Distress with medication side effects among persons with severe mental illness

The lived experience of Omani adolescents and young adults with mental illness: A qualitative study

There is currently limited knowledge about the firsthand experiences of adolescents and young adults with mental health problems and the meanings they ascribe to these experiences, particularly within Arab countries. This study, therefore, aimed to explore the lived experience of Omani adolescents and young adults with a mental health problem. A sample of 15 participants aged 13-22 diagnosed with a range of mental health problems took part in the study. A qualitative interview guide consisting of open-ended questions was used to allow participants to speak in-depth about their experiences. Using the thematic analysis approach to uncover patterns in the data, three major themes emerged: "living in darkness", "perilous journey" and "uncertain future". Results show that the progress of adolescents and young adults with mental health problems is characterized by several challenges; the most significant of which is having insufficient knowledge about their illness, leading to unnecessary delays in their treatment. These findings shed light on the breadth and depth of the experience of adolescents and young adults with mental health problems and lay the groundwork for further examinations. Implications lie in the development of approaches for preventing or mitigating difficulties faced by adolescents and young adults with mental health problems.

Medication Adherence in Patients with Hematologic Malignancies Who Are Hematopoietic Stem Cell Transplantation Survivors: A Qualitative Study

Medication adherence is critical for optimal health outcomes in patients with hematologic malignancies who have undergone allogeneic hematopoietic stem cell transplants (HSCT). However, this population struggles with medication nonadherence. Research that comprehensively describes the complex patient- and medication-related factors which impact medication adherence in this population is lacking. Hence, we used semistructured qualitative interviews to explore the diverse and complex factors contributing to medication adherence in HSCT recipients. We conducted 30 in-depth interviews with patients who were more than 180 days post-allogeneic HSCT at the Dana-Farber Cancer Institute. The interviews explored the physical, social, psychological, and sociodemographic factors that facilitate or discourage adherence to the post-transplantation medication regimen. Interviews were audio-recorded, transcribed, and coded using NVivo software. Two themes emerged that characterized the barriers patients face with their medication regimen. Patients reported factors outside of their control, such as managing multiple pharmacies, health insurance difficulties, and dosage timing, as significant barriers to medication adherence. Patients also reported barriers within their control, such as familial responsibilities. Important facilitators for medication adherence included caregiver and clinician support, previous experience managing a medication regimen, and tools that aid pill organization and timing. Furthermore, patients reported that although medication side effects and quantity of pills did not directly impact medication adherence, it increased their psychological distress. Facilitators and barriers to medication adherence can be physical, psychological, organizational, and social. There are many aspects of medication regimens that significantly increase patient distress. Hence, supportive interventions to improve medication adherence in patients undergoing HSCT may need to incorporate strategies to manage medication side effects and skills to improve psychological well-being and social support.

Exploring mental health clients' current medication knowledge, beliefs and experience with healthcare providers in the community in South Australia

In Australia, mental illness has been recognised as a National Health Priority area, with the coronavirus pandemic adding a layer of urgency to the need to address the multiple health problems faced by clients with mental illnesses. Whilst much has been done in efforts to support these clients, little is known about their medication knowledge and experience with health professionals. The aim of the study was to explore the knowledge and beliefs of clients on the use of psychotropic medications and study their experiences with healthcare providers. Adult participants at a not-for-profit community-managed specialist mental health service provider in Adelaide, South Australia were recruited. Four focus group sessions were conducted between February 2020 and March 2021. All sessions were co-facilitated by a peer practitioner with lived experience. Sessions were audio recorded and transcribed verbatim. Participants (n = 27) reported that provision of medication education was inadequate and, in some cases, non-existent. There was an apparent lack of support for monitoring and managing common side effects, such as weight gain. Participants described not being involved in any decision-making processes and that establishing and maintaining a therapeutic relationship with their healthcare providers was challenging. Perceived stigma remains a barrier in accessing healthcare. Despite participants regularly interacting with a range of healthcare providers, findings highlight key gaps in care, particularly medication education and establishing a therapeutic relationship with their healthcare providers. Future mental health reforms should consider the provision of additional medication education in community settings, such as at not-for-profit organisations. Moreover, healthcare providers should take a proactive approach in establishing therapeutic relationships.

Proxy WHO Disability Assessment Schedule 2.0 Is Clinically Useful for Assessing Psychosocial Functioning in Severe Mental Illness

AIMS

This study explores how well the World Health Organization Disability Assessment Schedule (WHODAS 2.0) assesses problems with psychosocial functioning in patients with severe mental illness (SMI). Further, we assessed the relationships between psychosocial functioning and psychopathology, medication side effects, treatment setting, and quality of life.

METHODS

We performed an observational, cross-sectional study on the island of Curaçao to assess psychosocial functioning in 77 patients with SMI; they mainly had psychotic disorders. We interviewed their healthcare providers using the proxy version of the WHODAS 2.0. In addition, patients were examined for psychiatric symptoms, medication side effects (including drug-induced movement disorders), and quality of life. Associations were examined with Spearman's rank correlation (ρ).

RESULTS

Difficulties in psychosocial functioning were reported by patients with SMI in the WHODAS 2.0 domains of understanding and communicating [mean (M)=34.5, standard deviation (SD)=18.6), participation in society (M=25.5, SD=15.6), and getting along with people (M=24.1, SD=16.1)]. Notably, outpatients had more problems participating in society than inpatients (M=33.6, SD=18.5 versus M=23.2, SD=14.1, p=0.03). A positive correlation was observed between drug-induced parkinsonism and the WHODAS 2.0 total score (ρ =0.30; p=0.02), as well as with various subscales, getting around, and household activities.

CONCLUSION

The proxy version of the WHODAS 2.0 is clinically useful for patients with severe mental illness. The highest scores on the WHODAS 2.0 were found in domains related to interactions with other people and to participation in society. Inpatient status appeared to aid participation in society; this might be due to living in the sheltered clinic environment and its associated daily activities. We further found that drug-induced parkinsonism was associated with a broad spectrum of psychosocial disabilities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02713672; retrospectively registered in February 2016.

Patient preferences concerning the efficacy and side-effect profile of schizophrenia medications: a survey of patients living with schizophrenia

BACKGROUND

Despite the availability of numerous antipsychotic medications, many patients with schizophrenia continue to experience side effects that contribute to the overall burden of the illness. The present survey of patients with schizophrenia and schizoaffective disorder aimed to assess patient attitudes toward antipsychotic treatment, and understand key factors about willingness to try a new medication.

METHODS

A cross-sectional survey was administered to 250 patients with a primary clinical diagnosis of a schizophrenia spectrum disorder across five outpatient clinics in the United States. The survey included self-reported gender, age, weight, and height, and questions about the importance of efficacy and side effects on the decision to take a prescribed antipsychotic medication.

RESULTS

Patients rated efficacy and side effects as important attributes of antipsychotic treatment, with 93.6% and 83.6% of patients listing these as "very" or the "most" important factors in taking prescribed medication. A total of 87.6% of respondents identified the ability to think more clearly as an important property of their medication. Patients identified weight gain, physical restlessness, and somnolence as important side effects of current treatments ("very" or "most" important by 61.6%, 60.8%, and 58.8%, respectively). When asked about willingness to change antipsychotic medication, anticipated weight gain had a negative influence on willingness to try the new treatment, with 22.0% declining to try a medication that would lead to weight gain of 2.7-4.5 kg (6-10 lb), 34.0% declining for anticipated weight gain of 5.0-9.1 kg (11-20 lb), and 52.4% declining for anticipated weight gain greater than 9 kg (20 lbs).

CONCLUSION

Patients living with schizophrenia spectrum disorders are influenced by many factors when considering whether to take their medication, including efficacy and side effects. It is important for clinicians to assess specific patient concerns to develop a comprehensive treatment plan that maximizes adherence to the prescribed therapy.

No Effect of Dose Adjustment to the CYP2D6 Genotype in Patients With Severe Mental Illness

Background: The CYP2D6 enzyme is involved in the metabolism of numerous psychopharmacological drugs. Guidelines recommend how to adjust the dose of medication based on the CYP2D6 genotype. Aims: To evaluate the effect of dose adjustment to the CYP2D6 genotype and phenotype, in patients with severe mental illness (SMI) already receiving psychopharmacological treatment. Methods: A total of 269 psychiatric patients (on the island Curaçao) receiving antipsychotic treatment were genotyped for CYP2D6. Of these, 45 patients were included for dose adjustment according to the clinical guideline of the Royal Dutch Association for the Advancement of Pharmacy, i.e., 17 CYP2D6 poor metabolizers, 26 intermediate metabolizers, and 2 ultrarapid metabolizers. These 45 patients were matched for age, gender, and type of medication with a control group of 41 patients who were CYP2D6 extensive metabolizers (i.e., with a normal CYP2D6 function). At baseline and at 4 months after dose adjustment, subjective experience, psychopathology, extrapyramidal side-effects, quality of life, and global functioning were assessed in these two groups. Results: At baseline, there were no differences between the groups regarding the prescribed dosage of antipsychotics, the number of side-effects, psychiatric symptoms, global functioning, or quality of life. After dose adjustment, no significant improvement in these parameters was reported. Conclusion: In psychiatric patients with SMI already receiving antipsychotic treatment, dose adjustment to the CYP2D6 genotype or phenotype according to the guidelines showed no beneficial effect. This suggests that dose adjustment guidelines are currently not applicable for patients already using antipsychotics. ClinicalTrials.gov: Cost-effectiveness of CYP2D6 and CYP2C19 Genotyping in Psychiatric Patients in Curacao; Identifier: NCT02713672; https://clinicaltrials.gov/ct2/show/NCT02713672?term=CYP2D6&rank=5.

Sex differences in aripiprazole sensitization from adolescence to adulthood

The present study investigated the potential sex differences in repeated aripiprazole (ARI) treatment-induced behavioral sensitization from adolescence to adulthood, and to determine whether ARI sensitization can be transferred to olanzapine (OLZ) and/or clozapine (CLZ) using the conditioned avoidance response (CAR) and phencyclidine-induced (PCP) hyperlocomotion tests of antipsychotic activity. Male and female Sprague-Dawley adolescence rats (P46) were first treated with ARI (10mg/kg) for 5 consecutive days (P46-50) and tested for avoidance response and ARI-induced inhibition of PCP-induced hyperlocomotion. After they became adults (>P68), rats were challenged with ARI (1.5mg/kg, sc) (P70), OLZ (0.5mg/kg, sc; P73), CLZ (5mg/kg, sc; P76) and again with ARI (1.5mg/kg, sc; P84) and tested for avoidance response and ARI-induced inhibition of PCP-induced hyperlocomotion again. During the drug treatment period in adolescence, repeated ARI treatment suppressed avoidance response, inhibited the PCP-induced hyperlocomotion, and these effects were progressively increased across the 5-day period in both males and females, confirming the induction of ARI sensitization. On the challenge days, rats previously treated with ARI in adolescence also had significantly lower avoidance and lower PCP-induced hyperlocomotion than the previous vehicle rats, confirming the expression of ARI sensitization and its persistence into adulthood. More importantly, female rats made significantly more avoidances than males in both ARI and vehicle groups, indicating higher sensitivity to the acute and long-term effects of ARI. Further, on the OLZ and CLZ challenge days, prior ARI treatment seemed to increase sensitivity to OLZ exposure, however, this increase was not significant. Similarly, rats also showed an ARI sensitization to OLZ and CLZ on challenge days. Collectively, results from this experiment demonstrated a sex difference in response to ARI and enhanced inhibition of PCP-induced hyperlocomotion in animals that were pretreated with ARI as compared to controls.

Improving medication adherence for severely mentally ill adults by decreasing coercion and increasing cooperation

Severe mental illnesses, mainly schizophrenia and bipolar disorders, often go untreated until the afflicted persons become dangerous to themselves or others. In such states, they must be hospitalized and medicated, often involuntarily due to the stigma and low insight into need for treatment that can be considered characteristic of severe illnesses. Hospitalization and medications can help the mentally ill stabilize. But these options also can have a demoralizing effect on future engagement with providers. Accordingly, the process of involuntary hospitalization and medication treatment must be maximally dignified and respectful of patient autonomy, within the limits of manifest illnesses. Literature that was reviewed and synthesized suggests best practice strategies for helping involuntary mentally ill patients grow into voluntary consumers of medication. In turn, risk of relapse is lowered and quality of life is enhanced. Best practice strategies included decreasing usage of coercive tactics, helping patients cope with medication side effects, and emphasizing the necessity of family involvement. The authors conclude with a review of the limitations of arguing for involuntary hospitalization and treatment as restoring patient autonomy, along with implications for future practice focusing on increasing the medication adherence of severely mentally ill populations.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness

BACKGROUND

Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system.

METHODS

We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics.

RESULTS

Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk.

LIMITATIONS

This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made.

CONCLUSIONS

Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Gender differences in antipsychotics prescribed to veterans with serious mental illness

OBJECTIVE

To examine gender differences in prescribing of antipsychotic medications (APMs) according to their liability for weight gain and other metabolic side effects.

METHOD

We identified 4510 patients with schizophrenia or bipolar disorders receiving usual care in a Veterans Affairs (VA) health care network in the U.S. mid-Atlantic region who initiated treatment with an APM between October 2006 and September 2011. We used multivariable logistic regression to examine gender differences in the likelihood of incident prescription of APMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and selected Veteran demographic, mental health and physical health characteristics.

RESULTS

Overall, 58% of women were prescribed an APM with a low risk of metabolic side effects compared to 45% of men (P<.001). In multivariable analysis, women Veterans were 1.47 times as likely as men to be prescribed a low-metabolic-risk APM (95% confidence interval: 1.26-1.73, P<.001). Several demographic and clinical covariates were also independently related to prescribing of APMs by level of metabolic risk.

CONCLUSIONS

The results may suggest that prescribing choices for APMs by VA mental health prescribers and female Veterans reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Prediction and prevention of the first psychotic episode: new directions and opportunities

In the last few decades, substantial research has focused on the possibility of early detection and prevention of the first psychotic episode in young individuals at risk of developing this mental disturbance; however, unresolved clinical and ethical issues still call for further investigations. New perspectives and opportunities may come from the identification of selective psychopathological and instrumental markers linking the appearance of subtle psychotic symptoms with the clinical outcome of specific mental pathologies. Furthermore, empirically derived algorithms and risk staging models should facilitate the identification of targeted prevention therapies, possibly improving the efficacy of well-tolerated therapeutic approaches, such as psychological interventions and natural compound supplementations. To date, the collected evidence on the efficacy and tolerability of pharmacological prevention therapies raises more doubts than hopes. A very early detection of risk and appropriate symptomatic pattern classifications may provide a chance to better match prevention strategies with the development of psychosis.

Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients

We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic medication (AP).

METHOD

A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP.

RESULTS

In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100 mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE.

CONCLUSION

There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.

Weight gain associated with taking psychotropic medication: an integrative review

People with serious mental illness have higher morbidity and mortality rates than general populations, and overweight/obesity-related conditions are prevalent. Psychotropic medications are a primary factor in significant weight gain. Adolescents and young adults, particularly those with first-episode psychoses taking atypical antipsychotics, are susceptible to weight gain. This paper reports findings from an integrative review of research investigating the impact and treatment of psychotropic-induced weight gain. Four databases were searched, yielding 522 papers. From these and hand-searched papers, 36 research reports were systematically classified and analysed. The review revealed people experiencing psychotropic-induced weight gain perceive it as distressing. It impacts on quality of life and contributes to treatment non-adherence. Weight management and prevention strategies have primarily targeted adults with existing/chronic illness rather than those with first-episode psychoses and/or drug naiveté. Single and multimodal interventions to prevent or manage weight gain produced comparable, modest results. This review highlights that the effectiveness of weight management interventions is not fully known, and there is a lack of information regarding weight gain prevention for young people taking psychotropics. Future research directions include exploring the needs of young people regarding psychotropic-related weight gain and long-term, follow-up studies of lifestyle interventions to prevent psychotropic-related weight gain.

Implications of CATIE for mental health services researchers

The authors discuss the implications of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for mental health services researchers, in particular the need to monitor and change prescriber behavior to encourage informed medication selection. Given the complexity and variability of response to antipsychotic medications in CATIE, use of restricted formularies is not the answer. Rather, services researchers should collaborate with service systems to develop interventions to identify questionable prescriber practices and develop interventions to change them. The CATIE results also suggest that some quality measures for antipsychotic treatment, such as the proportion of a population taking second-generation antipsychotics, need to be revisited by researchers. Also, because the CATIE findings highlighted the prevalence of cardiac and metabolic disorders among treatment populations and the potential impact of antipsychotics on these conditions, services researchers should use secondary data to monitor whether prescribers are providing appropriate screening and treatment. Given the health risks of some antipsychotics, services researchers should develop ways to identify individuals at risk, encourage behavior change among prescribers, and support informed and shared decision making about medications. Mental health services researchers can build relationships with multiple stakeholders, including service system administrators, service providers, and consumers, to help translate results from trials such as CATIE into policy and practice.