Isr J - Vol. 57 - No 1 (2020) Viewpoint: The Future of Psychiatry: From Whence it Came to a Brighter Future, Focus on Israel

Anatoly Kreinin, MD, PhD

University Psychiatric Department, Ma’ale Carmel Center, Affiliated with Bruce Rappaport Medical Faculty, Technion, Haifa, Israel

Abstract Introduction Historically, psychiatry has evoked strong, negative Psychiatry has always been regarded as if it were in a emotions, such as fear, anxiety and pity. Across time, “twilight zone,” often evoking strong, negative emotions, the attitude toward psychiatry has changed, and there is such as fear, anxiety, pity, and sometimes all combined. growing awareness that mental disorders are diseases. Though psychotropic medications and community-based Psychotropic medications and community-based services services have significantly contributed to the improve- have significantly improved mental health care; however, ment in care for the mentally ill, the issue of social stigma social stigma associated with psychiatric institutions associated with psychiatric institutions remains a painful remains a painful subject. Notwithstanding major subject (1). developments in the last century, psychiatry has yet to become an integral . The inferior History of Psychiatric Hospitals position of psychiatry is reflected in the significant gap in the investment of resources for development of new The first treatments for the mentally ill in medical facilities technologies in various fields of medicine in comparison to were in Bagdad. European researchers who travelled to funds allocated to psychiatry. The focus of the paper is the Arab countries wrote about the “Bimaristans” – hospitals need to close psychiatric hospitals in favor of dedicated that also treated people that suffered from lunacy (2, 3). psychiatric departments in general hospitals, based on In 872, following the order of the Cairo Commissioner the history and developments of psychiatry treatment Ahmed Ibn Tulun, a hospital that provided psychiatric throughout the ages. Beginning with a brief overview of services, including music therapy, was built (4). In Europe th the history of mental health care and the development until the beginning of the 10 century, the mentally ill of psychopharmacological treatment for psychiatric were generally offered refuge in monasteries. disorders, this paper focuses on how in line with the The first psychiatric institution in Europe was founded historical development of psychiatric treatment and in Valencia in 1410. The hospital was called Hospital de mental health reform in Israel, which transferred mental Nostra Dona Sancta Maria dels Innocents (Hospital of health care to the health funds, transfer of inpatient Our Lady St. Maria of the Innocents) (5). The German psychiatric care to general hospitals, with reimbursement Rudolf Virchow claimed that the first psy- of services comparable to that in other fields of medicine, chiatric institution was founded in Germany near the would benefit patients as well as health care providers city Elbing, where the institution for lepers was turned and advance psychiatric research. into a hospital for the mentally ill in 1326 (6, pp. 62-65). Following the establishment of the hospital in Valencia, hospitals were opened in Zaragoza (1425), Seville (1436), Barcelona (1481) and Toledo (1483) (7). During that same period psychiatric services began to open in hospitals in other European countries, such as the Priory of St. Mary of Bethlehem, London, which was later called Bedlam, founded in 1247, though the first psychiatric patients were

Address for Correspondence: Anatoly Kreinin, MD, PhD, Department Head, Ma’ale Carmel MHC, POB 9, Tirat Carmel 30200, Israel [email protected]

34 Anatoly Kreinin admitted at the beginning of the 15th century. In contrast services in Israel. At that time, what was called Palestine to the hospitals in Spain, the Priory of St. Mary was not was under Ottoman rule, and the establishment of the designated only for mentally ill patients. Het Dolhuys, hospital was made possible via the 1892 Ottoman Law, now a museum of psychiatry, was the first psychiatric Shelter for Lunatics (9), which regulated the opening of hospital opened in Haarlem, Holland. institutions for treatment of the mentally ill. The law was Psychiatric hospitals began to open in additional influenced by the 1838 French law for the hospitalization European countries and in Russia in the 17th and 18th of mentally ill patients and authorized the director of a centuries. In 1723 Peter the Great issued a decree forbid- to admit a person for hospitaliza- ding the referral of “lunatics” to monasteries and requiring tion, subject to a reasonable request backed by the local the construction of hospitals for them. The decree was Mukhtar’s approval and a doctor’s certificate. The director executed, and in 1764 the first hostel (Dollhaus) for the of the hospital was required to report on the admission mentally ill was built in Moscow (6, pp. 293-295). of a patient within three days and to submit a treatment During that period hospitals for the mentally ill were report within 15 days of admission, which also allowed opened in France and throughout England. La Maison for “community care,” including restraining and locking de Charenton, the first psychiatric hospital in France, a mentally ill individual in the family’s home, subject was established in 1641 in a suburb of Paris. In France to notification to the government representative and and England renowned of that period who examination by two physicians, one appointed by the treated the mentally ill changed society’s attitudes toward government and one appointed by the family (10). British mental disorders. In France, Philippe Pinel exchanged rule later expanded the public psychiatric infrastructure the monk’s cloak for a physician’s white coat, and from in Palestine, established a mental hospital in Bethlehem 1793 worked in Bicêtre Hospital where he met Jean- for the Arab sector in 1922, and converted the Geha Baptiste Pussin, who was employed as an administrative Hospital near the city of Petah Tikva which was estab- assistant and guard. In 1797 Pussin was the first person in lished in 1934 to a psychiatric hospital. In 1944 a camp history who removed the shackles from the mentally ill for Italian prisoners of war was evacuated, and converted (as recorded by Pinel (6, pp. 156-158). Three years later, to a psychiatric hospital now known as Abarbanel Mental in 1800, Pinel did the same in Salpêtrière Hospital. In Health Center in Bat Yam. England in the 19th century, the psychiatrist John Connolly In contrast to the support of the Ezrat Nashim associa- became the father of the non-restraint approach. tion for mentally ill patients which paralleled support In 1784, the infamous Lunatic’s Tower was built in to all other patients, the position of community leader- Vienna. It was a round tower decorated with stone carv- ship in the Land of Israel towards the mentally ill at the ings and it had square living quarters for physicians and beginning of the return to Zion and during the British guards. The patients, however, were confined to a limited Mandate period was discriminatory, as documented by space in the area between the walls of the rooms and the Sufian (11): walls of the tower, and they were put on display for a fee. Operating the British Mandatory Government’s It should be noted that until the “revolution” of Pinel overarching system with its increasingly strict immi- and Pussin, the directors of most asylums and shelters gration controls, Zionist leaders and doctors encour- for the mentally ill were police officers or guards, and not aged selective immigration policies repatriation to physicians. The reason for this may have been that there Europe or institutionalization of the mentally ill in was little treatment available for people suffering from order to contain and manage what they saw as a serious mental disorders. San Hipólito Hospital in Mexico was challenge to the achievement of an ideal society made the first psychiatric facility on the American continent. up of dedicated, resilient, unencumbered “new Jews” The first asylum for the mentally ill in the United States in Palestine. In so doing, they prioritized access to the was founded in Williamsburg in 1873. By the end of fledgling Jewish homeland to able-bodied individuals, the 1870s over 50 psychiatric hospitals were opened despite a broader promise, that Zionism would build throughout the United States. a homeland for all Jews. In general Zionist doctors The first hospital for the mentally ill was founded did not seem to recognize the tension between an in Palestine in 1895 (8) by the Jerusalem branch of the exclusionary immigration policy and larger Zionist women’s association, Ezrat Nashim. The establishment of ideological claims about Zionism’s potential to heal the hospital marked the beginning of public psychiatric all Jewish people in that land.

35 The Future of Psychiatry in Israel

David Ben-Gurion, the first Prime Minister of Israel, same time, community-based services began to develop, wrote in his diary: "There have recently been medical not only under the influence of social and political move- examinations in all countries, but there are still cases ments, but for purely pragmatic reasons. slipping through” (12). Due to the lack of resources aban- In recent years, in Israel as throughout the world, doned barracks were converted to psychiatric hospitals. there is increasing social recognition of the rights of Even the prison in Acre, where the British had a small persons with mental disabilities to fully integrate into ward for dangerous mental patients, was converted into a society. This conceptual change supported the enactment psychiatric hospital (13). In 1949, the Ministry of Health of the Law for the Rehabilitation of Mentally Disabled established Be’er Ya’akov psychiatric hospital, and the Persons in the Community (16). The goal of the law is Clalit Health Services established the Talbieh psychiatric to enable people with at least a 40% disability to receive hospital in Jerusalem for its members. In 1950, the Health rehabilitation services that will help improve their optimal Ministry established what is now Kfar Shaul Psychiatric integration in the community. The law requires establish- Hospital in Deir Yassin, an abandoned Arab village near ment of a national committee for rehabilitation, as well Jerusalem. In 1956, Clalit Health Services established as regional committees, and details the service basket Shalvata, the third psychiatric hospital for members of that rehabilitees are entitled to receive. The regional Clalit Health Fund. There are presently 11 psychiatric rehabilitation basket committees receive referrals from hospitals in Israel. In the early 1980s there were 8,598 professional bodies whose role is to decide on eligibility psychiatric hospital beds in Israel (14, p. 15). and suitability of the applicant for rehabilitation and to build tailored individual rehabilitation programs for each applicant. According to the law, rehabilitation services Deinstitutionalization in the community include housing services at various Deinstitutionalization is the process that aims to exchange levels, from sheltered housing to hostels for the mentally long-term psychiatric hospitalization with community- ill, employment, supported education, mentoring, social based psychiatric services. The term first appeared in and recreational services, coordination of physical care 1955, in relation to the opportunities created after the and dental care (17). development of antipsychotic medications. After World The process of deinstitutionalization enabled drastic War II, the liberal trend in western countries gained reduction of psychiatric inpatient beds in many western momentum while focusing on individual rights. In the developed countries and specifically in Israel. Thus, for early 1960s there were major advances in psychophar- instance, in 2015 after implementation of the mental macological treatment with the discovery of the thera- health reform, the number of psychiatric hospital beds peutic effect of chlorpromazine on people suffering from was reduced from 8,598 in 1980 to 3,503 in 2015 (18). schizophrenia. It is noteworthy that many medications used in psychiatry were initially developed for treatment of other medical disorders and their novel psychotropic Adjusting the Sails to the Direction of benefits were by-products of the original research. Davis the Wind (15) described the revolution as a deviation from the Psychiatry has come a long way since the beginning of pharmacological approach. In his opinion, the most the 19th century. There have been significant changes important emphasis was the elimination of dependency in institutional social, legal, medical and therapeutic on hospitalization as a component of treatment. domains in the second half of the 20th century. Following The therapeutic revolution initiated by Chlorpromazine reforms in the provision of psychiatric services in vari- went far beyond the mere pharmacological effects of the ous countries, the question arose regarding the place of drug. Today, schizophrenic patients who become ill can psychiatric hospitals in the continuum of psychiatric often be treated effectively by antipsychotic medication services for the population. General hospitals provided without hospitalization (15). fertile ground for the growth of psychiatric inpatient During the 1960s, social movements focused on the units, liaison psychiatry, , psy- rights of the mentally ill. In the early years of the move- chiatric clinics, and emergency psychiatric services. In ment, Ken Kesey’s book about psychiatric treatment, One addition, they provided the setting for field work for Flew Over the Cuckoo’s Nest, was published, and in 1975 the education and training of various mental health it was made in to a movie starring Jack Nicholson. At the professionals.

36 Anatoly Kreinin

In 1728, Guy’s Hospital in London was apparently the first general hospital to announce the need to pro- Mental Health Reform in Israel vide a response to the “lunatics” on its grounds (19). At In Israel, after a 20 year delay, the Mental Health Reform the beginning of the 18th century in the U.S., Quaker was implemented with the transfer of responsibility and Almshouse which later became Philadelphia General financial resources from the state to the health funds. Hospital treated “madness.” In 1755 Pennsylvania Hospital (35), meaning that mental health care was to be included designated a number of beds to “cure and treat lunatics” in health fund coverage. The goals of the reform were (20). However, most hospitals did not acknowledge a to improve the availability and accessibility of services, clear psychiatric presence until the 20th century. The to make mental health services more efficient, to tailor first psychiatric unit in an American general hospital was services to clients’ needs, and to implement appropriate established by James Mosher at Albany General Hospital discharge planning programs (36). in New York. The 12-bed unit was specifically designed The transfer of responsibility to the health funds was for severe psychiatric patients who required seclusion, based on the assumption that organizational change in treatment for addiction, emergency treatment and severe the system would introduce economic considerations and sometimes dangerous forms of mental disorders that and competition that would facilitate the services and appear during somatic disorders or following surgery and improve quality. These changes were intended to divert anesthesia. It is possible that this last function led to the the flow of patients from the hospital to the community formal introduction of consulting-liaison psychiatry (21). and ultimately move the focus of treatment of the men- The integration of psychiatry as it developed in the tally disabled to the community. In order to ensure the U.S. is characteristic of general hospital psychiatry dur- therapeutic continuum from inpatient to community- ing the past hundred years. The role of general hospitals based care, the community-based psychiatrist should be in the mental health network is of great interest in many involved not only in referral to hospitalization but also countries, but the timing and scope of development in the discharge process (37-41). Only after several peti- varies considerably from country to country, in line tions to the legal system, including petitions to the High with the differing interests, attitudes, professional avail- Court of Justice, on May 1, 2012, the Socio-Economic ability, needs, economies, medical systems, cultures, Cabinet approved implementation of the reform in a etc. (22-29). government order (37). Agreements were signed with Despite significant between-country differences it health funds, and budgetary supplements were approved seems that a universal desire for greater integration of wherein the Finance Ministry transferred funds to the mental and physical health has broad consensus and health funds to supplement community-based clinic that this combination is likely to be achieved within services. Implementation of the reform entered into the general hospital (30). Psychiatry has long sought a an interim period of three years. The transfer of full reintegration with medicine (31). The general hospital responsibility for the mental health sector to the health seems to be the most logical place for this. Discoveries funds began in July, 2015. The mental health reform is in the fields of neuroscience, immunology, imaging, based on advanced principles of integration of mental genetics, molecular biology, and health services into the health care system, arguing that have improved the chances of accepting psychiatry to disorders of the body and disorders of the mind should mainstream medicine. With these developments, ques- not be separated, and that health services should treat tions arise once again regarding the most appropriate both either one at a time or simultaneously (37). location of mental health services: in the community, in Similar to the role of other medical specialists, psychia- a smaller general hospital, or in a large institution (32- trists were recruited to the various clinics of the health 34). The attempts to join Psyche and Soma have always funds. In addition, the reform called for establishment of been difficult. If integration is successful, it is likely to mental health clinics run by the health funds to ease the occur in the general medical environment, where the burden in psychiatric hospitals and psychiatric depart- biopsychosocial approach to medicine is most common ments in general hospitals. The health funds, which needed and natural. In the collaboration between psychiatry and additional manpower for the mental health services, were primary medicine, liaison psychiatry will play a major role able to offer higher level jobs, higher pay and more potential in maintaining a reciprocal relationship in the healing of for promotion than those available to many professionals mental and physical disorders. in government service. This may have been related to the

37 The Future of Psychiatry in Israel shortage of psychiatrists in the country in general. Directors scenario, in the few hospitals that may still perform rou- of government-owned psychiatric hospitals complained tine blood tests on site, the laboratories are outdated. Thus, that many of positions in their hospitals were vacated and psychiatric hospitals do not benefit from the advanced would be difficult to fill (38). technologies and resources routinely available in general Indeed, in Israel, there is a growing shortage of physi- hospitals. It is clearly inconceivable that there would be cians in general and in psychiatry in particular. “There means for imaging, Deep Brain Stimulation, fMRI, or are at least 100 unfilled positions in psychiatric hospitals. PET scans in psychiatric hospitals. Physical examinations There are 400 doctors sitting at home waiting for residency and consultations are generally performed by internists placement, none of whom are interested in psychiatry” (39). and neurologists who are not full-time staff members Another issue that has distanced psychiatry from general at the hospitals and are thus not available on a daily medicine is the shortage of manpower in psychiatric medi- basis. Other consults are not readily accessible, and a cal and nursing sectors, which have become more serious cumbersome logistic process is necessary in order to since the implementation of the reform. As a result, the arrange such medical examinations. quality of care has been significantly impaired, thus there Psychiatric departments on the campuses of general is also a growing deterioration in the quality of psychiatry hospitals have clear benefits in comparison to psychiatric studies. There is a great disparity in the exposure of resident hospitals. In the U.S., “Most leading academic depart- psychiatrists to various disorders and medical conditions ments of psychiatry are based in general hospitals and in a general hospital (emergency department, consulta- perform the bulk of federally funded psychiatric research, tions from various departments in a general hospital) and the training of psychiatric residents, and the education of residents in a psychiatric hospital. On the other hand, medical students. The top 10 medical school departments resident psychiatrists in a general hospital are rarely, if of psychiatry by National Institutes of Health funding are at all, exposed to different psychiatric pathologies often all based in general hospitals linked academic medical common in psychiatric hospitals. Thus, the benefits of centers” (41). However, psychiatric services in general psychiatric units in general hospitals is bidirectional. hospitals are often vulnerable. The results of loss (reim- Some community-based clinics have been closed due bursement) and operating profit of psychiatric services to a shortage of psychiatrists and months long wait- in general hospitals tend to lag behind other medical ing periods for treatment, especially in outlying areas. services, while the high cost of psychiatric services poses Fifteen clinics have been closed because they were not a challenge that needs to be addressed in the context of economical. Clinics have closed because of a shortage general health care. of doctors. According to the data from the Ministry of Despite the prevalence of psychiatric illnesses in gen- Health from the beginning of 2018, the waiting period eral hospitals, major research projects in the prestigious for an appointment in mental health clinics range from academic medical centers and the growing understanding 8 to 12 months 40)). that neurobiology is at the basis of major psychiatric The dismal situation of the psychiatric inpatient system syndromes, the structure of reimbursement for psychi- began to develop even before the implementation of atric services is disconnected (39% less than their costs) the mental health reform in 2015. For many years the and vastly disproportionate in comparison to budgeting distancing of psychiatry not only from the general public, and reimbursement in the medical-surgical insurance but also from general medicine, was the consensus. It is system, leaving psychiatric departments significantly no accident that centers specifically for the treatment of underfunded (41). mentally ill people continue to be built. It seems that key To enhance the viability of psychiatric services in medical decision makers have yet to consider uniting general hospitals better reimbursement rates need to psychiatry with the medical specialties, not only at the be negotiated as it is incomprehensible that psychiatric declarative level, but also on the practical level. For the services should be paid less than their costs while other benefit of society mental disorders must be treated in hospital services can be very profitable. Hospitals need tandem with physical disorders, and vice versa. to apply leverage as major providers of medical-surgical With the advancement of biomedicine and biotech- care to ensure that adequate coverage for psychiatric care nologies, the gap between psychiatry and other medical is paid by insurers, and specialty mental health manage- specialties is widening. At present, in most psychiatric ment companies need to be pressured and funded by hospitals in Israel there is no laboratory. In the best-case legislators to pay adequate rates (41).

38 Anatoly Kreinin

There are similar economic problems in Israel that grounds of general hospitals; however, they did not let me must be solved in order to avoid distortions in health finish speaking. I repeated my idea after immigrating to care coverage between physical and mental disorders. Israel, at the 1997 Conference of the Israel Psychiatric For example, the mental health care budget should be Association. From that time onward, I have continued considered in its entirety and should include a budget to work towards realizing my dream – to promote the for psychiatric hospitalization, similar to the budget for understanding of the need to transfer mental health care psychiatric rehabilitation in the community under the to the domain of general medicine, globally, and in Israel Rehabilitation of the Mentally Disabled Persons Law. It in particular. Otherwise, I do not see a future for a pro- may be suggested that the main flaw in that law is that fession that on the one hand stubbornly adheres to the the money transferred to rehabilitation is earmarked only Diagnostic and Statistical Manual of Mental Disorders and for rehabilitation and cannot be transferred to any other all of the modern European and American guidelines that purpose or treatment, such as inpatient care, which is require ruling out any organic disorders prior to making often a necessary component in the rehabilitation of an a psychiatric diagnosis. On the other hand, in psychiatric individual with mental disorders. hospitals particularly in Israel, what laboratory tests or even basic imaging diagnostic test can be performed? What can an on-call psychiatrist do in the middle of the Memories of the Future night in a psychiatric emergency room with a “neurologi- Over the course of history, individuals with mental dis- cal hammer” and a stethoscope? What kind of evaluation orders have been treated as subjects of Satan, and were can be performed when there is a suspected organic brain shackled or burned in the Inquisition. The beginning of disorder, poisoning, etc.? What personalized drug therapy the 19th century marked the renaissance of psychiatry can be prescribed when there is no modern laboratory? which continued through the 20th century, including a Can groundbreaking research be conducted in a psychi- psycho-pharmacological revolution, the development of atric center in the absence of imaging tests such as MRI, community services and a change in attitudes regarding fMRI, PET, genetic testing etc? What type of samples can the mentally ill. Psychiatry, as a profession, continued to be evaluated using the available equipment in a mental develop parallel to but not together with other medical health center? Clearly, the unreasonable gap between specialties. Psychiatry has remained in a problematic place research in psychiatry and other medical specialties will – that is “marginal” to medicine. Psychiatry came closer only increase with the ongoing technological advances to conventional medicine in the mid-20th century with available only in general hospitals. the psychopharmacological revolution, but the advance The transfer of mental health care to general hospitals was short-lived, especially since the beginning of the 21st will pave the way for bidirectional integrative patient century. As cutting-edge medical technologies changed care. Psychiatric treatment in general hospitals will effec- the face of nearly all fields of medicine, psychiatry as a tively reduce the stigma of the “psychiatric patient.” The stand-alone specialty without the resources available to potential for thorough diagnostic evaluations can lead to general hospitals, remains behind. Only an immediate innovative and novel therapies, and will be a fertile ground transition of psychiatric facilities to centers of general for collaborative research, sharing technological, scientific medicine can prevent critical harm to the profession and professional resources in the fields of molecular and ensure the psychiatric profession and patients with genetics, neurobiology and more. Research options will mental disorders a better future considerably improve the quality of specialization studies in psychiatry, the quality of treatment. It is time to close psychiatric hospitals and to open appropriate psychiatric I Have a Dream services on the grounds of general hospitals with equal In 1985 I stood in the lecture hall holding the microphone access to medical technologies and equipment. at a conference of the Russian Psychiatric-Neurological Society in Moscow. The leaders of Soviet psychiatry and References the guest of honor, the president of the World Psychiatric 1. Sowislo JF, Lange C, Euler S, et al. Stigmatization of psychiatric symptoms and psychiatric service use: A vignette-based representative population Association, Prof. N. Sartorius, were on the stage. Already survey. Eur Arch Psychiatry Clin Neurosci 2017; 267:351-357. then, I tried to present the idea that it was time to close 2. Nagamia HF. Islamic medicine history and current practice. J Int Soc psychiatric hospitals and move psychiatric services to the History Islamic Med 2003; 2:19-30.

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3. Porter R . Madmen: A social history of madhouses, mad-doctors & 24. Botega NJ. Psychiatric units in Brazilian general hospitals: A growing lunatics. Stroud, Gloucestershire: Tempus, 2004: pp. 99-101, 308. philanthropic field. Int J Soc Psychiatry 2002; 48:97-102. 4. Koenig HG. Faith and mental health: Religious resources for healing. 25. Burvill PW. Psychiatric units in general hospitals. Med J Australia Conshohocken, Penn.: Templeton, 2005. 1977; 2:57-59. 5. López-Ibor JJ. The founding of the first psychiatric hospital in the world 26. De Jonge P, Huyse FJ, Herzog T, et al. Referral patterns of neurological in Valencia. Actas Espanolas Psiquiatria 2008; 36:1-9. patients to psychiatric consultation-liaison services in 33 European 6. Kannabich YV. The . Moscow: Medgiz Publishing, hospitals. Gen Hosp Psychiatry 2001;23:152-157. 1928 (Russian). 27. Hildebrandt LM, Alencastre MB. A insercao da psiquiatria no hospital 7. Roberts A. Index of lunatic asylums and mental hospitals,1815. geral. (The integration of psychiatry services in the general hospital). studymore.org.uk. (accessed March 27, 2019). Revista Gaucha Enfermagen 2001; 22:167-186 (Portuguese). 8. Witztum E, Margolin J. The establishment of “Ezrath Nashim” Psychiatric 28. Maksimowska M, Rut E. Niektore korzyci ekonomiczne tworzenia oddzia Hospital in Jerusalem: Selected issues. Harefuah 2004; 143:382-385, ow psychiatrycznych przy szpitalach ogolnych (Economic advantages 389 (Hebrew). deriving from attaching psychiatric wards to general hospitals). 9. Margolin J, Witztum E. Chapters in the history of psychiatry in Israel Psychiatria Polska 1977; 11: 335-337 (Polish). and its surroundings: The Asfouriyeh hospital for the insane in Lebanon. 29. Nomura S, Shigemura J, Nakamura M, et al. Evaluation of the first medical Harefuah 2001; 140:790-794 (Hebrew). psychiatry unit in Japan. Psychiatry Clin Neurosc 1996; 50:305-308. 10. Hualed R, Grinshpoon A. The law for the treatment of the mentally ill 30. Lipsitt DR. From fragmentation to integration: A history of comprehensive in Israel: Development to date and recommendations for the future. patient care. In: Haber JD, Mitchell GE, editors. Primary care meets Refuah U’Mishpat 2006;35:100-114 (Hebrew). mental health: Tools for the 21st century. Tiburon, California: Centralink 11. Sufian S. Mental hygiene and disability in the Zionist project .Disabilities ‏ Publications, 1997: pp. 3-12. Studies Quarterly 2007; 27: 4.http://dsq-sds.org/article/view/42/42. 31. Lipsitt DR.The remedicalization of psychiatry. Medical and health annual. 12. Ben-Gurion D. Diary, April 24, 1949. Ben-Gurion Archive, Sde Boker, Israel. Chicago: Encyclopedia Britannica, 1981: pp. 291-295. 13. Kalian M, Witztum E. The Israeli model of the “District Psychiatrist”: 32. Goldberg RJ. Financial management challenges for general hospital A fifty year perspective. Isr J Psychiatry Relat Sci 2006; 43:181-197. psychiatry. Gen Hosp Psychiatry 2001; 23:67-72. 14. Israel Ministry of Health. Mental Health in Israel Statistical Annual 33. Goldman HH, Sharfstein SS. Are specialized psychiatric services worth 2000. Jerusalem: Israel Ministry of Health. the higher cost? Am J Psychiatry 1987; 144: 626-628. 15. Davis JM. Antipsychotic drugs. In: Kaplan HI, Freedman AM, Sadock 34. Mechanic D. The future of inpatient psychiatry in general hospitals. BJ, editors. Comprehensive Textbook of Psychiatry/Ill. 1980. Baltimore, New Dir Ment Health Serv 1997;73:103-108. Md.: Williams & Wilkins: pp. 2257-2289. 35. Roe D, Kodesh A, Thornicroft G. Editorial: Mental health reform and a 16. Israel Book of Laws 1746, July 21, 2000: p. 231. window of opportunity for community mental health. Isr J Psychiatry 17. Israel Ministry of Health. Mental Health in Israel Statistical Annual Relat Sci 2016;53:3-5. 2012. Jerusalem: Israel Ministry of Health, 2013: p. 14. 36. Hasson-Ohayon I. The transition from psychiatric hospitalization to 18. The Quality Reform in Mental Health (Israel Psychiatry Association, community living: Local and current challenges. Isr J Psychiatry Relat Psychiatric Nursing Association, the Organization of the Administrative Sci 2016;53:40-44. Directors of the Government Hospital and their Deputies, Psychiatric 37. Ministry of Health. The socio-economic cabinet approved the mental Hospital Medical Directors Forum), 2016. https://www.health.gov.il/ health reform. 2012. https://www.health.gov.il/NewsAndEvents/ publicationsfiles/violence_commitee31072017_a.pdf (accessed March SpokemanMesseges/Pages/01052012_2.aspx (accessed March 31, 2019). 27, 2019) (Hebrew). 38. Aviram I, Azary-Viesel S. Mental health reform in Israel: Challenge 19. Mayou R. The history of general hospital psychiatry. Br J Psychiatry 1989;155: and opportunity Part II: Implementation of the reform – Issues and 764-776. problems. Isr J Psychiatry 2018; 55: 55-64. 20. Sederer LI, Katz B, Manschrek TC. Inpatient psychiatry: Perspectives 39. Yasur M. Psychiatrists are abandoning public medicine: The profession from the general, the private and the state hospital. Gen Hosp Psychiatry is in danger. Israel Today, November 6, 2018 (Hebrew). https://www. 1984; 6:180-190. israelhayom.co.il/article/605437?utm_source=mivzakimnet&utm_ 21. Mosher JM. The insane in general hospitals. Am J Insanity 1900; 57:325-329. medium=xhtml&utm_campaign=mivzakimnet (accessed March 31, 2019). 22. Ban TA, Klingner A,Warnes H. Comparing facilities in a psychiatric 40. Ministry of Health 2018. General Report of the Tel Aviv-Jaffa District unit of a general hospital and an admission unit of a psychiatric hospital. 2018, December (Community Medicine Division of the Ministry of Can J Psychiatry 1973; 18:159-162. Health), 2018: p. 39. 23. Barbato A. Psychiatry in transition: Outcomes of mental health policy 41. Liptzin B, Gottlieb GL, Summergrad P. The future of pychiatric services shift in Italy. Aust N Z J Psychiatry 1998; 32: 673-679. in general hospitals. Am J Psychiatry 2007; 164: 1468-1472.

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