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Objectives This study sought to determine the clinical correlates of adolescents with cannabis use and no additional drug use (CU) compared to adolescents with no drug use (NDU) among a group of adolescent psychiatric inpatients in Israel. Methods Two hundred and thirty-six patients consecutively admitted to an adolescent inpatient unit at a university-affiliated mental health center in Israel during a 3-year period were screened. Individuals with polydrug use were excluded from the study. Results Prevalence of cannabis use was 13%. In the CU group, 39% were diagnosed with attention deficit and disruptive behavior disorders compared with 16% in the NDU group. Antipsychotics were the most common medications prescribed in both groups. Mood stabilizers were more frequently prescribed to CU than to NDU patients (39% vs 16%, respectively). A higher prevalence of alcohol abuse and criminal behaviors was found among CU compared to NDU patients (61% and 39% vs 6% and 4%, respectively). Conclusions The high prevalence of disruptive behaviors and frequent treatment with antipsychotics and mood stabilizers in the CU group may be related to the strong association between externalizing behavior and cannabis use and the non-specific pharmacological treatment of disruptive behaviors. Formal screening for cannabis use should be considered in psychiatric facilities. Specifically, adolescents with disruptive behaviors could benefit from early interventions, before and after cannabis initiation.

A group of 34 children and adolescents suspected of having attention-deficit hyperactivity disorder were referred for a computerized evaluation that included sustained attention, working memory, planning, and set-shifting. Although only sustained attention had reasonable specificity, all tests had questionable contribution to the diagnostic evaluation.

This open-label pilot study examined repetitive transcranial magnetic stimulation as a possible treatment of adolescent resistant depression.Nine adolescents (aged 16-18 years) with severe resistant depression (determined by SCID) were recruited, and their depression, suicidality, and cognitive functions were evaluated before, during, and after a course of twenty 10-Hz, 2-second trains (intertrain intervals of 58 seconds) given over 20 min/d over 14 working days.Lower levels of depression with progression in therapy were recorded by both the Beck Depression Inventory and Child Depression Rating Scale measures (F1.7,14.01 = 4.52, P0.05; F4,32 = 6.645, P0.01, respectively). Three patients reached the primary outcome measure of less than 30% reduction in their Child Depression Rating Scale. The effect on suicidality was not significant. Side effects were considered mild.Repetitive transcranial magnetic stimulation might be a possible therapy for adolescent depression. Our preliminary findings warrant double-blind, controlled studies.

Background: Cognitive deficits are fundamental features in schizophrenia (SZ) and major determinants of psychosocial functioning. Cognitive deficits in bipolar disorder (BD) were only recently recognized, and research on them is limited, especially in the euthymic stage. Earlier attempts to establish and compare the cognitive profiles of these overlapping disorders were few, and their results were inconsistent. Methods: We compared the cognitive profile of age- and gender-matched euthymic BD patients, SZ patients in remission, and healthy controls (30 subjects in each group). Cognitive performance was evaluated using a well-validated computerized assessment battery (Cambridge Neuropsychological Test Automated Battery [CANTAB]). Results: The findings indicated both quantitive and qualitative differences in cognitive functioning of patients who were in the stable stage of the two disorders. While SZ patients exhibited more generalized cognitive deficits, those of the BD patients were more focused in the dom...

Cognitive impairments are recognized as a central feature of schizophrenia (SZ), largely independent of other symptoms, and a major cause of poor functioning. Studies indicate cognitive deterioration in the first years after the onset of SZ. These studies, however, have been criticized for using a small sample size, for having limited monitoring of confounding variables, and for the inclusion of cohorts of different ages. The current study compared the cognitive profile of first-episode schizophrenia patients, multi-episode schizophrenia patients and healthy controls (n = 44, n = 39, and n = 44; respectively). The study focused on the early stages of the disorder, recruiting only young patients. All subjects underwent an extensively validated computerized cognitive assessment (Cambridge Neuropsychological Test Automated Battery). The results revealed widespread cognitive impairments in SZ patients, compared with healthy control subjects. The multiepisode SZ patients were significantly more impaired than the first-episode ones, with deficits mainly related to psychomotor speed, pattern memory, and executive functioning. The functioning in other cognitive domains (ie, attention and spatial memory) was deficient even at an early stage of the disorder. These findings can help clarify the course of cognitive decline in young-aged SZ patients and aid in the development of phase-appropriate interventions.

Recent epidemiological studies have reported a world-wide increase in the rates of alcohol use among adolescents. Research has shown a strong link between alcohol abuse and psychiatric disorders. This study explored the clinical and demographic correlates of adolescents with a history of alcohol abuse (AA) compared to adolescents with no history of alcohol abuse (NAA) among a group of adolescent psychiatric inpatients in Israel.Two hundred and thirty-eight subjects were screened, all were patients consecutively admitted to an adolescent inpatient unit at a university-affiliated mental health center in Israel during a 4-year periodPatients in the AA group were more prone to have a history of suicide attempts and self-injury compared to patients in the NAA group. Prevalence of attentiondeficit disruptive behavior disorders was more common in the AA group, and these patients were more prone to have a history of criminal activity and drug use. Median length of hospitalization was greater in the NAA group.Limitations concerning attribution of causality due to the cross-sectional nature of this study.Higher prevalence of criminal behavior, selfinjury and suicide attempts associated with alcohol abuse may be related to higher levels of impulsivity, indicated by higher prevalence of attention-deficit disruptive behavior disorders. Alcohol-related disorders should be carefully screened and addressed in adolescent psychiatric units and in consequent ambulatory treatment settings.

Learned irrelevance (LIrr) is a pre-exposure effect in which uncorrelated presentations of a conditioned stimulus (CS) and an unconditioned stimulus (US) retard subsequent CS-US association. LIrr is closely related to the phenomenon of latent inhibition (LI). LI refers to the retarding effects of inconsequential stimulus pre-exposure on subsequent conditioning to that stimulus, and is considered to reflect the organism's capacity to ignore irrelevant stimuli. LI is disrupted in schizophrenia patients, due to faster learning of the association between the preexposed CS and the US. A new within-subject target-recognition LIrr procedure was applied. The target was either cued by a priming signal or appeared at random, and priming signals were novel or preexposed cues. Schizophrenia patients were compared to age- and sex-matched control subjects. Normal subjects (n = 24) have shown robust LIrr, namely, faster cue-target associations of novel compared to preexposed cues. Schizophrenia patients at the early stages of their first episode (n = 7) showed LIrr disruption, namely, cue-target associations to preexposed cues were as fast as for novel cues. Chronic patients during an acute phase (n = 18) did not show LIrr as they failed to learn the cue-target association. In addition to the LIrr paradigm the same subjects were tested in a covert-orientation task. No differences were observed between the groups on this task. The possible advantages of the new LIrr paradigm are discussed.

Introduction Long-acting depot injections of antipsychotic medications are an important way to monitor treatment noncompliance in patients suffering from schizophrenia. Pain and discomfort at the injection site may result in patients' refusal of depot injections. The present study is a pilot study that attempts a systematic characterization of injection site pain. Method Thirty-four consecutive outpatients suffering from DSM-IV-defined schizophrenia or schizoaffective disorder and treated with depot antipsychotic medications were evaluated. The pain they suffered from the injections was quantified using a visual analog scale. This evaluation was made 5 minutes before the injection, 5 minutes after. 2 days after, 10 days after, and before the next injection. Patients were also administered a modified version of the Rating of Medication Influences scale that included a specific question on the possible relationship between injection-associated pain and future compliance to depot treatment. Results The depot injections cause pain, which is maximal immediately after the injection, declines substantially 2 days after, and disappears by the tenth day after the injection. A correlation exists between reported injection site pain and the effect it has on patients' attitude toward the depot injection as reported by the patients. Zuclopenthixol depot injection is more painful than other depot medications. Conclusion Depot injections are painful. The pain they inflict has a typical course, and medication type is among the factors that influence this pain. This pain might have an effect on patients' attitude toward depot injections and thus is of importance in the management of patients suffering from schizophrenia.

Objective Information on the indications, technique, and effectiveness of electroconvulsive therapy (ECT) in adolescent patients is scarce. The recommendations for the use of ECT in this age group are similar to those in adults. This study compares the experience with ECT in the two age groups in the same community psychiatric institution, which adheres to the accepted protocols for diagnosis and treatment. Method The files of 24 consecutive adolescent patients treated in an ECT unit located in the center of Israel in the years 1991–1995 were retrospectively examined, and the findings were compared with those in 33 adult patients who started their ECT course on the same day. The technique for applying ECT was essentially the same in the two age groups. Results ECT was equally effective for adolescents and adults (58% in each group achieved remission). The main difference was the diagnosis for which patients were referred: most of the adolescents were in the “psychotic spectrum,” whereas most of the adults were in the “affective spectrum.” Conclusions The findings support the current medical recommendations for the use of ECT in adolescents. Possible explanations for the differences in diagnosis between the two age groups are discussed.

The co-occurrence of obsessive-compulsive disorder (OCD) in adult patients with schizophrenia has been increasingly recognized. However, the rate of OCD comorbidity in adolescent schizophrenia patients has yet to be systematically evaluated.The rate of DSM-IV OCD was evaluated in 50 adolescent inpatients with schizophrenia or schizoaffective disorder. The severity of schizophrenia and OCD symptoms was assessed with the Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms (SANS), and Yale-Brown Obsessive Compulsive Scale.Thirteen schizophrenia patients (26.0%) also met the DSM-IV criteria for OCD. This subgroup scored significantly higher on the SANS subscale for affective flattening or blunting. The total SANS score positively correlated with the total Yale-Brown Obsessive Compulsive Scale score.A substantial proportion of adolescent schizophrenia inpatients have concomitant OCD. A prospective study is needed to evaluate the clinical course, response to treatment, and prognosis for this complex disorder.

Repetitive transcranial stimulation (rTMS) affects dopaminergic secretion in the prefrontal cortex. Attention deficit hyperactivity disorder (ADHD) had been suggested to involve dopaminergic prefrontal abnormalities.In this crossover double-blind randomized, sham-controlled pilot study, patients diagnosed as having adult ADHD received either a single session of high-frequency rTMS directed to the right prefrontal cortex (real rTMS) or a single session of sham rTMS.A total of 13 patients (seven males, six females) who fulfilled the criteria for adult ADHD, according to DSM-IV criteria gave informed consent and were enrolled. There was a specific beneficial effect on attention 10 minutes after a real rTMS course. The post-real rTMS attention score improved significantly (M=3.56, SD=0.39) compared to the pre-real rTMS attention score (M=3.31, SD=0.5) [t(12)=2.235, P0.05]. TMS had no effect on measures of mood and anxiety. The sham rTMS had no effect whatsoever.Our findings should encourage future research on the possibility of amelioration of attention difficulties in patients suffering from ADHD by using high frequency rTMS directed to the right dorsolateral prefrontal cortex. (NIH registry NCT00825708).

We evaluated the level of adolescent psychiatric patients’ knowledge and understanding of their treatment in light of their competency to participate in decision-making processes related to their receiving treatment, and compared the adolescents’ levels of understanding and knowledge to those of adult psychiatric patients. The study group consisted of 30 adolescents and 30 adults who were randomly selected from the inpatients of our mental health center. Consenting participants were interviewed and their objective knowledge of psychiatric treatments was evaluated by a specially designed questionnaire. Adolescents knew significantly more about adverse effects of treatment and showed a higher level of comprehensive general knowledge. These data indicate that adolescents are no less knowledgeable than adults and should be regarded as competent partners in the process of therapeutic decision making.

Objective: In order to improve our understanding of the use of electroconvulsive therapy (ECT) in adolescent patients, we aimed to evaluate the reasons for referral for ECT in different age groups. Method: We compared the reasons for adolescent and adult referrals by a retrospective file review of 13 consecutive adolescents and 56 consecutive adults treated in our ECT unit during a 5-year period. Results: There was a significant association between age group and reason for referral. Non-response to pharmacotherapy was a significantly more common reason among adults. Adolescents were mainly referred due to catatonia and suicidal behaviour. Conclusion: Our results support the need to study reasons for referral to ECT, beyond non-response to pharmacotherapy, especially in adolescent patients.

We present the case of a patient whose definite TS coexisted with OCD and who responded dramatically and repeatedly to the tricyclic antidepressant CMI

A 14-year-old girl was admitted after attempting suicide by swallowing over 50 pins. On admission, she complained of abdominal pain. A flat abdominal X-ray revealed numerous needle-like objects in the large intestine. After a period of observation we were able to diagnose her as suffering from a major depressive episode with psychotic features, post-traumatic stress disorder, physical abuse, neglect and inhalant abuse. Medically, the pins were spontaneously evacuated with her stools without any intervention. The mode of the suicide attempt was an important clue to raise suspicion of a psychotic episode. Two issues are discussed: 1) A "psychiatric" issue: the way in which an attempt is made should be considered as a factor not just for the evaluation of the suicidal risk, but also for the psychopathology. This case demonstrates that a bizarre attempt should raise the suspicion of a psychotic disorder. 2) A "general medical" issue: our experience with this patient was in accordance with common medical expectant management for patients who have swallowed multiple sharp objects once they have reached the large intestine. We conclude: 1) In the preliminary psychiatric evaluation, more emphasis should be placed on how bizarre the means of the suicide attempt as a possible sign of a psychotic psychopathology. 2) Treatment for adolescents who swallow numerous sharp objects should consist of expectant management once those objects reach the large intestine.

There is a growing interest in gender differences of different psychiatric disorders, especially major depression. We sought a possible gender difference related to electroconvulsive therapy (ECT).This retrospective study compared 20 male and 23 female depressed adult patients treated by ECT. We compared their findings on gender differences to those of 12 female and 4 male bipolar patients and 11 male and 19 female schizophrenic patients, all treated in the same ECT setting.Depressed female patients underwent significantly fewer antidepressant drug trials than males before being referred to ECT (t41=2.09, P0.05). A similar gender difference was found in the treatment of patients suffering from schizophrenia: female patients underwent fewer pharmacological antipsychotic trials than males before being referred to ECT (t28=3.11, P0.01). ECT was significantly more effective in female patients than in male patients suffering from schizophrenia (U=38, P0.05).This is a retrospective pilot study whose results are based on subjective evaluations.The findings of this study may support a gender difference both in referral and in the outcome of ECT.there might be a need to consider lowering the number of pre-ECT drug trials for depressed males and to consider ECT as a viable therapeutic option for schizophrenic females.

The Ganser syndrome is rare in children and adolescents. Two cases of Ganser syndrome in adolescent brothers, both of whom developed the syndrome while in jail and awaiting trial, are presented. Both brothers subsequently developed signs and symptoms indicative of affective disorder. The differential diagnosis and the management of these two patients are discussed in the light of the nosological controversies surrounding this clinical entity. J. Am. Acad. Child Adolesc. Psychiatry , 1993, 32, 3:582–584.

Outcome according to diagnosis and stability of diagnosis were investigated in a follow-back study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15-19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sex-matched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group.

OBJECTIVE: To examine the relationship between anxiety and suicidal behavior in adolescents. METHOD: Forty-six adolescents who had been hospitalized in an inpatient psychiatric unit after a suicide attempt were compared on measures of anxiety and depression with 72 adolescent psychiatric inpatients who had no history of suicide attempts. RESULTS: The suicide attempters exhibited significantly higher levels of both state and trait anxiety. However, when controlling for depression, the attempters did not differ in their level of state anxiety from the nonattempters, but they still manifested significantly higher levels of trait anxiety than nonattempters. CONCLUSIONS: The results suggest that anxiety, both state and trait, is a risk factor for suicidal behavior in adolescents. Yet, only trait anxiety appears to be relatively independent of depression in its effect on suicidal behavior risk. These findings imply that clinicans should take into account anxiety, both state and trait, for assessment and treatment of adolescents at risk for suicidal behavior. Language: en

This study took place in Israel and examined the use of a local topical anesthetic cream to ameliorate the pain at the injection site caused by depot antipsychotic medications. Fifteen consecutive outpatients who had schizophrenia and who were under treatment with depot antipsychotic medications were enrolled in this randomized, double-blind, placebo-controlled crossover study. The patients received either lidocaine-prilocaine cream or a placebo one hour before the injection. The degree of pain at the injection site was quantified by the patients' use of a visual analogue scale five minutes after the injection. The application of the lidocaine-prilocaine cream led to a significant reduction of pain compared with the placebo.

The possible involvement of serotonin receptors of the 5HT2 type in aggressive behavior was studied in juvenile delinquents. A group of 28 delinquent adolescents (13-18 years old) who had committed violent crimes was compared with a group of age matched controls. Subjects were drug and medication free during the study. 5HT2 receptors were labeled on platelet membranes using tritiated ketanserin. Receptor binding in the delinquent adolescents was significantly lower than in age matched controls. Mean +/- SD of 76 controls was 32.3 +/- 14.2 fm/mg, compared to 16.6 +/- 8.2 fm/mg in 28 delinquents (P0.002, Student's t-test). These results support a role for serotonin in general and 5HT2 receptors in particular in human aggressive behavior.

Over a period of about 12 months a large number of Ethiopian Jews emigrated to Israel under very stressful conditions. Many of these immigrants were adolescents who came on their own, leaving their families behind. Despite the culture shock involved, most have done well. Nine of these youngsters, who developed psychiatric disabilities severe enough to warrant hospitalization, were referred to us. In this paper we describe the clinical and management problems posed by these patients.