Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care

Characteristics associated with psychiatrist-reported treatment-compliance problems were investigated using the 1999 Study of Psychiatric Patients and Treatments from the Practice Research Network of the American Psychiatric Institute for Research and Education (n=1,843). Logistic regression was used to study characteristics associated with compliance problems as perceived by treating psychiatrists. Among the 22 potential predictors of interest, all but three (age, gender, and problems with primary support group) were found to be significantly associated with treatment-compliance problems in bivariate analyses. A predictive model was developed consisting of eight independently significant predictors from diagnostic, clinical, psychosocial, and treatment-history domains. These predictors included substance use disorder diagnosis, medication side effects, moderate to severe psychotic symptoms, personality disorder diagnosis, economic problems, prior hospitalization, current Global Assessment of Functioning scale score, and duration of treatment with current psychiatrist. This predictive model correctly identified the presence or absence of treatment-compliance problems in 91% of patients in a sample randomly drawn from the dataset before model construction. These findings may be useful to clinicians, researchers, and program planners interested in addressing the important issue of treatment-compliance problems in psychiatric care settings.

Social risk and protective factors for suicide attempts in low income African American men and women

A case-control study was conducted to examine a broad array of potential social risk and protective factors for suicide attempt among 200 African American men and women receiving care at a large, public, urban hospital. Specifically, we examined the effect of the following potential risk factors for suicide attempt: life hassles, partner abuse, partner dissatisfaction, and racist events; as well as the following potential protective factors: effectiveness of obtaining resources, social embeddedness, and social support. Using logistic regression, suicide attempter status was predicted by two independently significant social variables: one risk factor (life hassles) and one protective factor (social support). Male versus female suicide attempters were not distinguished by the social variables. These findings, which support the utility of an ecological conceptualization of risk and protective factors for suicide attempt, help to clarify the independently significant social environment risk and protective factors for suicide attempts among economically disadvantaged African Americans in particular. Research on both risk factors and protective factors provide a basis for culturally competent interventions aimed at reducing both the risk of future suicide attempts and completions.

Smoking behavior in persons with a schizophrenia-spectrum disorder: a qualitative investigation of the transtheoretical model

Smoking rates among persons with schizophrenia are up to three times the rates of the general US population, and research has shown that it is difficult to design cessation programs for people with schizophrenia that take into account their various cognitive and social deficits. More research is needed on the attitudes and priorities of people with schizophrenia in order to design and implement effective smoking cessation programs. Additionally, more research should be conducted with first-episode psychosis and chronic schizophrenia patients to investigate possible differences between these two groups. The purpose of this study, conducted in Atlanta, USA, was to use qualitative methodology to assess the Transtheoretical Model (TTM) in the context of smoking behavior in a sample of participants with schizophrenia-spectrum disorders. Data were obtained via interviews with 12 participants with either first-episode or chronic schizophrenia-spectrum disorders who smoked cigarettes. Differences between the two subsets of the sample were assessed. Results clustered into the following prevalent themes: (1) pros and cons of smoking; (2) beliefs about smoking cessation; (3) external influences on smoking and quitting; and (4) negative attitudes toward nicotine replacement therapies (NRT). Findings indicate that the majority of participants were in the precontemplation stage of quitting smoking, and that the primary advantages of smoking for this sample were relief from anxiety and negative symptoms. Important differences were found between chronic and first-episode participants in the areas of readiness-to-quit and beliefs about smoking cessation. Other findings indicate a lack of cessation programs offered to this sample, and overall negative attitudes toward NRT. Future interventions should take into account the reported pros and cons of smoking in this population, as well as other beliefs and attitudes regarding smoking behavior.

Treatment delay in first-episode nonaffective psychosis: a pilot study with African American family members and the theory of planned behavior

This pilot study examined associations between three central constructs of the theory of planned behavior and the length of treatment delay among patients hospitalized for a first episode of nonaffective psychosis. The sample consisted of 21 relatives directly involved in initiating hospitalization for 14 first-episode patients. Spearman correlation coefficients were calculated to test associations between length of treatment delay and the hypothesized predictors. One of the 3 theory of planned behavior constructs, perceived behavioral control (PBC), was significantly inversely correlated with treatment delay (p = -0.44, P = .04). The other 2 theory constructs were not significant correlates. Perceived stigma was significantly inversely correlated with PBC (p = -0.51, P = .02). There has been no prior research using health behavior theories to study potential predictors of treatment delay or the duration of untreated psychosis. Findings from this pilot study indicate that some health behavior theory constructs, including PBC, may be useful in future early intervention efforts.

Self-reported psychotic symptoms predict impulsivity among African-American patients in an urban non-psychiatric medical setting

A variety of epidemiological studies have documented self-reported psychotic symptoms among individuals in the general population. Research has not been conducted on the associations between self-reported psychotic symptoms and enduring personality characteristics, such as impulsivity, among participants in non-psychiatric settings. We hypothesized that impulsivity scores, as measured by the Barratt Impulsiveness Scale (BIS-11), would be predicted partly by the presence of one or more of a variety of positive psychotic experiences, determined by the revised Symptom Checklist-90. The sample consisted of 100 African-American men and women seeking care in medical clinics in an urban public sector hospital. The sample was divided into those participants endorsing one or more of six psychotic symptoms and those not reporting psychotic symptoms. Multiple linear regression models examined predictors of impulsivity (as measured by the BIS-11 total score and the two derived subscales), including the effect of self-reported positive psychotic symptoms. The presence of psychotic symptoms was predictive of the total impulsivity score and the ideo-motor impulsivity subscale score, even after adjustment for the effects of other correlates of impulsivity, including gender, homelessness, history of conviction for a misdemeanor or felony, and history of past treatment or hospitalization for psychiatric or substance abuse problems. The findings suggest that there is an important link between the presence of self-reported psychotic symptoms and impulsivity, especially ideo-motor impulsivity, in a general sample of low-income African-American men and women seeking ambulatory medical care. Further research on self-reported psychotic symptoms in non-psychiatric populations is needed, as well as research on the personality correlates of such symptoms, including impulsivity.

Inverse correlations between symptom scores and spiritual well-being among African American patients with first-episode schizophrenia spectrum disorders

Spirituality, religiosity, and spiritual/religious well-being are relatively understudied in the context of severe mental illnesses. Nonetheless, individuals dealing with such disorders, including schizophrenia, often make use of spirituality and religious affiliation as coping resources. In this preliminary study, we examined correlations between psychopathology severity and spiritual well-being among first-episode schizophrenia-spectrum disorder patients. The sample consisted of 18 African American patients hospitalized on an inpatient psychiatric unit in a large, urban, public hospital. After confirmation of diagnosis with the Structured Clinical Interview for DSM-IV Axis I Disorders, symptom severity was rated with the Positive and Negative Syndrome Scale, and self-reported spiritual well-being was evaluated with the Spiritual Well-Being Scale. Spearman correlations revealed that negative symptom scores were inversely correlated with religious well-being scores (rho = -.614; p = 0.007), and that general psychopathology symptom scores were inversely correlated with existential well-being scores (rho = -.539; p = 0.021). These preliminary findings indicate that negative symptoms and general psychopathology symptoms may have a detrimental effect on religious and existential well-being in patients with a first episode of a schizophrenia-spectrum disorder, or that religious and existential well-being may have an effect on symptomatology.

Social environment factors associated with suicide attempt among low-income African Americans: the protective role of family relationships and social support

BACKGROUND

Suicide and suicide attempts are important public health concerns, and recent decades have witnessed a rising rate of suicide among African Americans. A history of prior attempts is a leading risk factor for completed suicide. Further research is needed into the social environment risk factors for suicide attempt among African Americans. This study focused on two important dimensions of the social environment, family relationships and social support, as well as an important person-level risk factor--depressive symptoms.

METHOD

Data were obtained from a case-control study of 200 African American men and women aged 18-64 years, who sought services at a large, urban, public hospital. Odds ratios adjusted for significant sociodemographic differences between groups (aORs) were calculated for environment risk factors for suicide attempt among the cases and controls. The role of depressive symptoms was also studied.

RESULTS

Lower levels of family adaptability and family cohesion increased the relative rate of suicide attempt in the sample. The aOR associated with the lowest quartile of family adaptability was 3.90, and the aORs associated with the first and second quartiles of family cohesion were 8.91 and 5.51, respectively. Lower levels of social embeddedness and social support increased the relative rate of suicide attempt in our sample. The aOR associated with the first and second quartiles of social embeddedness were 5.67 and 4.93, respectively, and the aOR associated with the lowest quartile of social support was 6.29. A mediating role of depression was discovered when depressive symptoms were entered into the logistic regression models.

CONCLUSIONS

Our findings indicate that social environment factors including deficits in family functioning and social support are associated strongly with suicide attempts among low-income African American men and women seeking treatment in a large, urban hospital. Thus, better family functioning and social supports can be considered protective factors in this population. The presence of depressive symptoms, a well-known risk factor for suicide attempts and suicide, appears to mediate the association between social environment factors and suicide attempt.

Barriers to initial outpatient treatment engagement following first hospitalization for a first episode of nonaffective psychosis: a descriptive case series

Due to the increasingly recognized importance of adequate treatment early in the course of schizophreniform disorder and schizophrenia, this report addresses the dearth of hypothesis-generating case series describing facilitators and barriers to engagement in initial outpatient care. This case series included six single, African-American first-episode patients. Narratives describing the initial hospitalization and the first outpatient appointments in an urban community mental health setting are presented. Several barriers to outpatient treatment engagement emerged from this relatively homogenous series of first-episode patients. Apparent barriers included inadequate remission of paranoia, impaired insight, and involvement with the criminal justice system between hospital discharge and the first outpatient appointment. Good family support appeared to be an important facilitator of treatment engagement during the first several months of outpatient treatment. A variety of other potential barriers, such as involuntary status at the time of hospital discharge, are considered. Though these are preliminary findings from a small case series, further research, based at least in part on the hypotheses generated here, is warranted. Many factors, at the level of the patient, the family, and the system of care, likely affect treatment engagement early in the course of schizophreniform disorder and schizophrenia. Clinicians should give special attention to this issue when caring for first-episode patients.

Preliminary evidence of an association between childhood abuse and cannabis dependence among African American first-episode schizophrenia-spectrum disorder patients

Cannabis dependence is a prevalent comorbid substance use disorder among patients early in the course of a schizophrenia-spectrum disorder. Determining risk factors for substance abuse may be helpful in designing interventions to reduce the psychosocial morbidity associated with substance abuse among this population. This study aimed to determine whether or not African American, socially disadvantaged, first-episode schizophrenia-spectrum patients with cannabis dependence experienced greater levels of childhood abuse and neglect compared to similar patients without comorbid cannabis dependence. Among 29 eligible patients, 18 participated in this pilot study. First-episode patients with comorbid cannabis dependence (n = 8) reported significantly greater childhood physical and sexual abuse compared to those without comorbid cannabis dependence (n = 10). This represents preliminary evidence of an association between childhood maltreatment and cannabis dependence among this especially vulnerable population. Childhood physical and sexual abuse may be a risk factor for the initiation of cannabis dependence and other substance use disorders in the early course of schizophrenia.

Lower negative symptom scores among cannabis-dependent patients with schizophrenia-spectrum disorders: preliminary evidence from an African American first-episode sample

Substance use disorders, especially cannabis abuse and dependence, are common comorbid diagnoses among patients in the early course of schizophrenia. Some prior research suggests that individuals with schizophrenia and related disorders and comorbid substance abuse may have fewer negative symptoms than those without substance abuse. This pilot study examined the association between cannabis dependence and negative symptoms in a relatively homogenous sample of 18 African American first-episode, first-hospitalization patients. Those with cannabis dependence had significantly lower Positive and Negative Syndrome Scale (PANSS) negative subscale scores compared to those without cannabis dependence (p<0.012). The two groups did not differ on PANSS positive and general psychopathology subscale scores. Additional research is needed on the correlates of substance abuse among first-episode patients, including socially disadvantaged African American patients.

A case of Sotos syndrome (cerebral gigantism) and psychosis

Sotos syndrome, or cerebral gigantism, is a syndrome of accelerated growth during early childhood, and a number of craniofacial and other physical abnormalities are commonly present. Behavioral and psychiatric manifestations of the disorder include attention deficits, aggressiveness, and social inhibition. The authors describe a case of psychosis that developed in a patient with Sotos syndrome.

Observations on parent/family factors that may influence the duration of untreated psychosis among African American first-episode schizophrenia-spectrum patients

The duration of untreated psychosis (DUP) is a concept of importance in schizophrenia research from the perspective of secondary prevention. Although findings to date are mixed, several studies have demonstrated an inverse association between the duration of treatment delay and a variety of clinical and psychosocial outcomes. Research is needed to better understand the multifactorial determinants of the DUP and family-level influences on the DUP may prove to be important predictors. The authors present basic descriptive statistics and case histories of 10 parents/siblings of 6 African American first-episode patients. The mean DUP reported by the family members (five mothers, two fathers, one stepfather and two siblings) was 59.5 weeks (range 2-234). Family members' levels of knowledge of schizophrenia may not necessarily have a major impact upon the length of treatment delays. Among this small sample of relatives, early psychotic symptoms were often attributed to depression, lack of motivation or relational stressors. Family members' decisions to seek help often were solidified only after the emergence of unbearable psychotic symptoms or socially disruptive behaviors. Low concordance among family members' reports of the DUP and perceived barriers to accessing psychiatric services were unexpected findings. These preliminary observations may serve to generate hypotheses for further research that aims to elucidate the determinants of treatment delays in the early course of schizophrenia, especially among African American populations.

Considering schizophrenia from a prevention perspective

Schizophrenia is a serious mental illness that causes major disability and psychosocial impairment. Recent advances in the neurosciences are prompting considerations of schizophrenia from a preventive perspective. An overview of the literature is provided on two important aspects of the development of a prevention orientation in schizophrenia research: elucidation of potential causal risk factors for schizophrenia and research on risk markers. Risk factors for schizophrenia include, but are not limited to, family history, older paternal age, velo-cardio-facial syndrome, maternal infections during pregnancy, pregnancy and delivery complications, and social adjustment difficulties in childhood and adolescence. Potential risk markers include structural brain pathology, minor physical anomalies and dermatoglyphic abnormalities, neurocognitive deficits, eye-tracking dysfunction, certain electrophysiologic findings, and olfactory identification deficits. Several early efforts at indicated preventive interventions targeting individuals at particularly high risk for developing the disorder are discussed. The preventive medicine and public health disciplines may have a role in future research and interventions that apply a preventive perspective to schizophrenia and other mental illnesses. Like any other chronic medical condition, schizophrenia can be considered from a preventive perspective.

Internet delusions

As the use of computers, the Internet, and Internet technology becomes more pervasive in society, psychopathological thought content characterized by the incorporation of the Internet into delusions and hallucinations will become increasingly common. In the following report, three cases of psychotic inpatients are briefly presented to exemplify this trend in pathoplasticity. Interestingly, patients with no real familiarity with the Internet may just as readily incorporate such computer-associated themes into delusional thought patterns. Clinicians should be familiar with the tendency for delusional thoughts to draw from ideas important to society in general. Several interesting points about these cases include the increasing prevalence of Internet delusions, the complete unfamiliarity of two of the patients with the Internet and computers in general, and the tendency for such delusions to be of the controlling, broadcasting, and persecutory types.

Antipsychotic-induced hyperprolactinemia and sexual dysfunction

This overview of antipsychotic-induced hyperprolactinemia provides a summary of the current literature in relation to conventional antipsychotic agents and the five atypical antipsychotics currently available in the United States--clozapine, risperidone, olanzapine, quetiapine, and ziprasidone. Dopaminergic antagonism within the tuberoinfundibular system causes elevation in plasma prolactin levels. Conventional antipsychotic medications and the atypical agent risperidone cause significant elevations in prolactin. Clozapine, olanzapine, quetiapine, and ziprasidone cause minimal effects on prolactin levels in adults, which may be due to a higher 5-HT2A:D2 binding ratio and differential effects on dopamine neurotransmission, with less interference in the tuberoinfundibular pathway. Antipsychotic-induced hyperprolactinemia presumably causes clinical side effects similar to those caused by other forms of hyperprolactinemia. Clinical and endocrinologic changes of hypogonadism also likely occur during chronic antipsychotic-induced hyperprolactinemia. Because hyperprolactinemia may cause clinically significant side effects in patients treated with antipsychotic medications, clinicians should be familiar with the evaluation and treatment of antipsychotic-induced hyperprolactinemia.