to worsen the patients' mental health status and even to accelerate aggression towards self or others. In rare cases a premature discharge based on legal considerations rather than medical evaluation may result in suicide, as demonstrated in one of the vignettes. The article discusses the unbalanced approach of legal versus medical consideration, preference of "liberty" over health and the "wish" of the patient rather than his well-being. The article considers the unbalanced approach of the legal system to appeals of therapists against the decision of the regional psychiatrists' committee, where prosecutors of the state decided an appeal of this kind over the staff treating the patient has no precedence. That was presented as justification that it should be rejected. A pilot study compared between patients discharged from compulsory hospitalization through regional psychiatrists' committee or court and patients discharged on a medical basis without legal interference. The study showed a shorter stay in the community in the first group (42%) compared to 75% stay in the community in the second group, after six months. We are of the opinion that the current provision of legal assistance is lacking the necessary balance between medical and legal considerations; the 'wish for freedom' as a default, although illogical, is within the new system of legal aid, and is more considerate and important than the 'best interests' of the patient and his health.

The aim of the present study was to compare the outcome of two legal indications for Compulsory Outpatient Treatment (COT) in Israel (a) as an alternative to compulsory hospitalization (CH) and (b) as a follow-up to CH. Demographic, clinical and legal measurements based on 326 COT orders issued in the Jerusalem and Southern district of Israel were compared according to the two legal provisions for COT contained in the Treatment of Mental Patients Law (1991). The COT order was found to be more effective when used as an alternative to CH (53.1%) than when it was used following CH (38.8%), p = 0.002. In the former case, there were fewer schizophrenic patients, fewer hospitalizations, fewer visits to psychiatric emergency services and longer remissions. Our results point to the influence of the legal indications on the efficacy of the COT order and help define the target population.

Psychiatric morbidity among foreign tourists is usually connected to external factors such as unfamiliar surroundings, language problems, and special religious experiences, as well as biological factors such as dyschronism of circadian rhythms. Long-range flights through several time zones are typically followed by symptoms of jet lag such as fatigue, severe sleep schedule disturbance, impairment of cognitive functions, and even mild depression. Jet lag is generally attributed to a conflict between external time cues and internal biological rhythms. This study examined the possible association between jet lag and psychiatric morbidity among long-distance travelers hospitalized in the Jerusalem Mental Health Center, Kfar Shaul Hospital between 1993 and 1998. This was a prospective open-label study. Patients (n = 152) were divided into two groups based on the number of time zones crossed in the flight to Israel: group I, seven time zones or more (n = 81); and group II, three time zones or less (n = 71). The direction of flight was mainly eastbound. After controlling the two groups for demographic and religious background, past psychiatric history, and diagnosis on admission (P > 0.1, Fisher's exact test), the possible association between jet lag and psychotic or major affective disorder was evaluated according to the following criteria: (1) absence of major mental problems before the flight or good remission of an existing disorder 1 year or more before flight; and (2) the appearance of psychotic or major affective syndromes during the first 7 days after landing. The number of first psychotic/major affective episodes in both groups presumed as associated with jet lag was found similar (P =.5), whereas the number of relapses conjoint with jet lag in the seven or more time zone group was significantly higher (P =.04). The results suggest that the dyschronism of circadian rhythms and jet lag possibly play a role in the exacerbation of major psychiatric disorders., (Copyright 2002 by W.B. Saunders Company)

We assessed the incidence of drug abuse among patients requiring psychiatric hospitalization, and characterized the population at risk. The data on drug abuse were obtained from self-reports and urine tests in 103 patients, aged 18-65, hospitalized in the Kfar Shaul Psychiatric Hospital (autumn 1998). There was close correspondence between the self-reports and the results obtained from urine tests. 1/3 admitted to having used illegal drugs and signs of drug abuse were found in about 1/4 of the urine tests. The most prevalent drugs were cannabis products (hashish and/or marijuana) and in 15 patients opiates. Drug users were younger than non-users. With regard to psychiatric symptomatology, fewer negative symptoms were recorded among cannabis abusers with schizophrenia, compared to schizophrenic patients with no history, past or present, of cannabis abuse. The present findings confirm the clinical impression that there has been an increase in drug abuse among mental patients, parallel to that found in society at large. Confirmatory surveys are necessary. Our findings clearly suggest that a change in attitude has occurred in Israel to what has been considered a marginal problem. Hospitalized mentally-ill patients, the younger in particular, should be considered at risk for drug abuse.

Psychiatrists from the former Soviet Union serve in the Department of Mental Health of the Israel Defense Forces. The new immigrant psychiatrists confront a wide range of difficulties during the process of integration to the military system and adaptation to the specifically military aspects of psychiatry. These include unfamiliarity with the military system, cultural clashes with the different groups of soldiers representing the various subgroups of the absorbing society, the psychopathology of soldiers, which is different from that seen in civil psychiatry, and the change in focus in the military mental health service, which emphasizes the importance of evaluating ego strength. Arbitrarily, one can describe four stages of adaptation that the immigrant psychiatrist has to pass through before recruitment and during service until adaptation and integration in the new role take place. Individual and group supervision are the main means by which the assimilation process is eased. The military service smooth the acculturation process and has an important role in helping the immigrant's adaptation to Israeli society and in building his or her professional identity.

Background: Jerusalem's psychiatrists expect to encounter, as the millennium approaches, an ever-increasing number of tourists who, upon arriving in Jerusalem, may suffer psychotic decompensation., Aims: To describe the Jerusalem syndrome as a unique acute psychotic state., Method: This analysis is based on accumulated clinical experience and phenomenological data consisting of cultural and religious perspectives., Results: Three main categories of the syndrome are identified and described, with special focus on the category pertaining to spontaneous manifestations, unconfounded by previous psychotic history or psychopathology., Conclusions: The discrete form of the Jerusalem syndrome is related to religious excitement induced by proximity to the holy places of Jerusalem, and is indicated by seven characteristic sequential stages.

The effectiveness of Israel's compulsory ambulatory treatment order was evaluated based on a one-year follow-up of the 326 orders served during the first four years of implementation. Demographic, epidemiological, clinical, and legal data were obtained from patient records. Success was defined as continuous treatment for the entire six-month period of compulsory ambulatory treatment, or as voluntary hospitalization during or after the compulsory treatment period. The compulsory ambulatory treatment order was found to be efficacious in 43.3 percent of the cases; in 32.5 percent it did not succeed in preventing compulsory hospitalization, and in the remaining cases (22.1 percent), success was partial.

Israel's "Treatment of Mentally Sick Persons Law" of 1955 was repealed and replaced by the "Treatment of Mental Patients Law" of 1991. Under the latter, the "Compulsory Hospitalization Order" (CHO) defines the new order based on accumulated experience with the old legislation, and on the philosophy that considers the CHO one of the most severely oppressive forms of deprivation of human liberty and rights. The new order sets limits and boundaries for CHO, guarding the rights of those unavoidably committed by force. According to the new law, the district psychiatrist decides upon and issues the order, while the tribunal (District Psychiatric Committee) considers appeals. The order is limited to 1 week, with an option for the district psychiatrist to prolong it on written request for up to 14 days. The tribunal can later prolong the order further. The objective of this study was to review changes that have occurred following enforcement of the new law in the Jerusalem district. A comparison was made between CHO's issued the year before the new legislation took effect and the year after. The comparison included review of all CHO's and medical files of all patients hospitalized by coercion during 1990 and 1992. It was assumed that there would be a decline in rate and length of hospitalization of patients forced to be committed by the new law. The main findings refuted this hypothesis. In 1992 there was an increase of 38% in the number of compulsory hospitalizations. This increase derived mainly from increased demands for CHO's from psychiatric emergency rooms. There was also an increase in patients hospitalized by order of the District Psychiatric Committee using its authority under section 10(C) of the law. Conversely, length of compulsory hospitalization was shorter under the new law. In light of these findings, it would seem that the new law has only partially fulfilled expectations of reform in individual rights. There is need for further evaluation and follow-up of the CHO in order to determine whether the "Treatment of Mental Patients Law" of 1991 has in fact fulfilled its objectives. Furthermore, it is necessary to determine means, medical or legal, that may possibly advance further the prospective of human rights while maintaining a suitable balance between civil liberties and clinical needs, of over-confinement versus under-treatment, which may lead to neglect or danger.

The importance of understanding the local culture and enhancing cultural sensitivity became evident during supervision of immigrant psychiatrists from the former Soviet Union. The aim of the present study was to describe enhancement of this cultural sensitivity in the supervision of 2 immigrant psychiatrists. In the first, understanding the patient's cultural world helped the immigrant psychiatrist form the therapeutic alliance. In the second, the immigrant psychiatrist's understanding of the patient's cultural background led him to change both diagnosis and treatment. In both cases, development of cultural sensitivity through supervision enabled successful treatment. Enhancement of cultural sensitivity may accelerate absorption of the immigrant psychiatrists themselves. Discussing cultural issues during work may accelerate the absorption of all immigrant physicians.

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the southern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.

Pseudopsychopathic schizophrenia (PPS) forms a diagnostic unity, comprising aspects of schizophrenic process and antisocial personality disorder. Perusal of the psychiatric literature reveals that this diagnostic entity has fallen into oblivion. Recognition of this neglected category is important from therapeutic, academic and medico-legal points of view.

This report explores psychological distress among immigrants seeking help from psychiatric outpatient clinics as compared with control nonpatient immigrants. Our hypothesis is that nonpsychotic mentally ill immigrants will react to acculturation by psychological distress similarly to healthy individuals. Three questionnaires were used in this survey: Demographic Psychosocial Inventory, Brief Symptom Inventory (BSI), and Psychiatric Epidemiology Research Interview-Demoralization Scale (PERI-D). They were completed by patient and control groups consisting of recent adult immigrants to Israel from the former Soviet Union. The patient group included 158 subjects seeking psychiatric help from outpatient clinics. Among them, 51 met ICD-10 criteria for neurotic, stress-related, and somatoform disorders; 41 for schizophrenia; 32 for mood disorders; 18 for organic illnesses; and 16 for personality disorders. The control group consisted of 222 immigrants with no previous psychiatric history, matched by gender and age to the patient group. Although all distress symptoms were significantly more severe in the patient group than in the control group, the BSI profile, showing a high level of depression, anxiety, interpersonal sensitivity, and obsessive-compulsive dimensions, was similar in both groups. The psychological distress level as measured by the PERI-D was 1.4 times higher in patients than in the control group. Within the patient group, the lowest distress level was found in patients suffering from organic disorders. No significant differences in the level of psychological distress were found among other diagnostic subgroups. The results suggest that mentally ill immigrants react to acculturation by a psychological distress syndrome similarly to nonpatient immigrants but more severely than nonpatient immigrants.

Koro syndrome is a triad which includes a deep-seated fear that the penis will shrink, disappear into the abdomen, and that death will follow. The patient experiences profound anxiety and performs preventive manoeuvres, such as pulling his penis outward. The disorder is considered culture-related, and is endemic in South-East Asia and China, where it occurs in epidemic and sporadic forms. Sporadic cases appear in the western hemisphere, often in association with an underlying psychiatric or organic disorder, usually of the central nervous system. 6 cases of koro have been published from Israel.

This article presents the data collected from 128 court appointed psychiatric evaluations (CAPEs) and their analysis. Issues addressed are: the link between type of criminal offence and mental disorder; rate of recidivism; efficacy of the early detection and follow-up systems; inherent psychiatric dilemmas; unacceptable lacuna in information recorded in the CAPEs; and the babel of legal and psychiatric terms. We advocate that a combined effort be made by the legal and psychiatric fraternities to create a uniform and standardized CAPE.

All cultures have a cognitive map characterizing their people and comprising a framework of orientation values, knowledge, beliefs, and verbal and nonverbal language. In countries such as Israel, where the population constantly varies due to immigration, the cultural framework continuously shifts as it adapts itself to transculturation. The cultural clash is more conspicuous in the field of health where the therapeutic encounter emphasizes the differences between the therapist and the patient. We present a patient who showed a clinical picture of "brain-fag." Ethiopians refer to the brain-fag syndrome as "overworking of the head" due to the strain of studying. Prince, who first described the syndrome in Nigerian students and characterized its symptoms, emphasized that it stems from a cultural clash between African and Western civilizations. Immigration and acculturation, which Ethiopian Jews face, force them to neglect their social and cultural customs and duties or to synthesize them with the new cultural values. A classification of the different types of suicide attempts according to Durkheim (altruistic, anomic & egoistic) and Hollan (indignant) as well as a description of mourning rites and customs of Ethiopian Jewry, and discussion of the brain-fag syndrome unknown to the local mental health system are presented by means of a case illustration. Understanding the phases of ethnic group rituals and clinical syndromes, such as brain-fag, can smooth the absorption process of Ethiopian Jews in Israel, throw light on difficulties immigrants encounter, and facilitate understanding by the absorbing society.

The legal status of the mentally impaired has been dealt with in Halachic literature since the third century. This article presents four Halachic viewpoints regarding the exemption of the mentally ill patient from legal responsibility in tort and criminal law: lack of mental awareness; lack of free will; lack of judgment; categorial personal status. Halachic legislations with regard to the liability of the insane predate the criteria as applied by modern psychiatry. The similarities between the Halachic and contemporary medicolegal approaches are presented.

Eighty-six survivors of the Holocaust from a nonclinical population were interviewed to examine the recent mental state, coping and adjustment of elderly Holocaust survivors. Most of the interviewees suffered after the war and are still suffering from the results of persecution. Death camp survivors suffer more than survivors who were subjected to other forms of Nazi persecution. Despite the mental suffering, Holocaust survivors succeeded to cope and to adjust. They are successful at work and in society. They managed to raise warm families. They behaved and still behave as if fulfilling a testament to those who perished.