Despite increasing psychiatric disorders and awareness, outpatient mental health care for children and adolescents remains limited worldwide. In Israel, a major reform a decade ago aimed to improve access and equity, but disparities and long waits still exist. This study examined service use patterns and parent-reported barriers to identify current challenges in accessing outpatient child and adolescent mental health services. A two-phase multicenter study was conducted. First, a retrospective analysis of 3,446 children’s records from 2015 to 2019 at a Jerusalem outpatient psychiatry clinic compared demographics and service use with regional census data. Second, a prospective survey of 300 parents from 2020 to 2024 across three clinics in Israel assessed delays in help-seeking and perceived barriers in structural, informational, attitudinal, and stigma domains. Service use rose over time but showed disparities. Boys, Jewish children, and higher SES families were overrepresented. Parents reported a mean delay of approximately 25 months from initial concern to first contact with the clinic; Major barriers included long waits and limited access; stigma was less common. Delays and barriers varied little across groups. Structural and systemic barriers, notably waiting times and limited service capacity, were the most frequently identified factors delaying families upon presentation at participating clinics. While stigma was less apparent at the point of clinic contact, our findings highlight barriers solely as delaying factors; their relative significance as deterrents among families who do not seek care may vary. The findings emphasize the necessity for policies aimed at expanding the workforce, reducing waiting times, and enhancing equitable access to services.

Objective: The aim of the study was to assess the effectiveness and safety of long-acting injectable anti-psychotic treatment (LAIA) amongst children and adolescents. Given the difficulty of performing an randomized controlled trial (RCT), we suggested comparing children and adolescents to young adults who were treated with LAIAs, and extrapolating data regarding efficacy and safety. Method: We compared data from medical files of adult inpatients treated with LAIAs to children and adolescent inpatients treated with LAIAs, between January 2014 and April 2021. Results: clinical global impression (CGI) scale score and rate of side effects (79% vs. 92%, p-value = 0.106) were not different between children and adolescents and young adults treated with LAIAs. There were no significant differences found between the groups in most demographic and clinical parameters such as gender distribution, legal status (voluntary or involuntary hospitalization), first hospitalizations and subsequent hospitalizations. Significant differences were found in duration of hospitalizations (144 days vs.50 days, p-value < 0.001), the indication for recommending LAIA treatment, diagnosis, the distribution of specific LAIAs and the rates of patients treated for side effects of anti-psychotic treatment. Conclusions: Results suggest that LAIA treatment may be as effective amongst children and adolescents as it is for adults. More research should be done to assess safety and efficacy of LAIA treatment in children and adolescents in the short and long term.

Twenty-seven war-like conflicts are currently extant globally, resulting in 30 million refugees, of whom 41% are children and adolescents. The ethical imperative for child and adolescent psychiatrists is to not ignore these facts, ask what interventions might benefit the traumatized victims, and inquire how the mental health professional (MHP) might advocate for them. The objectives are to expose attendees to the children’s plights, educate about the traumatic impacts, provide information about treatments for youths reeling from large-scale violence, and encourage child and adolescent psychiatrist engagement. A small percentage of children, collectively experiencing violence, receive care from a tiny cadre of child and adolescent psychiatrists and other MHPs. Four diverse international areas will be examined. Noshene Ranjbar, MD, discusses the Iranian government’s violent targeting of its youth; Jennifer Goldstein, MD, describes interventions provided to a frequently rocket-impacted child population in Israel; Ewa Dobiala, MD, describes a Polish mental health effort focused on Ukrainian refugee children; and Shawn Sidhu, MD, discusses South American migrant children crossing the US southwestern border. Adrian Sondheimer, MD, and Yoav Kohn, MD, serve as moderators/discussants. Each speaker will devote 12 1/2 minutes to presentation followed by 12 1/2 minutes of audience discussion. Audience questions might include, for example, impacts on families, efficacies of interventions, outcomes, and impacts on providers. The final 15 minutes is devoted to further audience discussion and summation by the moderators. Both national and international attendees will express varied degrees of concern, some moved to directly engage with refugee/migrant populations, others feeling unable to do so, all receiving exposure to established child and adolescent psychiatrist disaster intervention training. The children’s shared similarities of traumatic experience and needs for safety, social supports, and caring adult presence will prove salient. Child and adolescent psychiatrists’ ethical responsibilities include awareness of the traumatic impacts of violence on individual children and collectively, which grossly disrupt the basic human needs for safety, comfort, food, and shelter. This international presentation might inspire more attendees to engage in efforts designed to care for children affected by extreme violence.

Nurse Manager, Child and adolescent psychiatric ward, Jerusalem Mental Health Center, Jerusalem, Israel Head, Nursing Department, Ashkelon Academic College, Ashkelon, Israel Senior Coordinator, Nurses' Development, Nursing Administration, Jerusalem Mental Health Center, Jerusalem, Israel Director of Nursing, Jerusalem Mental Health Center, Jerusalem, Israel Director of Nursing Services, The Government Hospitals' Division, Ministry of Health, Jerusalem, Israel Head Nurse of Infectious Diseases Prevention, Jerusalem Mental Health Center, Jerusalem, Israel Director, Open Ward (B), Jerusalem Mental Health Center, Jerusalem, Israel Former Head of Infectious Diseases Prevention, Jerusalem Mental Health Center, Jerusalem, Israel Clinical Associate Professor of Psychiatry, Hebrew University‐Hadassah School of Medicine, Jerusalem, Israel Director, Child and Adolescent Psychiatric ward, Jerusalem Mental Health Center, Jerusalem, Israel

Childhood-onset schizophrenia (COS) is a rare form of schizophrenia with an onset prior to 13 years of age. Although genetic factors play a role in COS etiology, only a few causal variants have been reported to date. This study presents a diagnostic exome sequencing (ES) in 37 Israeli Jewish families with a proband diagnosed with COS. By implementing a trio/duo ES approach and applying a well-established diagnostic pipeline, we detected clinically significant variants in 7 probands (19 %). These single nucleotide variants and indels were mostly inherited. The implicated genes were ANKRD11, GRIA2, CHD2, CLCN3, CLTC, IGF1R and MICU1. In a secondary analysis that compared COS patients to 4721 healthy controls, we observed that patients had a significant enrichment of rare loss of function (LoF) variants in LoF intolerant genes associated with developmental diseases. Taken together, ES could be considered as a valuable tool in the genetic workup for COS patients.

Schizophrenia is a common, severe, and debilitating psychiatric disorder. Despite extensive research there is as yet no biological marker that can aid in its diagnosis and course prediction. This precludes early detection and intervention. Imaging studies suggest brain volume loss around the onset and over the first few years of schizophrenia, and apoptosis has been proposed as the underlying mechanism. Cell-free DNA (cfDNA) fragments are released into the bloodstream following cell death. Tissue-specific methylation patterns allow the identification of the tissue origins of cfDNA. We developed a cocktail of brain-specific DNA methylation markers, and used it to assess the presence of brain-derived cfDNA in the plasma of patients with a first psychotic episode. We detected significantly elevated neuron- (p=0.0013), astrocyte- (p=0.0016), oligodendrocyte- (p=0.0129), and whole brain-derived (p=0.0012) cfDNA in the plasma of patients during their first psychotic episode (n=29), compared with healthy controls (n=31). Increased cfDNA levels were not correlated with psychotropic medications use. Area under the curve (AUC) was 0.77, with 65% sensitivity at 90% specificity in patients with a psychotic episode. Potential interpretations of these findings include increased brain cell death, disruption of the blood-brain barrier, or a defect in clearance of material from dying brain cells. Brain-specific cfDNA methylation markers can potentially assist early detection and monitoring of schizophrenia and thus allow early intervention and adequate therapy.

Background: Attention-deficit/hyperactivity disorder (ADHD) is associated with increased risk for conduct problems (CP), as well as with callous-unemotional traits (CUt) and lower accuracy in face emotional recognition (FER). It is unclear, however, whether CUt and low accuracy in FER contribute to the risk for CP in ADHD. The present study investigated the possibility of such contribution. Methods: This pilot study’s participants included 31 children aged 7–17 years, diagnosed with ADHD, and treated in a psychiatric outpatient clinic. The parents rated their children on the ADHD Rating Scale, Inventory of Callous-Unemotional Traits, and the Child Behavior Checklist-Conduct Problems scale. Participants completed the Hebrew version of the children’s Reading the Mind in the Eyes Test (cRMET)—a Theory of Mind measure. A bootstrapped multiple mediator model was used, adjusting for age and gender. Results: ADHD symptoms were associated with CP. This association was not mediated by CUt or cRMET. CUt was associated with CP independent of ADHD symptom severity. Conclusions: ADHD symptoms and CUt both should be considered when assessing risk for CP and devising a treatment plan, in children with ADHD. Current results did not confirm the hypothesis that cRMET and CUt mediate between ADHD symptoms and CP. More studies employing larger samples, longitudinal design, and other emotion recognition measures are needed.

Abstract Objective This study aims to compare the reliability and acceptability of psychiatric interviews using telepsychiatry and face-to-face modalities in the emergency room setting. Methods In this prospective observational feasibility study, psychiatric patients (n = 38) who presented in emergency rooms between April and June 2020, went through face-to-face and videoconference telepsychiatry interviews in a non-randomised varying order. Interviewers and a senior psychiatry resident who observed both interviews determined diagnosis, recommended disposition and indication for involuntary admission. Patients and psychiatrists completed acceptability post-assessment surveys. Results Agreement between raters on recommended disposition and indication for involuntary admission as measured by Cohen’s kappa was ‘strong’ to ‘almost perfect’ (0.84/0.81, 0.95/0.87 and 0.89/0.94 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively). Partial agreement between the raters on diagnosis was ‘strong’ (Cohen’s kappa of 0.81, 0.85 and 0.85 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively).Psychiatrists’ and patients’ satisfaction rates, and psychiatrists’ perceived certainty rates, were comparably high in both face-to-face and telepsychiatry groups. Conclusions Telepsychiatry is a reliable and acceptable alternative to face-to-face psychiatric assessments in the emergency room setting. Implementing telepsychiatry may improve the quality and accessibility of mental health services. Key points Telepsychiatry and face-to-face psychiatric assessments in the emergency room setting have comparable reliability. Patients and providers report a comparable high level of satisfaction with telepsychiatry and face-to-face modalities in the emergency room setting. Providers report a comparable level of perceived certainty in their clinical decisions based on telepsychiatry and face-to-face psychiatric assessments in the emergency room setting.

The prevalence of children and adolescents who identify themselves as transgender is significant. Transgender youth are at a high risk for mental health problems, sometimes requiring hospitalization in a psychiatric ward. This situation is specifically complex and should be considered by all mental health professionals. In this case report, we describe the challenges that emerged during hospitalization of a transgender adolescent, followed by descriptions of our attempts to cope with these particular issues.

Childhood-onset schizophrenia (COS) is a rare form of schizophrenia with an onset before 13 years of age. There is rising evidence that genetic factors play a major role in COS etiology, yet, only a few single gene mutations have been discovered. Here we present a diagnostic whole-exome sequencing (WES) in an Israeli Jewish female with COS and additional neuropsychiatric conditions such as obsessive-compulsive disorder (OCD), anxiety, and aggressive behavior. Variant analysis revealed a de novo novel stop gained variant inGRIA2gene (NM_000826.4: c.1522 G > T (p.Glu508Ter)).GRIA2encodes for a subunit of the AMPA sensitive glutamate receptor (GluA2) that functions as ligand-gated ion channel in the central nervous system and plays an important role in excitatory synaptic transmission. GluA2 subunit mutations are known to cause variable neurodevelopmental phenotypes including intellectual disability, autism spectrum disorder, epilepsy, and OCD. Our findings support the potential diagnostic role of WES in COS, identifyGRIA2as possible cause to a broad psychiatric phenotype that includes COS as a major manifestation and expand the previously reportedGRIA2loss of function phenotypes.

Religiosity may be a potent protective factor against self-injurious and suicidal behaviors. However, no previous study has addressed this relationship in adolescent psychiatric population. This study aimed to examine the association between religiosity and non-suicidal self-injurious (NSSI) and suicidal behaviors, among hospitalized Jewish adolescents. This is a cross-sectional study of 60 hospitalized Jewish adolescents in two mental health centers. They were evaluated for religiosity, NSSI, and suicidal behaviors. The following religiosity measures were found to be protective against NSSI: a higher degree of adherence to religious practices (extrinsic measure) (beta = −0.083, p = .006), a higher level of belief in religious principles (intrinsic measure) (beta = −0.063, p = .008) and a self-reported higher religious affinity (χ2 = 7.64, p = .022). The severity of suicidal ideation inversely correlated with the extrinsic measure (standardized beta = −0.2, t = −2.5, p = .015) and with self-reported degree of religious affinity (analysis of variance, F = 3.5, p = .035). History of transition in religious affinity was associated with worse suicidal ideation (3.77 ± 1.8 vs. 2.26 ± 1.99, t = −3.25, p = .004) and with suicide attempts (OR = 3.89 (95% CI: 1.08 – 14.03), p = .004); however, these relationships were mediated by history of abuse. This study provides first evidence of a protective effect of some religiosity measures on NSSI and suicidal behaviors in hospitalized Jewish adolescents.

Background In 2015, mental health services were added to the Israeli National Health Insurance package of services. As such, these services are financed by the budget which is allocated to the Health Plans according to a risk adjustment scheme. An inter-ministerial team suggested a formula by which the mental health budget should be allocated among the Health Plans. Our objective in this study was to develop alternative rates based on individual data, and to evaluate the ones suggested. Methods The derivation of the new formula is based on our previous study of all psychiatric inpatients in Israel in the years 2012–2013 ( n = 27,446), as well as outpatients in one psychiatric clinic in the same period ( n = 6115). Based on Ministry of Health and clinic data we identified predictors of mental health services consumption. Age, gender, marital status and diagnosis were used as risk adjusters to calculate the capitation rates for outpatient care and inpatient care, respectively. All prices of services were obtained from the Ministry of Health tariffs. These rates were modified to include non-users using restricted models. Results The mental health capitation scales are typically “humped” with regard to age. The rates for ambulatory care varied from a minimum 0.19 of the average consumption for males above the age of 85 to a maximum of 1.93 times the average for females between the ages of 45–54. For inpatient services the highest rate was 409.25 times the average for single, male patients with schizophrenia spectrum diagnoses, aged 45–54. The overall mental health scale ranges from 2.347 times the average for men aged 45–54, to 0.191 for women aged 85+. The modified scale for the entire post-reform package of benefits (including both mental health care and physical health care) is increasing with age to 4.094 times the average in men aged over 85. The scale is flatter than the pre-reform scale. Conclusions The risk adjustment rates calculated for outpatient care are substantially different from the ones suggested by the inter-ministerial team. The inpatient rates are new, and indicate that for patients with schizophrenia, a separate risk-sharing arrangement might be desirable. Adopting the rates developed in this analysis would decrease the budget shares of Clalit and Leumit with their relatively older populations, and increase Maccabi and Meuhedet’s shares. Future research should develop a risk-adjustment scheme which covers directly both mental and physical care provided by the Israeli Health Plans, using their data.

Background: Sleep problems in infants negatively affect quality of life and mental health of both babies and parents. Appropriate guidance for parents can assist in prevention. We assessed whether a preventive behavioral plan, emphasizing dissociation of feeding from sleep, can encourage independent sleep induction in newborns, enable uninterrupted sleep and reduce maternal depression.Methods: Sixty-one mothers were recruited up to one month postpartum. Thirty-two were selected randomly to receive preventive sleep guidance. Twenty-nine served as controls. Mothers kept daily records of their infants' sleep up to 3 months postpartum. At endpoint participants filled out the Edinburgh Postnatal Depression Scale.Results: There were less night awakenings among the intervention group (1.25 vs. 3.58; p<0.05). These mothers reported significantly less tiredness and lower stress levels and had a trend towards less symptoms of depression.Conclusions: We suggest that preventive sleep behavioral guidance can be effective in sleep consolidation of infants and reduction of fatigue and stress among mothers. Our results call for more studies on early intervention programs as a means to reduce the impact of continuous sleep deprivation.

Nonalcoholic fatty liver disease (NAFLD) is regarded as a feature of metabolic syndrome in the liver. Metabolic syndrome is associated with a higher risk of bladder cancer. However, the association between NAFLD and bladder cancer is unclear. We aimed to investigate the association between NAFLD and bladder cancer.The records of all patients (n = 251) diagnosed with the bladder cancer in our hospital between 2009 and 2013 were reviewed. We also randomly collected the records of adults without cancer (n = 266) as the control group. Clinical characteristics, biochemical tests for liver and metabolic function and abdominal computed tomography were assessed.The incidence of NAFLD was 12.0% in the bladder cancer group and 4.9% in the control group. By multiple logistic regression analysis, NAFLD (P = 0.007; odds ratio [OR]: 2.61; 95% confidence interval [CI]: 1.30-5.22), male sex (P < 0.001; OR: 2.34; 95% CI: 1.61-3.41) and use of lipid lowering drugs (P = 0.001; OR: 0.43; 95% CI: 0.26-0.72) showed significant associations with bladder cancer. In bladder cancer patients, the median survival time was significantly longer in patients without NAFLD than in these with NAFLD (40 months versus 21.5 months, P = 0.022).NAFLD was positively associated with bladder cancer and was a poor prognostic factor of bladder cancer. Further studies are needed to confirm whether NAFLD is a factor for the development of bladder cancer.

Introduction: Though a career as a clinician-scientist is rewarding, few psychiatrists in Israel pursue this career choice.The aim of this study wa s to assess subjective and objective outcomes of the first cohort of Israel Society for Biological Psychiatry's unique "Clinician-Scientist Greenhouse" program, geared towards promoting research among early-career psychiatrists.Methods: Prior to initiation and after completion of the two-year program each participant completed a 23-item questionnaire. A mean score (on a 1-10 Likert scale) was calculated for each item and means of items in each of the five domains (career as a clinician-scientist, submitting a research proposal, conducting research, knowledge in biological psychiatry and the Clinician-Scientist Greenhouse) constructed the mean score for that domain. Pre-post program scores were compared using paired t-tests.Results: Out of 27 individuals beginning the program, 22 completed it, and 20 post-program questionnaires were filled. Significant improvements were found in subjective reports of competence in submitting a research proposal (4.1 +/- 1.92 to 6.9 +/- 1.67 [p<0.001]), conducting research (4.6 +/- 2.15 to 6.7 +/- 2.02 [p=0.001J) and knowledge in biological psychiatry (4.9 +/- 2.11 to 6.7 +/- 1.61 [p=0.003]). Six months following completion of the program, 60% of graduates reported submission of at least one original paper to a peer-reviewed journal and 65% of submissions have already been accepted for publication.Conclusions: Professional societies are a natural arena for promoting young psychiatrists' career development as clinician-scientists. The Israel Society for Biological Psychiatry's Clinician-Scientist Greenhouse appears to be effective in improving competence in conducting and disseminating psychiatric research among early-career psychiatrists in Israel.

Recently, Miodownik et al. reported in this journal the results of a study on seclusion and mechanical restraint of psychiatric patients in Israel (Isr J Health Policy Res 8:9, 2019). The study was a retrospective examination over a year of one inpatient ward in a psychiatric hospital. They found negative associations between length of use of coercive measures and the diagnosis of schizophrenia, being single, and the presence of academic nurses. Positive associations were found between length of use of coercive measures and the use of antipsychotic medications, violence towards oneself, and the use of restraint compared to seclusion. Interesting and important as they are, these results were obtained from data gathered in 2014. As the authors note, since then there has been a dramatic change in the official policy of the Israeli Ministry of Health on this topic and in the practice of seclusion and mechanical restraint in Israel. This commentary reviews and comments on the current situation.

Background: 5-HTTLPR and MAOA are traditionally considered to confer risk for negative outcome in the context of the gene-environment interaction. The aim of the current study was to further investigate this interaction in the context of a beneficial environment.Methods: Two hundred and one college students provided saliva samples for DNA extraction and completed self-reported questionnaires measuring attachment, perceived social support and experience of life events. ANOVA, Pearson correlation and linear regression analysis were used to examine the correlation between these explaining variables and an outcome measure of well-being.Results: Full data were available for one hundred and sixty-six subjects. We found a significant interaction between genotype and environment in their effect on happiness. Only individuals with the 5-HTTLPR short allele(s) or within MAOA intermediate and low activity genetic groups were happier when they perceived higher support from their friends.Conclusions: Even though the sample is small these results show that genetic polymorphisms confer not only resilience or vulnerability to stress, but also provide their carriers with sensitivity to a beneficial environment.

INTRODUCTION:The budget for health services in Israel was recently increased to cover mental health. It was suggested to divide funds for psychiatric hospitalization between the HMOs based on their share of insured members. For ambulatory care, it was suggested to add risk adjustment based on age only to the capitation formula used for allocating health care funds. This simplistic measure encourages risk selection and discrimination of costly individuals.AIMS:To identify predictors of mental health services consumption in Israel, in order to implement them in the capitation formula.METHODS:Data were gathered on 27,446 individuals hospitalized in psychiatric wards in Israel in 2012-2013, and 6115 outpatients treated during this period in one mental health clinic. The association between demographic and clinical variables with services consumption was studied.RESULTS:The average annual expenses per person on mental health were NIS 50,000 for hospitalization, NIS 1,700 for ambulatory care and NIS 7,000 for all services. Adult age and schizophrenia spectrum diagnoses predicted increased expenditure on all services. Being a male, single, Jewish and living in the economic periphery predicted increased expenditure mainly on hospitalization. Regression analysis using these variables explained up to 30% of variance.CONCLUSIONS:It is possible to predict, at least partially, mental health consumption in Israel based on clinical and demographic variables.DISCUSSION:Limitations of the study call or re-analysis using full databases, which are available only to the state authorities. Predictors of mental health consumption in Israel can be used for the risk adjustment of allocating funds for services.

5-HTTLPR and MAOA, are genetic segments that influence serotonin and monoamine neurotransmitters. They were found to be associated with depression, suicidality, aggressiveness and anti-social behavior, with an evidence for a gene-environment (GXE) interaction. 5-HTTLPR was found to be associated with resilience to the effect of stressful life events on depression and suicidality, and MAOA was found to be associated with aggressiveness and anti-social behavior following childhood maltreatment. Findings demonstrated the negative aspect of this association, namely the interaction between a stressful environment and the gene, in a manner that reflects vulnerability to pathology. Investigation of the positive end of the association has been the target of studies in more recent years, trying to prove that these are not "vulnerability genes" but "plasticity genes". The aim of the current study was to further investigate the GXE interaction in this positive context. We hypothesized that 5HTTLPR and MAOA will moderate the relation between a good, beneficial environment and well-being.