Medication adherence - older patients stay the course

An increasing amount of research has identified treatment non-adherence as a pervasive problem that can lead to relapse and hospitalization. Around 40% of patients with bipolar disorder do not adhere to their medication but there has been little research into whether older patients are more or less likely to adhere to their treatment than younger ones. A study of 32,991 people in the U.S. compared adherence to antipsychotic medication in older (over 60) and younger patients with bipolar disorder. The researchers found that among the older group 61% were fully adherent, 19% were partially adherent and 20% were non-adherent compared to 49.5%, 21.8% and 28.7% respectively for the younger patients. The researchers measured adherence by comparing the medication the patients had actually been given to the medication they should have received had they been taking all their pills. For both groups of participants drug abuse and homelessness had a negative effect on treatment adherence.

Sajatovic, Martha ... [et al] - Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder International Journal of Geriatric Psychiatry October 2007, 22(10), 992-998

Antipsychotics for depression in older people

Untreated or partially-treated depression in older people is associated with higher mortality due to illness and suicide. Failure of the depression to improve with antidepressant treatment is a common problem, since only 40-50% of patients respond to the first medication they are given. Recently the Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study provided important information about treating patients whose depression did not improve with antidepressants but this did not cover patients over 60. Atypical antipsychotics, in combination with anti-depressants, have been increasingly studied for partially or non-responsive patients with depression and a New York trial of the drug aripiprazole, on older patients, has found that six weeks taking the drug, in conjunction with anti-depressants, led to a 50% remission rate of depression. However, the drug did have side effects including a dry mouth, which affected 25% of the participants, agitation/anxiety (20%) and drowsiness (15%). A quarter of the participants dropped out of the trial before it finished.

Rutherford, Bret ... [et al] - An open trial of aripiprazole augmentation for SSRI non-remitters with late-life depression International Journal of Geriatric Psychiatry October 2007 22(10), 986-991

Depression in adolescence - what works best

At any one time 5% of adolescents are suffering from major depression.This can lead to poor health, an increased burden on families and, in the worst cases, suicide. In 1999 the National Institute of Mental Health in the U.S. set up the Treatment for Adolescents with Depression Study (TADS) to compare the effectiveness of treatments with drugs (fluoxetine hydrochloride), cognitive behaviour therapy (CBT) and a combination of the two. The latest study from TADS looked at 327 patients from 12-17 and found that rates of response were 73% for combination therapy, 62% for fluoxetine and 48% for CBT at week twelve, rising to 86%, 81% and 81% respectively after thirty-six weeks. Thoughts of suicide decreased with treatment but were more common (14.7%) in patients taking fluoxetine than those receiving combination therapy (8.4%) or CBT (6.3%)

The TADS team - The treatment for adolescents with depression study (TADS) : long-term effectiveness and safety outcomes Archives of General Psychiatry October 2007, 64(10), 1132-1144

Schizophrenia and cognition - pills or practice ?

Schizophrenia often leads to cognitive impairment and attempts to improve the cognition of people with schizophrenia have been seen as an important goal of medical trials. Several recent studies have suggested that second-generation antipsychotics can improve cognition but these studies - funded by the drug industry - did not include control groups to eliminate the possibility that the improvements in cognition described could have been due to the participants having had practice at taking the tests over the course of the study. A U.S. study compared 104 people taking olanzapine and risperidone with 84 healthy controls and found that after two sets of cognitive tests, after six and sixteen weeks, the control group had improved as much as the group taking the drugs suggesting that some, if not all, of the improvements in cognition reported in earlier trials could have been due to the practice rather than the pills.

Goldberg, Terry E. ... [et al] - Cognitive improvement after treatment with second-generation antipsychotic medications in first-episode schizophrenia Archives of General Psychiatry October 2007, 64(10), 1115-1122

Religion, schizophrenia and adherence to treatment

Despite overwhelming evidence for its effectiveness many people with schizophrenia do not continue to take their medication. Medication non-adherence among patients with schizophrenia ranges from 50%-60% in the first year after being discharged from hospital. There is a growing amount of literature suggesting that religion and spirituality may help people cope better with schizophrenia but there has been no research into how they affect people's adherence to medication. A study of 103 people with schizophrenia in Geneva has found that two thirds of them considered spirituality to be very important or even essential in everyday life. 57% of patients had ideas about their illness directly influenced by their spiritual beliefs (31% positive and 26% negative). However, 31% of non-adherent patients and 27% of partially-adherent patients saw an incompatibility or contradiction between their religion and taking medication, compared to only 8% of the adherent patients.

Borras, L. ... [et al] - Religious beliefs in schizophrenia : their relevance for adherence to treatment Schizophrenia Bulletin September 2007 33(5), 1238-1246

Schizophrenia, social skills and employment

Even with recommended treatments people with schizophrenia have problems looking after themselves, making and maintaining relationships and holding down jobs. Problems with social and communication skills have long been recognised to be a feature of schizophrenia but it is unclear how these problems are related to cognitive deficits and to everyday functioning. Researchers in Baltimore, U.S. compared people with schizophrenia who functioned well in the workplace with those who did less well. They found that social skills were significantly more impaired in those with poor vocational functioning and that people's levels of social skills were significantly associated with their verbal ability, processing speed and memory. However, even once all these factors had been taken into account social skill still had an independent effect on vocational performance.

Dickinson, Dwight, Bellack, Alan S. and Gold, James M. - Social/communication skills, cognition, and vocational functioning in schizophrenia Schizophrenia Bulletin September 2007 33(5), 1213-1220

PTSD and mental health problems

People suffering from mental health problems are much more likely to have experienced traumatic stress during their lives. More than 40% of adults receiving psychiatric care have suffered from post-traumatic stress disorder (PTSD) compared to only 7% of the rest of the population. PTSD can increase the severity of severe mental illnesses such as schizophrenia and bipolar disorder and cause an increased likelihood of problems with agitation, impulse control, social isolation and substance misuse. A study of 35 women receiving community mental health services for severe and chronic mental illness in the U.S. found that 98% of them had suffered exposure to multiple traumatic stressors and more than half had suffered from PTSD at some point during their lives with 44% of the sample suffering from PTSD at the time of the study. Current PTSD prevalence was highest when traumatic loss, sexual abuse, physical abuse, traumatic assault or community violence were reported. A history of childhood sexual abuse, or PTSD, or both was associated with use of multiple substances and complex psychosocial problems.

Ford, Julian D. and Fournier, Debra - Psychological trauma and post-traumatic stress disorder among women in community mental health aftercare following psychiatric intensive care Journal of Psychiatric Intensive Care June 2007 3(1), 27-34

Low secure unit shows encouraging results

A study of patients admitted to a low secure unit in South London has shown encouraging results. The study of 33 patients found that the typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The improvement that the patients had shown while they were on the unit, had, in most cases, been maintained at follow-up and none of the patients had been arrested since their discharge. All the patients were still taking their medication and only five of the patients had been readmitted to hospital.

Akande, Emmanuella, Beer, M. Dominic and Ratnajothy, Kalaanithi - Outcome study of patients exhibiting challenging behaviours four years after discharge from a low secure mental health unit Journal of Psychiatric Intensive Care June 2007, 3(1), 21-26

Domestic violence and self-harm

Estimates of the rate of domestic violence against women range from 6% to 58% with the rates being much higher among psychiatric inpatients and even higher among inpatients with suicidal ideation. It is estimated that about 1% of the population engage in self-harm (e.g. cutting, hitting or scratching themselves) although again this rate is much higher among psychiatric inpatients. However, there has been little research into the links between domestic violence and self-harm. Researchers in America studied 113 women in psychiatric hospitals and found that a history of domestic violence was a statistically significant predictor of bodily self-harm even after controlling for age and marital status.

Sansone, Randy A., Chu, Jamie and Wiederman, Michael W. - Self-inflicted bodily harm among victims of intimate-partner violence Clinical Psychology and Psychotherapy September-October 2007, 14, 352-357

Schemas and obese children

Many youngsters being treated for obesity also have psychological problems which can be caused by dysfunctional schemas and maladaptive coping styles. These dysfunctional schemas and maladaptive coping styles are unhelpful ways of looking at the world and dealing with problems and can develop when basic childhood needs, such as a secure attachment to others and the freedom to express emotions, are not met. Psychologists have come up with 18 different categories of maladaptive schema and researchers in Belgium compared teenagers being treated for obesity with normal-weight children to see how they differed in terms of their schemas (thought processes). The researchers found that, overall, the obese teenagers had more dysfunctional schemas than the normal weight ones. The obese children scored significantly higher for the Emotional Deprivation, Social Isolation/Alienation, Defectiveness/Shame, Failure to Achieve, Dependence/Incompetence and Subjugation schemas.

Vlieberghe, Leen Van and Braet, Caroline - Dysfunctional schemas and psychopathology in referred obese adolescents Clinical Psychology and Psychotherapy September-October 2007, 14, 342-351

TV watching and children's behaviour

A study of 2,707 children in the U.S. has found that toddlers (2.5 - 5.5 years old) who watch two or more hours of television a day are more likely to develop behavioural problems and poor social skills. The study, reported in the journal Pediatrics, found that 16% of two-and-a-half-year-olds watched more than two hours a day of TV and 15% of five-and-a-half-year-olds did so. Sustained exposure to TV was associated with behavioural problems. 41% of children in the study had a TV in their bedroom and this was associated with behavioural problems, poor social skills and poor sleep. Those children who started off watching a lot of television then reduced their vciwing time suffered no ill effects.

Panic attacks and health

An American study of 3,369 women between the ages of 51 and 83 has found that those who experienced at least one full-blown panic attack had an increased risk of having a heart attack or stroke within the next five years. At the start of the study the women filled out a questionnaire about the occurence of panic attacks in the previous six months. The women were then monitored for fivc years to see which of them had heart attacks, strokes or died of other causes. After allowing for other risk factors having one or more panic attacks was associated with four times the risk of myocardial infarction, three times the risk of heart attack or stroke and twice the risk of death from any cause.

Conscientiousness and Alzheimer's disease

A report in the October issue of the Archives of General Psychiatry suggests that people who are more conscientious are less likely to develop Alzheimer's disease. Conscientiousness refers to a person's tendency to control their impulses, be goal-directed and be reliable. Over a 12-year period researchers from Rush University Medical School studied 997 older Catholic nuns, priests and monks none of whom had Alzheimer's at the start of the study. Their conscientiousness was assessed by a questionnaire and those who were most conscientous had an 89% lower risk of developing Alzheimer's than those who were least conscientious. However, conscientiousness did not affect the tangles and plaques in the brain associated with the condition. The researchers thought that conscientiousness might be linked to educational or occupational success, both of which reduce the incidence of Alzheimer's, and that conscientiousness improved people's resilience and ability to cope with difficulties. Conscientiousness has also been linked to protecting against a wide range of mental and physical disorders.

Risk factors for eating disorders

A survey of 2,516 teenagers in Minnesota has found that both overweight and normal weight children had similar disordered eating behaviours. Overweight teenagers (who made up a quarter of the sample) were just as likely to binge eat and take diet pills. 44% of the girls surveyed suffered from food-related problems compared to 29% of the boys. The study in the Journal of Preventive Medicine found that a third of the overweight girls vomited or took diet pills or laxatives in an attempt to lose weight. A history of being teased about being fat was one of the strongest predictors of risk for being overweight and extreme dieting. Teasing by family members doubled the risk of being overweight. Eating together as a family and being close to one's family both helped to prevent eating-disordered behaviour.

Schizophrenia and mortality

A review of existing research in the Archives of General Psychiatry has found that people with schizophrenia are falling behind others when it comes to longevity, being 2.5 times more likely to die early than other people. Suicide was the biggest risk with people suffering from schizophrenia being almost thirteen times more likely to kill themselves. Schizophrenia also raised the death rate from cardiovascular diseases as new medications can cause weight gain and type 2 diabetes. People with schizophrenia are also prone to engage in high-risk behaviour such as drug-taking.

Depression and decline in elderly people

A study of more than seven hundred people in the American Journal of Psychiatry suggests that depression in elderly people can increase the risk of subsequent mental impairment and can act as a predictor of future intellectual decline. The researchers from the University of Rochester Medical Centre looked at the loss of executive functions such as making decisions, organizing, planning, and doing a series of things in a logical sequence and found that depression raised the risk of problems with these thought processes.

Mental illness and learning disability

A survey of 651 people with learning disabilities in Glasgow has found that over the two-year course of the study 16.3% of them suffered from mental illness, a rate 1.87 times higher than that of the population as a whole. Factors related to mental illness among this group of people included : type of accomodation and support, previous mental ill-health, urinary incontinence, having a more severe intellectual disability, being abused as an adult and parental divorce in childhood. Deprivation, child abuse, daytime occupation and marital smoking status showed no relation to mental illness in this group of people.

Smiley, E. ... [et al] - Incidence and predictors of mental ill-health in adults with intellectual disabilities British Journal of Psychiatry October 2007, 191, 313-319

Ethnicity and patient satisfaction

Patients from Black and ethnic minority groups are generally perceived to have a poor experience of mental health services but there is little hard data about this. A survey of about 27,000 users of community mental health services (of whom 10% were from ethnic minorities) has found that ethnicity had a smaller effect on patients' experience of mental-health services than other factors. Age, living alone, whether patients had been detained or not and whether they had been admitted as an inpatient were all stronger predictors of patients' experience than ethnicity. Relative to White people Black people did not report more negative experiences although Asian people were more likely to have had a negative experience of services.

Raleigh, Veena S. ... [et al] - Ethnic variations in the experiences of mental health service users in England British Journal of Psychiatry October 2007, 191, 304-312

Social factors and schizophrenia

A wide number of social factors have been linked to an increased incidence of schizophrenia including poverty, living in the inner-city and coming from an ethnic-minority background. A two-year study of 33 wards in South-East London looked at a number of different variables to see how they affected people's chances of developing the condition. The researchers found that low voter turn-out and ethnic segregation both increased the risk of developing schizophrenia. There was also some evidence that ethnic minority individuals were at greater risk of schizophrenia in areas with smaller proportions of minority groups.

Kirkbride, James B. ... [et al] - Neighbourhood-level effects on psychoses : re-examining the role of context Psychological Medicine 2007, 37, 1413-1425

Confabulation and schizophrenia

Confabulation is the production of false memories without the deliberate attempt to lie i.e. the person talking about them really believes they happened. It is a feature of Wernicke-Korsakoff amnesia and of frontal lobe syndrome and has also been documented in schizophrenia. Researchers in Spain looked at the links between confabulation, schizophrenia and other cognitive problems by asking a group of people with schizophrenia and a healthy control group to recall a series of short fables. If the participants in the trial added unecessary or superfluous details to the fables when they recalled them this was seen as evidence of confabulation. Confabulation was seen at a significantly higher rate in the schizophrenic patients than in the control group and predominated in schizophrenia sufferers with disordered thoughts. Confabulation was not related to intelligence or problems with episodic (for events) memory. However, confabulation was linked to problems with semantic (for words) memory.

Lorente-Rovira, E. ... [et al] - Confabulation in schizophrenia and its relationship to clinical and neuropsychological features of the disorder Psychological Medicine 2007, 37, 1403-1412