Improving treatment adherence among patients with chronic psychoses

This paper presents the literature on compliance as an ideology and then examines strategies to improve patient outcomes if non-compliance is identified as undermining the treatment regimen. We present strategies used by our team in a south London rehabilitation service for the severely mentally ill.

Ethnic and cultural factors in psychopharmacology

Barring a few exceptions (such as rauwolfia), most of the psychiatric medications have been developed in the West, especially the USA, the UK and Europe. Their safety trials have been conducted in the populations living in these parts of the world. Although these drugs are used all over the world there is a limited research to determine accurate pharmacodynamic and pharmacokinetic profiles across different ethnic groups. Hence, clinicians usually adopt a ‘universalist style’ (seeing every condition and treatment as similar) of managing psychiatric illnesses, but this appears to neglect the information from the emerging literature which advocates a relativist approach to pharmacotherapy (see Lin et al 1995 for review). Anthropologists have encountered ‘phenomenological absolutism’ in a general tendency of people from one culture to perceive and value other cultures in terms unconsciously based upon their own, but phenomenologically experienced as absolute and universally applicable (also known as ethnocentrism). In addition to ethno-biological determinants of drug response, there are significant cultural factors: the concurrent use of pluralistic health systems, alternative therapies and folk remedies which might support, hinder or complicate pharmacotherapy and treatment adherence. In this paper we highlight some key factors of which clinicians need to be aware. These include pharmacodynamic and pharmacokinetic principles, and application of these principles in pharmacological management of psychiatric conditions. Ethnic differences in pharmacodynamics are most clearly demonstrated in the greater sensitivity to a variety of drugs in Caucasians than in Asians or in African–Caribbeans.

Clinical management of patients across cultures

Clinical management of patients across cultures challenges the clinician's familiar tried and tested strategies. The relationship between the patient and the psychiatrist is often examined in isolation from a number of premises which both patient and professional bring to the encounter: previous experience of other cultures, contact with less familiar cultures, past experiences and socioeconomic status are some of the determinant influences. There are a number of ways in which the clinician can facilitate therapeutic effectiveness. However, a trusting relationship must first emerge such that the patient has faith in the treatment recommendations. Special difficulties can arise in the context of pharmacological, social, psychotherapeutic and psychological interventions. Community, out-patient, in-patient and emergency settings each require that consideration be given to the context of the assessment and treatment process, as well as the content and immediate outcome. The clinician must plan the assessment and intervention carefully. The rationale and goals of treatment should be discussed and agreed by participants in the therapeutic interaction. Special groups have unique cultural and historical obstacles to receiving health care. Potential problems are highlighted in this paper and suggestions made for managing conflicts when they arise.

Government-Sanctioned Torture: Status of the Rehabilitation Movement

Government-sanctioned torture remains widespread despite expansion of the rehabilitation movement and efforts towards prevention. This paper describes how the cultural and socio political contexts in which the survivor was tortured and receives help significantly affect perceptions of torture's con sequences and selection of the most appropriate interventions. The paper defines and describes torture, reviews the histori cal and philosophical antecedents in the evolution of the rehabilitation movement and discusses how these antecedents have affected perceptions of diagnosis, models of treatment and prognosis for torture survivors. Opportunities for future research and training are proposed.

Comparison of symptoms in African-American, Asian-American, Mexican-American and Non-Hispanic White patients with major depressive disorder

The study compared depressive and associated psychopathological symptoms in 17 African-American, 19 Asian-American, 22 Mexican-American and 41 Non-Hispanic White patients with unipolar major depressive disorder. Overall, severity of depression was comparable among the groups both on clinician-rated and subject-rated measures. However, ethnic-minority groups were more likely to experience diurnal variation of mood, with worsening in the evening. Furthermore, Asian-Americans and Mexican-Americans reported greater severity of anxiety and somatic symptoms. The findings suggest that clinicians should be aware of potential differences in symptom presentation when assessing and treating depressed patients from different ethnic groups.

Treatments for patients with dual diagnosis: a review

BACKGROUND

Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis.

METHODS

This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis.

RESULTS

Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes.

CONCLUSIONS

Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.

Pharmacogenetic studies of antidepressant response: how far from the clinic?

Because the US FDA has begun to focus on disclosure of pharmacogenetic testing results in applications for new drug approval and review of existing drugs (see, eg, http://www.fda.gov/OHRMS/DOCKETS/AC/05/slides/2005-4194S1_Slide-Index.htm), the application of such testing in a clinical setting is likely to increase substantially. Instead of small cohorts of patients, potentially nearly every participant in the large pivotal trials required for drug approval could help inform the future application of that drug. Psychiatry as a whole, and antidepressant prescribing ni particular, stands to benefit in the near term from the identification of newer treatment targets that may overcome some of the limitations of current therapeutics. On the other hand, despite the excitement about the rapid pace of development in psychiatric pharmacogenetics, a number of key issues remain to be addressed before these discoveries are applied in a clinical setting. Close coordination will be required between those who study treatment efficacy and effectiveness and those who study genetic variation in populations to ensure that studies yield results that have scientific importance and clinical importance as well.

Pharmacogenetics, race, and psychiatry: prospects and challenges

Although the field of pharmacogenetics has existed for nearly 50 years, it has begun to enter mainstream clinical practice only recently. Researchers and clinicians have now demonstrated that a wide assortment of genetic variants influence how individuals respond to medications. Many of these variants are relevant for psychiatry, affecting how patients respond to most antidepressants, antipsychotics, anxiolytics, and mood stabilizers. Enthusiasts hope that pharmacogenetics will soon usher in a new era of individualized medicine. However, determining the practical relevance of pharmacogenetic variants remains difficult, in part because of problems with study design and replication, and in part because a host of nongenetic factors (including age, diet, environmental exposures, and comorbid diseases) also influence how individuals respond to medications. Since individualized pharmacogenetic assessment remains difficult, some researchers have argued that race provides a convenient proxy for individual genetic variation, and that clinicians should choose medications and doses differently for different races. This approach remains extremely controversial because of the complexity of the genetic structure of the human population, the complexity of gene-environment interactions, and the complexity of the meanings of race in the United States.

Globalisation and mental disorders. Overview with relation to depression

BACKGROUND

Globalisation is the process by which traditional boundaries of cultures are changing. Industrialisation, urbanisation and influence of the media are influencing idioms of distress across cultures.

AIMS

To discuss the role of globalisation, using the epidemiology, diagnosis, clinical presentation and treatment of depression across various cultures as an example.

METHOD

Recent studies focusing on transcultural aspects of depression were reviewed and summarised.

RESULTS

Cultural, social and religious mores account for variations in the presentation of depression across cultures. Somatic symptoms are common presenting features throughout the world and may serve as cultural idioms of distress, but psychological symptoms can usually be found when probed. Feelings of guilt and suicide rates vary across cultures and depression may be underdiagnosed.

CONCLUSIONS

Training packages could enhance clinicians'cultural competency in multicultural settings. However, globalisation is likely to influence idioms of distress and pathways to care in ways that are difficult to predict.

Research priorities in the evolving demographic landscape of Alzheimer disease and associated dementias

The rapid increase of ethnically diverse late onset dementia-affected persons is bringing a special urgency to Alzheimer disease and associated disorders research. By this decade's end, non-European heritage ethnically diverse persons will account for 25% of the dementia-affected cohort and 33% by mid-century. These populations have received some attention in both dementia-focused basic biomedical and social-behavioral research. However, studies differ greatly with regard to the constructs of culture used, the methodologies used, and representativeness of the populations sampled. Moreover, social status factors are often confounded with cultural variables. Therefore, several clarifying research approaches are suggested. In biomedical research, categorically ascribed (US census type) definitions, or assumed (self-reported) ethnic group designators will not suffice where actual biophysiological sampling precision is needed. A strategy for the phenotypic sampling of cohorts is therefore suggested for this research domain. In social-behavioral research, the acceptance of a common operational definition of culture is urged. And, with reference to a specific social status confound, namely literacy, a neuroimaging research strategy is proposed to determine whether non-literates might not be misclassified relative to the determination of their actual cognitive functioning status. Additionally, two conceptual models for addressing and are briefly presented.

Relationship between CYP 2D6 metabolic status and sexual dysfunction in paroxetine treatment

This article describes the incidence of sexual dysfunction in 30 patients subjected to long-term treatment by paroxetine in dependence on the P 450 CYP 2D6 isoenzyme metabolic status. Measured on the Arizona Sexual Experience Scale (ASEX; McGahuey, Delgado, & Gelenberg, 1999), the incidence of sexual dysfunction in patients converted to CYP 2D6 poor metabolizers was markedly higher compared with patients who had no history of such conversion, a difference that reached the level of statistical significance. Our article discusses the incidence of sexual dysfunction in connection with reduced CYP 2D6 capacity.

Unpacking cultural factors in adaptation to type 2 diabetes mellitus

BACKGROUND

Race and ethnicity are used as predictors of outcome in health services research. Often, however, race and ethnicity serve merely as proxies for the resources, values, beliefs, and behaviors (ie, ecology and culture) that are assumed to correlate with them. "Unpacking" proxy variables-directly measuring the variables believed to underlie them-would provide a more reliable and more interpretable way of looking at group differences.

OBJECTIVE

To assess the use of a measure of ecocultural domains that is correlated with ethnicity in accounting for variance in adherence, quality of life, clinical outcomes, and service utilization.

DESIGN

A cross-sectional observational study.

PARTICIPANTS

Twenty-six Hispanic and 29 non-Hispanic white VA primary care patients with type 2 diabetes mellitus.

MEASURES

The independent variables were patient ethnicity and a summed score of ecocultural domains representing patient adaptation to illness. The outcomes were adherence to treatment, health-related quality of life, clinical indicators of disease management, and utilization of urgent health care services.

RESULTS

Patient adaptation was correlated with ethnicity and accounted for more variance in all outcomes than did ethnicity. The unique variance accounted for by adaptation was small to moderate, whereas that accounted for by ethnicity was negligible.

CONCLUSIONS

It is possible to identify and measure ecocultural domains that better account for variation in important health services outcomes for patients with type 2 diabetes than does ethnicity. Going beyond the study of ethnic differences alone and measuring the correlated factors that play a role in disease management can advance understanding of the phenomena involved in this variation and provide better direction for service design and delivery.

Cultural psychopathology: uncovering the social world of mental illness

We review cultural psychopathology research since Kleinman's (1988) important review with the goals of updating past reviews, evaluating current conceptualizations and methods, and identifying emerging substantive trends. Conceptual advances are noted, particularly developments in the definition of culture and the examination of both culture-specific and cultural-general processes. The contributions of the Culture and Diagnosis Task Force for DSM-IV and the World Mental Health Report are reviewed and contrasted. Selected research on anxiety, schizophrenia, and childhood disorders is examined, with particular attention given to the study of ataque de nervios, social factors affecting the course of schizophrenia, and cross-national differences in internalizing and externalizing problems in children. Within the last ten years, cultural psychopathology research has become a significant force. Its focus on the social world holds promise to make significant inroads in reducing suffering and improving people's everyday lives.

Pharmacogenetics and psychopharmacotherapy

Response to drugs can vary between individuals and between different ethnic populations. The biological (age, gender, disease and genetics), cultural and environmental factors which contribute to these variations are considered in this review. The most important aspect is the genetic variability between individuals in their ability to metabolize drugs due to expression of 'polymorphic' enzymes. Polymorphism enables division of individuals within a given population into at least two groups, poor metabolisers (PMs) and extensive metabolisers (EMs) of certain drugs. The two most extensively studied genetic polymorphisms are those involving cytochrome P450 2D6 (CYP2D6) and CYP2C19. CYP2D6 metabolizes a number of antidepressants, antipsychotics, beta-adrenoceptor blockers, and antiarrhythmic drugs. About 7% of Caucasians and 1% of Asians are PMs of CYP2D6 substrates. CYP2C19 enzyme participates in the metabolism of omeprazole, propranolol and psychotropic drugs such as hexobarbital, diazepam, citalopram, imipramine, clomipramine and amitriptyline. The incidence of PMs of CYP2C19 substrates is much higher in Asians (15-30%) than in Caucasians (3-6%). Variations in metabolism of psychotropic drugs result in variations in their pharmacokinetic parameters. This may lead to clinically significant intra- and inter-ethnic differences in pharmacological responses. Such variations are discussed in this review. Differential receptor-mediated response may play a role in ethnic differences in responses to antipsychotics and tricyclic antidepressants, but such pharmacodynamic factors remain to be systematically investigated. The results of studies of ethnic differences in response to psychopharmacotherapy appear to be discrepant, most probably due to limitations of study design, small sample size, inadequately defined study sample, and lack of control of confounding factors. The clinical value of understanding pharmacogenetics is in its use to optimize therapeutic efficacy, to prevent toxicity of those drugs whose metabolism is catalysed by polymorphic isoenzymes, and to contribute to the rational design of new drugs. Finally, applications and impact of pharmacogenetics in the field of psychopharmacotherapy are discussed.