Psychiatric Services in Israel: Need for a Continuum of Care Model

Vignette 1

One of the authors received a telephone call from a distraught father whose 21-year-old son had recently become acutely disturbed following his own wedding. The young man had returned to his parent's home after having gone missing and was described as ‘talking to the walls’ and threatening to set fire to himself. The father had tried to bring his son to the general hospital emergency room without success. He had approached the police for assistance but he was told that they could not forcibly transport the young man without an order from the District Psychiatrist. The father had also approached the local community mental health clinic requesting a home visit but he was told that home visits need to be booked 1 week in advance. The author contacted the clinic and the aforementioned protocol was confirmed. The medical director of the clinic subsequently acknowledged that as a result of inadequate resources the clinic was not open during afternoon hours. The author subsequently contacted the Deputy District Psychiatrist who explained that the young man required a psychiatric assessment prior to issuing an order for psychiatric hospitalization. After a number of frantic telephone calls from the father over a period of some hours, it was agreed that the psychiatrist would write to the deputy district psychiatrist requesting an order for psychiatric hospitalization on the basis of the information of the young man's condition conveyed by telephone. Following this action, the young man was conveyed to a psychiatric hospital by police.

This vignette highlights the need for a community crisis assessment team to provide an assertive outreach service. Such a service needs to work closely with the community mental health clinic, the inpatient psychiatry unit, and the office of the District Psychiatrist so as to provide a timely and appropriate response to the community needs. The vignette also highlights the need for community mental health clinics to be open during afternoon hours with the capacity for conducting home visits. Despite psychiatric hospital emergency units being open 24 h a day, the associated stigma limits their use by most people in the community.

Vignette 2

A 30-year-old woman had given birth to her fifth child 3 months earlier. She presented to a general hospital emergency room because of a deterioration in her mental state over the preceding week including ideas of grandiosity and reference. The patient's husband referred her to hospital after she complained of being pursued by spirits. It subsequently transpired that she had been assessed by psychiatrists in the past and had been recommended a variety of antipsychotic and mood stabilizer medications. She had been non-compliant with these recommendations.

Throughout the period of her assessment in the emergency room the patient demonstrated a restricted affect with significant perplexity and impaired insight as to her referral to the hospital. There was no evidence of hallucinations, delusions or suicidal ideation. On the basis of a presumptive diagnosis of a psychotic illness, she was commenced on risperidone, 1 mg daily with psychiatric hospitalization in mind. The district psychiatrist was consulted in relation to a compulsory order for hospitalization. In view of the fact that she did not present as an immediate risk to self or others, her case did nor satisfy the requirements of the Israeli Mental Health Act in respect of compulsory psychiatric hospitalization, namely evidence of a psychotic illness and immediate danger to self or others. ⁷ The patient's spouse was unwilling to agree to psychiatric hospitalization but after considerable discussion, it was agreed that she would be hospitalized in a regional psychiatric hospital with mother-baby facilities. The social worker who was involved notified the statutory protective worker of the situation in order to assess the ongoing risk to the 3-month-old baby of the patient.

The patient was discharged from the emergency room and referred to a psychiatric hospital. However, at the hospital the patient and her spouse changed their mind about the hospitalization and left the hospital without completing the admission process. The patient was taken by her spouse to a friend's house to rest for the night. When the patient awoke in the middle of the night, she believed that she was being pursued and, in the process of attempting to escape, she jumped from the third floor balcony thereby sustaining a closed fracture of the lumbar vertebra. She was hospitalized in the original general hospital and described being confused and frightened prior to jumping off the balcony. She denied suicidal intent at the time of the incident or at the time of the examination. There was no evidence of overt delusional material or perceptual disturbance on mental state examination but her judgement and insight were impaired. She was treated with haloperidol and promethazine and was closely supervised by security staff in the orthopaedic ward. She underwent surgical repair of the unstable vertebral fracture.

Postoperatively, it was intended to transfer the patient to a psychiatric ward attached to a general hospital under a compulsory hospitalization order. However, because of concern by the psychiatric unit staff about managing the patient in an open ward setting, the patient was transferred to a closed ward of a regional psychiatric hospital. She was subsequently transferred to the psychiatric ward in a general hospital for ongoing treatment of her psychiatric illness.

This vignette highlights the importance of a mother-baby psychiatric unit, which should be preferably attached to a general hospital psychiatric unit. Such a unit should have the capacity for managing both involuntary and voluntary patients. The patient would be managed in the one unit from the point of admission to the point of discharge rather than be transported between facilities as occurred in this vignette with the attendant difficulties of non-compliance and lack of continuity of care.

The balance between the rights of the individual and family to refuse treatment and the parens patriae or parental role of the community to determine who is in immediate need of treatment, needs to be critically reviewed. The vignette demonstrates the added physical, emotional and financial burden incurred by the patient, his/her family and the community when the needs of the individual are sacrificed in the interests of individual rights.

These two vignettes demonstrate the importance of a continuum of care model in the delivery of psychiatric services. On a practical level, such a model requires that community mental health clinics be open during afternoon working hours with the capacity for conducting home visits. Mobile crisis assessment teams are required in order to provide more assertive outreach to the community and in order to provide a gatekeeping role for persons in crisis referred for psychiatric hospitalization. Such teams would consist of a psychiatrist, psychiatric nurse, and social worker. General hospital psychiatric units with the capacity for treating both voluntary and involuntary patients are also needed.

Resources are urgently required in order to provide a more integrated mental health service embracing community mental health clinics, general hospital psychiatric units and psychiatric hospitals based upon a continuum of care model. Mental health services need to be seen by the community as being patient orientated, accessible and humane. The service needs to be responsive to special needs groups in the community with high morbidity such as those persons suffering from first-presentation psychosis and post-partum psychiatric illness.