Attitudes toward medication and the clinical variables in schizophrenia: Structural equation models

Treatment-resistant schizophrenia: Addressing white matter integrity, intracortical glutamate levels, clinical and cognitive profiles between early- and adult-onset patients

BACKGROUND

Treatment-resistance in schizophrenia is 30-40%. Its neurobiology remains unclear; to explore it, we conducted a combined spectrometry/tractography/cognitive battery and psychopathological rating study on patients with treatment-resistant schizophrenia (TRS), dividing the sample into early-onset (N = 21) and adult-onset TRS (N = 20). Previous studies did not differentiate between early- (onset 13-18 years) and adult-onset (>18 years at formal diagnosis of schizophrenia) TRS.

METHODS

We evaluated cross-sectionally 41 TRS patients (26 male and 15 female) and 20 matched healthy controls (HCs) with psychopathological and cognitive testing prior to participating in brain imaging scanning using magnetic resonance spectroscopy and diffusion tensor imaging to determine the relationship between their symptoms and their glutamate levels and white matter integrity.

RESULTS

TRS patients scored lower than HCs on all cognitive domains; early-onset patients performed better than adult-onset patients only on the Symbol Coding domain. TRS correlated with symptom severity, especially negative symptoms. Glutamate levels and glutamate/creatine were increased in anterior cingulate cortex. Diffusion tensor imaging showed low fractional anisotropy in TRS patients in specific white matter tracts compared to HCs (bilateral anterior thalamic radiation, cortico-spinal tract, forceps minor, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, superior longitudinal fasciculus, and right uncinate fasciculus).

CONCLUSIONS

We identified specific magnetic resonance spectroscopy and diffusion tensor imaging alterations in TRS patients. Adult-onset TRS differed little from early-onset TRS on most measures; this points to alterations being present since the outset of schizophrenia and may constitute a biological signature of treatment-resistance.

The validity and Reliability of the Turkish Version of Drug Attitude Inventory-10

Introduction

Compliance with drug treatment is an important issue in schizophrenia for which many scales have been devised. Turkish version of the Drug Attitude Inventory is frequently employed due to ease of use and high predictive value, although it is not as accurate as blood level testing.To determine the validity and reliability of the Turkish version of the Drug Attitude Inventory-10.

Methods

Eighty-two schizophrenia patients were included in the study. Subjects were evaluated using Drug Attitude Inventory-10, a Sociodemographic Data Form, Positive and Negative Symptom Scale PANNS, Social Functioning Scale, and Quality of Life Scale for schizophrenia patients.

Results

Reliability analysis revealed Cronbach's α coefficient for internal consistency to be 0.798 and item-total item correlation coefficients to be between 0.420 and 0.647. Test-retest correlation coefficient (r) was 0.809. Construct validity analysis revealed a tri-factorial construct which accounts for 62.68% of variance. Good conformity to single factor construct was found with confirmatory factor analysis.

Conclusion

Turkish version of the Drug Attitude Inventory-10 is valid and reliable for evaluation of schizophrenia patients which makes it suitable for research and clinical settings.

Assessing patient-rated vs. clinician-rated adherence to the therapy in treatment resistant schizophrenia, schizophrenia responders, and non-schizophrenia patients

The present study evaluated consistency, reliability, and determinants of two real-world measures of adherence to prescription in 57 schizophrenia and 61 non-schizophrenia patients. Treatment resistant schizophrenia (TRS) was additionally diagnosed in 28 of the schizophrenia patients. Patients were screened for clinical severity, cognitive functioning, and adherence by 10-item Drug Attitude Inventory (DAI-10) or Adherence-to-Therapy (AtT), a clinician-rated tool developed by our group. DAI-10 and AtT scores showed a significant correlation (p=0.039; ρ=0.21; df=103). Compared to the DAI-10 scale, a higher number of variables were associated with AtT. In schizophrenia and TRS patients, substance abuse was the only significant predictor of lower DAI-10 score (p=0.027, F=5.2, R²=0.07, and p=0.06, F=8.9, R²=0.23, respectively). Lower AtT score was significantly associated with first-generation antipsychotic use (p=0.001, RR: 2.00 [1.40-2.87]), positive symptoms (p=0.02, RR: 1.63 [1.05-2.53]), impaired verbal fluency (p=0.01, RR: 1.88 [0.81-4.32]) or problem solving (p=0.01, RR: 2.14 [0.92-4.98]). AtT, but not DAI-10, score correlated with the score on the Personal and Social Performance scale (p=0.02, F=5.86, R²=0.08). Overall, AtT score was predicted by pharmacological, psychopathological, and cognitive factors, and predictive of psychosocial functioning. Therefore, AtT measure may represent a convenient and practical tool to evaluate schizophrenia patients' adherence.

Attitudes towards antipsychotics among patients with schizophrenia on first- or second-generation medications

BACKGROUND

Given the paucity of research in this area, this study attempted to assess attitudes toward antipsychotic medications and its correlates among patients with schizophrenia, either on first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs) medications.

MATERIALS AND METHODS

Structured assessments of attitudes to antipsychotics, psychopathology, insight and side-effects were carried out in 120 patients with DSM-IV schizophrenia; 89 of these were on SGAs and 31 on FGAs.

RESULTS

Patients had predominantly positive attitudes toward antipsychotics. Severity of side-effects was the principal correlate of attitudes, explaining 19.5% of the variance, followed by greater insight (4.2% of the variance). Other factors such as younger age, male gender, employment, higher family income, urban residence and lower symptom-severity explained only a negligible proportion of the variance (0.2%) in attitudes. Patients on SGAs had more positive views of their medications than those on FGAs. They felt more normal on their medications, believed that their thoughts were clearer on medications, felt that good things about their medications outweighed the bad and believed that their medications helped them from falling ill again. In addition, they did not feel as tired and sluggish on their medications and did not believe that medications were unnatural or controlled their bodies.

CONCLUSIONS

Positive attitudes toward antipsychotics were common among patients with schizophrenia. Attitudes were principally determined by severity of side-effects and insight levels. Patients on SGAs had better attitudes, possibly because of less severe side-effects and greater insight among them. The importance of exploring patients' attitudes toward their antipsychotics is highlighted by this study.

Differential cognitive performances between schizophrenic responders and non-responders to antipsychotics: correlation with course of the illness, psychopathology, attitude to the treatment and antipsychotics doses

Multiple lines of evidence demonstrate that schizophrenia patients may perform worse than normal controls in several cognitive tasks. However, little is known on putative differences in cognitive functioning between schizophrenia patients responding to antipsychotics and those resistant to the treatment. In this cross-sectional study, 63 subjects (41 schizophrenia and schizoaffective patients and 22 age and sex-matched controls) were enrolled. Patients were divided in resistant (TRS, n=19) and non-resistant to pharmacological treatment (non-TRS, n=22) according to the American Psychiatric Association (APA) criteria for treatment resistance. The Brief Assessment of Cognition in Schizophrenia (BACS) was administered to patients and controls. The following rating scales were administered to schizophrenia patients: the Positive and Negative Syndrome Scale (PANSS), the Drug Attitude Inventory (DAI) and the Subjective Well-being under Neuroleptics (SWN). Statistically significant differences among non-TRS patients, TRS ones, and controls were detected at the BACS. TRS patients performed significantly worse than non-TRS ones on Verbal Memory task, exhibited higher PANSS total and subscales scores and were prescribed higher antipsychotic doses. Poorer performances at the BACS significantly correlated with more severe negative symptoms in TRS but not in non-TRS patients. These results may suggest that TRS patients suffer from a form of the disease with prominent cognitive impairment possibly related to negative symptoms.

Attitude towards second-generation antipsychotics among patients with schizophrenia and their relatives

OBJECTIVE

Given the paucity of research in this area, this study attempted to assess attitudes towards second-generation antipsychotic medications and their correlates among the patients with schizophrenia and their relatives.

METHODS

Structured assessments of attitudes to medications, psychopathology, insight/knowledge, side effects, functioning and treatment satisfaction were carried out in a random sample of 50 patients with DSM-IV schizophrenia and their relatives. All, except one of the patients, were on second-generation antipsychotics.

RESULTS

Most patients had positive attitudes towards second-generation antipsychotics. Severity of positive symptoms and higher burden of side effects (e.g. sexual dysfunction, weight gain and sedation) emerged as the principal correlates of negative attitudes among patients. Greater awareness of illness, being employed, better social functioning and greater treatment satisfaction were all associated with positive attitudes among patients. Relatives had significantly more positive attitudes towards antipsychotics than patients and were more satisfied with the treatment. They were well informed about the illness, and their level of knowledge had a significant association with positive attitudes.

CONCLUSIONS

Effective antipsychotic treatment, which improves functioning and minimises side effects could lead to more favourable attitudes towards antipsychotics among patients. Increasing awareness of illness, enhancing treatment satisfaction and involving relatives in treatment could also be of help.

Therapeutic alliance in schizophrenia: the role of recovery orientation, self-stigma, and insight

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.

Factors associated with antipsychotic medication adherence in community-based patients with schizophrenia in Hong Kong: a cross sectional study

The purpose of the present study was to examine the factors affecting adherence to antipsychotic medication in patients with schizophrenia registered with a community psychiatric nursing service in Hong Kong. The study was a cross-sectional observational survey; symptoms, drug attitudes, insight, side-effects, and sociodemographic characteristics were measured and explored in terms of their relationship with medication adherence. A total of 584 patients who were visited by community psychiatric nurses (CPN) participated, and 30% of these patients were non-adherent with their antipsychotic medication. Positive treatment attitudes, awareness of the need for treatment, being prescribed clozapine, receiving state benefits, lower levels of symptoms, and fewer side-effects were associated with adherence. The findings from this study suggest that the clinical efforts of CPN to improve adherence should aim to help patients amplify the personal relevance of treatment and modify patients' attitudes towards medication.

Focusing on the adult attachment style in schizophrenia in community mental health centres: validation of the Psychosis Attachment Measure (PAM) in a German-speaking sample

BACKGROUND

Assessing attachment style in people with schizophrenia may be important to identify a risk factor in building a strong therapeutic relationship and so indirectly to understand the development of mal-compliance as one of the major obstacles in the treatment of schizophrenia.

AIMS

The present study analysed the psychometric properties of the German version of the Psychosis Attachment Measure (PAM), which assesses avoidant and anxious attachment style.

METHODS

A sample of 127 patients suffering from chronic schizophrenia or schizoaffective disorder participated in this study. In testing discriminant validity, we assessed psychopathology, depression, therapeutic relationship and service engagement. Internal consistency, test-retest reliability and factor structure were analysed.

RESULTS

The German version of PAM exhibited acceptable to good internal and test-retest reliabilities and the two-factor structure of the English version could be replicated. Avoidant attachment style was related to higher levels of positive symptoms and to a poorer therapeutic relationship. In the context of external validation, a regression analysis revealed that a poor therapeutic relationship correlated with avoidant attachment style, independent of anxious attachment style and depressive symptoms. Anxious attachment was associated with higher treatment adherence. Both insecure attachment styles (avoidant and anxious) were found to be correlated with higher levels of depression, but only attachment anxiety had an independent predictive value for self-reported depression in regression analysis.

CONCLUSIONS

The German version of PAM displayed satisfactory psychometric properties and seems to be a reliable measure for assessing attachment style in individuals with schizophrenia. Validation of PAM led to the finding that only the avoidant attachment style might be a risk factor when building a strong therapeutic relationship in schizophrenia. In future studies, other factors influencing therapeutic relationship should be taken into account. Anxious attachment style may be a risk factor for depression, but it also has an enhancing effect on treatment adherence.

Short-term clinical stability and lack of insight are associated with a negative attitude towards antipsychotic treatment at discharge in patients with schizophrenia and bipolar disorder

PURPOSE

The primary aim of this study was to assess the range of attitudes towards antipsychotic treatment at hospital discharge in patients with schizophrenia and bipolar disorder. The secondary aim was to analyze the relationship between patients' attitudes and sociodemographic and clinical parameters.

PATIENTS AND METHODS

A cross-sectional study with a sample of patients admitted due to acute exacerbation of schizophrenia or a manic episode was conducted. Attitude towards pharmacological treatment at discharge was assessed with the 10-item Drug Attitude Inventory (DAI-10). Logistic regression was used to determine significant variables associated with attitude to medication.

RESULTS

Eighty-six patients were included in the study. The mean age was 43.1 years (standard deviation [SD] 12.1), and 55.8% were males. Twenty-six percent of the patients presented a negative attitude towards antipsychotic treatment (mean DAI-10 score of -4.7, SD 2.7). Most of them had a diagnosis of schizophrenia. Multivariate analysis showed that poor insight into illness and a greater number of previous acute episodes was significantly associated with a negative attitude towards medication at discharge (odds ratio 1.68 and 1.18, respectively).

CONCLUSION

Insight and clinical stability prior to admission were related to patients' attitude towards antipsychotic treatment at hospital discharge among patients with schizophrenia and bipolar disorder. The identification of factors related to the attitude towards medication would offer an improved opportunity for clinicians to select patients eligible for prophylactic adherence-focused interventions.

Social interaction and drug attitude effectiveness in patients with schizophrenia

This study aimed to explore the relationship between dosage of paliperidone and drug attitude, and also clarify the factors associated with drug attitude, using Intention-to-Treat (ITT) analysis. Three hundred thirty-one patients diagnosed with schizophrenia, who prescribed paliperidone between April 2008 and April 2009, from 10 hospitals in Taiwan were enrolled. By structural equation modeling, inpatient/outpatient status associated with occupation status, sex, and score on the Clinical Global Impression-Severity (CGIS) Scale. The score on the Personal and Social Performance (PSP) Scale associated with occupation status, inpatient/outpatient status, and the score on the CGIS Scale. The scores on the DAI-10 associated with the score on the PSP Scale and age. Good drug attitude and medication adherence significantly related to good social interaction. We should enhance the drug attitude and medication adherence of patients with schizophrenia who have poor social interaction to improve the outcome of schizophrenia.