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Seet V, Lee YY, Chua YC, Verma SK, Subramaniam M. Self-stigma and quality of life among people with psychosis: The protective role of religion. Early Interv Psychiatry 2024; 18:338-345. [PMID: 37726099 DOI: 10.1111/eip.13469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/12/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023]
Abstract
AIM The quality of life in people with psychosis has been consistently demonstrated to be lower than those without, with self-stigma contributing greatly to this impairment. Hence, it is imperative to address this gap in order to facilitate recovery-oriented and other outcomes. This study investigates the potential of religiosity in moderating the effects of self-stigma on quality of life among those with psychosis. METHODS Adults with psychosis (n = 99) were recruited from the Early Psychosis Intervention Programme in Singapore from 2018 to 2021, and administered the self-report Religious Commitment Index, Internalized Stigma of Mental Illness scale, and Abbreviated World Health Organization Quality of Life instrument. Linear regression analyses were conducted and the interaction between self-stigma and religious commitment scores calculated to investigate the moderation effects of religiosity on the relationship between stigma and quality of life. RESULTS Preliminary regression analyses revealed a significant association between sex and psychological quality of life. After controlling for sex, religiosity was found to moderate the relationship between self-stigma and psychological quality of life. CONCLUSIONS The results of the study demonstrate the potential of religiosity in buffering the effects of self-stigma on quality of life. This reveals an area that can be easily targeted and addressed in treatment programs to improve outcomes beyond the clinical setting among people living with psychosis, to facilitate their recovery journey and beyond.
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Affiliation(s)
- Vanessa Seet
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Ying Ying Lee
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Yi Chian Chua
- Early Psychosis Intervention Programme, Institute of Mental Health, Singapore, Singapore
| | - Swapna Kamal Verma
- Early Psychosis Intervention Programme, Institute of Mental Health, Singapore, Singapore
- Education Office, Duke-NUS Medical School, Singapore, Singapore
| | - Mythily Subramaniam
- Research Division, Institute of Mental Health, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Neil AL, Chappell KJ, Nevarez-Flores AG, Waterreus A, Ambrosi TL, Morgan VA. Exploring the relationship between baseline health-related quality of life (AQoL-4D utility values) and mortality during long-term follow-up for people living with a psychotic disorder. Schizophr Res 2023; 262:121-129. [PMID: 37948885 DOI: 10.1016/j.schres.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
Holistic summary measures of health-related quality of life (HRQoL) could provide useful information for screening and/or monitoring high-risk individuals. This study explores the association of baseline HRQoL (AQoL-4D values) with death from natural and external causes (such as suicide, overdose, or accident) in a prevalent cohort over a mean follow-up of 6.9-years. Baseline data were obtained from the 2010 National Survey of High Impact Psychosis (SHIP) and its 2012 sister survey, the North-Metro Survey of High Impact Psychosis. Follow-up data were obtained from the National Deaths Index (to January 18, 2018). Associations between baseline HRQoL (and the 12 individual items of the AQoL-4D) and deaths by cause, stratified by sex were investigated using multivariable Cox Proportional Hazards models, with age used as the time scale. Overall, 7.6 % of the cohort (137 of 1805 people meeting ICD-10 criteria for a psychotic disorder and agreeing to linkage) died, 4.2 % from natural causes (primarily heart disease and cancer) and 3.4 % from external causes. There was an association between low HRQoL (AQoL-4D ≤ 0.20) and mortality due to natural causes, primarily driven by difficulties with mobility and vision in men, and difficulty with household tasks in women. No significant associations were obtained between AQoL-4D utilities and death from external causes. Sleep problems were associated with death from external causes for men only. As people with psychotic disorders experience multiple causes of death with complex associations which are difficult to quantify, monitoring for low HRQoL using the AQoL-4D could be a useful indicator of increased mortality risk in this population. TWITTER: Monitoring for low HRQoL (AQoL-4D ≤ 0.20) could be a useful indicator of increased mortality risk from natural causes in people living with psychotic disorders, with differing but specific items of relevance to men and women.
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Affiliation(s)
- Amanda L Neil
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; The ALIVE National Centre for Mental Health Research Translation, University of Tasmania, Hobart, Tasmania, Australia.
| | - Katherine J Chappell
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Adriana G Nevarez-Flores
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; The ALIVE National Centre for Mental Health Research Translation, University of Tasmania, Hobart, Tasmania, Australia
| | - Anna Waterreus
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Taryn L Ambrosi
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Vera A Morgan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia; The ALIVE National Centre for Mental Health Research Translation, The University of Western Australia, Perth, Western Australia, Australia
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3
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Nevarez-Flores AG, Chappell KJ, Morgan VA, Neil AL. Health-Related Quality of Life Scores and Values as Predictors of Mortality: A Scoping Review. J Gen Intern Med 2023; 38:3389-3405. [PMID: 37653208 PMCID: PMC10682357 DOI: 10.1007/s11606-023-08380-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
Health-related quality of life (HRQoL) can be assessed through measures that can be generic or disease specific, encompass several independent scales, or employ holistic assessment (i.e., the derivation of composite scores). HRQoL measures may identify patients with differential risk profiles. However, the usefulness of generic and holistic HRQoL measures in identifying patients at higher risk of death is unclear. The aim of the present study was to undertake a scoping review of generic, holistic assessments of HRQoL as predictors of mortality in general non-patient populations and clinical sub-populations with specified conditions or risk factors in persons 18 years or older. Five databases were searched from 18 June to 29 June 2020 to identify peer-reviewed published articles. The searches were updated in August 2022. Reference lists of included and cited articles were also searched. Of 2552 articles screened, 110 met criteria for inclusion. Over one-third of studies were from North America. Most studies pertained to sub-populations with specified conditions and/or risk factors, almost a quarter for people with cardiovascular diseases. There were no studies pertaining to people with mental health conditions. Nearly three-quarters of the studies used a RAND Corporation QoL instrument, predominantly the SF-36, and nearly a quarter, a utility instrument, predominantly the EQ-5D. HRQoL was associated with mortality in 67 of 72 univariate analyses (92%) and 100 of 109 multivariate analyses (92%). HRQoL was found to be associated with mortality in the general population and clinical sub-populations with physical health conditions. Whether this relationship holds in people with mental health conditions is not known. HRQoL assessment may be useful for screening and/or monitoring purposes to understand how people perceive their health and well-being and as an indicator of mortality risk, encouraging better-quality and timely patient care to support and maximize what may be a patient's only modifiable outcome.
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Affiliation(s)
| | - Katherine J Chappell
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Vera A Morgan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia
| | - Amanda L Neil
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
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4
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Nevarez-Flores AG, Breslin M, Carr VJ, Morgan VA, Waterreus A, Harvey C, Sanderson K, Neil AL. Health-related quality of life in people with psychotic disorders: The role of loneliness and its contributors. Aust N Z J Psychiatry 2022; 56:1421-1433. [PMID: 35075914 DOI: 10.1177/00048674211072437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perception of loneliness has been identified as the strongest predictor of health-related quality of life assessed with the Assessment of Quality of Life-4D in people with psychotic disorders. We aimed to establish contributors to perceived loneliness, and ascertain the mediating role of loneliness in the relationship between identified contributors to loneliness and other known predictors of health-related quality of life with health-related quality of life. METHODS Data for 1642 people collected as part of the 2010 Australian National Survey of Psychosis were analysed. Health-related quality of life was assessed using the Assessment of Quality of Life-4D, and loneliness through a single-item five-level categorical variable. To identify independent contributors to loneliness, a statistical model was constructed with reference to a theoretical model comprising 23 variables. A predictive model with health-related quality of life as the dependent variable was then developed and tested to assess the mediating role of loneliness. RESULTS Nine contributors to loneliness were found (social dysfunction, experienced stigma, contact with friends, diagnosis, depressive symptoms, anxiety, mental health service utilisation, arthritis and traumatic events in childhood), with social dysfunction the strongest. In the prediction of health-related quality of life, all contributors to loneliness were partially mediated through loneliness (except service utilisation) as were negative symptoms and use of psychotropic/anticholinergic medications. CONCLUSION Assuming a plausible causal model of mediation, loneliness was found to have direct and indirect effects on health-related quality of life in people with psychotic disorders. Findings add impetus to efforts to develop and trial strategies aimed at reducing loneliness in this population, and, in turn, improving their health-related quality of life.
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Affiliation(s)
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Vaughan J Carr
- Research Unit for Schizophrenia Epidemiology, School of Psychiatry, University of New South Wales, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Department of Psychiatry, School of Clinical Sciences, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Vera A Morgan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia.,Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Anna Waterreus
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia.,Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Carol Harvey
- Psychosocial Research Centre, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.,North Western Mental Health, Melbourne, VIC, Australia
| | - Kristy Sanderson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,School of Health Sciences, University of East Anglia, Norwich, UK
| | - Amanda L Neil
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
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5
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Perez CSDH, Ciufolini S, Sood PG, Krivoy A, Young AH, Murray RM, Ismail K, Atakan Z, Greenwood K, Smith S, Gaughran F, Juruena MF. Predictive value of cardiometabolic biomarkers and depressive symptoms for symptom severity and quality of life in patients with psychotic disorders. J Affect Disord 2022; 298:95-103. [PMID: 34699852 DOI: 10.1016/j.jad.2021.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/11/2021] [Accepted: 10/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with psychotic disorders show higher rates of the metabolic syndrome (MS) between the cluster of severe mental illnesses. Depressive symptoms can worsen outcomes of individuals with psychotic disorders. However, research on the association between MS and depression in psychotic disorders and their relevance to outcomes is lacking. METHODS We investigated the association between depression and cardiometabolic biomarkers in psychotic disorders and the predictive value of depressive symptoms on psychopathological severity and quality of life (QoL). 406 patients with psychotic disorders were recruited as part of the Improving Physical Health and Reducing Substance Use in Severe Mental Illness randomised controlled trial. Depression, psychotic symptoms, QoL, waist circumference, triglycerides, high-density lipoprotein cholesterol (HDL-C), blood pressure, and fasting glucose of patients were assessed at baseline and 12 months. Sensitivity analyses were conducted to test the effect of treatment. RESULTS More severe baseline symptoms of depression significantly predicted worse 12-month psychotic symptoms and lower mental health related QoL at 12 months. These associations held after controlling for alcohol use, gender, ethnicity, education, and mental health related QoL Baseline. Depressive symptoms also correlated with waist circumference at both baseline and 12 months, after controlling for multiple testing. CONCLUSION Individuals with psychotic disorders experiencing more severe depressive symptoms are more likely to have larger waist circumference contemporaneously and 12 months later, as well as more severe psychotic symptoms and worse QoL at follow-up. This highlights the need for evaluation of strategies to address depression in the management of psychotic disorders.
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Affiliation(s)
| | - Simone Ciufolini
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | | | - Amir Krivoy
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Allan H Young
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Khalida Ismail
- Professor of Psychiatry and Medicine, Dept of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, United Kingdom
| | - Zerrin Atakan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, Kings' College London, Denmark Hill, London, United Kingdom
| | - Kathryn Greenwood
- Clinical Research Fellow, Sussex Partnership NHS Foundation Trust, and Hon Senior Research Fellow, School of Psychology, University of Sussex
| | - Shubulade Smith
- Clinical Senior Lecturer, Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London
| | - Fiona Gaughran
- Lead Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust and Professor, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, United Kingdom
| | - Mario F Juruena
- Lead Consultant Psychiatrist, Maudsley Advanced Treatment Service, South London and Maudsley NHS Foundation Trust and Clinical Senior Lecturer in Translational Psychiatry, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
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6
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Raciborski RA, Woodward EN, Painter JT. Economic analyses of behavioral health intervention implementation: Perspective on stakeholder engagement. Front Psychiatry 2022; 13:1031325. [PMID: 36620658 PMCID: PMC9815616 DOI: 10.3389/fpsyt.2022.1031325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.
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Affiliation(s)
- Rebecca A Raciborski
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Jacob T Painter
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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7
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Hoertel N, Rotenberg L, Blanco C, Camus V, Dubertret C, Charlot V, Schürhoff F, Vandel P, Limosin F. A comprehensive model of predictors of quality of life in older adults with schizophrenia: results from the CSA study. Soc Psychiatry Psychiatr Epidemiol 2021; 56:1411-1425. [PMID: 32415431 DOI: 10.1007/s00127-020-01880-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 05/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Numerous factors are known to influence quality of life of adults with schizophrenia. However, little is known regarding the potential predictors of quality of life in the increasing population of older adults with schizophrenia. The main objective of the present study was to propose a comprehensive model of quality of life in this specific population. METHODS Data were derived from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia or schizoaffective disorder recruited from French community mental-health teams. We used structural equation modeling to simultaneously examine the effects of six broad groups of clinical factors previously identified as potential predictors of quality of life in this population, including (1) severity of general psychopathology, (2) severity of depression, (3) severity of cognitive impairment, (4) psychotropic medications, (5) general medical conditions and (6) sociodemographic characteristics. RESULTS General psychopathology symptoms, and in particular negative and depressive symptoms, cognitive impairment, reduced overall functioning and low education were significantly and independently associated with diminished quality of life (all p < 0.05). Greater number of medical conditions and greater number of antipsychotics were also independently and negatively associated with quality of life, although these associations did not reach statistical significance in sensitivity analyses, possibly due to limited statistical power. CONCLUSION Several domains are implicated in quality of life among older adults with schizophrenia. Interventions targeting these factors may help improve importantly quality of life of this vulnerable population.
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Affiliation(s)
- Nicolas Hoertel
- DMU Psychiatrie et Addictologie, Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, Centre Ressource Régional de Psychiatrie du Sujet Agé (CRRPSA), Hôpital Corentin Celton, AP-HP.Centre, Université de Paris, Paris, France. .,Inserm U1266, Institut de Psychiatrie et Neurosciences de Paris, Paris, France. .,Faculté de Médecine Paris Descartes, Université de Paris, Paris, France.
| | - Léa Rotenberg
- DMU Psychiatrie et Addictologie, Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, Centre Ressource Régional de Psychiatrie du Sujet Agé (CRRPSA), Hôpital Corentin Celton, AP-HP.Centre, Université de Paris, Paris, France
| | - Carlos Blanco
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, USA
| | | | - Caroline Dubertret
- Inserm U1266, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Psychiatry, AP-HP, Louis Mourier Hospital, Colombes, France.,Faculté de médecine Paris Diderot, Université de Paris, Paris, France
| | - Véronique Charlot
- Department of Psychiatry, AP-HP, Louis Mourier Hospital, Colombes, France.,Faculté de médecine Paris Diderot, Université de Paris, Paris, France
| | - Franck Schürhoff
- AP-HP, DHU PePSY, Hôpitaux Universitaires Henri-Mondor, Pôle de Psychiatrie, 94000, Créteil, France.,Inserm, U955, Team 15, 94000, Créteil, France.,Fondation FondaMental, 94000, Créteil, France.,Faculté de médecine, UPEC, Université Paris-Est, 94000, Créteil, France
| | - Pierre Vandel
- Centre d'investigation Clinique-Innovation Technologique CIC-IT 1431, Inserm, CHRU Besançon, 25000, Besançon, France.,Neurosciences Intégratives et Cliniques EA 481, Université Franche-Comté, Université Bourgogne Franche-Comté, 25000, Besançon, France.,Service de Psychiatrie de l'adulte, CHRU Besançon, 25000, Besançon, France.,Centre Mémoire de Ressource et de Recherche de Franche-Comté, CHRU Besançon, 25000, Besançon, France
| | - Frédéric Limosin
- DMU Psychiatrie et Addictologie, Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, Centre Ressource Régional de Psychiatrie du Sujet Agé (CRRPSA), Hôpital Corentin Celton, AP-HP.Centre, Université de Paris, Paris, France.,Inserm U1266, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Faculté de Médecine Paris Descartes, Université de Paris, Paris, France
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8
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Nevarez-Flores AG, Breslin M, Carr VJ, Morgan VA, Waterreus A, Harvey C, Sanderson K, Neil AL. Proposing a causal pathway for health-related quality of life in people with psychotic disorders. J Psychiatr Res 2021; 138:550-559. [PMID: 33990026 DOI: 10.1016/j.jpsychires.2021.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/22/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
This study aimed to establish independent predictors for health-related quality of life (HRQoL) in people with psychotic disorders, and the mediating role of global functioning in those relationships. Data for 1642 people collected as part of the second Australian National Survey of Psychosis were analyzed. The Assessment of Quality of Life (AQoL)-4D and the Personal and Social Performance scale were used for assessing HRQoL and global functioning respectively. The study commenced with a theoretical model comprised of 26 sociodemographic and clinical variables. A predictive model for HRQoL was built up using a purposeful selection strategy to arrive at a set of clinically meaningful, independent predictors. The mediating effect of global functioning was then assessed. Seven variables were found to have an independent effect on HRQoL: perception of loneliness, number of negative symptoms, use of psychotropic and anticholinergic medications, course of disorder, lifetime histories of chronic pain and cardiovascular disease and living arrangements at the time of the interview. All variables except perceived loneliness and chronic pain were partially mediated through global functioning. This final model explained 46% of the variance in HRQoL, with loneliness and number of negative symptoms the strongest predictors. Evidence in support of a credible causal pathway for HRQoL in people with psychotic disorders, mediated by global functioning was presented. The importance of the quality of social relationships was highlighted, and potential targets for improving the HRQoL of this population identified.
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Affiliation(s)
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Vaughan J Carr
- Research Unit for Schizophrenia Epidemiology, School of Psychiatry, University of New South Wales, St Vincent's Hospital, Darlinghurst Sydney, New South Wales, Australia; Department of Psychiatry, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton Melbourne, Victoria, Australia
| | - Vera A Morgan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia; Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Crawley, Western Australia, Australia
| | - Anna Waterreus
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia; Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Crawley, Western Australia, Australia
| | - Carol Harvey
- Psychosocial Research Centre, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia; North Western Mental Health, Melbourne, Victoria, Australia
| | - Kristy Sanderson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; School of Health Sciences, University of East Anglia. Norwich Research Park Norwich, NR4 7TJ, UK
| | - Amanda L Neil
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
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9
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Neil AL, Carr VJ, Nevarez-Flores AG, Herrman H, Morgan VA. Evidence of Quantitative Measures of Preferences Over Health States in Schizophrenia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:602. [PMID: 33840439 DOI: 10.1016/j.jval.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Amanda L Neil
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
| | - Vaughan J Carr
- Research Unit for Schizophrenia Epidemiology, School of Psychiatry, University of New South Wales, St Vincent's Hospital, Darlinghurst Sydney, New South Wales, Australia; Department of Psychiatry, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton Melbourne, Victoria, Australia
| | | | - Helen Herrman
- Centre for Youth Mental Health, Division of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Vera A Morgan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia and Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Crawley, Western Australia, Australia
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10
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Associations between diet quality and knee joint structures, symptoms and systemic abnormalities in people with symptomatic knee osteoarthritis. Clin Nutr 2021; 40:2483-2490. [PMID: 33932790 DOI: 10.1016/j.clnu.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/06/2021] [Accepted: 03/09/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS The evidence of benefiting from a high-quality diet for knee osteoarthritis (OA) joint structures, symptoms, and systemic abnormalities is limited. Clarifying the relationship between diet quality and knee OA could provide useful information for knee OA management. To investigate the associations between diet quality and knee joint structures, symptoms, lower limb muscle strength, depressive symptoms, and quality of life in people with knee OA. METHODS This study was a post-hoc, exploratory analysis using data from a randomized controlled trial in symptomatic knee OA participants with a follow-up time of 24 months. In brief, eligible participants of the original study were aged 50-79 years, had symptomatic knee OA, and had a pain of 20-80 mm on a 100-mm visual analog scale. After excluding the patients without information on diet quality, 392 participants were included in this post-hoc analysis. Diet quality was assessed at baseline using the Australian Recommended Food Score (ARFS) which includes subscores of vegetable, fruit, grain, dairy products, fat, and alcohol. Knee joint structures (including cartilage volume, cartilage defect, bone marrow lesions, and effusion-synovitis volume assessed by magnetic resonance imaging), OA symptoms, lower limb muscle strength, depressive symptoms, and quality of life were assessed at baseline and follow up. Mixed-effects models were used to assess the associations of diet quality with those outcomes. RESULTS Diet quality mainly reflect diet variety within the core food was not associated with knee structures and OA symptoms, but was associated with greater lower limb muscle strength (β = 0.66, P = 0.001), lower depressive symptom (β = -0.08, P = 0.001), and better quality of life (β = -0.06, P = 0.002). In further analyses of food group-based sub-scores, only the vegetable sub-score had the similar associations with lower limb muscle strength (β = 1.03, P = 0.004), depressive symptom (β = -0.17, P < 0.001), and quality of life (β = -0.14, P < 0.001). CONCLUSIONS Higher diet quality, mainly vegetable diet quality, is associated with greater lower limb muscle strength, less depressive symptoms, and higher quality of life in knee OA patients, suggesting higher diet quality may have protective effects on knee OA.
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Fabricio A, Kaczam F, Obregon SL, de Almeida DM, Lopes LFD, da Veiga CP, da Silva WV. Quality of life: Flourishing in the work context. CURRENT PSYCHOLOGY 2020. [DOI: 10.1007/s12144-020-01203-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Aceituno D, Pennington M, Iruretagoyena B, Prina AM, McCrone P. Health State Utility Values in Schizophrenia: A Systematic Review and Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1256-1267. [PMID: 32940244 DOI: 10.1016/j.jval.2020.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 04/03/2020] [Accepted: 05/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Patient preferences are increasingly important in informing clinical and policy decisions. Health-state utility values (HSUVs) are quantitative measures of people's preferences over different health states. In schizophrenia, there is no clarity about HSUVs across the symptoms' severity spectrum. This meta-analysis aims to synthesize the literature on HSUVs in people with schizophrenia. METHODS We searched Medline, PsycInfo, Embase, EconLit, The Cochrane Library, and specialized databases. The studies reporting HSUVs in people with schizophrenia were selected and pooled in a random-effects meta-analysis. The primary outcome was the mean HSUV obtained from participants. RESULTS A total of 54 studies involving 87 335 participants were included. The pooled estimate using direct elicitation was a mean HSUV of 0.79 (95% CI: 0.70-0.88) for mild symptomatic states, 0.69 (95% CI: 0.54-0.85) in moderate states, and 0.34 (95% CI: 0.13-0.56) in severe states. Studies using indirect techniques resulted in a pooled mean HSUV of 0.73 (95% CI: 0.67-0.78) applying the EuroQol 5-dimension, 0.66 (95% CI: 0.62-0.71) in the Short-Form 6-dimension, and 0.59 (95% CI: 0.57-0.61) using the Quality of Well-Being scale. All the estimates resulted in considerable heterogeneity, partially reduced by meta-regression. CONCLUSION Our findings suggest that the severity of psychotic symptoms has an important effect on HSUVs in schizophrenia, with values mirroring patients with disabling physical conditions such as cancer and stroke. Decision makers should be aware of these results when including people's preferences in trials, models, and policy decisions.
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Affiliation(s)
- David Aceituno
- Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience. King's College London, London, United Kingdom; Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Mark Pennington
- Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience. King's College London, London, United Kingdom
| | - Barbara Iruretagoyena
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Early Intervention Program, J. Horwitz Psychiatric Institute, Santiago, Chile
| | - A Matthew Prina
- Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience. King's College London, London, United Kingdom
| | - Paul McCrone
- Healthcare Economics, Institute for Lifecourse Development, University of Greenwich, London, United Kingdom
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Psychiatric symptoms and quality of life in older adults with schizophrenia spectrum disorder: results from a multicenter study. Eur Arch Psychiatry Clin Neurosci 2020; 270:673-688. [PMID: 31134378 DOI: 10.1007/s00406-019-01026-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
The severity of psychopathology has a strong negative impact on quality of life (QoL) among older adults with schizophrenia spectrum disorder. However, because these subjects generally experience multiple psychiatric symptoms, it remains unclear whether decreased QoL in this population is due to specific symptoms (e.g., hallucinations), specific dimensions of psychopathology (e.g., negative symptoms), a general psychopathology dimension representing the shared effect across all psychiatric symptoms, or a combination of these explanations. Data were derived from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia spectrum disorder recruited from French public-sector psychiatric departments. We used structural equation modeling to examine the shared and specific effects of psychiatric symptoms on QoL, while adjusting for sociodemographic characteristics, general medical conditions, global cognitive functioning and psychotropic medications. Psychiatric symptoms and QoL were assessed face-to-face by psychiatrists using the Brief Psychiatric Rating Scale (BPRS) and the Quality of Life Scale (QLS). Among older adults with schizophrenia spectrum disorder, effects of psychiatric symptoms on QoL were exerted mostly through a general psychopathology dimension (β = - 0.43, p < 0.01). Negative symptom dimension had an additional negative effect on QoL beyond the effect of that factor (β = - 0.28, p < 0.01). Because psychiatric symptoms affect QoL mainly through two dimensions of psychopathology, i.e., a general psychopathology dimension and a negative symptom dimension, mechanisms underlying those dimensions should be considered as promising targets for therapeutic interventions to substantially improve quality of life of this vulnerable population.
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Zuppo IDF, Ruas CM, de Oliveira HN, Godman B, Castel S, Wainberg ML, Reis EA. Health equity and the usage of atypical antipsychotics within the Brazilian national health system: findings and implications. Expert Rev Pharmacoecon Outcomes Res 2020; 21:743-751. [DOI: 10.1080/14737167.2020.1804873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Isabella de Figueiredo Zuppo
- Postgraduate Program in Medicines and Pharmaceutical Services, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Cristina Mariano Ruas
- Department of Social Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Helian Nunes de Oliveira
- Psychiatrist and Professor in the Department of Preventive and Social Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa
- Health Economics Centre, University of Liverpool Management School, Liverpool, UK
| | - Saulo Castel
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Milton L. Wainberg
- New York State Psychiatric Institute, Columbia University, New York, United States
| | - Edna Afonso Reis
- Department of Statistics, Federal University of Minas Gerais, Belo Horizonte, Brazil
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Pequeno NPF, Cabral NLDA, Marchioni DM, Lima SCVC, Lyra CDO. Quality of life assessment instruments for adults: a systematic review of population-based studies. Health Qual Life Outcomes 2020; 18:208. [PMID: 32605649 PMCID: PMC7329518 DOI: 10.1186/s12955-020-01347-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 04/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Against a backdrop of population aging and improving survival rates for chronic noncommunicable diseases (CNCD), researchers are placing growing emphasis on health-related quality of life (HRQoL). The aim of this study was to identify the QoL assessment instruments used in population-based studies with adults conducted around the world. METHODS A systematic review of original research published in all languages between 2008 and 2018 was conducted. Systematic reviews and meta-analyses were excluded. RESULTS Sixty-three articles (38.1% conducted in the Americas) fitted the eligibility criteria. Based on the AHRQ checklist for cross-sectional studies and the Newcastle-Ottawa scale for cohort studies, methodological quality was shown to be fair in the majority of studies (55.6%) and good in 44.4%. The country with the highest number of publications was Brazil (20.6%). Twelve types of generic instruments and 11 specific instruments were identified. The generic instrument SF-36 was the most frequently used measure (33.3% of studies). In-home interviewing was exclusively used by 47.6% of the studies, while 39 studies (61.9%) reported the use of self-administered questionnaires. Over two-thirds of the studies (34.9%) used questionnaires to investigate the association between chronic diseases and/or associated factors. CONCLUSIONS It was concluded that the wide range of instruments and modes of questionnaire administration used by the studies may hinder comparisons between population groups with the same characteristics or needs. There is a lack of research on QoL and the factors affecting productive capacity. Studies of QoL in older persons should focus not only on the effects of disease and treatment, but also on the determinants of active aging and actions designed to promote it. Further research is recommended to determine which QoL instruments are best suited for population-based studies.
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Affiliation(s)
- Nila Patrícia Freire Pequeno
- Postgraduate Program in Public Health at the Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 1787, Lagoa Nova, Natal, RN, Brazil.
- Department of Nutrition at the Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 3000, Lagoa Nova, Natal, RN, CEP 59078-970, Brazil.
| | - Natália Louise de Araújo Cabral
- Postgraduate Program in Public Health at the Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 1787, Lagoa Nova, Natal, RN, Brazil
| | - Dirce Maria Marchioni
- Department of Nutrition of the School of Public Health at the University of São Paulo, Av. Dr. Arnaldo, 715, Cerqueira César, São Paulo, SP, Brazil
| | - Severina Carla Vieira Cunha Lima
- Department of Nutrition at the Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 3000, Lagoa Nova, Natal, RN, CEP 59078-970, Brazil
| | - Clélia de Oliveira Lyra
- Department of Nutrition at the Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 3000, Lagoa Nova, Natal, RN, CEP 59078-970, Brazil
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Shanahan M, Seddon J, Ritter A, De Abreu Lourenco R. Valuing families' preferences for drug treatment: a discrete choice experiment. Addiction 2020; 115:690-699. [PMID: 31506995 DOI: 10.1111/add.14816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/06/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS The burden on family members of those who are dependent on illicit drugs is largely unidentified, despite the presence of significant negative financial, health and social impacts. This makes it difficult to provide appropriate services and support. This study aimed to assess the preferences for treatment attributes for heroin dependence among family members affected by the drug use of a relative and to obtain a measure of the intangible economic benefit. DESIGN Discrete choice experiment. Data were analysed using mixed logit which accounted for repeated responses. SETTING Australia. PARTICIPANTS Eligible participants were Australian residents aged 18+ years with a relative with problematic drug use. Complete data on 237 respondents were analysed; 21 invalid responses were deleted. MEASUREMENTS Participant preference for likelihood of staying in treatment, family conflict, own health status, contact with police and monetary contribution to a charitable organization providing treatment. FINDINGS All attributes were significant, and the results suggest that there was a preference for longer time in treatment, less family discord, better own health status, less likelihood of their relative encountering police and, while they were willing to contribute to a charity for treatment to be available, they prefer to pay less, not more. In order of relative importance, participants were willing to pay an additional A$4.46 [95% confidence interval (CI) = 3.33-5.60] for treatment which resulted in an additional 1% of heroin users staying in treatment for longer than 3 months, A$42.00 (95% CI = 28.30-55.69) to avoid 5 days per week of family discord, A$87.94 (95% CI = 64.41-111.48) for treatment options that led to an improvement in their own health status and A$129.66 (95% CI = 53.50-205.87) for each 1% decline in the chance of police contact. CONCLUSIONS Drug treatment in Australia appears to have intangible benefits for affected family members. Families are willing to pay for treatment which reduces family discord, improves their own health, increases time in treatment and reduces contact with police.
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Affiliation(s)
- Marian Shanahan
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Jennifer Seddon
- Substance Misuse and Ageing Research Team, University of Bedfordshire, Luton, UK
| | - Alison Ritter
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia.,Drug Policy Modelling Program, Social Policy Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation and University of Technology Sydney, Sydney, Australia
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Mehralian G, Sharif Z, Abbasian G. Medication adherence in patients with psychiatric disorders in Tehran. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2019. [DOI: 10.1111/jphs.12312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Gholamhossein Mehralian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Zahra Sharif
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Ghazal Abbasian
- School of Pharmacy Ahvaz University of Medical Sciences Tehran Iran
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McKetin R, Voce A, Burns R, Shanahan M. Health-related quality of life among people who use methamphetamine. Drug Alcohol Rev 2019; 38:503-509. [PMID: 31144396 DOI: 10.1111/dar.12934] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION AND AIMS We assessed health-related quality of life amongst people who use methamphetamine, examined how this related to different patterns of methamphetamine use and what other factors were associated with decrements in quality of life in this sample. DESIGN AND METHODS A cross-sectional survey of 169 at least monthly methamphetamine users. Health utility scores were derived using the Assessment of Quality of Life - 4D for the past month (0 reflects death and 1 represents full health; the population mean Assessment of Quality of Life score in Australia is 0.81). Dependence on methamphetamine was a score of 4+ on the Severity of Dependence Scale. Other measures included days of methamphetamine use and other substance use in the past month, injecting methamphetamine, demographics, psychiatric symptoms (score of 4+ on the Brief Psychiatric Rating Scale items) and a lifetime DSM-IV diagnosis of schizophrenia. RESULTS The mean utility score was 0.52 (95% confidence interval 0.48-0.56). Methamphetamine dependence was associated with lower utility (-0.10, P = 0.003) after adjustment for other univariate correlates of utility. Other factors independently associated with lower utility were being a woman (-0.14, P < 0.001), depression (-0.10, P = 0.008), self-neglect (-0.08, P = 0.035), schizophrenia (-0.17, P = 0.003) and fewer years of schooling (0.02 per year, P = 0.037). DISCUSSION AND CONCLUSIONS We found poor quality of life in this sample of methamphetamine users relative to the general population, this being associated with both dependence on methamphetamine and other factors, particularly poor mental health. We also found poorer health amongst women.
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Affiliation(s)
- Rebecca McKetin
- National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia.,Research School of Population Health, Australian National University, Canberra, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Alexandra Voce
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Richard Burns
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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